MMI ethics questions on consent and autonomy

Every treatment a physician gives rests on a patient's agreement, and the right to refuse is what gives that agreement meaning. MMI ethics questions on consent put you beside a person making a choice you'd never make, and ask what respecting that choice requires. The choices include refusing a blood transfusion and keeping a car at 84 after two near misses.

What these questions test

Autonomy is a person's right to make decisions about their own body and life. Capacity is the ability to understand the information a decision needs, to appreciate its consequences and to communicate a choice. Informed consent is agreement given freely by a person with capacity who understands what is proposed, its risks and benefits and the alternatives. Raters score whether you can tell a bad decision from an incapable one, and whether you know that autonomy gives way when a choice puts other people at risk.

The stations are built to tempt you into paternalism, which is overriding a person's choice for what you judge to be their own good.

How to approach them

1. Start with capacity, and presume an adult has it. A decision you dislike, such as an older customer's cash withdrawal for someone he met online, isn't a sign of lost capacity on its own.
2. Separate the decision from its outcome. In the US and Canada, a capable adult can refuse any treatment, including one that would save their life. A choice that endangers others, such as driving with failing eyesight, is a different question.
3. Make sure the consent is informed and free. Say what the person needs to know in plain words, ask who is pressuring them, offer the alternative, and then accept the answer.
4. Where a person can't decide, find who decides for them. A substitute decision-maker is the person authorized to decide for someone who lacks capacity. They are bound by the person's known wishes and best interests. The person still gets a voice, and a 10-year-old who says he hates being filmed for his mother's video channel has used his.
5. Refuse the deceptive shortcut. Taking an 84-year-old's car keys while he sleeps solves the problem by removing the person's choice, and the rater scores your method as closely as the result.
6. For a policy prompt, test the policy against the definition of consent. Opt-out organ donation, cosmetic surgery under 18 and a click on unread terms each ask whether the agreement was informed, free and given by someone with capacity. In an MMI the interviewer plays a husband begging you to transfuse his wife, or a mother asking you to take her father's keys, and pushes you to override, so decide before the station what you won't do.

Common mistakes

• Treating a decision you disagree with as proof the person lacks capacity confuses your judgment with theirs.
• Letting a relative decide for a capable adult gives the wrong person the choice.
• Using respect for autonomy to end the conversation misses that autonomy includes making sure the person has the facts to decide with.