Every ethics question is really asking one thing: who gets to decide, and what rule controls when people disagree. Learn the rule, then learn exactly when it bends. Two facts carry most of the points: whether the patient has capacity, and whether the harm is serious, imminent, and unavoidable. Start with the case that catches the most students.
Medically reviewed by Fatima Ali, DO & Kaitlyn Cocuzzo, MD✦elite
Before you scroll
A 67-year-old man with severe gastrointestinal bleeding has a Hgb 6.4 (13.5 to 17.5) and needs urgent transfusion. He is fully alert, repeats back the risk of dying without blood, and calmly refuses transfusion on personal grounds. His adult daughter pulls you aside: "He is not thinking straight, just give him the blood, I am his next of kin." Who controls this decision?
What single fact decides this?
Whether he has capacity for THIS decision, judged by the physician at the bedside. Capacity is decision-specific and time-specific, not a global label.
Does he have it?
He is alert, understands the risk of dying, appreciates it applies to him, and expresses a consistent choice. He meets the test, so a capable adult may refuse even life-saving care.
Why not the daughter or the emergency rule?
A surrogate steps in only when the patient cannot decide; she cannot override a capable refusal. The emergency exception requires that the patient cannot consent. He can, and he said no. Transfusing over a capable refusal is battery.
Scroll ↓ the four principles come next
Section 1 · The Engine Behind Every Case
The Four Principles + the Theories
Tap each principle to see the bedside test and the classic conflict. Then flip the cards on the theories behind them.
Principle 1
Autonomy
What it is: respect the patient as a self-determining individual. This is the source of truth-telling, informed consent, and confidentiality.
Bedside test: a capable adult may accept or refuse anything, even if the choice looks unwise. Acting on a patient without consent is battery (assault and battery).
Landmark: Schloendorff v Society of New York Hospital (1914) created autonomy: "every competent adult has the absolute right to determine what is done with his own body."
Principle 2
Beneficence
What it is: do good. A fiduciary duty to act in the patient's best interest.
Bedside test: take a positive, helpful action. When it collides with autonomy in a capable patient, autonomy usually wins.
Conflict: beneficence can pull against society or against a refusal; the patient's interest is the anchor, not the family's preference or convenience.
Principle 3
Nonmaleficence
What it is: do no harm. The obligation to minimize risk and avoid further injury.
Bedside test: stop or decline a harmful action. Declining a harmful, non-beneficial intervention (such as a feeding tube in end-stage dementia) is nonmaleficence in action.
Pivot: nonmaleficence = avoid a harmful action; beneficence = take a helpful action. The same vignette can flip on that one verb.
Principle 4
Justice
What it is: distribute benefits and burdens equitably across a system.
Bedside test: treat fairly, not always identically. Triage and organ allocation go by medical need, never by social worth or ability to pay.
Note: the four-quadrant model uses all four principles together to work through a hard case.
Now adjudicate. In each conflict, tap the principle that wins, then tap the principle it overrides. The scale tips toward your call.
Quick reference: the four ethical theories behind the principles.
Kantianism
Duty, not outcome.
Deontology: rightness depends on fulfilling a duty, not on consequences. An act is right because it satisfies an obligation, regardless of how it turns out.
Utilitarianism
Maximize the good.
The right action maximizes happiness and minimizes unhappiness across everyone affected. Outcomes are everything.
Communitarianism
Goods across the community.
Concerned with how goods and services are distributed across a community, such as how a department balances critical-care spending against prevention.
Paternalism
Overriding the patient "for their own good."
A clinician overrides a patient or surrogate decision deemed unwise. Generally not acceptable when the patient has capacity, because it conflicts with autonomy.
ABNJ Autonomy · Beneficence · Nonmaleficence · Justice. The four-quadrant principles; every ethics case runs on these.
Section 2 · The Split clinical medicine Love
Consent, Capacity, and Competence
First the split, then the four-part capacity test, then the exceptions when you do not need standard informed consent.
Capacity
Clinical judgment, made by the physician at the bedside.
Decision-specific and time-specific: assessed for THIS choice, right now.
Can be present for one decision and absent for another.
A stable psychiatric diagnosis does not erase it.
Competence
Legal determination, made only by a court.
