“USMLE 100 ETHICS CASE NOTES”

Autonomy:-

-Operation without consent = Assault

-Only case where no consent needed = Emergency Situation

-Freedom to choose one’s own form of health care

-Follow patient pre-planned wishes……..even if he lose consciousness & capacity to make decisions

-Autonomy is more imp and takes precedence over Beneficence (Things for patient’s own good). Patient
can refuse Rx even it is better for him.

-Violate Confidentiality in……………….HIV, TB, STDs……..where there is harm for third party.

-Autonomy gives patient right to even make wrong choice for their health care.

Competence and Capacity to Understand:-

Only Court can decide = Competence = All Adults are considered Competent

All Physicians can decide = Ability to Understand………………if difficult only then Psychiatrist.

Under 18 Year = Minor

Immature Minor = <15 year

Mature Minor = >15 to <18 year

Consent for Minor = Only Parent………..or…….. Legal Guardian. (No one else, whether
relative/brother/neighbor)

Only Exception = Emergency Situation

Partial Emancipation = Can Give Consent themselves = STD, Prenatal Care, Contraception, Substance
Abuse

Minor Comes for Abortion = Encourage him to notify parents / Encourage Discussion / Family Meeting
Emancipated Minors = Can Give consent for everything = They are…. Independent, Military, Married,
Living Alone

Adult= Can refuse whatever Rx

Parents = Can’t refuse Life Saving Rx for child……Provide even if they refuse e.g. Blood Transfusion to
Jehovah’s Witness

Parents can’t refuse….even if…..Child is Developmentally Disabled or Permanent CNS Damage.

e.g.

They can’t refuse……….repair of TEF………just because child also has Down Syndrome.

ONLY EXCEPTION = If condition of Child is irreversible & death is imminent = Now parents can refuse Rx
= To stop futile care from Dr.

All Suicidal Patients = considered……..to LACK capacity to understand.

Psychiatric Patient = can be incompetent for life matter……….but still can have capacity to understand =
thus can consent/refuse

Adult with Mental age 10 year = can refuse Rx.

Informed Consent:-
Inform patient about……..

 all Rx options
 Their A-Ds
 What happens by disease if no Rx is done

Consent is taken for each patient. E.g. U do op. for appendectomy and find colon CA, u will not operate,
as consent only for appendix…….either there should be consent in advance………..or…….patient should
wake up, u explain and take consent for this.

No Presumed Consent in any case……except Emergency in unconscious patient…..unless patient has

terminal illness & a pre-signed DNR.

If patient loses capacity to understand or to communicate…….follow his last known wish (verbal or
written).
Consent is taken by the person who knows all this….e.g. U don’t know anything about procedure, Ur
resident calls & asks u to take consent. U will refuse and will ask the resident to take himself as u don’t
have info, so u can’t inform the patients everything.

Consent on Phone is Valid……even it is heart surgery……just have 1 health care worker/nurse as ur

witness + U take from appropriate surrogate e.g. Family member or health care proxy + Who knows
patient wishes.

If nurse says it’s not valid…………..ask some other nurse….& explain to this nurse later that it is valid.

Pregnant Mother = Can refuse or allow whatever she wants………if that harms her fetus.

Fetus = not individual person = no separate rights

e.g.

Mother + 34 week Intrauterine Fetus = Do whatever mother says

Mother + 34 week born Child = Child has emergency = Do ur Rx, even if mother refuses.

Maternal Consent = Enough……Father has no right over pregnancy related issue.

Patient never had Capacity to understand e.g. Down Syndrome….now What?

Whole Life…..Consent by = Parent or Guardian

Not Available = Substituted Judgment = Person who knows Patient….can decide what patient would
have wished.

Weakest Consent Method = Best Interest of Patient. = Best Method for those who never had Capacity. =
Court appoint a guardian or Medical Director to make the choice.

So Normally,

Consent from Patient himself > Can’t give Then Advance Directive (Health Care Proxy or Durable Power
of Attorney) > Substituted Judgment by Family Member or Guardian > Best Interest Method
 CONFIDENTIALITY:-

Always Maintain Patient Info Confidential…….Except = 1- Harm to 3rd Part 2- Court

Order/subpoena/search warrant 3- Patient gives consent

From Everyone = Friends, Family (Even if patient has good relations)

If someone asks = I’m sorry, I’m not authorized to give this info.

Patient had MI, now admitted & awake…..wife came now & asks = Take permission from patient first.

Other Dr. can take info = Only if directly involved in patient care.

Another Dr. asks for Patient records as He is the Dr. of patient now = Tell him to send Signed Patient
Release Form.

