A Pot Ignored Boils On: Sustained Calls for Explicit Consent of Intimate Medical Exams.

Unconsented intimate exams (UIEs) on men and women are known to occur for training purposes and diagnostic reasons, mostly during gynecological surgeries but also during prostate examinations and abdominal surgeries. UIEs most often occur on anesthetized patients but have also been reported on conscious patients. Over the last 30 years, several parties-both within and external to medicine-have increasingly voiced opposition to these exams. Arguments from medical associations, legal scholars, ethicists, nurses, and some physicians have not compelled meaningful institutional change. Opposition is escalating in the form of legislative bans and whistleblower reports. Aspiring to professional and scientific detachment, institutional consent policies make no distinction between intimate exams and exams on any other body part, but patients do not think of their intimate regions in a detached or neutral way and believe intimate exams call for special protections. UIEs are found to contribute to moral erosion and moral distress of medical students and compromise the sacred trust between the medical community and the general public. This paper refutes the main arguments in favor of the status quo, identifies a series of harms related to continuing the current practice, and proposes an explicit consent policy for intimate exams along with specific changes to medical school curriculum and institutional culture. Because patients are the rights-holders of their bodies, consent practices should reflect and uphold patient values which call for explicit consent for intimate exams.

Physician Integrity, Templates, and the 'F' Word.

The medical profession is increasingly dependent upon electronic health records. Along with documented benefits, a number of potential ethical abuses have been outlined. Herein, we describe an ethical abuse that has received almost no attention, namely falsified medical records. We present three cases in which the medical record cited facts from history that were not elicited and findings from physical examination that was not performed. This is fraud. Prepopulated templates were almost certainly responsible. If a template is used, it must begin free of results-a skeleton onto which flesh is placed. If coders and third-party payers insist on having information than health care providers think relevant, then we, as a profession should "push back," but a template that has been prepopulated puts fraudulent data into electronic health record, seriously damaging physician integrity.

Educational pelvic exams on anesthetized women: Why consent matters.

It is argued here that the practice of medical students performing pelvic exams on women who are under anesthetic and have not consented is immoral and indefensible. This argument begins by laying out the ethical justification for the practice of informed consent, which can be found in autonomy and basic rights. Foregoing the process of consent within medicine can result in violations of both autonomy and basic rights, as well as trust, forming the basis of the wrong of unauthorized pelvic examinations. Several objections to this argument are considered, all of which stem from the idea that this practice constitutes an exception to the general requirement of informed consent. These objections suggest that nonconsensual pelvic examinations on women under anesthetic are ethically acceptable on utilitarian grounds, in that they offer benefits either to the patient or to society, or on the grounds of triviality, in that consent is already presumed, or the practice is insignificant. Each of these objections is rejected and the practice is deemed indefensible.

Sexual Assault Examination of the Unconscious Patient: A Legal, Ethical and Professional Grey-area for the Forensic Physician.

When treating unconscious patients believed to have been victims of sexual assault, forensic physicians must decide whether to conduct physical examinations in order to collect evidence while patients are unconscious and cannot consent. The choice is urgent: potential evidence may be lost before the patient regains the ability to consent. The physician's choice affects not only the patient's bodily integrity, but also their ability to pursue criminal and potentially civil justice remedies if they were assaulted. This article bases its discussion on one such real-life situation. It first examines ethical models relevant to deciding whether to take evidence and finds that no one approach produces morally satisfactory outcomes in every case. It then examines the legal framework guiding these decisions, finding that while collecting evidence without consent may well be permissible under New South Wales (NSW) legislation, relevant guidelines disallow it, placing physicians in a legal grey-area. The article concludes with practical recommendations to address these ethical, professional and legal challenges.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

The ethics of full body skin examinations.

Full body skin examinations (FBSEs) are part of the purview of a dermatologic examination. Because this involves examination of sensitive or intimate areas, there are many ethical issues involved. Herein, we discuss whether screening patients with an FBSE is ethical and consistent with the ethical tenet of distributive justice, how to ethically deal with our patients with disabilities, how to ethically navigate patients who have been emotionally or physically traumatized in the past, and the ethical ramifications of the use of a chaperone.

Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective.

