Updated: 1/2/2021

Ethical Principles

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Core 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 
      • communicate with non-English speaking patients through a professional translator 
    • respecting confidentiality
  • Beneficence
    • acting in patient's best interest 
    • balance autonomy and beneficence, but autonomy trumps beneficence   
  • Nonmaleficence
    • "do no harm"  
    • do not help patients commit suicide 
  • Justice
    • distributive Justice
      • governs allocation of limited resources
    • formal Justice
      • equals must be treated equally
Other Principles
  • Breaking bad news  
    • set up the interview
    • assess the patient's perception
    • obtain the patient's invitation (i.e. permission)
    • give the patient the necessary knowledge
    • address the patient's emotions with empathetic responses
    • in pediatric cases, both parents and patients have a right to know the diagnosis and treatment 
      • group conversations can facilitate "right to know" conflicts while maintaining legal and ethical principles 
  • End of life care principles include:
    •  evaluate patients for hospice care if they have 
      • a life limiting diagnosis
      • prognosis of less than 6 months
    • give hospice patients antibiotics and pain medications 
      • treatments that enhance quality of life should be administered in hospice care
      • only treatments that sacrifice current well-being for future longevity should be avoided
    • informing patients about their diagnoses even against family wishes  
  • 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  
  • Confidentiality 
    • all patients, regardless of age, should have the option of speaking to their physician alone 
    • minors (<18 years-old) generally require their parents to consent to receive treatment, with the following exceptions (in most states):
      • care for 
        • sexual health (e.g. pregnancy, contraception, sexually transmitted infection treatment) 
        • mental health
        • substance abuse
      • emancipated minors
      • emergencies
    • parents should be asked to leave the room so teenage patients can discuss: 
  • 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 can not be determined by a physician
  • Adherence  
    • extended contact with physicians through follow-up appointments increases adherance with lifestyle changes
    • concerning reports of medication abuse should be discussed directly with the patient 
    • creating an organized written linear care plan is key to increasing medication compliance in patients 
  • Medication compliance in children 
    • multifaceted issue, with factors including age of patient, knowledge about disease, peer pressure, rebellion/independence, socioeconomic status, cultural issues and beliefs, and family structure
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Questions (37)
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(M1.ST.16.1114) A 27-year-old male presents for emergency surgery to reattach his left arm, severed during a high-speed car accident, and has lost significant amounts of blood. His wife arrives within minutes to the hospital exclaiming that under no circumstance should he receive any blood transfusions during surgery. After reviewing his medical chart, you see also see an annotation indicating no blood transfusions for religious reasons. Knowing that he needs a blood transfusion to save his life, what do you do? Tested Concept

QID: 107058
FIGURES:
1

Administer a blood transfusion to save the patient's life

0%

(0/26)

2

Call the ethics board of the hospital to discuss the issue

8%

(2/26)

3

Respect the patient's written instructions and do not adminster a blood transfusion

73%

(19/26)

4

Convince the wife to administer a blood transfusion to her husband

0%

(0/26)

5

Refuse to treat the patient as he will die without a blood transfusion

0%

(0/26)

M 1 D

Select Answer to see Preferred Response

(M1.ST.15.73) A 78-year-old woman is brought to the emergency ward by her son for lethargy and generalized weakness. The patient speaks in short utterances and does not make eye contact with the provider or her son throughout the interview and examination. You elicit that the patient lives with her son and daughter-in-law, and she reports vague weakness for the last couple days. The emergency room provider notices 3-4 healing bruises on the patient's upper extremities; otherwise, examination is not revealing. Routine chemistries and blood counts are unremarkable; non-contrast head CT demonstrates normal age-related changes. Which of the following is the most appropriate next step in management? Tested Concept

QID: 106585
1

Perform lumbar puncture

4%

(1/24)

2

Question the patient regarding abuse or neglect

25%

(6/24)

3

Question the patient's son regarding the home situation

0%

(0/24)

4

Ask the patient's son to leave the room

50%

(12/24)

5

Call Adult Protective Services to report the patient's son

4%

(1/24)

M 3 D

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(M1.ST.15.73) A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient? Tested Concept

QID: 106577
1

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

7%

(2/28)

2

"Is the diarrhea foul-smelling?"

