Montana’s governor signed the bill into law in April, Missouri has legislation that requires the governor’s signature to become law, and Ohio lawmakers are also considering it.

COLUMBUS, Ohio — A new group of states is looking to legislate the level of informed consent when it comes to medical students performing educational pelvic exams on unconscious patients.

Already at least 20 states there are laws of consent for this practice. Governor of Montana signed the bill in AprilMissouri has legislation that requires the governor’s signature to become law, and the Ohio legislature also consider it.

Colorado lawmakers want to go further, with Democratic Gov. Jared Polis expected to sign account that one bioethicist calls the broadest she’s seen — and says it might go too far — because of the requirement to name participating students in advance and introduce them to patients.

Supporters “view Colorado’s bill as a model that we hope other states will adopt,” said Elizabeth Newman, director of public policy for the Colorado Coalition Against Sexual Assault, which advocated for the bill.

It is difficult to track and quantify how often medical students are asked to perform intimate examinations—such as pelvic, rectal, or prostate examinations—on patients under anesthesia. Opponents of the various bills and laws, often doctors, argue that government overreach could jeopardize the established trust between patient and provider and that medical association recommendations should be left instead.

Typically, a patient signs a series of forms giving broad consent to a number of procedures that may be medically necessary while someone is under anesthesia. It may also include consent for educational purposes.

“Most people just sign them and assume they’re going to get the care they need,” said Rep. Jenny Wilford, D-Colorado, who co-sponsored the bill.

But patients often don’t know they’ve been scanned while unconscious, and if they do, they may be afraid to come forward, Newman said. Also, she said, medical students who can report it are often afraid to voice their concerns to superiors who have power over their careers.

Colorado’s bill would require an informed consent process and ensure that pelvic, breast, rectal or prostate exams are part of treatment. Although this would be required even without students, practitioners are excluded from the emergency consent process.

The bill goes beyond other bills in the US to provide whistleblower protections for medical students who want to speak out, as well as liability for doctors and hospitals if they don’t follow consent rules. It is also unique in requiring that the students involved be named on the consent form and be presented to the patient prior to the procedure.

Kate Spector-Baghdadi, a clinical ethicist, said Colorado’s proposal is the broadest she’s seen, and worries that listing the names of participating students could limit learning opportunities. Obtaining consent is usually done days or weeks in advance, but students may not be available the day of the procedure — and Colorado’s proposed law would prevent others from stepping in and learning, she said.

“We want people in general to know how to care for women, and (these exams are) an important component of that,” said Spector-Baghdadi, who co-authored the Association of Professors of Obstetrics and Gynecology’s 2019 recommendation for such exams. “It’s a balance between respecting our patients’ autonomy and making sure that the next time they go to the doctor, they know how to properly care for them.”

That association 2019 recommendationendorsed by major obstetrics and gynecology professional associations, says students should only perform pelvic exams that are “clearly appropriate” and “related to the planned procedure.”

Newman, however, said the mandates are important not only for patients to give fully informed consent, but also for medical students to know the client has given their consent and to learn the rules governing the consent process.

Alexandra Fontaine, a medical student at Ohio State University, was asked to examine an unconscious patient on her first day at OhioHealth Columbus by a doctor who was supervising Fontaine’s training.

She said she did not know whether the woman, who was being anesthetized for abdominal surgery, which Fontaine said does not require a pelvic exam, had consented.

Fontaine also did not ask the doctor if the woman had consented, telling the Associated Press that students are taught to “see, not hear.” Fontaine said her doctor assured her that a pelvic exam was good and “for her education.”

“I froze at first,” said Fontaine, who didn’t finish the exam but told the doctor she did when her back was turned. The experience led Fontaine to testify before an Ohio House committee; her school says it supports students “on their professional journey”.

OhioHealth, which has several teaching hospitals, told the AP in a statement that its policy “regarding patient consent is consistent with current law” and that doctors oversee patient exams that are “a component of the medical education process.”

There can be a strong disconnect between patient understanding and provider understanding of consent and procedures, said Phoebe Friesen, a bioethicist at McGill University in Montreal, whose research has helped refocus the practice in the wake of the #MeToo movement.

Providers see these unconscious exams as purely medical or educational; the vagina and other intimate areas are “just another body part” so specific informed consent is not necessary.

But for patients, Friesen believes it’s absolutely necessary. Such exams can leave the patient feeling disempowered, or even re-traumatize survivors.

“The solution is very simple,” Friesen said. “Just ask people if they are comfortable with the practice.”

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