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Handbook of WMA Policies
The World Medical Association, Inc.
Version History
© The World Medical Association, Inc.
Version 2010, Vancouver; Printed in March 2011
Version 2011, Montevideo; Printed in December 2011
• Replacements
Code Short Title
D-2000-01-2010 by
D-2000-01-2011
Prison Conditions on TB (amended in 2011)
S-1988-01-2005 by
R-1988-01-2005
Correction of misclassified document type
S-1988-05-2007 by
S-1988-05-2011
Tobacco Products Health Hazards (amended in 2011)
S-1996-05-2006 Replacement due to typo in the footer
S-1997-01-2007 Correction (in 2007 it was reaffirmed, not amended)
S-1997-02-2007 Correction of typo in the header
• Additions of the policies newly adopted by the 62nd
WMA General Assembly,
Montevideo, Uruguay, October 2011
D-2011-01-2011 Disaster Preparedness
D-2011-02-2011 End-of-Life Medical Care
D-2011-03-2011 Leprosy Control
S-2011-01-2011 Chronic Disease
S-2011-02-2011 Monitoring Tokyo Declaration
S-2011-03-2011 Protection and Integrity of Medical Personnel
S-2011-04-2011 Social Determinants of Health
S-2011-05-2011 Social Media
R-2011-01-2011 Adequate Pain Treatment
R-2011-02-2011 Bahrain
R-2011-03-2011 Economic Embargoes and Health
R-2011-04-2011 Independence of Medical Associations
Version 2012, Bangkok; Printed in October 2012
• Replacements
D-2002-04-2002 by
D-2002-04-2012
Advanced Technology (amended in 2012)
S-1956-01-2006 by
S-1956-01-2012
Armed Conflict (amended in 2012)
R-2002-05-2002 by
R-2002-05-2012
Abuse of Psychiatry (amended in 2012)
• Removals of the policies rescinded and archived by the 63rd
WMA General Assembly,
Bangkok, Thailand, October 2012
R-2002-03-2002 Health Care Services in Afghanistan
R-2002-04-2002 Pan American Health Organization
• Additions of the policies newly adopted by the 63rd
WMA General Assembly,
Bangkok, Thailand, October 2012
S-2012-01-2012 Electronic Cigarettes
S-2012-02-2012 Collective Action by Physicians
S-2012-03-2012 Forced and Coerced Sterilisation
S-2012-04-2012 Organ and Tissue Donation
S-2012-05-2012 Prioritisation of Immunisation
S-2012-06-2012 Violence in the Health Sector
R-2012-01-2012 Minimum Price for Alcohol
R-2012-02-2012 Plain Packaging of Cigarettes
R-2012-03-2012 Capital Punishment
R-2012-04-2012 Professor Cyril Karabus
Version 2013-1, Bali; Printed in April 2013
• Replacements
Code Short Title
D-1981-02-1999 by
D-1981-02-2010
Correction (in 2010 it was reaffirmed, not amended)
S-2003-02-2003 by
S-2003-02-2013
Living Wills (reaffirmed in 2013)
R-2002-01-2002 by
R-2002-01-2013
Euthanasia (reaffirmed in 2013)
R-2003-01-2003 by
R-2003-01-2013
Annual Medical Ethics Day (reaffirmed in 2013)
Version 2013-2, Fortaleza; Printed in February 2014
• Replacements
Code Short Title
S-2003-01-2003 by
S-2003-01-2013
Forensic Investigations of the Missing
(amended in 2013)
R-2002-06-2002 by
R-2002-06-2013
Women’s Right to Health Care
(amended in 2013)
• Removals of the policies rescinded and archived by the 64th
WMA General Assembly,
Fortaleza, Brazil, October 2013
R-2003-04-2003 SARS
• Additions of the policies newly adopted by the 64th
WMA General Assembly,
Fortaleza, Brazil, October 2013
S-2013-01-2013 Fungal Disease
S-2013-02-2013 Human Papillomavirus Vaccination
S-2013-03-2013 Natural Variations of Human Sexuality
S-2013-04-2013 Victims of Torture
S-2013-05-2013 Death Penalty
R-2013-01-2013 Criminalisation of Medical Practice
R-2013-02-2013 Healthcare Situation in Syria
R-2013-03-2013 Prohibition of Chemical Weapons
R-2013-04-2013 Standardisation in Medical Practice and Patient Safety
R-2013-05-2013 Support of the AMB
Version 2014-1, Tokyo; Printed in June 2014
• Replacements
Code Short Title
R-2004-01-2004 by
R-2004-01-2014
WFME (reaffirmed in 2014)
Version 2014-2, Durban; Printed in January 2015
• Replacements
Code Short Title
D-2002-01-2003 by
D-2002-01-2012
Biological Weapons (reaffirmed in 2012)
D-2002-03-2002 by
D-2002-03-2012
Patient Safety (reaffirmed in 2012)
S-2002-01-2002 by
S-2002-01-2012
Safe Injections in Health Care (amended in 2012)
S-2002-02-2002 by
S-2002-02-2012
Self-Medication (reaffirmed in 2012)
S-2003-03-2003 by
