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Michael M Daube
Professor of Health Policy, Division of Health Sciences, Curtin University of Technology, GPO Box U1987, Perth, WA 6845. m.daubeATcurtin.edu.au
To the Editor: Kerridge et al1 raise a number of concerns about religiously affiliated medical schools in general, but about the University of Notre Dame in particular. The implications to be drawn from their article are that the establishment of the University of Notre Dame medical school is of itself a cause for concern, that insufficient thought has been given to the ethical and other issues inherent in the establishment of a medical school of this nature, and that the Australian Medical Council (AMC) accreditation processes are inadequate by virtue of the inability to consider matters beyond the adequacy and quality of medical education.
The AMC has already noted2 that its processes enabled it to raise questions about religious and related ethical issues with the University, and that they did so.
As Director General of Health in Western Australia through the period of Notre Dame’s development of the medical school concept and accreditation, I observed at first hand the integrity of the Notre Dame application and the rigour of the AMC processes.
Far from being given insufficient attention, the matters raised by Kerridge et al were discussed locally (not least between the University and staff of the WA Department of Health), and with the AMC. The AMC also discussed these issues independently with the Department, as well as with the University. The AMC’s decision to provide accreditation, albeit subject to clearly specified requirements, may not please some, but this should not be cause to imply fault in the process or the protagonists.
It is unfortunate that Kerridge et al have not looked at the beneficial aspects of the development of a new and innovative medical school in Western Australia that will complement the University of Western Australia’s more traditional strengths. It is fair game to criticise religiously based institutions when there is evidence that they seek to impose their mores on the rest of society, but not when they bring in new ideas, new funds, and new and much-needed places for medical students — and when they and the accreditation processes have been at pains to avoid the sins of which they are accused.
George Larcos
Nuclear Medicine and Ultrasound Physician and Senior Clinical Lecturer, Westmead Hospital and University of Sydney, PO Box 533, Wentworthville, NSW 2145. nglATimag.wsahs.nsw.gov.au
To the Editor: Kerridge and colleagues1 live in an anaemic world ruled by relativism. They agree that everyone is entitled to an opinion, but they believe that there is no right or wrong and so rationalise dissimilar views by accepting all and dismissing none. In contrast, Christian doctors understand that there is an ultimate truth and, in an environment of love and forgiveness, minister to patients and teach students according to God’s design for His world.
Kerridge et al question whether the medical curriculum within a newly created medical school in Australia can be appropriate, given its Catholic affiliation. They seem to argue for the application of knowledge in a moral vacuum and miss the point that moral values enhance (rather than detract from) the value of knowledge. It is also evident that this moral compass cannot come from human beings.
In a sense, it is amusing to see the self-contradiction and entanglement inherent in ethicists’ faulty logic. On another level, I hope that the Centre for Values, Ethics and the Law in Medicine at the University of Sydney is not funded by taxpayer dollars.
Paul A Komesaroff
Physician, Department of Medicine, Monash University, Alfred Hospital, Commercial Road, Prahran, VIC 3181. paul.komesaroffATmed.monash.edu.au
To the Editor: The article by Kerridge et al1 raises important issues about the establishment of Australia’s first religiously based medical school at the University of Notre Dame. The authors draw attention to the need to consider the adequacy of the education provided in relation to accepted standards of medical practice, whether equitable access will be provided to potential students, and whether academic freedom and tolerance will be guaranteed to the levels required by the Australian public. The article is presented in a careful, measured and balanced manner. In essence, it concludes that the onus is on the University to show that it is both sensitive to these concerns and able to satisfy them.
The accompanying comment from the Australian Medical Council (AMC)2 acknowledges the problems and indicates that there are several key points that remain to be resolved, namely: “concerns over the theological context of the medical course”, the need to “develop a process for handling potential conflicts over the inconsistency between the medical school’s teaching program and the canonical statute defining the purpose of the University”, and the possibility that “students of some backgrounds may perceive themselves to be effectively discriminated against on the basis of their own religious conviction (or lack thereof)”. It is arguable that these issues are so important that the commencement of the course should not be contemplated until they are resolved.
