19.1 Ethics Principles & Decision-Making Capacity

19.1 Ethics Principles & Decision-Making Capacity

Quick Answer: Name the conflicting principle(s) → assess capacity (understand, appreciate, reason, express choice) → obtain informed consent or follow advance directives/surrogates → protect confidentiality unless a clear duty to warn/report applies. Capacity is clinical and decision-specific; competence is a legal status. Emergencies permit treatment under implied consent. Research needs IRB approval, informed consent, and equipoise.

Social sciences and communication skills account for roughly 6–9% of CBSE content (Communication & Interpersonal Skills), with ethics and decision-making woven through vignettes that look clinical but hinge on process. Score by labeling the ethical problem first, then applying a stepwise algorithm rather than “what feels nice.”

The Four Principles (Beauchamp & Childress Framework)

Worked vignette — autonomy vs beneficence

A 58-year-old with capacity declines coronary angiography after a non-STEMI. The team believes angiography is “clearly best.” Answer pattern: document informed refusal, explore reasons and barriers, offer alternatives, and do not force the procedure. Beneficence does not override a capable refusal.

Worked vignette — justice

Two patients need the last ICU bed: one has higher short-term survival probability and another has greater social status. Justice prioritizes medical need and prognosis criteria, not wealth, celebrity, or personal preference of staff.

Exam tip: When two principles clash, the correct option usually (1) preserves autonomy of a capable patient, (2) uses least-harm means, or (3) follows fair triage rules—not “do whatever the family wants” if it violates a known patient preference.

Informed Consent Elements

Valid informed consent requires three pillars:

1. Information — nature of the intervention; material risks and benefits; reasonable alternatives (including no treatment); expected course without intervention.
2. Capacity — the patient can perform the four capacities below for this decision.
3. Voluntariness — free of coercion, undue influence, or manipulation (including pressure from family or staff framed as “you have no real choice”).

Emergencies: If delay would cause serious harm and the patient cannot consent (unconscious trauma, acute MI with cardiogenic shock), treat under implied/emergency consent for life- or limb-saving care until the patient can participate or a surrogate is available. Do not perform non-urgent procedures under emergency consent.

Therapeutic privilege (withholding information because disclosure would cause severe harm) is narrowly construed and rarely the best answer; prefer graduated disclosure with support.

Decision-Making Capacity vs Competence

Four abilities (Appelbaum framework)

1. Understand relevant information (diagnosis, options, risks/benefits).
2. Appreciate that the information applies to oneself (not “people with cancer die” while denying personal illness).
3. Reason — weigh options consistently with one’s values; show a logical path (even if conclusion differs from the physician’s).
4. Express a choice — communicate a preference (verbally, writing, reliable yes/no).

High-yield traps

• Disagreeing with medical advice ≠ incapacity if the four abilities are intact.
• Psychosis, mania, severe depression, dementia, or delirium may impair capacity for some decisions but not automatically for all (a patient with schizophrenia may still refuse a finger-stick if they understand risks).
• Intoxication: reassess after sobriety when safe; stabilize emergently if needed.
• Sliding scale: consent for low-risk blood draw needs less cognitive demand than refusal of dialysis.

Worked vignette — capacity

A patient with schizophrenia refuses appendectomy for acute appendicitis, stating “surgeons implant tracking devices.” She cannot appreciate her acute illness or reason about infection risk. Lacks capacity for this decision → seek surrogate / emergency treatment pathway. Contrast: same patient calmly refuses optional cosmetic scar revision with clear understanding → likely has capacity.

Surrogates and Advance Directives

When capacity is lacking, decision-making follows known patient wishes, then appointed and default surrogates.

Typical surrogate hierarchy concepts (jurisdiction-specific; know the idea for exams):

1. Court-appointed guardian
2. Health-care agent named in DPOA
3. Spouse / domestic partner
4. Adult children
5. Parents
6. Adult siblings
7. Other relatives / close friends

Surrogates should use substituted judgment (what the patient would have wanted) when known, then best interests if wishes are unknown. They cannot demand clearly futile interventions that violate professional standards; ethics/legal consultation may be needed.

Worked vignette — directives

An unconscious patient has a living will refusing mechanical ventilation in permanent vegetative state and a daughter as DPOA who demands “everything.” If criteria for the living will are met, honor the living will; the agent implements the patient’s known wishes, not the agent’s own preferences.

Death, Dying, Brain Death, and Organ Donation

The official Social Sciences outline lists death and dying and palliative care explicitly, including life support, brain death, and organ donation. These items are rule-based, so learn the definitions rather than reasoning from sentiment.

