Consent Is Needed Even for Training: Ethicist

 Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at NYU Grossman School of Medicine.

For a long time in medicine, people who were learning to do intimate exams, such as pelvic exams, prostate exams, and rectal exams, learned to do so on patients who were undergoing procedures that required them to be put under anesthesia.

I think many people felt that if you're getting procedures done, let's say in a teaching hospital, then you forfeit your right to say yes or no. These exams are not going to harm you and it's important that students learn how to perform them and do them properly for the health of future patients. That's what teaching hospitals do.

Many places in the US, Canada, and elsewhere had a long history of doing this kind of examination without the consent — almost always of women but occasionally of men — to perform teaching of this intimate examination. Frequently, the patient never knew that kind of teaching or the intervention had been done. They weren't even aware.

I've long felt that using a patient in this way, without their permission or consent, even in a teaching hospital setting, is flat-out wrong. Sometimes we get gray zones in ethics where you can make a case for one side or the other. I don't see it here. I think you need permission from the patient before they undergo anesthesia, or even when they're conscious, that they're willing to serve as someone you train upon to do this kind of an exam.

It obviously has significant sensitivity in our culture. There are people who've been charged with sexual abuse for doing the same thing on a nonconsenting woman. That's viewed as criminal. I don't think that's the risk here, but I do think we lose trust and we lose a patient's confidence if we're found out to be doing this kind of examination with no permission.

Pennsylvania recently became the 20th state to pass a law demanding both written and oral consent prior to any type of examination, whether it involves anesthesia or not, for training purposes. Connecticut, where I live, passed a law last year that I was active in trying to push through the legislature here, and we got it.

I think asking patients, "Is it alright if we examine you and use that to teach students, either when you're conscious or when you undergo anesthesia for some other procedure?" is the way to go. Even in states that don't have those laws, I think that should be what we're doing.

I also believe that the number of people who say yes is surprisingly high. I've had the opportunity to track a little bit of the impact in Connecticut, and there doesn't appear to be much change in the willingness of people to make themselves available for this kind of teaching. Most patients actually want to help; they want to help the next generation of doctors learn. They know that they might be undergoing an examination that maybe could reveal something that wasn't suspected. There could be a tiny benefit in these exams for them.

Even if you don't get permission in the numbers expected, there are professional patients who, for pay — the pay isn't huge — will be happy to undergo examination as part of what they understand as important work to teach the next generation of doctors.

In sum, I don't think the practice of surreptitious, intimate examination, or any form of examination, should go on; I think we're at a point with informed consent where patients have the right to expect that they're going to be asked and give permission when something is undertaken that isn't part of their standard treatment.

I also think we ought to give patients the right to participate. As I said, at least in my state, the overwhelming majority of patients want to participate and help. Respecting that noble choice is something that bonds us with our patients and makes for a common cause in the battle against illness and disease, rather than being seen as people who might be doing things that are not trustworthy, sneaky, somehow shameful, and not even brought up with the patient.

That's not the position that medicine wants to be in if we want to keep securing trust from our patients.

https://www.medscape.com/viewarticle/999358