Ethics & Legal for USMLE Step 1

http://www.stomponstep1.com/ethical-principles-confidentiality-capacity-medical-ethics-beneficence-bioethics-law/

Ethical Principles
• Autonomy = respect patient's decisions about their own health
• Non-maleficence = do no harm. Can still take calculated risk if potential benefits outweigh the potential risks
• Beneficence = promote patients best interests
• Justice = distribute medical benefits fairly and do not discriminate against any particular group
Capacity/Competence
Capacity is a person's mental ability to make informed decisions about their own health. A capacitated individual has to be able to understand the medical information given to them, retain that information, use the information given to them to make an informed decision and communicate that decision to their providers. The decision they make must be in line with their previous beliefs and not be the result of psychiatric symptoms (hallucinations of delusions). Certain psychiatric disorders, neurologic diseases, lack of consciousness, developmental disorders, age, severe pain, drugs or alcohol can all temporarily or permanently prevent someone from being capacitated. A couple clinical indicators or concern by a family member is not enough to deem a patient incompetent. A thorough examination of the patient must be performed before a patient is deemed incompetent. Patients are assumed to be competent until there is substantial proof showing otherwise. An individual who lacks capacity cannot give informed consent. Capacity is similar to the legal term Competence.

When a lack of capacity is involved, the requirement for informed consent is not removed. In these situations the responsibility of informed consent is transferred to a family member, friend or social worker. The physician should not be making these decisions for patient. Deciding which person will speak for the incapacitated patient follows a set of criteria. The first option is the patient speaking for themselves through an advanced directive or will. In this case the patient decides ahead of time what types of treatment they will want in certain scenarios. However, there are an infinite number of different scenarios that cannot all be outlined by the patient so a person is also needed to speak for the patient. The first person chosen to fill this role should be an individual identified by the patient (before they became incapacitated) through medical power of attorney. This person (called a proxy or surrogate) is identified by the patient ahead of time. If no such person has been identified by the patient a family member such as a spouse receives the responsibility. Whoever ends up being selected to speak for the patient should not be choosing what they want for the patient. They should be trying to relay what they think the patient would want if they could speak for themselves.
Minors and Capacity
Minors (patients under the age of 18) are considered to not have the capacity to make medical decisions. This means that the patient's parents give consent for medical treatment instead of the patient and that certain rules of confidentiality don't apply to the parents.

Emancipation is the process in which a minor obtains the right to make their own medical decisions. For medical purposes a minor is emancipated if they file to become officially emancipated, live on their own, are married, have children of their own or are pregnant. In these cases a minor is treated as if they were an adult.

There are exceptions to the rule where minors have the right to confidentiality and do not need consent from a parent. The way I remember these exceptions is the phrase "sex, drugs and rock n' roll." Sex stands for contraception, treatment of STDs, treatment of pregnancy or just the fact that they are having sex which might be found during the history. Drugs stand for knowledge of alcohol or drug related activities as well as medical situations that may arise as a result of these substances. Rock N' Roll stands for emergency situation in which a parent may not be able to be contacted in time to provide care.

Abortion is a situation where informed consent and confidentiality for minors is handled a bit differently. Some states require parent's permission for an abortion (informed consent must be obtained from the parent) and other states only require parental notification (confidentiality is broken and parents are notified but they do not need to consent).

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