Fa: Behavioral Sciences - Ethics

Front 1

What is the term for the obligation to respect patients as individuals (truth-telling, confidentiality), to create conditions necessary for autonomous choice (informed consent), and to honor their preference in accepting or denying medical care

Back 1

Patient Autonomy

Front 2

What is the term for the special ethical (fiduciary) duty of physicians to act in the patient's best interest?

Back 2

Beneficence

Front 3

How do Patient Autonomy and Beneficence relate?

Back 3

- Patient Autonomy: patient's right to decide their medical care
- Beneficence: physician's ethical duty to act in the patient's best interest

* They may conflict, but if the patient can make an informed decision, ultimately, the patient has the right to decide

Front 4

What is the term for "do no harm"?

Back 4

Non-Maleficence

Front 5

How do Beneficence and Non-Maleficence relate?

Back 5

- Beneficence: physician's ethical duty to act in the patient's best interest
- Non-Maleficence: do no harm

* If the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries and medications fall into this category)

Front 6

What is the term for treating persons fairly?

Back 6

Justice

Front 7

What does informed consent legally require?

Back 7

1. Disclosure: discussion of pertinent information
2. Understanding: ability to comprehend (assess)
3. Mental capacity: unless incompetent (legal determination)
4. Voluntariness: freedom from coercion and manipulation

Front 8

What are the exceptions to informed consent?

Back 8

- Patient lacks decision-making capacity or is legally incompetent
- Implied consent in an emergency
- Therapeutic privilege: withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity
- Waiver: patient waives the right to informed consent

Front 9

What is necessary for a patient to have informed consent?

Back 9

- Patient must have an intelligent understanding of the risks, benefits, and alternatives, which include no intervention
- Written consent can be revoked by the patient at any time, even orally

Front 10

What are the informed consent requirements for minors (<18 years)?

Back 10

Consent must be obtained by parents/guardians unless the minor is emancipated (eg, married, self-supporting, has children, or is in the military)

Front 11

Under which conditions is parental consent not necessary for a minor (<18 years)?

Back 11

SEX: contraception, STDs, pregnancy
DRUGS: addiction
ROCK and roll: emergency / trauma)

- Emancipation: married, self-supporting, has children, or in the military
- Emergency situations
- Prescribing contraceptives
- Treating STDs
- Medical care of pregnancy
- Treatment of drug addiction

Front 12

What are the components of decision-making capacity?

Back 12

- Patient is >18 years old or otherwise legally emancipated
- Patient makes and communicates a choice
- Patient is informed (demonstrates knowledge and understanding)
- Decision remains stable over time
- Decision is consistent with patient's values and goals, not clouded by a mood disorder
- Decision is not a result of delusions or hallucinations

Front 13

What is an advanced directive?

Back 13

Instructions given by a patient in anticipation of the need for a medical decision; details vary per state law

Front 14

What are the types of advanced directives?

Back 14

- Oral advance directive
- Living will (written advanced directive)
- Medical power of attorney

Front 15

What information is gained from an "Oral Advanced Directive"? Pros / Cons?

Back 15

- Incapacitated patient's prior oral statements used as guide

- Pros: If patient was informed, directive was specific, patient made a choice, and decision was repeated over time to multiple people, oral directive is more valid

- Cons: Problems arise from variance in interpretation

Front 16

What information is gained from a "Living Will" (written advanced directive)?

Back 16

- Describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity
- Usually patient directs physician to withhold or withdraw life-sustaining treatment if they develop a terminal disease or enter a persistent vegetative state

Front 17

What information is gained from a "Medical Power of Attorney"?

Back 17

- Patient designates an agent to make medical decisions in the event that he/she loses decision-making capacity
- Patient may also specify decisions in clinical situations
- Patient can revoke anytime patient wishes (regardless of competence)
- More flexible than a living will

Front 18

What happens if a patient has not prepared an advance directive and becomes incompetent / unable to make decisions?

Back 18

- Individuals (surrogates) who know the patient must determine what the patient would have done if he/she were competent
- Priority of surrogates: spouse, adult children, parents, adult siblings, other relatives

Front 19

What are the general principles for exceptions to confidentiality?

Back 19

- Potential harm to others is serious
- Likelihood of harm to self is great
- No alternative means exists to warn or to protect those at risk
- Physicians can take steps to prevent harm

Front 20

What are some examples of exceptions to confidentiality?

