Under Oath Content Analysis of Oaths Administered in ADA

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					      Under Oath: Content Analysis of Oaths
      Administered in ADA-Accredited Dental
      Schools in the United States, Canada,
      and Puerto Rico
      Aaron B. Schwartz, D.D.S., M.P.H.; Erin M. Peterson, M.P.H.;
      Burton L. Edelstein, D.D.S., M.P.H.
      Abstract: This study reviews and analyzes the content of dental school oaths taken by students in the United States, Canada, and
      Puerto Rico in 2006. Each oath was qualitatively reviewed to determine its consistency with each of the five principles set forth in
      the American Dental Association (ADA)’s Principles of Ethics and Code of Professional Conduct. Fifty-eight oaths were received
      from sixty-one of sixty-six schools in response to information requests regarding use of oaths and manner of administration. Of
      these, thirty-nine employ one oath, administered at either graduation or ceremonies marking transition to clinical training; twelve
      employ an oath at both occasions, with five repeating the same oath; and ten have no formal oaths. Eighteen oaths follow the
      wording of “The Dentist’s Pledge,” nine follow the “Oath to the Profession/Professional Pledge,” three follow the Modern Hip-
      pocratic Oath, and twenty-eight are idiosyncratic. All five of the ADA principles (autonomy, nonmaleficence, beneficence, justice,
      and veracity) are addressed in thirteen oaths, four principles in nine oaths, and three or fewer principles in thirty-six oaths. Eleven
      make reference to care for the underserved. As oath-taking is an opportunity to instill and reinforce to students dentistry’s most
      important ethical obligations, recommendations are offered to make the content more meaningful and comprehensive.
      Dr. Schwartz is a Postgraduate Pediatric Dental Resident, Department of Pediatric Dentistry, Lutheran Medical Center; Ms. Pe-
      terson is Former Project Coordinator, Division of Community Health, College of Dental Medicine, Columbia University; and Dr.
      Edelstein is Professor of Dentistry and Health Policy and Management, College of Dental Medicine, Columbia University. Direct
      correspondence and requests for reprints to Dr. Burton L. Edelstein, College of Dental Medicine, Columbia University, 601 West
      168th Street, Suite 32, New York, NY 10032; 212-342-3505 phone; 413-677-4286 fax;
      Key words: dental students, oaths, ethics
      Submitted for publication 12/12/08; accepted 3/20/09

               t its sixth annual meeting in 1866, the                              The ADA principles and the ACD core values
               National Dental Association (soon after                        are echoed in dental school oaths that are recited by
               renamed the American Dental Association,                       students at various milestones in their professional
      ADA) adopted its first Code of Ethics1 to guide                         development. An oath is a promise or statement of
      dental professionals’ obligations when treating pa-                     fact, made binding by the presence of witnesses.
      tient needs. The 1979 revision of the ADA’s code of                     While oaths no longer hold the gravity of com-
      professional guidelines adopted the title “Principles                   mitment they once did, they are nevertheless clear
      of Ethics and Code of Professional Conduct” and                         statements of intention to act in a certain manner. For
      was most recently revised in 1998 to incorporate                        dental students, oaths mark an important aspect of
      bioethical principles associated with advancement                       professionalization by which they express ethical re-
      in dental technologies.2 Today’s version establishes                    sponsibilities to their patients, their school, and their
      five principles: patient autonomy, nonmaleficence,                      community. Furthermore, oaths stress commitment to
      beneficence, justice, and veracity (see Table 1 for                     the continuous process of professional improvement
      definitions). The recognized authority on standards                     of both the self and the field as a whole.
      of ethical conduct, the American College of Dentists                          In 1955, the ADA’s House of Delegates first
      (ACD), further refines the principles by nine core                      adopted its own formal pledge. This oath was reaf-
      values. In addition to patient autonomy, beneficence,                   firmed by the ADA in 1972 and again in 1991 but
      justice, and veracity, ACD expands the concept of                       was not universally accepted into the profession. The
      nonmaleficence to include competence, integrity, and                    language of oaths can be idiosyncratic or derived
      professionalism and adds two values: compassion                         from other sources. “The Dentist’s Pledge” origi-
      and tolerance.3                                                         nated at Virginia Commonwealth University and was

