By way of introduction
Given that it’s the season of school applications, below I’m sharing the personal statement I wrote for my PhD programs. I love how it tells the story of where I am as well as the story of where I am going. As I learn more about ethics and theory, and truthfully as I learn more about how much I still have to learn, this statement is a fantastic example of where I began ethics in this place, and in this time. I also welcome others using this as a draft framework for their own statements, because sometimes writing about who we are and what we want is one of the hardest things to do. This piece of writing may not be perfect, but it is honest and it ravaged me to figure it out at the time. Much love to you all, wherever you are in your journeys and arrivals.
Written Fall 2020
My journey into clinical ethics, bioethics, and medical humanities began with feminism. Early in my academic career, two midwives taught an introductory feminism course that created the foundation for ethical inquiry I embody into my midwifery practice today. Over the past eight years, my clinical work and expertise centered around the complexities of intimate exams, scripting for providers, and disrupting the hierarchical status quo. My writing and teaching of the trauma-informed care framework, in which I argued normalizing this approach for all encounters rather than exceptionalizing it for a select few, consistently met some resistance. Providers unabashedly challenged the concept of consent, specifically integrating intentional and ongoing consent into routine exams. Frequent rebuttals focused on time constraints, varying understandings of legal or medical definitions of consent, or actual disbelief of the importance of unabridged consent even in exceptional circumstances. Ethical pluralism persistently arose, and I found myself developing a polemic against arguments that consent can be conceptualized and defined by individual providers or institutions. I realized that without more holistic knowledge of consent, including the professional will to integrate new approaches into practice, trauma-informed care might continue to be a fringe concept. To persuade a provider to be sympathetic to the moral clinical life is to question fundamental power differentials in patient care, which reflect unjust inequalities in society. Changes in clinical practice take extraordinary effort on the part of the provider and the teacher: I aim to be both. Through the University of Chicago MacLean Center's Fellowship in Clinical Medical Ethics, I have the brief opportunity to delve into questions of epistemology and ontology of the consent process, which has only ignited my passion for continued learning in this field. It is time to turn away from clinical practice and toward questioning this moral dilemma.
Gynecologic and obstetric healthcare mirror patients' intimate and sexual lives. Given these similarities, consent in pelvic care demands heightened importance compared to consent in other clinical contexts. The minimum baseline for a patient's consent to pelvic exams should be equal to, if not exceed, expectations for consent in society, given high ethical standards applied to healthcare decision-making. As a provider in this field, I witness countless circumstances to the contrary: that which in social settings would be considered coercion or assault undergoes redefinition as clinically or medico-legally necessary within healthcare spheres. This reconfiguration of consent is especially problematic as it unnecessarily reinforces what society already sustains outside the healthcare setting: primarily, asymmetries of power and limitations to bodily autonomy for all identities other than cismen. Minoritized identities, including women, communities of color, queer and transgender individuals, and those whose identity or primary language is discordant from the healthcare team, further accentuate this imbalance. Critically, these same identities suffer higher rates of sexual violence in their lifetimes. Normalizing an ethical consent process in pelvic care is essential to ensure safe spaces for everyone, particularly those most likely to experience trauma or be activated by a prior trauma during their healthcare interactions.
Lesbian legal academic Ruthann Robson's theory of "dual theoretical demand" highlights the juxtaposition of pelvic care and sexual intimacy. It describes the paradoxical circumstance of integrating relevance and irrelevance as providers maintain a clinical environment while also being wholly attentive to the patient's sexual life and trauma history. Feminist legal scholars and activists Catherine MacKinnon and Andrea Dworkin posited that women could never fully consent to sex with men since both parties acculturated to asymmetrical scales of social and legal power, which historically and chronically tip toward men. Second-wave feminists, myself included, challenge this discussion, particularly its invalidation of female sexual autonomy. Still, their primary critique of equalizing power persists. The scales would comparably tip when extrapolating this concept to healthcare consent scenarios due to complementary power discrepancies. Healthcare providers, whose roles hold both power and knowledge, obtain consent; patients, disempowered by both knowledge and role, must decide whether to consent. The simplistic Hippocratic oath of 'do no harm' is insufficient without an alliance with the other medical ethics pillars of justice, autonomy, and beneficence. Implications for clinicians who do not obtain adequate consent for pelvic care are minimal, perhaps a hindsight regret and apologetic debrief about improving at subsequent visits. Ramifications for a patient who was not appropriately consented, who then undergoes forced, coercive, or rough pelvic care, include possibly identifying an experience of assault and avoiding or delaying future care.
The #MeToo movement catapulted modern feminism, along with updated definitions of bodily autonomy and consent, into the public conscience. This revolution breached the healthcare infrastructure with impressive force, initiated by the survivors of Larry Nassar's sexual violence disguised as pelvic care. Patients carry the knowledge of this mainstream news with them into their appointments, and providers must consider the implications as well. While there are essential distinctions between a provider knowingly assaulting a patient and erroneously believing they performed a thorough consent process, the professions of obstetrics and gynecology must strive toward zero disparity in the context of care provision. Current definitions of consent in healthcare are loosely worded and inconsistently actualized, as the practical implementation does not match its theoretical intentions. Some providers start exams without speaking, assume consent de facto by presentation to care, or ignore verbal and nonverbal cues of pain or rescinded consent. Interestingly, providers often exceptionalize robust consent processes in certain circumstances. These include pelvic care of queer communities, known sexual assault survivors, and people experiencing their first pelvic exam. Especially within the current cultural context, which questions patient safety in pelvic care, that which is exceptionalized should be normalized.
My goal in seeking doctoral studies is to reify consensual pelvic care within philosophical and medical ethical frameworks. As a new learner in this field, I quickly resonated with critical theory, relational ethics, and reflective equilibrium. Applying additional lenses of feminist theory, queer theory, and anti-racism, I seek to create a normative ethical argument regarding consent's application to respect for persons, autonomy, bodily integrity, and unwanted trespass. Though I identify as a novice in applying ethical scholarship as it might relate to these concepts, I appreciate Debra Satz's noxious markets, Leon Festinger's cognitive dissonance, Simone de Beauvoir's ambiguity, Lawrence Kohlberg's moral development, and Ezekiel and Linda Emanuel's deliberative medicine. Finally, examining negative and positive rights related to consent will be important in considering arguments to sway providers who remain uncertain in both will and articulation. To paraphrase Frantz Fanon, it is the mastery of this language that will afford me the power to embed ethical change in clinical practice. Ultimately my professional goal is to continue teaching clinicians, engaging in ethics consultations, and practicing as a Midwife.
