Article Text

Commentary
1. R Gillon1
1. Chairman, Institute of Medical Ethics and Emeritus Professor of Medical Ethics, Medical Ethics Unit, Department of Primary Health Care and GeneraI Practice, Charing Cross Campus, Imperial College Faculty of Medicine, Reynolds Building, St Dunstan's Road, London W6 8RP

## IN DEFENCE OF MEDICAL COMMITMENT CEREMONIES

I confess to an overwhelming astonishment on first reading my friend Bob Veatch's attack on white coat ceremonies. Surely, I had thought, everyone who considered the issue would want doctors to commit themselves to the basic moral goals of medicine and especially that ancient Hippocratic goal of working to benefit the health of their/our patients, and only risking or doing harm with the intention and likely outcome of producing their net health benefit? Surely, too, it's a good idea for the new medical student—or at least the new clinical student about to encounter and interact with real patients—to commit himself or herself to those goals? But as usual Professor Veatch is an incisive and thought-provoking critic and his three criticisms require careful reflection. Those criticisms were: (1) that the oaths or affirmations were not legitimate, especially because the students were unlikely to understand them or their implications; (2) that it is not clear which of the competing candidate oaths or commitments should be chosen and why, and (3) that the “bonding” aspect of the ceremony in which the new student is welcomed as a student member of the medical profession is undesirable in so far as it tends to remove medical students from their own cultures and place them instead in a medical culture “increasingly isolated from the people and cultures from which they have come”.

### Too ill informed, too young, too coerced to commit?

As for the first criticism, I suppose a sensible development of the white coat ceremony would be to send each medical school applicant a copy of the commitment that he or she would be expected to make on joining the medical school so that he or she can study, reflect on, and discuss it with family and friends. On the other hand if the white coat commitment I saw is typical of others, such commitments will not be unduly intellectually or emotionally taxing in their content. Furthermore, new medical students, at least in America, are all graduates and in their early twenties or older, so I find the ideas that they are not really giving adequately informed consent, that they are in some sense being coerced, and that they should be regarded as “youngsters [who] are not permitted to blindly sign binding contracts”, frankly implausible. Imagine a similar line of argument to try to stop students in their twenties from signing up to the rules and objectives of say a climbing or a flying club, or indeed from accepting some (non-urgent) surgical operation without first taking some medical classes that encourage them to consider the pros and cons. This first objection smacks of the very paternalism that Bob Veatch has spent so many successful years decrying when doctors indulge in it. None the less its positive result, so far as I am concerned, should be that medical school applicants are sent a copy of the commitment that they will, if accepted, be expected to make at the white coat ceremony.

### Which oath or commitment?

The second criticism is more substantial. There are indeed many modern variants and derivatives of the Hippocratic Oath, which itself is clearly unsuitable as a universal commitment for modern medicine. Not only does it require swearing by Apollo, Asclepius, Hygieia, Panaceia “and all the gods and godesses” but it binds new doctors to a special, and what most people now would regard as an excessive, commitment to their teachers and indeed to their teachers' offspring (or at least their male offspring!) It commits doctors to oppose abortion and euthanasia and to desist from surgery. None of these commitments could in contemporary times be included within a universal medical declaration of commitments in medical practice (though moral opponents of abortion and of euthanasia might wish it were otherwise). Moreover there are many inconsistencies between different modern alternatives to the Hippocratic Oath.1 None the less there are core commitments in the original Hippocratic Oath which remain fundamental to medical practice throughout the world and which, I suspect, most people—doctors and non-doctors alike—would wish to remain fundamental. The most important is the commitment to benefit the health of their/our patients and to do so with minimal harm; its important corollary is the commitment not to inflict or risk harm to patients unless this is intended—and sufficiently likely—to achieve their overall or net benefit. Concomitants of these commitments require doctors not to exploit to their own advantage—including their sexual advantage—their relative power over their patients, but instead to put the patients' interests before the doctors' interests in deciding on the appropriate intervention or non-intervention. And a further concomitant requires doctors to maintain confidentiality, exercising great discretion in any divulging of information acquired in the course of their professional activities (great discretion but not absolute discretion, as the original Hippocratic Oath is plausibly interpreted to make clear). Finally it commits doctors to behaving well and avoiding intentional wrongdoing.

