Katherine Branson Essay Prize winners 2014
'Should a medical graduate automatically be obliged to work as a doctor?'
by Sophie Fitzsimmons, 5th year Student, Cardiff University
A recent Daily Mail article, entitled "Why having so many women doctors is hurting the NHS" laments the fact that female doctors (now making up the majority of medical school intake and therefore representing the greater proportion of NHS medical student training funds) are more likely to leave medicine than men – requiring the NHS to "make up the shortfall in medical manpower by importing about 40 per cent of the doctors we need" (1) Despite the belligerent nature of the article, it brings up a point that should give medical students and doctors of both genders pause for thought – in the UK, where we are lucky enough to have our training heavily subsidised by the NHS, should we pay back our debt by being obliged to work as a doctor? An obligation to work in a particular profession after training, especially if funded by an external source, already exists elsewhere. The armed forces pay generous bursaries to students in exchange for a set number of years of service, law firms sponsor students through law school with the promise of a job at the end – why should medicine be different? A scheme such as this could also help to cover gaps in the workforce in specialties such as emergency medicine, general practice, geriatrics and psychiatry – all of which are facing "chronic shortages" (2).
However, there are three major problems with this plan. Firstly, that the current job market for doctors in the UK would not be able to support an 'obligatory' scheme; that we in fact need doctors to take up roles outside medicine; and finally, that medicine is not a profession that one can be obliged to undertake.
There is an imbalance between the numbers of medical graduates and places in postgraduate training programmes. Thanks to an increase in places at medical school, private medical schools and applicants from abroad, the 2014 UK Foundation Programme is oversubscribed by around 300 applicants for the fourth year in a row (3). This is a trend that may continue further up the medical hierarchy, with projected figures for 2020 predicting a surplus of 2,800 trainees at consultant level – or a cost of £2.2 billion to employ them all (4). Despite shortages in certain areas, most hospital-based specialties are in fact over-subscribed – there are plenty of graduates willing to be doctors, just not enough willing to be certain types of doctors. If the UK is unable to provide enough jobs for all medical trainees to pursue their chosen careers, a scheme that required graduates to become doctors would simply not function. Until training and vacancy numbers become better aligned, and disincentives to taking up careers in under-subscribed specialties are removed, such an obligation cannot be met.
Indeed, certain professions related to medicine are probably best served by having non-practicing doctors working in them. Jobs such as biomedical research, health policy, and health management all require an understanding of medicine that only training as a doctor and experience of medicine from the inside can bring. Indeed, there are plenty of medical graduates in seemingly unrelated fields that still make good use of their medical skills and knowledge. Journalist Michael Mosley produces documentaries that inform and engage the public about health and medicine. Sarah Wollaston MP draws on her 24 years' experience as a GP in influencing health policy. We need people to leave medicine in order to fulfil these translational roles, which are vital if we want medicine to be placed in its rightful context between science and society.
Ultimately, medicine is a vocation, not a conscription, and most importantly a vocation that involves being responsible for patients' lives – not a task that can be undertaken unwillingly. The introduction of the GMC's Good Medical Practice reads: "Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law." (5) If a graduate lacks the motivation to be a doctor, how can they possibly be expected to live up to this high standard? Many graduates feel 'trapped' in medicine after the extensive time, emotional and financial commitments required for training, and many enter medical school for the wrong reasons or become disillusioned during the course of their training. Adding an extra level of obligation will surely worsen this, and ultimately endanger patient safety, far more than employing a willing doctor trained abroad would do. Doctors must want to treat patients, not feel forced to.
In conclusion, training as a doctor (especially in the UK) leaves one with financial and moral obligations, which mean a decision to pursue a route other than medicine cannot be taken lightly. However, it is vital that doctors leave medical practice to take up other careers so that their expertise can be used in these alternative vocations – and indeed because there are simply not enough jobs to employ all medical graduates. Ultimately, it is vital that medicine remains a choice, rather than an obligation.
