50 Years of Medical Oaths

COMMENTARY

As an alumnus of Yale University School of Medicine (1971), I recently received an e-mail presenting the medical oath that the 2020 class of students put together and presented in a visual montage. Despite there being no live ceremony because of the pandemic, it brought tears to my eyes.

My, how medical oaths have changed over the 50 years of my psychiatric career. In the 70s, most medical school classes took the Hippocratic oath, but that is no longer the case.

Over the years, I have become more interested in medical and psychiatric ethics. A couple of my colleagues and I conducted a pilot study in the late 1980s about how well medical professionals recall the Hippocratic Oath.¹ At the time, responders indicated that 77% of their medical schools still recited the oath at graduation. Other than “do no harm,” people did not recall much else. That could be a clue about its potential impact. One commentator suggested some continuing education on studying the oath is in order.²

Of course, we have a traditional set of principles that could be taken as an oath—the AMAs’ Principles of Medical Ethics, which psychiatry has adopted and adapted.³ Yet, the Principles do not seem to be used and how well it is known by practitioners is unknown. Perhaps it is too dry or impersonal, or just taken for granted, to be used as an oath. Unfortunately, there have been times when medical ethics have been ignored, as in Nazi Germany.⁴ Therefore, it is important the oath is not forgotten.

Once I heard the new oath by the new class at Yale Medicine, I wondered about the status of current oath taking. An alumnus colleague at Yale sent to me several additional medical oaths recently used, as well as a review article. Students seemed to value their participation in developing their own oath. A recent book emphasized the need for current oaths to emphasize the social obligations of physicians.⁵ The author also made the point that unlike modern codes and principles, the Hippocratic Oath was meant to be proclaimed in the first person voice that would reflect personal commitment.

Other review articles in the last decade have examined medical oaths.⁶ Most oaths were taken upon graduation, but some schools have added them upon entry. More than half recently use an oath unique to that school, and some are written by the students. Only respecting confidentiality, avoiding harm, and upholding the professional’s integrity was included by at least 80% of schools upon graduation. Most emphasized the patient-physician relationship, but only a few expressed an obligation to teach, advocate, prevent disease, or conduct research. They tended not to emphasize the ensuring of safe systems, nor the well-being of the physician.

Since medical oaths reflect the ethical principles that physicians and society are essential to clinical practice, they can and do vary by country.⁷ The prevalence of oath-taking varies from 100% of medical students in the Netherlands and Brazil to about 60% in the United Kingdom and close to zero in many African countries.

My own psychiatric oath

Perhaps because my 50th class reunion is coming next year, I began to wonder why we never take medical oaths beyond medical school. After all, that is when we actually confront the practicalities of ethical decision-making. For example, we rapidly find out that “do no harm” is virtually impossible as most treatments have adverse effects, cause pain, or complicate matters. We don’t even take a medical oath if we are testifying in a deposition for a court expert witness testimony.

It has also struck me that medical oaths could vary depending on one’s specialty. For example, the field of psychiatry is particularly stigmatized, and the Goldwater Rule comes into play.

In addition, I wondered if age and experience make a difference. I am in retirement from clinical and administration responsibility, so do I still have certain ethical obligations as a psychiatrist and physician? I think so.

All these considerations led me to decide to compose my own medical oath at this time of my career. Much of it is modeled on the Hippocratic Oath and is taken in the first person. Here it goes.

I swear by my profession of psychiatry that I will continue to live up to these ethical principles:

1. Not Forgetting History

Although I am writing my own personal psychiatric oath, I will make sure to also always keep in mind the traditional Hippocratic oath, as much still has present relevance.

2. My Teachers

I will endeavor to thank all of my valued teachers who are still alive, which many include students and early career psychiatrists.

3. My Students

I will endeavor to teach any young psychiatrist the lessons I have learned in my career.

4. Avoid Harm

I will endeavor to do as little harm as possible in my interactions, words, and writings.

5. Confidentiality

I will endeavor to maintain confidentiality unless I judge that lives are at stake.

6. Personal Wellness

I will endeavor to take care of my own personal wellness and do what I can to reduce the epidemic burning out of my colleagues.

7. Terminology

I will endeavor never to use the word “provider” instead of physician, nor use any other term derogatory of my profession.

8. Community

I will endeavor to participate in any community efforts to improve the mental health of our citizens.

9. Racism and Xenophobia

I will endeavor to examine my own prejudices and help to reduce those in society.

10. Profession

I will endeavor to always remember that once a psychiatrist, always a psychiatrist, but never to use our knowledge inappropriately.

Consider writing your own oath. Or your organization create one. Put it on your wall or website. Send it to us at Psychiatric Times^®. I’m sure it will at least clarify your current psychiatric values.

Dr Moffic is an editorial board member and regular contributor to Psychiatric Times^®. He was a tenured professor at the Medical College of Wisconsin until he retired in 2012. Since then he has functioned as a private community psychiatrist providing pro bono services locally, nationally, and internationally. Currently, Dr Moffic is focused on 5 major advocacy initiatives: physician burnout, climate instability, Islamophobia, Anti-Semitism, and racism. He is co-editor of Combating Physician Burnout: A Guide for Psychiatrists, with Sheila LoboPrabhu and Richard F. Summers.

References

1. Moffic HS, Coverdale J, Bayer T. The Hippocratic oath and clinical ethics. J Clin Ethics. 1990;1(4):287-279.

2. Pellegrino ED. The Hippocratic oath and clinical ethics. J Clin Ethics. 1989;1(4):290-291.

3. American Psychiatric Association. The Principles of Medical Ethics, with annotations especially applicable to psychiatry. Washington, D.C: American Psychiatric Association; 2013.

4. Lifton R. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books, 2nd Edition, 2017.

5. Miles S. The Hippocratic Oath and the Ethics of Medicine. Oxford University Press, 2005.

6. Scheinman S, Fleming P, Niotis K. Oath taking at U.S. and Canadian medical school ceremonies: Historical perspectives, current practices, and future considerations. Acad Med. 2018;93(9):1301-1306.

7. Helmich E, Antonio M. Context, culture and beyond: medical oaths in a globalizing world. Med Educ. 2018;52(8):784-786.