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The issue of consent for student involvement with patient care was raised by the Cartwright Inquiry. Evidence was presented that medical students were required to perform vaginal examination on anaesthetised women without their knowledge or consent.[[1]] As a result of the Inquiry, the Code of Health and Disability Consumer Rights (HDC Code)[[2]] was established that includes rights on consent for teaching (Rights 5,6 and 7). There are concerns that this requirement is not being observed, and a Consensus Statement (CS) was developed by Auckland and Otago medical schools on informed consent for teaching.[[3]] Malpas et al. did a study based on a subset of reflective essays—“Ethics Reports”—that medical students had written that documented significant deviation from these recommendations.[[4]] They recommended further strengthening processes to ensure that the consensus is adhered to.

Like Auckland Medical School, Wellington campus-based University of Otago students write reflective pieces (called Thought Provoking Episode Reports (TPER)). I read over 100 every year, mostly from final year students. This paper is not based on a formal analysis of these reports, but they have significantly informed its development.

Summary of argument

In my view the CS is significantly flawed:

1. It is couched in ethical terms that prioritise patient autonomy. This is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[5]]

2. “Consent” as a term is too simplistic and hides all the relational elements that contribute to a patient agreeing to student involvement.

3. In requiring students to obtain consent for teaching, the recommendations are asking students to do something not required of graduate doctors. Whilst the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings.

4. My hypothesis is that ethics are culture bound so disagreements on ethical practice reflect different cultural views on what is right. In Malpas’s examples the views of those writing the CS conflicted with the practicing clinicians that students were exposed to. The concept of “cultural safety” is helpful in approaching this issue. The patient’s view of what is right is most important.

Patient autonomy and the quadruple aim

The HDC Code[[2]] was established in 1996 as a result of an inquiry into practice that significantly impinged on patient autonomy. The focus of the code is to protect patient autonomy, and the CS reflects the recommendations in the HDC Code. It is only in Section 3 of the HDC Code that other considerations of clinical circumstances and resource constraints are mentioned. Apart from the generic right referring to compliance to other law, there is no mention at all of decisions being affected by public health considerations.

The modern quality in healthcare movement was advanced by the US publication “Crossing the Quality Chasm” in 2001,[[6]] and the New Zealand Health Quality & Safety Commission was established in November 2010. Central to its work is the triple aim, a balance between:

• Improved health and equity for all populations,

• Improved quality, safety and experience of care for people and their whanau,

• Best value for public health system resources[[7]] (see Figure 1).

Figure 1: The Triple Aim.

Improved clinician experience has been added to this.[[5]] This framework provides a better description of clinical practice than the HDC Code. The value of this framework has been illustrated by the COVID-19 pandemic. There have been many instances where the importance of individual care has been secondary to population health. The CS asserts that “in the end the need to gain consent cannot be set aside on the grounds of inadequate time or resource”. This runs counter to the aims of the quality framework, which involves balancing the competing priorities. This is a higher standard than achieved in either clinical or research practice. In clinical practice, consent is not required in emergencies with unconscious patients. In research, we would have no information about the use of pharmaceuticals during pregnancy if we insisted on the consent of the foetus.[[8]] Medical students would never attempt Cardio Pulmonary Resuscitation for the first time if consent was required.

Consent or agreement?

Consent implies a binary decision (consent or no consent) and that there is a choice. Consent, especially signed consent, occurs in a moment in time. Consent implies that the decision is solely that of the patient, and therefore that patient autonomy is prioritised.

This provides a sparse description of a consultation that does not acknowledge all the relational work involved. The Calgary–Cambridge guide to the medical consultation[[9]] is the framework we use to teach students consultation skills. The focus is on first gaining an agreed understanding of the presenting problem(s), followed by reaching agreement on a management plan. In clinical practice, if a detailed shared decision-making process is followed and an agreed management plan is developed, then consent at the end of that process is of less importance.

Consent for involvement with a conscious patient is an ongoing process. A signed consent for an intimate examination in a conscious patient is no longer relevant if the patient during the exam asks the student to stop. In their study of what affects a woman consenting to an intimate examination, Armitage[[10]] unsurprisingly found that:

“An association existed between being willing to be examined and whether the student had engaged with the woman by finding out what her presenting complaint was.”

If the student attends to whakawhanaungatanga,[[11]] building trust, and continues to ensure the patient’s comfort through the involvement, then consent for an intimate examination may not need to be so formal.

“Consent” implies that the decision is solely that of the patient, whereas “agreement” implies that the clinician has had input into the decision. This appropriately allows for issues of wise use of resources, equity and population health and clinician wellbeing to be factored into the decision.

Should student standards differ from standards for graduates?

Malpas et al.[[4]] noted that at the Auckland Medical School their guidelines require that patients give informed written consent for any sensitive examination performed by a medical student. As a clinician, I have never asked for written consent for a sensitive examination in a conscious patient. seeking such consent would seem to have limited value. For what reason are we asking students to do something that practicing clinicians do not do?

The CS says that “before becoming involved in any patient’s care, the consent of the patient must be obtained”. From the context this is referring to medical students, but it is true for all clinicians. Any interaction in healthcare requires the patient to agree, and the extent of focus on agreement will vary depending on circumstances. The greater the risk and inconvenience, the greater the focus; the greater the existing relationship of trust, perhaps lesser the focus. If the patient has made an appointment to see a clinician, consent for involvement is implicit and not formally required. Rather than asking students to seek consent for involvement in teaching/learning, we should be teaching students what we do in relation to obtaining agreement for involvement with patients. This varies from grudging acquiescence (the nurse wanting to do observations on a patient before the patient sees the doctor) through to simple agreement (“is it okay if I examine you now?”) to formal consent for major procedures.

Agreement for involvement is a much more useful concept than agreement for involvement in teaching/learning. Whilst there are instances where the student involvement is just teaching/learning, as students progress through the course they are increasingly involved in providing care, either by, for example, taking a more detailed history because they have more time, or being actively involved, such as taking blood samples or performing CPR. This case study by one of my fourth-year students is a clear example of student involvement making a significant difference to the outcome for the patient.[[12]]

Why do we require medical students to seek consent for patient involvement in learning if we do not require graduate doctors to seek consent in the same circumstances? The CS suggests that:

“The process by which consent is obtained can and should be proportional to the involvement of the medical student and the nature of the interaction and consequent risk or inconvenience to the patient”.