746                                                                         Journal of Dental Education ■ Volume 73, Number 6
Table 1. Definitions of ADA principles of ethics
ADA Principles                                                              Definition

1. Patient autonomy                     The duty to actively involve the patient in treatment decisions and to respect patient
                                        needs and confidentiality.
2. Nonmaleficence                       The duty to “do no harm,” to always act in the best interest of the patient, and to keep
                                        knowledge and skills current.
3. Beneficence                          The duty to act for the benefit of others, carrying with it an obligation to improve the
                                        oral health of the public at large.
4. Justice                              The duty to be fair with the community to be served, to deliver dental care without
                                        prejudice, and to improve issues relating to access to care.
5. Veracity                             The duty to communicate truthfully with patients and colleagues.
Source: ADA principles of ethics and code of professional conduct. At: Accessed:
April 24, 2009. Definitions are paraphrased from this source.

later adopted by the ADA. Accordingly, one taking                      six schools were contacted between one and eight
this pledge promises to abide by the principles set                    times. Copies of each oath were requested together
forth in the ADA code.4 The “Oath to the Profes-                       with information about when and how each is admin-
sion/Professional Pledge” reflects wording from the                    istered. Each sentence of each oath was reviewed by
Hippocratic Oath, the Prayer of Maimonides, and                        a single reviewer to determine its consistency with
the 1947 Declaration of Geneva. The Modern Hip-                        each of the five ADA code principles and reference
pocratic Oath originated at Tufts University in 1964                   to commitment to contributing to dental education
as an adaptation of the classic Hippocratic Oath in                    and to caring for underserved populations.
response to the changing issues in medicine.5
      There are three events when oaths are admin-
istered to dental students: during the White Coat                      Results
Ceremony held in the first month of dental school,
during ceremonies signifying transition to clinical                           Of the sixty-six schools contacted, sixty-one
training, and during graduation from dental school.                    responded. A total of fifty-eight oaths were received.
The Arnold P. Gold Foundation established the White                    Oaths were utilized a total of sixty-three times by
Coat Ceremony at commencement exercises at Co-                         fifty-one schools.
lumbia University’s College of Physicians and Sur-                            All oaths are reportedly spoken aloud by stu-
geons in 1993, and the ceremony—now conducted                          dents. Six schools also have their students sign the
at most dental schools—is marked by students’ being                    oath. Thirty-nine schools reported the use of one oath,
formally cloaked in white coats to verify their status                 twelve schools reported the use of two oaths, and ten
as health care professionals.6                                         schools reported using no formal oaths. Of the thirty-
      While two studies performed content analyses                     nine schools that reported using one oath, thirty-two
of oaths administered by accredited allopathic and                     have their students recite it during the White Coat
osteopathic medical schools within the last fifteen                    Ceremony or at transition to clinical training, and
years,7,8 there is no published empirical study of                     seven use it at graduation. For the twelve schools
dental oaths administered by ADA-accredited dental                     that have two oaths, all administer an oath on two
schools. The purpose of this study is to perform a                     occasions. Five of the twelve schools whose students
review and content analysis of dental school oaths.                    recite two oaths have them repeat the same oath.
                                                                              Eighteen oaths follow the wording of “The
                                                                       Dentist’s Pledge,” nine oaths align with the “Oath to
Methods                                                                the Profession/Professional Pledge,” and three oaths
                                                                       are consistent with the Modern Hippocratic Oath.
      Information on dental school oaths was sought                    The remaining twenty-eight oaths use idiosyncratic
by email and repeated telephone contact with the                       wording, often developed by the school’s faculty
deans’ offices of all dental schools in the United States              and/or students.
(n=55), Canada (n=10), and Puerto Rico (n=1) during                           All five of the ADA code’s ethical principles are
the period April through June 2006. A total of sixty-                  addressed in thirteen of the oaths, and four principles

June 2009     ■   Journal of Dental Education                                                                                        747
      are addressed in nine oaths. Three or fewer principles                  Four oaths address God, two claim account-
      are addressed in the remaining thirty-six oaths, with             ability if the oath is not honored, eight mention the
      references to justice and veracity most frequently                importance of contributing to dental education, four
      missing. Table 2 shows the numbers of oaths citing                mention the need for students to adhere to their
      each principle and provides specific examples of                  school’s student conduct policies, and eleven express
      language from dental school oaths that support each               the need to actively treat or find new approaches to
      of the five principles.                                           care for the underserved.

