Legal and Ethical Issues
Legal and Ethical Issues tests whether you can apply consent, capacity, privacy, reporting, and restraint rules correctly under emergency conditions. Items usually ask for the next permissible action rather than the philosophically ideal one.
Consent and capacity
- Informed consent requires capacity, adequate disclosure, understanding, and voluntariness. The emergency exception permits treatment without consent when a patient lacks capacity and delay risks serious harm.
- Capacity is decision-specific and assessed at the bedside: can the patient understand, appreciate, reason, and express a choice? Capacity is not the same as a legal determination of competence.
- Minors: know your state's rules for emancipated minors, mature-minor statutes, and emergency treatment.
EMTALA and privacy
- The Emergency Medical Treatment and Labor Act requires a medical screening examination and stabilizing treatment for anyone presenting to a dedicated emergency department, without inquiry into insurance or ability to pay, and an appropriate transfer with a qualified accepting facility when needed.
- HIPAA permits disclosures for treatment, payment, and operations, and for mandated reporting, but the minimum necessary standard applies.
Restraint, reporting, and disputes
- Restraints require a physician or advanced practice order, the least restrictive effective device, monitoring, and, for violent or self-destructive restraint, an in-person evaluation within 1 hour and time-limited orders (commonly 4 hours for adults, shorter for children).
- Mandated reporting covers suspected child and elder abuse, certain communicable diseases, and impaired colleagues. Protect the patient while complying.
Worked example
A 30-year-old with suspected meningitis refuses lumbar puncture and antibiotics. They are alert, oriented, and can explain that they fear needles but understand the risk of death. Reasoning: this patient demonstrates capacity, so the refusal is honored after documented informed refusal and a discussion of alternatives; a surrogate decision-maker is not substituted unless capacity is genuinely absent. Document capacity assessment, the risks explained, and the plan for return.
Traps that cost marks
- Equating a psychiatric diagnosis or an unusual choice with incapacity.
- Charting later to "make the record complete" rather than as contemporaneous documentation.
- Documenting opinions and labels rather than observations and reasoning.
- Restraint renewal without reassessment or a new order.
- Delaying stabilization to confirm payment or insurance.