ethics interview questions

BU Medical Sciences
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riceman04 said:
yeah but now there are other options...such as synthetic blood options. Have you heard about how certain ambulance companies have gotten in trouble for testing out these new synthetic blood projects on trauma patients who were unaware they were not receiving real blood...pretty interesting.
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Actually,the problem with the synthetic blood substitutes (besides the issues of experimentation without subject's consent) is that they are made from blood so that they are unacceptable to those who have religious objections to blood transfusions. These two issues converge and there needs to be a means for people who for religious reasons don't want to participate in these clinical trials that are conducted with a waiver of informed consent to opt out (by wearing a special bracelet or tag, for example) .
 
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jota_jota said:
In your expereince, does this particular situation happen frequently, or are these just contrived examples with no "right" answer meant to stress out interviewees?
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The airline example really happened. Most of the examples that interviewers have are based on an experience of the interviewer or an interviewer's colleague.

The impaired physician is a serious issue that pits desire to protect a patient against the desire for self-preservation (if one is a student and the impaired physician is a resident or attending). Signs of mental illness in a fellow student would be another issue along the same lines but different....

Some of these ethical questions have more than one right answer but not every answer is appropriate.

In some instances, an interviewer may be interested in your ability to think on your feet, others may be interested in your ability to consider other points of view, some may want to see that you are flexible and others may want to be assured that you will stick to your principles. You can't please everyone so turn these issues over in your mind and be yourself at the interview.
 
so do you tell the kid despite the parents' objections that they're dying or are sick?
 
babaghannough said:
so do you tell the kid despite the parents' objections that they're dying or are sick?
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i think it would depend on a bunch of factors..

1) how old is the kid? if he is old enough to make competent decisions and understand the situation then it's probably your obligation to tell the kid. if the kid is extremely young i think that the parents have full authority over what you can tell the child..

2) how long does the kid have? if there is a great amount of time left I think you should try your hardest to persuade the parents to tell their child..
 
LizzyM, I always appreciate your posts. Thank you so much!

For the airline, I would write a letter saying that the son did indeed visit his mother in the hospital on X days (as long as the mother was okay with this technical "breach of confidentiality") and leave it at that. I wouldn't go out of my way to say that she was more sick than she was.

The drunk colleague: If patients were poised to be immediately harmed, I would intervene. Not, "Hey, you're drunk, go home" but more "you don't look too well. are you sure you don't want to go home? i can call dr. Y to cover for you." If that didn't work, then I would involve some higher-ups. If the person did go home, I'd later report it anonymously to the medical director's office. That stuff is not tolerated and would probably be dealt with pretty swiftly. So a delicate balance of patient safety vs. saving face/self-preservation, but of course 100% patient safety always wins.
 
Haemulon said:
Sometimes situations are not that clear. Its not always as simple as having a nice and clear signed paper with designated wishes stated, or even a single clear physician order. There can be conflicts and lack of clarity. It is when situations do not fall nicely into the rules that one has to really work through them carefully. But for many circumstances, I agree with you.
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That's why I said "Patient with a DNR." I think it's illegal to attempt to resuscitate someone with the full knowledge that they have a valid DNR. However, if it is unknown whether a DNR order exists or the DNR is "sketch," it is presumed that a health professional will do everything in their power to "save" the patient.

I'm pretty sure there are almost no circumstances under which a physician is entitled to label someone as a DNR due to their own personal beliefs. That generally only happens when the patient is so far gone that resuscitation would be ineffective.

Believe me. Internal Cardiac massage is no fun. Neither is normal CPR for that matter. Someone who is 80 and has osteoporosis... if you do CPR on them you're going to fracture every bone in their torso. Yikes. :scared:
 
here's another one: your patient experienced fetal loss and then tells you she has been beaten by her significant other in the past. she will not say that that's why she lost the baby, and she is very anxious that you do not report him for fear of retribution. what do you do? what if you reasonably think that it indeed was child/fetal abuse, which is reportable?
 
asunshine said:
here's another one: your patient experienced fetal loss and then tells you she has been beaten by her significant other in the past. she will not say that that's why she lost the baby, and she is very anxious that you do not report him for fear of retribution. what do you do? what if you reasonably think that it indeed was child/fetal abuse, which is reportable?
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You really have to do some research into whether or not the beating caused the fetal loss. Doctors aren't criminal detectives, but I think you have to see some signs of injury before reporting something like that. Also- how long in the past are we talking? I don't think that getting hit by someone in the distant past could cause you to lose a baby.

