Chapter 1: Patient Autonomy and Informed Consent

Refusal of Life-Saving Treatment Case Description: A 55-year-old man with severe heart disease is admitted with chest pain. The cardiologist recommends emergency coronary artery bypass graft (CABG) surgery, explaining that without it, he risks a fatal heart attack. The patient, fully alert and oriented, refuses, stating he’d rather die than undergo another operation. His family pleads with the team to proceed anyway. Ethical Question: What should the medical team do?

A. Proceed with the surgery to save his life, as the family wishes.
B. Respect the patient’s refusal and provide comfort care.
C. Seek a court order to override the patient’s decision.
D. Delay the surgery and consult psychiatry to assess his mental state.

Capacity to Consent in Mental Illness Case Description: A 30-year-old woman with schizophrenia is brought to the ER after a suicide attempt. She is conscious but refuses treatment, claiming doctors are trying to poison her. The psychiatric team believes her refusal stems from her illness, though she insists she understands the risks. Ethical Question: How should the team proceed?

A. Treat her against her will, as her mental illness impairs her capacity.
B. Respect her refusal, as she claims to understand the risks.
C. Wait for her condition to stabilize before deciding.
D. Seek consent from her family instead.

Advance Directive Interpretation Case Description: An 80-year-old man with advanced dementia is admitted with pneumonia. His advance directive states no mechanical ventilation. His daughter insists he’d want it “just this once” to see if he improves. The team is unsure how to interpret the directive. Ethical Question: What should the team do?

A. Follow the advance directive and avoid ventilation.
B. Honor the daughter’s request and ventilate the patient.
C. Consult the ethics committee for guidance.
D. Ventilate the patient temporarily while seeking legal advice.

Surrogate Decision-Making Conflict Case Description: A 65-year-old woman is in a coma after a stroke. Her husband, her legal surrogate, requests withdrawal of life-sustaining treatments, citing her wishes. Their adult children insist she’d want to keep fighting and demand continued treatment. Ethical Question: Whose decision should the team follow?

A. The husband’s, as he is the legal surrogate.
B. The children’s, as they are also family members.
C. Seek a consensus between the husband and children.
D. Continue treatment until a court resolves the dispute.

Cultural Beliefs and Treatment Refusal Case Description: A 40-year-old woman from a background distrusting Western medicine is diagnosed with breast cancer. She refuses surgery and chemotherapy, opting for herbal remedies. Her oncologist fears this will lead to her death. Ethical Question: How should the oncologist respond?

A. Respect her decision, as it reflects her cultural beliefs.
B. Try to persuade her to accept treatment for her own good.
C. Involve a cultural liaison to mediate the discussion.
D. Seek a court order to mandate treatment.

Informed Consent for High-Risk Procedures Case Description: A 25-year-old man with a rare genetic disorder is offered a novel, high-risk surgery with a 50% mortality rate that could cure him. He is eager to proceed, but his parents want more time to consider the risks. Ethical Question: What should the surgeon do?

A. Proceed with the surgery, as the patient has consented.
B. Delay the surgery to allow the family more time.
C. Refuse to perform the surgery due to the high risk.
D. Seek a second opinion from another surgeon.

Refusal of Treatment in Pregnancy Case Description: A 28-year-old woman at 32 weeks gestation has a life-threatening infection. The recommended antibiotics may harm the fetus, and she refuses them to prioritize the fetus’s health. Her partner urges the team to treat her against her will. Ethical Question: What is the most ethical action?

A. Respect her refusal, as she has the right to prioritize the fetus.
B. Administer the antibiotics to save her life.
C. Seek a court order to enforce treatment.
D. Wait and monitor her condition closely.

Capacity in Elderly Patients Case Description: A 90-year-old man with mild cognitive impairment is scheduled for hip replacement surgery. He seems confused about the risks and benefits during consent. The surgeon is unsure if he has capacity. Ethical Question: How should the surgeon proceed?

A. Proceed with surgery, assuming he has capacity.
B. Delay the surgery and assess his capacity formally.
C. Seek consent from his family instead.
D. Cancel the surgery due to his confusion.

Advance Directive vs. Best Interest Case Description: A 75-year-old woman with a living will stating “no artificial nutrition” is admitted with a stroke. She cannot communicate, and her condition is worsening. Her son argues she’d want feeding despite the will, valuing life. Ethical Question: What should the team do?

