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发帖数: 149 | 1 MEDICAL ETHICS 137 cases:
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1. A 25- year old mother refused immunization for her 2-month old son. The
social worker spoke to the mother. (Important for Board examination)
Next step in management: immunization should be given for the benefit of the
child.
2. A 30-year old mother refused surgery for suspected appendicitis for her 6
-year old daughter. The social worker spoke to the mother. (Important for
Board examination)
Next step in management: surgical removal of the appendix should be
preformed for the benefit of the child.
3. A 16-year old boy was diagnosed with osteosarcoma of the right thigh. The
surgeon recommended amputation. The boy refuses amputation. He is doing
very well otherwise. He is aware that death is certain without surgery. (
Important)
Next step in management: amputation should NOT be preformed.
Adolescent patients or adults who are competent in making decisions have an
absolute right to determine what shall be done with their own bodies.
However, most pediatric patients are not competent to make their own
decisions. Please remember, children (15 years or older) are usually able to
give a genuinely informed consent. Therefore physicians may respond to
their request, except in a case of irreversible sterilization.
4. A 17-year old girl is a Jehovah’s Witness. She refuses
a lifesaving blood transfusion. She is aware of the consequences. She spoke
to the social worker. (Important)
Next step in management: blood transfusion should NOT be given because she
is competent to make the decision.
5. A 5-year old girl is a Jehovah’s Witness. She requires
emergency blood transfusion. Her mother refuses blood transfusion. A social
worker along with two physicians spoke to the mother. (Important)
Next step in management: blood transfusion should be given because the
patient is not competent. Mother cannot refuse her daughterâ€&#
8482;s treatment.
6. A 2-year old boy was brought to the ER by his parents for an injury.
Physicians made the diagnosis of child abuse. There are three other children
living in the same household. Both parents confess to child abuse but
request the physician to keep it confidential. Social worker was involved. (
Important)
Next step in management: the case should be reported to Child Welfare Agency
(CWA). All children should be removed from the parents.
7. A 15-year old boy with STD (sexually transmitted disease) came to see a
physician. He asked the physician not to tell his parents. (VERY IMPORTANT)
Next step in management: the physician should treat the patient and notify
the appropriate health authority, but should not tell his parents.
8. A 16-year old boy wants to use a condom. He comes to the clinic for free
samples. He requested the physician, however, not to tell his parents. (
Important)
Next step in management: condom should be given and physician should not
tell his parents.
9. A 30-year old male patient is recently diagnosed with HIV. He lives with
his wife and two other children but is promiscuous. He requested the
physician not to tell his wife. He lost his job recently. Social worker
spoke to the patient. (Very Important)
Next step in management: physician should notify the appropriate authority (
e.g. department of health) for the safety of other specific persons who are
engaged in unsafe sexual practices. The physician however, should ask the
patient to divulge the diagnosis to his wife and other sexual partners.
10. A very small premature infant was born in the delivery room by NSVD (
normal spontaneous vaginal delivery). The attending physician decided not to
resuscitate the newborn. Physician spoke to the mother. Mother started to
cry. Newborn expired after 30 minutes. Is the physician liable for the
newborn’s death?
Answer: NO. Please remember, no physician in the USA has ever been found
liable for withholding or withdrawing any life sustaining treatment from any
patient for any reason.
11. A physician picked up a car accident victim from the street and brought
him to the ER in his car. He did not want to wait for an ambulance because
the patient’s condition was critical. Physical
examination in the ER reveals quadriplegia. Is the physician liable for this
consequence? (Very Important)
Answer: YES, because the physician did not protect the neck of the patient
resulting in quadriplegia.
12. A policeman brought an alcoholic patient to the ER. The policeman asked
the physician to give him a sample of gastric contents by putting a
nasogastric tube for laboratory study. The patient refused insertion of a
nasogastric tube. (Very Important)
Next step in management: nasogastric tube should not be placed. Blood
alcohol level however should be preformed. The policeman should not give
orders to a physician.
13. A 60-year old man with a history of myocardial infarction (MI) suddenly
develops ventricular tachycardia. A physician from another department was
present. The patient needs resuscitation. (Very Important)
Next step in management: the physician must resuscitate that patient.
Physician should not refuse treatment because he belongs to another
department.
14. A 15-year old homosexual boy wanted to change his sexual orientation. He
was not successful. He needed help. He requested the physician not to tell
his parents. (Important)
Next step in management: physician should help him avoid homosexual
activities. Physician should not tell his parents about his homosexual
activities.
15. A 15-year old homosexual boy is brought by his parents to a physician.
His parents do not accept their son’s sexual orientation.
The boy refuses to change. (Important)
Next step in management: physician should tell his parent that homosexual
activity is considered as an alternative life style. Parents should talk to
his son but should not force him to change his homosexual activities.
16. A 16-year old girl becomes pregnant. Her mother wanted her to abort this
pregnancy. The girl wanted to continue her pregnancy despite difficulties.
Her boyfriend is a high school drop out. (Important)
Next step in management: physician should advise to continue this pregnancy
because the girl is competent to make this decision.
17. A 15-year old girl recently becomes pregnant. She went to a doctor for
abortion. She told the doctor not to tell her parents about this pregnancy.
(Important)
Next step in management: abortion should be done and parents should not be
notified. Please remember, strict requirements for parental consent may
deter many adolescents from seeking health care.
18. Can a physician provide sterile needles for intravenous drug abusers? (
Important)
Answer: YES. It reduces the risk of acquiring HIV or hepatitis. The patients
should be referred to appropriate health facilities.
19. A 26-year old pregnant woman went for antenatal check up. Sonogram
revealed a 27-week old fetus with erythroblastosis fetalis. Doctor
recommended intrauterine fetal blood transfusion. She refused the procedure.
