1. A 25- year old mother refused immunization for her 2-month old son.

The social worker spoke to the mother. (Important for Board e amination! "e t step in mana#ement$ immunization should %e #i&en for the %enefit of the child. 2. A '(-year old mother refused sur#ery for suspected appendicitis for her )-year old dau#hter. The social worker spoke to the mother. (Important for Board e amination! "e t step in mana#ement$ sur#ical remo&al of the appendi should %e preformed for the %enefit of the child. '. A 1)-year old %oy was dia#nosed with osteosarcoma of the ri#ht thi#h. The sur#eon recommended amputation. The %oy refuses amputation. *e is doin# &ery well otherwise. *e is aware that death is certain without sur#ery. (Important! "e t step in mana#ement$ amputation should "+T %e preformed. Adolescent patients or adults who are competent in makin# decisions ha&e an a%solute ri#ht to determine what shall %e done with their own %odies. *owe&er, most pediatric patients are not competent to make their own decisions. -lease remem%er, children (15 years or older! are usually a%le to #i&e a #enuinely informed consent. Therefore physicians may respond to their re.uest, e cept in a case of irre&ersi%le sterilization. /. A 10-year old #irl is a 1eho&ah2s 3itness. 4he refuses a lifesa&in# %lood transfusion. 4he is aware of the conse.uences. 4he spoke to the social worker. (Important! "e t step in mana#ement$ %lood transfusion should "+T %e #i&en %ecause she is competent to make the decision. 5. A 5-year old #irl is a 1eho&ah2s 3itness. 4he re.uires emer#ency %lood transfusion. *er mother refuses %lood transfusion. A social worker alon# with two physicians spoke to the mother. (Important! "e t step in mana#ement$ %lood transfusion should %e #i&en %ecause the patient is not competent. 5other cannot refuse her dau#hter2s treatment. ). A 2-year old %oy was %rou#ht to the 67 %y his parents for an in8ury. -hysicians made the dia#nosis of child a%use. There are three other children li&in# in the same household. Both parents confess to child a%use %ut re.uest the physician to keep it confidential. 4ocial worker was in&ol&ed. (Important! "e t step in mana#ement$ the case should %e reported to 9hild 3elfare A#ency (93A!. All children should %e remo&ed from the parents. 0. A 15-year old %oy with 4T: (se ually transmitted disease! came to see a physician. *e asked the physician not to tell his parents. (;67< I5-+7TA"T! "e t step in mana#ement$ the physician should treat the patient and notify the appropriate health authority, %ut should not tell his parents. =. A 1)-year old %oy wants to use a condom. *e comes to the clinic for free samples. *e re.uested the physician, howe&er, not to tell his parents. (Important! "e t step in mana#ement$ condom should %e #i&en and physician should not tell his parents.

>. A '(-year old male patient is recently dia#nosed with *I;. *e li&es with his wife and two other children %ut is promiscuous. *e re.uested the physician not to tell his wife. *e lost his 8o% recently. 4ocial worker spoke to the patient. (;ery Important! "e t step in mana#ement$ physician should notify the appropriate authority (e.#. department of health! for the safety of other specific persons who are en#a#ed in unsafe se ual practices. The physician howe&er, should ask the patient to di&ul#e the dia#nosis to his wife and other se ual partners. ??? 1(. A &ery small premature infant was %orn in the deli&ery room %y "4;: (normal spontaneous &a#inal deli&ery!. The attendin# physician decided not to resuscitate the new%orn. -hysician spoke to the mother. 5other started to cry. "ew%orn e pired after '( minutes. Is the physician lia%le for the new%orn2s death@ Answer$ "+. -lease remem%er, no physician in the A4A has e&er %een found lia%le for withholdin# or withdrawin# any life sustainin# treatment from any patient for any reason. 11. A physician picked up a car accident &ictim from the street and %rou#ht him to the 67 in his car. *e did not want to wait for an am%ulance %ecause the patient2s condition was critical. -hysical e amination in the 67 re&eals .uadriple#ia. Is the physician lia%le for this conse.uence@ (;ery Important! Answer$ <64, %ecause the physician did not protect the neck of the patient resultin# in .uadriple#ia.

12. A policeman %rou#ht an alcoholic patient to the 67. The policeman asked the physician to #i&e him a sample of #astric contents %y puttin# a naso#astric tu%e for la%oratory study. The patient refused insertion of a naso#astric tu%e. (;ery Important! "e t step in mana#ement$ naso#astric tu%e should not %e placed. Blood alcohol le&el howe&er should %e preformed. The policeman should not #i&e orders to a physician. 1'. A )(-year old man with a history of myocardial infarction (5I! suddenly de&elops &entricular tachycardia. A physician from another department was present. The patient needs resuscitation. (;ery Important! "e t step in mana#ement$ the physician must resuscitate that patient. -hysician should not refuse treatment %ecause he %elon#s to another department. 1/. A 15-year old homose ual %oy wanted to chan#e his se ual orientation. *e was not successful. *e needed help. *e re.uested the physician not to tell his parents. (Important! "e t step in mana#ement$ physician should help him a&oid homose ual acti&ities. -hysician should not tell his parents a%out his homose ual acti&ities.

15. A 15-year old homose ual %oy is %rou#ht %y his parents to a physician. *is parents do not accept their son2s se ual orientation. The %oy refuses to chan#e. (Important! "e t step in mana#ement$ physician should tell his parent that homose ual acti&ity is considered as spamternati&e life style. -arents should talk to his son %ut should not force him to chan#e his homose ual acti&ities. 1). A 1)-year old #irl %ecomes pre#nant. *er mother wanted her to a%ort this pre#nancy. The #irl wanted to continue her pre#nancy despite difficulties. *er %oyfriend is a hi#h school drop out. (Important! "e t step in mana#ement$ physician should ad&ise to continue this pre#nancy %ecause the #irl is competent to make this decision. 10. A 15-year old #irl recently %ecomes pre#nant. 4he went to a doctor for a%ortion. 4he told the doctor not to tell her parents a%out this pre#nancy. (Important! "e t step in mana#ement$ a%ortion should %e done and parents should not %e notified. -lease remem%er, strict re.uirements for parental consent may deter many adolescents from seekin# health care. 1=. 9an a physician pro&ide sterile needles for intra&enous dru# a%users@ (Important! Answer$ <64. It reduces the risk of ac.uirin# *I; or hepatitis. The patients should %e referred to appropriate health facilities. 1>. A 2)-year old pre#nant woman went for antenatal check up. 4ono#ram re&ealed a 20week old fetus with erythro%lastosis fetalis. :octor recommended intrauterine fetal %lood transfusion. 4he refused the procedure. 4ocial worker discussed the case with the mother. (Important! "e t step in mana#ement$ doctor should recei&e a court to do the procedure which will help the fetal condition. 2(. A 2(-year old man tells his doctor that he is #oin# to kill #irlfriend. 4he li&es in the uni&ersity dormitory. :octor called the uni&ersity and alerted them a%out the threat. *owe&er, uni&ersity security people did not protect her. 4he was killed %y her %oyfriend. 3ho should %e responsi%le for this killin#@ (Important! Answer$ the 2(-year old man is responsi%le. :octor did the ri#ht thin# %y notifyin# the uni&ersity or the police. The uni&ersity is also responsi%le %ecause they did not take any pre&enti&e measures. 6&en mothers wont ha&e ri#hts on their fetuses B 21. A 2(-year old pre#nant woman refuses cesarean section for complete placenta pre&ia. Cetus is full-term and healthy. 4ocial worker spoke to mother. (Important! "e t step in mana#ement$ doctor can #o to court to #et permission for cesarean section for the %enefit of the fetus. 22. A '(-year old woman in#ested alcohol and illicit dru#s (e.#., cocaine, crack! which are harmful to the fetus. 3hat should a physician do@ (Important!

Answer$ the physician should %e careful in reportin# this case %ecause the pre#nant woman may not come %ack for prenatal care, which is important for %oth the mother and the fetus. *owe&er, if the %a%y2s urine to icolo#y test is positi&e for illicit dru#s, case should %e reported to 93A (child welfare a#ency!. 93A su##ests separate custody for the child.