7%

(2/28)

3

"Can you tell me more about the symptoms you have been experiencing?"

61%

(17/28)

4

"Does the diarrhea typically precede the constipation, or vice-versa?"

14%

(4/28)

5

"Are the symptoms worse in the morning or at night?"

0%

(0/28)

M 2 D

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(M1.ST.15.9) Last night you admitted a 72-year-old woman with severe COPD in respiratory distress. She is currently intubated and sedated and her family is at bedside. At the completion of morning rounds, the patient's adult son asks that you and the team take a minute to pray with him for his mother. What is the most appropriate response? Tested Concept

QID: 100009
1

"I'm sorry, but this is a public hospital, so we cannot allow any group prayers."

0%

(0/50)

2

"I understand what you are experiencing and am happy to take a minute."

70%

(35/50)

3

"I also believe in the power of prayer, so I will pray with you and insist that the rest of team joins us."

0%

(0/50)

4

"While I cannot offer you my prayers, I will work very hard to take care of your mother."

10%

(5/50)

5

"I don't feel comfortable praying for patients, but I will happily refer you to pastoral care."

8%

(4/50)

M 4 D

Select Answer to see Preferred Response

(M1.ST.15.73) A 15-year-old female presents to her family physician for an annual school physical exam and check-up. She is accompanied by her mother to the visit and is present in the exam room. The patient has no complaints, and she does not have any past medical problems. She takes no medications. The patient reports that she remains active, exercising 5 times a week, and eats a healthy and varied diet. Which of the following would be the best way for the physician to obtain a more in-depth social history, including sexual history and use of alcohol, tobacco, or recreational drugs? Tested Concept

QID: 106570
1

Ask the patient the questions directly, with her mother still in the exam room

0%

(0/24)

2

Ask the mother to step outside into the hall for a portion of the visit

75%

(18/24)

3

Give the patient a social history questionnaire to fill out in the exam room

4%

(1/24)

4

Speak softly to the patient so that the mother does not hear and the patient is not embarrased

0%

(0/24)

5

Disallow the mother to be present in the examination room throughout the entirety of the visit

0%

(0/24)

M 3 D

Select Answer to see Preferred Response

(M1.ST.15.73) A junior orthopaedic surgery resident is completing a carpal tunnel repair with the department chairman as the attending physician. During the case, the resident inadvertently cuts a flexor tendon. The tendon is repaired without complication. The attending tells the resident that the patient will do fine, and there is no need to report this minor complication that will not harm the patient, as he does not want to make the patient worry unnecessarily. He tells the resident to leave this complication out of the operative report. Which of the following is the correct next action for the resident to take? Tested Concept

QID: 106592
1

Disclose the error to the patient but leave it out of the operative report

3%

(1/29)

2

Disclose the error to the patient and put it in the operative report

14%

(4/29)

3

Tell the attending that he cannot fail to disclose this mistake

66%

(19/29)

4

Report the physician to the ethics committee

0%

(0/29)

5

Refuse to dictate the operative report

0%

(0/29)

M 1 D

Select Answer to see Preferred Response

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(M1.ST.15.78) A 73-year-old man is admitted to the hospital for jaundice and weight loss. He is an immigrant from the Dominican Republic and speaks little English. A CT scan is performed showing a large mass at the head of the pancreas. When you enter the room to discuss these results with the patient, his daughter and son ask to speak with you outside of the patient's room. They express their desire to keep these results from their father, who is "happy" and would prefer not to know his poor prognosis. What is the appropriate response in this situation? Tested Concept

QID: 105748
1

Explore the reasoning behind the children's reluctance to have their father know his prognosis

56%

(36/64)

2

Tell the children that you are obligated to tell the father his prognosis

22%

(14/64)