A. Follow the living will and withhold artificial nutrition.
B. Honor the son’s request and provide artificial nutrition.
C. Consult the ethics committee for a decision.
D. Provide artificial nutrition temporarily while investigating.

Surrogate Decision for a Minor Case Description: A 10-year-old boy with leukemia needs a bone marrow transplant. His parents refuse due to religious beliefs, opting for prayer. The team believes the transplant is in his best interest. Ethical Question: What should the team do?

A. Respect the parents’ decision based on religious freedom.
B. Seek a court order to proceed with the transplant.
C. Delay the transplant and try to persuade the parents.
D. Proceed with the transplant without parental consent.

Refusal of Blood Transfusion Case Description: A 35-year-old Jehovah’s Witness needs an urgent blood transfusion after a car accident to survive. She is conscious and refuses, citing her faith. Her husband, not a Jehovah’s Witness, begs the team to proceed. Ethical Question: What is the most ethical course?

A. Respect her refusal, as she is competent and informed.
B. Transfuse her to save her life, as her husband consents.
C. Seek an emergency court order to transfuse.
D. Delay the decision and consult the ethics committee.

Capacity in Intoxicated Patients Case Description: A 22-year-old man with a severe head injury from a bar fight is intoxicated and refuses a CT scan, claiming he feels fine. The neurosurgeon fears a possible brain bleed. Ethical Question: How should the neurosurgeon proceed?

A. Perform the CT scan against his will, as he is intoxicated.
B. Respect his refusal, as he is alert and oriented.
C. Wait for him to sober up before deciding.
D. Seek consent from his next of kin.

Advance Directive in Emergency Case Description: A 60-year-old man with a DNR order collapses at home and is brought to the ER unresponsive. Paramedics started CPR before knowing of the DNR. The ER team must decide whether to continue. Ethical Question: What should the ER team do?

A. Continue CPR, as it has already started.
B. Stop CPR immediately, respecting the DNR.
C. Consult the family before deciding.
D. Continue CPR until a physician confirms the DNR.

Surrogate Decision for Unknown Patient Case Description: An unidentified, unconscious man is admitted after a hit-and-run. He has no ID or advance directive, and family cannot be located. The team must decide on a high-risk surgery that could save him but may cause disabilities. Ethical Question: Who should decide?

A. The medical team, based on the patient’s best interest.
B. The hospital ethics committee.
C. The court, through an emergency guardianship.
D. Delay the decision until family is located.

Cultural Barriers to Consent Case Description: A 50-year-old immigrant woman with limited English is scheduled for a hysterectomy. She nods and signs the consent form, but the nurse suspects she doesn’t fully understand due to language barriers. Ethical Question: What should the nurse do?

A. Proceed with surgery, as she signed the form.
B. Delay the surgery and arrange for an interpreter.
C. Ask her family to explain the procedure.
D. Cancel the surgery due to lack of understanding.

Refusal of Treatment Due to Fear Case Description: A 40-year-old man with early-stage colon cancer refuses surgery due to an overwhelming fear of anesthesia. The surgeon believes the fear is irrational and the decision uninformed. Ethical Question: How should the surgeon respond?

A. Respect his refusal, as it is his choice.
B. Refer him to a psychiatrist for evaluation.
C. Proceed with surgery under sedation without consent.
D. Delay the surgery and provide more information.

Capacity in Adolescents Case Description: A 16-year-old girl with a chronic illness wants to stop painful treatments, prioritizing quality of life. Her parents insist on continuing, believing she’s too young to decide. Ethical Question: What should the team do?

A. Follow the parents’ wishes, as she is a minor.
B. Respect the girl’s decision, as she shows understanding.
C. Seek a court order to continue treatment.
D. Consult the ethics committee for guidance.

Advance Directive Ambiguity Case Description: A 70-year-old man’s advance directive says, “I do not want to be kept alive by machines.” He’s now in a coma after an accident, and the team is unsure if this includes ventilators for reversible conditions. Ethical Question: How should the team interpret the directive?

A. Withhold ventilator support, as per the directive.
B. Provide ventilator support, as the condition may be reversible.
C. Consult the family for clarification.
D. Seek legal advice on interpreting the directive.