2'. A physician wants to study a #roup of children a#in# from 1(-12 year old. -hysician #ot the consent from the parents. *owe&er, he didn2t discuss the study with the children. A child refused to participate. 4hould the physician force the child to participate@ (Important! Answer$ no, %ecause a child can refuse to participate in a research study. 2/. A /(-year old schizophrenic patient needs hernia repair. 4ur#eon discussed the procedure with the patient who understood the procedure. 9an the patient #i&e consent@ (Important! Answer$ yes. If a psychiatric patient understands the procedure, he or she can #i&e the consent. 25. A )5-year old schizophrenic patient needs coronary an#io#raphy %ecause of suspected myocardial infarction. 9ardiolo#ists e plained the procedure to the patient who did not understand the procedure. 3ho can #i&e the consent on %ehalf of the patient@ (Important! Answer$ the patient2s relati&e can #i&e the consent. If no%ody is a&aila%le to #i&e the consent, court order should %e o%tained. If a psychiatric patient does not understand the procedure, he or she cannot #i&e the consent. 2). A 25-year old woman de&eloped postpartum psychosis. The new%orn de&eloped cyanosis due to con#enital heart disease. The new%orn needs cardiac sur#ery. 4ur#eon discussed the procedure with the mother. 4he understood the procedure. 9an she #i&e the consent@ (Important! Answer$ yes, %ecause she understood the procedure. 20. A new%orn is dia#nosed with either trisomy 1= or 1' with T6 (tracheoesopha#eal! fistula which re.uires sure#ery. 5other re.uest sur#eon to repair the T6-fistula. 3hat should a sur#eon do@ (Important! Answer$ sur#eon should refuse to do the reparati&e sur#ery %ecause these conditions (trisomy 1= or 1'! are non&ia%le. If the patient sur&i&es, sur#eon can put a #astrostomy feedin# tu%e for nutrition. *owe&er, please remem%er that a patient with trisomy 21 (:own syndrome! with T6 fistula should %e operated on. 2=. A /5-year old terminally ill patient wanted to die. *e has pancreatic cancer and has %een sufferin# from constant pain. *e asked the physician to #i&e him some medication which can e pedite his death. 3hat should a physician do@ (;ery Important!

Answer$ physician cannot #i&e any medication which will e pedite the death. *owe&er, physician can prescri%e medication to minimize the pain. The dose should %e appropriate. -hysician-assisted suicide is ille#al e&erywhere (e cept in the state of +re#on!. 2>. A /0-year old man came to a doctor for chronic low %ack pain and dysuria. The dia#nosis of metastatic prostate cancer was made after appropriate in&esti#ation. 4hould the doctor tell the %ad news to the patient@ (Important! Answer$ yes physician must tell the truth to the patient. '(. A sur#eon wanted to perform cholecystectomy on a patient. The sur#eon is not sure whether the patient has decision-makin# capacity. 3hat is the ne t appropriate step@ (Important! Answer$ consultation with a psychiatrist or neurolo#ist may %e helpful. 4ometimes it is necessary to discuss the case with hospital attorneys, ethic committees, or ethic consultants. In a difficult case, the ultimate 8ud#e of a patient2s competency is a court. Do to court only in the end '1. A /5-year old widow was admitted to an I9A (intensi&e care unit! with ruptured intracranial aneurysm. 4he is comatose and is placed on a mechanical &entilator. 4he has a 2(-year old son who did not keep any relation with his mother. *owe&er, he came to see his mother. *is mother made a written pro y ad&ance directi&e which indicates that her 5(-year old female nei#h%or should make the su%stitute decision. 3ho is the ri#ht person to make the su%stitute decision in this situation@ (Important! Answer$ 5(-year old nei#h%or should make the su%stitute decision. -lease remem%er, the most appropriate person to make the su%stitute decision is someone desi#nated %y the patient while still competent, either orally or throu#h a written pro y ad&ance directi&e. +ther su%stitute decision makers, in their usual order of priority, include a spouse, adult child, parent, %rother or sister, relati&e, or concerned friend. Cor a patient who has no other decision maker a&aila%le, a pu%lic official may ser&e as a decision maker. '2. The ri#ht of patients to refuse medical inter&ention$ patients can refuse dialysis, cardiopulmonary resuscitation, mechanical &entilation, and artificial nutrition and hydration, e&en if such a decision results in the patient2s death. A patient2s decision to withdraw (discontinue! or to withheld (not to initiate! life-sustainin# treatment is not considered suicide and physician participation is not considered physician-assisted suicide. -hysicians do not ha&e any le#al risk. ''. 9an a medical student introduce himself or herself as a 2doctor2 to the patient@ (Important! Answer$ no. a patient can refuse a medical student from performin# any procedure. *owe&er, medical students are allowed to perform a procedure under appropriate super&ision If the patient a#rees to that. '/. 4hould a %us dri&er hide history of epilepsy from his employer@ (Important! Answer$ no. *e has re.uested his physician not to mention his epilepsy to the employer %ecause this would result in the loss of his 8o%. The physician is o%li#ated not only to his

patient %ut to the community. The patient should notify his employer and try to find a non-dri&in# 8o% in the company. If the patient disa#rees, physician may notify the appropriate authority for the safety of the patient and the community. '5. A 5(-year old male is dia#nosed with stomach cancer. *e re.uested the physician not to tell his wife. The followin# day, the wife calls to in.uire a%out her hus%and2s dia#nosis. (Important! Answer$ the physician should not di&ul#e the hus%and2s dia#nosis. *owe&er, the physician should encoura#e the patient to re&eal his dia#nosis to his wife. '). A 2>-year old man is dia#nosed with presymptomatic *untin#ton2s disease. This disease is an autosomal dominant (5(E chance of ha&in# the disease in each pre#nancy!. *e re.uested his physician not to tell the dia#nosis to his wife. The wife wants to ha&e children. (Important! Answer$ physician should ask the patient to seek #enetic counselin# and to ur#e him to discuss the matter with his wife. 4ince there is a risk of harm to the future children, physician can di&ul#e the dia#nosis to protect the future children. '0. A 1=-year old man is dia#nosed to ha&e suspected %acterial menin#itis. *e refuses therapy and returns to the colle#e dormitory. 3hat should a physician do in this situation@ (;ery Important! Answer$ physician should report to the colle#e authority and recommend that the suspected indi&idual should %e isolated durin# the course of his illness. '=. A '>-year old nurse is dia#nosed with hepatitis B anti#en-positi&e. 4he is workin# in a dialysis unit. 4he told her doctor. *owe&er, she did not tell the hospital authority %ecause she is afraid to lose her 8o%. (;ery Important! Answer$ physician should ask the nurse to di&ul#e her medical condition to the hospital authority. If she refuses, physician should notify the hospital authority for the protection of patients. '>. A 2(-year old man with se&ere head in8ury was admitted to a small hospital. The patient needs neurosur#ical inter&ention which is a&aila%le in a near%y uni&ersity hospital. *ospital refused to accept a patient who has no medical insurance. Answer$ uni&ersity hospital must accept the patient. /(. A '(-year old man needs a second prosthetic &al&e. *e is a dru# addict. 4ur#eon does not want to perform sur#ery %ecause the patient does not take care of himself. Is this the ri#ht decision@ (Important! Answer$ no. 4ur#ery should %e performed if it is medically indicated. /1. A new%orn male is dia#nosed with anencephaly. *is 1-year old si%lin# needs a kidney. *is parents re.uested the physician to remo&e the kidney from the anencephalic child and to transplant that kidney in the 1-year old si%lin#. 3hat should a physician do@ Answer$ sur#eon should perform the kidney transplant.