Risk and inconvenience are important, but they apply just as much to a graduate doctor learning to perform a procedure. Gawande[[13]] describes how he learned, and later taught, the insertion of a central line, and discusses the broad issue of how surgeons learn their trade. He describes how “learning as hidden behind drapes and anaesthesia and the elisions of language”. The risks and inconvenience incurred to patients as a result of involvement the of medical students are less than those resulting from the learning that Gawande describes. It may well be that practice in relation to consent for care by a training postgraduate doctor should be changed, but it makes no sense to have one set of standards for medical students and another for graduate doctors.

Ethical norms

In their book critiquing the use of the term “consent” in research and clinical practice, Manson and O’Neill criticised the term “consent” as being a metaphor for the process that highlights the element of choice but hides the transactional/communicative work that underlies reaching agreement. They pointed out that communication only succeeds within a rich practical and normative framework shared by speaker and audience, and where both parties adhere to and act in accordance with relevant communicative, epistemic and ethical norms. In chapter two, they argue that “consent” as a metaphor hides or downplays these essential aspects of communication.[[8]]

In referring to ethical norms, they use the term in the sense of descriptive ethics;[[14]] norms of understanding of what “right behaviour” is that are shared by the patient and clinician. For example, there is an accepted “ethical norm” outside of medicine that consent is not sought for teaching—the apprenticeship model. If you take your car to the mechanic, they will not ask whether you mind if the apprentice does some of the work. If you see your lawyer, they will not ask consent for the intern to do preparatory work on your document. Students learning to teach don’t ask for consent before conducting a lesson with children. This is part of the “normative framework”. The understanding is that the “senior” is responsible for the work, and that the work may be done by someone junior, including someone who is still learning. Implicitly, you agree to the team, led by the person with whom you reach agreement, providing the service you are expecting. The CS acknowledges that medical students learn in an apprenticeship model, but in requiring specific consent for medical student involvement, deviate from the usual expression of that model.

Culture

My hypothesis is that problems relating to consent for teaching represent different understandings of what right behaviour is, and that this varies according to cultural background.[[15]] At the time of the Cartwright Inquiry, the practice of medical students examining women under anaesthetic without telling them was the norm in Auckland Medical School, but also at the University of Otago, Wellington (personal experience) and probably with all medical training in New Zealand at the time. This was not the behaviour of rogue practitioners behaving badly, it reflected the cultural norms of medicine at the time. These were heavily male dominated and paternalistic. The culture in the wider society had moved towards a greater input from women and an expectation of more patient involvement in decisions. The culture of medicine was slow to adapt.

In the pluralist New Zealand society different communities may hold different ethical norms. I had a TPER from a Samoan student who described an interaction on a ward round where an older Samoan man was examined by the team. The team did not notice the extent of his embarrassment and clearly felt that their behaviour was appropriate. The student was very aware that the behaviour was culturally unsafe for this man and after the ward round went back to apologise to him. Arguably, all the cases that Malpas discusses in her study[[4]] are similar, where what the clinician thought was acceptable behaviour was unacceptable to the student, and possibly/probably for the patient, although without asking the patient we cannot know.

The CS is the ethical norm of those who wrote the statement. In the New Zealand setting, a norm such as this that makes no mention of what a Māori approach would be, is likely to be incomplete. The Hui process[[11]] describes a Māori approach to relating to patients that places much greater emphasis on relational work. “Consent” hides the relational work. For Pasifika, similarly, there would likely be a greater emphasis on the relationship and process given the importance of the concept of the Va:

“The Va or space that relates, is a tapu (sacred) space that connects and holds separate entities and things together in unity… Observing, nurturing and maintaining the sacred space[Va] and respecting relationships is thus pivotal to the fa’asamoa or Samoan way of life and living”[[16]]

In arguing that ethics is culture bound I am not suggesting that there is marked disagreement across cultures. I am arguing that different cultures weight the importance of the competing principles differently. The academic teachers of professionalism have prioritised the autonomy of the patient. The active clinicians put more weight on time constraints, the need for their juniors to learn and their own wellbeing. Māori and Pasifika put particular weight on the importance of the relationship. During a pandemic, judgements of what right behaviour is differ significantly from judgements made when public health issues are not so dominant. All these factors are important and in an ideal world would all be attended to in every interaction. In the real world, a judgement needs to be made in each instance as to what is possible.

Cultural safety

Cartwright identified a problem with consent for teaching. Despite 25 years of the HDC Code the problem identified persists. The CS suggests approaching this problem by a narrow focus on consent for student involvement and strengthening guidance documents. In my view, at the centre of the cases documented by Malpas’s students[[4]] is a problem of cultural dissonance. What the clinicians feel is right does not align with the view of those writing the CS, students and patients. This is a good example of a culturally unsafe interaction, and it may be that the best way to approach quality improvement in this area is to focus on cultural safety. The New Zealand Medical Council Statement says:

“Cultural safety focuses on the patient experience to define and improve the quality of care. It involves doctors reflecting on their own views and biases and how these could affect their decision-making and health outcomes for the patient”.[[17]]

This would lessen the focus on the gaining of consent and put more emphasis first on the quality of communication (for how else can you understand the patient experience?) and secondly on the views and biases of the doctors. Examples of inadequate consent are usually related to the clinician (or student) exerting power, often unconsciously, over a patient who is unable or unwilling to object. The statement further notes:

“Doctors inherently hold the power in the doctor-patient relationship and should consider how this affects both the way they engage with the patient and the way the patient receives their care. This is part of culturally safe practice”.[[17]]

An important feature of cultural safety is the concept that it can only be judged at each interaction, and whether an interaction was culturally safe is a judgement of the patient.

Conclusion

The requirement for consent for teaching came about due to the extreme case of teaching being imposed on anaesthetised women without their knowledge. In that setting formal consent is required.

Issues relating to conscious patients are inevitably interwoven with communication, trust and relationship.

Patients need to agree to the involvement of any clinician in their care. The degree of focus on that agreement will vary according to the expectations of the patient, the quality of the existing relationship, and the extent of risk or inconvenience. An interaction conducted in a culturally safe manner is likely to be satisfactory.

