How ethics is tested on Step 1

Questions give a scenario and ask for the most appropriate response. Prefer answers that are honest, patient-centered, and non-judgmental.

Core principlesAutonomyRespect informedchoicesBeneficenceAct in the patient'sinterestNonmaleficenceDo no harmJusticeTreat fairly andequally
Principles. When they conflict, the autonomy of a patient with capacity usually prevails.

Informed consent and capacity

Consent is valid only if the patient understands and chooses freely.

Communicates a choiceExpresses a stable decisionUnderstandsThe relevant information about the condition andoptionsAppreciatesHow the information applies to their own situationReasonsWeighs options consistently with their values
Capacity is decision-specific and can fluctuate (for example with delirium). A psychiatric diagnosis alone does not remove capacity.
Consent exceptionExplanation
EmergencyImplied consent when delay would cause serious harm and no surrogate is available
WaiverThe patient voluntarily declines to hear details
Lack of capacityA surrogate or advance directive guides the decision
Therapeutic privilegeRare; withholding information that would itself cause severe harm

Consent should be obtained by the physician performing the procedure, in the patient's preferred language with a professional interpreter when needed.

Surrogates and minors

Who decides when the patient cannot?

Adult without capacityAdvance directive or living willDurable power of attorney for healthcareThen family, per state lawSubstituted judgment: what the patientwould wantBest interest if wishes unknownMinors (under 18)Parental consent generally requiredEmergencies: treatEmancipated minors decide for themselvesMany states: contraception, STI,prenatal, substance use careParents cannot refuse life-saving carefor a childvs
Surrogates and minors. If parents refuse urgent treatment for a child, treat in an emergency and seek a court order otherwise. Laws on minors vary by state.

Confidentiality and end of life

Privacy is the default; its exceptions are narrow.

  • Exceptions to confidentiality: serious threat to an identifiable person (duty to warn and protect, after the Tarasoff case), suicidal or homicidal patients, reportable infectious diseases, suspected child or elder abuse, and some injuries such as gunshot wounds, depending on state law.
  • Advance directives: a living will states wishes; a durable power of attorney names a decision maker. A do-not-resuscitate order covers CPR only, not other treatments.
  • Withholding and withdrawing life-sustaining treatment are ethically equivalent.
  • Principle of double effect: giving opioids to relieve suffering is acceptable even if death may be hastened, because the intent is comfort.
  • Physician-assisted death is legal only in some states; euthanasia (the physician administering the drug) is illegal throughout the US.

Worked example

Respect a capable refusal.

functions Worked example — refusing a transfusion

A 35-year-old Jehovah's Witness with heavy bleeding after surgery is alert, understands that refusing blood may lead to death, and declines transfusion. Her husband asks you to transfuse anyway. What should you do?

  1. She communicates a stable choice and understands, appreciates, and reasons about it: she has capacity.
  2. A competent adult may refuse any treatment, including life-saving care.
  3. The husband's wishes do not override a capable patient.
  4. Respect the refusal, offer all acceptable alternatives (such as volume support and agents to reduce bleeding), and document carefully.

Answer. Do not transfuse; honor her informed refusal and offer acceptable alternatives.