The Art of Medical Paternalism

The first article in the discussion series will be an article from the files of the SSRN.  The article is called “Behavior in Private Place:  Sustaining Definitions of Reality in Gynecological Examinations”.  It was written on December 6, 2008 by Joan P. Emerson with a revision done on December 29, 2008.  It is in volume 74, No. 2 and can be found at: 

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1312385

This paper basically discusses how all parties should act during a gynecological exam but you can readily see that many of the exam and medical providers’ characteristics carry over into other aspects of how medical care is delivered.  I was shocked and offended while reading this even getting more so as I read through it.  It is easy to see why patients are harmed by medical providers once you read this article.

 Please keep in mind that all material in quotes is solely credited to: 

*https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1312385 written by Joan Emerson on December 6, 2008 and can be found on volume 74, No. 2 under the title:  Behavior in Private Places:  Sustaining Definitions of Reality in Gynecological Examinations.

The first few pages are merely an introduction as to the whys of this article.  It starts to get interesting when Emerson, the author, starts talking about the “persons may have to work at accepting the physician’s privileged access to the patient’s genitals.”*

 She goes on to say that “Participants are not entirely convinced that modesty is out of place.  Since a woman’s genitals are commonly accessible only in a sexual context, sexual connotations come readily to mind.” *This lies the groundwork for the whole article.  “Privileged access”* (which in my mind is consented for access) is most assuredly what it is and yes, most women do not like to be exposed.  Most women do believe they have a right to say who does or does not have access to their genitals.  In the real world, unconsented for access is called sexual assault.  There are various other labels for a woman’s genitals being exposed without her consent.  The issue here comes when a woman is exposed to more than just her doctor.  This may come when she is exposed to a MA (medical assistant), the office worker, student observers, those shadowing the doctor or especially when she is the victim of an unconsented for gynecological exam by medical students while she is sedated and has no knowledge of it happening beforehand.  In my state of Indiana, it is still being done.  To me, this is a deep violation of the “privileged access”* given to the doctor.  I consider it sexual assault.  The exam was not done for her health benefit but was done to the benefit of the medical student(s). 

The last paragraph on p. 77 is very enlightening as Emerson says the “physician guides the patient through the precarious scene in a contained manner:  taking the initiative, controlling the encounter, keeping the patient in line, defining the situation by his reaction, and giving cues that ‘this done’ and ‘other people go through this all the time.’”*  WOW!  We are just beginning to witness the paternalistic and insulting attitude that we witness in many medical providers we have encountered.  The idea they are “controlling the encounter”* and “keeping the patient in line”* is just pure and simple over-the-top statements.  Why do they need to control the encounter?  If the exam is a voluntary exam, the patient is well aware the doctor will be examining her genitals.  What does Emerson mean the patient needs to be kept in line?  The patient is submitting to the genital exam and is not in a sexual situation with the doctor.  Earlier in the article, Emerson states there is a chaperone present who is part of the doctor’s office staff.  They are there generally for the sole purpose of protecting the doctor (not the patient like is preached to us) from charges of sexual misconduct.  Is the use of the chaperone one way in which they control the patient?  I say it is. 

In the following paragraph Emerson says that all must believe “this is a gynecological examination”* but she states it is also their goal to assert it is “…a gynecological examination going right.”*   She specifies the definition must be believed as it is “(not a party, sexual assault, psychological experiment or anything else). * If it is a medical situation, then it follows that ‘no one is embarrassed’ and ‘no one is thinking in sexual terms.  Anyone who indicates the contrary must be swayed by some nonmedical definition.” * So all the women who have been sexually assaulted by their ob-gyn were imagining the sexual assaults?  No, they were not because not all adhered to it being non-sexual and it is generally on the part of the medical provider who has the power and control of the situation.  The fact it takes years for most to talk about the sexual assault or to file a complaint does prove there is a lot of forces out work that do indeed convince victims of medical assault it did not happen that way.  We do know that cases of medical sexual assault happens even when there is a chaperone present (who again is a paid employee of the predator) or even when there are multiple medical workers present as they tend to stay silent about what they witnessed.

