Conflicts of Ethical Principles

Core Principles Refresher

• Autonomy: Pt self-determination (overrides all if adult has decision-making capacity [DMC]).
• Beneficence: Act in Pt’s best interest.
• Non-maleficence: Do no harm / avoid inappropriate care.
• Justice: Fair distribution of healthcare resources.

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High-Yield Ethical Conflict Rules

1. Autonomy vs. Beneficence

• Adult w/ DMC Refuses Life-Saving Tx (e.g., Jehovah’s Witness blood refusal): Autonomy wins. Respect decision.
• Parent Refuses Life-Saving Tx for Minor: Beneficence wins. Override parents; give Tx immediately / get court order.
• Leaving AMA: Allow if DMC intact. Document risks + offer outpatient follow-up.

2. Autonomy vs. Non-Maleficence

• Pt Demands Harmful/Futile Tx (e.g., Abx for viral URTI, unnecessary opioids): Non-maleficence wins. Refuse inappropriate requests; offer safe options.
• Euthanasia / Assisted Suicide: Illegal on Step 2 CK. Refuse lethal doses.

3. Confidentiality vs. Public Safety (Non-Maleficence)

• Breach Confidentiality IMMEDIATELY for:
  • Tarasoff Rule: Specific, credible threat to harm a named individual (notify police + warn victim).
  • Reportable Communicable Diseases: HIV, Syphilis, TB, Measles (report to public health dept).
  • Impaired Driver / Colleague: Report to DMV / Physician Health Program.

4. Beneficence vs. Non-Maleficence

• Principle of Double Effect: Administer high-dose opioids for severe pain in terminal Pts, even if it secondarily risks respiratory depression/shortened life. Pain control is the priority.

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Surrogate Decision Hierarchy

1. Living Will / Advance Directives (Pt’s direct written wishes).
2. Healthcare Power of Attorney (HCPOA) (Designated surrogate).
3. Substituted Judgment (“What would the Pt choose?” based on prior statements).
4. Best-Interest Standard (“What is best for the Pt?” used if wishes unknown).