INTRODUCTION

Beyond the academic integrity expected of a chiropractic student, that is, honesty, avoidance of cheating, and not plagiarizing or demonstrating any inappropriate behavior, the student doctor must acquire and develop an attitude of professionalism during his or her years in chiropractic college. This sets the foundation for a career of professional behavior. Professionalism encompasses a variety of characteristics and behaviors that have been defined in many ways. Some examples include the conduct, aims, or qualities that characterize or mark a profession or a professional person;¹ the combination of all the qualities that are connected with trained and skilled people;² and the combination of qualities and conduct regarded as essential to professional practice. These include knowledge, skills, relevant competence, and behavioral qualities; values of honesty, integrity, and ethical probity; and the capability of working well with patients or clients, colleagues, and representatives of the public.³

It has been generally accepted that acquiring professional values and behavior by doctors in training has occurred primarily by observing the conduct and culture of college faculty, teachers, and mentors.⁴ Recently, there has been a growing awareness that, in addition to that informal monitoring of their teachers' behavior, it could be beneficial for a formal course or courses in professionalism to be incorporated into the curriculum.⁵ Classes in professionalism would be formally taught and graded, as with all other clinical subjects. That discussion is beyond the scope of this article.

There is a point in most chiropractic convocation ceremonies marking the transition from student to doctor. The desired academic integrity and professional attitude hopefully instilled in the newly graduating student throughout his or her time in school now matures and evolves into the lifelong ethical and professional behavior and attitudes soon to be practiced by the new doctor throughout his or her career. This powerful, solemn, and beautiful part of the ceremony is the administration of the chiropractic oath. Traditionally, this step marks the culmination of the student's schooling.

The chiropractic oath is more than a promise, sworn or affirmed by the graduating student. It declares a code of ethical behavior, subscribed to by the new graduate, that defines our profession. It is hoped that the formal recitation of the oath will help to reinforce and galvanize the new doctor's commitment and determination to behave ethically and professionally.⁵

It is the foundation of a social contract between the new doctor and his or her patients, colleagues, other professionals, and society in general wherein he or she voluntarily declares an obligation to practice according to the text.^6,7 The idea is that this declaration provides an “ethical code” to morally guide the new doctor, centered on such desirable qualities as honesty, altruism, compassion, and commitment to his or her patients.⁵ Of course, swearing an oath does not ensure moral behavior, nor can it enforce any legal obligations on the graduate;⁶ nonetheless, it is a pronouncement of the graduate's acceptance of his or her ethical responsibility to society.

This article, through an analysis of the relevant components of the many different chiropractic oaths relating to integrity and professional behavior, describes and addresses the variation currently existing among the oaths used at chiropractic commencement ceremonies.

METHODS

Data were obtained from 1988 and 2019 papers describing components of the oaths used at each existing chiropractic college as well as those used in the past by colleges that are no longer operational.^8,9 Two of the original 5 categories used in these papers, namely, patient interaction and professional attitude, were selected as being most optimally aligned with the theme of ethics, integrity, and professional conduct and containing the most relevant components in the author's subjective opinion. The data collected consisted of appropriate excerpts and phrases from the various oaths. Nine oath components, best related to ethics, integrity, and professional conduct, were then selected from the 26 topics originally studied in those papers (Table 1).⁹ Additionally, the 5 chiropractic programs opening post-2019 were contacted to obtain their oaths. Four of these schools replied that they had not yet decided on an oath: Australian Chiropractic College (Australia), London South Bank University (United Kingdom), Teeside University (United Kingdom), and Unidade Central de Educacao Faem Faculdade (Brazil). The fifth new school, Universidad Central del Caribe (Puerto Rico), had just graduated its first class on June 7, 2022, and its new oath was included in this study. In total, 42 oaths were studied. Full versions of each oath are not included here; contact information for each program can be found at https://www.wfc.org/website/index.php?option=com_content&view=article&id=141&Itemid=140&lang=en).

Table 1 - Oath Topics for Each Chiropractic Institution

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Each of the oaths was examined for the presence of the chosen components and the specific wording used to describe that component. The various oaths were then compared for their individual inclusion and emphasis of these components.