Social worker discussed the case with the mother. (Important)
Next step in management: doctor should receive a court to do the procedure
that will help the fetal condition.
20. A 20-year old man tells his doctor that he is going to kill girlfriend.
She lives in the university dormitory. Doctor called the university and
alerted them about the threat. However, university security people did not
protect her. Her boyfriend killed her. Who should be responsible for this
killing? (Important)
Answer: the 20-year old man is responsible. Doctor did the right thing by
notifying the university or the police. The university is also responsible
because they did not take any preventive measures.
21. A 20-year old pregnant woman refuses cesarean section for complete
placenta previa. Fetus is full-term and healthy. Social worker spoke to
mother. (Important)
Next step in management: doctor can go to court to get permission for
cesarean section for the benefit of the fetus.
22. A 30-year old pregnant woman ingested alcohol and illicit drugs (e.g.,
cocaine, crack) that are harmful to the fetus. What should a physician do? (
Important)
Answer: the physician should be careful in reporting this case because the
pregnant woman may not come back for prenatal care, which is important for
both the mother and the fetus. However, if the baby’s
urine toxicology test is positive for illicit drugs, case should be reported
to CWA (child welfare agency). CWA suggests separate custody for the child.
23. A physician wants to study a group of children aging from 10-12 year old
. Physician already got the consent from the parents. However, he didnâ
€™t discuss the study with the children. A child refused to
participate. Should the physician force the child to participate? (Important)
Answer: no, because a child can refuse to participate in a research study.
24. A 40-year old schizophrenic patient needs hernia repair. Surgeon
discussed the procedure with the patient who understood the procedure. Can
the patient give consent? (Important)
Answer: yes. If a psychiatric patient understands the procedure, he or she
can give the consent.
25. A 65-year old schizophrenic patient needs coronary angiography because
of suspected myocardial infarction. Cardiologists explained the procedure to
the patient who did not understand the procedure. Who can give the consent
on behalf of the patient? (Important)
Answer: the patient’s relative can give the consent. If
nobody is available to give the consent, court order should be obtained. If
a psychiatric patient does not understand the procedure, he or she cannot
give the consent.
26. A 25-year old woman developed postpartum psychosis. The newborn
developed cyanosis due to congenital heart disease. The newborn needs
cardiac surgery. Surgeon discussed the procedure with the mother. She
understood the procedure. Can she give the consent? (Important)
Answer: yes, because she understood the procedure.
27. A newborn is diagnosed with either trisomy 18 or 13 with TE (
tracheoesophageal) fistula, which requires surgery. Mother request surgeon
to repair the TE-fistula. What should a surgeon do? (Important)
Answer: surgeon should refuse to do the reparative surgery because these
conditions (trisomy 18 or 13) are nonviable. If the patient survives,
surgeon can put a gastrostomy feeding tube for nutrition. However, please
remember that a patient with trisomy 21 (Down syndrome) with TE fistula
should be operated on.
28. A 45-year old terminally ill patient wanted to die. He has pancreatic
cancer and has been suffering from constant pain. He asked the physician to
give him some medication which can expedite his death. What should a
physician do? (Very Important)
Answer: physician cannot give any medication which will expedite the death.
However, physician can prescribe medication to minimize the pain. The dose
should be appropriate. Physician-assisted suicide is illegal everywhere (
except in the state of Oregon).
29. A 47-year old man came to a doctor for chronic low back pain and dysuria
. The diagnosis of metastatic prostate cancer was made after appropriate
investigation. Should the doctor tell the bad news to the patient? (
Important)
Answer: yes physician must tell the truth to the patient.
30. A surgeon wanted to perform cholecystectomy on a patient. The surgeon is
not sure whether the patient has decision-making capacity. What is the next
appropriate step? (Important)
Answer: consultation with a psychiatrist or neurologist may be helpful.
Sometimes it is necessary to discuss the case with hospital attorneys, ethic
committees, or ethic consultants. In a difficult case, the ultimate judge
of a patient’s competency is a court.
31. A 45-year old widow was admitted to an ICU (intensive care unit) with
ruptured intracranial aneurysm. She is comatose and is placed on a
mechanical ventilator. She has a 20-year old son who did not keep any
relation with his mother. However, he came to see his mother. His mother
made a written proxy advance directive which indicates that her 50-year old
female neighbor should make the substitute decision. Who is the right person
to make the substitute decision in this situation? (Important)
Answer: 50-year old neighbor should make the substitute decision. Please
remember, the most appropriate person to make the substitute decision is
someone designated by the patient while still competent, either orally or
through a written proxy advance directive. Other substitute decision makers,
in their usual order of priority, include a spouse, adult child, parent,
brother or sister, relative, or concerned friend. For a patient who has no
other decision maker available, a phblic official may serve as a decision
maker.
32. The right of patients to refuse medical intervention: patients can
refuse dialysis, cardiopulmonary resuscitation, mechanical ventilation, and
artificial nutrition and hydration, even if such a decision results in the
patient’s death. A patient’s decision
to withdraw (discontinue) or to withheld (not to initiate) life-sustaining
treatment is not considered suicide and physician participation is not
considered physician-assisted suicide. Physicians do not have any legal risk.
33. Can a medical student introduce himself or herself as a â€&#
732;doctor’ to the patient? (Important)
Answer: no. a patient can refuse a medical student from performing any
procedure. However, medical students are allowed to perform a procedure
under appropriate supervision If the patient agrees to that.
34. Should a bus driver hide history of epilepsy from his employer? (
Important)
Answer: no. He has requested his physician not to mention his epilepsy to
the employer because this would result in the loss of his job. The physician
is obligated not only to his patient but to the community. The patient
should notify his employer and try to find a non-driving job in the company.
If the patient disagrees, physician may notify the appropriate authority
for the safety of the patient and the community.
