Legal and ethical considerations US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Legal and ethical considerations. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Legal and ethical considerations US Medical PG Question 1: A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?
- A. Have the patient sign a suicide contract before discharge
- B. Set up a next-day appointment with the patient’s psychiatrist
- C. Involuntarily admit the patient (Correct Answer)
- D. Call the patient’s parents
- E. Discontinue lithium and start valproate
Legal and ethical considerations Explanation: ***Involuntarily admit the patient***
- The patient's statement "I just want out of this life" combined with the **suicide attempt** (cutting her forearm after a text expressing suicidal ideation) indicates a high risk of self-harm. Despite her current verbalizations of feeling better, the **impulsivity** and severity of the attempt warrant involuntary admission for safety.
- The sudden shift in mood and desire to go home after a serious suicide attempt, stating "these ups and downs are common for me, but I feel better now," suggests potential **lability** and a continued risk that cannot be safely managed with outpatient follow-up alone.
*Have the patient sign a suicide contract before discharge*
- **Suicide contracts** have not been consistently shown to be effective in preventing suicide and can create a false sense of security.
- Given the **actual suicide attempt** and the patient's underlying psychiatric condition, a contract is insufficient to ensure her safety.
*Set up a next-day appointment with the patient’s psychiatrist*
- While follow-up with her psychiatrist is crucial, relying solely on a **next-day appointment** is inadequate given the acute and severe nature of the suicide attempt.
- There is a significant risk of another attempt before the appointment, and the patient needs the **structured environment and constant observation** of an inpatient setting.
*Call the patient’s parents*
- While involving the patient's support system is generally helpful, this action does not directly address the immediate **safety risk** posed by the recent suicide attempt.
- Parental involvement should be considered, but it is not the primary or most appropriate immediate management for a patient at **high risk of self-harm**.
*Discontinue lithium and start valproate*
- Modifying psychotropic medication is a decision made by a psychiatrist after a thorough evaluation, often over time, and is not the immediate or most appropriate "management" in the **emergency setting** for an acute suicide attempt.
- The priority is **safety and stabilization**, not an immediate medication change, especially given that she is already on a mood stabilizer.
Legal and ethical considerations US Medical PG Question 2: A patient with documented paranoid schizophrenia commits a violent crime. During trial, the defense argues that the patient should not be held responsible due to their mental illness. Under the M'Naghten Rule, which of the following criteria must be met for an insanity defense?
- A. History of psychiatric treatment
- B. Unable to control impulses
- C. Presence of any mental illness
- D. Unable to distinguish right from wrong (Correct Answer)
Legal and ethical considerations Explanation: ***Unable to distinguish right from wrong***
- The **M'Naghten Rule** primarily focuses on the defendant's cognitive capacity at the time of the offense.
- To be declared insane under this rule, the defendant must prove that, due to a **defect of reason, from disease of the mind**, they did not know the nature and quality of the act, or if they did know it, that they did not know they were doing what was wrong.
*History of psychiatric treatment*
- While a history of psychiatric treatment might be presented as evidence of mental illness, it is not a direct criterion for insanity under the **M'Naghten Rule**.
- The rule specifically assesses the defendant's mental state **at the time of the crime** regarding their ability to understand the wrongfulness of their actions, not their treatment history.
*Unable to control impulses*
- This criterion is more aligned with the **irresistible impulse test** or the **volitional prong** of the American Law Institute (ALI) test, which are broader concepts of insanity.
- The **M'Naghten Rule** primarily focuses on cognitive understanding (**knowing right from wrong**) rather than volitional control.
*Presence of any mental illness*
- The mere presence of a mental illness, even a severe one like **paranoid schizophrenia**, is not sufficient to establish insanity under the M'Naghten Rule.
- The illness must specifically impair the individual's ability to **understand the nature of their actions** or that these actions were wrong.
Legal and ethical considerations US Medical PG Question 3: A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?