RESULTS

The specific topics appearing in each individual oath are summarized in Table 1. Table 2 lists the overall frequency of each topic among programs. The concept of “keeping of a patient's confidence” was the most frequently occurring component, appearing in 31 of the 42 oaths. Graduates of 26 schools pledged to “refrain from wrongdoing.” Improving knowledge and keeping current was the third most common component, appearing in 25 oaths. Twenty-four oaths alluded to “showing no discrimination.” “Regard for colleagues” appeared in 21 oaths. Fifteen oaths mentioned “respect for teachers” and “relief of the sick/disease/suffering.” The least frequent component, found in 13 oaths, was the idea of “serving humanity.”

Table 2 - Topics Investigated and Frequency of Occurrence in Chiropractic Oaths

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DISCUSSION

Examples of the distinct phraseology used to describe the various components are provided, and it is noted where schools omit these aspects from their oaths. To provide an interesting and more comprehensive historical perspective, phrasing examples from a variety of formerly used oaths as well as oaths from nonoperational colleges are also presented here, although only the most current oath for each existing school was used in the analysis.

“Keeping of a patient's confidence” is considered so important that it ranked first overall in frequency at 76.2%. This phrase alludes to our position of great responsibility, that chiropractors are, in fact, professional confidants. The graduates of the now-defunct Pasadena College would state “that I will not reveal to anyone anything revealed to me in the course of my work, save with full knowledge and permission of the patient involved.” Sydney College (1959–1990) merged with Macquarie University in 1990, and all graduates, pre- and postmerger, pledged and continue to pledge to “guard their secrets with scrupulous honor and fidelity.” Graduates of the Universidade Centrale de Chile promise to “save and respect professional secrecy.” Welsh Institute graduates, until 2017, included “respecting and protecting confidential information” as part of their oath. The first graduating class at Universidad Central del Caribe pledged, “I will . . . hold in strict confidence all things revealed to me as a physician.”

National College graduates from at least 1935 through 1949 promised that “whatever in connection with my professional practice, or not in connection with it, I may see or hear in the lives of men and women which ought not to be spoken abroad, I will not divulge, reckoning that all such should be kept secret.” National graduates today say, “I will respect the secrets that are confided in me, even after the patient has died.”

Hand in hand with keeping a patient's confidence is the promise to generally “refrain from wrongdoing,” also a common theme for a professional pledge or oath (64.3%).

In the 1950s, graduates of the Chiropractic Institute of New York pledged to “abstain from all intentional mischief and harm.” Logan College graduates in the 1980s promised that “I will not misrepresent myself or my profession to others and will never use my knowledge of chiropractic to cause harm or injury to any person.”

The graduates of Sydney College (now Macquarie University) promise to “not engage in those practices which will in any way bring shame or discredit upon myself or my profession.” Current graduates at the Southern California University of Health Sciences pledge “to practice ethically and with honesty.” Many oaths (eg, Council on Chiropractic Education oath 1972, Texas Chiropractic College, and University of Bridgeport today), both past and present, mention “to abstain from whatever is deleterious and mischievous” or “to abstain from whatever is harmful or unethical” (Northwestern Health Sciences University since 1984). Palmer College of Chiropractic and Palmer College of Chiropractic West graduates currently promise to “not violate that which is moral and right,” as did the graduates of Pennsylvania College of Straight Chiropractic. The graduates of the Institut Franco-Européen de Chiropratique promise “to abstain from all intervention which may be dangerous.” Welsh Institute graduates would promise to “ not abuse my professional position and at all times I will be honest and trustworthy.”

With the understanding that every graduate is, in effect, an eternal student, the third most common component involved the pledge to keep learning, improving, and staying current (61.9%). This idea was expressed in a wide variety of phrases in which graduates pledge to “keep an open mind,” “continue to learn,” and “improve his/her knowledge.” Graduates of the Columbia Institute of Chiropractic (1966); Life Chiropractic College, Life Chiropractic College West, and Logan College of Chiropractic (all since 1987); and Palmer College of Chiropractic and Sherman College of Straight Chiropractic (1973–1978) stated, “I will keep an open mind regarding the progress of my profession.”

