AMA Journal of Ethics^®

Case

Emily, a medical school candidate, had high grades and MCAT scores and extensive volunteer experience. The committee members who interviewed her reported that Emily had spoken movingly about her desire to become a primary care physician in a rural setting.

The committee’s student member, Jason, looked up Emily on Facebook to see whether they had any friends in common. There he found a link to a blog post that attributed rising rates of contagious disease and unemployment to illegal immigrants. Emily had added: “I couldn’t agree more. People whose mothers just happened to sneak over the border at the right time are called ‘citizens’ when they’re just driving down wages, straining our infrastructure, and taking jobs that rightly belong to honest, hardworking taxpayers. Why should we take care of them?”

Emily’s Facebook post revealed a side of her that Jason knew the admissions committee hadn’t seen, and he wondered what he should do with this information.

Commentary

Just when access to information at a moment’s notice seems like old news, a growing trend in the virtual world is the ability to share personal experiences and ideas with one’s friends and family anywhere. Social networking sites like Facebook and Twitter have allowed insight into an individual’s life like never before, but in what situations is such insight appropriate? In the case of medical school hopeful Emily, online social networking activities should not be considered during the selection process for her admittance.

In order to narrow the applicant pool, medical schools have adopted a three-stage process: screening, interviewing, and selection [1]. Because there are a limited number of positions in the entering class, it can be said that admission represents a limited good to be disbursed at the admission committee’s will. Given this arrangement, one can see that justice becomes an important part of the selection process. In his book Beginning Bioethics, Aaron Ridleydefines justice as “giving people what is fair, due, or owed to them” [2], in other words giving people what they deserve. Applying this idea to the admissions process, if the committee determines that an applicant deserves admission, then the committee ought to grant it. The information the committee uses to determine whether the applicant’s academic achievements and character are deserving of admission is that which the applicant submits in the first two stages of the process: screening and interviewing. The end of the interview stage marks the point in the process after which the applicant cannot defend, expand upon, or put into context any information that the committee considers. Equally important is the fact that the applicant has only knowingly submitted information up to that point and has thus been in control of its content.

This is not unlike a trial proceeding, in which a jury (analogous to the admission committee) decides on a defendant’s deservingness of acquittal (or conviction) based upon information presented during the case. In this arena where, ideally, justice is preserved, the jury is only to consider the information presented formally in court, where the defendant has the opportunity to counter or defend the information presented. Indeed there have been cases in which jurors have used social networking sites, among other Internet resources, to convey or discover information not deemed admissible by the judge, which resulted in mistrials. For instance, in a Florida case where the defendant was accused of selling prescription drugs illegally over the Internet, 8 weeks of proceedings unraveled into a mistrial when several of the jurors conducted online research about the case [3]. Clearly, consulting resources beyond the confines of the proper pathways has been deemed unfair in the legal system, as the information no longer can be properly scrutinized, particularly by the party to whom the information pertains.

Proper, fair pathways also exist in the selection process for medical school. According to the Liaison Committee on Medical Education, which sets accreditation standards for all U.S. medical schools, an institution “must develop criteria, policies, and procedures for selection…that are readily available to…applicants” [4]. Furthermore, the Association of American Medical Colleges dictates that an institution develop “clear, consistent criteria and processes” [1] for selection. Thus, a just process guarantees the applicants both transparency and consistency in the admission guidelines. Indeed there are now actually two criteria for justice within the selection process: (i) that those to whom admission is due ultimately receive it, and (ii) that all applicants receive what they are owed from the onset (transparency and consistency). Since it appears that Jason took it upon himself to consult Facebook for his own reasons (common friends, likes, and dislikes), and he is left “wondering what to do with the information,” it is unlikely that this is an official committee procedure, so Jason’s activities would not have been disclosed to the applicants. He thus violates the transparency requirement of the process. Furthermore it appears that Jason was able to glean the extra (not gathered from the first two stages) information only about applicants who used Facebook and had an open account. Jason’s method is therefore inconsistent, unlike the screening and interviewing stages, which all applicants undergo. Thus, if the committee were to consider Emily’s social networking activities, then the selection process would be neither transparent nor consistent, making it unjust because all applicants would not be receiving what they are owed from the onset. Were the committee to use this type of inconsistent information, which may be out of context (remember that at this point applicants cannot defend or explain this information), then it could be argued that determining which applicants actually deserve admission becomes obscured, potentially preventing deserving applicants from being admitted while undeserving applicants receive admission. In this way the process would meet neither justice criterion.