/2. A 5(-year old man is in a persistent &e#etati&e state. -hysician decided to discontinue nutrition and hydration for that patient. Is this the ri#ht decision@ Answer$ yes. This is an accepta%le practice in most states. Cew states re.uire clear e&idence that the patient would ha&e chosen this course. /'. A medical student re.uested his attendin# to perform a pel&ic e amination on a patient who is anaesthetized for appendectomy. Is this ethically accepta%le@ Answer$ no. The patient did not #i&e consent to perform a pel&ic e amination. //. A 2(-year old woman slashed her wrists and wanted to die. 4he was unconscious and was %rou#ht to the 67. 3hat should a physician do@ (Important! Answer$ physician should take care of the patient. -sychiatric consultation and social worker e&aluation are indicated. A suicide attempt is &ery often a 2cry for help2. /5. A >(-year old man was dia#nosed with ha&in# Alzheimer2s disease 1( years a#o. It is difficult to feed him. *e cannot reco#nize his family mem%ers. *e de&eloped recurrent aspiration pneumonia. 3hat should a physician do@ Answer$ physician should discuss this with the family and should respect their decision. /). A 1-day-old infant was dia#nosed with hypoplastic left heart syndrome. The patient is sta%ilized with the use of prosta#landin. -hysician discussed this case in detail with the parents. 3hat should the parents decide in this situation@ Answer$ the parents can choose a sta#ed sur#ical repair of the heart, a final heart transplantation if the or#an is a&aila%le, or allow the infant to die. /0. A 55-year old woman with se&ere de&elopmental disa%ility recently is dia#nosed with %reast cancer. *er mental a#e is estimated at a 2-year old le&el. *er family mem%ers do not want any more inter&ention. 3hat should physician do@ Answer$ physician should discuss this case with the hospital ethics committee mem%ers. The usual consensus is 2not to do anythin#2 %ecause of her se&ere mental disa%ility. /=. A />-year old woman with cer&ical cancer has a history of noncompliance. 4he had sur#ery a month a#o. 4he missed se&eral appointments. 9an a physician force her for chemotherapy@ (Important! Answer$ no. -hysician can talk to her re#ardin# the importance of chemotherapy. *owe&er, the patient must make the final decision. />. An internist has %een mana#in# a dia%etic patient for the last 1( years. The patient2s condition is pro#ressi&ely #ettin# worse. The patient is also not happy with the physician2s mana#ement. 3hat should a physician do in this situation@ Answer$ physician should find another physician (e.#., endocrinolo#ist! who mi#ht %e more successful with the patient in this particular circumstance. 5(. An internist recently refused to see a patient who he has %een seein# for the last 5 years. Internist stated that the patient was rude to him. The patient went to see another physician who re.uested the patient2s medical record. 3hat should the internist do in this situation@ Answer$ internist should pro&ide the medical records of the patient to the new physician. 51. An internist refused to see a complicated hypertensi&e patient who he has seen for the last 1( years. Internist did not #i&e any notice to that patient. The patient was an#ry with the physician. The patient was recently admitted to a hospital with the dia#nosis of stroke. Is the internist responsi%le for the patient2s condition@ Answer$ yes. The le#al char#e of a%andonment can arise when the physician without #i&in# timely notice, ceases to pro&ide care for a patient who is still in need of medical

attention. Internist is not o%li#ated to find him another physician. *owe&er, patient should ha&e sufficient time to arran#e for another physician. 52. A physician went to &acation for 2 weeks. *e did not find another physician to co&er him. *e is &ery sincere. +ne of his patients with hypertension de&eloped se&ere headache. The patient has an appointment with the doctor as soon as he comes %ack from &acation. The patient did not look for another physician and decided to wait. The patient suddenly collapses and was dia#nosed to ha&e intracranial hemorrha#e. Is the physician responsi%le for this patient@ (Important! Answer$ yes. The physician has a le#al o%li#ation to arran#e for co&era#e %y another physician. 5'. An ophthalmolo#ist performed a cataract sur#ery on a patient who went home after the operation. In the e&enin#, the patient started &omitin# and complained of se&ere headache. The ophthalmolo#ist refused to accept that the symptoms were due to postoperati&e complications. The patient wanted to see the doctor immediately %ut he refused to see that patient. The patient went to the nearest 67 and was dia#nosed to ha&e dislocation of the lens and partial retinal detachment. Is the physician responsi%le for the patient2s condition@ Answer$ yes ophthalmolo#ist failed to 8ud#e the patient2s condition seriously enou#h to warrant attention. 5/. A 0(-year old 9hinese man is dia#nosed to ha&e se&ere osteoarthritis. *e told his doctor that he is usin# 9hinese her%al medicine. *e is feelin# %etter. *owe&er, he had two episodes of dizzy spells since he started that her%al product. 3hat should a doctor su##est to this patient@ (Important! Answer$ the doctor should su##est to discontinue the her%al product which may %e causin# the dizzy spells. 55. A '5-year old woman is dia#nosed to ha&e chronic throat infection. 4he is frustrated with the con&entional medicine. 4he told her doctor that she is usin# spamternati&e homeopathic medicine. 4he is feelin# much %etter and she has no other complications. 3hat should a doctor su##est to this patient@ Answer$ the patient can continue spamternati&e homeopathic medicine. Alternati&e medicine therapy is accepted in the society and is also used alon# with con&entional therapy. 5). A /5 year old woman is dia#nosed to ha&e ATI (urinary tract infection!. 4he told her doctor that she could not afford to purchase anti%iotics. *owe&er, she is usin# her%al medicine that is cheaper. 4he is complainin# of fe&er and dysuria. 3hat should a doctor su##est to this patient@ (Important! Answer$ the patient should discontinue the her%al medicine immediately and should start anti%iotics as soon as possi%le. 50. A 1'-year old %oy with suspected menin#itis refuses therapy. *is parents also support that decision %ecause they are supposed to #o on &acation the followin# day. 3hat should a physician do in this situation@ (Important! Answer$ the patient should %e admitted and treated in the hospital. If they refuse, le#al action should %e taken. 5=. A 2-year old #irl is admitted with the dia#nosis of intestinal o%struction. *er mother has a psychiatric pro%lem. *er mother is not capa%le of #i&in# the consent. *er father died one year a#o. 3hat should a sur#eon do in this situation@

Answer$ le#al steps may %e taken to pro&ide a surro#ate decision-maker. 5>. A )0-year old widow has %een usin# hypnotics for the last 5 years. 4he is addicted. *er doctor wants to withdraw her from her present medication %y trial on place%os. Is the physician makin# a ri#ht decision@ (Important! Answer$ no. The physician cannot use place%os %ecause his decision is decepti&e. The pro%lem of addiction should %e discussed directly with the patient. The use of decepti&e place%o is indicated in the followin# conditions$ (a! the patient insists on a prescriptionF (%! the patient wishes to %e treatedF (c! the alternati&e to place%o is either continue illness or the use of a dru# with know to icityF (d! hi#h response rates to place%o ( e.#., postoperati&e pain, mild mental depression!. )(. A 5(-year old man is dia#nosed to ha&e multiple sclerosis. In the mornin#, the sur#eon asked the man his opinion on the sur#ical procedure and he a#reed. In the e&enin#, the man refused to #i&e consent for the same sur#ical procedure. *e is also disoriented to place and time. Is the patient capa%le of makin# the decision@ Answer$ no the patient has impaired capacity. )1. A 55-year old woman with dia%etes is dia#nosed to ha&e #an#rene on %oth feet. 4he was %rou#ht to the hospital. 4he told the doctor the she is feelin# fine and she has no medical pro%lems. 9an she #i&e consent for the amputation of %oth le#s@ Answer$ no. The appointment of a surro#ate should %e sou#ht to #et the consent for the sur#ery. )2. A 10-year old %oy came to a sur#eon for %ilateral &asectomy. *e is the father of one child and does not want to ha&e any more children. *e does not want to tell his #irlfriend and parents. *e li&es with his parents. 3hat should a sur#eon do in this situation@ (Important! Answer$ sur#eon should not perform %ilateral &asectomy and should offer him less radical alternati&es. -lease remem%er, a mature minor may not comprehend the implications of this procedure. )'. A 1)-year old #irl came to a doctor for %ilateral tu%al li#ations. 4he is a mother of one child and does not want to ha&e any more children. 4he does not want to tell her %oyfriend and parents. 4he li&es with her parents. 3hat should a doctor do in this situation@ (Important! Answer$ o%#yn doctor should not perform %ilateral tu%al li#ation and should offer her less radical alternati&es. )/. A 1)-year old %oy wants to donate one of his kidneys to his friend who is sufferin# from 647: (end sta#e renal disease!. The %oy2s parents did not a#ree with his decision. 3hat should a physician do in this situation@ (Important! Answer$ the physician cannot accept his kidney. *owe&er, he can donate one of his kidneys if his parents a#ree. )5. A 15-year old %oy wants to participate in a research study. *e told his parents who did not a#ree. *e li&es with his parents. 9an this %oy participate in the research study@ Answer$ no the %oy needs consent from his parents to participate in a research study. )). A 10-year old %oy li&es independently. *e is married and has one child. *e wants to participate in a research study. :oes he need his parents permission@ (Important!

