WMJ_2022_04_final.jan23

ISSN 0049-8122
Official Journal of The World Medical Association, Inc. Nr. 4, December 2022 vol. 68
Contents
Editorial   3
Welcome Remarks, WMA General Assembly 4
Valedictory Speech by the WMA President, Dr. Heidi Stensmyren 6
Inaugural Address by the WMA President, Dr. Osahon Enabulele 9
WMA General Assembly Report 12
WMA International Code of Medical Ethics 29
WMA Declaration of Berlin on Racism in Medicine 32
WMA Declaration of Edinburgh on Prison Conditions and the Spread of Communicable Diseases 34
WMA Declaration of Venice on End of Life Medical Care 36
WMA Declaration on Discrimination against Elderly Individuals within Healthcare Settings 38
WMA Declaration on Patient Safety 40
WMA Statement on Assisted Reproductive Technologies 42
WMA Statement on Digital Health 45
WMA Statement on Health Hazards of Tobacco Products and Tobacco-Derived Products 49
WMA Statement on Physicians 
Treating Relatives 52
WMA Statement on the Professional and Ethical Use of Social Media 53
WMA Statement on the Global Burden of Chronic Non-Communicable Disease 55
WMA Declaration on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations of Violence 58
WMA Statement on Workplace Violence in the Health Sector 60
WMA Resolution for Providing COVID-19 Vaccines for All 62
WMA Resolution in Support of Medical Personnel and Citizens of Ukraine in the Face of the Russian Invasion 63
WMA Resolution on Humanitarian and Medical Aid to Ukraine 64
WMA Statement on Occupational and Environmental Health and Safety 65
Interview with the WMA Past President 67
Interview with the WMA President 69
Canada’s Medically Administered Death (MAD) Expansion for Mental Illness: Targeting the Most Vulnerable 72
2022 Monkeypox Outbreak - Teachings from Concurrent Public Health Emergencies 83
Towards the Ocean-Blue Nautical Medicine 86
WMA Members Share Reflections about One Health Day 2022 89
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care 101
World Medical Association Officers, Chairpersons and Officials
Dr. Osahon ENABULELE
President
Nigerian Medical Association
8 Benghazi Street,
off Addis Ababa Crescent
Wuse Zone 4, P.O. Box 8829
Wuse, Abuja
Nigeria
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
Chairperson, Finance and
Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40
Cheongpa-ro,
Yongsan-gu
04373 Seoul
Republic of Korea
Dr. Lujain ALQODMANI
President-Elect
Kuwait Medical Association
123 Fifth Avenue,
1202
Kuwait
Dr. Tohru KAKUTA
Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku, Tokyo
Japan
Dr. Jean-François RAULT
Chairperson,
Socio Medical Affairs Committee
French Medical Council (Conseil
National de l’Ordre des Médecins,
CNOM)
4 rue Léon Jost
75855 Paris Cedex 17
France
Dr. Heidi STENSMYREN
Immediate Past President
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Ravindra SITARAM
WANKHEDKAR
Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
Dr. Jacques de HALLER
Chairperson, Associate Members
Swiss Medical Association
(Fédération des Médecins Suisses)
Elfenstrasse 18, C.P. 300
3000 Berne 15
Switzerland
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Marit HERMANSEN
Chairperson,
Medical Ethics Committee
Norwegian Medical Association
P.O. Box 1152 sentrum 107
Oslo
Norway
www.wma.net
Official Journal of The World Medical Association
Editor in Chief
Dr. Helena Chapman
Milken Institute School of Public Health, George Washington University, United States
editor-in-chief@wma.net
Assistant Editor
Mg. Health. sc. Maira Sudraba
Latvian Medical Association
lma@arstubiedriba.lv, editor-in-chief@wma.net
Journal design by
Erika Lekavica
dizains.el@gmail.com
Publisher
Latvian Medical Association
Skolas Street 3, Riga, Latvia
ISSN 0049-8122
Opinions expressed in this journal – especially those in authored contributions –
do not necessarily reflect WMA policy or positions
3
Editorial
Editorial
BACK TO CONTENTS
Reflecting on the past year, our global medical community
has continued to articulate health priorities and needs to
policy stakeholders,lead clinical care and community health
activities, and support the delivery of resources to conflict-
affected areas.Physicians have disseminated robust research
findings and have presented such findings at conferences
and workshops, which dually advance the scientific
knowledge base and encourage the next generation of health
professionals. These selfless acts define our indispensable
role in health service delivery during endemic, epidemic,
and conflict periods – and our contributions are needed now
more than ever.
The World Health Organization has recently reported
the urgency to address 13 global challenges, of which
pandemic preparedness and the climate crisis are described
at length. However, four other challenges – delivering
health in conflict and crisis, investing in people who defend
our health, harnessing new technologies, and earning
public trust – resonate within our community. To address
these challenges, our WMA members have supported
our colleagues working in conflict and crisis settings (like
the Ukraine Medical Help Fund) and advised on ways to
strengthen medical education and training across countries
(likeourhomeinstitutionsandtheJuniorDoctorsNetwork).
Albeit limited economic resources, global health workforce
shortages, and workplace burnout, we can continue to
leverage our expertise across our specialties, examine how
technology (including telemedicine and digital applications)
can help enhance clinical diagnostics and management,and
streamline our public health messaging to improve health
literacy and build community trust.
Askeyglobalmeetingshavefocusedontheclimatecrisisand
sustainable actions to mitigate the negative effects of climate
change on human health, the focus on the One Health
concept is paramount. Notably, the Joint Plan of Action
(2022-2026),supportedbytheQuadripartite(WorldHealth
Organization,(WHO);FoodandAgricultureOrganization,
FAO; United Nations Environment Programme, UNEP;
World Organisation for Animal Health, OIE), aims to
expand activities and technical capacity across six areas: 1)
One Health capacities for health systems; 2) emerging and
re-emerging zoonotic epidemics; 3) endemic zoonotic; 4)
neglected tropical and vector-borne diseases; 5) food safety
risks; and 6) antimicrobial resistance and the environment.
As this framework can help guide global physicians in
clinical care, community health, education and advocacy,
laboratory diagnostics, policy, and research activities, we
collaborate on advancing such measures to safeguard global
health security and health system preparedness.
The 222nd World Medical Association (WMA) General
Assembly will be held in Nairobi, Kenya, from 20-22 April
2023. At this event, WMA members will discuss policy
statements, comment on relevant revisions to WMA
resolutions, and network with global colleagues. This
meeting will increase awareness on key global issues and
offer a platform for WMA discussion and debate.
In this issue, Dr. Klaus Reinhardt, Heidi Stensmyren,
and Osahon Enabulele provided welcome remarks, the
valedictory speech, and the inaugural presidential address,
respectively, at the WMA General Assembly. Mr. Nigel
Duncan prepared a comprehensive summary of the WMA
statements and resolutions that were presented at the 221st
WMA Council Session.Dr.Heidi Stensmyren and Osahon
Enabulele expressed their perspectives as the outgoing
and incoming WMA presidents, respectively, regarding
upcoming WMA activities. Dr. Sonu Gaind, Trudo
Lemmens, Ramona Coelho, and John Maher reviewed the
Canadian experiences and specific challenges related to the
expansion of the Medically Administered Death (MAD)
for mental illness. Ms. Priscilla Cruz and Dr. Caline Mattar
described the current state of the 2022 monkeypox outbreak.
Dr.Fang Xudong highlighted the value of nautical medicine
and research of the marine ecosystem.Dr.María Caraballo-
Lorenzo, Bienvenido Veras-Estévez, and Helena Chapman
promoted World Diabetes Day 2022 as a global call to
action to improve diabetes care.
We are pleased to share this fourth issue of the World
Medical Journal, which showcases the WMA declarations,
statements, and resolutions – on topics ranging from
medical ethics to occupational and environmental health
and safety – that have resulted from hundreds of hours
of committee discussions, debate, and revisions. Notably,
WMA members representing 12 countries presented
inspirational and timely national initiatives on One Health
Day 2022 and empowered calls to action on environmental
protection. We encourage WMA members to review this
fourth collaborative article and learn more about these
exciting National Medical Association (NMA) activities.
As we approach the end of the year, we hope that you can
take a moment to reflect on your invaluable contributions
to the WMA and the global community. We wish you and
your families a healthy, safe, and reflective holiday season,
and we look forward to connecting in-person in Nairobi.
Helena Chapman,MD, MPH,PhD
Editor in Chief of the World Medical Journal
editor-in-chief@wma.net
4
Physician, researcher, and politician
Rudolf Virchow once said, “Physicians
are the natural attorneys of the poor,
and social problems fall to a large
extent within their jurisdiction.”
He conducted his research here in
Berlin and was one of the first to
be firmly convinced of the impact
that a person’s living conditions can
have on health. He also stated that
“Education, prosperity, and freedom
are the only guarantors of the long-
term health of a population.”
He demonstrated the interdependence
of medicine and politics and
encouraged physicians to also focus on
social issues. According to Virchow,
serving the poor leads to improved
health in society.
It is this fundamental belief that
unites all of the National Medical
Associations who gather at this
meeting. It is one of the foundations
of the work of the World Medical
Association, the WMA.
As the medical profession,we have the
responsibility to address health care
issues and raise our collective voices
in support of our patients and society.
In the WMA General Assembly, the
global medical profession asserts its
positions and provides guidance to
physicians all over the world.
With all this in mind, it is my great
honour to welcome you − on behalf
of the German Medical Association,
the GMA − to Berlin for the World
Medical Association’s 73rd General
Assembly.
This year’s meeting coincides with the
75th anniversary of the establishment
of both the WMA and the GMA.
Thank you to all who attended our
celebration yesterday.
The WMA has always been an
important point of reference for the
GMA. Founded in the same year in
the aftermath of the Second World
War, they both have their roots in the
lessons learned from the crimes of the
National Socialist regime in Germany.
It was the crimes and misconduct of
German physicians, above all, that
made it clear that a global medical
organization was needed − one that
would define medical ethics more
precisely.
At the same time, 75 years ago, the
State Chambers of Physicians in
the newly founded federal states of
West Germany, decided to establish
the GMA as a working group of the
West German chambers. The initial
purpose of this organisation was to
coordinate and advocate for their
work at the federal level. You learned
more about these activities yesterday.
The GMA was accepted into the
WMA in 1951, after it had formally
distanced itself from its predecessor
organisation and the crimes of
German physicians as noted, for
example, in the “Doctors of Infamy:
The Story of the Nazi Medical
Crimes” publication. To this day,
addressing the past is an important
part of the GMA. We are convinced
to this day that confronting the past
is a process that can never be fully
completed.Only by remembering and
analysing the past, can we learn the
right lessons from it.
The GMA is committed to the
values of the WMA. It has always
felt a responsibility to contribute
to the medical ethics framework
of the global medical profession,
which it has done by chairing the
workgroups tasked with the revision
of the Declaration of Helsinki in
2012, the Declaration of Geneva in
2017, and currently the International
Code of Medical Ethics. We are very
grateful to the international physician
community for entrusting us with this
great privilege.For this reason,we also
proposed the theme “Medical Ethics
in a Globalized World”for yesterday’s
successful Scientific Session.
This is the first time that the General
Assembly has been held in Berlin.The
fractures of German and European
history have made Germany and
Europe what they are today. These
fractures are still visible in Berlin in
its buildings and monuments. I hope
that you will have the opportunity to
get to know the city which has many
different centres and is marked by
its history. Berlin is also a place to
discover many different ways of life –
and ways of living together.
Notably, it is also the first time we
have been able to gather in person for
the General Assembly since October
2019, and we are so pleased that you
are all here. At the same time, we are
poignantly aware of the hardships and
losses that many have experienced
and continue to experience due to
the pandemic and other ongoing
global crises. Physicians are currently
facing unique challenges. You have
arrived here from all over the world,
and some have conflicts and war right
at your doorstep. War has broken
Klaus Reinhardt
Welcome Remarks, WMA General Assembly
Berlin, Germany, 7 October 2022
Welcome Remarks, WMA General Assembly
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5
out in Europe again, and physicians
have an important role to play in
caring for and helping the wounded.
Many European countries, especially
Moldova, Slovakia, and Poland, have
played an especially important role in
helping the Ukrainian people.
The WMA has also turned its
attention to Ukraine and has
accomplished a great deal. We are
pleased that the Ukrainian Medical
Association is represented here.
A warm welcome to Prof. Andryi
Bazilevich and Prof. Iryna Mazur
who have made the journey to Berlin.
The WMA reaches out to all
colleagues who share the common
values of the medical profession.
With all the global conflicts and
challenges impacting the medical
profession, I hope we will find a way
forward through respectful dialogue
here in Berlin.
There are many important issues on
thisweek’sagenda.Racisminmedicine
is one that is particularly close to our
hearts at this General Assembly, as
it has received little attention so far,
but has such a devastating impact
on the health system, patients, and
doctors. I am looking forward to
seeing the conclusions of this week’s
deliberations.
Berlin should inspire you. It is a place
that is considered a little bit different,
a little more unusual, and a little more
innovative than other cities.
I would like to close with a final quote
from Rudolf Virchow as a sentiment
that should unite us all: “Only those
who regard healing as the ultimate
goal of their efforts can, therefore, be
designated as physicians.”
In closing, I would like to welcome
you to Berlin and wish you a successful
event!
Klaus Reinhardt, MD
President, German Medical Association
international@baek.de
Welcome Remarks, WMA General Assembly
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6
Thank you, Chair Dr. Montgomery,
Secretary General Dr. Kloiber,
officers, Council and Assembly
members, Junior Doctors, and
Associate members.
Dear colleagues, dear guests, and
observers, and friends,
Thank you for gathering, being part
of, and contributing to the medical
community. We are thankful that
we can finally meet in person for
the World Medical Association
(WMA)’s General Assembly. The
value of meeting in person cannot
be measured; as Warren Buffet says,
“You will never see eye-to-eye if you
never meet face-to-face.”
My presidential year has had many
obstacles to meeting in person.
Many of you are dear friends, and I
have seen the joy on your faces when
greeting each other after so long
apart. It warms my heart.
Our work is highly dependent on
actually getting together to trade
ideas and exchange views. Solutions
to complex problems occur by
working as a team, slowly taking one
step after another – together. Our
work is challenging and thought-
provoking, as the Chinese curse
states, “[we live in] interesting
times”. Difficulties remain due to
echoes of the pandemic, diseases,
and humanitarian catastrophes. The
WMA has a duty to work together,
stand for humanity, and advocate for
the highest ethical standards.
During my year as president, we have
advocated for equitable distribution
of the coronavirus disease 2019
(COVID-19) vaccines and pushed
for sufficient capacity in other
vaccine programs. Still, the world
has not caught up. Coupled with
the influence of anti-vaccination
campaigns, pandemic issues have led
to a measles outbreak in Zimbabwe,
leaving more than 700 children dead.
Supply chain issues and conflict have
made caring for the global population
an incredibly complex proposition.
War crimes that seemingly occur
daily, are cruel and unacceptable. We
have numerous reports of systematic
violence against women and
children. The WMA condemns the
ongoing attacks on the Ukrainian
people, health care professionals,
and facilities. The WHO tracks
confrontations and counts some
800 attacks on health care globally
this year. This is unacceptable, and
as president of the WMA, in my
Valedictory speech, I urge you that
WMA is needed now more than
ever.
Refugees pour across borders, and
humans flee for their lives, creating
incredible health care challenges. I
had hoped to spend time building
more robust, global governing
institutions during my presidency.
The world needs more collaboration,
and the WMA has a critical role
in this process. Sadly, we have had
to focus on war, threats of nuclear
weapons, and attacks on health
professionals and facilities. Health
careisavitalpartofsociety,andhealth
professionals should be considered
“neutral” in any conflict; instead, we
have become targets. The attacks
on health facilities have reached
never-before-seen levels. The crimes
against civilians and those who care
for others are horrible; it is a global
disgrace.
We are forced to focus on a world
threatened by nuclear weapons
Valedictory Speech by the WMA President, Dr. Heidi Stensmyren
Valedictory Speech by the WMA President, Dr. Heidi Stensmyren
Berlin, October 7, 2022
Heidi Stensmyren
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Photo 1. Dr. Heidi Stensmyren, WMA Past President. Credit: World Medical Association
7
and a despot with an appetite for
neighboring countries. Russia
continues to place the planet in
peril – through either arrogance or
ignorance – by failing to safeguard
Ukraine’s nuclear power plants
….not to mention the thinly-vailed
threat of unleashing nuclear weapons.
The Russian-controlled nuclear
plant in Zaporizhzhia, Ukraine, was
disconnected from the power grid for
the first time in its history. Many of
you vividly recall Chernobyl. In the
blink of an eye, this regional crisis
could become a global health disaster.
Every physician should take notice
and condemn this irresponsible,
reckless behavior.
Immense human suffering continues,
and the WMA opposes flagrant
violations of fundamental human
rights. We demand allegations of
war crimes be investigated and those
responsible brought to justice.
As physicians, working integrated in
society, meeting people in all stages
and situations, we have deep insights
in these humanitarian struggles.
Violence and injustice is not isolated
to war. Violence and injustice are
not isolated to war. Most violence
against women is within the family,
often perpetrated by a partner. I am
proud to stand for those without a
voice and foster equity and equality
in the name of the WMA.
Like you, I have been living in a
‘virtual’world.Despite this challenge,
you have graciously invited me to
meet. To all I have met this year,
thank you for sharing your knowledge
and wisdom. I have been constantly
impressed by your persistence and
sustained enthusiasm. Thank you
for funding the Ukrainian effort to
provide critical medical equipment.
Pandemic echoes rumble through
society, and in particular, the medical
community. With more than 600
million cases and over 6.5 million
deaths worldwide, the WHO
estimates that between 80,000 –
180,000 health professionals have
succumbed to COVID-19. Every
death is tragic, but the downstream
effect of lives lost from the health
community is compounded. Adding
to these losses are thousands of
health professionals leaving their
ranks early. Many, if not most,
have left due to fear, burnout, and
the (often overlooked) feeling of
helplessness, worried that they can
no longer make a difference. We
must continue to invest in vaccines
as well as other measures to aid our
colleagues. This pandemic will not
be our last, and those who do not
learn from the past are condemned to
repeat it. The WMA demands that
governments and other stakeholders
recognize the personal risk that
health professionals incur and make
every effort to protect them.
Our mental health professionals
tell me that the pandemic directly
correlates to the mental health
epidemic. While crisis levels of
patients seek aid, few find help. Our
psychiatric colleagues have been
devastated by many leaving the
profession or cutting back. Those
who remain are overwhelmed by the
unbelievable need. Our colleagues
say, as incredible as the current
mental health numbers are, there is
woeful underreporting.
This does not begin to address
the issues within our profession.
One recent survey, which was
administered to 1,119 health
professionals in the United States,
indicated reports of stress (93%),
anxiety (86%), frustration (77%),
exhaustion and burnout (76%), and
feeling overwhelmed (75%).
I have fostered engagement in ‘One
Health’ – a concept that promotes
the link between human health,
animal health, and a sustainable
environment. None of these exists
independent of the others, and an
integrated and unified balance is
needed. The COVID-19 pandemic
is not over; it will not be the last
pandemic, and it is far from the last
challenge that we will face. Signs are
everywhere that we are at a critical
capacity to provide health care for
our entire civilization. Sometimes, a
crisis is the crucible needed to make
substantial change. Let us lead this
change!
While I am very proud of our work
modernizing the International
Code of Medical Ethics, I am
deeply concerned about the growing
violence against physicians this year.
A recent study shows that violence
against physicians often involves
patients or relatives. Unfortunately,
for our Indian colleagues, this is
nothing new; their ongoing study
reveals that more than 75% of Indian
doctors have experienced workplace
violence. The Indian parliament
passed historic legislation to protect
health professionals and institutions.
Thank you to the Indian Medical
Association for leading the way.
I wish to thank Sunny Park, Clarisse
Delorme, Magda Mihaila, Nigel
Duncan, and the other WMA staff
for their support despite the effort
required, secondary to the pandemic
andgeopoliticalconflicts.Ialsowould
like to thank my fellow executive
committee members for our close
collaboration in these challenging
times – Drs. Montgomery, Kloiber,
Barbe, Enabulele, Matsubara,
Wankhedkar, Hermansen, Park,
and Rault. I would like to give
special recognition to Thomas
Hedmark, a remarkably efficient and
professional colleague, and a reliable
co-worker. I also thank the Swedish
Medical Association and our strong
and talented president, Dr. Sofia
Rydgren Stahle. I also thank Dr.
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Valedictory Speech by the WMA President, Dr. Heidi Stensmyren
8
Torsten Mossberg, chair of the
ethics committee – you have been
an invaluable colleague with your
humbleness and sharp mind – not to
mention your ability to sing!
Most importantly, I thank my
family, especially my beautiful girls,
Nora and Fröja, who cannot be here
today because of school. They have
been patient and waited during long
meetings and longer working hours.
They have a whole gallery of pictures
of me working at my computer every
holiday and weekend for many years.
They need me to come home now.
Finally, you have my humble
gratitude for entrusting me with this
office. It is a challenging and unique
position, and every day, I have strived
to surpass expectations of those who
have given me this opportunity of a
lifetime. My presidency was deeply
affected by the pandemic and the
war, but we adapted.
We in leadership are volunteers and
temporary volunteers at that. It is
vital to an organization’s future to
recognize this and realize that for the
organization to grow and improve,
the old must give way to the new.
We need to constantly invigorate the
WMA in order to make it relevant
to every member, every day. I am
fortunate to be succeeded by Dr.
Osahon Enabulele – a colleague who
I value highly. I am confident that he
will honor the office, and I wish him
great success.
It has been a fantastic journey. Now
that my role as president comes to an
end, I want to thank you for being
my colleagues and friends – and that
will never end.
Heidi Stensmyren, MD, MBA
Past President (2021-2022)
World Medical Association
heidi.stensmyren@regionstockholm.se
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Valedictory Speech by the WMA President, Dr. Heidi Stensmyren
9
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Inaugural Address by the WMA President, Dr. Osahon Enabulele
Distinguished guests, our highly
respected leaders and members of the
World Medical Association (WMA),
President Muhammadu Buhari
GCFR, President of the Federal
Republic of Nigeria, The Governor
of Edo State, Mr.Godwin Obaseki,
our revered Oba of Benin, His
Royal Majesty, Omo N’Oba N’Edo
Uku Akpolokpolo, Oba Ewuare
II OGIDIGAN CFR, my mum,
Evangelist Rachael Ayi Enabulele, my
beloved wife, Associate Professor Joan
Enabulele, and my children (Master
Efosa Enabulele,Omorovbiye Victoria
Enabulele,andOsarumwenseBenedict
Enabulele), my brothers and sisters,
esteemed friends from within and
outside Nigeria, and other participants
here present, I welcome you all, with
profound joy and humility, to my
inauguration as the 73rd President
of the World Medical Association,
having been democratically elected in
October 2021.
I congratulate the German Medical
Association (GMA) on their 75th
year Anniversary and for successfully
hosting this 73rd General Assembly.
I wish them many more attainments
and glories in the years ahead.
As I assume office today as President
of the World Medical Association, it
is with gratitude and a deep sense of
responsibility, that I wish to present
my inaugural presidential address.
I wish to express profound gratitude
to our Immediate-Past President,
Dr. Heidi Stensmyren, and all my
predecessors in office for their
tremendous efforts to promote and
develop the WMA to its present
status. I shall make great efforts to
consolidate upon their work, even as
we seek to pilot the WMA to a higher
pedestal.
This occasion is very humbling for me
and my family; it is one that evinces
lots of emotions, considering the
total uniqueness of the events, lasting
experiences, and the long tortuous
journey that characterized my over
15 years of engagement within the
WMA, that culminated in today’s
historic reality.
It evokes a great sense of pride for
me and my country, Nigeria, being
the first time, since the formation of
WMA in 1947 (75 years ago), that
a physician from the West African
region of the African continent of 54
countries; a physician from Nigeria
(the most populous country in the
African continent with a population of
over 200 million people), and indeed,
a physician from Edo State of Nigeria,
in particular, has been elected to lead
the WMA.
On behalf of the Nigerian Medical
Association, my country (Nigeria),
the African continent, and particularly
my wife and family, I wish to express
profound gratitude to all National
Medical Associations in all regions of
the WMA, and individual physicians
across the globe, for electing me to
serve as President of WMA for the
2022-2023 Executive Year.
Coming from an under-represented
and poorly understood African
continent that is largely deprived of
quality health care, I consider my
election to the office of President of
WMA as a propitious opportunity and
a call to make positive impact through
leading initiatives that shall enhance
the fortunes of the WMA as a whole,
the well-being, rights and professional
autonomy of physicians across the
globe, and strengthen health care
systems of countries, to help them
achieve Universal Health Coverage
(UHC) and the Sustainable
Development Goals (SDG 2030),
throughactionsonthesocio-economic,
commercial and environmental
determinants of health, and the
mitigation of the effects of climate
change.
As the World transits to a coronavirus
disease 2019 (COVID-19) pandemic
era, I would like to draw our attention
to a few critical areas, particularly
following lessons learnt during the
COVID-19 pandemic era; viz:
building resilient health systems;
human resources for health; safety
of physicians and other health care
providers; public communication and
engagement of physicians.
In building resilient health systems,
the WMA will have to continue to
champion the need for global solidarity
in health, equitable access to vaccines
and drug treatments, including their
research and development,appropriate
investments in the well-being, and
protection of physicians and other
health professionals.
The WMA will have to continue
to promote physician-led multi-
disciplinary primary health care,
ethical and person-centered care based
on best evidence, and appropriate
communication with patients, families
and the public (in a way that secures
Osahon Enabulele
Inaugural Address by the WMA President, Dr. Osahon Enabulele
Berlin, 7 October 2022
10
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their trust at all times).
During my tenure, our leadership will
uphold the vision and mission of the
WMA and implement the WMA
strategic plan, with full responsibility
as contained in Article 2 of the WMA
constitution.
The WMA mission states that
‘the WMA is to serve humanity by
endeavoring to achieve the highest
international standards in medical
education, medical science, medical
art and medical ethics, and health care
for all people in the world.’
This will be our starting point; we
can only move higher. In line with
the WMA strategic plan, the WMA
would be an untiring advocate of
Global Public Health interventions
to reduce or eliminate the staggering
health inequities and inequalities,
across the globe.
According to World Health
Organization estimates, by the year
2030, the world will need about 18-
20 million more health professionals,
to attain UHC. Therefore, to achieve
UHC and SDG, the critical issue of
Human Resource for Health which
afflicts every country, even though
worse in lower, ower-, low-, and
middle-income countries (LLMICs),
needs to be addressed robustly.
The WMA shall advocate that
countries take urgent steps to invest
more in the well-being, working and
living conditions of physicians and
other health professionals. This is to
help reduce or eliminate physical and
mental burn-out of physicians, and
the brain drain of physicians and other
health professionals (especially from
already underserved countries).
To motivate physicians and other
health professionals, the WMA shall
shall seek to establish a WMA Global
Healthcare Excellence Award Scheme
to reward excellence, and the sense
of duty, diligence and uncommon
commitment.
The WMA shall strongly promote
and advocate a template on physicians’
rights, to go along with physician
responsibilities, as a counter measure
to the increasing risk and cases of
violence against physicians and other
health professionals. We shall also
promote the practical implementation
of the WMA safe health care initiative.
The WMA is a rich repository of
policy documents on various health
issues, and continues to do important
work in the area of medical ethics.
While we shall promote ongoing
efforts to revise the Declaration of
Helsinki,we shall also seek to promote
the practical application of the
Declaration of Geneva and the revised
International Code of Medical Ethics,
in the work we do as physicians.
Undoubtedly, the WMA has
been doing great work since its
establishment in 1947, in line with
its objectives. But it is worrisome that
many members in its regions still have
little or no knowledge and appreciation
of the work the WMA does.
To address this situation, the WMA
shall encourage its constituent member
NMAs, to engage their members
more on the important work of the
WMA, while as WMA President,
we shall endeavour to take the WMA
to individual physicians through the
organization of a quarterly Regional
Roundtable to be called “Meet the
WMA President.’’
This Roundtable shall hopefully,create
greater awareness about the WMA,
deepen membership integration
and inclusiveness, and drive greater
participation of physicians and our
constituent members in the affairs of
the WMA.
Furthermore, the “Meet the WMA
President’’ Roundtable shall serve as
a platform to receive and share the
ideas and experiences of individual
physicians and members of the WMA,
no matter their location, and resolve
wrong perceptions about the WMA.
Sustained efforts shall also be made to
strengthen and promote the work of
the Junior Doctors Network and the
Associate Members of the WMA.
As the largest physician organization
in the world, we shall continue to
strengthen our partnership and
collaboration with governments
and bodies such as the World
Health Organization, the Medical
Women International Association,
the International Committee
of the Red Cross, the World
Organization of Family Doctors, the
Commonwealth Medical Association,
the World Veterinary Association,
the International Committee of
Military Medicine, the International
Federation of Pharmaceutical
Physicians, and many other
organizations with whom we
collaborate.
Conclusion
It is commonly said that at times,
history and fate meet at a single place
to shape a turning point. Surely, after
75 years, we are now at such a point
in the life of our association, where if
we must achieve our individual and
collective dreams,we must be prepared
to continuously organize for positive
action.
As we journey through the next one
year and seek to advance the fortunes
of the WMA, our noble Medical
Profession, and health systems around
the world, let us realize that our
Inaugural Address by the WMA President, Dr. Osahon Enabulele
11
individual and collective actions will
surely shape the course, character, and
destiny of the WMA.
Therefore, I urge all physicians and
members of WMA to commit putting
the WMA first, and make the needed
efforts to pilot it and health systems in
the world, to more progressive levels.
I call on governmental and non-
governmental bodies to join hands
with the WMA in our collective
quest to address the various challenges
confronting the health and well-being
of citizens,physicians,and other health
professionals.
Appreciation
IthankourAlmightyandOmnipresent
creator for His grace, guidance,
protection, favour, and blessings over
the years.
I am grateful to all individuals and
groups present at this occasion,
and those at home in Nigeria and
elsewhere,who,at various times,played
supportive roles in my journey towards
the presidency of the WMA.
I thank specially,the Nigerian Medical
Association, and all physicians in
Nigeria and Africa, and indeed all
physicians across the globe, for their
varied support.
I thank the Federal Government
of Nigeria, Edo State Government,
our revered Oba of Benin, His
Royal Majesty, Omo N’Oba N’Edo
Uku Akpolokpolo, Oba Ewuare II
OGIDIGAN CFR, His Eminence,
Alhaji Muhammad Sa’ad Abubakar
III, CFR, mni, The Sultan of
Sokoto, the Chief Medical Director
(Prof. Darlington Obaseki) and
Management Board of the University
of Benin Teaching Hospital (where
I practice), and the Chief Medical
Director (Prof. Christopher Bode)
and Management Board of Lagos
University Teaching Hospital (where
I serve as a Management Board
Member) for their strong expression
of support for my presidency.
I must specially acknowledge the
encouragement and support of my
special guests, colleagues, friends,
brothers, sisters, and in-laws from
Nigeria, United Kingdom, United
States, Finland, and elsewhere, who
made it to this event, as well as the
officers, officials, and staff of both
the WMA and the German Medical
Association (GMA), who helped to
facilitate the processing of visas.
I dedicate this day to:
(i) my parents; my mother, Evangelist
Rachael Ayi Enabulele, and my father,
Elder Jonathan Enabulele JP, both of
whom imbibed in me and my other
siblings, cardinal and theological
virtues, and inculcated in us a culture
of discipline, selflessness, and a life of
values.Sadly,my father,Elder Jonathan
Igbineweka Enabulele JP, who had
truly looked forward to a day like this,
never had the opportunity to witness
this moment, as he passed on in the
year 2013, while I was away serving
as President of Nigerian Medical
Association. Daddy, may your great
soul continue to Rest in Perfect Peace.
ii) my wife, Associate Professor
(Dr.) Joan Enabulele, and my
children (Efosa Benedict Enabulele,
Victoria Omorovbiye Enabulele, and
Osarumwense Michael Enabulele). I
thank them for their ceaseless prayers,
unimaginable sacrifices, patience,
tolerance, understanding, continuous
support, encouragement, love, and
care,in all my years of struggle,even in
the face of difficulties and frustrating
challenges. Thank you for always
enduring my long absence from
home in the course of my leadership
endeavours.
I thank my parents-in-law, my dear
cousin (Engr. Ferguson Enabulele),
my other siblings and in-laws (home
and abroad) for their sustained
prayers and support. I particularly
thank my elder brother (Mr. Ernest
Oghogho Enabulele), my elder sister
(Mrs. Akugbe Dorothy Ehigiator),
and my little dear sister (Mrs. Efe
Tracy Idahosa), and their spouses for
attending my inauguration and for
their strong support over the years.
I am exceedingly grateful to the Dr.
Benson Okwara-led Lionkiller’s
Inauguration Team for their
contributions towards the success of
my inauguration.
As we look forward to very exciting
times ahead, I promise to work very
hard to vindicate the initiatives that led
to the birth of WMA by its founders.
I promise to advance the principle of
collectivism by working with other
leaders and members of the WMA
to provide an emotionally intelligent
leadership, with the transformation of
the WMA into a beautiful symphony
of comradeship, that enables the
efficient and effective implementation
of the WMA strategic plans.
I cannot end this address without
paying special tribute to our colleagues
who lost their lives as a result of the
COVID-19 pandemic. May their
great souls continue to rest in perfect
peace.
My heart goes out to our colleagues in
Ukraine and other troubled parts of the
world who are battling to deliver care
in the worst of human conditions due
to wars, conflicts, disasters, sectarian
crises, and oppressive regimes.
I pray God to grant you all journey
mercies back to your respective homes.
I thank you for your kind attention.
Osahon Enabulele, M.B.B.S., MHPM,
FWACP, FNMA
President, World Medical Association
osahoncmavp@gmail.com
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Inaugural Address by the WMA President, Dr. Osahon Enabulele
12
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For the first time since 2019, the
WMA was able to meet in-person
for its annual General Assembly. The
venue of Berlin allowed both the
World Medical Association (WMA)
and the German Medical Association
to celebrate their 75th anniversaries.
Delegates from 57 National Medical
Association (NMA) constituent
members gathered at the Ritz-
Carlton Hotel in the heart of the city
(Photo 1).
Wednesday, 5 October
Council
The 221st Council session was called
to order by the Chair of Council, Dr.
Frank Ulrich Montgomery (German
Medical Association), who welcomed
delegates to Berlin.
Elections and Appointment
Dr. Tohru Kakuta (Japan Medical
Association) was elected unopposed
as Vice-Chair of Council.
The new legal advisor, Mrs.
Mervi Kattelus (Finnish Medical
Association), was introduced to the
meeting and her appointment was
confirmed.
President’s Report
Dr. Heidi Stensmyren (Swedish
Medical Association), the outgoing
President, in her written report, said
her presidential year had taken place
under the influence of the coronavirus
disease 2019 (COVID-19) pandemic
and the impact of global challenges
such as climate change and conflicts.
She referred to the thousands of
their professional brethren who
had left the profession early, most
through fear, burnout, labour, and
other economic pressures on their
practice. Economies around the
world continued to recover from
direct spending on COVID-19, and
many countries found it necessary to
cut spending on health care,including
investment in vaccines, as well as
preparedness for future health crises.
This pandemic would not be the last,
and those who did not learn from the
past were condemned to repeat it.
She also wrote about the devastating
effect that the pandemic has had on
mental health, with many psychiatric
colleagues leaving the profession or
cutting back. Those who remained
were simply overwhelmed by the
unbelievable need in the general
population. She said that the only
fruitful way to tackle global challenges
was through collaboration between
governmental institutions, as well as
non-governmental organizations.
She went on to say that the WMA
condemned the continuing attacks on
Ukraine and in particular Ukrainian
health care facilities. These overt
assaults were becoming all too
common in conflicts globally. She
referred to the aid given to the Ukraine
Medical Help Fund, founded by the
Committee of European Doctors
(CPME), the European Forum of
Medical Associations (EFMA), and
the WMA, as another example of
fruitful collaboration. She specifically
thanked those NMAs who has
contributed to these efforts.
She concluded by saying that she was
deeply concerned about the violence
against physicians around the globe
and she particularly thanked the
Indian Medical Association for
leading the way on this issue.
Secretary General’s Report
Dr. Otmar Kloiber, the Secretary
General, referred the meeting to the
lengthy written report that had been
tabled about the activities of the
Secretariat. He also reported on the
help for Ukraine and the substantial
assistance provided by the Japan
Medical Association. He particularly
thanked Dr. Leonid Eidelman
(WMA Past President) for his work
in delivering the help.
Chair of Council’s Report
In his written report, Dr. Frank
Ulrich Montgomery warned that
the COVID-19 pandemic was not
over. He was convinced that they
still had to remain cautious and
attentive of immunescapes, waning
immune responses and new variants
of concern. He said that they must
continue their prevention and
vaccination efforts. Demanding
access to vaccines for everyone,
overcoming fake news,and organizing
vaccination campaigns remained a
challenge to be met. Visiting several
NMA general assemblies had shown
him once again how similar their
problems were. From human rights
and ethical issues over violence
against health care professionals
and questions of a universal health
coverage to organizing medical care
for underserved communities – they
WMA General Assembly Report
Berlin, Germany, 5-8 October 2022
Nigel Duncan
WMA General Assembly Report
13
were all in the same boat. It was the
independence of the medical decision
for their patients that was at the heart
of their engagement.
Complaints Procedures
Dr. Frank Ulrich Montgomery
reported on two different sets of
complaints that had been made to the
Secretariat, where the first involved
the Chinese Medical Association and
the British Medical Association on
the issue of the Uyghur people, and
the second related the Polish Medical
Association and the Physician
Chamber of Russia and the physician
organisation of Belarus on the issue of
Ukraine.
On behalf of the Executive
Committee, he reported that there
had been many discussions and
video calls with the various parties.
He stressed that the WMA was a
discussion platform, where they could
discuss issues and exchange opinions,
even if they were of a totally different
opinion or condemned the actions of
a particular NMA. This was similar
to the Red Cross, the World Health
Organization (WHO), and the
United Nations (UN). He said it was
important to discuss the issues first,
followed by the complaints. On the
issue of Ukraine, he said that due to
the war, there were visa restrictions
in the European Union and so the
Russian delegation could not be
present. Therefore, his advice to the
Council was to postpone discussion
until the WMA Council in Kenya
next year.
A discussion then took place on the
issue relating to the treatment of the
Uyghur people in China. The British
Medical Association reminded the
meeting that the purpose of the
WMA was to serve humanity by
endeavouring to achieve the highest
international standards in medical
education, medical science, medical
art, and medical ethics. They
knew that the Chinese Medical
Association’s conduct in relation to
the Uyghur people was detrimental
to the honour and interests of the
medical profession and the WMA,
which brought their entire profession
into disrepute. A report from the
UN had found serious human rights
violations, discrimination against the
Uyghur people, arbitrary detention,
and allegations of torture and forced
medical treatment that might
constitute international crimes against
humanity. It was highlighted that the
WMA, by not calling these events
out, was now indirectly complicit in
this behaviour.
The Chinese Medical Association
had repeatedly denied knowledge of
any such events and had effectively
called the UN report a lie. They
responded that the allegations were
completely contrary to the articles of
the WMA, which stated that there
should be no political interference
in countries’ affairs. They said that
the UN report did not conform
to the facts, and that the British
Medical Association was fabricating
evidence. They commented that it
was a shameful act of bullying against
medical professionals, and that the
allegations were fabricated, which
violated the spirit of international
conventions and had caused serious
damage to the WMA. After a brief
discussion, the Council decided to
postpone the complaints procedure to
the next WMA Council meeting in
Kenya in April.
Support for Medical Personnel in
Ukraine
The Council then considered a minor
revision to its WMA Resolution in
Support of Medical Personnel and
Citizens of Ukraine in the face of the
Russian invasion, which was passed at
the WMA Council Meeting in Paris
in April 2022. The Resolution was
still valid and applicable, but needed
to be revised to delete the reference
about the number of people displaced
by the conflict. This would keep the
policy up-to-date in the intermediate
and long-term.
The Council meeting was adjourned.
Medical Ethics Committee
The chair, Dr. Marit Hermansen
(Norwegian Medical Association)
called the committee to order.
International Code of Medical Ethics
The committee considered the
proposed revision of the WMA
International Code of Medical Ethics.
Dr. Ramin Parsa-Parsi (German
Medical Association), chair of the
workgroup, said that the revision had
started four years ago and was one of
the most work-intensive tests that the
WMA had ever taken. He reported
on the regional meetings that had
been held and noted the extremely
comprehensive, inclusive, and fruitful
process of discussions that had taken
place. Not all the comments received
could be considered,but he assured the
meeting that the workgroup had taken
every single proposal seriously. He
said that the compromised wording
he was submitting to the committee
reflected a truly universal document
that would resonate globally. He
asked the committee to approve the
revised Code for forwarding to the
Council and the General Assembly
for adoption.
Without further debate, the
committee agreed unanimously to
this request.
Assisted Reproductive Technologies
The South African Medical
Association presented a major revision
to the WMA Statement on Assisted
Reproductive Technologies, drawn up
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14
in coordination with the Workgroup
on Genetics and Medicine. The
document, covering issues relating
to gamete donation and commercial
surrogacy, had been circulated for
comment. The committee was told
that revision had been a long process,
and that it had not been easy to
establish global consensus. However,
the recommendation was that it now
be sent to the General Assembly for
adoption. A brief discussion took
place, and an amendment was agreed.
The committee agreed that the
Statement be approved by Council
with the recommendation that it be
forwarded to the General Assembly
for adoption.
Organ Procurement from Executed
Prisoners
As part of the 10-year revision process
of WMA policies, the Chinese
Medical Association had asked to
rescind the WMA Resolution on
Organ Donation in China. This
had led to a workgroup being set up
to review the existing documents
related to the fight against coerced
organ procurement, including the
use of organs of prisoners sentenced
to the death penalty. The Spanish
Medical Association, which chaired
the workgroup, submitted a proposed
Declaration on Organ Donation
for Transplantation from Executed
Prisoners to the committee and
explained that if adopted, this policy
should replace the existing Council
Resolution on Organ Donation in
China.
This led to a lengthy debate about
whether the terms of reference of
the workgroup had been fulfilled,
what the reasoning for an additional
document was and if this new
policy should lead to rescinding the
existing WMA Resolution on Organ
Donation in China. The Chinese
Medical Association explained that it
had requested rescinding the existing
Resolution on the grounds that one
country should not be singled out for
condemnation.They emphasised their
determination to combat this practice
and to respect ethical principles.
Speakers differed as to whether the
practice of organ procurement from
executed prisoners was still occurring.
As a result, there was opposition to
rescindingtheoriginalResolution,and
the committee decided to recommend
that the proposed Declaration be
circulated for comment.
Declarations of Venice and on End-of-
Life Medical Care
Under the 10-year revision process, a
proposed major revision of the WMA
Declaration of Venice was submitted
by the American Medical Association.
The Council had agreed to merge the
Declaration of Venice with the WMA
Declaration on End-of-Life Medical
Care, and the proposed compromise
version had been circulated for
comment. The American Medical
Association suggested rephrasing
one sentence to read: ‘The WMA
remains firmly opposed to euthanasia
and physician-assisted suicide, as set
forth in the WMA Declaration on
Euthanasia and Physician-Assisted
Suicide.’ They proposed that the
document, as amended, be approved
by the committee and forwarded
to the council for adoption by the
Assembly.
The committee agreed to recommend
this course of action to the Council.
Medical Ethics in the Event of Disasters
The committee heard an oral report
from theTaiwan Medical Association,
led by the chair of the workgroup on
Medical Ethics during Public Health
Emergencies. The workgroup had
reviewed related existing policies
and had decided to address ethics
during public health emergencies in
a separate policy. It now requested
that the proposed WMA Statement
on Medical Ethics in the Event of
Disasters be circulated to constituent
members for comment for comment.
The committee decided to
recommend this course of action to
Council.
Medical Technology
A proposed revision of the WMA
Declaration on Medical Ethics and
Advanced Medical Technology was
submitted for consideration. The
committee was reminded that a
workgroup had been set up to review
current policy on medical technology,
and that the decision was to update
the statement to modern practice and
research. The workgroup wanted to
keep the statement general and was
now suggesting that the document be
circulated for comment by member
associations.
The committee agreed to recommend
this course of action to the Council.
Biological Weapons
The Swedish Medical Association
presented a major revision of the
WMA Declaration of Washington
on Biological Weapons, reaffirming
the WMA Statement on Weapons
of Warfare and their Relation to Life
and Health and condemning the use
of any form of weapons against human
beings. The workgroup suggested
that the document now be circulated
to NMAs for comment.
The committee agreed to recommend
this course of action to the Council.
Armed Conflict and Other Situations of
Violence
A major revision of the WMA
Regulations in Times of Armed
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15
Conflict and Other Situations of
Violence was submitted by the
Associate Members. It was suggested
that the title be changed from
Regulations to ‘Statement’. The
document stated that in situations of
armed conflict and other situations
of violence, governments, belligerent
armed forces, and others in positions
ofpowermustcomplywiththevarious
relevant international agreements,
and it set out various principles for
physicians in such situations. The
document added that physicians must
not be prosecuted for complying with
these ethical rules.
The committee recommended that
the document be circulated for
comment.
Statement on Safe Injections in Health
Care
The committee considered a
proposed minor revision to the
WMA Statement on Safe Injections
in Health Care,which made the point
that unsafe injections were a waste of
precious health care resources and
could be easily prevented.
The committee recommended that
the revised Statement be sent to
the Council for approval and to the
General Assembly for information.
Prohibition of Forced Anal Exami­nations
A minor revision was considered to
the WMA Resolution on Prohibition
of Forced Anal Examinations to
Substantiate Same-Sex Sexual
Activity. This document stated that
physicians should never engage in
acts of torture or other forms of cruel,
inhumane or degrading treatment.
The committee recommended that
it be sent to council and assembly for
information.
Socio-Medical Affairs Committee
The committee was called to order
by the chair of the committee, Dr.
Jean-François Rault (French Medical
Association, CNOM).
Medical Technology
The Chair of the workgroup on
Medical Technology (Israel Medical
Association) reported on the activities
of the group since the last Council
meeting. They submitted a proposed
revision of the WMA Declaration on
Advanced Medical Technologies, and
said they would continue to work on
the revision based on the comments
fromWMAmembers.Thecommittee
was told that the workgroup was
discussing the opportunity to develop
a new proposed policy on the misuse
of emerging medical technologies
and human rights violations. They
were also looking into the possibility
of developing a platform to enable
and facilitate physicians’ involvement
in medical innovation. A proposal
should be submitted at the next
Council meeting in Kenya in April
2023.
The committee forwarded this report
to the Council.
Declaration of Edinburgh on Prison
Conditions and the Spread of
Tuberculosis and Communicable
Diseases
A proposed revision of the
WMA Declaration of Edinburgh
on Prison Conditions and the
Spread of Tuberculosis and Other
Communicable Diseases was
presented by the Uruguayan Medical
Association, with the suggestion
that the document be approved by
the Council and forwarded to the
General Assembly for adoption. The
committee was told that the revised
document referred to the treatment,
diagnosis, and management of
communicable diseases in prison
environments, which must not be
used to violate the rights of prisoners
in terms of obtaining treatment
for their disease. The document
also highlighted that they should
not be forced to accept the risk of
communicable diseases in prison
environments. An amendment
was proposed to delete the word
‘tuberculosis’ from the title of the
document.
The committee recommended that
the revised Declaration, as amended,
be sent to the Council for adoption by
the General Assembly.
Global Burden of Chronic Disease
The committee considered a proposed
revision of the WMA Statement on
theGlobalBurdenofChronicDisease.
This document stated that the world
should pay more attention to chronic
non-communicable diseases, which
were the leading causes of mortality
and disability in both the developed
and developing world.
The committee recommended
that the Statement, as amended,
be approved by the Council and
forwarded to the General Assembly
for adoption.
Patient Safety and Professional
Regulation
The British Medical Association
introduced a proposed revision of the
WMA Declaration on Patient Safety.
It explained to the committee that this
was a new comprehensive statement
on systems regulation. They all knew
that significant numbers of medical
errors occurred within the context of
wider systemic factors and failings,
especially where doctors were working
within pressured environments,which
led to the inappropriate and unfair
targeting of individuals. There was a
toxic culture of fear and blame in the
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16
health service, resulting in doctors
being less likely to be open about
errors and safety concerns and more
likely to practice defensive medicine.
What they needed was a supportive
health care culture. The Declaration
had been merged with a proposed
Statementonimprovingpatientsafety
through whole system cultural change
and redefining the role of professional
regulation in order to have one single
consolidation document.
The committee recommended that
the revised document, as amended, be
sent for approval by the Council and
adoption by the General Assembly.
Acknowledgement and Condemnation
of the Genocide against the Uyghurs and
other Minorities in China
The committee then considered
the proposed WMA Resolution
on Acknowledgement and
Condemnation of the Genocide
against the Uyghurs and other
Minorities in China, along with
other relevant documents and
correspondence. The British Medical
Association opened the debate by
asking whether the WMA had a
role in this issue. They said that the
actions described in the UN report
about forced sterilization and medical
treatment without consent must
involvedoctors,sotheseactionsclearly
fell within the remit of the WMA.
This was a moral and ethical issue and
was clearly within the responsibility
of the WMA. They commented that
two questions needed to be considered
– was genocide being committed, and
who should be held accountable?
Under the 1948 Convention on
the Prevention and Punishment of
the Crime of Genocide, it was clear
that that the activities fell within
the definition of genocide. So the
question was whether the Chinese
Medical Association was able to
acknowledge what was happening.
The British Medical Association
wanted the proposed Resolution to
be circulated for comment.
However, this was opposed by the
Chinese Medical Association, who
argued that there was no genocide
behaviour or any involvement of
medical professionals. So why
should they be required to admit to
behaviours that had never taken place.
The Chinese Medical Association
said the WMA was welcome to visit
China to see for themselves. The
committee was told to stop reading
fabricated media reports and the
political motives behind these reports.
The Chinese Medical Association’s
proposal to reject circulating the
document was defeated. Further
debate took place, with the Chinese
Medical Association argued that
it could not represent the Chinese
Government.
On a further vote, the committee
agreed to recommend to Council
that the WMA Resolution
on Acknowledgement and
Condemnation of the Genocide
against the Uyghurs and other
Minorities in China be circulated for
comment.
Electronic Cigarettes
The American Medical Association
introduced a proposed major revision
of the WMA Statement on Electronic
Cigarettes and Other Electronic
Nicotine Delivery Systems. This
document recommended that
e-cigarettes and other electronic
nicotine delivery systems be subject
to the WHO Framework Convention
on Tobacco Control, and to local
smoke-free laws and regulations.
The committee recommended
to Council that the document
be circulated to the members for
comments.
Violence in the Health Sector
A proposed revision of the WMA
Statement on Violence in the Health
Sector by Patients and Those Close
to Them was submitted by the Indian
Medical Association. This document
states that governments should act to
prevent and eliminate all workplace
violence in the health sector. During
the debate that followed,it was argued
that this issue of violence should be
given a higher priority by the WMA.
It was proposed that the following
paragraph be inserted: ‘Cyber and
social media harassment particularly
includes online threats and
intimidation towards physicians who
take part in a public debate in order to
give adequate information and fight
disinformation. These physicians
are increasingly confronted with,
amongst others, malicious messages
on social media, death threats and
intimidating home visits.’
This amendment as well as several
other revisions were agreed upon,
and the committee recommended
that the document, as amended, be
recirculated to members for comment.
Support of the Medical Associations in
Latin America and the Caribbean
The Brazilian Medical Association
proposed a major revision to the
WMA Resolution in Support of
the Medical Associations in Latin
America and the Caribbean. One
important update was in relation to
Cuba’s practice of exporting medical
personnel. The proposed Resolution
listed the adverse effects of this
practice, including the widespread
allocation of doctors to non-
priority areas and local substitution
effects, and the fact that the Cuban
government kept three-quarters
of health personnel’s salaries. In
addition, the revised Resolution
calls for adequate and sustainable
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investment in national health care
systems as a matter of priority, to
provide the highest standard of care
to the entire population in a country.
The committee recommended that
the document be circulated within
the membership for comment.
Forced Sterilisation
A proposed minor revision to the
WMA Statement on Forced and
CoercedSterilisationwassubmittedto
the committee. Several amendments
were suggested. One amendment
proposed that the practice of coerced
sterilisation should be specifically
mentioned and condemned in the
document,while a second amendment
proposed that the Statement should
declare forced or coerced sterilisation
as a violation of fundamental human
rights. It was argued that because
of these substantive changes, the
document should be recirculated to
members for comment.
This course of action was agreed upon
by the committee.
Self – Medication
The committee considered a
proposed minor revision to the WMA
Statement on Self-Medication.
During a brief debate, the committee
added the sentence ‘Health
professionals should seek to identify
potentially relevant self-medication
during medical consultations,
drug dispensing at the pharmacy
and during home-based nursing
interventions.’ The committee also
agreed to modify another sentence
to read ‘Pharmacovigilance for self-
medication should be organized
and reinforced by both governments
and the industry to control the risks
associated with self-medication.’
The committee then recommended
that the document, as amended, be
sent to the Council for forwarding
to the General Assembly for
information.
Tuberculosis
A minor revision of the WMA
Resolution on Tuberculosis was
considered. The committee agreed
to add a new paragraph stating ‘To
address the burden of MDR and
XDR TB in prison populations by
ensuring drug susceptibility tests on
isolates from patients with active TB
are performed as soon as possible,
and when patient compliance is a
problem, implementing programs of
directly observed therapy.’
Further amendments were agreed,
and the committee recommended
that, as amended, the document
should be sent to the Council and
then the Assembly for information.
Ethical Implications of Collective Action
by Physicians
The committee considered a
proposed minor revision to the
WMA Statement on the Ethical
Implications of Collective Action by
Physicians. A brief debate followed
about adding the words ‘including
collective resignations’to the sentence
‘Physicians may carry out protests and
sanctions in order to improve direct
and indirect working conditions that
also may affect patient care.’
The committee agreed to this and
recommended that the document,
as amended, be forwarded to the
Council and then sent to the General
Assembly for information.
Medical Assistance in Air Travel
A proposed WMA Resolution on
Medical Assistance in Air Travel was
considered with a minor revision.The
American Medical Association put
forward a number of amendments,
which were approved. The first
added the sentence ‘Air travel can
significantly affect people who suffer
from mental health challenges and
resources for in-flight mental health
emergencies are often lacking.’
Another amendment called for
the International Civil Aviation
Organization to develop standards
relating to ‘Medical, inclusive of
mental health emergency procedures
and training programs for medical
personnel.’Thefinaladditioncalledon
the ICAO to’Define global guidelines
guaranteeing physicians immunity
from legal action when providing
appropriate emergency assistance
during in-flight medical incidents
and ensure its implementation by its
Member States.’ There was also a
debate about which language should
be used on emergency materials. It
was eventually agreed that planes
should be equipped ‘with a sufficient
and standardised set of medical
emergency materials and drugs that
are easily identifiable packaging
with instruction in English as well as
consideration of other languages.’
The committee recommended that
the Resolution, as amended, be
forwarded to the General Assembly
for information.
Medical Workforce
A major revision to the WMA
Resolution on Medical Workforce
was considered with a proposal that
that a workgroup be formed.
This course of action was agreed upon
by the committee.
Human Health as a Primary Policy
Focus
The British Medical Association
put forward for consideration a
proposed WMA Statement on
Human Health as a Primary Policy
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Focus for Governments Worldwide.
Its purpose was to move away from
using Gross Domestic Product as the
main measure of a nation’s progress,
with economic growth taking priority
over human health. If they could not
shift the focus to include health as a
measure of the progress of nations,
then they would never get health
onto the agenda. This Statement was
calling for a health for all policies
approach that emphasized the mutual
benefits from health and other policy
sectors working together.
The committee recommended
that the document be circulated to
members for comments.
Humanitarian and Medical Aid to
Ukraine
A proposed WMA Resolution
on Humanitarian and Medical
Aid to Ukraine was submitted for
consideration by the American
Medical Association. The committee
was told this was an urgent matter
with medical help badly needed for
those displaced in areas which had
been occupied by Russia.
The committee recommended to
the Council that the Resolution
be approved and forwarded to the
General Assembly for adoption.
Primary Health Care
The Brazilian Medical Association,
together with the Junior Doctors
Network, put forward a proposed
WMA Statement on Primary Health
Care. The Statement emphasized
the fact that primary health care
represented the first contact of the
patients in the health care system and
as such could address most population
health needs through comprehensive
and integrated services. Therefore,
primary health care should be
integrated to the core of every health
system.The committee’s attention was
drawn to one of the recommendations
in the document encouraging efforts
to align the representation of primary
health care physicians with specialized
and hospital-based physicians in
political decision-making as well as
the need to reduce salary imbalances
of physicians with a comparable
training between levels of care.
The committee recommended to the
Council that the proposed Statement
be circulated for comments.
Finance and Planning Committee
The Chair,Dr.Jung Yul Park (Korean
Medical Association), called the
committee to order.
Financial Statement
The committee considered the
Audited Financial Statement for
2021. The Treasurer, Dr. Ravindra
SitaramWankhedkar(IndianMedical
Association), and the Financial
Advisor, Mr. Adolf Hällmayr,
reported that the WMA’s finances
in 2021 were very solid again. The
committee was given further detailed
information relating to net income,
expenses, equity, and membership
dues.
The committee agreed that the
Audited Financial Statement for
2021 be approved by the Council and
forwarded to the General Assembly
for adoption.
Budget and Membership Dues Payments
The Committee considered the
Proposed Budget for 2023 vs. Actual
2021 Expenditures and recommended
that it be approved by the Council and
forwarded to the General Assembly
for adoption. It also received an oral
report from Mr. Adolf Hällmayr on
membership.
The Committee received the Dues
Categories 2023 and recommended
that the document be forwarded to the
General Assembly for information.
Strategic Plan
An oral report on the Strategic Plan
was given by Dr. Otmar Kloiber,
Secretary General. He reported that
the current activities were in line with
the Strategic Plan for 2020-2025 in
four areas:
• Ethics, Advocacy &
Representation, by proceeding
with the revision of the WMA
International Code of Medical
Ethics and setting up a workgroup
on the WMA Declaration of
Helsinki
• Partnerships & Collaborations,by
focusing on actions on universal
health coverage as well as human
rights and health issues with
other partner organisations, and
engaging in environmental and
health issues in connection with
the Conference of the Parties
(COP) process. Dr. Kloiber
stressed that a stronger focus on
pandemic preparedness would be
needed
• Communications & Outreach,
by organizing international and
regional meetings and expert
hearings
• Operational Excellence, by
renewing of the Associate
Members’ rules
Statutory Meetings
The committee considered plans for
future meetings. Dr. Simon Kigondu
(Kenya Medical Association)
extended an invitation to all members
to the Council Session in April 2023
in Nairobi. Dr. David Nirushwa
(Rwanda Medical Association)
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19
extended an invitation to all members
to the General Assembly in Kigali
in October 2023. He said the theme
of the Scientific Session would be
Global Health Security, and the sub-
sessions would be:
• Leaving no one behind: Together
to fulfil the Global Health
Security Mandate
• Walking towards a sustainable
Global Networking Era in
fighting emerging pandemics
• Sustainable Global Health
Security: The Role of
Multinational and Biotechnology
Firms
The committee received these reports.
Special Meetings
Dr.Otmar Kloiber said a major revision
process of the WMA Declaration
of Helsinki had started under the
leadership of the American Medical
Association as workgroup chair, and
the first expert meeting would be held
in Tel Aviv, Israel, with the support
of the Israeli Medical Association.
A series of regional meetings would
be needed for the revision process
and more commitment and support
from NMAs would be appreciated.
He added that in 2023 the WMA
Secretariat was hoping to organize a
leadership course in Africa to reach
out to the African members.
Membership
An application for constituent
membership was received from the
Saint Lucia Medical and Dental
Association.
The committee recommended that
the Council approve the application
for adoption by the General Assembly.
Associate Membership
An oral report was received from the
Associate Members. The interim
chair, Dr. Anthea Mowat, expressed
her honour to carry Dr. Joe Heyman’s
legacy forward. She hoped that the
revision of the Associate Members’
rules could be adopted. The written
report from the Associate Members
for the period up to 31 December
2021 stated that the total number
of Associate Members who were
in good standing was 1,682. The
regional breakdown was Japan with
604 members in good standing and all
other countries with 1,078 members,
comprising 366 paid embers plus 30
life members, 430 junior doctors, and
252 medical student members with
free membership.
Junior Doctors Network
In its written report, the Junior
Doctors Network reported that it had
made many important strides with the
deployment of numerous fully hybrid
activities,therevitalizationofactivities
which had been put on pause during
the first two years of the COVID-19
pandemic, and the expansion of work
into new areas. Membership had
risen to more than 500 from almost
100 countries. The Junior Doctors
Network had participated in many
of the WMA’s policy workgroups
and had once more adopted a joint
Management Team Strategy and
listed priorities for the term. It had
eight active working groups reporting
to the Junior Doctors Network bi-
annually, and their reports could be
found in the regular editions of the
JDN Newsletter.
The Chair,Dr.YassenTcholakov,gave
his last oral report before stepping
down as chair. He stressed that
the Junior Doctors Network could
increase engagement on policies in
various areas. The committee chair
congratulated the newly elected
Chair, Dr. Uchechukwu Arum, on his
election and thanked Dr. Tcholakov
for his contribution during his term.
Past Presidents and Chairs of Council
Network
The Committee received a report
of the Past Presidents and Chairs of
Council Network presented by the
Past Presidents and Chairs of Council
Network’s Secretary, Dr. Jón Snædal
(Icelandic Medical Association). He
said this group would have a meeting
during the week and planned to elect
new leadership.
Review Committee
A report was received from the
chair of the Review Committee, Ms.
Elizabeth LaRocca, who thanked the
past chair, Ms. Mervi Kattelus, who
had been appointed as the new Legal
Advisor.
Legal Seat of the WMA
Dr.Otmar Kloiber,Secretary General,
reported on the issue of the WMA
dissolving its legal seat in the United
States while retaining its existence
as an association in France. He said
that this discussion required a Special
General Assembly.
The committee agreed to recommend
this to the Council.
Green Guidelines for WMA Meetings
The Committee considered revisions
to the Green Guidelines for WMA
Meetings to create more sustainable
events. This was proposed by the
Secretariat following a cost analysis.
The proposals related to venues,
transport, food, and beverages at
meetings, and event materials and
merchandise.
The committee agreed that the
proposed guidelines, as amended,
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20
be approved by the Council and
forwarded to the General Assembly
for adoption.
World Medical Journal
The new Editor in Chief of the
Journal, Dr. Helena Chapman, gave
an oral report about the content of
recent editions and her plans to engage
with each NMA.The committee chair
welcomed Dr. Chapman and thanked
the previous editor,Dr.Peteris Apinis,
and Prof. Elmar Dopplefeld for their
long-term contributions.
Public Relations
The committee received a written
report on public relations, listing
the press releases that had been
issued during the year, and heard
an oral report on further activities.
Press releases would be issued on
the policies adopted at the General
Assembly and Council members were
asked to proactively promote them
within their own NMAs.
Public Relations Strategy
A further report on public relations
strategy was given by Dr. Ravindra
Sitaram Wankhedkar (Indian
Medical Association), who urged
members to engage in the public
relations activities, including social
media.
Thursday, 6 October
Associate Members Meeting
The meeting was called to order by
the interim chair of the Associate
Members,Dr.Anthea Mowat (British
Medical Association).
Election of Chair
In an election for Chair of the
Associate Members for the period
from 2022 to 2025, Dr. Jacques de
Haller (Swiss Medical Association),
a family doctor from Geneva,
Switzerland, was elected. Dr. de
Haller is a former President of the
Swiss Medical Association and a
former President of the Standing
Committee of European Doctors.
He told the meeting that as chair
he would continue his interest in
diversity and ethics. He was keen
on having the Associate Members
bringing their specific vision into
the WMA deliberations – a vision of
individuals doctors from throughout
the world.
Declaration of Helsinki
Dr. Mowat reported on her
membership of the workgroup set
up to revise the WMA Declaration
of Helsinki. This was expected to be
a two-year project, and the Associate
Members had set up an informal
subgroup to receive comments on the
revision.
Oral reports were received from the
Junior Doctors Network and the Past
Presidents and Chairs of Council
Network.
Resolution on international medical
meetings in countries persecuting
physicians against medical ethics and
human rights standards
Dr. Mowat reported that the original
proposal from the Austrian Medical
Association included examples
from named countries. The revised
Resolution was a generic proposal
calling on the medical community
worldwide to refrain from holding
international medical events in
countries where physicians were
persecuted, especially in detention
centres.
During a debate, the question was
asked about who was to decide
whether physicians were persecuted
or not?
Dr. Kloiber, Secretary General,
speaking as an associate member,
supported the motion,but had serious
concerns. In Turkey, physicians were
being persecuted, but the WMA
traveled to the country in order to
be seen, be present, and demonstrate
their support for these physicians. As
long as they could go, they should go,
he argued. They should try to help
these doctors and be influential in
the country. He did not think that
the proposal was either practical
or beneficial for doctors in these
countries. An amendment was
proposed to add the words ’scientific
meetings’ to the Resolution.
The committee recommended that
the Resolution, as amended, be
forwarded to the General Assembly.
The meeting was brought to a close.
Celebration of the 75th Anniversary
of the German Medical Association
On the Thursday morning, with
the WMA meetings adjourned, a
celebration took place for the 75th
anniversary of the German Medical
Association. With music provided by
Berlin’s Finest Jazzband, an audience
of German Medical Association’s
officials, members, and staff listened
to a number of speeches celebrating
the event. Dr. Klaus Reinhardt,
President of the German Medical
Association,spoke about ‘Professional
Independence as an Ethical Duty
in Medicine’, while Professor Alena
Buyx, Chair of the German Ethics
Council, spoke on ‘The future of
medicine – The changing role of the
physician’.
In her closing remarks, Dr. Heidi
Stensmyren, WMA President, spoke
about the importance of physicians
contributing their knowledge and
experiences to strategic discussions.
She said it was their professional task
to share their knowledge.
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Scientific Session
The title of the Scientific Session
was ‘Medical Ethics in a Globalized
World’.
Dr. Klaus Reinhardt, President of
the German Medical Association,
welcomed WMA delegates to Berlin.
He said that the principles of medical
ethics formed the foundation of
organized medicine in Germany,
and the German medical profession
had a tremendous responsibility to
confront the horrific ethical failures
of its past and to prevent them from
ever happening again. He said that
during these challenging times, it
was even more crucial to reaffirm the
fundamental and universal principles
of medical ethics worldwide.
The first speaker, Prof. Tom L.
Beauchamp, Professor Emeritus of
Philosophy at Georgetown University,
spoke about the principles of global
medical ethics, giving an overview
of basic universally valid principles.
He discussed the WMA Declaration
of Helsinki and addressed issues
such as respect for autonomy,
common morality, non-maleficence,
beneficence, and justice.
Prof. Ames Dhai, Chair of the
UNESCO International Bioethics
Committee, from South Africa,
spoke about the fair and just
allocation of resources in public
health emergencies. She referred
to the major infectious disease
outbreaks over the past two decades,
and the world’s unpreparedness for
the latest pandemic. She commented
that no country had adequate public
health structure, noting that even
those with the best systems were
unprepared. The political response
was poor, with inconsistent decision-
making. They had seen corruption,
with world leaders not taking into
consideration the poor on the ground.
The corruption had been a major
challenge.It had been an immoral and
unethical phenomenon, where people
in public offices used their power
for personal gain. With reference to
Africa in particular, she asked, ‘What
has happened to our moral compass?’
She said it was important now to
be proactive, learn the lessons, and
observe the lack of resources in the
areas of prevention, containment,
health services, equity, and global
innovation. She concluded that
solidarity, co-operation, shared
responsibilities, and integrity were all
necessary when it came to a fair and
just allocation of resources.
Prof. Raanan Gillon, Emeritus
Professor of Medical Ethics, at the
Imperial College in London, spoke
about the ‘four principles approach’
to medical ethics. He focused on
the international and intercultural
advantages for the medical and other
health care professions of adopting
it – as so many doctors around the
world already had. A major advantage
was that the four principles approach
provided a set of widely acceptable
moral commitments to which the
vast majority of the world’s doctors
could commit. Another advantage
was that it could provide a moral and
intellectual underpinning for the vast
range of substantive and more specific
moral norms and commitments
accepted by doctors in their practice.
He looked at how the principles
could morally underpin some of the
numerous obligations they had as
doctors and the issues of beneficence
and non-maleficence.He talked about
two more recently adopted principles
− respect for autonomy and justice –
as well as the issue of justice in health
care ethics.
During a session with the theme
‘Medical Ethics and Professionalism’,
Prof. James Childress, Professor
Emeritus of Ethics and Religious
Studies, from the University of
Virginia in the United States, talked
about respecting conscience while
protecting patients. He said that
physicians were expected to practice
with conscience and integrity. In
some cases, they believed that they
could not do so and at the same time
provide a legal and morally acceptable
service. Examples included abortion,
physician assisted suicide, and
active euthanasia. He discussed the
reasons for limiting conscientious
objection as well as the challenges of
balancing clinicians’ conscience and
the protection of patients’ interests.
He spoke about the revision of
the WMA International Code of
Medical Ethics and the compromised
wording on conscientious objection.
He concluded his speech by saying
that conscientious objection was
justifiable within limits, but not
conscientious obstruction. Moral
imagination was needed to ensure
the protection of patients’ interests
while also protecting physicians’
conscientious objection to provide a
particular service.
Prof. Urban Wiesing, Director of
the Institute of Ethics and History
of Medicine, at the University of
Tübingen in Germany, and ethics
advisor on the WMA International
Code of Medical Ethics revision
workgroup,spoke about globalisation
in medicine, where the world in
medicine was becoming culturally
more diverse. He argued that the
moral answer of the profession to
this globalisation was a global ethos.
He asked what should belong to
a global ethos, such as the central
obligation to patients and their
families. There were uncontroversial
and well-known core principles such
as avoiding harm, promoting health
and well-being, and confidentiality.
Also uncontroversial were dignity,
autonomy, no discrimination, mutual
respect, good medical practice, and
professionalism. He said that the
more concrete the moral norm was,
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the less chance there was for a global
consensus.
Prof. Wiesing looked at cultural
differences, where the question
arose about whether physicians
were allowed to advertise, and what
duty physicians have to help in
emergencies. These were complex
questions, and the only answer was
political compromise. As for the
responsible party, the answer was the
profession itself, and the WMA was
the only justifiable organisation to
make these decisions.
The final speaker, Dr. Helen
Oviasogie Eboreime, Director
Medical Services, at the Edo State
Ministry of Health in Nigeria, spoke
about the importance of upholding
ethical principles in teams while
maintaining interprofessional
respect. She looked at the barriers of
upholding these ethical principles,
and her conclusion was that
ethical principles with appropriate
knowledge and skills formed the
bedrock of good medical practice,
quality patient care, and improved
health outcomes. Practitioners must
strive to imbibe the core values of
professionalism, foster commitment
and team spirit, and display a good
customer service attitude in order
to ensure a positive societal image
and branding of the self and the
institution. Finally, government
funding, improved working
conditions, mandatory in-service
training and retraining, appropriate
and prompt renumeration, good
conflict management system, staff
motivation, and proper regulation of
publicandprivatepracticeswerekeyto
upholding ethical principles in teams
and maintaining interprofessional
respect.
Friday, 7 October
Reconvened Council Session
Medical Ethics Committee Report
Organ Procurement from Executed
Prisoners
The committee’s decision that the
proposed WMA Declaration on
Organ Procurement from Executed
Prisoners be circulated for comment
was raised by the Chinese Medical
Association. They said that during
the previous debate in committee,
the American Medical Association
claimed that China continued
to use prisoners’ organs without
providing any evidence. If there was
any evidence, the Chinese Medical
Association hoped the American
Medical Association would share
this information, as it was a serious
criminal activity,according to Chinese
law. This practice was ended in 2015,
but there were people profiting from
capitalising on claims that the practice
was still going on.
The Council agreed that the proposed
Declaration should be circulated
for comment. The Council agreed
that the following documents be
forwarded to the General Assembly
for adoption:
• Assisted Reproductive
Technologies
• Declarations of Venice and End-
of-Life Medical Care
Finance and Planning Committee
Report
Green Guidelines for WMA Meetings
Following an intervention by the
Secretary General about the cost
implications of these Guidelines,
it was decided to defer further
consideration until the next General
Assembly.
The Council agreed that the
following document be forwarded to
the General Assembly for adoption:
– Application for constituent
membership from the Saint Lucia
Medical and Dental Association
Socio-Medical Affairs Committee
Report
Health and the Environment
The Council received an oral report
on the previous day’s meeting of the
environment caucus, where reports
had been given about the forthcoming
Climate Change Conference
(COP27) in Egypt, the new fossil
fuel non-proliferation treaty and the
international chemicals management
meeting. A report had also been given
about Denmark’s new climate change
policy.
Acknowledgement and Condemnation
of the Genocide against the Uyghurs and
other Minorities in China
The Chinese Medical Association
reopened the debate on the
committee’s recommendation that the
Resolution be circulated for comment.
The Chinese Medical Association
said there was no genocide behaviour
in China and the Association firmly
opposed the proposed Resolution.
It proposed a motion to that effect,
but in the absence of a seconder, the
motion fell.
The Council agreed to recommend
to the General Assembly that the
Resolution be circulated for comment.
Violence in the Health Sector
The Council considered the
committee’s recommendation that
the proposed revision of the WMA
Statement on Violence in the Health
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23
Sector by Patients and Those Close
to Them be recirculated to members
for comment. The Indian Medical
Association argued that this was one
of the most pressing issues facing the
medical profession, and it proposed a
motion that the Resolution should be
forwarded to the General Assembly
for adoption. This was strongly
supported by several speakers. The
point was made that this was an issue
facing every physician in the world,
and they were looking to the WMA
for solutions. Governments needed to
put more money into providing safe
working areas. They was also pointed
out that social media harassment was
unrelenting.
The Council decided to forward the
Resolution to the General Assembly
for adoption.
Tuberculosis
The Council reconsidered the revised
WMA Resolution on Tuberculosis,
which the committee recommended
sending to the Assembly for
information. The American Medical
Association proposed re-inserting
into the Resolution a reference to
Directly Observed Treatment.
The Council agreed to send the
Resolution, as amended, to the
General Assembly.
In summary, the committee agreed
that the following documents be
forwarded to the General Assembly
for adoption:
• Revision of the WMA
Declaration of Edinburgh on
Prison Conditions and the Spread
of Communicable Diseases
• WMA Statement on the Global
Burden of Chronic Disease
• Revision of the WMA Declaration
on Patient Safety
• WMA Resolution on
Humanitarian and Medical Aid
to Ukraine
Advocacy and Communication Workgroup
AnoralreportwasgiventotheCouncil
about the workgroup’s activities.
The group had been dormant due
to a change in leadership, but would
resume its duties after this General
Assembly and would report to the
Council meeting in Kenya in April
2023.
General Assembly Ceremonial
Session
The Ceremonial Session was called
to order by the WMA President, Dr.
Heidi Stensmyren (Swedish Medical
Association).
Dr. Otmar Kloiber, WMA Secretary
General, carried out a Roll Call of
NMAs and welcomed honoured
guests from Nigeria. Delegates from
the Ukrainian Medical Association
were given a standing ovation.
Germany’s Federal President, Dr.
Frank-Walter Steinmeier, then
addressed the Assembly by video.
He said that abominable crimes
committed in many wars had shown
that the medical profession needed
an international and intercultural set
of values which laid down respect for
human life as an unalterable tenet.
In the 75 years of its existence, the
WMA had embraced the civilisational
progress of the medical profession
and had drawn up guidelines which
had been largely incorporated as
international standards into the codes
of professional conduct for physicians
in individual countries. He said
that during the Assembly, delegates
intended to adopt a Declaration
against racism in medicine.
“Your aim is to ensure that even
greater emphasis is placed on equality,
both that of patients and of doctors.
If your conference succeeds in
adopting this declaration, it would
mark an important step on the road
towards a global understanding of the
fundamental values of peaceful co-
existence among nations. I encourage
you to take it.”
Mr. Steinmeier referred to Russia’s
war of aggression against Ukraine and
doctors risking their lives in the war
zones to help the injured. He spoke
about the COVID-19 pandemic,
when many physicians were pushed
beyond their limits to save lives.
He said the COVAX initiative
remained relevant considering the
uneven distribution of vaccines. He
commented that “I therefore urge the
international community to provide
substantial help in the form of vaccine
supplies and health information,
especially to nations with weaker
economies. Only if we overcome the
pandemic in a spirit of cooperation,
we will be able to maintain trust, the
most valuable resource in the co-
existence among states.”
Dr. Klaus Reinhardt, President of
the German Medical Association,
then addressed the Assembly and
began with a quote from physician,
researcher, and politician Rudolf
Virchow, who once said “Physicians
are the natural attorneys of the poor,
and social problems fall to a large
extent within their jurisdiction.” He
demonstrated the interdependence of
medicine and politics and encouraged
physicians to focus on social issues.
This was one of the foundations of
WMA initiatives.
The WMA had always been an
important point of reference for
the German Medical Association.
Founded in the same year in the
aftermath of the Second World
War, they both had their roots in the
lessons learned from the crimes of the
National Socialist regime in Germany.
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It was the crimes and misconduct of
German physicians, above all, that
made it clear that a global medical
organization was needed – one that
would define medical ethics more
precisely.
Dr. Reinhardt said that physicians
were currently facing unique
challenges. War had broken out in
Europe again, and physicians had
an important role to play in caring
for and helping the wounded. The
WMA ha also turned its attention
to Ukraine and had accomplished a
great deal.
He closed with a final quote from
Rudolf Virchow, “Only those who
regard healing as the ultimate goal
of their efforts can, therefore, be
designated as physicians.”
The Assembly then stood to recite
the Physicians Pledge.
Dr. Frank Ulrich Montgomery paid
tribute to Dr.Stensmyren,the retiring
WMA President. She had taken
over in 2021, at the height of the
COVID-19 pandemic, and had been
tireless, hardworking, and diligent for
all WMA initiatives. She had helped
the WMA to conquer the infodemic
and had been a great role model for
women in medicine.
Dr. Heidi Stensmyren then delivered
her Valedictory Address.
Dr. Osahon Enabuleli then took the
oath of office as President of the
WMA for 2022/23. He was officially
installed as President and presented
with the Presidential Medal. Dr.
Enabuleli gave his Inaugural Address.
The Assembly then adjourned.
Saturday, 8 October
General Assembly Plenary Session
The morning’s events began with
a keynote speech from Dr. Chikwe
Ihekweazu, Director of the WHO
Hub for Pandemic and Epidemic
Intelligence, in Berlin. He spoke
about the hub’s work in detecting
diseases, and said that an estimated
15 million deaths were associated
with COVID-19 between January
2020 and December 2021.They were
continually facing an increasing risk
of disease emergence and spread, but
their response efforts were improving.
Since data sharing was one of the
challenges they faced, he said they
were getting the new hub up and
running and were building a very
exciting group.
Plenary Session
The plenary session opened with
delegates standing in silence to
remember the deaths of Dr. Jim
Appleyard, former WMA President,
and Dr. Joe Heyman, former Chair of
the Associate Members, as well as all
those physicians who had died during
the COVID-19 pandemic.
Election
Dr. Lujain Al-Qodmani (Kuwait
Medical Association) was elected
unopposed as President-elect of the
WMA. She is the first Arab to be
elected President and will take up her
post at the WMA General Assembly
in Kigali, Rwanda in October 2023.
Dr. Al-Qodmani said she was
honoured to accept the Presidency.
She said the world had entered a
difficult era with rising conflict,
worsening climate change, economic
turmoil, and a prolonged pandemic.
Asaresult,theirmandateasphysicians
and medical leaders was now more
crucial than ever to protect the health
and well-being of all people with no
discrimination, to secure a safe and
resilient environment for the practice
and delivery of medical care, and to
continue to champion the highest
ethical standards and professionalism
in their most noble of professions.
She went on to say, “When the
world was locked down, health care
professionals rose up. We rose up to
work longer. We rose up to treat and
cure those affected even in the face of
danger to our own lives.We rose up to
whatever challenges were thrown our
way. Many of our colleagues lost their
lives, many who worked side-by-side
with us. We remember, and honour
their memory.”
She said the WMA had always
been, and would continue to be, a
leading global organization in serving
humanity through its work in medical
ethics, medical education, and public
health advocacy because that was
their purpose − “to serve and to show
compassion” − as said by the Nobel
prize-winning Dr Albert Schweitzer.
Treasurer’s Report
The Treasurer, Dr. Ravindra Sitaram
Wankhedkar (Indian Medical
Association), presented his report,
covering a review of 2021 and 2022
as well as the 2023 budget. He said
that the finances were very solid, with
no financial losses to report, and very
controlled financial management.
The chief messages were that there
was a net income of €434,000 in 2021,
equity at the end of 2021 totalled
€3,275,000, and membership dues
were €2,336,000, which is 12 percent
higher than the previous year.
The Financial Statement for the year
ending 2021 and the Budget for 2023
were approved.
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Meetings
The Assembly was informed that the
General Assembly in 2026 would be
held from 23-25 April 2026, and that
an invitation had been received from
the Korean Medical Association to
host the Council session in 2024.
The meeting approved the theme
of ‘Global Health Security’ for the
Scientific Session at the General
Assembly in Kigali, Rwanda.
Associate Members
The revision of Associate Members
Rules was adopted.
Membership
The application for constituent
membership from the Saint Lucia
Medical and Dental Association was
approved.
Legal Seat of the WMA
Dr.Otmar Kloiber,Secretary General,
explained to the Assembly the plan to
dissolve the WMA’s legal entity in the
United States, and the requirement
for a Special General Assembly to
approve this. He said registration in
the United States was leading to legal
and financial complications, and the
solution was to keep the registration in
France as a French association, as the
WMA had been for several decades.
The WMA had left the United States
in 1974, and all its business had been
conducted in France.
The Assembly approved the proposal
to hold an immediate Special
Assembly.
Green Guidelines
The Assembly considered the
proposedGreenGuidelinesforWMA
Meetings to create more sustainable
events which have been approved by
the Council. A motion was received
that the Treasurer and the Secretariat
should further examine the potential
cost implications of the Guidelines
and report back in one year.
The motion was supported.
The Assembly then adjourned and
was called to order as a Special
General Assembly.
Special General Assembly
The Special Assembly meeting was
asked whether it wanted to accept
the dissolution of the WMA’s legal
entity in the United States. Delegates
voted unanimously in favour of the
proposal.
The General Assembly then resumed
and considered recommendations
from the Council meeting in Paris.
Support for Medical Personnel in
Ukraine
The Assembly considered a minor
revision to the WMA Resolution in
Support of Medical Personnel and
Citizens of Ukraine in the face of the
Russian invasion, that was passed at
the Council meeting in Paris earlier
this year.
It was decided that the Resolution
should be translated into Russian and
Ukrainian.
Violence in the Health Sector by Patients
and Those Close to Them
The proposed revision of the WMA
Statement on Violence in the Health
Sector by Patients and Those Close to
Them was presented to the Assembly
and unanimously adopted.
Physicians Treating Relatives
The Assembly agreed to adopt the
proposed revision of the WMA
Statement on Physicians Treating
Relatives.
Social Media
The proposed revision of the WMA
Statement on the Professional and
Ethical Use of Social Media was
presented, and the Assembly agreed
to its adoption.
International Code of Medical Ethics
The proposed revision to the WMA
International Code of Medical Ethics
was submitted to the Assembly. Prof.
Pablo Requena (Vatican Medical
Association) publicly thanked
everybody who had put in such an
effort on revising the Code, adding
that “We all are aware there are a
number of issues that we would have
liked to see a different drafting, more
consistent with our ideas. We know
everybody had shown interest in
having a common text and I thank
the group.”
Dr. Ramin Parsa-Parsi (German
Medical Association) also thanked
the workgroup which he chaired.
They had restructured the Code to
introduce new modern and gender
inclusive language, and they had
invested a great effort to see that
it could be applicable to different
cultures and political systems. It had
also been expanded to incorporate
the concept of patient autonomy,
physician wellbeing, equity, and
justice in health care and to elaborate
further on the principles of patient
confidentiality and informed consent.
It now included modern issues such
as remote treatment, environmental
sustainability, and social media. He
described it as a universal document
that would resonate globally.
In a vote, the revised Code was
unanimously adopted by the
Assembly.
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Assisted Reproductive Technologies
The Assembly considered the revised
WMA Statement on Assisted
Reproductive Technologies. Prof.
Requena said the Vatican Medical
Association could not support this
Statement because it still contained
a number of points on the moral
status of the embryo, the right of
every person to know who their
biological parents were, and issues
and concerns connected with the
surrogate motherhood. They all
knew that in most cases surrogate
mothers were used around the world
or money, which was damaging for
the body of women. It might help in
a small number of cases, but they had
not been able to put effective ethical
limits to the use of this practice. This
was a moral principle, based on the
respect for incipient human life.
With one vote against, the document
was adopted by the Assembly.
Declaration of Venice
The proposed WMA Declaration of
Venice came before the Assembly.
Dr. José Ramón (Spanish Medical
Association) proposed that the title
of the Declaration be changed to the
Declaration of Venice on End-of-
Life Medical Care.
The amendment was agreed and
the Assembly voted to adopt
the Declaration and rescind the
Declaration on End-of-Life Medical
Care. The Assembly adopted the
following documents:
• Revised Statement on Guiding
Principles for the Use of
Telehealth for the Provision of
Health Care
• Revised Statement on Health
Hazards of Tobacco Products and
Tobacco-Derived Products
• Revised Statement on the
Protection and Integrity of
Medical Personnel in Armed
Conflicts and Other Situations of
Violence
• Revised Resolution on
Occupational and Environmental
Health and Safety
Declaration on Racism
The Assembly considered the
WMA Declaration on Racism.
The American Medical Association
moved that the document be renamed
the Declaration of Berlin on Racism
in Medicine.
The action to rename the Declaration
was approved.
Dr.Ashok Philip (Malaysian Medical
Association) proposed that the first
sentence of the document which reads,
“Racism is rooted in a false ideology
that human beings can be grouped
into a hierarchy of racial categories
primarily based on inherited physical
traits”should be amended because, he
argued, to call racism an ideology was
to dignify it too much. He proposed
a new sentence to read, “Racism is
rooted in the false idea that human
beings can be ranked as superior or
inferior based on inherited physical
traits.”
The amendment was approved
and the Assembly agreed that the
document, as amended, should be
adopted.
The following documents were
adopted
• Declaration on Discrimination
against Elderly Individuals
within Health care Settings
• Resolution for Providing
COVID-19 Vaccines for All
The following documents were sent to
the Assembly for information:
• Statement on Self-Medication
• Resolution on Economic
Embargoes and Health
• Statement on the Ethical
Implications of Collective Action
by Physicians
• Resolution on Medical Assistance
in Air Travel
• Resolution on Tuberculosis
The following documents were
adopted:
• Declaration of Edinburgh on
Prison Conditions and Other
Communicable Diseases
• Statement on the Global Burden
of Chronic Disease
• Declaration on Patient Safety
• Resolution on Humanitarian and
Medical Aid to Ukraine
Complaints Procedure
The Assembly agreed to postpone
discussion about the two complaints –
involving Poland,Russia,and Belarus,
and the British and the Chinese
Medical Associations – until the next
meeting in Kenya.
Associates Members
Dr. Jacques de Haller, newly elected
chair of the Associate Members,
submitted a proposed Resolution
on international medical meetings
in countries persecuting physicians
against medical ethics and human
rights standards.The Resolution read,
“The WMA calls on the medical
community worldwide to refrain
from holding international medical
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27
events in countries where physicians
are persecuted, especially in detention
centres.”
Dr. de Haller said, “There are many
countries in the world where torture
takes place. However, in some
countries, the medical society is
unable to speak out against human
rights violations, even if they witness
them, due to the severe repression in
the country. It is our responsibility
to help our colleagues, to show that
the situation is recognized and that
fundamental changes are urgently
needed to guarantee to physicians
safe and sustainable working
conditions, allowing them to practice
their profession in line with medical
ethics standards. One way of showing
this recognition is to refrain from
holding international events in such
countries.”
The Assembly agreed to send
the Resolution to Council for
consideration.
Open Session
Indonesia
Dr. Khumaidi Adib (Indonesian
Medical Association) said that
the Indonesian Government was
proposing new health laws that
could potentially have an impact on
the welfare of doctors, and yet the
Indonesian Medical Association had
not been involved.
Ukraine
Dr. Iryna Mazur (Ukrainian Medical
Association) gave a graphic and
moving report to the Assembly
about the war and humanitarian
catastrophe in Ukraine. The Russians
had come to her country and killed
civilians, children, women, the elderly,
and physicians. After seven months
of war, more than 200 medical
institutions had been destroyed as
well as destroyed villages, weakened
infrastructure, and hospitals. City
doctors had been killed and about
200 wounded. Ukrainian physicians
had seen the results of the terrorist
activities of the Russian military.
