Chapter 1-1- Antibiotics:

1-00 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 Ibs, 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 Uustice].
-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 IHO, 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.
S-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.S. 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.

5-0n 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 willi 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 Jehovah's 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 812 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, 812 injections may have helped her because of unrecognized
812 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 iIIness--->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 in-
patient 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.
Medicine

1] a woman does not want to know that he has inoperable cancer pancreas,
he is expected to live 4 months, he could not attend the funeral of a friend
the previous year and was so weeping and depressed.
ans. When we tell a patient about his disease this must be in a sensitive
and supportive way.
In this case, the patient should not be deceived and should be informed
about his disease, if the patient does not want to know and prefers the
family to take care of that, do not burden the patient. Truth

2] Suzan, 25 yrs old suffers from progressive motor paralysis caused by

Guillain Barre syndrome for the last 2.5 years, she had been interlobated
and living on a respirator, respiratory muscles are atrophied, she was
informed that there was no cure for her. She wants to disconnect the
ventilator.
ans. that is her right respect her autonomy before starting diagnostic tests
ask for consent for life sustaining treatment e.g. CPR, ventilator, dialysis
and artificial nutrition. If there was a doubt about the capacity of the patient
to understand the consequences of the decision, consultation from
psychiatrist and hospital attorney could be helpful. Consent

3]Albert 70 yrs old, diabetic gangrene in the foot, wife died and he has 3
children, in conflict with them he had amputation of a toe 2 yrs ago and he
refuses the operation now and does not want to be a burden to his children
or to live in a nursing home as invalid.
ans. he has the right to refuse surgery and the decision for the capacity of
the patient is resolved by the clinician using a screening test as ACE [aid to
capacity evaluation]. But the declaration of incapacity may be appealed to
court. The patient should be informed in a sensitive manner that he is
incapable in case of doubt about assessment. Consult psychiatrist or
hospital attorney. Capacity

4] A woman 31 years old had car accident 6 years ago since then she has
been in a persistent vegetative state, she does not respond to her
environment but breathe on her own. A gastrostomy tube has been
implanted for her feeding her husband wants to stop tube feeding.
ans. the patient has the right to stop tube feeding and as she is incapable,
a substitute decision making can do that, the most appropriate person
would be
-someone appointed by the patient while competent.
-a court appointed guardian
-spouse
-child
-parent
-brother
 -relative or concerned friend.
Decisions should be according to wishes, values, beliefs and interests of
patient when competent.

5]A man was found to be HIV +ve after unprotected anal intercourse, he
doesn't want to tell his wife who is your patient and she has an
appointment with you the following week.
ans, You can breach confidentiality if there is increased risk that the patient
will cause serious harm to a specific person, this harm may be averted
through disclosure of confidentiality to a 3rd party. The physician may
make such disclosures directly, more legal protection by disclosing to a
legally authorized 3rd party such as public health agency or police.
Confidentiality

6] Conflict of interest
Set of conditions in which professional judgment concerning 1 ry interest
[e.g. pt's welfare or validity of research can be influenced by 2ry interest
[e.g. financial agent] so maintain public confidence by minimizing the
opportunity of improper influence or professional judgment.
i.e. you should not benefit from any situation in a way to affect you
judgment.

7] a- A man 62 yrs old with cancer lung metastasizing to the brain he is

competent, he demands full resuscitation in case of cardiac arrest.
b- 45 yrs old lady on persistent vegetative state for 2 years, receive
gastric tube and lives in a nursery home, admitted to hospital with
pneumonia, the family demands intubation, ventilation and critical care
and CPR for cardiac arrest. They are Jewish orthodox who care to maintain
life.
ans. In the first case, the man will die in a few months, in the second case
the woman will live but how the pt's family and care team value continued
life in a persistent vegetative state.
2nd step---> communicate to ask why, negotiate, mediation e.g. hospital
bioethist --->arbitration including your proceeding after legal advice.

8] Euthanesia or suicide is they legal or illegal?

Illegal in Canada.