Emerson says the “staff’s demeanor toward the patient: ‘Of course, you take this as matter-of-factly as we do.”*   “In the medical world the pelvic area is like any other part of the body; its private and sexual connotations are left behind when you enter the hospital.”*   How many of you have heard it said that a patient must leave their right to bodily privacy at the door when they become a patient?  Most have as it is a common argument used by medical providers in order to make you become compliant and submissive to the manner in which they will treat or most often abuse your bodily dignity.  I have said time and time again they are taught that patients do not have the right to the true definition of bodily privacy.  Far too many medical providers believe you must accept what is their definition of bodily privacy and that is they will cover and drape as they see fit and not as it really should be done as only the needed area should be expose (all other areas should be covered) and that exposure should be done in the quickest manner while they protect your dignity from those who do not need to be present. 

Emerson goes on to say that most medical providers want the patient to think the genital examination is no different for them as it would be for the examination of any other non-sexual body part.  We know this is not true as the Internet is full of stories of medical provider sexual misconduct.  However, we know this train of thought is dangerous because we know in many instances patients are not properly shielded from the outside looks of the public such as an exam room door being opened during the exam and anyone walking down the hall can see a patient’s genitals.  We also know sedated patients routinely have their bodily privacy violated as non-essential personnel are sometimes present.  Elderly patients tend to suffer bodily privacy violations more often like the example I heard from one care home worker of an older woman being undressed in front of an open window with male constructions workers being able to see.

 Emerson calls this type of thinking “the patient is a technical object to the staff.  It is as if the staff work on an assembly line for repairing body….staff have a particular job to do….”  Maybe some do but then some don’t.  I have talked to a nurse on Quora who used this same reasoning but in a short space also said if a patient had something “different” all the staff would want to see it.  Again, this does go back to what they say does not translate to what they do.  We generally think of objects in terms of ownership or property.  If we own something, we feel it is ours to use however we want.  Some take good care of their property while some tend to be careless.  Some want to share while others keep it private.  This is the danger of not believing each patient is a human who is entitled to be treated with basic human rights such as the right to bodily privacy.  Our bodies are not put there for their use.  We are there because we require their services.  When I take my car in for repairs, I am not giving the mechanic free rein to do whatever he wants.  I expect him to follow guidelines like adhering to what we discussed and not to take my car for a joyride.  While I acknowledge that I may give permission for a vaginal exam from a certain doctor, I do not give permission for his chaperone to stare into my vagina as well that if I am having shoulder surgery, I have not given expressed permission to be totally naked for periods of time just to make their job easier.  I am a human being and not an object.

In the first full paragraph on p. 79, Emerson states “The medical definition grants the staff the right to carry out their task.”  Yes, they are granted the right to examine the patient but they do not have the right to abuse the patient’s bodily privacy.  She goes on to say that “As for exposure and manipulation of the patient’s body, it would be a shocking and degrading invasion of privacy were the patient not defined as a technical object….The medical definition justifies the request that a presumably competent adult give up most of his autonomy to persons often subordinate in age, sex, and social class.  The patient needs the medical definition to minimize the threat to his dignity; the staff need it in order to inveigle the patient into cooperating.”*   There you have it.  As long as it is a medical provider providing care it does not matter in the manner in which they deliver it.  They do not have to respect a patient’s bodily dignity and this is why many patients suffer iatrogenic harm from medical encounters. 

Most patients want their bodily dignity respected.  Women do not want the door opened during a vaginal exam.  Men do not want the “strip as you go”, drop your pants/underwear around your feet, bend over, and clean up type of exam while a young female MA or office worker merely stands and watches as a chaperone for the doctor.  Many male patients even have the further trauma of having 2 females present if both the doctor and chaperone are female.  I haven’t heard of a woman having a gynecological exam with both a male doctor and a male chaperone nor have I heard of a female patient being told to drop her pants. 

Although Emerson talks about the patient’s body being draped so that only the part that needs the attention of the doctor is exposed, most of us know that is not always the case.  While this may be true for gynecological exams, it is not true for the male equivalent prostate exam nor is it true most of the time in a hospital.  I have heard so many people ask why is it necessary for their genitals to be exposed when that is not the area that needs to be examined.  There is no justification for this except it is easier for them to expose rather than take extra measures to preserve your dignity. 

