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One more pelvic exam.

Janet Chin, a third-year medical student, has just begun a clerkship in obstetrics and gynecology. For this six-week rotation she is assigned to work in clinics and on wards of a large public hospital that is affiliated with the medical school. She is especially looking forward to the work because ob-gyn is one of the specialties she is considering for a career.

During her second year, Janet received some instruction in how to do a pelvic exam, but she realizes that she needs more experience to become adept at this important part of the gynecological examination. On the second day of her clerkship, she is presented with an opportunity to gain some experience.

She is one of three students who is assigned to work two mornings a week with an attending physician whose practice includes gynecological surgery. She and the other two students scrubbed in for a case of a patient scheduled for surgery because of fibroids of the uterus. While the patient was under general anesthesia, the attending physician did a pelvic exam and explained to the students what he felt. He then said that this was the ideal time for students to do a pelvic exam: the woman would feel no discomfort, the students would discern much more than usual because the muscles are relaxed under anesthesia, and everyone would confirm an important finding.

The attending physician then motioned to the first student to step up to examine the patient. When the first student was done, the second student took his turn. When he finished, Janet would have to decide whether to take her turn or decline. Although she wanted very much to gain the experience, she still hesitated. In the minute she had to decide, conflicting thoughts rushed through her mind. "Are three extra exams too many? Did the patient consent to multiple exams? What would I think if I were the patient? Would we be doing this at the school's from hospital? How will I learn if I decline these opportunities? Won't future patients benefit from my learning things now?"

What should Janet do?

COMMENTARY

by James Dwyer

To clarify the problem in this case, it is helpful to consider two extreme views of learning on and from patients. One view is to regard patients primarily as learning material and to treat them primarily as a means. This view is uncaring and dehumanizing. The other view is to insist that no patient be subjected to multiple examinations or to procedures done by people who are not already very skillful and experienced. This view is absurd; it would bring the learning of medicine to a halt. Between these two extremes is a morally sensible view: learning on and from patients may proceed but should be done in a way that cares for their well-being, respects them as persons, and is just.

Since there is a tendency to focus too little attention on the social arrangements in which ethical problems arise, I want to begin with the question of justice. Future patients may benefit from what Janet Chin learns now, but her future patients may be of a different social class from her present patients. Students and residents who learn on poor and working-class patients at public hospitals often go on to establish private practices that serve middle- and upper-class patients. Although many medical schools have affiliations with private as well as public hospitals, students and residents do more hands-on learning at public hospitals and clinics. Thus in general, public patients bear more of the disadvantages associated with people learning to practice medicine: more risk and discomfort, less convenience and privacy.

In defense of the present arrangement, it is often said that students and residents who work at public hospitals are providing care for people who would otherwise lack access. But that the present arrangement is better than letting people go without care does not show that it is justified. All people should have access to care, and I cannot think of any good moral reason for subjecting poor and working-class patients to more risk, discomfort, and intrusions. No IRB would approve a study that imposed a higher level of risk and discomfort on public patients than on private patients. We would not tolerate such a disparity in the treatment of research subjects, and we should not tolerate it in the treatment of subjects of learning. If everyone had good medical coverage and a real choice, people of all classes could avail themselves of the advantages associated with a private teaching hospital. All people who draw upon these advantages could then be expected to contribute by agreeing to be subjects of learning that is done in a caring and respectful way.

Where does this reflection on social justice leave Janet Chin? Because she is participating in and benefiting from the current arrangement, she has a special obligation to work for a more just health care system and to consider ways to include economically disadvantaged patients in her future practice. But what should she do in this particular case? Since the social arrangement does not show the patient equal concern and respect, Janet Chin should make an extra effort to do so.

I shall assume that the pelvic exams in this case pose no added risk or discomfort for the patient, and so the staff is caring for the patient's physical well-being. There is, however, more to consider than risk and discomfort. There is also a question of respect. Pelvic exams, like breast exams and rectal exams, are physical examinations of private parts--parts that are charged with various meanings and protected from public view and touch. Thus patients may care about whether extra pelvic exams are done while they are under anesthesia. Indeed, they may be especially concerned about maintaining some control over what happens while they are unconscious. They may also care about how many exams are done. A patient who found out that ten students were allowed to perform pelvic exams on her would feel she had been treated as learning material, not as a person.

In this case the way to respect the patient's concerns and recognize her as a person is to talk to her and ask her permission beforehand. Janet Chin should not perform the exam until she is reasonably sure that the patient was spoken to about the matter and agreed to the exams. It will not be easy at this point to raise the issue with the attending physician, but Janet Chin owes it to the patient to try. Relying on the fact that the patient will probably never find out won't do. Neither will some notion of implied consent. The fact that this patient voluntarily entered a teaching hospital does not carry much moral weight, since she probably did not have much choice. Ironically, the notion of implied consent would carry more weight at the affiliated private hospital.

