PLAB 1 Medical Ethics, Consent & Evidence-Based Medicine — Questions and Answers
Question 1: A competent 35-year-old patient with a life-threatening condition refuses a blood transfusion on religious grounds. What should you do?
- Administer the blood transfusion as it is life-saving
- Respect the patient's decision, document it, and explore alternatives — a competent adult has the right to refuse any treatment (Correct answer)
- Apply to the Court of Protection to override the decision
- Delay treatment until a second opinion is obtained
Correct answer: Respect the patient's decision, document it, and explore alternatives — a competent adult has the right to refuse any treatment
A competent adult has an absolute right to refuse medical treatment, even if that refusal may result in death. This is enshrined in UK law (Mental Capacity Act 2005, common law). The patient must be given full information, their decision must be documented, and alternative treatments explored. Overriding consent is battery.
Question 2: What are the four components of valid informed consent?
- Signature, witness, medical assessment, and doctor's agreement
- Voluntary decision, capacity, adequate information/disclosure, and the ability to communicate the decision (Correct answer)
- Written form, two witnesses, patient's signature, and consultant approval
- Patient request, clinical indication, family agreement, and legal approval
Correct answer: Voluntary decision, capacity, adequate information/disclosure, and the ability to communicate the decision
Valid consent requires: (1) voluntariness — free from undue pressure; (2) capacity — the ability to understand, retain, weigh, and communicate information; (3) adequate information — enough to make an informed decision including risks, benefits, and alternatives; (4) communication of the decision. All four must be present.
Question 3: Under the Mental Capacity Act 2005 (England and Wales), what are the five principles that underpin the Act?
- Beneficence, non-maleficence, autonomy, justice, and veracity
- Presumption of capacity; support to make decisions; right to make unwise decisions; best interests; least restrictive option (Correct answer)
- Informed consent, autonomy, confidentiality, beneficence, and justice
- Competence, disclosure, understanding, voluntariness, and decision-making
Correct answer: Presumption of capacity; support to make decisions; right to make unwise decisions; best interests; least restrictive option
The MCA 2005 five principles: (1) Presume capacity unless proven otherwise; (2) Support people to make decisions; (3) Respect the right to make unwise decisions; (4) Any action/decision for those lacking capacity must be in their best interests; (5) Choose the least restrictive option. These apply to all healthcare decisions.
Question 4: A 16-year-old presents alone requesting contraception. She appears to understand the information given and the consequences of her decision. Under the Fraser guidelines, can you prescribe contraception without parental consent?
- No — anyone under 18 requires parental consent
- Yes — if she meets Fraser guidelines: understands advice, cannot be persuaded to involve parents, will likely have unprotected sex otherwise, her physical/mental health requires contraception, and it is in her best interests (Correct answer)
- Only if she is 'Gillick competent' but only for emergency contraception
- Only with a court order
Correct answer: Yes — if she meets Fraser guidelines: understands advice, cannot be persuaded to involve parents, will likely have unprotected sex otherwise, her physical/mental health requires contraception, and it is in her best interests
Fraser guidelines (from Gillick v West Norfolk, 1985) allow prescription of contraception to under-16s without parental consent if: they understand the advice; parental involvement cannot be achieved; they will likely proceed without contraception; their health requires contraception; it is in their best interests. Parental consent is not automatically required for 16–17-year-olds either.
Question 5: What does 'best interests' decision-making require under the MCA 2005 when a patient lacks capacity?
- Following the patient's family's wishes
- Considering all relevant factors including the patient's past wishes, values, and beliefs; consulting those close to them; and choosing the least restrictive option that meets their needs (Correct answer)
- Making the medically optimal decision regardless of personal values
- Applying for a court order before any decision
Correct answer: Considering all relevant factors including the patient's past wishes, values, and beliefs; consulting those close to them; and choosing the least restrictive option that meets their needs
Best interests under the MCA 2005 requires a structured approach: consider all relevant factors, consult family/carers/advocates (IMCA if needed), consider the patient's past and present wishes/values, do not make assumptions based on age/appearance, and identify the least restrictive option. It is broader than just medical best interests.
Question 6: What is the principle of 'Gillick competence' and how does it apply to children under 16?
- Children under 16 can never consent to medical treatment
- A child under 16 has capacity to consent to treatment if they have sufficient maturity and understanding to fully comprehend what is proposed — the competence level must match the complexity of the decision (Correct answer)
- All children under 16 need parental consent for any procedure
- Gillick competence only applies to contraception decisions
Correct answer: A child under 16 has capacity to consent to treatment if they have sufficient maturity and understanding to fully comprehend what is proposed — the competence level must match the complexity of the decision
Gillick competence holds that a child under 16 may consent to medical treatment if they demonstrate sufficient intelligence and maturity to understand the nature and implications of the proposed treatment. The more complex or serious the decision, the higher the threshold of understanding required. Parents cannot overrule a Gillick-competent child's consent.
PLAB 1 Medical Ethics, Consent & Evidence-Based Medicine
A competent 35-year-old patient with a life-threatening condition refuses a blood transfusion on religious grounds.
What should you do?