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Informed consent and intimate examinations
Israeli students are refusing to perform intimate examinations on anaesthetised women without their informed consent. Ohad Oren and Gershon Grunfeld argue their case
Early this year a group of morally disturbed medical students refused to participate in a gynaecological procedure they were
asked to participate in. They strongly objected to performing pelvic examinations on anaesthetised female patients without
first obtaining specific informed consent.w1
The medical community faced accusations of battery and assault. In response, Joseph Schenker, professor of obstetrics and
gynaecology at the Hadassah-University Hospital of Jerusalem, explained that the gynaecological examination was a critical
and irreplaceable part of every operation. He added that simulated exams on manikins, attempted half a century ago, were not
useful.
Some specialists consider pelvic examinations to be a part of ordinary medical practice in their discipline, for which, therefore,
specific consent is not needed.w2 Many gynaecologists at teaching hospitals even consider a patient’s consent to pelvic examination trivial. They assume that
patients understand that because they are in a teaching hospital, medical students and junior doctors will be involved in
their care.w3 “It’s pretty much all covered in the overall consent form,” explained William Dignam, emeritus professor of obstetrics and
gynaecology at the University of California in Los Angeles.w4
Such an attitude misses the point of informed consent, depriving the patient of her choice to accept or reject each individual
procedure. Some gynaecologists hold a more extreme view that specific consent for students to take part in the examination
should not be requested because the patient is likely to refuse.
Real world ethics
“Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply
as a means, but always at the same time as an end.”w5 In this proposition, well known from medical ethics courses, Immanuel Kant lays the groundwork for the principle of “respect
for persons.” According to this principle the patient should enjoy the rights of an independent decision maker with regard
to her own medical care.w6 Informed consent, a hallmark of modern medical ethics, is firmly grounded in respect for autonomy.
Informed consent is a legal requirement and not merely a perfunctory signature on a form. It is a process that aims to create
trust between the doctor and the patient and prevent coercion. It also provides the patient with realistic expectations about
her clinical condition, and it usually results in increased adherence to treatment.
At least in name, informed consent is integral to the routine practice of modern medicine. And doctors go through the process
for so many patients a day that they may lose sight of its original intent. As such, a distinct gap exists between the formal
teaching of ethics that we receive in lectures and the “hidden curriculum,” the informal ethical education that we convey
at the bedside.w7-w8
The renowned doctor William Osler thought that books and lectures were poor substitutes for ward based instruction. He emphasised
the value of teaching medicine in the wards.w9 The possibility of students having fewer opportunities for learning about and practising physical examinations were specific
consent always to be sought is a concern. But unlike junior doctors who perform the examination as part of patient care, medical
students take part for the sole benefit of our own training.
Patients come first
The examination of patients under anaesthesia is vital for medical students’ education and offers a unique opportunity for
practice with minimal distress of the patient. But at what cost? Performing intimate examinations on patients without their
explicit consent is a gross violation of the principle of respect for patients’ autonomy.w10-w11 The medical community cannot ignore such flagrant violations of basic human rights, not even to prepare better medical students,
which would ultimately benefit patients.
Clerkship directors understand their responsibility to show how best to perform practical procedures. But their responsibility
as a role model extends to acknowledging the importance of patient autonomy by obtaining adequate permission for procedures,
including examinations by students. So how can doctors, facing the daily pressures of clinical practice, secure learning opportunities
for students in an ethical manner?
To save time, some health professionals ask patients to watch online presentations before having specific procedures. In conjunction
with discussions with the doctor, these visual aids give the patient a better understanding of the details and risks associated
with an intervention. The result is a patient who is less anxious and more satisfied with the doctor.w12 The value of students’ involvement in the procedure could be introduced in these presentations.
In addition to innovative tools and well organised processes for obtaining consent, a responsible hospital policy is vital
for creating an environment that is conducive to ethical practice. Medical students must put their responsibility towards
patients before any learning opportunity. But ultimately, practising doctors are the moral front line and they must lead us.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
From the archive: "Intimate examinations and other ethical challenges in medical education" (BMJ 2003;326:62-3; doi: 10.1136/bmj.326.7380.62).
Ohad Oren third year medical student
ohadoren@tx.technion.ac.il
Gershon B Grunfeld senior lecturer in medical ethics and law Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
Student BMJ 2008;16:235 | 18
- Judy Siegel. Probe ordered into reports students performed gynecological exams on unconscious patients. Jerusalem Post; Jan 4, 2008; pg. 08.
- Osby L. MUSC May Change Pelvic Exam Practice, GREENVILLE NEWS, Mar. 13, 2003.
- Goldblatt A.D. Don’t Ask, Don’t Tell: Practicing Minimally-Invasive Resuscitation Techniques on the Newly Dead, Ann Emerg Med 1995;25:86-90.
- Warren A. Doctor training faces scrutiny: Allowing Student Exams on the Unconscious Raises Patient-Rights Issues. WALL ST. J (Europe), March 13, 2003, Tech. & Health.