Physicians were working at the limit
of their capabilities, and she said that
the voice of the WMA and each
NMA would help to stop the Russian
aggression.
Dr. Mazur expressed the gratitude
of Ukrainian physicians for the help
given by the WMA and its moral
support. She thanked the WMA for
its Ukraine Medical Help Fund, and
she ended her speech by presenting
WMA and German leaders with gifts
in appreciation.
Pakistan
Dr. Muhammad Ashraf Nizami
(Pakistan Medical Association) spoke
about the unprecedented floods in
Pakistan, which have costed the
country up to US $30-50 billion.
He said that his country was going
through the worst climate catastrophe,
which has affected 33 million people.
This country is a victim of the growing
climate crisis and needed help to
manage the disaster. More than a
million houses had been destroyed,
and hundreds of schools destroyed or
damaged. Millions of people needed
food tents and medicines, and most
flood victims were poor peasants and
small farmers. Time was running out
to save victims from starvation and
disease. Dr. Nizami concluded by
saying that Pakistan needed climate
justice.
Argentina
The Assembly heard a report about
the situation in Argentina, where
thousands of physicians had died as a
result of COVID-19. It was said that
the pandemic is not over, especially
for affected families left without any
social security support or protection.
Countries were encouraged to
establish a pension or a benefit for
the rest of their lives for families of
physicians who had died.
Bolivia
Dr. Luis Garcia (Bolivian Medical
Association) gave a report about
the situation in Boliva, where
many physicians had been locked
up for trying to defend the cause
of physicians and asking for better
medical infrastructure and better
access to medicines. Unfortunately,
the Bolivian Government was not
listening to doctors, and doctors were
being persecuted in Bolivia without
justice. The Assembly was urged
to adopt a statement to call for an
end to this persecution of doctors in
Bolivia. Dr. Kloiber responded that
the WMA would do what it could to
help the Bolivian physicians.
The Assembly ended with a round
of thanks from Dr. Kloiber to all
those who had made the meeting so
successful.
Council
Dr. Frank Ulrich Montgomery then
called a brief meeting of the Council,
with only two items on the agenda.
International Medical Meetings
The Council agreed to circulate to
constituent members the proposed
WMA Resolution on international
medical meetings in countries
persecuting physicians against
medical ethics and human rights
standards.
Iran
A proposed WMA Resolution on
Human Rights Demonstrations in
Iran was tabled. The Resolution read:
“The WMA is deeply concerned by
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28
the recent reports of violence against
protesters in Iran. Many people are
reported to have died in the ongoing
protests against the Iranian regime
and many more are said to have been
detained. In addition, reports indicate
that medical vehicles are being
abused by Iranian authorities to bring
protesters to detention.
The WMA calls on the Iranian
authorities to fully adhere to its
human rights obligations, including
the right to peaceful demonstration,
respect the autonomy of physicians
and in particular their ethical duty to
provide care to anyone on the basis of
medical need alone and ensure that
health care equipment and facilities
are used for health care purposes
only.”
Dr. Montgomery moved that this
should be treated as an emergency
Resolution. The Council agreed with
this course of action.
The meeting was adjourned.
Nigel Duncan
Public Relation Consultant
World Medical Association
nduncan@ndcommunications.co.uk
WMA General Assembly Report
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Photo 1. Group photo of the General Assembly in Berlin. Credit: World Medical Association
29
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WMA INTERNATIONAL CODE OF MEDICAL ETHICS
Adopted by the 3rd General Assembly of
the World Medical Association, London,
England, October 1949
Revised by the 22nd World Medical
Assembly, Sydney, Australia, August
1968, the 35th World Medical Assembly,
Venice, Italy, October 1983, the 57th WMA
General Assembly, Pilanesberg, South
Africa, October 2006 and by the 73rd
WMA General Assembly, Berlin, Germany,
October 2022
PREAMBLE
The World Medical Association (WMA) has
developed the International Code of Medical
Ethics as a canon of ethical principles for the
members of the medical profession worldwide.
In concordance with the WMA Declaration
of Geneva: The Physician’s Pledge and the
WMA’s entire body of policies, it defines and
elucidates the professional duties of physicians
towards their patients, other physicians and
health professionals, themselves, and society
as a whole.
The physician must be aware of applicable
national ethical, legal, and regulatory norms
and standards, as well as relevant international
norms and standards.
Such norms and standards must not reduce
the physician’s commitment to the ethical
principles set forth in this Code.
The International Code of Medical Ethics
should be read as a whole and each of its
constituent paragraphs should be applied with
consideration of all other relevant paragraphs.
Consistent with the mandate of the WMA,
the Code is addressed to physicians. The
WMA encourages others who are involved
in healthcare to adopt these ethical principles.
GENERAL PRINCIPLES
1. The primary duty of the physician is
to promote the health and well-being
of individual patients by providing
competent, timely, and compassionate
care in accordance with good
medical practice and professionalism.
The physician also has a responsibility
to contribute to the health and
well-being of the populations the
physician serves and society as a
whole, including future generations.
The physician must provide care with
the utmost respect for human life and
dignity, and for the autonomy and rights
of the patient.
2. The physician must practise medicine
fairly and justly and provide care based
on the patient’s health needs without bias
or engaging in discriminatory conduct
on the basis of age, disease or disability,
creed, ethnic origin, gender, nationality,
political affiliation, race, culture, sexual
orientation, social standing, or any other
factor.
3. The physician must strive to use health
care resources in a way that optimally
benefits the patient, in keeping with
fair, just, and prudent stewardship of
the shared resources with which the
physician is entrusted.
4. The physician must practise with
conscience, honesty, integrity, and
accountability, while always exercising
independent professional judgement and
maintaining the highest standards of
professional conduct.
5. Physicians must not allow their individual
professional judgement to be influenced
by the possibility of benefit to themselves
or their institution. The physician must
recognise and avoid real or potential
conflicts of interest.Where such conflicts
are unavoidable, they must be declared in
advance and properly managed.
6. Physicians must take responsibility for
their individual medical decisions and
must not alter their sound professional
medical judgements on the basis
of instructions contrary to medical
considerations.
7. When medically appropriate, the
physician must collaborate with other
physicians and health professionals who
are involved in the care of the patient or
who are qualified to assess or recommend
care options. This communication must
respect patient confidentiality and be
confined to necessary information.
8. When providing professional
certification, the physician must only
certify what the physician has personally
verified.
9. The physician should provide help in
medical emergencies, while considering
the physician’s own safety and
competence, and the availability of other
viable options for care.
10. The physician must never participate in
or facilitate acts of torture, or other cruel,
inhuman, or degrading practices and
punishments.
11. The physician must engage in continuous
learning throughout professional life
in order to maintain and develop
professional knowledge and skills.
12. The physician should strive to practise
medicineinwaysthatareenvironmentally
sustainable with a view to minimising
environmental health risks to current and
future generations.
Duties to the patient
13. In providing medical care, the physician
must respect the dignity, autonomy,
and rights of the patient. The physician
must respect the patient’s right to freely
accept or refuse care in keeping with the
patient’s values and preferences.
WMA International Code of Medical Ethics
30
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14. The physician must commit to the
primacy of patient health and well-being
and must offer care in the patient’s best
interests. In doing so, the physician must
strive to prevent or minimise harm for
the patient and seek a positive balance
between the intended benefit to the
patient and any potential harm.
15. The physician must respect the patient’s
right to be informed in every phase of the
care process. The physician must obtain
the patient’s voluntary informed consent
prior to any medical care provided,
ensuring that the patient receives and
understands the information needed to
make an independent, informed decision
about the proposed care. The physician
must respect the patient’s decision to
withhold or withdraw consent at any
time and for any reason.
16. When a patient has substantially
limited, underdeveloped, impaired, or
fluctuating decision-making capacity,
the physician must involve the patient as
much as possible in medical decisions. In
addition, the physician must work with
the patient’s trusted representative, if
available, to make decisions in keeping
with the patient’s preferences, when
those are known or can reasonably be
inferred. When the patient’s preferences
cannot be determined, the physician
must make decisions in the patient’s best
interests. All decisions must be made in
keeping with the principles set forth in
this Code.
17. In emergencies, where the patient is not
able to participate in decision making
and no representative is readily available,
the physician may initiate an intervention
without prior informed consent in the
best interests of the patient and with
respect for the patient’s preferences,
where known.
18. If the patient regains decision-
making capacity, the physician must
obtain informed consent for further
intervention.
19. The physician should be considerate of
and communicate with others, where
available, who are close to the patient,
in keeping with the patient’s preferences
and best interests and with due regard for
patient confidentiality.
20. If any aspect of caring for the patient is
beyond the capacity of a physician, the
physician must consult with or refer the
patient to another appropriately qualified
physician or health professional who has
the necessary capacity.
21. The physician must ensure accurate and
timely medical documentation.
22. The physician must respect the patient’s
privacy and confidentiality, even after the
patient has died.A physician may disclose
confidential information if the patient
provides voluntary informed consent or,
in exceptional cases, when disclosure is
necessary to safeguard a significant and
overriding ethical obligation to which
all other possible solutions have been
exhausted,even when the patient does not
or cannot consent to it. This disclosure
must be limited to the minimal necessary
information, recipients, and duration.
23. If a physician is acting on behalf of or
reporting to any third parties with respect
to the care of a patient,the physician must
inform the patient accordingly at the
outset and, where appropriate, during the
course of any interactions. The physician
must disclose to the patient the nature
and extent of those commitments and
must obtain consent for the interaction.
24. The physician must refrain from intrusive
or otherwise inappropriate advertising
and marketing and ensure that all
information used by the physician in
advertising and marketing is factual and
not misleading.
25. Thephysicianmustnotallowcommercial,
financial, or other conflicting interests
to affect the physician’s professional
judgement.
26. When providing medical care remotely,
the physician must ensure that this form
of communication is medically justifiable
and that the necessary medical care
is provided. The physician must also
inform the patient about the benefits
and limitations of receiving medical care
remotely, obtain the patient’s consent,
and ensure that patient confidentiality is
upheld. Wherever medically appropriate,
the physician must aim to provide care
to the patient through direct, personal
contact.
27. The physician must maintain appropriate
professional boundaries. The physician
must never engage in abusive,exploitative,
or other inappropriate relationships or
behaviour with a patient and must not
engage in a sexual relationship with a
current patient.
28. In order to provide care of the highest
standards,physicians must attend to their
own health, well-being, and abilities.
This includes seeking appropriate care to
ensure that they are able to practise safely.
29. This Code represents the physician’s
ethical duties. However, on some issues
there are profound moral dilemmas
concerning which physicians and
patients may hold deeply considered
but conflicting conscientious beliefs.
The physician has an ethical obligation
to minimise disruption to patient care.
Physician conscientious objection
to provision of any lawful medical
interventions may only be exercised if
the individual patient is not harmed
or discriminated against and if the
patient’s health is not endangered.
The physician must immediately and
respectfully inform the patient of this
objection and of the patient’s right to
consult another qualified physician
and provide sufficient information
to enable the patient to initiate such
a consultation in a timely manner.
Duties to other physicians, health
WMA International Code of Medical Ethics
31
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professionals, students, and other
personnel
30. The physician must engage with other
physicians,health professionals and other
personnel in a respectful and collaborative
manner without bias, harassment, or
discriminatory conduct. The physician
must also ensure that ethical principles
are upheld when working in teams.
31. The physician should respect colleagues’
patient-physician relationships and not
intervene unless requested by either
party or needed to protect the patient
from harm. This should not prevent
the physician from recommending
alternative courses of action considered
to be in the patient’s best interests.
32. The physician should report to the
appropriate authorities conditions
or circumstances which impede the
physician or other health professionals
from providing care of the highest
standards or from upholding the
principles of this Code. This includes
any form of abuse or violence against
physicians and other health personnel,
inappropriate working conditions,
or other circumstances that produce
excessive and sustained levels of stress.
33. The physician must accord due respect to
teachers and students.
Duties to society
34. The physician must support fair and
equitable provision of health care.
This includes addressing inequities in
health and care, the determinants of
those inequities, as well as violations of
the rights of both patients and health
professionals.
35. Physicians play an important role
in matters relating to health, health
education,and health literacy.In fulfilling
this responsibility, physicians must be
prudent in discussing new discoveries,
technologies, or treatments in non-
professional, public settings, including
social media, and should ensure that
their own statements are scientifically
accurate and understandable.
Physicians must indicate if their own
opinions are contrary to evidence-based
scientific information.
36. The physician must support sound
medical scientific research in keeping
with the WMA Declaration of Helsinki
and the WMA Declaration of Taipei.
37. The physician should avoid acting in
such a way as to weaken public trust in
the medical profession. To maintain that
trust, individual physicians must hold
themselves and fellow physicians to the
highest standards of professional conduct
and be prepared to report behaviour that
conflicts with the principles of this Code
to the appropriate authorities.
38. The physician should share medical
knowledge and expertise for the benefit
of patients and the advancement of health
care, as well as public and global health.
Duties as a member of the medical
profession
39. The physician should follow, protect,
and promote the ethical principles of
this Code. The physician should help
prevent national or international ethical,
legal, organisational, or regulatory
requirements that undermine any of the
duties set forth in this Code.
40. The physician should support
fellow physicians in upholding the
responsibilities set out in this Code and
take measures to protect them from
undue influence, abuse, exploitation,
violence, or oppression.
WMA International Code of Medical Ethics
32
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WMA DECLARATION OF BERLIN
ON RACISM IN MEDICINE
Adopted by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Racism is rooted in the false idea that
human beings can be ranked as superior or
inferior based on inherited physical traits.
This harmful social construct has no basis in
biological reality; however, racist policies and
ideas have been used throughout history and
are still used to perpetuate, justify, and sustain
unequal treatment.
Despite the fact that races do not exist in the
genetic sense,in some cultures racial categories
are used as a form of cultural expression
or identity, or a means of reflecting shared
historical experiences.This is one aspect of the
concepts of “ethnicity” or “ancestry”.
Acknowledging that the words “race” and
“racial” have different connotations in
different linguistic and cultural contexts, these
terms are used throughout this document to
denote socially constructed categories and not
a biological reality.
While the false conflation of racial categories
with inherent biological or genetic traits has
no scientific basis, the detrimental impact
racial discrimination has on historically
marginalized and minoritized communities
is well documented. The experience of racism
in all its forms – for example, interpersonal,
institutional, and systemic – is recognized as
a social determinant of health and a driving
force behind persistent health inequities,
as noted in the WMA Declaration of Oslo
on Social Determinants of Health. These
inequities can be compounded by other
factors like national origin, age, gender, sexual
orientation, religion, socioeconomic status,
disabilities, and more. Individuals subjected
to racism are often also affected negatively by
other social determinants of health.
Racially motivated violence and
overt bias, housing and employment
discrimination, education and health care
inequity, environmental injustice, daily
microaggressions, pay gaps, and the legacy of
intergenerational trauma experienced by those
who are subjected to racism are just some of
the many factors that may impact health and
illustrate why racism poses a serious threat
to public health. These and other structural
barriers faced by historically marginalized
communities can lead to disproportionate
rates of infant and maternal mortality and
certain illnesses, mental health struggles,
poorer health outcomes, as well as shorter life
expectancies.
Racism in medicine
With the WMA Declaration of Geneva,
the Physician’s Pledge, the physician vows to
respect the dignity of all patients, to respect
teachers, colleagues, and students, and to
“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 [the physician’s] duty
and [the] patient.”
Nonetheless, racism in all its forms also exists
in medicine throughout the world and has
a direct impact on patients and their health.
Systemic racial disparities in access to care and
health resources at a global and local scale can
translate to disparities in health outcomes.
At the interpersonal level, prejudice
and stereotypes held and acted upon by
medical professionals can lead them to be
reluctant to see patients or dismissive of
symptoms from patients from marginalized
communities, which can result in suboptimal
communication, as well as inappropriate or
delayed treatment. Racism can hinder or
undermine the foundation of trust that is
essential to a successful patient-physician
relationship.
Physicians from marginalized communities
also face racism from patients, other
physicians, and health professionals. This can
take the form of bullying, harassment, and
professional undermining in the workplace.
These distressing experiences may not only
impact the physician’s health and well-being,
but consequently the physician’s performance.
They may also leave marginalized physicians
less confident to raise concerns about patient
safety for fear of being blamed or suffering
adverse consequences. Large and growing
racial disparities in adequate professional
treatment and advancement opportunities
can have an impact on physicians’ career
trajectories.
Furthermore, systemic racism can create
barriers to entry to the medical profession
for certain historically excluded groups,
leading to a lack of representation, which may
contribute to adverse health outcomes for
patients.These barriers are caused by a variety
of factors, including implicit and explicit bias
in admissions and hiring practices, a dearth
in inclusive professional environments, and
lifelong racial disparities in educational
funding.
A medical profession that is representative of
the population is crucial to addressing health
disparities among patients.
Racism in medical education
In medical education, implicit and explicit
bias not only impact the admissions process,
but also the curriculum, faculty development,
and how marginalized students are treated
and assessed. Non-inclusive and harmful
learning environments can leave minoritized
students with an increased risk of anxiety
and depression. In addition, learning
materials and curricula often do not reflect a
diversity of experiences, imagery, and disease
presentations and fail to address the issue of
racism in medicine head-on.
Racism in medical research / medical
journals
Structural racism also influences participation
and therefore inclusivity in medical
research. Historical examples of unethical
WMA Declaration of Berlin on Racism in Medicine
33
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experimentation or research in the absence
of informed consent on marginalized
communities have led to a high level of
mistrust of the medical establishment. On the
other hand, exclusion of marginalized groups
from clinical trials results in a lack of data
about how certain drugs, treatments, or health
conditions might impact individuals in those
groups. A lack of racial data transparency can
lead to a lack of understanding about how
racial disparities lead to health inequities. It
can also jeopardize the potential of artificial
intelligence to reveal and override biases in
medicine. Algorithms are only as inclusive as
the health and technology professionals who
create them.
Furthermore, medical journals – the
gatekeepers of evidence-based research – have
generally been remiss in addressing the issue
of racism and its impact on health inequities,
as well as in addressing underrepresentation
among journal decision makers and authors.
DECLARATION
Therefore, the World Medical Association
• condemns unequivocally racism in all
its forms and wherever and whenever it
occurs;
• declares racism to be a public health
threat;
• acknowledges that racism is structural
and deeply engrained in health care;
• asserts that racism is based on a social
construct with no basis in biological
reality and that any effort to claim
superiority by exploiting racist
assumptions is unethical, unjust, and
harmful;
• recognizes that the experience of
racism is a social determinant of health
and responsible for persistent health
inequities;
• commits to actively promote equity
and diversity in medicine and to strive
for an inclusive and equitable health
environment.
RECOMMENDATIONS
The WMA urges its members and all
physicians to:
1. enact the above-mentioned declaration
in their own organizations;
2. acknowledge the harmful impact of
racism on the health and well-being of
marginalized communities and act upon
it;
3. promote equitable access to health and
other societal resources locally, nationally
and on a global scale;
4. commit to actively work to dismantle
racist policies and practices in health care
and advocate for antiracist policies and
practices that support equity in health
care and social justice;
5. implement organizational and
institutional changes to foster diversity
in the medical profession and the
organizations that support it;
6. support and, where possible, implement
admissions and curriculum changes
in medical education that promote
inclusivity and raise awareness about the
harmful impact of racism on health;
7. promote just and safe learning
environments in medical education;
8. promote equitable access to quality
medical and public health education;
9. center the experiences of physicians from
underrepresented communities to ensure
the visibility of role models and foster a
feeling of inclusivity and empowerment
among prospective students from
historically marginalized communities;
10. ensure safe, supportive, and respectful
work environments for all physicians,
including those from historically
marginalized communities;
11. establish channels for physicians and
students of medicine to safely report
cases of racially motivated harassment or
bias;
12. enact disciplinary measures against
perpetrators of racial harassment or bias
in the medical profession and implement
measures to prevent such harassment
and discrimination, to protect those who
suffer from it and to eliminate it from the
medical field;
13. take measures to identify research gaps
and promote evidence-based research on
the health impact of racism;
14. encourage medical journals to amplify
the voices of medical researchers and
health experts from underrepresented
and historically excluded communities;
15. makealleffortstopromoterepresentation
in ethically conducted clinical trials in
accordance with the WMA Declaration
of Helsinki as a means of advancing
health equity;
16. promote further research on the impact
of racism in the health system.
WMA Declaration of Berlin on Racism in Medicine
34
WMA DECLARATION OF EDINBURGH
ON PRISON CONDITIONS AND
THE SPREAD OF COMMUNICABLE DISEASES
Adopted by the 52nd WMA General
Assembly, Edinburgh, Scotland, October
2000
Revised by the 62nd WMA General
Assembly, Montevideo, Uruguay, October
2011 and by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
The WMA Declaration of Lisbon on the
Rights of the Patient states ‘Every person is
entitled without discrimination to appropriate
medical care’.
The Constitution of the World Health
Organization states that “The enjoyment of
the highest attainable standard of health is
one of the fundamental rights of every human
being without distinction of race, religion,
political belief, economic or social condition”.
Persons deprived of liberty (“prisoners”)
should receive the same standard of health
care as people outside prisons. They have the
same rights as all other people. This includes
the right to humane treatment and appropriate
medical care. The standards for the treatment
of prisoners have been set down in a number of
United Nations Declarations and Guidelines,
in particular the Standard Minimum Rules
for the Treatment of Prisoners – known as
the Nelson Mandela Rules in its 2015 revised
version, they are supplemented by the UN
Bangkok Rules on women.
The term “persons deprived of liberty”refers to
all regardless of the reason for their detention
as well as of their legal status, from pre-trial
detainees to sentenced persons.
It is the responsibility of the states to guarantee
the right to life and health of persons deprived
of liberty. This implies caring for them
with the aim that prison does not become a
determining factor of communicable disease.
The relationship between physician and
persons deprived of liberty is governed by the
same ethical principles as that between the
physician and any other patient. However, the
particular prison setting can lead to tensions
within the patient/physician relationship as a
result of the physician potentially being subject
to pressure from authorities and seeming to be
hierarchically subordinate to his/her employer,
the prison service, and of the general attitude
of society towards persons deprived of liberty.
Beyond the States responsibilities to treat all
persons deprived of liberty with respect for
their inherent dignity and value as human
beings, there are strong public health reasons
for ensuring the adequate implementation of
the Nelson Mandela Rules.The high incidence
of tuberculosis and other communicable
diseases amongst prisoners in a number
of countries reinforces the urgent need to
consider public health as a critical element
when designing new prison regimens, and for
reforming existing penal and prison systems.
Individuals facing imprisonment are often
from the most vulnerable sections of society.
They may have had limited access to health
care before imprisonment, may suffer worse
health conditions that many other citizens
and as a result may have a high risk of entering
prison with undiagnosed, undetected and
untreated health problems.
Overcrowding, lengthy confinement within
tightly enclosed, poorly lit, badly heated and
consequently poorly ventilated and often
humid spaces are all conditions frequently
associated with imprisonment and all of which
contribute to the spread of communicable
disease and ill-health. Where these factors
are combined with poor hygiene, inadequate
nutrition and limited access to adequate
health care, prisons can represent a major
public health challenge.
Keeping persons deprived of liberty in
conditions that expose them to substantial
medical risk, poses a serious humanitarian
challenge.The most effective and efficient way
to reduce disease transmission is to improve
the prison environment.
It is the responsibility of states to dedicate
sufficient resources to ensure adequate
prison conditions, that prison health care
is appropriate in relation to the size and
needs of the prison population, and to
define and implement sustainable health
strategies to prevent communicable diseases
transmission. The organization of health care
in prison requires a suitable team of health
personnel capable of detecting and treating
communicable diseases as part of its essential
mission to provide care and treatment to their
patients in detention.
The increase in active tuberculosis in prison
populations and the development of resistant,
especially “multi–drug” and “extensively-
drug” resistant forms of TB, as recognised
by the World Medical Association in its
Resolution on Tuberculosis, is reaching very
high prevalence and incidence rates in prisons
in some parts of the world. Likewise, the
Covid-19 pandemic has severely impacted
prisons with outbreaks reported around the
world. Other conditions, such as hepatitis C
and HIV disease, pose transmission risks from
blood-borne spread, exchange of body fluids.
Overcrowded prison conditions also promote
the spread of sexually transmitted diseases,
while intravenous drug use contributes to the
spread of HIV as well as hepatitis B and C.
RECOMMENDATIONS
Recalling its Declaration of Lisbon on the
Rights of the Patient, the World Medical
Association calls on all relevant actors to
take the necessary measures to guarantee
the highest attainable standard of health for
persons deprived of liberty, in particular:
Governments, prison and health authorities
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WMA Declaration of Edinburgh on Prison Conditions and the Spread of Communicable Diseases
35
1. To protect the rights of persons deprived
of liberty according to the various
United Nations instruments relating to
conditions of imprisonment,in particular
the Nelson Mandela Rules for the
Treatment of Prisoners.
2. To allocate the necessary resources to
health care in prisons, proportionate to
the number and needs of the persons
deprived of liberty and including
adequate funding for health personnel
and appropriate level of staffing of such
personnel.
3. To define and implement robust health
strategies that ensure a safe and healthy
prison environment,through vaccination,
hygiene, surveillance and other measures
to prevent transmission of communicable
diseases.
4. To guarantee that persons deprived of
liberty with an infectious illness are
treated with dignity and that their rights
to health care are respected, in particular
that they are not isolated, or placed in
solitary confinement, as a response to
their infected status, without adequate
access to health care and the appropriate
medical treatment.
5. Toensurethattheconditionsofdetention,
at any stage from arrest to sentencing or
once sentenced, do not contribute to the
development, worsening or transmission
of diseases.
6. To ensure that diagnosis and treatment of
non-communicable chronic disease and
acute non-communicable illness and/
or injury is reasonably and adequately
treated so as to not cause undue burden
on health personnel or increase risk of
communicable disease spread due to
prisoners with decompensated illness or
injury.
7. To ensure the appropriate planning
for and provision of continuing care as
essential elements of prison health care,
coordination of health services within
and outside prisons facilitates, including
continuity of care and epidemiological
monitoring of prisoner patients when
they are released.
8. To ensure that, upon admission to or
transfer to a different prison, individuals’
health status is reviewed within 24 hours
of arrival to ensure continuity of care.
9. To avoid disruption of care within
the institution, particularly when the
prisoner is receiving opiate substitution
treatment by continuing the prescribed
treatment.
10. Imprisonment is unacceptable in
cases where infection or the risk of
transmission is the cause of deprivation
of liberty. Imprisonment is not an
effective way to prevent the transmission
of infectious diseases, and further, it is
a cause of concealment of the diagnosis
due to fear, leading to greater aggregate
dissemination.
11. To respect autonomy and responsibilities
of physicians working in prisons who
must observe principles of medical ethics
to protect health of persons deprived of
liberty.
12. To conduct independent and transparent
investigations to prevent denial of health
care to inmates in prison.
WMA constituent members and the medical
profession
13. To work with national and local
governments, and health and prison
authorities to prioritize health and health
care, including that for mental health
issues, in prisons and to adopt strategies
that ensure a safe and healthy prison
environment.
14. In accordance with the ethical principles
of the medical profession, to encourage
physicians to report and document
any deficiency in health care provision,
leading to ill-treatments of persons
deprived of liberty.
15. To support and protect physicians
encountering difficulties as a result of
their attempts to denounce deficiencies
in prison health care provision.
16. To support improving prison conditions
and prison systems from a viewpoint of
health of persons deprived of liberty.
Physicians working in prisons
17. To report duly to the health authorities
and professional organisations of their
country any deficiency in health care,
including that for mental health issues,
provided to the persons deprived of
liberty and any situation involving high
epidemiological risk.
18. To follow national public health
guidelines, where these are ethically
appropriate, particularly concerning the
mandatory reporting of infectious and
communicable diseases.
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WMA Declaration of Edinburgh on Prison Conditions and the Spread of Communicable Diseases
36
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WMA DECLARATION OF VENICE
ON END OF LIFE MEDICAL CARE
Adopted by the 35th World Medical
Assembly, Venice, Italy, October 1983
Revised by the 57th WMA General
Assembly, Pilanesberg, South Africa,
October2006andbythe73rdWMAGeneral
Assembly, Berlin, Germany, October 2022
PREAMBLE
When a patient is seriously ill and the
restoration of health may not be possible, the
physician and the patient are often faced with
a complex set of decisions regarding medical
treatment.
The end of life must be recognized and
respected as an important part of a person’s
life.
Advances in medical science have improved
the ability of physicians to address many
issues associated with end-of-life care. While
the priority of research to cure disease should
not be compromised, more attention must be
paid to developing palliative treatments and
improving assessment and response to the
physical, psychological, social and spiritual or
existential components of terminal illnesses
and other conditions at the end of life.
WMA remains firmly opposed to euthanasia
and physician-assisted suicide, as set forth in
the WMA Declaration on Euthanasia and
Physician-Assisted Suicide.
Ethically-appropriate care at the end of life
should routinely promote patient autonomy
and shared decision-making, and be respectful
of the values of the patient, his or her family
or intimate associates, and surrogate(s).
The WMA recognizes that attitudes and
beliefs toward death and dying vary widely
from culture to culture and among different
religions, and palliative care resources
are unevenly distributed. The approach
to medical care at the end of life will be
influenced significantly by these factors, and
thus attempting to develop detailed universal
guidelines on terminal care is neither practical
nor wise.Therefore, the WMA articulates the
following:
RECOMMENDATIONS
Pain and Symptom Management
1. Palliative care at the end of life is part
of good medical care. The objective of
palliative care is to maintain patient
dignity and freedom from distressing
symptoms. Care plans should emphasize
keeping a patient as comfortable as
possible and the patient’s pain controlled
while recognizing the importance of
attention to the social, psychological and
spiritual needs of the patient, and his or
her family and intimate associates.
2. The clinical management of pain in
patients at the end of life is of paramount
importance in terms of alleviating
suffering. The WMA Resolution on
Access to Adequate Pain Treatment
(2020) makes recommendations for
physicians and governments that
optimize treatment of pain and other
distressing symptoms. Physicians
and National Medical Associations
should promote the dissemination and
sharing of information regarding pain
management to ensure that all physicians
involved in end-of-life care have access
to best practice guidelines and the
most current treatments and methods
available. National Medical Associations
should oppose laws or regulations that
unduly inhibit physicians from providing
intensive, clinically appropriate
symptoms management for patients at
the end of life in keeping with recognized
best practices.
3. When a patient at the end of life
experiences severe pain or other
distressing clinical symptoms that do
not respond to intensive, symptom-
specific palliation, it can be appropriate
to offer sedation to unconsciousness as
an intervention of last resort. Sedation
to unconsciousness must never be used
to intentionally cause a patient’s death
and should be restricted to patients in
the final stages of life. Thorough efforts
should be made to obtain consent of the
patient or the patient’s surrogate(s).
4. Palliative care is often provided by
multidisciplinary healthcare teams.
When possible, the physician should be
the leader of the team, being responsible,
amongst other obligations, for diagnosis
and medical treatment plans. A
carefully kept medical record is of the
utmost importance. The rationale for
all symptom management interventions,
including medications for symptom relief,
should be documented in the medical
record, including the degree and length
of sedation and specific expectations for
continuing, withdrawing, or withholding
future life-sustaining treatments.
5. The health care team should promote
collaborative care of the patient and offer
bereavement support after the patient’s
death.The needs of children and families
or intimate associates may require special
attention and competence, both when
children are patients and when they are
dependents of patients.
Education and Research
6. Education of healthcare professionals
should include the teaching of end-
of-life medical care. Where it does not
exist, the establishment of palliative
medicine as a medical specialty should be
considered. In countries where palliative
medicine is not a recognized specialty,
post-graduate training in palliative
medicine can nevertheless improve the
quality of palliative care provided.
7. Physician education should help to
develop the skills necessary to increase
the prevalence and quality of meaningful
patient advance care planning for patients
with life-threatening illness and the
WMA Declaration of Venice on End of Life Medical Care
37
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WMA Declaration of Venice on End of Life Medical Care
right of patients to use written advance
directives that describe their wishes and
goals regarding care in the event that they
are unable to communicate. Physicians
should receive education to encourage
their patients to formally document their
goals, values and treatment preferences
and to appoint a substitute health care
decision maker with whom the patient
can discuss in advance his or her values
regarding health care and treatment.
8. Governments and research institutions
are encouraged to invest additional
resources in developing treatments to
improve end-of-life care. This includes,
but is not limited to, supporting research
on general medical care, specific
treatments, psychological implications
and organization to improve end-of-life
care.
9. When employing treatments, the
physician must carefully consider the
balance between the intended benefits
to the patient and the potential harm.
National Medical Associations should
support the formulation of palliative
treatment guidelines.
10. The physician must also communicate to
the patient a willingness to discuss at any
time the natural course of the disease and
what to expect during the dying process,
while also providing guidance about
treatments and alternatives that could
ease the patient’s suffering, including
palliative care or psychotherapy. If
a patient indicates a desire to die or
expresses suicidal thoughts, the physician
has a duty to engage in open and
confidential discussions with the patient
to understand the motives and reasoning
behind these thoughts.
11. Physicians should assist the dying patient
in maintaining an optimal quality of life
by controlling symptoms and addressing
psychosocial and spiritual needs, to
enable the patient to die with dignity
and in comfort.Physicians should inform
patients of the availability, benefits
and other aspects of palliative care.
Discussions about patient preferences
should be initiated early,routinely offered
to all patients and should be revisited
regularly to explore any changes patients
may have in their wishes, especially
as their clinical condition changes.
Information and communication among
the patient, his or her family or intimate
associates, surrogates and members
of the health care team are one of the
fundamental pillars of quality care at the
end of life.
12. Physicians should endeavor to identify,
understand and address the psychosocial
and spiritual needs of their patients,
especially as they relate to patients’
physical symptoms. Physicians should
try to ensure that psychological, social
and spiritual resources are available to
patients, their families and intimate
associates, to help them deal with the
anxiety, fear and grief associated with the
end of life.
13. Physicians should encourage patients to
designate a substitute decision-maker/
surrogate to make decisions that are not
expressed in an advance directive. In
particular, physicians should discuss the
patient’s wishes regarding the approach
to life-sustaining interventions as well as
palliative measures that might have the
additional effect of accelerating death.
Because documented advance directives
are sometimes not available in emergency
situations, physicians should emphasize
to patients the importance of discussing
treatment preferences with individuals
who are likely to act as substitute
health care decision-makers/surrogates.
Whenever possible and consented to
by the patient, the patient’s substitue
decision-makers/surrogates should be
included in these conversations.
14. If a patient has decision-making capacity,
his or her autonomous right to refuse
any medical treatments or interventions
must be respected even if the patient’s
life may be shortened. Physicians should
make sure that the patient is adequately
treated for pain and discomfort before
consent for end-of-life care is obtained in
order to ensure that unnecessary physical
and mental suffering do not interfere
with decision making. Laws regarding
the decision-making capacity of minor
patients vary greatly, but discussions
with the family, and child, if possible, are
encouraged.
15. Upon a patient’s death, physicians may
apply such means as are necessary to
keep organs viable for transplantation,
provided that they act in accordance
with the ethical guidelines established
in the WMA Declaration of Sydney
on the Determination of Death and
the Recovery of Organs. In addition,
any transplantation must be in
accordance with the principles in the
WMA Statement on Organ and Tissue
Donation.
38
Adopted by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
The ageing of the population due to increased
life expectancy is one of the main challenges
of many health systems given the increasing
amount of resources needed to provide
healthcare for the elderly population. This
puts a strain on these systems, since ageing
often causes a higher demand for care, with a
high dependence on medical, pharmaceutical
and hospital services.On the other hand,older
people are perceived as recipients of help, care
and financial support, which is inaccurate, as
they make significant contributions to the
well-being of their environment, which has a
high social value.
Theincreaseinlongevitymustbeaccompanied
by appropriate quality-of-care standards,
promoting health, reducing risk factors, and
providing accessible and sustainable quality
health and social services that are accessible,
affordable, sustainable and which are of
quality.
Biological age should never be used as a basis
for discrimination,although it can be a relevant
factor in medical decision-making. Reference
to age can therefore be professionally sound.
Health discrimination in elderly patients
Elderly individuals experience all kinds of
discrimination with one of the main types
of discrimination being related to health.
The elderly may be perceived as a burden
on the healthcare systems and their financial
sustainability. Elderly individuals are not
uniquely responsible for the increase in
healthcare costs in developed countries.
There are other factors that play a key role
in healthcare costs, such as the improvement
in standards of living, accessibility to health
services, quality of care and the use of new
technologies.
Rationing of certain costly and time-
consuming diagnostic or therapeutic
procedures or particular settings that have
a certain more expensive intensity of care
is more common in the elderly population.
Clinical trials often exclude patients of a
certain age, even if they meet the criteria for
enrolment.
Age has become a barrier when putting
patients forward for certain interventions.The
reasons tend to be physical; however, these
may be underpinned by economic motivations,
such as the recovery time being higher which
increases the length of hospital stay, or by
arguing that there are scarce resources and that
elderly people have a shorter life expectancy.
There is consensus that from a physiological
and psychological point of view, the
determining factors for health in ageing
patients are intrinsically linked to gender;
therefore, the solutions need to address the
differences between genders in order to reduce
inequalities.
Health discrimination experienced by elderly
individuals may have a negative impact on their
physical, mental and social well-being and
contributes to deterioration in their quality of
life, loss of autonomy, confidence, safety and
an active lifestyle, in turn, decreasing their
levels of health. Is therefore a complex topic
that requires the involvement of professionals,
institutions, healthcare systems and
authorities. Dealing with such discrimination
requires awareness and coordination aided by
moral and legal principles.
The need for a holistic approach
Healthcare systems do not always adapt to
the changing population needs, as may occur
with some hospitals, designed to care for adult
patients with acute illnesses yet not elderly
patients with chronic illnesses.
An increase in longevity must be accompanied
by the highest quality-of-care standards, and
should promote health, reduce risk factors,
and provide accessible, sustainable and quality
health and social services. Emphasis should be
on patient-focused medicine that heals, cares
for, alleviates and comforts.
The ethical duty of physicians
In line with the WMA Declaration of Geneva,
physicians must strive to improve the health,
well-being and quality of life for all patients
without any forms of discrimination towards
the elderly.
RECOMMENDATIONS
Recalling its Declarations of Geneva and of
Lisbon on the Rights of the Patient, and its
Statement on Ageing, the WMA makes the
following recommendations:
To governments, medical associations and
physicians
1. As priority actions, to defend the human
rights and health of all individuals,
including the elderly, as well as to ensure
that their dignity is respected;
To governments
2. Develop appropriate and non-
discriminatory healthcare policies for
the elderly based on the efficient use of
available healthcare resources;
3. To establish measures to eradicate
discrimination against elderly individuals
in healthcare;
4. Provide sufficient resources which
ensure adequate healthcare for elderly
individuals;
WMA DECLARATION ON DISCRIMINATION
AGAINST ELDERLY INDIVIDUALS WITHIN
HEALTHCARE SETTINGS
WMA Declaration on Discrimination Against Elderly Individuals Within Healthcare Settings
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39
To the WMA, its members and the medical
profession in general
5. To commit to eliminating all forms of
discrimination due to health and age;
6. Promote training for primary care
physicians on how to approach health
problems in elderly individuals;
7. Promote development of the geriatric
specialty or supplementary post-
graduate training and increase of the
number of physicians in this field, an
increase of the number of physicians in
this speciality and an adequate number
of geriatric departments in hospitals
and consultants, in order to ensure the
availability of comprehensive care for
elderly individuals;
8. Raise awareness and take action against
discrimination of elderly individuals;
9. Promote ethical, responsible, effective
and efficient practices for treating the
elderly;
10. To set ethical standards that aim to
prevent discrimination against any
individual due to age;
11. To actively try to include elderly patients
in medical scientific research;
To physicians
12. Not limit or impede patients’ autonomy
on the basis of their age;
13. Provide healthcare of scientific and
human quality according to good
medical practice to all patients, without
any discrimination;
14. Not apply limitations solely based on age
in protocols for diagnosis and treatment;
15. To report any discrimination against the
elderly that is observed in healthcare.
WMA Declaration on Discrimination Against Elderly Individuals Within Healthcare Settings
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Adopted by the 53rd WMA General
Assembly, Washington, DC, USA, October
2002,reaffirmed by the 191stWMA Council
Session, Prague, Czech Republic, April
2012,and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Physicians strive to provide safe, high-quality
health and medical care to patients.
Progress in medical and allied science and
technology has transformed how modern
medicine is delivered in advanced and complex
health systems.
Inherent risks always exist in clinical
medicine. Developments in modern medicine
often reduce risk but may also introduce new
or increased risks – some avoidable, others
inherent.
Physicians and healthcare organisations
should attempt to foresee these risks and
manage them to the best of their ability.
Many health services continue to struggle
with demand exceeding capacity, often
with an inadequate infrastructure due to
underinvestment by governments or other
providers of healthcare. Patient safety is at
risk where physicians work in systems under
pressure.
Patient safety is affected by the working
culture that physicians operate within.In many
healthcare systems there is often a culture of
blame, where individuals are targeted rather
than examining wider organisational causes of
error (such as resource constraints, workforce
shortages, or systemic failures).
Many physicians fear being unfairly blamed
for medical errors which may have been
caused or exacerbated by systemic factors, and
often feel unable to be open or raise concerns.
A workplace culture of learning assures and
improves patient safety. Embedding a just and
learning culture approach can be an antidote
to cultures of blame and fear.
In a just and learning culture, the initial focus
is on what went wrong when patient safety
incidents took place, rather than seeking
to determine who may individually be
responsible.
Medical regulation and a fear of litigation
can compromise physicians’ ability to be
open about medical error. A system where
physicians feel unable to speak up, due to fear
of personal recrimination, will compromise
the identification of systemic causes of error
or poor care and imped measures to improve
patient safety.
Working in a system under pressure that has a
culture of fear and blame can erode physician
wellbeing. Physicians’performance in stressful
working environments may be impaired,
potentially leading to error or poor patient
outcomes.
Improving physician wellbeing significantly
improves productivity, care quality, patient
safety and the sustainability of health services.
Positive cultures within workplaces are vital
to minimize medical error, improve physician
wellbeing and assure patient safety.
PRINCIPLES
1. Physicians must ensure that patient
safety is always considered during their
medical decision-making.
2. Individuals and processes are rarely solely
responsible for errors. Rather, separate
elements combine and together produce
a high-risk situation. Therefore, there
should be a non-punitive culture for
confidential reporting healthcare errors
that focuses on preventing and correcting
systems failures and not on individual or
organization culpability.
3. A realistic understanding of the risks
inherent in modern medicine requires
physicians to cooperate with all relevant
parties, including patients, to adopt a
proactive systems approach to patient
safety.
4. To create such an approach, physicians
must continuously absorb a wide range
of advanced scientific knowledge and
continuously strive to improve medical
practice.
5. All information that concerns a patient’s
safety must be shared with the patient
and all relevant parties. However, patient
confidentiality must be strictly protected.
6. When medical error or a patient safety
incident occurs, investigations should
always begin by fully reviewing the wider
environment that the physician operates
within to identify systemic factors and
pressures that may have contributed to
the error.
7. Where medical error is found to have
been caused fully or partly by systemic
factors,any judgement by the regulator(s)
should also hold the healthcare providing
organisation to account.
8. Regulators of healthcare providing
organisations must promote and ensure
positive, just, and learning workplace
cultures, where physicians and patients
feel supported and empowered to learn
when adverse events occur.
9. Regulators have a responsibility to
identify systemic and contextual
constraints that impact on patient
safety, including a lack of resources and
infrastructure.
RECOMMENDATIONS
Recognizing the importance of system
pressures, workplace culture, physician
wellbeing, and healthcare regulation on
patient safety, the WMA recommends that its
WMA DECLARATION ON PATIENT SAFETY
WMA Declaration on Patient Safety
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Constituent members:
1. promote policies on patient safety to all
physicians in their countries;
2. encourage individual physicians, other
health care professionals, patients
and other relevant individuals and
organizations to work together to
establish systems that secure patient
safety;
3. encourage the development of effective
models to promote patient safety
through continuing medical education/
continuing professional development;
4. cooperate with one another and
exchange information about adverse
events, including errors, their solutions,
and “lessons learned” to improve patient
safety;
5. demand that the investigation of medical
error and patient safety incidents always
consider wider contextual and systemic
factors or pressures;
6. demand that healthcare providing
organisations foster a culture of learning,
support and improvement that facilitates
patient safety;
7. work to ensure that the regulation of
the medical profession encourages and
supports patient safety;
8. support regulation that works to prevent
medical error, promoting good practice
and learning among individuals and
organisations providing healthcare;
9. work to ensure healthcare environments
have the necessary resources,
infrastructure, and workforce to support
patient safety.
