Master Medical Ethics & Patient Safety
for USMLE Step 3

Core Concepts

Medical ethics and patient safety are foundational to medical practice. Understanding these principles is crucial for navigating complex clinical scenarios and ensuring optimal patient care.

• Four Pillars of Medical Ethics:
  • Autonomy: Respecting a patient's right to make decisions about their own medical care, provided they have decision-making capacity.
  • Beneficence: Acting in the best interest of the patient; doing good.
  • Non-maleficence: "First, do no harm"; avoiding actions that cause harm.
  • Justice: Fair distribution of healthcare resources and fair treatment of patients.
• Informed Consent: Requires three elements: Capacity (ability to understand & appreciate information, reason, and make a choice), Voluntariness (absence of coercion), and adequate Information (risks, benefits, alternatives, prognosis). Implied in emergencies.
• Confidentiality (HIPAA): Protecting patient health information. Exceptions include duty to warn (Tarasoff), reportable diseases, child/elder abuse, court order.
• Advance Directives: Legal documents outlining patient wishes for future medical care.
  • Living Will: Specific instructions about medical treatment (e.g., no intubation).
  • Durable Power of Attorney for Healthcare (DPOA-HC)/Healthcare Proxy: Designates a surrogate decision-maker.
  • DNR/DNI: Do Not Resuscitate/Do Not Intubate orders.
• Decision-Making Capacity vs. Competency: Capacity is a clinical assessment made by a physician. Competency is a legal determination made by a court.
• Surrogate Decision-Making Hierarchy: (When patient lacks capacity) DPOA-HC/Healthcare Proxy > Legal Guardian > Spouse > Adult Children > Parents > Adult Siblings.
• Medical Futility: Interventions that are unlikely to achieve any physiological benefit or desired outcome.
• Patient Safety Terminology:
  • Adverse Event: Harm to a patient caused by medical care, not underlying condition.
  • Medical Error: Failure of a planned action to be completed as intended, or use of a wrong plan.
  • Near Miss: Error that could have caused harm but did not, either by chance or active prevention.
  • Sentinel Event: Unexpected occurrence involving death or serious physical/psychological injury, or risk thereof (e.g., wrong-site surgery, suicide in a facility). Requires immediate investigation (RCA).
  • Root Cause Analysis (RCA): A structured process for identifying underlying factors that contribute to an error or adverse event, focusing on system failures rather than individual blame.
• EMTALA (Emergency Medical Treatment and Labor Act): Mandates medical screening exam for anyone presenting to an ED, and stabilization of emergency medical conditions (including active labor) regardless of insurance status or ability to pay, before transfer or discharge.

Clinical Presentation

• Patient refusing life-sustaining treatment, or family demanding "everything" despite futility.
• Requests for patient information from family/friends without patient consent.
• Suspected child/elder abuse or neglect.
• Healthcare provider impairment (substance abuse, mental health issues, boundary violations).
• Medical errors occurring (e.g., medication error, wrong-site surgery).
• Conflicts of interest (e.g., industry relationships, self-referral).
• Resource allocation dilemmas (e.g., organ transplantation, ICU bed scarcity).
• Patient experiencing an adverse event during hospitalization.
• Requests for physician-assisted suicide/euthanasia (illegal in most US states).
• Patient expressing religious/cultural beliefs that conflict with recommended treatment.

Diagnosis (Gold Standard)

For ethical dilemmas, the "diagnosis" involves identifying the core ethical principles in conflict and assessing the patient's decision-making capacity. For patient safety events, it's recognizing the type of event (error, near miss, adverse event, sentinel event) and its contributing factors.

• Identify the primary ethical principles violated or in conflict (e.g., autonomy vs. beneficence).
• Assess patient's decision-making capacity (often the first step in autonomy-related conflicts).
• Determine if the event is a medical error, adverse event, near miss, or sentinel event.
• Recognize violations of legal statutes (e.g., HIPAA, EMTALA).

Management (First Line)

• Ethical Dilemmas:
  • Assess patient's decision-making capacity. If capacity present, respect autonomy.
  • If capacity absent, identify surrogate decision-maker and respect their decisions (within legal/ethical bounds).
  • Facilitate open communication between patient/family and healthcare team.
  • Consult hospital Ethics Committee for complex, unresolved issues.
  • Document all discussions and decisions thoroughly.
• Patient Safety & Errors:
  • Immediate action to mitigate harm to the patient.
  • Open and honest disclosure of errors to the patient and/or family (apology, explanation, steps to prevent recurrence).
  • Internal incident reporting (hospital safety system).
  • For sentinel events: Initiate Root Cause Analysis (RCA) to identify system failures.
  • Implement system-based changes to prevent future errors.
  • For impaired colleagues: Report to supervisor, medical director, or state licensing board.
• Confidentiality Breaches: Secure information, report internally per institutional policy, notify patient if required.
• EMTALA Violations: Stabilize the patient. Do not transfer an unstable patient unless benefits outweigh risks and specific conditions are met.

Exam Red Flags