Medical Ethics / Bioethics for MMIs

Respect for autonomy

The duty to let patients make their own choices about their own body and care, as long as they understand what they are choosing. In a station: "If she has capacity and understands what happens next, her refusal stands even if the team disagrees."

Nonmaleficence

The duty to avoid harming the patient, including harm that comes from being careless or from working beyond your training. In a station: "I'd weigh the risk of the procedure against the risk of doing nothing, which is not zero."

Beneficence

The duty to actively do good for the patient, not just to avoid harm. It is why doctors owe patients a recommendation. In a station: "I wouldn't just list the options neutrally. I owe him my recommendation and my reasoning."

Justice

The duty to be fair in how benefits, costs, and risks get shared, and to treat similar patients similarly. In a station: "If I move him up the list, I should be able to explain that choice to the person I moved down."

Principlism

The most common approach to medical ethics, from Beauchamp and Childress. Work through a case by applying and balancing autonomy, nonmaleficence, beneficence, and justice. Name the framework once, then use it, so it does not sound memorized.

Prima facie duty

A duty you must follow unless a stronger duty outweighs it in that specific case. None of the four principles automatically beats the others. In a station: "Both duties apply here. The question is which one matters more given these facts."

Four Topics Method (Four Box Method)

A grid for analyzing any case, from Jonsen, Siegler, and Winslade. The four boxes are medical indications, patient preferences, quality of life, and contextual features. In a station: a silent checklist to run during your two minutes of reading time.

Medical indications (Box 1)

The medical facts. What is the diagnosis, what is likely to happen with and without treatment, what are the options, and how likely are they to work. Connects to beneficence and nonmaleficence.

Patient preferences (Box 2)

What the patient actually wants. Do they have capacity, were they told enough to decide, and if they cannot decide, who speaks for them. Connects to autonomy.

Quality of life (Box 3)

What life would realistically look like for the patient with and without treatment, judged by the patient rather than by the team. Watch for clinicians projecting their own idea of a life worth living.

Contextual features (Box 4)

Everything around the case. Family, money, insurance, law, hospital policy, culture, religion, and anyone's competing interests. Connects to justice.

Paternalism

Overriding or going around a patient's choice because you think you know what is better for them. Usually the thing to name and avoid, though it can be justified when the patient clearly cannot decide for themselves.

Soft vs. hard paternalism

Soft paternalism steps in when a choice is not really free or informed, such as impaired capacity or pressure from others. Hard paternalism overrides a fully free and informed choice. Only the soft version is usually defensible.

Doctrine of double effect

It can be acceptable to do something with a bad side effect if the act itself is not wrong, you intend only the good effect, the bad effect is not how you get the good one, and the good outweighs the bad. Classic use: pain medication high enough to relieve suffering even if it may shorten life.

Harm principle

The rule that you only override someone's choice, or a parent's authority, to prevent a significant risk of serious harm. Tied to Diekema's work on parental refusals and used as the bar for stepping in against parents.

Informed consent

A conversation, not a signature, in which the doctor gives a patient with capacity enough information to freely accept or refuse a treatment. In a station: "The form is the documentation. The conversation is the consent."

Elements of informed consent

What the decision or procedure involves, the reasonable alternatives including doing nothing, the risks and benefits and unknowns of each, a check that the patient understood, and the patient's free agreement.

Decision-making capacity

A judgment any doctor can make about whether a patient can understand their situation, appreciate what the choice means for them, reason through the options, and say what they want. In a station: "Capacity applies to one decision at a time and it can change day to day."

Competence

A legal ruling by a court about whether someone can make decisions in general. People use it loosely to mean capacity, but the two are not the same and using the right word shows care.

Refusal is not evidence of incapacity

Disagreeing with the doctor does not mean a patient lacks capacity. In a station: "His refusal is a reason to ask why, not a reason to question whether he can decide."

Reasonable patient standard

The rule that you must tell a patient what a typical patient would need to know to make the decision. This is the standard in Washington and most states.

Reasonable physician standard

The older rule that you tell a patient what a typical doctor would tell them. Criticized for focusing on the profession rather than the patient, and because doctors historically told patients very little.

Subjective standard

The rule that you tell this particular patient what they personally need to know given their own values and situation. The most appealing in theory and the hardest to actually do.

Voluntariness

The requirement that a patient's agreement be free of pressure. Patients often feel powerless in a hospital, so this takes real effort. In a station: "I'd make clear that she can say no and it will not change how we care for her."

Implied or presumed consent

Assuming consent in an emergency when the patient cannot speak for themselves, no surrogate is available, and acting will prevent death or serious disability. Being in a hospital does not mean agreeing to everything.

Waiver of consent

A patient with capacity who chooses not to hear the details, or who asks a family member to decide instead. Honoring that choice is itself a form of respecting autonomy.

Shared decision making

The doctor brings medical knowledge and a recommendation, the patient brings their values and goals, and they decide together. It sits between paternalism and just handing the patient a menu.

Teach-back

Asking the patient to explain the plan back in their own words so you know it landed. In a station: something concrete to name instead of saying "I'd make sure she understands."