- A. Schizophrenia
- B. Brief psychotic disorder
- C. Schizophreniform disorder (Correct Answer)
- D. Schizoid personality disorder
- E. Schizotypal personality disorder
Legal and ethical considerations Explanation: ***Schizophreniform disorder***
- The patient exhibits classic symptoms of **psychosis**, including delusions, disorganized speech, flat affect, and social withdrawal, which are characteristic of schizophrenia spectrum disorders.
- The duration of symptoms (3 months) fits the criteria for **schizophreniform disorder**, which is when psychotic symptoms last between 1 month and 6 months.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for at least **6 months**, including at least 1 month of active-phase symptoms.
- While this patient's symptoms are consistent with psychotic disorder, the **duration criteria** for schizophrenia have not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by symptoms lasting from **1 day to 1 month**, with eventual full return to premorbid functioning.
- The patient's symptoms have persisted for **3 months**, exceeding the maximum duration for brief psychotic disorder.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- While the patient exhibits social withdrawal, the presence of **delusions, disorganized speech, and flat affect** indicates a psychotic disorder, not merely a personality disorder.
*Schizotypal personality disorder*
- Schizotypal personality disorder involves pervasive social and interpersonal deficits with **cognitive or perceptual distortions** and eccentric behaviors.
- While it can involve odd beliefs, it does not typically include the prominent, fixed, and systematized **delusions and disorganized speech** seen in this patient's presentation.
Legal and ethical considerations US Medical PG Question 4: A 28-year-old woman dies shortly after receiving a blood transfusion. Autopsy reveals widespread intravascular hemolysis and acute renal failure. Investigation reveals that she received type A blood, but her medical record indicates she was type O. In a malpractice lawsuit, which of the following elements must be proven?
- A. Duty, breach, causation, and damages (Correct Answer)
- B. Only duty and breach
- C. Only breach and causation
- D. Duty, breach, and damages
Legal and ethical considerations Explanation: ***Duty, breach, causation, and damages***
- In a medical malpractice lawsuit, all four elements—**duty, breach, causation, and damages**—must be proven for a successful claim.
- The healthcare provider had a **duty** to provide competent care, they **breached** that duty by administering the wrong blood type, this breach **caused** the patient's death and renal failure, and these injuries constitute **damages**.
*Only duty and breach*
- While **duty** and **breach** are necessary components, proving only these two is insufficient for a malpractice claim.
- It must also be demonstrated that the breach directly led to the patient's harm and resulted in legally recognized damages.
*Only breach and causation*
- This option omits the crucial elements of professional **duty** owed to the patient and the resulting **damages**.
- A claim cannot succeed without establishing that a duty existed and that quantifiable harm occurred.
*Duty, breach, and damages*
- This option misses the critical element of **causation**, which links the provider's breach of duty to the patient's injuries.
- Without proving that the breach *caused* the damages, even if a duty was owed and breached, and damages occurred, the claim would fail.
Legal and ethical considerations US Medical PG Question 5: A psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?
- A. Warn the ex-girlfriend and notify law enforcement (Correct Answer)
- B. Only notify the patient's family
- C. Warn only law enforcement
- D. Maintain patient confidentiality
Legal and ethical considerations Explanation: ***Warn the ex-girlfriend and notify law enforcement***
- This scenario directly triggers the **"duty to warn"** and **"duty to protect"** principles, primarily stemming from the **Tarasoff v. Regents of the University of California** case.
- The psychiatrist has a legal obligation to take reasonable steps to protect the identifiable victim, which includes directly warning the intended victim and informing law enforcement.
*Only notify the patient's family*
- Notifying the patient's family alone does not fulfill the **legal obligation to protect** an identifiable third party from a serious threat of harm.
- While family involvement might be part of a comprehensive safety plan, it is insufficient as the sole action in this critical situation.
*Warn only law enforcement*
- While notifying law enforcement is a crucial step, the **Tarasoff duty** specifically mandates warning the **intended victim** directly (or those who can reasonably be expected to notify the victim).
