Medical Student Experiences with Ethical and Legal Cases

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Author: David Fine, Medical Student Council President

Originally published: Common Sense
May/June 2020

The purpose of medical education is to train future providers to be prepared for the multitude of patients, presentations, and complications that they might face in their future careers. Ethical and legal dilemmas are incredibly complicated and vary based on where you practice, so they are often less discussed than our essential medical fundamentals. Being somewhat familiar with common problems, however, is relevant not only to your future career but your rotations as well. I aim to share a few of the complex situations that I faced, which may apply to your rotations in the emergency department or on the floors.

Dilemma 1: A patient who was frustrated with long wait times starts the patient interview by stating that they are recording the conversation. 

Legally, most states fall under the cover of single-party jurisdictions where only one party in the recording needs to assent (in this case the patient recording the conversation). In California, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire, Oregon, Pennsylvania, and Washington both parties must assent to the recording.4 Hospital policies and guidelines can also help clarify these confrontational situations. Context is everything, and some patients may want to record conversations so that they may refer to them in the future rather than relying on memory. The issue arises when this action makes somebody uncomfortable and, particularly, when this begins to affect patient care. In this situation, the patient was first asked why they were recording the conversation. They vocalized that they wanted to prevent being taken advantage of as they have in prior encounters with medical providers. The physician assented to the recording and asked the resident to pick up a different patient.

Dilemma 2: A patient is brought to the ED after overdosing on an unknown substance. The contact information of the substance provider is available but patient is altered and unable to approve disclosure.

This is another fairly straightforward dilemma in the sense that the urge is to reach out to someone who may be able to quickly identify the culprit substance. The issue is that the patient is altered and unable/unwilling to provide consent to disclose information about their hospitalization. HIPAA exceptions include court orders, public health organization requests, cases of neglect/abuse, cases of organ donation, and the threat to themselves or public safety.3 In the balance of patient privacy and patient well-being this is a situation where we must be more reliant on physical exams, a solid understanding of toxidromes, and laboratory testing.

Dilemma 3: An inebriated patient is brought in by the police after an MVC and is refusing care.

HIPPA prohibits the release of information without consent, which includes law officials (aside from the exceptions above). A conflict can arise where they may not be able to differentiate questioning for the purposes of law enforcement vs. health care. A study evaluating patient perspectives on Philadelphia police transporting trauma victims showed that some patients appreciated the expedited transport to the hospital while others felt that police questioning was an added stressor that disrupted essential medical interventions.2 Police presence is often unavoidable, but steps should be taken that allow patients to feel safe and build the physician-patient relationship. Furthermore, you should assess the necessity of testing. Having a drug screen, for example, can quantitate levels of drugs in the patient’s system. This could help estimate the time that the drug will be in their system, but clinically may not be relevant. Capacity to refuse treatment won’t be determined by a blood alcohol level, but rather their mental status assessment. In determining capacity, you should consider the patient’s ability to communicate a choice, understand the risks and benefits, and use reasoning to arrive at their choice.1 This patient remained in a C-collar until they were no longer clinically inebriated. They were then cleared of spinal precautions after fulfilling the NEXUS criteria and discharged without imaging.

The common goals of all three cases are to understand patient perspectives and deescalate conflicts. Knowing your state and hospital policies can go a long way in building comfort while handling these situations. Learning from your experiences and the experiences of others is another great way to supplement your medical school education.

References:

1. Colwell, Christopher. “Know When Uncooperative Patients Can Refuse Care and Transport.” Journal of Emergency Medical Services, vol. 41, no. 8, 1 Aug. 2016, www.jems.com/2016/08/01/know-when-uncooperative-patients-can-refuse-care-and-transport/.

2. Jacoby, Sara F. "When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?" Health Affairs, 1 Oct. 2018, www.healthaffairs.org/do/10.1377/hblog20180926.69826/full/.

3. Raines, Rebeccah Therkelson. “Evaluating the Inebriated: An Analysis of the HIPAA Privacy Rule and Its Implications for Intoxicated Patients in Hospital Emergency Departments.” University of Dayton Law Review, vol. 40, no. 3, 2016, pp. 479–498.

4. Saleh, Naveed. “What to Do If Your Patient Is Recording You.” MDLinx, 22 May 2019, www.mdlinx.com/internal-medicine/article/3723.