Surrogate decision maker

The person who decides for a patient who cannot, named either in an advance directive or by a legal ranking of relatives that varies by state. If no one can be found, the team acts in the patient's best interest and may ask a court to appoint someone.

Substituted judgment

Deciding based on what this patient would have wanted, using their known values and things they said before. The preferred standard whenever the patient once had capacity.

Best interest standard

Deciding based on what a reasonable person would want, weighing benefits against burdens. Used when the patient's own wishes are unknown, or when they never had capacity, as with a young child.

Advance care planning

The ongoing process of working out your values, naming someone to speak for you, writing it down, and updating it over time. The conversation matters more than the paperwork.

Advance directive

A document recording what treatment you would want, or who should decide for you, if you later cannot speak for yourself. It is autonomy extended into the future.

Living will

A type of advance directive listing which treatments you would want or refuse in specific situations, usually terminal illness or permanent unconsciousness.

Durable power of attorney for health care

A document naming a specific person to make medical decisions for you if you lose capacity. Often more useful than a living will because a person can respond to situations no document predicted.

POLST

Physician orders for life-sustaining treatment. Real medical orders, signed by a clinician, that follow a seriously ill patient between home, nursing facility, and hospital. Unlike an advance directive, paramedics can act on it immediately.

Psychiatric advance directive

A directive recording what mental health treatment a person would want if a psychiatric illness later left them unable to decide.

Guardian ad litem

Someone a court appoints to represent an incapacitated patient's interests when no family member or surrogate can be found.

DNAR / DNR order

An order written by a doctor with the patient or surrogate saying CPR will not be attempted if the heart or breathing stops. In a station: "DNAR" (do not attempt resuscitation) is the better term because it makes clear that CPR is attempted, not guaranteed to work.

DNR - Do Not Resuscitate

An order instructing the team not to attempt chest compressions or other resuscitation if the patient's heart or breathing stops. It applies only to that. All other treatment continues, including antibiotics, fluids, dialysis, surgery, and intensive care, unless each one is separately limited by its own order. Watch for the case where a team member treats this order as a reason to quietly withhold other care.

Medical futility

The judgment that a treatment has no real chance of helping this patient in a way that matters. Contested because "helping" depends on the goal. Quantitative futility means it almost certainly will not work. Qualitative means it works but does not benefit the patient.

Withholding vs. withdrawing treatment

Never starting a treatment and stopping one already started are ethically and legally the same, even though stopping feels harder. In a station: "The question is whether this treatment still serves his goals, not whether we already started it."

Palliative care

Care aimed at relieving symptoms and improving quality of life. It can start at diagnosis and run alongside treatment meant to cure.

Hospice

A specific kind of palliative care for patients near the end of life, usually once treatment aimed at cure has stopped and life expectancy is short. Not a synonym for palliative care.

Palliative sedation

Sedating a dying patient, sometimes into unconsciousness, to relieve suffering that no other treatment has been able to control. Justified through intent and double effect. Different from aid-in-dying because the goal is comfort, not death.

Physician aid-in-dying

A doctor writing a prescription that a terminally ill patient with capacity can take themselves to end their life. Legal in some states with specific safeguards. Many professional groups avoid the word "suicide" here because it implies impaired judgment.

Euthanasia

A doctor directly giving something that causes death. The difference from aid-in-dying is who performs the final act. Not legal anywhere in the United States.

Treatment refusal

A patient with capacity can refuse anything, including treatment that would save their life. In a station: honor it, but treat it as the beginning of a conversation about why, not the end of one.

Goals of care

The shared answer to what treatment is supposed to accomplish for this patient. Cure, more time, comfort, function, or a peaceful death. In a station: "I'd want to revisit goals of care before we decide about the ventilator."

Confidentiality

The duty to protect what patients tell you. It rests on respect for the person and on the fact that patients only speak honestly if they trust you. Strong, but not absolute.

Limits of confidentiality

The accepted exceptions are serious and immediate danger to a specific person, legally required reports, and court orders.

Duty to warn (Tarasoff)

When a patient poses a serious and immediate threat to a person you can identify, protecting that person can outweigh confidentiality. In a station: acknowledge how hard it actually is to judge whether a threat is serious and imminent.

Mandatory reporting

Things the law requires you to report whether or not the patient agrees, including certain infectious diseases and suspected abuse or neglect of children, elders, and dependent adults.

HIPAA

The federal law governing how patient information can be used and shared. Shows up in stations about elevator conversations, family asking questions in the hallway, and social media.

Truth-telling

The default duty to be honest about diagnosis, outlook, and treatment. It respects autonomy and it is what keeps patients trusting doctors. Research consistently shows most patients want to be told, including about cancer and dementia.

Therapeutic privilege

Withholding information because telling the patient would itself seriously harm them. In a station: call it narrow and easy to abuse. Expecting the patient to be upset is not enough to justify it.

Family request to withhold a diagnosis

A common cross-cultural case. The usual answer is to ask the patient directly how much they want to know and who they want in the room, which respects the patient and the family's concern at the same time.

SPIKES protocol

A structure for delivering bad news. Setting, Perception, Invitation, Knowledge, Emotions, Strategy and summary. Useful for any station asking how you would tell someone.

