Abstract

Oath-taking came into existence through Hippocrates (2^nd AD) and Charak (4^th AD) thereafter to set a uniformly ethical conduct of physicians for maintaining the quality of healthcare. In tobacco control, it is administered usually at the end of an awareness activity. It is done with an expectation that the participants sensitized on the adverse effects of tobacco use will never ever be its users and shall lead a tobacco-free life. The moot questions are: Is it useful and is it effective? We have do not have any evidence to prove it yet. Through this communication we wish to rationalize the use of oath-taking as an effective strategy through evidence-based data thorough consideration of its applicability, implementation and outcome. Multi-center prospective studies may be the way forward to either recommend it as a norm or omit it altogether instead of its currently practiced belief-based emotive application.

Keywords: Tobacco; Tobacco Control; Oath-taking

Introduction

The Premise

Oath-taking means following the principles of the discipline and practicing what one preaches based on the discipline, failing which there will be serious consequences. It also means staying honest with oneself and the work for which one is accepting to work under the oath.

Oaths have been in the existence from the times of Hippocrates (2^nd AD) and Charak (4^th AD) as the product of sociocultural factors which existed then. These were meant primarily to set the standards of the conduct of physicians in terms of ethics and quality of the practice of medicine according to the best of one’s ability and judgement [1]. These now appear to have several limitations in view of giving the medical education for a fee, allowing abortion up to a certain gestational age, accepting euthanasia in some countries to end the life, inclusion of patient autonomy and justice as bioethical principles which are not the part of the oath and widening of the initial tripartite agreement between the physician, patient and illness to pharma- and insurance- industry and malpractice [1]. Also, without any legal binding, these appear confusing the young physicians in taking some critical decisions, whether to uphold the oath or the law. Most recently these do not appear relevant due to an access to Google which enables patients the status of a semi-literate when they come to seek a medical consultation [1]. It appears relevant here to refer the readers of this communication to the Maharishi Charak Shapath prescribed by the National Medical Commission in the year 2022 as part of Undergraduate Medical Education Board [2]. However, these do not appear to address the concerns stated in the preceding para. Oath delivery under tobacco control: Oath-taking for those working in tobacco control is a serious lifetime commitment. Its conduct for not using tobacco, informing family and others about its harms and keeping the respective premises and environment tobacco- free is frequently an observed usual practice in India following conduct of awareness sessions countrywide delivered to strengthen the governmental efforts to regulate tobacco and reduce its use.

Here is an example of a typical oath: “On this occasion of World No Tobacco Day, I pledge that I shall never smoke or consume any type of tobacco products in my life and shall motivate my family members and acquaintances not to smoke or consume any type of tobacco products. I shall keep the campus of my office tobacco free and shall also motivate my colleagues for the same”[3].

Many takes oath without even thinking about its implications. Although it means that in the light of what you have heard and vowed to abide to it, you will abide by it lifelong what has been recommended. But usual observations made from these oath-taking ceremonies conducted in a public training or a simple awareness-creating session have been that the element of seriousness is missing in the majority after the act is over. Usually, it is a one-time utterance. As an example, in a school if a teacher who has been selected as the one to be the focal point for monitoring tobacco use, her job is considered to oversee what is happening among children and other teachers in terms of using any tobacco product, when she will conduct an oath taking. Several times, it has been seen that many participants put forth their arms to oath taking without listening carefully to what they have been asked to follow. A usual expression is “I just did it as part of that group”. Therefore, conducting such an oath-taking makes very little sense. While this is considered and used as an acceptable community practice because no one declines or stand apart not to be a part of oath-taking, for the people with scientific temperament it is intriguing. This is because no study, reference or overview could be found that demonstrates any strength of evidence specific to the domain of Tobacco Control (TC) by the authors to suggest its utility or efficacy or to omit it altogether. Following questions arose in our skeptic minds:

1. Why at all the oath-taking should be used at the end of awareness sessions?
2. Is it not a waste of time, energy and effort of the unwilling participating individuals?
3. Through an askance at the individual level to stay tobacco-free, is it not diverting attention of the participants from the core issue of strengthening TC through the new information they received through the awareness session?
4. Is oath-taking solely based on currently prevailing beliefs at the societal- level that what is committed socially will make the participating individuals commit for an ideal behavioral pattern despite easy access of tobacco products and a social acceptance of those using tobacco products?
5. How will an individual live through the conditions set or recommendations made under the oath if at the societal- and ethical- levels abiding to a promise made is not the part of the currently prevailing value-system?
6. Why has anyone not studied yet the impact and the outcomes of oath-taking scientifically as a tool to lead a tobacco-free life as is the norm under scientific practice?
7. Should it not be studied as a multi-center randomized study to establish evidence of its utility? And, also to know the strength of evidence it has to make a recommendation as is the norm under TC?

