When Obstetric Violence is Justified as a Teaching Tool: Unauthorized Pelvic Exams

By: Juliana Nicolais

Juliana Nicolais is currently a medical student at McMaster University and has received a Bachelor of Science from the University of Toronto. After studying physiology and global health as an undergraduate student, her areas of interest include focusing on how various determinants of health affect individuals across the world and in our local communities, as well as how equitable healthcare can be promoted and achieved during an age of innovation and emerging technological advances.

Over the last few years she has become incredibly interested in women’s health, and before writing this paper she came across an article in the New York Times about the administration of unauthorized pelvic exams on female patients. After reading about the experiences of so many women that had been subject to this practice, she knew that she wanted to raise awareness about this issue so that we can work towards creating an environment within the healthcare system that allows female patients to feel seen, heard, and most importantly, respected.

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A woman lies on an operating table, unconscious and unclothed. Upon waking she discovers that she was unknowingly given a pelvic exam by a medical student and that the most intimate part of her body had been invaded while she lay unaware. This is a frequent reality for many women as the practice of performing unauthorized pelvic exams (UPEs), those enacted without explicit consent while women are under anesthesia, is common in much of the United States (Goldberg, 2020).

A woman lies on an operating table, unconscious and unclothed. Upon waking she discovers that she was unknowingly given a pelvic exam by a medical student and that the most intimate part of her body had been invaded while she lay unaware. This is a frequent reality for many women as the practice of performing unauthorized pelvic exams (UPEs), those enacted without explicit consent while women are under anesthesia, is common in much of the United States (Goldberg, 2020).

This article will argue that the performance of UPEs to increase a physician’s learning is an unethical practice as it violates the bodies of women while at their most vulnerable and perpetuates obstetric violence under the guise of medical training. The ethical permissibility of this practice will be examined through the lenses of principlism and virtue ethics.

In reference to principlism, the concept of autonomy encompasses negative rights, such as the right to one’s own body and the assurance that it will not be interfered with; this is not adhered to when UPEs occur. An argument made in favour of UPEs occurring during a gynecological procedure is that the patient has already consented to her healthcare team conducting care within her genital region (Wall & Brown, 2004). Many teaching hospitals believe that consent to a student’s participation in gynecological procedures such as this one should simply be assumed as part of the general informed consent process (Friesen, 2018). However, the consent process is not this simple, as informed consent involves a true understanding of what the patient is about to go through so that they have enough information to exercise their autonomy, either agreeing to or refusing treatment, and feel comfortable with that decision (Greene, 2020).

While medical students must be comfortable performing gynecological procedures, patients often do not take such encounters lightly, so even when a patient has consented to such a procedure, they may feel that their consent was given solely to their attending physician (Bruce, 2020).

An additional issue that arises is when UPEs occur during procedures that have no bearing on a woman’s reproductive system. Such was the case of a woman from Arizona who awoke from abdominal surgery and learned that she was given a Pap smear by a medical resident simply because she was due for one soon (Goldberg, 2020). Pelvic exams act as a useful learning tool for future physicians, and this means that students are often invited into the operating room to assist with such procedures in order to gain insight, however as seen in the aforementioned case, they are often performed without the patient’s prior knowledge because they act as a learning opportunity for the students present. The patient has no reason to think that anything more than a predetermined procedure will occur while anesthetized, whether that procedure is gynecological or otherwise, and imposing a different procedure, such as a UPE in this case, violates autonomy over one’s body and can cause incredible harm.

A pelvic exam is an invasive physical procedure, yet the most significant harms that arise from their unauthorized imposition are those to the patient’s emotional and psychological wellbeing. Countless reports exist of women waking to discover that their bodies had been penetrated by an individual conducting this exam as they slept, and the act has been, and continues to be, compared to rape (Friesen, 2018). Women may carry this psychological burden and trauma for the rest of their lives, a weight that could have been alleviated had they been given a choice beforehand (Bruce, 2020). On a societal level, the use of UPEs for teaching perpetuates gynecological violence, particularly if medical students are taught that informed consent is all-encompassing or even insignificant, and carry such assumptions into their careers (Ubel et al., 2003). This poses a grave issue if future physicians believe that they do not need to take the time to ensure a patient is entirely informed regarding what they are about to go through and that they are offered the chance to voice their concerns and have them taken into consideration.

Regarding beneficence, an argument favouring medical student involvement in pelvic exams is that clinical skills are especially important, and that without doing so, the medical system risks producing doctors who are underdeveloped in their abilities to provide gynecological services (Wall & Brown, 2004). With that line of reasoning, one can argue that UPEs benefit patients as a whole in terms of the valuable training and practice they offer future physicians, even when individual patients may find the practice uncomfortable or disturbing. The question that arises is whether such benefits outweigh the aforementioned harms. Is there ever a situation within the field of healthcare whereby a patient can be harmed in order to provide a better education to a medical student or physician so that they may better treat the community at large?

