AMA Journal of Ethics^®

Since its inception in 1993, the white coat ceremony (WCC) has become a national phenomenon. It is now practiced at the beginning of the first year for students at more than 100 medical schools and is supported by grants from a foundation set up specifically to endorse and encourage professional development and humanism in medicine. While some literature addresses the symbolism and history of the white coat itself, only a few sources consider the meaning of the ceremony. Materials from the Arnold P. Gold Foundation and other sources that support the WCC appeal mainly to the emotion and good will felt at the event. Although these feelings are (critically) important, the ceremony's supporters ought to offer a more complete justification. Several critics have addressed various aspects of the ceremony and suggested that the WCC is misused, improper, or even unethical. These critiques have serious flaws of their own. In this article, I will examine 3 critiques of the WCC and offer an interpretation of the WCC as a contemporary medical ritual that holds a beneficial place in the professional development of a medical student.

The Gold Foundation views the WCC as an experience by which beginning students become aware of the need to balance excellence in science with compassionate patient care. A typical WCC includes the presence of family and friends, a welcome from the school administration, an inspirational message from a role model, receipt of the white coat from a physician, the swearing of an oath, and a reception with a "party atmosphere." Raanan Gillon, a physician at the University of London, describes his experience as an observer enthusiastically, and takes a significant step toward helping us understand why the WCC is important and useful. He notes the similarity between student and physician commitments, and the utility of connecting students to the idea of humanistic competence and not just scientific or technical ability at the beginning of their careers.¹

Support for the WCC is not unanimous. In response to Gillon's editorial, philosopher and bioethicist Robert Veatch presents a harsh "second opinion" of the WCC. He attacks the WCC on 2 points: the use of a Hippocratic-style oath, and the premature connection of students and faculty.²

Concerning the use of oaths, Veatch complains that students have an oath thrust upon them before they are able to decide whether they agree with it or can live up to it. He adds that there is no recourse for a student who does not agree with the oath, and that some oaths are insensitive to student beliefs. He suggests the use of an honor code instead. He goes on to attack the use of a single oath because of the diversity of ethical traditions available today. He concludes, "an oath to practise [sic] medicine according to one particular, idiosyncratic moral code, however, is not defensible".²

Veatch considers the bonding process between students and their faculty to be detrimental to patients because it separates students from the "lay" population, making them more like priests and disconnected from the needs of lay groups. He claims that the WCC asks students to abandon their own "religious, cultural, ethnic, and national identities," and to take on the stark, empty identity of contemporary medicine. He suggests that instead, students should strengthen their personal cultural identities and then "each subscribe to the medical ethic that is appropriate for that tradition".²

Both of Veatch's arguments make the mistakes of confusing a medical oath for a complete moral code and assuming that a professional identity or responsibility must derive exclusively from an individual or personal one. In addition, Veatch misunderstands the use of oaths in this context, and neglects the importance of community among physicians.

An oath is a statement of intent, not a complete ethical stance. Clearly it is a mistake to think that all of medical ethics is only a footnote to the Hippocratic Oath.³ However, there are certain values and responsibilities in medicine that are, in principle, not very negotiable because they represent medicine's characteristic pattern of organizing values. Just as some behavior is different in a medical context than outside it, so are the responsibilities that come from being in a medical context, so it does not follow that individual values or upbringing are sufficient to reveal how to act in a medical situation.

When a student takes an oath, he or she is pledging to ethical and honorable behavior as a student, not as a physician. In the context of a WCC, the pledge is to learn within the confines these values. At graduation, one may swear to embody those values as a physician, if one desires to live that way. The examination of the professional (and shared) values of medicine (both the written codes and the demonstrated values of educators and practitioners) is part of the students' process of professional development. This is a process that should begin at the WCC.⁴ Swearing to an honor code is not enough. There is more to being a medical student than being an honest academic. Promising to cooperate and forgo cheating doesn't cover the responsibilities a student will have as a clinician-apprentice. Similarly, student-generated codes are lacking because they ask the students to decide what is important about the practice of medicine before they have ever experienced it.

Veatch's argument for a separation between students and faculty is ridiculous. The bonding between the 2 groups at the WCC is a sign of the faculty's confidence in the students, not a removal of the students' character and culture. It is a statement that medical school is difficult, made by those who contribute to its rigor, and followed by a supportive gesture that says "I believe you can do it."

