DOUBTS ABOUT PRO FORMA WHITE COAT OATHS

First, as quoted by Dr Gillon, the account of the ceremony from the philanthropic foundation promoting it specifies that one of the components of the ceremony should be a “swearing of the Hippocratic Oath or other similar oath before the student's `peers, family, friends and mentors'.” Dr Gillon calls this “a public acknowledgment by the students in front of `very significant witnesses' of their willingness to assume the obligations and responsibilities of the medical profession”. While he implies that the actual ceremony he attended did not actually administer such an oath but rather used an “affirmation of professional commitment”, presumably the emotional impact and perhaps its moral significance are similar.

But how can an oath or code or affirmation administered “right at the beginning of the medical course before the students have taken any lectures or laboratory classes” possibly be understood by the students? Similar events I have witnessed involve printing the oath in the programme for the ceremony or distributing copies at the beginning of the event and then having students stand at the appropriate moment and read the text cold. Even if the students have had a chance to read it over in advance, it is unlikely that they will have had an adequate opportunity to explore the controversial aspects of the text or study alternative language.

Asking incoming students to recite a preprinted code as their first task upon arrival in an education process implies that the newly arrived student can, on the spot, understand the nature of the commitment he or she is being asked to make. That, in turn, implies little respect for the moral learning that should be expected to take place during socialisation into a profession. To ask students blindly to subscribe to the school's preselected code, no matter which one it is, seems unfair, indeed, unethical. It asks students to subscribe to some moral code without any opportunity to examine it and determine whether they can, in fact, commit to its tenets. In one specific case, for example, an avowed atheist was asked by her school to swear by the Judaeo-Christian deity.

Confronted with such a requirement in the form of a public show, what is a morally conscientious incoming student to do? Some students might ritualistically recite what they are asked to recite, perhaps assuming they agree with the content as they read it even though they have not had an opportunity to study it. Alternatively, the student with integrity might, with reason, refuse to participate in the recitation on the grounds that a moral oath-taking should not be done without forethought. It should not be a mere show before parents and future professors.

Only one conclusion seems possible: those who take the oath or make the affirmation on the spot do so from blind trust, not from reasoned conviction. The oath or pledge or affirmation is merely pro forma. The student cannot be expected to really know or understand what is being pledged. But taking a solemn oath in a pro forma way is a controversial way to begin an academic career. Fairness seems to require that, much as youngsters are not permitted to blindly sign binding contracts, so incoming medical students before they have had any exposure to the issues and controversies of medical morality should not be permitted blindly to swear professional oaths. If they do such swearing surely they should not be held to what they swear until they have had a time for reasoned consideration of alternatives.

There is an alternative that is not quite as offensive. Some schools ask students to take an oath, not to a profession about which they know nothing, but to the duties of their role as students. An oath to subscribe to the school's academic honour code would be appropriate—especially if the new student has had a chance to study it before coming to the ceremony. An oath to practise medicine according to one particular, idiosyncratic moral code, however, is not defensible.

KNOWING WHICH OATH OR AFFIRMATION TO ADMINISTER

There is a second, more complex, problem. Assuming that it is morally legitimate to spring an oath on a group of incoming students before they have had any opportunity to contemplate its moral implications or its alternatives, how would the administrators of a medical school know which oath or pledge or affirmation to impose?

The organisation encouraging such ceremonies suggests using the Hippocratic Oath or other similar oath,¹ but does the staff of that group realise just how controversial the Hippocratic-type oaths can be? Taken in its unmodified, original form (as at least one medical school is known to do), it includes swearing by the Greek gods and goddesses, a blatant paternalism, a very controversial confidentiality provision full of loopholes, opposition to abortion, a prohibition on surgery, and a kind of reward-and-punishment morality that should be offensive to Jews, Christians, and members of other religious traditions, as well as modern secular students.

Of course, most medical schools do not accept the unmodified Hippocratic Oath, but that raises the question of just who should have the authority to modify it. In fact, each school that uses an oath or code, either as part of a white coat ceremony or as part of a graduation ritual, must adopt some language. The options differ significantly.

