Socio-demographic characteristics of the group of students surveyed: The distribution of the students by sex, age, citizenship, year of study and religion is presented in Table 1.
Distribution by sex: Two thirds of the respondents are women - 122 (66.7%), which is in correspondence to the process of feminization of the medical profession. The average age of the respondents is 23.82 years (SD = 1.9), the extreme one is 42 years for one student. The majority of the students are citizens of the Republic of Bulgaria - 167 (91.3%). Respondents’ religion: A significant proportion of students have Christian religion - 133 (72.7%), Muslims are 44 students (24.0%) and 6 students pointed out another religion. Thus, a group of respondents is formed, relatively homogeneous by age; predominantly female; Bulgarian citizens; with Christian religion affiliation.
Distribution by year of study: The students in their 5th grade comprise the largest share: 75 (41%), followed by the 4th grade: 67 (36.6%), and in 6th grade, with share of 41 (22.4%). Students in 5th and 6th grade together represent almost two thirds of the respondents - 63.4%. It is important to note that they have either completed their 10-semesters education (6th grade trainee-doctors) or are in their final semester. Students in 4th grade continue their university theoretical and practical education. During the discussions of the selection criteria for the students to be included in the survey, we considered the importance of the learning phase in which they currently are. Students in the second half of their education would have their own experience, skills, impressions, formed in practical training and helping them to get closer to the professional thinking and professional moral of the medical profession. All students participating in the survey have completed a mandatory course in Medical Ethics during their first year, early stage of undergraduate education without having at that point direct contact with real clinical practice. (Medical Ethics mandatory training as a separate course for medical students was introduced in the early 1990s in medical schools in Bulgaria. In the general part of the syllabus the ethical codes are accentuated with a thorough presentation and analysis during lecture course and practical sessions.)
Students’ preference as overall perception for one of the two versions of the Oath presented:
At a closed response binominal question force choice format: “Which of the two versions of the Oath you prefer more?” the students respond as follows: almost two-thirds - 113 (61.7%) of the students prefer Version-1 the Hippocratic Oath; the remaining 70 students (38.3%) – Version-2 the Declaration of Geneva of the proposed versions. Format of the question, the subjective assessments and attitude of both students and researchers are of great importance for interpretation of this result. It is obvious and undisputed that the majority of students give preference to Version-1 - the adapted version of the Hippocratic Oath. However, this does not provide a clear trend therein as almost 40% of the respondents prefer Version-2 - the newly-revised Declaration of Geneva. We do not find statistically significant differences in students’ answers according to the basic socio-demographic characteristics described above - evaluated using the Pearson Chi-Square test - p> 0.05 for all hypotheses presented in Table 2. This preference is much more likely to be influenced by the value orientations and beliefs of young people, who have gained some experience during their medical training.
The main elements of the preferred version that students consider to be decisive are presented based on a request to students to select and mark the three most important clauses from the version preferred by them. Ranking of the selected clauses is presented in Table 3 and Table 4.
Students choosing Version-1: Ranking of the selected and tagged clauses indicates the highest preference for: “To always be ready to help those in medical need”, in the answers of 60 students (54.5%), in the first position followed by “To dedicate all my abilities and knowledge to protect and improve the health of humans“ - indicated by 54 students (49.1%) and the next “To recommend a healthy lifestyle to my patients, to protect them from things dangerous and harmful, to treat them with care and to keep the confidentiality” - according to 50 students (45.5%).
Students choosing Version-2: Ranking of the selected and tagged clauses show preference in the highest extent for the: „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“, reported in the answers of 29 students (41.4%), in the first position followed by „The health and the well-being of my patient will be my first consideration“, in the second position - indicated by 28 students (40.0%) and the next „I will maintain the utmost respect for human life“, indicated by 24 students (34.3%).
Through this ranking we strive to focus on the most significant texts and wording of the preferred version of the Oath presented through the prism of future physicians. The non-discrimination of the patient is mainly indicated by the students who preferred Version 2, and the important feature of the professional ethics of the doctor to always provide medical care is mainly indicated by the students who preferred Version-1.
The next task we pursue in our study is to outline students’ positions towards the way the relations between teachers, students and colleagues, the respect for human life, and the relationships with patients in both versions of the Oath are presented. To achieve this, we asked questions with an alternative choice of wordings from both versions.
