EI-DER ABUSE The same critcria described for chilcl abuse generally apply to elder abuse. Instead of child protective services, thcre are adult protective scrvices. Reports made i’good faitl.r can be clone rvithout liability to the rcporter. The circurnstances with ercler abuse are ress crear than with child abuse, because the elderly person is often a still_cornpetent adult who mar objcct to the report of the abuse on thc basis that they are afraid of repcrcu.sion. in the home or the loss of the home. Nevertheles., ynu -or, report elder abuse, and partiallv breaching the confidentiality of the patient antr fanr y is permissible in the interest of protecting a vulnerable person.
The other reason that elder abuse reporting is less clear is that there is no uniform national standard fbr it in all 50 states.‘l.he vast najority ofstates, however,lrave a reportrng slstem similar to that for reporting child abuse.‘r’he botto’line for USMLE is that you should answer to "report the abuse to adult protective services,’ if the case rs Drese.ted.
IMPAIRED DRIVERS The rules on reporting impaired drivers vary enormously nationally. There is no other aspect of medical ethics and heaitrr-care regarity that has such state-to-state variab ity as the m.rnagement of the in.rpaired drivcr, All states require the patient to report setzure c.lis orders; howcver the period of tilrre that the crriver must stay off the .oacl varles vastry from one state to another and therefore cannot be tested on the USMLE. Physicians cannot suspend driving privileges. Or.rly the state sponsored Department of Motor Vehicles (DMV) can suspend or revoke driving privileges. \Arhen a rlriver is impaired ln any way, thc first step is to encourage the driver to report the impatrnent, to the DMV In additio’, the physician should encourage all impaired drivers to rimit or curtair their driving. There is no uniform agrecment of what, beside seizure disorders and visual impairment should be reportecl in all states. Only a few states have specific laws requiring reporting of sy’copal episodes. Not ail states offer immunity to physicians, such as the protections offered for reporting child abuse, for reporting an impaired driver.
For example, yo:u are the attending physician on a patient admitted to the hospital with a first-time seizure. The head CT and EEG are normal. you will not be start_ ing antiseizure medications. The patient drives to work regularly. What should you do concerning the patient,s ability to drive Mandatory self-reporting of seizures is required in all 50 states. If there is an answer that says “encourage refraining from driving” or “counsel on alternate forms of transportation,” that is the best thing to do first. If that is not one of the answers then choose “recommend fte patient inform the DMV” is the best choice .
For example, you are evaluating an 87,year-old man in your office for markedly rvorsening cognitive dysfi-rnction, He is on a number ofcardiac medications as well that lear.r him sornewhat dizzy. There is evidence of psychonrotor retardation and delayed reaction time on your examination. You are concerned that the patient regularly drives. What should you do about his driving?
If the patient does not have a specific disease such as a seizure disorder that makes him potentiallv unsafe, then it is much less clear what your responsibilities are toward both the patient as well as to society. In cases like this the best answer is to recommend that the patient with cognitive problems curlail his driving or find alternate forms of transportation. Given that the reporting requirements are so variable on a state-to-state basis this is often the best answer that rvould be uniformlv true in all states.
For extmple, yo:uhave a 65-year-old man with progressive glaucoma in your o1fice. His vision is severely impaired and getting worse. You strongly doubt that he can read traffic signs on the highway. You have repeatedly encouraged him to curtail his driving but he has not. What is your responsibility toward this patient?
ln those cases where the patient’s visual acuity is so severely impaired that you suspect he 1s a danger to himself and to others when driving, you must strongly encourage the patient to stop driving. You can intervene directly in the states that require intact vision for recer tification of the driver’s license by refusing to provide recertification. In those cases where this is not possible you must inform the patient that it is your duty to notify the DMV of his inpairment. You do not have the right to remove or suspend drivir.rg privileges. you do, however, have a duty to report a visually inpaired driver to the DMV so that the DMV may make its orvn determination of whether the patient’s license should be removed or limited.
PHYSICIAN PARTICIPATION IN EXECUTIONS
A physician can not ethically participate in executions in prisons. This is true even though the execution is legal in that state. Participating as a physician in any \'ay in an execution directly opposes the ejthical imperative to preserve life. The physician’s ethical duty to relieve suffering and to protect life supersedes any ability to participate in the execution.
