Question of ethics..?

[truffle]

On one hand, selection process should not be based on race, ethnicity, gender, religious background etc. Put it this way, if these criteria are used during selection process, then what prevents certain school to only select certain population not others? You may have in your hand allegations regarding to profiling. On the other hand, there is a need for greater representation of minority physicians in the community. Especially for the multi-cultural landscape of Canada, many people would feel more comfortable with doctors who can speak their native language and understand their cultural concerns. As it stands right now, the representation of those minority groups in the medical profession does not match their representation in the population. So the key is to maintain a balance, in that consideration should be given, but not to the point it jeopardize the integrity and overall objectiveness of the selection process. Keep in mind that the goal of the medical profession is ultimately to best serve the community's need.

 

okay i like your argument for a balance.

[truffle]

For example, women with a history of hypertension are still eligible for IVF although the risk of pre-eclampsia and a plethora of other health issues is much greater.

this is a good one. i'm not too sure about the details of IVF for hypertensive women. are only mildly hypertensive women eligible? or even moderately and severely hypertensive women also eligible? do you mind elaborating?

 

i think it all depends on a balance between the patient's wish and a reasonably low risk. and i don't think it's much of a matter of agism and sexism. the differential treatment between the sexes on the basis of age is mostly dictated by the biological differences between the sexes. men do not get pregnant. and in our consideration of the case, we should differentiate between active intervention and withholding active intervention. active intervention by doctors should not lead to harm for the patient. while a doctor can refuse active treatment if it's deemed unnecessary or too risky.

 

in trudeau's case, the risk for him or his baby is not tremendous. and besides, i don't think he used in vitro fertilization which is an active intervention. (i may be wrong). doctors should do no harm through their intervention, but when things just happened (like natural fertilization), they can't be blamed.

i think a better example would be celine dion and her husband who did use in vitro fertilization. (he was older and had testicular cancer or something). but still in that case the risk for all 3 parties involved wasn't tremendous (baby, mother and father).

 

Even in high risk pregnancies, women cannot be forced to deliver their baby in hospital, despite the clear risk of complications.

 

forcing would be an active action. doctors should not actively do harm/actively limit people's autonomy and rights.

 

in the 60 yo woman's case, the canadian doctors refused an active intervention that may lead to significant harm to her and her future baby (the baby only matters after birth). they didn't actively do harm. and they didn't limit the woman's reproductive rights because at her age they can't be assumed. maybe they did infringe her autonomy a bit, but IVF is kind of irresponsible.

[silvermen85]

you have some good points, but IMO your argument applies more when patients refuse treatments.

even if she understands the risks of having a child at 60, doctors can refuse her request because 1) doctors should not actively do harm and giving her embryos would be doing active harm, 2) doctors should not refuse treatment but she doesn't strongly need any treatment except for psychological reasons, but this can be offset by physical harm.

yeah she has her reproductive rights, but in vitro fertilization is a medical intervention that enhances people's chances. not giving her in vitro fertilization IMO is not an infringement of her reproductive rights, but only deprives her of possible enhanced chances. also, a woman in her situation (60 yo) cannot be reasonably expected to have kids naturally, so her reproductive rights cannot be assumed (it's like nature taking away her rights already).

 

 

 

i am aware of this, but my argument was based on health risks to the baby and medical costs after birth. you can argue that the patient of the fertility doctors is the woman, and the baby after birth likely won't be their patient. this only weakens my argument, but doesn't refute it.

 

abortion is not a similar issue. under canadian laws, abortion is like removing an unwanted growth on your body (e.g. corn on your foot, benign cyst in your ovary). (i'm just saying this for comparison's sake, not because it's my personal opinion. and i hope i'm not offending anyone). this definitely is not equal to in vitro fertilization.

 

abortion doesn't have a high risk of harming the mother, whereas in vitro fertilization can harm the mother who is 60 yo. abortion leads to a dead fetus, who is not a patient. in vitro fertilization can lead to live babies, who can become patients.