Emerson even goes so far as to explain how the demeanor of all involved in the gynecological exam should be.  This goes way too far.  “Her facial expression should be attentive and neutral, leaning toward the mildly pleasant, self-confident, and impersonal.  Her facial expression should be attentive and neutral, leaning toward the mildly pleasant and friendly side, as if she were talking to the doctor in his office, fully dressed and seated in a chair.  The patient is to have an attentive glance upward, at the ceiling, or at other persons in the room, eyes open, not dreamy or ‘away’, but ready at a second’s notice to revert to the doctor’s face for a specific verbal exchange.  Except for such verbal exchange, the patient is supposed to avoid looking into the doctor’s eyes during the actual examination because direct eye contact between the two at this time is provocative.  Her role calls for passivity and self-effacement.  The patient should show willingness to relinquish control to the doctor….So as not to point up her undignified position, she should not project her personality profusely.”*   A lot of rules one must remember.  In applying this line of thinking to other medical situations, it is no small wonder why once a patient is gowned for a procedure they are given a little something to help them to relax (usually a drug called versed that makes the patient uninhabited and forget what happens).  Why?  Because most medical providers do not want to deal with a patient during the time they are prepping them for a procedure as many do not respect a patient’s right to dignity.  Many times patients are unnecessarily stripped for procedures while all in the room can go about their business either making remarks about the patient or about what they plan to have for lunch.  Patients are objects and the owner gets to decide how they want the object to exist.

Did you ever wonder why some medical providers treat patients as if they were toddlers?  Emerson goes on to explain this.  “Most patients are not sufficiently relaxed when the doctor is ready to begin.  He then reverts to a primitive level of communication and treats the patient almost like a young child.  He speaks in soft, soothing voice, probably calling the patient by her first name, and it is not so much the words as his manner which is significant.”*   I have said time and time again they use words and actions to control.  One way is for you to call them Doctor ____ but they use your first name.  Another way is you are naked and they are wearing the whitecoat or scrubs of authority.  They use certain key words such as you must, you shall, etc.  Rather than ask a question:  May I examine your ____ because this why they will instead simply start the exam or say I am examining your ____ now.  They have been schooled in methods to gain the upper hand.  It is the manner they use in order “to keep a patient in line.”*

On page 86, the one item that stands out to me is “Even if they are complying, they may indirectly challenge the expert status of the staff, as by ‘asking too many questions.’”.*   There you have it in black and white:  Some medical providers feel threatened by patients who want information.  This is huge.

On page 87, Emerson goes on to say, “Some patients fail to  know when to display their private parts unashamedly to others and when conceal them like anyone else.  A patient may make an ‘inappropriate’ show of modesty, thus not granting the staff the right to view what medical personnel have the right to view and others do not…If a patient becomes nonchalant enough to allow herself to remain uncovered for much longer than is technically necessary she becomes a threat.”*  Most patients rely on the medical provider to keep them covered appropriately.  Many feel they would interfere with the medical provider if they were to cover themselves before the medical tells them to do so.  Yes, it is true some have no issue with being exposed and aren’t afraid to be inappropriately exposed.  However, what the above quote says to me is there really is no winning situation for the patient because patients really are not sure when they should re-cover themselves.  Patients who are given drugs such as versed (which encourages the patient to be uninhibited) are not generally capable of covering themselves. 

On page 90, Emerson comes in with this little scenario, “While in most encounters the nurse remains quietly in the background….one of the main functions of her presence is to provide a team member for the doctor in those occasional instances where the patient threatens to get out of line…Doctor and nurse may collude against an uncooperative patient, as by giving each other significant looks.  If things reach the point of staff collusion, however, it may mean that only by excluding the patient…cast the patient into the role of an ‘emotionally disturbed person.’”*   Is this what happened that night they decided to medically assault my husband?  Did they decide by their private looks that because he was advocating for his care instead of being the typical heart attack patient (the one who says “Dr. do whatever you have to in order to save my life) that he should be excluded from his care and they would treat him as an ‘emotionally disturbed person’?  Realize the significance of it being confirmed the nurse, the chaperone, is being used against the patient.  Emerson goes on to say “Whatever an ‘emotionally disturbed person’ may think or do does not count against the reality the rest of us acknowledge.”*   This certainly goes a long way in giving proof they do feel justify to defy patient consent.

I think that although this articles deals primarily with the gynecological exam, the principles Emerson expressed here does apply to other areas in the medical field.  This article is from 2008 and many, many medical providers from that time are still in practice.  It appears to represent the view many of them have about patient autonomy and patients in general thus clearly explaining out many have a paternalistic view of patients.