If it was abuse- report it. You're required to. Not only that, but not doing so is just obviously wrong.
 
RokChalkJayhawk said:
If it was abuse- report it. You're required to. Not only that, but not doing so is just obviously wrong.
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i always thought it was only in cases of child abuse, where the child is your patient, that you have the right to report abuse. i thought if it were a domestic violence case outside of your scope, you didn't have the right to report it. however, the case you're speaking of may not involve patient confidentiality because it was between the mother and father, not having to do with the child directly. maybe someone else knows more about the laws on this.
 
I think the best way to answer these questions is to give a firm answer (and don't always go for the answer which seems right) but also address the other side.

For example, I've actually had someone ask the following:

Imagine that two men need surgery immediately for the same problem. One is an old man who arrives and the other is a man in his 20s who arrives 15 minutes later. Which one should receive the treatment?

a. (the one I chose) I would choose to treat the old man because I would have no right to judge whoever's life is more valuable. Thus, it makes sense to help the patient who arrived first, who happened to be the old man. As for the man in his twenties, it is unfortunate that in this situation, he could not receive help, but it is important to not give preference and to not cross one's boundaries as a physician (ie: choosing who ought to live).

b. (the one you can choose) Although the old man did arrive first, you have to also consider the ramifications of your actions. While it would be very beneficial to give the old man the surgery, it is most likely that he can look forward to years of more procedures, and at best, a tranquil life. However, the man in his 20s has yet to live a full life, and if this procedure is successful, he can look forward to many more events in his life, and his success would have greater benefits.

Either one (if you think about it), is the wrong answer (a. It is illogical to help an old man before a young man, the old man doesn't have much to look forward to b. It's wrong to assume that the 20 year old will do anything eventful, and you would deny a patient care even though he arrived early).

Point is, there's no way you're going to "win" in this scenario. It's best to take a stance, explain why, and also address the other side.

You should know that I have very little experience with such questions, so take my advice with a grain of salt.
-Dr. P.
 
yourmom25 said:
i'd agree with you on the parents and child since the child is your patient. you have a duty to your patient not the parents.

on the actual patient refusing, i'd inform them of the risks of not receiving the transfusion i.e. death or debilitation, and strongly urge them to take the transfusion. in the end, they have the right to deny medical treatment, just as there are DNR orders (another grey area). shrugs, we can discuss this more; i just don't see a compelling reason to force a patient to receive a transfusion when he/she is well informed.
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How would you feel if a doctor went against your wishes and performed an operation on your child?

You follow the parents' wishes unless there's a court order saying otherwise.
 
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yourmom25 said:
i always thought it was only in cases of child abuse, where the child is your patient, that you have the right to report abuse.
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Good post. Since the kid wasn't born yet, I think if the mother was under your care for any reason you'd be required to report it.

For another twist, what if you knew that reporting the case might put the woman in even more danger of her abuser?
 
Dr. Pepper said:
I think the best way to answer these questions is to give a firm answer (and don't always go for the answer which seems right) but also address the other side.

For example, I've actually had someone ask the following:

Imagine that two men need surgery immediately for the same problem. One is an old man who arrives and the other is a man in his 20s who arrives 15 minutes later. Which one should receive the treatment?


Point is, there's no way you're going to "win" in this scenario. It's best to take a stance, explain why, and also address the other side.
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Excellent point. With any of these scarce resource questions you can always consider not the value of one life over another (with age/youth being the issue) but the likelihood of success. Who is more likely to survive the surgery? If the older man is in his 50s the likelihood of survival might be equal that of a 20 year old but if the man is in his 90s then the likelihood of comorbid conditions that will hinder his recovery (or make the surgery more dangerous than it is for the younger fellow) is higher. Of course, the young guy could have all sorts of chronic conditions and poor health that makes him a poorer candidate for surgery than the old man. You can always say that you'd need a lot more information before making a decision as to which is the better candidate for surgery and avoid being sucked into saying that resources should be allocated to the young over the old.
 
asunshine said:
Good post. Since the kid wasn't born yet, I think if the mother was under your care for any reason you'd be required to report it.

For another twist, what if you knew that reporting the case might put the woman in even more danger of her abuser?
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The whole idea behind reporting abuse is so the abuser goes to prison/the abused person is protected.