35. A 50-year old make is diagnosed with stomach cancer. He requested the
physician not to tell his wife. The following day, the wife calls to inquire
about her husband’s diagnosis. (Important)
Answer: the physician should not divulge the husband’s
diagnosis. However, the physician should encourage the patient to reveal his
diagnosis to his wife.
36. A 29-year old man is diagnosed with presymptomatic Huntingtonâ&#
8364;™s disease. This disease is an autosomal dominant (50% chance of
having the disease in each pregnancy). He requested his physician not to
tell the diagnosis to his wife. The wife wants to have children. (Important)
Answer: physician should ask the patient to seek genetic counseling and to
urge him to discuss the matter with his wife. Since there is a risk of harm
to the future children, physician can divulge the diagnosis to protect the
future children.
37. A 18-year old man is diagnosed to have suspected bacterial meningitis.
He refuses therapy and returns to the college dormitory. What should a
physician do in this situation? (Very Important)
Answer: physician should report to the college authority and recommend that
the suspected individual should be isolated during the course of his illness.
38. A 39-year old nurse is diagnosed with hepatitis B antigen-positive. She
is working in a dialysis unit. She told her doctor. However, she did not
tell the hospital authority because she is afraid to lose her job. (Very
Important)
Answer: physician should ask the nurse to divulge her medical condition to
the hospital authority. If she refuses, physician should notify the hospital
authority for the protection of patients.
39. A 20-year old man with severe head injury was admitted to a small
hospital. The patient needs neurosurgical intervention which is available in
a nearby university hospital. Hospital refused to accept a patient who has
no medical insurance.
Answer: university hospital must accept the patient.
40. A 30-year old man needs a second prosthetic valve. He is a drug addict.
Surgeon does not want to perform surgery because the patient does not take
care of himself. Is this the right decision? (Important)
Answer: no. Surgery should be performed if it is medically indicated.
41. A newborn male is diagnosed with anencephaly. His 1-year old sibling
needs a kidney. His parents requested the physician to remove the kidney
from the anencephalic child and to transplant that kidney in the 1-year old
sibling. What should a physician do?
Answer: surgeon should perform the kidney transplant.
42. A 50-year old man is in a persistent vegetative state. Physician decided
to discontinue nutrition and hydration for that patient. Is this the right
decision?
Answer: yes. This is an acceptable practice in most states. Few states
require clear evidence that the patient would have chosen this course.
43. A medical student requested his attending to perform a pelvic
examination on a patient who is anaesthetized for appendectomy. Is this
ethically acceptable?
Answer: no. The patient did not give consent to perform a pelvic examination.
44. A 20-year old woman slashed her wrists and wanted to die. She was
unconscious and was brought to the ER. What should a physician do? (
Important)
Answer: physician should take care of the patient. Psychiatric consultation
and social worker evaluation are indicated. A suicide attempt is very often
a ‘cry for help’.
45. A 90-year old man was diagnosed with having Alzheimer’
;s disease 10 years ago. It is difficult to feed him. He cannot recognize
his family members. He developed recurrent aspiration pneumonia. What should
a physician do?
Answer: physician should discuss this with the family and should respect
their decision.
46. A 1-day-old infant was diagnosed with hypoplastic left heart syndrome.
The patient is stabilized with the use of prostaglandin. Physician discussed
this case in detail with the parents. What should the parents decide in
this situation?
Answer: the parents can choose a staged surgical repair of the heart, a
final heart transplantation if the organ is available, or allow the infant
to die.
47. A 55-year old woman with severe developmental disability recently is
diagnosed with breast cancer. Her mental age is estimated at a 2-year old
level. Her family members do not want any more intervention. What should
physician do?
Answer: physician should discuss this case with the hospital ethics
committee members. The usual consensus is ‘not to do
anything’ because of her severe mental disability.
48. A 49-year old woman with cervical cancer has a history of noncompliance.
She had surgery a month ago. She missed several appointments. Can a
physician force her for chemotherapy? (Important)
Answer: no. Physician can talk to her regarding the importance of
chemotherapy. However, the patient must make the final decision.
49. An internist has been managing a diabetic patient for the last 10 years.
The patient’s condition is progressively getting worse.
The patient is also not happy with the physician’s
management. What should a physician do in this situation?
Answer: physician should find another physician (e.g., endocrinologist) who
might be more successful with the patient in this particular circumstance.
50. An internist recently refused to see a patient who he has been seeing
for the last 5 years. Internist stated that the patient was rude to him. The
patient went to see another physician who requested the patientâ€
;™s medical record. What should the internist do in this situation?
Answer: internist should provide the medical records of the patient to the
new physician.
51. An internist refused to see a complicated hypertensive patient who he
has seen for the last 10 years. Internist did not give any notice to that
patient. The patient was angry with the physician. The patient was recently
admitted to a hospital with the diagnosis of stroke. Is the internist
responsible for the patient’s condition?
Answer: yes. The legal charge of abandonment can arise when the physician
without giving timely notice, ceases to provide care for a patient who is
still in need of medical attention. Internist is not obligated to find him
another physician. However, patient should have sufficient time to arrange
for another physician.
52. A physician went to vacation for 2 weeks. He did not find another
physician to cover him. He is very sincere. One of his patients with
hypertension developed severe headache. The patient has an appointment with
the doctor as soon as he comes back from vacation. The patient did not look
for another physician and decided to wait. The patient suddenly collapses
and was diagnosed to have intracranial hemorrhage. Is the physician
responsible for this patient? (Important)
Answer: yes. The physician has a legal obligation to arrange for coverage by
another physician.
53. An ophthalmologist performed a cataract surgery on a patient who went
home after the operation. In the evening, the patient started vomiting and
complained of severe headache. The ophthalmologist refused to accept that
the symptoms were due to postoperative complications. The patient wanted to
see the doctor immediately but he refused to see that patient. The patient
went to the nearest ER and was diagnosed to have dislocation of the lens and
partial retinal detachment. Is the physician responsible for the patient&#
226;€™s condition?
