Professionalism in the Practice of Osteopathic Medicine
Professionalism in the Practice of Osteopathic Medicine tests the obligations that come with licensure: honesty, patient welfare, boundaries, confidentiality, and self-regulation. Most items hinge on capacity, consent, or the limits of confidentiality, and the answer is usually the option that protects patient autonomy while documenting clearly.
Ethical framework and capacity
Autonomy, beneficence, nonmaleficence, and justice anchor the analysis. Capacity is decision-specific; assess four abilities: communicating a choice, understanding the information, appreciating the consequences, and reasoning about options. Capacity is not the same as compliance, and a patient with capacity may refuse a recommended treatment.
Informed consent
Elements include the diagnosis, nature of the proposed intervention, risks and expected benefits, alternatives including no treatment, and consequences of refusal. Exceptions are emergency, a narrow therapeutic privilege, and patient waiver. Document the discussion, not just the signature.
Surrogates and end of life
Typical hierarchy: court-appointed guardian, health care agent, spouse, adult child, parent, sibling. Use substituted judgment when wishes are known and best interests when they are not. Withdrawing and withholding life-sustaining treatment are ethically equivalent. Futile interventions demanded by family are addressed through ethics consultation, not capitulation. Opioid titration for pain at the end of life is acceptable under the principle of double effect.
Confidentiality exceptions
Mandatory reporting includes child, elder, and dependent adult abuse, gunshot wounds, certain communicable diseases, and impaired driving. Duty to warn or protect exists in some jurisdictions (Tarasoff). Minors may consent confidentially to STI, contraception, and substance use care in many states, so know local law.
Boundaries, impairment, and conflicts
No sexual relationships with patients; avoid treating family or friends except in emergencies; disclose gifts and industry relationships; report a colleague's impairment to the physician health program, which is confidential and nonpunitive.
Worked example
A 72-year-old man with metastatic cancer and intact capacity refuses intubation, and his daughter demands 'everything.' His refusal stands. The physician meets the family separately, validates grief, explains that comfort-focused care is active care, offers palliative care, and documents the conversation and the surrogate hierarchy.
Traps
Equating depression with incapacity. Letting family override a capacitated patient. Disclosing information to a spouse without permission. Accepting the wrong surrogate decision-maker.