 

I agree with you that as a doctor they should not provide IVF to the 60 yo patient if they clearly believe the risks involved is greater than the benefit. Physicians are under no legal obligation to provide non-emergency services to patients which they believe are unethical. Like abortion, despite it is legal in Canada, many physicians would refuse to perform the service due to their moral/ethical belief. This is totally acceptable as long as they make it clear to the patient their refusal is based on the ground other than gender/race/religious view. I don't know if IVF for woman over certain age or with certain risk factors are legally banned in Canada. If not, then it is totally in the discretion of the physician. Keep in mind that you may argue it is natural that a 60 yo woman doesn't have baby and she can live happily as is, but then that is assume all patient should have the same/similar concept of quality of life as the physician.

 

It is perhaps best to argue that the physician can provide additional consultation to the patient and family and the alternative to IVF that can fulfill the patient's desire to become a mother such as adoption. Emphasis on communication and mediation.

[japlanet]

your argument is quite easy to refute.

 

if your claim stands, then it's unethical:

- for med schools to give preferential consideration to applicants of aboriginal descent

- for any university program to give preferential consideration to people of aboriginal descent, or disadvantaged groups (e.g. harvard has this summer research program that favours african americans and latinos because there aren't enough of them in science)

- for any university to offer scholarships preferentially to disadvantaged individuals

- for companies to advertise for jobs in the southern parts of canada, when the jobs are in northern parts of canada (i.e. anyone who wants the job must move to northern canada)

- etc. etc.

 

it's one thing to force everyone to work in rural areas after graduation, it's another thing to give preference in the admission process to people who are more likely to work in rural areas. the first action is an infringement of people's liberty. the second action gives some opportunity for everyone to study medicine. it is totally allowable because medical care is still in some aspects an industry where supply and demand should ideally be matched.

 

I follow your first three points, and I agree that these programs are equally questionable. They may be 'ethical' based on past wrongs etc, but they certainly aren't 'fair.'

 

As for your fourth point, I'm not sure if I follow as to how it is related to the first three.

 

As for the argument that it "gives some opportunity for everyone to study medicine," I disagree because it doesn't give everyone an opportunity, it gives highly qualified applicants from anywhere, and less-qualified applicants from certain places an opportunity. I'm not sure about the ethics of that, but I certainly wouldn't consider it 'fair.'

 

As for the concept of certain groups being 'underrepresented' in certain fields, I agree that argument has merit when discussing the fact that people of certain ethnicities may be more comfortable having a physician of the same ethnicity, but I fail to see how why it is somehow considered ideal for every group to be equally represented in any occupation. It may be by chance that there simply isn't an even distribution of interest or ability over all groups.

 

That said, I think all admissions etc should be done on the basis of ability etc and have nothing else have any bearing. If there are inequalities in opportunities between groups, every effort should be made to correct these, but preferential admissions programs cast too wide a net and are not effective (i.e. why accept the Latino child of two researchers into your summer program over the white child of a waitress).

[truffle]

i used the 4th example because i was likening the health care field to an industry.

 

 

I'm not sure about the ethics of that, but I certainly wouldn't consider it 'fair.'

with regard to disadvantaged groups, please stop thinking only within the scope of the medical school admission process, or the scope of medicine, just for one second. if a certain social/ethnic group is disadvantaged, don't the more privileged groups have an obligation to help their brothers out? don't we have an obligation to help out the homeless, low-income, etc.? right now there's a cholera epidemic in Zimbabwe, should the more privileged nations say "screw them"?

inequality in income, rights and freedoms, and privileges in general breeds conflict and even more inequality. (when the people at the top are mostly of the privileged groups, of course the opinions of these groups would be better represented). this is why canada redistributes privileges through universal health care, welfare, and so on. and this is why i'm proud to be a canadian.

 

i live in toronto right now and don't get any brownie points with rural medicine. what i do is suck up and improve my competitiveness. maybe if the preferential treatment were unreasonably tilted toward rural applicants, i'd whine about it. but i'm not whining now.

i'd do the same if i were white and both my parents had a degree and my family's income were >$100,000. and i advise everybody to suck up and work harder.

 

one more point: even if people from rural areas don't return there to work, they can be advocates for rural medicine. if too many urban people became doctors, rural areas may be even more screwed over.

 

 

i was only giving one example with the harvard program (i saw it online the other day). people from low-income families, whose parents don't have university degrees or are wards of the state generally get nice perks in the university system, whether they are white or latino.

