“Ethics and other” is a whole feedback area on your PLAB 1 result, and it’s where a lot of people lose easy marks. The trick is that most answers follow the same pattern: talk to the patient first, try to persuade, escalate only if others are at risk, and write it down. Below are 12 rules that come up again and again, each checked against the GMC guidance or the law, with the trap that usually catches people.

1. A patient who shouldn’t be driving (DVLA)

• The rule: it’s the patient’s legal duty to tell the DVLA, not yours. You explain the condition, tell them about that duty, and tell them you may have to inform the DVLA if they keep driving when unfit.
• If they carry on driving: make every reasonable effort to persuade them to stop. If that fails and others are at risk, contact the DVLA’s medical adviser promptly. Try to tell the patient first, then confirm in writing that you’ve done it, and note it in the record.
• If they can’t understand the advice (e.g. dementia), inform the DVLA as soon as practicable. If they dispute the diagnosis, offer a second opinion and advise them not to drive in the meantime.
• Trap: “inform the DVLA” is rarely the first step.

2. Gunshot and knife wounds

• The rule: the police should usually be informed for any gunshot wound (even an accident with a lawfully held gun) and for wounds from an attack with a knife or blade.
• Not usually for knife injuries that look accidental or self-inflicted.
• Don’t give the patient’s name or address in the first call. Police can’t see the patient if that would delay treatment, and the patient can refuse to talk to them.

3. Contraception for under-16s (the Fraser criteria)

You can give advice and treatment without the parents knowing if the young person:

• understands the advice and its implications;
• can’t be persuaded to tell their parents or let you tell them;
• is very likely to have sex anyway;
• would suffer physically or mentally without it;
• and it’s in their best interests.

Keep the consultation confidential even if you decide not to prescribe, except in the exceptional circumstances the guidance sets out.

4. Competent young people

• Capacity depends on understanding, not age. At 16, a young person can be presumed to have capacity.
• Parents cannot override a competent young person’s consent to treatment that’s in their best interests.
• Overriding a competent young person’s refusal is legally complex in England, Wales and Northern Ireland. Involve colleagues and seek legal advice; in Scotland parents can’t do it.
• Emergency treatment to save life or prevent serious deterioration can be given without consent.

5. Capacity (Mental Capacity Act 2005, England and Wales)

• Five principles: assume capacity; take all practicable steps to help the person decide; an unwise decision doesn’t mean lack of capacity; decisions for someone without capacity must be in their best interests; choose the least restrictive option.
• Lacking capacity means being unable to: understand the information, retain it, use or weigh it, or communicate a decision.
• Trap: “the patient refuses, so assess capacity” is only right if there’s a reason to doubt capacity, not just because you disagree.

6. When something has gone wrong (duty of candour)

• Speak to the patient as soon as possible. You don’t have to wait for the investigation.
• Tell them what happened and the likely consequences, and apologise. An apology is not an admission of legal liability.
• Record the apology in the notes.

7. Intimate examinations and chaperones

• Offer a chaperone and explain their role. A relative or friend is not usually a suitable chaperone, but they can be present as well if the patient asks.
• No suitable chaperone? You can offer to delay the exam, if the delay won’t harm the patient.
• The patient declines a chaperone and you’re not comfortable? Explain why you want one. If they still decline, consider referring them to a colleague.
• Record the discussion.

8. Prescribing for yourself or someone close to you

• Avoid it wherever possible. If you do it, make a clear record of the relationship and why it was necessary.
• Controlled drugs only if no other prescriber is available without delay and emergency treatment is immediately necessary.

9. Gifts and hospitality

• You must not ask for or accept gifts, hospitality or incentives that may affect, or be seen to affect, how you treat, prescribe or refer.
• The test is influence, not the price.

10. Boundaries

• You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.

11. Conscientious objection

• If a procedure conflicts with your beliefs, tell the patient they have the right to see another suitably qualified colleague, and make sure they can.
• With young people, you make sure the arrangements are made.
• Trap: the right answer is never to just refuse and leave it there.

12. Notifiable diseases

• Doctors in England must notify suspected notifiable diseases on clinical suspicion, without waiting for lab confirmation (Health Protection (Notification) Regulations 2010).
• It’s a legal duty, so you don’t need consent. Telling the patient is still good practice.

Sources

• GMC: Patients’ fitness to drive and reporting concerns to the DVLA
• GMC: Reporting gunshot and knife wounds
• GMC 0–18 years: Contraception, abortion and STIs
• GMC 0–18 years: Making decisions
• Mental Capacity Act 2005, section 1
• GMC: Openness and honesty when things go wrong
• GMC: Intimate examinations and chaperones
• GMC: Good practice in prescribing and managing medicines
• GMC Good medical practice: Domain 4, Trust and professionalism
• UKHSA: Notifiable diseases and how to report them

Which ethics topic catches you out most: confidentiality, capacity, or young people? (Please don’t post live exam questions.)