If Everyone is awaiting result of a test (e.g. biopsy) = Always inform Patient first, ask permission, then
you can tell family.

If family members comes first = Say I will tell to the patient first.

Only 1 exception = Psychiatric Disorder + New medical illness may cause Suicidal Attack = Tell family
immediately to protect patient.

If Government Employee comes & asks = Tell info. Only if he has……….Subpoena, Court Order or Search
Warrant…..Otherwise = refuse.

Harm to 3rd Party =

i- Psychiatric Patient with Intent to Kill……….Inform Polics + Victim

ii- STDs……. 1st Encourage Patient to tell partner himself…..if he doesn’t… Then Do it yourself.

Medical Record = Property of Dr. or Hospital

Info in it = Property of Patient.

So patient has = Free access, anytime.

Patient was very rude + didn’t pay your fee & now asks for records = Give him…….It his property,
Records cant be held hostage if he hasn’t paid.
Medical Record Error = Don’t smudge it……..Don’t Remove Page………… Draw a line through it…..and
then write correction. So everyone knows, what was previously there, and what you corrected.

Missed writing some info yesterday in Chart = Cant write today with Yesterday’s date…….Write in
current date and time.

End Of Life Issues:-

If Patient has capacity to understand = Patient can refuse Rx at start….or any time even after starting of
Rx. E.g. after getting that Rx for 1 week or month etc…………….even they will die without it

e.g.

Renal Failure………Patient can refuse Dialysis from Start………….or………..can refuse any further after
having it for 6 months.

COPD…Now Mechanical Ventilation = Patient can refuse.

Quadriplegia + Wants to have mechanical ventilation for whole life = honour his wishes, Don’t say u will
never improve.

Aplastic Anemia + Now no more Transfusions = Explain the consequence that she’ll die, and stop Rx and
honour wish.

But…. If Patient has Depression = Means No Capacity to understand = Psychiatric Consultation/ Trial of
Behavior Rx / Anti-Depressants.

Advance Directive = Patient communicates in advance of becoming unable to communicate his wishes.

2 Methods = Living Will …………….&………………….Health Care Proxy.

Health Care Proxy = Medical Power of Attorney = Durable Proxy = Effective even when patient loses
Decision Making capacity ( Unlike Financial Proxies which become invalid)

Proxy Speaks for the Patient…… A messenger of patient………Proxy over rules all other decision makers
(Family, wife etc).

Proxy Says = What were patient directed instructions or what patient would have wanted.
If No Advanced Directive…….Now Sequence of Decision makers is…

Normal Family = Wife > Parents > Adult Children > Siblings > Friends

Split Family = Ethics Committee or Court Order.

Living Will =

a- If Specific Details = Useful = Overrule everyone

b- If vague like no heroic care = Useless = Diffilcult to understand and follow.

Patient + no Advanced Directive =

i- Family Agrees = Follow it ( Oral Advanced Directive)

ii- If Disagrees = Encourage Consensus/ Request Discussion/Talk with involved parties……………if
not possible = Refer to Ethics Committee…….Last Step = Court Order / Judicial Intervention

So Order is = Patient Decision himself > Advanced Directive (Proxy, Living will) > Oral Advanced Directive
> United Family Decision > Family Disagreement Resolved with Discussion > Resolved with ethics
committee > Court Order.

DNR = Donot Resuscitate = Chest Compression, Cardioversion, Acute Anti-Arrhythmics only………….can

do everything else.

Can do Surgery, biopsy, Rx etc etc….just no CPR if patient loses pulse,BP or breath.

Healthy Person can also sign DNR, he doesn’t have to be a terminal patient to sign that.

DNR doesn’t mean you let the patient die by other means or be less careful e.g.

Patient in OT for some surgery + DNR + Surgeon says, great, if surgery goes wrong & patient dies,
nothing to worry, he has DNR. = Wrong, Be careful, Save him.

What about Intubation in DNR..?

If Patient is Normal…..but has respiratory disease = intubate

If Patient is Unstable = Don’t Intubate (as here Intubation is part of resuscitation).

What about Artificial Nutrition..?

Capacity to understand = Artificial Nutrition (NG, Jejunostomy etc) and TPN (Hyperalimentation) also
with consent.
e.g. ALS Patient + Cant take orally = Give NG only with consent…….or……….if it was previously there, now
wants to remove = remove it.

Just make sure = He is not Depressed.

If No Capacity = Do whatever in……….Living Will or Health care Proxy.

