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50 Cards in this Set
- Front
- Back
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CHAPTER 24: Medical Ethics and Legal Issues
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CHAPTER 24: Medical Ethics and Legal Issues
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What are the four principles of medical ethics?
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① Patient Autonomy
② Beneficence ③ Nonmaleficence ④ Justice |
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What is Autonomy?
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The patient has the right to make their own decisions regarding their care.
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What is Beneficence?
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The principle that physicians should be of benefit to their patients.
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What is Nonmaleficence?
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Do no harm.
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What is Justice?
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The allocation of resources in a fair and just manner, including equal treatment.
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Of these principles, which one tends to take precedence in ethical questions, especially on the USMLE?
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Patient Autonomy
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What is the principle of double-effect?
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When an action that has a primarily good effect may also cause an unintended bad effect, but is still permissible.
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What is the classic example of double-effect?
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Giving morphine to relieve the pain of a dying patient, even if it causes respiratory depression hastening the patient’s death. As long as the primary intent of the treatment is to reduce pain and not to kill the patient, it is ethically permissible so long as there is pain to be relieved.
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Is malpractice a crime?
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No—malpractice is a civil court matter.
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What four elements in a malpractice case must exist in order to find liability with the treating physician (otherwise referred to as the 4 D’s)?
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Duty: There must be an established doctor-patient relationship.
Deviation or dereliction: Treatment strayed from established standard of care. Damages: Physical, psychological, or social damage was done. Direct cause: Damages were caused directly by negligence or dereliction. |
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How is a deviation from standard of care decided upon?
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A jury decides if there has been a deviation from the standard of care. The jury makes this determination based upon testimony of one or more expert witnesses who testify as to the standard of care as generally recognized by the medical community and how the defendant deviated from that standard of care.
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What is the best way to avoid a malpractice suit?
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If an error is made, admit when you are wrong and apologize to the patient.
Maintain a healthy physician-patient relationship. Keep current with standards of care. |
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When can a physician become impaired?
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When clinical judgment is affected by the following:
Physical illness Mental illness Substance abuse |
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Is it acceptable to work with an impaired health-care provider?
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No. It is the ethical duty of a physician to report an impaired health-care provider to the proper authorities.
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How does a physician’s human immunodeficiency virus (HIV) status affect his or her ability to practice medicine?
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Under the American Medical Association (AMA) ethical guidelines, an HIV physician should not engage in any activity that would put a patient at risk of contracting HIV (eg, an HIV-positive surgeon may be precluded from practicing surgery. Some states require that an HIV-positive physician disclose, as part of the informed consent process, his or her HIV status before engaging in an invasive procedure that would put the patient at risk).
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Is it acceptable for a physician to establish a romantic relationship with a patient or former patient?
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No—it’s not acceptable under any circumstances.
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What is competence?
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Competence is the ability to evaluate situations and make sound judgments that are:
Consistent throughout time Consistent with the patient’s belief system (unless the belief system is delusional) |
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Who is considered legally competent?
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All adults >18 years of age and emancipated minors—including adults with mental illness or mental retardation—unless declared incompetent by a court of law
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Who is an emancipated minor?
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Someone < 18 years of age who is:
Financially independent of his or her parents Married Serves in the armed forces |
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Can a person be competent in some areas and not others?
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Yes. Legal competence is situation specific (eg, competence to stand trial) and can change with time. A patient can be legally competent, but not medically competent if he or she lacks the capacity to make, understand, or communicate his or her health-care decisions.
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Can a physician deem a patient incompetent?
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No. Legal incompetence is determined in a court of law. Any physician (not just a psychiatrist) can determine if a patient has the capacity to make medical decisions.
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If a patient is ruled incompetent, how does the patient become competent again?
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The case must be brought before the judge again, and after reviewing the medical evidence, the judge determines whether the patient has regained legal competence.
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Who may give informed consent for a patient?
