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May 28, 2001
 Vatsal Doshi Photo by Jeff Cleary |
Panel Questions Ethics of Student Debt
Every spring many returning students at HMS and HSDM file an application for financial aid. After receiving the award packages over the summer, we are momentarily reminded of the educational debt we are accruing. We are well aware that the loans hanging over us, to some extent, have an impact on our daily lives and may affect our career paths. Yet many of us may be unaware of the collective impact of this effect.To approach the issue of increasing student debt and, in particular, the ethical dilemmas it creates, the Division of Medical Ethics sponsored a panel discussion titled "Speculating on the Future: Ethics and Medical Student Debt," held on May 8 in the TMEC amphitheater. The discussion was moderated by Dr. Daniel Federman and included four individuals with various perspectives on debt and student financial aid: Dr. Nakela Cook, HMS '00 and currently a clinical fellow in medicine at Massachusetts General Hospital; Dr. Robert Dluhy, assistant director of the Endocrinology–Hypertension Division at Brigham and Women's Hospital and chair of the HMS Financial Aid Committee; Ehrin Johnson, a second-year HMS student who serves on the Financial Aid Committee; and Dr. Carl Marci, HMS '97 and a clinical fellow in psychiatry at MGH. The panel provided an interesting and often enlightening discussion of the social and ethical issues surrounding the increased burdens of financing medical education.
The Debt Balloon
Medical student debt is a significant problem and will become an even bigger one, based on current projections. From 1990 to 1998, the average student debt at HMS increased 63 percent, from $47,357 to $76,969. The figures correspond to the 62 percent climb in the national average over a similar period. This increase can only partly be explained by the rise in tuition; other factors, including cost of living, come into play. But the situation also has a historical basis.As Dr. Federman explained, starting in the late 1960s, the obligation to pay for education shifted from the family to the student. And whereas most students on financial aid previously had a work obligation, they began to rely more heavily on student loans. This change was fueled by an increased demand for doctors in the 1970s, which the federal government responded to by providing direct student loans and later passing laws to guarantee them.
With the level of student debt rising, the most obvious ethical challenges are whether students place finances ahead of educational objectives and whether debt has an influence on specialty and career choices. Though earlier studies did not demonstrate a correlation between debt and specialty choices, more recent work (JAMA 1998, 280(21); 1879-1880) by Dr. Marci and his classmate Dr. Tom Roberts supports this hypothesis. As HMS students, they administered a questionnaire to second-year classes between 1995 and 1998 to assess the level of students' debt and the students' perception of how much this would influence their specialty and career choices (e.g., academics vs. private practice). At debt levels between $25,000 and $75,000, they found a positive linear correlation between debt and influence on specialty and career choices. (Beyond $75,000 the relationship plateaus.) Many of the panelists viewed the correlation as troubling, especially if student debt continues to rise and inflation-adjusted physician incomes continue to fall, particularly for those working in primary care and similar specialties or in underserved areas.
Dependent Decisions
There may be ethical challenges beyond the influence of debt during medical training. A disheartening example that was mentioned is the case of alumnus Mike Myers, HMS '85, who despite firm advice to the contrary decided to pursue his dreams of doing primary care and opened up a private practice in a local community. Ultimately, however, faced with the combined financial burdens of his medical school loans and the costs of his practice, he realized he could not deliver care the way he was trained, closed the office, and accepted a salaried position at a university health clinic. This seems to be only one of the examples of the changes in career that have occurred based on financial considerations. The influence of debt on career choices has been readily apparent to Dr. Dluhy, who as an endocrinologist at BWH has seen many of his fellows quit their clinical education and research activities. The two biggest alternatives have been private practice and industry, which is always seeking talented individuals who have completed a significant amount of training. Dr. Dluhy points out that ultimately student debt has a significant societal cost since intelligent and talented people are drawn away from academic research. Eventually, there may be fewer advances and a decline in the quality of American medicine.The potential impact of medical student debt may also include a loss of diversity. As Dr. Federman pointed out, there may be a certain self-selection discouraging some students from applying to Harvard due to cost as well as students opting for more lucrative careers. Among those who decline an offer from Harvard, the top three reasons for choosing other schools are 1) getting into an MD–PhD program elsewhere, which may have some financial advantages; 2) being involved in a personal relationship in another city; and 3) not being able to bear the cost of attending Harvard.
