Here’s how I remember it: The year is 1985, and several medical students are gathered around an operating table where an anesthetized woman is being prepared for surgery. The attending physician, a gynecologist, asks the group: This is your chance. She takes turns inserting two of her gloved fingers into the unconscious woman’s vagina.
Did the woman consent to a pelvic examination? Did she understand that once the lights went down, she would be treated like a clinical practice dummy and her genitals would be palpated with untrained hands? I don’t know. Like most medical students, I just did what I was told.
Last month, the Department of Health and Human Services announced new guidelines requiring written informed consent for pelvic exams and other intimate procedures performed under anesthesia. Much of the force behind the new requirements came from distressed medical students who believed these pelvic exams were wrong and who mustered the courage to speak out.
We do not know whether this guidance will actually change clinical practice. Medical traditions are notoriously difficult to uproot, and academic medicine does not tolerate ethical dissent easily. It is questionable whether medical professionals can be trusted to reinvent themselves.
Why do rare individuals say no to deceptive, exploitative, or harmful behavior when others think it’s okay? For a long time, I said no primarily to I thought it was a matter of moral courage. A related question was: “If you were a witness to wrongdoing, would you have the courage to speak up?”
But then I started talking to insiders who had blown the whistle on abusive medical research. I soon realized that I had overlooked the importance of moral awareness. Before you speak out about wrongdoing, you need to recognize it for what it is.
This is not as simple as it seems. One of the things that makes medical training so unsettling is that you are frequently forced into situations where you don’t really know how to act. Nothing in my life up until that point had prepared me for dissecting a cadaver, performing a rectal exam, or delivering a baby. I have never seen a mentally ill patient sedated unconscious and tied to a bed, or a brain-dead corpse taken from a hospital room to have its organs harvested for transplant. Your first reaction is often a combination of disgust, anxiety, and self-consciousness.
Embarking on a career as a doctor is like moving to a foreign country whose customs, rituals, manners, and language you don’t understand. When you arrive, your main concern is how to blend in and avoid causing discomfort. This is true even if local customs seem backward or cruel. Furthermore, the country has an authoritarian government and a strict class hierarchy, where dissent is not only discouraged but punished. To live happily in this country, you have to convince yourself that the discomfort you feel comes from your own ignorance and inexperience. Over time you learn how to assimilate. You might even learn to laugh at how naive you were when you first arrived.
Rarely do people hang on to that discomfort and learn from it. When Michael Wilkins and William Bronston began working as young doctors at Willowbrook State School on Staten Island in the early 1970s, they placed thousands of mentally ill children in the most horrifying conditions imaginable. I found it covered. That is, naked children shaking and moaning on a concrete floor in a puddle. own urine. An overwhelming stench of disease and filth. A research unit where children were intentionally infected with hepatitis A and hepatitis B.
“It was truly an American concentration camp,” Dr. Bronston told me. But when he and Dr. Wilkins tried to enlist Willowbrook’s doctors and nurses to reform the facility, they were met with indifference or hostility. It was as if no one else on the medical staff could see what they saw. It wasn’t until Dr. Wilkins went to a reporter and showed the world what was happening behind the walls of Willowbrook that something began to change.
When I asked Dr. Bronston how doctors and nurses were able to work at Willowbrook without seeing it as a crime scene, he said it started with the structure and way the facility was organized. I did. “It’s medically secured, medically supervised and doctor-verified,” he said. Healthcare workers are simply adapting to the current situation. “You join a program because that’s what you’re hired to do,” he said.
One of the great mysteries of human behavior is how institutions create a social world in which unthinkable acts appear normal. This applies not only to prisons and military units, but also to academic medical centers. When we hear about horrific medical research scandals, we assume we will see them the way whistleblower Peter Baxtan saw the Tuskegee syphilis study. It is an abuse so shocking that only a sociopath would fail to recognize it.
However, this rarely happens. It took Mr. Baxtan seven years to help others see the abuse for what it was. Other whistleblowers took even longer. Even if the outside world condemns the behavior, the medical establishment usually claims that it is not really understood by outsiders.
According to Yale psychologist Irving Janis, who popularized the concept of groupthink, the power of social conformity is especially powerful in organizations driven by a deep sense of moral purpose. If the purpose of the organization is legitimate, members feel that it is wrong to put up barriers to that purpose.
This observation helps explain why academic medicine not only defends, but sometimes rewards, researchers accused of misconduct. Many of the researchers responsible for some of the most notorious abuses in recent medical history—the Tuskegee Syphilis Study, the Willowbrook Hepatitis Study, the Cincinnati Radiation Study, and the Holmesburg Prison Study—continued to specialize even after the abuse was first identified. It was praised with great praise.
Healthcare cultures are notoriously resistant to change. In the 1970s, the solution to medical malpractice was thought to be formal education in ethics. Major academic medical centers began establishing bioethics centers and programs in the 1980s and 1990s, and ethics training is now required at nearly every medical school in the country.
However, it is debatable whether the training had any effect. Many of the most egregious ethical abuses in recent decades have occurred at medical centers with prestigious bioethics programs such as the University of Pennsylvania, Duke University, Columbia University, Johns Hopkins University, and even my own institution, the University of Minnesota. It has occurred.
It is not unreasonable to conclude that the only way healthcare culture will change is if change is forced from outside, such as regulators, legislators, and litigators. For example, many states have responded to the controversy surrounding pelvic exams by passing laws that prohibit pelvic exams unless the patient explicitly consents.
It may be difficult to understand how performing a pelvic exam on an unconscious woman without her consent can seem like nothing more than a gross invasion. However, the central purpose of medical training is to change sensibilities. You are taught to brace yourself against natural emotional reactions to death and disfigurement. Setting aside habitual views about privacy and shame. Viewing the human body as something to be examined, tested, and studied.
One of the dangers of this change is that people will be afraid to speak up when they see a colleague or boss doing something terrible. But the more subtle danger is that we no longer recognize what they’re doing as horrible. You’ll just think: This is how it’s done.
Carl Elliott (@twst_twst) teaches medical ethics at the University of Minnesota. He is the author of the forthcoming book, The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No, from which this essay is taken.
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