Those who support use of social networking media in the selection process may say that the process is already unjust, as it is nearly impossible to know absolutely who does and does not deserve admission. Furthermore, if committees officially made social networking investigation part of their process, it would allow them access to more material with which to make a more informed decision. It can also be argued that, given the limited spots, not every applicant who deserves admission receives it, so the selection process is also unjust in this way. In response, I assert that, while there are inherent limitations on how much information the committee can gather in the first two stages due to finite interview time and class sizes, those limitations are consistent and institutionally enforced. For instance, all applicants are limited to the same number of characters in writing their personal statements, and all interviews last generally the same amount of time. Conversely, social networking sites are virtually limitless, and the amount and content of information is determined only by the user. If the committee were to disclose its utilization of Facebook, which it would be required to do if it made such sites an official part of the selection process, then an applicant would be free to alter and add information as he or she saw fit, in effect undermining the candid quality of Facebook that would have been attractive to the committee in the first place. In addition, some candidates may not have social networking accounts, making the process inconsistent, unless the committee required such accounts at the onset. Certain information fields would then need to be specified as mandatory, and the social networking account would become just another element in the formal application to be submitted during the screening stage. Although it is unfortunate that not all deserving applicants gain admission, I argue that it is not the committee’s job to grant admission to every deserving applicant; rather, they must ensure to the best of their ability that available space is filled only with deserving applicants—that it is as just a selection process as possible.

A more pressing argument may be that future patients’ care is at stake if Emily harbors biases that may influence her ability to fulfill a physician’s responsibility to all patients. As a result, this argument goes, Jason has an obligation to inform the committee, even at the risk of making the selection process unjust. Here it is important to look more closely at Emily’s comments, which, when the “tone of disgust” is removed, essentially state her opinion against noncitizens who have illegally immigrated and are placing an apparent economic strain on American society. She is not necessarily morally opposed to immigrants or immigration in general. While immigrants (documented and undocumented) do not cost a disproportionate amount of money to treat, their treatment is more likely to be classified as uncompensated care [5], which, one could argue, can cause an economic strain. It’s possible that Emily may decide in the future not to provide uncompensated care, meaning that patients who do not have health insurance will not receive her care. This may even include American citizens without insurance, since many fit this profile, although the percentage of uninsured is lower among citizens than non-citizens. In reality this is not unlike what is currently happening in health care; some physicians have decided not to provide services to the uninsured or even to patients who do have a particular level of insurance [6].

Another illustration of the fact that physicians can deny care is the legal protection they have in refusing to participate in abortions if they are religiously or morally opposed to doing so [7]. In fact no physician, simply because he or she is a physician, is required by any oath or law to treat all persons; physicians are traditionally held to the principle of nonmaleficence, but not necessarily that of beneficence. After all, Hippocratic writings say “help or at least do no harm” [8], indicating that above all physicians should not harm patients. Whether physicians are morally obligated to help all others is still debated among philosophers and ethicists. Any policies requiring physicians to treat all patients would most likely be contractually enforced by the individual practice or institution by which the physician is employed, and such requirements are not universal. While arguments can be made that patients should receive care regardless of their circumstances, whether or not such universal mandates should be placed upon physicians as a result is beyond the scope of this discussion. So although the physicians whose ranks Emily desires to join do treat a significant number of documented and undocumented immigrants, they are not universally required to do so. Therefore to deny Emily admission based upon her apparent bias is to impose upon her a requirement as a potential future physician that physicians are not currently subject to. Such imposition would be unfair unless all physicians had the same requirement, and, because it is not the admission committee’s place to impose requirements on current doctors, it should not consider her comments as detracting from her future ability to be a physician. Because the potential outcome of Emily’s bias would not prevent her from fulfilling the responsibilities of a current physician, Jason has no obligation to inform the committee, especially when doing so would cause the process to become unjust.

Nevertheless, Emily’s comments do sound rather crass, most likely because she expressed her opinions in an unprofessional way. Indeed, unprofessional content posted on social networking sites is not uncommon, with 60 percent of medical schools reporting similar activities among their students [9]. However, professionalism has been identified, together with ethics and communication skills, as a competency that graduates of medical education must meet and that academic medical institutions must incorporate into their teaching [4]. While Emily did display unprofessional behavior in her comments, denying her admission would be undermining the recognized ability of medical students and graduates to grow into professional, respectful physicians as well as the medical institution’s ability to help its students become sensitive to and aware of cultural differences. Moreover, through lessons and personal experiences throughout medical training, it is perfectly reasonable to believe that Emily can learn to conduct herself appropriately in the future and even overturn her present bias. Emily’s responsibility is merely to be cautious of what she posts online; her medical training should subsequently prepare her to meet the professionalism standards of a physician.

In summary, it would be unjust for the admission committee to consider social networking activities during the selection process because such practices would violate the principles of transparency (the application process does not state that networking activities are considered by the committee) and consistency (not all applicants post on social networks), while potentially denying deserving applicants due admission. Furthermore, use of such information may lead committees to impose upon applicants standards that are not imposed upon practicing physicians or professional values that the medical curriculum has a responsibility to cultivate in future physicians.