Answer: yes ophthalmologist failed to judge the patient’s
condition seriously enough to warrant attention.
54. A 70-year old Chinese man is diagnosed to have severe osteoarthritis. He
told his doctor that he is using Chinese herbal medicine. He is feeling
better. However, he had two episodes of dizzy spells since he started that
herbal product. What should a doctor suggest to this patient? (Important)
Answer: the doctor should suggest to discontinue the herbal product which
may be causing the dizzy spells.
55. A 35-year old woman is diagnosed to have chronic throat infection. She
is frustrated with the conventional medicine. She told her doctor that she
is using an alternative homeopathic medicine. She is feeling much better and
she has no other complications. What should a doctor suggest to this
patient?
Answer: the patient can continue an alternative homeopathic medicine.
Alternative medicine therapy is accepted in the society and is also used
along with conventional therapy.
56. A 45 year old woman is diagnosed to have UTI (urinary tract infection).
She told her doctor that she could not afford to purchase antibiotics.
However, she is using herbal medicine that is cheaper. She is complaining of
fever and dysuria. What should a doctor suggest to this patient? (Important)
Answer: the patient should discontinue the herbal medicine immediately and
should start antibiotics as soon as possible.
57. A 13-year old boy with suspected meningitis refuses therapy. His parents
also support that decision because they are supposed to go on vacation the
following day. What should a physician do in this situation? (Important)
Answer: the patient should be admitted and treated in the hospital. If they
refuse, legal action should be taken.
58. A 2-year old girl is admitted with the diagnosis of intestinal
obstruction. Her mother has a psychiatric problem. Her mother is not capable
of giving the consent. Her father died one uear ago. What should a surgeon
do in this situation?
Answer: legal steps may be taken to provide a surrogate decision-maker.
59. A 67-year old widow has been using hypnotics for the last 5 years. She
is addicted. Her doctor wants to withdraw her from her present medication by
trial on placebos. Is the physician making a right decision? (Important)
Answer: no. The physician cannot use placebos because his decision is
deceptive. The problem of addiction should be discussed directly with the
patient. The use of deceptive placebo is indicated in the following
conditions:
(a) the patient insists on a prescription;
(b) the patient wishes to be treated;
(c) the alternative to placebo is either continue illness or the use of a
drug with know toxicity;
(d) high response rates to placebo (e.g., postoperative pain, mild mental
depression).
60. A 50-year old man is diagnosed to have multiple sclerosis. In the
morning, the surgeon asked the man his opinion on the surgical procedure and
he agreed. In the evening, the man refused to give consent for the same
surgical procedure. He is also disoriented to place and time. Is the patient
capable of making the decision?
Answer: no the patient has impaired capacity.
61. A 55-year old woman with diabetes is diagnosed to have gangrene on both
feet. She was brought to the hospital. She told the doctor the she is
feeling fine and she has no medical problems. Can she give consent for the
amputation of both legs?
Answer: no. The appointment of a surrogate should be sought to get the
consent for the surgery.
62. A 17-year old boy came to a surgeon for bilateral vasectomy. He is the
father of one child and does not want to have any more children. He does not
want to tell his girlfriend and parents. He lives with his parents. What
should a surgeon do in this situation? (Important)
Answer: surgeon should not perform bilateral vasectomy and should offer him
less radical alternatives. Please remember, a mature minor may not
comprehend the implications of this procedure.
63. A 16-year old girl came to a doctor for bilateral tubal ligations. She
is a mother of one child and does not want to have any more children. She
does not want to tell her boyfriend and parents. She lives with her parents.
What should a doctor do in this situation? (Important)
Answer: obgyn doctor should not perform bilateral tubal ligation and should
offer her less radical alternatives.
64. A 16-year old boy wants to donate one of his kidneys to his friend who
is suffering from ESRD (end stage renal disease). The boy’
;s parents did not agree with his decision. What should a physician do in
this situation? (Important)
Answer: the physician cannot accept his kidney. However, he can donate one
of his kidneys if his parents agree.
65. A 15-year old boy wants to participate in a research study. He told his
parents who did not agree. He lives with his parents. Can this boy
participate in the research study?
Answer: no the boy needs consent from his parents to participate in a
research study.
66. A 17-year old boy lives independently. He is married and has one child.
He wants to participate in a research study. Does he need his parents
permission? (Important)
Answer: no. He is an emancipated minor who lives independently from his
parents physically and financially.
67. A 70-year old man is diagnosed with terminal esophageal cancer and
requires an insertion of a gastrostomy tube. He has signed a DNR (Do Not
Resuscitate) order about a month ago. Should the preexisting DNR order stand
or be suspended during the surgical procedure? (Very Important)
Answer: attending physician, surgeons, and the patient or surrogate should
discuss the matter and either affirm or suspend the order in anticipation of
surgery. If a patient is competent and wishes a preexisting DNR order to
stand, resuscitation should not be performed in the event of an
intrasurgical arrest.
68. An infant, born at 30 weeks gestation, appears to be SGA (small for
gestational age) with multiple malformations. Amniocentesis study was not
performed. Infant needs resuscitation at birth. What should a physician do
in this situation? (Important)
Answer: physician must resuscitate the patient in the delivery room because
the diagnosis is uncertain.
69. A 60-year old man is diagnosed with terminally ill colon cancer and
needs resuscitation. He did not sign a DNR order. The physician has decided
to perform a ‘slow code’ on his own. Is
this the right decision? (Important)
Answer: no. Please remember, a performance of ‘slow code&#
226;€™ or ‘show code’ is
not acceptable to the patient. This decision by the doctor represents the
failure to come to a timely and clear decision about the patientâ€
;™s resuscitation status.
