Ethics & Law — MCQs
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A 71-year-old woman with metastatic lung cancer and capacity is receiving end-of-life care at home. Her pain is increasingly difficult to control and the palliative care team recommends a continuous subcutaneous infusion of diamorphine and midazolam. She agrees but says 'I don't want to become unconscious - I want to stay alert to talk to my family'. The doses proposed would likely cause significant sedation. How should this be managed?
A 37-year-old man with newly diagnosed HIV infection (CD4 250, undetectable viral load on treatment) works as a dentist. He has capacity and refuses to inform his employer or occupational health, citing concerns about discrimination. He follows standard infection control procedures. What is your professional obligation regarding disclosure?
A 56-year-old man with motor neurone disease attended his GP 6 months ago when mobile and made a written advance decision refusing 'ventilation of any kind' if he developed respiratory failure. He is now admitted with type 2 respiratory failure. He has lost speech but can communicate by eye movements. When asked about non-invasive ventilation (NIV), he consistently indicates he wants it. What is the legal status of his advance decision?
A 49-year-old woman with widely metastatic cervical cancer is dying in hospital. She has capacity and pain is well controlled. She specifically requests that her elderly mother, who lives abroad and has dementia, not be informed of her deterioration or death. Her brother strongly objects, saying their mother has a 'right to say goodbye'. What should you do?
An 82-year-old woman with severe dementia (MMSE 6/30) and recurrent urosepsis is admitted from a nursing home. She has no advance decision or LPA. Her son (only relative) says 'Mum always said if she got dementia she wouldn't want to be kept alive with antibiotics'. There is no documented evidence of this. She appears comfortable but has sepsis requiring IV antibiotics. What weight should be given to the son's account?
Ethics & Law UK Medical PG Practice Questions and MCQs
Question 1: A 71-year-old woman with metastatic lung cancer and capacity is receiving end-of-life care at home. Her pain is increasingly difficult to control and the palliative care team recommends a continuous subcutaneous infusion of diamorphine and midazolam. She agrees but says 'I don't want to become unconscious - I want to stay alert to talk to my family'. The doses proposed would likely cause significant sedation. How should this be managed?
- A. Start the infusion as planned - adequate pain control is the priority
- B. Reduce the doses even if pain control is suboptimal to maintain alertness
- C. Explain the likely effects of medication and explore her priorities regarding symptom control versus alertness (Correct Answer)
- D. Defer starting the infusion until she becomes less concerned about sedation
- E. Start lower doses and increase without further discussion once she becomes too drowsy to participate
Explanation: ***Explain the likely effects of medication and explore her priorities regarding symptom control versus alertness*** - Respecting **patient autonomy** requires a shared decision-making process where the patient is fully informed of the trade-offs between **analgesia** and **sedation**. - The patient possesses **capacity**, meaning her personal values and preferences for **alertness** over complete pain relief must be prioritized and documented in her care plan. *Start the infusion as planned - adequate pain control is the priority* - Prioritizing pain control against the patient's explicit wish to remain alert violates the principle of **informed consent** and self-determination. - Clinicians must not paternalistically decide that **symptom relief** is more important than the patient's desire for **social interaction** at the end of life. *Reduce the doses even if pain control is suboptimal to maintain alertness* - While this respects her wish for alertness, it should not be done unilaterally without discussing the potential for **distressing pain** and exploring other **palliative options**. - The goal is to reach a **consensual plan** where the patient accepts the specific level of pain relief achieved by a lower dose. *Defer starting the infusion until she becomes less concerned about sedation* - Deferring necessary treatment without further discussion risks leaving the patient in **unnecessary pain** and avoids addressing her actual concerns. - It fails to utilize the patient's current **mental capacity** to make a proactive, informed choice about her **end-of-life care**. *Start lower doses and increase without further discussion once she becomes too drowsy to participate* - Increasing doses without discussion as the patient's condition changes ignores the need for **ongoing consent** and transparency in clinical management. - This approach disregards the **patient-centered** model of care and removes her ability to dictate the terms of her remaining **lucid time**.
Question 2: A 37-year-old man with newly diagnosed HIV infection (CD4 250, undetectable viral load on treatment) works as a dentist. He has capacity and refuses to inform his employer or occupational health, citing concerns about discrimination. He follows standard infection control procedures. What is your professional obligation regarding disclosure?