[japlanet]

 

i live in toronto right now and don't get any brownie points with rural medicine. what i do is suck up and improve my competitiveness. maybe if the preferential treatment were unreasonably tilted toward rural applicants, i'd whine about it. but i'm not whining now.

i'd do the same if i were white and both my parents had a degree and my family's income were >$100,000. and i advise everybody to suck up and work harder.

 

one more point: even if people from rural areas don't return there to work, they can be advocates for rural medicine. if too many urban people became doctors, rural areas may be even more screwed over.

 

 

I don't think that we shouldn't help those who are disadvantaged, I think that certainly we should do everything in our power to help people improve their situations. What I *don't* think we should do (and I'm referring specifically to admissions, because this is what we are talking about) is accept people into competitive programs who by all objective standards, shouldn't be there, except that they came from a certain area etc.

 

I'm from an underserviced, rural community and my parents are not wealthy. But because I'm not up North and not in a region near an university, there are no programs to attract doctors to our area.

 

And, so, I do suck it up. I worked hard all through university and have a 3.96 GPA while working 2 part time jobs, and I will pay my own way through medical school so that I can go back and help out the people I grew up with.

 

Meanwhile, I have friends applying to NOSM with a 3.6 GPA but since they are from up North they have a good shot in getting in, but who hate it up North and love the GTA and have absolutely no intention of going back.

 

So, no, I don't think it's 'fair.'

[truffle]

I don't think that we shouldn't help those who are disadvantaged, I think that certainly we should do everything in our power to help people improve their situations. What I *don't* think we should do (and I'm referring specifically to admissions, because this is what we are talking about) is accept people into competitive programs who by all objective standards, shouldn't be there, except that they came from a certain area etc.

 

I'm from an underserviced, rural community and my parents are not wealthy. But because I'm not up North and not in a region near an university, there are no programs to attract doctors to our area.

 

And, so, I do suck it up. I worked hard all through university and have a 3.96 GPA while working 2 part time jobs, and I will pay my own way through medical school so that I can go back and help out the people I grew up with.

 

Meanwhile, I have friends applying to NOSM with a 3.6 GPA but since they are from up North they have a good shot in getting in, but who hate it up North and love the GTA and have absolutely no intention of going back.

 

So, no, I don't think it's 'fair.'

 

i think having undeserving individuals admitted is a flaw of the administration of the admission process, not of the philosophy of helping out rural areas. i might get flamed for saying this, but i know of this uoft med student who wore a ton of perfume to her clerkship, refused to touch the patients because she thought they were gross and just sat there fiddling with her hair (i was a volunteer there). i'm only giving this example to illustrate the point that undeserving individuals get admitted all the time to every school, whether it's because of school policies or they are just really good actors. (i might get flamed for this too).

i'm pretty sure med schools have tallied up the numbers of students from different areas and calculated the %s of these who ultimately chose rural medicine. and the % for people from rural areas is significantly higher than people from non-rural areas. hence the schools screw a few deserving individuals over in favor of the evidence in the general trend and %s.

 

what i think should happen is a better system for recognizing people who are interested in rural medicine.

 

as for underrepresented groups, these should continue to receive some preferential treatment, but nothing too unreasonable.

[rmorelan]

i'm pretty sure med schools have tallied up the numbers of students from different areas and calculated the %s of these who ultimately chose rural medicine. and the % for people from rural areas is significantly higher than people from non-rural areas. hence the schools screw a few deserving individuals over in favor of the evidence in the general trend and %s.

 

Indeed they have, and indeed rural students have a greater chance to return to rural areas. A significantly higher chance actually.

 

Frankly I think they are desperately trying to find a way to help a very large and unserviced part of our population, without spending any more money (which they don't have to spend). There is a huge socialital issue here - the canadian health act forces (and rightly so) reasonable access to care for all individuals. If for no other reason they are required by law to find a way.

 

and none of us are going to like any of the answers to solving the problem. If you cannot spend money on it you have to either do some seleciton bias, force people to go there, or create a big advertising campaign to push the rural medicine case. The latter has been used quite a bit actually, but I think for many reasons many/most? med students just don't want to go there and we are people who don't fall for advertising easily

 

The long term solution would be to open up many, many more med school slots and residency positions- I will be over here holding my breath on that one

[Halcyon]

Indeed they have, and indeed rural students have a greater chance to return to rural areas. A significantly higher chance actually.