WMA Declaration on Patient Safety
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Adopted by the 57th WMA General
Assembly, Pilanesberg, South Africa,
October 2006, and revised by the 73rd
WMA General Assembly, Berlin, Germany,
October 2022
PREAMBLE
Assisted Reproductive Technology [ART]
encompasses a wide range of techniques
designed primarily to aid individuals unable
to conceive without medical assistance.
ART is defined as any fertility treatments in
which either gametes or embryos are handled.
Assisted reproductive technologies may raise
profound ethical and legal issues. Views and
beliefs on assisted reproductive technologies
vary both within and among countries and
are subject to different regulations in different
countries.
Central to much of the debate in this area are
issues around the moral status of the embryo,
the way in which ART is viewed morally,
societally and religiously, the child/ren born
from ART, and the rights of all participants
involved, i.e. donors, surrogates, the child/
ren and the intended parents are just some
of the issues central to the debate in ART.
Whilst consensus can be reached on some
issues, there remain fundamental differences
of opinion that are more difficult to resolve.
Assisted conception differs from the treatment
of illness in that the inability to become a
parent without medical intervention is not
always regarded as an illness.Notwithstanding,
the inability to conceive may also be as a result
of prior illness.
In many jurisdictions, the process of obtaining
consent must follow a process of information
giving and the offer of counselling and might
also include a formal assessment of the patient
in terms of the welfare of the potential child.
Faced with the progress of new technologies
of assisted reproduction, physicians should
keep in mind that not everything that is
technically feasible is ethically acceptable.
Genetic manipulation that does not have a
therapeutic purpose is not ethical, nor is the
manipulation on the embryo or foetus without
a clear and beneficial diagnostic or therapeutic
purpose.
RECOMMENDATIONS
1. Physicians involved in providing assisted
reproductive technologies should always
consider their ethical responsibilities
towards all parties involved in a
reproductive plan, which may include
the future child/ren, donor, surrogate or
parents. If there is compelling evidence
that a future child, donor, surrogate or
parent would be exposed to serious harm,
treatment should not be provided.
2. As with all other medical procedures,
physicians have an ethical obligation
to limit their practice to areas in which
they have relevant expertise, skill, and
experience and to respect the autonomy
and rights of patients.
3. In practice this means that informed
consent is required as with other medical
procedures; the validity of such consent
is dependent upon the adequacy of
the information offered to the patient
and their freedom to make a decision,
including freedom from coercion or
other pressures or influences to decide in
a particular way.
4. The consent process should include
providing the participant/s with
understandable, accurate and adequate
information about the following:
• the purpose, nature, procedure, and
benefits of the assisted reproductive
technology that will be used.
• the risks, burdens and limitations of the
assisted reproductive technology that will
be used.
• the success rates of the treatment and
possible alternatives, such as adoption.
• the availability of psychological support
for the duration of the treatment and, in
particular, if a treatment is unsuccessful.
• the measures protecting confidentiality,
privacy and autonomy, including data
security measures.
5. The following should be discussed
during the informed consent process:
• detailed medical risks;
• whether or not all biological samples
involved in ART, including but not
limited to donor eggs, sperm, gametes
and genetic information, may be used for
research purposes;
• the risks of multiple donations and
donating at multiple clinics;
• confidentiality and privacy issues;
• compensation issues.
6. Donors, surrogates and any resulting
child/ren seeking assisted reproductive
technologies are entitled to the same
level of confidentiality and privacy as for
any other medical treatment.
7. Assisted reproductive technology
involves handling and manipulation of
human gametes and embryos. There
are different levels of concern with the
handling of such material, yet there is
general agreement that such material
should be subject to specific safeguards
to protect from inappropriate, unethical,
or illegal use.
8. Physicians should uphold the principles
in the WMA Statement on Stem
Cell Research, WMA Statement on
Human Genome Editing, the WMA
Declaration of Helsinki, and the WMA
WMA STATEMENT ON ASSISTED
REPRODUCTIVE TECHNOLOGIES
WMA Statement on Assisted Reproductive Technologies
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Declaration of Reykjavik – Ethical
Considerations Regarding the Use of
Genetics in Health Care.
9. Physicians should, where appropriate,
provide ART in a non-discriminatory
manner. Physicians should not
withhold services based on nonclinical
considerations such as marital status.
Multiple pregnancies
10. Replacement of more than one embryo
will raise the likelihood of more than
one embryo implanting. This is offset by
the increased risk of premature labour
and other complications in multiple
pregnancies, which can endanger the
health of both the mother and child/ren.
Practitioners should follow professional
guidance on the maximum number of
embryos to be transferred per treatment
cycle.
11. If multiple pregnancies occur, selective
termination or fetus reduction will
only be considered on medical grounds
and with the consent of all participants
involved to increase the chances of the
pregnancy proceeding to term, provided
this is compatible with applicable laws
and codes of ethics.
Donation
12. Donation should follow counselling and
be carefully controlled to avoid abuses,
including coercion or undue influence
of potential donors. Explicit instructions
should be provided about what will be
done with any donated samples if the
donor is known to have died prior to
implantation.
13. The WMA holds the view that
gamete donation should at best
not be commodified, thus serving a
humanitarian benefit.
14. To ensure appropriate controls and limits
on methods used to encourage donations,
this must be done in a manner that
complies with national law and ethical
guidance. Physicians should advocate for
and contribute to such ethical guidance if
it does not exist.
15. Due to the widespread use of genetic
technology and registries, it has become
possible to identify donors, despite
clinics and donors’ attempts to maintain
strict confidentiality.A child/ren born as
a result of donation may in future contact
donors. Potential donors must be made
aware of this possibility as part of the
consent process.
16. Where a child is born following
donation, families should be encouraged
and supported to be open with the child
about this, irrespective of whether or
not domestic law entitles the child to
information about the donor. This may
require the development of supportive
materials, which should be produced to
a national normative standard.
Surrogacy
17. Where a woman is unable, for medical
reasons, to carry a child to term,
surrogate pregnancy may be used to
overcome childlessness unless prohibited
by national law or the ethical rules of the
National Medical Association or other
relevant organizations. Where surrogacy
is legally practiced, great care must be
taken to protect the interests of all parties
involved.
18. Prospective parents and surrogates should
receive independent and appropriate
legal counsel.
19. Medical tourism for surrogacy purposes
should be discouraged.
20. Commercial surrogacy should be
condemned. However, this must not
preclude compensating the surrogate
mother for necessary expenses.
21. The rights of surrogate mothers must be
upheld, and great care must be taken to
ensure that they are not exploited. The
rights of surrogate mothers include, but
are not limited to:
• having her autonomy respected;
• where appropriate, having health
insurance;
• being informed about any medical
procedure and the potential side effects;
• where possible, choosing her medical
team if side effects develop;
• having psychological help at any point
during the pregnancy;
• having medical expenses such as doctor
visits, the actual birthing process,
fertilization and any examinations related
to the surrogacy covered by the intended
parent/s;
• loss if income covered if unable to work
during the pregnancy;
• receiving the compensation and/or
reimbursements agreed to in any legal
agreement
Pre-implantation Genetic Diagnosis (PGD)
22. Pre-implantation genetic diagnosis
(PGD) and pre-implantation genetic
screening (PGS) may be performed on
early embryos to search for the presence
of genetic or chromosomal abnormalities,
especially those associated with severe
illness and very premature death, and
for other ethically acceptable reasons,
including identifying those embryos
most likely to implant successfully
in women who have had multiple
spontaneous abortions.
23. It is recommended to encourage
screening for infectious diseases in sperm
donors and to determine whether to
inform donors of positive tests.
24. Physicians must never be involved
WMA Statement on Assisted Reproductive Technologies
44
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with sex selection unless it is used to
avoid a serious sex-chromosome related
condition, such as Duchenne’s Muscular
Dystrophy.
Research
25. Physicians have an ethical duty to comply
with such regulation and to help inform
public debate and understanding of these
issues.
26. Research on human gametes and
embryos should be carefully controlled
and monitored and in accordance with
all applicable national laws and ethical
guidelines.
27. Views and legislation differ on whether
embryos may be created specifically for,
or in the course of, research. Physicians
should act in accordance with the
declarations of Taipei and Helsinki,
as well as all applicable local laws and
ethical and professional standards advice.
28. The principles of the Convention on
Human Rights and Biomedicine should
be followed.
WMA Statement on Assisted Reproductive Technologies
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Adopted by the 60th WMA General
Assembly, New Delhi, India, October 2009
and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
1. Digital health is a broad term that
refers to “the use of information
and communication technologies in
medicine and other health professions
to manage illnesses and health risks and
to promote wellness.” Digital health
encompasses electronic health (eHealth)
and developing areas such as the use of
advanced computer sciences (including
‘big data’, bioinformatics and artificial
intelligence). The term also includes
telehealth, telemedicine, and mobile
health (mHealth).
2. The term “digital health” may be
used interchangeably with “eHealth.”
These terms also include within
them: Telehealth” or “Telemedicine,”
which both utilize information and
communications technology to deliver
healthcare services and information at a
distance (large or small). They are used
for remote clinical services, including
real-time patient monitoring such as in
critical care settings. Also, they serve for
patient-physician consultation where
access is limited due to physicians’/
patients’ schedules or preferences, or
patient limitations such as physical
disability. Alternatively, they can be used
for consultation between two or more
physicians. The difference between the
two terms is that “Telehealth” refers
also to remote clinical and non-clinical
services: preventive health support,
research,training,andcontinuingmedical
education for health professionals.
3. Technological developments and the
increasing availability and affordability of
mobile devices have led to an exponential
increase in the number and variety of
digital health services in use in both
developed and developing countries.
Simultaneously, this relatively new and
rapidly evolving sector remains largely
unregulated, which could have potential
patient safety and ethical
4. The driving force behind digital health
should be improving quality of care,
patient safety and equity of access to
services otherwise unavailable.
5. Digital health differs from conventional
health care in the medium used, its
accessibility, and its effect on the patient-
physician relationship, as well as on the
traditional principles of patient care.
6. The development and application of
digital health has expanded access to
health care and health education in both
regular and emergency situations. At
the same time, its effect on the patient-
physician relationship, accountability,
patient safety, multistakeholder
interactions, privacy and data
confidentiality, fair access, and other
social and ethical principles should be
taken into consideration. However, the
scope and application of digital health,
telemedicine or telehealth are context-
dependent. Factors such as human
resources for health, size of service area
and level of healthcare facilities should
also be taken into consideration.
7. Physicians should be involved in the
development and implementation of
digital health solutions to be used in
health care, in order to ensure they
meet the needs of patients and health
professionals.
8. Consistent with the mandate of the
WMA, this statement is addressed
primarily to physicians and their role
in the health care setting. The WMA
encourages others who are involved in
healthcare to develop and adhere to
similar principles, as appropriate to their
role in the healthcare system.
Physician autonomy
9. Acceptable boundaries in the patient-
physician relationship necessary for the
provision of optimal care, should exist
in digital as well as physical practice.
The nearly continuous availability of
digital health care has the potential
to unduly interfere with a physician’s
work-life balance due to theoretical 24/7
availability. The physician should inform
patients about his or her availability and
recommend services when he or she is
not available.
10. Physicians should exercise their
professional autonomy in deciding
whether digital health consultation is
appropriate. This autonomy should
consider the type of visit scheduled, the
physician’s comfort with the medium,
and the physician’s assessment, together
with the patient, of the patient’s comfort
level with this type of care.
Patient-physician relationship
11. Face to face consultation should be
the gold standard where a physical
examination is required to establish a
diagnosis, or where there is a wish on
the part of the physician or patient
to communicate in person as part of
establishing a trusted physician-patient
relationship. Face to face consultations
may be preferable in some circumstances
to take stock of non-verbal cues, and
for consultations where there may be
communication barriers or discussion
of sensitive matters. Ideally, the patient-
physician relationship in the context
of digital health, should be based on a
previously established relationship and
sufficient knowledge of the patient’s
medical history.
12. However, in emergency and critical
situations, or in settings where access
to doctors is not available other than
via telemedicine, delivery of care via
WMA STATEMENT ON DIGITAL HEALTH
WMA Statement on Digital Health
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telemedicine should be prioritized
even when a prior patient-physician
relationship was not established.
Telemedicine can be employed when a
physician cannot be physically present
within a safe and acceptable period. It
can also be used to manage patients
remotely including self-management
and for chronic conditions or follow-up
after initial treatment, where it has been
proven to be safe and effective.
13. The physician providing telemedicine
services should be familiar with the
technology and/or should receive
sufficient resources, training and
orientation in effective digital
communication. Additionally, the
physician should strive to ensure that
quality of communication during a digital
health encounter is maximized. It is also
important that the patient is comfortable
using the technology employed. Any
significant technical deficiencies should
be noted in the documentation of the
consultation and reported, if applicable.
14. The patient-physician relationship
is based on mutual trust and respect.
Therefore, the physician and the patient
must identify each other reliably when
telemedicine is employed. However, it
must be recognized that sometimes third
parties or ‘surrogates’ such as a family
member should become involved in the
case of minors, the frail, the elderly, or in
an emergency situation.
15. The physician should give clear and
explicit direction to the patient during
the telemedicine encounter regarding
who has ongoing responsibility for any
required follow-up and ongoing health
care.
16. In a digital consultation between two or
more professionals,the primary physician
remains responsible for the patient’s care
and coordination. The primary physician
remains responsible for protocols,
conferencing, and medical record
review in all settings and circumstances.
Physicians providing consultation
should be able to contact other health
professionals and technicians, as well as
patients, in a timely manner.
Informed consent
17. Proper informed consent requires that the
patient be informed of, have capacity for,
and provide consent specific to the type
of digital health being used.All necessary
information regarding the distinctive
features of digital health, in general,
and telemedicine, in particular, must be
explained fully to patients including, but
not limited to: how telemedicine works,
how to schedule appointments, privacy
concerns, the possibility of technological
failure, including confidentiality
breaches; possible secondary use of data;
protocols for contact during virtual visits,
prescribing policies and coordinating
care with other health professionals. This
information should be provided clearly
and understandably without coercion or
undue influence of the patient’s voluntary
choices, while taking into account the
patient’s perceived level of health literacy
and other resource limitations specific to
the type of digital health being used.
Quality of care
18. The physician must ensure the standard
of care delivered via digital health is at
least equivalent to any other type of care
given to the patient, considering the
specific context, location and timing, and
relative availability of face to face care. If
the standard of care cannot be satisfied
via digital technology, the physician
should inform the patient and suggest an
alternative form of healthcare delivery.
19. The physician should have clear and
transparent protocols for delivering
digital health care such as clinical
practice guidelines, whenever possible,
to guide the delivery of care in the
digital setting, recognizing that certain
modifications may need to be made to
accommodate specific circumstances.
Changes to clinical practice guidelines
for the digital setting should be approved
by the appropriate governing and/or
regulatory body or association. If the
digital health solution is equipped with
automated clinical practice support, this
support must be strictly professionally
based and not influenced by economic
interests in any way.
20. The physician providing digital
services should follow all regulatory
requirements and relevant protocols and
procedures related to informed consent
(verbal, written, and recorded); privacy
and confidentiality; documentation;
ownership of patient records; and
appropriate video/telephone behaviors.
21. The physician providing care by means
of telehealth should keep a clear and
detailed record of the advice delivered,
the information on which the advice was
based and the patient’s informed consent.
22. The physician should be aware of and
respect the particular challenges and
uncertainties that may arise when
in contact with the patient through
telecommunication. The physician must
be prepared to recommend direct patient-
physician contact whenever possible if
he/she believes it is in the patient’s best
interests or will improve compliance.
23. The possibilities and weaknesses of
digital health in emergencies must be
duly identified. If it is necessary to
use telemedicine in an emergency, the
advice and treatment suggestions will be
influenced by the severity of the patient’s
medical condition and the patient’s
technological and health literacy. To
ensure patient safety, entities that deliver
telemedicine services should establish
protocols for referrals in emergency
situations.
Clinical Outcomes
24. Entitiesprovidingdigitalhealthprograms
should monitor and continuously strive
to improve the quality of services to
achieve the best possible outcomes.
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25. Entities providing digital health
programs should have a systematic
protocol for collecting, evaluating,
monitoring and reporting meaningful
health care outcomes, safety data and
clinical effectiveness. Quality indicators
should be identified and utilized. Like
all health care interventions, digital
technology must be tested for its
effectiveness, efficiency, safety, feasibility,
and cost-effectiveness. Quality assurance
and improvement data should be shared
to improve its equitable use.
26. Entities implementing digital health are
urged to report unintended consequences
to help improve patient safety and further
the overall development of the field.
Countries are encouraged to implement
these guiding principles in their own
legislation and regulation.
Equity of care
27. 27. Although digital health can provide
greater access to distant and underserved
populations, it may also exacerbate
existing inequalities due to, among
other things, age, race, socioeconomic
status, cultural factors, or literacy issues.
Physicians must be aware that certain
digital technologies might be unavailable
or unaffordable to patients, impeding
access and further widening the health
outcomes gaps.
28. Digital technologies should be
implemented and monitored carefully
to avoid inequity of access to these
technologies. Where appropriate,
social or healthcare services should
facilitate access to technologies as part
of basic benefit packages while taking
all necessary precautions to guarantee
data security and privacy. Access to vital
technologies should not be denied to
anyone based on financial status or a lack
of technical expertise.
Confidentiality and data security
29. In order to ensure data confidentiality,
officially recognized data protection
measures must be used. Data obtained
during a digital consultation must be
secured to avoid unauthorized access
and breaches of identifiable patient
information through appropriate and up-
to-date security and privacy measures. If
data breaches do occur, the patient must
be notified immediately in accordance
with the law.
30. Digital health technologies generally
involve the measurement or manual
input of medical, physiological, lifestyle,
activity, and environmental data to fulfill
their primary purpose.The large amount
of data generated also may be used for
research or other purposes to improve
healthcare and disease prevention.
However, secondary uses of personal
mHealth data can result in misuse and
abuse.
31. Robust policies and safeguards to
regulate and secure the collection,storage,
protection, and processing of digital
health users’ data, especially personal
health data, must be implemented
to assure valid informed consent and
guarantee patients’ rights.
32. If patients believe that their privacy
rights have been violated, they may file
a complaint with the covered entity’s
Privacy Officer or data protection
authorities, in accordance with local
regulations.
Legal principles
33. A clear legal framework must be drawn up
to address potential liability arising from
the use of digital technologies.Physicians
should only practice telemedicine in
countries/jurisdictions where they are
licensed to practice and should adhere
to the legal framework and regulations
as defined by the country/jurisdiction
where the physician originates care and
the countries in which they practice.
Physicians should ensure that their
medical indemnity includes telemedicine
and digital health coverage.
34. Reimbursement models must be set up
in consultation with national medical
associations and healthcare providers to
ensure that physicians receive appropriate
reimbursement for providing digital
health services.
Specific principles of mHealth technology
35. Mobile health (mHealth) is a form of
electronic health (eHealth) for which
there is no fixed definition. It has
been described as medical and public
health practice supported by mobile
devices, such as mobile phones, patient
monitoring devices, personal digital
assistants (PDAs), and other devices
intended to be used in connection
with mobile devices. It includes voice
and short messaging services (SMS),
applications (apps), and the use of the
global positioning system (GPS).
36. A clear distinction must be made
between mHealth technologies used for
lifestyle purposes and those that require
physicians’ medical expertise and meet
the definition of medical devices. The
latter must be appropriately regulated,
and users must be able to verify the source
of medical information provided,as these
applicationscouldpotentiallyrecommend
non-scientific or non-evidence-based
treatments. The information provided
must be comprehensive, clear, reliable,
non-technical, and easily understood by
laypeople.
37. Concerted work must improve the
interoperability, reliability, functionality,
and safety of mHealth technologies, e.g.,
through the development of standards
and certification schemes.
38. Comprehensive and independent
evaluations must be carried out
regularly by competent authorities
with appropriate medical expertise to
assess the functionality, limitations,
data integrity, security, and privacy of
mHealth technologies. This information
must be made publicly available.
WMA Statement on Digital Health
48
BACK TO CONTENTS
39. mHealth can only positively contribute
to improvements in care if services
are based on sound medical rationale.
As evidence of clinical usefulness is
developed, findings should be published
in peer-reviewed journals and be
reproducible.
RECOMMENDATIONS
1. The WMA recognizes the value of
digital health to supplement traditional
ways of managing health and delivering
healthcare. The driving force behind
digital health should be improving
quality of care and equity of access to
services otherwise unavailable.
2. The WMA emphasizes that the
principles of medical ethics, as outlined
in The Declaration of Geneva: The
Physician’s Pledge and the International
Code of Medical Ethics, must be
respected in the practice of all forms of
digital health.
3. The WMA recommends that the
training of digital health literacy and skills
be included in medical education and
continuing professional development.
4. The WMA urges patients and physicians
to be discerning in their use of digital
health and to be mindful of potential
risks and implications.
5. The WMA recommends further
research in digital health to assess safety,
efficacy, cost-effectiveness, feasibility of
implementation, and patient outcomes.
6. The WMA recommends monitoring
the risks of excessive or inappropriate
use of digital health technologies and
the potential psychological impact on
patients and ensuring that the benefits
of such technologies outweigh the risks.
7. The WMA recommends special
attention be given to patients’ disabilities
(audio-visual or physical) and patients
who are minors, when using digital
healthcare.
8. Where appropriate, National Medical
Associations should encourage the
development and update of ethical
norms, practice guidelines, national
legislation, and international agreements
on digital health.
9. The WMA recommends that other
regulatory bodies, professional societies,
organizations, institutions, and private
industry, monitor the proper use of
digital health technologies and share
these findings widely.
WMA Statement on Digital Health
49
BACK TO CONTENTS
Adopted by the 40th World Medical
Assembly, Vienna, Austria, September 1988
Revised by the 49th WMA General
Assembly, Hamburg, Germany, November
1997, the 58th WMA General Assembly,
Copenhagen, Denmark, October 2007,
the 62nd WMA General Assembly,
Montevideo, Uruguay, October 2011 and
the 73rd WMA General Assembly, Berlin,
Germany, October 2022
PREAMBLE
Over 80 percent of the world’s 1.3 billion
smokers live in low- and middle-income
countries. Smoking and other forms of
tobacco use adversely affect every organ system
in the body, and are major causes of cancer,
heart disease, stroke, chronic obstructive
pulmonary disease, fetal damage, and many
other conditions. Smokers have up to a 50%
higher risk of developing severe disease and
death from COVID-19. Eight million deaths
occur worldwide each year due to tobacco and
tobacco- derived products. Tobacco will kill
one billion people in the 21st century unless
effective interventions are implemented.
Exposure to secondhand smoke occurs
anywhere the burning of tobacco products
occurs in enclosed spaces. There is no safe
exposure level to secondhand smoke, which
causes millions of deaths each year. It is
especially damaging to children and pregnant
patients. On May 29, 2007, the WHO
called for a global ban on smoking at work
and in enclosed public places to eliminate
secondhand smoke and encourage people to
quit.
The phenomenon known as “thirdhand
smoke” occurs when nicotine and other
chemical residues occur on indoor surfaces
from smoking, which can persist long after
the smoke itself has cleared. It is increasingly
recognized as a potential danger, especially to
children, who not only inhale fumes released
by these residues but also ingest residues that
get on their hands after crawling on floors or
touching walls and furniture.
World Health Organization Action
With the hope of mitigating the effects of
tobacco use, the World Health Organization
(WHO) Member States unanimously
adopted the WHO Framework Convention
on Tobacco Control (WHO FCTC) in
2003. In force since 2005, it currently has 182
parties covering more than 90 percent of the
world’s population. Further strengthening
implementation of the milestone treaty is
specifically included in the 2030 Agenda for
Sustainable Development Goals (SDG) as
Target 3.a. The WMA has long supported
the WHO FCTC (see WMA Resolution on
Implementation of the WHO Framework
Convention on Tobacco Control). The
Protocol to Eliminate Illicit Trade in Tobacco
Products, the first protocol to the WHO
FCTC,was adopted in 2012 in response to the
growing international illicit trade in tobacco
products. The objective of the Protocol is
the elimination of all forms of illicit trade
in tobacco products, in accordance with the
terms of Article 15 of the WHO FCTC.
New and Emerging Nicotine Products
The WMA Statement on Electronic
Cigarettes and Other Electronic Nicotine
Delivery Systems outlines the still-unknown
risks associated with these products. The
use of e-cigarettes by young people has risen
dramatically, and in some regions is more
popular than tobacco smoking. Nicotine
exposure, no matter how it is delivered, can
affect brain development and lead to addiction.
New and rediscovered forms of tobacco
and nicotine ingestion are also emerging,
including:
• dissolvable tobacco, from sweet, candy-
like lozenges that contain tobacco and
nicotine that are held in the mouth,
chewed, or sucked until they dissolve;
• snus, a finely ground form of moist snuff
that that contains carcinogens and is
usually packaged in small pouches;
• hookahs, a water pipe that burns tobacco
mixed with flavors such as honey,
molasses or fruit, where the smoke is
inhaled through a long hose. The WHO
reports that one hookah smoking session
is the same as smoking 100 cigarettes,
largely due to the length of time a user
smokes;
• bidis, flavored cigarettes that are
unfiltered and deliver up to five times
more nicotine than regular cigarettes,and
clove cigarettes (also called Kreteks) also
deliver more nicotine, carbon monoxide,
and tar than regular cigarettes;
• other heated tobacco products that
typically use an electronic heating
element to heat specially designed sticks,
plugs, or capsules containing tobacco.
The heat releases nicotine (and other
chemicals) that can then be inhaled into
the lungs, but the tobacco does not get
hot enough to burn. These devices are
not the same as e-cigarettes, and
• nicotine pouches,tobacco free pouches of
nicotine with different flavors which are
placed in the mouth.
Pregnant Patients and Children
Smoking or using nicotine during pregnancy
is linked with a range of poor birth outcomes
including low birth weight and preterm birth,
restricted head growth, placental problems,
increased risk of still birth and increased risk
of miscarriage. Breathing secondhand smoke
during pregnancy also increases the risk of
having a low-birth-weight baby, and babies
who are exposed to secondhand smoke have
WMA STATEMENT ON HEALTH
HAZARDS OF TOBACCO PRODUCTS
AND TOBACCO-DERIVED PRODUCTS
WMA Statement on Health Hazards of Tobacco Products and Tobacco-Derived Products
50
BACK TO CONTENTS
an increased risk of Sudden Infant Death
Syndrome.
Health and developmental consequences
among children have also been linked to
prenatalsmokeexposure,includingpoorerlung
function, (including coughs, colds, bronchitis
and pneumonia), persistent wheezing, asthma
and visual difficulties such as strabismus,
refractive errors and retinopathy. Children
who breathe more secondhand smoke have
more ear infections, coughs, colds, bronchitis
and pneumonia. Children who grow up with
parents who smoke are themselves more likely
to smoke and to have long term health effects
similar to adults who smoke.
Health Equity
Health equity in tobacco prevention and
control focuses on the opportunity for all
people to live a healthy life, regardless of their
race, level of education, gender identity, sexual
orientation, occupation, geographic location,
or disability status.Tobacco control programs,
including evidence-based cessation services,
can work toward health equity by focusing
efforts on decreasing the prevalence of
tobacco use, and second-hand and thirdhand
smoke exposure, and by improving access to
tobacco control resources, among populations
experiencing greater tobacco-related health
and economic burdens.
Tobacco Industry Marketing
The tobacco industry spends billions
of dollars annually around the globe on
advertising, promotion and sponsorship. The
tobacco industry’s manipulative and predatory
marketing tactics increase consumption of its
products and replace smokers who quit or die.
By investing huge sums of money in low- and
middle-income countries, the industry hopes
to increase the social acceptability of tobacco
and tobacco companies. The tobacco industry
has also long employed strategies targeting
children, from developing special packaging
or candy-flavored cigarettes and e-cigarette
cartridges, and has used the internet, text
messaging and youth-oriented social
networking sites to advertise sponsored events
or promotions.
The best strategy to combat the tobacco
industry’s marketing tactics is to adopt and
enforce comprehensive bans on tobacco
advertising, promotion and sponsorship, as set
forth in the WHO FCTC.
The tobacco industry claims that it is
committed to determining the scientific truth
about the health effects of tobacco, both by
conducting internal research and by funding
external research through jointly funded
industry programs. However, the industry has
consistently denied, withheld, and suppressed
information concerning the deleterious effects
of tobacco smoking.
Tobacco companies also manipulate the
public’s attitude about their reputation and
have often engaged in so-called ‘corporate
social responsibility’, which are activities to
promote their products while portraying
themselves as good corporate citizens.
RECOMMENDATIONS
The WMA recommends that national
governments:
1. Increase taxation of tobacco and tobacco-
derived products, which is the single
most effective tobacco control measure
to reduce tobacco use according to the
World Health Organization (WHO).
Taxation is also a highly cost-effective
and inexpensive tool. Increased revenues
should be used for prevention programs,
evidence-based cessation programs and
services, and other health care measures.
2. Urge the WHO to add tobacco cessation
medications with established efficacy
to the WHO’s Model List of Essential
Medicines.
3. Ratify and fully implement the WHO
Framework Convention on Tobacco
Control.
4. Implement comprehensive regulation
of the manufacture, sale, distribution,
and promotion of tobacco and tobacco-
derived products, including total bans
on tobacco advertising, promotion and
partnership, including abroad. Require
plain packaging of tobacco products
(as set forth in the WMA Resolution
on Plain Packaging of Cigarettes,
e-Cigarettes and Other Smoking
Products), and packaging that includes
prominent written and pictorial warnings
about health hazards of tobacco.
5. Prohibit smoking in all enclosed public
places, including public transportation,
prisons, airports and on airplanes.
Require all medical schools, biomedical
research institutions, hospitals, and other
health care facilities to prohibit smoking,
and the use of smokeless tobacco and
other tobacco-derived products on their
premises.
6. Prohibit the sale, distribution, and
accessibility of cigarettes and other
tobacco products to children and
adolescents. Ban the production,
distribution and sale of candy products
that depict or resemble tobacco products.
7. Prohibit all government subsidies for
tobacco and tobacco-derived products
and assist tobacco farmers in switching
to alternative crops. Exclude tobacco
products from international trade
agreements, and work to curtail or
eliminate illegal trade in tobacco and
tobacco-derived products and the sale of
smuggled tobacco products.
8. Provide for research into the prevalence
of tobacco use and the effects of tobacco
and tobacco-derived products on the
health status of the population.
The WMA recommends that national medical
associations:
9. Refuse funding or educational materials
from the tobacco industry, and urge
medical schools, research institutions,
and individual researchers to do the same.
10. Adopt policies opposing smoking and
the use of tobacco and tobacco-derived
products and publicize the policy.
Endorse or promote clinical practice
WMA Statement on Health Hazards of Tobacco Products and Tobacco-Derived Products
51
guidelines on the treatment of tobacco
use and dependence.
11. Prohibit smoking, including use of
smokeless tobacco and vaping, in
national medical association premises
and at all business, social, scientific, and
ceremonial meetings of national medical
associations, in line with the decision
of the World Medical Association to
impose a similar ban.
12. Develop, support, and participate in
programs to educate the profession and
the public about the health hazards of
tobacco use (including addiction) and
exposure to secondhand smoke.
13. Introduce or strengthen educational
programs for medical students and
physicians to prepare them to identify
and treat tobacco dependence in their
patients.
14. Speak out against the shift in focus of
tobacco marketing from developed to
less developed nations, from adults to
youth, and urge national governments to
do the same.
15. End investment in companies or firms
producing or promoting the use or sale
of tobacco or tobacco-derived products.
Divest current assets that support
tobacco production or promotion.
The WMA recommends that physicians:
16. Be positive role models by not using
tobacco or tobacco-derived products, and
by acting as spokespersons to educate
and raise the awareness of the public
about the deleterious health effects of
tobacco use and the benefits of tobacco-
use cessation.
17. Support widespread access to evidence-
based treatment for tobacco dependence
through individual patient encounters,
counseling, pharmacotherapy, cessation
classes, telephone quit-lines, web-based
cessation services, and other appropriate
means.
18. Recognize that tobacco and second-hand
smoke exposure to adult tobacco use
cause harm to children. Special efforts
should be made by physicians to:
• promote tobacco-free environments for
children
• target parents and pregnant patients who
smoke for tobacco cessation interventions
• promote programs that contribute to the
prevention and decreased use of tobacco
and tobacco-derived products by youth
• support policies that control access to
and marketing of tobacco and tobacco-
derived products and make pediatric
tobacco-control research a higher
priority.
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WMA Statement on Health Hazards of Tobacco Products and Tobacco-Derived Products
52
Adopted by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
The interaction between the physicians
and their relatives seeking medical care
can be complex. Moreover, this possibility
is highly conditioned by cultural aspects.
Interaction can start with asking for simple
advice, consultation for minor ailments, and
general questions about healthcare and health
promotion. This can escalate to seeking
medical care and even surgery. Physicians
are often their relatives’ first point of call for
medical and emotional support. Physicians
may be able to offer immediate care in
cases of emergency and contribute to welal-
informed, evidence-based self-care. Other
than in emergencies, offering general health
information or for minor health problems,
physicians should avoid treating those close
to them.
The ethical principles governing the work of
physicians are equally important and valid
when treating relatives. Respect for autonomy
may be compromised by lack of privacy,
unintentional breaches of confidentiality,
and failure to seek informed consent. The
relationship with the physician might
compromise the patient’s ability to make
independent decisions.
Treating relatives may pose challenges in the
following circumstances:
• when objectivity is compromised and
decisively affected by emotional factors,
there could be a risk of either under- or
over-treating relatives or of encountering
problems that are beyond the physician’s
expertise or abilities, which could cause
serious harms.
• when there are potential barriers to
considering sensitive medical history
and/or conducting an appropriate
physical examination, which may result
in incorrect medical diagnosis and
treatment.
• when the physician fails to fulfil
requirements concerning patient clinical
records, which may result in difficulties
if the related patient needs follow-up
treatment or when liability issues arise.
• when a negative medical outcome could
compromise the relationship between the
physician and the related patient.
• when the treatment is not in the best
interest or against the will of the related
patient.
• when the physician risks providing
relatives, perhaps unintentionally and
unconsciously, with undue advantages.
RECOMMENDATIONS
1. Physicians should avoid routinely acting
as a relative’s primary care physician or
serving as the attending physician when
treating a potentially life-threatening
condition. Physicians may provide care
to a relative in emergencies, for minor
health problems or when there is no
other qualified physician available.
2. Related patients may ask for a second
opinion about another physician’s care. If
a second opinion is shared, it should be
consistent with these recommendations
and fulfil the duties of physicians to
colleagues. Care should be taken to only
discuss the treatment, which is most
appropriate and recommended, rather
than any judgements about the other
treating physician’s care and advice.
3. If a physician treats a relative, the
physician should be mindful of the
following:
• strict respect for medical ethics, the
patient’s autonomy and consent, with
special consideration for minors.
• the physician has the duty to respect
a patient’s right to confidentiality and
should not share information with
anyone else without a lawful basis,
including other family members, with
the exception of necessary clinical
documentation when referring to other
health care personnel.
• if a relative indicates an intention to
seek a second opinion about another
physician’s care, that intention must be
respected.
• consent for treatment must be given by
the patient, including competent minors,
and for that consent to be valid, it must
be fully informed.
• depending on the nature of the
relationship,taking a sensitive history and
performing a physical examination may
be emotionally difficult or uncomfortable
for the patient or the physician. In such
situations the physician and the patient
should consider consulting another
physician.
• clear and concise patient records must be
maintained at all times.
4. If the physician cannot accommodate the
recommendations above, the physician
should avoid treating relatives.
5. While physicians are encouraged not
to treat relatives except in certain
circumstances, it is acknowledged that
physicians are often approached by their
relatives for medical advice or treatment,
and their help is frequently beneficial and
appreciated.
6. In all circumstances, physicians shall
maintain the highest professional and
ethical standards, in accordance with
the Declaration of Geneva, the WMA
International Code of Medical Ethics,
and the WMA Declaration of Lisbon on
the Rights of the Patient.
WMA STATEMENT ON PHYSICIANS
TREATING RELATIVES
WMA Statement on Physicians Treating Relatives
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53
Adopted by the 62nd WMA General
Assembly, Montevideo, Uruguay, October
2011 and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Social media is a collective term for the
different interactive platforms, websites and
applications intended for digital networking,
that allow individuals and organizations
to create and share user-generated content
digitally.
The objectives of this policy are to:
• examine the professional and ethical
challenges related to the increasing usage
of social media by physicians, medical
students, and patients.
• establish a framework that protects their
respective interests.
• ensure trust and reputation by
maintaining high professional and
ethical standards.
• promote the availability of quality
information across social media.
• stand against misinformation and
disinformation on social media.
The use of social media has become a fact of
life for billions of people worldwide including
physicians, medical students, and patients.
Interactive, collaborative tools such as wikis,
social networking platforms, chat applications
and blogs have transformed passive Internet
users into active participants. These tools are
meansforgathering,sharinganddisseminating
information, including healthcare and science
information, socializing and connecting with
friends, relatives, professionals etc. They can
be used to seek medical advice, and patients
share their health and healthcare experiences.
They can also be used in research, public
health, and education.
The positive aspects of social media should
be recognized such as in promoting a healthy
lifestyle, the dissemination of medical
knowledge to society and in reducing patients’
isolation.
Areas, which may require special attention
include:
• sensitive content, photographs, videos,
other personal materials posted on online
social forums often exist in the public
domain and have the capacity to remain
on the internet permanently. Individuals
may not have control over the ultimate
distribution of material they post on-line.
• patient portal, blogs and tweets are not
a substitute for one on one consultation
with physicians but may widen
engagement with health services amongst
certain groups. Online “friendships”
with patients may also alter the patient-
physician relationship, and may result
in unnecessary, possibly problematic
physician and patient self-disclosure.
• each party’s privacy may be compromised
intheabsenceofadequateandconservative
privacy settings or by their inappropriate
use. Privacy settings are not absolute;
social media sites may change default
privacy settings unilaterally, without the
user’s knowledge. Social media sites may
also make communications available to
third parties.
• misinformation and disinfor­
mation
often spread more rapidly through
social media than fact-based accurate
information. It may cause harm to the
health of individuals as well as to public
health and foster doubt and distrust
towards professionals seeking to promote
truth and science-based evidence.
• appropriate disclaimers to include in
biographical information (e.g., “my
opinions are my own”, “posts are not
personalized medical advice”, etc).
The dissemination of medical knowledge,
best practices and treatment options on
social media can increase and expedite
access to new and valid information among
medical professionals. However, individuals
or companies can take advantage of these
channels in misleading ways, including to
market or promote their medical products or
treatments.
RECOMMENDATIONS
The WMA urges National Medical
Associations (NMA) to establish social media
guidelines for their members addressing the
following objectives:
1. To maintain appropriate boundaries
of the patient-physician relationship
in accordance with professional ethical
guidelines just as they would in any other
context.
2. To ensure that no identifiable patient
information is posted in any social
media by their physician, by increasing
the understanding of privacy provisions
of social networking sites and their
limitations while considering intended
audience and the technical feasibility
to restrict access to the content to
predefined individuals or groups.
3. To exercise care when using applications
that might compromise the security of
the data, including when consulting with
colleagues.
4. To promote and apply the principles in
the WMA Guidelines on Promotional
Mass Media Appearances by Physicians
to all social media activities by physicians.
5. To encourage physicians to routinely
monitor their own Internet presence to
ensure that the personal and professional
information on their own sites and,
to the extent possible, content posted
about them by others is accurate and
appropriate.
WMA STATEMENT ON THE PROFESSIONAL AND
ETHICAL USE OF SOCIAL MEDIA
WMA Statement on The Professional and Ethical Use of Social Media
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54
WMA Statement on The Professional and Ethical Use of Social Media
6. To prevent the use of technological
devices from diverting our attention
during direct consultation with the
patient.
7. To provide factual, concise,
understandable information, declare any
conflicts of interest and adopt a sober tone
when discussing professional matters.
8. To avoid inappropriate use of the
networks, frivolous, insensitive attitudes
or light-hearted opinions on medical
matters.
9. To draw the attention of physicians to
the fact that social media content posted
by health professionals may contribute to
the public perception of the profession
and should be done in accordance with
the principles in the WMA Declaration
of Geneva and the International Code of
Medical Ethics.
10. To include education on the use of
social media in medical curricula and
continuing medical education.
11. To behave in the media and on social
networks with the same scientific
rigor and the same approach as in a
consultation and show the same respect
to patients and colleagues.
12. To create mechanisms for accountability
in professional settings when
inappropriate behavior on social media is
observed and reported.
13. To promote health literacy and knowledge
among populations and with individual
patients by using objective and evidence
based messages in accordance with the
principles in the WMA Declaration
of Geneva, the WMA International
Code of Medical Ethics, and the WMA
Statement on Healthcare Information
for All.
14. To combat misinformation,
disinformation, and the promotion of
pseudoscience and pseudotherapy on
social media, all of which can result in
negative health outcomes for patients and
communities.
15. To counsel fellow physicians who engage
in misinformation, disinformation, or
violation of patient trust on social media
and/or report to relevant authorities for
ongoing deliberate acts of the same.
16. To raise awareness among physicians and
medical students about the possibility
that information shared on social media
could be used in misleading ways by
individuals or companies.
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55
Adopted by the 62nd WMA General
Assembly, Montevideo, Uruguay, October
2011 and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Chronic non-communicable diseases
(NCDs), are the leading cause of mortality
and disability in both the developed and
developing world. The four main NCDs
are cancers, cardiovascular diseases, chronic
respiratory diseases, and diabetes (referred
to as NCD4 hereafter) and they account for
seven of every ten deaths worldwide. Eighty
per cent of deaths due to NCDs occur in low-
and middle-income countries (WHO).
NCD4 are not replacing existing causes
of disease and disability, such as infectious
disease and trauma, but are adding to the
disease burden. While all countries face the
triple burden of infectious diseases, traumas
and chronic diseases,it is a much more difficult
challenge for developing countries. This
increased burden is straining the capacity of
many countries to provide adequate healthcare
services as well as increase life expectancy.
Chronic diseases are not equally distributed,
which has a significant effect on health
inequalities. For example, NCDs occur
more frequently among socioeconomically
underprivileged individuals with inferior
chronic disease outcomes. Conversely, life
expectancy and other health outcomes are
markedly higher in more developed countries
than in less developed countries, and in the
higher socio-economic segments of society.
In addition, this burden is also undermining
nations’ efforts to spur economic growth.
NCDs are a barrier to development. In low-
and middle-income countries (LMICs),
poverty exposes people to lifestyle-mediated
risk factors for NCDs and in turn, resulting
NCDs become an important driver for
poverty. Chronic diseases and poverty are
linked in a vicious circle, hindering economic
development and worsening poverty.
Ongoing and anticipated global trends that
will lead to more chronic disease problems
in the future include an aging population,
urbanization and inadequate community
planning, increasingly sedentary lifestyles,
increasing psychosocial stress, climate change
and the rapidly increasing cost of medical
technology to treat NCDs. Chronic disease
prevalence is closely linked to global social
and economic development, globalization and
mass marketing of unhealthy foods and other
products.
The prevalence and cost of addressing the
chronic disease burden is expected to rise in
coming years. In addition to the individual
and public expenses, chronic diseases lead
to a marked economic burden because of
the mutual effects of healthcare costs and
lost productivity from disability and death.
The WHO considers the global burden of
chronic diseases as one of the most important
challenges facing the field of health for this
century.
The rapid increase in chronic diseases
represents a major health challenge for global
development, for which immediate global
action is needed.
Eighty percent of the global burden of
chronic diseases affects LMICs, where most
of the world’s population lives. The impact
of this devastating burden is constantly
growing. Chronic diseases and poverty are
linked in a vicious circle, hindering economic
development and worsening poverty.
Solutions
The NCD4 merit global attention. The
primary solution for these diseases is
prevention. Tobacco use, poor diet, physical
inactivity and alcohol abuse are the four most
common modifiable risk factors for NCDs.
Poor mental health has recently been included
as an additional risk factor for NCD. National
policies that help people achieve healthy
lifestyles and behaviours are the foundation
for all possible solutions.
Increased access to primary care combined
with well-designed and affordable disease-
control, disease prevention and health
promotion programs can greatly improve
healthcare. Partnerships of national ministries
of health with institutions in developed
countries may overcome many barriers in
the poorest settings. In addition, having
health insurance improves health outcomes.
Conversely, in some countries the lack of
health insurance hinders the practice of
preventive and primary care and is linked
with adverse health outcomes. Uninsured
individuals may postpone pursuing assistance
when ill or injured, and they are more likely
to be hospitalized for chronic illnesses such
as diabetes or hypertension. Furthermore,
children without health insurance are less
likely to receive immunizations, and regular
primary care.