- A. You must immediately inform the General Dental Council
- B. You must inform UK Health Security Agency who will inform his employer
- C. You should maintain confidentiality as he poses minimal risk with standard precautions (Correct Answer)
- D. You must inform his employer as patients have a right to know
- E. You should seek advice from the GMC ethics department before taking any action
Explanation: ***You should maintain confidentiality as he poses minimal risk with standard precautions*** - Current guidelines state that **healthcare workers with HIV** who are on effective **antiretroviral therapy (ART)** and have an **undetectable viral load** can safely perform clinical duties, including exposure-prone procedures. - Because the patient maintains **standard infection control** and is virally suppressed, there is no **serious risk of harm** to others that justifies breaching **patient confidentiality**. *You must immediately inform the General Dental Council* - Reporting a colleague or patient to a **regulatory body** without their consent is only appropriate if there is evidence of **professional misconduct** or a risk to public safety that cannot be managed locally. - Being **HIV-positive** is not a ground for an automatic fitness-to-practise referral, and maintaining **medical confidentiality** remains the priority. *You must inform UK Health Security Agency who will inform his employer* - While **HIV** is a notifiable condition in some contexts for surveillance, the **UKHSA** does not exist to bypass **confidentiality** for the purpose of informing employers about a worker's health status. - Disclosure to an **employer** without consent is a breach of the **Data Protection Act** and GMC ethical guidance unless a significant risk of transmission is identified. *You must inform his employer as patients have a right to know* - Patients do not have an automatic **right to know** the personal health status of their healthcare providers if there is no **material risk** of transmission. - Providing this information to the **employer** against the patient's will violates **autonomy** and is unnecessary given the **negligible risk** associated with an undetectable viral load. *You should seek advice from the GMC ethics department before taking any action* - While seeking advice is a reasonable step in complex cases, the **professional obligation** to maintain **confidentiality** in this specific scenario is already clearly defined by existing **GMC and Public Health** guidance. - The clinician should first apply known **ethical frameworks** and guidelines regarding **blood-borne viruses** before escalating to formal ethical committees.
Question 3: A 56-year-old man with motor neurone disease attended his GP 6 months ago when mobile and made a written advance decision refusing 'ventilation of any kind' if he developed respiratory failure. He is now admitted with type 2 respiratory failure. He has lost speech but can communicate by eye movements. When asked about non-invasive ventilation (NIV), he consistently indicates he wants it. What is the legal status of his advance decision?
- A. It is valid and binding - NIV should not be started
- B. It is not applicable as it was made more than 3 months ago
- C. It is not valid as it was not registered with a solicitor
- D. It is not applicable as his current wishes differ from the advance decision (Correct Answer)
- E. Court of Protection authorization is required to override the advance decision
Explanation: ***It is not applicable as his current wishes differ from the advance decision*** - An **Advance Decision to Refuse Treatment (ADRT)** only becomes active if the patient **lacks capacity** to make the decision at the relevant time. - Because the patient can still communicate through eye movements and clearly indicates a desire for **non-invasive ventilation (NIV)**, his current, contemporaneous decision takes precedence over the previous written document. *It is valid and binding - NIV should not be started* - A decision is only **binding** if the patient lacks the capacity to change it; here, the patient is currently expressing a different choice, which nullifies the ADRT's applicability. - Clinicians must respect the **autonomy** of a clear decision made by a patient with capacity, regardless of what was written in the past. *It is not applicable as it was made more than 3 months ago* - There is no **fixed time limit** for the validity of an advance decision under the **Mental Capacity Act 2005**. - As long as the ADRT was made when the patient had capacity and remains consistent with their current wishes, it remains legally valid indefinitely. *It is not valid as it was not registered with a solicitor* - An ADRT does not require **legal registration** or a solicitor's signature to be valid; it only needs to be written, signed, and witnessed if it concerns life-sustaining treatment. - The legal focus is on the patient's **intent** and **capacity** at the time of writing, not the involvement of legal professionals. *Court of Protection authorization is required to override the advance decision* - The **Court of Protection** is only involved if there is a dispute or ambiguity regarding the patient's capacity or the validity of the ADRT. - No court intervention is needed when a patient with **current capacity** makes a clear choice that supersedes their prior instructions.