We need to focus on the overall quality of care, on the quadruple aim. The patient experience and improved quality, safety and experience of care is important, but so is improved health and equity for all populations, best value for public health system resources, and improved clinician experience. This means that in any setting a judgement needs to be made as to the best course, and that judgement will not be the same for all people. We should maintain a broad view of quality rather than a narrow focus on just patient experience. We should strengthen the emphasis on culturally safe care by paying attention to eliciting patient views, being cognisant of power imbalances and the effects of unconscious bias. Such an approach holds more promise in improving the care of patients when involved with students than strengthening codes of practice.

Summary

Abstract

Consent for teaching was introduced as a result of the Cartwright Inquiry and is part of the Health and Disability Code of Health and Disability Consumer Rights. A consensus statement developed by Otago and Auckland medical schools states that the need to gain consent cannot be set aside on the grounds of inadequate time or resource. This viewpoint argues that a singular focus on patient experience, whilst ignoring the other elements of the quality framework, is not appropriate. “Consent” is a poor word in most circumstances to describe the complex interaction with a patient over time. Rather than strengthening codes of behaviour, an approach of a broader view of the overall quality of the interaction and a focus on cultural safety holds more promise.

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Associate Professor Ben Gray: Primary Health Care and General Practice, University of Otago, Wellington. 0273314440.

Correspondence Email

Ben.gray@otago.ac.nz

Competing Interests

Nil.

1) Cartwright Sylvia. Report of the committee of inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters, http://www.moh.govt.nz/notebook/nbbooks.nsf/0/64D0EE19BA628E4FCC256E450001CC21?OpenDocument (1988, accessed 12/3/13).

2) The Code of Health and Disability Services Consumers' Rights. The Code of Health and Disability Services Consumers' Rights. New Zealand 1996.

3) Bagg W, Adams J, Anderson L, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. The New Zealand Medical Journal 2015;128: 27.

4) Malpas P J, Bagg W, Yielder J, et al. Medical students, sensitive examinations and patient consent: a qualitative review. NZ Med J 2018;131:29-37.

5) Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. The Annals of Family Medicine 2014;12:573-576.

6) Committee on Quality of Health Care in America. Crossing the Quality Chasm. Washington DC: National Academy Press, 2001.

7) Health Quality and Safety Commission. The Triple Aim, https://www.hqsc.govt.nz/our-programmes/building-leadership-and-capability/about-us/ (2018, 2021).

8) Manson N C and O'Neill Onora. Rethinking informed consent in bioethics. Cambridge University Press, 2007.

9) Silverman J, Kurtz S and Draper J. Calgary Cambridge guide to the medical interview - communication process. http://www.gp-training.net/training/communication_skills/calgary/calgary.pdf (1998, accessed 24/12/15).

10) Armitage A J and Cahill D J. Medical students and intimate examinations: What affects whether a woman will consent? Medical teacher 2018;40:1281-1286.

11) Lacey C, Huria T, Beckert L, et al. The Hui Process: a framework to enhance the doctor–patient relationship with Māori. Journal of the New Zealand Medical Association 2011;124.

12) Parry R, Jones B, Gray B, et al. Applying a Māori-centred consultation approach for engaging with Māori patients: an undergraduate medical student case study. Journal of Primary Health Care 2014; 6: 254-260.

13) Gawande A. Complications :a surgeon's notes on an imperfect science. 1st ed. ed. New York: Metropolitan Books, 2002, p.x,269.

14) Beauchamp T L and Childress J F. Principles of biomedical ethics. 7th ed. ed. New York: Oxford University Press, 2013, p.xvi,459.

15) Gray B. (Bio)Ethics in a Pluralistic Society. Challenges 2019;10:12.

16) Tiatia J. Commentary on ‘Cultural Diversity Across the Pacific’: Samoan Cultural Constructs of Emotion, New Zealand-Born Samoan Youth Suicidal Behaviours, and Culturally Competent Human Services. Journal of Pacific Rim Psychology 2012; 6: 75-79. Article. DOI: 10.1017/prp.2012.9.

17) Medical Council of New Zealand. Statement on Cultural Safety, https://www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf (2019, accessed 3/12/19).

For the PDF of this article,
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The issue of consent for student involvement with patient care was raised by the Cartwright Inquiry. Evidence was presented that medical students were required to perform vaginal examination on anaesthetised women without their knowledge or consent.[[1]] As a result of the Inquiry, the Code of Health and Disability Consumer Rights (HDC Code)[[2]] was established that includes rights on consent for teaching (Rights 5,6 and 7). There are concerns that this requirement is not being observed, and a Consensus Statement (CS) was developed by Auckland and Otago medical schools on informed consent for teaching.[[3]] Malpas et al. did a study based on a subset of reflective essays—“Ethics Reports”—that medical students had written that documented significant deviation from these recommendations.[[4]] They recommended further strengthening processes to ensure that the consensus is adhered to.

Like Auckland Medical School, Wellington campus-based University of Otago students write reflective pieces (called Thought Provoking Episode Reports (TPER)). I read over 100 every year, mostly from final year students. This paper is not based on a formal analysis of these reports, but they have significantly informed its development.

Summary of argument

In my view the CS is significantly flawed:

1. It is couched in ethical terms that prioritise patient autonomy. This is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[5]]

2. “Consent” as a term is too simplistic and hides all the relational elements that contribute to a patient agreeing to student involvement.

3. In requiring students to obtain consent for teaching, the recommendations are asking students to do something not required of graduate doctors. Whilst the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings.

4. My hypothesis is that ethics are culture bound so disagreements on ethical practice reflect different cultural views on what is right. In Malpas’s examples the views of those writing the CS conflicted with the practicing clinicians that students were exposed to. The concept of “cultural safety” is helpful in approaching this issue. The patient’s view of what is right is most important.

Patient autonomy and the quadruple aim

The HDC Code[[2]] was established in 1996 as a result of an inquiry into practice that significantly impinged on patient autonomy. The focus of the code is to protect patient autonomy, and the CS reflects the recommendations in the HDC Code. It is only in Section 3 of the HDC Code that other considerations of clinical circumstances and resource constraints are mentioned. Apart from the generic right referring to compliance to other law, there is no mention at all of decisions being affected by public health considerations.