Answer$ no. *e is an emancipated minor who li&es independently from his parents physically and financially. )0. A 0(-year old man is dia#nosed with terminal esopha#eal cancer and re.uires an insertion of a #astrostomy tu%e. *e has si#ned a :"7 (:o "ot 7esuscitate! order a%out a month a#o. 4hould the pree istin# :"7 order stand or %e suspended durin# the sur#ical procedure@ (;ery Important! Answer$ attendin# physician, sur#eons, and the patient or surro#ate should discuss the matter and either affirm or suspend the order in anticipation of sur#ery. If a patient is competent and wishes a pree istin# :"7 order to stand, resuscitation should not %e performed in the e&ent of an intrasur#ical arrest. )=. An infant, %orn at '( weeks #estation, appears to %e 4DA (small for #estational a#e! with multiple malformations. Amniocentesis study was not performed. Infant needs resuscitation at %irth. 3hat should a physician do in this situation@ (Important! Answer$ physician must resuscitate the patient in the deli&ery room %ecause the dia#nosis is uncertain. )>. A )(-year old man is dia#nosed with terminally ill colon cancer and needs resuscitation. *e did not si#n a :"7 order. The physician has decided to perform a 2slow code2 on his own. Is this the ri#ht decision@ (Important! Answer$ no. -lease remem%er, a performance of 2slow code2 or 2show code2 is not accepta%le to the patient. This decision %y the doctor represents the failure to come to a timely and clear decision a%out the patient2s resuscitation status. 0(. A 2(-year old man is dia#nosed with suspected %acteremia and menin#itis. *e refuses anti%iotic therapy. *e collapses and re.uires resuscitation. 3hat should a physician do in this situation@ Answer$ the physician should resuscitate the patient despite the patient2s refusal to anti%iotic therapy. 01. A 5(-year old woman is dia#nosed with se&ere aortic stenosis. 4he collapsed in a doctor2s office and is re.uired resuscitation. 4he is waitin# for &al&e replacement sur#ery. 3hat should a physician so in this situation@ Answer$ this condition is called 2physiolo#ical futility2. In se&ere aortic stenosis, &i#orous resuscitation is hi#hly unlikely to restore ade.uate cardiac output. Therefore, the physician mi#ht reasona%ly refrain from resuscitation. 02. A 1/-year old %oy is dia#nosed with terminally ill cancer. *e is not respondin# to chemotherapy. *is parents want to continue the treatment. *owe&er, the %oy does not want to continue his sufferin#. The physician told the parents that chemotherapy will not %e helpful. 3hat is the appropriate decision at this point@ (Important! Answer$ the %oy2s decision should %e respected %ecause the treatment is futile. 0'. A surro#ate pre#nant mother made a surro#acy contract with a couple in which she will #i&e the %a%y to the couple. 4he de&eloped complications in the first trimester and wanted to a%ort. Is she allowed to do that@ (Important! Answer$ yes. If her life or health %ecomes threatened from continuin# the pre#nancy, she should retain her ri#ht to a%ortion. 0/. A physician %ecame se ually in&ol&ed with a current patient who initiated or consented to the contact. Is it ethical for a physician to %ecome se ually in&ol&ed@ Answer$ no. 4e ual in&ol&ement %etween physicians and former patients raises concern. The physician should discuss with a colle#e or other professional %efore %ecomin#

se ually in&ol&ed with a former patient BBB . The physician should terminate the physician-patient relationship %efore initiatin# a romantic or se ual relationship with a patient. 05. A physician decided to take care of his own family mem%ers and relati&es. *e is a &ery smart physician. Is this a ri#ht decision@ Answer$ no. The physician should encoura#e all friends and family mem%ers to ha&e their own personal physician. 0). A male patient wants to ha&e a copy of his medical records. 3hat should a physician do in this situation@ Answer$ the physician should retain the ori#inal of the chart. Information should only %e released with the written permission of the patient or the patient2s le#ally authorized representati&e ( e.#., attorney!. 00. A '(-year old female wants to ha&e an a%ortion. *er physician o%8ects to a%ortion on moral, reli#ious, or ethical #rounds. 3hat should a physician do in this situation@ (Important! Answer$ physician should not offer ad&ice to the patient. 0=. A physician sees patients at a reduced fee. *e spends &ery little time with each patient. Is the physician doin# the ri#ht thin#@ Answer$ no. The physician is not pro&idin# optimal care. 0>. A surro#ate pre#nant mother si#ned a surro#acy contract with a couple. 5ale partner #a&e sperms which were artificially inseminated to the surro#ate mother. 4urro#ate mother has a #enetic relation to the child. 4he wants to &oid the contract after the %a%y is %orn. Is she allowed to %reach the contract@ (Important! Answer$ yes. 4urro#ate contracts, while permissi%le, should #rant the %irth mother the ri#ht to &oid the contract within a reasona%le period of time after the %irth of the child. =(. A surro#ate pre#nant mother si#ned a surro#acy contract with a couple. Both male and female parents #a&e sperm and o&ums respecti&ely. The surro#ate mother wants to &oid the contract and she has no #enetic relation. Is she allowed to %reach the contract@ (Important! Answer$ no. Denetic parents ha&e e clusi&e custody and parental ri#hts. =1. A surro#ate pre#nant mother si#ned a surro#acy contract with a couple. The couple #ot di&orced. 5ale partner #a&e sperms and the female partner #a&e o&ums. They do not want to continue the surro#ate pre#nancy. 3hat should %e the decision at this point@ (Important! Answer$ the couple is #enetically related to the fetus. They ha&e the ri#ht not to continue with this pre#nancy. =2. A surro#ate pre#nant mother si#ned a surro#acy contract with a couple. The couple #ot di&orced. 5ale partner #a&e sperms %ut the female partner could not #i&e o&ums. They do not want to continue the surro#ate pre#nancy. 3hat should %e the decision at this point@ (Important! Answer$ female partner has no ri#ht to terminate this pre#nancy %ecause she has no #enetic relation. 4urro#ate mother has #enetic relation and she has the ri#ht to continue this pre#nancy e&en if the male partner disa#rees. ='. A '-year old #irl is dia#nosed with %lood cancer. 4he has %een waitin# for an um%ilical cord transfusion. *er mother deli&ered a new%orn %a%y #irl. Am%ilical cord

%lood was o%tained and was transfused to the '-year old si%lin#. 3hat is the duty of the physician@ Answer$ physician should o%tain an informed consent of the risks of donation and he or she should follow the normal um%ilical cord clampin# protocol. -hysician should protect %oth the children. =/. A '1-year old man has decided to donate one of his kidneys for a lar#e amount of money. Is this the ri#ht decision@ Answer$ no. *owe&er, the donor can recei&e some payment to co&er his medical e penses. +nly the potential donor not the donor2s family or another third party may accept financial incenti&e. -ayment should occur only after the or#ans ha&e %een retrie&ed and 8ud#e medically suita%le for transplantation. =5. A couple has decided to ha&e a child throu#h artificial insemination. They asked the physician for se selection of the child. 3hat should a physician ad&ise in this situation@ (Important! Answer$ physician should not participate for se selection for reasons of #ender preference. *owe&er, se selection of sperm for the purpose of a&oidin# a se -linked inherita%le disease is appropriate. =). A '(-year old man has donated his sperms which were kept frozen. *e died in a car accident. *e did not lea&e any specific instructions re#ardin# sperm donations. *is wife wants to make use of them. A woman re.uested her to donate his sperms. 3hat is the appropriate decision@ (Important! Answer$ the donor2s wife can use the semen for artificial insemination %ut not to donate it to someone else. The donor should #i&e clear instructions at the time of donation. The donor has the power to o&erride any decision. =0. The donor and recipient of sperms are not married. 3ho would %e considered the sole parent of the child@ (Important! Answer$ the recipient. 6 cept in cases where %oth donor and recipient a#ree to reco#nize a paternity ri#ht. ==. The residents and medical students were asked %y an attendin# to follow certain orders for a patient. The residents and medical students %elie&e the orders reflect serious errors in clinical or ethical 8ud#ment. 3hat is the appropriate way to handle the situation@ (Important! Answer$ The residents and medical students should not follow those orders. They should discuss with the attendin# issuin# those orders. They should also discuss the situation with a senior attendin# physician, a chief of staff, or a chief resident. =>. A physician used a newly prescri%ed dru# to his patient. The patient #ot sick after the dru# was in#ested and re.uired hospitalization. 4hould the physician report this dru#2s side effect to C:A (Cood and :ru# Administration!@ (Important! Answer$ yes. C:A should %e notified only if the dru# causes serious ad&erse e&ents such as those resultin# in death, hospitalization, or medical or sur#ical inter&ention. >(. A '>-year old female has %een sufferin# from chronic cholecystitis. The sur#eon ad&ised cholecystectomy. The patient wants a second opinion. The sur#eon a#reed. The patient went to another sur#eon and has decided to %e operated %y the second sur#eon. 3hat should the second sur#eon do in this situation@ (Important! Answer$ the second sur#eon should accept the patient %ecause the patient has the ri#ht to choose the sur#eon. Cirst sur#eon should accept the patient2s decision.