Of course this is a modern gloss of the enduring moral commitment within the Hippocratic Oath but it seems highly improbable that there are many reflective people, either in medicine or outside it, who would be unhappy for doctors to make such a commitment. Many may wish to add to this ancient commitment. In particular, it contains no explicit reference to respecting patients' autonomy, in the sense of thought-out choices for themselves, at least so far as is compatible with equal respect for the autonomous choices of others potentially affected. And it contains no explicit reference to fairness or justice, whether distributive, rights-based, including human rights-based, or legal. Thus undoubtedly even this modern gloss on the potentially universally acceptable components of the Hippocratic Oath can not be sufficient for a modern doctor's professional moral commitment and there is work to be done before a fuller commitment becomes widely, let alone universally, accepted within the medical profession.

In this regard perhaps I might pay tribute to the declaration drawn up and affirmed shortly after they graduated last year by the final year students at my own medical school at Imperial College.2 Reviewing a wide range of existing oaths and commitments, they drew up a declaration that the whole year would feel happy to affirm. In it (see Declaration of a new doctor, below) they make quite a few commitments, including commitments to the service of humanity, care for the sick, prevention of disease, promotion of good health, and the alleviation of pain and suffering. They undertake not to abuse their privileges; to work to meet their patients' needs, helping them to make informed decisions “that coincide with their own values and beliefs”; to oppose and not participate in policies that breach human rights, to “work towards a fairer distribution of health resources”; and “to practise medicine with integrity, humility, honesty, and compassion”.2

As I understand it, however, the promoters of the white coat ceremony3 are not prescriptive about the content of the oath—or, less anachronistically, commitment or declaration—to be made by the new medical students. Rather, they simply wish to see those students affirming some of the traditional but still fundamental commitments that should apply to all doctors, as outlined above. The commitment at the white coat ceremony that I attended—which it should be added was itself drawn up by a “student ethics task force”, assisted by a senior doctor—affirmed a responsibility for continuing pursuit of knowledge and understanding, and a responsibility: to put patients' interests first; to respect and value fellow health professionals; to regard classmates as colleagues (as distinct from competitors); to be tolerant, compassionate and honest; to adhere to the student honour code; to manifest integrity, to strive to be honourable and good, and never to abuse the privilege of becoming and being a doctor.

Professor Veatch's second criticism is thus well taken as a warning to those who organise them not to include in the white coat ceremony, or indeed in the post medical graduation ceremony, commitments that would not be accepted as appropriate for doctors to make, either by substantial numbers of doctors themselves, or which would be opposed by substantial moral communities served by those doctors (the scope of the term “substantial” being here left deliberately vague).

### Declaration of a new doctor

Now, as a new doctor, I solemnly promise that I will to the best of my ability serve humanity; caring for the sick, preventing disease, promoting good health, and alleviating pain and suffering.

I recognise that the practice of medicine is a privilege with which comes considerable responsibility and I will not abuse my position.

I will practise medicine with integrity, humility, honesty and compassion; working with my fellow doctors and other colleagues to meet the needs of my patients.

I shall never intentionally do or administer anything to the overall harm of my patients.

I will not permit considerations of gender, race, religion, political affiliation, sexual orientation, nationality, or social standing to influence my duty of care.

I will oppose policies in breach of human rights and will not participate in them. I will strive to change laws that are contrary to my profession's ethics and will work towards a fairer distribution of health resources.

I will assist my patients to make informed decisions that coincide with their own values and beliefs and will uphold patient confidentiality.

I will recognise the limits of my knowledge and seek to maintain and increase my understanding and skills throughout my professional life. I will acknowledge and try to remedy my own mistakes and honestly assess and respond to those of others.

I will seek to promote the advancement of medical knowledge through teaching and research.

I make this declaration solemnly, freely and upon my honour.