Brain death is legal death in every U.S. jurisdiction — it is not coma and not a vegetative state. Determination requires an established irreversible cause; exclusion of confounders (hypothermia, sedative or paralytic effect, severe metabolic derangement); coma with no cerebral response; absent brainstem reflexes at every level (pupillary, corneal, oculocephalic/oculovestibular, gag, cough); and a positive apnea test — no respiratory effort despite PaCO₂ rising to roughly 60 mm Hg or more.

Spinal reflexes do not exclude brain death. Triple flexion or a Lazarus sign is generated below the foramen magnum and is a standard distractor.

Consequences that follow from the determination:

• Once brain death is declared the patient is dead, so stopping the ventilator is not withdrawal of care from a living patient and surrogate consent is not required for it. Consent is required for organ donation.
• Withholding and withdrawing life-sustaining treatment are ethically and legally equivalent. A time-limited trial of ventilation that is later stopped is permissible, which is why "we can never turn it off once it is on" is always a wrong answer.
• Artificial nutrition and hydration are legally medical treatments and are refusable like any other.
• Titrating opioids to relieve terminal dyspnea or pain is permitted even if it may hasten death — the doctrine of double effect, because the intent is symptom relief and the dose is titrated to that effect. Deliberately administering a lethal dose is a categorically different act.

Organ donation. The treating clinician should not be the one to raise donation; the trained organ procurement organization (OPO) approaches the family, preserving separation between the team managing the patient and the transplant decision. A signed donor card or first-person registry entry is legally sufficient authorization in most states even over family objection, although OPOs generally work toward family agreement. Hospice eligibility rests on a prognosis of six months or less if the disease follows its usual course, and it does not require a DNR order — a frequent distractor.

Minors and Emancipated Minors

Parents generally cannot refuse clearly life-saving, low-burden treatment for a minor (e.g., transfusion for life-threatening hemorrhage in a child of Jehovah’s Witness parents). Seek emergency court order / ethics support while stabilizing; do not simply “respect parental autonomy” when the child will die from a highly effective intervention.

Confidentiality and Duty to Protect

Confidentiality is a core autonomy/privacy duty but is not absolute.

Worked vignette — Tarasoff

A psychiatric patient states he will kill his named ex-partner tonight and has a plan. Duty to protect: take steps to warn the identifiable victim and involve authorities as required; hospitalization may also be indicated. Do not only “encourage the patient to tell her himself” as the sole action.

Worked vignette — confidentiality

A competent adult asks that STI results not be shared with a spouse. Counsel about partner risk and reporting laws; do not casually disclose to the spouse outside legal public-health channels.

Research Ethics: Belmont, IRB, Equipoise

• IRB (Institutional Review Board): reviews protocols for ethics, risk, consent language, and subject protections before research begins and during continuing review.
• Clinical equipoise: honest professional uncertainty about which arm is superior; unethical to randomize when one arm is known inferior for the study population.
• Vulnerable populations: children, prisoners, pregnant persons, cognitively impaired — additional safeguards; assent + parental permission for children when applicable.
• Placebos: acceptable when no proven effective therapy exists or under carefully justified designs; not when withholding known effective therapy would cause serious harm without justification.

Truth-Telling, Withholding, and Errors

Default: capable patients are entitled to accurate diagnostic and prognostic information. Withholding “to protect hope” is usually wrong if the patient wants information.

• Ask preferences: some patients prefer less detail or family-mediated disclosure (cultural preferences); still confirm with the patient when possible rather than assuming.
• Therapeutic privilege: rare; requires serious likelihood that disclosure would cause immediate harm (e.g., precipitating suicide in an unstable patient) and a plan to disclose later with supports.
• Family requests to withhold cancer diagnosis: explore reasons; generally inform the patient unless the patient has declined information or clear harm standards are met.
• Medical errors: disclose honestly, apologize appropriately, explain next steps, and report through institutional systems (expanded in §19.3).

Integration algorithm for CBSE ethics items

1. Is the patient capable for this decision?
2. If yes → honor informed consent/refusal after adequate disclosure.
3. If no → advance directive → designated proxy → default surrogate → best interests.
4. Is there an emergency exception?
5. Is there a reporting / duty-to-protect override of confidentiality?
6. Is this research (IRB/consent/equipoise) rather than clinical care?
7. Name the principle the correct option upholds.

Master that sequence and most ethics stems reduce to a short checklist rather than a philosophical debate.