Increasing diversity at the cost of decreasing equity? Issues raised by the establishment of Australia's first religiously affiliated medical school

Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW. Ian H Kerridge, MPhil, FRACP, FRCPA, Director; Christopher F C Jordens, PhD, Researcher; Wendy L Lipworth, BSc(Med)(Hons), MB BS, PhD Student. Unit for History and Philosophy of Science, University of Sydney, NSW. Rachel A X Ankeny, PhD, Director. Reprints will not be available from the authors. Correspondence: Associate Professor Ian H Kerridge, Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW 2006. ikerridge@ehlc.net The Medical Journal of Australia ISSN: 0025729X 4 July 2005 183 1 28-30 ©The Medical Journal of Australia 2005 www.mja.com.au For Debate land, and the University of Notre Dame in Frema Australia, are particularly noteworthy developme article in the Journal claimed the new medical scho diversity and are commited to fill “particular work We argue that increasing the range of options for m tion is not an unquestionable good, as it may threa freedom and equity in medical education as well as ed ch inc M ical education in Australia is about to undergo major anges, with the founding of six new medical schools, luding the first private medical school and the first religiously affiliated medical school in Australia. The establishment of medical schools at Bond University on the Gold Coast, Queensntle, Western nts. A recent ols will foster force needs”. edical educaten academic just provision of health care. This article aims to stimulate awareness, conversation and debate on these issues, not only within the medical community but in the wider Australian community. While there are no prima facie reasons why religiously affiliated or private medical schools should not exist, in practice there are a series of curricular and administrative concerns that should be addressed before the establishment of any medical school — religiously affiliated, private or otherwise. There are important ethical and sociocultural issues associated with establishing religiously affiliated medical schools, and the principles underlying such schools must be made clear, particularly as interest may develop in establishing additional religiously affiliated medical schools (eg, based in the Islamic, Jewish or Hindu faiths). The recent article in the Journal outlined concerns raised about the Notre Dame program, including the inclusion of a mandatory theology course, and more generally how the institution’s Catholic ethos may affect the medical education provided and the skills and attitudes of physicians being trained. While many factors, including postgraduate education and clinical experience, may influence a doctor’s values or practice, it is undeniable that medical education is formative. Thus we concentrate here primarily on the issues raised by the establishment of religiously affiliated medical schools, and the University of Notre Dame’s medical school in particular. The important issue is not whether spirituality and religion are valid fields of enquiry within medical teaching, as there would seem to be little argument about including consideration of these in medical education. Both have been increasingly recognised as determinants of the values that people attach to their lives, the manner in which they understand and cope with illness, the health care decisions they make and the care they receive. Nor do we deny that values have a central role in medical education. Indeed, a general consensus has emerged over the past decade that examining values is fundamental to developing an understanding of ethics and professional responsibility in medicine. All Australian medical schools in fact now incorporate study of professionalism, values and ethics within their medical curricula. Furthermore, it is clear that different medical schools will have special emphases depending, in part, on their student and local populations. For instance, the private medical school at Bond University will emphasise organisation, administration, and information technology skills, along with communication, law, and ethics. Indeed, provided there are structural safeguards, it may be desirable for different schools to produce graduates with not only core attributes necessary for the practice of medicine, but also additional specialised skills suited to particular fields of practice or sociocultural contexts. There are, however, at least three major areas of concern with regard to religiously affiliated medical schools: (1) the adequacy of the medical education provided and potential resulting limitations on patient access to health services and provision of comprehensive care; (2) equitable access to medical education in an increasingly competitive environment; and (3) issues associated with academic freedom and tolerance of diverse beliefs. In theory, none of these problems are insurmountable, but all should be acknowledged and addressed. First, it has been well documented that patient access to health care services can be limited either directly (because of explicit religious concerns) or indirectly (by inadequate postgraduate education provided to health care practitioners). The restriction of health care services and the limitation of exposure to the full range of health care services required for professional competency have been major issues worldwide, particularly in obstetrics and gynaecology, and have resulted in legal action in the United States. Although individual physicians can conscientiously object to involvement in procedures that violate their own religious/moral values, it is reasonable to assume that all physicians should receive appropriate education about the range of health care services publicly available in Australia, including termination of pregnancy, provision of contraception, assisted reproductive technologies, genetic counselling, prenatal diagnosis and end-oflife care, as well as about the mechanisms for and limits to expressing conscientious objections. The existence of conscience clauses in codes of professional conduct is indicative of the fact that guidance is needed to mitigate the impact of religious beliefs on medical judgement and the delivery of care. Although Notre Dame officials have stated that their graduates will be educated to discuss these issues in a “non-judgemental, respectful and ethical manner . . . in relation to [the patient’s] needs and circumstances”,