STUDENT VOICES | HONORABLE MENTION for the 2023 CHYNN ETHICS paper prize
Uninformed Consent: Pelvic Examinations under Anesthesia
by Anna Rubio Rodriguez, Fordham College Lincoln Center ’24
When my primary care doctor diagnosed me with polycystic ovarian syndrome (PCOS), a hormonal disorder that causes cysts on the ovaries, she explained that ovarian surgery was a high likelihood in my future. Terrified at this possibility, I immediately went home and tried to familiarize myself with ovarian surgery. What I learned during my research, however, shocked me more than anything about the actual medicine could. Countless women across the U.S. undergo gynecological surgery while unconscious from anesthesia, expecting a smooth procedure and entrusting the surgical staff to only perform the necessary steps for a successful operation; what they do not expect is their unconscious bodies to be used as a teaching tool for medical students. Yet, allowing medical students to learn how to perform pelvic examinations with women under anesthesia without the patient’s knowledge or consent is a “practice that is age-old and universally performed” (Goedken, 2005, p. 232). This custom grossly violates the trust between the patient-provider relationship, completely dismissing female patients’ right to make informed decisions about their body. Although an increasing number of states recently outlawed this practice in response to controversy, I argue that it should become federally illegal as a step to protect the bodily autonomy of women.
Performing pelvic examinations without consent dates back decades, spanning outside just the U.S. to several teaching hospitals throughout the globe (Wilson, 2003). The procedure involves medical students’ waiting until a female patient falls unconscious from anesthesia before a surgery and then practicing the examination, without asking permission or informing the patient that this will occur. The leading argument for this practice emerges from the exam’s position as an essential skill for medical students. A pelvic exam is used for detecting abnormalities, such as a tumor, in the female anatomy (Goedken, 2005), rendering it necessary for students to learn it. The struggle with garnering consent serves as the primary contributor to this practice. This procedure differs from a routine physical where consent could be acquired from a conscious patient, because the patient is unable to provide consent under anesthesia (Cundall et al., 2019). A notable justification of the practice arises from many medical instructors’ belief that most patients would not consent to the teaching prior to surgery, leaving students with no way to learn the important skill. However, almost half of female patients typically consent to “pelvic examinations for educational purposes” (Wilson, 2003, p. 218), casting doubt on this worry.
Other problems stem from the argument that patients automatically consent to these examinations by obtaining medical care from a teaching hospital, or that they should expect one as an integral part of gynecological surgery, preventing doctors from asking for explicit consent for the procedure beforehand. However, most patients have little knowledge of the intricate parts of gynecological surgery, leaving an examination completely unexpected (Cundall et al., 2019). The issue of consent also surfaces with the medical students, who often feel pressure from supervisors to perform these procedures despite their personal opinions on the matter. Many medical students report struggling with “the moral aspects of performing nonconsensual pelvic examinations” (Friesen, 2018, p. 299), but continue at the instruction of attending doctors. These factors establish the ethical dilemmas present in allowing this procedure to continue.
Firstly, this practice blatantly disregards several guidelines of research ethics, a relevant application to such a controversial practice. The Belmont Report (1979), which applies to biomedical research involving human subjects, clearly defines ethical principles and should hold relevance to this procedure as it directly deals with human patients. It discusses the gravity of informed consent, which stresses that persons should “be given the opportunity to choose what shall or shall not happen to them” (1979, p. 6). In these situations, the doctors fail to inform the patient that a pelvic exam will be performed while under surgery, much less allow them to choose whether they would approve this practice. The lack of informed consent should solely act as the factor that diminishes this procedure, aligning with ethical code. Further, the Belmont Report also outlines several ethical principles that researchers must consider before conducting an experiment. Their principle of “respect for persons”, specifically, asserts that “individuals should be treated as autonomous agents” (1979, p. 4). Performing invasive examinations on unconscious women without their consent treats them as inanimate props rather than autonomous agents, viewing their bodies as simply a tool for advancing medical knowledge.