Back 20

- Reportable diseases (STDs, TB, hepatitis, food poisoning) - may have a duty to warn public officials who will then notify people at risk
- Tarasoff decisions - requirement to directly inform and protect potential victim from harm
- Child and/or elder abuse
- Impaired automobile drivers
- Suicidal / homicidal patients

Front 21

What is the appropriate response to a patient who is not adherent?

Back 21

- Attempt to identify patient's reason for non-adherence and determine their willingness to change
- Do not attempt to coerce the patient into adhering or refer the patient to another physician

Front 22

What is the appropriate response to a patient who desires an unnecessary procedure?

Back 22

- Attempt to understand why the patient wants the procedure and address underlying concerns
- Do not refuse the patient or refer him/her to another physician
- Avoid performing unnecessary procedures

Front 23

What is the appropriate response to a patient who has difficulty taking medications?

Back 23

- Provide written instructions
- Attempt to simplify treatment regimens
- Use teach-back method (ask patient to repeat medication regiment back to physician) to ensure patient comprehension

Front 24

What is the appropriate response to a patient's family members who ask for information about the patient's prognosis?

Back 24

Avoid discussing issues with relatives without the permission of the patient

Front 25

What is the appropriate response to a child's wishes to know more about his/her illness?

Back 25

- Ask what the parents have told the child about his/her illness
- Parents of a child decide what information can be relayed about the illness

Front 26

What is the appropriate response to a 17-year old girl who is pregnant and requests an abortion?

Back 26

- Many states require parental notification or consent for minors for an abortion
- Unless she is at medical risk, do not advise a patient to have an abortion regardless of her age or condition of the fetus

Front 27

What is the appropriate response to a 15-year old girl who is pregnant and wants to keep the child, but who's parents want you to tell her to give the child up for adoption?

Back 27

- The patient retains the right to make decisions regarding her child, even if her parents disagree
- Provide information to the teenager about the practical issues of caring for a baby
- Discuss the options, if requested
- Encourage discussion between the teenager and her parents to reach the best decision

Front 28

What is the appropriate response to a terminally ill patient whom requests physician assistance in ending their own life?

Back 28

- Refuse involvement in any forms of physician assisted suicide
- You may prescribe medically appropriate analgesics that coincidentally shorten the patient's life

Front 29

What is the appropriate response to a patient who is suicidal?

Back 29

Assess the seriousness of the threat
- If it is serious, suggest that they remain in the hospital voluntarily
- Patient can be hospitalized involuntarily if he/she refuses

Front 30

What is the appropriate response to a patient that states that he/she finds you attractive?

Back 30

- Ask direct, closed-ended questions and use a chaperone if necessary
- Romantic relationships with patients are never appropriate
- Never say "there can be no relationship while you are a patient" because this implies that a relationship may be possible if the individual is no longer a patient

Front 31

What is the appropriate response to a woman who had a mastectomy and says she feels ugly when she undresses?

Back 31

- Find out why the patient feels this way
- Do not offer falsely reassuring statements (eg, "you still look good")

Front 32

What is the appropriate response to a patient who is angry about the amount of time he/she spent in the waiting room?

Back 32

- Find out why the patient feels this way, but do not take a patient's anger personally
- Apologize for any inconvenience
- Stay away from efforts to explain the delay

Front 33

What is the appropriate response to a patient who is upset with the way he/she was treated by another doctor?

Back 33

- Suggest that the patient speak directly to that physician regarding the concerns
- If the problem is with another member of the office staff, tell the patient you will speak to that individual

Front 34

What is the appropriate response to a drug company offering a "referral fee" for every patient a physician enrolls in a study?

Back 34

- Eligible patients who may benefit from the study may be enrolled, but is never acceptable to receive compensation from a drug company
- Patients must be told about the existence of a referral fee

Front 35

What is the appropriate response to a physician ordering an invasive test for the wrong patient?

Back 35

No matter how serious or trivial a medical error, a physician is ethically obligated to inform a patient that a mistake has been made

Front 36

What is the appropriate response to a patient that requires a treatment not covered by his/her insurance?

Back 36

- Never limit or deny care because of the expense in time or money
- Discuss all treatment options with patients, even if some are not covered by their insurance