Consent for Intimate Exams on Unconscious Patients: Sharpening Legislative Efforts

Is Specific Consent for Educational Sensitive Exams on Anesthetized Patients Necessary? Arguments for and Against From Canadian Medical Students

OBJECTIVE

Discussions related to the importance of seeking specific consent for sensitive (e.g., pelvic, rectal) exams performed on anesthetized patients by medical students have been growing. The perspectives of Canadian medical students on this topic have never been sought.

DESIGN

An anonymous questionnaire related to experiences and beliefs regarding consent and sensitive exams under anesthesia (EUAs) within medical training was distributed to medical students across Canada.

SETTING

Of 17 medical schools in Canada, 6 confirmed distribution, 8 schools expressed an intention to distribute but did not confirm whether distribution had occurred, and 3 did not share the questionnaire.

PARTICIPANTS

134 respondents answered at least 1 question. Canadian medical students who had begun clerkship or previous students enrolled within the last 5 years were eligible.

RESULTS

Our data indicates that, of Canadian medical students surveyed, the majority (72%) believe that specific consent for educational sensitive EUAs is a moral requirement, while 20% are unsure, and 8% do not share this belief. Respondents offered a variety of reasons why specific consent is necessary, including patient rights, autonomy, respect, and integrity, as well as concerns related to nonconsensual exams being abusive or constituting assault. Some respondents noted that consent is already implied, is unnecessary because of clinical benefit, or requiring it could lead to missed educational opportunities, especially for male and/or racialized medical students.

CONCLUSION

These results indicate that while most respondents support specific consent for educational EUAs, confusion regarding the purpose of these exams and the moral basis of specific consent exists in training.

Consent and Educational Sensitive Exams on Anesthetized Patients: Experiences of Medical Students Across Canada

OBJECTIVES

This study investigates experiences of medical students across Canada related to consent for educational sensitive (i.e., pelvic, rectal) exams under anesthesia (EUAs).

METHODS

A bilingual online questionnaire was developed and distributed to medical students across Canada.

RESULTS

Of 134 respondents, 63% had performed a pelvic EUA, 35% a rectal EUA, and 11% another sensitive EUA during their training. For those who had performed pelvic EUA, 28% were unsure if consent had taken place, 26% reported no specific consent, 20% reported specific consent, and 25% had mixed experiences of consent. For rectal EUAs, 48% reported no specific consent, 37% were unsure if consent had taken place, 13% reported that there had been specific consent, and 2% reported mixed experiences. Most respondents were uncomfortable (36%) or not sure if they were comfortable (32%) with how the consent process was handled for student pelvic EUAs; 31% were comfortable. In open-ended responses, respondents described experiences related to variability, discomfort, and authority.

CONCLUSIONS

Non-consensual educational sensitive EUAs continue to take place in medical training across Canada, although practices of consent are highly variable. The majority of respondents reported being uncomfortable or unsure if they were comfortable with how consent for educational sensitive EUAs was practised during their training, and some respondents struggled to express their discomfort given the power dynamics at play.

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Patient Consent for Medical Student Pelvic Exams under Anesthesia: An Exploratory Retrospective Chart Review

AbstractObjective: We performed this study to examine patients' choices to permit or refuse medical student pelvic examinations under anesthesia (EUAs) during planned gynecologic procedures.

DESIGN

We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent.

RESULTS

We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups.

CONCLUSIONS

We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

Consent for trainee participation in abortion care: A qualitative study of patient experiences and preferences in the United States

OBJECTIVES

Abortion training for clinicians is crucial to ensure patients' future access to full-spectrum reproductive healthcare. Given the complex sociopolitical context of abortion, consent to allow a trainee's involvement in abortion care requires careful attention to avoid harm to patients while also ensuring adequate clinician training for the future provision of care. In order to inform the development of patient-centered recommendations, we assessed patient experiences and preferences around consent for trainee participation during abortion care.

STUDY DESIGN

We interviewed participants who received abortion care at sites with medical trainees in the United States. We conducted interviews via zoom (video-off) between August 2021 and January 2022. We audio-recorded and transcribed the interviews. We coded transcripts using NVivo software and analyzed inductively using thematic analysis.

RESULTS

Twenty-four (n = 24) participants reflected a diverse range of sociodemographics as well as location of abortion service. Some reported experiences of coercion related to trainee involvement, ranging from subtle to overt. Participants preferred consent for trainee involvement in abortion care be a process outside the procedure room, while clothed, without the trainer or trainee present to allow for time to consider options without pressure to say yes.

CONCLUSIONS

Patient-centered approaches to seeking consent for trainee involvement in abortion care must reduce potential for coercion. A standardized consent before the procedure room by a trained staff member without the trainer or trainee present can help prioritize patient autonomy. Understanding care team member roles and upholding confidentiality and privacy are paramount to patients feeling safe with trainees present.

IMPLICATIONS

Our finding that patients experience varying levels of coercion to allow trainee participation in their abortion care highlights the dire need for patient-centered systemic changes-such as ensuring that consent take place outside the procedure room in a scripted fashion at eye level, while patients are clothed, and without trainers/trainees present-to maintain patient autonomy.