Bioethics Discussion Blog: July 2011





Thursday, July 28, 2011

Making Clinical Ethical Decisions: Common Fallacies: 5. Argumentum ex Silentio

argumentum ex silentio is a fallacy appealing to ignorance as evidence to argue that something exists or doesn't exist. For example, the argument goes:" since we have no evidence that God doesn't exist, therefore he must exist". Or "because we have no knowledge of alien visitors to our earth from other planets, that would mean that alien visitors don't exist."

The state law allows the CEO of a hospital to permit organ donation of a patient was without friends who know him or family and who died without any sign that the patient had previously stated whether or not to allow his organs donated at death. An ethics committee met to decide the ethics of whether it was appropriate ethically for the hospital CEO to give permission for organ retrival on this patient. The ethical principle of beneficence would suggest that procurement of a vital organ from this deceased patient and transfer to a needy patient would be an ethical decision to consider. There are no other facts for the ethics committee to consider.

Yet, a troublesome factor can be introduced if the fallacy argumentum ex silentio is not rejected but used to make a decision. One can say, that even in death, patient autonomy while alive should be respected and since there is no information that the patient had accepted organ donation therefore one could argue that organ donation was unwanted. Or.. since there is no information that the patient rejected organ donation therefore one could argue that organ donation would have been acceptable to the patient. One could also argue one way or the other with regard to whether the patient had religious restrictions to transplant.

Avoiding the fallacy would have allowed the following logic: "we are ignorant regarding whether or not the patient had made any decision about organ donation, therefore there are no other facts for us to use to make a decision about whether or not it would be unethical for the CEO to decide to authorize organ procurement except the fact that donation would be considered as beneficence toward the recipient and thus on that basis the CEO's approval would be considered ethical."

Can you think of some other examples of use of this fallacy in making an argument? ..Maurice.

Sunday, July 24, 2011

Making Clinical Ethical Decisions: Common Fallacies: 4. Argumentum ad Verecundiam

Argumentum ad verecundiam literally meaning "argument from authority" may be an easy way to get a point across in the process of discussion or debate regarding an ethical decision of a medical situation but alone it is incomplete. Simply saying that "Professor Jones has concluded that such an approach is ethical" or "Doctor Smith says that this will be the clinical outcome" without Professor Jones or Doctor Smith presenting the factual basis and logic for each to arrive at their conclusions is inadequate. It is essential that in a clinical ethics consultative meeting, both the ethics committee members and the stakeholders of the case are made aware of all the facts and how the doctor interpreted the facts to come to his or her conclusion. The academic degree of the individual is of value to be aware of the individual's area of training but tells nothing about how some conclusion expressed by that individual was reached.

Looking at these professional resources as an "authority" is misleading with regard to any specific case. Authority may mean that the individual has the training, has the experience, may have done research and may have published articles or books and may be recognized by others for all this and for their value as a resource for others but realistically that is still not enough to accept an authority's conclusion without having been presented and understanding the basis for that conclusion. That is why when a case is being discussed in ethics consultation, it is important that the professor or doctor are present either better in person or, if unable, by phone communication rather than by a view presented by another person "second handed". The authority must be able to hear the active discussion and reply to direct questions.

Authorities are of value for their general knowledge and specific knowledge and relationship of facts regarding which neither the members of the ethics committee or stakeholders of the case may be so educated. Everyone should be dealing with the one specific medical case at hand and not generalized scenarios and that is why frank and unquestioned acceptance of an argument from authority is unacceptable. ..Maurice.

Saturday, July 23, 2011

Patient Modesty: Volume 43

Continuing on with the concerns of a former medical student as begun in Volume 42:


July 11,2011

I was a [Moderator: school name deleted] medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming [My Medical School] students, I did not know about these exams when I first moved to [Moderator: city name deleted] to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) course in our second year [Moderator: Link is in error and cannot be completed]. You can see from the link how insensitive and immature my classmates are to sell such T-shirts.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues directly with faculty over the summertime.

I started reading Dr. Bernstein's Blog as a medical student, and contacted him back when I was trying to resolve my concerns with faculty. He bought to my awareness today that the essay I wrote for the Blog does not mention my personal career aspirations, which is something I told him about last summer. I realize this is a pertinent detail that several readers have asked about in their responses.

I entered the program at my school to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology.