For example, you are a p\sician ir a state prison.
‘fhe
warcien has asked your
assistance in checking the apparatus that clelivers a lethal injection scheclulecl for use in an execution tonrorrow. He is not asking ynu to aclnlinister the injection. You have never met the patient before and you have no prior doctor/patient rcla tionship with the condemned prisoner. {}rat should you tell the warden?
A physician cannot participate in any way in an executiol’r as a physician. Participating in an execution irnpairs your physician/patient relationships rvith the other prisoners who arc ,vour paticnts. It is ethically inpcrmissible to participate even at the level of a technical cor.rsultant-cven if you have no doctor/paticnt relationship with the prisoner. You ma1’ not give the injeclion, start the IV lir.re, mix thc medications for injcction, or dcsign the formulation for the lethal injection. It is not even permissible for you to ccrtift that dcath has occurred unless anothcr party has dctcnnined it first.
TORTURE
Physicians cannot partjcipate in torture at any level. 'l’he knowJedge of torture must be reportecl ancl opposed as you ivould report and oppose elder abuse, child abuse, or an impaired driver. You may treat those injurecl by torture once the victins have been removed from an environment $'here tofiure may occur; you cannot treat injuries to allorv paticnts to bccome well enough to withstand nlore tor ture SPOUSAT ABUSE The cthics ar.rcr legalities surrotinding spousar abuse.rc somcwhat difrere’t from those for child abuse and etder ab,se. tn the case of spousal “b;;;, .;;;;;. dealing with a. adultpatient that.is generilllv competent consequentl). 1.ou do not have the samc authority toreport the abuse against the wishes .f thclvictim as ,., .”;i;i;; " ;;; ilffi;Nlany victims expcricncing spousar abuse berieve thci “;” Il;’;;r’; position to be abre toleave the relationship or to report the abusc for fear of worse oli.rre. Co,r"q.r.lrtly ynucal]n-ot report the abuse to the police or to alyone .lr. \rithout the ."press consent of thevlctim.
For example, a 45_vear_old rvrin g h a cr he r n os e b - o n, n J,T,",lilli , ::il:"":iilf i:i:ij[T:ijl]“past. \rhcn 1.oLr tell her,vou rvill report the injury to th. poli.” ,lr. beconres vcryanxious and insists you tcll no one because hcr husbara ir, ffi officer. {,hatshould you do?
Wher.th_e patient r.vill not givc co’sent to havc the injury reportccl, you s’ould answer that vou w,ill “encourilgc the victim to rcport, or ,offer .ou,.r.ling., ,
GUNSHOT WOUNDS Rcporting ofgrLnshot rvounds is mandatorybut from a clifferent perspective than the other tonru ofreportinpl. The mandatory reportrng of gunshot wounds is criminat invcstigation of rhe person doing the shooti’g. o.o”* " ,.;:T:l;:.i#:H:,?the 'ictinr objects. The societal need fu, ,"‘f.,y ,.,p…r.a’., iiri" orrr""., ,r rn. patient in thecase of gunshots.
GIFTS AND INDUSTRY FUNDING cifts from industry arc to be limitetr in both type and by numericai monerary value. Thc presumption is that all gifts fronr industry are an indirect attempt to obtain influence from phyricians in tcrrns of thcr’r prcscribing patteflrs. Modest gif*;;r, than $100 in valueare acccptable only if they are netlical or educational in *,ur". fn oaf,., words, you can receive $100 .i.vorth of books or medical equipment nr, ,., ."r."i ;“st get a $100 check l”.l::1-1:1OUt::, the industry.mal. slonsor educatior.ral prcsentatrons as long as theyco not lnterlere witll the content. Physicians nray accclrt mea.s that are in association with educational experiences such as lectures or contcrenccs. Phvsicians are prohibited from accepting gifts from the industry that are purely geared to enhance the inconte of the physician or D.terelv for entcrtairrrr,"r,t. Fn. ""0-ple, the physi-clan cannot accept tickcts to baskctball gantcs or otlter sportitrg e\€r]ts, tlteater tickets, skitrtps, or gift certificates to cleparfpsll 51e1g5.