S-2003-03-2014
International Migration of Health Workers
(amended in 2014)
S-2004-03-2004 by
S-2004-03-2014
Water and Health (amended in 2014)
R-2002-02-2002 by
R-2002-02-2012
Female Foeticide (reaffirmed in 2012)
R-2003-03-2003 by
R-2003-03-2014
Non-Commercialization of Human Reproductive
Material (amended in 2014)
• Removals of the policies rescinded and archived by the 65th
WMA General Assembly,
Durban, South Africa, October 2014
S-2004-01-2004 Health Emergencies Communication & Coordination
• Additions of the policies newly adopted by the 65th
WMA General Assembly,
Durban, South Africa, October 2014
D-2014-01-2014 Protection of Healthcare Workers
S-2014-01-2014 Aesthetic Treatment
S-2014-02-2014 Air Pollution
S-2014-03-2014 Solitary Confinement
R-2014-01-2014 Ebola Viral Disease
Version 2015-1, Oslo; Printed in June 2015
• Replacements
Code Short Title
D-1981-01-2005 by
D-1981-01-2015
Lisbon (Patient’s Rights) (reaffirmed in 2015)
D-1987-01-2005 by
D-1987-01-2015
Euthanasia (reaffirmed in 2015)
D-1989-01-2005 by
D-1989-01-2015
Hong Kong (Elderly Abuse) (reaffirmed in 2015)
S-2005-02-2005 by
S-2005-02-2015
Drug Substitution (reaffirmed in 2015)
S-2005-04-2005 by
S-2005-04-2015
Medical Liability Reform (reaffirmed in 2015)
R-1988-01-2005 by
R-1988-01-2015
Academic Sanctions or Boycotts (reaffirmed in 2015)
Version 2015-2, Moscow; Printed in June 2016
• Replacements
Code Short Title
S-2011-04-2011 by
D-2011-04-2015
Social Determinants of Health (adopted in 2011 and
the title (S to D) changed in 2015)
S-1995-02-2006 by
S-1995-02-2015
Patients with Mental Illness (amended in 2015)
S-1985-01-2005 by
S-1985-01-2015
Non-Discrimination in Professional Membership and
Activities of Physicians (amended in 2015)
S-1998-01-2008 by
S-1998-01-2015
Nuclear Weapons (amended in 2015)
R-1999-01-1999 by
R-1999-01-2015
Curriculum of Medical Schools World-wide (amended
in 2015)
• Additions of the policies newly adopted by the 66th
WMA General Assembly,
Moscow, Russia, October 2015
Code Short Title
D-2015-01-2015 Alcohol
S-2015-01-2015 Mobile Health
S-2015-02-2015 Physicians Well-Being
S-2015-03-2015 Health Support to Street Children
S-2015-04-2015 Riot Control Agents
S-2015-04-2015 Riot Control Agents
S-2015-05-2015 Transgender People
S-2015-06-2015 Vitamin D Insufficiency
S-2015-07-2015 Promotional Mass Media Appearances by Physicians
R-2015-01-2015 Healthcare In Turkey
R-2015-02-2015 Bombing on the Hospital of MSF in Kunduz
R-2015-03-2015 Global Refugee Crisis
Version 2016-1, Buenos Aires; Printed in January 2019
• Replacements
Code Short Title
S-1988-04-2006 by
S-1988-04-2016
Environmental Issues (reaffirmed in 2016)
S-1993-03-2006 by
S-1993-03-2016
Patient Advocacy and Confidentiality (reaffirmed in
2016)
S-1989-01-2006 by
S-1989-01-2016
Animal Use in Biomedical Research (reaffirmed in
2016)
R-2006-02-2006 by
R-2006-02-2016
Child Safety in Airline Travel (reaffirmed in 2016)
R-2006-04-2006 by
R-2006-04-2016
Nuclear Testing in North Korea (reaffirmed in 2016)
Version 2016-2, Taipei; Printed in January 2019
• Replacements
Code Short Title
D-1968-01-2006 by
D-1968-01-2016
Determination of Death and the Recovery of Organs
(amended in 2016)
D-1975-01-2006 by
D-1975-01-2016
Medical Doctors concerning Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment in
relation to Detention and Imprisonment (amended in
2016
D-2002-02-2002 by
D-2002-02-2016
Ethical Considerations regarding Health Databases and
Biobanks (amended in 2016)
S-1984-01-2006 by
S-1984-01-2016
Child Abuse and Neglect (amended in 2016)
S-1990-01-2006 by
S-1990-01-2016
Injury Control (amended in 2016)
S-1990-04-2006 by
S-1990-04-2016
Traffic Injury (amended in 2016)
S-1991-01-2006 by
S-1991-01-2016
Adolescent Suicide (amended in 2016)
S-1992-01-2006 by
S-1992-01-2016
Alcohol and Road Safety (amended in 2016)
S-1993-01-2005 by
S-1993-01-2016
Body Searches of Prisoners (amended in 2016)
S-1993-02-2005 by
S-1993-02-2016
Female Genital Mutilation (amended in 2016)
S-1995-04-2006 by
S-1995-04-2016
Physicians and Public Health (amended in 2016)
S-1996-05-2006 by
S-1996-05-2016
Weapons of Warfare and Their Relation to Life and