As physicians encounter an increasingly diverse patient population, socioeconomic circumstances, religious values and cultural practices may present barriers to the delivery of quality care. Increasing cultural competence is often cited as a way to reduce healthcare disparities arising from value and cultural differences between patients and providers. Cultural competence entails not only a knowledge base of cultural practices of disparate patient populations, but also an attitude of adapting one's practice style to meet patient needs and values. Gender roles, relationship dynamics and boundaries are culture specific, and are frequently shaped by religious teachings. Consequently, religion may be conceptualised as a cultural repertoire, or dynamic tool-kit, by which members of a faith adapt and negotiate their identity in multicultural societies. The manner in which Islamic beliefs and values inform Muslim healthcare behaviours is relatively under-investigated. In an effort to explore the impact of Islam on the relationship between patients and providers, we present an Islamic bioethical perspective on cross-gender relations in the patient-doctor relationship. We will begin with a clinical scenario highlighting three areas of gender interaction that bear clinical relevance: dress code, seclusion of members of the opposite sex and physical contact. Next, we provide a brief overview of the foundations of Islamic law and ethical deliberation and then proceed to develop ethicolegal guidelines pertaining to gender relations within the medical context. At the end of this reflection, we offer some practice recommendations that are attuned to the cultural sensitivities of Muslim patient populations.

[Assessment of fitness for police custody: the physicians' responsibility and legal liability]. / Gewahrsamstauglichkeitsuntersuchung - Ärztliche Pflicht und rechtliche Verantwortung.

In contrast to several other European countries, German law provides only insufficient regulations on who is responsible for the medical assessment of persons in police custody. The police frequently report that doctors refuse to assess fitness for custody. Under consideration of the current legal background, we will discuss whether and, if so, which physicians can be obligated to carry out these assessments. We also examine a physician's possible exposure to criminal and civil liability if he or she refuses to assess fitness for custody or fails to render a correct assessment.

Using a Diagnostic OSCE to Discern Deficit From Disability in Struggling Students.

PROBLEM: When medical students with disabilities fail, identifying the underlying cause is challenging. Faculty unfamiliar with disability-related barriers or accommodations may falsely attribute academic struggles to disability. Fear of legal action may prompt inappropriate promotion of students with disabilities who are struggling to meet competencies. Therefore, a clear understanding of the origin of difficulty is critical to determining an appropriate response to the student's failure, including revision of accommodations, academic remediation, probation, and dismissal. APPROACH: A large Midwestern medical college created an innovative approach to differentiate between disability-related barriers and academic deficits by creating a diagnostic objective structured clinical examination (OSCE). The goal of this OSCE was to determine the need for additional or refined accommodations versus clinical remediation, and to guide future decision making about a student on academic probation. Using 3 simulated cases that drew on a cross section of clinical knowledge, a team of clinical and disability specialists observed a disabled student to determine the origin of that student's difficulties in a clinical rotation. OUTCOMES: Using the diagnostic OSCE, the team quickly identified clinical reasoning and fund of knowledge deficits, and need for further accommodations. As a result, the team was able to remediate the clinical deficits, augment the current accommodations in vivo, and determine the potential impact on performance. The team approach was documented and facilitated the legally required interactive process for determining additional barriers, efficacy of existing accommodations, and need for additional reasonable accommodations. All parties reported a positive experience. The collective knowledge and expertise of the team helped confirm the origin of the deficit: a fundamental lack of knowledge and reasoning skills versus a disability-related barrier. NEXT STEPS: The next step is to formalize this process to ensure appropriate evaluation of students with disabilities.

Patient involvement in teaching and assessing intimate examination skills: a systematic review.

OBJECTIVES: There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills. METHODS: For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills. RESULTS: A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported. CONCLUSIONS: There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.

A Right to Privacy and Confidentiality: Ethical Medical Care for Patients in United States Immigration Detention.

Recently, John Doe, an undocumented immigrant who was detained by United States Immigration and Customs Enforcement (ICE), was admitted to a hospital off-site from a detention facility. Custodial officers accompanied Mr. Doe into the exam room and refused to leave as physicians examined him. In this analysis, we examine the ethical dilemmas this case brings to light concerning the treatment of patients in immigration detention and their rights to privacy. We analyze what US law and immigration detention standards allow regarding immigration enforcement or custodial officers' presence in medical exams and documentation of detainee health information. We describe the ethical implications of the presence of officers in medical exam rooms, including its effects on the quality of the patient-provider relationship, patient privacy and confidentiality, and provider's ability to provide ethical care. We conclude that the presence of immigration enforcement or custodial officers during medical examination of detainees is a breach of the right to privacy of detainees who are not an obvious threat to the public. We urge ICE and the US Department of Homeland Security to clarify standards for and tighten enforcement around when officers are legally allowed to be stationed in medical exam rooms and document detainees' information.

Virginity testing: recommendations for primary care physicians in Europe and North America.

Virginity testing is a complex, culturally mediated practice that is poorly understood by Western clinicians. While advocating for global elimination of the practice of virginity testing as a human rights violation, clinical practice is often more complicated and ethically nuanced, and the clinician must act in the best interest of her patient. Upholding human rights does not have to be incompatible with providing a needed service to a patient, which should never include an invasive exam if not medically necessary, but should include education and safety assessments.