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The patient only unless:
It is an emergency, delay puts the patient’s life at risk, and there is no one available to give consent on the patient’s behalf. The patient is legally incompetent (depending upon state law, the legally appointed guardian, or the agent named in a durable power of attorney for health care gives consent). The patient lacks the capacity to make, understand, or communicate his or her health-care decisions (a surrogate decision-maker gives consent as provided by state law, usually in the following order of priority: health-care agent, spouse, an adult child, parent, an adult sibling, or a grandparent). The patient is a nonemancipated minor (parent or legal guardian gives consent, and in some states, someone standing in the place of a parent may also give consent). |
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What happens if a patient lacks the capacity to make, understand, or communicate his or her health-care decisions and has not named a healthcare agent under a durable power of attorney for health care or been appointed a legal guardian by the court?
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A surrogate decision-maker may give consent on the patient’s behalf and should make a good-faith effort to make decisions based upon what the patient would have chosen. State law designates a list of surrogate decision-makers, usually in the following order of priority (in the absence of a health-care agent or legal guardian): spouse, adult child, parent, adult sibling, or a grandparent. State laws may differ.
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What is an advance directive?
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A decision made by a patient about what type of medical care he or she wishes to receive in case that he or she is not able to make decisions in the future.
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What is a durable power of attorney for health care?
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A durable power of attorney for health care (or health-care proxy) is a legal document that allows the patient to designate a health-care agent to make health-care decisions on behalf of the patient when and if the patient is unable to do so. It is an advance directive.
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What is a living will?
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A living will is a legal document that allows a patient to decide, in advance, whether he or she wants to be kept alive by artificial means if two doctors diagnose that the patient is (1) terminally and incurably ill, (2) in a persistent vegetative state, or (3) in an irreversible coma. State laws may differ as to conditions under which a living will may be honored.
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What is a DNR (do not resuscitate) order?
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A DNR order is an order written by a physician, after determining whether the patient is a candidate for nonresuscitation and obtaining the appropriate consent that directs medical personnel not to resuscitate a patient in the event of cardiopulmonary arrest.
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Do DNR orders mean no interventions are done on a patient?
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No. Patients may choose to still have antibiotics, fluids and nutrition, or other 'non-heroic' means depending on their wishes.
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When does a judge consent for medical treatment of a minor?
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When a parent or legal guardian refuses to consent to medical treatment on the minor’s behalf, and the physician believes that the treatment is medically necessary and justifies court intervention. A court is more likely to intervene when the proposed treatment carries a low risk and high benefit or when the minor’s life is threatened.
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Does this apply to a fetus?
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No. The competent pregnant mother, in most circumstances, has a right to refuse any intervention on the part of the fetus even if it compromises her own or the fetus’ life. In some states, courts have intervened on behalf of a viable fetus.
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Under what circumstances can a nonemancipated minor receive treatment without the consent of his or her parent or legal guardian?
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Although the answer is state dependent, most states allow minors to consent for treatment involving sexually transmitted diseases (STDs), contraception and pregnancy, and alcohol or illegal substance use. Some states also allow minors to consent for an abortion. Other states allow a minor to consent to an abortion, but require parental notification or a court order waiving parental notification.
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When can a patient refuse treatment even though refusal is life threatening?
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Anytime, as long as they have the capacity to refuse the treatment, and the refusal is an informed refusal.
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Does this include artificial life support?
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Yes
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Is removing artificial life support the same as physician-assisted suicide?
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No. Removing artificial life support is a decision that the competent, informed patient is allowed to make. It does not accelerate the natural course of the patient’s disease process. Physician-assisted suicide is illegal in most states because it purposely accelerates death.
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When can a physician decide to remove life support without the consent of the patient or patient’s decision-maker?
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A physician may remove life support without consent if the patient is legally dead. The patient must be 'brain dead' in order to be declared legally dead in the United States, which includes global dysfunction of the brain (coma) and absent brainstem reflexes.
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Is palliative care of the terminal patient the same as euthanasia?
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No. Palliative care is not done with the intention of accelerating death. It is done with the intention of making the patient comfortable through the natural end point of a terminal illness. However, palliative care may unintentionally accelerate death as a side effect.
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What is an informed consent?