Most readers would see this debate as unremarkable and would assume that it would lead to a negotiated compromise. However, the reply by the University3 is alarming. In spite of the importance of the questions, the public acknowledgement by the AMC that there are key unresolved issues and the obvious public interest in the subject, Professor Bower, speaking on behalf of the University, simply states that “we do not see a need to respond to this article”. In fact, this is a potent response in itself, which may be taken to suggest a lack of openness to criticism and an unwillingness to engage with philosophical or ethical perspectives that vary from those promoted by the University.
It is neither the right of the AMC to proceed with accreditation nor that of the University to press doggedly ahead with its agenda independently of public accountability. There are both ethical and legal issues that need to be addressed, and the community is entitled to a full and unqualified assurance that questions raised in serious debate are satisfactorily answered. Both bodies must serve the interests of the wider community and operate according to the standards demanded by it. It may be that the issues raised can or have been satisfactorily addressed. If so, the public is entitled to know how this has occurred; if not, it would appear that further steps need to be taken before accreditation comes into effect.
Edward D Watt
Dean (retired), Faculty of Arts, University of Western Australia. lifewaATq-net.net.au
To the Editor: In their articles on the new University of Notre Dame Australia (NDA) medical school, Kerridge and colleagues1 and Frank and Walters2 have revealed rather more than they may have intended.
We are told by Kerridge et al that Australia’s “secular, pluralist society” is in favour of “diversity of beliefs and values”,1 and by Frank and Walters that “the Australian Medical Council supports diversity”.2 But the authors reject diversity in favour of their firm commitment to a particular, positive, proselytising version of medical ethics, from which no deviation should be tolerated in Australian medical education.
They list their “concerns” about the NDA medical course. The two lists are almost identical, and contain no surprises. There is no doubt in their minds about what NDA medical students are likely to be taught about termination of pregnancy, contraception, assisted reproductive technologies, embryo research, and what one article delicately labels “end-of-life care”.1 Whether this will be so remains to be seen. Statements from NDA convey hints that what their medical students get in practice may be no more than a Catholic-lite version of medical ethics, at most. If so, our authors may turn out to have less to worry about than they fear.
But running through their list of “conncerns”, we may reasonably ask them to specify what it is that every medical student must be taught about the matters they men-tion in order to meet the requirements of a “secular, pluralist society”. For example, will they be satisfied if NDA promises that its medical ethics lecturers will teach that:
there is no ethical objection to terminating a pregnancy even where there is no medical indication, either maternal or fetal, for the termination;
there is no ethical objection to cutting off food and fluids from an unresponsive patient in a stable condition with the intention of hastening the patient’s death.
I do not deny that some doctors agree with the values and beliefs that, the authors suggest, reflect a “secular, pluralist society”. But their opinions are not beyond reasonable dispute. They represent a particular standpoint in medical ethics. Other doctors, and other people, disagree. On these matters there is no such thing as an impartial position.
There is no justification, therefore, for demanding that every Australian medical school comply with one particular standpoint in teaching its students, or risk losing accreditation.
John E Murtagh
Adjunct Professor of General Practice, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165.
murtaghATbigpond.com
To the Editor: As a Foundation Professor of the University of Notre Dame’s Graduate School of Medicine, I would like to add a comment to recent writings on the subject of a religiously affiliated medical school.1,2 In the process of accepting my honorary appointment, I looked into the issue of possible religious bias in the curriculum and was eventually reassured and convinced that there was no cause for concern.
The subject of theology, presented by Peter Black (Lecturer in Theology, University of Notre Dame), is not based on Catholic dogma but is essentially a reflection on the spirituality of illness and its impact on people. My understanding is that, to date, the students seem to be comfortable and impressed with the subject and the teacher. It must also be appreciated that the students will disperse to a wide spectrum of experienced clinical teachers of various persuasions who will carry out bedside and office teaching in a similar way to that of all other medical schools. One wonders what all the fuss is really about!