>1. A /5-year old male was admitted to the hospital with mild chest pain. *e wants to lea&e the hospital %efore completion of therapy. *ow do you mana#e the patient@ (Important! Answer$ The patient is asked to si#n a statement that he is lea&in# a#ainst medical ad&ice (A5A!. The patient may howe&er lea&e without si#nin# that statement. This document is a le#al e&idence that the patient was warned %y the physician a%out the risk of lea&in#. -lease remem%er, dischar#e A5A does not apply to children. >2. A 55-year old man re.uested his physician to misrepresent his medical condition to recei&e disa%ility or insurance payment. 3hat is the appropriate response of the physician in this situation@ Answer$ The physician must refuse that re.uest. >'. 3hat is the responsi%ility of a fellow physician who is aware of dru# a%use, alcohol a%use, or psychiatric illness of his collea#ues or of a medical condition that is harmful to patients@ (;ery Important! Answer$ the physician should protect the patients. The fellow physician should report to the appropriate authority ( i.e., report to the hospital authorityF report to the :ean for a medical student2s pro%lem!. >/. A )(-year old male has %een sufferin# from se&ere pain due to terminal prostate cancer. The patient is recei&in# lower doses of narcotics and sedati&es. *ow can a physician relie&e his sufferin#@ (Important! Answer$ The physician should increase the dosa#e of narcotics and sedati&es up to the ma imum recommended amount. The sufferin# can %e reduced %y listenin#, spendin# more time with him, and reducin# psycholo#ical distress. >5. A 25-year old female medical student or resident noticed a mistake made %y a 8unior attendin# physician durin# rounds. 4he is afraid of that attendin# physician. 3hat is the appropriate way to handle the situation@ (Important! Answer$ 4he should discuss the situation with a more senior attendin# physician for appropriate interpretation, ad&ice, and assistance. >). A 2)-year old male medical student or resident made a mistake durin# patient care. *e is afraid of what mi#ht result. 3hat is the appropriate way to handle the situation@ Answer$ *e should disclose the mistake to the attendin# physician and try to learn from that mistake. The patient should %e notified as well. >0. A )'-year old female health care worker is concerned a%out takin# care of patients with *I; infection or multidru#-resistant tu%erculosis. 3hat is the appropriate way to handle the situation@ (Important! Answer$ The physician should pro&ide appropriate care to patients despite personal risk. Institutions should reduce the risk of infection %y appropriate e.uipment, super&ision, and trainin#. *er concern should %e taken seriously. >=. A '(-year old male physician has an opportunity for financial incenti&e if he sees more patients and refers them unnecessarily. 3hat is you opinion a%out this@ Answer$ The physician should pro&ide only care that is in the patient2s %est interest. >>. Two physicians are discussin# a case inside the ele&ator of a hospital. 3hat is your opinion a%out this@ Answer$ They should not do that %ecause they ha&e to maintain the patient2s confidentiality.

1((. The patient2s confidentiality should %e maintained e cept in the followin# situations$ -hysicians should o&erride third parties in case of domestic &iolence, child a%use, elderly a%use, #unshot wounds, syphilis, and tu%erculosis. They should report these cases to appropriate #o&ernmental authorities. 1(1. A physician is e periencin# a &ery difficult ethical issue re#ardin# a complicated case. *e is confused. 3hat should %e the ne t step@ Answer$ he should discuss the matter with other faculty mem%ers in his health care team, collea#ues, or hospital ethics committee. 1(2. 3hat is the final plan of action in an ethical issue@ Answer$ Both patient and physician should a#ree re#ardin# final mana#ement. The patient should %e well-informed a%out the medical condition. The physician should %e sympathetic and knowled#ea%le re#ardin# the rele&ant medical condition. 1('. :"7 (do not resuscitate! order. This is appropriate if the patient or surro#ate si#ned that order or if 9-7 (cardiopulmonary resuscitation! would %e futile. -hysicians should write :"7 orders and the reason for them in the chart. -lease remem%er, GslowG or GshowG codes are not accepta%le. Coods and fluids are considered therapies that should %e stopped. (Important! 1(/. (A!Brain death (adult!$ (Important! (i! :efinition %y the -resident2s 9ommittee$ :eath is an irre&ersi%le cessation of circulation and respiratory functions or irre&ersi%le cessation of all functions of the entire %rain and %rain stem. (ii! The criteria of %rain death %y the staff of 5assachusetts Deneral *ospital and the *ar&ard 9ommittee$ :eath occurs when there is a%sence of all si#ns of recepti&ity, responsi&ity, and all %rainstem refle es, and the 66D is isoelectric. 4ometimes meta%olic disorders and into ications may mimic the a%o&e findin#s. (iii! The #uidelines of %rain death$ (a! The dia#nosis should %e made also %y another physician and confirmed %y clinical findin#s and 66D. (%! The family should %e notified. They should not make the decision a%out discontinuin# medical treatment e cept in a situation where the patient has directed the family to make the decision. (c! The physician should discuss with another physician %efore remo&in# supporti&e measures (e.#., &entilators!. (d! Camily mem%ers may re.uest or#an donation, and in many states physicians may re.uest the family to make an or#an donation. (B! Brain death (children!$ (i! :efinition$ same as in adults. (ii! 9riteria$ similar in children and adults, %ut the period of o%ser&ation is lon#er in children. 9hildren 1wk-2mo of a#e$ two separate e aminations /= hours apart 9hildren 2mo-1yr of a#e$ two separate e aminations 2/ hours apart 9hildren more than 1 yr of a#e$ two separate e aminations 12 hours apart 4pontaneous mo&ements must %e a%sent, with the e ception of spinal cord refle withdrawal and myocolnus.

Deneralized flaccidity should %e present. The presence of clinical criteria for 2 days in term and ' days in preterm infants indicates %rain death in ma8ority of asphy iated new%orns. The a%sence of cere%ral %lood flow on radionuclide scan and silence of electrical acti&ity on 66D are not always o%ser&ed in %rain-dead new%orns. There is no uni&ersal consensus a%out the definition of neonatal %rain death. The decision is made after discussion with the family and health care team. If there is difference of opinion, the ethics committee should %e consulted. The decision is made on the %asis of what is in the %est interest of the infants and children. 1(5. -ractice #uidelines for physicians$ (i! The %est way to practice medicine is to select useful dia#nostic techni.ues and therapeutic measures which are most appropriate to a particular patient and clinical condition. (ii! -ractice #uidelines can reduce the health care costs, which impro&es health care to patients who e&en do not ha&e ade.uate health care %enefits. (iii! -lease remem%er, #uidelines do not and should not %e the only way of mana#in# an indi&idual patient. 1(). 4ome important points a%out patients$ (i! Cor a patient with an incura%le disease, the ma8or #oal of therapy should %e the enhancement of the .uality of life. (ii! The patient care %e#ins with a personal relationship %etween the patient and the physician. If a patient has confidence on the physician, reassurance may %e the %est therapy. The patient must understand that the physician is #i&in# the %est possi%le care a&aila%le. 1(0. -atients who do not ha&e decision-makin# capacity a%out their medical care$ The patients who do not ha&e decision-makin# capacity usually arran#e for surro#ates who make decisions for them. Their choices depend on their &alues. -sychiatrists are helpful in mentally impaired patients. Camily mem%ers are usually the surro#ates, %ecause they know the patients &ery well Ad&anced directi&es$ statements made in ad&ance in case patients lose their decisionmakin# capacity in the future. These directi&es indicate the names of surro#ates and which inter&entions are accepta%le or not accepta%le to them. These are achie&ed %y oral con&ersation (most common form!, li&in# will, health care power of attorney, or physicians can ask the patient in ad&ance. A%sence of ad&ance directi&es and surro#ates$ physicians can make the decision usin# all information and should respect the patient2s &alues. -hysicians must know the laws of the state in which they practice. -atient preferences are known$ The decision is made with the patient2s %est interest in mind. :isa#reements %etween potential surro#ates or %etween the physician and surro#ate$ -hysicians can consult with the hospital ethics committee or with other physicians. The courts should %e only the last resort. 1(=. :own syndrome with different medical conditions$ (;ery Important! (a! :uodenal atresia at %irth$ sur#ical repair is recommended as it is done re#ularly. (%! ;4: (&entricular septal defect! in new%orn period$ initial conser&ati&e medicals mana#ement is followed %y sur#ical repair as it is done re#ularly.