Other statements related to keeping current included the following: “I shall keep abreast of the advancements in my profession” (Lincoln Chiropractic College), “I will actively continue to learn and to improve my skills” (Logan College of Chiropractic 1986), “I will keep an open mind regarding the changes in my profession” (Pennsylvania College of Chiropractic), and “I pledge to . . . constantly maintain my knowledge” (Institut Franco-Européen de Chiropratique). McTimoney College graduates humbly admit that “recognizing the limits of my competence, I will keep my professional skills and knowledge up to date.” New York Chiropractic College graduates pledge that “through lifelong learning I will keep my skills and mind sharp.” At the University of Western States, graduating students promise that “I will continue learning throughout my life so that I may provide for the good of my patients.” Universidad Central del Caribe graduates promise that “through lifelong learning I will keep my skills current.” The graduates of Murdoch University pledge that “I will continually and judiciously improve my knowledge and skill.” Welsh Institute graduates, until administration of their oath ceased in 2017, would pledge that they “will look to contemporary science and evidence for what I do.”

Improving knowledge and skill is an important component of the promise made by a chiropractor at graduation. As early as 1948, Palmer College had the foresight to comment on advancement in the profession as part of its oath. It is the graduates' responsibility to their patients to remain contemporary in academic and clinical knowledge to best serve them. Thus, improving knowledge would seem to be a proper inclusion in the graduation pledge. Perhaps any proposed universally accepted chiropractic oath should include a phrase to that effect.

Because throughout his or her career a new graduate cannot rely exclusively on the education and skills he or she acquired in school, lifelong learning and maintaining currency becomes a duty of the practicing doctor.¹⁰ Furthermore, society expects that a health care professional will seek excellence and attempt to improve the standards of care through ongoing research and development of their knowledge base.¹¹ It is therefore appropriate that graduates avow their commitment to improving their knowledge and skills throughout the duration of their practice.

The Chiropractic Institute of New York's oaths (1956–1960) mentioned “to impart, unreservedly, instruction in the Art and Science of Chiropractic to my colleagues, but to none others.” This unique phrase ties in the idea of cooperation and regard for colleagues with the concept that chiropractors can teach each other and learn from each other.

An important aspect of ethical, professional behavior for the practicing doctor is not discriminating against patients. This was a popular concept in oaths, appearing in 59.5% of the oaths, and phrased in a variety of ways. The Welsh Institute and McTimoney College oaths include “I will never discriminate unfairly against patients or colleagues.”

Universidade Feevale graduates add simply “without any form of discrimination.” “Without distinction of race, creed or color,” state the graduates at Canadian Memorial Chiropractic College and D'Youville College as well as those at Anglo-European College of Chiropractic, Northwestern Health Sciences University, Parker University, Texas College of Chiropractic, University of Bridgeport, and graduates from Durban University of Technology and the University of Johannesburg in South Africa. Southern California University of Health Science's oath changes the order to “race, color or creed.” The Barcelona College of Chiropractic oath has changed that to “without distinction of race, creed or beliefs.” The Madrid College of Chiropractic graduates pledge to “always respect political and religious beliefs, nationalities, races, and social and economic levels, ensuring that they avoid interfering between my professional services and my patients.” Sherman College of Chiropractic graduates promise that “my best service will be available to all, regardless of their cultural, racial or religious background, or their ability to pay.” The graduates of the Keiser University program include in their oath “I will respect . . . without regard to gender, race, national origin, religion or sexual orientation.” National University of Health Sciences has the most inclusive list in its oath, stating, “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.” Institut Franco-Européen de Chiropratique graduates promise to “provide bountiful help at all times to my neighbor, without distinction of race or belief.” The New Zealand College of Chiropractic oath states, “My best service will be available to all, regardless of their cultural, racial or religious background, or their ability to pay.”

Expressing positive comments and respect regarding other health care professionals, be they colleagues or other types of practitioners, is a desired professional quality, and 52.4% of current oaths mentioned having a “positive regard for colleagues.” This addresses the issue of respecting other chiropractors and promoting professional unity and harmony as well as other health professionals. This is perhaps most explicitly stated in the 1986 Logan College of Chiropractic oath: “I will not denigrate those in my profession who choose to use methods different from mine.” National University of Health Sciences graduates today maintain that “my colleagues will be my sisters and brothers.” Graduating Murdoch University students state that “I will regard my fellow health professionals with courtesy and good faith.” A Macquarie University graduate promises that “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.” The Universidad Central del Caribe oath states, “Recognizing their unique skills, I will refer to, and collaborate with, other health professionals when it serves the best interest of my patients.”

