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Medical Ethics & Consent

Name: Medical Ethics & Consent
Creator: Veli Bakalov, MD

The four principles, informed consent, capacity, and who can decide

Ethics, Biostatistics & Patient Safety·Ethics·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Four principles: autonomy, beneficence, nonmaleficence, justice; a capacitated patient's autonomy usually prevails when they conflict.
A patient with capacity may refuse any treatment, even life-saving (a Jehovah's Witness declining transfusion); treating over an informed refusal is battery.
Informed consent = capacity + disclosure (diagnosis, procedure, risks, benefits, alternatives, risks of no treatment) + understanding + voluntariness, then authorization.
Consent exceptions: emergency (implied consent), waiver, incapacity (surrogate decides), and rare therapeutic privilege.
Capacity (communicate a choice, understand, appreciate, reason) is clinical, decision-specific, and assessed by any physician; competence is a legal status decided only by a court.
A durable power of attorney for health care outranks the default surrogate hierarchy; surrogates use substituted judgment, then best interests.
Parents cannot refuse life-saving treatment for a child: treat if the danger is imminent, otherwise get an emergency court order.
Emancipated minors (married, military, self-supporting, court-declared) consent as adults; a minor parent consents for her child (and in many states for herself); minors may self-consent confidentially for STIs, contraception, and pregnancy care.
Disclose medical errors honestly and apologize; justice includes EMTALA emergency care regardless of ability to pay and IRB protection of vulnerable research subjects.

The four principles and truth-telling

Four pillars. Most ethics vignettes turn on four principles. When they conflict, the autonomy of a patient who has decision-making capacity usually prevails over the physician's view of what is best.

The four principles of medical ethics

Principle	Meaning	Classic application
Autonomy	Self-determination: the patient decides	Informed consent; a capacitated patient may refuse any treatment
Beneficence	Act in the patient's best interest	Recommend the best option; treat in emergencies
Nonmaleficence	Do no harm	Weigh risks against benefits; avoid futile or harmful interventions
Justice	Fair, nondiscriminatory distribution of care and burdens	Treat like cases alike; emergency care regardless of ability to pay

Justice in practice. Justice requires fair allocation of care and of research burdens. Protect vulnerable research groups (children, prisoners, the cognitively impaired) with informed consent and institutional review board (IRB) oversight. EMTALA requires hospitals to provide a medical screening exam and stabilizing treatment for emergencies regardless of insurance or ability to pay.

Disclosing errors. Physicians have an ethical duty to disclose medical errors to the patient: explain what happened, its effects, and the next steps, and apologize. Honest disclosure preserves trust and is distinct from admitting legal liability. Disclose even when the error caused no harm or the patient would never find out.

Informed consent and its exceptions

CapacityThe patient is able to make this decision.
DisclosureDiagnosis, the proposed procedure, its risks and benefits, alternatives, and the risks of no treatment.
UnderstandingThe patient comprehends; use plain language, an interpreter, and teach-back.
VoluntarinessNo coercion or manipulation.
AuthorizationThe patient agrees; a signed form documents consent but is not the consent itself.

Elements of valid informed consent

Exceptions. Informed consent is not required in four situations:

Emergency: implied consent to save life or limb when the patient cannot consent and no surrogate is available. Treat without delay.
Waiver: a capacitated patient explicitly chooses not to hear the details.
Incapacity: the patient lacks capacity, so a surrogate consents.
Therapeutic privilege: withholding information that would itself cause serious harm. It is rarely justified and never applies merely because the news is bad.

A minor generally needs a parent's consent unless emancipated or seeking legally confidential care (see below).

Capacity, competence, and surrogates

Four components of capacity. The patient must (1) communicate a choice, (2) understand the relevant information, (3) appreciate the situation and its consequences, and (4) reason about the options. Capacity is decision-specific and can fluctuate: a patient may have capacity for a simple decision but not a complex one, and delirium can remove it temporarily. Higher-stakes decisions call for a more rigorous assessment. Age, diagnosis, and disagreement with the physician are not tests of capacity.

Capacity vs competence

Feature	Capacity	Competence
Nature	Clinical judgment	Legal status
Who decides	Any physician, at the bedside	Only a court
Scope	Decision-specific; can fluctuate	Global
If lacking	A surrogate decides	A guardian is appointed

When a confused or delirious patient refuses care or tries to leave against medical advice, the first step is to assess decision-making capacity. The refusal is valid only if capacity is present.

Advance directives. A living will states specific wishes (for example, no ventilator) if capacity is lost. A durable power of attorney for health care (healthcare proxy) names a person to decide, and that proxy outranks the default surrogate hierarchy. Without a proxy, most states turn to the spouse, then adult children, then parents, then adult siblings. Every surrogate uses substituted judgment, meaning what the patient would want, and falls back on best interests only when the patient's wishes are unknown.

Refusal of treatment: adults versus children

A capacitated adult can refuse anything. This includes life-saving care, such as a Jehovah's Witness declining transfusion for a GI bleed. Respecting an informed refusal upholds autonomy, and treating over it is battery regardless of good intent. Do not wait until the patient loses consciousness to transfuse, and do not seek a court order to override the refusal. Explore alternatives the patient accepts (such as cell salvage or erythropoiesis-stimulating agents) and document the discussion.

Parents cannot martyr their child. Parents make most decisions for a child but cannot refuse life-saving treatment, such as a transfusion for a bleeding child or antibiotics for bacterial meningitis. An adult may refuse for themselves but cannot impose a fatal refusal on a child; doing so is neglect.

Imminent dangerTreat immediately (give the antibiotics or transfusion) and seek the court order in parallel.
Not immediately life-threateningSeek an emergency court order before treating.
ThroughoutKeep engaging the parents respectfully; involve the ethics team.

Parents refuse life-saving care for a child

Minors and confidential care

Emancipated minors consent to their own care as adults. A minor is emancipated if married, on active military duty, financially self-supporting and living independently, or declared emancipated by a court. Being a parent does not emancipate a minor in every state, but a minor parent can consent for her child's care and, in many states, for her own. Being almost 18, holding a driver's license, or getting good grades does not count. Some states also recognize a mature-minor doctrine for an adolescent who shows adult-level understanding.

Who consents for a minor?

Situation	Who consents	Notes
Most non-urgent care	Parent or guardian	Default rule
STI diagnosis and treatment, contraception, pregnancy care	The minor, confidentially	Allowed in most states; keep the encounter confidential
Substance use or mental-health treatment	Often the minor	Varies by state
Emancipated minor	The minor, fully	Treated as an adult for all care
Emergency	No consent needed	Emergency care is always provided

Abortion is the major exception to minor self-consent: many states require parental involvement, often with a judicial bypass.

A 15-year-old requesting contraception, or a 16-year-old with a possible STI, gets confidential evaluation and treatment. Encourage, but do not require, involving a trusted parent.