(c! 9yanotic heart disease at %irth$ immediate medical mana#ement, which is followed %y sur#ical repair as it is re.uired routinely. (d! 9osmetic sur#ical condition (e.#., rhinophyma or %i# nose!$ there is no ur#ency to repair the underlyin# condition, %ut it can %e done as it is performed re#ularly. (e! "eural tu%e defects (e.#., menin#omyelocele!$ sur#ical repair is recommended as it is done re#ularly. -lease remem%er, a patient2s mana#ement should %e discussed with hisHher parents and the decision made with the %est interest of the patient in mind. 1(>. A healthy male patient with :own 4yndrome li&es independently. *e went to a doctor for facial cosmetic sur#ery. 9an he make his own decision@ (Important! Answer$ yes. The patient can make his decision if he understands the procedure and the conse.uences. *e li&es independently which indicates that he is capa%le of makin# his own decision. 11(. A patient went to the doctor due to throat pain. The doctor asked the patient what her pro%lem was. The patient said that she woke up at si o2clock in the mornin#, went to the %athroom, ate %reakfast, and went to drop her children at school. 4he then came %ack home, stared cookin# and continues to talk a%out irrele&ant thin#s. 3hat should the doctor do to stop the patient from ram%lin#@ (Important! Answer$ the doctor should ask the patient to tell him what pro%lems she has related only to her throat. 111. A patient went to a doctor for a%dominal pain %ut remained .uiet throu#hout the &isit. *e did not tell the doctor enou#h a%out his symptoms. 3hat should the doctor do@ (Important! Answer$ the doctor must ask the patient detailed .uestions a%out his a%dominal pain. It is the doctor2s o%li#ation to find out as much as he can a%out the patient. 3ithout enou#h information, the doctor will not %e a%le to make an accurate dia#nosis. 112. A patient walked into his doctor2s office with acute a%dominal pain. *e has %een sufferin# from ulcerati&e colitis. The patient is noncompliant and did not &isit for the past si months. 3hat should the doctor do in this situation@ (;ery Important! Answer$ The doctor should find out more a%out the patient2s a%dominal pain %efore makin# any other decision. The doctor should always %e responsi%le with the patients. 11'. A terminally ill pancreatic cancer patient with multiple metastasis is admitted to the hospital. *e is in critical condition. The patient wants to know his pro#nosis. 3hat should the doctor say@ Answer$ the doctor should tell the patient politely that he will discuss his condition with him and his family. The doctor should ne&er specify the lon#e&ity of the patient. The doctor should tell the truth e&en when the patient is a child. The doctor should not hide any medical information from the patient. 11/. A patient is recently dia#nosed with cancer. *e is ner&ous %ut is ea#er to know a%out his medical dia#nosis. 3hat should the doctor2s reply %e@ (Important! Answer$ the doctor should #ently tell the patient his condition. 115. A patient is recently dia#nosed with cancer. -re&iously, he had an episode of a ner&ous %reakdown after hearin# a family death and had to %e admitted to a hospital. *e lo&es his family mem%ers and tends to %e &ery open with them on all issues. *ow should the doctor tell the patient a%out his current state@ (Important!

Answer$ the doctor should call his family mem%ers and discuss the patient2s medical condition openly and politely. 11). A male patient was admitted with se&ere myocardial infarction. *e was admitted to the I9A and his condition is &ery critical. *e does not know the reason for his admission. The patient is unsta%le. 3hat should the doctor tell the patient@ (Important! Answer$ the doctor should wait until the patient is sta%ilized and then #ently tell him his medical condition. 110. A mother #a&e %irth to a premature %a%y who was admitted to the "I9A (neonatal intensi&e care unit!. The %a%y is on a mechanical &entilator. The mother wants to hold the %a%y. 3hat should the doctor do in this situation@ (Important! Answer$ the mother should %e allowed to hold the %a%y. 11=. A male patient is recently dia#nosed with *I;. 4hould the doctor ask a%out his se ual orientation (i.e., male, female, or %oth!@ (Important! Answer$ yes, the doctor should ask the patient directly %ut politely a%out his se ual orientation. 11>. A homose ual male patient went to a doctor. The patient2s partner was recently dia#nosed with *I;. 4hould the doctor ask the patient whether he is %ein# penetrated %y his partner or he penetrates his partner@ Answer$ yes, %ecause the person who is %ein# penetrated has a hi#her incidence of *I; due to trauma in perispam area. 12(. A )-year old %oy comes to the 67 after drownin#. *e e pired in the 67 despite appropriate resuscitations. The family mem%ers %ecame an#ry which is a reflection of a sense if #uilt and helplessness. 3hat is the appropriate way of #i&in# information to the family mem%ers@ Answer$ the physician should #i&e the information clearly and compassionately when there is no hope for sur&i&al. -arents need to know that e&erythin# was done to sa&e the child. 121. A pre#nant woman who is 7h(-!&e %ecame sensitized. 4he had *H+ induced a%ortions. *er hus%and is not aware of his wife2s pre&ious a%ortions. *e wants to know from the physician how she %ecame sensitized. (;ery Important! Answer$ the physician should tell the man to ask his wife. The physician should not mention anythin# a%out the patient2s *H+ a%ortions. 122. A mother %rou#ht her infant to the 67. The radiolo#ist test re&eals old fractures of the ri%s. 4he did not know anythin# a%out that. (;ery Important! Answer$ this is a case of child a%use. This case should %e reported to child welfare a#ency. 12'. A physician is e aminin# a child with respiratory distress. The child2s mother %ecame an ious durin# the physical e amination. -lease remem%er, a patient2s mana#ement should %e discussed with hisHher parents and the decision made with the %est interest of the patient in mind. (Important! Answer$ child a%use. 12/. A mentally retarded patient %ecame pre#nant. The patient does not want an a%ortion. *er mother and hus%and want an a%ortion. 3hat should a physician do in this situation@ (Important! Answer$ a%ortion should not %e performed.

125. A male physician is e aminin# an adolescent or adult female patient. 3hat should a physician do in this situation@ (Important! Answer$ a chaperone should %e present durin# the physical e amination. The same rules apply when a physician is e aminin# a patient who appears to %e seducti&e. (Important! 12). A female physician is e aminin# an adolescent or adult male patient. 3hat should a physician do in this situation@ (Important! Answer$ a chaperone should not %e present durin# the physical e am. 120. A suspected *I; patient e pired in a car accident. *e si#ned for or#an donations. 3hat should a physician do in this situation@ Answer$ his *I; status is not certain. The or#ans can %e preser&ed until the *I; status is confirmed. If the test for *I; is positi&e, or#ans should %e discarded. 12=. A patient who e pired in a car accident si#ned in his license foe or#an donations. *is license has e pired. *e always wanted to donate his or#ans. 3hat should a physician do in this situation@ (Important! Answer$ physican cannot accept or#ans %ecause the si#ned consent has e pired. 12>. A male physician se ually harassed a female patient durin# the physical e amination. The patient complained to a nurse. 3hat should the nurse do in this situation@ Answer$ the nurse should tell the patient to make an official report to the hospital authority or to an appropriate a#ency. 1'(. A chronic male smoker comes to the physician for his heart pro%lems. The physician wanted his patient to .uit smokin#. 3hat should the physician ad&ise in this situation@ Answer$ the physician should ask the patient to .uit smokin# immediately %ecause patients are usually more responsi&e when they are ill. The physician should assist the smoker to mo&e one step closer to .uittin#. 1'1. A terminally ill patient did not si#n a :"7 (do not resuscitate! order, howe&er, he si#ned a :"I (do not intu%ate! order. 3hat should the physician do in this situation@ Answer$ the physician should follow his orders i.e., the patient should %e resuscitated %ut should not %e intu%ated, despite se&ere hypo ic condition of the patient. 1'2. A terminally ill patient si#ned a :"7 order, howe&er, he did not si#n a :"I (do not intu%ate! order. *e wants to %e intu%ated %ut not resuscitated. 3hat should a physician do in this situation@ Answer$ the physician should follow his orders i.e., the patient should %e intu%ated %ut should not %e resuscitated. 1''. An adolescent car accident &ictim was %rou#ht to the 67 in an unconscious state. The patient needs immediate sur#ical inter&entions. The sur#eon was una%le to contact any family mem%er to o%tain consent. 3hat should a sur#eon do in this situation@ (Important! Answer$ the sur#eon should do the procedure without waitin# to o%tain a consent for the %enefit of the patient. 1'/. An o%#yn doctor is recently dia#nosed with *I; infection. *e is recei&in# medication for *I;. *is physical and mental conditions are normal. 4hould he tell his patients or fellow physicians a%out his *I; status@ Answer$ no, howe&er, the doctor should take appropriate precautions for infection control. *e does not ha&e to tell his fellow physicians a%out his *I; status includin# the