 

Frankly I think they are desperately trying to find a way to help a very large and unserviced part of our population, without spending any more money (which they don't have to spend). There is a huge socialital issue here - the canadian health act forces (and rightly so) reasonable access to care for all individuals. If for no other reason they are required by law to find a way.

 

and none of us are going to like any of the answers to solving the problem. If you cannot spend money on it you have to either do some seleciton bias, force people to go there, or create a big advertising campaign to push the rural medicine case. The latter has been used quite a bit actually, but I think for many reasons many/most? med students just don't want to go there and we are people who don't fall for advertising easily

 

The long term solution would be to open up many, many more med school slots and residency positions- I will be over here holding my breath on that one

 

As one of these crazy pre-meds that wants to go into rural medicine, I don't think we get that much extra special treatment. You still have to meet cut-offs, MCAT scores, etc just like everyone else does. GPA and MCAT scores still prevail. Yes, there's NOSM (58 seats, mostly for N. ON apps) and some Western schools that let you write extra essays about how rural you are, but for the most part, we haven't done enough to get more rural kids into medicine.

[Halcyon]

Another thought: As urban applicants that have lived in cities for the duration of their life, it might be difficult to truly understand why there are challenges/barriers to getting into med school as a rural applicant.

[rmorelan]

As one of these crazy pre-meds that wants to go into rural medicine, I don't think we get that much extra special treatment. You still have to meet cut-offs, MCAT scores, etc just like everyone else does. GPA and MCAT scores still prevail. Yes, there's NOSM (58 seats, mostly for N. ON apps) and some Western schools that let you write extra essays about how rural you are, but for the most part, we haven't done enough to get more rural kids into medicine.

 

As a potentially future rural doctor I would argree

[Halcyon]

As a potentially future rural doctor I would argree

 

 

Rmorelan is going into rural medicine?!

 

Aussie-land apparently has some progressive rural med admissions at some schools.

[japlanet]

As one of these crazy pre-meds that wants to go into rural medicine, I don't think we get that much extra special treatment. You still have to meet cut-offs, MCAT scores, etc just like everyone else does. GPA and MCAT scores still prevail. Yes, there's NOSM (58 seats, mostly for N. ON apps) and some Western schools that let you write extra essays about how rural you are, but for the most part, we haven't done enough to get more rural kids into medicine.

 

I agree, but I was saying that the programs that we do have are not effective (i.e. many NOSM seats end up going to people who don't plan on serving that area, and many rural areas are not part of any program catchment at all).

 

And, if you are rural and do happen to fall into a program catchment, your GPA cutoffs are lower, so that is special treatment.

 

All I am arguing is that we need to make programs to attract rural doctors more fair (such that equally qualified applicants fill those spots as fill the other spots), more comprehensive (to address all areas which are under-served, not just the north and areas which happen to surround medical schools), and more efficient (so that people admitted under these programs actually DO return to the areas we are trying to serve, either by monetary enticement or contractual agreement or otherwise).

[truffle]

Another thought: As urban applicants that have lived in cities for the duration of their life, it might be difficult to truly understand why there are challenges/barriers to getting into med school as a rural applicant.

 

i agree with this.

 

i know these people who went to highschool in small towns and sometimes i wonder whether they had gone to highschool.

[Alastriss]

I don't see why any of these policies mandate that you spend x years practicing in rural areas. I *think* they use past living history as a criteria to make sure you can adjust living in rural areas, but a non-rural applicant with volunteer in rural experience who signs a return of service contract will more than do the trick.

 

here's the REAL problem. The fact that these policies actually do lead to increasing physicians. It is just that they do so at an inefficient rate, which eventually takes these seats from urban kids who could really use it. However, I don't really think anyone cares for these urbanites.

 

 

ok so based on what halcyon and truffle said, it seems that these rural applicants are academically hindered. I think this really articulates why "lower cutoff" policies are a bandaid to the problem. The objective here should be to improve education delivery, supply, and accessibility so these "lower cutoff" policies are eventually removed, but that's easier said than done.

[SpanishFly]

Ok here's my take on this issue: forcing anybody to do anything is definitely unethical due to the obvious infringement upon their rights (as in the right to live/work wherever you want without the threat of losing your career over it). I do think that if students wish to sign a contractual agreement with schools prior, knowing about the commitment, then that's a different story since they've made an informed decision, so it really comes down to the details of whether or not they knew (although the words 'forced' imply they didn't).