I'm pretty sure killing a fetus after a certain point in the pregnancy (or at any point) is now considered homicide in any state. This was enacted after the whole Laci Peterson thing, but had been in the works for a longer time.
 
asunshine said:
The drunk colleague: If patients were poised to be immediately harmed, I would intervene. Not, "Hey, you're drunk, go home" but more "you don't look too well. are you sure you don't want to go home? i can call dr. Y to cover for you." If that didn't work, then I would involve some higher-ups. If the person did go home, I'd later report it anonymously to the medical director's office. That stuff is not tolerated and would probably be dealt with pretty swiftly. So a delicate balance of patient safety vs. saving face/self-preservation, but of course 100% patient safety always wins.
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wasnt this a greys anatomy episode?
 
Erina said:
right, that's what i was thinking. that one was easy. it's the child that seems to get trickier.
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Just keep in mind that there is generally a medical ethics board at every hospital... Technically the parent makes the decisions for the child, but if a doctor feels that the decisions of the parents will be detrimental for the child's wellbeing they can go to the medical ethics board who will consult with lawyers, etc. to find a way to allow you to go over the parent's heads to treat their child.

I was also wondering what do you do when you have the old patient (90s+) and their children ask you not to tell them what is wrong with them because "they can't handle it".
Also, about the patient who has HIV and asks you not to tell their partner.
Ethically, I think you would have to tell the people, but I am not sure what the real protocol is...
 
yourmom25 said:
i always thought it was only in cases of child abuse, where the child is your patient, that you have the right to report abuse.
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You ALWAYS have the RIGHT to report abuse....heck you can report abuse just by overhearing someone talking about abusing their child.

nekrogg said:
wasnt this a greys anatomy episode?
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Oh, is Grey's Anatomy a medical show? I admit I've only seen 4 episodes but I thought it was just about sex. :confused:

{start diatribe}
Seriously…here's a summary of the first two episodes I saw. Handsome guy doctor likes main female doctor, but is married to redhead doctor who slept with handsome visiting doctor several years ago. Main female doctor sleeps with fellow doctor but thinks it was a mistake. Supporting actress female doctor sleeps with supporting actor male doctor with much emphasis placed upon her sexual desires. All the while supporting actress female Asian doctor sleeps with and moves in with handsome African-American surgeon. As for patients….well they seem to be more like set props, but the main story of the first episode was a female patient who couldn't stop having orgasms. Medical show or cheesy sex drama…you tell me. I can't say much more for scrubs, but at least it's funny >)!
{/end diatribe}
 
DE12MD said:
Also, about the patient who has HIV and asks you not to tell their partner.
Ethically, I think you would have to tell the people, but I am not sure what the real protocol is...
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The conflict here is between keeping information confidential and the desire to protect someone from serious harm. With HIPAA, I suspect some people are being even more cautious about releasing private information. On the other hand, federal regulations aside, some states permit the disclosure of HIV status under certain circumstances and to particular parties. In one state that I'm familiar with, one is permitted (but not required) to tell the patient's spouse but other partners are not included in the law. I guess the legislature presumes that a pateint is having sex with a marriage partner but other relationships are not recognized by law and it would be hard to define relationships that would justify "telling".
 
LizzyM said:
The conflict here is between keeping information confidential and the desire to protect someone from serious harm. With HIPAA, I suspect some people are being even more cautious about releasing private information. On the other hand, federal regulations aside, some states permit the disclosure of HIV status under certain circumstances and to particular parties. In one state that I'm familiar with, one is permitted (but not required) to tell the patient's spouse but other partners are not included in the law. I guess the legislature presumes that a patient is having sex with a marriage partner but other relationships are not recognized by law and it would be hard to define relationships that would justify "telling".
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There have been several court cases where people were convicted for having AIDS and sleeping with others and not telling them. It may be necessary to prove "intent to transmit" though. Anyway, if a patient has informed you who they have slept with I would think there is at the very least an ethical obligation to inform the partners that one of their sexual partners may have had AIDS. As far as I know, HIPAA only applies to a patient's personal information. By informing their partners without naming your patient I don't see how that would be a HIPAA violation, and even if it was there is no court on this side of the world that would convict a doctor for something like this {opinion}. It may be easy for them to figure out who it is (e.g. if they've only ever slept with your patient), but that's really not a doctor's concern. To do nothing is to be complicit in their unethical ways. Patients DO have a right to privacy and a certain amount of confidentiality, but doctors are not priests. I say do everything you possibly can to preserve your patient's privacy, but you cannot compromise when it comes to public safety or the safety of any other people. What if a patient came in with a highly-infectious airborne disease? That patient would be immediately secluded and those people to come in contact with them would be tested...we wouldn't be sitting around debating whether people should know about their condition or not. I think the same thing should be true of AIDS patients; if you know they've come in contact with someone they must be tested whether the patient is willing to inform them or not.
 
