CONTENT ANALYSIS OF OATHS ADMINISTERED IN MEDICAL SCHOOLS IN 1993

1. CONTENT ANALYSIS OF OATHS ADMINISTERED IN MEDICAL SCHOOLS IN 1993 Robert D. Orr, M.D. Norman Pang, M.D. Loma Linda University

2. Hippocratic Oath • ancient (~500 BCE) • revered • standard for comparison

3. Classical Hippocratic OathEdelstein - 1943 I swear by Apollo Physician and Asclepias and Hygieia and Panaceia and all gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold the one who has taught me this art as equal to my parents and to live in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art---if they desire to learn it---without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

4. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining clear of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

5. Modern Hippocratic Oath I do solemnly swear by that which I hold most sacred: That I will be loyal to the profession of medicine and just and generous to its members; That I will lead my life and practice my art in uprightness and honor; That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself aloof from wrong, from corruption, from the tempting of others to vice; That I will exercise my art solely for the cure of my patients, and will give no drug, perform no operation for a criminal purpose, even if solicited, far less suggest it; That whatsoever I shall see or hear of the lives of men which is not fitting to be spoken, I will keep invoilably secret. These things I do promise and in proportion as I am faithful to this oath may happiness and good repute be ever mine---the opposite if I shall be forsworn.

6. 450 BCE 335 words 14 content items < 1928 165 words 10 content items “The Hippocratic Oath”ancient modern

7. Comments on Hippocratic Oath • it “calls physicians to a higher ethical standard than that of society in general” CE Koop • it is “still the standard that my colleagues use to evaluate the moral quality of their own lives as physicians” ED Pellegrino • “medical oaths [have] failed to address the changing doctor-patient relationship emerging in the 1990’s” E Dickstein, et al • “the Hippocratic ethic is dead” R Veatch

8. PURPOSE • to determine what oaths were administered to medical graduates in North America in 1993 • to study the changes in usage of oaths in this century • to analyze the contents of currently used oaths • to compare the content of currently used oaths with the content of the Hippocratic Oath

9. METHODS • an 11-item survey was mailed to the academic deans of 142 allopathic and 15 osteopathic schools of medicine in the United States and Canada • the oaths used were categorized and their content was analyzed using a modification of the content analysis of Leon Kass

10. CONTENT ANALYSIS OF LEON KASS • covenant with deity • covenant with teachers • commitment to students • covenant with patients • appropriate means - justice • appropriate ends - chastity • limit on ends - confidentiality • limit on means • accountability

11. RESULTS 97% return 150 useable responses 146 could be analyzed for content

12. RESULTS • oath usage in 1993 • oath usage this century • contents of oaths used in 1993 • changes in oath contents

13. ADMINISTRATION OF OATHS • 5 schools do not administer an oath • optional at 89, obligatory at 52 • 5 schools require signature • 20 schools give one oath at beginning and another at graduation

14. DURATION OF USE • 14 have used same oath >50 years • 6 of those for > 100 years • 1 has used some version of the Hippocratic Oath for 170 years • 11 allow students to select oath each year

15. OATHS USED IN 1993 Oath of Hippocrates - classical version 1 1% - modern version 45 30% - modified version 22 15% - unknown version 1 1% Declaration of Geneva 1948 10 7% Declaration of Geneva 1983 24 16% Osteopathic Oath 15 10% Oath of Louis Lasagna 5 3% Prayer of Maimonides 4 3% Other oath 20 13% No oath 3 2%

16. CONTENT ANALYSIS - 1993 • deity 16 11% • teachers 125 86% • students 89 61% • accountability 63 43% • patients 146 100%

17. CONTENT ANALYSIS - patients • means 98 67% • ends 133 91% • limit ends 95 65% • abortion 11 8% • euthanasia 20 14% • limit means 78 53% • justice 104 71% • chastity 5 3% • confidentiality 141 97%

18. Significant 1993 OmissionsCompared toClassical Hippocratic Oath • proscription of sexual contact 3% • forswearing abortion 8% • swearing to deity 11% • forswearing euthanasia 14% • accountability 43%

19. Oath Usage this Century 1928 1958 1977 1989 1993 classical H.O. 5 7 6 1 modern H.O. 5 14 45 modified H.O. 3 45 22 total H.O. 13 21 51 60 69 Dec. of Geneva 12 30 47 34 Prayer of Maimonides 11 14 4 Louis Lasagna 4 5 Osteopathic Oath 15 Other 6 35 16 20

