FRCS Statistics, Ethics & Law 2 — Questions and Answers
Question 1: What is 'Bolam test' in the context of medical negligence law in the UK?
- A test requiring that all possible treatment options must be offered to patients
- A standard that a doctor is not negligent if their practice is accepted by a responsible body of medical opinion (Correct answer)
- A statutory test under the Consumer Rights Act 2015
- A test requiring the highest possible standard of care in all circumstances
Correct answer: A standard that a doctor is not negligent if their practice is accepted by a responsible body of medical opinion
The Bolam test (Bolam v Friern Hospital Management Committee, 1957) states that a doctor is not negligent if they act in accordance with a practice accepted by a responsible body of medical professionals, even if other practitioners would have acted differently. The Bolitho modification (1997) requires that the body of opinion must also be logically defensible.
Question 2: A patient has signed a consent form but during surgery a new finding is discovered that requires an additional procedure not discussed preoperatively. The patient is unconscious. What is the appropriate action?
- Perform the additional procedure as you have the patient on the table
- Only perform the additional procedure if it is immediately necessary to save life or prevent serious harm (Correct answer)
- Ask the patient's next of kin for consent by telephone
- Document the finding and close — complete the additional procedure at a subsequent operation
Correct answer: Only perform the additional procedure if it is immediately necessary to save life or prevent serious harm
Consent is specific to what was discussed and agreed preoperatively. Under anaesthesia, the patient cannot consent to additional procedures. The additional procedure should only be performed without consent if it is immediately necessary to save life or prevent serious harm, and if delaying poses unacceptable risk. Non-urgent procedures should be deferred.
Question 3: What is the ethical principle of 'non-maleficence' in surgery?
- The obligation to always do what is best for the patient
- The duty to avoid causing unnecessary harm through actions or omissions (Correct answer)
- The principle of respecting a patient's autonomous decision
- The equal distribution of healthcare resources
Correct answer: The duty to avoid causing unnecessary harm through actions or omissions
Non-maleficence ('first, do no harm' — primum non nocere) is the duty to avoid causing unnecessary harm. In surgery, it requires weighing the risks of intervention against benefits, ensuring procedures are technically performed to the highest standard, and not proceeding when risk outweighs benefit.
Question 4: What does the Montgomery ruling (2015) require regarding informed consent?
- Consent must always be obtained by a consultant surgeon
- Patients must be informed of any risks a reasonable patient would want to know about, not merely what the clinician considers material (Correct answer)
- Written consent forms can replace verbal discussion
- Consent is only valid if signed 24 hours before surgery
Correct answer: Patients must be informed of any risks a reasonable patient would want to know about, not merely what the clinician considers material
Montgomery v Lanarkshire Health Board (2015) replaced the Bolam-based approach to consent with a patient-centred standard: clinicians must disclose all material risks that a reasonable patient in that patient's position would want to know. This shifts the standard from 'what doctors consider material' to 'what patients consider material'.
Question 5: A patient who is a competent adult refuses an amputation that is likely to save their life from gas gangrene. What is the surgeon's legal and ethical obligation?
- Perform the amputation as the patient's life is at stake
- Respect the refusal, ensure the patient has full information, document extensively, and seek ethics support (Correct answer)
- Obtain a court order to override the refusal
- Proceed with surgery after 48 hours to allow the patient to reconsider
Correct answer: Respect the refusal, ensure the patient has full information, document extensively, and seek ethics support
A competent adult's refusal of treatment is legally and ethically binding, even when it results in death. The surgeon must ensure the decision is informed, not subject to undue influence, and made with capacity. Detailed documentation, ethics consultation, and support for the patient and family are essential.
Question 6: Which type of research bias occurs when patients lost to follow-up are systematically different from those who remain?
- Selection bias
- Attrition bias (Correct answer)
- Measurement bias
- Confirmation bias
Correct answer: Attrition bias
Attrition bias occurs when participants drop out or are lost to follow-up in a non-random manner — often those who drop out are sicker, poorer, or have experienced adverse effects. If these patients are different from those retained, the results may overestimate or underestimate the treatment effect.
FRCS Statistics, Ethics & Law 2
What is 'Bolam test' in the context of medical negligence law in the UK?