All these question about morality, values,...etc. Which would you save, the convict or old lady...etc. Am I wrong for thinking that I would save the person with the higher probability of survival. The convict can be the most evil person in the world, but I cannnot judge his life as less than another. All life is equal in the eyes of God, so I would take a much more objective approach and decide based on which person would likely to survive. Does anybody else feel this way?
 
kypdurron5 said:
I would think there is at the very least an ethical obligation to inform the partners that one of their sexual partners may have had AIDS.
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The ethical obligation is to keep confidential information that has been shared with you in confidence. You can, and should, encourage the patient to share this information with others who may have become infected due to contact with the patient. (sex or sharing of needles, etc) If HIV-AIDS is reportable to the health department you should report it. (I don't know the laws in every jursidiction.) You should also find out if the health department in your area does "contact tracing" to inform the patient's contacts that they may have been exposed and should consider getting tested. This usually means contacting the patient you reported, getting contact information and going out and finding these others and informing them that they may have been exposed (without saying who may have exposed them -- although someone with only one partner may figure it out pretty quickly).
 
UIC Killa said:
All these question about morality, values,...etc. Which would you save, the convict or old lady...etc. Am I wrong for thinking that I would save the person with the higher probability of survival.
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Yes, I think that is a good approach. You'd want to be careful about judging quality of life (e.g. do you not treat someone with good odds of surviving because that person has Down's syndrome?)
 
UIC Killa said:
All these question about morality, values,...etc. Which would you save, the convict or old lady...etc. Am I wrong for thinking that I would save the person with the higher probability of survival. The convict can be the most evil person in the world, but I cannnot judge his life as less than another. All life is equal in the eyes of God, so I would take a much more objective approach and decide based on which person would likely to survive. Does anybody else feel this way?
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Well, what is "objective" is very subjective in these ethical matters...that's kinda the point. You see an old life as being "worth less" than a young life due to the number of years left....who says that's objective? Ok, there's my criticism, now I'll support your position >).

Let's say you have two patients, both need an organ transplant which they will die without. They are the same age, but one person is otherwise healthy and one person has an unrelated terminal illness. Now, transplant lists would always give it to the otherwise healthy individual...so obviously there's no problem with reasoning that the person who will live longer should get the life-saving treatment. Well, I would argue that old age is a terminal condition. Everyone has this condition, but the more advanced the condition is, the fewer years we can expect the person to have. Thus, given the decision to save an old person or a young person shouldn't we always choose the younger person? The only problem is that I've seen variants of this question that add the fact that the treatment for the younger person has a lower success rate, and the treatment for the older person has the higher success rate (and you can only choose one). Thus the question is whether you should go with the one who is certain to survive but for a shorter life span, or the one which is most risky but would have a longer lifespan. There really is no "right" or "wrong" answer to any of this, but I think that's especially true when you add something like this to the problem.
 
Average life expectancy for a 65 year old American is about 17 years. Average life expectancy for an American who makes it to age 85 is about 6 years. So, on average, senior citizens can't be classified as "close to death".
 
MilkofAmnesia said:
I really don't know. There are so many laws regarding juveniles I'm just not sure. And they also vary by state. Some states require that the parents of underage girls must be notified of an abortion. In that case, I think they would find out pretty quickly who got her pregnant and justice would follow its course.

I know that as a physician you have to notify the authorities if you suspect child abuse. So I don't know why it would be different for sexual abuse/underage rape. (I know that adults have the option to press charges or not.) But I'm not sure about consensual statuatory rape. There are just so many variables.
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The difference between reporting child abuse and statutory rape is clear when you have the proper information.