If No Advanced Directive =

a- Family Uniform in decision that patient wanted no tubes = Do that

b- Not Clear = Ethics committee and courts

Physician Assisted Suicide = U don’t do anything yourself, you just assist it by providing means for
it…….Always Wrong……..Unacceptable……..even if patient requests it………or even if…..the local state law
permits procedure. ( Legal doesn’t mean its also Ethical ) (Giving the drug yourself is not the only
condition……………Don’t even provide means to patients by which they can end their life.)

Euthanesia = U yourself give lethal drug and kill the patient on his request = Super Duper Wrong….in
every State.

Law Of Double Effect = Same Drug……can be doing good but at same time killing the patient (Shortening
duration of life)……

In this situation,

a- If Intention is to do good = Do it………..even if it kills

b- If intention is to kill = Never do it.

e.g.

Metastatic Cancer + COPD + Intense Pain = Pain Killers relieve pain + Decrease Respiratory drive = Give
the required amount of Opiod Pain Killer….even if he later dies due to COPD………..You can’t keep patient
suffering.

Futile Care:-

If Clear that it is futile = Don’t do it………..even if Patient….or……Family is demanding it.

e.g. Cirrhosis + Varices + Encephalopathy not responding to Lactulose………..You suspect death in a few
days due to liver disease………Now develops Hepatorenal Syndrome and Uremia = Don’t Place Fistula for
Dialysis as no change in outcome.
Death:-

Brain Death = Actual or Legal Death………….even if the heart is beating.

e.g.

Man robbed a female and hit her in head…………She is Brain Dead…….Court asks ur opinion = Tell him
She is Legally dead, charge that man with murder

Brain Death = Exclude all simulating causes……….and there is Loss of Brainstem Reflexes i.e.

Light Reflex, Corneal Reflex, Doll’s Eye (Occulocephalic), Caloric Response to Ice Water Stimulation to
Tympanic Membrane, Spontaneous Respiration.

If Patient on Ventilator = Remove it……to look for spontaneous respiration.

If Clinically Found Dead = No invex.

Simulating Causes Must be excluded = Barbiturates, Hypothermia, HypoTN, NMBs like Pancuronium,
Succinyl choline etc.

e.g

Seizure at Party + Loss of Respiration, Brainstem reflexes…………Next Step = Drug Screen……….if

normal…….Next Step = Discuss with family to stop ventilator/Explain Findings/Build Consensus/Explain
meaning of brain death to family………but you actually don’t require their permission to stop ventilator
as patient is already dead…………….donate organ now ? = Only if family consents.

Who Decides Brain Death ? = Physician………..Neurologist not required.

Reproductive Issues:-
Abortion:

1st Trimester = Clearly Available………Do whatever patient says

2nd Trimester = Less Clear…..But Still do as patient wishes.

3rd Trimester = Clearly Restricted…..as Fetus Viable.

Consent = Only from Mother in all Trimesters…………Nothing from Father.

Physician has right to deny doing it………..Patient can’t force you to do it…..Refer to another physician.

Gender Selection = Unethical

Getting Fetus Gender Checked….& Later abortion due to it = Unethical

Contraception = Freely available…….from Minors to Adults……..No Parental Consent required.

Sterilization = Freely Available……..Only Patients consent required…..No Consent from Spouse.

Prenatal Care/Abortion = No consent from Parents…..but always Encourage patient to tell parents.

Sperm Donation or Selling = Completely Ethical

Egg Donation or Selling = Completely Ethical

Fertilized Egg = Can only be donated…..but can’t be sold.

Organ Donation:-
Autonomy Rules.

e.g.

Patient need Liver + Brother exactly HLA Matched + Don’t want to give = No one can force him……..not
even court.

Who can ask for Donation ? = Only Organ Donor Network……or……….Uniform Network for Organ
Sharing………..Physician treating the patient can’t ask for donation.

e.g.

My Patient is Brain Dead + Many People in hospital need organs + I have a good repute with patient’s
family = Still I being patient’s physican cant ask for donation ( also Against court law to obtain consent
)………….only the donor network dr can come ask for their consent.

Why…? = Because Organ Donor Netwrok……… are trained to do so……..their success rate of obtaining
consent is greater + if care giver physician takes consent, family thinks they are not doing everything to
save him.

Payment for Donation = Only for Renewable Tissues = Sperm, Unfertilized Egg, Blood.

All Other = Unethical

If In business of selling organs = Unethical.

Give Organ to = Person who needs the most…………not a preferably to rich.

Organ Donor Card = Means if he dies……..donate organs……..but Still Family Consent required.

e.g.

Organ Donor Card + Family says don’t donate = You will not donate any organ.

