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Declarations made by graduating medical students in Australia and New Zealand

Paul M McNeill and S Bruce Dowton
Med J Aust 2002; 176 (3): 123-125.
Abstract

Objective: To survey the use of declarations of ethical commitment made by graduating medical students in Australia and New Zealand.

Methods: Information, obtained by email and telephone, from faculty officers of all faculties of medicine (or medicine and health sciences) in Australia and New Zealand.

Results: Declarations are made by graduating medical students at seven of 12 Australasian faculties of medicine. To date, declarations have been based on the Declaration of Geneva or the Hippocratic Oath or have been formulated by academic staff or the students themselves. In six of the seven universities, declarations are made as part of a special declaration ceremony (usually combined with a prize-giving ceremony). One university includes a declaration as part of the official graduation ceremony.

Discussion: We discuss the relative merits of a declaration selected for students by staff members and a declaration written anew by each group of graduating students.

In medical faculties throughout Europe, North America and Australasia there is a growing trend for medical students to make a declaration or take an oath of ethical commitment at the time of their graduation and admission to the medical profession.1-3 Most medical schools have adopted variations of the Declaration of Geneva,4 which was recommended for this purpose by the World Medical Association in 1949 in response to atrocities committed by doctors in Germany during World War II.

We describe the processes for formulating declarations within schools of medicine in Australia and New Zealand and outline the nature of the declarations themselves and the manner in which they are declared. We also discuss the merits of final-year students taking responsibility for formulating their own declaration, as has occurred at the University of New South Wales (UNSW).

Methods

Between mid-November 2000 and mid-January 2001, we contacted faculty officers of all faculties of medicine (or medicine and health sciences) in Australia and New Zealand. We asked them to describe current practices of final-year medical students (for the class of 2000) in making declarations at the time of their graduation, and requested copies of any declarations made.

Findings

Of the 12 faculties of medicine from Australasian universities that have had graduate students (the 13th school of medicine, at James Cook University, will not have graduates until 2005 or 2006), seven faculties allow graduating medical students to make a declaration of ethical commitment at or around the time of graduation (see Box 1). Six of those incorporate it as a part of a "declaration ceremony" that is held before or immediately after an official graduation ceremony, while one incorporates the declaration into the graduation ceremony itself. Three universities have adopted the Declaration of Geneva or a modification of it; two have declarations written by a staff member that are based on the Declaration of Geneva (but briefer and more modern in expression); while one uses a modified version of the Hippocratic Oath (see Box 1).

Most declaration ceremonies are combined with a prize-giving ceremony. In five universities, graduating students lead the reading of the declaration: students chosen for this task are usually those who have achieved prominence in some way (eg, by winning an esteemed prize or gaining high marks). Two faculties also accommodate other cultural groups: at Auckland University (NZ) a Mäori student reads a version of the declaration in Mäori, while Islamic student graduates at the University of Adelaide (of which there were more than 30 in 2000) read the "Oath of a Muslim Physician".5 All seven universities provide printed statements of their declarations and four of those provide space for students to sign.

The experience of the University of New South Wales Faculty of Medicine

At UNSW, from 1998 onwards, we have encouraged graduating medical students to write their own declaration, drawing on a number of sources (see Box 2). During the final year, the Dean invites students to meet with himself and another academic staff member to discuss whether or not the students wish to make a declaration and to decide on its wording. Materials offered to the students include the Hippocratic Oath, the World Medical Association's Declaration of Geneva, and examples of oaths and declarations from medical faculties in North America and the United Kingdom, together with declarations from previous graduating classes.

In 1998, a representative group of students met on four occasions with one or both of us and exchanged emails until there was agreement between themselves and the whole class on the substance of a declaration. The only role played by us was to suggest alterations to the grammatical expression and style of presentation. A final version, distributed to faculty staff members, gave staff an opportunity to comment but not to amend the document. Faculty members were supportive, although there were queries about whether the declaration was realistic (eg, in a situation of threat).

The 1999 graduating class reworked the previous year's version with the intention of writing a "realisable" rather than an "idealistic" statement. For example, the statement "I will not breach these obligations, or abuse the trust placed in me, either under threat or for personal gain" (Box 2) was softened in 1999 to "I will not compromise these ideals under duress or for personal gain".

In 2000, the process started afresh, with students identifying their own values then drawing on published declarations to assist them in expressing those values. This introduced two new elements: a commitment to support the carers of patients and a desire to "enjoy my work and maintain my wellbeing whilst supporting those who are close to me" (Box 2). While the latter sentiment has been criticised (in a Harvard declaration),6 the UNSW class of 2000 recognised a need for balance between commitment to others and to themselves, both in their work and in their personal and family lives.6

Each year, 30–40 students (out of a total of about 180) have responded to the invitation and taken an active role at various stages, with two or three students persisting through to the preparation of a final statement. It has been apparent that students are sensitive to a need for the declaration to be appropriate as a public statement. While it is conceivable that a cohort of students would wish to embrace a value that academic staff did not consider appropriate, it is unlikely that faculty staff would intervene, although that option has not been ruled out.