70. A 20-year old man is diagnosed with suspected bacteremia and meningitis.
He refuses antibiotic therapy. He collapses and requires resuscitation.
What should a physician do in this situation?
Answer: the physician should resuscitate the patient despite the patient&#
226;€™s refusal to antibiotic therapy.
71. A 50-year old woman is diagnosed with severe aortic stenosis. She
collapsed in a doctor’s office and is required
resuscitation. She is waiting for valve replacement surgery. What should a
physician so in this situation?
Answer: this condition is called ‘physiological futility&#
226;€™. In severe aortic stenosis, vigorous resuscitation is
highly unlikely to restore adequate cardiac output. Therefore, the physician
might reasonably refrain from resuscitation.
72. A 14-year old boy is diagnosed with terminally ill cancer. He is not
responding to chemotherapy. His parents want to continue the treatment.
However, the boy does not want to continue his suffering. The physician told
the parents that chemotherapy will not be helpful. What is the appropriate
decision at this point? (Important)
Answer: the boy’s decision should be respected because
the treatment is futile.
73. A surrogate pregnant mother made a surrogacy contract with a couple in
which she will give the baby to the couple. She developed complications in
the first trimester and wanted to abort. Is she allowed to do that? (
Important)
Answer: yes. If her life or health becomes threatened from continuing the
pregnancy, she should retain her right to abortion.
74. A physician became sexually involved with a current patient who
initiated or consented to the contact. Is it ethical for a physician to
become sexually involved?
Answer: no. Sexual involvement between physicians and former patients raises
concern. The physician should discuss with a college or other professional
before becoming sexually involved with a former patient. The physician
should terminate the physician-patient relationship before initiating a
romantic or sexual relationship with a patient.
75. A physician decided to take care of his own family members and relatives
. He is a very smart physician. Is this a right decision?
Answer: no. The physician should encourage all friends and family members to
have their own personal physician.
76. A male patient wants to have a copy of his medical records. What should
a physician do in this situation?
Answer: the physician should retain the original of the chart. Information
should only be released with the written permission of the patient or the
patient’s legally authorized representative (e.g.,
attorney).
77. A 30-year old female wants to have an abortion. Her physician objects to
abortion on moral, religious, or ethical grounds. What should a physician
do in this situation? (Important)
Answer: physician should not offer advice to the patient.
78. A physician sees patients at a reduced fee. He spends very little time
with each patient. Is the physician doing the right thing?
Answer: no. The physician is not providing optimal care.
79. A surrogate pregnant mother signed a surrogacy contract with a couple.
Male partner gave sperms which were artificially inseminated to the
surrogate mother. Surrogate mother has a genetic relation to the child. She
wants to void the contract after the baby is born. Is she allowed to breach
the contract? (Important)
Answer: yes. Surrogate contracts, while permissible, should grant the birth
mother the right to void the contract within a reasonable period of time
after the birth of the child.
80. A surrogate pregnant mother signed a surrogacy contract with a couple.
Both male and female parents gave sperm and ovums respectively. The
surrogate mother wants to void the contract and she has no genetic relation.
Is she allowed to breach the contract? (Important)
Answer: no. Genetic parents have exclusive custody and parental rights.
81. A surrogate pregnant mother signed a surrogacy contract with a couple.
The couple got divorced. Male partner gave sperms and the female partner
gave ovums. They do not want to continue the surrogate pregnancy. What
should be the decision at this point? (Important)
Answer: the couple is genetically related to the fetus. They have the right
not to continue with this pregnancy.
82. A surrogate pregnant mother signed a surrogacy contract with a couple.
The couple got divorced. Male partner gave sperms but the female partner
could not give ovums. They do not want to continue the surrogate pregnancy.
What should be the decision at this point? (Important)
Answer: female partner has no right to terminate this pregnancy because she
has no genetic relation. Surrogate mother has genetic relation and she has
the right to continue this pregnancy even if the male partner disagrees.
83. A 3-year old girl is diagnosed with blood cancer. She has been waiting
for an umbilical cord transfusion. Her mother delivered a newborn baby girl.
Umbilical cord blood was obtained and was transfused to the 3-year old
sibling. What is the duty of the physician?
Answer: physician should obtain an informed consent of the risks of donation
and he or she should follow the normal umbilical cord clamping protocol.
Physician should protect both the children.
84. A 31-year old man has decided to donate one of his kidneys for a large
amount of money. Is this the right decision?
Answer: no. However, the donor can receive some payment to cover his medical
expenses. Only the potential donor not the donor’s
family or another third party may accept financial incentive. Payment should
occur only after the organs have been retrieved and judge medically
suitable for transplantation.
85. A couple has decided to have a child through artificial insemination.
They asked the physician for sex selection of the child. What should a
physician advise in this situation? (Important)
Answer: physician should not participate for sex selection for reasons of
gender preference. However, sex selection of sperm for the purpose of
avoiding a sex-linked inheritable disease is appropriate.
86. A 30-year old man has donated his sperms which were kept frozen. He died
in a car accident. He did not leave any specific instructions regarding
sperm donations. His wife wants to make use of them. A woman requested her
to donate his sperms. What is the appropriate decision? (Important)
Answer: the donor’s wife can use the semen for artificial
insemination but not to donate it to someone else. The donor should give
clear instructions at the time of donation. The donor has the power to
override any decision.
87. The donor and recipient of sperms are not married. Who would be
considered the sole parent of the child? (Important)
Answer: the recipient. Except in cases where both donor and recipient agree
to recognize a paternity right.
88. The residents and medical students were asked by an attending to follow
certain orders for a patient. The residents and medical students believe the
orders reflect serious errors in clinical or ethical judgment. What is the
appropriate way to handle the situation? (Important)
Answer: The residents and medical students should not follow those orders.
They should discuss with the attending issuing those orders. They should
also discuss the situation with a senior attending physician, a chief of
staff, or a chief resident.