Health (amended in 2016)
S-2006-05-2006 by
S-2006-05-2016
Physician’s Role in Obesity (amended in 2016)
S-2006-06-2006 by
S-2006-06-2016
Responsibilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug Abuse
(amended in 2016)
CR-2005-05-2005 by
R-2005-05-2016
Implementation of the WHO Framework Convention
on Tobacco Control (amended in 2016)
CR-2016-01-2016 by
R-2016-03-2016
Refugees and Migrants (adopted as a Council
Resolution in April 2016 and adopted as a Resolution in
October 2016)
CR-2016-02-2016 by
R-2016-04-2016
Zika Virus Infection (adopted as a Council Resolution in
April 2016 and adopted as a Resolution in October
2016)
• Removals of the policiers and archived by the 67th
WMA General assembly,
Taipei, Taiwan, October 2016
Code Short Title
R-2006-03-2006 Combating HIV/AIDS
• Addition of the resolution newly adopted by the 67th
WMA General Assembly,
Taipei, Taiwan, October 2016
S-2016-01-2016 Ageing
S-2016-02-2016 Cyber-Attacks on Health and Other Critical
Infrastructure
S-2016-03-2016 Divestment from Fossil Fuels
S-2016-04-2016 Ethical Considerations in Global Medical Electives
S-2016-05-2016 Obesity in Children
R-2016-01-2016 Protection of Health Care Facilities and Personnel in
Syria
R-2016-02-2016 Occupational and Environmental Health and Safety
Version 2017-1, Livingstone; Printed in January 2019
• Replacements
Code Short Title
R-2007-01-2007 by
R-2007-01-2017
Health and Human Rights Abuses in Zimbabwe
(reaffirmed in 2017)
Version 2017-2, Chicago, United States; Printed in January 2019
• Replacements
Code Short Title
D-1948-01-2006 by
D-1948-01-2017
Declaration of Geneva (amended in 2017)
D-1991-01-2006 by
D-1991-01-2017
Hunger Strikers (amended in 2017)
D-1997-02-2007 by
D-1997-02-2017
Support for Medical Doctors Refusing to Participate in,
or to Condone, the Use of Torture or Other Forms of
Cruel, Inhuman, or Degrading Treatment (reaffirmed in
2017)
D-2009-01-2009 by
D-2009-01-2017
Health and Climate Change (amended in 2017)
D-2015-01-2015 by
D-2015-01-2017
Alcohol (amended in 2017)
S-1983-01-2005 by
S-1983-01-2017
Boxing (amended in 2017)
S-1984-01-2016 by
S-1984-01-2017
Child Abuse and Neglect (amended in 2017)
S-1988-02-2006 by
S-1988-01-2017
Access to Health Care (amended in 2017)
S-1992-05-2007 by
S-1992-05-2017
Noise Pollution (reaffirmed in 2017)
S-1994-01-2006 by
S-1994-01-2017
Medical Ethics in the Event of Disasters (amended in
2017)
S-1996-04-2007 by
S-1996-04-2017
Family Planning and the Right of a Woman to
Contraception (reaffirmed in 2017)
S-2004-03-2014 by
S-2004-03-2017
Water and Health (amended in 2017)
S-2006-03-2006 by
S-2006-03-2017
HIV/AIDS and the Medical Profession (amended in
2017)
S-2006-04-2006 by
S-2006-04-2017
Medical Education (amended in 2017)
S-2012-04-2012 by
S-2012-04-2017
Organ and Tissue Donation (amended in 2017)
R-1997-02-2007 by
R-1997-01-2017
Economic Embargoes and Health (reaffirmed in 2017)
R-2006-01-2006 by
R-2006-01-2017
Medical Assistance in Air Travel (amended in 2017
R-2006-05-2006 by
R-2006-05-2017
Tuberculosis (amended in 2017)
R-2007-02-2007 by
R-2007-02-2017
Support of the Medical Associations in Latin America
and the Caribbean (reaffirmed in 2017)
• Removals of the policies rescinded and archived by the 68th
WMA General Assembly,
Chicago, United States, October 2017
S-1997-01-2007 Unites Nations Rapporteur on the Independence and
Integrity of Health Professionals
S-2005-01-2005 Reducing the Global Impact of Alcohol on Health and
Society
R-2012-01-2012 Minimum Price for Alcohol
• Additions of the policies newly adopted by the 68th
WMA General Assembly, Chicago,
United States, October 2017
D-2017-01-2017 Quality Assurance in Basic Medical Education
D-2017-02-2017 Fair Medical Trade
S-2017-01-2017 Bullying and Harassment within the Profession
S-2017-02-2017 Armed Conflicts
S-2017-03-2017 Medical Cannabis
S-2017-04-2017 Cooperation of National Medical Associations during or
in the Aftermath of Conflicts
S-2017-05-2017 Epidemics and Pandemics
S-2017-06-2017 Role of Physicians in Preventing Exploitation in
Adoption Practices
R-2017-01-2017 Poland
R-2017-02-2017 Prohibition of Forced Anal Examinations to
