What’s the Point of Swearing?

At my medical school we didn’t swear an oath. Well, not a professional oath. And once I’d seen my name on the pass list the oath I swore was never again to cross the threshold of my training hospital. But the medical school didn’t put on a passing out ceremony and it was left to a group of students to organise a party at which we celebrated our qualification and wished each other well in our careers.

hippocratesWe have all heard of the Hippocratic Oath, and many patients still believe we swear it, though they, like most doctors, have hazy and often incorrect ideas about what it says. Most US students swear a professional oath on qualification and many French students sign a written one, but apparently only about 50% of UK students are required to swear. (If it’s expected of you, can you refuse, I wonder?) What is it that students are being asked to commit to, and does swearing an oath make a difference?

Professional oaths have a long history. The Hindu vaidya’s oath dates from the 15th century BC. The Hippocratic Oath was probably written, not by Hippocrates, between the 5th and 3rdcenturies BC. Oaths from Jewish philosophers, from Japan and from China, all have a long history. The Declaration of Geneva was written in 1948, after the revelations of the role of physicians in Nazi extermination camps. A recent development is the White Coat Ceremony, for students moving from the classroom to the wards for their clinical studies.

All these oaths are remarkably similar. The god they ask you to swear on may vary, but all stressthat physicians’ first duty is to their patients, that doctors must respect patient confidentiality, and that they must be loyal to their profession. And all oaths give some practical guidance on personal and professional conduct.

Contemporary versions of the oaths don’t tamper with the statements of general principle. Putting patients first and respecting their confidentiality retain their importance. Maintaining the honour of the profession is still emphasised, even if the wording of some oaths could be interpreted as an instruction to close ranks to protect colleagues, even errant colleagues.

The most contentious sections of the oaths concern what doctors should and should not do in the course of their work. Perhaps not surprisingly. Such clauses tend to reflect the issues current at the time of writing, and so may be interpreted now as meaning something rather different from what they meant to physicians practicing in, say, ancient Greece. For instance, the traditional version of the Hippocratic Oath appears to forbid abortion. In fact, abortion was legal at that time and the oath merely advises doctors not to use unsafe methods to terminate a pregnancy. Modern oaths tend to avoid such directives, but include an ever­lengthening list of people who should not be subject to prejudice – an indication of what exercises us in the twenty­first century.

What is the purpose of swearing a professional oath?

When the first oaths were written, there were no registers of those considered fit to practise, so the oath was the passport to the profession. Those who had professed the oath were called professionals. People who offered medical services without having professed were quacks. Now, the rite of passage is marked by final exams, registering with the GMC and signing on with a defence organisation.

So are the oaths any more than mission statements; meaningless because no doctor would ever espouse the opposite, for instance, that patients’ consultations should not be confidential? Are oaths now in fashion because there are concerns about unethical behavior? And if so, does swearing an oath make you a more principled doctor? Surely doctors who are indiscreet with patients or who provide substandard care are not confined to the unsworn.

However, oaths still stand for something important: the obligations that doctors feel are an essential element of their professional duty. In the twenty­first century we work in a managed health service where such principles are under threat. Can swearing a professional oath protect doctors from submitting to managers’ demands that they put an institution’s perceived needs before those of patients? Would that stand up as a defence in an industrial tribunal, a GMC hearing or the law courts?

These are unresolved questions. Meanwhile, I suggest we could revivify the oath. What if all students spent their first morning at medical school discussing the text of an oath, and then four years later, after their final exams, their last teaching session were a review of how their student experiences had changed their views? They could discuss what it means to be a professional in the twenty­first century. The oath would then become a living document.

Finally, the rite of passage from carefree student to responsible professional should be marked with a party to remember.

Originally published in the February/March 2013 NASGP Newsletter

1 Response

  1. Judith
    In his memoir, published after his death from cancer at the age of 37, neurosurgeon Paul Kalathini recalls that when his class at Yale were discussing their post-qualification ‘commencement oath’ , many wanted to remove the one commitment that has always been in every such oath, the promise to place their patients’ interests above their own. In many countries, medicine is a seen as a job, not a calling. It is happening here too, only more slowly, as the NHS requires a dedication to more than money and status. The quid pro quo should be a respect and appreciation of doctors’ professional commitment. If instead they are subject to irrelevant diktats and their ability to treat patients is frustrated by unsympathetic management, is it any wonder they drop out?

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