The Hippocratic Oath holds a venerable place in medical history. It apparently was created by a Pythagorean sect 2,500 years ago in ancient Greece.1 Rather than reflecting prevailing mores of the time, the Hippocratic Oath was a protest document, condemning prevalent activities such as abortion and euthanasia.1 The Hippocratic Oath was Christianized in the Middle Ages, fell into disuse during the 19th and early 20th centuries, but has been revived as a testament to what it means to be a good doctor.2 Unlike codes or other sources of medical ethics authority, the Hippocratic Oath has become a powerful symbol outside of the medical profession, invoked in novels, television shows, films, and other sources of popular culture.3 Although there have been many other oaths in the history of medicine (e.g., Prayer of Maimonides, the Declaration of Geneva's Physician's Oath, and the Oath of Louis Lasagna9), the Hippocratic Oath garners the most attention from physicians and members of the public.
Growing attention to and interest in medical oaths and oath taking has led to the use and creation of non-Hippocratic oaths, oftentimes authored by medical students and/or clinical faculty. The emergence of student-authored oaths can be partly attributed to the establishment of the white coat ceremony. Initiated in 1993 at Columbia University College of Physicians and Surgeons, white coat ceremonies are currently conducted at more than 100 U.S. medical schools.4 In these ceremonies, first-year medical students are presented with their white coats and publicly profess their commitment to abide by the ideals espoused in the Hippocratic Oath or other medical oaths.
To our knowledge, there has been no published empirical study of medical oaths administered at allopathic and osteopathic medical schools in the United States since the emergence of the white coat ceremony. In this article, we report on the analyses of medical oaths that were administered at all of these schools in the year 2000.
Method
In 2000, we collected the medical oaths used in all 122 accredited allopathic5 and 19 osteopathic6 medical schools in the United States (excluding those in the territories). At the same time, we mailed a short questionnaire to the deans of students at each school asking them to report on the type of medical oath that was administered, when the oath is administered, and in what year this oath was first administered.
We developed a content-analysis methodology based on a conceptual framework developed by Baker.2 According to Baker, medical oaths such as the Hippocratic Oath typically have four sections: (1) a preamble, in which the oath taker invokes various gods as witnesses and states the performatives of oath-swearing; (2) a covenant, stating the swearer's duties to the profession; (3) a code, stating the duties of the swearer to patients; and (4) a peroration, in which the swearer affirms the belief that reputation is dependent upon the faithful execution of the oath.2
We identified content domains within the relevant oath sections. The preamble section contained two content domains: (1) covenant with deity or god, and (2) covenant with secular figure or ideal. The covenant section included one content domain dealing with swearer's loyalty to colleagues, the medical profession, and teachers. The code section contained content domains reflecting conduct based on (1) conduct grounded in historical relevance and import (e.g., euthanasia, confidentiality, and sexual misconduct); (2) actions consistent with well-accepted biomedical ethics principles (e.g., patient autonomy and social justice); and (3) conduct grounded in contemporary social and legal norms (e.g., avoiding prejudice, respecting the law, and promoting peace). The peroration section contained two content domains: (1) sanction for violating the oath, and (2) reward for adhering to the oath.
We calculated content domain frequencies for the different types of medical oaths. We conducted chi-square analyses to assess content differences of administered oaths according to the medical school's ownership status (private versus public school), religious affiliation (faith based or secular), and the existence of a white coat ceremony. We used SPSS statistical software (SPSS Inc., Chicago, IL) for these data analyses.
Results
Just less than half (49.2%) of all U.S. allopathic schools administered the Hippocratic Oath or a modified version of it (see Table 1). Nearly one quarter (24.6%) of the allopathic schools' oaths had been authored by medical students or others at the school. Eighteen schools offered more than one oath option to their medical students. All 19 osteopathic schools used the Osteopathic Oath.7
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Table 1: Characteristics of 122 Allopathic and 19 Osteopathic Medical Schools in the United States Administering Professional Medical Oaths, 2000
Based on the content analyses, the majority of oaths included some form of a preamble that either had the oath taker swear to a god (25 schools) or secular ideal (93 schools). Most allopathic and osteopathic (87.2%) schools administered an oath that also contained a covenant section whereby the oath taker publicly professed loyalty to colleagues, profession, and teachers.
Based on our analyses of the code sections of administered oaths (see Table 2), most oaths explicitly addressed the need for physicians to protect a patient's confidentiality (129 schools) and to put the patient's welfare first (115 schools). On the other hand, few schools administered oaths that explicitly addressed the inappropriateness of having sexual relations with patients (four schools) and respecting patient autonomy (11 schools). Only one school used an oath that explicitly prohibited abortion as an acceptable practice. Many schools continued to administer oaths that included a peroration section in which the oath taker was sanctioned for violating the oath (53 schools) or rewarded for adhering to the oath (67 schools).
Table 2: Content Domains of Administered Oaths at 122 Allopathic and 19 Osteopathic Medical Schools in the United States
Content analyses based on type of administered oath revealed differences within and between oath types (see Table 3). As compared with the Hippocratic Oath or a modification of it, the Osteopathic Oath does not have a preamble or peroration section. Among the schools that used a modification of the Hippocratic Oath, most administered oaths that explicitly stated the importance for physicians to act with beneficence (78%), but fewer explicitly characterized the need for nonmaleficence or the “first do no harm” principle (24%). (This famous admonition does not actually appear in the Hippocratic Oath but rather in the Epidemics, part of the Hippocratic corpus that deals primarily with clinical cases.1) A minority of schools that administered student- and/or faculty-crafted oaths explicitly stated the importance of beneficence (37%) or nonmaleficence (30%). However, more student-crafted oaths explicitly required physicians to avoid bias or prejudice (43.3%) when compared with the content of modifications of the Hippocratic Oath (6.8%).