It is worthy of reflection that the time-honoured model that guided our ethical standards was the Hippocratic Oath and, subsequently, the Declaration of Geneva.3 The enshrined principles are virtually synonymous with basic Catholic teaching and, indeed, with that of most other religious groups.4
It would be most appropriate for the Australian Medical Council to conduct an evaluation of the Notre Dame students at the end of this year. It might also be interesting and appropriate to evaluate the messages emanating from teachers of bioethics in other medical schools, some of whom tend to promote quite opposing and unbalanced viewpoints. From first-hand experience and the comments of aggrieved students, I suggest there are other causes for concern, especially in view of the multicultural background of students studying medicine in Australia. For example, to ridicule students for their beliefs — especially for their belief in God — is a terrible dereliction of reasonable teaching responsibilities.
I feel confident that the medical students of Notre Dame will enjoy a balanced curriculum, especially with people of goodwill supervising the course.
Robert G Batey
Area Director, Drug and Alcohol Clinical Services, Hunter New England Area Health Service, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. robert.bateyAThunter.health.nsw.gov.au
To the Editor: I wish to congratulate Bower for his amazingly clear, concise and unemotive response to the article on religiously affiliated medical schools in this country.1
Having a great respect for the University of Sydney and its Centre for Values, Ethics and the Law in Medicine, I was disappointed in the article that was designed to stimulate debate on a subject that is clearly of major interest but not necessarily of major concern.2 I am disappointed because the article suggested that bodies (churches) responsible for the foundation of our original university system might now have problems in delivering unbiased and appropriate medical education. This approach to stimulating debate seems, at best, mischievous and, at worst, ill-informed. The response was a gem, and I again commend the author for taking such a positive stand.
Ian H Kerridge,* Rachel A X Ankeny,† Christopher F C Jordens,‡ Wendy L Lipworth§
* Director, †Senior Lecturer, ‡Researcher, §PhD Student, Centre for Values, Ethics and the Law in Medicine, Blackburn Building, University of Sydney, NSW 2006. iankATicpmr.wsahs.nsw.gov.au
In reply: All Australians have a legitimate interest in the education of health professionals. In our article1 we outlined some of our concerns — shared by the Australian Medical Council (AMC)2 — about several features of the current University of Notre Dame program, including compulsory theology courses and procedures for student selection. However, the public’s interest extends beyond the purview of the AMC’s accreditation process. For example, how will the introduction of religiously affiliated medical schools affect access to a full range of health care services and accord with the broad range of needs, values and beliefs in Australian society?
Because we seek to foster critical reflection and further public discussion on this and other questions, it does not follow (as Daube suggests) that we seek to dismiss benefits that may arise from the establishment of religiously affiliated medical schools. Nor does it follow (as he also suggests) that we are impugning the integrity of the AMC’s accreditation process. New ideas, new funds and new places for medical students may go hand in hand with the imposition of religious mores on secular society. We can applaud the former and question the latter. Daube implies that we must choose between applause and criticism, but this is simply not true.
Murtagh welcomes the upcoming AMC evaluation, but reassures us on the basis of his own personal reflections and impressions that there is no cause for concern. However, his experience is confined to the students in the medical program. The concerns we have raised extend to other groups likely to be affected by the Notre Dame curriculum, including (a) people in rural areas who may not be able to access the full range of health services because of the religious convictions or limited training of their local general practitioner, and (b) potential medical-school applicants who choose not to apply to Notre Dame. We also note that ridiculing people for their religious beliefs (or indeed, lack thereof) is unacceptable not only in education, but in any context.
The commitment to an ultimate truth that is defined in religious terms, as affirmed by Larcos, is fundamentally what is at issue in the establishment of religious medical schools in Australia. We would be the first to agree that the pursuit of knowledge can not and should not occur in a moral vacuum. However, we challenge his implication that religion has some kind of monopoly on morals and values. Any secular, liberal society also rests on moral principles, such as tolerance of difference, and values, such as respect for human life, freedom and equality.
Watt suggests we reject diversity in order to advance a monolithic bioethical, educational and health care agenda. This is an odd reversal indeed. To reiterate the central issue: many religious institutions are explicitly doctrinaire. We wish to open a public discussion about the potential problems created when such institutions take on the function of medical education. As we stated in our article, none of the problems we have raised are insurmountable, but all should be acknowledged and addressed. Along with Komesaroff, we are therefore disturbed by the University of Notre Dame’s decision not to take up the Journal’s invitation to respond to our article — even as an issue “for debate”.
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©The Medical Journal of Australia 2005 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377