Surrogate Decision for Experimental Treatment Case Description: A 55-year-old woman with advanced cancer is unconscious. Her husband, as surrogate, consents to an experimental treatment with unknown risks. The team is concerned about proceeding without her direct consent. Ethical Question: What should the team do?

A. Proceed with the treatment, as the surrogate consented.
B. Refuse the treatment due to lack of patient consent.
C. Seek a second opinion from another oncologist.
D. Consult the ethics committee before proceeding.

Refusal of Treatment in Infectious Disease Case Description: A 30-year-old man with tuberculosis refuses medication due to unbearable side effects. He lives with family, and the public health department fears transmission risks. Ethical Question: How should the team respond?

A. Respect his refusal, as it’s his choice.
B. Isolate him to prevent transmission.
C. Seek a court order to enforce treatment.
D. Provide alternative medications with fewer side effects.

Informed Consent for Telemedicine Case Description: A rural diabetic patient is offered a telemedicine consultation. The physician explains benefits but not privacy risks. The patient agrees to proceed. Ethical Question: Has informed consent been adequately obtained?

A. Yes, as the patient agreed.
B. No, because privacy risks were not disclosed.
C. Yes, because telemedicine is standard.
D. No, because in-person consent is required.

Capacity in Patients with Cognitive Impairment Case Description: An 85-year-old woman with early Alzheimer’s is scheduled for cataract surgery. She understands the procedure but forgets details soon after. Her daughter insists on proceeding, but the surgeon questions her capacity. Ethical Question: What should the surgeon do?

A. Proceed, as she understood at the time of consent.
B. Delay and assess her capacity over time.
C. Seek consent from her daughter instead.
D. Cancel the surgery due to cognitive impairment.

Advance Directive for Psychiatric Care Case Description: A 40-year-old man with bipolar disorder has an advance directive refusing electroconvulsive therapy (ECT). He’s now in a severe depressive episode and lacks capacity. His psychiatrist believes ECT is best. Ethical Question: What should the psychiatrist do?

A. Respect the directive and avoid ECT.
B. Proceed with ECT, as it’s in his best interest.
C. Seek family consent for ECT.
D. Consult the ethics committee.

Surrogate Decision in Conflict with Medical Advice Case Description: A 60-year-old man in a persistent vegetative state has a wife who, as surrogate, requests continued life-sustaining treatment despite the team’s view that it’s futile. The team worries about prolonging suffering. Ethical Question: How should the team proceed?

A. Continue treatment, respecting the surrogate’s decision.
B. Withdraw treatment, as it’s medically futile.
C. Seek a court order to withdraw treatment.
D. Transfer care to another provider.

Refusal of Treatment Due to Misinformation Case Description: A 50-year-old woman with breast cancer refuses chemotherapy after reading online it’s “poison,” believing alternatives are safer. Her oncologist fears she’s uninformed. Ethical Question: What should the oncologist do?

A. Respect her decision, as it’s her choice.
B. Provide accurate information and address concerns.
C. Refer her to a psychiatrist.
D. Proceed with chemotherapy against her will.

Capacity in Patients with Language Barriers Case Description: A 70-year-old Spanish-speaking man needs emergency surgery. The consent form is in English, and a telephone interpreter is used. He seems confused, and the surgeon doubts his understanding. Ethical Question: How should the surgeon proceed?

A. Proceed, as an interpreter was used.
B. Delay and find an in-person interpreter.
C. Seek family consent instead.
D. Cancel due to the language barrier.

Advance Directive for Research Participation Case Description: A 65-year-old woman with a terminal illness has an advance directive wanting research participation after losing capacity. She’s now unconscious, and a trial is available. Her son is hesitant. Ethical Question: Should the team enroll her?

A. Yes, as per her directive.
B. No, because she can’t consent in real-time.
C. Yes, but only if the son agrees.
D. No, because research requires capacity.

Surrogate Decision for Organ Donation Case Description: A 25-year-old man is brain-dead after a motorcycle accident. His parents, as surrogates, are asked about organ donation but are unsure of his wishes and overwhelmed. Ethical Question: How should the organ procurement team proceed?

A. Proceed with donation, as it saves lives.
B. Respect the parents’ uncertainty and not proceed.
C. Provide information and time for them to decide.
D. Seek a court order for donation.

Refusal of Treatment in Minors Case Description: A 14-year-old girl with curable leukemia refuses chemotherapy, tired of being sick. Her parents want to proceed, but she insists on stopping. Ethical Question: What should the team do?

A. Respect her refusal, as she understands the consequences.
B. Follow the parents’ wishes and proceed.
C. Seek a court order to enforce treatment.
D. Delay and involve a child psychologist.

Informed Consent for Genetic Testing Case Description: A 35-year-old woman is offered genetic testing for a cancer syndrome. The counselor explains the test but not the psychological impact of results. She consents. Ethical Question: Has informed consent been adequately obtained?

A. Yes, as the test was explained.
B. No, because psychological risks weren’t discussed.
C. Yes, because genetic testing is routine.
D. No, because it requires written consent.

Capacity in Patients with Severe Pain Case Description: A 45-year-old man with pancreatic cancer in severe pain requests immediate surgery. The surgeon worries his pain impairs his understanding of risks. Ethical Question: How should the surgeon proceed?

A. Proceed, as he needs relief.
B. Delay and manage his pain first.
C. Seek family consent instead.
D. Cancel due to impaired capacity.

Advance Directive for Mental Health Treatment Case Description: A 50-year-old man with severe depression has an advance directive refusing psychiatric hospitalization. He’s now suicidal and refuses admission. His psychiatrist believes it’s necessary. Ethical Question: What should the psychiatrist do?

A. Respect the directive and avoid hospitalization.
B. Hospitalize him involuntarily, as he’s a danger.
C. Seek family consent for hospitalization.
D. Consult the ethics committee.

Surrogate Decision for Withdrawal of Care Case Description: A 70-year-old woman with advanced Alzheimer’s develops pneumonia. Her daughter, as surrogate, requests withholding antibiotics for natural death. Her son wants full treatment. Ethical Question: Whose decision should the team follow?

A. The daughter’s, as legal surrogate.
B. The son’s, as he wants treatment.
C. Seek a consensus between siblings.
D. Continue treatment until resolved.

Refusal of Treatment in Emergency Case Description: A 20-year-old man with a gunshot wound is conscious but refuses treatment, wanting to die. The team believes shock and pain impair his thinking. Ethical Question: How should the team proceed?

A. Respect his refusal, as he’s conscious.
B. Treat him against his will, as he may lack capacity.
C. Wait for him to lose consciousness before treating.
D. Seek family consent.

Informed Consent for Experimental Drugs Case Description: A 60-year-old man with end-stage heart failure is offered an experimental drug tested only in animals. The physician highlights benefits but downplays risks to encourage participation. Ethical Question: Is this ethical informed consent?

A. Yes, as the drug may save him.
B. No, because risks weren’t fully disclosed.
C. Yes, because experimental drugs are risky.
D. No, because consent isn’t required.

Capacity in Patients with Developmental Disabilities Case Description: A 25-year-old woman with moderate intellectual disability needs a kidney transplant. She understands the procedure simply but not long-term implications. Her parents want to proceed. Ethical Question: Can she provide informed consent?

A. Yes, as she understands basics.
B. No, because she can’t grasp long-term implications.
C. Yes, with parental consent.
D. No, and cancel the surgery.

Advance Directive for Do-Not-Resuscitate (DNR) Case Description: A 55-year-old man with a terminal illness has a DNR order. During a routine procedure, he goes into cardiac arrest. The anesthesiologist, unaware, starts resuscitation. Ethical Question: What should the team do upon discovering the DNR?

A. Continue, as it’s started.
B. Stop immediately, respecting the DNR.
C. Consult the family first.
D. Complete resuscitation then honor the DNR.

Surrogate Decision for Reproductive Health Case Description: A 30-year-old woman in a persistent vegetative state is pregnant. Her husband, as surrogate, requests an abortion, believing she wouldn’t want the pregnancy. The team is unsure of her values. Ethical Question: Should the team proceed?

A. Yes, respecting the surrogate’s decision.
B. No, because her wishes are unknown.
C. Seek a court order.
D. Delay and consult the ethics committee.

Refusal of Treatment Based on Religious Beliefs Case Description: A 45-year-old Muslim man refuses a life-saving surgery involving a porcine implant, against his faith. An alternative exists but is less effective. Ethical Question: How should the surgeon proceed?

A. Respect his refusal and offer the alternative.
B. Proceed with the porcine implant to save him.
C. Seek a religious exemption from his imam.
D. Delay and find a non-porcine option.