89. A physician used a newly prescribed drug to his patient. The patient got
sick after the drug was ingested and required hospitalization. Should the
physician report this drug’s side effect to FDA (Food and
Drug Administration)? (Important)
Answer: yes. FDA should be notified only if the drug causes serious adverse
events such as those resulting in death, hospitalization, or medical or
surgical intervention.
90. A 39-year old female has been suffering from chronic cholecystitis. The
surgeon advised cholecystectomy. The patient wants a second opinion. The
surgeon agreed. The patient went to another surgeon and has decided to be
operated by the second surgeon. What should the second surgeon do in this
situation? (Important)
Answer: the second surgeon should accept the patient because the patient has
the right to choose the surgeon. First surgeon should accept the patient&#
226;€™s decision.
91. A 45-year old male was admitted to the hospital with mild chest pain. He
wants to leave the hospital before completion of therapy. How do you manage
the patient? (Important)
Answer: The patient is asked to sign a statement that he is leaving against
medical advice (AMA). The patient may however leave without signing that
statement. This document is a legal evidence that the patient was warned by
the physician about the risk of leaving. Please remember, discharge AMA does
not apply to children.
92. A 55-year old man requested his physician to misrepresent his medical
condition to receive disability or insurance payment. What is the
appropriate response of the physician in this situation?
Answer: The physician must refuse that request.
93. What is the responsibility of a fellow physician who is aware of drug
abuse, alcohol abuse, or psychiatric illness of his colleagues or of a
medical condition that is harmful to patients? (Very Important)
Answer: the physician should protect the patients. The fellow physician
should report to the appropriate authority (i.e., report to the hospital
authority; report to the Dean for a medical student’s
problem).
94. A 60-year old male has been suffering from severe pain due to terminal
prostate cancer. The patient is receiving lower doses of narcotics and
sedatives. How can a physician relieve his suffering? (Important)
Answer: The physician should increase the dosage of narcotics and sedatives
up to the maximum recommended amount. The suffering can be reduced by
listening, spending more time with him, and reducing psychological distress.
95. A 25-year old female medical student or resident noticed a mistake made
by a junior attending physician during rounds. She is afraid of that
attending physician. What is the appropriate way to handle the situation? (
Important)
Answer: She should discuss the situation with a more senior attending
physician for appropriate interpretation, advice, and assistance.
96. A 26-year old male medical student or resident made a mistake during
patient care. He is afraid of what might result. What is the appropriate way
to handle the situation?
Answer: He should disclose the mistake to the attending physician and try to
learn from that mistake. The patient should be notified as well.
97. A 63-year old female health care worker is concerned about taking care
of patients with HIV infection or multidrug-resistant tuberculosis. What is
the appropriate way to handle the situation? (Important)
Answer: The physician should provide appropriate care to patients despite
personal risk. Institutions should reduce the risk of infection by
appropriate equipment, supervision, and training. Her concern should be
taken seriously.
98. A 30-year old male physician has an opportunity for financial incentive
if he sees more patients and refers them unnecessarily. What is you opinion
about this?
Answer: The physician should provide only care that is in the patientâ&
#8364;™s best interest.
99. Two physicians are discussing a case inside the elevator of a hospital.
What is your opinion about this?
Answer: They should not do that because they have to maintain the patient&#
226;€™s confidentiality.
100. The patient’s confidentiality should be maintained
except in the following situations:
Physicians should override third parties in case of domestic violence, child
abuse, elderly abuse, gunshot wounds, syphilis, and tuberculosis. They
should report these cases to appropriate governmental authorities.
101. A physician is experiencing a very difficult ethical issue regarding a
complicated case. He is confused. What should be the next step?
Answer: he should discuss the matter with other faculty members in his
health care team, colleagues, or hospital ethics committee.
102. What is the final plan of action in an ethical issue?
Answer: Both patient and physician should agree regarding final management.
The patient should be well-informed about the medical condition. The
physician should be sympathetic and knowledgeable regarding the relevant
medical condition.
103. DNR (do not resuscitate) order. This is appropriate if the patient or
surrogate signed that order or if CPR (cardiopulmonary resuscitation) would
be futile. Physicians should write DNR orders and the reason for them in the
chart. Please remember, “slow†or â
;€œshow†codes are not acceptable. Foods and
fluids are considered therapies that should be stopped. (Important)
104. (A)Brain death (adult): (Important)
(i) Definition by the President’s Committee:
Death is an irreversible cessation of circulation and respiratory functions
or irreversible cessation of all functions of the entire brain and brain
stem.
(ii) The criteria of brain death by the staff of Massachusetts General
Hospital and the Harvard Committee:
Death occurs when there is absence of all signs of receptivity, responsivity
, and all brainstem reflexes, and the EEG is isoelectric. Sometimes
metabolic disorders and intoxications may mimic the above findings.
(iii) The guidelines of brain death:
(a) The diagnosis should be made also by another physician and confirmed by
clinical findings and EEG.
(b) The family should be notified. They should not make the decision about
discontinuing medical treatment except in a situation where the patient has
directed the family to make the decision.
(c) The physician should discuss with another physician before removing
supportive measures (e.g., ventilators).
(d) Family members may request organ donation, and in many states physicians
may request the family to make an organ donation.
(B) Brain death (children):
(i) Definition: same as in adults.
(ii) Criteria: similar in children and adults, but the period of observation
is longer in children.
Children 1wk-2mo of age: two separate examinations 48 hours apart
Children 2mo-1yr of age: two separate examinations 24 hours apart
Children more than 1 yr of age: two separate examinations 12 hours apart
Spontaneous movements must be absent, with the exception of spinal cord
reflex withdrawal and myocolnus.