### Bonding with the medical profession

The third criticism is of the medical bonding process that the white coat ceremony is explicitly intended to promote—the bonding of the new student with both a professional institution and with a worldwide group of people who have a special “calling”, as Veatch puts it—a calling to benefit sick people and help others avoid becoming sick. Professor Veatch's objection is that bonding with the culture of medicine is likely to reduce or even replace the student's bonding with his or her own culture, and indeed with laypeople generally. Once again there is an important warning here for all of us in the medical profession. The warning is that it is too easy for doctors to become detached and isolated from the communities and the patients we serve, and see ourselves as a privileged quasi priestly class, unaccountable to any except our peers. But the bonding process promoted by both white coat ceremonies and graduation commitment ceremonies is neither intended to encourage such detrimental attitudes nor, so far as I know, is there any reason to believe that it does. On the contrary the intention is to enhance students' and new doctors' understanding of their special responsibilities to their patients and potential patients. The bonding process encouraged by these ceremonies is a bonding with important moral commitments of the medical profession towards those who are, for the most part, non-medical people. It is intended as an enhancement and expansion of a medical student's and a doctor's moral and cultural commitments, not a replacement of those they already have.

Professor Veatch asks: “Is it good for physicians to see themselves as called apart' as members of a profession who are, thereby, less closely identified with the lay groups they have left?” There are two halves to this question. The second half, concerning identification with lay groups, is complex and somewhat opaque. No, physicians should not allow themselves to become less closely concerned with the lay groups from which they stem; no, becoming a doctor should not cause doctors to lose the values of their own social cultures unless those values are inimical to their moral commitments as doctors. Veatch's question implies that by seeing themselves as “called apart” as members of a profession, doctors necessarily become “less closely identified with the lay groups they have left”. If this is a claim in logic it may be true, but banally so. Thus if I am identified only with A and then become identified also with B then, by now being identified with both A and B I can be said to be “less closely identified” with A. But so what? On this basis membership of any professional or indeed occupational group in a trivial way reduces the closeness of one's identity with the group with which one was previously solely identified. Given its triviality that can't be what Professor Veatch had in mind. More likely his worry is about doctors reducing their involvement, empathy and in those senses their “identification” with the concerns of the non-doctors whom, for the most part, doctors serve. But here, as argued above, the white coat and medical graduation ceremonies, and the medical bonding they are intended to promote, are on his side—and so am I!

But Bob Veatch and I may possibly disagree about the answer to the first part of his question, taken alone: “Is it good for physicians to see themselves as called apart' as members of a profession ...?” The alternative, of course, is for physicians to see themselves as just like any other occupational group, with no special moral commitments over and above those that everyone has, or else no special moral commitments over and above those undertaken by the moral communities of which particular doctors are members, for example their religious faith communities. Here let me once again nail my colours to the mast.4 The medical profession is a moral community and it has its own special moral commitments over and above the moral obligations that we all have to each other. In particular doctors take on commitments to benefit the health of their patients (at least their patients) and a commitment not knowingly to inflict harm on a patient (or not more than what has come to be known as “minimal harm”—the level of harm justifiably accepted as imposable on others in everyday life) unless that harm is a necessary and minimised part of achieving overall health benefit for that same patient.

It is that latter commitment which underlies the assertion in the World Medical Association's Declaration of Helsinki that in the context of medical research “Concern for the interests of the subject must always prevail over the interests of science and society”.5 These moral commitments are integral to the profession of medicine, and in making them physicians quite properly “see themselves as `called apart' as members of a profession”. They are not the only occupational group to take upon themselves special obligations of beneficence to their clienteles, but not all occupational groups do so. By all means let there be more such groups—group undertakings of beneficence should be encouraged.

But while all the warnings noted above must be taken seriously, it would be a social disaster if the medical profession, encouraged by egalitarian calls not to see themselves as “called apart”, dropped their ancient special commitments and saw themselves as just one occupational group among others, bound by the applicable laws and by the moral obligations that apply to us all and by no more. On that basis doctors would be justified, like any other trade or business people, to charge what the market will bear and the law permits; to sell their wares—medications and operations alike—to whomsoever will buy, provided no law forbids. On that basis too, doctors in a community that legally permitted its doctors to carry out medical research with high risk for subjects in order either to obtain faster medical advances to benefit the community, or simply to make larger commercial profits, would be justified in doing so. Doctors would doubtless profit—at least materially—from such erosion of their professional calling. After all they possess highly saleable skills. Their societies, however, would, as indicated, lose inestimably. Let doctors strengthen, not diminish, their sense of a special calling, their awareness of their special obligations. But let them do so in keen awareness of the dangers of elitism, the “club culture”6 and detachment from the concerns of their societies that fellow travel with that sense of special calling. And let them commit themselves to that special calling no later than the time they start, as student members of the medical profession, to become involved with real patients—and preferably once again when they qualify as doctors.

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