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Informed consent is required if the proposed treatment or procedure involves a material risk to the patient. An informed consent includes the voluntary agreement by a patient to proceed with treatment after the physician has discussed the procedure, risks, benefits, and outcome of the procedure or treatment, alternative treatments (including no treatment), and the risk, benefits, and outcomes of those alternatives.
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Does consent have to be written?
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No. Basic consent (eg, consent to touching contact during a physical examination) need not be in writing and is often implied. An informed consent should be in writing and documented in the chart.
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Can a physician refuse to treat patients based on race, financial status, and presence of mental illness or HIV status?
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Generally, a physician may refuse to treat a patient as long as the reasons for refusal are not illegal. Illegal reasons to refuse treatment include race, national origin, gender, religion, and disability (which include mental illness and HIV status). Except in emergency situations, a physician may refuse to treat a patient based upon inability to pay.
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If a patient is homicidal, is a physician allowed to break patient confidentiality?
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Yes. In almost all states, the Tarasoff decision applies, which requires a physician to warn the person in severe danger and notify law enforcement. In states such as Georgia, Tarasoffhas not been adopted. Instead, the physician has a duty to prevent harm by the patient if there is a right to control. In other words, if a physician has the legal right to initiate involuntarily commitment proceedings and fails to exercise this right, the physician may be held liable for harm done by the patient to third parties if the harm was foreseeable. Georgia has not specifically recognized a duty to warn, and thus, a physician may be breaching confidentiality in warning an intended victim.
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In what other circumstances is a physician required to break patient confidentiality by law?
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A patient is considered suicidal
Reporting child abuse, elder abuse, or domestic violence (call Child Protective Services, Adult Protective Services, or the police) Court order (except to the extent the information is privileged) Patient driving without cognitive abilities to do so (some states have specific procedures and forms) Reporting certain infectious diseases, including HIV/acquired immunodeficiency syndrome (AIDS) |
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In what other circumstances can a physician breach patient confidentiality ?
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If the patient signs a written authorization, the physician may disclose private health information consistent with the authorization. State law may also authorize a physician to share private health information with specified people who are at risk for contracting HIV from a patient. Disclosure of this information is controlled by state law, and physicians must proceed carefully because if state law does not authorize disclosing HIV/AIDS information, the physician may be guilty of violating Health Insurance Portability and Accountability Act of 1996 (HIPAA) which may result in fines and a prison sentence.
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When can a patient be 'committed' or involuntarily hospitalized?
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The process varies by state, but a patient who presents a substantial risk of imminent harm to himself or herself or others, or if a patient is so unable to care for his or her own physical safety as to create an imminently life-endangering crisis, then the patient needs involuntary inpatient treatment.
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If a patient is involuntarily hospitalized, can a physician administer any treatment they want?
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No. Even an involuntarily committed patient has the right to refuse medical treatment.
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How do mentally ill patients receive treatment even if they refuse treatment?
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A judge can order the administration of treatment if the patient is found incompetent to refuse treatment. Also, if the patient is violent and posing an immediate, severe danger to himself or herself or others, this is considered a medical emergency and the physician may administer treatment without the patient’s consent.
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CLINICAL VIGNETTES
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CLINICAL VIGNETTES
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Your patient has metastatic lung cancer and he is nearing the last weeks of his life. He is in considerable pain and is having trouble breathing without being intubated. His wishes were to not be intubated or having any life-prolonging measures. His son asks if you can do anything for his pain. You ask the nurse about giving him more morphine and she says that the respiratory depression will kill him. Is it ethical to do this?
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Yes—it is ethically permissible under the principle of double-effect even if it causes his death, as long as your primary goal is to treat his pain.
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A 72-year-old woman comes in with a gangrenous foot. The orthopedic service would like to amputate the foot to save her life. You are worried about the risks involved in the surgery. The man in the bed next door also needs a surgical procedure, but he is unable to afford it. The woman with the gangrenous foot doesn’t want the surgery because she wants to keep herself 'whole.' Of the four parties involved in this story (Patient, Orthopedic service, the man next door, and you), which ethical principles is each representing?
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Patient: Patient Autonomy
Orthopedic service: Beneficence Man next door: Justice You: Nonmaleficence |