3

Respect the children's wishes to hold prognosis information from their father

2%

(1/64)

4

Deliver the information in English so that you have not withheld information but the patient will not understand

2%

(1/64)

5

Bring the situation to the hospital ethics panel

5%

(3/64)

M 4 D

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(M1.ST.14.18) A 68-year-old man is being evaluated in your radiation oncology clinic for treatment of a solid tumor. Your hospital has just purchased a new proton beam purported to deliver targeted radiation with fewer side effects than traditional radiation therapy. The patient expresses strong interest in receiving proton beam therapy, and you feel that he may have a better outcome with this new treatment modality. Later that day, an executive from the patient's insurance company calls to tell you that proton beam therapy will cost the company (but not the patient) a much larger amount of money than traditional therapy. They are willing to pay for proton beam therapy, but request that you convince the patient to undergo traditional therapy instead. You have a longstanding relationship with this insurance company as well as this particular executive. How should you proceed? Tested Concept

QID: 103670
1

Discuss the issue of cost to the insurer with your patient, pointing out that keeping his insurance company happy may make them more likely to cover additional treatments in the future

0%

(0/35)

2

Proceed with proton beam therapy as discussed at your patient's appointment

57%

(20/35)

3

Tell the patient that proton beam therapy will not be covered by his insurance company, so you will need to proceed with traditional radiation therapy

3%

(1/35)

4

Discuss the issue of cost to the insurer with your patient, relaying the company's request to him without making further commentary or recommendation

9%

(3/35)

5

Call your hospital's ethics committee for a formal consultation

11%

(4/35)

M 3 E

Select Answer to see Preferred Response

(M1.ST.14.1) A 74-year-old woman is brought to her primary care doctor by her adult son. The son says she has been very difficult at home and is "losing it". He seems very frustrated about her diminishing ability to take care of herself the way she used to and no longer thinks he can trust her watching his children. At her last visit you noted mild cognitive impairment. Today, she appears withdrawn and hesitates to make eye-contact with you. She lets her son do most of the talking. Which of the following is the most appropriate next step? Tested Concept

QID: 105638
1

Discuss with the son the challenges of having a parent with dementia

0%

(0/27)

2

Complete a mini-mental exam

15%

(4/27)

3

Assess the patient's risk for depression

4%

(1/27)

4

Order a head CT

0%

(0/27)

5

Ask the son to step out so you can speak with the patient alone

63%

(17/27)

M 1 E

Select Answer to see Preferred Response

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(M1.ST.13.3) A 16-year-old female patient with a history of mental retardation presents to your clinic with her mother. The mother states that she wants her daughter to have a bilateral tubal ligation after she recently discovered her looking at pornographic materials. She states that her daughter is not capable of understanding the repercussions of sexual intercourse, and that she does not want her to be burdened with a child that she would not be able to raise. Upon discussions with the patient, it is clear that she is not able to understand that sexual intercourse can lead to pregnancy. What should your next step be? Tested Concept

QID: 103366
1

Schedule the patient for the requested surgery

11%

(7/61)

2

Wait until the patient is 18 years old, and then schedule for surgery

3%

(2/61)

3

Refuse the procedure because it violates the ethical principle of autonomy

64%

(39/61)

4

Refer the patient to a psychiatrist to get informed consent

10%

(6/61)

5

Refuse the procedure because it is unlikely that the patient will get pregnant

0%

(0/61)

M 1 D

Select Answer to see Preferred Response

(M1.ST.13.20) A 65-year-old male is referred by his primary care physician to your general surgery clinic for further work-up and assessment of a right inguinal hernia. While you are obtaining the patient's history, he embarks on a lengthy diatribe voicing his dissatisfaction with the care he is receiving from his primary care physician. Specifically, he believes that his diabetes medications are being mismanaged and is frustrated with the lengthy wait times he experiences prior to office visits. Which of the following is the most appropriate action or response? Tested Concept

QID: 100020
1

Agree with the patient that his diabetes is being poorly managed and suggest that the patient bring up the topic at his next appointment

