The four principles, US consent law, HIPAA, EMTALA, end-of-life care and the post-Dobbs landscape — written for MMIs, Casper, AAMC PREview and traditional interviews. Everything is on this page; no email needed to read it.
The four principles, and why US bioethics weights autonomy so heavily
Informed consent under Canterbury v. Spence, plus capacity vs. competence
HIPAA in practice, the Tarasoff duty to protect, and mandatory reporting
EMTALA, coverage and the justice problem at the centre of US medicine
End-of-life law: Quinlan, Cruzan, Schiavo, and medical aid in dying by state
A five-step structure that survives an eight-minute MMI station
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Before answering any American ethics question that touches abortion, aid in dying, minors’ consent, duty to warn or scope of practice, ask yourself one question: is the answer federal or state? American medical ethics runs on a thin layer of federal law — HIPAA, EMTALA, the Common Rule — sitting on top of fifty separate state legal regimes, and most of the contested questions live in the states.
Applicants who say “the law says…” about a state-variable topic mark themselves out immediately. Applicants who say “this varies by state, and in most states…” sound like people who have read something real. That single habit is worth more than any amount of memorised case law.
Principlism is the shared language of US bioethics. The principles are not ranked — the work of ethics is adjudicating the conflict between them in a specific case.
Respect for a capacitated patient’s right to decide about their own body, including decisions their physician considers unwise.
The obligation to act for the patient’s benefit.
Primum non nocere — avoid causing harm, and ensure the harms of an intervention are proportionate to its benefits.
Fair distribution of benefits, risks and costs, and fair treatment of individuals.
American consent law rests on Justice Cardozo in Schloendorff v. Society of New York Hospital (1914): “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” The modern doctrine of informed consent developed through Salgo v. Leland Stanford (1957), which coined the term, and Canterbury v. Spence (1972), which set the disclosure standard most states now follow.
The physician-based (professional) standard asks what a reasonable physician would disclose, and still applies in a minority of states. The patient-based (materiality) standard from Canterbury asks what a reasonable patient would want to know in order to decide — and most states now use it. The shift from the first to the second is the shift from paternalism to autonomy, expressed in law.
Capacity; disclosure of the diagnosis, the intervention, its risks and benefits, the reasonable alternatives and the consequences of doing nothing; understanding, which is why teach-back beats “any questions?”; voluntariness; and authorisation.
Competence is a determination made by a court. Capacity is a bedside judgement any physician can and should make about a specific decision at a specific time. Capacity is decision-specific and time-specific — a delirious patient may lack it at 2 a.m. and have it at 10 a.m.
Follow a valid advance directive — a living will states preferences, a durable power of attorney for health care appoints an agent. Otherwise apply substituted judgement: decide as the patient would have decided, not as you would. Best interests is the fallback only where wishes are genuinely unknown.
Applicants routinely overstate what HIPAA does. Precision here is cheap and it is noticed.
In Tarasoff v. Regents (1976), a patient told his university psychologist he intended to kill Tatiana Tarasoff. Nobody warned her; he killed her. The California Supreme Court held that “the protective privilege ends where the public peril begins.” It is best described as a duty to protect, not merely to warn — it can be discharged by hospitalisation or by notifying police, not only by telephoning the intended victim.
The Emergency Medical Treatment and Labor Act (1986) requires any hospital with an emergency department participating in Medicare to provide a medical screening examination to anyone who presents, regardless of ability to pay or immigration status, and to stabilise any emergency medical condition — including active labour — before transfer or discharge.
EMTALA is the only federal statute that comes close to guaranteeing a right to health care in the United States, and it is worth understanding what a narrow right that is. It is an unfunded mandate covering emergencies only. A patient stabilised for diabetic ketoacidosis and discharged without affordable insulin will be back, and EMTALA will be complied with each time.
The cases
In re Quinlan (NJ, 1976) recognised a right to refuse life-sustaining treatment exercisable by a surrogate, and effectively created the hospital ethics committee. Cruzan (US Supreme Court, 1990) assumed a constitutionally protected liberty interest in refusing unwanted treatment but held that a state may require clear and convincing evidence of an incompetent patient’s wishes — which is why advance directives matter, and which prompted the Patient Self-Determination Act the same year. Terri Schiavo (1990–2005) showed that the substantive law was already clear; what was missing was a written directive and a functioning family process.
The distinction
US consensus holds that withholding and withdrawing life-sustaining treatment are ethically equivalent — because if withdrawal felt worse, clinicians would become reluctant to start time-limited trials, and patients would be harmed by that reluctance. Giving enough opioid to relieve severe pain, accepting that it may hasten death, is permissible; giving a lethal dose in order to cause death is not. The distinction rests on intention, and the Supreme Court endorsed this reasoning in Vacco v. Quill (1997).
Terminology
MAID means a physician prescribes a lethal medication that the patient self-administers. Physician administration — voluntary active euthanasia — is illegal throughout the United States. Do not use the terms interchangeably.
Dobbs v. Jackson Women’s Health Organization (2022) overruled Roe and Casey, holding that the Constitution confers no right to abortion and returning the question to the states. The result is the most fragmented area of American health law, and it continues to move through ballot measures, state constitutional litigation and legislative sessions — so check the current position before you interview rather than relying on any guide.
As of 2026, roughly thirteen states enforce near-total bans, several more enforce limits at around six weeks, and a number of states plus the District of Columbia impose no gestational limit.
Frameworks are only useful if they hold up under time pressure. This one does.
The Four Box Method (Jonsen, Siegler and Winslade) is the standard US clinical-ethics grid — medical indications, patient preferences, quality of life, contextual features — and naming it is a genuine differentiator. SPIKES is the standard protocol for delivering bad news and comes up constantly in MMI acting stations.
Patient safety first if there is immediate risk; check your facts and separate observation from inference; speak to the person directly where it is safe; escalate through the proper channel; document; and support the colleague. Most states have a confidential Physician Health Program offering evaluation and monitoring rather than discipline — knowing that lets you frame reporting as getting a colleague help rather than ending their career.
Ethical reasoning is a performance skill under time pressure. Book a mock interview with a tutor who has sat these stations, or take the full PDF version of this guide with you.
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