- Kant I. Groundwork of the metaphysics of morals. New York: Harper Torchbooks, 1964. Translated by Paton HJ.
- Hoehner P. Ethical Aspects of Informed Consent in Obstetrics Anesthesia – New Challenges and Solutions. J Clin Anesth 2003;15:587-600.
- Hafferty FW, Franks R. The hidden curriculum, ethics teaching and the structure of medical education. Acad Med 1994; 69: 861-71.
- Westall J. Making an issue of informed consent. StudentBMJ (April 1998).
- Sokol D. William Osler and the jubjub of ethics; or how to teach medical ethics in the 21st century. J R Soc Med 2007;100:544-546.
- Cohen DL, Wakeford R, Kessel RWL, McCullough LB. Teaching vaginal examinations (letter). Lancet 1988;2:1375.
- Hicks LK et al. Understanding the clinical dilemmas that shape medical students’ ethical development: Questionnaire survey and focus group study. BMJ. 200;32:709-710.
- Thomas H Moseley et al. Effects of presentation modality on the understanding of informed consent. Br. J. Ophtalmol. Published online 10 May 2006.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Sandeep Basnet
(June 23rd, 2008)
4th year, M.B.B.S., BP Koirala Institute of Health Sciences, Dharan, Nepal sandeepbasnet2@yahoo.com
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I appreciate Ohad & Gerson putting such an issue in the frontline. This controversial issue is widely discussed in our medical university as well.
It is a fact that informed consent is important legally as well as to create a good doctor patient relationship. When it comes to performing physical examination in anaesthetized patients, which is irreplaceable as said by Prof. Joseph Schenker, I appeal medical students around the world not to be disturbed morally. I think our noble reason to serve humanity with our clinical acumen has a balance with the issue since there is nothing to support the gross violation of patient's autonomy and rights.
Violation of her modesty comes in question when she is either distressed or some of her confidential details is out of the theatre. As trainees, we have been taught right from the beginning about maintenance of confidentiality which we strictly adhere to even with family and colleagues. Thus, the so called flagrant violation of basic human rights in question doesn't fulfill either of the obvious criteria.
Ethics that has come between procedures and patient's autonomy has remained unsolved from centuries if we think this way only, especially in teaching hospitals. On the other hand, it is simplified if we can achieve a balance. It is the duty of clerkship directors to make sure that patients are not annoyed by repeated examination by students. Any distress to patients should indicate that examination be stopped. In fact, this makes us more sincere while dealing with patients.
Visual presentation given by some practitioners to patients before procedure should include the role of students as well. Though this isn't available in my hospital, it will definitely make the patients more understanding.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Simon H. Y. Tso
(June 26th, 2008)
Final year medical student, University of Cambridge st415@cam.ac.uk
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Dear Editor,
Oren and Grunfeld have raised the important issue of informed consent and performing intimate examinations on anaesthetised women. Such informed consent can be obtained from competent patients prior to anaesthesia. By doing so, patients, students and medical practitioners will be reassured that students performing examinations when the patient is under anaesthesia is ethically, morally and legally acceptable.
The wider issue here is the ethical and moral appropriateness for students to examine patients who are not in the position of giving valid consent (and there is no window of opportunity to do so) and never made the advanced decision not to allow medical students to examine them. Consider patients with dementia and unconscious patients in the intensive care unit, would it be appropriate for students to examine them or for clinicians to demonstrate signs from these patients in order to teach students?
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Kamala.S.Raj
(July 17th, 2008)
FY2 Doctor ,Leicester Royal Infirmary, Leicester k.sweta.raj@gmail.com
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I trained at Leicester and during my O&G placement at Leicester Royal Infirmary it was absolutely essential that written informed consent ( recoreded in patient notes) was obtained from every patient so that I would be able to perform supervised pelvic examination on them while under anaesthetic.
It became a part of my history taking for pre-op patients in O&G and taught me not to take for granted the opportunity that patients give us to practice and learn. Not a single patient denied consenting to examination.
Oren and Grunfeld's article brings to a light different viewpoints but ultimately it is relatively quick and straightforward to get consent and improves communication with the patient. I cannot see how this is not compulsory in all O&G medical student training.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Phillippa Wills
(July 20th, 2008)
emergency physician, John Fawkner Hospital, Melbourne, Australia, John Fawkner Hospital, Melbourne, Australia piplloyd@hotmail.com
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I am appalled by some of the attitudes expressed in the article by Ohad Oren and Gershon Grunfeld, and some responses. The issue was debated in New Zealand 20 years ago, and since then it has been compulsory for students to get informed, written consent from all patients to all intimate examinations whether the patient be under anaesthetic or not. This is not a controversial issue in the 21st century. It is very straightforward. For a student to place their fingers in a woman's vagina without her consent is sexual assault. No matter what "noble reason" may be behind it.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Mavis Duncanson
(July 22th, 2008)
Post-grad, Sydney mavis.duncanson@bigpond.com
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It rather horrifies me to hear this issue still circulating. As a medical student in the late 1970s I was a member of a class that took exactly the same action. Our profession risks even further alienation from our communities if we persist in such antiquated and paternalistic attitudes. Of most concern is the notion that consent is not sought because it is likely to be refused!
