THE DISABLED MEDICAL STUDENT
1
1102 MARKETS IN KIDNEYS StR,-Attempts at buying and selling kidneys from living donors have met strong resistance from the medical community. The Inter- national Transplantation Society has denounced these ventures; it will expel any of its members who participate in such endeavours and has initiated efforts to make kidney brokerage illegal. Presumably entrepreneurs intended to buy kidneys from Third World "volunteers" and then sell them at a profit. Most people would recoil from the idea, horrified by the defilement of the body that such a plan would involve and at the blatant exploitation of poverty inherent in persuading a donor to give up a vital organ and put himself at risk. From this vantage, kidney brokerage appears unacceptable. But seen through utilitarian glasses, there are advantages. If the money earned from undergoing this relatively safe procedure saves his children from starvation or even allows them to live in relative comfort, the donor will see himself as coming out ahead-he earns a lot of money while taking a few risks. From a utilitarian perspective, even though such a transaction does exploit the donor’s poverty and involve some risks, it could, on balance, help him. Should we reject kidney bartering out of hand if the donor could benefit from the exchange, while his kidney may save the recipient’s life? Some argue that we have no right to subject a donor to any danger, however small. Does this argument also apply to our accepted use of living related organ donors? For family members, people offer their kidneys freely, but also under deeply ingrained societal pressure. Proponents maintain that the overall benefit to the recipient (and the donor’s emotional payback) far outweigh the donor’s risk. Might not this argument apply equally well to paid donors? Combining money and medicine generates further moral issues; some believe that commercialisation of transplantation is unethical. But transplantation (at least in the United States) already functions as a business; well-managed transplant services earn considerable profits (which allow for research support and other expenses), and most transplant surgeons take home a generous salary. Certainly kidney sales would generate inequity, favouring the rich who can afford kidneys, and leaving the poor to wait in line for cadaver organs. We must ask, therefore, whether it is better to help only the rich, or no one at all. The utilitarian answer is clear. Even if we have no philosophical objection to kidney brokerage, we must still face a multitude of practical and very difficult questions before rendering judgment on this issue. Could we ensure that paid kidney donors are healthy, well informed of their risks, properly recompensed, well-cared for, and truly willing? Could we ensure that their organs are healthy? Could we fulfil our moral obligations to donors after their surgery? How would this business affect a Third World social structure? Would this business stimulate a reduction in voluntary organ donation? I cannot propose simple answers to, nor even compile an adequate list of, these questions. I thus offer this letter not to advocate kidney brokerage, but rather to open it up as an issue for discussion among the medical community. Harvard Medical School, Boston, Massachusetts, USA DAVID L. BACH THE DISABLED MEDICAL STUDENT SIR,-For most disabled people with a determination to succeed the greatest handicap they are likely to face is other people’s attitudes. I speak from personal experience. The only additional arrangement I needed to pursue a university course and career in medicine was the use of an amanuensis for examinations. An injury to my wrists many years ago has left me incapable of writing without great pain. I was offered a place on academic grounds and the medical school must have known of my disability because I had used an amanuensis at school for my 0 and A level examinations and this was mentioned on my UCCA references. My disability was not discussed at the interview but an assistant registrar told me that it had been discussed at length before a place was offered. I was allowed to take my mid-sessional examination by dictation but the medical school then changed its mind and said that I must write my answers or leave. A letter from another medical school had read: "competition for places is so great that applicants with disabilities have to be outstanding to stand a chance of selection". This discrimination means that disabled people frequently need to be, not just equal to other candidates, but better, before they are even considered. Third World countries now recognise that a disabled person can often make a more empathetic and effective doctor as a result of his or her experience, and this view is now being put into practice in training. Perhaps it is time that UK medical schools learnt from the insight of developing countries. 