The modern quality in healthcare movement was advanced by the US publication “Crossing the Quality Chasm” in 2001,[[6]] and the New Zealand Health Quality & Safety Commission was established in November 2010. Central to its work is the triple aim, a balance between:

• Improved health and equity for all populations,

• Improved quality, safety and experience of care for people and their whanau,

• Best value for public health system resources[[7]] (see Figure 1).

Figure 1: The Triple Aim.

Improved clinician experience has been added to this.[[5]] This framework provides a better description of clinical practice than the HDC Code. The value of this framework has been illustrated by the COVID-19 pandemic. There have been many instances where the importance of individual care has been secondary to population health. The CS asserts that “in the end the need to gain consent cannot be set aside on the grounds of inadequate time or resource”. This runs counter to the aims of the quality framework, which involves balancing the competing priorities. This is a higher standard than achieved in either clinical or research practice. In clinical practice, consent is not required in emergencies with unconscious patients. In research, we would have no information about the use of pharmaceuticals during pregnancy if we insisted on the consent of the foetus.[[8]] Medical students would never attempt Cardio Pulmonary Resuscitation for the first time if consent was required.

Consent or agreement?

Consent implies a binary decision (consent or no consent) and that there is a choice. Consent, especially signed consent, occurs in a moment in time. Consent implies that the decision is solely that of the patient, and therefore that patient autonomy is prioritised.

This provides a sparse description of a consultation that does not acknowledge all the relational work involved. The Calgary–Cambridge guide to the medical consultation[[9]] is the framework we use to teach students consultation skills. The focus is on first gaining an agreed understanding of the presenting problem(s), followed by reaching agreement on a management plan. In clinical practice, if a detailed shared decision-making process is followed and an agreed management plan is developed, then consent at the end of that process is of less importance.

Consent for involvement with a conscious patient is an ongoing process. A signed consent for an intimate examination in a conscious patient is no longer relevant if the patient during the exam asks the student to stop. In their study of what affects a woman consenting to an intimate examination, Armitage[[10]] unsurprisingly found that:

“An association existed between being willing to be examined and whether the student had engaged with the woman by finding out what her presenting complaint was.”

If the student attends to whakawhanaungatanga,[[11]] building trust, and continues to ensure the patient’s comfort through the involvement, then consent for an intimate examination may not need to be so formal.

“Consent” implies that the decision is solely that of the patient, whereas “agreement” implies that the clinician has had input into the decision. This appropriately allows for issues of wise use of resources, equity and population health and clinician wellbeing to be factored into the decision.

Should student standards differ from standards for graduates?

Malpas et al.[[4]] noted that at the Auckland Medical School their guidelines require that patients give informed written consent for any sensitive examination performed by a medical student. As a clinician, I have never asked for written consent for a sensitive examination in a conscious patient. seeking such consent would seem to have limited value. For what reason are we asking students to do something that practicing clinicians do not do?

The CS says that “before becoming involved in any patient’s care, the consent of the patient must be obtained”. From the context this is referring to medical students, but it is true for all clinicians. Any interaction in healthcare requires the patient to agree, and the extent of focus on agreement will vary depending on circumstances. The greater the risk and inconvenience, the greater the focus; the greater the existing relationship of trust, perhaps lesser the focus. If the patient has made an appointment to see a clinician, consent for involvement is implicit and not formally required. Rather than asking students to seek consent for involvement in teaching/learning, we should be teaching students what we do in relation to obtaining agreement for involvement with patients. This varies from grudging acquiescence (the nurse wanting to do observations on a patient before the patient sees the doctor) through to simple agreement (“is it okay if I examine you now?”) to formal consent for major procedures.

Agreement for involvement is a much more useful concept than agreement for involvement in teaching/learning. Whilst there are instances where the student involvement is just teaching/learning, as students progress through the course they are increasingly involved in providing care, either by, for example, taking a more detailed history because they have more time, or being actively involved, such as taking blood samples or performing CPR. This case study by one of my fourth-year students is a clear example of student involvement making a significant difference to the outcome for the patient.[[12]]

Why do we require medical students to seek consent for patient involvement in learning if we do not require graduate doctors to seek consent in the same circumstances? The CS suggests that:

“The process by which consent is obtained can and should be proportional to the involvement of the medical student and the nature of the interaction and consequent risk or inconvenience to the patient”.

Risk and inconvenience are important, but they apply just as much to a graduate doctor learning to perform a procedure. Gawande[[13]] describes how he learned, and later taught, the insertion of a central line, and discusses the broad issue of how surgeons learn their trade. He describes how “learning as hidden behind drapes and anaesthesia and the elisions of language”. The risks and inconvenience incurred to patients as a result of involvement the of medical students are less than those resulting from the learning that Gawande describes. It may well be that practice in relation to consent for care by a training postgraduate doctor should be changed, but it makes no sense to have one set of standards for medical students and another for graduate doctors.

Ethical norms

In their book critiquing the use of the term “consent” in research and clinical practice, Manson and O’Neill criticised the term “consent” as being a metaphor for the process that highlights the element of choice but hides the transactional/communicative work that underlies reaching agreement. They pointed out that communication only succeeds within a rich practical and normative framework shared by speaker and audience, and where both parties adhere to and act in accordance with relevant communicative, epistemic and ethical norms. In chapter two, they argue that “consent” as a metaphor hides or downplays these essential aspects of communication.[[8]]

In referring to ethical norms, they use the term in the sense of descriptive ethics;[[14]] norms of understanding of what “right behaviour” is that are shared by the patient and clinician. For example, there is an accepted “ethical norm” outside of medicine that consent is not sought for teaching—the apprenticeship model. If you take your car to the mechanic, they will not ask whether you mind if the apprentice does some of the work. If you see your lawyer, they will not ask consent for the intern to do preparatory work on your document. Students learning to teach don’t ask for consent before conducting a lesson with children. This is part of the “normative framework”. The understanding is that the “senior” is responsible for the work, and that the work may be done by someone junior, including someone who is still learning. Implicitly, you agree to the team, led by the person with whom you reach agreement, providing the service you are expecting. The CS acknowledges that medical students learn in an apprenticeship model, but in requiring specific consent for medical student involvement, deviate from the usual expression of that model.