2%

(1/46)

2

Tactfully disregard the patient's complaints and continue with the interview; contact the primary care physician at a later date to alert him/her to their patient's dissatisfaction

9%

(4/46)

3

Acknowledge the patient's frustration and suggest that he express his concerns directly to his primary care physician

74%

(34/46)

4

Evaluate the patient's current regimen of diabetes medications and make changes as you see necessary

2%

(1/46)

5

Suggest that the patient transfer his care to another primary care physician

2%

(1/46)

M 3 E

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(M1.ST.13.17) A 72-year-old woman with a 40 pack-year history of smoking presents to your office with jaundice. After a thorough workup, you determine that the patient has pancreatic cancer. Which of the following is the most appropriate initial statement to inform the patient of her condition? Tested Concept

QID: 100017
1

"Have you ever heard of pancreatic cancer?"

18%

(6/34)

2

"I have bad news I need to share with you. Please sit down so we can discuss."

59%

(20/34)

3

"Have you designated a healthcare proxy?"

3%

(1/34)

4

"We just received your test results and we have bad news to share with you. The resident will be in to explain the diagnosis to you."

6%

(2/34)

5

"Your test results are consistent with a pancreatic adenocarcinoma."

3%

(1/34)

M 1 E

Select Answer to see Preferred Response

(M1.ST.13.6) You are the team physician for an NBA basketball team. On the morning of an important playoff game, an EKG of a star player, Mr. P, shows findings suspicious for hypertrophic cardiomyopathy (HCM). Mr. P is an otherwise healthy, fit, professional athlete.

The playoff game that night is the most important of Mr. P's career. When you inform the coach that you are thinking of restricting Mr. P's participation, he threatens to fire you. Later that day you receive a phone call from the owner of the team threatening a lawsuit should you restrict Mr. P's ability to play. Mr. P states that he will be playing in the game "if it's the last thing I do."

Which of the following is the most appropriate next step?
Tested Concept

QID: 100006
1

Consult with a psychiatrist to have Mr. P committed

0%

(0/23)

2

Call the police and have Mr. P arrested

0%

(0/23)

3

Allow Mr. P to play against medical advice

4%

(1/23)

4

Educate Mr. P about the risks of HCM

74%

(17/23)

5

Schedule a repeat EKG for the following morning

0%

(0/23)

M 4 D

Select Answer to see Preferred Response

(M1.ST.13.26) On a Sunday afternoon, a surgical oncologist and his family attend a football game in the city where he practices. While at the game, he runs into a physician colleague that works at the same institution. After some casual small talk, his colleague inquires, "Are you taking care of Mr. Clarke, my personal trainer? I heard through the grapevine that he has melanoma, and I didn't know if you have started him on any chemotherapy or performed any surgical intervention yet. Hopefully you'll be able to take very good care of him." In this situation, the surgical oncologist may confirm which of the following? Tested Concept

QID: 100026
1

The patient's name

0%

(0/30)

2

The patient's diagnosis

0%

(0/30)

3

The patient's treatment plan

3%

(1/30)

4

No information at all

57%

(17/30)

5

Only that Mr. Clarke is his patient

23%

(7/30)

M 1 E

Select Answer to see Preferred Response

(M1.ST.13.2) A 26-year-old patient presents to your office with rhinorrhea that you believe to be viral in origin. He respectfully requests treatment with antibiotics, and he demonstrates an understanding of the risks, benefits, and alternatives to treatment. His mental status is intact, and you believe him to have full decision-making capacity. Which of the following is the best course of action? Tested Concept

QID: 100002
1

Prescribe ciprofloxacin

4%

(2/56)

2

Prescribe amoxicillin

14%

(8/56)

3

Prescribe zidovudine

4%

(2/56)

4

Refer the patient to an infectious disease specialist

21%

(12/56)

5

Deny the patient's request

50%

(28/56)

M 3 E

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Evidence (34)
Topic COMMENTS (27)
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