Aspects of relations between teachers and colleagues: alternative choice between: „I pledge to my teachers the respect and gratitude that is their due”; in Version-1and „I will give to my teachers, colleagues, and students the respect and gratitude that is their due“; in Version-2. 99 (54.4%) out of the 182 students who answered the question, opted for the text of Version-2. The other 83 students (45.6%) point they prefer the wording in Version-1. Concerning this area of relationship, the respondents’ preference is toward the wording of the newly-revised Declaration of Geneva presented by more than half of them.
The respect for human life: alternative choice between: “To refuse of any call for use of lethal venom”; in Version-1 and „I will maintain the utmost respect for human life“; in Version-2. 115 (63.2%) out of the 182 students who answered the question, opted for the text of Version-2 and the remaining 67 students (36.8%) point they prefer the wording in Version 1. The result shows that in this particularly sensitive and controversial area, such as professional duty and responsibility, the wording of the newly-revised Declaration of Geneva is preferable.
Relationships with patients: alternative choice between: “To recommend a healthy lifestyle to my patients, to protect them from things dangerous and harmful, to treat them with care and to keep the confidentiality” in Version-1and “I will respect the autonomy and dignity of my patient.“ and „I will respect the secrets that are confided in me, even after the patient has died.”; in Version-2. The larger part of the students select as preferred the wording in Version-1 - 108 (59.3%) out of the 182. The remaining 74 students (40.7%) state they like more Version 2 formulation. In this area a greater preference is given to the wording of the adapted Hippocratic Oath – Version-1.
Despite the above presented overall preference of students towards Version-1 - the modified Hippocratic Oath in the particular aspect of the relations between teachers, students and colleagues and the respect for human life the preferences are rather pointing to Version-2, i.e. the newly revised Declaration of Geneva. We could assume that these preferences are associated with the above presented overall preference for a particular version of the Oath. This is especially impressive with regard to students who preferred Version- 2 and chose the corresponding wording from the same Version: 81.2% for the respect for teachers and colleagues; 94.2% for the respect for human life; 72.5% for doctor - patient relationships. The assessment of the hypotheses confirms the existence of a statistically significant difference between the preference for the corresponding version and the choice of formulations presented in the three areas - for all three hypotheses assessed using the Pearson Chi-Square test - p <0.001 (not shown here).
The survey contains an open-ended question asking students to write in their own words at least one argument in favor of their preferred version. Students selecting Version-1 as preferred: It is noteworthy that most of the arguments presented often contain expressions and words that we could summarize in the following directions: 1. The most commonly used comments are those related to the tradition, the historical roots of the profession, the continuity of the generations of physicians with words and phrases such as: “tradition”, “Hippocratic”, “established in time”, “classical”, “history”, “the historical roots of medicine”, “because of the tradition and the fact that, despite the pagan gods, the words spoken in it are principles that have been and will always be relevant to the art of the medical profession”; “the symbol of the medical profession since ancient times has been the Hippocratic Oath ....it is a tradition that must continue”; “... a pillar between the past, the present and the future...”; “respect for history”; 2. Next are those related to the impact and sound of the oath: “more prominent and stronger”, “more solemn”, “more emotional”, “sounds more poetic”, “would make me feel part of something very important ...”, “the text is more beautiful”; 3. “Clear”, “understandable”, “accurate” also appear in some of the comments. Students selecting Version-2 as preferred: The arguments are mainly related to the topicality of the oath, its modern sounding and its impact: 1. The most commonly used are: “modern”, “up-to-date”, “closer to present-day times”, “supports more accurately the progressive ideals of today’s medicine”, “meets today’s norms in society”, “realistic”, “adequate to current trends”, “... contemporary version, in which phrases are closer to the nowadays’ physician”, “more prevailing”, “More up-to-date and embracing aspects and values that in the past were not in the foreground and do not appear in the oath”; 2. some arguments emphasize certain aspects of the moral image, obligations and rights in the practice of the profession, especially in the field of doctor-patient relationship: “... I think it reflects much better the duties doctor owes to the patient and the profession integrity”, “Takes into account the patient’s autonomy and awareness”, “...meets modern requirements for understanding the patient and our responsibilities”, “... reflects in a realistic way the moral values that a physician must possess and duties to perform ... ” ; 2. The sound and impact of the oath are also expressed: “sounds progressive”, “sounds more contemporary”, “more understandable and comprehensive”, “more detailed”, “more balanced and better sounding”, “Sounds more modern”.