A physician’s duty is first and foremost to their patient over the education of their students, meaning that learning should not be prioritized over patient welfare (Bruce, 2020). Patients should not be expected to undergo undue pain and suffering so that those that come after them can receive better treatment.

There is also the concern about the potential injustices that arise from this practice, such as those facing vulnerable populations. Medical students in the U.S. have reported increased clinical practice using UPEs in healthcare facilities for those without insurance than those with private insurance, presenting an issue of inequality in treatment (Goldberg, 2020). The denial of bodily autonomy, and significant harms and injustices outweigh any potential benefits, deeming this practice impermissible according to principlism.

Alternatively, virtue ethics is a theory rooted in fostering individual virtue through one’s lived experiences and personal context. It allows one to do so by balancing vices of excess and deficiency to find a golden mean that exemplifies those actions of a virtuous person. As preceptors request that their unpracticed medical students perform UPEs, it is their values that will be examined using this theory. I believe that in this situation the golden mean lies in medical professionals having empathy for their patients, showing that they understand a patient’s fear and apprehension, and acknowledging their wishes and values when helping patients to make medical decisions. An empathetic individual would consider the profound emotional and psychological implications that come with knowing that an intimate part of one’s body was invaded without one’s knowledge. Moreover, sexual violence against women in the U.S. is at 33% prevalence, and women who have experienced such violence can have incredible difficulties with such exams in terms of “pronounced fears, anxiety, pain, and discomfort” (Bruce, 2020). An empathetic individual would also be likely to acknowledge that this practice may irreparably destroy an individual’s trust in the healthcare system, affecting their future relationships with practitioners and their wellbeing.

Extending from this golden mean are the vices of excess and deficiency, or paternalism and apathy, respectively. A paternalistic individual does what they believe is in the patient’s best interests, even when the patient does not believe that to be the case. Acting upon this paternalism can override a patient’s wishes and autonomy. Such was the case of an American woman with a history of sexual assault who refused a pelvic exam in the emergency room to assist in determining why she could not stop vomiting (Bruce, 2020). She then fell unconscious, only to wake up terrified mid-pelvic exam from the same physician to whom she had refused consent. Alternatively, an apathetic individual would be one deficient in empathy, someone who treats their patient’s body solely as a tool for teaching and their relationship merely as a contract that involves completion of a service, despite how the patient may feel about the actions taken to do so. Cases exemplifying such behaviour have been documented where physicians allowed the hands of multiple individuals to examine inside the patient’s vaginal canal (Bruce, 2020). While a physician may not always agree with their patient’s decision regarding a pelvic exam, it should ultimately be the patient’s wishes and values that matter most when deciding how to treat their body. Taking this information into consideration, I argue that a virtue ethicist would consider UPEs to be ethically impermissible.

UPEs are an ethically problematic practice used within teaching hospitals as physicians are trained in women’s health. This practice violates the autonomy of the unknowing women and can lead to lifelong suffering associated with the knowledge that one’s body was interfered with while one was powerless to stop it. UPEs also pose societal harms and injustices through the perpetuation of gynecological violence. Additionally, a virtuous physician or student would ensure empathy for their patient through recognition of the potential consequences of such actions whereby patients may undergo immense suffering when they are not treated with dignity and allowed to determine for themselves what they are comfortable with. Despite the teaching benefits it may reap, UPEs pose significant harms to women, their autonomy, and society, and therefore, they are an ethically impermissible practice.

References

1. Bruce, L. (2020). A Pot Ignored Boils On: Sustained Calls for Explicit Consent of Intimate Medical Exams. HEC Forum, 32(2), 125–145. https://doi.org/10.1007/s10730-020-09399-4

2. Friesen, P. (2018). Educational pelvic exams on anesthetized women: Why consent matters. Bioethics, 32(5), 298–307. https://doi.org/10.1111/bioe.12441

3. Goldberg, E. (2020, February 17). She Didn’t Want a Pelvic Exam. She Received One Anyway. The New York Times. https://www.nytimes.com/2020/02/17/health/pelvic-medical-exam-unconscious.html

4. Greene, M. F. (2020). Examining Examinations Conducted under Anesthesia. New England Journal of Medicine, 383(12), 1099–1101.

5. Pelvic exam. (n.d.). Mayo Clinic. Retrieved February 5, 2021, from https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135

6. Ubel, P. A., Jepson, C., & Silver-Isenstadt, A. (2003). Don’t ask, don’t tell: A change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. American Journal of Obstetrics and Gynecology, 188(2), 575–579. https://doi.org/10.1067/mob.2003.85

7. Wall, L. L., & Brown, D. (2004). Ethical issues arising from the performance of pelvic examinations by medical students on anesthetized patients. American Journal of Obstetrics and Gynecology, 190(2), 319–323. https://doi.org/10.1016/j.ajog.2003.08.035