(1) Merion Thomas, J. (2014). Why having so many women doctors is hurting the NHS: A provocative but powerful argument from a leading surgeon. Available: http://www.dailymail.co.uk/debate/article-2532461/Why-having-women-doctors-hurting-NHS-A-provovcative-powerful-argument-leading-surgeon.html#ixzz2rXyEG8Ys. Last accessed 25/02/2014.
(2) Campbell, D. (2013). NHS faces chronic shortage of staff, warns King's Fund. Available: http://www.theguardian.com/society/2013/jul/25/nhs-staff-shortage-pay-kings-fund. Last accessed 25/02/2014.
(3) The BMA. (2013). Foundation programme oversubscribed for fourth year. Available: http://bma.org.uk/news-views-analysis/news/2013/october/foundation-programme-oversubscribed-for-fourth-year. Last accessed 25/02/2014.
(4) Centre for Workforce Intelligence (2012). Report. Shape of the Medical Workforce: Starting the debate on the future consultant workforce via The King's Fund. (2014). Trends in the medical workforce. Available: http://www.kingsfund.org.uk/time-to-think-differently/trends/professional-attitudes-and-workforce/medical-workforce. Last accessed 25/02/2014.
(5) General Medical Council. (2013). Good Medical Practice. Available: http://www.gmc-uk.org/guidance/good_medical_practice/professionalism_in_action.asp. Last accessed 25/02/2014.
Abortion is still illegal in parts of the UK. Is this right?
by Louisa Chenciner, 2nd year student, Nottingham University
Northern Ireland became part of the UK in 1801 despite possessing its own strong national and cultural identity1. When the 1967 Abortion Act was passed in the UK it was not extended to Northern Ireland due to strong opposition by the Nationalist and Unionist parties2. The 1967 Abortion Act permits the termination of pregnancy within 24 weeks if certain criteria are met and agreed by two healthcare professionals, and beyond 24 weeks in exceptional circumstances3. However in Northern Ireland decisions regarding abortion are based upon the Offences against the Person Act 1861, the Criminal Justice Act 1945 and the recent Protection Against Life During Pregnancy Act 20134. Behind these laws there is seemingly indefinite ambiguity, as represented by the Bourne5 judgement of 1939. In this case a consultant who granted an abortion to a 14 year old, who was pregnant following rape, was brought to court. He was found to be not guilty after careful examination of what was deemed to constitute the word "unlawfully", with reference to a clause of the Offences against the Person Act that stated that physicians must not "procure an abortion...unlawfully". The Bourne judgement is considered to be a landmark that demonstrated that abortion was lawful if it would otherwise render the woman a "physical or mental wreck"4. However, if the lowest limit of legality is defined by a woman being reduced to a wreck, it is therefore required of Irish doctors to assess a women's potential for wretchedness if the pregnancy continues to term. Unsurprisingly it follows that there is much opportunity for misinterpretation of the law6.
Is the law right?
It is informative to review this question in the context of Fuller's7 description of morality of duty and morality of aspiration. The morality of duty constitutes the fundamentals of social living, put simply: the bread and butter of decency, whereas the morality of aspiration constitutes the sort of soaring, transcendental hope that human power has the potential to be omnibenevolent. It appears that abortion law in Northern Ireland is contentious for this very reason. Between these two kinds of morality there is disagreement as to whether there is a duty to the rights of the unborn child or mother and whether the prevention of termination is a wrong against women or an act of pure compassion towards a future being.
