USMLE STEP 3
Medical Ethics & Quality Improvement
50 High-Yield Vignettes · UWorld Format
Questions 50
Format 5-Choice Single Best Answer
Topics Ethics, Consent, Confidentiality, QI Methodology, Error Analysis
Includes Explanations, Key Points, Comparison Tables
Dr. Shafqat Ali · MRCP(UK) · FCPS IMM · USMLE Step 2 CK 253
,QUESTION 1 OF 50
A 72-year-old man with ESRD on hemodialysis tells his nephrologist that he wants to stop dialysis.
He states, 'I've lived a full life and I'm tired of the machine.' He correctly explains that he will likely die
within 2 weeks of stopping. His wife is crying and begs the physician to override his decision. The
patient has no psychiatric illness. What is the most appropriate next step?
✓ Honor the patient's request to discontinue dialysis
B. Obtain a psychiatric evaluation before proceeding
C. Convene a hospital ethics committee
D. Defer to the wife as the surrogate decision-maker
E. Continue dialysis and arrange palliative care consult without stopping
EXPLANATION
This capacitated adult has made an informed, consistent decision to refuse life-sustaining treatment — the
cornerstone of patient autonomy. He demonstrates understanding, appreciation of consequences,
reasoning, and consistent communication. A psychiatric evaluation is only needed if capacity is in question
— it is not here. The wife's distress does not override his wishes. Ethics committees are helpful for
conflicts, but this is ethically clear. Autonomy of a capacitated adult > beneficence/family wishes.
HIGH-YIELD KEYPOINT
Capacitated adult refusing life-sustaining treatment → respect refusal, even if fatal.
CAPACITY VS COMPETENCE
Capacity Decision-specific; determined by physician; can fluctuate
Competence Global legal status; determined by a court
QUESTION 2 OF 50
A surgeon is performing a laparoscopic cholecystectomy when she discovers an incidental 4 cm
ovarian mass. The ovary appears grossly normal aside from the mass. The patient had consented
only for cholecystectomy. What should the surgeon do?
A. Remove the ovarian mass since the patient is already anesthetized
B. Biopsy the mass and await frozen section results
✓ Complete the cholecystectomy, close, and discuss findings with the patient post-operatively
D. Call the patient's husband for permission to proceed
, E. Consult gynecology to remove the mass intraoperatively
EXPLANATION
Informed consent was given only for cholecystectomy. The ovarian mass is not immediately
life-threatening, so there is no emergency exception to consent. The correct action is to complete the
consented procedure, wake the patient, and have a full discussion — including risks, benefits, alternatives
— before any intervention on the mass. Calling the husband violates autonomy. Extending the surgery
without consent is battery.
HIGH-YIELD KEYPOINT
Incidental non-emergency finding during surgery → complete consented procedure, discuss with
patient postoperatively.
CONSENT EXCEPTIONS
Emergency (implied consent) Unconscious, no surrogate reachable, life-threatening
Waiver Patient voluntarily declines information
Therapeutic privilege Very narrow; information would directly harm patient
Lack of capacity Use surrogate hierarchy
QUESTION 3 OF 50
A 16-year-old girl presents to a teen clinic requesting oral contraceptives. She asks that her parents
not be notified. She is not sexually active under coercion and denies abuse. What is the most
appropriate response?
A. Refuse to prescribe without parental consent
✓ Prescribe contraceptives and maintain confidentiality
C. Notify parents because she is a minor
D. Report to child protective services
E. Prescribe only after notifying one parent
EXPLANATION
Adolescents have confidential access to contraception, STI testing/treatment, pregnancy care, substance
use, and mental health services in nearly all US states. No parental consent or notification is required or
appropriate. This protects adolescent health by removing barriers to care. There is no indication of abuse
here, so CPS is not warranted.
, HIGH-YIELD KEYPOINT
Adolescents have confidential access to: STIs, contraception, pregnancy, substance use, mental
health.
MINOR CONSENT RULES
Emancipated minor Treated as adult — married, military, financially independent, has own child
Emergency Treat first, notify parents after
Parental refusal of life-saving Override with court order
care
Confidential adolescent STI, contraception, pregnancy, substance use, mental health
services
QUESTION 4 OF 50
A patient confides to his psychiatrist that he plans to shoot his ex-girlfriend 'next Friday.' He names
her specifically and says he has access to a firearm. The psychiatrist assesses him as credible. What
is the most appropriate action?
A. Maintain confidentiality per the therapeutic relationship
B. Hospitalize the patient involuntarily and take no other action
✓ Warn the ex-girlfriend and notify police
D. Notify the patient's family only
E. Document and follow up at the next session
EXPLANATION
This is a classic Tarasoff scenario (duty to protect). When a patient poses an imminent, credible threat to
an identifiable third party, the physician must warn that person AND notify law enforcement. Confidentiality
must be breached. Hospitalization alone is insufficient — the duty to warn the potential victim and involve
police is mandatory.
HIGH-YIELD KEYPOINT
Tarasoff duty = warn the identified victim + notify police. Both required.
