Update

Volume 14, Number 1 (March 1998)

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The practice of medicine has long been regarded as one of the learned professions. In recent times, however, there has been concern that physicians individually and collectively are less aware of professionalism. Cruess and Cruess recently lamented that physicians have become increasingly focused on science and disease, and on income and power, and at the same time decreasingly concerned about inequities in the health-care system. They conclude that medicine's professional associations and academic institutions should ensure that all physicians understand professionalism and accept its obligations.¹

But what is professionalism, and how can it be taught and/or ensured? Professionalism is the conduct, aims, or qualities that characterize a profession or a professional person. A moral code is often the basis of professionalism. That is, being a professional is more than just Doing a particular type of work; it is about Being a particular type of person. It involves "professing" openly that one is that type of person, usually by taking vows or an oath.

Individuals entering the medical profession have taken vows for at least 2500 years. The students of Hippocrates of Cos were required to swear an oath before beginning their training. Although the precise origin of the text of this Oath of Hippocrates is still debated by historians, there is no doubt that this document is ancient and revered. It is often used even today as a standard for comparison of behavior. When speaking at commencement for the LLU School of Medicine in 1991, C. Everett Koop, former Surgeon General of the U.S., stated that the Hippocratic Oath "calls physicians to a higher ethical standard than that of society in general."² Others, however, have criticized the Oath because it "fail[s] to address the changing doctor-patient relationship emerging in the 1990s."³

For these and other reasons, it seemed prudent to investigate the prevalence of oath-taking by medical school graduates today, and further, to assess the content of the oaths in use, comparing the content to that of the classical Hippocratic Oath. With help from Norman Pang, who at the time was doing an elective with me in clinical ethics during his fourth year of medical school, I did an empiric study and analysis of oath usage in 1993.

Methods: We surveyed the deans of all 157 allopathic and osteopathic schools of medicine in the U.S. (including Puerto Rico) and Canada to assess current practices regarding oath administration, and compared this data to results from similar surveys done in 1928, 1958, 1978, and 1989. We did a content analysis of oaths currently used and compared the results with content items of the original Hippocratic Oath as translated into English by Edelstein.⁴

Results: There has been a progressive and marked increase in percentage of schools administering an oath over the past 65 years. The graduates of 98 percent of the 150 responding schools took an oath in 1993. In 1928 only 24 percent (19/79) of schools administered an oath;⁵ by 1958 the percentage had increased to 72 percent (69/96),⁶ and by 1977 it was done in 90 percent (115/128) of schools.⁷

In 1993, only one school used the classical version of the Oath, 45 used a shorter (165 vs. 335 words) modern version, 22 used oaths which were based on the Hippocratic Oath but included significant modifications, and one used an unknown version of the Hippocratic Oath. In addition, 10 used the original 1948 Declaration of Geneva, 24 used the 1983 revision of that Declaration, 15 used the Osteopathic Oath, five used the Oath of Louis Lasagna, four used the Prayer of Maimonides, and 20 used other unique oaths. Six schools reported that they had used the Hippocratic Oath, but while reviewing the content, we found that the wording of these six oaths was actually some other oath which had been erroneously labeled "The Hippocratic Oath," and we counted these six in the proper categories. Although this was not asked in the survey, 11 deans volunteered that their school allowed the graduating students to either select from one of several existing oaths or write their own unique oath.

To assess the content of the oaths in use in 1993, we used the excellent content analysis of the classical Hippocratic Oath done by Leon Kass.⁸ He identified 14 content items, including (1) a covenant with deity, (2) a covenant with teachers, (3) a commitment to students, (4-13) a covenant with patients which included eight items, and (14) an agreement to be accountable for one's actions.

When we examined the contents of all oaths in current use, we discovered that although 100 percent and 86 percent respectively still pledge a commitment to patients and to teaching, only 43 percent vow to be accountable for their actions, only 14 percent include a prohibition against euthanasia, only 11 percent invoke a deity, only 8 percent foreswear abortion, and only 3 percent retain a proscription against sexual contact with patients.

We noted that the newer oaths often contain other content items not found in the classical Hippocratic Oath, including such items as the prevention of disease, respect for human life, commitments to science and learning, avoidance of greed, humility, care of the whole person, autonomy of patients, and wording suggesting that it may be acceptable to end a patient's life.

It is interesting to note that while the classical Hippocratic Oath contains 14 content items, the shorter "modern" version which was already in use in 1928 contains only 10, the Osteopathic Oath (1936) has nine, the 1948 Declaration of Geneva has seven, the 1983 Declaration of Geneva has six, and the Oath of Louis Lasagna written in 1964 has four. The Prayer of Maimonides, which dates from the 17th century but is conceptually different from the other oaths, contains five of the content items found in the classical Oath.

Summary of data: There has been a steady increase in the use of professional oaths at the time of graduation from medical school during this century. At the same time, there has been a decrease in the number of content items found in the original Hippocratic Oath.

A more complete presentation of our data, along with an analysis of the implications, appears in a recent issue of the Journal of Clinical Ethics.⁹

Conclusion: If, as Cruess and Cruess suggest, it is important that academic medical institutions understand and teach about professionalism, this trend of diluting the content of the Hippocratic ethic should be of major concern to the profession and its teachers.

REFERENCES

1. Cruess RL, Cruess SR, "Teaching medicine as a profession in the service of healing," Academic Medicine 1997;72:941-52.

2. Koop CE. "Whither Hippocrates?" Scope (LLU 1991) 27:12-15.

3. Dickstein E, Erlen J, Erlen JA, "Ethical principles contained in currently professed medical oaths," Academic Medicine 1991;66:622-4.

4. Edelstein L, "The Hippocratic Oath: text, translation, and interpretation," Ancient Medicine: Selected Papers of Ludwig Edelstein, Temkin O, Temkin CL, eds. Baltimore, MD: (Johns Hopkins Press, 1987) 3-63.

5. Carey EJ, The formal use of the Hippocratic Oath for medical students at commencement exercises. Bulletin of the Association of American Medical Colleges 1928;3:159-66.

6. Irish DP, McMurray DW, "Professional oaths and American medical colleges," Journal of Chronic Diseases 1965;18:275-89.

7. Friedlander WJ, "Oaths given by U.S. and Canadian medical schools," Social Science and Medicine 1982;16:115-20.

8. Kass LR, "Is there a medical ethic?: The Hippocratic Oath and the sources of ethical medicine," Toward a More Natural Science; (New York: The Free Press, 1985) 224-46.

9. Orr RD, Pang N, Pellegrino ED, Siegler M, "Use of the Hippocratic Oath: A review of twentieth century practice and a content analysis of oaths administered in medical schools in the U.S. and Canada in 1993," Journal of Clinical Ethics Winter 1997;8(4):374-85. *

Robert D. Orr, MD
Director, Clinical Ethics
Loma Linda University Medical Center

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