The complexity of chaperoning  

The use of chaperones for intimate examinations can present ethical and practical dilemmas 

I can recall standing in an outpatient room as a medical student, chaperoning the consultant surgeon who was carrying out a rectal examination on a female patient. It was a long time ago, but I remember not fully grasping why I had been brought into the room by the nurse running the clinic.

Nowadays, there is still limited guidance available for chaperones setting out what their role is, what they are being asked to observe, and their responsibilities to the patient. Chaperoning is primarily about the patient’s right to dignity and respect during a physical examination where they are being asked to remove their underwear.

A common misconception is that chaperones need only be offered to female patients, or even only to young female patients. Patients of any gender or any age are likely to feel uncomfortable during an intimate examination, so offering a chaperone to all patients recognises the inherent vulnerability of every patient in this situation.

Doctors are also vulnerable during an unwitnessed intimate examination. They risk their actions or words during the examination being misinterpreted by the patient who may be feeling a hundred different emotions at the time. The presence of a chaperone as a witness, who is aware of their duty to the patient, is a measure of protection for the doctor.

When considering having a chaperone present with a patient, it is important that the role of the chaperone is explained to the patient, and their consent is requested for the presence of this additional person. Patients should also be told that they can decline the chaperone proposed by the doctor and choose someone else to act in the role.

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (ninth edition, 2024) states: “A chaperone can act as a safeguard for both the doctor and the patient during an intimate examination. You should ask the patient if they would like a chaperone to be present and record their wishes.”

A more difficult question to answer is whether the patient ought to be informed if there is a specific reason for a doctor asking for their agreement to have a chaperone present; for example, if a doctor has restrictions on their professional licence due to previous concerns about their conduct during physical examinations.

Patients should be informed of any risk that is material to their care or likely to impact on their decision to accept care from a healthcare professional. A risk was defined by the UK Supreme Court as ‘material’, if a reasonable person in the patient’s position would be likely to attach significance to it. When a restriction is applied to a doctor’s practice, it is generally to mitigate a question raised about a risk to patient safety.

The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 section 8(2)(d) makes provision for “the application of knowledge about a health service, which is required for the purposes of patient safety and avoiding, lessening, or eradicating the repetition of such an incident”. This has not been tested yet in the context of a health system which has knowledge about restrictions due to previous incidents.

It is not yet clear whether this provision in the Act would be interpreted by the courts to mean that patients have a right to be informed of restrictions on practice; for example, if a doctor is not permitted to physically examine children, or if the Act and the HSE open disclosure policy applies only to patients affected in past incidents. It is clear, however, that patients are front and centre and should be treated as partners in the decision-making process regarding their treatment and care. As this new legislation beds into our health system, it will be important to monitor how it is applied to the issue of chaperoning, among a myriad of other patient safety considerations. 

But back to the chaperone, be they a nurse, healthcare assistant, intern or medical student. What are their responsibilities in this role? Currently, the role of chaperone is not regulated and how each case would be viewed would turn on its individual details. Healthcare staff acting as chaperones are in the invidious position where they feel a duty to help by acting as chaperones, but risk exposing themselves to criticism from the patient, their employer, and beyond.

If I were catapulted back in time to be a medical student again, I would ask questions about the information provided to the patient, the context of any intimate examination and request for a chaperone, and my individual duty to that patient.