Medical Ethics, Informed Consent & Capacity

The Four Core Principles of Medical Ethics

Autonomy: Respecting the patient’s right to make decisions regarding their own medical care, including refusal of life-sustaining treatment.
Beneficence: Acting in the patient’s best interest.
Non-maleficence: Primum non nocere — Do no harm.
Justice: Equitable, non-discriminatory distribution of healthcare resources.

Decision-Making Capacity vs Competency

Feature	Capacity	Competency
Evaluated By	Any licensed physician at the bedside	Judge / Court of law (Legal determination)
Duration	Dynamic: Can fluctuate with delirium, intoxication, metabolic encephalopathy	Static: Long-term legal status until reassessed
Scope	Decision-specific: A patient may have capacity to accept a blood draw but lack capacity to consent to complex neurosurgery	Global status

Four Elements Required for Capacity (CURB)

Communicate a clear and consistent choice.
Understand the relevant clinical information (diagnosis, proposed intervention, alternative options).
Reason rationally through consequences of choices.
Appreciate the personal reality of the illness and outcomes.

Surrogate Decision-Maker Hierarchy

When an adult patient lacks decision-making capacity:

flowchart TD
    Start["Patient Lacks Capacity"] --> AD{"Is there a valid Living Will or Advance Directive?"}
    AD -- Yes --> FollowAD["Follow Living Will / Advance Directive"]
    AD -- No --> DPOA{"Is there a Designated Durable Power of Attorney (Healthcare Proxy)?"}
    DPOA -- Yes --> FollowDPOA["Follow Healthcare Proxy's Decision (Substituted Judgment)"]
    DPOA -- No --> Hierarchy["Statutory Surrogate Hierarchy"]

    Hierarchy --> S1["1. Spouse / Domestic Partner"]
    S1 --> S2["2. Adult Children (Majority Consensus)"]
    S2 --> S3["3. Parents"]
    S3 --> S4["4. Adult Siblings"]
    S4 --> S5["5. Nearest Living Adult Relative"]
    S5 --> S6["6. Court-Appointed Guardian / Ethics Committee"]

[!IMPORTANT] Substituted Judgment Standard: The surrogate must decide based on what the patient would have wanted, NOT what the surrogate prefers for themselves.

Confidentiality, HIPAA & Legal Disclosure Rules

Under the Health Insurance Portability and Accountability Act (HIPAA), Protected Health Information (PHI) may be disclosed without explicit patient authorization for three specific purposes:

Treatment: Coordinating care with consulting physicians, nurses, specialists, and pharmacists.
Payment: Transmitting diagnostic codes, clinical summaries, and billing records to the patient’s health insurance company or clearinghouse to adjudicate reimbursement claims.
Health Care Operations: Quality assessment, medical training audits, and legal compliance reviews.

Strict Prohibitions & Violations

Family & Spouses: Physicians cannot disclose diagnostic findings, pregnancy status, STI results, or substance abuse history to a spouse, partner, or family member without express, documented patient consent.
Employers: Health information cannot be released to an employer or supervisor without written authorization.
Medical Records Withholding: A medical clinic or hospital cannot hold medical records hostage or refuse to transfer records to a new physician because of unpaid medical bills. Patients own the right to their information; providers may charge only a reasonable, cost-based administrative copying fee.

Mandatory Exceptions to Confidentiality

flowchart TD
    Conf["Confidentiality Obligation"] --> Exc{"Is There a Mandatory Exception?"}

    Exc -- "Imminent Violent Threat" --> Tarasoff["Tarasoff Ruling: Warn & Protect identifiable victim + notify law enforcement"]
    Exc -- "Vulnerable Populations" --> Abuse["Child Abuse / Neglect or Elder Abuse: Immediate report to Protective Services"]
    Exc -- "Public Health" --> Reportable["Reportable Communicable Diseases: Syphilis, TB, HIV, Gonorrhea, Chlamydia to Dept of Health"]
    Exc -- "Public Safety" --> Driving["Impaired Drivers with uncontrolled epilepsy/syncope to DMV"]
    Exc -- "None of the above" --> Maintain["Maintain Strict Medical Confidentiality"]

Professional Conduct & Impaired Colleagues

The Impaired Physician Protocol:
- If a physician, resident, or nurse arrives intoxicated, smells of alcohol, or exhibits cognitive impairment while on duty:
  1. Immediate Action: Relieve the colleague from all clinical duties immediately to guarantee patient safety.
  2. Reporting: Report the incident promptly to the supervisor, residency program director, or the state Physician Health Program (PHP).
  3. The Trap: It is unethical and dangerous to ‘cover’ for a colleague, allow them to finish a case/shift, or confront them privately without reporting. Patient safety takes absolute precedence over colleague loyalty.

Category	Legal Status	Consent Authority
Emancipated Minor	Married, active-duty military, financially self-supporting living independently, or court decree	Full adult consent and refusal authority for all medical and surgical care.
Unemancipated Minor: Sensitive Services	Age < 18 residing with legal guardians	Can consent confidentially WITHOUT parental consent or notification: Contraception, STI screening & treatment, pregnancy care, substance abuse treatment, and outpatient mental health counseling.
Unemancipated Minor: Routine / Surgical Care	Age < 18 residing with legal guardians	Requires parental / guardian informed consent, plus minor’s assent when age-appropriate.
Emergency Exception	Life- or limb-threatening emergency in any minor	Implied consent: Proceed immediately with life-saving treatment without delaying for parental contact.

Communication Standards & Certified Medical Interpreters

Mandatory Protocol: In patients with limited English proficiency (LEP), always utilize a trained, certified medical interpreter (in-person, phone, or secure video).
The Step 3 Trap: Never utilize family members, spouses, children, or non-certified bilingual clinic staff to translate clinical encounters. Family members frequently filter distressing information, alter instructions, introduce critical translation errors, and violate patient autonomy and HIPAA privacy.

Billing Ethics, Copayments & Advance Directive Revocation

Insurance Copayment Waiver Fraud:
- Routinely waiving mandatory insurance copayments or coinsurance without verified, documented individual financial hardship constitutes health care billing fraud (violating federal Anti-Kickback and False Claims statutes).
- Providers cannot advertise medical services as “free” when billing an insurance carrier.
Revocation of Advance Directives:
- A patient has the absolute right to revoke or modify an advance directive or DNR order at any time, in any manner (verbally, in writing, or by physical destruction).
- Revocation does not require formal legal paperwork; a verbal statement to the treating physician (“I want full code now”) immediately supersedes any prior living will. Surrogates cannot override a valid directive unless explicitly authorized in the document.