20. Usage of Oaths at U.S. and Canadian Medical Schools 1928 19/79 24% 1958 69/96 72% 1977 115/128 90% 1993 147/150 98%

21. Usage of Oaths at U.S. and Canadian Medical Schools U.S. Canada 1958 74% 58% 1977 94% 63% 1993 100% 80%

22. Conclusions • there has been a progressive increase in usage of medical oaths this century • there has been a nearly steady decrease in usage of several content items from the classical Hippocratic Oath

23. The Use of the Hippocratic Oath:A Review of 20th Century Practiceand a Content Analysis of OathsAdministered in Medical Schoolsin the U.S. & Canada in 1993 Robert Orr, Norman Pang Edmond Pellegrino, Mark Siegler Journal of Clinical Ethics, winter 1997 Frederick, Maryland, USA

24. Possible Reasons for Increased Use of Oaths • a recognition of how important it is for physicians to make a public promise to be trustworthy • when we no longer agree on content, we become more concerned with process

25. Possible Explanations forChanging Content of Oathscore values of HippocraticMedicine are being diluted • we are entering a “post-Hippocratic” era • specialization has made medicine less monolithic • in a secularized, pluralistic society it is difficult to reach agreement on content

26. ConcernOrr, Pang, Pellegrino, Siegler • when we eliminate content on which we can’t agree, we are left with a very different kind of oath, and a very different kind of medicine

27. Declaration of Geneva (WMA) 1948 At the time of being admitted as a member of the medical profession: I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets which are confided in me, even after the patient has died; I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; My colleagues will be my brothers; I will not permit consideration of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception; even under threat and I will not use my medical knowledge contrary to the laws of humanity. I make these promises solemnly, freely, and upon my honor.

28. Declaration of Geneva (WMA) 1983 At the time of being admitted as a member of the medical profession: I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets which are confided in me, even after the patient has died; I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; My colleagues will be my brothers; I will not permit consideration of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity. I make these promises solemnly, freely, and upon my honor.

29. Prayer of Maimonides Be thou with me, Almighty Father of Mercy, in all my efforts to heal the sick. Grant that I may be filled with love for my fellowmen. May the thirst for gain and the desire for fame be far from my heart. Preserve my strength, that I may be able to restore the strength of the rich and the poor, the good and the bad, the friend and the foe. Let me see in the sufferer the man alone. When wiser men teach me, let me be humble to learn; for the mind is so puny, and the art of healing is so vast. But when fools are ready to advise, or to find fault with me, let me not listen to their folly. Let me be intent on one thing, O Father of Mercy, to always be merciful. Give me strength, and leisure, and zeal to enlarge my knowledge. Our work is great and the mind of man presses forward forever! Thou has chosen me in Thy Grace to watch over the life and death of Thy creatures. Guide me in this immense work, so that it me be of avail.

30. Oath of Louis Lasagna - 1 I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say, “I know not,” nor will I fail to call in my colleague when the skills of another are needed for a patient’s recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play God.

31. Oath of Louis Lasagna - 2 I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being, whose illness may affect his family and his economic stability. My responsibility includes those related problems if I am to care adequately for the sick. I will prevent disease whenever I can; for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow men, those sound of mind and body, as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

32. Osteopathic Oath - 1 I do hereby affirm my loyalty to the profession I am about to enter. I will be mindful always of my great responsibility to preserve the health and the life of my patients, to retain their confidence and respect both as a physician and a friend who will guard their secrets with scrupulous honor and fidelity, to perform faithfully my professional duties, to employ only those recognized methods of treatment consistent with good judgment and with my skill and ability, keeping in mind always nature’s laws and the body’s inherent capacity for recovery. I will be ever vigilant in aiding in the general welfare of the community, sustaining its laws and institutions, not engaging in those practices which will in any way bring shame or discredit upon myself or my profession. I will give no drugs for deadly purposes to any person, though it be asked of me. I will endeavor to work in accord with my colleagues in a spirit of progressive cooperation, and never by word or act cast imputations upon them or their rightful practices.

33. Osteopathic Oath - 2 Iwill look with respect and esteem upon all those who have taught me my art. To my college I will be loyal and strive always for its best interests and for the interests of the students who will come after me. I will be ever alert to further the application of basic biologic truths to the healing arts and to develop the principles of osteopathy which were first enunciated by Andrew Taylor Still.