Marriage below 18 years: Unfair burden on Judges?

The interest of the girl child and her protection will be better served by legislators fulfilling their duty and responsibility by enacting legislation founded on such solid medical evidence

By Dr R Neerunjun Gopee

The debates over the Children’s Bill have not been completed, and whether or not they will take place will depend on whether there will be further parliamentary sessions, as persistent rumours are going around about a possible dissolution of the National Assembly.

We are concerned here with the related issue of the age of marriage, which is defined in the Code Civil in sections 144 -147. In a nutshell, these allow a marriage under 18 but over 16 to be contracted with the consent of one or both parents. In their absence, a Judge in chambers can give the authorization on a plea by a responsible party, on the condition that ‘La demande est instruite par le Ministère Public. Si la demande parait fondée, le Ministère Public saisit le Juge en chambre qui statue conformément aux dispositions de l’article 145’, which in its second paragraph specifies that ‘il est loisible au Juge en Chambre d’accorder une dispense d’âge au
mineur lorsqu’elle est nécessaire à l’intérêt de celui-ci’. (italics added)

To us the ‘parait fondée’ and ‘à l’intérêt de celui-ci’ are very vague and confusing. No objective criteria are set out; instead the burden of decision is left to a public officer and a Judge without any further element being provided regarding on what basis they can take that decision, which is bound therefore to be subjective and may contradict the principle of being in the interest of the child – for after all that is what the ‘mineur’ is!

This will particularly be the case where the parents or responsible party are concerned, for they may coerce the girl-child into marriage for pecuniary, economic or other obscure reasons as other observers have already pointed out.

But it is instructive to look at what the French Code Civil says on this issue. As regards the girl, she must have attained ‘cette condition dite de “puberte legale” ’ – but what follows is even more relevant to the debate: ‘ “Puberte” ou plus exactement maturite car la perspective est plus desormais d’eviter un engagement hatif que de s’assurer des fonctions procreatrices du couple’.

The protection of the girl child must therefore begin with this perspective, and it is here that the medical dimension of this issue assumes its critical importance because, precisely, it is about the anatomical and physiological maturity of the girl child to procreate.

This was explained in detail in a brief by Dr CS Ramdaursingh, Obstetrician/Gynecologist, in last week’s edition of this paper. The essential point is that the immaturity of the pelvis below the age of 18 predisposes pregnancy taking place in that age group to a high risk of complications which include, among others, higher rates of both maternal and infant deaths.

Besides the other elements that must imperatively be factored into an eventual decision on this issue, which have been clearly set out in the excellent paper by M Sheila Bunwaree also in last week’s issue of this paper, we pray therefore that this medical/obstetric dimension be taken into serious consideration when the debates take place and that the Code Civil be amended in consequence so that the age of marriage is fixed at 18 instead of shifting the responsibility to a Judge.

Both as a layman and a medical professional I think that this is putting an unfair and unreasonable burden on our Judges. After all, they are not expected to be knowledgeable about the medical minutiae which relate to childbearing below the age of 18, an aspect which, as outlined above, is critical in setting the minimum age.

The interest of the girl child and her protection will be better served by legislators fulfilling their duty and responsibility by enacting legislation founded on such solid medical evidence as well as the human rights and other considerations that concerned stakeholders have been publicly voicing out. Clearly, when the relevant sections in the Code Civil were inserted there was insufficient medical/obstetric evidence. But this has evolved, and so too the other aspects relating to the overall physical, emotional and psychological development of the girl child, not forgetting the social environment and her legitimate aspirational expectations. It is high time therefore to correct this anomaly by making the appropriate amendment, thus absolving the need to have recourse to the judiciary and ensuring her genuine protection.

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Government U-turn on pre-registration examination for doctors

I welcomed the news that Government has taken the decision to abolish the examination for newly-qualified doctors before they undertake their period of training prior to their obtaining full registration – hence Pre-registration – by the Medical Council of Mauritius (MCM). This would then entitle them to practise as independent medical practitioners. That means they then begin to assume full clinical and legal responsibility for their medical acts, on the spectrum from diagnosis to treatment. They will now only have to take an examination at the end of the completion of their period of training, lasting 18 months, that is an exit examination.

In an article titled ‘Why an examination for pre-registration trainee doctors?’ which I wrote in this paper on September 2, 2016, I had given an account of how the training – which goes by different names in different countries (internship, housemanship) – takes place in other countries, especially the UK and countries such as India which are broadly based on the UK model too but with variations. It may be noted that the MCM was set up based essentially on the UK’s General Medical Council. My continuing interest in the issue stems from the fact that at various stages and levels of my career I have been involved with both medical education, and the regulatory and policy aspects of medical practice and professional development.