More troubling than Veatch's misinterpretation of bonding and support as isolation and detachment is his implication that students should reject any culturally based "medical ethic" that is not their own or of their choosing. This intense individualism suggests that the title of physician is empty and one of convenience to be used to legitimate whatever personal ethic or tradition students happen to bring with them to medical school. It says that you don't have to act rightly, you just have to be consistent with your personal ethic. Cultural and religious moral traditions are important. They are how many of us make decisions for ourselves. An understanding of that process is indispensable for physicians because it is often how patients will make decisions for themselves. It is not necessarily how decisions should be made in medicine. Medicine has an evolving characteristic pattern of balancing values that exists within a reflective equilibrium.⁵ If one's personal values conflict violently with those of the "good doctor," then it is not necessarily reasonable or defensible to ignore the professional values. A reassessment of one's career plans seems more in order. The professional development that begins with the WCC should include reflection on these possible conflicts, and a pledge to explore them ethically and honestly as a student begins the process.

As noted by medical educator Delese Wear, the WCC is not the end of professional development.⁶ In fact, it is meaningless if the institution does not embody and demonstrate the values it professes at the WCC. While she suggests getting rid of the WCC altogether, I would argue that it should stay as an important ritual in contemporary medical education. The WCC is a ritual that appropriates meaning to the white coat and helps students cross the temporal and physical boundary from wherever they were before (college, a different career) into the world of thinking and learning about the practice of medicine. It is a ritual of initiation, not one of graduation or completion. Like any good ritual, it has symbols, its own language, and an appeal to an idea larger than the individual. It begins the development of a particular type of identity: that of the medical professional. It should be a little exciting and a little terrifying because of the perceived gravity of the situation. The white coat emerges from the ritual as a symbol of professional development and humanism, and remains a tacit reminder throughout medical school. When viewed in this light, the WCC is a useful and important step in the professional development of a contemporary medical student.

An essential feature of ritual is the creation and appropriation of meaning. Philip Russell, a fourth-year student at MCP-Hanneman, fails to grasp this point in his critique of the WCC.⁸ While he is to be commended for his reflection on the components of his own medical education, his analysis is shortsighted and incorrect.

Russell complains that the WCC picks and chooses the meanings it appropriates to the white coat and therefore to medical students. I would argue that this is precisely the point of a ritual. The creation of ritual meaning allows us to reclaim a symbol from its muddled or contradictory historical connotations, which several authors have characterized. It is true that the ceremony is disingenuous if it proposes values that do not exist elsewhere in medicine, but this is not the case with the WCC.

Further, much like Veatch, Russell mistakes a ritual of initiation for one of completion. The WCC is more like a bar mitzvah or confirmation than a medical school graduation. It says, "you have studied enough to be admitted, now go about becoming a full-fledged member." When the WCC is viewed as an initiation and first step, Russell's confused complaint of the appropriation of status trust and merit trust becomes moot.

Finally, and most disturbingly, Russell seeks to link the WCC to a perceived decline in the power (by which he means autonomy and financial status) of the medical profession. He grounds this attack in a misunderstanding of the definition and meaning of professionalism. Citing Eliot Freidson, Russell describes the "most basic tenet of any profession: [as] restricted access to a protected body of information".⁷ He calls the decline of such restricted access erosion of professional power. A closer reading of Freidson reveals that the restriction is not on the information itself, but rather on what one may do with that information.⁸ Any professional who thinks that patients are better off by knowing less about their health, or that medical power is generated solely through the withholding or restricting of information is sorely mistaken. From public health education campaigns to relationship-centered care, medicine has moved to increase patient autonomy and health through endorsing understanding of one's own health and body. Medical power comes from relationships and the fostering of healing, not the careful doling out of data.

Anthropologically, the white coat, like medicine itself (and as a symbol of medicine) has had different meanings in recent history.⁶ On this point, Russell is correct. While he objects to the ritual because it creates meaning, viewing this as somehow corrupt, I would argue instead that the appropriation of meaning is the explicit purpose of a WCC as ritual. When viewed in light of the Gold Foundation's objectives, the WCC is a step in professional development that associates some of the best qualities we would like to see in physicians with the incoming students themselves.

The WCC is a well-crafted ritual that appropriates meaning to a symbol and helps initiates move through an exciting yet daunting time in their lives. Taking an oath of initiation and being supported by the community of physicians places the student at the beginning of the development of a professional identity. The content and expression of this identity will be more greatly influenced by the student's experiences in the hidden curriculum and demonstrated values of the training institution. Nevertheless, the WCC is a useful first step in the professional development of a caring, humanistic physician, and should be continued and encouraged as a practice in medical education.