physicians who are referrin# patients to him. The doctor is allowed to see patients if he takes appropriate precautions. *owe&er, he should notify the hospital authority. 1'5. A physician is scared of seein# an *I; patient with an open wound. 9an a physician refuse to see a patient@ Answer$ yes, howe&er, a physician2s refusal to see a patient is unethical %ut is le#al. 1'). An elderly semicomatose patient may re.uire sur#ical inter&ention. *is family mem%ers are confused a%out the sur#ery. They asked the sur#eon for his opinion. 3hat should the sur#eon2s response %e@ Answer$ the sur#eon can #i&e his opinion and act as a moral surro#ate for the %enefit of the patient. (;ery Important! 1'0. A 12-year old %oy is dia#nosed with a terminal illness (e.#., mali#nancy!. *e asked the doctor a%out his pro#nosis. *is parents re.uested the doctor not to tell him the %ad news. 3hat should the doctor do in this situation@ (;ery Important! Answer$ the doctor should tell the truth politely and compassionately to the patient. 1'=. A 55-year old woman is recently dia#nosed with ri#ht %reast cancer. The doctor told the patient that she will re.uire sur#ery for remo&al of the ri#ht %reast. 4he started to cry. 3hat should a doctor do in this situation@ Answer$ first, the doctor should #i&e her some tissue paper for wipin# her tears. Then, the doctor should %e sympathetic to her and console her. *e mi#ht tell her that similar reactions are usually e pected from other patients with %reast cancer. -lease do not mention that she will %e fine with a %reast implant or without a ri#ht %reast %ecause she is already 55-years old. 1'>. A mother is carryin# a 5(( #ram premature fetus which de&elops acute fetal distress. The physician wanted to perform a cesarean section. 5other refused cesarean section. 3hat should the doctor do in this situation@ Answer$ the physician should arran#e a %edside conference with the mother alon# with other physicians, social worker, and administrator to discuss the matter. 1/(. <ou are a resident at the 67. An irate parent comes to you furious %ecause the social worker has %een askin# him a%out strikin# his child. The child is a 5 yr old who has %een in the 67 / times this year with se&eral episodes of trauma that did not seem related. Today, the child is %rou#ht with a complaint of Islippin# into a hot %athtu%J with a %urn wound on his le#s. The parent threatens to sue you K saysJ how dare you think that a%out me , I lo&e my son BJ. 3hat should you do@ a. #i&e assurance to the parents K treat the patientLs in8ury appropriately %. ask risk mana#ement to e&aluate the case c. admit the child to remo&e him from possi%ly dan#erous en&ironment

d. call the police e. ask the father yourself if there has %een any a%use f. speak to the wife pri&ately a%out possi%le episodes of a%use #. e plain to the parents that ne t time this happens you will ha&e to call child protecti&e ser&ices h. report the family to child protecti&e ser&ices i. #i&e the parents referral to a family therapist they can see with the child the foll week

Answer$ *. report the family to child protecti&e ser&ices. 7eportin# of child a%use is mandatory e&en %ased on suspicion alone. The physician is le#ally protected e&en if it turns out to %e no a%use as lon# as the report was made honestly and without malice. <ou do not ha&e the authority to remo&e the child from the parents only the child protecti&e ser&ices or the courts can do that. The police should %e called if the assault is happenin# at the e act moment, %ut the police are not appropriate to in&esti#ate child a%use. 3hen u ha&e suspicion of child a%use, it doesnLt matter what parents ha&e to say. That is why talkin# directly to the mother or father is incorrect. 5any answered :. call the police thinkin# that they ha&e to protect the doctor as well as the child. G call the police G refers to the child a%use not Gassault of the doctorG . hospital security can take care of the father if he is assaultin# the doctor, the child is not in any imminent dan#er as lon# as he is in the hospital

1/1. 2. <our patient has 8ust recently %een dia#nosed with familial adenomatous polyposis

(CA-!. The patient has %ecome di&orced and refuses to #i&e you consent to inform his e wife who now has custody of their children. *e threatens to sue u if u re&eal elements of his medical care to his e -wife. 3hat should u do@ a.respect the patients ri#ht to confidentiality. %.transfer the patientLs care to another physician c.ask the health dept to inform the e -wife d.seek a court order to inform the e -wife e.inform the e -wife of the risk to the children. f.inform the e -wifeFs doctor Ans$e. inform the e -wife of the risk to the children The patients ri#ht to confidentiality ends when it comes into conflict with the safety of other people. The children ha&e a ri#ht to know whether their li&es will %e cut short %y the disease.The most important element is to %e#in screenin# at 12 yrs with si#moidoscopy e&ery year. In addition the mother has a ri#ht to know whether her children will %e come ill K how to plan that. As a part of di&orce ,the stipulation that each parent must inform the other parent of health care issues for the children as they arise is a standard part of the a#reement. The ri#ht to one personLs pri&acy is not as important as the ri#ht to another persons safety. this is an esta%lished standard K does not re.uire a court order. <ou will ha&e more lia%ility from the e -wife if you :+ "+T inform than &iolatin# the confidentiality of the patient.The health dept does not do notification of #enetic diseases. It notifies partners and the population at risk of transmissi%le diseases such as TB,*I;,4T:s and food and water %orne diseases

1/2. <ou are seein# a pt who has TB.he is undocumented (ille#al ! immi#rant .*is family will need to %e screened for TB with --: testin#. *e is fri#htened of %ein# deported if

the dept of health learns of his ille#al status. 3hat should u tell him @ a.dont worry the dept of health does not ask or report immi#ration status %.only people who are noncompliant with medications are reported to the #o&t. c.dont worry I will fully treat u %efore we deport u. d.iam sorry %ut there is nothin# I can do a%out this. There is mandatory reportin# of TB Ans$A. dont worry the dept of health does not ask or report immi#ration status. The immi#ration status is not the concern of the physician or the dept of health. There Is not mandatory reportin# to the #o&t either %efore ,durin# or after the treatment of TB. Incarceration to take TB medications may occur for a noncompliant patient %ut they do not specifically face deportation for health reasons. Actually impaired health is one of the #ranta%le reasons for asylum. 5andatory reportin# to immi#ration status would %e a direct impairment of physician Hpt relationship.

1/'. A couple comes to see you after ha&in# tried in&itro fertilization K artificial insemination. They are &ery happy %ecause now they ha&e a child. They ha&e a si#nificant amount of left o&er sperm ,e##s, and some fertilized em%ryos K are thinkin# a%out sellin# them. 3hat should u tell them@ a.it is le#al to sell only e##s %.it is le#al to sell only sperm c.it is le#al to sell %oth the sperm and e##s not the em%ryos d,it is ille#al to sell any of them

e.it is le#al to sell all of them Ans.9, it is le#al to sell %oth the sperm and e##s not the em%ryos. The pt can sell or donate unfertilized #ametes such as sperm K e##s. An em%ryo can also %e donated , howe&er it is currently ille#al to sell em%ryos.

1//. <ou ha&e a pt with se&ere 54 that is ad&anced K pro#ressi&e who now de&elops renal failure secondary to :5, the pt is alert K has erected to put :"7 order in place at her own discretion. The pts M le&els are now ele&ated at = me.Hl. 3hich of the followin# is most appropriate@ a.dialysis cannot %e done %ecause of the :"7order %.you can do the dialysis if the :"7 is re&ersed for the procedure c.#o ahead with the dialysis, i#nore the :"7 order d.Di&e kaye alate until :"7 status is discussed with the family. Ans$ c.#o ahead with the dialysis, i#nore the :"7 order A :"7 order is &ery specifically defined as refrainin# from 9-7 efforts such as chest compressions ,anti arrythmics medications, or electrical cardio&ersion in the e&ent of cardiac arrest. A :"7 order has nothin# to do with any other forms of care.<ou should pretend the :"7 order does not e ist while e&aluatin# the use for dialysis. *yperkalemia is life threatenin#. It is illo#ical to use an inferior therapy such as kaye alate. The ptFs family is not rele&ant in makin# the decision if the pt has the capacity to understand his or her own medical pro%lems.

1/5. A '5 yr old female comes to your office with a lar#e form to %e filled certifyin# that she is in #ood health. This is part of her pre employment e&aluation. The form also asks for the results of the patientFs adenomatous polyposis coli #ene. This is in order for the company to deternmisne which of its lon# term employees will need care. 3hat should %e your response@ a.perform the test

%perform the test %ut do not share the results with the employer. c., do not perform the test d.ask the pt if she wants the test done and the results reported. e. perform the colonoscopy ,the employer is entitiled to know a%out current health pro%lems not future ones, f.include the test only if pt has family mem%ers with the disease. Ans. d.ask the pt if she wants the test done and the results reported 6mpoyers do not ha&e the ri#ht to the confidential health info. you may perform certain tests K report them to the employer with the consent of the pt.