Discussion

While oath taking is considered a time-tested ancient process in medical profession and it may transiently motivate participants to be thoughtful and truthful for an ethical behavior, the observed change appears rather insignificant [4-6]. Hence, it appears quite pertinent to introspect and ask stakeholders working in TC why practice the delivery of oath in tobacco control to the participants of awareness sessions or on specific occasions such as World No Tobacco Day. Should oath-taking be the part of tobacco control, then the whole delivery of the training and the discussion will have to be taken to a different level: (1) Oath-taking as such should not be for all the participants of a training or a discussion; (2) It should be only for those who make the commitment and want to follow pursuing that promise; and, (3) For this group of participants the training should be conducted in a manner which indicates what the oath is referring to. So, for those who are taking/given the oath, in the real sense their training should include solid education based on the user needs and gaps. As an example, if we are conducting a session on why young people should not indulge in tobacco use, we must clarify all their doubts through satisfactory explanations beforehand, so that it becomes a very intimate knowledge, totally comprehensive and all inclusive. In such a situation observing the oath may become almost automatic. In addition, since the narrative may differ for different oath takers to stay determined, e.g. when they get tempted to use a tobacco product when they see someone use it, then they should be able to access the oath-conductor/mentor in tobacco control in their environment to understand and get supported why it is happening, how their experimenting with any tobacco product will ruin their resolve and to say no to tobacco use at every such vulnerable moment. Also, individuals alone cannot make the right choice based solely on the information provided to them (through awareness sessions since the industry too provides it albeit differently and in a shorter manner). Balbach, et al., have suggested a multi-level, multi-stakeholder model that also considers the impact of environment- and community- based interventions. This can happen only when tobacco control is at its strongest. Also, one must consider the fact that information provided by the schools (as is done by the Tobacco Industry for the adults) does not help adolescents to go for preventive measures [7]. To sum-up, in tobacco control, oath-taking need not be a part of every training or discussion. It should be delivered only to those who shall make a commitment to and for stronger and effective tobacco control and follow-up on that commitment lifelong.

Conclusion

Taking oath has been a widely practiced process in the field of tobacco control during the awareness sessions countrywide. We have raised this issue since no evidence could be found in the available literature on efficacy of its implementation to strengthen tobacco control. We consider the subject should be researched prospectively to obtain the strength of evidence in support, to either sustain this practice or omit it altogether.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.

Data Availability Statement

Not applicable.

Ethical Statement                                                

The project did not meet the definition of human subject research under the purview of the IRB according to federal regulations and therefore, was exempt.

Informed Consent Statement

Informed consent was taken for this study.

Authors’ Contributions

All authors contributed equally to this paper.

References

1. India V, Radhika MS. Hippocratic oath: Losing relevance in today’s world? Indian J Psychiatry. 2019;61(Suppl 4):S773-5.
2. National Medical Commission. Brief transliteration of Maharishi Charak Shapath. Implementation of new competency-based medical education for undergraduate course curriculum. New Delhi: National Medical Commission. 2022.
3. Sudan P. Pledge ceremony on the eve of World No Tobacco Day, 31 May 2019. Letter to secretaries of all ministries and departments. New Delhi: Ministry of Health and Family Welfare, Government of India. 2019.
4. Jacquemet N, James AG, Luchini S, Murphy JJ, Shogren JF. Do truth-telling oaths improve honesty in crowd-working? PLoS One. 2021;16(1):e0244958.
5. Aleksic J, Alexa A, Attwood TK, Chue Hong N, Dahlö M, Davey R, et al. Open science peer review oath. F1000Res. 2014;3:271.
6. Gamble N, Holler B, Thomson S, Murata S, Stahnisch FW, Russell G. Is the writing on the wall for current medical oaths? A brief historical review of oath taking at medical schools. Med Sci Educ. 2019;29(2):603-7.
7. Balbach ED, Smith EA, Melone R. How the health belief model helps the tobacco industry: Individuals, choice and “the information”. Tob Control. 2006;15(Suppl 4):iv37-43.