With respect to preferential admissions (which is very different from forcing people to practice in rural areas), I don't think its unethical, although I do think it is unfair, however, life is unfair (like the fact that ares of Nunavut don't even have physicians and use telehealth as their major source of health care).

 

what i think should happen is a better system for recognizing people who are interested in rural medicine.

 

as for underrepresented groups, these should continue to receive some preferential treatment, but nothing too unreasonable.

 

can you elaborate on the system you would rather see?

 

The long term solution would be to open up many, many more med school slots and residency positions- I will be over here holding my breath on that one

 

I'm curious, aside from creating more physicians, what makes you think this will solve the rural shortage? If the problems we currently face are more complex than just numbers, than wouldn't these extra physicians just do the same thing as their predecessors and move to urban centers? (sure by the sheer numbers, perhaps a few more will go to rural regions, but how many spots will it take to make an adequate impact?).

[Alastriss]

Ok here's my take on this issue: forcing anybody to do anything is definitely unethical due to the obvious infringement upon their rights (as in the right to live/work wherever you want without the threat of losing your career over it). I do think that if students wish to sign a contractual agreement with schools prior, knowing about the commitment, then that's a different story since they've made an informed decision, so it really comes down to the details of whether or not they knew (although the words 'forced' imply they didn't).

With respect to preferential admissions (which is very different from forcing people to practice in rural areas), I don't think its unethical, although I do think it is unfair, however, life is unfair (like the fact that ares of Nunavut don't even have physicians and use telehealth as their major source of health care).

 

 

 

 

can you elaborate on the system you would rather see?

 

 

 

I'm curious, aside from creating more physicians, what makes you think this will solve the rural shortage? If the problems we currently face are more complex than just numbers, than wouldn't these extra physicians just do the same thing as their predecessors and move to urban centers? (sure by the sheer numbers, perhaps a few more will go to rural regions, but how many spots will it take to make an adequate impact?).

 

 

 

Well determine rural eligibility by a set of criteria. This could be living in a rural area, going to a high school in a rural area, or showing commitment to a rural area. Then you have then sign a return of service agreement to stay in rural areas for x number of years. UHawaii does this with their med school, where something along the lines of serving in hawaii for 2 years (don't know the deets). In any case, even if they leave after x years, its not THAT bad (although there go all these therapeutic relationships you build) because of the turnover.

 

Sure rural health care is not just about doctors, but there is a profound doctor shortage and working on this aspect is a (damn good) start.

 

If they want physicians in rural areas, then cut to the f&%*in chase and make them go there in exchange for leaner admission cutoffs. Don't diddle-daddle by accepting applicants based on something that *correlates* with the possibility of them practicing. Just make sure they have a good understanding of the challenges of living there before they do sign anything, otherwise they wouldn't really be informed.

 

Some people may look at this and say that returns of service is impinging on your freedom. I say pigeonholing applicants based on where their parents chose to live and not letting them escape the pigeonhole is practically an epitaph to a lot of the principles this country is founded on.

[SpanishFly]

Well determine rural eligibility by a set of criteria.

If they want physicians in rural areas, then cut to the f&%*in chase and make them go there in exchange for leaner admission cutoffs.

 

Don't you think this would lead to a deterioration in the quality of health care? (Not saying that people with a 3.5 GPA are inferior physicians, but I'm playing devils advocate here). At least now, they're going based on some studies that correlate place of residence to future place of practice. If they were to forgo the political correctness of it all, sure it would make things more transparent, but wouldn't it lead to a downward spiral of less and less qualified people applying to these programs?

[Alastriss]

Don't you think this would lead to a deterioration in the quality of health care? (Not saying that people with a 3.5 GPA are inferior physicians, but I'm playing devils advocate here). At least now, they're going based on some studies that correlate place of residence to future place of practice. If they were to forgo the political correctness of it all, sure it would make things more transparent, but wouldn't it lead to a downward spiral of less and less qualified people applying to these programs?

 

No I dont, because these individuals would have demonstrated a true devotion to rural medicine, as the eligibility criteria for them to be considered in our "rural" stream involves them demonstrating interest.

 

If you are talking about marks being lower, lol, that IS what they are doing right now. They ARE lowering cutoffs. SWOMEN, NOSM are such examples.