9] a- Resource allocation: distribution of goods and services to programs

and people competing for them.
you've got one heart to transplant and 2 pts how to choose one pt. in ICU
and another one to be admitted with a worst condition and you don't have
beds, what would u do?
b- Rationing: when people's needs could not be met because of scarcity of
resources.
c- Criteria when rationing decisions are made;
1- Age alone, gender and religion are not relevant criteria for allocation.
2-greater benefit or greater need are morally relevant.

10]A patient with recent stroke, on CT no haemorrage but infarction-->can

you take him as a candidate for a double blind placebo, control trial?
ans. Ticlopidine and clopidogrel are never drugs or ttt according to ACA
and withholding effective ttt for 2 weeks is not justified or even giving
inferior ttt.---> unethical trial.
It is unethical to introduce patients into trial that includes one inferior ttt
versus one superior ttt.
In case of making a study, the trial plan must be approved by ethics
board.[independent]

Obstetrics and Gynaecology

1- Maternal fetal dilemmas

primi in labour, no progress, fetal distress, pulse is 60, pt. does not want to
do CIS.
ans. the mother has the right to refuse CIS and this may lead to death of
fetus who has no legal right until delivered, you respect the patient's
autonomy provided she is competent.
Also clarify why she is refusing ttt, continue to care for her.
Try to get consent before providing ttt or diagnostic tests to competent
patients.
Once delivered, the baby has the legal right of a person.

2- A pregnant woman wants to abort her fetus scared that the baby might
have Huntington chorea {family history], the spouse refuses.
ans. she has the right to terminate preg. and if her spouse say he is
defending the right of his child, the child is not born and has no rights.
and the husband has the right to refuse to be tested for the disease.
abortion

3- Hysterectomy disclosure
40 yrs old woman has fibroid was referred to the gynaecologist to do
hysterectomy, is it enough that she signed a consent form that has been
witnessed and datedl
ans. the consent is an important document but it will be invalidated if the
process of informed consent did not provide reasonable discussion and
disclosure of information which may be facilitated by team approachor
classes with nursing and physiotherapy staff. The ultimate responsibility is
 always that of the physician.
-risks, benefits of proposed intervention and alternative tests or ttt.[ you
should inform the prof. dancer of the car after operation and inform the
preg woman who's leaving on a trip that you fear ectopic and U/S is
needed.

4-Surrogate motherhood
A woman who wants to implant her fetus in her sister's uterus for she has
undergone hysterectomy.
The physician has an obligation to consider potential surrogate gestational
women as a patient, get her informed consent [she has to know the
physical and psychological conditions of carrying a fetus which is not
hers.

5- Substitute decision making;

A 36 yrs old pregnant woman who is unconscious after MVA, DIC she is
Jehovah' witness with a no bl. transfusion card, should you transfer blood?
ans. No but some critical issues are to be addressed, is the paper sound
and signed and how worse is her condition is she still under her beliefs.
If she were a child [J.Witness] the court is not supporting withholding of
life saving measures, especially for the too young to make their own
decisions.
- Substitute decision maker can make decisions for incapable patients
according to the patient's written expressed wishes.

6-Sterility
Teenager with severe cerebral palsy mental age like 5 years, her mother
wants to sterilize her to avoid unwanted pregnancy.
ans. No, the law protects such an individual from unjust loss of
reproductive potential but is not permissive for alternative. The girl is
incompetent so there is no way to take her consent.

7 -When to break confidentiality

a- psychiatric pt who threatens violence against a third party.
b-HIV who continues to have sexual intercourse and refuses to disclose the
risk to his partner.
c-Other reportable infectious diseases.
d- Child abuse
e-people unfit to drive.

8-Can a15 year old give consent to HIV testing, D&C prescription and
terminate pregnancy?
ans. yes to all but must understand nature and consequences of
consenting or refusing ttt.

9- A patient who informs you that she has a sexual affair with another
doctor and she asks you not to report this.
ans. you have an ethical duty to report this doctor but you must respect the
confidentiality and may not release her name to the authorities without her
permission. You will report the doctor to the appropriate licensing authority
which in most provinces is called College of Physicians and Surgeries.
You are neither an investigator nor a Judge, you report the story as you
heard it and you encounter no legal liability.
If you do not report the patient, another doctor may complain about you to
the college because you have had not reported the allegation.

10- Resource allocation

Morally relevant criteria of benefit and need, morally unaccepted criteria for
allocation of resources include: age alone, gender, ethnic origin, religion,
sexual performance and race.
a case; a woman became pregnant through IVF and she went to labour
Scan showed there was footling and in her 23rd week and the mother
wants to save the fetus and you know that her chances are weak on CIS
ans. Respect autonomy, she is competent, can make her own decision for
herself and her fetus.

Psychiatry;

1- 60 yrs old lady with recurrent depression and psychotic features [hears
voices] did not respond fully to anti psychotic was told that EL T is the best
ttt for her.
ans. The most obvious reasons for giving EL T is that she agreed to the ttt
and it is necessary for her. There are doubts that the consent is valid, it is
unclear if it fits the emergency exception to the rule of obtaining consent.
-3 elements of consent: each must be notified
- disclosure: physician should inform the patient about proposed tests &
ttt.
-voluntaries: pt. makes the decision of ttt without undue external coercion
-capacity: pt. must be capable to understand the consequences of a
decision or lack of decision.

Consent in psychiatry includes the right to start ECT ttt.

Consent in emergency: To save patient's life, preserve their health and a
delay jeopardizes life or death and pt. cannot make decisions.
if a substitute decision maker can be contacted, emergency consent is not
used.

2-Diabetic foot patient's case no 3, the psychiatrist has been asked to

assess his capacity to give consent.
• The patient has the right to refuse surgery provided he is competent.
Capacity is ability to understand information and appreciate consequences
of a decision or lack of decision.
Severe depression can affect cognition, ACE [Aid to capacity evolution]
assist clinicians decide capacity.
To be capable;
a- understand situation
b-understand risk and consequences of proposed ttt.
c-understand risk and consequences of refusing ttt.
d- the choice to be made without coercion
Psychiatrist usually decides capacity of patient.

3- Substitute decision making

Patients have the right to refuse ttt. based on their autonomy but
incompetent patients cannot exercise this right - substitute decision
making can do on his or her behalf, decision making should be someone
appointed by the patient while he is competent or the patient's nearest
relative.
-If the disability is permanent and there is disagreement about care -->
appointed guardian by court.

4- Psychotherapist treats a pt. who wants to close his file.

Contact third party [family, friends, police officer, social worker]
Involuntary hospitalization, to whom disclosure should be made.
ans. in case of threat involving body harm, the victim and the police should
be notified without delay. confidentiality.

5- Rationing decisions or allocation are considered for greater benefit or

greater need.
-resource allocation.

6- When can you hospitalize a patient involuntaryl

-when he is a source of harm for others or himself.
-In North America, the police power is the preliminary justification for
involuntary hospitalization.
-Hospitalization without ttt does not seem to be in the patient's best
interest but necessary to protect the public [patient may be hospitalized
but refuse psychiatric ttt.] Involuntary hospitalization.

7- Transference and counter transference

A female 29 yrs , pianist ttt of drug abuse, alcoholic, and history of suicidal
attempts treated by Dr Jones every 2 weeks for 6 months, she is
demanding more visits to Dr Jones, called him twice to tell him she got
overdose of alcohol and drugs, he called the ambulance for her, she does
not take treatment regularly, her father committed suicide when she was
12 yrs and her mother is alcoholic. She has bad reputation in work being
moody.
She admits taking drugs to overdose to attract Dr Jones' attention to give
her more frequent sessions.
Dr Jones referred her to the psychiatrist, he starts to feel uncomfortable
treating her and she wants the psychiatrist's opinion.
ans. Borderline personality. The psychiatrist would recommend to Dr
Jones; refer the patient, hospitalize if necessary. The ethical principles
here are beneficence and non maleficience.
Legal aspects here: Therapists working with borderline personality are
often sued for suicide and sexual misconduct. Both the proper
maintenance of treatment boundaries and management of patient's
transference are crucial to avoid ethical & legal pitfalls.

