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Consent in a society of mind

I hold consent as something pretty close to a Fundamental Good Thing. I absorbed it first from nursing culture, along with a few other deontological, maybe-incoherent principles like ‘Autonomy’ and ‘Dignity.’ (I’m not sure how to define dignity, except that my brain screams at me when it sees an example of it being violated). Then I absorbed consent as a Fundamental Good Thing from the social justice community, too.

And it is a good thing. There’s no doubt about that. So many of the ways in which humans hurt one another are because consent isn’t taken seriously, and taking it seriously does make a difference. This is one of the things that it’s great to have a word for.

It’s also kind of complicated.

A few months ago, I had my first PAP smear. I’m sure these aren’t fun for anyone, but as someone with pretty severe vaginismus, I’d been putting it off, and dreading it, for years. As a nurse, though, I can appreciate the importance of public health screening measures. No one likes prostate exams, either, but they’re Recommended.

I called my doctor’s office, booked the appointment, and went in of my own free will–I gave my consent for the procedure, explicitly and implicitly. I told my family doctor, who I like and trust, to keep going even if I was screaming, which I probably would be, because I really wanted to just get it over with.

It still felt really fucking awful, and I was actually mad at her, afterwards. I’d been screaming in pain and she hadn’t stopped. The part of me that was mad didn’t care that I’d asked her not to.

“Personhood” and unitary selves

At first glance, my PAP-smear reaction doesn’t make any sense. The explaining factor is that I don’t speak for all of myself. Having a unitary ‘self’ at all is an abstraction, a simplification over the various drives and desires and inconsistent preferences that make up a human being.

As Melting Asphalt writes:

A person (as such) is a social fiction: an abstraction specifying the contract for an idealized interaction partner. Most of our institutions, even whole civilizations, are built to this interface — but fundamentally we are human beings, i.e., mere creatures. …Even the most ironclad person among us will find herself the occasional subject of an outburst or breakdown that reveals what a leaky abstraction her personhood really is.

I have mixed feelings about this article, but I think it says something important. Society–including laws and norms about consent–runs on the assumption that humans have unitary selves, singular agency. A lot of the time, that model works. And the medical field’s laws and norms about consent also have a way to handle humans who don’t and can’t hold up their end of the “personhood contract” and aren’t able to offer their informed consent; young children, psychotic patients, comatose patients, suicidal patients. Thus: power of attorney, substitute decision makers, “Form One” and forced hospitalization, “assumed consent” to treatment for anyone found unconscious. And there are new norms in the making for general society, like the norm that intoxicated people can’t consent to sex.

Ultimately, though, those are exceptions, special cases. Medicine, and society as a whole, assume that there exists a baseline population who can give their informed consent, who can speak for themselves as unitary agents.

But no one is a unitary agent. We are all societies of mind–more or less coherent, more or less unified.

I don’t want to die of cervical cancer that was diagnosed too late. I’m pretty clear on that, and I’m also pretty sure that five minutes of pain once every several years is worth it. I can do the math–or, at least, the ‘I’ that speaks for me understands math. But I can’t bring all the parts of myself on board with this. The part of me that doesn’t want anything or anyone anywhere near my vagina is…well, not convinced by math, probably not capable of math, and also doesn’t give a shit about reasonable explanations.

Grey areas in consent

I take care of a lot of patients whose “personhood” is somewhat broken down. There’s a continuum here. On the bottom end, I’ve got my intubated, sedated, critically ill patients, who basically can’t communicate any preferences at all, aside from squirming or making faces or trying to pull tubes out. Taking care of them is a bit like having an infant. I don’t feel bad about tying their hands down. I don’t ask them if/when they want to be turned or cleaned or suctioned. I do my best to explain what’s going on.

Midway up the scale, I’ve got patients who are awake and able to talk to me, but might be forgetful or confused or delirious. I hate tying awake patients’ hands, because BASIC HUMAN DIGNITY!!!, but if they’ve pulled out their feeding tube more than twice, or if they really need their oxygen but keep taking it off, I am going to do it. I try to listen to their preferences in other ways, and give them choices, like ‘which side do you want to turn on?’, but ultimately it’s kind of a token effort–I do it to try to comfort them, to make the loss of autonomy slightly less bad.

There’s a converse to this. I don’t hold my patients to the same standard that I would a coworker. If they’ve pulled their feeding tube out for the third time, I do my very, very best not to show any frustration or annoyance. In some sense, ‘it’s not their fault.’ When delirious patients yell swearwords at me, I politely tell them to please stop, but I’m not upset.

After my PAP-smear experience, I went back to work and felt like I was seeing things for the first time. In my doctor’s office, on the exam table, my illusion of singular agency broke down. I left feeling violated and traumatized, even though it was five minutes of discomfort that I’d undertaken voluntarily for a benefit that I thought was worth it.

Most of my patients consented to treatment at some point, unless they came into the ER unconscious with no previous directives. We’re pretty good about, for example, respecting patients’ decisions not to be intubated, not to receive CPR, not to receive dialysis or blood transfusions etc etc etc.

But even for the patients who, at the beginning, consented to “take all reasonable measures to keep me alive”…at some point, a couple of days down the road, they’re loopy on drugs and have a tube down their throat and their hands tied to the bedrails – and when this happens, the part of them that can do math is probably on vacation and the rest of them is screaming.

Ozy writes:

Our culture is really really bad about dealing with sex that you gave permission for but that is still experienced as violating or even traumatizing. Sex where you dissociate to get through it; sex that makes you feel like an object, an orifice being used, rather than a participant; sex where you feel gross and cry afterward and scrub yourself because you don’t want to have had it.

Sex might not be a special case. I kind of feel like our society is bad at dealing with all experiences that were consented to but still traumatizing–that were consented to, but not with all the parts of the mind. Maybe because a society is, basically, a charade where humans put on their “person”-faces and do their best to present as singular agents.

And then what?

If there’s a solution to this, it’s probably a complicated and many-faceted one.

Anecdote: I had a patient recently who refused to be turned. She had an infected bedsore, and it was important that we turn her, but she was afraid of falling out of bed. I think she knew it wasn’t a rational fear; she was a bit self-deprecating about it. But she flat-out refused. She was all there, “alert and oriented” in medical-speak, and so I wasn’t going to do it against her will.

But I did ask her if she thought that, if I asked the doctor to order more medications to control her anxiety, and they were effective, whether maybe then she would agree to turn. She said “maybe, I think so.”

(I ended up turning her at 4 am after I’d given her Gravol for nausea, which made her very drowsy. I felt a little bit bad about that–it was sneaky–but she wasn’t panicking while I did it, at least.)

I had strongly considered asking my family doctor if she could do my PAP smear under conscious sedation. I ended up not asking because it would be inconvenient–I wouldn’t be able to bike home unaccompanied afterwards. But it would have appeased the part of me that was upset about it.

Sometimes, changing societal norms will make there be fewer conflicts. Ozy writes about the societal norm of ‘compulsory sexuality'; changing this, making it more acceptable and normal and okay not to want sex, might take off some of the pressure to consent to it. There are societal norms that would make my job easier, too–I’ve had my fair share of patients who wanted to be tough and thus wouldn’t ever say when they were in pain, or who were ashamed of all their bodily functions.

Sometimes, the only option is to very carefully try to listen to and address all of the parts, whether you’re doing it for yourself or for another person.