Substantiate Same-Sex Sexual Activity
Version 2018-1, Riga; Printed in January 2019
• Replacements
Code Short Title
R-1998-05-2008 by
R-1998-01-2018
Supporting the Ottawa Convention on the Prohibition
of the use, stockpiling, production and transfer of anti-
personnel mines and on their destruction (reaffirmed
in 2018)
Version 2018-2, Reykjavik, Iceland; Printed in January 2019
• Replacements
Code Short Title
D-2008-01-2008 by
D-2008-01-2018
Professional Autonomy and Clinical Independence
(amended in 2018)
D-1970-01-2006 by
S-1970-01-2018
Medically-Indicated Termination of Pregnancy (name
changed and amended in 2018)
S-1997-02-2007 by
S-1997-02-2018
Physicians convicted of Genocide or Crimes (name
changed and amended in 2018)
S-1998-01-2015 by
S-1998-01-2018
Nuclear Weapons (amended in 2018)
S-2006-02-2006 by
S-2006-02-2018
Avian and Pandemic Influenza (amended in 2018)
S-2007-02-2007 by
S-2007-01-2018
Ethics of Telemedicine (amended in 2018)
S-2008-02-2008 by
S-2008-02-2018
Reducing the Global Burden of Mercury (reaffirmed in
2018)
S-2010-01-2010 by
S-2010-01-2018
Environmental Degradation and Sound Management
of Chemicals (amended in 2018)
R-2008-03-2008 by
R-2008-01-2018
Collaboration Between Human and Veterinary
Medicine (reaffirmed in 2018)
• Removals of the policies rescinded and archived by the 69th
WMA General Assembly,
Reykjavik, Iceland, October 2018
Code Short Title
S-1996-03-2006 Professional Responsibility for Standards of Medical
Care
R-1981-01-2008 Physician Participation in Capital Punishment
R-2008-01-2008 The Economic Crisis: Implications for Health
R-2008-02-2008 Poppies for Medicine Project for Afghanistan
• Addition of the resolution newly adopted by the 69th
WMA General Assembly,
Reykjavik, Iceland, October 2018
S-2018-01-2018 Biosimilar Medicinal Products
S-2018-02-2018 Development and Promotion of a Maternal and Child
Health Handbook
S-2018-03-2018 Gender Equality in Medicine
S-2018-04-2018 Medical Tourism
S-2018-05-2018 Sustainable Development
R-2018-01-2018 Migration
R-2018-02-2018 Prohibition of Physician Participation in Capital
Punishment
Version 2019-1, Santiago, Chile; Printed in May 2019
• Replacements
Code Short Title
S-1999-01-2009 by
S-1999-01-2019
Patenting Medical Procedures (reaffirmed in 2019)
R-2009-03-2009 by
R-2009-03-2019
Task Shifting from the Medical Profession (reaffirmed
in 2019)
Handbook of WMA Policies
World Medical Association
PREFACE
Before World War II came to an end, a number of medical associations gathered in Lon-
don to reinvent the approach to international collaboration among the world’s physicians.
The old model, represented by the pre-war “Association Professionnelle Internationale des
Médecins” (APIM), would no longer meet the needs of the post-war medical profession.
It was time to create something new.
After only two years of preparation, 27 national medical associations met in Paris on Sep-
tember 18th, 1947 for the inauguration of a new global physicians’ association, the World
Medical Association (WMA). The lead-up to this first Assembly was paralleled by the
Nuremberg trial against Nazi doctors, which was a key driver of the mission focus of the
new WMA. This terrible episode in the history of medicine dictated that the organization
must seek to become the authoritative voice on global standards for medical ethics and
professional conduct, rather than focus solely on protecting the interests of the profession.
Effectively coordinating an international organization was anything but easy in the late
1940s. There was no internet, e-mail, mobile phones, personal computers, fax, or even
photocopiers. For many physicians, attending the Assembly required a cross-continental,
multi-day journey across a deeply scarred planet, by train and ship and only in exceptional
circumstances by plane. Yet the commitment of these founding WMA members to their
vision was even greater than the challenges they faced in achieving it. That vision, and the
accompanying goals, ideals, and unity of purpose, are as relevant today as they were during
those early days. They are now ours to carry on.