Reportable Diseases:-
Always Report = To interrupt spread

If e.g. Meningococcemia Patient comes = Always Report………..otherwise Epidemic………….but Don’t

reveal name of Source Pateint.

If STD e.g AIDS, Syphillis, Gonorrhea = Encourage patient to tell partner……….if doesn’t……….Tell yourself.

In Case of TB = Not only report……….but can isolate/incarcerate patient for 2 weeks…….to avoid
spread….as in 2 weeks of ATT….Sputum becomes Negative.

So Autonomy Ends…….where Safety of other begins.

Sequence is..

TB Patient = Give ATT + Isolate for 2 weeks ……..If Refuses Drugs…..Discuss with Patient…..still
refuses….Offer DOT (Directly Observed Therapy at Home)…..Still refuses………Don’t give ATT without
consent but to avoid spread, incarcerate/isolate patient in hospital.

HIV Related Issues:-

If Patient gives consent for routine tests……that doesn’t include HIV.

Separate Consent = Even for Testing HIV…………if he says No……U cant Test for HIV.

e.g.

Pregnant Lady with STDs + U offer HIV Testing + She refuses = U will not do it.

HIV +ve Pregnant Lady + U offer Anti-Retrovirals + She Refuses = U will not give them………….even
though this will transmit virus to her baby.

(Autonomy of Mother > Safety of Child)

HIV +ve Pregnant + Refuse C Section = Do SVD….U can’t forcefully do C Section

Do Notify the Partner = To interrupt spread and Treat him.

HIV +ve Patient + Doesn’t want to tell partner = Discuss with him/Encourage to tell partner…………..still
refuses……Inform Health Department…..Which will make list of partners from patient and notify
them…….if patient refuses to give name of partner = No penalty or incarceration for patient + If u have
any idea about partner, notify by yourself, u r protected.

HIV +ve Health Care Worker = Not obligatory to inform patient about ur own HIV status….just take extra
pre-cautions.

Refusal to Treat HIV +ve Patient = Unethical……………but no one can force a Dr to treat him… so Best
choice = Refer the patient to another physician.

STDs:-
Trace Contact……..Report…….and Notify..!

But only those = Can be Treated/Eradicated = HIV, Gonorrhea, Syphilis

Not for those = Can’t be Eradicated = Herpes Simplex

e.g

Syphillis Patient = Next Step = Ask have you told your partner ? ……..No………Encourage him to
tell………..Refuses…… Tell him That Health Dept. will make a list of all at risk persons + will invite to
hospital + then will inform them + will not tell about u (Source Patient)….. Still refuses …. Discuss….. Still
refuses… You say I will notify………..he threatens to sue…. U r legally protected, go notify.

Malpractice:-

3 Rules = 1- Error in Care 2- Evidence for error 3- Harm done to patient

If 1,2 are still there…..but no harm done patient = Its not malpractice

e.g.
Osteomyelitis + U gave oral drug = Patient became fine but found out that Biopsy & IV drug is standard
care + files suit = No Malpractice as no harm done.

Patient had Surgery + U forgot to give DVT Prophylaxis + He didn’t develop it = No malpractice

Has nothing to do with being polite/sweet or a harsh person.

e.g

Great Repute Dr. + Very good relation with patient’s family + Amputated wrong leg = Malpractice

Very Nice Dr. + Gave wrong drug due to poor handwriting = Malpractice

But,

A harsh surgeon + took informed consent + CVP line  Pneumothorax + Patient greatly angry & sued =
Not Malpractice.

Deviation from Local Standard of Care can cause Malpractice.

e.g

Staging of Cancer = U do laparotomy as everyone does locally there. = Later patient had a scar and lost
career in swimming = Malpractice

(Theoretically yes, Laparotomy was the best choice, but it could have been avoided.)

Also,

Breast CA + Axillary Lymph Node Biopsy = Later Edema and Cellulitis = Malpractice

(Although we know all lymph nodes must be checked….but now Sentinel Biopsy would have been
enough)

Consent can save you from malpractice.

Complications of Procedure = Not Malpractice….if all were explained and consent was taken.

(So here harm occurs to patient but is not malpractice)

Informed Refusal: Also Imp.

Patient Refuse Rx……….Inform him about all harm that will occur without Rx…..if Still refuses…. Only Now
no Malpractice.

e.g.

MI Patient = U offer Thrombolytics but can cause intracranial bleed. = Patient refuses = U do nothing =
Dies = Malpractice (Because you didn’t mention that he will die without it. )

If patient didn’t understand about informed refusal because of he couldn’t understand English =
Malpractice = Always double check with translater.

