When as a medical student you dissected a cadaver, were there things said and done that left you deeply worried about the respect that you might be shown when you are dead? Do you remember the first time you performed a vaginal or a rectal examination? Were you in a queue of students lining up to practise on an anaesthetised patient who might or might not have known what was going to be done to them? Were you a bit embarrassed then as well? Perhaps this was expressed as ribald humour, a common defence in ethically challenging situations. Or was the examination performed on an uncomplaining conscious patient, who felt that they did not have the right to question why this nasty thing had to be done again and again? You may have felt a sense of unease at the time. You may even have decided that the procedure was wrong. But you were quickly taught that those doubts were immature and not to be heeded. And you lost something valuable.
Doctors need to show even more respect when patients are asleep than when they are awake
A while ago the practice of students performing vaginal or rectal examinations on anaesthetised patients who had not given proper consent was discussed in the literature and condemned, but it still continues. Some surgeons, unduly enamoured of the initiatory aspects of a training in medicine or with a misapplied concern for the sensitivities of their patients, are continuing to encourage students to perform examinations on anaesthetised patients who have not properly given consent. They appear to labour under several misapprehensions. Firstly, their action implies the belief that warning patients that a student might be present functions as informed consent. Secondly, they may be confusing the act of putting fingers into an orifice with that of sensitively performing an examination, which is a blend of communication, respect, and technical skill. Thirdly and most importantly, they seem to believe that anyone minds less what is done to them when they are unconscious than when they are awake.
How would you feel if you knew as you were wheeled into the anaesthetic room that you would be stripped of your rights the moment you fell asleep and your body would be fair game? Many of us might consent to students practising a rectal examination on us awake, but most of us would be incensed if the same act was performed on us unconscious and without our knowledge or consent. Those surgeons and their students probably believe they are sparing the feelings of the patient by going through this ritual while the patient is asleep. In the short term they may be right, but in the practice of medicine the longer term should hold sway.
Doctors need to have even more respect and care for patients' feelings when patients are asleep, or for that matter dead, than when they are awake. The patient's consent is needed for training procedures as well as treatment. If a doctor is in training then we should explain this to the patient. A specific contract needs to be drawn up with each patient. They must be fully aware of what is proposed and in a position to decline without feeling under any moral obligation. “What the eye does not see the heart will not grieve” may have seemed valid at a time when most people were treated as if they had neither the knowledge nor the sense to make rational decisions for themselves. The medical profession will not survive if it continues to assume that this attitude is acceptable in a sophisticated democracy. There may have been a time when doctors could get away with being trustworthy in public but despicable in private, but this is an age when no secret is kept for long and really all doctors should know better. As soon as the practice of students practising examination technique on unconscious and unconsenting patients becomes widely known, what remaining trust the public has in the medical profession will be further undermined.
Doctors are now required to be accountable, and cannot afford to pretend ignorance of that fact. If as clinicians and trainers we can manage to be honest and open about the problems arising in training and in making decisions, then we may be able to retain the trust that patients have so far been only too willing to offer. In doing so, we may stand as sorely needed role models for our students. In the long term this would make for a better respected and more trustworthy profession.
In the short term, however, there is an uncomfortable path to be trodden as the weaknesses and insecurities of the profession are addressed. If anyone is wondering what the weaknesses might be, they should ask the nearest medical student. Provided we have not yet trained the perception or intimidated the honesty out of them, they will be able to spot those weaknesses long before we can. The medical profession urgently needs to learn respect for the living and for the dead, and thereby earn the public respect that is its lifeblood.
See pp 685, 709