Medical student debt may have greater consequences for minority applicants and students. As an African-American woman, Dr. Nakela Cook provided a personal perspective on the discussion. Though she was offered an excellent scholarship at a public university, she decided to attend Harvard to gain the best possible experience and leadership skills she could bring to her work as a primary care physician in medically underserved communities. Dr. Cook pointed out that based on a recent HMS graduation survey, minorities are more likely to choose working with indigent populations, yet traditionally they have averaged higher levels of debt.
Monopoly Money
Ethical issues are also raised in terms of personal fiscal responsibility. Money in the form of loans can be dangerous since the student often never actually sees it: the loan amount goes straight from an award letter to a credit on the student term bill. One would think that with such high levels of debt, students might not think much about taking out an extra $1,000 to help pay for car expenses or go on vacation. And there is some data from the Marci and Roberts study supporting this assumption. Their survey shows a decrease in comfort level and increase in worry for debt levels up to $75,000, but beyond that the curves reach a plateau.To maintain a realistic appreciation of indebtedness, students should have a lifestyle within their means because every small excess adds up. Whether we have a tendency to splurge or not, some of the panelists emphasized how important it is for all of us on financial aid to plan and maintain a monthly budget.
Institutional Responsibility
The issues surrounding medical student debt should not only be centered on student decisions and actions, but to some extent should also include the institution itself. For instance, what are the ethical dilemmas that schools with large endowments, like Harvard, face when they have a student body with exorbitant debts? Such ethical concerns are highlighted by the finding that from 1985 to 1995, scholarship support kept pace with tuition increases at public schools but lagged behind the increases at private schools (Academic Medicine 1996, 71(10);1124-1134).Though much of the Harvard endowment is earmarked for specific uses, it includes discretionary funds whose purpose is up to the School. Even some leaders within the administration would agree that more of the discretionary spending could be devoted to reduce student debt.
There also are choices that must be made when deciding how to calculate the financial aid awards. How much home equity, for example, should be included as part of assets, and should stepparent income be considered a source of family support? The HMS Financial Aid Committee has had to deal with these very questions and, through the efforts of its members, has instituted changes that have benefited students. Two years ago, a decision was made to discontinue the practice of using income data from more than two parents in cases where they divorce and remarry. And currently the use of home equity has an upper limit set at 1.5 times the parental income. Future efforts may be undertaken to lower this even further. The administration also has escalated fund-raising programs to increase scholarship support for students.
Though most of us will eventually pay back our debts, it is the decisions we make in light of these debts—ranging from how many nights we eat out to what specialty we choose or whether we get married before graduating or pursue another degree—that will ultimately make a large impact on our lives. And as is usually the case in the realm of ethics, dilemmas will continue to exist. For instance, is it fair for 30-year-olds to ask their parents to contribute to their education? Should HMS discourage prospective students from applying if they are interested in primary care and have significant financial needs? Should the School make an effort to devote more of its funds to scholarships or should it continue to invest more resources in those areas that make it a leader in medicine?
As we continue to grapple with these issues, it may be helpful to keep in mind the three principles that Dr. Marci offers. First, sublimation is a better defense mechanism than denial. Rather than ignoring our debts, we can take a more active approach by managing our personal finances appropriately or becoming involved in efforts to change the financial aid system. Second, data matters because having good data gets people's attention. And finally, though the market will bear certain costs and decisions, this does not necessarily mean they are right.
—Vatsal Doshi, a third-year medical student at HMS