SPEX Exam Medical Ethics and Legal Medicine — Questions and Answers
Question 1: A 45-year-old alert, oriented man with newly diagnosed cancer refuses a recommended curative surgery after being fully informed of the risks, benefits, and alternatives. He understands his prognosis without treatment. The physician should:
- Consult psychiatry to assess competency because the decision is irrational
- Respect his decision and document the informed refusal (Correct answer)
- Contact his family to obtain surrogate consent for the procedure
- Petition the court for an emergency guardian to authorize surgery
Correct answer: Respect his decision and document the informed refusal
A decisionally capable adult has an absolute right to refuse any medical intervention, even life-saving treatment. Competency is not diminished by making a decision that others consider irrational. There is no role for surrogate decision-makers when the patient is clearly competent. Psychiatric referral to override a competent patient's refusal is unethical. The physician must document that informed refusal was obtained.
Question 2: A 16-year-old presents alone requesting treatment for a sexually transmitted infection. She asks that her parents not be told. In most U.S. jurisdictions, the physician should:
- Refuse to treat without parental consent because she is a minor
- Treat her and maintain confidentiality, as minors may consent to STI care (Correct answer)
- Treat her but is legally required to notify her parents
- Report the case to child protective services as suspected sexual abuse
Correct answer: Treat her and maintain confidentiality, as minors may consent to STI care
All 50 states permit minors to consent to diagnosis and treatment of sexually transmitted infections without parental consent or notification. This mature-minor exception exists to encourage adolescents to seek care. Requiring parental consent for STI treatment would deter testing and worsen public health outcomes. Mandatory parental notification is not required. CPS reporting applies to abuse by an adult, not consensual adolescent sexual activity.
Question 3: A physician is treating a patient with schizophrenia who discloses during a session that he has detailed plans to stab his neighbor next week. He names the specific neighbor. The physician's legal and ethical obligation under the Tarasoff duty is to:
- Maintain confidentiality because the patient-physician relationship is privileged
- Notify only the police and document the disclosure
- Warn the identifiable potential victim and/or notify law enforcement (Correct answer)
- Involuntarily hospitalize the patient without any obligation to warn the third party
Correct answer: Warn the identifiable potential victim and/or notify law enforcement
The Tarasoff v. Regents (1976) ruling established the 'duty to protect' identifiable third parties from serious, credible threats. This requires the clinician to take reasonable protective steps: warning the potential victim, notifying law enforcement, or both, as well as considering hospitalization. Confidentiality is not absolute when there is a credible, specific threat to an identifiable person. Hospitalization alone without warning the victim may not fulfill the duty.
Question 4: An 80-year-old patient with end-stage COPD has a valid living will stating she does not want mechanical ventilation. She is now obtunded and in acute respiratory failure. Her son (healthcare proxy) insists the team 'do everything.' The appropriate action is:
- Intubate the patient because the proxy has superseded the living will
- Honor the living will and forgo intubation; explain this to the son (Correct answer)
- Convene an ethics committee before making any clinical decision
- Provide non-invasive ventilation as a compromise measure
Correct answer: Honor the living will and forgo intubation; explain this to the son
A valid advance directive expressing the patient's competent prior wishes has legal and ethical force and takes precedence over surrogate decisions that contradict those wishes. The proxy's authority is to substitute judgment for the patient—to act as the patient would wish, not to override the patient's documented instructions. The living will is clear and specific; the physician must honor it. An ethics consult is useful for ambiguous cases, not for clear, applicable directives.
Question 5: A physician discovers that a colleague is regularly performing procedures while impaired by alcohol. The most ethically and legally appropriate first step is:
- Confront the colleague privately and advise him to seek treatment before reporting
- Report the behavior to the hospital's physician health program or appropriate authority (Correct answer)
- Do nothing unless a patient is actually harmed
- Inform patients seen by the impaired physician so they can file complaints
Correct answer: Report the behavior to the hospital's physician health program or appropriate authority
Physicians have a professional and in many states a legal obligation to report an impaired colleague who poses a risk to patient safety. Waiting for actual harm violates the duty to protect patients. Private confrontation alone is insufficient and delays the intervention needed. Informing patients bypasses the proper institutional and regulatory channels and could violate privacy. Most institutions have physician health programs designed to address impairment while supporting the colleague's rehabilitation.
Question 6: For a procedure to meet the standard of informed consent, the physician MUST disclose all of the following EXCEPT:
- Nature of the proposed procedure
- Material risks, including low-probability but severe outcomes
- Reasonable alternatives including no treatment
- The physician's personal success rate compared to national benchmarks (Correct answer)
Correct answer: The physician's personal success rate compared to national benchmarks
Informed consent requires disclosure of the diagnosis, the nature of the proposed intervention, material risks (those a reasonable patient would consider significant in deciding), benefits, and reasonable alternatives including non-treatment. While transparency about outcomes is encouraged, the legal and ethical standard does not require disclosure of a physician's individual statistics versus national benchmarks. The reasonable patient standard governs what risks are 'material.'
SPEX Exam Medical Ethics and Legal Medicine
A 45-year-old alert, oriented man with newly diagnosed cancer refuses a recommended curative surgery after being fully informed of the risks, benefits, and alternatives.
He understands his prognosis without treatment.
The physician should: