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FM10.{1-6,16-17,20,22-24,28} | Medical Ethics & Professional Conduct — PBL Case
CLINICAL SETTING
Community teaching hospital, urban India — Tuesday afternoon. Dr. Ananya, a surgical resident, is preparing a 42-year-old woman, Mrs. Kavitha, for an elective laparoscopic cholecystectomy. During the pre-operative assessment, Mrs. Kavitha — a schoolteacher — appears nervous and asks a series of questions about the procedure, the risks, and whether there is an alternative. She also quietly tells Dr. Ananya that her husband has told her to 'just sign whatever the doctor gives' and not to ask too many questions. On reviewing her file, Dr. Ananya notices that the consent form was signed by Mrs. Kavitha's husband three days ago, not by the patient herself. The consultant surgeon, Dr. Rao, is running late and has told the nurse to 'get everything ready' and not to delay the list.
Trigger 1: The Consent Form Problem
Dr. Ananya examines the signed consent form. It is signed by the husband with a note: 'Wife agreed verbally'. Mrs. Kavitha tells Dr. Ananya: 'I trust my husband's judgement, but I still have questions.' She appears to have capacity — she is articulate, understands her condition, and has clearly thought about her concerns.
DISCUSSION POINTS
- Is the consent form as signed by the husband legally and ethically valid for this procedure? What are the three elements required for valid consent?
- What is the significance of Mrs. Kavitha's statement that her husband 'told her to sign'? Which ethical principle does this raise?
- What should Dr. Ananya do before proceeding with the operation?
Click to reveal Trigger 2: Competing Pressures (discuss previous trigger first!)
Trigger 2: Competing Pressures
Dr. Rao arrives, reviews the file and says 'She's already consented, let's not delay.' When Dr. Ananya raises the issue, Dr. Rao says: 'She's a simple woman — she doesn't really understand these details. I've been doing this for 25 years and she trusts me. That's enough.' He adds: 'If she starts asking questions, it'll just scare her.' He instructs the team to proceed.
DISCUSSION POINTS
- Identify and name the ethical error in Dr. Rao's reasoning. What outdated doctrine does his approach represent?
- What is the doctrine of therapeutic privilege, and does this situation qualify for its application? Justify your answer.
- What are Dr. Ananya's professional options at this point? What do the NMC Regulations say about her duty?
Click to reveal Trigger 3: The Intraoperative Discovery (discuss previous trigger first!)
Trigger 3: The Intraoperative Discovery
The laparoscopic cholecystectomy proceeds. During the operation, Dr. Rao discovers an unexpected mass on the liver — suspicious for malignancy. He shows it to Dr. Ananya and says: 'I'm going to take a biopsy right now. It's in the patient's interest and she'd want to know.' The original consent was for cholecystectomy only. Dr. Ananya notes there is no extended consent for additional intraoperative procedures.
DISCUSSION POINTS
- Can Dr. Rao perform the liver biopsy without additional consent, given the patient is under general anaesthesia? What is the legal and ethical standard for intraoperative extension of procedures?
- Apply the four principles to this decision: which principles support biopsy, which oppose it, and which should prevail?
- What should be documented, and how should the patient be informed post-operatively?
Click to reveal Trigger 4: Post-Operative Disclosure (discuss previous trigger first!)
Trigger 4: Post-Operative Disclosure
Mrs. Kavitha recovers well but is not immediately told about the liver finding. Dr. Rao says: 'Let's wait until we get the histology before we upset her.' One week later, the biopsy shows benign haemangioma. Dr. Rao says: 'Good — no need to tell her anything then.' Mrs. Kavitha independently asks Dr. Ananya about the procedure and says: 'I felt there was something else done to me — my right side is sore in a different place.'
DISCUSSION POINTS
- Does Mrs. Kavitha have a right to know that an additional procedure was performed on her — even if the result was benign? What would you say to her?
- What is the difference between 'duty to disclose' and 'therapeutic privilege' in the context of post-operative truth-telling?
- Could Dr. Rao face any professional or legal consequences for the intraoperative biopsy and post-operative non-disclosure? Under which regulations or laws?
Learning Issues
Research these questions and bring your findings to the discussion.
- [FM10.16] Define the four principles of biomedical ethics and apply them to the competing interests of patient, family, and physician in a consent dispute.
- [FM10.5] What does 'valid informed consent' require in terms of disclosure, comprehension, and voluntariness? What makes consent invalid?
- [FM10.20] Define therapeutic privilege. Under what narrow conditions is it ethically justifiable, and how does it differ from mere paternalism?
- [FM10.6] What are the rights and duties of a registered medical practitioner regarding disclosure of information and performance of procedures?
- [FM10.4] What are the professional conduct obligations of a junior doctor when their senior's actions appear to violate the NMC Code of Ethics?