Culture

My hypothesis is that problems relating to consent for teaching represent different understandings of what right behaviour is, and that this varies according to cultural background.[[15]] At the time of the Cartwright Inquiry, the practice of medical students examining women under anaesthetic without telling them was the norm in Auckland Medical School, but also at the University of Otago, Wellington (personal experience) and probably with all medical training in New Zealand at the time. This was not the behaviour of rogue practitioners behaving badly, it reflected the cultural norms of medicine at the time. These were heavily male dominated and paternalistic. The culture in the wider society had moved towards a greater input from women and an expectation of more patient involvement in decisions. The culture of medicine was slow to adapt.

In the pluralist New Zealand society different communities may hold different ethical norms. I had a TPER from a Samoan student who described an interaction on a ward round where an older Samoan man was examined by the team. The team did not notice the extent of his embarrassment and clearly felt that their behaviour was appropriate. The student was very aware that the behaviour was culturally unsafe for this man and after the ward round went back to apologise to him. Arguably, all the cases that Malpas discusses in her study[[4]] are similar, where what the clinician thought was acceptable behaviour was unacceptable to the student, and possibly/probably for the patient, although without asking the patient we cannot know.

The CS is the ethical norm of those who wrote the statement. In the New Zealand setting, a norm such as this that makes no mention of what a Māori approach would be, is likely to be incomplete. The Hui process[[11]] describes a Māori approach to relating to patients that places much greater emphasis on relational work. “Consent” hides the relational work. For Pasifika, similarly, there would likely be a greater emphasis on the relationship and process given the importance of the concept of the Va:

“The Va or space that relates, is a tapu (sacred) space that connects and holds separate entities and things together in unity… Observing, nurturing and maintaining the sacred space[Va] and respecting relationships is thus pivotal to the fa’asamoa or Samoan way of life and living”[[16]]

In arguing that ethics is culture bound I am not suggesting that there is marked disagreement across cultures. I am arguing that different cultures weight the importance of the competing principles differently. The academic teachers of professionalism have prioritised the autonomy of the patient. The active clinicians put more weight on time constraints, the need for their juniors to learn and their own wellbeing. Māori and Pasifika put particular weight on the importance of the relationship. During a pandemic, judgements of what right behaviour is differ significantly from judgements made when public health issues are not so dominant. All these factors are important and in an ideal world would all be attended to in every interaction. In the real world, a judgement needs to be made in each instance as to what is possible.

Cultural safety

Cartwright identified a problem with consent for teaching. Despite 25 years of the HDC Code the problem identified persists. The CS suggests approaching this problem by a narrow focus on consent for student involvement and strengthening guidance documents. In my view, at the centre of the cases documented by Malpas’s students[[4]] is a problem of cultural dissonance. What the clinicians feel is right does not align with the view of those writing the CS, students and patients. This is a good example of a culturally unsafe interaction, and it may be that the best way to approach quality improvement in this area is to focus on cultural safety. The New Zealand Medical Council Statement says:

“Cultural safety focuses on the patient experience to define and improve the quality of care. It involves doctors reflecting on their own views and biases and how these could affect their decision-making and health outcomes for the patient”.[[17]]

This would lessen the focus on the gaining of consent and put more emphasis first on the quality of communication (for how else can you understand the patient experience?) and secondly on the views and biases of the doctors. Examples of inadequate consent are usually related to the clinician (or student) exerting power, often unconsciously, over a patient who is unable or unwilling to object. The statement further notes:

“Doctors inherently hold the power in the doctor-patient relationship and should consider how this affects both the way they engage with the patient and the way the patient receives their care. This is part of culturally safe practice”.[[17]]

An important feature of cultural safety is the concept that it can only be judged at each interaction, and whether an interaction was culturally safe is a judgement of the patient.

Conclusion

The requirement for consent for teaching came about due to the extreme case of teaching being imposed on anaesthetised women without their knowledge. In that setting formal consent is required.

Issues relating to conscious patients are inevitably interwoven with communication, trust and relationship.

Patients need to agree to the involvement of any clinician in their care. The degree of focus on that agreement will vary according to the expectations of the patient, the quality of the existing relationship, and the extent of risk or inconvenience. An interaction conducted in a culturally safe manner is likely to be satisfactory.

We need to focus on the overall quality of care, on the quadruple aim. The patient experience and improved quality, safety and experience of care is important, but so is improved health and equity for all populations, best value for public health system resources, and improved clinician experience. This means that in any setting a judgement needs to be made as to the best course, and that judgement will not be the same for all people. We should maintain a broad view of quality rather than a narrow focus on just patient experience. We should strengthen the emphasis on culturally safe care by paying attention to eliciting patient views, being cognisant of power imbalances and the effects of unconscious bias. Such an approach holds more promise in improving the care of patients when involved with students than strengthening codes of practice.

Summary

Abstract

Consent for teaching was introduced as a result of the Cartwright Inquiry and is part of the Health and Disability Code of Health and Disability Consumer Rights. A consensus statement developed by Otago and Auckland medical schools states that the need to gain consent cannot be set aside on the grounds of inadequate time or resource. This viewpoint argues that a singular focus on patient experience, whilst ignoring the other elements of the quality framework, is not appropriate. “Consent” is a poor word in most circumstances to describe the complex interaction with a patient over time. Rather than strengthening codes of behaviour, an approach of a broader view of the overall quality of the interaction and a focus on cultural safety holds more promise.

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Associate Professor Ben Gray: Primary Health Care and General Practice, University of Otago, Wellington. 0273314440.

Correspondence Email

Ben.gray@otago.ac.nz

Competing Interests

Nil.

1) Cartwright Sylvia. Report of the committee of inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters, http://www.moh.govt.nz/notebook/nbbooks.nsf/0/64D0EE19BA628E4FCC256E450001CC21?OpenDocument (1988, accessed 12/3/13).

2) The Code of Health and Disability Services Consumers' Rights. The Code of Health and Disability Services Consumers' Rights. New Zealand 1996.

3) Bagg W, Adams J, Anderson L, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. The New Zealand Medical Journal 2015;128: 27.

4) Malpas P J, Bagg W, Yielder J, et al. Medical students, sensitive examinations and patient consent: a qualitative review. NZ Med J 2018;131:29-37.

5) Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. The Annals of Family Medicine 2014;12:573-576.

6) Committee on Quality of Health Care in America. Crossing the Quality Chasm. Washington DC: National Academy Press, 2001.

7) Health Quality and Safety Commission. The Triple Aim, https://www.hqsc.govt.nz/our-programmes/building-leadership-and-capability/about-us/ (2018, 2021).

8) Manson N C and O'Neill Onora. Rethinking informed consent in bioethics. Cambridge University Press, 2007.

9) Silverman J, Kurtz S and Draper J. Calgary Cambridge guide to the medical interview - communication process. http://www.gp-training.net/training/communication_skills/calgary/calgary.pdf (1998, accessed 24/12/15).

10) Armitage A J and Cahill D J. Medical students and intimate examinations: What affects whether a woman will consent? Medical teacher 2018;40:1281-1286.

11) Lacey C, Huria T, Beckert L, et al. The Hui Process: a framework to enhance the doctor–patient relationship with Māori. Journal of the New Zealand Medical Association 2011;124.

12) Parry R, Jones B, Gray B, et al. Applying a Māori-centred consultation approach for engaging with Māori patients: an undergraduate medical student case study. Journal of Primary Health Care 2014; 6: 254-260.

13) Gawande A. Complications :a surgeon's notes on an imperfect science. 1st ed. ed. New York: Metropolitan Books, 2002, p.x,269.

14) Beauchamp T L and Childress J F. Principles of biomedical ethics. 7th ed. ed. New York: Oxford University Press, 2013, p.xvi,459.

15) Gray B. (Bio)Ethics in a Pluralistic Society. Challenges 2019;10:12.

16) Tiatia J. Commentary on ‘Cultural Diversity Across the Pacific’: Samoan Cultural Constructs of Emotion, New Zealand-Born Samoan Youth Suicidal Behaviours, and Culturally Competent Human Services. Journal of Pacific Rim Psychology 2012; 6: 75-79. Article. DOI: 10.1017/prp.2012.9.

17) Medical Council of New Zealand. Statement on Cultural Safety, https://www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf (2019, accessed 3/12/19).

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The issue of consent for student involvement with patient care was raised by the Cartwright Inquiry. Evidence was presented that medical students were required to perform vaginal examination on anaesthetised women without their knowledge or consent.[[1]] As a result of the Inquiry, the Code of Health and Disability Consumer Rights (HDC Code)[[2]] was established that includes rights on consent for teaching (Rights 5,6 and 7). There are concerns that this requirement is not being observed, and a Consensus Statement (CS) was developed by Auckland and Otago medical schools on informed consent for teaching.[[3]] Malpas et al. did a study based on a subset of reflective essays—“Ethics Reports”—that medical students had written that documented significant deviation from these recommendations.[[4]] They recommended further strengthening processes to ensure that the consensus is adhered to.

Like Auckland Medical School, Wellington campus-based University of Otago students write reflective pieces (called Thought Provoking Episode Reports (TPER)). I read over 100 every year, mostly from final year students. This paper is not based on a formal analysis of these reports, but they have significantly informed its development.

Summary of argument

In my view the CS is significantly flawed:

1. It is couched in ethical terms that prioritise patient autonomy. This is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[5]]

2. “Consent” as a term is too simplistic and hides all the relational elements that contribute to a patient agreeing to student involvement.

3. In requiring students to obtain consent for teaching, the recommendations are asking students to do something not required of graduate doctors. Whilst the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings.

4. My hypothesis is that ethics are culture bound so disagreements on ethical practice reflect different cultural views on what is right. In Malpas’s examples the views of those writing the CS conflicted with the practicing clinicians that students were exposed to. The concept of “cultural safety” is helpful in approaching this issue. The patient’s view of what is right is most important.

Patient autonomy and the quadruple aim

The HDC Code[[2]] was established in 1996 as a result of an inquiry into practice that significantly impinged on patient autonomy. The focus of the code is to protect patient autonomy, and the CS reflects the recommendations in the HDC Code. It is only in Section 3 of the HDC Code that other considerations of clinical circumstances and resource constraints are mentioned. Apart from the generic right referring to compliance to other law, there is no mention at all of decisions being affected by public health considerations.

The modern quality in healthcare movement was advanced by the US publication “Crossing the Quality Chasm” in 2001,[[6]] and the New Zealand Health Quality & Safety Commission was established in November 2010. Central to its work is the triple aim, a balance between:

• Improved health and equity for all populations,

• Improved quality, safety and experience of care for people and their whanau,

• Best value for public health system resources[[7]] (see Figure 1).

Figure 1: The Triple Aim.

Improved clinician experience has been added to this.[[5]] This framework provides a better description of clinical practice than the HDC Code. The value of this framework has been illustrated by the COVID-19 pandemic. There have been many instances where the importance of individual care has been secondary to population health. The CS asserts that “in the end the need to gain consent cannot be set aside on the grounds of inadequate time or resource”. This runs counter to the aims of the quality framework, which involves balancing the competing priorities. This is a higher standard than achieved in either clinical or research practice. In clinical practice, consent is not required in emergencies with unconscious patients. In research, we would have no information about the use of pharmaceuticals during pregnancy if we insisted on the consent of the foetus.[[8]] Medical students would never attempt Cardio Pulmonary Resuscitation for the first time if consent was required.

Consent or agreement?

Consent implies a binary decision (consent or no consent) and that there is a choice. Consent, especially signed consent, occurs in a moment in time. Consent implies that the decision is solely that of the patient, and therefore that patient autonomy is prioritised.

This provides a sparse description of a consultation that does not acknowledge all the relational work involved. The Calgary–Cambridge guide to the medical consultation[[9]] is the framework we use to teach students consultation skills. The focus is on first gaining an agreed understanding of the presenting problem(s), followed by reaching agreement on a management plan. In clinical practice, if a detailed shared decision-making process is followed and an agreed management plan is developed, then consent at the end of that process is of less importance.

Consent for involvement with a conscious patient is an ongoing process. A signed consent for an intimate examination in a conscious patient is no longer relevant if the patient during the exam asks the student to stop. In their study of what affects a woman consenting to an intimate examination, Armitage[[10]] unsurprisingly found that:

“An association existed between being willing to be examined and whether the student had engaged with the woman by finding out what her presenting complaint was.”

