CMDA's The Point

Nonconsensual Intimate Physical Examinations: Time to Stop

December 13, 2018
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by Robert E. Cranston, MD, MA (Ethics)

Recently, a law professor I was breakfasting with asked an interesting question, “Is it ethical to perform pelvic exams on patients who are under anesthesia without their permission?” My immediate response was a quick, “No!” and then, “That is something that was done in the distant past, but the question was settled long ago. Without permission, this would be battery, essentially rape.”

To my surprise, she informed me that, in fact, this is still an open question in some doctor’s minds. In the early 2000s, the Federal Trade Commission and the Association of American Medical Colleges roundly denounced this practice, plus it was officially outlawed in several states. Despite this, recent student surveys indicate it is still a common practice in some medical schools.

My breakfast companion, Robin Fretwell Wilson, along with Anthony Michael Kreis, recently published a commentary in the Chicago Tribune, noting that despite the obvious ethical offense, it is still practiced in some medical schools and remains legal in 45 states. They detail a true story of a survivor of previous sexual assault who was informed after a routine stomach surgery in 2016 that, without her consent, she had again been invaded in the most intimate way. She was traumatized and shocked at her doctor’s betrayal.

While most physicians and physicians-in-training recognize the obvious immorality and indefensibility of this practice, a large group of professionals continue to support and endorse the exercise.

In a 2018 journal article, one student describes how he was urged into performing these exams, and the shame he subsequently experienced over his actions. In her thoughtful article, Phoebe Friesen documents how this inappropriate practice remains condoned and prevalent, and she describes how student doctors become acculturated to these actions. Prior to their OB/Gyn clinical rotations, the majority of students strongly oppose this. After their OB/Gyn rotations, the percentage of students who view this negatively drops dramatically. It is likely that much of this change occurs after students have been encouraged to perform and have performed multiple nonconsensual pelvic exams as part of their training. The mindset in much of medical training is that their medical authorities know what is right and wrong and should be obeyed. There is also the strong continuing awareness that should they object or disagree with supervising physicians, they will be labeled insubordinate and this will be reflected in their grades or letters of recommendation. Thus, following gynecological rotations, many have convinced themselves of the necessity and appropriateness of this practice in the training process.

The arguments for allowing this fall primarily along utilitarian lines—this is for the good of many future patients, and what the patient doesn’t know won’t hurt her. Wilson and Kreis specifically outline four frequently given rationalizations:

  • The patient might say no,
  • Anyone admitted to a teaching hospital knows students will be involved in their care,
  • The blanket hospital and surgical consents cover this, and
  • A variation on #1, above, if we ask patients they will refuse, and student education will suffer.

These flimsy justifications in no way override the abuse of autonomy and personal physical invasion performed without consent. Ironically, in regard to #1 and #4, good literature shows that many women willingly permit student pelvic examinations if asked. This is the crux of the issue. Why not ask?

Beauchamp and Childress’ Four Principles—autonomy, beneficence, non-maleficence and justice—are often quoted as our primary considerations in ethical decision-making, but there are several others consistent with the late Edmund Pellegrino’s Virtuous Physician model: truth-telling, integrity and transparency. Almost all of these principles are broken with non-consensual pelvic exams.

Wilson and Kreis call on the American Medical Association, the Joint Commission on the Accreditation of Healthcare Organizations, the American Hospital Association and the Association of American Medical Colleges “to give women the respect envisioned by Justice Benjamin N. Cardozo more than 100 years ago, ‘every human being of adult years and sound mind has a right to determine what shall be done with his (or her) body.’”

Hoping to garner support through social media, referring to their Twitter campaign, Wilson and Kreis state, “It is time to treat women like adults. It is time to #JustAsk.” I couldn’t agree more.

Robert E. Cranston, MD, MA (Ethics)

About Robert E. Cranston, MD, MA (Ethics)

Robert E. Cranston, MD, MA (Ethics), MSHA, FAAN, CPE, is a board certified neurologist, with additional training and experience in palliative medicine, executive coaching and medical leadership. He currently serves at Carle Foundation Hospital, in Urbana, Illinois, as an attending neurologist, Medical Director for Talent Development and Learning and (Past Chair—14 years) of the Carle Ethics Committee. He is a clinical associate professor of medicine (neurology) at University of Illinois College of Medicine, Urbana-Champaign and Carle Illinois College of Medicine, and he is a member of the CMDA Ethics Committee.

2 Comments

  1. Avatar Roger D. Nunn, MD, FACS on December 13, 2018 at 9:59 am

    As a medical student at The Ohio State University & Hospitals from 1963 through 1967, it was never my/our experience to do any kind of physical examination on a patient without explicit written & verbal consent. All exams were done on a consensual basis. I neither witnessed, performed, nor was asked to perform any nonconsensual physical exam, intimate or otherwise.

    I’’m curious, just how prevalent is the practice in the USA, which is addressed in this article?

  2. Avatar Bob Cranston on December 13, 2018 at 3:30 pm

    It is almost impossible to know, since there is no centralized reporting, and most doctors who would do this don’t tell anyone else they are doing it. Nonetheless, in anonymous surveys and student support websites there is good evidence it is still being practiced. In the 5th paragraph, above, the article by Friesen probably does the best job of looking at this, but numbers are not really available. On the other hand, once is too often.

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