Medical education systems should become
more socially accountable. The World
Health Organization (WHO) defines social
accountability of medical schools as the
obligation to direct their education, research
and service activities towards addressing the
priority health concerns of the community,
region, or nation they have a mandate to
serve. The priority health concerns are to
be identified jointly by governments, health
care organizations, health professionals and
the public. There is an urgent need to adopt
accreditation standards and norms that
support social accountability and community
engagement. Educating physicians and other
health care professionals to deliver health
care that is concordant with the needs of the
population and the resources of the country
must be a primary consideration. Led by
primary care physicians, teams of physicians,
nurses and community health workers will
provide care that is driven by the principles of
quality, equity, relevance and effectiveness.
Distributions of funds for health should be
based on all individual nation needs.No nation
can accomplish positive NCD4 outcomes by
tackling a single cause of death.
WMA STATEMENT ON THE GLOBAL BURDEN
OF CHRONIC NON-COMMUNICABLE DISEASE
WMA Statement on the Global Burden of Chronic Non-Communicable Disease
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56
Strengthening the healthcare infrastructure,
including training the primary healthcare
team, chronic disease surveillance, public
health promotion campaigns, quality
assurance and establishment of national and
local standards of care, is important in caring
for the increasing numbers of patients with
NCD4. Most premature deaths due to NCDs
are preventable; however, in most developing
countries health systems are inadequate, or
unprepared to appropriately act on NCDs.
One of the most important components of
healthcare infrastructure is human resources;
well-trained and motivated health care
professionals led by primary care physicians
are crucial to success. International aid and
development programs need to move from
“vertical focus” on single diseases or objectives
to a more sustainable and effective primary
care health infrastructure development.
RECOMMENDATIONS
Recalling its Statement on Hypertension and
Cardiovascular Disease and its Declaration
of Oslo on Social Determinants of Health,
the WMA calls on:
National Governments to:
1. Recognize the importance of socio-
economic development for health and
reduce socioeconomic status disparities
in income, education, and occupation;
2. Support global immunization strategies;
3. Support global tobacco and alcohol
control strategies, as well as control
strategies addressing other forms of
addiction, particularly drug use;
4. Promote healthy living and implement
comprehensive, collaborative policies
and strategies at all relevant levels and
divisions of government that support
prevention and healthy lifestyle
behaviours;
5. Setasideafixedpercentageofthenational
budget for healthcare infrastructure
development and promotion of healthy
lifestyles and invest in better management
of NCDs4 including detection, care and
treatment;
6. Advocate for trade / commercial
agreements that protect rather than
undermine public health;
7. Develop and execute global and national
action strategies for mitigating the health
effects of climate change;
8. Promote research for prevention and
treatment of NCDs, including research
on occupational health hazards leading
to chronic diseases;
9. Promote access to good quality effective
medicines to treat NCDs;
10. Develop monitoring and surveillance
systems for NCDs and,
11. Reinforce primary health care, human
resources and infrastructure.
Its Constituent Members to:
12. Increase physician, public and NGO
awareness of optimal disease prevention
behaviours;
13. Enhance skills and capacity to promote
a team-based multidisciplinary approach
to chronic disease management;
14. Advocate for integration of NCD
prevention and control strategies in
government-wide policies;
15. Promote high quality training and
professional associations for more
primary care physicians and advocate for
their equitable distribution;
16. Advocate for high quality readily
accessible resources for continuing
medical education that is responsive to
societal needs;
17. Support establishing evidence-based
standards of care for NCDs;
18. Promote an environment of support for
continuity of care for NCDs, including
collaborative efforts to encourage patient
education and self-management;
19. Support strong public health
infrastructure and,
20. Recognize and support the concept
that addressing and acting on social
determinants are part of prevention and
health care.
Medical Schools to:
21. Develop curriculum objectives that meet
current societal needs;
22. Create primary care departments;
23. Provide community-oriented and
community-based primary care training
opportunities in primary care specialties
that allow students to become acquainted
with the basic elements of chronic care
infrastructure and continuity of care;
24. Promote the use of
interdisciplinary, interprofessional,
intersectoral and other collaborative
training methodologies within primary and
continuing education programs and,
25. Include instruction in chronic disease
prevention, including nutrition and
lifestyle promotion counselling, in the
general curriculum.
Individual Physicians to:
26. Work to create communities that
promote healthy lifestyles and prevention
behaviours;
27. Offer patients smoking cessation,
weight control strategies, substance
abuse counselling, early screening, self-
management education and support,
nutritional counselling, and ongoing
coaching;
28. Inform patients about the dangers of
illusory or insufficiently proven remedies
WMA Statement on the Global Burden of Chronic Non-Communicable Disease
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57
or procedures,and charlatanism practices;
29. Promote a team-based multidisciplinary
and value-based approach to chronic
disease management;
30. Ensure continuity of care for patients
with chronic disease;
31. Model healthy lifestyles by maintaining
personal health;
32. Become community advocates for
improved social determinants of health,
equity in health care and for best
prevention methods and,
33. Work with parents and the community
at large to ensure that parents have the
best advice on maintaining the health of
their children.
WMA Statement on the Global Burden of Chronic Non-Communicable Disease
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58
Adopted by the 62nd WMA General
Assembly, Montevideo, Uruguay, October
2011 and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
The right to health and medical assistance is a
basic human right that should be guaranteed
at all times; ethical principles of healthcare
remain the same in times of emergencies and
in times of peace. Healthcare personnel must
be duly protected.
Various international agreements, including
the Geneva Conventions (1949), Additional
Protocols to the Geneva Conventions (1977,
2005) and the Basic Principles on the Use
of Force and Firearms by Law Enforcement
Officials of the United Nations, must
guarantee safe access to medical assistance as
well as the protection of healthcare personnel.
The United Nations Security Council
Resolution 2286 (2016) condemns attacks and
threats against health care personnel,demands
an end to impunity for those responsible, and
that all parties to armed conflict comply fully
with their obligations under international law.
Despite recognized international standards
and the mobilization of humanitarian and
human rights stakeholders over the last years
denouncing the surge of violence against
healthcare worldwide, the WMA notes with
great concerns persistent attacks and misuses
of hospitals and other medical facilities, as
well as threats, killings and other violence
against patients and healthcare personnel in
emergency contexts.
The WMA condemns in the strongest terms
this scourge of violence against healthcare
personnel and facilities, which has disastrous
humanitarian implications with critical
impacts on the capacity of the health system
to provide the care needed, resulting in
unjustifiable suffering and death. Violence
against healthcare personnel constitutes an
international emergency, requiring urgent
actions.
Recalling its Statement on Armed Conflicts,
the WMA reaffirms that armed conflicts
should always be a last resort and that States
and other authorities who enter into armed
conflict must accept responsibility for the
consequences of their actions.
The safety and personal security of physicians
and other healthcare personnel are essential
in enabling them to provide care and save
lives in situations of conflicts. They must
always be respected as neutral and should
never be prevented from fulfilling their duties.
Healthcare personnel and facilities should
never be instrumentalised as means of war.
Recalling its Regulations in Times of Armed
Conflict and Other Situations of Violence,the
WMA reaffirms that the primary obligation
of physicians and other healthcare personnel
is always to their patients; they have the
same ethical responsibilities in situation of
violence or armed conflicts as in peacetime,
the same duty of preserving health and saving
lives; they shall at all times act in accordance
with the ethical principles of the profession,
relevant international and national law, and
their conscience.
RECOMMENDATIONS
The WMA calls upon all parties involved in
situations of violence to:
1. Fully comply with their obligations under
international law,including human rights
law and international humanitarian law,
in particular with their obligations under
the Geneva Conventions of 1949 and the
obligations applicable to them under the
Additional Protocols of 1977 and 2005;
2. Ensure the safety, independence
and personal security of healthcare
personnel at all times, including during
armed conflicts and other situations of
violence, in accordance with the Geneva
Conventions and their additional
protocols;
3. Respect and promote the principles of
international humanitarian and human
rights law which safeguard medical
neutrality in situations of conflict;
4. Protect medical facilities, medical
transport and the people being treated
in them, provide the safest possible
working environment for healthcare
personnel,and protect them from threats,
interference and attack;
5. Never misuse hospitals and other health
facilities for military purposes and
dedicate them exclusively to health care;
6. Enable healthcare personnel to treat
injured and sick patients, regardless of
their role in a conflict, and to carry out
their medical duties freely, independently
and in accordance with the principles
of their profession without fear of
punishment or intimidation;
7. Ensure that safe access to adequate
medical facilities for the injured and
others in need of medical aid is not
unduly impeded;
8. Ensure that the equipment, including
personal protection equipment,necessary
for the safety of healthcare workers, is
available to them as needed, and that the
staffing is adequate;
9. Support and strictly respect the ethical
rules of the medical profession as defined,
among other documents, in the Ethical
Principles of Health Care in Times of
Armed Conflict and Other Emergencies
and in the WMA Regulations in Times
of Armed Conflict and Other Situations
WMA DECLARATION ON THE PROTECTION AND
INTEGRITY OF MEDICAL PERSONNEL IN ARMED
CONFLICTS AND OTHER SITUATIONS OF VIOLENCE
WMA Declaration on the Protection and Integrity of Medical Personnel
in Armed Conflicts and Other Situations of Violence
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59
of Violence, and to never require from
physicians or force them to breach or
renounce these rules, in particular:
• privileges and facilities afforded to
physicians and other health care
professionals in times of armed conflict
and other situations of violence must
never be used for purposes other than
health care;
• physicians must at all times show
appropriate respect for medical
confidentiality;
• physicians must never accept acts of
torture or any other form of cruel,
inhuman or degrading treatment under
any circumstances; they must never be
present at nor take part in such acts;
• physicians have a duty to recognize
and support vulnerable populations,
including women, children, refugees, the
disabled and displaced persons;
• physicians and WMA constituent
members should alert governments
and non-state actors of the human
consequences of warfare;
• where conflict appears to be imminent
and inevitable, physicians should
ensure that authorities are planning
for the protection of the public health
infrastructure and for any necessary
repair in the immediate post-conflict
period.
The WMA calls upon governments to:
10. Establish efficient, secure and unbiased
reporting mechanisms with sufficient
resources to collect and disseminate
data regarding assaults on physicians,
other healthcare personnel and medical
facilities;
11. Provide to the WHO the necessary
support to fulfil its leadership role in
documenting attacks on healthcare
personnel and facilities [1];
12. Foster the mechanisms of investigating
and bringing to justice those responsible
for reported violations of the
international agreements pertaining to
the protection of healthcare personnel in
armed conflicts and other situations of
violence, and of enforcing the sanctions
when such have been decided;
13. Develop and implement more efficient
legal protection for medical and other
healthcare personnel, so that whoever
attacks a nurse, physician or another
healthcare personnel knows that such
actions will be severely penalised.
The WMA calls upon governments, its member
organisations and the appropriate international
bodies to:
14. Raise awareness of international
norms on the protection of healthcare
personnel and cooperate with different
actors to identify strategies to tackle
threats to healthcare and strengthen the
mechanism of investigating the reported
violations;
15. Raise awareness at both national and local
level of the fundamental importance of
protecting the healthcare personnel and
of upholding their neutrality in times of
conflict;
16. Support the development of pregraduate,
postgraduate and continuous education
for the healthcare personnel to ensure
their competencies and their security and
to minimize the psychological toll when
confronted with armed conflicts and
other situations of violence.
The WMA recognizes that in some
circumstances, documenting and denouncing
acts of torture or other violence may put
the physician, and those close to him or her,
at great risk. Doing so may have excessive
personal consequences. Physicians must avoid
putting individuals in danger while assessing,
documenting or reporting signs of torture and
cruel, inhuman and degrading treatment and
punishments.
WMA Declaration on the Protection and Integrity of Medical Personnel
in Armed Conflicts and Other Situations of Violence
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60
Adopted by the 63rd WMA General
Assembly, Bangkok, Thailand, October
2012 and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Violence in the health sector has increased
substantially in the new millennium,especially
in time of COVID-19 pandemic. All persons
have the right to work in a safe environment
without the threat of violence. Workplace
violence includes both physical and non-
physical, such as (psychological) violence,
intimidation and cyber harassment, among
others.
Cyber and social media harassment
particularly includes online threats and
intimidation towards physicians who take part
in a public debate in order to give adequate
information and fight disinformation. These
physicians are increasingly confronted with,
amongst others, malicious messages on social
media, death threats and intimidating home
visits.
For the purposes of this document, the broad
WHO definition of workplace violence
will be used: “The intentional use of power,
threatened or actual, against another
person or against a group, in work-related
circumstances, that either results in or has a
high degree of likelihood of resulting in injury,
death, psychological harm, mal-development,
or deprivation”.
In addition to the numerous consequences
on victims’ health, violence against health
personnel has potentially destructive social
effects. It affects the entire healthcare system
and undermines the quality of the working
environment, ultimately impacting the
quality of patient care. Furthermore, violence
can affect the availability of health care,
particularly in impoverished areas.
While workplace violence is indisputably a
global issue,various cultural differences among
countries must be taken into consideration in
order to accurately understand the concept
of violence on a universal level. Significant
differences exist in terms of what defines
various levels of violence and what specific
forms of workplace violence are most likely
to occur. This may create tolerance for some
levels of violence in those places. However,
threats and other forms of psychological
violence are widely recognized to be more
prevalent than physical violence.
Causes of violence in the healthcare setting
are extremely complex. Several studies
have identified common triggers for acts of
violence by patients and relatives to be delays
in receiving treatment, dissatisfaction with
the treatment provided, aggressive patient
behavior caused by the patient’s medical
condition, the medication they take or the
use of alcohol and other drugs. Additionally,
individuals may threaten or perpetrate violence
against health personnel because they oppose
a specific area of medical practice, based on
their social, political or religious beliefs. Cases
of violence from the bystanders are reported
as well. Co-worker violence, such as bullying,
including initiation ceremonies and practical
jokes, or harassment, constitutes another
important pattern of workplace violence in
the health sector.
Collaboration among various stakeholders
(including governments, medical
associations, hospitals, general health services,
management, insurance companies, trainers,
preceptors, researchers, media, police and
legal authorities) together with a multi-
faceted approach encompassing the areas of
legislation, security, data collection, training/
education, environmental factors, public
awareness and financial incentives is required
in order to successfully address this issue. As
the representatives of physicians, medical
associations should take a proactive role in
combating violence in the health sector and
also encourage other key stakeholders to act,
thus further protecting the quality of the
working environment for health personnel
and the quality of patient care.
RECOMMENDATIONS
The WMA condemns in the strongest terms
any forms of violence against healthcare
personnel and facilities, which may include
coworker violence, aggressive behavior
exhibited by patients or family members,
as well as acts of malicious intent from
individuals in the general public, and calls on
its constituent members,the health authorities
and other relevant stakeholders to act through
a collaborative, coordinated and effective
strategy approach:
Policy-making
1. The state has obligations to ensure the
safety and security of patients,physicians,
and other health personnel.This includes
providing an appropriate physical
environment.
2. Governments should provide the
necessary framework so that the
prevention and elimination of workplace
violence in the health sector be an
essential part of national/regional/local
policies on occupational health and safety,
human rights protection, healthcare-
facility management standards and
gender equality.
Financial
3. Governments should allocate appropriate
and sustainable funds in order to
effectively tackle violence in the health
sector.
Protocols for situation of violence in healthcare
facilities
4. Healthcare facilities should adopt a
zero-tolerance policy towards workplace
violence eliminating its “normalization”
through the development and
implementation of adequate protocols
including the following:
• a predetermined plan for maintaining
WMA STATEMENT ON WORKPLACE VIOLENCE
IN THE HEALTH SECTOR
WMA Statement on Workplace Violence in the Health Sector
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61
security in the workplace; including
recognition of non-physical abuse as a
risk factor for physical abuse.
• a designated plan of action for health
personnel when violence takes place.
• a strengthened internal communication
strategy, involving the staff in decisions
concerning their security.
• a system for reporting and recording acts
of violence, which may include reporting
to legal and/or police authorities.
• a means to ensure that employees who
report violence do not face reprisals.
5. In order for these protocols to be effective,
the management and administration of
healthcare facilities should communicate
and take the necessary steps to ensure
that all staff are aware of the protocols.
Managers should be urged to verbalize a
no-tolerance policy towards violence in
healthcare settings.
6. Patients with acute, chronic or illness-
induced mental health disturbances or
other underlying medical conditions may
act violently toward health personnel;
those taking care of these patients must
be adequately protected. Except in
emergency cases, physicians might have
the right to refuse to treat and, in such
situations,they must ensure that adequate
alternative arrangements are made by the
relevant authorities in order to safeguard
the patient’s health and treatment.
Training/Education
7. Awell-trainedandvigilantstaffsupported
by management can be a key deterrent
of violent acts. Constituent members
should work with undergraduate and
postgraduate education providers to
ensure that health personnel are trained
in the following areas: communication
skills, empathy as well as recognising and
handling potentially violent persons and
high-risk situations in order to prevent
incidents of violence.
8. Continuous education should include
ethical principles of healthcare and the
cultivation of the patient-physician
relationships based on respect and
mutual trust. This not only improves the
quality of patient care but also fosters
feelings of security resulting in a reduced
risk of violence.
Communication and Social Awareness
9. Medical associations, health authorities
and other stakeholders should work
together to increase awareness of violence
in the health sector, creating networks of
information and expertise in this area.
When appropriate, health personnel and
the public should be informed of acts of
violence.
10. Broadcasting agencies, newspapers,
and other news outlets are encouraged
to thoroughly verify their sources in
order to keep the information shared
to the highest standard of professional
reporting. Social media companies and
associated stakeholders should also take
active steps to create a cyber-violence-
free environment for its users. This
includes strengthening policies to protect
user data, making reporting and flagging
such violence easy and accessible, and
engaging law enforcement for proper
legal action when warranted.
Security
11. Appropriate security measures should
be in place in all healthcare facilities and
acts of violence should be given a high
priority by law-enforcement authorities.
A routine violence risk audit, including a
risk assessment, should be implemented
in order to identify which jobs and
locations are at highest risk for violence,
especially in places where violence has
already occurred, and to determine
weaknesses in facilities’ security.
Examples of high-risk areas include
general practice premises, mental health
treatment facilities and high traffic areas
of hospitals including the emergency
department.
12. The risk of violence may be ameliorated
by a variety of means which include
placing security personnel in high-risk
areas and at the entrance of buildings,
the installation of security cameras and
alarm devices for use by health personnel,
the use distinguishable items to identify
the staff and by maintaining sufficient
lighting in work areas, contributing to
an environment conducive to vigilance
and safety. The implementation of a
system to screen patients and visitors
for weapons upon entering certain areas,
especially the high-risk ones, should be
considered.
Support to Victims
13. Adequate medical, psychological and
legal support should be provided to
victims of violence. Such support should
be free of access for all the health
personnel.
Investigation
14. In all cases of violence there should be
investigation to better understand the
causes and to aid in prevention of future
violence. The investigation may lead
to prosecution of perpetrators under
civil or criminal codes. The procedure
should be led by relevant officials
in law enforcement and should not
expose the victim to further physical or
psychological harm.
Data Collection
15. Appropriate reporting systems should be
established to enable health personnel to
report anonymously and without reprisal,
any threats or incidents of violence.
Such a system should assess in terms
of number, type and severity, incidents
of violence within an institution and
resulting injuries. The system should
be used to analyse the effectiveness of
preventative strategies. Aggregated data
and analyses should be made available
to health professional organizations and
other relevant stakeholders.
WMA Statement on Workplace Violence in the Health Sector
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62
Adopted by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
SARS-COV-2 Pandemic caused more
than 400 million cases and nearly 6 million
deaths. It is quite comforting that vaccines
that ensure protection from the disease have
been produced, and data relating to the
course of the pandemic in countries with high
vaccination coverage is promising. 62.3% of
the world population has received at least one
dose of a COVID-19 vaccine. Only 11.4% of
people in low-income countries have received
at least one dose. Deep inequalities in access
to vaccines are still observed globally and
failure to achieve collective immunity leads to
the -further spread of new, more contagious
and immunity-evading variants of the disease
through mutation. Worldwide application
of vaccines is of critical importance in
terminating the Covid-19 pandemic. Every
minute of delay in vaccinations means further
spread of the disease at global scale and more
lives lost. It is not sufficient to immunize all
citizens in any given country; immunization
has to reach a sufficient level in the world as
a whole to effectively combat and control the
pandemic.
RECOMMENDATIONS
The WMA urges all parties to:
1. Remove barriers to promote equity of
access to COVID-19 vaccines that are
globally proven to be safe and effective;
2. Work with governmental and appropriate
regulatory bodies to encourage
prioritization of equity when providing
COVID-19 pandemic-related resources
such as diagnostics, free medications,
therapeutics, vaccines, raw materials for
vaccine production, personal protective
equipment, and/or financial support, and
guarantee universal accessibility and free
distribution;
3. Establish vaccination strategies that
consider the specific peculiarities,
challenges and vulnerabilities of each
region, prioritising the most vulnerable
people, including health professionals;
4. Insist on the importance of vaccination
and take action to achieve maximum
coverage and protect the population in
need;
In this context,
5. Confront vaccine hesitancy by providing
evidence-based guidance on the safety
and necessity of vaccines;
6. Share of knowledge required for
vaccine production to the COVID-19
Technology Access Pool created by
WHO to ensure that vaccines are
produced at as many centres as possible
and sharing of this knowledge;
7. Allocate public funds to improve the
capacity of vaccine production centres
and increase the channels of safe
distribution so as to ensure fair access,
to provide equitable and efficient vaccine
supply and distribution;
8. Design national vaccine programmes
that take into account a global analysis
rather than only national considerations;
9. Promote sustainable solutions to patent
issues. This may include the temporary
lifting of patents on COVID-19
vaccines under the Trade-Related
Aspects of Intellectual Property Rights
(TRIPS) and similar agreements to
promote equity of access in global
emergency situations, while ensuring
fair compensation for the intellectual
property of the patent holders if asked,
global investment in manufacturing sites,
training of personnel,quality control,and
the transfer of knowledge, technology
and manufacturing expertise;
10. Support WHO efforts and initiatives
to increase production and distribution
of therapeutics and vaccines necessary
to combat COVID-19 and future
pandemics in order to provide vaccine
doses to low and middle-income
countries with limited access, including:
• technological transfers relevant for
vaccine production;
• other support, financial and otherwise,
necessary to scale up global vaccine
manufacturing; and
• measures that ensure the safety and
efficacy of products manufactured by
such means.
11. Call on governments and the United
Nations to take all necessary measures
to facilitate equitable access to vaccines
throughout the world by supporting
and promoting the sharing of all
vaccine-related processes for combating
pandemics (R&D, patenting, production,
licensing, procurement and application).
WMA RESOLUTION FOR PROVIDING
COVID-19 VACCINES FOR ALL
WMA Resolution for Providing Covid-19 Vaccines for All
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63
BACK TO CONTENTS
Adopted as Council Resolution by the 220th
WMA Council Session, Paris (hybrid),
France, April 2022 and as Resolution by
the 73rd WMA General Assembly, Berlin,
Germany, October 2022
PREAMBLE
Reminding that the World Medical
Association was founded on the backdrop
of the atrocities of war and how the medical
profession was abused for violation of human
rights and dignity;
Reaffirming the WMA Declaration of
Geneva as a beacon of fundamental principles
to which the world’s physicians are committed;
Deeply shocked by the Russian army’s
bombing of Ukrainian civilians and hospitals,
including maternity wards, thus infringing
on medical neutrality in conflict zones. The
WMA and its members express their solidarity
with the Ukrainian people and provide their
support for Ukrainian and international
healthcare workers mobilized under extremely
difficult conditions;
Recalling the WMA’s Statements on
the Cooperation of National Medical
Associations during or in the Aftermath
of Conflicts, on Armed Conflicts, the
Regulations in Times of Armed Conflict and
Other Situations of Violence, the Statement
on the Protection and Integrity of Medical
Personnel in Armed Conflicts and Other
Situations of Violence, the Declaration on
the protection of healthcare workers in
emergency situations and the Statement on
Medical Care for Migrants;
Emphasizing the need to respect the Geneva
Conventions and their protocols as the core of
international humanitarian law, as well as the
United Nations Security Council Resolution
2286;
Considering the suffering and human tragedy
caused by the Russian invasion of Ukraine,
including a refugee crisis on a massive scale;
RECOMMENDATIONS
1. The Constituent Members of the WMA
stand in solidarity with the Ukrainian
Medical Association and all healthcare
professionals.
2. The WMA condemns Russia’s invasion
of Ukraine and calls for an end to
hostilities.
3. The WMA considers that Russia’s
political leadership and armed forces bear
responsibility for the human suffering
caused by the conflict.
4. The WMA calls on Russian and
Ukrainian doctors to hold high the
principles in the WMA Declaration of
Geneva and other documents that serve
as guidance for medical personnel during
times of conflict.
5. The WMA demands that the parties
to the conflict respect relevant
Humanitarian Law and do not use health
facilities as military quarters, nor target
health institutions, workers and vehicles,
or restrict the access of wounded persons
and patients to healthcare, as set out in
the WMA Declaration on the Protection
of Health Workers in Situations of
Violence.
6. The WMA stresses that the parties to
the conflict must strive to protect the
most vulnerable populations.
7. The WMA underlines that it is essential
that access to medical care be guaranteed
to all victims, civil or military, of this
conflict, without distinction.
8. Physicians and all other medical
personnel, both Ukrainian and
international, involved in NGOs, must
not under any circumstances be hindered
in the exercise of their unwavering duty,
in accordance with the international
recommendations provided in the
WMA declaration on the protection
of healthcare workers in emergency
situations, the WMA’s position on the
protection and integrity of medical
personnel in armed conflicts and other
violent situations and in the declaration
of the United Nations General Assembly
on the rights and responsibility of
individuals, groups and organs of society
to promote and protect human rights
and universally recognized fundamental
freedoms.
9. The WMA calls on the parties to ensure
that essential services are provided
to those within areas damaged and
disrupted by conflict.
10. The WMA calls on the international
community and governments to come
to the aid of all persons displaced by this
conflict who may choose their country as
a destination following their departure
from Ukraine.
11. The WMA urges all nations receiving
persons fleeing the conflict to ensure
access to safe and adequate living
conditions and essential services to all
migrants, including appropriate medical
care, as needed.
12. The WMA calls on the parties to the
conflict as well as the international
community to ensure that when the
conflict ends, priority must be given to
rebuilding the essential infrastructure
necessary for a healthy life, including
shelter, sewerage, fresh water supplies,
and food provision, followed by
the restoration of educational and
occupational opportunities.
WMA RESOLUTION IN SUPPORT OF
MEDICAL PERSONNEL AND CITIZENS OF UKRAINE
IN THE FACE OF THE RUSSIAN INVASION
WMA Resolution in Support of Medical Personnel and Citizens of Ukraine
in The Face of The Russian Invasion
64
BACK TO CONTENTS
Adopted by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
The ongoing war in Ukraine has led to
millions of refugees who have experienced
trauma and an unprecedented mental health
crisis situation. Aid workers and some
physicians who are assisting the refugees may
not be well prepared to treat this war-related
trauma.
Through the Ukraine Medical Help Fund,
the WMA is leading a successful effort to
provide material aid to Ukrainian refugees.
The longevity and brutality of the war now
require even more dedication to this effort and
the expansion of aid to include mental health
personnel trained in war-related trauma.
RECOMMENDATIONS
1. That the WMA, through the Ukraine
MedicalHelpFundandotherappropriate
means, its constituent members and the
medical community, continue to send
medical supplies to Ukraine and offer
support to organizations providing
humanitarian missions and medical
care to Ukrainian refugees, resource
permitting.
2. That the WMA,its constituent members
and the medical community, advocate
for early implementation of mental
health measures, including suicide
prevention efforts, and for addressing
war-related trauma and post-traumatic
stress disorder when assisting Ukrainian
refugees.Special attention should be paid
to disadvantaged groups.
3. That the WMA,its constituent members
and the medical community, advocate for
educational measures to enhance the
understanding of war-related trauma
in war survivors and promote broad
protective factors for war-affected people
such as employment, housing, and food
stability, especially in disadvantaged
groups.
WMA RESOLUTION ON HUMANITARIAN
AND MEDICAL AID TO UKRAINE
WMA Resolution on Humanitarian and Medical Aid to Ukraine
65
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Adopted by the 67th WMA General
Assembly, Taipei, Taiwan, October 2016
and revised by the 73rd WMA General
Assembly, Berlin, Germany, October 2022
PREAMBLE
Occupational and environmental health and
safety (OEHS) is an integral part of public
health, and the primary health care (PHC)
system in particular, since it is often the first
level of contact of individuals, the family and
the community with a health system, bringing
health care as close as possible to where people
live and work.
Workers represent at least half of the world’s
population and are the backbone of many
economies, but many may have inadequate
access to occupational and environmental
health services and do not operate in a safe
working environment.
The International Labour Organization
(ILO) defines decent work as opportunities
for work that are productive and deliver fair
income with dignity, equality, and within safe
working conditions. Despite the fact that
the right to decent work is recognized in the
Universal Declaration of Human Rights,every
15 seconds, a worker dies from a work-related
accident or disease , resulting in an annual 4%
loss in global GDP.
Despite this, the proportion of work accidents
and occupational diseases that are recorded
and reported worldwide is incredibly small. It
is estimated that less than 1% of occupational
diseases are recorded.
Additionally, as many workers face greater
pressures to meet the demands of working
life, many of them are at risk to develop
work-related stress which may occur when
the demands of the job do not match or
exceed the capabilities, resources or needs
of the worker or when the knowledge or
abilities of an individual worker or group to
cope are not matched with the expectations
of the organizational culture of an enterprise.
High-level of stress can result in health
impairments such as burnout, depression,
anxiety, cardiovascular disease or even suicide.
Recently and even more due to the
COVID-19 pandemic, the world has
witnessed an increased number of employees
working outside the employer’s premises
using digital information and communication
technologies either full-time or part-time.
Despite some positive aspects, there are risks
associated with this work arrangement as it
isolates employees, particularly individuals
living alone and can result in increased levels
of stress and anxiety. Extended working hours
and employee availability in addition to
diminished boundaries between personal and
professional life may impact work-life balance.
A healthy digital working environment needs
to be in place to ensure employee health and
safety.
The United Nations Development
Programme’s Sustainable Development
Goals 3, 5, 8 and 13 call for action in health
promotion for all people of all ages, gender
equality, decent work and management of
the impact of climate change; OEHS is well
positioned to maintain physical, mental and
social well-being for all workers,that will result
in poverty reduction, sustainable development
and saving millions of lives every year.
Physicians have a critical role in preventing,
diagnosing,monitoring,treating and reporting
work accidents and occupational diseases. In
addition, physicians should promote equal,
decent and inclusive work environments for
all regardless of age, gender, ethnic origin,
nationality, religion, political affiliation,
race, sexual orientation, or the presence of a
disability.
Despite many governments and employers’
and workers’ organizations placing greater
emphasis on the prevention of occupational
diseases. prevention is not receiving the
priority warranted by the scale and severity of
the occupational disease epidemic.
Physicians and medical associations can
contribute to the identification of problems,
development of national reporting systems,
and formulation of relevant policies in the
field of OEHS.
Unsatisfactory and unsafe working conditions
play a significant role in the development
of occupational diseases and injuries, which
are subsequently causes of mortality in the
working population.
RECOMMENDATIONS
1. Physicians should play a pivotal role
in the development of a workforce
that is educated in and raise workplace
awareness about the social determinants
of health.
2. The field of occupational and
environmental health and safety (OEHS)
should be accorded the necessary
importance in both graduate and post-
graduate medical studies
3. Physicians must cooperate with the
healthcare and occupational authorities
to promote health and safety in the
workplace.
4. All workers should have access to risk
based OEHS services from the first
day of work and extending beyond the
last day at work in order to account for
occupational diseases with a long latency
period. Service content should be
standardized and the role of physicians
in the planning and implementation
of OEHS systems that are essentially
preventive/protective must be recognized.
5. WMA Constituent members should act
proactively and encourage the expansion
of the scope of OEHS services, in order
to prevent and reduce occupational
diseases, and injuries, reproductive health
issues and protect the environment.They
should also promote workplace gender
equality and encourage improvement
WMA STATEMENT ON OCCUPATIONAL AND
ENVIRONMENTAL HEALTH AND SAFETY
WMA Statement on Occupational and Environmental Health and Safety
66
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of recording and reporting systems for
OEHS-related metrics.They should also
focus on workforce capacity building,
teaching and training, and collaborative
research.
6. WMA Constituent members, together
with governments, should take an
active role, where appropriate, in the
formulation and development of national
systems that facilitate OEHS prevention,
and the recording and reporting of
occupational diseases and incidents in
their respective countries.
7. Physicians who are evaluating workers’
compensation patients should be
experienced in occupational and
environmental medicine. When a
relationship between the diagnosis
and occupational and environmental
exposures is established, the physician
should report it through the appropriate
reporting system.
8. Occupational diseases and injuries
are often addressed in the context of
insurance and compensation. Where
these mechanisms are not in place,
WMA Constituent members should
advocate for the protection of workers by
means of insurance or social security.
9. When rendering services for an employer,
physiciansshouldadvocatethatemployers
fulfil the minimum requirements set in
the International Labour Organization’s
(ILO) occupational standards, especially
when such requirements are not set by
national legislation.
10. Employers should provide a safe working
environment, recognising and addressing
the impact of adverse working conditions
on individuals and society.
11. Employers should consider promoting
and offering essential vaccines to
employees.
12. WMA Constituent members should
consider forming an internal body for
addressing the problems of physicians
working in OEHS and encourage them
to contribute to research and related
scientific studies.
13. Governments should collaborate in
setting up an international system to
assess occupational hazards and develop
strategies to protect the health of workers.
14. Governments should establish legislative
frameworks that protect the rights and
health of workers, including reproductive
health and health effects of work at
home.
15. Governments and NMAs must promote
the development of training, information
and research programs in occupational
health to their members.
67
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For this interview, Dr. Heidi
Stensmyren, the WMA Past
President, shares her perspectives
on current and upcoming WMA
activities with Dr. Helena Chapman,
the WMJ Editor in Chief
Please share three quotes and describe
how these quotes reflect your journey
as WMA president (2021-2022).
As our global health leaders
develop timely initiatives to protect
population health, we realise that
health disparities still exist across
our communities. The global
health workforce shortage remains
a significant challenge to provide
optimal health services and address
such health disparities. With
technological advancements,we must
find novel approaches to transform
health care delivery and strengthen
health system resiliency. I believe
that “The whole world shares the
same challenges: insufficient access
to healthcare and an overburdened
health workforce. Working faster
is not the solution. We need to
transform the way we provide health
care and utilise new technologies.”
The value of teamwork cannot
be overlooked by our medical
community. As World Medical
Association (WMA) members, we
must find opportunities to share our
expertise and develop innovative
collaborations, in order to enhance
health care service delivery. The
reality is that “Shared problems
cannot be solved solely by a few
stakeholders. I am strengthened in
my conviction of the importance
of collaboration – we are stronger
together”.
As physicians, we recognize our
unique role in patient care, where we
often serve as detectives when there is
no known cure. We are trained to be
observant, balanced, and empathetic
in our medical evaluations.My career
path is a testament to being prepared
to manage and solve complex clinical
cases. For example, “My years as
a global health leader have been
filled with several challenges and
situations that could not have been
foreseen. This is very similar to the
clinical practice: acting on unsolved
problems is part of a physician’s
role. We are trained to manage new
situations, even when there are no
established pathways, and adapt
to new disease spectra. If there is
no established treatment, then we
will work to find an appropriate
treatment. These challenges during
my leadership journey – whether as
president of the WMA or as chief
at Karolinska University Hospital
– have been very similar to those
experienced in clinical practice.”
Over the past year, what do you
consider to be your most important
leadership achievements as WMA
president (2021-2022)?
I hope that I have been a role
model for doctors, showing that it is
possible to take on a high leadership
position even at a mid-career level
with children at home. Although I
have had limited travel opportunities
during the coronavirus disease 2019
(COVID-19) pandemic, I believe
that in-person meetings – combined
with virtual meetings – are essential.
However, working solely with
in-person meetings can exclude
some individuals from their active
participation and ultimately result
in homogenous, not heterogenous,
team dynamics. The WMA must
promote diversity, as it is core for our
mandate to represent all physicians
across the world. After all, it is a duty
for all leaders to pave the way for the
next generation of individuals who
follow our paths.
Over the years, I have been honoured
to gain many organisational contacts
across our WMA meetings and
initiatives. Specifically, I have
prioritised our close work with the
World Veterinarian Association
to engage in dialogue and explore
potential collaborations around
the One Health concept. After all,
humans do not live in a vacuum
separated from animals or our
surrounding environment. Joint
collaborations are key to mitigate the
risk of zoonotic disease transmission
(including COVID-19) and
antimicrobial resistance.
Aside from the ongoing COVID-19
pandemic, what are the three key
priorities that WMA members should
address in the next f ive years?
Over the next five years,I recommend
that our WMA community
promote continued dialogue on
three key priorities. First, we can
collaborate on initiatives that expand
community access to health care
services. To succeed, we need to
work with political priorities, invest
in technological advancements, and
promote innovative solutions that
can scale up health care service
Interview with the WMA Past President
Interview with the WMA Past President
Heidi Stensmyren
68
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delivery. Second, we must address
the global health workforce shortage
with new solutions, which do not
lie in increasing work schedules for
the current workforce. We should
still focus on and promote expanded
training for medical, nursing, and
other allied health professions
across all countries. The workforce
needs to be utilised in a sustainable
way through new and user-friendly
technologies and robust systems
that provide more cost-efficient
patient care services. Third, we
should promote patient-provider
relationships in shared decision-
making, where community members
can easily access health care services,
and that physicians can regularly
their health status and outcomes.
Physicians can empower community
members to select healthy lifestyle
behaviours and prioritise their
personal and their family’s health
and well-being.
As WMA Past President, what do
you hope to accomplish over the next
six months, and how can WMA
leadership help support these efforts?
Over the next six months, I hope
to establish a collaboration with
the United Nations and participate
in the development of their Code
of Conduct for Medicine. The
International Code ofMedical Ethics
is a valuable resource that offers
a well-established framework for
future initiatives focusing on medical
ethics. I am also excited to be able to
contribute to the upcoming revisions
of the Declaration of Helsinki. And
foremost, as chief at the Karolinska
University Hospital, I am proud to
form part of international health
care and work to cure tomorrow
what cannot be cured today.
Heidi Stensmyren, MD, MBA
Past President (2021-2022)
World Medical Association
heidi.stensmyren@regionstockholm.se
Interview with the WMA Past President
69
Interview with the WMA President
For this interview, Dr. Osahon
Enabulele, the WMA President,
highlights his academic background
and training as well as his perspectives
on upcoming WMA activities with
Dr. Helena Chapman, the WMJ
Editor-in- Chief
Please share a brief summary of your
professional education and training in
Medicine.
I had my university education at the
School of Medicine of the University
of Benin, Benin City, Edo State,
Nigeria, from where I received my
Bachelor’s degree in Medicine and
Surgery (M.B.,B.S.). I completed my
internship training at the University
of Benin Teaching Hospital (UBTH),
after which I participated in the
NationalYouthServiceCorps(NYSC)
program at the Comprehensive Health
CentreinIkotEffiong-OtopOkoyong
(Odukpani Local Government Area)
in Cross River State, Nigeria. From
2000-2006, I pursued my postgraduate
medical training in Family Medicine
at the University of Benin Teaching
Hospital, and I obtained a Masters’
degree in Health Planning and
Management (MHPM) from the
University of Benin in 2001. In 2007,
I obtained the Fellowship of the
West African College of Physicians
(WACP), following which I was
appointed as a Consultant Family
Physician at the University of Benin
Teaching Hospital.
Currently, I hold the position of
Consultant Special Grade I at the
University of Benin Teaching Hospital
in Benin City, Edo State, Nigeria. In
this position, which is recognized as
the peak of the public service career
for physicians employed in public
hospitals in Nigeria, I undertake the
delivery of clinical care services as a
Chief Consultant Family Physician.
Additionally, I teach and train Family
Medicine residents in the Department
ofFamilyMedicine,aswellassupervise
the Part II Fellowship dissertations of
resident doctors completing training
in Family Medicine.I am also a Senior
Lecturer at the University of Benin,
where I teach Family Medicine courses
to undergraduate medical students. I
have special interests in primary health
care, health systems development,
family violence and violence in
health, health legislation, professional
leadership, and medical ethics.
In the West African College of
Physician’s (WACP) Faculty of Family
Medicine, I serve as a Postgraduate
Examiner and Reviewer.I also serve as
a member of its Accreditation Team,
which is responsible for inspecting
health institutions and recommending
suitable institutions for postgraduate
training in Family Medicine.
What has motivated you to pursue this
WMA leadership position, and what
national and international impacts do
you hope to achieve over your tenure?
My decision to serve as the World
Medical Association (WMA)
President is centred on a strong
resolve, passion, and commitment to
work with my colleagues around the
world to engender better health care
across the globe. I am also dedicated
to the promotion of the ideals and
objectives of the WMA,particularly as
it concerns Universal Health Coverage,
physician well-being, physicians’rights
and autonomy, patients’ rights, and
medical ethics. While I admit that the
WMA has made remarkable strides
since its formation over 75 years ago,
it is evident that a lot can still be done
to make the WMA derive significant
dividends from the enormous
potentials at its disposal. These efforts
will make the WMA resonate loudly
amongst its members.
Over the past 30 years, I have
served as a medical leader, health
activist, and civil and human rights
activist in Nigeria, across Africa, and
internationally.I have had an extensive
history of commitment to our noble
medical profession, my physician
colleagues, my patients, and citizens,
through advocacy efforts to strengthen
health systems and promote universal
access to care, promote physicians’and
medical students’ well-being, rights,
and autonomy, and support patients’
rights and citizens’ health-related
human rights.
When I served as President of the
Nigerian Medical Association (2012-
2014), I humbly recall our leadership’s
strategic efforts that led to the historic
reversal of a state government’s
dismissal of 788 physicians in public
service who courageously spoke out
about their working conditions and
ethical obligations. Our leadership’s
leading role in the public campaigns
for a national legislative framework for
health in Nigeria, largely contributed
to the enactment of Nigeria’s
first comprehensive national legal
framework for the development,
management, and regulation of
Nigeria’s national health system
(National Health Act).
Osahon Enabulele
Interview with the WMA President
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70
Leveraging on these experiences in
medical leadership and health activism,
I hope to have a positive impact
through active advocacy that shall
help enhance the fortunes of WMA,
improve physicians’well-being,protect
physicians’ rights and autonomy,
engender better health systems and
Universal Health Coverage, protect
patients’rights,and improve adherence
to ethical standards by practitioners.
Aside from the ongoing COVID-19
pandemic, what are the three greatest
challenges that physicians currently
face in Africa, and how can the WMA
address these challenges?
First, physicians practising across the
54countriesinAfricahavealwaysfaced
the challenge of uncompetitive wages.
This situation is exacerbated by the
socio-economic challenges facing most
African countries, including inflation
that further undermines wages. Most
times, physicians are not granted the
needed incentives,amenities,and other
fringe benefits that could ameliorate
this economic challenge. Sadly, some
African governments owe physicians
several months of legitimately earned
wages without repercussions for those
governments.
Second, with rising societal and family
expectations and the alluring working
conditions and remunerative schemes
available in high-income countries,
physicians have migrated to practise
in these high-income countries (brain
drain), with negative impacts on
African health systems and health
outcomes. Other limitations include:
1) inappropriate and unsatisfactory
workplace conditions; 2) limited
postgraduate career development
pathways; 3) lack of government’s
recognition of professional worth
linked to underutilization of available
expertise and skills; 4) general lack
of standard health infrastructure,
working equipment, technology, and
training facilities; and 5) workplace
insecurity and with physicians having
experiences of violent assaults, abuse,
and kidnapping.
Third, there is increasing physician
burnout which is traceable to the
unmitigated brain drain of physicians
and other health professionals from
Africa to high-income countries. This
effect has led to the African health
workforce shortage, with negative
impact on physicians’ physical and
mental well-being, increased patients’
waiting time, and negative impacts on
health care service delivery and health
outcomes.
In my inaugural presidential address
at the WMA General Assembly,
which was held in Berlin, Germany,
on 7 October 2022, I cited that the
World Health Organization (WHO)
estimated that the world will need
about 18-20 million more health
professionals to attain Universal
Health Coverage by 2030. Africa,
which is characterised with about 25%
of the global disease burden and 3% of
the global health workforce, is greatly
affected by the health workforce
shortage. This challenge is therefore
one that demands urgent attention
and resolution.