Global: applies broadly, not to a single decision.
"Only a court can declare a patient incompetent."
Reserve the courts for genuine doubt, not for a clear bedside refusal.
Capacity has four parts, all required. Tap each step.
U
Understand
The patient grasps the relevant facts: the diagnosis and the proposed plan.
A
Appreciate
The patient applies those facts to their own situation and consequences.
R
Reason
The patient weighs options logically, including the alternative of no treatment.
E
Express
The patient communicates a consistent choice. Stating a preference alone is not capacity.
Now run the test. For each patient, toggle each pillar present or absent from what they say. The gauge fills only when ALL FOUR are green; capacity is decision-specific, all-or-nothing for THIS choice.
Tap a pillar to toggle it present (green) or absent (red).
📝Informed consent = risks, benefits, and alternatives (including no treatment) in language the patient understands. Consent is revocable anytime, even orally. If a patient asks your level of experience, you must answer honestly for consent to be valid.
Suicidality vs refusal
Active suicidal ideation is deemed to impair judgment, so suicidal patients are treated as lacking capacity. But refusing unwanted treatment is not the same as wanting to die. A patient with mental illness or intellectual disability may still retain the right to refuse if THIS specific decision is intact.
Build a valid informed consent. Tap each element that belongs in the disclosure; the form stays INVALID until every required element lands. Decoys do not belong.
Consent status: INVALID · 0 of 6 required elements
The disclosure
Consent is a disclosure set, not a signature. Tap the elements that make it valid.
When you do NOT need standard informed consent: the WIPE exceptions.
W · Waiver
"Just do what you think is best, do not tell me."
The patient explicitly relinquishes the right to be informed. This is the patient's choice, not the family's.
I · Incompetent
No capacity for this decision.
The patient lacks capacity. Obtain consent from the legal surrogate. Surrogate or proxy consent is valid even over the phone; substituted judgment means deciding as the patient would.
P · Privilege
Therapeutic privilege (rare).
Withhold information only if disclosure itself would severely harm the patient or undermine capacity. NOT "the family says they cannot handle it."
E · Emergency
Implied consent.
Life-saving treatment when the patient cannot consent and no surrogate or advance directive is available. No court order, no ethics committee; police cannot consent.
WIPE Exceptions to informed consent: Waiver · Incompetent · therapeutic Privilege · Emergency.UARE Capacity, read as "you ARE capable": Understand · Appreciate · Reason · Express.Clinician vs Court Two C's, two deciders. The physician judges capacity at the bedside; only a court rules on competence.
Section 3 · The Default, and When It Breaks
Confidentiality + Reportable Illnesses
Confidentiality is the default. It breaks only for serious, imminent, otherwise-unavoidable harm. Start with the case the rule is named after, then study the breaks and sort the scenarios.
Case File · October 1969
Intake · Session 01Confidential
He sat across from you. Calm. Organized.
He told you he is going to kill a woman who turned him down.
He said her name.
Then he asked you to keep it between the between the two of you.
The Choice
The threat is serious, the victim is named, the harm is imminent, and there is no safe alternative. One move is yours to make.
The Consequence
The Rule, Locked
Tarasoff · the duty to protect
TriggerSerious + imminent harm to an identifiable victim, with no safer alternative.
ActionWarn the victim AND notify law enforcement.
TrapHis capacity makes a named, dated threat MORE dangerous, never an excuse.
The chart knew what was coming. She never did.
🔒Threshold to breach (all three): harm is serious AND imminent, there is no alternative way to protect the person, and the breach can actually prevent it. Records go to the PATIENT first; a transfer needs the patient's signed consent; you must comply with a subpoena or court order; never disclose immigration status or genetic info to third parties; patients may inspect records within 5 business days of a written request.
The five exceptions that break confidentiality: SAVED.
S · Self/others at risk
Active suicidal or homicidal ideation.
A credible, active threat ends confidentiality. Capacity makes a named, dated threat MORE dangerous, not less.
A · Abuse
Children, elders, prisoners.
Suspected child abuse goes to Child Protective Services; elder abuse to Adult Protective Services. Report in good faith and you are protected even if no abuse is later found.
V · Protect the Victim
Duty to warn.