If the student attends to whakawhanaungatanga,[[11]] building trust, and continues to ensure the patient’s comfort through the involvement, then consent for an intimate examination may not need to be so formal.

“Consent” implies that the decision is solely that of the patient, whereas “agreement” implies that the clinician has had input into the decision. This appropriately allows for issues of wise use of resources, equity and population health and clinician wellbeing to be factored into the decision.

Should student standards differ from standards for graduates?

Malpas et al.[[4]] noted that at the Auckland Medical School their guidelines require that patients give informed written consent for any sensitive examination performed by a medical student. As a clinician, I have never asked for written consent for a sensitive examination in a conscious patient. seeking such consent would seem to have limited value. For what reason are we asking students to do something that practicing clinicians do not do?

The CS says that “before becoming involved in any patient’s care, the consent of the patient must be obtained”. From the context this is referring to medical students, but it is true for all clinicians. Any interaction in healthcare requires the patient to agree, and the extent of focus on agreement will vary depending on circumstances. The greater the risk and inconvenience, the greater the focus; the greater the existing relationship of trust, perhaps lesser the focus. If the patient has made an appointment to see a clinician, consent for involvement is implicit and not formally required. Rather than asking students to seek consent for involvement in teaching/learning, we should be teaching students what we do in relation to obtaining agreement for involvement with patients. This varies from grudging acquiescence (the nurse wanting to do observations on a patient before the patient sees the doctor) through to simple agreement (“is it okay if I examine you now?”) to formal consent for major procedures.

Agreement for involvement is a much more useful concept than agreement for involvement in teaching/learning. Whilst there are instances where the student involvement is just teaching/learning, as students progress through the course they are increasingly involved in providing care, either by, for example, taking a more detailed history because they have more time, or being actively involved, such as taking blood samples or performing CPR. This case study by one of my fourth-year students is a clear example of student involvement making a significant difference to the outcome for the patient.[[12]]

Why do we require medical students to seek consent for patient involvement in learning if we do not require graduate doctors to seek consent in the same circumstances? The CS suggests that:

“The process by which consent is obtained can and should be proportional to the involvement of the medical student and the nature of the interaction and consequent risk or inconvenience to the patient”.

Risk and inconvenience are important, but they apply just as much to a graduate doctor learning to perform a procedure. Gawande[[13]] describes how he learned, and later taught, the insertion of a central line, and discusses the broad issue of how surgeons learn their trade. He describes how “learning as hidden behind drapes and anaesthesia and the elisions of language”. The risks and inconvenience incurred to patients as a result of involvement the of medical students are less than those resulting from the learning that Gawande describes. It may well be that practice in relation to consent for care by a training postgraduate doctor should be changed, but it makes no sense to have one set of standards for medical students and another for graduate doctors.

Ethical norms

In their book critiquing the use of the term “consent” in research and clinical practice, Manson and O’Neill criticised the term “consent” as being a metaphor for the process that highlights the element of choice but hides the transactional/communicative work that underlies reaching agreement. They pointed out that communication only succeeds within a rich practical and normative framework shared by speaker and audience, and where both parties adhere to and act in accordance with relevant communicative, epistemic and ethical norms. In chapter two, they argue that “consent” as a metaphor hides or downplays these essential aspects of communication.[[8]]

In referring to ethical norms, they use the term in the sense of descriptive ethics;[[14]] norms of understanding of what “right behaviour” is that are shared by the patient and clinician. For example, there is an accepted “ethical norm” outside of medicine that consent is not sought for teaching—the apprenticeship model. If you take your car to the mechanic, they will not ask whether you mind if the apprentice does some of the work. If you see your lawyer, they will not ask consent for the intern to do preparatory work on your document. Students learning to teach don’t ask for consent before conducting a lesson with children. This is part of the “normative framework”. The understanding is that the “senior” is responsible for the work, and that the work may be done by someone junior, including someone who is still learning. Implicitly, you agree to the team, led by the person with whom you reach agreement, providing the service you are expecting. The CS acknowledges that medical students learn in an apprenticeship model, but in requiring specific consent for medical student involvement, deviate from the usual expression of that model.

Culture

My hypothesis is that problems relating to consent for teaching represent different understandings of what right behaviour is, and that this varies according to cultural background.[[15]] At the time of the Cartwright Inquiry, the practice of medical students examining women under anaesthetic without telling them was the norm in Auckland Medical School, but also at the University of Otago, Wellington (personal experience) and probably with all medical training in New Zealand at the time. This was not the behaviour of rogue practitioners behaving badly, it reflected the cultural norms of medicine at the time. These were heavily male dominated and paternalistic. The culture in the wider society had moved towards a greater input from women and an expectation of more patient involvement in decisions. The culture of medicine was slow to adapt.

In the pluralist New Zealand society different communities may hold different ethical norms. I had a TPER from a Samoan student who described an interaction on a ward round where an older Samoan man was examined by the team. The team did not notice the extent of his embarrassment and clearly felt that their behaviour was appropriate. The student was very aware that the behaviour was culturally unsafe for this man and after the ward round went back to apologise to him. Arguably, all the cases that Malpas discusses in her study[[4]] are similar, where what the clinician thought was acceptable behaviour was unacceptable to the student, and possibly/probably for the patient, although without asking the patient we cannot know.

The CS is the ethical norm of those who wrote the statement. In the New Zealand setting, a norm such as this that makes no mention of what a Māori approach would be, is likely to be incomplete. The Hui process[[11]] describes a Māori approach to relating to patients that places much greater emphasis on relational work. “Consent” hides the relational work. For Pasifika, similarly, there would likely be a greater emphasis on the relationship and process given the importance of the concept of the Va:

“The Va or space that relates, is a tapu (sacred) space that connects and holds separate entities and things together in unity… Observing, nurturing and maintaining the sacred space[Va] and respecting relationships is thus pivotal to the fa’asamoa or Samoan way of life and living”[[16]]

In arguing that ethics is culture bound I am not suggesting that there is marked disagreement across cultures. I am arguing that different cultures weight the importance of the competing principles differently. The academic teachers of professionalism have prioritised the autonomy of the patient. The active clinicians put more weight on time constraints, the need for their juniors to learn and their own wellbeing. Māori and Pasifika put particular weight on the importance of the relationship. During a pandemic, judgements of what right behaviour is differ significantly from judgements made when public health issues are not so dominant. All these factors are important and in an ideal world would all be attended to in every interaction. In the real world, a judgement needs to be made in each instance as to what is possible.