Question 4: A 49-year-old woman with widely metastatic cervical cancer is dying in hospital. She has capacity and pain is well controlled. She specifically requests that her elderly mother, who lives abroad and has dementia, not be informed of her deterioration or death. Her brother strongly objects, saying their mother has a 'right to say goodbye'. What should you do?
- A. Inform the mother as she has a right to know about her daughter's condition
- B. Support the brother to inform the mother as this is a family matter
- C. Respect the patient's confidentiality and wishes (Correct Answer)
- D. Arrange a best interests meeting to decide what to tell the mother
- E. Compromise by informing the mother only after the patient dies
Explanation: ***Respect the patient's confidentiality and wishes***- A **capacitous patient** has the absolute right to **autonomy** and confidentiality, including the right to restrict who is informed about their medical condition or death.- The legal and ethical duty of **confidentiality** persists even after death; therefore, the patient's specific request must be honored over the wishes of family members.*Inform the mother as she has a right to know about her daughter's condition*- Relatives do not have a legal **"right to know"** medical information if the patient explicitly withholds consent.- Overriding a patient's wishes without a **public interest justification** is a breach of professional guidance and medical ethics.*Support the brother to inform the mother as this is a family matter*- While healthcare is often family-centered, the clinician's primary duty is to the **patient**, not the family unit.- Supporting the brother to bypass the patient's refusal would facilitate a **breach of confidentiality** and undermine the patient's trust.*Arrange a best interests meeting to decide what to tell the mother*- **Best interests meetings** are utilized for patients who **lack capacity**; they are not applicable when a capacitous patient has made a clear decision.- The mother's dementia does not grant the medical team the authority to override the **capacitous daughter's** explicit instructions.*Compromise by informing the mother only after the patient dies*- This approach is incorrect because the patient specifically requested not to be informed of her **deterioration OR death**.- Respecting a patient’s wishes regarding **post-mortem confidentiality** is a requirement of GMC and other professional standards.
Question 5: An 82-year-old woman with severe dementia (MMSE 6/30) and recurrent urosepsis is admitted from a nursing home. She has no advance decision or LPA. Her son (only relative) says 'Mum always said if she got dementia she wouldn't want to be kept alive with antibiotics'. There is no documented evidence of this. She appears comfortable but has sepsis requiring IV antibiotics. What weight should be given to the son's account?
- A. No weight as there is no written advance decision to refuse treatment
- B. It should be determinative as he is the next of kin
- C. It forms part of the best interests assessment but is not binding (Correct Answer)
- D. It constitutes a valid oral advance decision and antibiotics should be withheld
- E. It should be ignored as the son may have ulterior motives
Explanation: ***It forms part of the best interests assessment but is not binding***- Under the **Mental Capacity Act 2005**, clinicians are legally required to consider the patient's **past wishes and feelings** when they lack capacity, which the son's testimony provides insight into.- While this information is crucial for a **holistic best interests assessment**, it is not legally binding as it does not meet the formal requirements of an **Advance Decision to Refuse Treatment** (ADRT). *No weight as there is no written advance decision to refuse treatment*- Medical professionals are legally obligated to consult with **relatives and friends** to ascertain the patient's past values and beliefs when the patient lacks capacity and no formal ADRT exists.- Ignoring the son's account would constitute a failure to properly conduct a **best interests assessment** by not considering all relevant information about the patient's potential preferences. *It should be determinative as he is the next of kin*- In UK law, being the **next of kin** does not confer legal authority to make medical decisions for an adult, unlike holding a **Lasting Power of Attorney (LPA)**.- The ultimate decision for an incapacitated patient without an LPA rests with the **healthcare team**, who must act in the patient's best interests after considering all relevant factors. *It constitutes a valid oral advance decision and antibiotics should be withheld*- An **Advance Decision to Refuse Treatment (ADRT)** concerning life-sustaining treatment must be **written, signed by the patient, and witnessed** to be legally valid and binding.- The son's report of verbal statements does not meet these strict **statutory criteria** for a legally enforceable ADRT to withhold life-saving antibiotics. *It should be ignored as the son may have ulterior motives*- It is professionally inappropriate and unethical to assume **ulterior motives** without clear evidence or specific concerns that warrant investigation.- The son's input, like that of other individuals who know the patient well, is a vital component of the **best interests assessment** and must be considered with due diligence.
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