Generalized flaccidity should be present. The presence of clinical criteria
for 2 days in term and 3 days in preterm infants indicates brain death in
majority of asphyxiated newborns. The absence of cerebral blood flow on
radionuclide scan and silence of electrical activity on EEG are not always
observed in brain-dead newborns. There is no universal consensus about the
definition of neonatal brain death. The decision is made after discussion
with the family and health care team. If there is difference of opinion, the
ethics committee should be consulted. The decision is made on the basis of
what is in the best interest of the infants and children.
105. Practice guidelines for physicians:
(i) The best way to practice medicine is to select useful diagnostic
techniques and therapeutic measures which are most appropriate to a
particular patient and clinical condition.
(ii) Practice guidelines can reduce the health care costs, which improves
health care to patients who even do not have adequate health care benefits.
(iii) Please remember, guidelines do not and should not be the only way of
managing an individual patient.
106. Some important points about patients:
(i) For a patient with an incurable disease, the major goal of therapy
should be the enhancement of the quality of life.
(ii) The patient care begins with a personal relationship between the
patient and the physician. If a patient has confidence on the physician,
reassurance may be the best therapy. The patient must understand that the
physician is giving the best possible care available.
107. Patients who do not have decision-making capacity about their medical
care:
The patients who do not have decision-making capacity usually arrange for
surrogates who make decisions for them. Their choices depend on their values
. Psychiatrists are helpful in mentally impaired patients. Family members
are usually the surrogates, because they know the patients very well
Advanced directives: statements made in advance in case patients lose their
decision-making capacity in the future. These directives indicate the names
of surrogates and which interventions are acceptable or not acceptable to
them. These are achieved by oral conversation (most common form), living
will, health care power of attorney, or physicians can ask the patient in
advance.
Absence of advance directives and surrogates: physicians can make the
decision using all information and should respect the patientâ€&#
8482;s values. Physicians must know the laws of the state in which they
practice.
Patient preferences are known:
The decision is made with the patient’s best interest in
mind.
Disagreements between potential surrogates or between the physician and
surrogate: Physicians can consult with the hospital ethics committee or with
other physicians. The courts should be only the last resort.
108. Down syndrome with different medical conditions: (Very Important)
(a) Duodenal atresia at birth: surgical repair is recommended as it is done
regularly.
(b) VSD (ventricular septal defect) in newborn period: initial conservative
medicals management is followed by surgical repair as it is done regularly.
(c) Cyanotic heart disease at birth: immediate medical management, which is
followed by surgical repair as it is required routinely.
(d) Cosmetic surgical condition (e.g., rhinophyma or big nose): there is no
urgency to repair the underlying condition, but it can be done as it is
performed regularly.
(e) Neural tube defects (e.g., meningomyelocele): surgical repair is
recommended as it is done regularly.
Please remember, a patient’s management should be
discussed with his/her parents and the decision made with the best interest
of the patient in mind.
109. A healthy male patient with Down Syndrome lives independently. He went
to a doctor for facial cosmetic surgery. Can he make his own decision? (
Important)
Answer: yes. The patient can make his decision if he understands the
procedure and the consequences. He lives independently which indicates that
he is capable of making his own decision.
110. A patient went to the doctor due to throat pain. The doctor asked the
patient what her problem was. The patient said that she woke up at six o&#
226;€™clock in the morning, went to the bathroom, ate breakfast,
and went to drop her children at school. She then came back home, stared
cooking and continues to talk about irrelevant things. What should the
doctor do to stop the patient from rambling? (Important)
Answer: the doctor should ask the patient to tell him what problems she has
related only to her throat.
111. A patient went to a doctor for abdominal pain but remained quiet
throughout the visit. He did not tell the doctor enough about his symptoms.
What should the doctor do? (Important)
Answer: the doctor must ask the patient detailed questions about his
abdominal pain. It is the doctor’s obligation to find out
as much as he can about the patient. Without enough information, the doctor
will not be able to make an accurate diagnosis.
112. A patient walked into his doctor’s office with acute
abdominal pain. He has been suffering from ulcerative colitis. The patient
is noncompliant and did not visit for the past six months. What should the
doctor do in this situation? (Very Important)
Answer: The doctor should find out more about the patient’
;s abdominal pain before making any other decision. The doctor should always
be responsible with the patients.
113. A terminally ill pancreatic cancer patient with multiple metastasis is
admitted to the hospital. He is in critical condition. The patient wants to
know his prognosis. What should the doctor say?
Answer: the doctor should tell the patient politely that he will discuss his
condition with him and his family. The doctor should never specify the
longevity of the patient. The doctor should tell the truth even when the
patient is a child. The doctor should not hide any medical information from
the patient.
114. A patient is recently diagnosed with cancer. He is nervous but is eager
to know about his medical diagnosis. What should the doctorâ€&#
8482;s reply be? (Important)
Answer: the doctor should gently tell the patient his condition.
115. A patient is recently diagnosed with cancer. Previously, he had an
episode of a nervous breakdown after hearing a family death and had to be
admitted to a hospital. He loves his family members and tends to be very
open with them on all issues. How should the doctor tell the patient about
his current state? (Important)
Answer: the doctor should call his family members and discuss the patient&#
226;€™s medical condition openly and politely.
116. A male patient was admitted with severe myocardial infarction. He was
admitted to the ICU and his condition is very critical. He does not know the
reason for his admission. The patient is unstable. What should the doctor
tell the patient? (Important)
Answer: the doctor should wait until the patient is stabilized and then
gently tell him his medical condition.
117. A mother gave birth to a premature baby who was admitted to the NICU (
neonatal intensive care unit). The baby is on a mechanical ventilator. The
mother wants to hold the baby. What should the doctor do in this situation?
(Important)
Answer: the mother should be allowed to hold the baby.
118. A male patient is recently diagnosed with HIV. Should the doctor ask
about his sexual orientation (i.e., male, female, or both)? (Important)
Answer: yes, the doctor should ask the patient directly but politely about
his sexual orientation.
