Interview question bank – ethics

Ethical questions are a significantly important part of medical school interviews - they assess your reasoning, empathy, decision-making skills and ability to handle complex situations - these are all essential parts of being a doctor. Whether you are assessed in Multiple Mini Interviews (MMIs) or traditional interviews, it is highly likely that you will be tested on ethics - whilst there is not always a clear right or wrong answers, it is still important to prepare for ethical questions. This article will guide you on how to approach these questions and give some examples throughout. At Future Doc, we offer a 1 on 1 coaching programme which offers regular teaching on ethics and mock interviews. To find out more about our unique programme, click here.

Depending on your type of interview, you may be asked questions differently. For example, in Multiple Mini interviews, candidates will typically be presented with an ethical scenario to discuss and resolve; these scenarios may cover things such as patient confidentiality, end of life care or resource allocations in the NHS. The key to answering these questions is to demonstrate a clear understanding of the four ethical principles (discussed below). As well as this, it is important to demonstrate that you see issues from multiple perspectives, and to justify your decisions with balanced arguments.

In a traditional interview, ethical questions may be linked to current events or personal experiences. For example, you may be asked how you would handle a specific situation you have previously encountered in education, work or voluntary experience. For these questions, it's important to be able to reflect on personal experiences and to have knowledge of current hot topics.

The 4 Pillars of Medical Ethics

The four medical ethics pillars are fundamental principles that guide healthcare professionals when making ethical decisions.  During your interviews, particularly in ethics stations, you may be asked to discuss scenarios involving these principles. Familiarising yourself with them will enable you to answer questions more effectively. As well as this, if nerves get the better of you and your mind goes blank, you can always rely on these core principles to guide and structure your responses.

Here is a breakdown of what each principle means, and how this would apply in clinical practice:

Autonomy

Autonomy refers to the rights of patients to make informed decisions about their own health. This principle emphasises the importance of respecting patient rights and personal values. In practice, this means that healthcare professionals are required to ensure patients are informed about their treatment options and outcomes, allowing them to decide. For example, a patient consenting to surgery must understand the risks and benefits of this.

Beneficence

Beneficence refers to healthcare professionals acting in the best interest of the patient; in simple words, this means “to do good”. In practice, this means that doctors must prioritise actions that would benefit the patient. A simple example of beneficence would be recommending a treatment that will most likely result in a positive outcome for the patient.

Non maleficence

Non maleficence simply means to “do no harm”. This principle guides healthcare professionals to avoid treatments or actions that could lead to unnecessary harm or suffering. For instance, choosing a less invasive procedure when possible.

Justice

The final pillar of ethics is justice. This means to be fair and equal in the distribution of healthcare resources. In practice, this means to treat all patients equally without discrimination, and ensuring that all patients, regardless of their background have an equal level of care.

Patient confidentiality

Patient confidentiality means that healthcare professionals are required to keep patient information private within the healthcare team, apart from very specific circumstances. Some of these exceptions include:

• Where the patient has consented to sharing their information
• Where not sharing patient information puts the patient or others in danger
• Where the patient lacks capacity and sharing the information is of overall benefit to the patient

Confidentiality is important in building trust between patient and healthcare providers. It is important that personal and medical information shared by a patient remains private, as this fosters a safe environment for the patient to disclose their personal information. If patient confidentiality is broken without a justified reason, this could lead to patients under-reporting their symptoms and losing trust in the medical profession.

Consider the following confidentiality scenario:

One of your patients is a teacher at a local primary school. She tells you that she is experiencing severe anxiety and panic attacks, leading to her misusing prescription medications to cope. She assures you that her teaching is unaffected, but based on the severity of her symptoms, you are concerned regarding her performing duties safely. You contemplate informing the school about her condition and the potential risk it could pose to her students.

What needs to be considered when making this decision?

The GMC states that the following considerations are made before breaching confidentiality:

• Is it likely that anyone will be harmed from the teacher’s drug habits?
• What impact will revealing this information without consent have on the teacher?
• Is there any other option which does not break confidentiality?