The WMA Handbook of Policies is evidence that the engagement of the world medical
profession does, in fact, persist. The WMA now is bigger, stronger and more active then
ever before, and our Handbook is the product of physicians coming together for more than
half a century to provide ethical guidance, moral support and practical advice to help their
colleagues serve their patients to the best of their ability. From the Declaration of Geneva,
often referred to as the “Modern Hippocratic Oath” to the Declaration of Helsinki advising
physicians doing medical research on human subjects, to the Declaration of Tokyo prohi-
biting physicians from participating in torture and degrading treatment − to mention just a
few of WMA’s landmark policies − the guidance provided by the WMA is as necessary
now as it has ever been.
There are many other policies in this world dealing with physician conduct, many of
which try to be “modern”, “easily readable” and “politically correct”. The WMA has never
capitulated against the “Zeitgeist”, but has stood firm with its values, the most important
of which are caring, ethics and science.
Sir William Osler said: “The most important thing is caring, so do it first, for the caring
physicians best inspires hope and trust.” Hope and trust are the basis for any treatment. A
physician who cannot generate trust will face more challenges than the one who receives
the trust of the patients. A patient with hope is far better off than one without.
World Medical Association
But caring must go hand-in-hand with medical ethics and proper conduct. Physicians are
often confronted with questions of life and death, resource allocations, and dual loyalties
when serving a single patient and at the same time respecting the needs of a community or
population. The questions are often too difficult and the problems too burdensome for one
person alone. We are far away from having answers for all such questions, but for many,
the WMA can provide the ethical guidance that protects patients, supports physicians, and
duly considers the interests of the communities and populations they both belong to.
Finally, science is what distinguishes medicine from well-intended kindness. In medicine,
quality care and ethical conduct cannot be separated from sound science. Still, despite our
sincere and continual quest for increased scientific knowledge, understanding and solu-
tions, we will never be protected from all mistakes. Therefore, practicing the science of
medicine with faithful adherence to clear ethical guidance is the best we can do.
This new handbook*
provides a good part of this guidance. It is proof of our continued
engagement with our colleagues in the different parts of this world and our commitment to
our patients, wherever and whoever they may be. It is a living document and the WMA
will continue to improve and expand it, in service to the profession and the health of those
we serve as physicians.
J. Edward Hill Otmar Kloiber
Chairman of Council Secretary General
Wonchat Subchaturas
President 2010-2011
*
The World Medical Association is most grateful to the Korean Medical Association for
seconding Ms. Seongmi LEE to the WMA Office at Ferney-Voltaire, providing valuable
help in putting this collection of policies together.
Handbook of WMA Policies
Chronological Order
D-1948-01-2017
D-1949-01-2006
D-1964-01-2013
D-1968-01-2016
D-1970-01-2006
D-1975-01-2016
D-1981-01-2015
D-1981-02-2010
D-1983-01-2006
D-1987-01-2015
D-1989-01-2015
D-1991-01-2017
D-1997-01-2009
D-1997-02-2017
D-1998-01-2009
D-2000-01-2011
D-2002-01-2012
D-2002-02-2016
D-2002-03-2012
D-2002-04-2012
D-2008-01-2018
D-2009-01-2017
TABLE OF CONTENTS
– Chronological Order –
DECLARATIONS
Declaration of Geneva ……………………………………………………………………………….
International Code of Medical Ethics ……………………………………………………………
Declaration of Helsinki
– Ethical Principles for Medical Research involving Human Subjects …………….
Declaration of Sydney
on the Determination of Death and the Recovery of Organs ………………………
Declaration of Oslo on Therapeutic Abortion ………………………………………………..
Declaration of Tokyo with guidelines for Medical Doctors concerning
Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment in relation to Detention and Imprisonment ……………………………
Declaration of Lisbon on the Rights of the Patient …………………………………………
Declaration on Principles of Health Care for Sports Medicine ………………………….
Declaration of Venice on Terminal Illness ……………………………………………………..
Declaration on Euthanasia ………………………………………………………………………….
Declaration of Hong Kong on the Abuse of the Elderly …………………………………..
Declaration of Malta on Hunger Strikers ………………………………………………………
Declaration on Guidelines for
Continuous Quality Improvement in Health Care ………………………………………
Declaration of Hamburg concerning Support for Medical Doctors Refusing to
Participate in, or to Condone, the Use of Torture or Other Forms of Cruel,
Inhuman, or Degrading Treatment ………………………………………………………….
Declaration of Ottawa on Child Health …………………………………………………………
Declaration of Edinburgh on Prison Conditions and the Spread of Tuberculosis
and Other Communicable Diseases …………………………………………………………
Declaration of Washington on Biological Weapons ………………………………………..
Declaration on Ethical Considerations regarding Health Databases …………………..
Declaration on Patient Safety ………………………………………………………………………
Declaration on Medical Ethics and Advanced Technology ………………………………
Declaration of Seoul on Professional Autonomy and
Clinical Independence ……………………………………………………………………………
Declaration of Delhi on Health and Climate Change ……………………………………….
