Informed Consent To Involvement Of Medical Students In Procedures Must Be Obtained

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 full
report of this case will be available on HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.

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.

More information for the media and HDC’s
naming policy can be found on our website here.

HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code). See also HDC’s media release – We
must do better on informed consent, 23 May
2022

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