Ethics · Advanced · Ethics

Refusing Recommended Cancer Treatment

Practise this PLAB 2 ethics station on Invasive Ductal Carcinoma. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on an oncology ward. Mrs Lola Bello, a 56-year-old woman with newly diagnosed locally advanced breast cancer, has declined the recommended chemotherapy plus surgery pathway. She has been counselled extensively by the oncology team but remains adamant in her refusal. She says the side effects and risks are unacceptable given her values and life circumstances. Please explore her reasons, assess her capacity, and discuss alternative options while respecting her autonomy.

Background notes: PMH: Hypothyroidism, Migraines (intermittent)

What this station tests

  • Informed refusal: ensuring she understands prognosis with and without treatment before accepting her decision
  • Not withdrawing care after treatment refusal: monitoring, symptom management, and support continue
  • Exploring her reasoning: mother's suffering through chemo is an experience-based concern, not irrational
  • Addressing alternative therapies honestly: no evidence base, risk of losing curative treatment window
  • Offering second opinion as compromise: another perspective without coercion

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

A capacitous patient refusing recommended treatment must have their autonomy respected, but the candidate must ensure the refusal is fully informed. Mrs Bello is 56, newly diagnosed breast cancer, refusing chemotherapy and mastectomy in favour of alternative therapies. Open with: 'Mrs Bello, I understand you have been thinking carefully about your treatment options. Can you share your thinking with me?'

Core approach

Listen to her reasoning before responding. She has researched alternative therapies (dietary changes, supplements, meditation). She watched her mother suffer through chemotherapy and die anyway. She believes conventional treatment is worse than the disease. These are understandable, experience-based views.

Ensure the refusal is informed. She must understand: the prognosis without treatment (disease progression, likely metastasis), the prognosis with treatment (cure rates for her stage), and the specific risks she is accepting. This is not coercion: it is ensuring informed refusal. 'I want to make sure you have the full picture so your decision is based on complete information.'

Address her specific concerns. Her mother's suffering: 'Cancer treatment has improved significantly. Side effects are much better managed now.' Alternative therapies: 'I understand the appeal, but there is no evidence that dietary changes or supplements can treat breast cancer. I would not want you to lose the window for curative treatment.'

Closing and safety netting

If she still refuses after informed discussion: respect her decision. Document it as an informed refusal with full understanding of consequences. Offer: 'If you change your mind at any point, we are here. The door is always open.' Do not withdraw care: she still needs monitoring, symptom management, and support.

Offer compromise if possible: 'Would you consider a second opinion from another oncologist?' This gives her another perspective without pressuring. Macmillan for support. Follow-up: open appointment. Document the conversation, her reasoning, capacity assessment, and that she was fully informed.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Supporting)

Scores well: Reasoning explored. Capacity assessed. Understanding of prognosis confirmed. Mother's experience understood.

Costs marks: Not exploring reasoning. Not confirming understanding.

Domain 2 (Primary focus)

Scores well: Informed refusal documented. Ongoing care offered. Second opinion suggested. Alternative therapy evidence discussed honestly. Door left open.

Costs marks: Being coercive. Withdrawing care. Not documenting.

Domain 3 (Primary focus)

Scores well: Listening before responding. Respecting autonomy. Acknowledging her mother's experience. Honest about alternatives without being dismissive.

Costs marks: Being dismissive. Being coercive. Not listening. Paternalistic.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Being coercive: pressuring her to accept treatment violates autonomy
  2. Withdrawing care: refusing treatment does not mean refusing all medical care
  3. Dismissing alternative therapies contemptuously: this closes the conversation

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How should I approach this invasive ductal carcinoma ethics station in PLAB 2?

A capacitous patient refusing recommended treatment must have their autonomy respected, but the candidate must ensure the refusal is fully informed. Mrs Bello is 56, newly diagnosed breast cancer, refusing chemotherapy and mastectomy in favour of alternative therapies.

What are examiners marking in this invasive ductal carcinoma station?

Marks are won for: Reasoning explored. Capacity assessed. Understanding of prognosis confirmed. Mother's experience understood. Marks are lost for: Not exploring reasoning. Not confirming understanding.

What is the most common mistake candidates make in this invasive ductal carcinoma station?

Being coercive: pressuring her to accept treatment violates autonomy. Another frequent error: Withdrawing care: refusing treatment does not mean refusing all medical care.

How do I prepare for this station if I have not managed invasive ductal carcinoma in clinical practice?

Structure beats experience here. Focus on not withdrawing care after treatment refusal: monitoring, symptom management, and support continue. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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