The five-step answer to any ethics question
Most MCCQE ethics items resolve in this order. Stop at the first step that settles it.
Imminent threat to life or limb and no one can consent → treat what is needed, respect any known refusal.
Capacity is decision-specific. Capable patient's informed choice wins — even a refusal you disagree with.
SDM follows prior capable wishes; if none known, decides in the patient's best interests.
Mandatory report if the law says so; permitted disclosure if serious, imminent harm to an identifiable person.
Explore the patient's concerns, involve the team or ethics, seek CMPA/College advice, write it down.
Answer options that "override", "convince", "ask the family to decide" or "call security" for a capable adult are almost always wrong. The best answer usually explores the reason and respects the choice.
Four principles, one professional
Use them to name the conflict. In Canadian law, a capable patient's autonomy usually decides it.
Autonomy
Self-determination: informed consent, refusal, privacy, truth-telling.
A capable Jehovah's Witness refuses blood → respect it.
Beneficence
Act in the patient's best interests; offer what helps.
Recommend the evidence-based option clearly.
Non-maleficence
Avoid harm; weigh burdens against benefits.
You are not obliged to give non-beneficial treatment.
Justice
Fair use of resources; no discrimination; equal access.
Triage by need, not by status or ability to pay.
The CMA Code of Ethics and Professionalism (2018) adds virtues (compassion, honesty, humility, integrity, prudence) and commitments to the patient, to self-care and colleagues, and to the profession. CanMEDS calls this the Professional role.
Valid consent needs three keys
Turn each key to unlock the padlock. Missing any one means no valid consent — and treatment may be battery.
0 of 3 keys turned.
Reasonable patient
- Disclose what a reasonable person in this patient's position would want to know (Reibl v Hughes).
- Material risks: common, or rare but serious (death, paralysis).
- Higher bar for elective and cosmetic procedures and for research.
Implied vs express
- Implied: rolling up a sleeve for a BP; low-risk care.
- Express (written): surgery, invasive tests, sedation or anaesthesia, appreciable risk.
- A signed form is not consent — the conversation is. Document it.
The one who does it
- The physician performing the procedure is responsible.
- May delegate only to someone able to explain it (e.g. a trained resident).
- Tell patients about trainee involvement; they may decline.
Can I treat this patient now?
Patients may withdraw consent mid-procedure — stop unless stopping would put life or health at serious risk (Ciarlariello). Extend surgery beyond the consent only if needed to avoid a serious risk to life or health; otherwise wait and ask. Informed refusal must also be documented.
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