43/45 St Michael’s Hill, Bristol BS2 8DZ ELIZABETH A. CROW 1. Shirky O, ed. A cry for health: Poverty and disability in the third world London: Third World Group for Disabled People/AHRTAG, 1983. CLICHES IN MEDICAL EDUCATION SIR,-Professor Roddie (Oct 13, p 860) has been self-indulgent in selecting his own aunt sallies to shy at. Few would doubt the importance of medical students learning anatomy since a knowledge of the subject is one of the few things that really distinguish doctors from other people and it is virtually the only medical science whose teachers can lay claim to knowledge of the subject rather than simply informed speculation. Similarly, most people would accept that it is more important to select medical students for intelligence rather than compassion since compassion can be taught and intelligence can not. Presumably these two readily demolishable propositions were selected so as to distract the reader from the nonsense Roddie wishes to put across in relation to the value of psychology and sociology as disciplines relevant to medical education. The casual.observation of the behaviour of one’s senior colleagues is no more a substitute for a study of psychology than is casual observation of their dyspnoea on exertion a substitute for the study of respiratory physiology. If we were to avoid exposing medical students to scientific subjects in which there is still much to learn, the medical curriculum would be much briefer and less demanding. Faculty of Community Medicine of the Royal Colleges of Physicians of the UK, 28 Portland Place, London W1N 4DE ALWYN SMITH SIR,-Professor Roddie (Oct 13, p 860) asserts that medical students gain an understanding of human relationships and behaviour through the process of apprenticeships to senior clinicians. The evidence, however, fails to support this contention. Students have been shown to fail to register a substantial proportion of patients’ personal relationships and feelings about their illnesses. Further, their deficiencies are not remedied by later clinical training.’ Anyone supporting the primacy of the clinical interview as a method of investigation must therefore question whether we train clinicians to achieve their maximum effectiveness. There remain many who doubt whether communication and empathetic skills can be formally taught but there exists now a substantial body of evidence showing that training in these areas is effective.2 I find it heartening to see that teaching of these skills, so long neglected in undergraduate courses, is increasingly finding a place in general practitioner training schemes. Glenside Hospital, Stapleton, Bristol J. C. BARNES 1. Sonsan-Fisher R, Maguire P. Should skills in communicating with patients be taught in medical schools? Lancet 1980; ii: 523-27. 2. Maguire P, Roe P, Goldberg D, Jones S, Hyde C, O’Dowd T. The value of feedback in teaching interviewing skills to medical students. Psycho! Med 1978; 8: 695-704. SIR,-Professor Roddie provides us with food for thought in his amusing account of cliches in medical education (Oct 13). I was intrigued to hear that learning Latin or Greek inculcates neatness, precision, and logic in thinking, and that learning anatomy provides good practice in the use of mental strategies to store large amounts of information in the brain. However, after searching the considerable body of research on learning strategies for the source of this conclusion, I must confess that I cannot find it. This is especially frustrating since Roddie is rightly sceptical about whether we really know anything about the mind anyway-so he must require convincing proof of his firm statements about the effects of learning anatomy and so forth.
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Transcript of THE DISABLED MEDICAL STUDENT
1102
MARKETS IN KIDNEYS
StR,-Attempts at buying and selling kidneys from living donorshave met strong resistance from the medical community. The Inter-national Transplantation Society has denounced these ventures; itwill expel any of its members who participate in such endeavoursand has initiated efforts to make kidney brokerage illegal.Presumably entrepreneurs intended to buy kidneys from ThirdWorld "volunteers" and then sell them at a profit. Most peoplewould recoil from the idea, horrified by the defilement of the bodythat such a plan would involve and at the blatant exploitation ofpoverty inherent in persuading a donor to give up a vital organ andput himself at risk. From this vantage, kidney brokerage appearsunacceptable. But seen through utilitarian glasses, there are
advantages. If the money earned from undergoing this relativelysafe procedure saves his children from starvation or even allowsthem to live in relative comfort, the donor will see himself as comingout ahead-he earns a lot of money while taking a few risks. From autilitarian perspective, even though such a transaction does exploitthe donor’s poverty and involve some risks, it could, on balance,help him. Should we reject kidney bartering out of hand if the donorcould benefit from the exchange, while his kidney may save therecipient’s life?Some argue that we have no right to subject a donor to any danger,
however small. Does this argument also apply to our accepted use ofliving related organ donors? For family members, people offer theirkidneys freely, but also under deeply ingrained societal pressure.Proponents maintain that the overall benefit to the recipient (andthe donor’s emotional payback) far outweigh the donor’s risk. Mightnot this argument apply equally well to paid donors?Combining money and medicine generates further moral issues;
some believe that commercialisation of transplantation is unethical.But transplantation (at least in the United States) already functionsas a business; well-managed transplant services earn considerableprofits (which allow for research support and other expenses), andmost transplant surgeons take home a generous salary. Certainlykidney sales would generate inequity, favouring the rich who canafford kidneys, and leaving the poor to wait in line for cadaverorgans. We must ask, therefore, whether it is better to help only therich, or no one at all. The utilitarian answer is clear.Even if we have no philosophical objection to kidney brokerage,
we must still face a multitude of practical and very difficult