      Table 2. ADA principles of ethics and examples of descriptive language used in dental student oaths
                             Number of
                             Oaths That
      ADA                     Address
      Principles              Principle      Examples of Descriptive Language Used in Oaths

      1. Patient autonomy        44          Confidence:
                                             • “My privileges depend upon the trust of my patients. I will not violate that trust.”
                                                (Oath to the Profession)
                                             • “I will hold in confidence all that my patients entrust to me.” (Oath to the
                                             • “I will provide absolute discretion and confidentiality for those who entrust me
                                                with their care.” (University of Southern Illinois)
                                             • “To maintain an impeccable relationship with them [patients] that will warrant
                                                their trust and confidence.” (University of Florida, University of Nebraska)
                                             • “I will respect the confidences of my patients and will not improperly divulge
                                                them.” (University of Manitoba)
                                             Informed consent:
                                             • “I will partner with each patient in decision making.” (Harvard)
                                             • “I will be responsible for . . . providing respectful and informed counsel and
                                                 care.” (University of Louisville)
                                             • “I shall include my patients in all important decisions about their care.” (Oath to
                                                 the Profession)
      2. Nonmaleficence          54          Consultation/referral:
                                             • “I will seek knowledge and inspiration from my colleagues whenever my patients’
                                                needs require.” (Oath to the Profession)
                                             • “I will recognize my own limitations and will seek help when my level of
                                                experience is inadequate to handle a situation.” (University of Alberta)
                                             Continuing education:
                                             • “I will strive to improve the knowledge and skills I profess to have.”
                                                (Oath to the Profession)
                                             • “I will always practice my profession with . . . skills derived from scientific
                                                evidence.” (University of Southern California)
                                             • “I will strive to advance my profession by seeking new knowledge . . . [and] will
                                                attend to my own intellectual and professional development in the best interest
                                                of serving others.” (Oath to the Profession)
                                             • “I commit to being a lifelong scholar, continuously refining the skills I have
                                                acquired.” (Harvard)
      3. Beneficence             48          Community service:
                                             • “I am responsible for contributing to the improvement of the community.”
                                               (Oath to the Profession)
                                             • “I further commit myself to the betterment of my community and to all members
                                               of society.” (The Dentist’s Pledge)
                                             • “I will always conduct myself . . . with the health and well-being of my . . .
                                               community as the first consideration.” (University of Southern California)


748                                                                   Journal of Dental Education ■ Volume 73, Number 6
                                                                  study addressed all five ADA principles of ethics
Discussion                                                        suggests missed opportunities to highlight the full
                                                                  range of ethical responsibilities that accompany the
       Dentists hold a place of high esteem and trust
                                                                  privilege of being a dentist.
within society because of the unique knowledge they
                                                                         Oaths are not necessarily intended to address
possess relative to patients’ asymmetrically poor
                                                                  the full range of ethical concerns faced by dentists.
knowledge needed to make decisions about their own
                                                                  Curtis, author of “Under Oath: Examining the Role
care. In return, dentists are held to high standards
                                                                  of the Hippocratic Oath in Dentistry,” points out that
of conduct that are embodied in the ADA code. As
                                                                  although the Hippocratic Oath serves as a foundation
dental schools endeavor to develop and instill in
                                                                  for many dental oaths, it was not written with a view
their students a sense of professionalism and ethical
                                                                  to the contemporary legal or educational systems. In-
conduct to carry into further professional practice,
                                                                  stead, he finds that the value of oaths is to “help bring
oath-taking provides an opportunity for schools to
                                                                  dentistry’s sweeping obligations to a personal level.”9
develop content for oaths that is more meaningful
                                                                  While this allows the ethical principles in the oaths to
and comprehensive and an opportunity for dental
                                                                  be applied to situations not explicitly detailed in the
students to make binding statements for future ac-
                                                                  pledge, there may be additional value to highlighting
tions. That only thirteen of fifty-eight oaths in this

