Medical Ethics

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Paul Banaszkiewicz Paul Banaszkiewicz Section Editor
Lorgan Lorcan McGonagle Segment Author

Section editor: Paul Banaszkiewicz

Segment author: Lorcan McGonagle

Document history: 1/8/2019

  • Valid consent must be confirmed before starting treatment, physical investigation or providing personal care.
  • For consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question (this will be the patient or someone with parental responsibility for a patient under the age of 18 years, someone authorised to do so under a Lasting Power of Attorney or someone who has the authority to make treatment decisions as a court-appointed deputy). Acquiescence when the person does not know what the intervention entails is not “consent.”
  • A person lacks capacity if:
  1. They have an impairment or disturbance (for example a disability, condition or trauma or the effect of drugs or alcohol) that affects the way their mind or brain works.
  2. That impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made.1
  • A person is unable to make a decision if they cannot do one or more of the following things:
  1. Understand the information given to them that is relevant to the decision
  2. Retain that information long enough to be able to make the decision
  3. Use or weigh up the information
  4. Communicate their decision
  • People may have capacity to consent to some interventions but not to others, or may have capacity at some times but not others.
  • Some people may wish to know very little about the treatment that is being proposed. If information is offered and declined, it is good practice to record this fact in the notes. However, it is possible that individuals’ wishes may change over time, and it is important to provide opportunities for them to express this.
  • GMC and BMA guidance encourages doctors to explain to patients the importance of knowing the options open to them while respecting a person’s wish not to know, and states that basic information should always be provided about what the treatment aims to achieve and what it will involve.
  • During an operation it may become evident that the person could benefit from an additional procedure that was not within the scope of the original consent. If it would be unreasonable to delay the procedure until the person regains consciousness (for example because there is a threat to the person’s life) it may be justified to perform the procedure on the grounds that it is in the person’s best interests. However, the procedure should not be performed merely because it is convenient. For example, a hysterectomy should never be performed during an operation without explicit consent, unless it is necessary to do so to save life.
  • The task of seeking consent may be delegated to another person, as long as they are suitably trained and qualified.
  • No one is able to give consent to the examination or treatment of an adult who lacks the capacity to give consent for themself, unless they have been authorised to do so under a Lasting Power of Attorney or they have the authority to make treatment decisions as a court-appointed deputy.
  • People aged 16 or 17 years are presumed to be capable of consenting to their own medical treatment, and any ancillary procedures involved in that treatment, such as an anaesthetic. As for adults, consent will be valid only if it is given voluntarily by an appropriately informed young person capable of consenting to the particular intervention. However, unlike adults, the refusal of a competent person aged 16–17 years may in certain circumstances be overridden by either a person with parental responsibility or a court.
  • Gillick competence: children (under 16 years) who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the capacity to consent to that intervention.43
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QUESTION 1 OF 4

Due to the COVID pandemic you are required to prioritise your cases in knee surgery.
Which patient will you give top priority to in your elective list?

QUESTION ID: 1266

1. A 18-year-old 1 week ago sustained an isolated mid-substance ACL tear confirmed on MRI scan with a range of motion from 20 to 80 degrees
2. A 20-year-old with a patellar dislocation sustained 3 days ago. MRI demonstrates a 5x8mm osteochondral fragment in her lateral gutter from non-weight bearing area of her lateral femoral condyle.
3. A 35-year-old 3 days ago sustained a bucket handle tear of the medial meniscus confirmed on MRI scan. Range of motion 20 to 110 degrees
4. A 45-year-old with symptoms of locking and pain medially. His range of motion is from -5 to 130 degrees. MRI demonstrates a complex medial meniscal tear.
5. A 70-year-old with an infected knee replacement with a discharging sinus over 2 months. She is systemically well on oral antibiotics with a CRP 30. She has a history of COPD, obstructive sleep apnoea and aortic stenosis
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QUESTION 2 OF 4

In the case of a patient who has religious beliefs prohibiting blood transfusions, what should occur?

QUESTION ID: 1337

1. If the immediate family informs the doctor that an unconscious patient has the aforementioned religious beliefs, but no advance directive is presented then the doctor should still comply with the wishes expressed by the family
2. In an elective setting the treating doctor has the right to choose not to treat the patient if they feel that possible risks are more than what they can accept
3. In an emergency setting and where blood transfusion is needed, if the patient carries clear documentation stating that they refuse blood transfusion (such as the signed and witnessed advance decision cards), but now is unconscious, then the family should be consulted as the patient is unable to consent in their current status
4. In cases of a child whose parents / legal guardians refuse blood transfusion, and where no immediate decision is required, advice from another doctor stating that a blood transfusion is needed would provide sufficient basis to proceed. Equally the parents will have to be informed of the decision
5. In cases of absolute emergency in a child, the blood products should be given, and no further authorisation is needed
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QUESTION 3 OF 4

When facing a COVID-19 pandemic, treatment guidelines change to minimise hospital stay and unnecessary intervention.
Which of the following is applicable during said circumstances?

QUESTION ID: 1338

1. A 6-week-old child with structural CTEV who is brought to the clinic for the first time should have his Ponseti casting started if the parents are happy to proceed
2. A 7-year-old child presenting with a suspected clavicle fracture after a fall should have an x-ray to decide on treatment
3. A 9-year-old patient with a stable lateral malleolus fracture could be treated in a boot and should have one clinic follow-up appointment in 4–6 weeks
4. An 8-week-old child with congenital talipes equinovarus CTEV who has already had his first 2 Ponseti casts should have the rest of his casts and his tenotomy as planned
5. Gartland type II supracondylar fractures must be treated in a rigid full cast rather than a soft cast to minimise the risk of displacement
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QUESTION 4 OF 4

During a COVID-19 pandemic and following the relevant BOA guidance, an adult patient presents to the ED triage with a deformed wrist after a fall. The middle grade on-call orthopaedic surgeon is unsure how to proceed and asks for advice.
YOUR management advice would be which of the following?

QUESTION ID: 1339

1. If operative treatment is decided via plate fixation under regional block to avoid general anaesthetic as an aerosol-generating procedure (AGP), then regular theatre attire (gown, surgical mask with visor, double gloves) could be used, assuming that the patient has not been tested for the virus
2. If plate fixation was used, then one face-to face follow-up appointment is warranted for a wound check or removal of sutures and initiation of physiotherapy
3. If the decision is to undergo surgical treatment with K-wire fixation, the aim is to attempt the procedure under regional blocks, performed as a day-case, burying the wires to minimise the risk of pin-site infection, and aim to use removable casts rather than a full cast thereafter
4. The patient should be forwarded directly to fracture clinic as per the guidance for the pandemic without being managed by ED staff prior to that
5. The patient should not have an x-ray and should have a plaster, accepting that there is a chance of malunion and further corrective procedures might be needed after the pandemic
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