Informed consent is the cornerstone of medical ethics. And every physician must defend this sacred principle from every form of evil that would seek to dismantle, degrade and debase it. If informed consent is the sun, then privacy, confidentiality, dignity, and trust are planets that go around it. For without informed consent, the descent of health care into amorality is inevitable, and the doctor-patient relationship is doomed to ruination, oblivion, and despair. It is also important to acknowledge the fact that a lack of informed consent has become endemic to our health care system.
This betrayal of patient trust is inextricably linked to three violations: a rape of the body, a rape of the mind and a rape of the soul. The rape of the mind is anchored in a willful nondisclosure of common long-term side effects associated with powerful drugs, such as opioids and certain types of chemotherapy. When a patient starts a chemotherapy regimen, they are typically briefed by a nurse, who proceeds to educate them regarding common short-term side effects such as mouth sores, constipation, and nausea, while failing to mention any of the typical long-term side effects, such as cognitive difficulties and early menopause. It is the long-term side effects that underscore the tragedy of having to resort to chemotherapy, as they can have a devastating impact on a patient’s quality of life, even long after remission has been attained.
On a breastcancer.org forum devoted to chemo brain, a writer named kcat2013 writes, “I’m almost 3 years out of chemo and my brain function has never returned to it’s [sic] pre-chemo state.” On a lymphoma.com forum devoted to chemo brain, sunshinebird writes, “By profession, I am an editor of a scholarly journal. My copy editing and proofreading skills have gone in the dumper.” JenLuvs2Run says, “I’m fine for a while, but then I suddenly find myself unable to pay attention — like my brain has entered into a fog. I will snap out of it, but it’s something that so far has kept me from returning to work full-time.”
The second violation that is intertwined with a lack of informed consent is the rape of the body, which is characterized by having medical students perform practice pelvic or rectal exams on anesthetized patients. It seems all but impossible for a patient to know precisely which teaching hospitals are still doing this and which have abandoned the practice. What we do know, is that the deplorable and heinous practice still occurs and has yet to be officially banned. Indeed, it is difficult to conceive of a more diabolical method for training medical students, as it inculcates them with the notion that privacy and consent are of little consequence and that the physician is above the law.
Let me pose a question. I am on gynecological surgery and several different residents and attendings have told me that before surgery, it is a great idea to perform a pelvic exam on the anesthetized woman to get practice. Many have said it is not traumatic to the patient and you get a more technically adequate exam since the patient is not guarding. Sure enough, before every procedure, the attending and resident (and I have worked with six attendings and four residents, both males and females, at two different hospitals, both community and academic hospital) perform a quick pelvic exam. Is this wrong?
The fact that a medical student in the 21st century can ask such a question speaks volumes about the glaring lack of a bioethics curriculum in our medical schools. One student flippantly replies, “It is standard procedure. How else do you think the residents and students are going to learn?” Lamentably, such is the general tenor of this disturbing discussion.
The third violation tied to a lack of informed consent is the rape of the soul and is rooted in the presence of unwanted observers during office visits. A line from the Hippocratic Oath reads, “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.” Physicians that have the gall to defend nonconsensual physician shadowing and who defend the presence of other unwanted observers during doctor’s visits, such as nurses and chaperones, clearly lack even the faintest trace of respect for that which forms the bedrock of medical ethics.
Teaching medical students, residents, and fellows that they have the right to observe a patient’s office visit, regardless of whether or not the patient’s consent has been obtained, inculcates ambitious doctors in training with the pernicious idea that the very notion of patient privacy is anachronistic and obsolete.
The abhorrent practice is particularly widespread in dermatology, where impressionable residents are immersed in an environment where patients with the best insurance plans are able to meet with an attending in private, while patients with less glamorous plans are often coerced into being clinical teaching tools, and frequently examined with residents voyeuristically looking on. Patients have also grown increasingly aware of the fact that, while they can sometimes be arm-twisted into accepting the presence of interlopers, their doctors are in turn able to use their superior insurance plans to avoid this very thing when it is time for them to be a patient.
Once a physician has betrayed their sacred duty to defend informed consent, privacy, trust, and confidentiality invariably fall to the wayside. And it is then that such an individual ceases to be a real doctor in moral terms, having transformed themselves into a soulless technocrat. For they have debased and defiled the dignity of their own profession.
David Penner is a writer.
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