- Relying solely on law enforcement might not ensure the immediate safety of the ex-girlfriend, especially if there's a delay in their response or ability to locate her.
*Maintain patient confidentiality*
- Patient confidentiality is a cornerstone of psychiatric practice, but it is **not absolute** when there is a serious and imminent threat of harm to an identifiable individual.
- The **duty to protect** a potential victim *outweighs* the duty to maintain confidentiality in such extreme circumstances.
Legal and ethical considerations US Medical PG Question 6: A 69-year-old woman with acute myeloid leukemia comes to the physician to discuss future treatment plans. She expresses interest in learning more about an experimental therapy being offered for her condition. After the physician explains the mechanism of the drug and describes the risks and benefits, the patient then states that she is not ready to die. When the physician asks her what her understanding of the therapy is, she responds "I don't remember the details, but I just know that I definitely want to try it, because I don't want to die." Which of the following ethical principles is compromised in this physician's interaction with the patient?
- A. Patient competence
- B. Patient autonomy
- C. Decision-making capacity (Correct Answer)
- D. Information disclosure
- E. Therapeutic privilege
Legal and ethical considerations Explanation: ***Decision-making capacity***
- This refers to a patient's ability to **understand information relevant to a medical decision**, appreciate their situation, reason through options, and communicate a choice. The patient's statement indicates a lack of understanding of the details of the complex treatment, despite being explained.
- While she expresses a choice, her inability to recall details suggests she cannot adequately **weigh risks and benefits**, which is central to capacity.
*Patient competence*
- **Competence is a legal determination** made by a court, not by a physician in a clinical setting.
- Physicians assess **decision-making capacity**, which is a clinical judgment, whereas legal competence has broader implications.
*Patient autonomy*
- **Autonomy is the right of a patient to make their own choices** about their medical care. While the patient is attempting to exercise a choice, the issue here is whether she is able to make an adequately informed choice.
- For autonomy to be truly upheld, the patient must have the **capacity to make an informed decision**, which is compromised by her stated lack of understanding.
*Information disclosure*
- The physician *did* disclose information about the drug's mechanism, risks, and benefits, indicating that the act of disclosure itself was performed.
- The problem is not that information was withheld, but that the patient **did not retain or understand the disclosed information** sufficiently.
*Therapeutic privilege*
- **Therapeutic privilege** is when a physician withholds information from a patient if they believe the disclosure would cause significant harm.
- In this scenario, the physician *did* explain the treatment, so information was not withheld under privilege.
Legal and ethical considerations US Medical PG Question 7: A 23-year-old woman presents to the emergency department with acute alcohol intoxication. Her blood alcohol level is 280 mg/dL. She becomes increasingly agitated and attempts to leave against medical advice. Which of the following determines her capacity to refuse treatment?
- A. Age of the patient
- B. Family's wishes
- C. Blood alcohol level
- D. Understanding of risks and benefits (Correct Answer)
Legal and ethical considerations Explanation: ***Understanding of risks and benefits***
- A patient's capacity to refuse treatment is primarily determined by their **ability to understand the nature of their condition**, the proposed treatment, and the **potential risks and benefits** of both accepting and refusing treatment.
- Even with intoxication, if a patient can demonstrate this understanding, they technically have the capacity to make decisions, though the intoxication itself often impairs this ability.
- Capacity assessment includes four key elements: understanding information, appreciating how it applies to their situation, reasoning through options, and communicating a choice.
*Age of the patient*
- While age is a factor in pediatric care (requiring parental consent for minors), for adults, it does not solely determine capacity; an adult of any age can be deemed to lack capacity for various reasons.
- The patient's age (23 years old) indicates she is legally an adult, but it does not automatically confer or deny treatment capacity, which is assessed based on mental status.
*Family's wishes*
- Family wishes are important for patients who **lack decision-making capacity** and have no advance directives, but they do not override the decisions of a fully capacitated patient.
- In situations where capacity is questionable, family input might be considered, but the direct assessment of the patient's understanding remains paramount.