Moving forward, the WMA can
address these challenges through
strident advocacy and engagement
of the various African governments
and Ministries of Health, as well
as strengthening the capacity of its
constituent members. Also, African
governments that place little value on
their physicians should be encouraged
to show greater political commitment
to health. These steps can help bring
economic prosperity to countries
as well as help physicians receive
appropriate recognition, competitive
wages, safe working conditions, and
adequate incentives in health care
service delivery.
Furthermore, WMA leadership plans
to develop a comprehensive action
plan as well as sensitise physicians on
the physician’s pledge and the Revised
International Code of Medical Ethics,
as next steps for global physicians.
WhichongoingornewWMAinitiatives
are top priorities for this year, and how
can the WMA support collaborations
across national medical associations?
Forthisupcomingyear,wewillprioritise
the ongoing efforts to revise the
Declaration of Helsinki and promote
the Revised International Code of
Medical Ethics. We will support
several new initiatives that focus on
expanding research, reducing violence
against physicians and other health
professionals, addressing challenges
related to brain drain, physician burn
out, and working conditions, and
improving commitment to Universal
Health Coverage. Specifically, we
will promote the “Meet the WMA
President Roundtable: Leadership and
Educational Platform”, which aims
to build the capacity of physicians
and our constituent members, as well
as help to improve the knowledge,
understanding, and perception of the
WMA.WewillalsosupporttheWMA
Global Healthcare Excellence Award
Scheme, which highlights rewarding
excellence, sense of duty, diligence,
and uncommon commitment of
physicians and other health advocates.
To implement these initiatives, the
WMA will require the support and
collaboration of National Medical
Associations and use existing WMA
platforms to encourage collaborative
work.
As WMA President, what do you hope
to accomplish over the next few months,
and how can WMA leadership help
support these efforts?
In addition to the previously described
initiatives, I would like to use every
opportunity of my professional
engagements around the world to
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Interview with the WMA President
71
showcase these important WMA
initiatives. Recently, I was happy to
receive favourable responses from
my engagements with the Swedish
Medical Association in Stockholm
and the Japan Medical Association in
Fukuoka and Tokyo.
With the support of the WMA
leadership and constituent members,
I am certain that we will achieve our
objectivesfortheseproposedinitiatives,
including the “Meet the WMA
President Roundtable: Leadership and
Educational Platform” and the WMA
Global Healthcare Excellence Award
Scheme. I am convinced that by
working together, we shall succeed in
our collective tasks and aspirations, to
the glory of the WMA,our physicians,
our patients, and health systems across
the world.
Osahon Enabulele, M.B.B.S., MHPM,
FWACP, FNMA
President, World Medical Association
osahoncmavp@gmail.com
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Interview with the WMA President
72
Canada’s Medically Administered Death (MAD) Expansion for Mental Illness: Targeting the Most Vulnerable
In the previous issue of the World
Medical Journal, we described the
evolution and expansion of Canada’s
assisted dying laws [1]. The Medical
Assistance in Dying (MAiD) law was
initially implemented in 2016,through
Bill C-14,for those whose deaths were
reasonably foreseeable. The law was
expanded in 2021 through Bill C-7,
to what is more appropriately termed
Medically Assisted Death (MAD),
for those living with disabilities who
otherwise could have years or decades
left to live. This article focuses in
more detail on the pending expansion
of MAD by March 2023, to those
suffering solely from mental illness.
Background
Canada’s assisted dying policies
have been shaped by two pieces of
legislation that arose following two
different court cases. The first was a
Supreme Court case, and the second
was a trial level Quebec Superior
Court decision. Bill C-14, which was
enactedin 2016in response tothe 2015
Supreme Court Carter v Canada AG
ruling, created a legislative exemption
to the absolute prohibition of assisted
suicide and euthanasia, allowing it in
specific circumstances surrounding
the end-of-life context [2,3]. MAiD
became legal for mentally capable
adults who had an irremediable disease
that caused enduring and intolerable
suffering that could not be alleviated
under conditions the person found
acceptable,with an“irreversible decline
of capability”, and when their natural
death was “reasonably foreseeable”.
Comments in the Carter case indicate
that the Supreme Court did not have
MAiD for mental illness in mind
when declaring that the Canadian
parliament had to carve out an
exemption to the absolute prohibition
of assisted suicide and euthanasia.
Rejecting “evidence from Belgium”
related to problematic developments
in that country, which was invoked to
justify the prohibition,the Court stated
that “high-profile cases of assistance
in dying in Belgium…would not fall
within the parameters suggested in
these reasons, such as euthanasia for
minors or persons with psychiatric
disorders or minor medical conditions”
[3].
From the beginning, however, there
was pressure to allow MAiD for
mental illness. Advocates of expansive
MAiD and some politicians invoked
the Supreme Court’s reference to
intolerable physical or psychological
suffering to argue MAiD for mental
illness had to be permitted. They
felt emboldened in their view by an
Alberta Court of Appeal ruling in
the case of a woman with conversion
disorder, or unexplained physical
symptoms, who received permission
to have MAiD for this condition
[4]. The Alberta court invoked the
broad Supreme Court parameters and
reference to psychological suffering in
a case that was decided prior to the
enactment of Canada’s first law (the
Supreme Court had given parliament
one year to develop new legislation),
and the Court explicitly mentioned
that it was ruling in the absence of
legislation. Experts later argued that
it was unlikely that this woman had
received proper specialized care for
this highly unusual mental disorder
with psychosomatic components [5].
Early on, this case revealed challenges
of offering MAiD for mental illness.
Ramona Coelho
K. Sonu Gaind
Canada’s Medically Administered Death (MAD)
Expansion for Mental Illness: Targeting the Most Vulnerable
Trudo Lemmens John Maher
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73
Notwithstandingthiscaseandpressure
on the government to provide broad
access to MAiD, including for mental
illness, the first law restricted MAiD
to just those who were approaching
their natural death. Persons with
mental illness were not excluded from
accessing MAiD, but could do so
only, as all others, if their death was
“reasonably foreseeable” [2]. Bill C-7
was enacted in 2021 in response to the
2019 Quebec provincial superior court
Truchon ruling [6,7].This case, as the
Carter case, involved plaintiffs with
neurodegenerative medical conditions
including ALS and spinal stenosis.
Of note, neither the 2015 Carter case
nor the 2019 Truchon case involved
individuals suffering from mental
illness.
Following the single Quebec judge
ruling in the 2019 Truchon case that
having a foreseeable natural death
to qualify for MAiD was overly
restrictive, the federal government
chose not to appeal that lower court
ruling [8]. With some academics and
advocacy organizations pushing for
expansion,the stage was set for MAiD
(now more appropriately termed
MAD once extended outside near
end-of-lifeconditions)beingprovided
to those living with disabilities, as
well as people with any chronic
health condition and concurrent life
suffering, and potentially to people
who had a mental illness as their sole
medical condition.
The initial draft legislation of Bill C-7
introduced by the federal government
in 2020, in response to the Truchon
ruling, specifically excluded sole
mental illness conditions from
qualifying for MAD [9]. At the time,
federal Justice Minister Lametti
acknowledged that “there is a greater
risk of providing medical assistance in
dying to people whose condition could
improve” and that “in the case of some
mental illnesses, the desire to die is itself
a symptom of the illness, which makes
it particularly difficult to determine
whether the individual’s request is truly
voluntary” [10].
For the year following the introduction
of the initial draft C-7 legislation,
the federal Minister of Justice
maintained assurances that Bill C-7
would safeguard against MAD for
sole mental illness, and it was in this
context that a significant majority
of the House of Commons voted in
favour of the bill. However, during
subsequent Senate consultations,
advocates for MAD expansion pressed
to allow MAD for mental illness.
Despite neither Carter nor Truchon
involving cases of mental illness, one
legal scholar (and prominent advocate
for expansive MAiD) claimed in her
Senate testimony that direction to
implement MAD for mental illness
hadalreadybeenprovidedbythecourts
in these cases. She suggested that the
only question that remained was “how
to implement MAiD for a mental
disorder as the sole underlying medical
condition rather than whether, as the
whether question has already been
answered by the courts in Carter and
Truchon” [11]. It bears repeating that
the Supreme Court explicitly stated
in Carter that it was not providing a
ruling about MAiD for mental illness,
and that, furthermore, the Truchon
decision was a Quebec lower court
decision, not binding on other courts.
In fact the Quebec lower court was
criticized for its treatment of evidence
[8].
Following its separate, limited
consultation process during its
discussion of the Bill, the Senate
went against the Justice Minister’s
prior assurance. Citing input from
the Canadian Psychiatric Association
(discussed further below),a psychiatrist
senator formally proposed that the
Senate recommend a “sunset clause”to
Bill C-7’s mental illness exclusion [12].
In February 2021 the Senate accepted
this proposal and recommended
that the exclusion of mental illness
from MAD be subject to a time-
limited “sunset clause” to ensure that
MAD for sole mental illness would
be provided following expiry of the
clause [13]. On 23 February 2021,
the federal government radically
and unexpectedly changed course
to ensure fast adoption of the Bill. It
renounced its previous assurances that
MAD would not be provided for sole
mental illness, and altered Bill C-7 to
add a sunset clause to make MAD
for mental illness available within two
years. On 17 March 2021, the sunset
clause was adopted, following a single
three-hour debate on the sunset clause
in the House of Commons that was
foreshortened by a closure motion
by the governing Liberal party. The
parliamentary vote occurred largely
along party lines. What happened
to allow for this dramatic change in
trajectory?
Expert Consultations Informing
Bill C-14 and Bill C-7
With the passage of the sunset clause
in 2021, the Canadian government
committed to providing MAD for sole
mental illness by March 2023,without
further deliberation on whether
psychiatric euthanasia should, or could,
safely be provided. The only question
remaining was how MAD for mental
illness would be implemented. In such
circumstances, one might expect that
a thorough and deliberative process
involving appropriate evidence-based,
clinically oriented input from expert
medical consultations and extensive
consultation with patient advocacy
groups focusing on mental health had
already been undertaken to inform the
decision to provide MAD for mental
illness. Disturbingly, it had not.
In fact, the Canadian government and
parliament could have studied detailed
reports on the evidence which the
government had itself commissioned
recently. The initial law (Bill C-14)
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required the government to report
back to parliament within five years
of its enactment, in reference to
three controversial areas which were
not part of the initial legislation:
MAiD for sole reasons of mental
illness, MAiD for mature minors,
and MAiD on the basis of advanced
requests.
The government commissioned
three reports from the Council of
Canadian Academies (CCA), an
independent scientific organization
mandated to provide evidence-based
assessments on important policy
issues. The CCA established three
large expert subcommittees to study
the evidence related to these issues,
each of which produced substantial
reports (Note: Authors KSG and
TL sat on two different CCA
subcommittees) [14-16]. The report
of the CCA subcommittee studying
mental illness documents the
significant challenges, evidentiary
gaps, and controversial applications
of MAiD for mental illness in the
few countries that have allowed this
practice. Following the launch of
this neutral report, a small number
of members of the original CCA
committee set up another panel,
the Halifax Group, and issued
sweeping recommendations for
legalizing MAiD for mental illness
[17]. In response, another group,
the Expert Advisory Group on
MAiD (including KSG and TL)
issued a report making contrasting
recommendations and pointing to
the lack of evidence supporting the
recommendations of the Halifax
Group [18].
Normally, one would have expected
an expansive and inclusive discussion
of the evidence by the Canadian
parliament prior to expanding the
law especially regarding the evidence
in the commissioned CCA reports
on MAiD. However, this discussion
did not happen. Why not?
Lack of Critical Engagement of
Professional Organizations
Prior to Bill C-14 in 2016, the
Canadian Medical Association
(CMA)’s Committee on Ethics was
consistent with affirming its stance
against euthanasia and assisted
suicide. This was clearly stated in
its CMA policy in 2007 and upheld
in 2013. However, when the CMA
intervened in the Supreme Court
of Canada Carter case in 2015, it
declared that it would change its
ethicalpolicybasedontheconclusions
of the justices [19]. Hence, the
CMA conceded and changed its
policy to support physician assisted
suicide and euthanasia subject only
to legal constraints. It is remarkable
that an association whose duty it is
to safeguard the ethical practice of
medicine would afford primacy to
political dictates and legal fiat. Many
physicians questioned where this left
our collective Hippocratic oaths in
the equation.
Following the Truchon ruling in
2019, the Canadian Psychiatric
Association (CPA) leadership
adopted and published a position
statement on assisted dying in 2020,
despite not having engaged in any
member, expert or stakeholder
consultations since 2018, well prior
to the Truchon ruling [20]. The
CPA position statement failed to
reference any mental illness literature
or scientific evidence, it did not raise
any concerns about mental illness
related suicidality, and it failed to
mention the importance of suicide
prevention. Instead of evidence or
expert clinical input, and despite it
being known that the basis of MAD
in Canada was intended to be for
medical conditions that could be
assessed as being irremediable (or
could be predicted to not improve),
the CPA statement presented an
ideological opinion that patients
with a psychiatric illness “should have
available the same options regarding
MAiD as available to all patients”
without having any consideration of
whether or how irremediability of
mental illness could be assessed [21].
During Bill C-7 consultations on
mental illness and death, Canada’s
national psychiatric association,
the CPA, never once mentioned
suicide, mental illness related suicide
risk or the importance of suicide
prevention. Indeed, no variant of
the word “suicide” was used in any
context in any of its written or oral
submissions during the consultation
process prior to Bill C-7. Despite
maintaining that it had no official
position on MAD for mental illness,
CPA leadership publicly described
any proposed exclusion of MAD for
sole mental illness as “discriminatory”,
“unconstitutional”, “inaccurate”,
“stigmatizing”,“vague”,“arbitrary” and
“overbroad” [22-26]. CPA’s repeated
claims of it being “discriminatory”
not to provide MAD for mental
illness, while failing to issue known
evidence-based cautions regarding
suicidality and mental illness, was
reasonably interpreted by politicians
and the public as the CPA strongly
supporting MAD for mental illness
[13].
Abdication of Expert Medical and
Professional Roles
Medical experts and professional
medical associations are provided
platforms by virtue of their medical
expertise. In return, it is expected that
suchexpertsandassociationscontribute
that expertise to policy discussions.
Through Canada’s rapidly expanding
assisted dying expansion from MAiD
to MAD, key associations have failed
to provide medical evidence-based
cautions about risks of expansion,
and instead have ceded professional
responsibility and accepted whatever
political winds were shaping policy
agendas. One could even argue that
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they thereby renounced the rationale
that underpins professional self-
regulation, which is a key component
of Canada’s health care system;namely,
that the professions play a critical role
in the development and enforcement
of professional standards because of
their unique expertise [27].
InCanada,provincialregulatorybodies
are charged with ensuring physicians
adhere to accepted standards of care.
Instead, many have supported and
reinforced a patient’s priority of access
to timely MAD over patient safety and
protections and emphasized “effective
referral” requirements for MAD [28].
Death wishes can arise from many
sources: because of undiagnosed
depression,because a patient’s pain has
been inadequately treated, because the
patient is a victim of abuse or trauma,
and other factors that may take time
to address but importantly, could
potentially be addressed and mitigated.
To ignore these factors and simply
refer a patient for MAD in these cases
would be viewed by many physicians
as an abandonment of their duty. To
demand that a physician refer a patient
for MAD in such situations,even if the
physician believes it is counter to the
best interest and health of the patient
and that the patient would likely
improve with adequate treatment,
is to demand that the physician act
against their professional obligations
to provide required care [27].
Furthermore, there are no current
evidence-based or established
standards of care for determining
irremediability of mental illness for
the purposes of MAD assessments.
Despite that, provincial regulatory
bodies have focused attention on
forcing physicians to make an
“effective referral” for any MAD
request a patient makes [28].
This creates a remarkable situation of
physicians being forced by regulatory
bodies to engage in a fundamental
change in medical practice and
provide “effective referrals” for services
potentially leading to patient deaths
for which there are no standards of
care. In this regard, the Canadian
Association for Suicide Prevention
(CASP) has pointed out that forcing
“effective referral” in such situations
could force psychiatrists to commit
professional misconduct.CASP wrote,
“With respect to psychiatrists not willing
to provide MAiD being required to make
a referral of a patient to a psychiatrist
that will, does this not leave the
referring psychiatrist open to committing
professionally unethical behaviour? If
the grounds for not providing MAiD is
not based on morality but rather on the
fact that there is insufficient evidence to
support MAiD as a medical treatment,
then the requirement to refer a patient
forces them to commit professionally
unethical behaviour” [29].
Perhaps the most explicit abdication
of providing expert input came during
2020 Senate hearings, when the
association that might be expected
to be the most ardent at offering
evidence-based input related to suicide
risks and suicide prevention declined
to do so. When asked whether the
CPA agreed with other experts,
including the CCA, who cautioned
that there was insufficient knowledge
about mental disorders and that more
research was needed before providing
MAD for mental illness, and whether
that warranted precautions, the CPA
president responded, “I guess that is a
legislative decision” [30].
We offer this flow of events as a
cautionary tale for other countries
where the leadership of professional
associations may adopt an ideological
position at odds with scientific
evidence and the established ethics
of their membership. In Canada, the
furtherance of an ideological agenda in
support of facilitated suicide has been
served by professional associations
that should, as a matter of principle
and duty, have been the most adamant
advocates of demanding that national
policy be based on relevant evidence-
based clinical input rather than
ideology.
Others have written how, on policy
discussions of medically administered
death, “neutrality by organized
medicine is neither neutral nor
appropriate” [31,32]. We agree and
believe that in this debate, medical
organizations have a moral and
professional obligation to provide
expert evidence-based input, rather
than taking refuge behind a false
neutrality. Indeed, in many ways the
1948 Declaration of Geneva, the 1949
International Code of Medical Ethics,
and the very foundation of the World
Medical Association were prompted
by the realization that medical
bodies had a moral and professional
obligation to provide responsible input
to societal policies, and not simply sit
on the sidelines [33].
After Bill C-7, the Road to March
2023 Implementation
Following the passage of the sunset
clause in 2021 pre-ordaining MAD
for mental illness by 2023, debate has
continued within the mental health
field regarding the appropriateness and
safety of providing MAD for mental
illness.There is longstanding evidence
in the few European countries that
allow psychiatric euthanasia that
unresolved psychosocial life suffering
such as poverty and loneliness fuels
many requests [34]; that unlike
assisted dying for terminal conditions,
which follows a 50:50 male to female
ratio, twice as many women as men
are euthanized for mental illness [35];
and that those seeking psychiatric
euthanasia could not be differentiated
from suicidal individuals [14,36]. The
2:1 female to male ratio of psychiatric
euthanasia is particularly concerning,
since it parallels the 2:1 female to
male ratio of those who attempt
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suicide, most of whom do not end up
dying by suicide, and most do not try
again. This raises obvious concerns of
whether psychiatric euthanasia risks
converting transient suicidality in
some to a permanent death by MAD,
which is 100% lethal.
Furthermore, evidence continues to
grow of individuals with physical
disabilities in Canada being driven to
MAD for poverty and life suffering
[37]. In some cases, individuals have
explicitly and publicly declared they
had sought MAD due to poverty and
not due to illness related suffering
[38]. Research has also recently
begun to reveal the very real concern
about potential non-assisted suicide
contagionastheresultofnormalization
of euthanasia in the Benelux countries,
especially for women [39].
Despite these developments creating
reasonable grounds for caution, some
groups favouring MAD expansion
continued to advocate for further
expansion. Dying With Dignity
Canada labelled it a “myth” that
“vulnerable populations can be eligible
for MAID if they are suffering from
inadequate social supports”, and claimed
“No one can receive MAID on the basis of
inadequate housing, disability supports,
or home care” [40]. In contrast, others
such as the Expert Advisory Group on
MAiD pointed out that, “This ignores
common sense and established scientific
evidence that one’s cumulative suffering is
not just from illness but often fueled by life
distress” [41]. Furthermore, the tragic
reality is that MAD has already been
provided to individuals in Canada who
themselves acknowledged they had
been driven to seek and receive MAD
because of their psychosocial suffering.
Expert Panel Process
After the abrupt inclusion of mental
illness as a basis for MAD in the
new legislation, the government
appointed an expert panel to design
protocols, guidelines, and safeguards
to allow for the planned March 2023
implementation. The panel began its
work late in 2021. It should be noted
that the purpose of this panel was not
to consider whether it was appropriate,
safe or supported by evidence to allow
provision of MAD for mental illness.
It bears repeating that parliament had
committed to including MAD for
mental illness prior to a parliamentary
study of the evidence commissioned
from the CCA by the government for
this very purpose.
The members of this new advisory
panel were specifically selected and
tasked to provide instructions on
how to implement MAD for mental
illness, not whether this expansion
should occur. The chair of this panel
(who also sat on the Halifax Group
advocating for expansion) and several
members of the committee were
recognized as being among the most
ardent public advocates for legalizing
MAD for mental illness [42].
The panel’s report was delivered
in May 2022 [43]. Rather than
suggesting any additional safeguards
the panel report opined that “no further
legislative safeguards are required” prior
to providing MAD for mental illness.
In terms of protocols and guidelines,
the panel report failed to deliver
any specific guidance, evidence or
standards, instead stating that, “It is
not possible to provide fixed rules for how
many treatment attempts, how many
kinds of treatments,and over what period
of time” treatment should be tried
prior to providing death by MAD
for mental illness. Surprisingly to
many who work in the field of suicide
prevention, the panel acknowledged
that MAD for mental illness and
suicide could be the same thing
yet claimed Canadian society had
already made a choice that psychiatric
euthanasia should be provided anyway.
The panel stated that “society is making
an ethical choice to enable certain people
to receive MAiD…regardless of whether
MAiD and suicide are considered to be
distinct or not”.
To be clear, no public policy
consultations have shown broad
societal support to provide MAD to
suicidal individuals. The majority of
Canadians are likely unaware that the
law will allow persons with mental
illness to refuse treatments, or even
social interventions, and still qualify
for MAD, no matter the potential
likelihood of routine interventions
reducing their suffering or their desire
for suicide. It is remarkable in this
context that the federal expert panel
recommended no further legislative
safeguards, while concurrently
acknowledging suicide and psychiatric
euthanasia could be the same.
The 2017-2018 CCA Expert Panel
process, which reviewed evidence for
nearly a year and a half and had all 14
panelists sign off on the final report,
openly identified several significant
key unresolved issues related to
MAD for mental illness. In contrast,
the 2022 government appointed
expert panel had two of the initial 12
members resign. These two panelists
publicly wrote about their concerns
regarding both the panel process, and
its outcome and recommendations.
This included the panel’s health care
ethicist,who wrote in an editorial after
he resigned that “in good conscience” he
could not sign off on the report, and
cited process flaws including “the chair
being a nationally-recognized, strong
advocate” for MAD for mental illness
and a “lack of reporting transparency
regarding dissenting opinions or views”
[42]. The patient consumer advocate
with lived experience who resigned
also wrote publicly, and testified in
parliamentary hearings, that she had
been shamed by other panelists when
she attempted to introduce cautions
about MAD for mental illness and
described the panel process as flawed
and rushed. She stated that “panel
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members simply did not want to put
forward any serious safeguards that
would require the law to change” [44],
and she also raised concerns that her
disability accommodation requests
had not been addressed.
Others on the panel defended
the panel process. Some testified
in parliamentary hearings that
parliamentarians should not give
credence to those expressing cautions
about MAD who were not also
MAD providers themselves, going
as far as suggesting committee
members may have been given “false
information” by others “who are not
involved in MAID assessment or
provision” [45]. Such suggestions
implied that testimony or evidence
provided by conscientious objectors,
or by those who expressed concerns
but were not MAD providers, should
be rejected or discounted because
those individuals themselves were
not already participating in Canada’s
MAD assessments. Some witnesses
in the hearings raised concerns about
the hearing process reflecting political
theater rather than true consultation,
with some parliamentarians being
dismissive of testimony provided by
those expressing any cautions about
MAD expansion and preventing
them from responding to questions
[46]. In one case, presumably in an
attempt to question the credibility
of an international invited witness,
the senator who proposed the sunset
clause insisted on short answers
to a series of questions, including
whether that witness was trained as a
MAiD assessor, and when the answer
was “no”, asked how many MAiD
assessments that witness had done,
and proceeded to ask if the witness
knew of specific drug dosing protocols
used to administer MAiD in Canada.
This particular witness was an expert
consultation-liaison psychiatrist from
Ireland, where assisted suicide is not
legal and there are no assisted suicide
cases, assessments or assessors [47].
A Rare Area of Agreement
The path towards MAD expansion
for mental illness in Canada has been
a controversial one. There has not
been any consensus in the psychiatric
profession that MAD for mental
illness should be provided, and many
have expressed concern that Canada’s
policies have not been driven by, or
have even actively ignored, medical
evidence [48,49]. One perhaps
unexpected area of agreement between
those cautioning against expansion of
MAD for mental illness, and some
groups advocating for it has been the
area of predicting irremediability of
mental illness.
Those cautioning against MAD
expansion for mental illness cite
evidence, consistent with the CCA
Expert Panel findings,that predictions
of irremediability in individual cases
of mental illness cannot be made [14].
As Toronto’s Centre for Addiction and
Mental Health concluded in its report
on mental illness and assisted dying,
“At any point in time it may appear
that an individual is not responding to
any interventions – that their illness
is currently irremediable – but it is not
possible to determine with any certainty
the course of this individual’s illness.
There is simply not enough evidence
available in the mental health field at this
time for clinicians to ascertain whether a
particular individual has an irremediable
mental illness” [50]. Given the high
degree of concurrent psychosocial
suffering in those with mental illness,
others have also raised concerns about
what is potentially being considered
irremediable: is it illness symptoms,
social suffering, or other issues which
could potentially be remediated, and
are fueling MAD for mental illness
requests [51].
Evidence continues to demonstrate the
inability to make accurate or scientific
predictions of irremediability in cases
of mental illness. In fact, science tells
us the chance of such predictions being
right amounts to chance or less. A
recent review demonstrated that even
when using precision modeling only
47% of “irremediability” predictions
for depression ended up being correct,
which is worse than flipping a coin
[52].
Consistent with this evidence, even
the Quebec psychiatrist association
(Association des Médecins Psychiatres
du Québec, AMPQ) that supported
MAD for mental illness acknowledged
that predictions of irremediability
cannot be made in mental illness. In a
2020 report co-authored by the same
2022 federal panel chair, the AMPQ
acknowledged that, “It is possible that a
person who has recourse to MAID could
have regained the desire to live at some
point in the future” [53]. The authors
then go on to say that determining
eligibility for MAD would be an
“ethical question each and every time”
an individual assessor evaluates a
request (instead of an evidence-
based or accurate medical assessment
determining that nothing more can
be done, or that recovery or reduced
suffering is not possible).
The risks of proceeding with an
absence of standards or evidence are
obvious, and have already been shown
in Canada. As mentioned,prior to Bill
C-14 in 2016, a 58-year-old woman
suffering from conversion disorder
(unexplained physical symptoms) was
granted access to MAD by the Court
of Appeal in the province of Alberta
[4]. Public court filings show that the
psychiatrist,who assessed the situation
as being irremediable in this case, also
opined that the patient had capacity
to consent. However, the psychiatrist
never saw or spoke with the patient,
and remarkably, the psychiatrist’s
opinions were based only on a chart
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review [4].
It cannot be denied that we
lack the evidence, protocols, and
medical standards for predicting
irremediability in individual cases of
mental illness. Canada’s assisted dying
laws did not anticipate or stipulate that
determining irremediability was to
be each individual assessor’s “ethical”
decision. Such a glaring lack of
standards leaves it open to the vagaries
of guesswork and individual assessors’
ideologies, which risks providing a
sanction of death under the guise of a
faulty scientific assessment for many
who would have otherwise recovered.
Conclusion and the Path Forward
The road to MAD expansion for
sole mental illness in Canada has not
been paved with evidence or expected
expert medical association guidance.
As discussed in our previous piece in
this journal, providing assisted death
to vulnerable and disabled individuals
who are not otherwise dying represents
a fundamental shift not just in medical
practice, but also reflects a sea change
in public policy and the social contract.
As assisted dying in Canada is
increasingly being provided to those
outside end-of-life situations, this sea
change includes what many would
have previously thought unimaginable
– a normalization of death as a
treatment for otherwise resolvable
social suffering.
The scope of this normalization is
becoming increasingly apparent.
When asked in the House of
Commons about concerns regarding
“the vulnerable falling through the
cracks and serious abuses under the
MAiD regime”, the Prime Minister
defended Canada’s MAD expansion
[54]. Minister of Justice Lametti,
who in 2020 expressed concern about
the risk of providing MAD to patients
who could improve, now seems to
believe we should make it easier for
those ambivalent about suicide to
die. When asked about concerns
raised regarding Canada’s pending
MAD expansion to mental illness, he
defended the expansion and suggested
thatMAD“providesamorehumaneway
for [people with mental illness] to make a
decision” about dying when “for physical
reasons and possibly mental reasons,
[they] can’t make that choice themselves
to do it themselves” [55]. The Minister
also said in the same interview that
the Supreme Court had confirmed
in the Carter decision a ‘right to
suicide’ in Canada, even though no
such explicit recognition can be found
in the decision. These remarkable
statements, coming from one of the
key persons entrusted with responsibly
implementing Canada’s assisted dying
laws,were shocking to many of us who
understand the purpose and premise
of suicide prevention.
Regardless of the various opinions
regarding assisted dying, it is clear that
neither evidence nor expert input has
informed Canada’s pending expansion
of MAD for sole mental illness, and
that Canada’s MAD expansion
policies are being fueled by a
remarkable ignorance of the principles
of suicide prevention versus suicide
facilitation. This raises troubling
questions for society in general
but particularly for the medical
community. If a psychiatry trainee
failed to ask about suicidality during
their clinical licensure examinations,
they would likely not pass their exams.
If a psychiatrist failed to ask about
suicidality and a depressed patient
subsequently harmed themselves, that
psychiatrist could face medico-legal
and professional consequences. When
a national psychiatric organization
fails to mention suicide risks associated
with mental illness during public
consultations on persons with mental
illness seeking death, and national
policies are shaped accordingly, what
consequences ensue?
Canada is now in the remarkable
position of being a few short months
away from providing MAD to
non-dying individuals suffering
solely from mental illness, despite
an ongoing absence of standards or
evidence-based guidance. We cannot
honestly or scientifically assess these
vulnerable individuals as having
irremediable conditions, we cannot
predict who could and would improve,
and we cannot distinguish suicidal
individuals who would benefit from
suicide prevention from those seeking
facilitated suicide by physician. We are
planning to provide this because of a
“sunset clause” based on less evidence
than required for introducing any
sleeping pill [56], and following our
federal panel’s guidance that provides
fewer guidelines than required to bake
a cake [57].
Canada’s rapid MAD expansion is
understandably garnering worldwide
attention. We are hopeful that
outlining the process so far followed
in Canada assists other jurisdictions
in following more deliberative and
evidence-informed processes in
shaping their policies.
Within Canada, many mental
health leaders and psychiatrists are
understandably concerned, regardless
of personal views on assisted dying in
general, about the continued vacuum
regarding basic standards related to
our imminently pending fundamental
shift of psychiatric practice. There
are increasing public calls to defer
the planned March 2023 MAD for
mental illness expansion to allow
for further deliberative review [58],
including a formal “Call to Action”
issued 10 November 2022 calling on
mental health and policy leaders to
advocate for delay of any potential
implementation of MAD for mental
illness pending proper evidence-based
review and recommendations [59].
This Call has been endorsed by the
Canadian Association for Suicide
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Prevention, and on 1 December 2022,
the Association of Chairs of Psychiatry
in Canada joined in calling for a delay
and issued a statement that more
time is needed to develop standards
of care before allowing MAD for
mental illness [60]. However, at the
time of writing, we remain uncertain
which patients, as of 1 March 2023,
we will engage in established suicide
prevention programs, and which may
be referred instead for assisted suicide.
The primary author, Dr. K. Sonu, is
a former president of the Canadian
PsychiatricAssociation,testifiedbefore
Bill C-14 and Bill C-7 parliamentary
committees, and acted as an expert
for the former Minister of Justice/
Attorney General of Canada in the
Truchon and Lamb cases. Along
with co-author Dr. John Maher,
he has initiated a Call to Action
to defer Canada’s planned March
2023 expansion of MAD for mental
illness (https://www.socpsych.org/
calltoaction).
Addendum: Following the submission
of this piece on 15 December 2022,
the federal government announced
that it would delay the March 2023
implementation of MAD for mental
illness. However, although it did not
indicate the length of such delay, it
emphasized that it still intends to
introduce MAD for mental illness.
References
1. Coelho R, Gaind K, Lemmens
T, Maher J. Normalizing death
as “treatment” in Canada: whose
suicides do we prevent, and whose
do we abet? World Medical Jour-
nal. 2022;70(3):27-35.
2. Parliament of Canada. Bill C-14
[Internet]. 2016 [cited 2022
Nov 27]. Available from: https://
www.parl.ca/DocumentViewer/
en/42-1/bill/C-14/royal-assent
3. Supreme Court of Canada.
Carter vs. Canada (Attorney
General) [Internet]. 2015 [cited
2022 Oct 4]. Available from:
https://scc-csc.lexum.com/scc-
csc/scc-csc/en/item/14637/index.
do
4. Alberta Court of Appeal. Canada
(Attorney General) vs E.F. 155
[Internet]. 2016 [cited 2022
Nov 27]. Available from: https://
www.canlii.org/en/ab/abca/
doc/2016/2016abca155/2016ab-
ca155.html
5. Hurwitz T. Euthanasia in mental
illness: a four part series − Part I:
the case of EF. J Ethics in Mental
Health. 2018;10:1-10.
6. Parliament of Canada. Bill C-7
[Internet]. 2021 [cited 2022 Nov
27]. Available from: https://parl.
ca/DocumentViewer/en/43-2/
bill/C-7/royal-assent
7. Cour Supérieure. Truchon c.
Procureur General du Canada,
2019 QCCS 3792. 2019 [cited
2022 Nov 27]. Available from:
https://www.canlii.org/en/qc/
qccs/doc/2019/2019qccs3792/201
9qccs3792.html
8. Lemmens T, Jacobs L. The latest
medical assistance in dying
decision needs to be appealed:
here’s why. The Conversation
[Internet]. 2019 [cited 2022 Oct
5]. Available from: https://the-
conversation.com/the-latest-med-
ical-assistance-in-dying-deci-
sion-needs-to-be-appealed-heres-
why-124955
9. Parliament of Canada. Bill C-7
First Reading [Internet]. CTV
News. 2020 [cited 2022 Nov
27]. Available from: https://parl.
ca/DocumentViewer/en/43-2/
bill/C-7/first-reading
10. Open Parliament Canada.
Statement by David Lametti on
criminal code [Internet]. 2020
[cited 2022 Oct 30]. Available
from: https://openparlia-
ment.ca/debates/2020/2/26/
david-lametti-1/only/
11. Parliament of Canada. Senate
Hearings Testimony [Internet].
2020 [cited 2022 Nov 29].
Available from: https://
s e n c a n a d a . c a / e n / C o n –
tent /Sen /Commit tee/432/
LCJC/03EV-55073-E
12. Senate of Canada. Bill to
Aamend Criminal Code – Third
Reading – Debate [Internet].
2021 [cited 2022 Nov 29].
Available from: https://sencana-
da.ca/en/senators/kutcher-stan/
interventions/553870/11
13. Bryden J. Senators amend MAID
bill to put 18-month time limit on
mental illness exclusion [Internet].
2021 [cited 2022 Oct 30].
Available from: https://www.
ctvnews.ca/politics/senators-
amend-maid-bill-to-put-18-
month-time-limit-on-mental-
illness-exclusion-1.5302151
14. Council of Canadian Academies.
The state of knowledge on
medicalassistanceindyingwherea
mental disorder is the sole
underlying medical condition.
Ottawa (ON): The Expert
Panel Working Group on MAID
where a Mental Disorder is
the Sole Underlying Medical
Condition [Internet]. 2018 [cited
2022 Nov 27]. Available from:
https://cca-reports.ca/reports/
medical-assistance-in-dying/
15. Council of Canadian Academies.
The state of knowledge on
advance requests for medical
assistance in dying. 2018 [cited
2022 Nov 27]. Available from:
Canada’s Medically Administered Death (MAD) Expansion for Mental Illness: Targeting the Most Vulnerable
BACK TO CONTENTS
80
https://cca-reports.ca/reports/
medical-assistance-in-dying/
16. Council of Canadian Academies.
The state of knowledge on
medical assistance in dying for
mature minors. 2018 [cited
2022 Nov 27]. Available from:
https://cca-reports.ca/reports/
medical-assistance-in-dying/
17. The Halifax Group; Andrew MK,
Chandler JA, Downie J, Flood
CMM, Frank A, Gupta M, et al.
MAiD Legislation at a Crossroads:
Persons with Mental Disorders
as their Sole Underlying
Medical Condition. IRPP Report.
2020. Available from: https://dig-
italcommons.schulichlaw.dal.ca/
reports/14/
18. Expert Advisory Group on
MAiD. Canada at a Crossroads:
Recommendations on Medical
Assistance in Dying and Persons
with a Mental Disorder − An
Evidence‐based Critique of the
Halifax Group IRPP Report.
[Internet]. 2020 [cited 2022 Oct
30]. Available from: https://www.
eagmaid.org/report
19. Murphy S. Canadian Medical
Association and euthanasia
and assisted suicide in Canada:
Critical review of CMA approach
to changes in policy and law
[Internet]. 2018 [cited 2021 Apr
11]. Available from: https://www.
consciencelaws.org/background/
procedures/assist029-01.aspx
20. Chaimowitz G, Freeland A,
Neilson G, Mathew N,
Rasasingham R, Snelgrove N,
et al. Medical Assistance in
Dying Position Statement.
Canadian Psychiatric Association.
2020;65(9):664-7.
21. Gaind KS. What does
“irremediability” in mental
illness mean? Can J Psychiatry.
2020;65(9):604-6.
22. Gaind S. Professional medical
associations failing to provide
evidence in MAID debate
[Internet]. The Hamilton
Spectator. 2021 [cited 2022
Oct 4]. Available from: https://
w w w.thespec.com/opinion/
contributors/2021/03/09/pro-
fessiona l-medica l-associa-
tions-failing-to-provide-evi-
dence-in-maid-debate.html
23. Canadian Psychiatric Association.
Brief to the Standing Committee
on Justice and Human Rights Bill
C-7 [Internet]. 2020 [cited 2022
Oct 4]. Available from: https://
www.cpa-apc.org/wp-content/up-
loads/Brief-JUST-12-Nov-2020-
FIN.pdf
24. Canadian Psychiatric Association.
Brief to the Senate of Canada
Standing Committee on Legal
and Constitutional Affairs Bill
C-7 [Internet]. 2020 [cited 2022
Oct 4]. Available from: https://
www.cpa-apc.org/wp-content/up-
loads/Brief-LCJC-23-Nov-2020-
FIN.pdf
25. Canadian Psychiatric Association.
Letter from CPA, to the Hon
Mobina Jaffer, Chair, Standing
Committee on Legal and
Constitutional Affairs [Internet].
2021 [cited 2022 Oct 4]. Available
from: https://sencanada.ca/Con-
tent/Sen/Committee/432/LCJC/
briefs/CanadianPsychiatricAsso-
ciation_e.pdf
26. SenateofCanada.43rdParliament,
2nd Session testimony
[Internet].2020[cited2022Oct4].
Available from: https://
s e n c a n a d a . c a / e n / C o n –
tent /Sen /Commit tee/432/
LCJC/02ev-55071-e
27. Lemmens T, Shariff M, Herx L.
How Bill C-7 will sacrifice the
medical profession’s standard of
care [Internet]. Policy Options.
2021 [cited 2022 Oct 4]. Available
from: https://policyoptions.irpp.
org/magazines/february-2021/
how-bill-c7-will-sacrifice-the-
medical-professions-standard-of-
care/
28. College of Physicians and
Surgeons of Ontario. CPSO’s
effective referral requirement
affirmed by Superior Court
[Internet]. 2018 [cited 2022 Nov
27]. Available from: https://www.
cpso.on.ca/News/News-Articles/
CPSOs-Effective-Referral-Re-
quirement-Affirmed-by
29. Krausert S. Letter re:CPA’s
Discussion Paper on Medical
Assistance in Dying (“MAID”)
[Internet]. 2021 [cited 2022
Nov 30]. Available from:
https://static1.squarespace.
com/static/5ec97e1c4215f502­
6a674116/t/619bc64ac4828­­
15740760931/16375987950­
7 0­/ L e t t e r + t o + C PA+ r e + ­
Discussion+Paper+­on+MAiD+­
%2820­21­+11+20%29.pdf
30. Senate of Canada. 43rd
Parliament, 2nd Session
Testimony [Internet]. 2020
[cited 2022 Oct 4]. Available
from: https://sencanada.ca/en/
Content/Sen/Committee/432/
LCJC/02ev-55071-e
31. Sulmasey D, Finlay I, Fitzgerald
F, Foley K, Payne R, Siegler M.
Physician-assisted suicide: why
neutrality by organized medicine
is neither neutral nor appropriate.
J Gen Intern Med. 2018;33(8):
1394-9.
32. Kheriaty A. First, take no
stand: on assisted suicide, the
medical profession ducks behind
Canada’s Medically Administered Death (MAD) Expansion for Mental Illness: Targeting the Most Vulnerable
BACK TO CONTENTS
81
“neutrality” [Internet]. The New
Atlantis. 2019. [cited 2022 Nov
27]. Available from: https://www.
thenewatlantis.com/publications/
first-take-no-stand
33. Murphy S, Coelho R, Violette
PD, Goligher EC, Lau T, Ru-
tledge Harding S. The WMA
and the Foundations of Medical
Practice: Declaration of Gene-
va (1948), International Code of
Medical Ethics. World Medical
Journal. 2020;66(3):2-8.
34. Verhofstadt M, Thienpont L,
Peters G. When unbearable
suffering incites psychiatric
patients to request euthanasia:
qualitative study.British Journal of
Psychiatry. 2017;211(4):238-45.
35. Kim SYH, De Vries RG, Pet-
eet JR. Euthanasia and assisted
suicide of patients with
psychiatric disorders in the
Netherlands 2011 to 2014.JAMA
Psychiatry. 2016;73(4):362-8.
36. Nicolini M, Gastmans C, Kim
SYH. Psychiatric euthanasia,
suicide, and the role of gender.
British Journal of Psychiatry.
2022;220(1):10-3.
37. Cribb R, Buckley C, Gribilas
T. Michael’s Choice [Internet].
Toronto Star. 2022 [cited 2022
Nov 10] Available from: https://
www.thestar.com/2022/assist-
ed-death.html
38. Hoye B. Winnipeg woman
who chose to die with medical
assistance said struggle for
home care help led to decision
[Internet]. CBC News. 2022
[cited 2022 Nov 27]. Available
from: https://www.cbc.ca/news/
canada/manitoba/sathya-dharma-
kovac-als-medical-assistance-in-
death-1.6605754
39. Jones DA. Euthanasia, assisted
suicide, and suicide rates in
Europe. J Ethics in Mental
Health. 2022;11:1-35.
40. Dying with Dignity Canada.
Myth: Vulnerable populations
can be eligible for MAID if they
are suffering from inadequate
social supports, including housing
[Internet]. 2022. [cited 2022 Nov
27]. Available from: https://www.
dyingwithdignity.ca/advocacy/
myths-and-facts-medical-assis-
tance-in-dying-maid-in-canada/
41. Expert Advisory Group
on MAiD. EAG Brief to
Parliamentary Committee on
MAiD [Internet]. 2022 [cited
2022 Nov 27]. Available from:
https://www.eagmaid.org/brief
42. Kirby, J. MAiD expert panel
recommendations are inadequate,
contends panel member who
resigned [Internet]. Hill Times.
2022 [cited 2022 Nov 27].
Available from: https://www.
hilltimes.com/story/2022/06/16/
maid-expert-panel-recommen-
dations-are-inadequate-con-
tends-panel-member-who-re-
signed/270807/
43. Health Canada. Final Report of
the Expert Panel on MAID and
Mental Illness [Internet]. 2022
[cited 2022 Nov 27]. Available
from: https://www.canada.ca/en/
health-canada/news/2022/05/
final-report-of-the-expert-panel-
on-maid-and-mental-illness.html
44. Cohen, E. Why I resigned from
the federal expert panel on
medical assistance in dying
[Internet]. Globe and Mail. 2022.
[cited 2022 Nov 27]. Available
from: https://www.theglobeand-
mail.com/opinion/article-ex-
pert-panel-maid-mental-illness/
45. Parliament of Canada. AMAD
Parliamentary Committee
Meeting Testimony [Inter-
net]. 2022 [cited 2022 Nov 27].
