Chapter 1-1- Antibiotics:

1-Do not prescribe antibiotics but instead try to educate patient about viral
disease. If he is reasonable and you have good communication skills, you
may sway him to your view. If he is not insisting, you may give him but you
are lessening your ethical resistance and it is less likely that you will act
properly in the future.
Core ethical questions:
1- What does the patient want? (autonomy)
2- What can be done for the patient and what are the harms and benefits
(beneficence)
3-Are the patients' requests fair and justifiable? (Justice)
Non maleficience or above all no harm can be included in the principle of
beneficence.
2- 46 year old man dying of aggressive adenocarcinoma, he was
cooperative all the time now he refuses to be transferred to a palliation care
facility.
-Try to persuade him to change his mind but you should respect his wish.
-Open and direct communications with the patients and their families and
can help the physician understand the alternative ways.
-State what the central problem is and try to solve it.
-You need not agree to the patient's wishes if they were illegal or can hurt
others.
-Do not be pushed to do something that your conscience or emotions tell
you are wrong.
-If in doubt, find time to consider some literature or consult more
experienced colleagues.
3- A 22 yrs old lady has history for repeated admission for severe loss of
weight (anorexia nervosa) and the last time she had forceful feeding. She
did not express her wish to die but said she does not want any more
forceful feeding. Now she is < 60 lbs, what should you do? [she thinks she
is obese or overweight]
-The patient is not competent regarding her nutrition [anatomy] most
starving anorexic patients are force-fed [justice].
-The patient's best interest is to force-feed her or she will die otherwise.
Forceful feeding should be withheld if she had a terminal illness like
cancer, in this case she is going to die anyway but with this patient we
should proceed to give her nutritional support at least until a further
assessment can be done.
In this case patient was not force-fed and she died shortly afterwards.

Chapter 2- Autonomy:
1-A 54 yrs old lady has recently undergone menopause you suggested to
give her estrogen and she refused.
-you should respect her choice and try to find her an alternative.
-You should be sure she knows the benefits and risks of having or not
having treatment.
N.B. even in life threatening circumstances, anatomy suppresses
beneficence.
2-Mrs Maleth has had a car accident, she carries a card that she is Jehovah
Witness [not dated nor witnessed] she needs bl. transfusion; court
reported that the carrier of such a card carries on the responsibility and
results accordingly.
3- Living well = adverse directives.
a- instruction directives= what decisions are to be made.
b- Proxy directives= who makes decisions.
- In Ontario, anyone can specify another person [surrogate] to make
decisions for him [power of attorney].
4- 54 yrs old woman in an emergency room in coma due to drug overdose,
most probably suicidal, she has an advance direction that she does not
want ventilation, her case needs artificial ventilation.
-Her wish should not be ignored but try to assure the trustworthy of her
wish so that you are not aiding in her suicidal attempt.
5- 84 yrs old female with ttt of IHD, insists on prescribing Triazolam
[hypnotic] that she has been using for years.
-At least educate the patient as regards the risks of hypnotics in her case
and discuss alternatives, if she insists, follow her wishes.
6-94 years old male living on his own admitted to hospital for acute
ischemic attack with H.F. He is not depressed but he wants to go home and
is quite prepared to die.
- Patient left hospital and stopped all medications and food and died
shortly after.
-N.B. while the patients' wishes deserve respect they should not always be
followed, they should be at least questioned in a nice and respectful way.
-Physicians should not give anabolic steroids to youth athletes or fulfill
every request for narcotics from drug addicts.
7- A drug addict 32 years old takes 8-10 narcotic tablets per day and claims
to have lost his prescription, now asks for more narcotic tablets.
-Do not give the drug and discuss with him his addictive state if he was

unwilling to admit it and agree to take steps to end it, you are justified to
fire the patient.
8-The patient in case 5 , 84 years old the following year had MI was
admitted to hospital found to have subtle changes in her mental processes
she was using higher doses of trizolam.
The doctor decided to involve her with the geriatric community team to try
to help her cope with her losses and end her dependence on drug.
-The patient's anatomy was compromised by her illness and drug use.
9- A patient going to a new family doctor telling him about previous
operation for D.V., the doctor knows from the previous family doctor's
charts that he was told twice that he had inoperable cancer pancreas.
-This patient is denying his illness, you may ask him if he wished to know
all about his disease or you just know and take care of him.
N.B. when patient and doctor clash, neither view should prevail try to
negotiate and reach a common ground through mutual understanding.

