Ethics, Law & Good Medical Practice

A 70-year-old man with epilepsy tells his GP he has continued to drive despite being advised to stop and inform the DVLA. What should the GP do?

• AExplain again that he must stop and inform the DVLA, and if he continues to drive, inform the DVLA directly✓
• BInform the police straight away that he is driving illegally, since driving with uncontrolled epilepsy is a criminal offence
• CRespect confidentiality absolutely and take no further action, since what a patient does with medical advice is entirely their own decision
• DRefuse to see him again until he surrenders his driving licence, since a doctor cannot continue to treat a patient who ignores medical advice

Answer: GMC guidance says that where a patient continues to drive against medical advice, the doctor should try to persuade them to stop and, if they will not, disclose relevant information to the DVLA's medical adviser, telling the patient. Public safety justifies the disclosure.

An 80-year-old woman with advanced dementia lacks capacity to decide about a proposed operation. Her daughter has no lasting power of attorney. Who makes the decision?

• AThe clinical team, in her best interests, after consulting her daughter about her wishes and values✓
• BHer daughter, as next of kin, who automatically takes over decisions once her mother lacks capacity
• CThe patient's GP alone, as the doctor who has known her longest and understands her wishes best
• DThe hospital's legal department, which must authorise any treatment of a patient who lacks capacity

Answer: Under the Mental Capacity Act, a decision for someone who lacks capacity is made in their best interests by the person providing the treatment, taking into account the views of family and carers. A relative can consent on the patient's behalf only if they hold a health and welfare lasting power of attorney.

A patient asks which of the four questions a doctor must consider to decide whether they can make a particular decision. Which of these is one of the four?

• AWhether their decision is one that most people would make
• BWhether they agree with the doctor's recommendation
• CWhether they can use or weigh the information as part of the decision✓
• DWhether they have a diagnosis of a mental illness

Answer: The Mental Capacity Act's functional test asks whether the person can understand the information, retain it, use or weigh it, and communicate their decision. Disagreeing with the doctor or making an unusual choice does not show a lack of capacity, and a diagnosis alone is never enough.

A 15-year-old girl attends alone requesting the contraceptive pill. She understands the advice, cannot be persuaded to involve her parents, and is likely to continue having sex regardless. What should the doctor do?

• AReport the request to the police as a matter of course, since any sexual activity under 16 is an offence
• BRefuse to prescribe, because a person under 16 cannot lawfully consent to contraception without a parent
• CPrescribe if satisfied she is Gillick competent and it is in her best interests, and explore any safeguarding concerns✓
• DContact her parents before prescribing anything, since they hold parental responsibility until she is 16

Answer: The Fraser guidelines allow contraceptive advice and treatment for a young person under 16 without parental knowledge if she understands the advice, cannot be persuaded to tell her parents, is likely to continue, would suffer without it, and it is in her best interests. Safeguarding concerns, such as an older partner, must still be assessed.

A competent 45-year-old Jehovah's Witness has signed a written, witnessed advance decision refusing blood transfusion even if her life is at risk. She is now unconscious after a road accident and bleeding. What should the team do?

• AAsk her husband to consent to transfusion on her behalf, as her next of kin
• BApply to the court before doing anything
• CRespect the advance decision and manage without blood products✓
• DTransfuse, because a patient who is unconscious cannot refuse and the priority is to save life

Answer: A valid and applicable advance decision to refuse life-sustaining treatment — made with capacity, in writing, signed and witnessed, and stating that it applies even if life is at risk — is legally binding under the Mental Capacity Act. Relatives cannot override it, and the team should use alternatives such as cell salvage.

A doctor makes a prescribing error that leads to a patient needing extra treatment. What does the professional duty of candour require?

• ARecord the error accurately in the notes and inform the pharmacy, but avoid alarming the patient with details of what went wrong
• BTell the patient what happened, apologise, and explain what will be done to put matters right✓
• CReport the error to the GMC and the medical defence organisation before speaking to the patient, so that the disclosure is properly advised
• DTell the patient only if they ask directly about it, since volunteering the information would undermine their confidence in their care

Answer: Good Medical Practice requires doctors to be open and honest with patients when something goes wrong: tell them promptly, apologise, offer a remedy, and explain the effects. The incident is also reported through the organisation's systems so that lessons are learned.

A junior doctor believes a consultant colleague is regularly turning up to work smelling of alcohol. What should the junior doctor do?