Table of Contents
D-2009-02-2009
D-2011-01-2011
D-2011-02-2011
D-2011-03-2011
D-2011-04-2015
D-2014-01-2014
D-2015-01-2017
D-2017-01-2017
D-2017-02-2017
S-1956-01-2012
S-1970-01-2018
S-1983-01-2017
S-1984-01-2017
S-1984-02-1984
S-1985-01-2015
S-1988-01-2017
S-1988-04-2016
S-1988-05-2011
S-1989-01-2016
S-1990-01-2016
S-1990-04-2016
S-1991-01-2016
S-1992-01-2016
S-1992-05-2017
S-1992-06-2015
S-1993-01-2016
S-1993-02-2016
S-1993-03-2016
S-1994-01-2017
Declaration of Madrid on Professionally-led Regulation …………………………………
Declaration of Montevideo on Disaster Preparedness and
Medical Response …………………………………………………………………………………
Declaration on End-of-Life Medical Care ………………………………………………………
Declaration on Leprosy Control around the World and
Elimination of Discrimination against persons affected by Leprosy ……………..
Declaration on Oslo on Social Determinants of Health ……………………………………
Declaration on the Protection of Health Care Workers
in Situations of Violence ………………………………………………………………………..
Declaration on Alcohol ………………………………………………………………………………..
Declaration of Chicago on Quality Assurance in Medical Education ………………….
Declaration on Fair Trade in Medical Products and Devices ……………………………..
STATEMENTS
Regulations in Time of Armed Conflict and Other Situations of Violence ………….
Statement on Medically-Indicated Termination of Pregnancy ………………………….
Statement on Boxing ………………………………………………………………………………….
Statement on Child Abuse and Neglect ………………………………………………………..
Statement on Freedom to Attend Medical Meetings …………………………………….
Statement on Non-Discrimination in Professional Membership and
Activities of Physicians …………………………………………………………………………..
Statement on Access to Health Care …………………………………………………………….
Statement on the Role of Physicians in Environmental Issues …………………………
Statement on Health Hazards of Tobacco Products and
Tobacco-Derived Products ……………………………………………………………………..
Statement on Animal Use in Biomedical Research …………………………………………
Statement on Injury Control ……………………………………………………………………….
Statement on Traffic Injury …………………………………………………………………………
Statement on Adolescent Suicide ………………………………………………………………..
Statement on Alcohol and Road Safety ………………………………………………………..
Statement on Noise Pollution ……………………………………………………………………..
Statement on Physician-Assisted Suicide ………………………………………………………
Statement on Body Searches of Prisoners …………………………………………………….
Statement on Female Genital Mutilation ……………………………………………………..
Statement on Patient Advocacy and Confidentiality ………………………………………
Statement on Medical Ethics in the Event of Disasters …………………………………..
Handbook of WMA Policies
Chronological Order
S-1995-02-2015
S-1995-04-2016
S-1996-01-2008
S-1996-02-2010
S-1996-04-2017
S-1996-05-2016
S-1997-02-2018
S-1997-01-2007
S-1998-01-2018
S-1998-02-2010
S-1999-01-2019
S-1999-02-2010
S-2000-01-2006
S-2002-01-2012
S-2002-02-2012
S-2003-01-2013
S-2003-02-2013
S-2003-03-2014
S-2003-04-2008
S-2004-02-2009
S-2004-03-2017
S-2005-02-2015
S-2005-03-2009
S-2005-04-2015
S-2006-01-2006
S-2006-02-2018
S-2006-03-2017
S-2006-04-2017
Statement on Ethical Issues concerning Patients with Mental Illness ……………….
Statement on Physicians and Public Health …………………………………………………..
Statement on Resistance to Antimicrobial Drugs …………………………………………..
Statement on Family Violence …………………………………………………………………….
Statement on Family Planning and the Right of a Woman to Contraception ……..
Statement on Weapons of Warfare and Their Relation to Life and Health ………..
Statement on Physicians convicted of Genocide, War Crimes or Crimes Against
Humanity …………………………………………………………………………………………….
Proposal for a United Nations Rapporteur on the Independence and
Integrity of Health Professionals ……………………………………………………………..
Statement on Nuclear Weapons ………………………………………………………………….
Statement on Medical Care for Refugees, including Asylum Seekers,
Refused Asylum Seekers and Undocumented Migrants, and
Internally Displaced Persons …………………………………………………………………..
Statement on Patenting Medical Procedures ………………………………………………..
Statement on the Relationship between Physicians and Pharmacists
in Medical Therapy ……………………………………………………………………………….
Statement on Human Organ Donation and Transplantation ……………………………
Statement on Safe Injections in Health Care …………………………………………………
Statement on Self-Medication …………………………………………………………………….
Statement on Forensic Investigations of the Missing …………………………………….
Statement on Advance Directives (“Living Wills”) ………………………………………….
Statement on the Ethical Guidelines for the International Migration of
Health Workers …………………………………………………………………………………….
Statement on Violence and Health ………………………………………………………………
Statement concerning the Relationship
between Physicians and Commercial Enterprises ……………………………………..
