Master Ethics & Law (GMC Guidelines)
for PLAB 1

Core Concepts

• Four Pillars of Medical Ethics (Beauchamp and Childress):
  • Autonomy: Patient's right to make their own informed decisions. Requires capacity.
  • Beneficence: Acting in the patient's best interest.
  • Non-maleficence: Do no harm.
  • Justice: Fair and equitable distribution of healthcare resources.
• Confidentiality: Duty to protect patient information.
  • Exceptions: Patient consent, public interest (e.g., unfit driver, serious crime), court order, statutory requirement.
• Consent (VIC): Must be Voluntary, Informed, and given by a person with Capacity.
  • Types: Implied (e.g., offering arm for BP), Expressed (verbal), Written (surgery).
  • Children:
    • Gillick Competence (Under 16): Can consent if they understand the proposed treatment/implications, even without parental consent. Doctors must assess.
    • Fraser Guidelines (Contraception for Under 16): Specific guidance for contraception without parental knowledge if Gillick competent and certain criteria met.
  • Advance Decisions to Refuse Treatment (ADRTs): Legally binding if valid (written, signed, witnessed, applies to situation, patient had capacity when made).
  • Lasting Power of Attorney (LPA) for Health & Welfare: Appointed by patient to make decisions if they lose capacity.
• Capacity (Mental Capacity Act 2005):
  • Two-Stage Test:
    1. Diagnostic: Does the person have an impairment of the mind or brain?
    2. Functional: Does this impairment mean they are unable to make a specific decision when needed? (Unable to understand information, retain information, weigh information, communicate decision).
  • Presumption of capacity. Decisions must be in patient's best interests if they lack capacity.
• Duty of Candour (GMC): Openness and honesty when something goes wrong with patient care, including explaining what happened, potential effects, and offering an apology.
• Raising Concerns (Whistleblowing): Professional duty to raise concerns about patient safety, colleague's conduct/performance (Public Interest Disclosure Act 1998 protects whistleblowers).
• Professionalism: Maintain boundaries, manage personal beliefs (cannot refuse treatment based on personal beliefs if it affects patient care), declare conflicts of interest.
• Record Keeping: Clear, accurate, contemporaneous, legible, attributable.

Clinical Presentation

• Patient refusing life-saving treatment (Autonomy, Capacity).
• Family requesting patient's medical information (Confidentiality).
• Concern about a colleague's substance misuse or poor practice (Raising Concerns).
• Adolescent requesting contraception without parental knowledge (Gillick/Fraser).
• Patient with fluctuating mental state requiring urgent decision (Capacity, Best Interests).
• Patient making a complaint about care received (Duty of Candour, Professionalism).
• Doctor asked to provide a report for court (Confidentiality, Record Keeping).
• Dilemma over allocating scarce resources (Justice).
• Managing an adverse event or medical error (Duty of Candour).

Diagnosis (Gold Standard)

Applying the ethical framework (Four Pillars) to the specific scenario. Performing a formal capacity assessment if doubt exists (MCA 2005). Identifying and referencing relevant GMC guidelines. Seeking advice from senior colleagues, ethics committees, or legal teams for complex cases. Documenting the entire decision-making process thoroughly.

Management (First Line)

• Patient-centred Approach: Prioritise the patient's best interests and autonomy.
• Communication: Engage in open, honest, and clear communication with the patient (or their LPA/next of kin if lacking capacity).
• Documentation: Maintain meticulous, contemporaneous records of all discussions, decisions, assessments (especially capacity), and rationale.
• GMC Guidelines: Always adhere to "Good Medical Practice" and specific GMC guidance relevant to the situation.
• Escalation & Discussion: Discuss complex ethical dilemmas with senior colleagues, the multidisciplinary team, ethics committees, or legal services.
• Reflection & Learning: Reflect on the situation and learn from outcomes, especially adverse events, in line with Duty of Candour.

Exam Red Flags