Students might rhetorically ask whether they should insist on explicit permission to take a history, start an IV, or put in sutures. I see these as real questions that are especially difficult to answer because of our two-class system of health care.

COMMENTARY

by Julie Rothstein

This case illustrates a complex wrinkle in the relationship between patients, physicians, and the health care system. One might argue that if the patient receives appropriate care, she has an obligation to give something back to medicine or to society. Might she have an obligation to further the public good by aiding the progress of medical education? Is this an obligation that is shared, acknowledged, and agreed upon?

If some sacrifice for the social good is appropriate, it must be closely tied to the issue of consent, which would be based in a shared understanding of medicine as a public asset to be used and supported by all. In this case the physician may be assuming that the necessary consent may be inferred from the patient's signature on the surgical consent form. The signed form allows the health care team certain flexibility to deal with any contingencies that may arise during surgery while the patient is anesthetized and unable to provide specific consent. In some surgical situations, multiple examinations are necessary because each participant in the surgery must have precise knowledge of the location of an otherwise elusive tumor or tissue if the team is to perform the surgery successfully. In the case confronting Janet Chin, however, the concern is less medical than educational: the opportunity to practice examinations that otherwise might not be available

remains the primary reason for proceeding with the exams while the patient is anesthetized.

Does the case involving Janet Chin count as a legitimate exception to informed consent? Exceptions to the obligation to disclose do exist under limited circumstances, for example, if the patient is incompetent, a medical emergency has arisen, or if there is a danger to the public health. The exceptions exist to safeguard and promote the value placed on health in our society--a value as highly regarded as the values of individualism and self-determination.

In the present scenario, however, none of the standard exceptions obtain. Uterine fibroids are not imminently life-threatening. Furthermore, the incompetence exception is not valid if, as Janet assumes, the woman was competent and able to give surgical consent before the procedure began. The one exemption from usual obligations to obtain informed consent that might be thought to apply here is public health necessity. Just as an individual's right to autonomy may need to be compromised by legally mandated immunization, one could argue that performing invasive physical examinations on anesthetized patients without consent is just an unpleasant social necessity, an instance where respect for the patient must be sacrificed to promote medical education and better overall care for all.

This line of reasoning will not do. The arguments about the social necessity of such procedures would have to be pretty compelling to justify the blatant battery that is involved in multiple pelvic exams. Genital examinations are at the far end of a continuum of invasiveness and sensitivity, which should allow patients the maximal justification for refusal to participate. Patients must be the final arbiters in the decision of how much to contribute to the public medical good.

Explicit consent regarding the purpose of the procedure is crucial if the procedure is outside of the realm of usual care. It is reprehensible to fail to obtain this consent on the grounds that if the patient were asked to submit to multiple nontherapeutic pelvic exams she would certainly refuse. In this case study, the physician should have attempted to obtain consent while the woman was awake by explaining that submitting one's body to such touching is part of a shared notion of sacrifice and responsibility to the public good, a way to give something back to the medical establishment or society. A number of patients who share such a view of medicine and who are approached sensibly and sensitively will agree to participate in such examinations.

What is lost by performing these procedures without consent? First, patient autonomy is sacrificed. Federal and professional guidelines exist that require patients in teaching hospitals to be informed of the educational status of their health care providers and be given the opportunity to participate in medical education on a voluntary basis.

Second, the moral relationship between responsible mentor and receptive student is threatened. In these situations, the physicians is not only teaching the students about proper technique for physical examination but also modeling what one hopes is an appropriate attitude toward patients. The attitude presented by Janet Chin's attending physician is one that neglects patient autonomy and respect for persons. Because of the intensity of the experience of learning clinical medicine in these situations and the growing responsibility involved, students may be less able independently to judge the rightness or wrongness of a given act if it is presented by the attending physician as just part of everyday functioning on the wards. Another complication is that the student may be depending upon that physician for a recommendation for residency, making it even more difficult to challenge the attending if the student is unsure of the appropriateness of a given task. The power imbalance in such scenarios is both stark and very weighty.

Janet Chin should refuse to perform the pelvic examination. She can justify refusal through her discomfort regarding whether the patient consented or not, expressing the desire for further opportunities to practice the exams at a later time. She can discuss the case further with the attending once they are out of the operating room.

The medical school has certain responsibilities regarding such scenarios. In addition to the existing guidelines, faculty and students should all explicitly be informed of the obligations to obtain appropriate consent in the educational setting, especially concerning the status of the students and the educational nature of extra procedures, interviews, and exams. By clarifying responsibilities ahead of time, some of these troubling cases will be avoided.

James Dwyer is an adjunct assistant professor of philosophy and clinical assistant professor of psychiatry, New York University, New York, N.Y.
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Title Annotation:includes commentaries
Author:Dwyer, James; Rothstein, Julie
Publication:The Hastings Center Report
Date:Nov 1, 1993
Words:2181
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