Statement on Water and Health ………………………………………………………………….
Statement on Drug Substitution ………………………………………………………………….
Statement on Genetics and Medicine …………………………………………………………..
Statement on Medical Liability Reform ………………………………………………………..
Statement on Assisted Reproductive Technologies ………………………………………..
Statement on Avian and Pandemic Influenza ………………………………………………..
Statement on HIV/AIDS and the Medical Profession ………………………………………
Statement on Medical Education …………………………………………………………………
Table of Contents
S-2006-05-2016
S-2006-06-2016
S-2007-02-2018
S-2008-01-2008
S-2008-02-2018
S-2009-01-2009
S-2009-02-2009
S-2009-03-2009
S-2009-04-2009
S-2010-01-2018
S-2011-01-2011
S-2011-02-2011
S-2011-03-2011
S-2011-04-2015
S-2011-05-2011
S-2012-01-2012
S-2012-02-2012
S-2012-03-2012
S-2012-04-2017
S-2012-05-2012
S-2012-06-2012
S-2013-01-2013
S-2013-02-2013
S-2013-03-2013
S-2013-04-2013
S-2013-05-2013
Statement on The Physician’s Role in Obesity ……………………………………………….
Statement on the Responsibilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug Abuse ………………………………………….
Statement on the Ethics of Telemedicine ……………………………………………………..
Statement on Reducing Dietary Sodium Intake ……………………………………………..
Statement on Reducing the Global Burden of Mercury …………………………………..
Statement on Conflict of Interest ………………………………………………………………..
Statement on Embryonic Stem Cell Research ………………………………………………..
Statement on Inequalities in Health …………………………………………………………….
Statement on Guiding Principles for the Use of Telehealth
for the Provision of Health Care ……………………………………………………………..
Statement on Environmental Degradation and
Sound Management of Chemicals …………………………………………………………..
Statement on the Global Burden of Chronic Disease ………………………………………
Recommendation on the Development of a Monitoring and
Reporting Mechanism to permit Audit of
Adherence of States to the Declaration of Tokyo ………………………………………
Statement on the Protection and Integrity of Medical Personnel
in Armed Conflicts and Other Situations of Violence ………………………………….
Statement on Social Determinants of Health ………………………………………………..
Statement on the Professional and Ethical Usage of Social Media …………………..
Statement on Electronic Cigarettes and
Other Electronic Nicotine Delivery Systems ……………………………………………..
Statement on the Ethical Implications of Collective Action by Physicians …………
Statement on Forced and Coerced Sterilisation ……………………………………………
Statement on Organ and Tissue Donation ……………………………………………………
Statement on the Prioritisation of Immunisation ………………………………………….
Statement on Violence in the Health Sector by Patients and
Those Close to Them ……………………………………………………………………………..
Statement on Fungal Disease Diagnosis and Management …………………………….
Statement on Human Papillomavirus Vaccination …………………………………………
Statement on Natural Variations of Human Sexuality ……………………………………
Statement on the Right to Rehabilitation of Victims of Torture ………………………
Statement on the United Nations Resolution for a Moratorium on the
Use of the Death Penalty ………………………………………………………………………
Handbook of WMA Policies
Chronological Order
S-2014-01-2014
S-2014-02-2014
S-2014-03-2014
S-2015-01-2015
S-2015-02-2015
S-2015-03-2015
S-2015-04-2015
S-2015-05-2015
S-2015-06-2015
S-2015-07-2015
S-2016-01-2016
S-2016-02-2016
S-2016-03-2016
S-2016-04-2016
S-2016-05-2016
S-2017-01-2017
S-2017-02-2017
S-2017-03-2017
S-2017-04-2017
S-2017-05-2017
S-2017-06-2017
S-2018-01-2018
S-2018-02-2018
S-2018-03-2018
S-2018-04-2018
S-2018-05-2018
R-1988-01-2015
R-1997-01-2017
R-1997-03-2008
Statement on Aesthetic Treatment …………………………………………………………..
Statement on the Prevention of Air Pollution and Vehicle Emissions ………………
Statement on Solitary Confinement ……………………………………………………………
Statement on Mobile Health ………………………………………………………………………
Statement on Physicians Well-Being ……………………………………………………………
Statement on Providing Health Support to Street Children …………………………….
Statement on Riot Control Agents ……………………………………………………………….
Statement on Transgender People ………………………………………………………………
Statement on Vitamin D Insufficiency ………………………………………………………….
Guidelines on Promotional Mass Media Appearances by Physicians ………………..
Statement on Ageing …………………………………………………………………………………
Statement on Cyber-Attacks on Health and Other Critical Infrastructure ………….
Statement on Divestment from Fossil Fuels ………………………………………………….
Statement on Ethical Considerations in Global Medical Electives …………………….
Statement on Obesity in Children ………………………………………………………………..
Statement on Bullying and Harassment within the Profession ………………………..
Statement on Armed Conflicts …………………………………………………………………….
