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When Ari Silver-Isenstadt was a medical student at Penn, he was asked to do something that he believed was unethical -- perform pelvic exams on anesthetized women without their consent. Though for him the request was a morally problematic one, it was simply part of a widely-used procedure. During their normal ob-gyn training, some medical students perform pelvic exams on women without their knowledge, after they had already undergone an initial exam by a surgeon. The student-performed exams are for educational purposes only and are not done for the sake of the patients, who often have no knowledge that students performed their exams. Although Silver-Isenstadt complied with the policy as a med student, he has since decided to challenge it, increasing the level of concern over an already debated issue. In 1995, he began conducting a study to determine how other medical students felt. His survey, recently published in the American Journal of Obstetrics and Gynecology, focused on how students felt about performing pelvic exams on patients who had not provided their consent. He found that performing these exams without consent "causes a change in medical students' attitudes" and that their willingness to do so varied according to their experience level. The more times that a student had performed an ob-gyn rotation, the more likely they were to "not identify themselves as students" because they thought it was less important to do so. Among students that had not yet completed their ob-gyn training, 17 percent of the respondents said that receiving the patient's consent was unimportant. After the training was complete, the number rose to 24 percent, as reported in The Philadelphia Inquirer. For Silver-Isenstadt, now a pediatrician at Franklin Square Hospital in Baltimore, the issue is a moral one. Being asked to perform the exams constituted a "difficult period in my education," he explained. "I was asked to do something I thought was wrong," he said. "But it was one of the requirements to pass the ob-gyn rotation." "I had to choose between compromising my integrity or obtaining an MD," he added. "I felt that if I did it once, I would sacrifice something." Silver-Isenstadt's main concern is that "when you are going through medical school and are asked to do these things to patients and know that they did not give consent and bury your concern, something happens to you." You are "crossing an ethical line," and your "integrity is given up." And Silver-Isenstadt is not alone in his concern. The ethical issues exemplified by his study and others done on the subject have prompted policy changes at some medical schools, including Penn. According to Paul Wolpe, senior fellow at the Center for Bioethics, Penn medical students are now trained through a process that uses "surrogate patients" who are paid and give consent to have practice exams performed on them. Still, under certain circumstances, they are asked to examine actual patients without patient consent. "My understanding is that Penn stopped using regular women except in special cases," Wolpe said, adding that he agrees with Silver-Isenstadt that it is a violation to use patients for educational purposes without first notifying them. Despite claims of changes at some schools, Silver-Isenstadt noted that the "training process still hasn't changed" and that "medical students are upset." The changing policies have also led to a larger discussion about whether the educational experience the students gain from this outweighs a sensitivity to women's rights. "Medical students are part of the team, but what they're doing when they're part of the team is fundamentally different," Silver-Isenstadt said. "They're there for education." Rather than not asking medical students to perform pelvic exams altogether, Silver-Isenstadt believes they should simply be required to introduce themselves to patients as students and ask for their consent. He found that most patients do give consent if asked, and that the lowest percentage of women willing to provide consent was 50 percent on more serious operations. Some physicians, though, argue that the problem with asking a patient for consent is that medical students have to learn and if the patients say no, then their learning is compromised. But Silver-Isenstadt believes that "there are more than enough people in this world" who would be willing and that a lack of consent wouldn't be a problem. "I very rarely had anyone turn me away, and I was always clear about who I was," said Silver-Isenstadt, referring to his experiences as a student. "I was there for education." Wolpe echoed Silver-Isenstadt, noting that in most cases, women who are asked will give consent for the exam. "There is a fear that women will say no, and therefore, you have to engage in what turns out to be both an objectionable and destructive kind of examination that offends both the patient and the medical students," Wolpe said. "Honesty is the best way to handle this." "In a perfect world, everyone would be identified, people are involved in making the decision and are allowed to make that decision," Silver-Isenstadt concluded. "There is no obligation to participate."

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