Discussion

The value of student declarations at the beginning or end of a medical course has been discussed in various quarters.1,6,7 In the United States there has also been a recent rise in "white coat ceremonies" on entry to medical school, some of which include an affirmation of professional commitment.8 While we have reservations about the symbolism of white coats,9 we recognise the value of a ceremony to support moral commitment at the beginning of a medical course.9-11 In contemporary medical education, the whole course should support students in analysing issues from the perspective of values.12 Consistent with this view, we encourage students to formulate their own declaration. Of two references6,7 to medical students formulating declarations for themselves, one is supportive, although it concerns oaths at the beginning of medical education rather than at graduation.7 The other opposes such graduation declarations on the grounds that students tend to write self-serving statements without the benefit of wisdom that comes through serving the sick.6

There are obvious advantages in having a staff member choose, or write, a declaration for the students: it is less time-consuming, and the staff member is likely to have skill in writing and access to relevant documents. The disadvantages are that the students may have little "ownership" of the words presented to them, they may not understand some of the words (especially if archaic language is retained), or may object to statements they are asked to declare. An opportunity is lost for students to work through these issues in advance of the relevant ceremony.

Hurwitz and Richardson state that one of the purposes of a medical oath is to "declare the core values of the profession and to engender and strengthen the necessary resolve in doctors".1 Those "core values" are constantly under review and need to be rethought by new members to the profession. We believe that young graduates are more likely to be committed to a declaration and give it greater significance if they, or their representatives, have created (or at least chosen) the wording. The process is as important as the final product in that students are developing and expressing their own values, working towards a consensus and taking ownership of "their" declaration. In so doing and in making a public commitment, the declaration becomes more meaningful to them and is likely to have a greater impact on their lives as doctors and on themselves as human beings.

This view is supported by Kolb's model of adult education, in which self-reflection is regarded as a critical element in the "learning cycle".13 By reflecting on their experience in medicine and in life, students develop a generalised statement of values that is unique to each graduate year. The literature on self-assessment and learning through experience supports a view that, even when statements are adopted from previous declarations, graduates are more likely to act consistently with those values when the formulation results from a process of self-reflection.14-16 For these reasons, we believe new graduates will find strength and support in a clear statement, determined by themselves, of their priorities and obligations in the practice of medicine.

1: : Medical graduation declarations of universities in Australia and New Zealand that have adopted a declaration

University

Source of declaration

Nature of ceremony at which oath is given

Students read out loud

Reading led by

Students sign

Flinders University

Full Geneva Declaration

Declaration and prize-giving ceremony

Yes

Dean

*

University of Adelaide

Modified Geneva Declaration

Declaration and prize-giving ceremony

Yes†

Students

*

University of Auckland

Faculty formulated

Declaration and prize-giving ceremony

Yes‡

Students

*

University of Otago

Faculty formulated

Declaration and prize-giving ceremony

Yes

Student

Provision to sign

University of New South Wales

Student formulated

Formal graduation

Yes

Dean

Provision to sign

University of Tasmania

Full Geneva Declaration

Declaration and prize-giving ceremony

Yes

Student

Signed before ceremony

University of Western Australia

Modified Hippocratic Oath

Declaration ceremony

Yes

Students

Provision to sign


* Not known (information not supplied). † Oath of a Muslim Physician5 read also. ‡ Read in Mäori also.

2 : Medical graduation declarations at the University of New South Wales

Class of 1998 declaration

I declare that I will practise my profession to the best of my knowledge and ability, in good conscience and with integrity.

In my practice, the care of patients will be my first consideration.

I will strive to prevent and treat disease, improve the quality of life, provide support in times of suffering.

I will respect the autonomy, confidences and dignity of my patients, in their living as well as in their dying.

I will promote the health and welfare of the community.

I will treat with respect my colleagues and all who contribute to the well-being of my patients.

I will seek constantly to gain in knowledge and understanding, and to pass on the art and science of medicine to others, as my teachers have done before me.

I will treat all patients equally and without prejudice.

I will not breach these obligations, or abuse the trust placed in me, either under threat or for personal gain.

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

Class of 2000 declaration

In acknowledging the privilege of practising medicine, I make this declaration freely and sincerely in front of my family, friends, colleagues and esteemed teachers.

Patients are my first concern and in caring for them I undertake to use my knowledge and skill to the best of my ability.

I will seek to enhance the quality of patients' lives, maintain their dignity, support their carers, and treat all people equitably.

I will strive at all times to be worthy of my patients' respect and never to abuse their trust or confidence.

My commitment extends beyond individuals to the health and wellbeing of the community.

I hold myself accountable for my actions, and will not stray from these commitments for personal gain.

I recognise that to honour these commitments I must seek to enjoy my work and maintain my wellbeing whilst supporting those who are close to me.

May these affirmations guide and inspire me in practising the art and science of medicine.

Paul M McNeill, MA, LLB, PhD, Associate Professor of Ethics and Law in Medicine, School of Public Health and Community Medicine
S Bruce Dowton, MD, FACMG, FRACP, Dean
Faculty of Medicine, University of New South Wales, Sydney, NSW.
Correspondence: 
Acknowledgements: 

The authors thank the staff of all medical and health science faculties in Australian and New Zealand universities for their assistance in providing information on declarations made within their own faculties. We also thank Dr Chris Hughes (Medicine Curriculum Unit, University of New South Wales), and Professor David Boud (Associate Dean, Faculty of Education, University of Technology, Sydney) for their helpful comments and suggestions. Any errors or omissions are the responsibility of the authors.

Competing interests: 

None declared.

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