In terms of the ethical principles, you need to consider the following:

• Breaking confidentiality without consent breaks patient autonomy and could mean that the patient may be reluctant to seek further help from healthcare professionals
• When it comes to beneficence and non-maleficence, you should consider that breaking confidentiality could potentially mean the patient is at risk of losing their job. On the other hand, not breaking confidentiality could mean that students may come to harm because of unsafe action from the teacher.
• Keep in mind when it comes to justice that a breach of confidentiality could result in damage to the public’s trust and perception of healthcare professionals.

Euthanasia

Euthanasia is a hot topic that could potentially come up in your medical school interview. It is defined as ending a patient’s life who is suffering from an incurable disease or is in an irreversible coma. There are two types of euthanasia:

1. Active euthanasia – when the person deliberately intervenes to end someone’s life. For example, a doctor may purposely inject a higher dose of a muscle relaxant to end a patient’s life who has terminal cancer.
2. Passive euthanasia – When a person causes death by withholding life-saving treatment. For example, withholding antibiotics in a patient with sepsis.

It’s worthwhile understanding the following two term: assisted suicide and assisted dying:

1. Assisted suicide – The physician intentionally gives a patient the means to take the lethal medication themselves. The difference between this and active euthanasia is that the patient administers the medication themselves (rather than the physician).
2. Assisted dying – This is used in the context of a patient who is already dying (e.g. terminally ill) who is asking for help to die.

Euthanasia in the UK

Euthanasia and assisted suicide are illegal in the UK. It’s important to note that passive euthanasia is different to withdrawing life-sustaining care in the patient’s best interests as part of good palliative care.

Arguments in support of euthanasia:

1. Respect for autonomy – euthanasia honours the principle of patient’s rights to make decisions about their own body and life.
2. Relief from suffering – euthanasia provides a compassionate way to end intense psychological and physical torture for patients experiencing a low quality of life due to incurable medical conditions.
3. Dignity in deathSome people view euthanasia to die with dignity as it prolongs deterioration that can happen in terminal illness.
4. Resource allocation – Allowing euthanasia can potentially free up hospital beds and allow medical resources to be directed from patients with a better chance of recovery.

Arguments against euthanasia:

1. Slippery slope – Legalising euthanasia can lead to broader and potentially unethical practices. It can be argued that the euthanasia criteria could gradually be broadened to include non-terminal conditions or those unable to consent – this would be unethical.
2. Potential for abuse – Euthanasia could be abused by individuals or systems, patients may be pressured into sparing their carers of the burden of looking after them. This could be due to financial or emotional reasons.
3. Undermining trust in healthcare – Physicians are taught to save lives, and ending life through euthanasia could diminish patient trust in the healthcare system.
4. Moral and ethical concerns – Many argue that legislation could turn doctors into “executioners”. This is against the ethical principle of non-maleficence.

Potential interview questions:

• Do you agree with euthanasia?
• How does euthanasia relate to a patient’s autonomy and consent?
• What alternatives to euthanasia could you offer to a patient experiencing unbearable suffering at the end of life within the UK?

Abortion

Abortion is the medical process of ending a pregnancy, this can be through medications or a surgical procedure. Under the 1967 abortion act, abortion is legal in England, Wales and Scotland up to 24 weeks of pregnancy (in most situations). For an abortion to be legally performed, two doctors must agree that continuing the pregnancy would pose a risk to the woman’s physical or mental health, or negatively impact the wellbeing of her existing children. After 24 weeks, abortion would only be permitted if the woman’s life is at risk, the foetus is likely to be born with a severe disability, or if there is a significant risk of serious physical or mental harm to the woman.

Northern Ireland and abortion rights

On the 31st of March 2020, under new regulations, termination of pregnancy is allowed in Northern Ireland under the following circumstances:

• Unconditionally before 3 months
• Up to 24 weeks when continuing pregnancy would risk mental or physical injury to the woman or girl that is greater than the risk of terminating the pregnancy
• Up to 24 weeks when there is significant risk of impairment to the fetus, including when death is likely before, during or shortly after giving birth.