Table 2. ADA principles of ethics and examples of descriptive language used in dental student oaths (continued)
                         Number of
                         Oaths That
ADA                       Address
Principles                Principle    Examples of Descriptive Language Used in Oaths

                                       Research and design:
                                       • “[I promise] to embrace investigation and education in order to expand medical
                                          and dental knowledge.” (Harvard)
                                       • “I will conduct research in an ethical and unbiased manner, report results
                                          truthfully.” (University of Alberta)
                                       • “I will strive to advance my profession by . . . re-examining the ideas and
                                          practices of the past.” (Oath to the Profession)
                                       • “I will continue to seek to attain the latest knowledge and finest skill.”
                                          (New York University)
                                       • “Beginning today, we will make a lifelong commitment to enhancing
                                          professionalism within the practice of dentistry and the entire health care
                                          delivery system.” (University of Washington, Marquette University)
4. Justice                   22        Patient selection:
                                       • “I will always provide oral health care without consideration of religion,
                                           nationality, race or ethnicity, gender or sexual preference, disabilities, political
                                           choices, or social and economic standing.” (University of Southern California,
                                           University of Alberta)
                                       • “I will abstain from greed and prejudice.” (Stony Brook University)
                                       • “I will not discriminate against any person in my decisions and care.” (University
                                           of the Pacific)
                                       • “Without discrimination, I will honor my patient’s dignity while I provide
                                           compassionate and empathetic care.” (Louisiana State University)
                                       • “I will use my skill to serve those in need, with openness and without bias.”
                                           (Oath to the Profession)
5. Veracity                  22        Representation of care:
                                       • “I will be truthful with patients and not misrepresent my qualifications.”
                                          (University of Alberta)
                                       • “I will record accurately all historical and physical findings, test results, and
                                          other information pertinent to the care of the patient.” (University of Alberta)
                                       • “The high regard of my profession is born of society’s trust in its practitioners;
                                          I will strive to merit that trust.” (Oath to the Profession)

