Source: Health and Disability Commissioner
The need to obtain explicit consent for the involvement of medical students in sensitive medical procedures was highlighted in a decision by Health and Disability Commissioner Morag McDowell.
This case concerns care provided to a woman in her twenties, who had a mild intellectual disability, by Southern District Health Board, now Te Whatu Ora Southern – specifically, the non-consented involvement of medical students in the insertion of a mirena intrauterine device (IUD) under general anaesthetic.
In her decision Ms McDowell found Te Whatu Ora Southern in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for providing services involving teaching to the woman without first notifying her, and not obtaining her informed consent. Ms McDowell further considered that systems for obtaining consent were demonstrably lacking.
Ms McDowell was critical of a registrar, who was delegated responsibility for the procedure by a consultant doctor and permitted the student’s involvement, for not reviewing the consent form to ensure consent to student involvement had been obtained. She was also critical of an anaesthetist for not acting on another anaesthetist’s concern about the woman’s capacity to consent to her anaesthesia.
The Cartwright Cervical Cancer Inquiry (1988) was critical of practices at that time where students, under supervision, undertook internal vaginal examinations on anaesthetised women without their consent. Among other things, this informed the rights contained in the Code.
Ms McDowell acknowledged “the importance of medical education, and that students training to become doctors need to learn how to perform sensitive examinations and procedures”.
“However, there is a clear expectation that such examinations can be conducted only with unequivocal informed consent, given the vulnerability of the person being examined. It is at the heart of patient-centred care.
“The Consensus Statement on medical students and informed consent published in 2015 by the New Zealand Medical Journal highlighted the need for meticulous care to seek and document consent for the involvement of medical students in the performing of sensitive examinations, particularly those under anaesthesia,” says Ms McDowell.
Ms McDowell recommended that Te Whatu Ora Southern conduct an audit of cases within Obstetrics & Gynaecology in which students have observed or performed sensitive procedures, to check whether consent was given and recorded; provide further training to staff within Obstetrics & Gynaecology on informed consent, capacity, communication between clinicians, and the requirement to review clinical records; and apologise to the woman for the identified breaches of the Code. She further recommended that the registrar undertake training on informed consent, and the registrar and anaesthetist provide a written apology to the woman.
Ms McDowell noted that following these events SDHB reviewed its policies, process, and forms concerning student involvement.
“Clear ethical leadership is required to embed a culture of vigilance around informed consent. This requires positive and ethical role modelling, and students must feel empowered to question any examination if a patient has not given informed consent.
“I have recently written to all DHBs, medical schools, and Te Whatu Ora – Health New Zealand to reinforce the message that informed consent must be sought for student involvement in sensitive examinations.
“I will continue to monitor this issue closely, and I encourage anyone who has knowledge of, or is concerned about sensitive examinations having taken place without informed consent to report their concerns to my office directly at 0800 11 22 33 or to make a complaint at www.hdc.org.nz,” says Ms McDowell.
The Commissioner will usually name providers and public hospitals found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.