When I learned about these invasive genital exams, I found them violating enough to refuse when unnecessary. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."


Over the summer, the first person I contacted was the head instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other instructors of the course first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.


I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at [My Medical School], I was shocked to discover she wrote an entire chapter about [My Medical School] students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at [My Medical School] that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at [My Medical School], hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.


After I spoke with all physical exam instructors, they sent me to the "Associate Dean for Curriculum", who is also an OBGYN. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about [My Medical School] students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams (

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control (, but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN Dean of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed the head ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the "Associate Dean for Curriculum" asked me if I had anything else to add, I said I was concerned about the head ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The Dean scolded me, and said he applauded the instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgement or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harasses female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this Dean, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.


The OBGYN "Associate Dean for Curriculum" said he did not support my conflicts with the curriculum, and sent me to the "Senior Associate Dean for Educational Affairs". This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at [My Medical School]. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at [My Medical School] stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients: (

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from [My Medical School]. I strongly suspect this because when I was sent to the OBGYN "Associate Dean for Curriculum", he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at [My Medical School]:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."


When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN "Associate Dean for Curriculum", he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."


I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN "Associate Dean for Curriculum" for not following the law that women can get birth control without pelvic exams, as well as report both him and the head ECM instructor for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.


Graphic: Photograph of Statue "Water" (1939-1943) by Aristide Maillol taken by your moderator 8-13-2011 at the Norton Simon Museum, Pasadena, CA.

Friday, July 22, 2011

Making Clinical Ethical Decisions: Common Fallacies: 3. False Dichotomy

False dichotomy is where, in formulating a decision, the decision is based on a belief of “all or none” and forgetting that there may be a middle ground. Not all decisions need to be made as “black vs white” since often there are shades of “gray”, that middle ground.

This concept is particularly important in clinical ethics consultations where in most cases decisions are not emergent. Yes, in an emergency room environment, often decisions regarding diagnosis and therapy need to be made promptly without time available to philosophize over an issue and either something specific in therapy is done or something is not done. In contrast, by the time an issue of management comes to the hospital ethics committee consultation there may be a sense of urgency to some but in most cases there is time to look at and consider the whole clinical, ethical and legal picture in order to come to a satisfactory conclusion. And what first comes to the table as a decision for either a “this” or a “that” may actually during discussion find some middle decision as the most viable and beneficent solution. This finding of a “middle ground” is one of the functions of an ethics committee consult and is part of the process of mediation of conflicts.

As an example, a 75 year old man with chronic emphysema and diabetes who has had a massive stroke and is still unconscious in the critical care unit of the hospital after 2 weeks and there is advice by the attending physician that the patient should undergo a tracheotomy (semi-permanent opening to the windpipe for breathing) since he is expected to continue on the ventilator for a unknown period of time. Also at this time a tube inserted into the abdomen and entering the stomach (PEG procedure) was the professional advice for longer term feeding and hydration. One son sitting at a hospital ethics committee consultation agreed with the advice of the physician. He wants these procedures performed since he wants to continue life-supportive treatment to continue until his father recovers. Another son with whom the father had lived since the mother had died a few years earlier present at the meeting argued against these procedures. He said that his father would never awaken and if he did he would not want to be alive after such a stroke. The son wanted the ventilator to be turned off even if it meant the death of his father. A neurologist on the case presented her opinion that the current 2 weeks duration might be too soon to make a judgment about the prognosis though it was probably poor and if the patient survived he might continue either in a persistent vegetative state or profoundly neurologically impaired. So the possible decisions would seem to be 1) continue with supportive therapy, do a tracheotomy and PEG or 2) terminate life-support now. But this is where overriding the “false dichotomy” comes in: there is a middle ground which was offered by the ethics committee. The neurologist told the family that she might be able to give a more accurate prognosis on examining the patient in one or two weeks. The attending physician said that the ideal time to perform the procedures was now but he would wait for a week or two more but not much longer. The ethics committee suggested to both sons that a compromise of having a followup ethics meeting in 10 days after the patient was evaluated at that time may be the best decision at present. This also provided time for each son to re-evaluate his position on a final decision. This middle ground satisfied all parties who were present and they all shook hands as they left the meeting.

If this was your father and the physicians were in agreement with the conclusion of the consult would you too be satisfied that it was not necessary to have the decision end if not the one way then the other? ..Maurice.