Placebo deception

Giving an inactive treatment without telling the patient. Generally not acceptable because it only works through lying, though open-label placebo is an active debate.

Parental permission

The right term for what parents give for a child, since consent by definition is something you give for yourself. Using this word signals precision.

Assent

A child's agreement to treatment, asked for at whatever level they can understand, in addition to the parents' permission. In a station: "I'd explain it to the ten-year-old in words she can follow and ask whether she's willing."

Emancipated minor

A minor with full legal authority to make their own decisions, usually through marriage, military service, or a court order.

Mature minor doctrine

Laws letting some minors consent for themselves, often for specific areas like sexual and reproductive health, mental health, and substance use. Varies a lot by state.

Threshold for overriding parents

Challenge a parent's decision when it puts the child at significant risk of serious harm. The ladder is respectful conversation first, then ethics consultation, then child protective services, then a court order.

Professionalism

What you owe people because they trust you. Competence, honesty, putting patients first, showing up for the team, and answering for your mistakes.

Disclosure of medical error

The duty to tell a patient when a mistake has harmed them, what it means, and what is being done about it. Most errors are not negligence. They come from incomplete knowledge, lapses in attention, or system pressures like fatigue and rushing.

Just culture

Treating most errors as failures of system design rather than as bad individuals, so people report problems instead of hiding them and the real causes get fixed.

Impaired colleague

A coworker whose substance use, illness, or condition is putting patients at risk. In a station: patient safety comes first. Talk to the person, then a supervisor or the physician health program. Staying silent is not an option.

Boundary crossing vs. boundary violation

A crossing is a small and often harmless step outside professional norms. A violation uses the patient for the clinician's own benefit and causes harm. A romantic relationship with a current patient is a violation.

Conflict of interest

When something else you care about, like money, career, or a personal relationship, could bend your professional judgment. In a station: disclose it, and step aside when it is serious.

Conscientious objection

Refusing to provide a legal service because of your own moral or religious beliefs. Generally accepted only if you give notice ahead of time, do not abandon or judge the patient, and refer them promptly to someone who will help.

Nonabandonment

The duty not to walk away from a patient, including when you disagree with them or when there is nothing left to cure. Pairs with conscientious objection. You can decline to provide a service, but not to care for the person.

Moral distress

Knowing what the right thing is and being blocked from doing it. Useful language for stations about a student or junior team member who disagrees with the plan.

Ethics committee and ethics consultation

A group drawn from across the hospital that helps clarify the issue, mediate conflict, and lay out options. It advises, it does not decide. In a station: a real, specific next step you can name.

Interdisciplinary team conflict

Disagreement between doctors, nurses, social work, pharmacy, and others about the right plan. In a station: nurses often know things the doctor does not, and the move is to talk to the person directly before going over their head.

Belmont Report

The 1979 report that set respect for persons, beneficence, and justice as the ground rules for research involving people.

Institutional Review Board (IRB)

The committee that reviews and monitors research on human subjects to check that risks are minimized and reasonable, that consent is real, and that subjects are chosen fairly.

Clinical equipoise

Real disagreement among experts about which treatment in a trial is better. It is what makes it acceptable to randomize patients instead of just giving everyone the better option.

Therapeutic misconception

When someone in a study wrongly believes it was designed to help them personally, rather than to answer a research question. A consent problem worth watching for.

Vulnerable populations

Groups whose ability to freely agree may be compromised by their situation, including children, prisoners, people with cognitive impairment, and anyone dependent on the institution or the payment.

Resource allocation

How scarce things like ICU beds, organs, clinician time, and medications get divided up. The usual criteria are equal shares, need, effort, contribution, merit, and ability to pay. The last one is the hardest to defend.

Decent minimum

The idea that everyone should have access to a basic level of care that sustains life, prevents illness, and relieves suffering, so each person gets a fair shot at a normal range of opportunity.

Triage

Deciding who gets care under sudden scarcity based on who is most likely to benefit, rather than who arrived first. In a station: criteria should be set in advance, applied the same way for everyone, and ideally decided by someone other than the doctor at the bedside.

Rule of rescue

Our tendency to spend huge resources saving one identified person we can see, while spending little to save a larger number of anonymous people we cannot. A town spends millions rescuing one trapped child, but the same money on prenatal care would save more lives invisibly. In a station: useful for admitting a pull you feel yourself rather than posing as a neutral calculator.

Least restrictive means

When public health overrides individual liberty through quarantine, isolation, or mandatory treatment, it should use the least intrusive option that still achieves the health goal. If voluntary isolation would contain an outbreak, you do not impose an enforced lockdown. The burden falls on whoever proposes the more coercive measure. Goes with proportionality, transparency, and reciprocity, which means supporting the people you are asking to bear the cost.

Cultural humility

Staying curious and aware of the limits of your own perspective. Contrasts with cultural competence, which suggests you could finish learning about a group and be done.

Health literacy

How well someone can find, understand, and use health information to make decisions. Low health literacy is common and invisible unless you check for it.

Structural determinants of health

The conditions that shape health beyond personal choices, including housing, income, racism, insurance, and transportation.