Why more states are requiring consent for pelvic exams on unconscious patients

Medical schools, medical students and state legislatures are grappling with the little-discussed but sometimes common practice of performing pelvic exams for training purposes on unconscious patients without their knowledge. Alexandra Fountaine, a medical student in Ohio, and Phoebe Friesen, a bioethicist at McGill University, join Lisa Desjardins to discuss.

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  • John Yang:

    Medical schools, medical students and state legislatures are grappling with a little discussed but sometimes common practice performing pelvic and other intimate exams on unconscious patients without their knowledge. Word of caution, this segment discusses sexual health. Lisa Desjardins has more.

  • Lisa Desjardins:

    These procedures include student exams of a vagina or a prostate. They most often are conducted when a patient is anesthetized, unconscious for surgery. After the surgeon has performed a necessary exam, then students without the patient knowing repeat it. Intended as a learning opportunity. This came to light in the early 2000s following surveys of medical students, 21 states already have moved to ban the practice. Colorado and others are considering bans now, but the non-consensual exams are still allowed in 29 states.

    For more, I'm joined by Alexandra Fontaine, a medical student in Ohio advocating for a bill to require explicit consent there, and Phoebe Friesen, a bioethicist at McGill University. She's written and taught about this practice.

    Phoebe, let's start with you. Can you help us understand clearly what exactly is happening here and why?

  • Phoebe Friesen, Bioethicist, McGill University:

    I think it's often seen as a practical, efficient way to teach medical students how to perform a pelvic exam, which is an essential skill. For a while that certainly more recently, there's been a lot of pushback about the fact that consent is not always sought for these exams. And I think what's significant is we see a real disconnect between a lot of people within the medical community who see this as normal and non-problematic and people who are patients or members of the public who see this as morally disturbing or abhorrent.

  • Lisa Desjardins:

    It clear if this is assault or not?

  • Phoebe Friesen:

    It's a good question. You know, my background is in philosophy, and there is a debate about whether this constitutes assault. I mean, usually assault has some intention tied to it. I think, you know, there's absolutely no intention of violation going on in these cases. But there's absolutely a violation of bodily rights and autonomy and trust. And I think that's really important to keep in mind.

  • Lisa Desjardins:

    Alex, you're at the center of that disconnect, can you tell us about your experience and also the kind of pressure on medical students in this situation?

  • Alexandra Fontaine, Medical Student:

    I was put into a situation where I was asked to perform an unconscious pelvic exam and was able to maneuver my way out of doing that. But there is an enormous amount of pressure placed on students to perform the exams that are asked of us by our seniors, by our residents, by our attendants. And if we're not comfortable with the exam, it's difficult to say no. And as a student, I'm not comfortable performing exams that are unconscious as any of my classmates in the same boat.

  • Lisa Desjardins:

    Why is there such a disconnect between the way medical professionals who've been doing this for years, see this ethically and the way most of the public sees it when they first learn about it?

  • Phoebe Friesen:

    Medical school is a wild time, as I'm sure Alex can attest to. And you're bombarded with so many new practices and norms and things that feel weird and confusing. And we talk about the hidden curriculum in medicine, how a lot of especially moral practices are just learned through observing what physicians around you do, how they speak to patients, joke about patients. And I think over time, you inherit the norms of that world you're entering. Like any career, there's all sorts of justifications for it. I'm part of the team. The consent covers all of us, et cetera. But there really is nothing malicious happening. I think it's really just a norm that has stuck around and is now starting to really be questioned.

  • Lisa Desjardins:

    Yeah. Alex, can you talk about this culture in medicine? Do you think there is a culture of questioning things like this behind the scenes?

  • Alexandra Fontaine:

    Yeah, there's definitely a culture of students questioning things. My classmates are invested in this. I was part of a group with the American Medical Student Association where we talked every week about things like these. The culture can be malignant, and it's up to students like myself and others to combat it. And I think we have a strong sense of coalition toward the ethical thing going forward.

  • Lisa Desjardins:

    Phoebe, can you talk about that moment ethically? We're coming out of the "Me Too" era, but this is also an era of great distrust of medicine. Where does this fit in with all of that?

  • Phoebe Friesen:

    When I first learned about it and first started writing about it nearly ten years ago now, I desperately tried to get medical students to come, even speak to journalists off the record and say they've done this, and they were terrified to do so. But many of them had spoken to me about their discomfort. And now, I still teach medical students, and just like Alex says they are angry and they want change and they are engaged. And I think your point about distrust is also significant when we look at this particular issue, because when we look at the history of medicine, there is very good reasons for many people in many communities to have a lot of distrust. And we're very aware of that right now, thinking about the distrust around vaccines and COVID, et cetera. So, I think when we consider that in the history of medicine, a lot of individuals we think about prisoners, slaves, sex workers, all of their bodies were utilized in medical research and medical practice without their consent and that was really normal in the history of medicine.

    So, I think we have to kind of consider the history of problematic practices and lack of consent in this discipline when we think about this practice.

  • Lisa Desjardins:

    Alex, I wonder, do you think these new laws will change how things work?

  • Alexandra Fontaine:

    I do. I'm hopeful that they will. I think once health systems understand that they're laws and they have to abide by them, that will trickle down through, you know, supervising physicians, attending residents, all the way down to med students. But I think it's also going to take things at the other end where med students have to be empowered to push back and say, hey, we know that this is the law and we're going to follow it. And that takes support from everybody.

  • Lisa Desjardins:

    Alex Fountaine and Phoebe Friesen, thank you both very much.

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