Criminal records and studying medicine

Authors: John McMillan, Barry Wright, Giles Davidson, Jonathan Bennett 

Publication date:  27 May 2009


Should a spent conviction prevent entry to medical school? John McMillan, Barry Wright, Giles Davidson, and Jonathan Bennett consider the main arguments for and against rejecting applicants on the basis of a criminal record

Although academic excellence is usually a prerequisite for admission to medical school, other attributes and achievements can enhance an applicant’s chances. Given the competition for medical school places, any blemish on an applicant’s record, whether it is academic or relating to illegal behaviour, is likely to put that applicant’s chances of admission to a medical course in jeopardy. Majid Ahmed’s rejection by Manchester, Cambridge, Leeds, Sheffield, and Imperial medical schools was related to his conviction for “burglary dwelling” when he was 16.[1] Imperial Medical School withdrew an offer on fitness to practise grounds and because Majid Ahmed had not disclosed his conviction on application. On appeal, Manchester reconsidered its earlier rejection and offered him a place.[2] [3]

This article considers some of the main arguments for and against rejecting applicants on the basis of a previous conviction for a minor criminal offence.

Who should decide?

In many countries, including the United States and the United Kingdom, applicants to medical school all undergo a criminal records check. Although professional bodies such as the General Medical Council and the Association of American Medical Colleges think that criminal convictions are relevant to a student’s suitability for medicine, they do allow medical schools to make the final judgment.[4] This approach seems right, given that these decisions can involve a number of mitigating factors, as was the case for Majid Ahmed. How these decisions are made is likely to very considerably among medical schools in different parts of the world. In the UK, the decision will probably be taken by the admissions tutor after they have sought advice about the importance of a conviction for that student’s fitness to practise. Although the decision is left to medical schools, the discussion that Majid Ahmed’s case generated serves as a precedent for similar decisions in the future. We have not seen the material that informed the decisions that the medical schools made, so we cannot comment on whether we think they made the right decision. Some general considerations should be taken into account when making such decisions, however, and these have been incorporated into the procedures at Hull and York.

Minor criminal convictions

What implications do minor criminal convictions have for fitness to practise, and is it acceptable to use these as a basis for choosing the best students? Is it reasonable to say that where there are two equivalent students we should choose the one without a criminal record over the person who has one?

For more serious offences this approach does seem reasonable because previous offences are one of the most robust predictors of future offences—for example, with sexual offences[5] or violence.[6] The picture becomes more blurred when considering minor offences. Many, but not all, minor criminal convictions give reason to doubt a person’s honesty. When someone shoplifts, it shows that they are capable of being dishonest, in so far as theft implies a willingness to deceive or not honour an implicit agreement. Dishonest behaviour, such as cheating, has been shown to be one of the most powerful predictors of future dishonest behaviour.[7]

Some other offences, however—such as using illegal drugs, inappropriate sexual behaviour, or violence—don’t necessarily imply that a person is dishonest. If they imply a problem, it has more to do with a willingness to partake in behaviour that is illegal and harmful to themselves or others. Clearly such offences raise serious questions about possible risks to patients, the possibility of more serious crimes being committed, or other unprofessional behaviours.

In the UK, the General Medical Council has instructed medical schools to be mindful of the impact that a criminal conviction could have on patients, the general public, and the profession.[8] These broad considerations seem to imply that all kinds of criminal offence could be relevant to whether or not behaviour is appropriate. In addition to the kind of criminal offence, the seriousness of the offence is also important.

Seriousness of criminal offences

Assessing the importance of crimes for fitness to practise entails making case by case judgments about any implications for future behaviour.

The implications of an offence are likely to depend on a number of factors, such as the context in which it occurred, whether it was a repeat offence, the age at which the offence took place, and whether there were other mitigating factors such as peer pressure. The complexity of these judgments means that a case by case assessment of mitigating factors is important.

A number of extenuating circumstances surrounded Majid Ahmed’s conviction: it occurred after his parents had separated; and he had joined a different school and come into contact with older peers.[1] It seems likely that Manchester University weighed considerations such as these in the balance when considering and accepting his appeal.

Applicants versus admitted students

Although the importance of patient safety is paramount, fitness to practise proceedings should aim to help medical students rather than punish them.[9] If a medical student’s behaviour is inappropriate and calls into question their fitness to practise, things can usually be done to decrease the chance that this behaviour will be repeated. For example, if a complaint is made about a medical student expressing frustration at a patient, helping the student to avoid that reaction is likely to be more appropriate than punitive measures such as suspension. Helping the student might include pointing out the importance of controlling this behaviour and the ramifications of failing to do so, as well as equipping the student with additional skills for self awareness and coping.