*Blood alcohol level*
- A high blood alcohol level strongly suggests impaired judgment and cognitive function, making it a red flag for potential lack of capacity, but it is not a direct measure of capacity itself.
- Some individuals may maintain a degree of understanding even with high levels, so a direct assessment of their comprehension is still necessary, not just assuming based on the level alone.
Legal and ethical considerations US Medical PG Question 8: A 24-year-old woman presents with her husband to a physician with the complaints of fever, cough, and cold for the past 5 days. When the physician asks her if she has taken any medication for her symptoms, she answers, “My husband and I possess great powers to heal sickness. So I tried to cure my symptoms with my power. However, due to some divine cause, it did not work this time, so I thought I should seek medical advice”. Upon asking her husband about this, he says, "I have always had an immense ability to heal others through my powerful thoughts. It is only after I married her that she came to realize the powers within herself.” The physician examines her and prescribes appropriate medications for her symptoms. A year later, the woman presents again to the same physician with a cough and cold for 2 days. The physician asks her why did she not use her ‘power’ this time. She replies, “I separated from my husband 6 months ago, and I no longer believe that I nor my husband had any special power.” The woman denies any hallucinations, mood disturbances, and socio-occupational impairment to date. Which of the following conditions was this patient most likely suffering from?
- A. Brief psychotic disorder
- B. Folie à deux (Correct Answer)
- C. Culture-specific psychosis
- D. Residual phase of schizophrenia
- E. Schizophreniform disorder
Legal and ethical considerations Explanation: ***Folie à deux***
- This condition is characterized by a **shared delusional belief** between two or more people who are in a close relationship. One person, typically the dominant partner, has a primary psychotic disorder with delusions, and the other person adopts these delusions.
- In this case, the husband likely initiated the delusional belief about healing powers, which his wife subsequently adopted. Her belief resolved when she separated from him, indicating the **dependent nature** of her delusion.
*Brief psychotic disorder*
- This disorder involves a sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) lasting more than one day but less than one month, with eventual full return to premorbid functioning.
- While the patient exhibited a delusional belief, the **shared nature** with her husband and the **resolution upon separation** are more characteristic of folie à deux than an independent brief psychotic episode.
*Culture-specific psychosis*
- This refers to psychotic symptoms and syndromes that are recognized within a particular culture and associated with specific cultural explanations.
- Although some cultures may have beliefs in spiritual healing, the specific scenario of a **delusional belief shared between two individuals** in a close relationship points more directly to folie à deux rather than a broad culture-specific psychosis.
*Residual phase of schizophrenia*
- This phase occurs after an acute episode of schizophrenia, where prominent positive symptoms (delusions, hallucinations) have subsided, but milder negative symptoms (e.g., social withdrawal, blunted affect) or attenuated positive symptoms persist.
- The patient explicitly **denies hallucinations, mood disturbances, and socio-occupational impairment**, and her delusional belief was directly linked to her husband, which does not fit the diagnostic criteria for a residual phase of schizophrenia.
*Schizophreniform disorder*
- This disorder is characterized by symptoms similar to schizophrenia (delusions, hallucinations, disorganized speech, negative symptoms) but lasts for more than one month and less than six months.
- The patient's presentation does not describe the broad range of symptoms or the duration required for a schizophreniform disorder, and the **resolving nature of her delusion upon separation** is a key differentiating factor.
Legal and ethical considerations US Medical PG Question 9: A 44-year-old man is brought to the clinic by his wife insisting that her husband has been acting strange lately. He is a dentist by profession and has no known medical conditions. For the past 6 weeks, he has insisted on listening to the 6 PM news on the radio. He is adamant that the news anchor is referencing his life during the broadcasts. Apart from this, his wife states that her husband is fine. He and his wife deny the use of any prescribed medications or illicit drugs. He is a non-smoker and drinks alcohol only on social occasions. Physical examination and routine laboratory investigations are normal. What is the most likely diagnosis?
