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Medical ethics questions and answers
Medical Ethics
Texila American University
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LEGAL MEDICINE & MEDICAL ETHICS
EXAM QUESTIONS & ANSWERS
LEGAL MEDICINE & MEDICAL ETHICS
Source: Bioethics Topics
University of Washington School of Medicine
depts.washington/bioethx/topics/index
The following multiple-choice Questions and Answers
were developed in this format by the ABLM based on the
Bioethics Case-based scenarios published by the
University of Washington School of Medicine. There are
discussions linked to each of the following topics. Links
to additional readings and related websites are included
at the end of each topic.
1. Advance Care Planning
2. Advance Directives
3. Breaking Bad News
4. Complementary Medicine
5. Confidentiality
6. Cross-Cultural Issues and Diverse Beliefs
o with an Emphasis in Pediatrics
7. Difficult Patients
8. Do Not Resuscitate Orders
o during Anesthesia and Urgent Procedures
LEGAL MEDICINE & MEDICAL ETHICS
9. End-of-Life Issues
10. Ethics Committees and Consultation
11. Futility
12. Genetics
13. HIV and AIDS
14. Informed Consent
o in the Operating Room
15. Interdisciplinary Team Issues
16. Law and Ethics
17. Managed Care
18. Maternal / Fetal Conflict
19. Mistakes
20. Neonatal ICU Issues
21. Parental Decision Making
22. Personal Beliefs
23. Physician Aid-in-Dying
24. Physician-Patient Relationship
25. Prenatal Diagnosis
26. Professionalism
27. Public Health Ethics
28. Quality of Life
29. Research Ethics
30. Resource Allocation
31. Spirituality and Medicine
32. Student Issues
33. Termination of Life-Sustaining Treatment
34. Treatment Refusal
35. Truth-telling and Withholding Information
LEGAL MEDICINE & MEDICAL ETHICS
Advance Care Planning
2. A patient who has coronary artery disease and congestive heart failure shows his physician his advance directive that states he wants to receive cardiopulmonary resuscitation and other forms of life-sustaining treatment has deeply held beliefs that suggest that not trying to live is tantamount to committing suicide.
What should the doctor do and say to the patient in response to this? 2
a. The doctor should educate the patient about the near futility of CPR under these circumstances. b. The doctor might want to ask the patient to explore this further with the chaplain. c. The patient's expression of a preference should be explored to understand its origins. d. All the above.
2 Answer: d
The patient's expression of a preference should be explored to understand its origins. It is possible that the patient believes, based on television shows, that CPR is usually effective. If this is the case, the doctor should educate the patient about the near futility of CPR under these circumstances. However, the physician may learn that the patient has deeply held beliefs that suggest that not trying to live is tantamount to committing suicide which he perceives as morally wrong. In this situation, the doctor might want to ask the patient to explore this further with the chaplain. depts.washington/bioethx/topics/adcared2
LEGAL MEDICINE & MEDICAL ETHICS
Advance Care Planning
3. A patient tells his family that he would never want to be "kept alive like a vegetable". The term "vegetable" should be understood by the doctor to mean: 3
a. The patient does not want any heroics or extraordinary treatments. b. Pull the plug if the patient is ever in terminal state on a respirator. c. If the patient is in a comatose state, let him die. d. The doctor should interpret the term as vague and not helpful in advance care planning discussions unless it is clarified.
3 Answer: d
The use of this expression is as vague as saying, "I don't want any heroics or extraordinary treatments" or, "Pull the plug if I'm ever in ...." If these types of comments in advance care planning discussions are not clarified, they are not helpful. For some patients being a "vegetable" means being in a coma, for others it means not being able to read. depts.washington/bioethx/topics/adcared3
LEGAL MEDICINE & MEDICAL ETHICS
Advance Directives
5. The same patient described in Question #4 presents confused and somnolent. A copy of a signed and witnessed living will is in his chart stipulates that he wants no "invasive" medical procedures that would "serve only to prolong my death." No surrogate decision maker is available.
Should mechanical ventilation be instituted? 5
a. Mechanical ventilation should NOT be instituted because it serve only to "prolong death" in this patient. b. Mechanical ventilation should be instituted because of the intent of the directive in the living will is evident. c. Mechanical ventilation should be instituted because the patient’s pneumonia represents a potentially reversible condition from which the patient may recover fully. d. The living will is NOT a helpful guide to mechanical ventilation decision-making in this patient.
5 Answer: c
If the man has deteriorated to the point that he can no longer communicate, his living will may be a helpful guide to decisionmaking. The language of the directive, however, is difficult to interpret in this case. Pneumonia represents a potentially reversible condition from which the patient may recover fully. Mechanical ventilation does not serve only to "prolong death" but offers a significant chance to return to his previous level of functioning. Most patients with even end-stage emphysema can be successfully weaned from mechanical ventilation. The intent of the directive, whether to avoid intubation and ventilation at all costs or simply to withhold such therapies when they are clearly futile, is not evident. In the absence of other information to aid the decision, mechanical ventilation should be instituted, with the plan that it be discontinued if it becomes evident that the patient cannot be weaned. depts.washington/bioethx/topics/advdird2
LEGAL MEDICINE & MEDICAL ETHICS
Breaking Bad News
6. Jose is a 62-year-old man who just had a needle biopsy of the pancreas showing adenocarcinoma. You run into his brother in the hall, and he begs you not to tell Jose because the knowledge would kill him even faster. A family conference to discuss the prognosis is already scheduled for later that afternoon.