June 2009     ■   Journal of Dental Education                                                                                     749
      some of the more pressing contemporary concerns            and nonessential care.14 Ozar, in an article discussing
      within the dental oath. These issues include access        ethics, access, and care, argued that health care needs
      to care, obligations to contribute to dental education,    are identified by “comparing the patient’s situation
      and academic integrity.                                    with an understanding of ideal human health,”15 with
             Only eleven oaths in our study demonstrate          the assumption that the professional has specialized
      some commitment to caring for the underserved,             knowledge that an average layperson does not. In a
      which is of concern because solutions to leveling          related article, Chambers countered that there are too
      oral health disparities are limited without atten-         many variations in the interpretations dentists give
      tion. Access to care remains one of contemporary           to objective oral conditions and, thus, health needs
      dentistry’s most pressing issues, as evidenced by the      and priorities are largely dependent on the individual
      disproportionate distribution of dental care across        dentist’s personal values.14 Chambers’s view lends
      racial and socioeconomic communities in the United         support to the importance of consistently building
      States.10 The basic assertion of justice, the principle    upon these values throughout one’s professional ca-
      most closely associated with ensuring access to the        reer. Highlighting these values within school oaths
      best dental care for all people without prejudice, is      is one vehicle to do so.
      that honorable dental professionals “have a respon-              A new approach initiated at the University of
      sibility to ensure fairness in the promotion of the        North Carolina at Chapel Hill in 2004 to address
      societal good,” as Mouradian, author of “Ethics and        access to care is an additional pledge entitled “A
      Leadership in Children’s Oral Health,” has affirmed.11     Commitment to Serve.” Students pledge to regularly
      Additionally, in an argument for best practices in         devote work hours to community service for the
      dentistry, Zarkowski et al. discussed how dental           duration of their professional careers.16 This pledge
      education programs will need to adapt to identify          may have some value that could be incorporated into
      core curricula that best accommodate dentistry’s           school oaths or administered in adjunct to them.
      changing demographics, oral health trends, and those             Student professionalism in dental school
      trends’ significant implications for dental education,     continues to be a source of considerable concern
      “including professional attitudes concerning social        among students and faculty alike. A student’s lack
      responsibility and awareness.”12                           of ethical conduct in school may continue as he or
             A 2006 American Dental Education Associa-           she enters clinical practice. A study focusing on
      tion (ADEA) survey of graduating dental school se-         medical students’ knowledge and attitudes about
      niors demonstrated their understanding of the issue’s      professionalism in medicine found that, once in
      importance. That study found that 75.9 percent of          medical school, students express great enthusiasm for
      graduating students agreed or strongly agreed that         “being service-oriented” and “doing good,” but they
      access to oral health care is a major problem in           don’t necessarily believe they are obliged to act with
      the United States and 84.4 percent either agreed or        such accord.7 Reinforcing expectations of students
      strongly agreed that ensuring and providing care to        to act honestly, while confronting issues associated
      all segments of society are ethical and professional       with unethical behavior, is a difficult task for dental
      obligations. Furthermore, 90.8 percent said they felt      educators. In an article discussing ethics in dental
      adequately prepared to administer oral health care         education, Bertolami argued that there is a need
      for a diverse society, and 84 percent felt adequately      to supplement existing courses on ethics in dental
      prepared to practice adaptive treatment planning for       school and that they should come “very early in the
      low-income populations/individuals.13 Yet there is a       dental educational experience to address the discon-
      disconnect between student reports of intent to care       nect between knowledge and action.”17 Incorporating
      for the underserved and actual practice in the field,      statements regarding student conduct policies can be
      evidenced by ongoing and worsening disparities in          an ideal place to introduce students to this ethical
      oral health care delivery.                                 obligation. Among dental schools, only four oaths
             This disconnect may possibly be due to the lure     identify the ethical obligation students have towards
      of more lucrative incomes in private practices that        their student conduct policies while enrolled. This
      serve affluent populations or provide greater propor-      seems inadequate, given cheating scandals within
      tions of cosmetic dentistry and thus suggests a focus      dental schools.
      away from improving the health of the public at large            New students should be made aware of the cur-
      and a growing segmentation of dentistry into essential     rent crisis in dental education, specifically the dental

750                                                             Journal of Dental Education ■ Volume 73, Number 6
school faculty shortage; this crisis places in jeopardy    dental students to important ethical responsibilities.
the general and oral health of the public. According to    Many oaths fall short of this opportunity.
the American Association of Dental Schools (AADS;                We urge dental schools to consider the follow-
now ADEA) Task Force on Future Dental School               ing recommendations regarding oaths:
Faculty, dental schools should promote an immedi-          1. Establish oaths in all dental schools.
ate recognition of this predicament to all students,       2. Incorporate all five ADA principles of ethics into
along with those not yet in dental school.18 There is           all oaths.
a place within dental oaths to address the need for        3. Increase emphasis on the importance of oath
dental educators. This can serve as one strategy to             value. For example:
introduce and potentially impart a lasting desire to be         •	 During interviews, applicants could be asked
involved in dental education. According to the 2006                 to read the school’s dental oath and ask ques-
ADEA survey of graduating dental school seniors,                    tions relating to issues discussed in it.
from 2001 to 2006 less than 2 percent of respondents            •	 The school’s oath could be sent with accep-
expressed an interest in pursuing a teaching, research,             tance letters to applicants granted admission
or administrative position after dental school.13                   in order to highlight the gravity of oaths and
       While the simple act of reciting an oath does                impart ethical expectations.
not in itself guarantee adherence to its obligation,            •	 A “Commitment to Serve” pledge could be-
there are certain characteristics that can make oaths               come an adjunct to oaths.
seem more binding. Verbal recitation in front of an
audience creates a sense of accountability, and all        Acknowledgments
the oaths surveyed were carried out in this manner.              We gratefully acknowledge the contribution of
Six schools have their students additionally sign their    Dr. David Chambers, Editor, Journal of the American
oaths as if they were contracts. Chambers describes        College of Dentists, for his comments and guidance
the particular power of a promise, such as an oath, as     in interpreting the findings of this study.
being a form of performative language: “Sentences
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752                                                                   Journal of Dental Education ■ Volume 73, Number 6

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