When a patient names a credible target, warn the identifiable victim AND notify law enforcement. First make every effort to enlist the patient; the trigger is the danger, not the name of any one case.
E · Epilepsy / impaired drivers
A danger behind the wheel.
Encourage the patient to self-report first; if they will not, the physician notifies the DMV. The physician reports but cannot suspend a license; only the DMV can.
No mandatory HIV testing without specific informed consent (pregnant women may refuse testing and antiretrovirals). If an identifiable partner is at risk and the patient will not notify, notify the Department of Health to start confidential partner notification, or notify the partner yourself with legal protection. A patient who refuses anti-TB therapy can be isolated or incarcerated (in hospital) for about 2 weeks until sputum is AFB-negative.
The case behind the rule
The chart knew what was coming. She never did.
In 1969 a graduate student told his university psychologist exactly what he meant to do: kill a young woman named Tatiana Tarasoff, who had turned him down. The therapist believed him and alerted the campus police, who questioned the man, Prosenjit Poddar, decided he seemed rational, and let him walk. No one warned Tatiana. No one warned her family. Two months later he came to her door and stabbed her to death.
Her parents sued, and the court's answer became the rule you carry now: when a patient names a victim who can still be reached, silence is not a choice you are allowed to make. The chart knew what was coming. She never did.
Drag each scenario into the correct bucket.
Scenarios
Mandatory report / breach
Keep confidential
Drag (or tap a chip, then a bucket) to sort each scenario.
SAVED When confidentiality breaks: Self/others · Abuse · protect the Victim · Epilepsy/impaired drivers · reportable Diseases.
Section 4 · Who Consents for the Young Patient
Minors + Reproductive Issues
A parent decides for a minor, with specific carve-outs. Read the rules, then drag each scenario to the right bucket.
The rules in one breath
A parent or legal guardian decides for a minor, EXCEPT a minor may consent confidentially to contraception, STI care, prenatal care, and substance-use treatment (partial-emancipation categories), plus emergencies.
An emancipated minor has full adult rights: married, self-supporting, in the military, a parent themselves, or homeless / living independently. Pregnancy alone does NOT fully emancipate, though a pregnant minor consents for her own pregnancy care.
Parents cannot refuse proven life-saving treatment for their child on religious grounds (the state's interest in the child); an adult may refuse for himself. Reproductive: a first-trimester abortion is unrestricted and needs no one else's consent; third-trimester is restricted (potential viability); no paternal or spousal consent is required for abortion, contraception, or sterilization; abortion for gender selection is unethical; if you are not comfortable performing an abortion you must refer; fertilized eggs may be donated, not sold.
Route each minor through the tree. Answer the branching questions; the path you take decides who consents, and each branch shows you the rule.
Quick check: drag each scenario into the right bucket.
Scenarios
Parent decides
Minor consents (confidential)
Drag (or tap a chip, then a bucket) to sort each scenario.
Section 5 · When the Patient Cannot Speak
End-of-Life Decisions
Predict each branch before you reveal it. Pick an answer to see where it leads, then flip the fixed-fact cards.
Node A: Does the patient have decision-making capacity right now?
The patient decides everything. They may refuse or stop any life-sustaining treatment, even mid-course (dialysis, ventilator), and a valid DNR/DNI cannot be overridden by family.
No capacity. Go to Node B: is there an advance directive or healthcare proxy?
Node B: Is there a valid advance directive or healthcare proxy?
Follow it. A healthcare proxy / durable medical power of attorney (patient-chosen agent) is more flexible than a living will and can respond to unforeseen situations. A clear, repeated oral advance directive still guides care.
No directive. Go to Node C: use the surrogate hierarchy with substituted judgment.
Node C: No directive. Build the surrogate ladder in priority order.
Drag (or use the handle on touch) to put the decision-makers in the correct priority order, then check it. Substituted judgment governs: decide as the patient would.
Order them top (highest priority) to bottom.
Note for recognition: some study decks list the order as "spouse, parents, adult children, friends," swapping parents and adult children. clinical medicine use the standard above (spouse → adult children → parents → adult siblings); know both wordings so neither throws you. If the patient's prior wishes are known, they win over the surrogate's personal preference. If there is no directive AND the family disagrees, take it to the ethics committee.
Now work the console. Set the inputs to match each case and read how the verdict shifts. Change one input and the recommendation can flip, because end-of-life answers depend on who holds authority.
The fixed end-of-life facts clinical medicine test.
DNR = CPR only
Not "do not treat."
A DNR means no chest compressions, cardioversion, or intubation at the time of arrest. The patient may still be intubated or ventilated BEFORE arrest, and still gets surgery, dialysis, and routine care.
Double effect vs palliation
Comfort can hasten death.
Double effect: palliative therapy that relieves suffering is ethical even if it may hasten death, as long as the intent is comfort. Palliation = comfort meds without treating the cause. Futile care is not obligatory.
Euthanasia vs PAS
Who administers?
Euthanasia: the provider administers the lethal agent. Physician-assisted suicide: the patient self-administers, the provider only prescribes. Hospice is interdisciplinary palliative care for a prognosis under 6 months.
Brain death = death
Legally dead.
Irreversible loss of brainstem reflexes: pupillary light, corneal, oculocephalic (doll's eyes), and caloric (oculovestibular), plus no spontaneous respiration. Organs may be harvested; movement on touch is a spinal reflex.
DNR = CPR only A DNR blocks compressions, cardioversion, and intubation at arrest. The patient may still want intubation before arrest, a feeding tube, or chemo.Surrogate ladder Spouse → Adult children → Parents → Adult siblings → other relatives, deciding as the patient would (substituted judgment).
Section 6 · The Physician in the System
Doctor & Society / Professionalism
Reporting duties split in ways clinical medicine love to test. Pick before you reveal, then check each professionalism rule.
A competent victim of intimate-partner abuse asks you NOT to report it. Do you report anyway?
Not quite. Spousal / intimate-partner abuse is the key contrast: you do NOT report it over a competent adult victim's objection.
Correct. For a competent adult victim of intimate-partner abuse, encourage reporting, offer counseling and resources, but do not report without consent. This contrasts with child abuse (CPS), elder abuse (APS), and gunshot wounds (mandatory, over objection).
A patient just had a first seizure and drives daily. Can you suspend his license?
No. A physician cannot suspend or revoke a license.
Correct. Encourage the patient to stop driving and self-report; if needed, the physician notifies the DMV. Only the DMV or state can suspend the license. The physician reports, the state acts.
The professionalism rules clinical medicine test.
Executions and torture
May a physician participate?
No. Physicians may not participate in executions or torture even where legal, and may not even certify an execution death.
Pharma gifts
What is acceptable?
Modest gifts under $100 that are medical or educational. Sponsored meals and talks are OK if they do not control content. No gifts purely to boost income or for entertainment. The Federal Anti-Kickback Statute bars payment to induce referrals.
Impaired colleague
Who do you tell?
Remove from patient care first, then report up the chain. A resident or trainee goes to the program director / department chair; a self-employed private attending goes to the state board of medical conduct.
Ending the relationship
Gifts, exits, boundaries.
You are not required to accept a patient. Ending a relationship needs at least 30 days notice, or it is abandonment. Small patient gifts are fine; sexual contact with a patient is ALWAYS inappropriate.
Section 7 · The Courtroom Vocabulary
Malpractice + Legal Essentials
Eliminate the wrong terms until one stands. Tap a wrong term to cross it out, then flip the fixed-fact cards.
A surgeon leaves a sponge inside a patient. The injury would not happen without negligence and the cause was under the surgeon's exclusive control. Which legal doctrine is this?
Cross out the doctrines that do not fit until one is left.
A nurse employed by the hospital harms a patient during the shift, and the employer is held liable for the employee's act. Which doctrine is that?
Cross out the wrong terms until one is left.
Now build the case. Tap the fact that satisfies each of the four D's. The proof bar fills only when all four segments are green; miss one D and the claim collapses. Decoys satisfy none of them.
Match each fact to the element it proves: Duty, Dereliction, Damages, Direct causation.
An apology to the patient after a medical error: does saying "I am sorry" admit legal liability?
Not quite. Errors must be disclosed, and in many states an apology is protected and is not treated as an admission of liability.
