Medical oaths and declarations

A declaration marks an explicit commitment to ethical behaviour

The newly qualified doctors of Imperial College School of Medicine recently adopted a ceremony in which they declare their commitment to assume the responsibilities and obligations of the medical profession. The decision to create a declaration ceremony was widely supported by the final year students and it reflects a recent resurgence in interest in medical oaths in the United Kingdom. 1 2

Some 98% of American 1 3 and nearly 50% of British medical students 1 4 swear some kind of oath, either on entry to medical school5 or at graduation.4 One reason why oaths are more common in America may be that American children are brought up to swear their allegiance to the flag, so the concept of affirming their beliefs is less alien than to British students.

Oaths are neither a universal endeavour 3 4 nor a legal obligation, and they cannot guarantee morality. So why should doctors take an oath at all? In 1992 a BMA working party found that affirmation may strengthen a doctor's resolve to behave with integrity in extreme circumstances. This group recommended that “medical schools incorporate medical ethics into the core curriculum, and that all medical graduates make a commitment, by means of affirmation, to observe an ethical code.”6 The increasing complexity of healthcare arrangements and interagency collaboration, and the need to look at rationing resources, has forced the medical profession to re-examine its core values. In view of this, and with public confidence in doctors diminishing and morale at an all time low, it is perhaps unsurprising that the concept of an entire year of newly qualified doctors freely declaring their intentions to act ethically and professionally proved popular with both staff and students at Imperial College.

Oath taking does, however, have its critics. Some think it only encourages self importance and fuels paternalism. Others see it as a bid for respectability—the church, the bar, and the armed forces all swear oaths.

We devised the declaration with support and guidance from Raanon Gillon, emeritus professor of medical ethics. The final version (box) was approved by the whole year group. We decided early on that oaths were anachronistic and settled on creating a declaration instead. Of all the institutes that swear oaths, only three use the classic Hippocratic oath.3 The remainder use modified alternatives, covenants, and prayers. 1 3 4 Making a declaration, rather than swearing an oath, is important. We are not swearing allegiance to an introverted, self serving club but declaring our intentions to help those who place themselves in our care and the community at large.

The task of composing the declaration was long and more difficult than we expected. We started by consulting existing oaths including the original Hippocratic oath, the World Health Organization revised Hippocratic oath, the prayer of Maimonides, the Geneva declaration, the University of Naples declaration, and the General Medical Council's Duties of a Doctor. Although all contained many relevant principles, we wanted to compose a succinct declaration that the year group would feel at ease with.

The declaration encompasses the principles of respect for patient autonomy, non-maleficence, beneficence, and justice. We also included some of the virtues (humility, honesty, compassion) and core working values and principles (confidentiality, informed consent, non-prejudice) that guide modern medical practice. The declaration highlights the importance of continued medical education and professional development and encourages openness and accountability in dealing with adverse clinical events. The place of research and public health in medicine is also recognised.

The “affirmation of a new doctor” ceremony took place on 27 July 2001. With friends and family looking on, all the newly qualified doctors stood to confirm their commitment. The ceremony was designed to be unifying and celebratory as well as offering an ethical framework to guide new doctors as they embark on their medical careers. It was timed to immediately precede the start of our house jobs. We hope that the proximity between accepting responsibility for patient safety and promising to act professionally will etch the association indelibly into our minds.