Informed Consent for Placebo-Controlled Trials Case Description: A chronic pain patient joins a placebo-controlled trial. The consent form mentions a placebo chance but doesn’t explain it. She feels deceived upon learning she got the placebo. Ethical Question: Was consent adequate?

A. Yes, as placebo was mentioned.
B. No, because placebo wasn’t explained.
C. Yes, because placebos are standard.
D. No, because placebos shouldn’t be used.

Capacity in Patients with Addiction Case Description: A 35-year-old man with opioid addiction needs a liver transplant. He understands the procedure but says withdrawal impairs his judgment. The team questions his consent. Ethical Question: How should the team proceed?

A. Proceed, as he understands.
B. Delay and treat withdrawal first.
C. Seek family consent.
D. Cancel due to addiction.

Advance Directive for Pain Management Case Description: A 60-year-old woman with terminal cancer has an advance directive for aggressive pain management, even if it hastens death. She’s unconscious, and her family fears opioids will shorten her life. Ethical Question: Should the team follow the directive?

A. Yes, as it’s her wish.
B. No, because it may hasten death.
C. Seek a compromise with family.
D. Consult the ethics committee.

Surrogate Decision for Pediatric Patients Case Description: A 5-year-old girl with a rare disorder needs a risky experimental treatment. Her parents refuse, preferring alternative medicine. The team believes it’s her only survival chance. Ethical Question: What should the team do?

A. Respect the parents’ decision.
B. Seek a court order to proceed.
C. Delay and provide more information.
D. Proceed without consent.

Refusal of Treatment in Psychiatric Patients Case Description: A 28-year-old man with severe depression refuses antidepressants after a suicide attempt, wanting to “feel naturally.” The psychiatrist believes medication is vital. Ethical Question: How should the psychiatrist proceed?

A. Respect his refusal, as he’s competent.
B. Administer medication against his will.
C. Seek a court order for treatment.
D. Provide psychotherapy instead.

Informed Consent for Cosmetic Procedures Case Description: A 22-year-old woman requests breast augmentation. The surgeon explains risks but emphasizes benefits to boost self-esteem. She signs without questions. Ethical Question: Has consent been adequately obtained?

A. Yes, as she signed.
B. No, because she didn’t ask questions.
C. Yes, because risks are low.
D. No, because benefits were overemphasized.

Capacity in Patients with Temporary Impairment Case Description: A 40-year-old man with a severe migraine is offered a new pain medication. In extreme pain, he agrees without fully hearing risks. The nurse doubts his capacity. Ethical Question: What should the nurse do?

A. Administer, as he agreed.
B. Delay and explain risks after pain subsides.
C. Seek spousal consent.
D. Refuse to administer.

Advance Directive for Experimental Procedures Case Description: A 70-year-old man with a rare disease has an advance directive for experimental treatments if standard care fails. He’s unconscious, and an experimental option is available. His daughter is unsure. Ethical Question: Should the team proceed?

A. Yes, per his directive.
B. No, because it’s too risky.
C. Yes, with daughter’s agreement.
D. Seek a second opinion.

Surrogate Decision for Withdrawal of Feeding Tube Case Description: A 90-year-old woman with severe dementia has a feeding tube. Her son, as surrogate, requests removal, saying she wouldn’t want this life. The staff feels it’s premature. Ethical Question: How should the team respond?

A. Remove the tube, respecting the surrogate.
B. Refuse, as it may be premature.
C. Seek consensus with staff.
D. Consult the ethics committee.

Refusal of Treatment Due to Financial Concerns Case Description: A 55-year-old man with a treatable infection refuses hospitalization due to cost, knowing it risks sepsis. The physician respects his decision. Ethical Question: Is this approach ethical?

A. Yes, as he can refuse based on finances.
B. No, because financial aid wasn’t explored.
C. Yes, because costs are his responsibility.
D. No, because he should be admitted against his will.

Informed Consent for Organ Donation Case Description: A 40-year-old man considers donating a kidney to his brother. The coordinator explains risks, but he’s driven by guilt and pressure. He signs but seems conflicted. Ethical Question: Has consent been adequately obtained?

A. Yes, as he signed.
B. No, because it may not be voluntary.
C. Yes, because pressure is common.
D. No, because it requires psychological evaluation.