119. A homosexual male patient went to a doctor. The patientâ€&#
8482;s partner was recently diagnosed with HIV. Should the doctor ask the
patient whether he is being penetrated by his partner or he penetrates his
partner?
Answer: yes, because the person who is being penetrated has a higher
incidence of HIV due to trauma in perianal area.
120. A 6-year old boy comes to the ER after drowning. He expired in the ER
despite appropriate resuscitations. The family members became angry which is
a reflection of a sense if guilt and helplessness. What is the appropriate
way of giving information to the family members?
Answer: the physician should give the information clearly and
compassionately when there is no hope for survival. Parents need to know
that everything was done to save the child.
121. A pregnant woman who is Rh(-)ve became sensitized. She had H/O induced
abortions. Her husband is not aware of his wife’s
previous abortions. He wants to know from the physician how she became
sensitized. (Very Important)
Answer: the physician should tell the man to ask his wife. The physician
should not mention anything about the patient’s H/O
abortions.
122. A mother brought her infant to the ER. The radiologist test reveals old
fractures of the ribs. She did not know anything about that. (Very
Important)
Answer: this is a case of child abuse. This case should be reported to child
welfare agency.
123. A physician is examining a child with respiratory distress. The child&#
226;€™s mother became anxious during the physical examination.
Please remember, a patient’s management should be
discussed with his/her parents and the decision made with the best interest
of the patient in mind. (Important)
Answer: child abuse.
124. A mentally retarded patient became pregnant. The patient does not want
an abortion. Her mother and husband want an abortion. What should a
physician do in this situation? (Important)
Answer: abortion should not be performed.
125. A male physician is examining an adolescent or adult female patient.
What should a physician do in this situation? (Important)
Answer: a chaperone should be present during the physical examination. The
same rules apply when a physician is examining a patient who appears to be
seductive. (Important)
126. A female physician is examining an adolescent or adult male patient.
What should a physician do in this situation? (Important)
Answer: a chaperone should not be present during the physical exam.
127. A suspected HIV patient expired in a car accident. He signed for organ
donations. What should a physician do in this situation?
Answer: his HIV status is not certain. The organs can be preserved until the
HIV status is confirmed. If the test for HIV is positive, organs should be
discarded.
128. A patient who expired in a car accident signed in his license foe organ
donations. His license has expired. He always wanted to donate his organs.
What should a physician do in this situation? (Important)
Answer: physican cannot accept organs because the signed consent has expired.
129. A male physician sexually harassed a female patient during the physical
examination. The patient complained to a nurse. What should the nurse do in
this situation?
Answer: the nurse should tell the patient to make an official report to the
hospital authority or to an appropriate agency.
130. A chronic male smoker comes to the physician for his heart problems.
The physician wanted his patient to quit smoking. What should the physician
advise in this situation?
Answer: the physician should ask the patient to quit smoking immediately
because patients are usually more responsive when they are ill. The
physician should assist the smoker to move one step closer to quitting.
131. A terminally ill patient did not sign a DNR (do not resuscitate) order,
however, he signed a DNI (do not intubate) order. What should the physician
do in this situation?
Answer: the physician should follow his orders i.e., the patient should be
resuscitated but should not be intubated, despite severe hypoxic condition
of the patient.
132. A terminally ill patient signed a DNR order, however, he did not sign a
DNI (do not intubate) order. He wants to be intubated but not resuscitated.
What should a physician do in this situation?
Answer: the physician should follow his orders i.e., the patient should be
intubated but should not be resuscitated.
133. An adolescent car accident victim was brought to the ER in an
unconscious state. The patient needs immediate surgical interventions. The
surgeon was unable to contact any family member to obtain consent. What
should a surgeon do in this situation? (Important)
Answer: the surgeon should do the procedure without waiting to obtain a
consent for the benefit of the patient.
134. An obgyn doctor is recently diagnosed with HIV infection. He is
receiving medication for HIV. His physical and mental conditions are normal.
Should he tell his patients or fellow physicians about his HIV status?
Answer: no, however, the doctor should take appropriate precautions for
infection control. He does not have to tell his fellow physicians about his
HIV status including the physicians who are referring patients to him. The
doctor is allowed to see patients if he takes appropriate precautions.
However, he should notify the hospital authority.
135. A physician is scared of seeing an HIV patient with an open wound. Can
a physician refuse to see a patient?
Answer: yes, however, a physician’s refusal to see a
patient is unethical but is legal.
136. An elderly semicomatose patient may require surgical intervention. His
family members are confused about the surgery. They asked the surgeon for
his opinion. What should the surgeon’s response be?
Answer: the surgeon can give his opinion and act as a moral surrogate for
the benefit of the patient. (Very Important)
137. A 12-year old boy is diagnosed with a terminal illness (e.g.,
malignancy). He asked the doctor about his prognosis. His parents requested
the doctor not to tell him the bad news. What should the doctor do in this
situation? (Very Important)
Answer: the doctor should tell the truth politely and compassionately to the
patient.
138. A 55-year old woman is recently diagnosed with right breast cancer. The
doctor told the patient that she will require surgery for removal of the
right breast. She started to cry. What should a doctor do in this situation?
Answer: first, the doctor should give her some tissue paper for wiping her
tears. Then, the doctor should be sympathetic to her and console her. He
might tell her that similar reactions are usually expected from other
patients with breast cancer. Please do not mention that she will be fine
with a breast implant or without a right breast because she is already 55-
years old.
139. A mother is carrying a 500 gram premature fetus which develops acute
fetal distress. The physician wanted to perform a cesarean section. Mother
refused cesarean section. What should the doctor do in this situation?
Answer: the physician should arrange a bedside conference with the mother
along with other physicians, social worker, and administrator to discuss the
matter. |
