Denying disabled people the right to be doctors unfair on many grounds - Guest Column by Dr Upreet Dhaliwal
March 4, 2019
Our guest column this week is my Dr Upreet Dhaliwal, Visiting Scholar, Institute for Medical Humanities, UTMB, Galveston and Former Director-Professor of Ophthalmology, University College of Medical Sciences, University of Delhi. In her column, she makes an eloquent argument against the new Medical Council of India guidelines regarding disabled medical aspirants.
The Medical Council of India (MCI)'s new guidelines regarding disabled medical aspirants is unfair for a variety of reasons.
It states that those with 40-80% locomotor disability will be eligible for the medical course. Even better, they add that "Persons with more than 80% disability may also be allowed; but after their selection, their functional competency will be determined with the aid of assistive devices."
This sounds like a progressive way to view disability, but then, in the very next column (Not Eligible for Medical Course), the MCI contradicts itself by stating that those with more than 80% locomotor disability will not be eligible.
A self-confounding document such as this one, which both enables and disables a person with more than 80% disability from being eligible can only confuse admissions committees. Denying admission to students who fall in the category of "more than 80%" locomotor disability without considering functional competence is unfair to the student.
A footnote in the above document states that: *Persons with disabilities of 40% or more may be allowed to pursue medical education, if the extent of disability can be brought down to below 40% with aid of assistive devices."
How is this to be assessed? Do we need to bring down the 'extent of the disability' or improve the 'ease of accessibility'?
Medicine is increasingly being aided by technology. Newer advances have made it easier for medical students and doctors with disability to negotiate the medical course and medical practice with the help of assistive devices. The problem is not with the disability but with the absence of accessible spaces and with the lack of will on the part of institutions and regulatory bodies to make reasonable accommodations for the disability.
With technological advancements, it has become easier to make accommodations that are reasonable and affordable. In the West, it is recognized that disability does not prevent learning - and there is no reason why medical students with locomotor disability cannot learn how to provide competent care. Denying them the opportunity is untenable from the point of view of social justice.
Apathy is the barrier
In accessible spaces, it is not impossible to imagine that a medical practitioner in a motorized wheelchair may, in response to an urgent call, reach the emergency department sooner than a colleague who goes on foot. By the same reasoning, a student who is a wheelchair user may have no difficulty in getting to the learning spaces in a timely manner. The problem, clearly, is not the disability but the inability or unwillingness of the teaching institution to provide reasonable accommodation. Teaching institutions should take the lead in this area and should consider it a matter of pride that they are providers of equal opportunity and are accessible in the real sense.
Functional competence is the keyword to determine if a person with greater than 80% disability can fulfil the arduous physical requirements of the profession.
How is it to be measured? Do we have guidelines? Is it appropriate and fair to have blanket guidelines that apply to all disciplines across the board? Apparently not - some medical schools in the United States, in response to the Americans with Disabilities Act (ADA), are beginning to orient themselves towards a more liberal interpretation of functional competence or technical standards depending on the specialty in question. This flexibility is in line with disability accommodation and policy makers recognize that, while learners must learn a little bit about everything, they will eventually specialize in only one discipline.
Thus, during rotations through different disciplines, a medical student may be given as much accommodation as is appropriate, but when choosing a subject of specialization, the student must consider if she can possibly acquire the expected competencies - with the degree of accommodation that is allowable in that discipline - keeping in mind patient safety.
Guided by the curriculum objectives, and aided by ethical and compassionate faculty who have an understanding of the social model of disability, it is only fair that the student herself decide if a specialty is the right fit for her. She can base her final decision on her own experience with her disability and on the accommodations that the institution is willing to make. The institution must display their requirements (must be able to perform cardio-pulmonary resuscitation, for example) and the accommodations they will offer (a convertible wheelchair that allows a learner with paraplegia to stand) so as to better inform applicants of what to expect.
Path to true inclusion
As per Office of the Registrar General & Census Commissioner, India, more than 21 million people in India have a disability of some kind. These are people who are expected to need greater healthcare but are likely to find it harder to receive it because of accessibility problems and due to financial and other disparities resulting from their disability.
The disabled are thus already vulnerable, and, as patients, their vulnerability is magnified when their bodies are misunderstood and lived experiences, disregarded. This will continue to happen as long as we see disability as a weakness and as a deficiency.
For healthcare providers and policy makers to understand and to see the potential or 'ability' in people with disability, it is important to recruit more people with disability into the healthcare scenario. True inclusion is more than just lip service. Integrating people with and without disability into the same spaces can, over a period of time, change our understanding of disability. True inclusion is to make the people visible and their assistive devices (and hence their disabilities) invisible.
One may ask why the MCI has drawn up a document that causes as much confusion as it seeks to clear up with regard to disability of more than 80%. One simple answer would be that the people drafting the advisory are not coming from a place of understanding. They have not lived the socio-scientific reality of disability.
It is not entirely their fault. Do we know how many doctors have disability? No, because there is no data in our country. Are there any studies on how a particular disability affects a doctor's ability to perform in her chosen field? Not in our country, although guidelines were formulated nearly a year ago by the Association of American Medical Colleges (AAMC) in collaboration with the University of California, San Francisco, School of Medicine.
The AAMC guidelines were based on the experiences of students with disabilities, which begs the question in the case of the MCI guidelines - on what basis is a person without disability competent to decide what a person with disability can or cannot perform with competence? This is ableism and it is unfair when policy decisions about people with a particular disability are made without involving the people who have that disability.
The message that people with disability may get is that they are not welcome in medicine or that they cannot possibly contribute in a meaningful way. Nothing could be further from the truth. By denying people with disability their right to train as doctors, we deny patients with disabilities access to medical professionals who understand their bodies and their reality from first-hand experience.
The literature, especially in our country, is replete with instances of how people with disability work for the benefit of others with disability. Clearly, it would be in tandem with the ethos of the country's policy towards the disabled community to have more physicians with disabilities on the workforce. Further, medical professionals - who are currently 'temporarily able' - are denied a chance to understand disability in the real sense if we don't facilitate the sharing of workspaces which allow them to bear witness to the lived experience of colleagues with disability.
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