Available from: https://parl.
ca/DocumentViewer/en/44-1/
AMAD/meeting-16/evidence
46. Campbell I. Committee treating
MAID as ‘beneficial solution
to all forms of suffering’ despite
‘deeply problematic reports of
its use’, warn disability advocates
[Internet]. Hill Times. 2022
[cited 2022 Nov 23] Available
from: https://www.hilltimes.
com/story/2022/11/23/commit-
tee-treating-maid-as-benefi-
cial-solution-to-all-forms-of-suf-
fering-despite-deeply-problemat-
ic-reports-of-its-use-warn-disa-
bility-advocates/356442/
47. Parliament of Canada. AMAD
Parliamentary Committee
Meeting Testimony [Internet].
2022 [cited 2022 Nov 27].
Available from: https://parl.
ca/DocumentViewer/en/44-1/
AMAD/meeting-18/evidence
48. Gaind KS. Medical assistance
in dying for mental illness
ignores safeguards for vulnerable
people [Internet]. The
Conversation. 2020 [cited 2022
Nov 27]. Available from: https://
bit.ly/3OJwUTv
49. Sinyor M. Lack of evidence-based
medicine in debate around new
MAID law should concern
Canadians [Internet]. CBC
News Opinion. 2021 [cited 2022
Nov 27]. Available from: https://
www.cbc.ca/news/opinion/opin-
ion-medical-assistance-in-dy-
ing-maid-1.5934977
50. Centre for Addiction and
Mental Health. Policy Advice on
Medical Assistance in Dying and
Mental Illness [Internet]. 2017
Canada’s Medically Administered Death (MAD) Expansion for Mental Illness: Targeting the Most Vulnerable
BACK TO CONTENTS
82
[cited 2022 Oct 4]. Available
from: https://www.camh.ca/-/
media/files/pdfs—public-poli-
cy-submissions/camh-position-
on-mi-maid-oct2017-pdf.pdf
51. Gaind KS. The next national
apology: future Canadians might
regret expansion of medically
assisted dying laws [Internet].The
Conversation. 2021 [cited 2022
Nov 27]. Available from: https://
bit.ly/3F4cotz
52. Nicolini ME, Jardas E, Zarate
CA, Gastmans C, Kim SYH.
Irremediability in psychiatric
euthanasia: examining the
objective standard. Psychological
Medicine. 2022:1-19.
53. Association des Médecins
Psychiatres du Québec. AMPQ
Discussion Paper on Access to
Medical Assistance in Dying for
People with Mental Disorders
[Internet]. AMPQ. 2020. [cited
2022 Nov 27]. Available from:
https://ampq.org/wp-content/up-
loads/2020/12/mpqdocreflexion-
ammenfinal.pdf
54. MSN News. Trudeau defends
MAID legislation after
ConservativeMPpointsto‘serious
abuses’[Internet].2022[cited2022
Nov 27]. Available from: https://
w w w.msn.com/en-ca/news/
world/trudeau-defends-maid-leg-
i s l a t i o n – a f t e r- c o n s e r v a-
tive-mp-points-to-serious-abuses/
vi-AAXatLt?category=foryou
55. Raj A. Is Canada extending
Medical Assistance in Dying
too quickly [Internet]? Toronto
Star. 2022 [cited 2022 Nov 18].
Available from: https://www.
thestar.com/podcasts/its-po-
litical/2022/11/18/is-cana-
da-expanding-medical-assis-
tance-in-dying-too-quickly.html
56. Health Canada. How drugs are
reviewed in Canada [Internet].
2015 [cited 2022 Nov 27].
Available from: https://www.
canada.ca/en/health-canada/
services/drugs-health-prod-
ucts/drug-products/fact-sheets/
drugs-reviewed-canada.html
57. Food Network. How to bake
a cake: a step-by-step guide
[Internet]. 2015 [cited 2022 Nov
27]. Available from: https://www.
foodnetwork.com/how-to/arti-
cles/how-to-bake-a-cake-a-step-
by-step-guide
58. Star Editorial Board. We need
to put the brakes on expanding
access to MAiD [Internet].
Toronto Star. 2022 [cited 2022
Nov 25]. Available from: https://
www.thestar.com/opinion/edito-
rials/2022/11/25/medically-as-
sisted-deaths.html?rf
59. Society for Canadian Psychiatry.
Call to Action [Internet]. 2022
[cited 2022 Nov 27]. Available
from: https://www.socpsych.org/
calltoaction
60. Anderssen E. Medical experts call
on government to delay expansion
of MAID for mental illness [In-
ternet].Globe and Mail.2022 [cit-
ed 2022 Dec 1]. Available from:
https://www.theglobeandmail.
com/canada/article-maid-de-
lay-mental-illness-medical-ex-
perts/
K.Sonu Gaind, MD,
FRCP(C), DFAPA
Professor, University of Toronto
Chief, Psychiatry and Physician
Chair Assisted Dying Team,
Humber River Hospital
Toronto, Ontario, Canada
sonu.gaind@utoronto.ca
Trudo Lemmens, LicJur
LLM (Bioethics), DCL
Professor and Scholl Chair,
Faculty of Law and Dalla Lana
School of Public Health
University of Toronto.
Toronto, Ontario, Canada
Trudo.Lemmens@utoronto.ca
Ramona Coelho, MDCM, CCFP
Family Doctor
London, Ontario, Canada
drramonacoelho@gmail.com
John Maher,MD, FRCPC
President, Ontario Association
for ACT & FACT
Editor-in-Chief, Journal of
Ethics in Mental Health
Barrie, Ontario, Canada
jmaher@cmhastarttalking.ca
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83
2022 Monkeypox Outbreak – Teachings from Concurrent Public Health Emergencies
As we approach the end of 2022, we
find ourselves combatting two large-
scale viral outbreaks simultaneously
in the global health landscape.
While the monkeypox outbreak has
not yet reached a scale comparable
to the coronavirus disease 2019
(COVID-19),close attention must be
paid to its current paradigms of spread,
if we are to avoid the development of
another pandemic.
Monkeypox is a viral zoonosis
that is very closely related to other
poxes, such as the variola (smallpox),
cowpox, and vaccinia viruses [1,2].
This virus was first isolated in 1958
from a colony of captive monkeys at a
research institute in Copenhagen [3].
However,monkeypox was not isolated
from a human case until 1970, when
an infant fell ill with a pox-like disease
in an area of the Democratic Republic
of the Congo (DRC) that had already
eradicated smallpox [4]. Since then,
two clades of the monkeypox virus
have become endemic in tropical
forest regions in Africa, with Clade
I dominating in Central Africa and
Clade II dominating in West Africa
[2]. Human-to-human transmission
can occur through close physical
contact with an infected person or
recently contaminated object, as well
as less commonly through contact
with respiratory droplets. Prior
to 2022, outbreaks of monkeypox
outside of its two endemic regions
have largely been small and self-
contained, primarily caused by tourist
or medical travel from one of these
two regions [5].
Current State of Monkeypox
Since the beginning of this outbreak
in May 2022, the burden of reported
monkeypox cases has shifted from
Europe and Africa towards the
Americas. As the focus of reporting
and resource allocation shifts similarly,
it is important to recognize potential
flaws in the metrics associated with
this outbreak. Monkeypox cases
in Africa are likely to be severely
underreported due to a combination
of limited testing resources, access
to health care, and ongoing fear
of acquiring COVID-19 in health
facilities in some regions [6].
On 23 July 2022, Dr.Tedros Adhanom
Ghebreyesus, the Director-General
of the World Health Organization
(WHO), formally declared this year’s
monkeypox outbreak to be a public
health emergency of international
concern (PHEIC) [7]. This decision
came after over 16,000 cases had been
reported across 75 countries globally,
on the grounds of rapid and novel
spread as well as a determined risk to
human health. Perhaps more notably,
this decision came despite the WHO
Emergency Committee not reaching
a consensus on the subject – a notable
digression from the protocol of
previously declared PHEICs [8].
Regardless, after this declaration,
reported case rates peaked and have
since begun to decline globally [9].
As of 9 December 2022, 82,474
cases have been confirmed, with
over 82,474 of those coming from
regions that historically had not
reported cases of monkeypox [10].
Though case rates are currently
declining, it is important to consider
the socioeconomic factors that have
played into the demographics of this
outbreak as we seek to prevent future
spikes.
Disparities in Diagnostics and
Treatment
In the Global North, the declining
monkeypox case rates may be
attributed in part to increased
public health campaigning around
vaccination in at-risk communities
[11]. In these regions, communities
of men who have sex with men
(MSM) have been the most
affected by this outbreak, with social
stigma around sexual transmission
contributing to miseducation and
underdiagnosis [12,13]. Members of
this community who are also human
immunodeficiency virus (HIV)-
positive find themselves at greater
risk of infection and complications,
particularly within otherwise
marginalised communities due to
racial or ethnic backgrounds [12,14].
African countries involved in this
outbreak, such as the DRC and
Nigeria, also find themselves at a
similar disadvantage in reporting
and resource acquisition. Testing has
been extremely limited in these areas,
Priscilla Cruz
Caline Mattar
2022 Monkeypox Outbreak –
Teachings from Concurrent Public Health Emergencies
BACK TO CONTENTS
84
with the Africa Centres for Disease
Control and Prevention recognizing
that their statistics are underreporting
the extent of the outbreak on the
continent [6]. Combined with
similarly limited preventative and
treatment options, this has led to over
100 reported monkeypox deaths in
the DRC this year [15].As of October
2022, no monkeypox vaccines are
widely available in these affected
regions,with the majority of currently
available vaccine doses remaining in
the United States and Europe [6,16].
Management Options
For most mild-to-moderate cases
of monkeypox, symptoms will
resolve merely with supportive
care. Additionally, there are several
therapeutic options for management
ofmoreseverecases.Smallpoxantiviral
therapies such as tecovirimat and
brincidofovir may be used with some
success, although these treatments
have not undergone extensive studies
for monkeypox usage yet [17,18].
Where available, these options are
particularly indicated in patients who
may have a higher risk for developing
severe complications, such as children
and the immunocompromised.
In resource-rich areas, the primary
management strategy used to control
this outbreak has been vaccination
[16]. Information from existing
literature on the efficacy and
effectiveness of existing pox vaccine
formulations against monkeypox
infection is currently minimal and at
times contradictory [17,19].However,
historical smallpox vaccines have
been shown to produce monkeypox-
neutralising antibodies, and third-
generation modified vaccinia Ankara
(MVA) vaccines have become
more widely available for use in the
Americas and Europe during this
outbreak [16].
Conclusion
The monkeypox outbreak is not the
first time that stigma and inequities
have caused an infectious epidemic to
go out of control, and it will likely not
be the last.High-income countries are
well resourced to combat a potential
pox outbreak, whereas the areas that
are hardest hit continue to struggle
without any access to vaccines or
treatments. As a global medical
community, we must advocate for
a more equitable distribution of
resources, surveillance, and workforce.
If we have learned anything from the
COVID-19 pandemic, it should be
thatearlypreventionandmanagement
is crucial in preventing disease spread
– and that the consequences of not
doing so can be catastrophic.
References
1. Kaler J, Hussain A, Flores
G, Kheiri S, Desrosiers D.
Monkeypox: a comprehensive
review of transmission,
pathogenesis, and manifestation.
Cureus. 2022;14(7):e26531.
2. KumarN,AcharyaA,Gendelman
HE, Byrareddy SN. The 2022
outbreak and the pathobiology
of the monkeypox virus. J
Autoimmun. 2022;131:102855.
3. Magnus P von, Andersen EK,
Petersen KB, Birch-Andersen A.
A pox-like disease in cynomolgus
monkeys. Acta Pathol Microbiol
Scand. 1959;46(2):156-76.
4. Ladnyj ID, Ziegler P, Kima E.
A human infection caused by
monkeypox virus in Basankusu
Territory, Democratic Republic
of the Congo. Bull World Health
Organ. 1972;46(5):593-7.
5. World Health Organization.
Monkeypox [Internet]. 2022
[cited 2022 Nov 15]. Available
from: https://www.who.int/
news-room/fact-sheets/detail/
monkeypox
6. Al Katanty D, Mcallister
E. In Africa’s monkeypox
outbreak, sickness and death
go undetected [Internet].
Reuters. 2022 [cited 2022 Nov
15]. Available from: https://
www.reuters.com/business/
healthcare-pharmaceuticals/
a f r i c a s – m o n k e y p o x –
outbreak-sickness-death-go-
undetected-2022-10-31/
7. World Health Organization.
WHO Director-General’s
statement at the press conference
following IHR Emergency
Committee regarding the
multi-country outbreak of
monkeypox – 23 July 2022
[Internet]. 2022 [cited 2022
Nov 15]. Available from: https://
www.who.int/director-general/
speeches/detail/who-director-
general-s-statement-on-the-
press-conference-following-
IHR-emergency-committee-
regarding-the-multi–country-
outbreak-of-monkeypox–23-
-july-2022
8. Wenham C, Eccleston-
Turner M. Monkeypox as a
PHEIC: implications for global
health governance. Lancet.
2023;400(10369):2169-71.
9. World Health Organization.
2022 Monkeypox outbreak:
global trends [Internet]. 2022
[cited 2022 Nov 15]. Available
from: https://worldhealthorg.
shinyapps.io/mpx_global/
10. U.S. Centers for Disease
Control and Prevention. 2022
Monkeypox outbreak global map
[Internet]. 2022 [cited 2022 Dec
12].Available from: https://www.
cdc.gov/poxvirus/monkeypox/
BACK TO CONTENTS
2022 Monkeypox Outbreak – Teachings from Concurrent Public Health Emergencies
85
response/2022/world-map.html
11. Reardon S. What does the future
look like for monkeypox? Nature.
2022;610(7931):250-2.
12. Morland S. Monkeypox apathy
will “condemn people to suffer,”
Latin American activists say
[Internet]. Reuters. 2022 [cited
2022 Nov 15]. Available from:
ht t ps://w w w.reuters.com /
world/americas/monkeypox-
apathy-will-condemn-people-
suffer-latin-american-activists-
say-2022-09-01/
13. World Health Organization.
Perceptions of monkeypox from
those most at risk: men who have
sex with men having multiple
sexual partners [Internet]. 2022
[cited 2022 Nov 15]. Available
from: https://www.who.int/
europe/news/item/26-08-2022-
perceptions-of-monkeypox-
from-those-most-at-risk–men-
who-have-sex-with-men-having-
multiple-sexual-partners
14. Miller MJ, Cash-Goldwasser S,
Marx GE, Schrodt CA, Kimball
A, Padgett K, et al. Severe
monkeypox in hospitalized
patients — United States, August
10–October 10, 2022. MMWR
Morb Mortal Wkly Rep.
2022;71(44):1412-7.
15. Africa Centres for Disease
Control and Prevention.
Outbreak Brief 11: Monkeypox
in Africa Union Member States
[Internet]. 2022 [cited 2022
Nov 15]. Available from: https://
africacdc.org/disease-outbreak/
outbreak-brief-11-monkeypox-
in-africa-union-member-states/
16. Rigby J, Grover N. Analysis:
Experts question reliance on
monkeypox vaccine with little
data, short supply [Internet].
Reuters. 2022 [cited 2022 Nov
15]. Available from: https://
www.reuters.com/business/
healthcare-pharmaceuticals/
experts-question-reliance-
monkeypox-vaccine-with-little-
data-short-supply-2022-08-23/
17. Rizk JG, Lippi G, Henry BM,
Forthal DN, Rizk Y. Prevention
and treatment of monkeypox.
Drugs. 2022;82(9):957-63.
18. Adler H, Gould S, Hine P, Snell
LB, Wong W, Houlihan CF, et al.
Clinicalfeaturesandmanagement
of human monkeypox: a
retrospective observational study
in the UK. Lancet Infect Dis.
2022;22(8):1153-62.
19. Zaeck LM, Lamers MM,
Verstrepen BE, Bestebroer TM,
van Royen ME, Götz H, et al.
Low levels of monkeypox virus
neutralizing antibodies after
MVA-BN vaccination in healthy
individuals. Nat Med. 2022.
Priscilla Cruz, BA
Medical Student, Washington
University School of Medicine
St. Louis, Missouri, United States
c.priscilla@wustl.edu
Caline Mattar, MD
Associate Professor of Medicine
and Associate Program Director,
Infectious Diseases
Fellowship Program, Washington
University School of Medicine
St. Louis, Missouri, United States
cmattar@wustl.edu
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2022 Monkeypox Outbreak – Teachings from Concurrent Public Health Emergencies
86
The ocean is the cradle where life
on the Earth occurs. The total area
of the ocean is about 361 million
square kilometres, which is 1.4 times
larger than the land area [1]. The
total volume of seawater is about 1.37
billion cubic kilometres, accounting
for more than 97% of the total water
volume of the Earth [2]. The ocean,
which plays an enormous role in
regulating the environment for human
survival and global climate change,
is a fundamental part of the global
life-support system. So far, only 5%
of the ocean floor has been explored
by humans, and the rest remains
unknown. It is far more difficult for
human beings to “catch the giant
turtles in the sea”than to “bring down
the moon from the ninth heaven”, so
the study of nautical medicine has a
long way to go.
Importance of the Ocean to Human
Beings
The importance of the ocean to
human beings is mainly reflected in
the following aspects:1) It is the cradle
of life in our planet, and evidence
shows that life began in the ocean;
2) It receives and absorbs most of the
solar energy reaching the surface of
the Earth; 3) It indirectly affects the
climate through material and energy
exchanges with the atmosphere; 4) It
regulates temperature; 5) Its chemical,
mineral, power, and biological
resources have brought great influence
on human production and life; 6)
The surface of seawater evaporates
and absorbs heat, where seawater
flows and spreads heat throughout
the whole water body through waves,
tides, and currents; 7) It is a source
of water vapour over land; and 8) As
the ocean continues to absorb carbon
dioxide and acidifies the ocean water,
the influx of fresh water from melting
glaciers could change climate-driven
ocean currents. This article describes
nautical medicine and marine
scientific research, which further
stresses the importance of oceans to
human beings.
Role of Nautical Medicine in
Chinese History
Nautical medicine, which has been
conducted in China for over 600
years, is a comprehensive subject
which includes medical research on
issues under seafaring conditions.
Between 1405 and 1433, the Chinese
navigator Zheng He led a large fleet
on seven explorations of vast regions,
known as the “West Oceans”. These
explorations opened the world-
renowned Maritime Silk Road,which
depended on the advanced nautical
medicine in China.These efforts were
demonstrated through three specific
observations.
Value of simple nautical preventive
medicine. Zheng He’s fleet was
equipped with a strong team of
doctors,with an average of one skilled
doctor for every 150 crew members.
They had sufficient food, fresh water,
and traditional Chinese medicine,
which formed an effective system of
preventive medicine. During these
voyages, cabin hygiene, personal and
diet hygiene, and living habits all
helped prevent the spread of scurvy,
“ship fever”, enteric diseases, and
other infectious diseases.
Complete logistical support system for
navigation. Zheng He’s fleet had
additional support ships,such as grain
vessels, water supply vessels, overseas
“support bases”, and procurement
of supplies along the route. On the
ships, nutritional resources aimed
to meet crew members’ needs over
several months. Fresh vegetables (e.g.
cabbage, turnips, bamboo shoots),
fruit (e.g. limes, lemons, organs,
grapefruit, coconuts), grains (e.g.
flour, millet, rice), and legumes (e.g.
soybeans) were bought on each route.
They also raised bean sprouts on the
ships for additional vitamins.
Geographical research conducted by
medical experts. The medical experts
of Zheng He’s fleet completed
the earliest nautical medical and
geographical research by applying
their profound knowledge with sea
travel. For example, the Records of
Countries in the Western Oceans, by
authorsYingyaShenglanandXingcha
Shenglan, offered a detailed travel
account to countries, regions, and
seaports. It also provided information
reported along the voyage about
mountains and rivers, weather and
climate, geography and surrounding
environments, local customs and
diets, hygiene practices and clothing,
and epidemic diseases.
Major Research and Development
of Nautical Medicine
(1) Marine Biological Research
Research of marine ecosystems is an
important field of nautical medicine.
The ocean is the largest “treasure
trove of resources” on the Earth,
accounting for more than 65%
Fang Xudong
Towards the Ocean-Blue Nautical Medicine
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Towards the Ocean-Blue Nautical Medicine
87
natural resources and 200,000 marine
species on our planet [3]. The wide
variety of marine microorganisms
has an inestimable influence on the
future development of medicine. For
example, cephalosporin antibiotics,
which are derived from the marine
fungus Cephalosporium acremonium,
have become the main drugs for the
prevention and treatment of infectious
diseases across the world. As the
research and development of marine
drugs is flourishing worldwide, the
total annual market demand is
expected to exceed US $100 billion.
Great progress has been made from
the basic research of marine natural
products and bioactive substances
to the biotechnology of marine
medicine and traditional Chinese
medicine. These advancements also
include the research and development
of crustacean resources and the
large-scale cultivation of genetically
modified marine species and
medicinal microalgae.
Marine drugs have shown unique
efficacy and research prospects in the
drug development of major harmful
diseases such as tumours, viral
infections, and cardiovascular and
cerebrovascular diseases. For example,
omega-3 fatty acids in fish oil have the
effects of preventing and managing
cardiovascular disease, as well as
anti-inflammatory, anti-cancer, and
immunity enhancement. Research
has shown that active substances
from shark cartilage can block
tumour angiogenesis. Additional
studies demonstrate marine
biotoxins, with high bioactivity and
unique pharmacological effects,
can serve as resources for biological
medicines, such as antibiotics,
anticancer agents, hemolysis agents,
anticoagulants, sedatives, anti-
radiation, and anti-aging medicines.
(2) Diving and Hyperbaric
Oxygenation Medicine
The high-pressure underwater
environment is key for future ocean
development, especially as we better
understand the physiology of diving
and hyperbaric oxygenation medicine.
In recent years, the capabilities of
diving operations across various
countries have developed steadily.
For example, the maximum effective
depth of conventional air diving is
around 60m,and the depth of helium-
oxygen saturation diving operation
can reach 150-200m or 300-350m.
The depth of laboratory simulation
reaches 675m, and the depth of deep-
sea training is about 450m.
In recent years, Chinese researchers
have contributed to scientific
advancements on high pressure
physiology, helium-oxygen diving
physiology, and submarine rescue and
physiology. Also, in-depth studies
have been conducted on neurological,
circulatory, respiratory, endocrine,
and other physiological functions,
including blood biochemical indices
and histopathological changes, laying
a foundation for future research
toward kilometre depth dives.
(3) Nautical Diseases
Ongoing research on nautical diseases
includes the protection against low-
dose, long-term nuclear radiation,
ergonomics of ships, man-machine
environment sciences, food and
housing resources of crew members,
impacts of electromagnetism on
humans, and physical, chemical, and
biological impacts of ship cabins
and air on humans. For example,
motion sickness refers to car, air, sea,
space motion or simulator sickness.
Females may be more susceptible
to motion sickness than males, and
the incidence rate varies greatly
with different motion environments.
Chinese researchers have contributed
to advancing the scientific knowledge
base within this field, including the
development of several effective anti-
motion sickness drugs and training
systems.
(4) Nautical Psychology
Nautical psychology incorporates the
study of the psychological phenomena
of seafarers who participate in all
types of navigation activities. It is
essential to closely examine the health
and well-being of crew members
by conducting psychological
assessments, identifying the
psychological values for completing
challenging navigation tasks, and
supporting clinical management for
diagnosed mental health problems.
The special environmental conditions
of marine operations – recognized
as a relatively closed environment,
high temperature, high humidity, and
high-intensity operation – requires
continuous improvement in the
technical elements and psychological
health of crew members. Also, such
workplace stressors can increase their
risk of experiencing psychological
imbalance and other mental health
challenges.
To explore the relationship between
seafarers’ illness and mental fatigue
during voyages, Chinese researchers
analysed blood hormone levels to
estimate the incidence of their illness
during the voyages by examining their
psychological state before,during,and
after these voyages. Results showed
that the adverse mental factors of
seafarers affected their immunity,
as an important observation linked
with the rising incidence of nautical
diseases.
Conclusion
China represents a country with
a vast maritime territory, with
access to long coastlines and seas.
Clinicians and researchers in nautical
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88
medicine can promote the value of
scientific research on the blue ocean
and national priorities to maintain
human and marine ecosystem health.
As colleagues, we can work and
make progress together as we better
understand, care for, and protect the
ocean in efforts to live in harmony
with nature.
References
1. NOAA Ocean Exploration.
How much of the ocean has been
explored? [Internet]. n.d. [cited
2022 Oct 1]. Available from:
https://oceanexplorer.noaa.gov/
facts/explored.html
2. World Bank Blogs. 7 things
you may not know about water
[Internet]. 2013 [cited 2022
Oct 1]. Available from: https://
blogs.worldbank.org/opendata/7-
things-you-may-not-know-
about-water
3. National Geographic.Sustainable
Earth: Oceans [Internet]. n.d.
[cited 2022 Oct 1]. Available
from: https://www.national­
geographic.com/environment/
article/oceans
Fang Xudong, MD
Chinese Society of Nautical Medicine,
Chinese Medical Association
cmazhaoweili@163.com
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89
WMA Members Share Reflections about One Health Day 2022
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The One Health concept highlights
the intricate links between the
health of humans, animals, and the
environment and showcases the need
for transdisciplinary collaborations
to address complex global health
challenges [1]. These emerging risks
affect the delicate balance within the
ecosystem, including the harmful
effects of air pollution, extreme
temperatures, vector-borne disease
transmission, and potential zoonotic
transmission on health. One Health
Day (https://onehealthday.com/
onehealthday) is commemorated on
November 3, and individuals and
groups across the world organize
various campaigns to increase
awareness of the One Health
concept through events, media
releases, and social media campaigns.
This international health day was
established in 2016, with support
from the One Health Initiative,
One Health Commission, and the
One Health Platform, to highlight
the One Health concept, promote
the need to leverage expertise across
disciplines to solve emerging health
risks, and share a list of community
activities on a global map.
The World Health Organization
(WHO) reported 13 urgent health
needs – including climate action,
infectious disease preparedness,
improving scientific communication,
and increasing access to health care
services and medications – that
should be prioritized as we approach
the deadlines of the 2030 Agenda
for Sustainable Development [2].
According to the WHO, 12.6 million
premature deaths each year due
to living or residing in unhealthy
environments, and thus the intricate
links of humans, animals, and the
environment cannot be overlooked
[3].The operational definition of One
Health includes 4Cs – collaboration,
communication, cooperation,
and capacity building – as well as
important links to diverse rural,urban,
and mobile communities among
society and ensured inclusivity, equity,
and access to health care services [1].
Upon reflection of the One Health
concept, our global community
can better understand that all 17
Sustainable Development Goals
(SDGs) – not just SDG 3 as good
health and wellbeing – are related to
links between human, animal, and
environmental health. The One Health
Joint Plan of Action (2022‒2026),
which was launched in October 2022,
provides a global framework that
facilitates collective prevention and
response efforts to address emerging
health threats [4]. Global leaders can
incorporate the One Health concept
in their decision-making activities,
which can guide the development of
innovative educational programs and
policies that ensure sustainable action
for a healthy planet. In this article,
physicians from 12 countries – Brazil,
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Credit:
Romolo
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/
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WMA Members Share Reflections about One Health Day 2022
90
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
Dominican Republic, Germany, Italy,
Japan,Myanmar,Nigeria,Philippines,
Republic of Korea, Spain, Trinidad
and Tobago, and United Kingdom
– highlighted insightful reflections
about One Health Day activities
across their countries.
Brazil
Brazil, the largest country in South
America with an estimated 209
million residents, has experienced
unique health challenges, including
socioeconomic inequalities that
influence access to health care
services, deforestation impacting
wildlife preservation and biodiversity,
wildfires and air pollution,and vector-
borne disease transmission. In 2007,
the Wildlife Conservation Society
held the “One World, One Health”
Symposium in Brasilia, marking the
inaugural discussion about direct links
between environmental destruction as
well as wild animals as reservoirs for
disease spread [5]. With increased
global interactions and observed
effects of climate change, health
professionals should understand and
apply the One Health concept in
their daily clinical and public health
responsibilities.
Over the past decade, the Brazilian
health system has recognized these
challenges and has helped lead several
national initiatives that promote the
One Health concept. First, leaders
withintheBrazilianhealthsystemhave
developed scientific conferences and
workshops, prepared textbooks and
publications,supported collaborations
with professional associations, and
provided funding of international
research collaborations [5,6]. These
efforts have successfully leveraged
national and regional expertise
and strengthened epidemiological
surveillance programs. Second, the
Health Surveillance System (HSS) is
comprised of the Human and Animal
Health Surveillance (Epidemiological
Surveillance System, ESS; Training
program in Applied Epidemiology
to the Services of the Unified Health
System, EpiSUS; Occupational
Health Surveillance, OHS) and the
Environmental Health Surveillance
(Agropecuary Surveillance,
VIGIÁGUA; Health Surveillance of
Populations Exposed to Chemical
Contaminants, VIGISOLO;
Environmental Health Surveillance
related to Natural Disasters,
VIGIDESASTRES; Air Quality
Monitoring Program, VIGIAR;
and Sanitary Surveillance System,
ANVISA) [6].
Third, the One Health Brazilian
Resistance (OneBR), funded by the
Bill & Melinda Gates Foundation
and the Brazilian Ministry of Health,
represents the first genomic database
for surveillance of antimicrobial
resistance across Brazilian states
[7]. Finally, the development of
the One Health Brasil website has
provided a One Health platform –
and during the coronavirus disease
2019 (COVID-19) pandemic – has
fostered partnerships with three
major One Health knowledge hubs
– One Health Commission, One
Health Initiative, and One Health
Platform [8].
Furthermore, forests cover almost
50% of Brazilian landscape, which
includes the Atlantic rainforest along
coastal regions as well as two-thirds
of the Amazon rainforest. Over the
past decade, significant levels of
deforestation have been observed, as
a result of road construction and land
clearing for livestock. Hence, two key
federal regulations were developed to
support environmental conservation,
as an essential element to protect
biodiversity, maintain the ecosystem
balance, and combat the effects of
climate change. First, the Brazilian
Forest Code (Law No.12.651),which
was developed in 1934 and modified
in 1965 and 2012, sets a framework
to protect native landscapes across the
country, including requirements for
some landowners to maintain forests
on their properties [9]. Second, at the
G20 summit,which was held in Bali in
November 2022, leaders from Brazil,
Democratic Republic of Congo, and
Indonesia – countries that represent
half of the world’s rainforests –
signed the Rainforest Protection
Pact to support funding for forest
conservation. This robust legislation
holds promise for substantial national
and regional advancements to combat
the climate crisis and protect the
planet.
Dominican Republic
Climate change, which is recognized
as the leading health threat to our
global society, will significantly affect
how low-income countries develop
preparedness and response measures
to mitigate harmful effects on public
health. Over the next two decades,
health leaders estimate that climate
change will be linked to 250,000
annual premature deaths from
infectious (e.g. vector-borne diseases,
enteric pathogens) and chronic (e.g.
malnutrition,heat-related) conditions
or complications [10]. By considering
the One Health framework in our
global health initiatives, we can
identify emerging health risks and
affected populations and develop
novel solutions to protect population
health from the effects of climate
change.
The Dominican Republic (DR),
an island nation with an estimated
11 million residents, has witnessed
the effects of climate change due to
natural and man-made phenomena.
To combat these risks, national
administrators and heath leaders have
stressed efforts to reform the health
system and strengthen ongoing
programs that prioritize population
health and well-being. In April
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91
2021, the Abinader Administration
adopted the Decree 284-21 (Decreto
284-21), which confirmed the
political commitment to reform the
DR health system that supports 278
municipalities [11]. In March 2022,
Ministry of Health leaders launched
the National Health Plan 2022-2032
(Plan Nacional Decenal de Salud,
PLANDES, 2022-2032), which
proposed steps to strengthen the
social security program and reinforce
a holistic vision of primary health
care [6]. This national plan aims to
expand the elements of the General
Health Law 42-01 (Ley General de
Salud 42-01), which was adopted by
the Mejía Administration in March
2001 [11].
According to the Global Risks Report
2022, the DR is most at risk of
extreme weather events, employment
crises, debt crises in large economies,
and digital inequality coupled with
inefficient cybersecurity measures
[12]. In the Americas region, an
estimated 67% of health centers are in
disaster-prone areas, and 24 million
people have had limited access to
medical care due to weak or damaged
health center infrastructure over the
past decade [13]. These challenges
were observed in September 2022,
when Hurricane Fiona directly hit
the eastern region of the country,
affecting the physical infrastructure
(e.g. damaged bridges), leaving
flooded areas, and causing electricity
outages. In October 2022, a recent
cholera case diagnosed in Haiti and
an imported case diagnosed in the
DR led to an immediate response
by the DR Ministry of Health to
increase public health surveillance at
the border control and national health
centers [14].
Since an estimated 75% of emerging
human pathogens have a zoonotic
origin, focus on animal health will
be fundamental to reduce zoonotic
disease transmission and maintain
food security and safety. For example,
African swine fever appeared in the
Americas after 40 years, which was
officially reported in Montecristi
and Sánchez Ramírez provinces in
the north and central regions of the
country in July 2021, and in Haiti in
September 2021 [15]. This disease
spread from Europe and Asia to the
Americas was a significant concern
for the health, agricultural, and
tourism sectors.
To address these global health
challenges, building sustainable
policies with political commitment
will be essential to strengthen disease
surveillance programs, connect
stakeholders in human, animal, and
environmental health sectors, and
prioritize health system resiliency.
Academic administration and faculty
should consider incorporating such
global health challenges in health
curricula, in order to prepare the next
generation to manage emerging risks
and promote population health. For
example, the Universidad Católica
del Cibao (UCATECI) is the first
known DR institution to develop
a One Health course, as part of the
Master in Public Health program.
In a constantly changing world, the
One Health framework will offer a
holistic vision to develop innovative
approaches to address future risks to
human, animal, and environmental
health.
Germany
Climate change − with heat waves,
extreme weather events, and the
spread of infectious diseases to
previously unaffected regions −
represents a medical emergency. For
decades, scientists have observed an
increase in greenhouse gas emissions
and the overshooting of the so-called
planetary carrying capacity limits. In
2021, the 125th German Medical
Assembly, the annual conference
of the German medical profession,
included a discussion about the link
between climate protection and
health protection, and delegates
concluded that climate change was
an urgent environmental challenge
with significant societal and health
impacts. The health and well-being
of present and future generations
depend on a sustainable lifestyle that
protects natural resources and halts
ongoing environmental degradation.
The medical profession represented
by the German Medical Assembly
pledged to make the health sector
climate-neutral by 2030,including the
operations of the German Medical
Association. The health care sector,
whichservesapopulationof82million
residents, should also prepare for the
increased health care utilization of
conditions caused or exacerbated by
climate change. Climate protection
should be integrated into the day-to-
day activities of medical organisations
as well as physicians’ education and
training. As the medical community,
we recognise that it is the physician’s
duty to educate patients about the
health effects of climate change and
actively promote best practices to
protect physical and mental health
and well-being.
Italy
Over the past few years, the Italian
health system has adopted the One
Health concept within a planetary
vision to serve as a framework for its
national health initiatives [16].Italian
health leaders have led three specific
efforts to continue to pave the way
toward effective and sustainable action
that promotes population health.
First, the National Health System
(Sistema Sanitario Nazionale, SSN)
and the National Environmental
Protection System (Sistema
Nazionale di Protezione Ambientale,
SNPA) have prioritized the areas
of informatics, chain-of-command
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WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
92
communication, preparedness and
response training, and research.
Second, recognizing the emerging
risk of antimicrobial resistance due to
the intersection of ecological,climatic,
and anthropogenic factors, the Italian
health system launched the National
Action Plan on Antimicrobial
Resistance (PNCAR) 2017-2020,
which aligned with the WHO
guidance [17]. Third, since family
doctors are primarily responsible for
patient care related to communicable
and non-communicable diseases,
they have led community initiatives
that help inform local and national
decisions to address climate change
[18,19].
In 2022, three substantial laws that
focus on health promotion and disease
prevention have been implemented in
Italy, including the Italian National
Recovery and Resilience Plan (Piano
Nazionale di Ripresa e Resilienza,
NRRP) (https://www.mef.gov.it/en/
focus/The-National-Recovery-and-
Resilience-Plan-NRRP/) (Missione
Salute, M-6), the National System
of Health Prevention (Sistema
Nazionale di Prevenzione Sanitaria,
SNPS) (Law 79/22) (https://www.
inail.it/cs/internet/istituto/sistema-
nazionale-per-la-prevenzione.html),
and the Re-arrangement of the
Primary Health Care (Ministerial
Decree 77/2022). Many educational
and communication activities have
promoted the use of the One Health
approach among diverse disciplines
to address complex environmental
health topics. For example, the Local
Colleges of Physicians (Ordine
dei Medici e degli Odontoiatri,
OMCeO), University of Modena
and Reggio Emilia, and International
Society of Doctors for the
Environment (ISDE) promoted the
One Health Bibliographic Service
in Modena in October 2022, and
the OMCeO of Pavia organized the
OMCeO International Conference
in Pavia in November 2022. Also, the
next Code of Ethics for all Italian
physicians, which should be adopted
in 2024,will promote the One Health
approach in all professional activities.
The coronavirus disease 2019
(COVID-19) pandemic has
challenged health systems worldwide
– including our Italian health system
– raising the need to implement and
incorporate the Planetary Health
and One Health paradigms to
support future action [20]. Together
with other WMA members, Italian
physicians can collaborate to develop
relevant health policies based on
environmental health principles that
support the primary health care [21].
Japan
Japan is an archipelagic nation in
East Asia with 126 million residents,
characterized by four main islands
of Hokkaido, Honshu, Shikoku and
Kyushu. Since Japan is surrounded by
oceans, the island is a popular tourist
destination for its culture, history, and
landmarks. Notably, Japanese cuisine
incorporates seafood and vegetables,
recognized globally for its high
nutritional value that influences life
expectancy.
In Japan, the history of One Health
began in the small city of Fukuoka,
where two influential Japanese
leaders grew up together in the
same neighbourhood. Dr. Yoshitake
Yokokura, the past president as well
as president emeritus of the Japanese
Medical Association (JMA), and
Dr. Isao Kurauchi, the president of
the Japanese Veterinary Association
(JVA), fostered a close relationship
over the years. Together, they
encouraged collaborations between
human and veterinary medicine
and promoted the One Health
concept through their professional
activities. Notably, in 2013, they
developed an academic agreement
entitled, Agreement on the Promotion
of Academic Cooperation based on
One Health, which was subsequently
adopted nationwide.
As these continued efforts have
strengthened collaborations between
physicians and veterinarians,the JMA
and JVA hosted the global conference
on One Health in Fukuoka in 2016.
At this event, the World Veterinary
Association (WVA), WMA, JMA,
and JVA adopted the Fukuoka
Memorandum,whichensuredthefour
elements that: 1) promote cooperative
relationships and the exchange of
information aimed at preventing
zoonotic disease transmission;
2) ensure the responsible use of
antimicrobials in human and animal
healthcare; 3) strengthen human
and veterinary medical education,
including understanding the One
Health concept; and 4) foster national
and international dialogue in order
to develop innovative solutions to
resolve health challenges and achieve
a healthy and safe society.
The Fukuoka Prefecture and the
Federation of Asian Veterinary
Association (FAVA) organized
the One Health International
Forum 2022 (https://one-health-
fukuoka2022plusfava.com/en/
index.html) in Fukuoka from 12-13
November 2022. Using the theme,
“Now and Future of One Health
Practice: From Fukuoka to Asia, and
the World”, this event highlighted
the essential role of the One
Health concept in our global health
initiatives. The agenda included a
lecture from Dr. Osahon Enabulele,
the president of the WMA, and Dr.
Rafael Laguens, the president of the
WVA. During the conference, leaders
opened the One Health Park (https://
www.onehealth-park.jp) and agreed
to create the FAVA office in Fukuoka.
We hope that these One Health
events encourage all physicians,
Japanese citizens, and global citizens
to learn more about the One Health
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concept and appreciate the intricate
links between human, animal, and
environmental health.
Myanmar
The One Health concept offers a
unified strategy to enhance disease
prevention and control efforts across
nations. It is critical to foster equal
and inclusive collaboration among
doctors, veterinarians, dentists,
nurses, and other allied health and
environmental experts in order to
promote and safeguard human,
animal,and environmental health and
welfare. In Myanmar, however, the
military takeover has hindered disease
surveillance efforts, and security
forces have arrested, assaulted, and
killed health professionals, branding
them as enemies of the state [22].
The Myanmar health system is
experiencing extreme challenges to
maintain a delicate balance between
human, animal, and ecosystem
health. First, with limited food and
unsanitary conditions, malnutrition
and diarrhoea are afflicting children
and the elderly. Military and security
forces have stolen and destroyed
medical equipment and drugs from
hospitals during raids, and aid
organizations were forced to stop
visiting refugee camps [22]. Second,
military-related fires, explosions,
and landmines release smoke, ash,
and gases that can affect acute and
chronic respiratory health. Although
landmine deployment is prohibited
globally, numerous landmines were
placed by Myanmar military forces in
villages and farms, and bombs from
Myanmar military airplanes have
killed and gravely maimed individuals
and animals [23].
Third, natural ecosystems as well as
livestock and wildlife are affected
by this military conflict, which may
ultimately affect farmers’ economic
livelihood for animal and crop
production. Heavy metals and other
harmful compounds released by the
military’smissiles,militaryequipment,
and ammunition are contaminating
groundwater and soil. Fourth, injuries
to humans and animals remain
a significant cause of death and
consequence of war and conflict.These
wounds frequently need surgery, and
pre- and post-operative antibiotic
administration is crucial to minimize
infection and other complications.
However, Myanmar military and
security forces have interfered with
clinical health services by destroying
essential antibiotics and targeting
health professionals who supply and
transport these antimicrobial agents.
These actions can hinder treatment
regimens and hence increase the
risk of infection, complications, and
antimicrobial resistance in human
and animals [22].
A global humanitarian response is
crucial to address rising food shortages
and provide resources for human and
animal health professionals as well as
other key community leaders [24]. By
prioritizing the One Health concept,
Myanmar citizens can advocate for
strengtheninghealthsystemresiliency,
protecting natural environmental
resources, and restoring economic
independence [23].
Nigeria
Nigeria, a country of an estimated
218 million residents, is recognized
to have the largest populace in Africa
and one of the top ten most populated
countries in the world [25]. Noting
these demographics, global health
systems should promote the One
Health concept, which focuses on
direct interactions between humans,
animals, and the environment, and
channel resources towards effective
disease prevention and management
strategies. Over the past decade,
Nigerian physicians have widely
accepted One Health as a framework
for health promotion and disease
prevention that can enhance society’s
health and well-being.
Some medical professional
associations, such as the Nigerian
Medical Association (NMA),
Nigerian Association of Resident
Doctors (NARD), and Medical
Women’s Association of Nigeria
(MWAN), are actively involved in
health promotion activities that use
media platforms (e.g. billboards,
newspapers, radio, television, social
media) to spread health messages to
the Nigerian populace.They have also
conducted public fora on community
streets, town halls, places of worship,
open markets, playgrounds, and
motor parks. To enhance health
literacy, regional campaigns have
disseminated educational materials
in Pidgin English (creole form of
English combined with words from
the local language) as well as local
dialects (e.g. Ibo in eastern Nigeria,
Yoruba in western Nigeria, Ibani in
Grand Bonny Kingdom which is in
southern Nigeria).
Over the past few years, Nigerian
leaders have led local and national
efforts to control zoonotic disease
outbreaks, such as Lassa fever,
monkey pox, yellow fever, and
the coronavirus disease 2019
(COVID-19). The Nigerian health
system has discouraged the populace
from consuming unpasteurized cow
milk and eating bush meat, such as
giant rats (including the cane rat or
“grass cutter” in Nigeria), squirrels,
antelopes,deer,andporcupine.Various
Nigerian states and local governments
have also enacted specific days for
environmental clean-up days, where
there is restricted movement (except
for essential workers) to encourage
residents to collect trash and beautify
their surrounding environment. For
example, in Rivers State (southern
Nigeria), the state environmental
clean-up day is the last Saturday
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94
morning (7:00-10:00AM) of each
month.
In 2019, the National Action Plan
for Health Security (NAPHS) 2018-
2023 was launched to promote the
One Health concept and health
security across Nigeria [26]. This
is comprehensive, multi-sectoral
collaboration integrates blueprints
from various sources: 1) national
organizations including the Regional
Disease Surveillance Systems
Enhancement Project (REDISSE),
Nigeria Centre for Disease Control
(NCDC), Federal Ministries of
Health, Agriculture and Rural
Development (FMARD); 2) national
antimicrobial and immunization
action plans; and 3) report findings
(2017) from the International Health
Regulations (IHR) and Performance
of Veterinary Services (PVS) [26,27].