Patient has responsibility to check Dr Everything…..otherwise harm will not be malpractice.

e.g

DVT Patient + Informs nothing about recent Gastric Banding = U gave Heparin = Has massive bleeding =
No Malpractice.

U ask about Penicillin Allergy + Patient says no + but has reaction with penicillin = No Malpractice

Medical Error…

If Affects Care & Rx = Inform Patient

If Doesn’t = Don’t inform = Minor error e.g test result delayed.

Doctor Patient Relationship:-

Both Patient and Dr…………can choose their Dr / Patient………..No one can force anyone.

e.g.

Only One Endocrinologist but all patients full + Patient with V. bad DM = There is moral
obligation………but no legal obligation… so no one can force to treat him.

Exception = Emergency Cases = Have to give Emergency Care to everyone

Dr. can’t end suddenly = Give Reasonable Notice so that patient can find reasonable alternate.

Gifts = If some intent behind it or Large……don’t accept.

Dr/Patient Sexual Contact = Unethical……No matter who initiates it………..If Indication…..Both should
mutually terminate Dr/Patient Relationship.

Physician = No Sexual Contact with Present Patients……………..but can for Previous Patients.

Psychiatrist = Can’t Have not only with Present….but also not with all past previous patients.

Doctor and Society:-

Child Abuse = Always report……….. to Child Protective Services.

Report even if its just suspected.

Elder Abuse = Report to…..Adult Protective Services…..even if the competent adult refuses.

(You can Partially breach confidentiality of Patient and Family here).

Impaired Drivers:

Can’t Drive = Seizure Disorder / Vision Impairment / Syncope (Some States)

You can’t suspend or give Driving Licence………The Dept. of Motor Vehicles will.

If Found Impaired Driver = Encourage Self Refraining from Driving > Using Alternate Transportation >
Encourage to Tell DMV…..if he refuses…..tell yourself (but immunity to u not given in all states)

Prisoner Execution = You cannot participate at……ANY Level….even if u don’t know prisoner, he is not ur
patient, he is legally being executed by state…..You Just Cannot..!

(Why..? = It impairs your relation with other fellow prisoners who come to u as patients + Opposes a
Doctors Oath to save life)

e.g.

Say NO to following:

- Giving a lethal injection to prisoner

- Not giving it, just checking the equipment that they are fine
- Mixing the inj.
- Design formulation
You cant even announce/certify death of that person……1st of all someone else will announce death by
checking pulse…… later u can certify.

Torture = Cant participate……always report & try to remove patient from places like that.

Spousal Abuse = You Cant do anything without patient’s consent…..so = Encourage him/her to report to
police / Offer Counselling……………later if she gives consent = report to Police.

Gunshot Wound = Always Report…………even if the patient objects.

Gifts from Pharmaceuticals =

- Accept if………..<100$ + Educational/Medical

- They Can Sponsor Educational Presentation……..if they don’t interfere with content.
- Can Accept meals on those Educational Conferences.
- Can’t Accept………if hidden agenda/ >100$ / Entertainment things like Movie ticket, Sports Ticket
etc.

Doctor Doctor Relationship:-

Impaired Doctor = Alzheimers/Substance Abuse/Psychiatric Disorder/Emotional Disturbance = Report…

-First to……..Local Supervisor (Like Program Director) (e.g. Medical Student to Dean)

-If Private Physician………Report to Dept. of health.

Rate of Substance Abuse in Doctors = Rate of Substance Abuse in General Population.

If No Patient Care affected e.g. just Wild Parties, bad language, Motorcycle gangs on weekends, tattoos
= Don’t report.

Physician Disagreement:

If Attending….disagree….with Resident = Follow Attending as he is senior.

If Resident….Disagrees = Discuss/Confer/Try to reach consensus with evidence based medicine……if not
resolved…………go to Higher Local Authority like PD.

(Don’t answer………..inform the patient)

Experimentation:-
Voluntary + Only with Informed Consent……….Everyone can refuse.

If Child = Then consent from parent/guardian

Same Rules for Prisoners…..no changes.

IRB (Institutional Review Board) Approval Required……..constantly monitors all activities.

If Study does definite harm to patient = Unethical….not Approved

e.g.

Not giving Abx to Pneumonia………..just to see what Placebo will do.

Not giving Anti Retroviral to AIDS……..just to see its efficacy comparing to placebo.

Checking Efficacy of Steroids on Minimal Change….when efficacy is already clear.

When Publish research = All Financial Support List should be given……for Correct Interpretation.

e.g.

I say Thermometer A is better…………later they find that my own company makes thermometer A.

So in this case we do………..Double Blind Placebo Controlled Trial… to check correct result.