A thumbnail history of admission by lottery in Dutch medicine studies

Translation by Lambert Schuwirth of the original Dutch by Ben Wilbrink

In 1975, a special constellation of influencers and decision-makers existed (after education minister Mauk de Brauw had previously had use a lottery system for entry into medical school due to an acute emergency situation after a court ruling in 1972). Secretary of State Ger Klein (Labour Party, PvdA) initiated a legislative proposal for an enabling law that was meant to more systematically regulate admission into studies with a so-called numerus fixus (limited number of available spots). Both in society and in the House of Representatives heated discussion were had when the draft law was being considered: in 1975.

It is important to consider which principles were at stake? According to the law, everyone who passed the appropriate high-school final examinations was eligible for admission. So, the mere concept of a ‘numerus fixus’ infringed on this principle. In order to be able to perpetuate this infringement enabling legislation was required. This is a serious matter indeed from a deontological perspective and it begs the question ‘who has the right to study medicine?’

Professor Hofstee (well known from the Hofstee standard setting method) voiced a strong opinion. In his view, we – the legislator and society – should not play God and decide about young people’s lives frivolously. Instead, he proposed utilitarian and morally purer methods like using a lottery. [see note 1]

Moreover, a lottery had already been initiated by minister De Brauw which constituted a precedent. In the cabinet of prime minister Den Uyl, secretary Ger Klein proposed a lottery system with equal chances. A key argument by Klein at that time against selection solely based on final exam grades was that this would be discriminatory towards girls. This is noteworthy, because in later years, girls would indeed reverse the roles.

In this debate, the liberals (MP Ginjaar-Maas), strayed from their principles and favoured selection purely based on grades. But selecting on the basis of grades would further undermine the law. The law stipulated that admission to university is granted by passing the exam and not by a particular grade point average. But by that time, the House of representatives was already working on a ‘definitive’ enabling law to regulate the ‘numerus fixus’ studies, and so it would theoretically be possible to also authorize selection based on grades.

But the factual question is to what extent final exams predict success in studies/professional life. The answer is fairly simple: they do to a small extent, but not enough to justify such high-impact decisions. Dutch secondary education is tiered and only the top two tiers give automatic access to university education. Selection takes, therefore, place at the end of primary school. At the end of

year 6, students receive an advice as to which tier of secondary school they are eligible for. This advice is based on the teachers experiences with the children but also the results of a large national test and carries a lot of weight in the decision of the parents to which school to send their child but also in the receiving schools’ decision whether or not to accept the child. So, selection has already taken place at that time – and there is much that can be said against this – but it means that there is little to no further gain to be made with a selection later on.

But proponents of selection mounted a principal/normative argument: candidates should be able to influence their fate, have their ‘fate in their own hands’. So, when there is competition for scarce places, candidates should have some agency about their own position in the process. Even more so: the ‘best candidates’ deserve to be admitted first. This was already an issue during the lottery by De

Brauw (in the opening paragraph of this piece), with the so-called 7.5/10 rule (those with a GPA of 7.5 or higher on a 10-points scale gained direct entry) he had to introduce instead of his comprehensive lottery. So, there was already also a precedent for selecting based on grades. This principle of ‘the best candidates first’ is now often referred to as ‘meritocracy’ (Michael Sandel). It is an ideology of the winners, with a dark side for the losers and it negates that not everybody was born and raised in an context with equal opportunities.

The fierce public/political debate about these principles continued and even the parliament (the House of Representatives) could not reach a conclusive decision; it was perfectly divided between both positions: lottery and selection. Member of parliament Arend Vermaat (Anti-revolutionary party) submitted an amendment that comprised a compromise: a GPA weighted lottery. Higher grades meant better chances.

That amendment was accepted universally across the board. And the weighted lottery held for more than 40 years. But in 1998, a high-profile case of a student who with a GPA of 9.6/10 had been unsuccessful in the lottery three times challenged the system. The student was eventually admitted into medical

school and this started a renewed discussion about the lottery system versus selection. A new committee (committee Drenth) was tasked with an analysis of the problem and suggested some changes (Direct entry with a GPA of 8/10 and higher, stronger weightings, etc.).

In the ensuing neoliberal era, constant attempts were made to replace the lottery with selection. For example, the board of Leiden University initially wanted to select, then thoroughly examined the possibilities but reached the conclusion selection was not advisable.

Eventually, In the end, Labour Party minister for education Jet Bussemaker abruptly put an end to the weighted lottery and decided that numerus fixus studies from now on had to select themselves and using any form of lottery was banned by law! This was clearly a political decision that went against.

Currently, a new law is in preparation that will allow numerus fixus studies to admit students by three different pathways:

1 selection,

2 weighted lottery, or

3 general (unweighted) lottery

Although initially this proposal was foreseen to turn into law in 2023, the political situation has delayed the process and it is now foreseen for 2024.

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Note (Schuwirth).

Here it is important to mention that Dutch culture and governments generally tend more towards teleological/utilitarian legislation than deontological/normative ones in such situations. Some of the considerations for lottery and against selection are:

1 In general (in medicine) the predictive validity of selection interviews is extremely low, especially with respect to the future performance as a doctor.

2 Selection processes are time and resource consuming. Using these resources for a process that does not work (selection) and taking them from a process that does work (education) in a finite resourced environment is not socially accountable.

3 Selection processes are repeatedly found to be biased against certain subgroups. Which groups these are is dependent on the specific process and societal/cultural context. However, a negative bias against applicants from lower SES classes is likely in almost all situations. In the Netherlands, recent research found that the system was biased against anybody who was not a white female applicant.

4 Although a lottery seems to be entirely based on luck of the draw, so is being born intelligently and into a family that supports learning and is rich enough.

5 Dutch culture is not one that supports meritocratic views, and selection is based on meritocracy – you only get chance to become a good doctor based on your ‘merits’ before the selection process.

6 Selection processes are not sensitive enough to pick out undesirable candidates (for example with signs of psychopathy or likely to exhibit severe unprofessional behaviour later one).

7 Using sub-quota to counteract bias against sub populations leads to the perception that those students got in undeservedly and only through a form of affirmative action