8- A female 31 yrs old teacher brought to the emergency by a friend who is

concerned about her depression and withdrawn condition. She had
therapeutic abortion 6 months ago. Her boyfriend left her when he knew
about her preg. and she did not want to have a baby without a father. She
lost interest in life lost weight in the last 2 months, sometimes leaves her
work crying, she collects aspirin and tylenol to kill herself but lacks energy
to do so, her uncle committed suicide.
ans. there is risk that she may commit suicide but this is not certain she is
presumed to be capable but suicidal ideation raises doubt about
competence, you could offer her short hospitalization to assess capacity,
risk of suicide and the success of treatment. Involuntary admission should
be considered if she refuses.

9- Sexual impropriety
A woman who has an affair with her psychiatrist after 3 years of this affair
he referred her on basis of her suffering from psychotic symptoms and he
cannot treat her any more. And she is bashful and does not want to report
her story.
ans. you have to report the case as you heard it to the appropriate
licensing authority because if the allegation was true he may be harmful to
others but you do not release her name without her permission. You are
neither an investigator nor a judge and he is innocent till proved guilty.
You encounter no legal liability to report but if you do not report, you may
be reported by a patient or another professional.
-A medical doctor should not initiate any sexual advance to a patient nor
respond sexually to any sexual advance from the patient.

10-research ethics;
You are on a study on a new antipsychotic drug and you need a pt to try it
on her as she is not regular on her drug intake but her WBe is 45x(10)9 and
it should be 3.5x(10)9 and she wants to try the new drug.
ans. Violating research protocol leads to immediate distrust, you can use
your patients in research provided that there is plan for research which is
approved by ethics board [independent] and the patient gives you consent.
 They may be given placebo versus a drug but they should never be put at a
disadvantage by their participation in research and be assured to be given
the best proven diagnostic and therapeutic method.

Surgery:

1- Telling the truth

A woman who doesn't want her husband to know that he suffers from acute
inoperable cancer pancreas for he cannot stand being upset and he fears
death as he didn't attend his friend's funeral over the past year,
ans. patient should not be deceived should be informed in a sensitive and
supportive environment. Generally patients may be asked before surgery if
they would like to have all information and reports directed to them or they
prefer the family to take care of that. If the problem arise before
establishing guidelines it is reasonable to say to the patient "your wife told
me that she will handle all information and you would prefer not to be
involved". I will follow this recommendation if that was your wish."

2- Consent & capacity

70 years old pt. with foot gangrene and his wife had died and he has 3 sons
and he had his toe amputated a couple of years ago and now he refuses to
amputate his foot
ans. the patient has definitely the right to refuse treatment [autonomy]
provided he is capable. Most patients who accept ttl are judged capable
only when they refuse ttl. A psychiatrist is called. You discuss the issue
with the patient before you write in his sheet "the patient has explained that
he does not want surgery because ... "
Physicians should seek consent before providing diagnostic tests or
treatment. A patient should know his condition know about the tests and
offered ttt. [ benefits and risks] and know the consequences of refUSing of
refusing ttl. If in doubt, call psychiatrist to assess capacity
In case of incompetent patients, substitute decision making.

Advance directive; sometimes pts record their wishes in an instruction

advance directive, this is a written document about life sustaining ttt. 2
types;
A-proxy directives which state who will make treatment decisions.
B-instruction directives which state ttt accepted or refused.

Consent in emergency:
In real emergencies where seeking consents can enhance life of the
patient, go ahead without consent unless you know that the patient would
not want ttl in the situation that has arisen.