• ARaise the concern promptly with an appropriate person, such as the clinical director or the responsible officer✓
• BIgnore it, because challenging a senior colleague without concrete proof could harm the junior doctor's own career and training
• CConfront the consultant publicly during a ward round so that the rest of the team witnesses the concern being raised
• DPost the concern anonymously on social media so that the hospital is forced to take action that it might otherwise avoid

Answer: Good Medical Practice requires doctors to act without delay when they have good reason to think a colleague may be putting patients at risk, by raising the concern with an appropriate person in the organisation. Silence leaves patients at risk; public confrontation and social media are neither professional nor effective.

A 78-year-old man with metastatic cancer and a poor prognosis is admitted. The team considers a 'do not attempt CPR' decision. What is the correct approach?

• AMake the decision within the team and record it without telling the patient, since discussing resuscitation with a dying patient would only cause distress
• BObtain the patient's signed written consent before the decision can be recorded, since a DNACPR order is a treatment decision that belongs to the patient alone
• CAsk the family to decide whether CPR should be attempted, since the decision about resuscitation should rest with the next of kin when the outlook is poor
• DDiscuss the decision with the patient (and, with his agreement, his family) and record it, since it is a clinical decision that requires communication rather than consent✓

Answer: A DNACPR decision is a clinical judgement about whether CPR would work, but the law requires that the patient is informed and involved unless doing so would cause physical or psychological harm; the Tracey judgment made this clear. Consent is not needed for a decision that CPR would be futile, but the conversation is mandatory.

A 30-year-old man with a learning disability needs a dental extraction under general anaesthetic and lacks capacity to consent. He has no family. What should happen?

• AA best-interests decision by the clinical team, with an independent mental capacity advocate (IMCA) appointed✓
• BThe court must decide every treatment for him, because he has no family to consent on his behalf
• CThe procedure cannot go ahead without consent, so the extraction must wait until he is able to understand and agree to it
• DThe dentist decides alone without consulting anyone else, since the professional doing the treatment is responsible for it

Answer: The Mental Capacity Act requires an IMCA to be instructed for serious medical treatment decisions when a person lacks capacity and has nobody appropriate to consult; the team then decides in his best interests.

A patient asks a doctor to record a false date of injury on a sick note so that a claim is paid. What should the doctor do?

• AAgree but note privately that the date is wrong
• BAgree, since the patient will otherwise lose money that they need to pay their rent
• CReport the patient to the police immediately for attempted fraud
• DRefuse, explain that certificates must be truthful, and record the accurate information✓

Answer: Good Medical Practice requires doctors to be honest in all documents they sign; a false certificate is fraud and a probity issue for the doctor. Refusing with an explanation is proportionate.

A 17-year-old with anorexia nervosa and a dangerously low BMI refuses admission for refeeding. Her parents want her treated. What is the legal position in England?

• ANothing can be done until she turns 18, at which point she can be detained under the Mental Health Act if she still lacks the capacity to decide
• BOnly the police can authorise her admission, using their powers under section 136 of the Mental Health Act to remove her to a place of safety
• CHer refusal is absolute because she is over 16, since the Family Law Reform Act 1969 gives 16- and 17-year-olds exactly the same rights as adults to refuse any treatment
• DHer refusal is not the end of the matter: she should be assessed for detention under the Mental Health Act, and the court can authorise treatment — but if she has capacity, her parents cannot consent to admission on her behalf✓

Answer: A 16- or 17-year-old can consent to treatment, but a refusal of life-saving treatment is not necessarily final: anorexia nervosa is a mental disorder for which the Mental Health Act can be used (including feeding as treatment), and the court can override a refusal. Section 131(4) of the Mental Health Act 1983 means a person with parental responsibility cannot consent to admission for a 16- or 17-year-old who has capacity and refuses, and the GMC says the law on parents overriding a competent refusal is complex, so legal advice should be sought.

A doctor discovers a colleague has been looking at the records of a celebrity patient who is not under their care. What should the doctor do?

• ARaise the concern through the organisation's process, since accessing records without a legitimate reason is a breach of confidentiality✓
• BConfront the colleague directly and threaten to tell the press unless they stop looking at the records
• CIgnore it, since the colleague did not share the information with anyone outside the hospital and no harm has come to the patient
• DLook at the records too to see what the fuss is about

Answer: Accessing records without a clinical or legitimate reason breaches confidentiality and data protection law, and Good Medical Practice requires the concern to be raised through proper channels.