1/). <ou ha&e a pt who is a *I; N physician. *e has recently found out his status K you are the only one who know a%out it. 3ho are u le#ally o%li#ated to inform@@ a.his insurance company %.state #o&t. c.his patients d.his patients only if he performs sur#ery where transmission is possi%le e.no one without his written consent f.his employer #.the hospital *7 dept. Ans$ e.no one without his written consent. patients with *I; ha&e a ri#ht to pri&acy as lon# as they are not puttin# others at risk. you ha&e "+ 5A":AT+7< +BOIDATI+" to inform the state, his insurance or his employer. <ou and the patient :+ "+T *A;6 A 5A":AT+7< +BOIDATI+" to inform his patients of his *I; status e&en if he is a sur#eon. this is %ecause a *I; N physician poses

"+ si#nificant risk of transmission to the patient. Ani&ersal precautions are supposed to pre&ail in order to pre&ent transmission. 6&ery patient re.uires mana#ement as if he were *I; N in order to interrupt transmission. this is the meanin# of Guni&ersalG precautions

1/0. <ou are a resident mana#in# a pt with cellulitis . the pt has a history of 99C and a normal 6MD. The pt is on di#o in, A96 inhi%itor K diuretic %ut not a %eta %locker. <ou cannot find a 9I to the use of a %eta %locker in the chart or in discussion with pt. u ask the attendin# why there is no %eta %locker K he looks at u as if u had an ano ic encephalopathy., he says I I ha&e %een in practice for /( yrs , donLt u think I know what am doin# @@@@@.%eta %lockers are dan#erous in 99CJJ. The pt looks proudly at the attendin# K says I I ha&e the smartest doctor in the worldJ. 3hat should u do@@ a.wait for the attendin# to lea&e K #i&e pt a prescription for car&edilol %.su##est the pt tofind another doctor. c.report the physician to the state licensin# %oard d.do nothin# he is the attendin# on record e.%rin# the disa#reement to the chief of staff f.help the pt find a #ood lawyer K &olunteer to testify. Ans. e.%rin# the disa#reement to the chief of staff <our first duty if to the pt. howe&er u cannot dama#e the physician Hpt relations ship %etween the attendin# K pt. u cannot chan#e therapy without his knowled#e

1/=. A /0 yr old man with end sta#e renal failure has asked u to stop his dialysis. The pt fully understands he will die if dialysis is stopped for more than a few days or weeks . he is not depressed and not encephalopathic 3hat should u tell him@ a.I need a court order first %.iam sorry ,I donLt feel comforta%le doin# that. c.I cant do that. -hysician assisted suicide is not ethical. d.I will stop when u #et a kidney transplant e.Althou#h I disa#ree with your decision I will stop dialysis. Ans $ 6. Althou#h I disa#ree with your decision I will stop dialysis the patient is competent K wishes dialysis to %e stopped. he is not #oin# to die the ne t moment or the comin# hours, so it is not physician assisted suicide, anyway, #oin# to the courts or ethics %oard, we should keep as our last option. if pt in coma, family mem%ers ha&e conflict of interest K pt has no written order, then we #o to the ethics %oard, then to court , etc,......

1/>. A patient comes to the 67 with a #un shot wound in his thi#h. *e says he was shot accidentally while huntin# with his cousin . <ou treat the wound K #i&e him anti%iotics. 3hat should u do now@ a.report to the police %.do not report to the police c.it was accidental ,so It does not warrant to report d.encoura#e the patient to report to the police e report only if patient consents to it. Ans$ A report to the police

7eportin# of #un shot wounds is mandatory %ut from a different perspecti&e than other forms of reportin#. The mandatory reportin# is %ased on pursuin# a criminal in&esti#ation of the person# doin# the shootin#. 7eport e&en if the &ictim o%8ects. The societal need for safety supersedes the pri&acy of the patient in the case of #unshot wounds.

15(. <ou are a / yr medical student with a pt who has %een in a se&ere motor &ehicle accident. the pt has a su%dural hematoma that led to cere%ral herniation %efore it coudl %e drained. o&er the last few days ,the pt has lost all %rain stem refle es nas is now %rain dead. i ha&e the closest relationship with the family than anyone on the team. the &entilator is to %e remo&ed soon and or#an donation is considered. who should ask for consent for or#an donation@@@ a.you, %ecause you hae& the %est relationship with the family % the resident since u are only a student c.attendin# on record d.hospital administration e.or#an donor network. Ans$e. or#an donor network The rules concernin# or#an donation are .uite specific that the medical team takin# care of the pt 5A4T "+T %e the ones askin# for the donation. This is a conflict of interest. 3e as physicians must play our role is preser&in# life. The or#an donor network doin# the askin# %oth preser&es the ethical inte#rity of the medical team in the eyes of the family as well as markedly increasin# the supply of &ia%le or#ans a&aila%le for donation.

151. A man arri&es at the 67 on a &entilator after an accident. *e is %rain dead %y all

criteria. *e has an or#an donor card in his wallet indicatin# his desire to donate. The or#an donor team contacts the family. The family refuses to si#n consent for donation. 3hat should %e done@@ a.remo&e or#ans anyway %.wait for the pts heart to stop to remo&e or#ans. c.4top the &entilator K remo&e or#ans d.4eek a court order to o&errule the family e.*onor the wishes of the family , no donation Ans.e-Althou#h an or#an donor card indicates ptFs wishes ,it is still unaccepta%le to har&est or#ans a#ainst the direct wishes of the family. If we were to o&errule the family, there would %e no point in askin# them consent. The or#an donor card is an indication of the ptFs wishes %ut it is not fully %indin#.

152. <ou are the staff physician in a state penitentiary in a state where capital punishment is le#al. An e ecution is in pro#ress K the warden calls u %ecause the technician is una%le to start the I; line. The warden wants u to start the line K super&ise the pharmacist. 3hat should u tell him@ A no pro%lem, I will start the line %.I can start the line %ut I will no push the medications c.I am sorry I cannot participate d.I can take care of all of it. Ans$9 .Iam sorry I cannot participate The ethical #uideline of the A5A e press clearly that the physician 9A""+T

-A7TI9I-AT6 in any action which would directly cause the death of the condemned or assist another indi&idual to directly cause the death of the condemned. This includes startin# I; lines, mi in# medications, formulatin# medication, administerin# , or e&en #i&in# technical ad&ice. It is in fact e&en unethical to o%ser&e an e ecution. *owe&er it is ethically permissi%le to #i&e an iolytic medications prior to the day of the e ecution to relie&e the sufferin# of the condemned.

15'. <ou ha&e %een in&ited toe participate in a Imedical 8eopardyJ #ame sponsored %y a pharmaceutical manufacuterer. the winners recei&e a 1((P #ift certificate to the medical school %ookstore. All the participants recei&e a stethoscope. The audience are participants recei&e a free meal. 3hich of the foll is most appropriate to accept@ A,all the #ifts %.only the meal c. only the stethoscope d.the meal ,stethoscope, not the #ift certificate e.none of it ans$ a all the #ifts #ifts under 1((P &alue are accepta%le. At the same time, personal items like scarf, paper wei#ht, etc, if pt #i&es to physician are also accepta%le. #ifts from patientsF are accepted so as to maintain the docHpt relationship.

15/. A 1) yr old female comes to your clinic .her pre#nancy test is N. 4he wants to start prenatal care with you . she is adamant that you keep the pre#nancy confidential from her

parents.what should u tell her@ a.i will #i&e u the care K keep the info confidential %. I will not mention it to your parents unless they ask , I cant lie c.iam sorry %u t I must tell them d.i will not tell your parents %ut I must inform the father of the %a%y. Ans$ a.i will #i&e u the care K keep the info confidential -renatal care is the #eneral e ception to the parental notification rule and consent for treatment of minors. <ou do not ha&e to inform the parents or the father of the %a%y. This confidentiality also e tends to protectin# the pt if the parents were to ask. The .uestion arose when we were discussin# this Q as to whether or not this patient is emancipated, The Q stem #i&es no indication of that.

6mancipated or not, we are not o%li#ated for parental notification in cases of 1.-re#nancy 2.9ontraception '.4u%stance a%use /.4T:s In an emer#ency dealin# with minors there is no need for parental consent. that came up, %ut this Q is not a%out consent ,it is a%out notification, they are 2 seperate entities. If there is an option of I encoura#e discussion with parentsJ that is the B64T choice. Althou#h there is no o%li#ation to notify parents, the A45O6 wants to Iencoura#e the pt to discuss with the parentsJ