Table 3: Content Domains by Type of Medical Oath at 122 Allopathic and 19 Osteopathic Medical Schools in the United States, 2000
Based on chi-square analyses, we did not find any substantive content differences in oaths based on a school's ownership status, religious affiliation, or use of white coat ceremony.
Discussion
Taking an oath is a symbolic, integral, and shared aspect of professionalization. Lawyers swear to an oath when being admitted to their state bar,8 members of the clergy take a vow when entering the ministry, and physicians in the Western tradition have typically taken the Hippocratic Oath (or some variant). Although oath taking is commonly performed among the major professions, its impact varies a great deal. For lawyers, taking an oath is closely tied to passage of the bar and licensure. This ritual is typically done at a ceremony after graduation from law school. Oath taking in medical school, however, typically occurs during medical school or commencement. Moreover, the medical oath has no connection to medical licensure, which occurs upon passage of the various steps of the U.S. Medical Licensing Examination. Physicians are never asked to swear to an oath after licensure. Differences in timing may explain the varying levels of impact such oath taking has upon these different professions. Despite the lack of legal authority the medical oath holds, over the last 100 years, the prevalence of oath taking in U.S. medical schools has grown from only 28% of U.S. and Canadian medical schools in 1928 (19 out of 79 schools) to all allopathic and osteopathic schools.9
Our study revealed that the majority of allopathic medical schools administer some version of an oath other than the Hippocratic Oath. Even when versions of the Hippocratic Oath were administered, they varied in their content's focus. Likely catalyzed by the proliferation of white coat ceremonies, a significant minority of schools used oaths that have been authored by medical students or others in the school. These student-crafted oaths differed widely in their substantive content. Some schools even offered students a menu of oaths to pick from for use in graduation ceremonies and other relevant events.
Oaths are deontological in that they bind the swearer to certain kinds of duties and obligations.1 Some believe that contemporary oaths no longer retain the spirit of a covenant, which is the heart of the traditional Hippocratic Oath. This traditional covenant was between the oath taker and some kind of deity, and it exposed the oath taker to dire consequences. Breach of the oath would invoke the wrath of the deity. One commentator claims that contemporary oaths have been so diluted they have very little impact on physicians' behaviors. Moreover, the lack of enforceable sanctions makes them almost toothless in their impact.10 Yet our study revealed that many schools still administer oaths that contain language that harkens to traditional Hippocratic language of sanction and reward. This language would typically appear in the peroration of the traditional oath. Baker has commented that potential censure by other physicians serves an “enforcement mechanism … suggesting the idea of a self-regulating discipline.”2
Given the growing attention to professionalism education in medical training, our findings fuel an emerging debate about the implications of administering a nonstandard medical oath in medical school, and thus, its implications for educating the next generation of physicians in ethics and professionalism. To some, the use of nonstandard oaths (e.g., student-authored oaths) should be encouraged. These efforts may address some of the anachronistic aspects of the Hippocratic Oath (i.e., prohibitions against surgery), while making oaths and oath taking more relevant and useful as a means of strengthening physicians' professionalism.11,12 New ethical duties that have no historical antecedent in the traditional Hippocratic Oath did appear in many of the oaths we reviewed. For instance, nearly a third (30.5%) of the oaths contained some kind of language that prohibited discrimination or bias (e.g., “I will not permit consideration of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient”).
On the other hand, to many the medical oath represents a set of moral and ethical precepts common to, and binding on, all physicians. Thus, the emergence of “boutique” oaths can lead to fragmentation and confusion about the ethical values of the medical profession and, thus, dilute the value of a professionally binding oath.7 Beyond the variation in content and language found in the different oaths being used in U.S. medical schools, perhaps the most potentially troubling finding was the fact that several medical schools offered their students a menu of oaths to choose from. This practice may be defended as a way to personalize the oath-taking process for students. Yet, if students at the same school are swearing to different oaths year-to-year, are those schools sending mixed messages to their students—that medical oaths are ultimately flexible documents that can be shaped in whatever manner the swearer wishes? If, as one commentator states, the class oath is selected by the majority, where does that leave the remainder of the class?13
Although there has been little empirical study of whether taking oaths has much impact upon medical students' behaviors, there has been some study of medical students' attitudes toward oath taking.14 Medical students in an Israeli study indicated that, although they doubted the oath's influence, they believed the oath should be legally enforceable. Such a level of authority is virtually nonexistent in the United States, where oath taking plays mostly a powerful symbolic role for not only students but also members of the public. We believe that the growing trend of student-authored oaths suggests that students are taking more seriously the importance of oaths and oath taking in promoting professionalism in medicine.
Our study has some limitations. Oaths currently administered in medical schools may have changed since our study was conducted in 2000. It is unlikely, however, that the pattern of using different oaths, especially those crafted by students, has reversed given the continuing proliferation of white coat ceremonies. We also did not directly assess to what extent the use of different oaths impacted a medical student's understanding of the profession's ethical values and principles and, in turn, their professional behavior. Therefore, such research would be helpful in better understanding the importance that students and physicians place on oath taking and its potential impact on their professional ethics.
In our study, we found that U.S. medical schools are administering oaths that vary in substantive content. Swearing to different oaths, an act that all physicians share in, and its potential impact on inculcating common ethical values in medicine should be examined.
Acknowledgments
This study was funded by the American Medical Association. The opinions expressed in this article are those of the authors and may not reflect the official policy of the funder.
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