I had pointed out that ‘the examination for pre-registration trainee doctors has been of concern off and on at the Medical Council of Mauritius and at the government level. The idea and rationale for the examination has developed in leaps and bounds over the course of several years, and not at all coherently, given that there is no specific body dealing with medical education in the country in all its aspects. There has therefore never been any serious, focused thinking in this regard with the participation of all stakeholders’.

I had then pointed out that ‘after discussions between the two major stakeholders, the Medical Council and the Ministry of Health, it was decided that an exit exam would be a better alternative’, so as to be ‘fair to those who had not studied in English’, since the examination is conducted in English. Further, these aspiring trainees faced a major constraint, namely a lack of coaching facilities to make them conversant with English medical jargon. This facility is available in countries such as India which do a screening at entry, that is before undergoing pre-registration training (internship).

Following a technical recommendation, a decision was taken to conduct the local exit examination using Multiple Choice Questions. This would supersede the earlier system of assessment twice yearly, which covered five major specialties as had been agreed upon. There had been some criticism of that system, and its organization was at times not quite satisfactory. The recommendation was implemented until the incoming government decided to go for an entry-level examination, that is before doing the training. No explanation was given for this change, and as a result many newly-qualified doctors have been penalized, especially those who could not pass the exams.

But earlier too, the setting of the paper and the organization of the examination was entrusted to a foreign (Indian) entity instead of to the Mauritius Institute of Health as had also been recommended, as the latter institution has been involved in organizing and conducting examinations in the medical, paramedical and allied medical fields at certificate, diploma and post-graduate levels for nearly three decades. Again, why the choice was made to have the paper set by foreigners, in this case the National Board of Examinations of India (NBE), was never explained.

On the other hand, the MCM has to date never been able to have access to samples of the question papers that they set, and this may be part of the reason for the high percentage of failures in these exams. Foreigners do not know the local context of the practice of medicine, and the Multiple Choice Questions may reflect problems of their country that have less relevance for Mauritius. With access to the papers, MCM could have guided them in the preparation.

The chapter of exit examination for the trainees is therefore not closed. Now that the entry-level examination has been abolished, the next step is to seriously consider commissioning the Mauritius Institute of Health to conduct the exit exam for reasons mentioned above, with the help of the Mauritius Examinations Syndicate if need be.

It is not rocket science to have a periodically revisited bank of Multiple Choice Questions prepared with local expertise by medical practitioners who would factor in the local specificities in terms of epidemiology, pathologies and management of medical problems. This would certainly be more appropriate and a logical follow-up to the decision to conduct only an exit-examination.

This said however it is also up to the trainees to apply themselves with the required degree of seriousness during their various postings so as to learn as much as possible and begin to acquire the basic skills – such as examination of patients, proper presentation of cases especially in emergency situations, performance of basic procedures, communication with patients and their responsible parties, etc – that they will require in their future careers as full-fledged doctors. This applies particularly to graduates who studied in a language other than English, so that they are better prepared when they sit for the exit examination.

This is all the more necessary as we do not have enough of a teaching/learning culture in our health system, which is essentially service-oriented. The majority of specialists are not interested in teaching juniors, and this, coupled with a lackadaisical attitude on the part of some of the latter who ought to know better, complicates matters. The advent of Continuing Medical Education (CME) as part of Continuing Professional Development (CPD) over the past few years, which has become an institutional requirement rather than being an individual option on the part of the practitioner, has forced doctors to attend lectures, seminars and conferences to refresh and update themselves. Pre-registration trainees should certainly take maximum benefit of these, as well as pursue self-learning because at this stage of their career they should not expect spoon-feeding.

Inevitably, the situation will continue to evolve, especially as regards CPD, which took decades to shape up – and is still developing — to the satisfaction of both medical regulatory bodies and doctors in the countries where CPD was initiated (UK and US in particular). But at least a beginning has been made, and with other measures this is bound to improve the quality of medical care.

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* Published in print edition on 4 October 2019

Tags:Children’s Bill, Code Civil, Continuing Medical Education, Continuing Professional Development, Dr R Neerunjun Gopee, Mauritius Examinations Syndicate, Mauritius Institute of Health, Medical Council of Mauritius, Minimum Marriageable Age, National Board of Examinations of India, Pre-registration Examination for Doctors