Nearly half of the oaths (47.6%) mention “living up to the principles” of the profession. This is stated in a variety of ways. At Canadian Memorial Chiropractic College, it is stated that “insofar as my science is in the highest precepts of my alma mater and harmonious with the Vis Medicatrix Naturae.” At Cleveland Chiropractic College–Kansas City (since 1980), it is worded as “to live up to the highest principles of my profession.” At Cleveland Chiropractic College–Kansas City (before 1956) and Cleveland Chiropractic College–Los Angeles (since 1950), this was phrased as “to always live up to the high principles of my profession.”

Several programs, including Bahcesehir University (present); Columbia Institute of Chiropractic (1966); Durban University of Technology (present); Hanseo University, International Medical University (present); Life Chiropractic College, Life Chiropractic College West, and Logan University (all 1987–present); Murdoch University (present); Pennsylvania College of Chiropractic (1977–1995); Sherman College of Chiropractic (1973–1978); University of Johannesburg (present); and Universidad Veracruzana (present) state, “I will observe and practice every acknowledged rule of professional conduct in relation to my profession, my patient, my colleague and myself.” Previously (1930), Logan Basic College of Chiropractic included “to hold my profession and the practice of my profession to the height for which its value provides.” Later (1986), Logan College stated, “I will strive to bring credit to . . . my profession.” Both Palmer College of Chiropractic (1983–present) and Palmer College of Chiropractic West (after 1988) include “I will adhere to the code of ethics espoused by the chiropractic profession.” Finally, Pasadena College of Chiropractic stated from 1974 to 1995 “that I will adhere faithfully to the principles and practice of Chiropractic Art and teachings.”

Of all components of the oath, the “relief of suffering and of disease” might seem to be the most logical inclusion, as it constitutes the ultimate raison d'être of our profession. However, in a surprising observation, only 38.1% of current oaths contain some reference to relief of suffering and disease.

Respect for teachers, commonly referred to as “those who taught me this chiropractic healing art,” was found in 38.1% of the oaths. While the oath is a professional promise, it is recited as a final act within the academic environment, and thus respect for teachers ties in well with the transition from student to practitioner. Institut Franco-Européen graduates pledge to “always respect the pioneers of the chiropractic art, and those who taught it to me.”

“Serving humanity” (33.3%) is referred to in the oath shared by Palmer College of Chiropractic and Palmer College of Chiropractic West, with the phrase “help to grow in service to the benefit of all humanity.” Until sometime in the 1980s, Cleveland College of Chiropractic–Kansas City graduates would “champion the right of all humanity to enjoy the benefits and blessings of chiropractic.” Students graduating from the National University of Health Sciences today pledge that “I will not use my medical knowledge contrary to the laws of humanity, even under threat.” Current New York College and Northwestern University graduates pledge “to stand ready at all times to serve humanity.”

The chiropractic oath provides and affirms the values and ethics that should ideally guide the new doctor's regular daily conduct for the duration of his or her career.¹² It is the author's contention that many of the oaths in current use demonstrate significant omissions or deficiencies regarding components related to ethics, integrity, and professional behavior. The wide variation and discrepancies in the occurrence and emphasis of these themes in the chiropractic oaths may be seen as a direct reflection of the importance assigned to these attributes in the graduates by the various chiropractic colleges. Each chiropractic college is encouraged to revisit the contents of its own particular oath in order to examine whether the wording adequately reflects the attributes desirable in its graduates. Additionally, perhaps consideration of a singular, hybrid, universally accepted oath can be discussed and proposed and will help each graduate commit to a fulsome, all-encompassing pledge to become the ethical professional that best represents chiropractic to the communities these new doctors will serve.

CONCLUSION

The elements of the chiropractic oath, the recitation of which marks the transition from student to doctor, identify and galvanize the important traits and responsibilities that go beyond technical knowledge and clinical ability, which define the new graduate doctor as a professional. This study found wide variation and discrepancies in the occurrence and emphasis of various themes in chiropractic oaths and provides information for institutions to consider with regard to the content of the oath they administer. The results of this paper may also inform the creation of a universally accepted chiropractic oath that will help each graduate commit to a fulsome, all-encompassing pledge to become the ethical professional that optimally represents chiropractic.