A recent feminist legal paper8 proposes that the debate on abortion in Northern Ireland has been excessively engineered into a profoundly moral issue that therefore inevitably evokes strong religious responses from both sides. This overemphasis of morality serves to disguise the more significant societal norms and values which undermine women's autonomy. Healthcare professionals are taught that patient autonomy should govern their practice, alongside the three other ethical principles: beneficence, non-maleficence and justice9. Autonomy must be prioritised in cases where it has been otherwise stripped from an individual, such as rape and abuse. Sociologists Martin and Powell10 proposed that inappropriate handling of sexual assault victims by health care professionals, amongst others, constituted a "second assault" against victims. Arguably this presents consequences of the same magnitude to the first abuse and certainly equates to the same level of injustice.
The paired promise undertaken by doctors to promote beneficence and non-maleficence is compromised by laws in Northern Ireland. Women are being forced to purchase unregulated 'abortion drugs' online and more than one in ten GPs there have encountered the consequences of amateur abortions4. Most tragic was a case that cannot fail to override most 'moral' objections to abortion. Last October 2013, a Hindu woman who was suffering from a miscarriage at 17 weeks pregnancy was refused her requests for abortion and was told by her consultant that "Ireland was a Catholic country", she passed away from septic shock11. A report published by the Health Service Executive NI stated that "interpretation of the law related to lawful termination in Ireland...is considered to have been a material contributory factor in this regard"12. It leads to the very crux of the issue, if repeated misinterpretation of the law occurs, perhaps the law itself is at fault.
These laws do not champion justice for the vulnerable or needy, or show compassion or understanding of the emotional and psychological impact of an unwanted pregnancy. Women from Northern Ireland are not even entitled to NHS abortions on the UK mainland and are therefore forced to fund their own abortions if they choose to travel to seek help4. Furthermore, women from Northern Ireland are three times as likely as British women to terminate after 20 weeks4, which shows that if anything the law delays but does not prevent abortion, undermining the pro-life campaigners' determination that the law saves the lives of the unborn.
Sylvia Plath's writing presents intimate reverberations within this bleak legal landscape, 'I am terrified by this dark thing/That sleeps in me;/All day I feel its soft, feathery turnings, its malignity'13. The definition of what constitutes wrongdoing may vary, but it is clearly not right that abortion is still illegal in parts of the UK.
1The Economist Explains: Why is Northern Ireland part of the United Kingdom? The Economist, 2013 [viewed 16/2/14]. Available from: www.economist.com/node/21586504
2BIRCHARD, K. Northern Ireland resists extending abortion Act. The Lancet, 2000, 356, 52.
3The Abortion Act 1967.
4JACKSON, Emily. Abortion. In: Medical Law: Texts, Cases and Examples. 3rd Ed. Oxford: Oxford University Press, 2013, 664-723.
5 R v Bourne  1 KB 687.
6BLOOMER, F., FEGAN, E. Critiquing recent abortion law and policy in Northern Ireland. Critical Social Policy, 2013, 34, 109-120.
7FULLER, L. Lon. The Morality of Law. 2nd Ed. Connecticut: Yale University Press , 1969.
8FEGAN, E.V., REBOUCHE, R. Northern Ireland's Abortion Law: The Morality of Silence and the Censure of Agency. Feminist Legal Studies, 2003, 11, 221-254.
9GILLON, R. Medical ethics: four principles plus attention to scope. British Medical Journal, 1994, 309, 184.
10MARTIN, P.Y., POWELL. R.M. Accounting for the "Second Assault": Legal Organisations' Framing of Rape Victims. Law and Social Inquiry Journal of the American Bar Foundation, 2006, 19, 853-890.
11 HARRISON, S. How Savita Halappanavar's death called attention to Irish abortion law [online]. BBC, 2013 [viewed on 6/2/14]. Available from: www.bbc.co.uk/news/world-europe-22204377
12ARULKUMARAN, S. Investigation of Incident 50278 from time of patient's self referral to hospital on the 21st of October 2012 to the patient's death on the 28th of October, 2012. Northern Ireland: Health Service Executive, 2013
13PLATH, Sylvia. 'Elm'. Sylvia Plath Poems selected by Ted Hughes. London: Faber and Faber, 2004.