3- Substitute decision Making:

11 yrs old girl comatosed after an accident and she needs bl. transfusion
and her mother refuses being of Jehovah's witnesses in spite of her
husband's dying in the accident for refusing bl. transfusion.
ans. according to the court transfusion was withheld from the father based
on his prior written or verbal expression of belief but the situation
changes with the child ," parents may make martyrs of themselves but
may not make martyrs of their children. and bl. transfusion was given to
the child.
Always ask the relative or nursing home attendant about any advance
directive.
In case of children who have never been competent. If the parents are not
competent or are competent and against the child benefit, then call the
case on court.

4-Conflict of interest
there is a research and you advanced a 100 $ on the resident to give you
cases for your research as you lack some cases and you want to finish.
there is an inhibition on paying residents for cases from the research
ethics board.
ans. residents should not be paid from advanced microbiotics for the
research.

5-Surgical competence
the doctor who is operating on a pt. and the resident feels he is drunk.
ans. the resident should contact the surgeon in chief.

6-End of life issues:

One patient has advanced cancer and they removed his ventilator after his
family's consent but he still breathes with difficulty and morphia is not
sedating his pain.
ans. the term euthanasia does not appear in criminal code, it is a form of
homicide, assisting suicide is a crime, prototype of euthanasia is injection
of Kcl it involves injection of a lethal substance or discrimination of a life
sustaining ttt. The law permits discontinuation under defined conditions.

7- Resource allocation:
you have 2 cases for lung transport and one lung whom to choose and you
have a pt. in ICU who is better than another case who is critical and needs
admission, ans. overall goal of clinicians is to provide optimal care for their
patients within the limits improved by allocation of resources.
Order investigations really needed only
Prescribe the needed ttt which is less costly
And be careful on who needs what and when and be careful not to be
legally sued.
the rule is relevant criteria are benefits and needs.
.

•
8-You are attempting a new surgical technique for esophageal reflux and a
diabetic pt wants to go into trial while it is not possible as she is not a
candidate for such a surgery
ans. as she does not meet inclusion criteria she should not be admitted in
the trial.
you can enroll your patients in research trials with certain conditions;
a-research must have a plan
b- protocol should be approved by an independent research ethics board.
c-patients must understand they are participating in a research and must
approve of that freely.
d- If there is a consensus that one treatment is superior to the alternatives,
then it is unethical to enter patients into a trial that includes an inferior ttt.

Pediatrics;
the absence of statutory age of consent in many provinces requires
pediatricians to include their capable patients in decision making and
respect their health care choices, sometimes contrary to the wishes of the
parents.
The doctor must preserve the confidentiality of patients even from family
members unless the patient consents to disclosure.
In case of infants and younger children who cannot consent for themselves
usually parents or guardians are the decision makers. [Surrogate decision
maker]
Adolescents and older children should be presumed to be competent and
make their own decision.
the parents serve as partners in these decisions.
Foe children in between neither incompetent as infants nor competents as
adolescents a delicate balance is needed when a decision is to be made.

A competent child must:

1- Receive communication information.
2-understand communication information.
3- Appreciate the effect of intervention and know the alternative.
The individual who is asked to write consent must be competent to do so.
At 12-13 yrs of age, most children begin to understand, by 14-15 yrs they
are generally competent.
6-9 yrs children do not see themselves deciding
8-11 years children are usually developing the skill.
By the age 12-14 yrs skills are developed and support decision capacity.

-Witholding ttt;
Medical decision to refrain from initiating ttt that may sustain life.
-withdrawing ttt;
Medical decision to refrain from further prOVision of life sustaining ttt.
-Palliative ttt;
•

It's a treatment which soothes pain on patient and family and improves the
quality of life of dying people.
-Terminal care;
Care directed towards a relief of sufferings in a patient who is dying.
-Futility
Useless physicians are not obligated to offer and pts are not obligated to
accept.
-DNR do not resuscitate
-CPR cardiopulmonary resuscitation.

Are withholding and withdrawing ttt morally equivalent?

Not starting ttt that might be for the patient's best interest is more likely to
be considered morally and legally wrong than stopping ttt that proved to be
futile or useless
Most care givers have an emotional resistance to the idea of withholding
nutrition and fluids from a dying child as it is intrinsic for patient's comfort
and dignity.