What is the best way for the doctor to handle the situation? 6
a. The doctor should honor the request of the family member who is protecting his beloved brother from the bad news. b. The doctor should tell Jose's brother that withholding information is not permitted under any circumstance. c. Jose should withhold informing the patient about the pancreatic cancer because of the grave diagnosis. d. The doctor should ask Jose how he wants to handle the information in front of the rest of the family, and allow for some family discussion time for this matter.
6 Answer: d
It is common for family members to want to protect their loved ones from bad news, but this is not always what the patient himself would want. It would be reasonable to tell Jose's brother that withholding information can be very bad because it creates a climate of dishonesty between the patient and family and medical caregivers; also, that the only way for Jose to have a voice in the decision making is for him to understand the medical situation. Ask Jose how he wants to handle the information in front of the rest of the family, and allow for some family discussion time for this matter. In some cultures it is considered dangerous to talk about prognoses and to name illnesses (e., the Navajo). If you suspect a cultural issue it is better to find someone who knows how to handle the issue in a culturally sensitive way than to assume that you should simply refrain from providing medical information. For many invasive medical interventions which require a patient to critically weigh burdens and benefits, a patient will need to have some direct knowledge of their disease in Western terms in order to consider treatment options. depts.washington/bioethx/topics/badnwsd1
LEGAL MEDICINE & MEDICAL ETHICS
Complementary Medicine
8. A young mother has just been informed that her 2-year-old son has leukemia. The mother refuses permission to begin chemotherapy and informs the oncology team that their family physician (a naturopath) will follow the child's illness.
What should you do as the team physician? 8
a. I should wait to hear from the family physician. b. I should honor the mother’s request in this situation. c. I should arrange promptly a care conference with both the mother and the family's naturopathic physician to discuss the chemotherapy. d. If chemotherapy offers a clear and compelling survival benefit as the only hope this child has, and the mother refuses treatment, I am professionally obligated to seek a court order to appoint a guardian for the child.
8 Answer: d
Of utmost importance are the child's best interests, which include getting good medical care and maintaining a close connection with his mother. One way to achieve both is by requesting a care conference with both the mother and the family's naturopathic physician. If the mother refuses this meeting and you remain convinced that chemotherapy is the only hope this child has, you are professionally obligated to seek a court order to appoint a guardian for the child. If chemotherapy offers a clear and compelling survival benefit, the justification for seeking legal intervention increases. depts.washington/bioethx/topics/compld1
LEGAL MEDICINE & MEDICAL ETHICS
Complementary Medicine
9. Your patient has been suffering from chronic low back pain for many years now. She voices her frustration with the various treatment modalities that you have been trying and says her friend had recommended a homeopath.
How do you respond? 9
a. Encourage your patient to consult with local experts or the library to find out more about what homeopathy can offer. b. Inform the patient that homeopathy is ineffective in treating her medical condition. c. Respond by saying that complementary medical therapy is reasonable for her condition and definitely not harmful. d. Encourage your patient to see a homeopath and discourage her from staying in contact with you.
9 Answer: a
In this case, there are few clearly effective treatments for the medical condition. Hence, complementary approaches may be a reasonable recommendation, assuming they are not harmful. While you may know little about homeopathy yourself, you may encourage your patient to consult with local experts or the library to find out more about what homeopathy can offer. It may be appropriate to seek alternative therapies, but they should be researched or recommended. Encourage your patient to stay in contact with you and explore opportunities. depts.washington/bioethx/topics/compld2
LEGAL MEDICINE & MEDICAL ETHICS
Confidentiality
11. A 75-year-old woman shows signs of abuse that appears to be inflicted by her husband. As he is her primary caregiver, she feels dependent on him and pleads with you not to say anything to him about it.
How would you handle this situation? 11
a. This is a case of elder abuse and the doctor is required to always report incidents of abuse to the authorities. b. The doctor is not permitted under HIPAA (Health Insurance Portability and Accountability Act) to report the abuse. c. The laws supporting reporting elder abuse allow the doctor to break confidentiality and report suspected abuse. d. The patient should not be reported. Instead, she should obtain support and access to other services in order to maintain her primary caregiver.
11 Answer: c
In this case, the required reporting laws can be interpreted in a number of justifiable ways. The laws supporting reporting elder abuse (and child abuse) allow you to break confidentiality and report suspected abuse. However, if you think it is possible to give this woman support and access to other services without reporting the case immediately, those alternatives will help her more in the long run. Either way, you have an obligation to address her abusive situation. depts.washington/bioethx/topics/confidd2
LEGAL MEDICINE & MEDICAL ETHICS
Confidentiality
12. A 60-year-old man has a heart attack and is admitted to the medical floor with a very poor prognosis. He asks that you not share any of his medical information with his wife as he does not think she will be able to take it. His wife catches you in the hall and asks about her husband's prognosis.