The obligation to work with medical students so that inappropriate behaviour is not repeated is a duty that all medical schools have in educating and training medical students to become doctors. Although a medical school is obliged to help admitted students meet required levels of fitness to practise, it’s not clear whether they have the same duty when considering the fitness to practise of an applicant.

Two views about applicants

It could be argued that any previous conviction or other minor misdemeanour is sufficient for rejecting an application—let’s call this the “hardnosed view.” An alternative position is that we should consider each case individually and make a determination that balances the positive and negative aspects of each applicant. This approach would not automatically dismiss an applicant with a criminal conviction, but it could include consideration of a criminal conviction as a negative on the “balance sheet.” It could also allow that factors arising from that negative, such as remorse and whether there is evidence that the student has learnt from the experience, might partially mitigate the negative. Let’s call this the “contrition view.” Contrition involves seeing why something that you’ve done is bad and learning from this so that you don’t do it again.

Although the hardnosed view seems a particularly stark and unforgiving position, in its favour are some reasonably good arguments.

A medical school has a number of duties to students once they are admitted: among other things, it has an obligation to give them an appropriate education. Medical schools do not, however, have this obligation to people who are not current students. Providing reasonable measures to help students become fit to practise and considering carefully any mitigating circumstances for unprofessional behaviour are also duties that schools have to students who have been admitted.

What is less clear is whether medical schools have the same kind of duty to applicants. Medical schools have many duties when considering applications. However, because an applicant is not yet a student, the obligations to educate and train that follow from standing in this kind of relationship do not apply, and this is another argument in favour of the hardnosed view.

It is clear that medical schools are right to take into account the importance of criminal convictions for fitness to practise. For admitted students, criminal convictions should be considered on a case by case basis, which seems to be the approach taken by Manchester. ON the other hand, the right response to applicants who have a minor criminal conviction is less obvious. Medical schools are likely to adopt a hardnosed view for certain convictions and may vary (between hardnosed and various interpretations of a contrition view) for other convictions, at least partly because of the difficulty in weighing up a number of complicated factors, such as the importance of diversity and the degree of misfortune. Although it would be good to be able to recommend a standard approach to cases such as Majid Ahmed’s, the complexity of these issues and the fact that a number of these issues are highly arguable mean that it’s likely that variation between medical schools will continue.

Summary

  • Fitness to practise for medical students amounts to ensuring patient and public safety and public confidence in the medical profession

  • Fitness to practise should be formative rather than punitive

  • Plausible arguments exist for and against using spent convictions for selection

Links

Competing interests: All authors are members of the Hull York Medical School’s fitness to practise committee.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Colquhoun J. Student rejected because of conviction is granted interview. BMJ  2008;337:133.
  2. Colquhoun J. Student with spent conviction gains places at medical school. BMJ  2008;337:370-1.
  3. Colquhoun J. Barred. Student BMJ  2008;16:308-9.
  4. Association of American Medical Colleges. Report of the AAMC Criminal Background Check Advisory Group, 2006. www.aamc.org/members/gsa/cbc_final_report.pdf
  5. Hanson RK, Bussiere MT. Predicting relapse: a meta-analysis of sexual offender recidivism studies. J Consult Clin Psychol   1998;66:348-62.
  6. Bonta J, Hanson K, Law M. The prediction of criminal and violent recidivism among mentally disordered offenders: A meta-analysis. Psychol Bull  1998;123:123-42.
  7. Whitley BE. Factors associated with cheating among college students. A review. Humanities, Social Sciences and the Law  1998;39:235-74.
  8. General Medical Council. Medical students: professional behaviour and fitness to practise. www.gmc-uk.org/education/undergraduate/undergraduate_policy/professional_behaviour.asp
  9. R (on the application of Higham) v University of Plymouth [2005] EWHC 1492 paras 27 and 47.

John McMillan senior lecturer in medical ethics  Hull York Medical School, University of Hull, Hull
Barry Wright consultant psychiatrist and senior lecturer  Hull York Medical School, University of York, Heslington, York
Giles Davidson head of administration  Hull York Medical School, University of York, Heslington, York
Jonathan Bennett associate dean for students  Hull York Medical School, University of Hull, Hull

J McMillan  john.mcmillan@hyms.ac.uk

Cite this as BMJ Careers ; doi: