A Guide to Answering Medicine Interview Ethics Questions
Welcome to our series of Medicine interview guides. This specific guide is about answering ethics questions for your Medicine interview. Ethics questions are found in almost all traditional and MMI interviews so it is essential that you can answer Medicine interview ethics questions well.
Are Medicine interview ethics questions difficult to answer?
Ethics questions are often viewed as a mysterious and difficult aspect of the medical school interview. However, they are actually easy to answer and often fun once you learn a few basic principles of Medical ethics and then practise a few questions. You do not need to wade through hundreds of ethical scenarios because after learning a few basic principles, you will be able to answer virtually any Medical ethics scenario.
Why are ethical questions so common in Medicine interviews? What are ethical scenarios assessing?
Ethics questions are a great assessment tool for interviewers. They aim to see that you have the right attitudes to become a doctor. They test your ability to recognise what ethical (and other) considerations arise from different situations; how well you see things from multiple perspectives and your ability to recognise that people have differing opinions. Ethics questions test your communication skills by examining how well you can tie together all of these pieces and express them in a concise well-structured answer. Ethics questions will also test your ability to answer follow up questions and handle some pressure from interviewers if they probe your responses. If you are asked to debate ethical scenarios in a group setting it will also test your group discussion skills.
General tips on approaching Medicine interview ethics questions
Do not rush to give your opinion or an answer too early. Ethics questions are not a test to see if you “know” the right answer, or a piece of law or legislation (and often there is no right or definitive answer). Instead, they are primarily testing your ability to see things from multiple perspectives, your thought process and your communication skills in presenting an answer.
In order to show these skills when answering an ethical question in your Medicine interview, you should first discuss the multiple issues and perspectives of a situation, evaluate them and then include your overall final opinion. Do not sit too much on the fence and give your opinion where possible, but be aware that many questions do not have a definitive answer. The panel may ask you a few probing questions or challenge your answer. Do not be intimated by this and immediately fold just because you have received some resistance. Be prepared to defend your opinions. This must be done appropriately as you do not want to come across as bigoted or inflexible. Be open and respectful of different viewpoints. If something the panel says makes you realise you were actually wrong earlier, then acknowledge this and do not try to cover it up. Trying to cover up your mistakes is a very bad trait for someone who wants to be a doctor.
If the question is along the lines of, “you are a doctor in x situation, and y happens, what would you do?”, part of your answer could include that you would also discuss the situation with seniors and refer to any guidance if it is available, e.g. GMC guidance. In real life, this is what doctors often do. Even experienced consultants discuss cases with other consultants or colleagues for their opinions. For complex ethical situations, doctors sometimes consult medico-legal advice from organisations such as the Medical Defence Union or Medical Protection Society. Be careful to not use this as a cop-out for giving your opinion; it is merely one component of your answer.
The four pillars of Medical ethics and other key concepts
When reading about medical ethics, one concept that you will see come up frequently is the four pillars of medical ethics. These are autonomy, beneficence, non-maleficence and justice. We will discuss them in more detail below. You usually will not frame an actual answer to an interview ethics questions using the four pillars or even name them, but they are essential background knowledge before you start looking at ethics scenarios and start practising answering ethics questions. You can think of these four pillars as four different perspectives. When approaching a medical ethics scenario, you can think how is the situation viewed from each one of the four perspectives? You can use the four pillars as a checklist to ensure that an answer is balanced and has represented the four different perspectives.
The four different perspectives often conflict with each other. For example, active euthanasia (assisted dying) via lethal drugs may be respecting a patients autonomy but goes against the principle of non-maleficence (avoid doing harm). Respecting a patients wishes not to undergo chemotherapy to treat their cancer respects the patient’s autonomy but conflicts with the principle of beneficence (doing what is best for the patient).
Pillar 1 – Autonomy: Respecting a patients wishes
Autonomy literally means self-rule. In a medical ethics context, it is the patients right to come to their own decisions about what is best for them even if these decisions are viewed as unwise by health care providers or wider society. Healthcare professionals will provide advice and opinions, but it is ultimately the patients choice whether or not they want to accept a course of action.
Note, although patients are free to refuse any treatment or pick a treatment from a range of treatment options, they cannot demand a specific treatment or action that a doctor does not deem to be suitable. For example, doctors do not have to prescribe any medication, treatment or perform any operation or procedure just because a patient wants it if the doctor does not feel it is in the patients best interest. This could be because it is not indicated for their condition, is not available (e.g. not offered on the NHS), will not work, there are better alternatives, it will harm the patient or it is not appropriate for any other reason.
Autonomy requires that the patient is competent and has the capacity to make a decision, for example, the decision to accept or refuse treatment. A two-year-old child does not have the capacity to refuse an operation to treat their life-threatening appendicitis or their broken leg (which if not treated will lead to permanent deformity). Someone else will have to make these decisions on the child’s behalf. Someone who is heavily intoxicated or deliriously unwell also does not have the capacity to make informed decisions. In these two cases, the lack of capacity is temporary, i.e. it will come back after the patient is no longer intoxicated or unwell. If it is feasible, it would be best to wait for the patient to regain capacity, instead of trying to make serious decisions on their behalf but sometimes this is unavoidable in emergencies. Someone with advanced dementia may not be competent to make decisions about their healthcare or finances, and alternative ways of doing what is in their best interest will have to be explored. For example, advanced directives in which patients with capacity can specify how they wish to be treated if they lose their capacity in the future.
Pillar 2 – Beneficence
This means doing what is best for a patient. This leads to the moral dilemma of who decides what is best for patients? In the earlier example of a child with appendicitis or a child with a broken leg, what if the parents do not want to proceed with the surgery and prefer a medical treatment (i.e. non-surgical) instead? Alternatively, what if the doctors do not want to proceed with the surgery as they deem it too risky but the parents want an operation as they think the better outcome from surgery is worth the risk? Beneficence in medical ethics typically means what would an independent health care professional deem to be in the patients best interest. The patients perspective is already covered by the pillar of autonomy.
Autonomy and beneficence may conflict when a competent patient chooses an action which is not in their best interests. For example, a patient refusing the antidote/treatment after he or she has taken a drug overdose. This is a frequent scenario seen many times every day in emergency departments across the country. In a nutshell, if the patient is deemed to have capacity and is making an informed decision, then in the UK they have the right to refuse this life-saving treatment. To forcibly treat this patient, who has capacity and is making an informed decision, would be assault. Healthcare professionals and wider society may view this person’s decision as unwise, but it is one a patient is free to make. If the person was instead deemed to not have capacity, i.e. was too intoxicated or had a mental illness (it would have to be a mental illness which directly meant that they did not have the capacity for this specific decision. This is because mental illness or any health condition in of itself does not automatically mean that a patient does not have the capacity to make decisions. Similarly, if a patient does not have the capacity to make a decision on one matter, it does not mean that they do not have the capacity to make decisions on other matters) then it would be possible to treat the patient against their will given certain steps are followed.
Beneficence and non-maleficence may conflict also. For example, if a patient is approaching the end of their life and suffering, giving them morphine will reduce their pain and suffering. Giving them morphine represents beneficence. However, the morphine can have the effect of accelerating their death so doing this action would be harming them also. Again this is a very common scenario, happening countless times every single day throughout hospitals and hospices around the world. Generally, in the UK, the way that this situation is approached is that if the primary intention is to treat the patient’s pain than this is acceptable. Not giving morphine if the patient wishes it would be cruel. If the intention is to kill the patient then this is active euthanasia and is against the law.
Pillar 3 – Non-Maleficence
This means avoiding harming patients.
Pillar 4 – Justice
Justice is about fairness across the wider population. For example, it should be expected that patients in similar situations are treated similarly. Additionally, resources are limited and should be distributed fairly across society. Justice considers that providing resources to one set of patients will have an impact on what can be offered to others in a society with limited resources. Is it right to spend millions of pounds to mount a search and rescue team to find one missing mountain climber, while we would not usually spend this much money to save a person with cancer? Should we perform three life-saving operations or spend the same amount of money giving 5,000 people medications to reduce their daily pain from chronic conditions which they suffer? Should we determine what treatment we are prepared to give to people based on their ability to pay, their job or status in society?
Other factors to consider…
Besides the four pillars of medical ethics, there are other concepts which are important to consider when dealing with ethical scenarios and ethics questions in your Medicine interview. They are discussed below.
Working within the law
Doctors are expected to work within the law. The law covers many ethical matters. In the UK active euthanasia and assisted dying are illegal. In other countries, it is legal with certain restrictions. Abortion is covered by law also. Laws often reflect a societies views. Laws change over time (although not always at the same pace as public opinion or in keeping with public opinion) and vary even within the same country. For example, abortion laws are different in Northern Ireland compared to the rest of the UK. Many laws are different state by state in the USA.
The Duty of Confidentiality
Confidentiality is a consideration that has relevance in many ethical scenarios. For example, when should doctors give information to the police or social services? Should they at all? Can a 12-year-old girl ask that doctors do not tell her parents she is on birth control or that she wants an abortion? What is a doctors responsibility if a patient discloses that they smoke cannabis? What if they reveal they have or are intending to murder someone? We cover how to answer some of these specific questions in our free Medicine interview question database and our interview courses.