WHEN TO BREAK CONFIDENTIALITY
Tarasoff / duty to protect Imminent threat to identifiable third party → warn + police
Child/elder abuse Report on suspicion alone
Medical Ethics & Quality Improvement
50 High-Yield Vignettes · UWorld Format
Questions 50
Format 5-Choice Single Best Answer
Topics Ethics, Consent, Confidentiality, QI Methodology, Error Analysis
Includes Explanations, Key Points, Comparison Tables
Dr. Shafqat Ali · MRCP(UK) · FCPS IMM · USMLE Step 2 CK 253
,QUESTION 1 OF 50
A 72-year-old man with ESRD on hemodialysis tells his nephrologist that he wants to stop dialysis.
He states, 'I've lived a full life and I'm tired of the machine.' He correctly explains that he will likely die
within 2 weeks of stopping. His wife is crying and begs the physician to override his decision. The
patient has no psychiatric illness. What is the most appropriate next step?
✓ Honor the patient's request to discontinue dialysis
B. Obtain a psychiatric evaluation before proceeding
C. Convene a hospital ethics committee
D. Defer to the wife as the surrogate decision-maker
E. Continue dialysis and arrange palliative care consult without stopping
EXPLANATION
This capacitated adult has made an informed, consistent decision to refuse life-sustaining treatment — the
cornerstone of patient autonomy. He demonstrates understanding, appreciation of consequences,
reasoning, and consistent communication. A psychiatric evaluation is only needed if capacity is in question
— it is not here. The wife's distress does not override his wishes. Ethics committees are helpful for
conflicts, but this is ethically clear. Autonomy of a capacitated adult > beneficence/family wishes.
HIGH-YIELD KEYPOINT
Capacitated adult refusing life-sustaining treatment → respect refusal, even if fatal.
CAPACITY VS COMPETENCE
Capacity Decision-specific; determined by physician; can fluctuate
Competence Global legal status; determined by a court
QUESTION 2 OF 50
A surgeon is performing a laparoscopic cholecystectomy when she discovers an incidental 4 cm
ovarian mass. The ovary appears grossly normal aside from the mass. The patient had consented
only for cholecystectomy. What should the surgeon do?
A. Remove the ovarian mass since the patient is already anesthetized
B. Biopsy the mass and await frozen section results
✓ Complete the cholecystectomy, close, and discuss findings with the patient post-operatively
D. Call the patient's husband for permission to proceed
, E. Consult gynecology to remove the mass intraoperatively
EXPLANATION
Informed consent was given only for cholecystectomy. The ovarian mass is not immediately
life-threatening, so there is no emergency exception to consent. The correct action is to complete the
consented procedure, wake the patient, and have a full discussion — including risks, benefits, alternatives
— before any intervention on the mass. Calling the husband violates autonomy. Extending the surgery
without consent is battery.
HIGH-YIELD KEYPOINT
Incidental non-emergency finding during surgery → complete consented procedure, discuss with
patient postoperatively.
CONSENT EXCEPTIONS
Emergency (implied consent) Unconscious, no surrogate reachable, life-threatening
Waiver Patient voluntarily declines information
Therapeutic privilege Very narrow; information would directly harm patient
Lack of capacity Use surrogate hierarchy
QUESTION 3 OF 50
A 16-year-old girl presents to a teen clinic requesting oral contraceptives. She asks that her parents
not be notified. She is not sexually active under coercion and denies abuse. What is the most
appropriate response?
A. Refuse to prescribe without parental consent
✓ Prescribe contraceptives and maintain confidentiality
C. Notify parents because she is a minor
D. Report to child protective services
E. Prescribe only after notifying one parent
EXPLANATION
Adolescents have confidential access to contraception, STI testing/treatment, pregnancy care, substance
use, and mental health services in nearly all US states. No parental consent or notification is required or
appropriate. This protects adolescent health by removing barriers to care. There is no indication of abuse
here, so CPS is not warranted.
, HIGH-YIELD KEYPOINT
Adolescents have confidential access to: STIs, contraception, pregnancy, substance use, mental
health.
MINOR CONSENT RULES
Emancipated minor Treated as adult — married, military, financially independent, has own child
Emergency Treat first, notify parents after
Parental refusal of life-saving Override with court order
care
Confidential adolescent STI, contraception, pregnancy, substance use, mental health
services
QUESTION 4 OF 50
A patient confides to his psychiatrist that he plans to shoot his ex-girlfriend 'next Friday.' He names
her specifically and says he has access to a firearm. The psychiatrist assesses him as credible. What
is the most appropriate action?
A. Maintain confidentiality per the therapeutic relationship
B. Hospitalize the patient involuntarily and take no other action
✓ Warn the ex-girlfriend and notify police
D. Notify the patient's family only
E. Document and follow up at the next session
EXPLANATION
This is a classic Tarasoff scenario (duty to protect). When a patient poses an imminent, credible threat to
an identifiable third party, the physician must warn that person AND notify law enforcement. Confidentiality
must be breached. Hospitalization alone is insufficient — the duty to warn the potential victim and involve
police is mandatory.
HIGH-YIELD KEYPOINT
Tarasoff duty = warn the identified victim + notify police. Both required.
WHEN TO BREAK CONFIDENTIALITY
Tarasoff / duty to protect Imminent threat to identifiable third party → warn + police
Child/elder abuse Report on suspicion alone