At St George's University in Grenada where I sometimes teach and which I have reason to believe is much like the school at which Dr Gillon witnessed his first white coat ceremony, the students represent significantly different moral traditions and perspectives. The students come from many different religious and secular traditions, many different national and ethnic groups. Once, in teaching medical ethics to a class of 250 such students, after exposing the students to approximately ten hours of exploration of the nature and content of different medical ethical traditions, I asked them to choose from among ten different medical ethical codifications. They ranged from religious codes (the Ethical and Religious Directives for Catholic Health Facilities, the Jewish Oath of Asaph, and the Hindu Caraka Samhita); professional codes (the American Medical Association's code, the Hippocratic Oath, and the British Medical Association's code), and other privately generated codes (such as the American Hospital Association's Patients' Bill of Rights), to public codifications such as the Council of Europe's Convention for Protection of Human Rights and Biomedicine. The result was that no codification received more than 22 per cent of the class's support. Given the diverse religious, cultural, and national mix of the students, this result is hardly surprising.

The implications are, however, radical. At least in this case we know that students who have been exposed to several plausible alternative codes of ethics will not agree on which one they prefer. This means, however, that there is no reason to believe that anyoath or code or affirmation selected by the faculty for its white coat ceremony (or its graduation exercises) would be likely to have the support of any more than a minority of students. If those students were presented with a plausible list of alternative codes representing different religious, ethical, ethnic, and national traditions, it seems only reasonable that they would not all select the same content. It may actually be that a large majority of students, if they were given time to study the alternatives and compare different codes, would reject the faculty's preferred document—no matter what that document said.

I would not find that troubling; in fact, I would find it encouraging. It would mean that the school is preparing students with a wide range of ethical perspectives and that, therefore, it is possible that patients with a similar range of ethical perspectives would be able to find competent medical assistance without creating ethical tensions between them and their physicians. A strong case can be made that health care ought to be available reflecting a great range of ethical traditions.

The point is that expecting all students in an incoming medical-school class to subscribe to any one code of ethics or oath—whether they do it without thinking or with careful study and preparation—seems implausible and unwise. No matter which words are placed before the new students, most of them should probably reject at least some aspects of the content.

THE MORAL IMPLICATIONS OF THE “BONDING PROCESS”

This brings us to a third and final problem with the white coat ceremony. One of the important elements of the ceremony is supposed to be a “bonding process” by which physicians demonstrate “their faith and confidence personally delivered”. This ritual symbolises the “calling apart” of the medical students to begin a process of leaving behind their identity as ordinary lay people to become members of a profession. They are taking on a profession, a “calling”. It is not surprising then that the ceremony is described in quasi-religious language as a “a gift of faith”.

This “bonding process” is, however, not without controversy. The ceremony is nothing less than a symbolic “setting apart” of the student from the lay population with a concomitant “bonding” with the members of the professional group. In the language of religious metaphor, this ceremony is the first step in the “conversion” of the lay person into new priestly status set apart from the laity. It is not by accident that terms such as “robing” and “cloaking” are used.

This, however, raises the issue of whether the proper moral purpose of medical education is to carry out the process of converting the student from one bonded with fellow lay people—patients—into one bonded with professional colleagues. 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? Is it good for physicians to abandon the religious, cultural, ethnic, and national identities that they bring with them on their first day of medical school and replace them with a new identity bonded to a new group who share none of those rich identities but replace them with a new professional-priestly bond? Perhaps it would be better if, instead of attempting to create a new moral bond with the medical profession, medical educators attempted to strengthen the existing identities incoming students have with their cultural traditions. They could then each subscribe to the medical ethic that is appropriate for that tradition, even if it is quite alien from those they are with in medical school—fellow students and the faculty alike.

CONCLUSION

The white coat ceremony may be an impressive ritual for the beginning of medical school. It may add an ominous drama to the first days of a student's new career. In the process, however, the ceremony raises serious ethical questions. It is doubtful that any code recitation has any legitimate meaning when that code is imposed on a group of students too new to their profession to understand its meaning or even whether its content is controversial. It is doubtful that any code recitation is legitimate if the vast majority of students, when they are better informed and have had more time to think, would really prefer some other commitments. It is doubtful that a “bonding process” is tolerable if its real function is symbolically to remove students from the culture from which they and their future patients come and to place them in a new culture bonded with medical practitioners from all manner of traditions but increasingly isolated from the people and cultures from which they have come.