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In2Med

Example Cases

This article goes through key ethical principles and medical laws to help you answer those challenging interview questions…
ethics, right, wrong

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Example Cases

Now we come onto dealing with scenarios in the medical interview.

Avoid the pitfall of starting your answer with a strong opinion one way or the other. A better course of action is to first discuss arguments both for and against, before coming up with a balanced conclusion that appreciates the nuances of the scenario. This should be done, where possible, within the framework of the four pillars of medical ethics, including relevant laws and specific pros and cons of the scenario.

We will go through how you can structure your answer with some example questions:

Do you agree with abortion?

  1. For this scenario you will want to start by acknowledging that it is a complex issue with arguments on both sides.
  2. Then you may refer to the current abortion law in the UK. I.e it is legal under 24 weeks and after that time the laws become stricter such that there must be risk of severe disability of the child or risk to the life of the mother. In law the foetus does not have human rights till birth.
  3. Represent different views.

Pro-choice

  • Women’s rights to be able to do what she wants with her own body

Pro-life

  • Foetus is considered a human since conception and abortion is equivalent to murder.

Gradualist

  • Late abortions as worse than early abortions.
  • 24 weeks is the earliest point at which the foetus is considered to be viable and able to survive outside the womb and as such this is reflected in law.
  1. Finish with a conclusion such as: Overall, I agree with the gradualist view that the rights of the woman should be respected but that abortion should be avoided and carried out as early as possible.

Should euthanasia be legalised?

  1. To really stand out when answering this question, first demonstrate knowledge of UK law.
  2. Represent some of the views for and against before coming to a conclusion.

For euthanasia

Beneficence:

  • Doctors have a duty to relieve suffering
  • Compassionate

Autonomy:

  • Doctors should respect a patient’s wish to die with dignity
  • Patient is the only person who knows when life becomes too difficult to bear.

Justice:

  • Frees up medical costs to help others.

Against Euthanasia

Non-maleficence:

  • Duty not to kill
  • We can use good palliative care as an alternative way to relieve patients’ suffering without intent to kill.

Autonomy:

  • Euthanasia may become non-voluntary e.g. If legalised disabled/elderly may feel a burden and that it is their duty to ask to be euthanised.

Other points:

  • Legalisation implies that some lives are not worth living.
  • Slippery slope: may not be used just for the terminally ill.
  1. Example conclusion: therefore, this is a complex issue with valid arguments on both sides, however due to the slippery slope and potential for non-voluntary euthanasia I agree with the current UK law and we should optimise palliative care to act in the patient’s best interests.

Q1) A patient refuses treatment for a life-threatening condition. What are the ethical issues to consider?

In this question the interviewers have specifically asked you about the ethical issues you may want to consider and so it is the perfect opportunity to use the 4 principles of medical ethics as a framework for your answer.

Example:

    1. The key ethical issues to consider in this case is the patient’s autonomy, non-maleficence and beneficence.
    2. Patients are assumed to have capacity and so we must respect this patient’s autonomy, however we also have a duty not to cause harm to our patients and therefore obeying their wishes may be directly harmful.
    3. To mitigate against this, we may wish to delve deeper into the reasons why the patient is refusing treatment and if we are happy that they understand their decision then perhaps it is autonomy that must be respected first and foremost.

Q2) A patient refuses treatment for a life-threatening condition. What will you do as a doctor?

This question is a bit trickier and relies on one recognising that respecting the patient’s autonomy is of utmost importance and we can deny treatment only if they do not have capacity. Therefore, to tackle this question you may want to go through these steps:

  1. In any scenario where you are the doctor in a situation faced with a patient, the first step is always to explore a patient’s concerns. Before jumping to any conclusions, you need to take a step back and find out why they are refusing treatment for a life-threatening condition.
  2. This can then let you assess capacity – whether they understand their decision and the consequences of it.
  3. If it is clear that they do not understand the consequences of refusing treatment then you want to help the patient reach capacity.
  4. Do this by explaining the consequences of their decision.
  5. If the patient can understand the consequences, weigh up their decision, retain and communicate their decision then they have capacity and respect their wishes.
  6. On the other hand, if you have taken the necessary steps to help the patient reach capacity and they are still deemed not competent then act in the patient’s best interests, against their wishes.
  7. You should aim to give them the treatment which is least restrictive of their rights and freedom.

N.B if the patient was 17 or under then we may be able to override refusal with parental consent.

Q3) A patient is diagnosed with HIV and does not wish to tell their partner. What are the ethical issues to consider?

This scenario requires a consideration of the autonomy, non-maleficence, as well as confidentiality.

    1. Whilst we have to respect a patient’s right to make their own decisions (autonomy), we have to make sure their decision is informed. We should assess whether the patient understands the implications of their decision and why they do not want to tell their partner in the first instance.
    2. Secondly, we also have to consider confidentiality which should be respected where-ever possible to uphold the patient-doctor relationship. Exceptions to this are where other people could be harmed due to non-disclosure.
    3. Therefore, you have to weigh up benefits of not harming the other patient versus the damage done to trust by breaking confidentiality with this patient.
    4. In any cases where you are unsure it is always safe to say that whilst these are my thoughts it would be helpful to refer to the GMC’s ethical guidelines in cases like these.

Q4) What are the pros and cons of bariatric surgery?

Bariatric surgery is a treatment used for obese people to help them lose weight by making their stomach size smaller. It can reduce obesity and improve conditions such as diabetes and high blood pressure thereby having a beneficial effect on life expectancy.

  1. Consider the pros and cons taking first the principle of justice and then beneficence.

Pros

Justice:

  • The surgery may improve quality of life and life expectancy so may be a good allocation of resources.

Beneficence:

  • Doctors have a duty to act in the best interests of patients and for those with intractable obesity this may be the last option they have to lose weight.

Alternatives:

  • Alternative options may have been exhausted or not acceptable to the patient.

Cons

Justice:

  • The surgery is costly and has an opportunity cost. You have to consider justice and quantify whether the surgery is the best allocation of resources? What is the cost per QALY?

Beneficence:

  • It could be argued it is not in the patient’s best interest as there are complications with any procedure and perhaps more conservative measures such as exercise and diet should be considered first.

Consider alternatives:

  • Diet and exercise.

 

 

  1. Come to a conclusion: e.g. I would judge the intervention as acceptable based on the cost per QALY, alternatives available and the level of benefit versus harm it does to the patient.

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