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Judith Dwyer
(July 23rd, 2008)
Professor of Health Services Management, Flinders University judith.dwyer@flinders.edu.au
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Like Dr Wills in New Zealand, I am appalled that this matter has not been resolved. I suggest that the practice represents very poor teaching - doctors need to be able to do competent and respectful intimate examinations on conscious women. But more fundamentally, it is an unconscionable violation of the woman's autonomy to assume her consent. The 'hidden curriculum' in the assumption that consent is automatic or implied doesn't bear thinking about.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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Sinan R Eccles
(July 27th, 2008)
FY2, Royal Glamorgan Hospital, South Wales sinane1@hotmail.com
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A very interesting article by Oren & Grunfield. During my Obs & Gynae placement in medical school, it was not a case of me refusing to perform intimate examinations on anaesthetised women , I was told on the first day to document informed consent in the notes or on the consent form, signed by the patient, if I wanted to perform an examination in theatre. This was checked by the theatre staff and if consent was not documented, I was not allowed to examine the patient. As a male medical student, I felt slightly awkward gaining this consent at first, although I was soon able to incorporate it as a natural step in clerking pre-operative patients, having already built up a rapport with them. However, the debate raises questions about other examinations. Should rectal examinations under anaesthesia be subject to a similar procedure? I had my General Surgery placement in the same hospital, but no equivalent system for gaining consent was in place.
There is no doubt that examining anaesthetised patients is of great educational benefit to students, allowing tutors to offer guidance and explanations more freely than if the patient were awake. However, this must not be at the expense of patient autonomy. We know that we effectively need informed consent at one level or another for every interaction we have with patients, but medical students need practical advice on when, where and what to document. On my Obs & Gynae placement, we made things easier by having pre-printed consent stickers that patients could sign for the notes and consent forms.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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J Robin
(August 1st, 2008)
Obstetric SpR, Manchester, UK jewishboy@lycos.com
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Dear Sir
It is a disgrace that this article should even be debated. And even more when someone eminent in the subject says it's fine to consider a women has consented when anaesthetised for an intimate examination to be done by medical students.
Cheers to the medical students who recognised the dignity of a woman. Its time the medical fraternity implement policies in the so called developed countries, which are not so, to protect patients.
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EDITORIALS
Informed consent and intimate examinations
(Ohad Oren and Gershon Grunfeld, July 2008)
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MC Kean
(September 4th, 2008)
retired, philosopher, medical ethics, life smallrevolution@peoplepc.com
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Yes, well I thanks for considering our rights, but this still does not go far enough.
I can tell you these exams as practiced are not harmless. I am not a particularly modest woman, but not a nudist either. My issue is not modesty, but that I do not trust men. 60% of men admit they would rape if they knew they could get away with the offense. Those same men find depictions of rape erotic. 10% of men find violence against women erotic with little or no sexual content. Now, I know many of you will claim that doctors are different. Yet, the level of sexual harassment reported by students and female residents is quite significant. In fact, rather than less likely to offend, male doctors are 10 times more likely to engage in some form of sexual misconduct. Given that they are more able to hide such misconduct stats are likely under reporting. This much higher rate of offenders amoung medcial professionals is mostly likely due to access. Anesthesia provides opportunity for the perfect rape. Therefore, while I am willing to accept male students and exams on a case by case basis while not drugged, I requested, "no males" present nor involved in my care while I was under anesthesia for a mastectomy and GYN surgery and then again for a colonoscopy. In all cases my request were violated. From practice exams to cath, to the mastectomy to the colonoscopy, as soon as I was sedated my requests were violated. Male students, residents, nurses, and doctors came in to prep, observe, and participate. I was left in male care post op while still sedated. In fact, I did not see another woman until the next day. Before it was over, somehow, I was infected with Herpes 2. My husband of 20+ years is not infected. Harm done? Well, from my perspective I suffered a gang medical rape, and most likely at least one sexual assault. I have suffered unexplained physical trauma to my rectum, a rectal herpes infection (I do not practice anal sex), a serious case of PTSD, and a sexless life at the age of 50 as I am afraid of infecting my husband.
Solution is:
Patient directed care. Listen and follow our instructions.
Gain all informed consent including for student participation in exams or procedures prior to any mind-altering drugs including valium or other like drugs.
DO NOT LEAVE A WOMEN UNDER ANESTHESIA ALONE WITH A MALE
Practice exams should be done on paid standard patients, not patients.
I know this may offend some of you. My experience is, however, is that those that are offended are also not to be trusted. The 40% of males who would not rape no matter how secure the opportunity and do not find depictions of rape erotic are also the males who are not offended by a women’s exclusions or limitations.
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