questions before rendering judgment on this issue. Could we ensurethat paid kidney donors are healthy, well informed of their risks,properly recompensed, well-cared for, and truly willing? Could weensure that their organs are healthy? Could we fulfil our moralobligations to donors after their surgery? How would this businessaffect a Third World social structure? Would this business stimulatea reduction in voluntary organ donation? I cannot propose simpleanswers to, nor even compile an adequate list of, these questions. Ithus offer this letter not to advocate kidney brokerage, but rather toopen it up as an issue for discussion among the medical community.Harvard Medical School,Boston, Massachusetts, USA DAVID L. BACH
THE DISABLED MEDICAL STUDENT
SIR,-For most disabled people with a determination to succeedthe greatest handicap they are likely to face is other people’sattitudes. I speak from personal experience. The only additionalarrangement I needed to pursue a university course and career inmedicine was the use of an amanuensis for examinations. An injuryto my wrists many years ago has left me incapable of writing withoutgreat pain. I was offered a place on academic grounds and themedical school must have known of my disability because I had usedan amanuensis at school for my 0 and A level examinations and thiswas mentioned on my UCCA references. My disability was notdiscussed at the interview but an assistant registrar told me that ithad been discussed at length before a place was offered. I wasallowed to take my mid-sessional examination by dictation but themedical school then changed its mind and said that I must write myanswers or leave.A letter from another medical school had read: "competition for
places is so great that applicants with disabilities have to be
outstanding to stand a chance of selection". This discriminationmeans that disabled people frequently need to be, not just equal toother candidates, but better, before they are even considered.Third World countries now recognise that a disabled person can
often make a more empathetic and effective doctor as a result of hisor her experience, and this view is now being put into practice intraining. Perhaps it is time that UK medical schools learnt from theinsight of developing countries.
43/45 St Michael’s Hill,Bristol BS2 8DZ ELIZABETH A. CROW
1. Shirky O, ed. A cry for health: Poverty and disability in the third world London: ThirdWorld Group for Disabled People/AHRTAG, 1983.
CLICHES IN MEDICAL EDUCATION
SIR,-Professor Roddie (Oct 13, p 860) has been self-indulgent inselecting his own aunt sallies to shy at. Few would doubt theimportance of medical students learning anatomy since a knowledgeof the subject is one of the few things that really distinguish doctorsfrom other people and it is virtually the only medical science whoseteachers can lay claim to knowledge of the subject rather thansimply informed speculation. Similarly, most people would acceptthat it is more important to select medical students for intelligencerather than compassion since compassion can be taught andintelligence can not.Presumably these two readily demolishable propositions were
selected so as to distract the reader from the nonsense Roddie wishesto put across in relation to the value of psychology and sociology asdisciplines relevant to medical education. The casual.observation ofthe behaviour of one’s senior colleagues is no more a substitute for astudy of psychology than is casual observation of their dyspnoea onexertion a substitute for the study of respiratory physiology. If wewere to avoid exposing medical students to scientific subjects inwhich there is still much to learn, the medical curriculum would bemuch briefer and less demanding.Faculty of Community Medicine
of the Royal Colleges of Physicians of the UK,28 Portland Place, London W1N 4DE ALWYN SMITH
SIR,-Professor Roddie (Oct 13, p 860) asserts that medicalstudents gain an understanding of human relationships andbehaviour through the process of apprenticeships to seniorclinicians. The evidence, however, fails to support this contention.Students have been shown to fail to register a substantial proportionof patients’ personal relationships and feelings about their illnesses.Further, their deficiencies are not remedied by later clinical
training.’ Anyone supporting the primacy of the clinical interviewas a method of investigation must therefore question whether wetrain clinicians to achieve their maximum effectiveness. Thereremain many who doubt whether communication and empatheticskills can be formally taught but there exists now a substantial bodyof evidence showing that training in these areas is effective.2 I find itheartening to see that teaching of these skills, so long neglected inundergraduate courses, is increasingly finding a place in generalpractitioner training schemes.
Glenside Hospital,Stapleton, Bristol J. C. BARNES
1. Sonsan-Fisher R, Maguire P. Should skills in communicating with patients be taught inmedical schools? Lancet 1980; ii: 523-27.
2. Maguire P, Roe P, Goldberg D, Jones S, Hyde C, O’Dowd T. The value of feedback inteaching interviewing skills to medical students. Psycho! Med 1978; 8: 695-704.
SIR,-Professor Roddie provides us with food for thought in hisamusing account of cliches in medical education (Oct 13). I wasintrigued to hear that learning Latin or Greek inculcates neatness,precision, and logic in thinking, and that learning anatomy providesgood practice in the use of mental strategies to store large amounts ofinformation in the brain. However, after searching the considerablebody of research on learning strategies for the source of thisconclusion, I must confess that I cannot find it. This is especiallyfrustrating since Roddie is rightly sceptical about whether we reallyknow anything about the mind anyway-so he must requireconvincing proof of his firm statements about the effects of learninganatomy and so forth.
