Medical ethics
Title Page
Medical Ethics for the Boards
Third Edition
Authors: Conrad Fischer, MD & Caterina Oneto, MD
Publisher: McGraw Hill Education
Contents (Selected)
Introduction and How to Use This Book
Chapter 1: Autonomy
Chapter 2: Competence and the Capacity to Make Decisions
Chapter 3: Informed Consent
Chapter 4: Confidentiality and Medical Records
Chapter 5: End-of-Life Issues
Chapter 6: Reproductive Issues
Introduction and How to Use This Book
Medical ethics questions appear in Behavioral Science section of Step 1 and in patient management in Step 3.
Topics cover half of the Behavioral Science questions on Step 1 and are considered difficult on Step 3.
The book includes practical questions likely encountered on the USMLE board exams.
It avoids philosophical discussions and aims for concrete, definite answers to help in exams.
Input from students is encouraged to improve the book.
About the Authors
Conrad Fischer, MD:
Residency Program Director in Internal Medicine at Brookdale University Hospital, Brooklyn.
Ordained interfaith minister studying religiously motivated violence.
Associate Professor of Physiology, Pharmacology, Medicine at Touro College of Medicine.
Caterina Oneto, MD:
Department of Gastroenterology, New York University Langone Medical Center, New York.
Chapter 1: Autonomy
Patient autonomy is the fundamental principle in health care ethics.
Competent adults have the right to make their own health care decisions.
Informed consent is mandatory before any treatment.
Justice Cardozo's 1914 court case established that surgery without consent is considered assault.
Rights to refuse treatment are recognized similarly to constitutional rights.
Key Concepts in Autonomy
Informed Consent: Right to choose based on complete understanding of the treatment.
Property Rights of the Body: Individuals view their bodies as personal property.
Exceptions: Autonomy can be overridden in cases of immediate danger to self or others.
Advance Directives: Patients can express wishes for care before losing capacity.
Chapter 2: Competence and the Capacity to Make Decisions
Definitions:
Competence: A legal term determined by a court; adults are presumed competent unless proven otherwise.
Capacity: A clinical assessment of understanding and decision-making ability made by any physician.
Categories of Patient Population
Minors: Generally lack the capacity to consent; consent from guardians is required.
Emancipated Minors: May consent for themselves under specific conditions such as living independently or pregnant.
Psychiatric Patients: May retain the right to refuse treatment despite other incompetencies.
Chapter 3: Informed Consent
All Options Must Be Described: Patients should know all risks, benefits, and alternatives before consenting.
Major Adverse Effects: Patients should be informed about potential adverse effects.
Specific Procedure Requirement: Consent is necessary for each distinct procedure.
Consent Is Required for Surgery: No assumption of consent is permissible.
Implied Consent in Emergencies
In emergencies, consent may be implied if the patient is unconscious and requires urgent treatment.
Chapter 4: Confidentiality and Medical Records
Confidentiality: Strong obligation to maintain patient privacy; broken only when risking harm to others or legal obligations arise.
Release of Information: Requires patient consent, except under specific conditions such as subpoenas or threats to public safety.
Medical Records
Patients own the information in their medical records; hospitals own the physical documents.
Patients may access their records regardless of reasons for requests.
Chapter 5: End-of-Life Issues
Withdrawal of Treatment: Patients can refuse or withdraw treatment without any distinction between active and passive withholding.
Advance Directives: Clearly stated wishes must be honored even in the emergency or incapacity.
DNR Orders: DNR specifies no CPR but does not limit other medical treatments.
Special Topics
Physician-Assisted Suicide: Generally considered ethically unacceptable in medical practice.
Euthanasia: Also seen as unethical, with no legal framework supporting practice in most jurisdictions.
Chapter 6: Reproductive Issues
Access to abortion is generally unrestricted in the first trimester, with varying regulations in later trimesters.
Counseling and Referral: Physicians must refer patients seeking procedures they are opposed to ethically or personally.
Chapter 7: Organ and Tissue Donation
Organ donation requires clear voluntary consent from the donor or their family.
No financial compensation for organs; reimbursements for donation logistics are acceptable.
Chapter 8: Reportable Illnesses
Physicians are mandated to report certain communicable diseases (e.g., AIDS, syphilis, tuberculosis) to health authorities.
Chapter 9: HIV-Related Issues
HIV testing requires patient consent, particularly amidst stigma and legal protections for HIV-positive patients.
Chapter 10: STDs
Reporting of STDs is mandated for public health reasons while maintaining the confidentiality of patients.
Chapter 11: Malpractice
Malpractice involves deviation from standard care resulting in patient harm, irrespective of intent.
Chapter 12: Doctor/Patient Relationship
Physicians must maintain a professional relationship alongside ethical obligations to patients.
Ending professional relationships must be done with reasonable notice and care.
Chapter 13: Doctor and Society
Mandatory reporting in cases of child and elder abuse; ethical dilemmas in spousal abuse reporting.
Chapter 14: Doctor/Doctor Relationship
Duty to report impaired colleagues; navigating disagreements in medical practices.
Chapter 15: Experimentation
Ethical consideration in research, including informed consent and the role of Institutional Review Boards (IRBs).
Practice Questions
Engage with numerous scenarios to test understanding of medical ethics principles as applied in practice.