Correct. Medical errors must be disclosed to the patient, and in many states an apology or expression of sympathy is legally protected and is not, by itself, an admission of liability. Disclosure plus an apology is the standard, not silence.
The fixed legal facts clinical medicine test.
The 4 D's of negligence
All four, or the claim fails.
Duty owed → Dereliction (breach of duty) → Damages (actual harm) → Direct causation. Miss any one element and the malpractice claim collapses.
Standard of care
The objective yardstick.
What a reasonably prudent physician of similar training would do under similar circumstances. Deviation PLUS harm equals malpractice; deviation with no harm does not.
Key terms
Quick definitions.
Battery: contact without consent. Tort: a civil wrong with a remedy. Subpoena: an order to testify. Captain of the ship: the surgeon is responsible in the OR. Good Samaritan Act: protects voluntary emergency aid at the scene. Abandonment: unlawful one-sided end of the relationship.
Reporting bodies
Who tracks what.
National Practitioner Data Bank tracks malpractice actions. HIPDB (Healthcare Integrity and Protection Data Bank) tracks fraud and abuse.
Organ donation
Family has the final say.
Donation is voluntary; organs are never bought or sold. Only the organ-procurement organization / UNOS obtains consent, never the treating team. Even with a signed donor card, the FAMILY has the final say.
Surrogate order if a directive is silent: Spouse → Adult children → Parents → Adult siblings (deck wordings vary).
Research (IRB)
Approval before you begin.
An Institutional Review Board must approve any study before it starts, and researchers must disclose all funding sources.
4 D's of negligence Duty · Dereliction · Damages · Direct cause. All four required; missing any one means the claim fails.
Test Yourself
Ten Quick Calls, Five Per Round
Five clinical cases pulled from a bigger pool, reshuffled every visit. Know the rule, know exactly when it bends. Cross out (right-click / long-press) and highlight (select text) as you read.
Shared decision-making: consent is a conversation, not a signature.Capacity is assessed at the bedside, by the clinician, for one decision.End-of-life care follows the patient's prior wishes over a surrogate's preference.Confidentiality is the default; it breaks only for serious, imminent, unavoidable harm.
clinical Practice
Walk the Cases
Ten full vignettes, one at a time, in a shuffled order. Pick your answer, then walk every option one beat at a time. The deciding clues in the stem glow once you commit. Cross out (right-click / long-press) and highlight (select text) as you go.
From the Attending
These ten vignettes are written the way the real exam writes them: who decides, and what single fact controls when people disagree. Cover the choices, find whether the patient has capacity, then ask whether the harm is serious, imminent, and unavoidable. Most ethics traps are one criterion you skipped. Read every explanation, not just the one you missed.
Tip: kill the wrong choices first, then read the explanation chain for every option.
American Medical Association. Code of Medical Ethics. Consent, confidentiality, end-of-life, professionalism, and the patient-physician relationship.
Schloendorff v Society of New York Hospital (1914). The origin of autonomy and informed consent.
Tarasoff v Regents of the University of California (1976). The duty to protect an identifiable victim.
Beauchamp and Childress. Principles of Biomedical Ethics. The four-principle framework.
CDC and state health departments. Nationally Notifiable Conditions. Reportable diseases and partner notification.
Reviewed by Fatima Ali DO and Kaitlyn Cocuzzo MD. Vignettes are original clinical teaching cases; demographics, values, and answer order are written for practice. State law on minors, reproductive care, and reporting varies; confirm against your jurisdiction at the point of care.
Bone Wizardry is an independent educational resource for visual learning in the medical sciences. It is not affiliated with, endorsed by, or sponsored by any licensing or examination board, contains no real or recalled examination questions, and does not guarantee any educational or examination outcome.
That was the free half
You know who decides. Now make every ethics call automatic.
The four principles, the consent exceptions, and the capacity-versus-competence split are yours free. Everything that turns "I get it" into a 10-second answer on exam day lives in Elite:
Confidentiality breaks, reportable illnesses, and the duty to warn
Minors and reproductive consent, with the drag-to-sort game
End-of-life: DNR, directives, the surrogate ladder, brain death
Professionalism, impaired colleagues, and malpractice doctrines
The quiz plus ten clinical vignettes with walkthrough chains