Ethics - pro-life:

1. Potential for abuse – legalising abortion may lead to a slippery slope, where the value of human life is diminished, potentially leading to the devaluation of life in other areas, particularly in cases of disability, age or socioeconomic status
2. Psychological and emotional impact Abortion can potentially have long term psychological impacts on women, including guilt, depression and anxiety
3. Alternative options: There are alternatives to abortion, such as adoption, which would allow the child to live whilst addressing the concerns of the mother.

Ethics - pro choice

1. Almost all abortions are carried out in the first three months of pregnancy, where the foetus would not be a living organism outside of the mother’s womb.
2. Psychological distress – In the case of rape or incest, forcing a woman to continue with pregnancy could be more psychologically damaging than having an abortion
3. Preventing illegal abortions – Legalising abortion ensures that death and complications from illegal, unsafe, backstreet operations are prevented

Potential abortion questions:

1. Do you agree with abortion?
2. What do you think may be some practical issues that people in the UK face regarding abortion access?
3. How does abortion relate to the four ethical principals?

Gillick competence and Fraser guidelines

A child is deemed Gillick competent if they are under 16 years old and are fully able to understand medical treatments or procedures that are proposed by healthcare professionals. It’s important to note that children can be deemed Gillick competent for one decision and not another, as medical decisions will vary in levels of complexity. For example, a child may be able to consent to being prescribed antihistamines, but not to a complex surgical procedure.

Fraser guidelines are a set of criteria used in the UK to assess if a child under 16 years old can consent to contraception (without parental knowledge of consent). The Fraser guidelines include the following criteria:

1. The child understands the medical advice proposed
2. The child cannot be persuaded to involve their parents or guardians.
3. The child will continue to have sexual activity with or without contraception.
4. The child’s physical or mental health will suffer if they do not receive treatment or contraception.
5. It is in the best interest of the young person to receive contraceptive advise or treatment

Gillick competence and Fraser guidelines are common topics in medical school interviews, so it is important to be able to apply the four ethical principles to these.

• Autonomy: Gillick’s competence and Fraser’s guidelines are both in favour and against autonomy. The autonomy is respected when these guidelines are applied, however, parents or guardians will be deprived of their autonomy over their children.
• Beneficence/non-maleficence: It is important for healthcare professionals to consider if that no harm comes to the child when assessing their Gillick competence and Fraser guidelines.
• Justice: It is vital to assess children fairly when assessing their competence. Just because a child is 13 years old, it does not automatically mean they are unable to make a medical decision themselves.

Preparing for a medicine interview: Gillick competence and Fraser guidelines

When preparing for a medical school interview, it’s essential to understand the concepts of Gillick competence and Fraser guidelines. During the interview, be prepared to discuss what these principles are, how they balance ethical considerations such as autonomy and confidentiality, and how they are applied in real-life scenarios. You may be asked directly about these principles, or you may be given a scenario in which you can refer to these in your answer. If your answer deals with a question or scenario involving children, you should bring up Gillick competence, and if the scenario specifically relates to sexual health or contraception in children, refer to the Fraser guidelines.

Potential questions relating to Gillick competence and Fraser guidelines:

1. Can you explain Gillick competence and how it is applied in practice?
2. What factors should you consider when assessing capacity and competence in those under 16?
3. You are a doctor in the GP practice and a child’s wishes regarding their own treatment are conflicting with their parents. How would you approach this situation?
4. You are a GP and a 14-year-old presents to you seeking advice regarding contraception. What do you need to consider during the consultation?

How to approach answering medical ethics interview questions

1. Understand and apply the four ethical principles - these will guide your responses
2. Be objective and non-judgemental: present a balanced view by considering different perspectives.
3. Apply to real life scenarios: If you can think of examples from work experience or voluntary work, use these to illustrate your points
4. Reflect

Top tips:

For an in-depth article on top tips for ethics stations, see our Future Doc article here.

• Don’t express opinions straight away
• Always relate to the ethical principles – this can give you a framework
• Summarise your answer at the end
• Practice makes perfect!
• Get to know hot topics well – at Future Doc regularly run courses which go through hot topics in detail.

Written by Dr Mahsa Kabuli