Chapter 3- confidentiality:
-You are not allowed to give information regarding patient's condition
without his permission unless required by law.
1- A man was accused of sexual assault to a lady whose psychiatrist knew
about her credibility. The psychiatrist contacted the prosecutor and
claimed he had info, but he did not provide any information. The
prosecutor contacted defence council who applied to the court to interview
the psychiatrist the interview was held in another secret city away from
hometown to preserve pt's confidentiality.
The psychiatrist breach of confidentiality was to prevent serious harm to
others.
The consequences were in spite of the court's approval, the psychiatrist
was condemned by the Canadian Mental health association in spite of the
fact that the suspect was found guilty.
2- A45 yrs old female admitted to hospital with syncope and possible
seizures . A previous history of admission 3 months earlier with
neurological workup and CT scan was -ve. The patient admitted to her
family doctor later that the cause of the attack was domestic abuse [beaten
by husband]. This time the treating physician ordered the same workup
which was already done 3 months before.
-Unless the patient is in imminent danger, her family doctor should not
disclose her secret unless she is willing and ready for that. The worry is
about the return of the woman to the abusing husband, the family doctor

should ensure that her physical safety is protected by referring her to local
services and shelters.
In this case the family doctor convinced the lady to disclose her secret and
they were able to avoid unnecessary investigations and the lady was
protected from her husband. In such cases the doctor could advise and
convince the lady without any pressures and with due respect to her will.
3-A doctor discovered by chance that one of his lady pts is on very bad
terms with her children and she refused and denied his help to fix matters,
after he received a call from her children who claimed that she acts strange
and condemns them and blames them out of no reason. The doctor
recruited the patient for full psychiatric assessment and she was treated
and became better. In this case the doctor made use of info from a third
person on his patient and treated the patient from late onset schizophrenia.
4- A businessman contacted sexually transmitted disease [STD] and he is
under treatment and wants to treat his wife without telling her of the cause.
-you cannot give the wife antibiotics without her consent.
-you should encourage him to tell his wife and use it as an opportunity to
discuss their marriage.
-If he refuses, you may tell the wife, or the local public authorities, that she
may have convicted contagious disease that requires medical attention.
You need not tell her but she will know unless she has extra marital affairs.
5-An HIV positive patient who is apparently healthy is to undergo
arthroscopy and the orthopedic doctor doesn't know of his HIV case, would
the family doctor inform the specialist of this or no?
A- the family doctor should clearly ask the patient his permission to inform
the specialist if he refuses he should discuss the reason.
B-Try to convince the patient that it is for his own safety [occurrence of
complications] also it is not fair for the surgical team.
C-If the risk of infection to the orthopedician is low, most jurisdiction in
Canada do not allow the doctor to break the secret or if the risk was high,
tell the surgeon to protect him.
N.B. Persons exposed to HIV through sexual contact should be informed of
the risk.
Physician either contacts the persons themselves or through public
authorities.
6-An HIV patient does not want to inform his wife and she is not your
patient.
- report the name of the patient to the public health authority.
- Child abuse: report without consent from abuser.
-Elderly abuse: Ontario and Alberta allow but do not oblige physicians to
report elderly abuse.
-Driving safety: due to disease disability or drugs ----> report, reporting is

mandatory and on very slight suspicion.

