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