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I shared Raanan Gillon’s1 surprise at Robert Veatch’s criticism of the white coat ceremonies,2 and I think that the points raised by Veatch were quite adequately countered by Gillon’s response. The provocative points raised by Veatch do stimulate some valuable critical thinking about the process, although I think Veatch was carried away a bit by hyperbole. To label the drama of the ceremony as “ominous” goes a bit far by any criterion.
I should like to describe an oath taking initiation ceremony in use at the Ben Gurion University Faculty of Health Sciences for almost three decades, its history, features, current practice, and conclusions. I believe that Veatch’s specific objections are addressed by our process and merit consideration by other institutions as well.
When the medical school was founded in 1974 the then dean (and university president as well), Professor Moshe Prywes, met with the just entering class several weeks before the onset of the academic year during a summer preliminary orientation period (of several weeks duration). Professor Prywes, an imaginative, charismatic innovator with a flair for public relations and the dramatic, suggested to the entering class that they take the physician’s oath during the first weeks of the academic year, coinciding with their first exposure to patients (the programme provided for one clinical day each week from the very first week of studies—then an unusual curricular innovation). He explained that he wanted the students to regard themselves as already bearing responsibilities and duties, and not just rights. He saw them as “change agents” working to upgrade the medical care and the health of the patients and community, right from the first days of their schooling.
I had just arrived in Israel as a new immigrant to assume the foundation professorship of medicine, coming from a medical school which had a very conventional American curriculum. I sat at the back of the classroom as Professor Prywes discussed his proposal for oath taking to the entering class. To my surprise a number of prospective students raised objections to the proposal. There were two reasons cited by those opposing the oath taking. Firstly some felt that as they were not physicians, there was a degree of dishonesty associated with taking an oath almost before even starting medical school. The other objection voiced was that it seemed almost beyond their ability to live up to the degree of commitment apparently required by the oath.
Professor Prywes, a consummate diplomat and experienced educator, did not disparage or put down their objections. Instead he suggested that the class meet among themselves, discuss the pros and cons and reach a class decision as to whether or not to take the oath. He would respect their decision. Of course the class ultimately agreed to take the oath and this has remained part of the school’s tradition.
When the first class was graduated six years later the ceremony was modified so that the graduation of the final year class coincided with the initiation of the newcomers.
The incoming class oath was taken in the presence of the graduates as witnesses, and in effect the graduates were reaffirming the oath they had taken themselves six years earlier. This combination, linking old with new, creates a unique and moving ceremony.
The ceremony is not thrust upon the new students without preparation.
By the time of the oath taking they have had several weeks of a summer pre-academic year course, during which time they hear talks as to what it means to be a physician from several faculty members, old and young. There are several discussions of ethical issues. In addition there is a detailed discussion of the history of oaths, of their significance, as well as of all the components of the oath, before the ceremony.
These discussions have even resulted in some modifications of the oath in response to student suggestions and\or objections.
The oath taken by our students is an oath written by Professor Lipman Halperin at the occasion of the first graduation of an Israeli medical school in 1952 (Appendix A). Having been written in the 20th century the oath is sufficiently modern not to seem anachronistic, yet sufficiently rooted in an ancient tradition to provide a valuable link with the past. While Jewish in spirit it does not cite specifically Jewish themes and is not objectionable to non-Jews or to non-believers. I believe it presents values which most senior physicians, medical educators, and medical students can accept as ideals without reservations.
In addition to this “traditional” oath we started a new practice some five years ago. After a discussion with the incoming class during the summer orientation period, we asked the class to compose their class’s own ethical code. This exercise provides the students, who are essentially strangers to one another, with the opportunity and challenge of getting to know each other and of working cooperatively on an important project which will codify their expected behaviour as a community for at least the next six years as classmates. Each class has created its own document, each by its own methodology. The debates and discussions, arrangements and compromises focus the students’ thinking about their ethical behaviour—an exercise which for many students represents a first in their adult lives. Each class code is framed and posted in the corridor alongside the classrooms during the duration of their class’s stay in medical school.
I believe the process outlined here responds to all the objections presented by Veatch. Students are prepared for the oath before they take it. The oath is a relatively modern one, universalistic in nature. The students are not “bonded” to a group which has special privileges, but to one which has unique responsibilities. In addition to the “traditional” oath, and preceding it, students actually engage in creating a code of their own. Finally the oath is essentially reconfirmed at graduation.
Oath taking by physicians has a long history, and, as pointed out recently,3 the Hippocratic Oath was originally administered to entering students rather than to those completing their studies. While over the years the Western practice has been to administer the oath at graduation, I agree with Reiser and Ribble,3 that it is preferable to administer the oath upon entering medical school, especially now that many schools introduce students to patients from the first year of their studies. Students are more idealistic and impressionable at that time and are more supportive of the importance of oath taking.4
One should not minimise the importance of ritual. Rituals of passage are an almost universal phenomenon in many societies. When the Soviet Union banned religious ceremonies, these were quickly replaced by other no less ritualistic practices. One has but to remember the lines of Soviet citizens waiting for hours in subzero Moscow temperatures just for the opportunity of viewing Lenin’s body.
In concluding, I would urge medical schools to continue and to expand rituals and oath taking at the start of medical school, giving careful consideration to the neutralisation of possible harmful effects of the process, and perhaps finding even better ways of enhancing and enriching the process.
THE PHYSICIAN’S OATH
You stand today in the presence of your teachers of medicine and its precepts.
You enter into a covenant with medicine to fulfil its commitments to the best of your ability with wisdom and integrity.
That there may be established a generation of physicians motivated actively and dedicated faithfully to aid the suffering human being.
This is the covenant into which I enter with you today:
You are charged to stand at the side of the suffering individual day and night at all times and at all hours.
You shall protect human life maximally from the mother’s womb, and let its welfare ever be your chief concern.
You shall help the ill whether stranger, alien or citizen, whatever his social status.
You shall seek to fathom the soul of the sick, to restore his spirit, through understanding and compassion.
Do not be hasty in judgment but consider your advice carefully tempering wisdom in the crucible of experience.
Be faithful to those who put their trust in you: Do not reveal their secrets, nor act as gossip.
Honour and respect your teachers who have laboured to guide you in the path of medicine.
Guard the honour of your colleagues zealously, for their honour is your own.
Increase wisdom and do not become worn down by the struggle, for wisdom is your life and it has the power to sustain life.
Use your wisdom for the health of the public as well as to bring healing to the ills of the community.
May the words of this covenant be close and dear to you, articulated clearly and felt deeply that you may carry them out.
And you will all respond—AMEN
AMEN—we will act accordingly.
May your efforts to enhance the heritage of medicine throughout the world flourish.