Child abuse is done (or facilitated) by a parent or guardian, i.e. the one with legal authority over the child. If I hit my kid, it's child abuse (reportable) and the family court gets involved, and I might lose custody. The punishment is very rarely any kind of jail time, but rather I lose my rights/access to the child. (Contrast this with what happens if I hit your kid - it's assault, the criminal court gets involved, and I go to jail.)

Rape, whether forcible or "statutory", is not reportable by third parties, out of respect for the victims (and in recognition of the grueling process involved for them). It does not involve the investigation and/or reconsideration of parental rights. The criminal court is involved, not the family court. The punishment involved is jail time, not loss of rights/access. You can't report the 14-year-old who has a 20-year-old boyfriend to the police, without her consent, any more than you can do so for the college girl who got roofied. You can, in both cases, counsel intensively and try to get them to tell their folks and/or press charges. But if they won't, they won't. And you can't tell the parents either, against the patient's wishes - confidentiality.

The exception is when the execution of the statutory rape involves the parents/guardians; e.g. the mother knowingly allows her boyfriend to sleep with her kid. Then, it is reportable because the legal rights of the parent are brought into question and the situation must be investigated for that purpose (mandatory reporting exists because parental abuse/neglect is visible only to "care workers" usually, and not the public at large).

It's also interesting to note that most states that require parental notification of an abortion do so regardless of whether the pregnancy is the result of abuse or incest - a 13-year-old in Idaho, Spring Adams, was forced to tell her incesting dad that she was pregnant by him and wanted an abortion. He realized that the secret would probably come out at the clinic, so before she went for her appointment (there's always a waiting period attached to the notification), he killed her with a shotgun as she slept.

I don't like parental notification laws. Even in families where "things work out as they should", i.e. parents are supportive of the kid but throw the guy in jail, the outcome is bad - you are just creating a "Romeo & Juliet" circumstance (remember, the kid fully consented) where this teen will allow their adolescent rebellion to intensify their bad choices and flawed perspective. When it's the parents vs. the lover, the lover always wins (in the kid's eyes). Especially if he "goes to jail...just for loving you! [swoon]".
 
LizzyM said:
The ethical obligation is to keep confidential information that has been shared with you in confidence. You can, and should, encourage the patient to share this information with others who may have become infected due to contact with the patient. (sex or sharing of needles, etc) If HIV-AIDS is reportable to the health department you should report it. (I don't know the laws in every jursidiction.) You should also find out if the health department in your area does "contact tracing" to inform the patient's contacts that they may have been exposed and should consider getting tested. This usually means contacting the patient you reported, getting contact information and going out and finding these others and informing them that they may have been exposed (without saying who may have exposed them -- although someone with only one partner may figure it out pretty quickly).
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In LA, you can send someone an anonymous e-card that says, "you've got AIDS." www.inspotla.org I think that's a pretty good idea.

Also, if the person tests positive, if they voluntarily give you a list of names of past sexual partners, cities have public health counselors that can contact them and give the news that they might have been exposed to HIV and need to be tested.
 
yourmom25 said:
1) patient should know the diagnosis. i don't see how there would be any dilemma here, but i'm inexperienced.
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I would disagree with you in certain situations. Consider the following situation. A patient has pancreas cancer and undergoes a Whipple surgery. His five year survival chance is 20%. Do you tell him that he is most likely going to die within 5 years? I would tell the family but i definitely wouldn't tell the patient.
 
ggman said:
I would disagree with you in certain situations. Consider the following situation. A patient has pancreas cancer and undergoes a Whipple surgery. His five year survival chance is 20%. Do you tell him that he is most likely going to die within 5 years? I would tell the family but i definitely wouldn't tell the patient.
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How can you not tell the patient? They have to know these things in order to make an informed decision regarding their surgery. That's why it's called "informed consent."
 
Actually, now that i think about it some more, maybe i would tell the patient after all. I would take him 5 minutes tops to find on the internet what his chance for survival is so there is no point in not telling him. However, if there was no easy way for him to find out by himself what his survival chances are I wouldn't tell him.
 
MilkofAmnesia said:
How can you not tell the patient? They have to know these things in order to make an informed decision regarding their surgery. That's why it's called "informed consent."
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Well, i wasn't thinking about informed consent. I was just thinking about the ethical question of whether it is better for a person to know that they are going to die in 5 years and not be able to sleep peacefully at night, or not know that they are going to die and at least have 5 more years of normal life. But, i guess since you have to get informed consent from your patient, the situation i described is more or less an impossibility
 
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