Flying safety
-Danger to others: duty to disclose.
-sexual impropriety: patient who reports doctors harassment ---> report.
Chapter 4- Truth , Lies
1-The specialist diagnosed a case of MS and he assured the patient and
asked the family doctor not to inform her.
Tell the patient after consulting with the specialist the diagnosis and his
reasons for not telling her.
2- A daughter calls you and blames you about your dealing with her 88
years old father who visited you and asked you when he would die and you
replied that he suffers from HF and he could die any time, you should
respond in a decent way that this is a reminder to,as to tell the truth but
always in a nice way.
3- A 20 years old patient who was not informed that she was genetically
male and that they removed her testes as she suffered from gonad cancer
and they asked all doctors in future not to tell her. You should tell her in a
nice way after sensitive counseling.
When the girl was informed she found a reason for all her sensing that she
was different and laughed but got angry with her mother and doctors who
did hide this from her.
4-A mother got pregnant with her precious baby and refused to perform an
U/S and asked to be delivered by a mid-wife but in her 12th week of
pregnancy she contaminated chicken pox the family doctor informed her of
part of the complications but she refused to end her pregnancy after
labour, she sued the doctor for he did not reveal all of the complications in
details, the court denied the trial for she opted against termination of
pregnancy but advised that the doctor had to explain all complications in
full detail to the patient.
5-On examining an infant he fell slipped from you and both his parents
were in another room not attending will you tell them of what occurred?
You have to tell them cause this is not necessary to be negligence cause
the court is to decide that but you should warn the parents of the fall and
the possible occurrence of complications.
N.B.
Four exceptions to disclosure:
a- Patient's wavering, his refusal to know beforehand of his disease.
b-Incapacity of the patient.

c-medical emergencies.
d-therapeutic privilege. The doctor is to decide who is competent to know
and this is controversial and open to misuse.
6-An elderly lady who suffers from inoperable cancer and her family do not
want her informed and she does not speak English and after seeking an
interpreter you find out that she really does not want to know details and
she left this for her children to decide.
N.B. It is the ability of the child and not the chronological age of the child
the ability to understand consequences of giving or withholding consent.
7- A 74 year old male several days after his wife's death suicidal ideated
then you discover he has cancer prostate.
It would be better to delay telling the patient until his condition stabilizes
and tell him while in a hospital where he could be monitored better.
8-Your patient is in the operating room and his condition is serious and he
asks you will I get through this. Your immediate reaction is to reassure him
[reassuring lie]
A more measured reply would be to tell the patient that he is seriously ill
and everything will be done to help him.
9-You are a medical student and meet with a patient who suffers from
cancer whereas his family and doctor told him that he suffers from a virus
and he seeks your advice.
Better to say I am not certain and seek the advice of a senior resident or
the attending staff person. You always reveal bad news to a patient
delicately and without shocking him.
Chapter 5- One care and informed consent;
imp. The best way to prevent suits is to communicate faithfully with your
patients and help them make the best decisions.
You have to discuss properly with the patient the nature of his disease and
the advantages and complications or the side effects and the probabilities
of other alternatives for the patient's consent to be sound.
1- An elderly lady 80 years old accompanied with her daughter coming to
take the influenza vaccine while explaining the side effects to her you
discover she does not fully understand you and on revising her sheet you
discover she suffers from progressive dementia for years of course her
consent could not be provided but her daughter who lives with her informs
you that her mother always opted to take this vaccine, thus you take her
daughter's consent.

2- A patient who has undergone an elective surgery and later he became

paralyzed and the doctor never did warn him before of this paralysis. The
court incriminated the doctor for if the patient was warned beforehand he
could have refused to undergo a surgery with such complications.
It's the patient's right to know all details as regards his surgery.
Patient's consent should be obtained not only before surgery but before
examining him as well especially before rectal or vaginal examination, and
if patient was unconscious you should also seek the consent of a
surrogate.
-The patient should be informed in a specific way of all steps and
procedures and consent is obtained accordingly.
3- The doctor who prescribed antipsychotic and anti depressants for a
patient without informing the patient of their side effects, was found guilty
of failing to maintain the standards of profession because he did not inform
the patient about the serious side effects of the drug.
Mature Minor rule: the child who is mature, you can obtain his consent but
the prudent physician will try to obtain the parents' involvement for
procedures that are of great importance for minor's health welfare.
4-A 15 yr old boy of Jehovahs witnesses the court allowed his reusal of
blood transfusion to save his life, the court found he was capable.
- A consent form is simply evidence that discussion of the procedure took
place.
-Patients may waive the normal consent process---> discuss with them why
they do not wish to be informed, in this case, a substitute decision maker
should be sought .
-If a patient is incapable, consent is still required from a substitute decision
maker.
-Exception: emergency rule when seeking consent endangers the life of the
patient.
-If a patient withdrew his consent, respect his decision.
5-A lady after performing colonoscopy after giving her consent was in
severe pain and asked them to stop ''Stop , I cannot take this anymore .''
The physician would be unwise to continue examination.
-Elective procedure:
Patients must know all possible risks and their decision should not be
influenced by doctor's opinion.
-Research;
Cannot take place without the free, fully informed consent of the
participants.