Cultural safety

Cartwright identified a problem with consent for teaching. Despite 25 years of the HDC Code the problem identified persists. The CS suggests approaching this problem by a narrow focus on consent for student involvement and strengthening guidance documents. In my view, at the centre of the cases documented by Malpas’s students[[4]] is a problem of cultural dissonance. What the clinicians feel is right does not align with the view of those writing the CS, students and patients. This is a good example of a culturally unsafe interaction, and it may be that the best way to approach quality improvement in this area is to focus on cultural safety. The New Zealand Medical Council Statement says:

“Cultural safety focuses on the patient experience to define and improve the quality of care. It involves doctors reflecting on their own views and biases and how these could affect their decision-making and health outcomes for the patient”.[[17]]

This would lessen the focus on the gaining of consent and put more emphasis first on the quality of communication (for how else can you understand the patient experience?) and secondly on the views and biases of the doctors. Examples of inadequate consent are usually related to the clinician (or student) exerting power, often unconsciously, over a patient who is unable or unwilling to object. The statement further notes:

“Doctors inherently hold the power in the doctor-patient relationship and should consider how this affects both the way they engage with the patient and the way the patient receives their care. This is part of culturally safe practice”.[[17]]

An important feature of cultural safety is the concept that it can only be judged at each interaction, and whether an interaction was culturally safe is a judgement of the patient.

Conclusion

The requirement for consent for teaching came about due to the extreme case of teaching being imposed on anaesthetised women without their knowledge. In that setting formal consent is required.

Issues relating to conscious patients are inevitably interwoven with communication, trust and relationship.

Patients need to agree to the involvement of any clinician in their care. The degree of focus on that agreement will vary according to the expectations of the patient, the quality of the existing relationship, and the extent of risk or inconvenience. An interaction conducted in a culturally safe manner is likely to be satisfactory.

We need to focus on the overall quality of care, on the quadruple aim. The patient experience and improved quality, safety and experience of care is important, but so is improved health and equity for all populations, best value for public health system resources, and improved clinician experience. This means that in any setting a judgement needs to be made as to the best course, and that judgement will not be the same for all people. We should maintain a broad view of quality rather than a narrow focus on just patient experience. We should strengthen the emphasis on culturally safe care by paying attention to eliciting patient views, being cognisant of power imbalances and the effects of unconscious bias. Such an approach holds more promise in improving the care of patients when involved with students than strengthening codes of practice.

Summary

Abstract

Consent for teaching was introduced as a result of the Cartwright Inquiry and is part of the Health and Disability Code of Health and Disability Consumer Rights. A consensus statement developed by Otago and Auckland medical schools states that the need to gain consent cannot be set aside on the grounds of inadequate time or resource. This viewpoint argues that a singular focus on patient experience, whilst ignoring the other elements of the quality framework, is not appropriate. “Consent” is a poor word in most circumstances to describe the complex interaction with a patient over time. Rather than strengthening codes of behaviour, an approach of a broader view of the overall quality of the interaction and a focus on cultural safety holds more promise.

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Associate Professor Ben Gray: Primary Health Care and General Practice, University of Otago, Wellington. 0273314440.

Correspondence Email

Ben.gray@otago.ac.nz

Competing Interests

Nil.

1) Cartwright Sylvia. Report of the committee of inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters, http://www.moh.govt.nz/notebook/nbbooks.nsf/0/64D0EE19BA628E4FCC256E450001CC21?OpenDocument (1988, accessed 12/3/13).

2) The Code of Health and Disability Services Consumers' Rights. The Code of Health and Disability Services Consumers' Rights. New Zealand 1996.

3) Bagg W, Adams J, Anderson L, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. The New Zealand Medical Journal 2015;128: 27.

4) Malpas P J, Bagg W, Yielder J, et al. Medical students, sensitive examinations and patient consent: a qualitative review. NZ Med J 2018;131:29-37.

5) Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. The Annals of Family Medicine 2014;12:573-576.

6) Committee on Quality of Health Care in America. Crossing the Quality Chasm. Washington DC: National Academy Press, 2001.

7) Health Quality and Safety Commission. The Triple Aim, https://www.hqsc.govt.nz/our-programmes/building-leadership-and-capability/about-us/ (2018, 2021).

8) Manson N C and O'Neill Onora. Rethinking informed consent in bioethics. Cambridge University Press, 2007.

9) Silverman J, Kurtz S and Draper J. Calgary Cambridge guide to the medical interview - communication process. http://www.gp-training.net/training/communication_skills/calgary/calgary.pdf (1998, accessed 24/12/15).

10) Armitage A J and Cahill D J. Medical students and intimate examinations: What affects whether a woman will consent? Medical teacher 2018;40:1281-1286.

11) Lacey C, Huria T, Beckert L, et al. The Hui Process: a framework to enhance the doctor–patient relationship with Māori. Journal of the New Zealand Medical Association 2011;124.

12) Parry R, Jones B, Gray B, et al. Applying a Māori-centred consultation approach for engaging with Māori patients: an undergraduate medical student case study. Journal of Primary Health Care 2014; 6: 254-260.

13) Gawande A. Complications :a surgeon's notes on an imperfect science. 1st ed. ed. New York: Metropolitan Books, 2002, p.x,269.

14) Beauchamp T L and Childress J F. Principles of biomedical ethics. 7th ed. ed. New York: Oxford University Press, 2013, p.xvi,459.

15) Gray B. (Bio)Ethics in a Pluralistic Society. Challenges 2019;10:12.

16) Tiatia J. Commentary on ‘Cultural Diversity Across the Pacific’: Samoan Cultural Constructs of Emotion, New Zealand-Born Samoan Youth Suicidal Behaviours, and Culturally Competent Human Services. Journal of Pacific Rim Psychology 2012; 6: 75-79. Article. DOI: 10.1017/prp.2012.9.

17) Medical Council of New Zealand. Statement on Cultural Safety, https://www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf (2019, accessed 3/12/19).

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