- A. Persecutory delusions
- B. Delusion of control
- C. Erotomanic delusions
- D. Delusion of reference (Correct Answer)
- E. Grandiose delusions
Legal and ethical considerations Explanation: ***Delusion of reference***
- This is characterized by the belief that **events, objects, or people in the environment** have a particular and unusual significance, often of a negative or threatening nature, specifically directed at oneself.
- The man's belief that the **news anchor is referencing his life** during broadcasts, despite no actual connection, is a classic presentation of a delusion of reference.
*Persecutory delusions*
- **Persecutory delusions** involve the belief that one is being tormented, followed, tricked, spied on, or ridiculed.
- While the delusion involves external references, it does not explicitly state that the news anchor is actively *harming* or *conspiring against* him, making it less specific than a delusion of reference, which describes the belief that common occurrences refer to oneself.
*Delusion of control*
- This delusion involves the belief that **one's thoughts, feelings, impulses, or actions are not one's own** but are being imposed or controlled by some external force.
- The patient's symptom is about external events referring to him, not about his internal experiences being controlled by an external force.
*Erotomanic delusions*
- This involves the belief that **another person, usually of higher status, is in love with the individual**.
- There is no indication in the scenario that the man believes the news anchor is in love with him.
*Grandiose delusions*
- This is characterized by beliefs of **inflated worth, power, knowledge, identity, or a special relationship to a deity or famous person**.
- The patient's delusion does not involve exaggerated self-importance or a belief in special abilities, but rather a misinterpretation of external communications.
Legal and ethical considerations US Medical PG Question 10: A 45-year-old man visits a psychiatrist with his wife asking for help with their ongoing family problem. The couple has been married for 20 years and the last 2 months the patient is fully convinced that his wife is cheating on him. He has hired numerous private investigators, who deny any such evidence for an extramarital affair. This persistent belief has begun to stress both sides of the family. The spouse has never in the past nor currently shown any evidence of infidelity. He is still able to hold a steady job and provide for his 2 children. Which of the following statements below is a diagnostic criterion for the above condition?
- A. Delusions are better explained by another DSM-5 diagnosis
- B. Must have prominent hallucinations in addition to delusions
- C. Daily functioning must be impaired
- D. Must have active symptoms for 1 month followed by 6 months total duration
- E. Delusions must be non-bizarre (Correct Answer)
Legal and ethical considerations Explanation: ***Delusions must be non-bizarre***
- This is a key diagnostic criterion for **delusional disorder**, where the delusions are plausible and involve situations that could conceivably happen, even if they aren't true (e.g., being cheated on, followed, or having a disease).
- The patient's belief that his wife is cheating on him, despite evidence to the contrary, is a **plausible but false belief**, fitting the definition of a non-bizarre delusion.
*Delusions are better explained by another DSM-5 diagnosis*
- This is an **exclusion criterion**; if delusions are better accounted for by another disorder (e.g., schizophrenia, mood disorder with psychotic features, substance-induced psychosis), then delusional disorder is not diagnosed.
- The patient's presentation does not suggest other DSM-5 diagnoses that would better explain the delusions.
*Must have prominent hallucinations in addition to delusions*
- **Prominent hallucinations** are usually associated with disorders like **schizophrenia** or **schizoaffective disorder**.
- In **delusional disorder**, hallucinations, if present, are not prominent and are typically related to the delusional theme.
*Daily functioning must be impaired*
- A distinguishing characteristic of delusional disorder is that **daily functioning is typically not markedly impaired**, and behavior is not obviously bizarre, apart from the direct impact of the delusion.
- The patient in the vignette is able to hold a steady job and care for his children, which supports this point.
*Must have active symptoms for 1 month followed by 6 months total duration*
- This criterion (1 month active symptoms, 6 months total duration) is specific to the diagnosis of **schizophrenia**, not delusional disorder.
- For delusional disorder, the duration of delusions is **1 month or longer**, without necessarily requiring a specific active phase or total duration like in schizophrenia.
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