Chapter 6- Beneficence and non- maleficience:

1- The patient whom you advised to perform HIV test and after his consent
and sample taking, they objected he and his wife claiming that this will
harm their feelings and will categorize them with a group they don't want to
be in and you tried to convince them they still refused, you should not
perform the test.
2-A hypertensive and diabetic pt. who has visited lots of doctors and
visited you lately uncontrolled simply for she skips taking her medication.
Mostly these type of patients do not comply with taking their medications
and what is required of you is not to prescribe her medications but to build
up a therapeutic alliance with this patient.
For she is not going to take medications now but what is more important is
that you want her to change her attitude by time.
-When a patient refuses his life-sustaining treatment, you may assess his
capacity, if he is competent; you have to respect his wishes.
But If he is incompetent, you should hospitalize against his wishes.
-Acceptable paternalism:
When an incompetent patient refuses treatment, the determining principle
is the beneficence; his wishes are not to be taken at face value.
-In most cases, beneficence comes secondary to autonomy and informed
consent.
Futility and hopelessly ill:
Futility means useless, not much intervention should be offered to these
patients [e.g. patient dying from advanced metastatic cancer and his family
wants him to be put on ventilator.
3- A 28 yr old pt. was admitted in ICU, his brain stem reflexes are absent,
his family are consistent that he will recover and you want to perform an
apnea test;
In Canada brain death means dead, so perform the apnea test if it reveals
no respiratory activity, the patient should be declared dead and all medical
treatment should be discontinued.
N.B. Only keep dead patients in the ICU on life support if they were
candidates for organ donation.
Chapter &- Justice:
1- An elderly woman 92 years old visits the doctor monthly not due to any
disease but due to depression and she needs to speak up to the doctor to
be able to feel that she's better. Does he need to see her when he is very
busy and there are lots of other patients who are really sick/
The physician should continue to see the patient and should tell her that

she needs to wait longer if he had other patients with urgent needs.
2- An elderly lady 82 yrs old who suffers from renal failure was admitted to
hospital and she called and she suffers from dementia and she wants to be
let out of the hospital to her home on her own and the doctors do not want
to discharge her.
She should be discharged home now that the emergency that brought her
in had abated.
Minimal justice:
System which is free from unjustifiable discrimination or prejudice and
assault or punishment without due cause.
Optimal justice:
Fair distribution of health care or for e.g.
Discrimination between people seeking coronary bypass on the grounds
of medical needs.
3- 80 yrs old pt suffers from macular dementia, IHD and CRF needs
dialysis, do you treat?
-The patient should not be denied treatment on ground of age alone, ask
him and if he wishes to be treated and he has a reasonable chance then
treat him.
Just rationing of medical care:
a- Choosing fairly among needy persons.
b-Allocating resources fairly.
4- A 83 year old patient was under the care of another doctor for years and
now she is your patient and she used to administer B12 injections for 10
years and she requests a home-care nurse, after complying with her
request, the physician in charge of home care calls you and asks why did
you order this home service when she is well.
The home care coordinator may not realize but she is asking the question
of justice, B12 injections may have helped her because of unrecognized
B12 deficiency, at last her wishes should be considered.
-Acceptable criteria for resource allocation:
a- Benefit to the patient.
b- Improvement of quality of life.
c-Duration of benefit.
d-urgency of patient's condition
-In cases of organ transplantation, patients are ranked according to a
computerized point system [fair system]
5-A couple who are very demanding and they were mad at their new