What are you required to do legally? 12
a. The doctor should inform the wife about her husband’s poor prognosis. b. The doctor is should not divulge the prognosis to the wife, but he should ask the nurse to let the wife know about her husband’s condition. c. The wife is certainly affected by her husband's health and prognosis and every effort should be made to encourage an open dialogue between them. d. The doctor should not encourage the patient to talk to his wife about his condition.
12 Answer: c
The duty to maintain confidentiality remains strong in this case as information about the patient's health does not directly concern others' health, welfare, or safety. There is no imminent danger to others here. However, the wife is certainly affected by her husband's health and prognosis and every effort should be made to encourage an open dialogue between them. It remains his responsibility to do so. depts.washington/bioethx/topics/confidd3
LEGAL MEDICINE & MEDICAL ETHICS
Cross-cultural Issues & Diverse Beliefs -- Emphasis Pediatrics
14. A 23-year-old Navajo man has injured his leg after a fall. He presents to the emergency room of the reservation hospital where he is complaining of pain. His leg appears to be broken. The man requests that you call a medicine man before doing anything further.
What should the doctor do? 14
a. Call the local medicine man before proceeding with treatment of the leg fracture. b. The emergency room medical doctor is under no obligation to communicate with a medicine man about the patient’s leg fracture. c. Tell the patient that he will not call his medicine man. d. Because the patient came to the emergency room, the doctor is allowed to begin treatment then call the medicine man.
14 Answer: a
As a competent adult, this patient has the right to make decisions about his medical care. You must respect his wish not to be treated until he gives you permission to do so. Calling the local medicine man will show your respect for the patient and strengthen the patient's trust in you and your abilities. depts.washington/bioethx/topics/crossd2
LEGAL MEDICINE & MEDICAL ETHICS
Cross-cultural Issues & Diverse Beliefs -- Emphasis Pediatrics
15. A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, " We'd prefer to take him home and have our minister pray over him."
How should the physician handle this? 15
a. The physician should do what the parents request to take the child home. b. The physician should call the parent’s religious leader and have him come to the hospital before providing standard medical therapy. c. The physician has no duty to provide treatment to the child when the parents refuse treatment. d. When efforts to obtain parental permission to treat the patient fail, the physician is justified in seeking legal help or may be legally authorized to proceed with the procedure and treatment of the child.
15 Answer: d
The physician has a duty to provide treatment to a child when denying that treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his view with the family and seek to elicit their cooperation through respectful discussion. Inviting their religious leader to the hospital while also providing standard medical therapy may prove to be an acceptable compromise. Should these efforts not result in parental permission, the physician is justified in seeking legal help so as to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm. depts.washington/bioethx/topics/crossd3
LEGAL MEDICINE & MEDICAL ETHICS
Do Not Resuscitate Orders
17. Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code."
Can you write a DNR order anyway? 17
a. No, because the patient requested “a full code.” b. Yes, because Mrs. W is elderly, has a diagnosis of recurrent metastatic cancer, and the chance of a successful DNR is 0%. c. No, because the CPR for Mrs. W and in her condition could not be called "futile." d. Yes, because hospital policy allows doctors to write a DNR in this situation.
17 Answer: b
Mrs. W is elderly and has a diagnosis of metastatic cancer. In several prospective outcome studies of CPR in the hospital, patients like Mrs. W had 0% survival. Thus CPR for Mrs. W could be called "futile." Nevertheless, current policy at UWMC/Harborview and the VAMC state that one should not write a DNR order, even if CPR is judged to be futile, without patient or family concurrence. Rather, you should allow Mrs. W some time to come to grips with her diagnosis, while periodically re-addressing the CPR question with her. This is best done in the context of other medical decision that occur during her care. It is important to review other care goals with her, to allay possible fear that a DNR order may mean she will be abandoned or not cared for. depts.washington/bioethx/topics/dnrd2
LEGAL MEDICINE & MEDICAL ETHICS
Do Not Resuscitate Orders
18. Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Mrs. W still wants to be a "full code." Your intern suggests that you sign her out as a "slow code."
Should you do this? 18
a. Yes, because slow codes are ethically justifiable. b. Yes, because the "slow code" allows the appearance of respecting the patient's desire for CPR. c. No, because the slow code is not actually complying with the request for a “full code” and is ethically unjustifiable. d. No, because slow codes are illegal.
18 Answer: c
A "slow code" allows the appearance of respecting the patient's desire for CPR while not actually complying with the respect. Slow codes are not ethically justifiable. Rather, you should continue efforts to discuss the DNR order with Mrs. W, perhaps with the help of her family or religious advisors. depts.washington/bioethx/topics/dnrd3
Medical ethics questions and answers
Course: Medical Ethics
University: Texila American University
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