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Health Care Ethics USA Informed Consent: A Cautionary Tale One can be forgiven for believing that the basic elements of the principles of bioethics have been more than sufficiently addressed since the 1970s. Surely this is so of the principle of informed consent—the right to control access to one’s body. After all, conversation has long since moved on to such fine points as advance consent, proxy consent, consent for minors, and the determination of a person’s ability to consent in some but not all circumstances. Undoubtedly there can be only a few old misfits remaining who fail to grasp the essentials of this most basic tenet of bioethics. Unfortunately, it seems that this is not the case, and that too many remain who still just don’t get it. This is a challenge to all in health care, because if there are cracks in the basic appreciation of one principle, we must be vigilant in watching for cracks elsewhere as well. A serious concern about informed consent arose in the spring of 2003, when stories appeared in the U.S. press about medical students being trained to give pelvic exams by practicing on anesthetized women. The problem was not the participation in routine pre-surgery exams by students who were members of the patient’s care team. The problem was those students who were there for no reason but the enhancement of their own skills, examining women who had not agreed to be part of the noble cause of educating future physicians. Though this reality has been addressed, and changes have been made at many U.S. medical schools in the last two years, the fact that this practice existed into the twenty-first century should at the very least provoke us to examine our own health care institutions to see if we are assuming more understanding, acceptance, and application of ethical principles than actually exists. Principles Discussion of the principle of informed consent over the last few decades has worked its way through an assessment of the physician’s obligation to disclose, to focus now on the quality of patient consent. What we are considering here, unfortunately, is a far more basic ethical and legal dictate than either of those concerns. U.S. Supreme Court Justice Cardoza stated it clearly in 1914, in noting that, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Essentially, that means that in most circumstances a person’s body cannot be touched without his or her consent. Certainly, it is necessary for the common good that medical students develop expertise in the skills of their profession, and much of this learning requires the good will and cooperation of patients. Problems arise, however, when these virtues of human kindness are assumed by the physician, rather than clearly offered by the patient. It is then that matters of consent become deeply problematic. Discussion Much of the response to allegations that groups of three or four medical students were present in operating rooms to perform pelvic exams on anesthetized woman skirted the issue by pointing out that medical students are often members of a patient care team, or that surgeons routinely perform pelvic exams on anesthetized patients before gynecological surgeries. These facts are true, but are not at issue here. The real issue was brought to the fore by three physicians in an article in the American Journal of Obstetrics and Gynecology in March 2003.1 One of them, pediatrician Ari Silver-Isenstadt, had himself been offended by gynecological practice sessions while a medical student at the University of Pennsylvania, and had refused to take part in them. “My problem was that if [the women] found out about it, they might be really upset, and it was really only being done for my benefit. I felt like I would be violating their trust.”2 An article in Student Life, a newspaper at Washington University in St. Louis, MO, echoes this in stating that the controversy concerns students practicing their examination skills, noting that the practice was not for the benefit of the patient, “but intended only to enhance the clinical skills of the medical student.”3 What is troublesome in reading through the many articles that addressed this issue in the spring and summer of 2003 is that a number of students and medical professors continued not to see a problem. One unnamed female physician in Charlotte, North Carolina, is quoted as saying that she never thought of these exams as harmful, even if consent was not given. She opined paternalistically that patients “have much more important things to worry about in medical care.” Some point out that patients entering a facility where medical students are trained sign a form explaining that students will be involved in their care, and that that is sufficient notice. But others ask how that information can be understood to cover the practice of allowing groups of students not on the care team to examine anesthetized patients for training purposes alone. One of the more disturbing elements is the finding by the journal study mentioned above that medical students who have not completed OB/GYN rotations have a higher general regard for the need to obtain informed consent from patients than do those who have, by a margin of 70% to 51%. “The OB/GYN clerkship seems to be the defining event in this erosion, as opposed to gradual erosion throughout students’ many clerkships or rotations,” concludes Dr. Peter Ubel, one of the study’s authors.4 This suggests the need to search out and address practices in our hospitals that might have a detrimental effect on the fundamental and practical value placed on any ethical principle by health care professionals. Conclusion It is sad that some have learned so little over the years. We blanche, for example, at the details of a 1932 case in which a woman in labor asked to see a physician instead of a medical student, only to have the student call in a dozen of his peers, each of whom examined her as she screamed for them to stop.5 While the issue we discuss here is not similarly malicious, it does nevertheless involve the same fundamental disregard for the human dignity of patients, by disregarding or circumventing the need to inform them and seek their consent. It is sad that the practice places so little value on the need for trust between physician and patient, and so little faith in the goodness of patients and their willingness to participate in physician education if asked. Dr. Daniel Federman, senior dean for clinical teaching at Harvard University Medical School, is quoted as saying that after the complaints of 2003 led to a new policy requiring that women be asked to consent to exams for training proposes, “Very few patients decline.”6 Silver-Isenstadt notes that, “... the simple solution is to ask people’s permission. They’ll say yes. And it teaches the lesson to medical students that it’s really all about the patient. Not all about the medical student.” All of this serves to remind us that medicine constantly involves new players and new issues, and that even the most fundamental ethical principles must not only be taught theoretically, but that their application must be reconsidered and revisited on a consistent basis when real patients are involved. 
Ann K. Suziedelis, PhD
Suggested Readings Peter Ubel and Ari Silver-Isenstadt, “Are Patients Willing to Participate in Medical Education?” Journal of Clinical Ethics 11 (2000): 230-35. “Concern Over ‘Intimate Checks’,” BBC.com, January 10, 2003, at <http://news.bbc.co.uk/1/hi/health/2642861.stm> Sandra Coney, The Unfortunate Experience (New York: Penguin Books, 1988). Questions For Discussion
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