Confidential medical care is recognised by law to be in the public interest as it benefits society as well as the individual if people are confident in accessing good medical healthcare. Members of the public are less likely to underreport symptoms or avoid medical help if they are not worried that their information could be disclosed to others or not handled carefully. It also benefits doctors as confidentiality ensures that patients are more likely to tell doctors all the facts which helps doctors in their decision making.
There are, however, instances where the public interest outweighs an individual’s right to confidentiality. For example, if it is in the case of serious crime or if people are in danger, or at the request of a court order. Even this is a careful process where doctors must make sure it is indeed justified to break confidentiality and doing so is better than the other options. Where acceptable and practical, doctors usually try to encourage the patient to make a disclosure to the relevant body themselves.
Healthcare professionals should also be careful with patients data. Who has access to patient data and how much of it is an ethical consideration. Not all information needs to be shared. Reception staff will need patient demographics to do their job, but they do not typically need access to confidential medical files. When reporting statistics or in other situations where it is possible data should be anonymised i.e. identifiable information such as names and addresses should be removed as they are not relevant or required for the task.
Healthcare professionals should ask consent to share information. This can include implied consent. For example, if a patient is happy to be referred to a specialist by their GP, this implies that they are happy for that specialist to receive their relevant health information. As a general rule implied consent should be restricted to situations which are small and do not have serious consequences.
Obtaining Informed Consent
Informed consent is the process of getting permission from a patient before a healthcare intervention is performed or for example when sharing their confidential data. For consent to be valid, the patient must have capacity to make decisions, be making a voluntary choice (i.e. free from coercion or pressure from others) and be given the relevant facts. This would typically include the risks and benefits of an intervention, alternatives, the consequences of not taking the intervention etc. If a person is not given the relevant facts or purposefully misled or coerced then the person’s consent is not informed, so they have not given informed consent. Sometimes in emergencies consent cannot be taken, e.g. if the patient is unconscious. If the person’s previous wishes are not known (for example in a legal document called an advanced directive) or there is not enough time to ascertain this, then doctors can proceed to do what is deemed in the patients best interests in the meantime.
Competence and Capacity
Consent can only be taken from patients who have the capacity to make decisions. Competence is often used interchangeably with capacity to mean the same thing. Competence is usually used as a legal term and capacity is used in medical contexts so we will use the latter term. In the UK, everyone above the age of 16 is assumed to have capacity unless proven otherwise. Capacity can be assessed by doctors.
You cannot judge capacity by age, appearance, condition or behaviour alone. It is also important to make clear that just because a decision is viewed as unwise or irrational by doctors or wider society, it does not mean that person does not have capacity. For example, a Jehovah’s witness who refuses a life-saving blood transfusion would not be considered to lack capacity. They understand their situation and the consequences of their actions. From their perspective their choice is rational.
Things which may impair capacity include mental or physical illness, intoxication, severe stress or psychological trauma. Capacity is decision specific. This means that someone can have the capacity, for example, to decide when to wash or to choose their lunch menu but not on some aspects of their healthcare. It is also time specific, just because someone lacks capacity at one point in time does not mean that they will at another time.
If someone does not have capacity, then there are three main ways for healthcare professionals to proceed in making decisions for them. The first is if the patient has an advanced directive which states how they wish to be treated in the event that they lose capacity in the future. In this case, the doctors can use this to make decisions.
Patients can give someone else that they choose the power of attorney (commonly a spouse, relative or friend) which means that they can nominate them to be able to make healthcare decisions on their behalf. Someone with power of attorney must still make decisions in the persons best interests and there are systems to ensure that people are not exploited.
Lastly, if the patient has not previously made their wishes known then doctors will act in the best interests of the patient. Family members may be consulted to help in coming to decisions, but they cannot consent on behalf of a patient unless they have power of attorney.
We cover capacity, consent and confidentiality for people under 16 years of age in a brief separate blog as it is different. We also have many examples and detailed answers to ethics questions about consent, confidentiality and capacity for young people in our free Medicine interview question database.
Summary of what has been covered
This guide has covered the reasons why ethics questions are so common in Medicine interviews. We have given some tips on how to approach answering Medicine interview ethics questions. We then covered some of the key concepts you should know before attempting to answer ethics questions. For example, the four pillars of medical ethics, confidentiality, informed consent and capacity.
After reading this guide you can practice questions using our free Medicine interview question database which includes answers. We also offer a comprehensive one day Medicine interview course as well as tailored one to one medicine interview tutoring which thoroughly covers medical ethics. All of our courses and one to one tutoring is delivered only by fully qualified doctors who passed all four of their own Medicine interviews and have sat on both sides of interview panels.