HY ethics questions

MEDICAL ETHICS:
________________________ 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 daughter?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 which 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. She was killed by her
boyfriend. 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) which 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 didn?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
suregery. 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 ?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
Huntington?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
patient?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?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? 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
patient?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?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?. 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?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 patient?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?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 ?show? 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 patient?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?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 doctor?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?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
patient?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?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.