[truffle]

 

 

can you elaborate on the system you would rather see?

 

 

 

I'm curious, aside from creating more physicians, what makes you think this will solve the rural shortage? If the problems we currently face are more complex than just numbers, than wouldn't these extra physicians just do the same thing as their predecessors and move to urban centers? (sure by the sheer numbers, perhaps a few more will go to rural regions, but how many spots will it take to make an adequate impact?).

 

i'm totally for the promotion of rural medicine, even if that puts me at a disadvantage.

i was just saying that there needs to be a more selective and efficient system for increasing the number of rural doctors. i don't know what i'd do, so i'd say i'm for the lower academic cutoff for applicants from rural areas.

[engineer2doc]

Interesting thread, and very relevant and understandable. Here's one comment ref rural physicians. The military has some separate streams at some schools with different GPAs, similar to the rural applicant situation. However, there is a return of service for this (typically 4-5 years), and you will go where you are told to go. If you try to get out early, the $ penalties can be quite eye-watering. This is just the same as any other part of the military funding any other higher education. In this case, the military owns you, sends you to the Med school for a while, then uses you as it sees fit for the next few years. It's a bargain we go into with our eyes open though, so I would argue it's "fair" from that point of view.

 

However, this could be seen as a special situation, as most other groups would not put up with such an infringement of personal liberty. The difficulty then arises as to how to influence physicians to go rural without forcing them to do so contractually or by other means. Hence the lower GPA on the assumption (probably true) that you are playing the percentages and will come out ahead in aggregate, although there are no guarantees in any individual case. So, it may be the least worst solution. At least the schools are open about it rather than for instance doing it by stealth selection.

 

It certainly is a good interview question. For the record on the other thread in this one, one of my elderly relatives fathered a child when he was over 80. We understand it was in vivo fertilization;)

[truffle]

It certainly is a good interview question. For the record on the other thread in this one, one of my elderly relatives fathered a child when he was over 80. We understand it was in vivo fertilization;)

 

how old was the mother? was it really his sperm?

[engineer2doc]

how old was the mother? was it really his sperm?

 

He was a lifelong bachelor, and kept them all around the 40-50 mark:cool: . She was, I think, 42. Origin of sperm I cannot authenticate, but by all accounts he was a randy old goat, so maybe one tadpole had the necessary impetus - not sure if the milkman called early though. He's now long gone, but most of the family lived well into their 80s and early 90s. If I get into med school, with those genes, I'll be practicing for another 40 years - maybe I'll even move to the country...

[SpanishFly]

No I dont, because these individuals would have demonstrated a true devotion to rural medicine, as the eligibility criteria for them to be considered in our "rural" stream involves them demonstrating interest.

 

If you are talking about marks being lower, lol, that IS what they are doing right now. They ARE lowering cutoffs. SWOMEN, NOSM are such examples.

 

no, now they are giving people from those areas the opportunity to increase their chances of getting into medical school by using lower admission cut-offs. It doesn't mean they are guaranteed an in. You were saying "make them go there in exchange for leaner admission cutoffs" which is very different for two reasons: 1) right now, those who get in through a SWOMEN/NOSM advantage don't agree to anything and 2) just because they have that advantage doesn't mean they are guaranteed admission. So if we start telling people "sign here and we'll let that 3.X slide" then my question to you is, doesn't that jeopardize the system?

 

Someone already mentioned some of the factors that deter people from rural medicine, I think those need to be addressed if we want a long-term solution.

[meme me]

I don't see why any of these policies mandate that you spend x years practicing in rural areas. I *think* they use past living history as a criteria to make sure you can adjust living in rural areas, but a non-rural applicant with volunteer in rural experience who signs a return of service contract will more than do the trick.

 

here's the REAL problem. The fact that these policies actually do lead to increasing physicians. It is just that they do so at an inefficient rate, which eventually takes these seats from urban kids who could really use it. However, I don't really think anyone cares for these urbanites.

 

 

ok so based on what halcyon and truffle said, it seems that these rural applicants are academically hindered. I think this really articulates why "lower cutoff" policies are a bandaid to the problem. The objective here should be to improve education delivery, supply, and accessibility so these "lower cutoff" policies are eventually removed, but that's easier said than done.

I hope you were on drugs when you wrote this post.