internist for his not ordering ERG and PSA for the husband like their
previous internist who use to do this every year and he does not have any
new complaints.
-Screening test such as ERG and prostate blood test should be done only
when there is evidence that they are beneficial try to discuss that with
them, but if they insist on their request do it for them.
- Physicians decisions regarding individual patients must be guided by
reasonable professional practice standards and by patients' preferences.
Chapter 8- capacity and duty to protect:
N.B. to be competent to stand trial one must understand the nature of any
quality of one's actions and nature of right or wrong.
-To be competent, one must know one's assets and debts, be aware of
one's heirs, can perform financial calculations.
1- a 78 yrs old pt. got a stroke and his wife claims that he is agitated and
needs more assistance in making decisions and you informed the Ministry
of transportation and they suspended his driving license temporarily but he
passed all his driving tests later and reclaimed his license back.
You have done right in notifying the Ministry of Transportation
Competence: requires all of the following:
-ability to communicate
-ability to understand information
-ability to reason a debitate
-ability to choose
Most frequently used tests for competence
a-tests for ability to understand information necessary to make a decision
b-tests to appreciate one's situation and its consequences.
A competent patient must;
1] understand his condition
2] Understand nature of the proposed treatment.
3] Understand alternative to treatment
4] Consequences of accepting or rejecting treatment.
5] Risks and benefits of various options.
2- A 50 years old lady , suffers from chronic depression and is under ttt but
presents with acute exacerbation due to death of her only daughter , she is
clearly suicidal in the past responded to ECT but now refuses treatment her
refusal is not competent authorization of involuntary treatment should be
sought.

3= 84yrs old male pt lives alone, has gangrene of the right foot, refuses
amputation saying that her foot will get better on its own.
If he understands that he has gangrene and is going to die without surgery
but he still refuses operation, do not operate, but if he denies the
seriousness of illness--->incompetent substitute decision maker. After
discussion and reassurance he decided to perform amputation.
4-24 yrs old patient with paranoid disorder ,untreated, requires surgery, he
suspects people but still willing to have the operation.
The important factor is not if he has a mental disease or no but does the
mental disease affect his decision. In this case his consent is considered
valid and no need for substitute decision maker.
5- A 60 yr old female patient and suffers from Parkinsonism and on eating
aspiration occurs a gastronomy tube was opted for after acquiescence of
her son but it was noted that he feeds her through the mouth secretly and
after her discharge from hospital she came back with new complaints thus
the son could not or he didn't know how to take care of his mother,, thus
legal advice was in order to name another proxy for the patient.
6- A 24 years old man with medical disability needs treatment with
injections for serious disease but he refuses injections.
IV injections are appropriate under authorization from a substitute decision
maker to save this patient.
-Even in emergency [p.165] mentally disordered patients may not be
administered treatment if they refused while competent.
-Allowing patients to refuse ttt means that patient could be committed to an
institution but not be treated.
This is mainly allocated to psychiatrists who cause he will have an inpatient in his ward and under no treatment and they could increase in
aggravity in others [they constitute about 20% who refuse to be treated].
And mostly they will be discharged to roam the streets in their same
previous condition.
7- A psychotic patient told the doctor that he will bomb the dentist's office
because he treated him once badly.
Assess the seriousness of patient's intention and arrange for involuntary
assessment of the patient if not warn the authorities and the dentist.
Chapter 9- End of life decisions
Persistent vegetative state:
Permanent loss of higher cortical activity but with some maintenance of
brain stem functions.

1-76 yrs old man, advanced dementia, 24 hrs nursing care, stopped eating ,
bad quality of life . Should we feed him artificially?
No the right thing is to discuss this judgment with the patient's substitute
decision maker.
When no reasonable medical goals are achievable, life supporting
treatment can be withdrawn.
Physicians are prohibited from directly planning or helping a patient's
death.
Physicians should:
a- honour a competent patient's refusal of life sustaining care and so allow
death to come.
b-provide palliative care to terminally ill patients.
revise euthanasia and assisted suicide.