Notably, Nigeria is a leading African
nation to inaugurate this robust
strategic plan, recognizing that
significant efforts are required to
combat environmental challenges
(e.g. disease outbreaks, flooding and
droughts, food shortages) as a result
of climate change.
Philippines
In the Philippines, education is
highly valued and prioritized in
every household, and it is viewed
as an indispensable legacy passed
down to generations. National
leaders have focused on showcasing
a holistic view to health and well-
being through three key initiatives,
including launching the Department
of Education (DepEd)’s Healthy
Lifestyle Initiative, uniting public
schools to promote healthy lifestyles,
and strengthening the adoption of the
Healthy Lifestyle Initiative across all
public schools.
First, the DepEd established the
DepEd Order No. 28 entitled,
“Healthy Lifestyle Initiative of DepEd”
[“Oplan Kalusugan sa DepEd (OK
sa DepEd)”] in 2018, which was a
nationwide initiative to strengthen
health and nutrition programs
at public schools. The campaign
highlighted six programs: 1) School-
Based Feeding Program (SBFP); 2)
Medical,DentalandNursingServices,
including School Dental Health
Care Program (SDHCP); 3) Water,
Sanitation, and Hygiene (WASH)
in Schools (WinS) Program; 4)
Adolescent Reproductive Health; 5)
National Drug Education Program,
supported by comprehensive tobacco
control; and 5) School Mental Health
Program. Each school year, the One
Health Week celebration showcases
the DepEd programs, which aim to
ensure the safety, health, and well-
being of students [28,29].
Second, the DepEd’s Bureau of
Learner Support Services – School
Health Division (BLSS-SHD)
celebrated One Health Week from
6-11 September 2021. Using the
theme, of “Unity for Health: Healthy
Lifestyle Initiative for DepEd,
Institutions, and Community”
[“Bayanihan para sa Kalusugan:
OK sa DepEd, sa Paaralan, at sa
Tahanan”], the event aimed to
emphasize how school partnerships
are essential to support student health
and well-being, especially adapting
to changes in the educational system
in a post-COVID-19 world. Each
day, coordinated activities targeted
these six flagship programs and
created virtual activities with 1,869
elementary schools. As a result, the
SBFP reached 3.5 million student
learners enrolled in grades 1-6,and the
WinS Program’s Seal of Excellence
Award 2021 recognized schools that
had attained and maintained global
standards for a minimum of three
consecutive years [30,31].
Finally,theDepartmentsofEducation
and Health commemorated One
Health Week 2022 from 31 October
to 4 November 2022.Using the theme,
“Strengthening of Healthy Lifestyle
Initiative of DepEd in all Learning
Institutions” [“Pinalakas na Oplan
Kalusugan sa DepEd, Pinatatag na
Healthy Learning Institutions”], the
event highlighted the importance of
a holistic approach of government
and society in strengthening school
health programs. These efforts aim to
improve access to health care, provide
a conducive learning environment,
strengthen intersectoral linkages, and
reinforce health skills and education
[32].
Republic of Korea
The Republic of Korea, a country of
51 million people, has developed its
robust national health system through
the central government’s rapid and
mandatory implementation of health
policies [33]. National policymakers,
who recognize the direct links
between human, animal, and
environmental health, have promoted
the One Health concept as a new
health paradigm across all sectors.
However, the medical community has
overlooked the One Health concept,
which has impacted how physicians
and other health professionals are
trained in their diverse specialties.
Over the past four years, the national
leaders prioritized three significant
milestones that promote population
health. First, for World Health Day
2018, the MoHW announced that
the One Health concept would
represent the overarching theme,
offering the opportunity for citizens
to reflect on the development of
the robust national health system.
Second, in 2018, the government
published a National Plan for the
Management of Zoonotic Diseases,
2019-2022, as a joint proposal of
the Ministry of Health and Welfare
(MoHW), Ministry of Agriculture,
Food and Rural Affairs, Ministry
of Environment, and many One
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Health experts [34]. Finally, from
2019 to 2022, the Korean Disease
Control and Prevention Agency
(KDCA) and Korean Society for
Zoonoses organized biannual One
Health Fora, as part of a proactive
response to strengthen diagnosis and
management of zoonotic diseases
[35].
The development of One Health
policies in the Republic of Korea
has been challenging, where policies
are strictly focused on antimicrobial
resistance and zoonotic disease
transmission with limited support
from the scientific literature. In order
to identify One Health risks, Korean
physicians should actively conduct
academic research, collaborate to
develop reasonable One Health
policies, and advocate for the delivery
of prompt health interventions
that reach all citizens. Alongside
medical educators, they should also
help strengthen medical education
by developing innovative classroom
lectures, clinical courses, and
conferences, where young doctors can
learn about the One Health concept
and collaborate on multidisciplinary
teams to address emerging health
risks [36].
Spain
The coronavirus disease 2019
(COVID-19) pandemic has marked
a global turning point. The high cost
of human lives and economic and
social repercussions, rapid geographic
spread favoured by increased human
mobility between countries, scientific
debate on transmission (e.g. potential
zoonotic transmission), and vaccine
development are evidence that our
society was not prepared for the
possibility of a pandemic in the 21st
century.
As a global community, we
should promote the formation of
multidisciplinarycollaborationstoraise
awareness of emerging health risks,
design short- and long-term strategies
to mitigate such risk, and implement
programmes, policies, legislation, and
research that can help health systems
achieve better population health
outcomes. This integrated approach
to health – known as the One Health
concept – recognizes that human,
animal, and environmental health are
interdependent. It would strengthen
preventive actions to enhance the early
detection of harmful risks, achieve
the objectives of the Sustainable
Development Goals, and ultimately
restore the ecological balance of our
planet.
As such, the Spanish General Medical
Council (Consejo General de Colegios
Oficiales de Médicos, CGCOM)
has led four specific actions to raise
community awareness of the One
Health concept. First, the CGCOM
and the Scientific Medical Societies
(Sociedades Científicas Médicas,
SCM) have supported the Medical
Alliance against Climate Change,
which has developed courses and
conferences for health professionals on
thehealtheffectsofclimate changeand
the need for collective action to reduce
the carbon footprint generated by the
health sector [37]. Second, by forming
part of the One Health Platform’s
Executive Committee, they have
fostered dialogue with key decision-
making institutions to develop
policies aligned with the One Health
concept, prepare consensus documents
on strategic health issues, promote
opportunities for interdisciplinary
and intersectoral collaborations, and
educate the public on the One Health
concept. Third, the CGCOM has
coordinated seminars for doctors and
the general public that encourage the
application of the One Health concept
as a holistic vision of physical and
mental health and well-being. Finally,
they have stressed that sustainable
actions to support ecosystem health
of the planet is an ethical duty of our
medical professional practice.
Moving forward, we cannot combat
thehealthchallengesofthe21st
century
with the vision and tools of the 20th
century. As we learned this valuable
lesson throughout the COVID-19
pandemic, we recognize that humans
caused this ecological imbalance
and that we must collaborate across
disciplines to promote global health
security.
Trinidad and Tobago
In Trinidad and Tobago, One Health
means improving the quality of
human health through gaining a
better understanding of how disease
processes are influenced by changing
environmental conditions and animal
habitats. As a result of urbanization,
deforestation has resulted in animal
species being displaced from their
natural habitats and forced into spaces
occupied by humans. Flooding events
may increase the risk of exposure to
rodents and contaminated water,
which can lead to zoonotic outbreaks
of leptospirosis. The effects of
climate change have been noted
with increased rainfall and periods
of drought that have facilitated the
mosquito-breeding sites for Aedes
aegypti mosquitoes, the vector for
dengue virus (DENV), chikungunya
virus (CHIKV), and Zika virus
(ZIKV).
Biodiversity disruptions attributable
to climate change and other
environmental factors, like the use of
pesticides, have noteworthy impacts
on human and animal health. First,
there has been a reported loss of
pollinators that are central to fruit
and vegetable production. In fact, the
honey industry has been significantly
affected as the bee population is
threatened by extinction. Second, the
proliferation of the arthropod hibiscus
mealybug destroyed agricultural and
horticultural systems in Trinidad and
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Tobago in 1995. It almost completely
devastated the sorrel industry, a
popular tangy drink made from a
flower of the Hibiscus family and
served during the Christmas season.
Third, reported dwindling fish stocks
and recent fish kills on shorelines
have no clear answers. To address
these animal health challenges, the
National Animal Disease Centre
(NADC) has the mission to promote
public health through rabies control,
poultry surveillance, imported animal
and animal products, and horse and
livestock health.
Trinidad and Tobago is a member
state of the One Health Caribbean
Initiative, with a mission to find
sustainable solutions for problems
that threaten healthy planetary
systems, through partnerships and
collaborative approaches [38]. From
2014 to 2016, Trinidad and Tobago’s
One Health Project aimed to identify
heavy metal contamination in edible
commercial fish species that constitute
an important national economic
resource [39,40]. A total of 11 other
national teams presented their
research findings to implement One
Health solutions related to reducing
risk of iron deficiency anaemia in
Dominica communities and the use
of pesticides in agricultural practices
across Haiti. The ongoing work of
the One Health Project includes
capacity building of individuals
and organizations through the
Climate Change and Health Leaders
Fellowship Training Program.
In 2012, the Trinidad and Tobago
Partners’ Forum Action for Chronic
Non-communicable Diseases was
initiated to provide strategic direction
for policy initiatives that empower
communities to take ownership of
their health through improved diets,
physical activity, and environmental
awareness [41]. As physicians, our
national and international call to
action is to close knowledge gaps
through education, research, and
communication as well as initiate
sustainable programs and policies
that support One Health. After all,
policy changes are envisioned as
game-changers.
United Kingdom
In the United Kingdom (UK),
doctors have expressed significant
concern about the threat of a “post-
antimicrobial age”, where current
antimicrobials will be ineffective due
to increasing levels of resistance. This
has the potential to severely limit
doctors’ ability to conduct routine
and complex medical treatments,
where antimicrobials are necessary to
prevent infection, including surgery
and chemotherapy.
We are ever aware of the global
threat to human health posed by
antimicrobial resistance (AMR) and
the firm linkage to inappropriate
usage both in human health and
agricultural practices. The British
MedicalAssociation(BMA)therefore
supports a One Health approach to
tackling AMR, which recognises
that action is required across human
medicine, veterinary practice, and
agriculture, to minimise unnecessary
or inappropriate use of antimicrobials
as well as ensure that they continue to
be effective in treating infections.
The UK Government’s five-year
action plan, Tackling Antimicrobial
Resistance 2019-2024, advocates for
an approach to tackling AMR that
focuses on reducing the need for and
exposure to antimicrobials,optimising
their use, and investing in innovation
[42]. The plan sets targets to reduce
UK antimicrobial use in humans by
15% by 2024 and in food-producing
animals by 25% between 2016 and
2020. While the BMA welcomed the
government’s plan, it is essential that
more specific commitments should
be made, supported by investments
that meet the scale of the threat. For
example, the BMA has called for
tighter regulations at the country
level to significantly reduce the
inappropriate use of antimicrobials
in farming practices, through
banning the routine preventive use
of antimicrobials for healthy groups
of animals and restricting the use of
critically important antimicrobials in
agriculture.
Since AMR is a borderless and
multi-sectoral threat, the regulatory
response required to reduce the use of
antimicrobials requires global efforts
and co-ordination. Consumption
of non-prescribed antimicrobials
is commonplace in many low- and
middle-income countries, and there
is heavy misuse of antimicrobials in
farming practices globally. We firmly
believe that the UK should lead
efforts to establish an international
legally binding AMR treaty, which
can enhance global knowledge
sharing and surveillance. A treaty
would coordinate country efforts,pool
funding to support low- to middle-
income countries, incentivise action,
and hold countries accountable.
Since the global challenge of AMR is
analogous to that of climate change,
international agreements on climate
change should be implemented and
serve as a model for a future AMR
treaty.
Conclusion
As we recognize One Health Day, we
learn about an array of comprehensive
health policies and community
initiatives that have been successfully
implemented across 10 countries.
These timely initiatives are key
examples of how multi-disciplinary
collaborations coupled with political
commitment can drive local and
national action toward achieving
established health priorities. As
WMA members with diverse training,
we must leverage our clinical expertise
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97
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to empower scientific discourse on
addressing emerging health risks
such as reducing air pollution,
improving antimicrobial prescribing
practices, educating community
members about communicable and
non-communicable disease risks.
We can share our valuable insight
through a myriad of venues, including
participating in legislative or advocacy
events, contributing to formal
conference and roundtables,preparing
peer- and non-peer reviewed
publications, and leading community
seminars or townhall meetings.
As we collaborate with local
and national decision-makers
and stakeholders, we can apply
key elements of evidence-based
guidelines by the WHO, UN, and
professional medical associations
– like the One Health Joint Plan of
Action (2022‒2026) – and strengthen
our ongoing activities that raise
awareness of urgent health challenges
that influence population health
outcomes. Our collective actions can
truly pave the way to identify disease
burden, develop timely approaches,
and ultimately achieve the milestones
of the 2030 Agenda for Sustainable
Development.
References
1. One Health High-Level Expert
Panel (OHHLEP), Adisasmito
WB, Almuhairi S, Behravesh
CB, Bilivogui P, Bukachi SA,
et al. One Health: A new
definition for a sustainable and
healthy future. PLoS Pathog.
2022;18(6):e1010537.
2.
World Health Organization.
Urgent health challenges for the
next decade. 2020 [cited 2022
Nov 20]. Available from: https://
www.who.int/ne ws-room/
photo-story/photo-story-detail/
urgent-health-challenges-for-
the-next-decade
3.
World Health Organization.
Preventing disease through
healthy environments: a global
assessment of the burden of
disease from environmental risks.
Geneva: WHO; 2018. World
Health Organization.
4.
World Health Organization.
One health joint plan of action
(2022‒2026): working together
for the health of humans, animals,
plants and the environment.
Available from: https://www.
w h o . i n t / p u b l i c a t i o n s / i /
item/9789240059139
5. Espeschit IF, Santana CM,
Moreira MAS. Public Policies
and One Health in Brazil: the
challenge of the disarticulation.
Front Public Health.
2021;9:644748.
6.
Pettan-Brewer C, Martins
AF, de Abreu DPB, Brandão
APD, Barbosa DS, Figueroa
DP, et al. From the approach
to the concept: One Health in
Latin America-experiences and
perspectives in Brazil, Chile, and
Colombia. Front Public Health.
2021;9:687110.
7.
Laboratory of Resistome,
Virulome, and Therapeutic
Alternatives, Brazil. One Health
Brazilian Resistance integrated
genomic database [Internet].2022
[cited 2022 Dec 1]. Available
from: http://www.onehealthbr.
com/
8. One Health Brasil. One Health
Brasil [Internet]. 2018 [cited
2022 Dec 1]. Available from:
ONE HEALTH BRASIL
9. Presidência da República, Brasil.
Lei Nº 12.651, de 25 de maio
de 2012. 2012 [cited 2022 Dec
5]. Portuguese. Available from:
https://www.planalto.gov.br/
ccivil_03/_ato2011-2014/2012/
lei/l12651.htm
10.
World Health Organization.
Climate change and health
[Internet]. 2021 [cited 2022 Nov
13]. Available from: https://www.
who.int/news-room/fact-sheets/
detail/climate-change-and-health
11. Ministry of Health, Dominican
Republic. [Ministerio de
Salud Pública presenta el Plan
Nacional de Salud 2022-2032]
[Internet]. [cited 2022 Nov 13].
Spanish. Available from: https://
presidencia.gob.do/noticias/
ministerio-de-salud-publica-
presenta-el-plan-nacional-de-
salud-2022-2032
12.
World Economic Forum. The
GlobalRisksReport2022,17thed.
Cologny: WEF; 2022. Available
from: https://www.weforum.org/
reports/global-risks-report-2022
13.
Pan American Health
Organization. Climate change
and health [Internet]. n.d. [cited
2022 Nov 18]. Available from:
https://www.paho.org/en/topics/
climate-change-and-health
14. Ministry of Health, Dominican
Republic. [Ministro de Salud
supervisa y refuerza la vigilancia
enloscuatropuntosfronterizos,en
prevención del cólera] [Internet].
2022 [cited 12 Nov 2022].
Spanish. Available from: https://
www.msp.gob.do/web/?p=15912
15. Gonzales W, Moreno C, Duran
U, Henao N, Bencosme M, Lora
P, et al. African swine fever in the
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
98
DominicanRepublic.Transbound
Emerg Dis. 2021;68(6):3018-9.
16. Rabinowitz PM,Pappaioanou M,
Bardosh KL,Conti L.A planetary
vision for one health. BMJ Glob
Health. 2018;3(5):e001137.
17.
World Health Organization.
One Health and the fight against
antimicrobial resistance in Italy
[Internet]. 2021 [cited 2022 Nov
12]. Available from: https://www.
who.int/europe/news/item/17-
11-2021-one-health-and-the-
fight-against-antimicrobial-
resistance-in-italy
18.
Steele SG, Toribio JA, Booy
R, Mor SM. What makes an
effective One Health clinical
practitioner? Opinions of
Australian One Health experts.
One Health. 2019;8:100108.
19. Lauriola P, Pegoraro S, Serafini
A, Murgia V, Di Ciaula A, De
Tommasi F, et al. The role of
general practices for monitoring
and protecting the environment
and health. Results and proposals
of the Italian project aimed at
creating an “Italian Network
of Sentinel Physicians for the
Environment” (Rimsa) within
an international perspective. J
Family Med Community Health.
2018;5(5):1160.
20.
Lauriola P, Serafini A,
Santamaria M, Guicciardi S,
Kurotschka PK, Leonardi GS,
et al. Family doctors to connect
global concerns due to climate
change with local actions: State‐
of‐the art and some proposals.
World Medical & Health Policy.
2021;13(2):199-223.
21.
Lauriola P, Martín-Olmedo
P, Leonardi GS, Bouland C,
Verheij R, Duckers MLA, et al.
On the importance of primary
and community healthcare in
relation to global health and
environmental threats: lessons
from the COVID-19 crisis. BMJ
Glob Health. 2021;6(3):e004111.
22. GelineauK,MilkoV.InMyanmar,
the military declares war on
medical workers [Internet]. The
Los Angeles Times. 2021 [cited
2022 Nov 21]. Available from:
https://www.latimes.com/world-
nation/story/2021-07-07/in-
myanmar-the-military-declares-
war-on-medical-workers
23. Amnesty International.
Myanmar: Military’s use of
banned landmines in Kayah State
amounts to war crimes [Internet].
Amnesty International. 2022
[cited 2022 Nov 21]. Available
from: https://www.amnesty.
org/en/latest/news/2022/07/
myanmar-militarys-use-of-
banned-landmines-in-kayah-
state-amounts-to-war-crimes/
24. Chan OSK, Naing T, Tun HM.
Upholding veterinary services as
a pillar of one health in Myanmar.
One Health. 2021;13:100329.
25. United Nations Department of
Economic and Social Affairs,
Population Division. (2022).
World Population Prospects
2022: Summary of Results. UN
DESA/POP/2022/TR/NO.
3. New York: United Nations;
2022. Available from: https://
www.un.org/development/desa/
pd/content/World-Population-
Prospects-2022
26.
Nigeria Centre for Disease
Control. Press Release – Nigeria
launches One Health Strategic
Plan. 2019 [cited 2022 Nov 15].
Available from: https://ncdc.
gov.ng/news/207/press-release-
–nigeria-launches-one-health-
strategic-plan
27.
World Health Organization.
Joint external evaluation of IHR
core capacities of the Federal
Republic of Nigeria. WHO/
WHE/CPI/REP/2017.46.
Geneva: WHO; 2017. Available
from: https://www.who.int/
publications/i/item/WHO-
WHE-CPI-REP-2017.46
28.
Department of Education,
Republic of Philippines. Oplan
Kalusugan sa DepEd ensures
safe school operations, well-
being of learners [Internet].
2022 [cited 2022 Oct 30].
Available from: https://www.
deped.gov.ph/2022/04/13/oplan-
kalusugan-sa-deped-ensures-
safe-school-operations-well-
being-of-learners/
29. Barbara EP. DepEd to conduct
One Health Week Celebration
every SY. News BEaST Ph –
Your Digital News Portal. 2021
[cited 2022 Oct 30]. Available
from: https://newsbeastph.
c o m / 2 0 2 1 / 0 9 / d e p e d – t o –
conduct-one-health-week-
celebration-every-sy/
30.
Department of Education,
Republic of the Philippines. One
Health Week highlights OK sa
DepEd milestones, initiatives
to support learners’ welfare
[Internet]. 2021 [cited 2022 Oct
30]. Available from: https://www.
deped.gov.ph/2021/09/29/one-
health-week-highlights-ok-sa-
deped-milestones-initiatives-to-
support-learners-welfare/
31.
Republic of the Philippines
– Department of Education.
Scheduled/Suggested activities
during the One Health Week
celebration on 6-11 September
2021.Division Memorandam No.
205, s. 2021. 2021 [cited 2022
Oct 30]. Available from https://
www.depedkabankalancity.com/
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
BACK TO CONTENTS
99
uploads/7/4/2/6/74269293/dm_
no._205_s._2021.pdf
32.
Department of Education,
Republic of the Philippines.
DOH, DEPED launch healthy
learning institutions to strengthen
schoolhealthprograms[Internet].
2022 [cited 2022 Oct 30].
Available from: https://www.
deped.gov.ph/2022/10/12/doh-
deped-launch-healthy-learning-
institutions-to-strengthen-
school-health-programs/
33.
Organisation for Economic
Cooperation and Development.
OECDReviewsofPublicHealth:
Korea: A Healthier Tomorrow.
Paris: OECD Publishing, Paris;
2020. Available from: https://doi.
org/10.1787/be2b7063-en
34. Lee K. Strategies for promoting
Korean One-Health to secure
public health.The Korean Society
for Zoonoses. 2019;1:13-24.
35. Ministry of Culture, Sports and
Tourism, Republic of Korea.
Korean Policy Briefing: “One
Health Policy Forum” for the
joint response to zoonotic
diseases [Internet]. 2022
[cited 2022 Nov 15]. Korean.
Available from: https://www.
korea.kr/news/pressReleaseView.
do?newsId=156498747#sitemap-
layer
36.
Rabinowitz PM, Natterson-
Horowitz BJ, Kahn LH, Kock R,
Pappaioanou M. Incorporating
onehealthintomedicaleducation.
BMC Med Educ. 2017;17(1):45.
37.
Consejo General de Colegios
Oficiales de Médicos. Grupo
de Trabajo Salud y Cambio
Climático [Internet]. 2022
[cited 2022 Nov 15]. Spanish.
Available from: https://www.
cgcom.es/grupo-de-trabajos/
salud-y-cambio-climatico
38.
University of the West Indies
St Augustine Campus; Oura C,
Mahase-Gibson A, Stephen C
(eds). Caribbean Resilience and
Prosperity through One Health.
Trinidad & Tobago: University
of the West Indies; 2017 [cited
2022 Nov 11]. Available from
http://www.cwhc-rcsf.ca/docs/
technical_reports/Caribbean_
Resilience.pdf
39.
Inter-American Institute for
Cooperation on Agriculture.
One Health Leadership in
the Caribbean [Internet].
2020 [cited 2022 Nov 11].
Available from: https://
www.iica.int/en/press/news/
one-health-leadership-caribbean
40.
Institute of Marine Affairs
(Trinidad). Preliminary
investigation on heavy
metals in fish and the mobile
bioavailable phase of sediment
from Trinidad and Tobago
[Internet]. 2018 [cited 2022
Nov 8]. Available from: https://
www.ima.gov.tt/portfolio-item/
preliminary-investigation-on-
heavy-metals-in-fish-and-the-
mobile-bioavailable-phase-of-
sediments-from-trinidad-and-
tobago/
41.
Lewis Y. The Trinidad and
Tobago Partners’ Forum for
Action on NCDs: Proceedings
of the Healthy Caribbean
Coalition Meeting, May 2012
[Internet]. 2012 [cited 2022
Nov 11]. Available from: https://
www.healthycaribbean.org/wp-
content/uploads/2017/05/Dr-
Yvonne-Lewis-PARTNERS-
FORUM-PRESENTATION.
pdf
42.
Department of Health and
Social Care, United Kingdom
Government. UK 5-year action
plan for antimicrobial resistance
2019 to 2024 [Internet]. 2019
[cited 2022 Nov 15]. Available
from: https://www.gov.uk/
government/publications/
uk-5-year-action-plan-for-
antimicrobial-resistance-2019-
to-2024
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100
Yakubu Ahmadu, MBBS
Old CBN Layout, Along Bypass
Adamawa, Nigeria
Dabota Yvonne Buowari, MBBS
Department of Accident
and Emergency,
University Of Port Harcourt
Teaching Hospital
Port Harcourt, Nigeria
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
Maymona Choudry, RN, MD, MPH
Department of General Surgery,
Vicente Sotto Memorial Medical Center
Cebu City, Philippines
Luciana Dornfeld Bichuette, MD
Heart Institute, University
of São Paulo
São Paulo, Brazil
Manuela García Romero, MD
2nd Vicepresident, Spanish General
Medical Council (CGCOM)
Madrid, Spain
Paula Henry, MBBS, MBA
Trinidad and Tobago
Medical Association
Port of Spain, Trinidad and Tobago
Dr. rer. pol. Alexander Jäkel
Policy Adviser, Department
for International Affairs,
Bundesärztekammer / German
Medical Association
Berlin, Germany
Paolo Lauriola, MD
Researcher, International Society
of Doctors for the Environment
Member, Environment and
Health Commission,
National Federation for the Orders of
Doctors and Dentists (FNOMCeO)
Rome, Italy
Jihoo Lee, MD
Resident of Internal Medicine,
Seoul National University
Seoul, Republic of Korea
Claudio Lisi, MD
President, Medical Order of Pavia
Coordinator, Environment
and Health Commission,
National Federation for the Orders of
Doctors and Dentists (FNOMCeO)
Rome, Italy
Maki Okamoto, MD
International Affairs Officer,
Japan Medical Association −
Junior Doctors Network
Tokyo, Japan
Latifa B. Patel, MBChB,
MPhil, MRCPCH
WMA Council member
Representative Body Chair,
British Medical Association
London, United Kingdom
Marcos Pita Lottenberg, MD
Heart Institute, University
of São Paulo
São Paulo, Brazil
Carlos Vicente Serrano Junior, MD
Director of International Relations,
Brazilian Medical Association
São Paulo, Brazil
Wunna Tun, MBBS, MD
Fellow, Medical Education
JDN Secretary
Yangon, Myanmar
Bienvenido Veras-Estévez,
MD, MPH
Department of Epidemiology,
Hospital Regional Universitario
José María Cabral y Báez &
Faculty of Health Sciences,
Universidad Católica del Cibao
Santiago de los Caballeros & La Vega,
Dominican Republic
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101
World Diabetes Day (https://www.
who.int/campaigns/world-diabetes-
day/2022) is recognized annually on
November 14, to increase awareness
of the global diabetes burden – 536
million cases and 6.7 million deaths
reported in 2021 – and the need for
prompt diagnosis and treatment [1].
This international day was founded
by the World Health Organization
(WHO) and the International
Diabetes Federation (IDF) in 1991,
and later confirmed as an official
United Nations (UN) day by the UN
Resolution 61/225 in 2006 [2,3].
Notably, November 14 recognizes
Sir Frederick Banting’s birthday, who
togetherwithCharlesBest,discovered
insulin in 1922 [2]. Supporting the
World Diabetes Day 2021-2023
theme of “Access to Diabetes Care”,
this campaign promotes a holistic
view of population health and well-
being and encourages citizens to
engage in healthy lifestyle behaviours
to reduce risk of developing diabetes.
Over the past four decades, the global
prevalence of diabetes in adults has
increased significantly, with a steeper
rise in low- and middle-income
countries [4]. According to IDF data,
1 in 10 adults (between ages 20-79) are
living with diabetes,and almost half of
adults with diabetes are undiagnosed
[1]. The number of adults living with
diabetes (between ages 20-79) was
reported as 151 million in 2000, 366
million in 2011, and 536 million in
2021 [1]. These prevalence rates are
expected to increase to 642 million
by 2030 and 783 million by 2045
[1]. Similarly, the total annual health
expenditure for diabetes-related
conditions was reported as US $465
million in 2011 and US $966 million
in 2021 – a 300% increase over the
past two decades – and projected to
be over US $1 million in 2030 and
2045 [1].
As a part of the global multi-year
theme, the World Diabetes Day
2022 theme of “Access to Diabetes
Education” stresses the importance of
knowingourriskfactorsfordeveloping
non-communicable diseases (like
diabetes) and accessing regular
primary care consultations. These
global efforts are essential to advance
progress to achieving the Sustainable
Development Goal (SDG) target
3.4 (Reduce by one third premature
mortality from non-communicable
diseases through prevention and
treatment and promote mental health
and well-being) by 2030 [5]. With an
estimated 239 million undiagnosed
cases of diabetes – and an increasing
prevalence of diabetes across the
globe – early diagnosis and targeted
pharmacological and behavioural
interventions will promote optimal
health outcomes and quality of life
as well as reduce the risk of diabetes-
related complications.
Priorities and Recommendations to
Improve Diabetes Care
Over the past 100 years, significant
clinical advancements – namely, the
discoveries of insulin, biguanides
and sulfonylureas for type 2 diabetes
management, rapid-acting and long-
acting insulin analogues for type 1
diabetes management,and biomedical
technologies – have decreased risk of
complications and death [7]. Clinical
management guidelines highlight
the need for robust educational
programs for diabetic patients and
families as well as the fundamental
role of patient-centred approaches
led by multidisciplinary health teams.
In this section, we describe three
main priorities in diabetes care and
management and describe evidence-
based recommendations that can
mitigate risk of morbidity and
mortality.
Early Diagnosis and Prompt
Diabetes Care and Management
With the increasing global prevalence
of diabetes in low- and middle-
income countries and persons under
age 40, the rapid identification
María Caraballo-Lorenzo
Bienvenido Veras-Estévez
World Diabetes Day 2022: A Global Call to Action
to Improve Diabetes Care
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care
Helena Chapman
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102
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care
of individuals who are at-risk of
developing diabetes type 2 will be
important for taking immediate
preventiveactiontomaintainglycemic
levels [8]. Since universal screening
practices are not recommended
as cost-effective secondary-level
prevention, individuals with family
medical history or poor lifestyle
factors (e.g. unhealthy meals,
sedentary behaviors, overweight or
obese) should be closely evaluated
and monitored [8]. However, social
and structural determinants of health,
coupled with limited access to and
availability of health care services,
can hinder optimal diabetes care and
management and negatively influence
population health outcomes.
To address these challenges,
physicians can develop and lead
key community interventions
– considering the cultural,
demographic, and socioeconomic
factors of each community – that
encourage adopting healthy lifestyles
and understanding the risk factors
of non-communicable diseases like
diabetes. For youth initiatives, the
Ministries of Health and Education
can collaborate to strengthen
academic curricula at primary and
secondary schools and universities
with strict health courses. Students
can acquire valuable knowledge and
approaches to maintain appropriate
nutrition at school and home,
participate in regular physical activity,
and seek annual preventive medical
evaluations [9]. For adult initiatives,
the Ministry of Health can promote
the implementation of preventive
health seminars at workplaces, which
can educate staff about the risk
factors of diabetes, encourage diets
with low sodium and sugar levels and
adoption of regular exercise routines,
and highlight the importance of
knowing family history and personal
health values. Employees can learn
about their risk factors and available
screening laboratory tests, to take
action and reduce their risk of
developing early-onset diabetes type
2, diabetes-related complications or
other non-communicable diseases
[10].
Third, technological advancements,
including interactive websites (e.g.
American Diabetes Association,
ADA: https://diabetes.org/tools-
support/tools-know-your-risk) and
smartphone apps, can improve health
literacy about the risk factors of non-
communicable diseases like diabetes
and encourage the adoption of
healthy lifestyles.These resources can
provide additional information on
healthy and balanced meals and water
intake, proper sleep hygiene, and
exercise routines.These platforms can
also offer novel data-driven tools to
support individualised treatment for
patients with diabetes type 2 [11].
Monitoring of Co-morbidities
Since diabetes management is
complex and costly for patients
and health systems, patient-centred
care can promote individualised
management to meet diabetes target
goals [12]. Professional associations,
like the ADA, European Association
for the Study of Diabetes (EASD),
and Endocrine Society, disseminate
evidence-based reports, offer
continued education opportunities,
and support scientific conferences.
These resources highlight the
importance of a holistic and person-
centred approach to help patients
reach glycemic level goals, including
weight loss and reducing risk factors
for cardiovascular and renal disease
[8].
The ADA recommends that the
six elements of the Chronic Care
Model – 1) proactive care delivery
system; 2) self-management support;
3) evidence-based decision support;
4) clinical registries; 5) community
resources; and 6) cultural awareness
– help guide diabetes care for
individual patients, with research
evidence documenting the reduction
of complications and mortality rates
[12]. This approach can help health
professionals monitor physical and
mental health and well-being and
use tertiary-level prevention for
microvascular or macrovascular
complications, including
cardiovascular disease, diabetic foot,
nephropathies, neuropathies, and
retinopathies.
To minimise the risk of co-morbidities,
oral pharmacological therapies have
traditionally served as a cost-effective
option that has demonstrated efficacy
in glycemic control. However,
side effects include hypoglycemia,
gastrointestinal manifestations, fluid
retention, weight gain, heart failure,
and decreased bone mineral density
[8]. Over the past few years, two
new medication families – SGLT2
inhibitors and GLP-1 receptor
agonists – have been recognized by
the WHO as essential medicines, due
to their benefits for cardiovascular,
neurological, and renal health, weight
loss, and less hypoglycemia [13].
Primary care physicians can lead
educational campaigns to discuss the
benefits of these medications as well as
ensure their availability and insurance
coverage for at-risk populations.
National Guidance and Political
Support for Diabetes Care and
Management
The global management of diabetes
and other non-communicable diseases
requires political commitment to
support collaborative, multi-sectoral
efforts that expand research, clinical
care, policy development, and
community outreach [14]. Local
action plans should integrate the
participation of public and private
sector stakeholders to identify
community needs and gaps, develop
quantitative and qualitative research
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103
studies that explore novel inquiries,
evaluate the progress and challenges
of current health programs, and
implementtimelyhealthinterventions
toward the advancement of
established national health objectives.
Successful interventions can serve as
key examples for other communities
and countries, especially for learning
techniques about modifying practices
when faced with limited resources and
encouraging community participation
and adoption of healthy behaviours.
National action plans should support
the preparation of relevant public
policies that address important
challenges, robust surveillance
programs that identify health
priorities, and public activities that
promote social participation and
inclusion [15]. Health leaders can use
evidence-based guidance documents
from professional medical societies
as well as national and international
organisations to support preventive
health evaluations that focus on
modifiable risk factors (primary
prevention), screening (secondary
prevention), and reducing risk of
complications (tertiary prevention)
in their clinical and community
settings. In order to promote lifestyle
changes among the populace, they
can also organise virtual or in-person
community health seminars, develop
continuing education programs
in collaboration with community
leaders, serve as advisors for diabetes
support groups, and participate in
strengthening surveillance programs
(e.g. exploring the benefits of a pre-
diabetic registry) [16].
By recognizing these challenges in
diabetes care and management,health
leaders understand that national
and global action must be applied
collectively to achieve established
national and global health objectives.
Changing the course of diabetes
is no longer limited to glycemic
control. Diabetes management must
incorporate protective measures for
cardiovascular, renal, and vascular
health for all patients, including
at-risk populations. By focusing
on patient-centred care, clinicians
can also identify novel therapeutic
interventions that have the potential
to minimise side effects and enhance
health outcomes and quality of life.
Global Initiatives
Recent global resolutions, action
plans, and technical guidance have
helped health professionals identify
health risks, apply evidence-based
recommendations to clinical and
community practice, and empower
community members to select healthy
lifestyles to reduce risk of non-
communicable disease [17]. Over the
past decade, key WHO publications
were published – such as the WHO
Global Action Plan for the Prevention
and Control of Non-communicable
Diseases 2013-2020 (2013), WHO
Global Report on Diabetes (2016), and
WHO HEARTS D: Diagnosis and
Management of Type 2 Diabetes (2020)
[18-20]. Ongoing consultations,
discussions, and feedback,
especially on best practices for non-
communicable disease prevention
and control, are being provided by
the global community on the draft
versions of the WHO Global Action
Plan for the Prevention and Control of
NCDs 2023-2030.
Furthermore, recent global summits
and assemblies have offered an open
platform for health leaders to leverage
expertise, debate scientific discourse,
and determine the next course of
action [21]. In April 2021, the WHO
Global Diabetes Compact initiative
was announced at the Global Diabetes
Summit 2021, which aims to enhance
collaborations with public and private
sector stakeholders and develop novel
solutions for diabetes prevention and
control [22]. Then, in May 2021,
the Resolution on strengthening
diabetes prevention and control was
approved at the 74th WHO World
Health Assembly [21].Three months
later, the WHO Technical Advisory
Group of Experts on Diabetes was
appointed to share technical expertise
on strengthening global efforts for
diabetes [22]. Later, in May 2022,
five new diabetes targets to achieve
by 2030 were confirmed at the 75th
World Health Assembly: 1) 80%
of persons living with diabetes are
diagnosed; 2) 80% of diabetics have
appropriate glycaemic control; 3)
80% of diabetics have optimal blood
pressure control; 4) 60% of diabetes
(>40 years) receive statins; and 5)
100% of type 1 diabetics can access
inexpensive insulin and self-monitor
glucose levels [6].
Conclusion
As the global community
commemorates World Diabetes
Day 2022 – and the multi-year
theme “Access to Diabetes Care”
– global leaders can support the
WHO guidelines and UN SDGs
(like SDG 3.4). Robust WHO and
World Health Assembly (WHA)
efforts – ranging from the WHO
Global Diabetes Compact initiative
in April 2021 to the WHA plan
and new diabetes targets in May
2022 – will surely propel global
change in strengthening surveillance
programs, developing innovative
interventions, and expanding access
to health services to promote
population health and reduce health
expenditure. Notably, the WMA
Statement on the Global Burden of
Chronic Non-communicable Disease
presented clear evidence of the global
burden and cited recommendations
to national governments, WMA
members, medical schools, and
individual physicians [23]. In fact,
the IDF School of Diabetes offers
free continuing education courses
(https://www.idfdiabeteschool.org/)
for health professionals on diabetes
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care
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104
care and management, including
health counselling techniques, best
nutrition practices, living with co-
morbidities, and encouraging regular
physical activity.
As we approach the established
deadlines for the 2030 Agenda for
Sustainable Development, especially
SDG 3 (target 3.4), nations will
need to examine ongoing efforts
and pledge funding, resources, and
support for the health workforce.
Local and global action will be
imperative to combat the rising global
prevalence of diabetes and other non-
communicable diseases by promoting
patient-centred care and shared
physician-patient decision-making.
References
1. International Diabetes
Federation.Global Diabetes Data
Report 2000-2045.IDF Diabetes
Atlas, 10th ed [Internet]. 2021
[cited Dec 1]. Available from:
https://diabetesatlas.org/data/en/
world/
2. World Diabetes Federation.
World Diabetes Day [Internet].
2022 [cited 2022 Nov 20].
Available from: http://worlddia­
betesday.org/about/
3. United Nations. Resolution
adopted by the General
Assembly on 20 December
2006. 61/225: World Diabetes
Day [Internet]. 2007 [cited
2022 Nov 20]. Available from:
https://daccess-ods.un.org/
tmp/3544268.01204681.html
4. World Health Organization.
Diabetes [Internet]. 2022
[cited 2022 Nov 20]. Available
from: https://www.who.int/
news-room/fact-sheets/detail/
diabetes
5. World Health Organization.
GlobalHealthObservatory:SDG
Target 3.4 non-communicable
diseases and mental health. 2022
[cited 2022 Nov 25]. Available
from: https://www.who.int/data/
gho/data/themes/topics/sdg-
target-3_4-noncommunicable-
diseases-and-mental-health
6. World Health Organization.
First-ever global coverage targets
for diabetes adopted at the
75th World Health Assembly
[Internet]. 2022 [cited 2022
Nov 25]. Available from: https://
w w w.who.int /news-room /
feature-stories/detail/first-ever-
global-coverage-targets-for-
diabetes-adopted-at-the-75-th-
world-health-assembly
7. Chatterjee S, Davies MJ.
Current management of diabetes
mellitus and future directions
in care. Postgrad Med J.
2015;91(1081):612-21.
8. Ahmad E, Lim S, Lamptey
R, Webb DR, Davies MJ.
Type 2 diabetes. Lancet.
2022;400(10365):1803-20.
9. Pansier B, Schulz PJ. School-
based diabetes interventions
and their outcomes: a systematic
literature review. J Public Health
Res. 2015;4(1):467.
10. Brown SA, García AA, Zuñiga
JA, Lewis KA. Effectiveness of
workplace diabetes prevention
programs: A systematic review
of the evidence. Patient Educ
Couns. 2018;101(6):1036-50.
11. Buse JB, Holst I, Knop FK, Kvist
K,Thielke D,Pratley R.Prototype
of an evidence-based tool to aid
individualized treatment for
type 2 diabetes. Diabetes Obes
Metab. 2021;23(7):1666-71.
12. American Diabetes Association
Professional Practice Committee.
1.Improving Care and Promoting
Health in Populations:
Standards of Medical Care in
Diabetes-2022. Diabetes Care.
2022;45(Suppl 1):S8-16.
13. Brown E, Heerspink HJL,
Cuthbertson DJ, Wilding JPH.
SGLT2 inhibitors and GLP-1
receptor agonists: established and
emerging indications. Lancet.
2021;398(10296):262-276.
14. Bergman M, Buysschaert
M, Schwarz PE, Albright A,
Narayan KV, Yach D. Diabetes
prevention: global health policy
and perspectives from the
ground. Diabetes Manag (Lond).
2012;2(4):309-21.
15. Afshari M,Ahmadi Teymourlouy
A, Asadi-Lari M, Maleki M.
Global Health diplomacy for
noncommunicable diseases
prevention and control: a
systematic review. Global Health.
2020 May 6;16(1):41.
16. Chapman HJ, Veras-Estévez BA.
Strengthening national health
priorities for diabetes prevention
and management. MEDICC
Rev. 2018;20(4):5.
17. World Health Organization.
Diabetes [Internet]. 2022
[cited 2022 Dec 1]. Available
from: https://www.who.int/
news-room/fact-sheets/detail/
diabetes
18. World Health Organization.
Implementation roadmap
2023-2030 for the global
action plan for the prevention
and control of NCDs 2013-
2030 [Internet]. 2021 [cited
2022 Dec 1]. Available from:
https://www.who.int/teams/
noncommunicable-diseases/
governance/roadmap
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care
BACK TO CONTENTS
105
19. World Health Organization.
Global Report on Diabetes.
Geneva: WHO [Internet]. 2016
[cited Dec 1]. Available from:
https://w w w.who.int /pub­­-
l i c a­­t i o n s­- d e t a i l –
redirect/9789241565257
20. World Health Organization.
HEARTS D: Diagnosis and
Management of Type 2 Diabetes.
Geneva: WHO [Internet].2020
[cited 2022 Dec 1]. Available
from: https://www.who.int/
publications-detail-redirect/
who-ucn-ncd-20.1
21. World Health Organization.
New WHO Global Compact
to speed up action to tackle
diabetes [Internet]. 2021 [cited
2022 Dec 1]. Available from:
https://w w w.who.int/news/
item/14-04-2021-new-who-
global-compact-to-speed-up-
action-to-tackle-diabetes
22. World Health Organization.
WHO Technical Advisory
Group of Experts on Diabetes
[Internet]. 2021 [cited 2022 Dec
1]. Available from: https://www.
who.int/groups/who-technical-
advisory-group-of-experts-on-
diabetes-(tag-d)/
23. World Medical Association.
WMA Statement on the
Global Burden of Chronic
Non-communicable Disease
[Internet]. 2022 [cited 2022 Nov
30].Available from: https://www.
wma.net/policies-post/wma-
statement-on-the-global-burden-
of-chronic-disease/
María Caraballo-Lorenzo, MD
Internist and nephrologist
Santo Domingo, Dominican Republic
dra.mcaraballonefro@gmail.com
Bienvenido Veras-Estévez,
MD, MPH
Department of Epidemiology,
Hospital Regional Universitario
José María Cabral y Báez &
Faculty of Health Sciences,
Universidad Católica del Cibao
Santiago de los Caballeros & La
Vega, Dominican Republic
bienvenido.veras@ucateci.edu.do
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
hjchapman@gwu.edu
World Diabetes Day 2022: A Global Call to Action to Improve Diabetes Care
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