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; firstname.lastname@example.org.
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: www.ada.org/prof/prac/law/code/principles_01.asp. 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
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)
• “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
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)
• “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
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)
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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