The examinations also broach the nuanced complications involved specifically with women’s reproductive health care. In the U.S., sexual violence against women remains concerningly prevalent, with 1 in 5 women reporting an experience with rape (NSVRC, 2015). This fact haunts the practice of pelvic examinations under anesthesia, as the lack of consent with such a sensitive procedure can feel extremely violating to patients. Almost 75% of women surveyed on the topic “expected to be asked for explicit consent before a medical student performed an examination under anesthesia”, with about half expressing they would feel “physically assaulted” otherwise (Cundall et al., 2019, p. 1298). The clear opinion by female patients against the practice strengthens the evident violation of ethical standards. Further, each patient perceives this procedure in relation to their own body differently, based on factors ranging from their “cultural background”, “religious beliefs”, and “sexual orientation” (Cundall et al., 2019, p. 1299). Because each patient holds individual beliefs, a further defense for informed consent arises, as a practitioner cannot assume that their patient would be comfortable with the examination. The individual autonomy of each patient must be considered before such a procedure is performed.
So why are these pelvic examinations still in use? Despite the ethical controversy surrounding the procedure, 29 states still legally allow the practice to continue. Defenders of the practice argue that the other relevant method of realistic practice involves “[paying] standardized patients to guide students through sensitive genital exams” (Goedken, 2005, p. 233), which would cause financial strain on medical institutions and limit the number of students who could learn the vital procedure. Alternative options, such as mannequins or animal models, are deemed too inaccurate and therefore an insufficient method of instruction. Recently, however, medical advancements call the accuracy of the pelvic exam under anesthesia into question. A study by Ueland et al. (2005) found that the pelvic exam under anesthesia only detected ovaries 44% of the time, compared to 85% by a transvaginal ultrasound (TVS). This finding contests the exam’s necessity, highlighted by recent technology such as the TVS demonstrating greater accuracy. The pelvic examination’s significantly lower accuracy refutes the argument for nonconsensual examinations to proceed, as its importance lessens with medical advancements.
The ongoing use of this practice, regardless of the numerous moral issues and greater efficacy of TVS, highlights the larger problem of women’s autonomy being dismissed in the medical field. For example, the issue of informed consent occurs during discussions of intrauterine device (IUD) insertion, another form of reproductive health care. Many patients report their clinicians “[downplaying] the potential for excruciating pain” (Ruff, 2019, p. 4) that occurs during IUD insertion, often to prevent them from choosing a different form of contraceptive. This lack of detail does not allow patients to make an informed decision regarding their bodies, emphasizing once again the importance of informed consent in healthcare.
As a woman who relies on reproductive healthcare, the pattern of uninformed consent in women’s medical care greatly worries me. A doctor’s office should be a safe space where women can access necessary medical treatment without fear of violation, especially because many depend on reproductive healthcare for lifesaving procedures. I hope to see the practice of nonconsensual pelvic examinations nationally outlawed, as a path towards a world where confidence in bodily autonomy can be regained.
For more information about the prize, past winners, and submission requirements for 2024, please visit the Chynn Ethics Paper Prize webpage. The deadline to submit is Friday, March 15th, 2024 and is open to ALL undergraduates.
Works Cited
Cundall, H. L., MacPhedran, S. E., & Arora, K. S. (2019). Consent for Pelvic Examination Under Anesthesia by Medical Students: Historical Arguments and Steps Forward. Obstetrics and gynecology, 134(6), 1298–1302. https://doi.org/10.1097/AOG.0000000000003509
Friesen, P. (2018). Educational pelvic exams on anesthetized women: Why consent matters. Bioethics, 32(5), 298-307.
Goedken, J. (2005). Pelvic examinations under anesthesia: an important teaching tool. J. Health Care L. & Pol’y, 8, 232.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. U.S. Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the- belmont-report/index.html
National Sexual Violence Resource Center (NSVRC). (2015). Statistics [Graph]. Retrieved from https://www.nsvrc.org/statistics
Ruff, T. (2019, May 1). Surprisingly Painful IUD Insertion Doesn’t Match Contraceptive Counseling, Compromising Informed Consent. Women’s Health Activist, 44(3), 4.
Ruff, T. (2019, May 1). Surprisingly Painful IUD Insertion Doesn’t Match Contraceptive Counseling, Compromising Informed Consent. Women’s Health Activist, 44(3), 4.
Wilson, R. F. (2003). Unauthorized practice: teaching pelvic examination on women under anesthesia. American Medical Women’s Association, 58(4), 217-220.
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