Statement on Medical Cannabis ………………………………………………………………….
Statement on the Cooperation of National Medical Associations
during or in the Aftermath of Conflicts …………………………………………………….
Statement on Epidemics and Pandemics ………………………………………………………
Statement on the Role of Physicians in Preventing Exploitation
in Adoption Practices …………………………………………………………………………….
Statement on Biosimilar Medicinal Products …………………………………………………
Statement on the Development and Promotion of a Maternal
and Child Health Handbook ……………………………………………………………………
Statement on Gender Equality in Medicine …………………………………………………..
Statement on Medical Tourism …………………………………………………………………..
Statement on Sustainable Development ………………………………………………………
RESOLUTIONS
Resolution on Academic Sanctions or Boycotts ……………………………………………..
Resolution on Economic Embargoes and Health ……………………………………………
Resolution on Access of Women and Children to Health Care and
the Role of Women in the Medical Profession ………………………………………….
Table of Contents
R-1998-03-2009
R-1998-04-2009
R-1998-01-2018
R-1999-01-2015
R-2002-01-2013
R-2002-02-2012
R-2002-05-2012
R-2002-06-2013
R-2003-01-2013
R-2003-02-2007
R-2003-03-2014
R-2004-01-2014
R-2005-01-2016
R-2006-01-2017
R-2006-02-2016
R-2006-04-2016
R-2006-05-2017
R-2007-01-2017
R-2007-02-2017
R-2008-01-2018
R-2009-01-2009
R-2009-02-2009
R-2009-03-2019
R-2010-01-2010
R-2010-02-2010
R-2011-01-2011
R-2011-02-2011
Resolution on Improved Investment in Public Health …………………………………….
Resolution on the Medical Workforce ………………………………………………………….
Resolution supporting the Ottawa Convention ……………………………………………..
Resolution on the Inclusion of Medical Ethics and
Human Rights in the Curriculum of Medical Schools World-wide ………………..
Resolution on Euthanasia …………………………………………………………………………..
Resolution on Female Foeticide …………………………………………………………………..
Resolution on Political Abuse of Psychiatry …………………………………………………..
Resolution on the Women’s Right to Health Care and
How that Relates to the Prevention of Mother-to-Child HIV Infection …………
Resolution on the Designation of an Annual Medical Ethics Day ……………………..
Resolution on the Responsibility of Physicians in the Denunciation of
Acts of Torture or Cruel, Inhuman or Degrading Treatment ……………………….
Resolution on the Non-Commercialization of
Human Reproductive Material ……………………………………………………………….
Resolution on WFME Global Standards for
Quality Improvement of Medical Education ……………………………………………..
Resolution on Implementation of the WHO Framework Convention
on Tobacco Control ……………………………………………………………………………….
Resolution on Medical Assistance in Air Travel ……………………………………………..
Resolution on Child Safety in Airline Travel …………………………………………………..
Resolution on North Korean Nuclear Testing ………………………………………………..
Resolution on Tuberculosis …………………………………………………………………………
Resolution on Health and Human Rights Abuses in Zimbabwe ………………………..
Resolution in Support of the Medical Associations
in Latin America and the Caribbean …………………………………………………………
Resolution on Collaboration Between Human and Veterinary Medicine …………..
Emergency Resolution on Legislation against Abortion in Nicaragua ………………..
Resolution supporting the Rights of
Patients and Physicians in the Islamic Republic of Iran ………………………………
Resolution on Task Shifting from the Medical Profession ……………………………….
Resolution on Drug Prescription ………………………………………………………………….
Resolution on Violence against Women and Girls ………………………………………….
Resolution on the Access to Adequate Pain Treatment ………………………………….
Resolution on Bahrain ………………………………………………………………………………..
Resolution reaffirming the WMA Resolution on
Handbook of WMA Policies
Chronological Order
Economic Embargoes and Health ……………………………………………………………
Resolution on Independence of Medical Associations ……………………………………
Resolution on Plain Packaging of Cigarettes ………………………………………………….
Resolution to reaffirm the WMA’s Prohibition of Physician Participation in
Capital Punishment ……………………………………………………………………………….
Resolution in Support of Professor Cyril Karabus ……………………………………………
Resolution on Criminalisation of Medical Practice ………………………………………….
Resolution on the Healthcare Situation in Syria ……………………………………………..
Resolution on the Prohibition of Chemical Weapons ………………………………………
Resolution on Patient Safety and Standardisation in Medical Practice ………………
Resolution in Support of the Brazilian Medical Association ……………………………..
Resolution on Ebola Viral Disease …………………………………………………………………
Resolution on Migrant Workers’ Health and Safety in Qatar ……………………………
Resolution on Unproven Therapy and the Ebola Virus …………………………………….
Resolution to Stop Attacks Against Healthcare Workers
and Facilities In Turkey ………………………………………………………………………….
Resolution about the Bombing on the Hospital of MSF in Kunduz ……………………
Resolution on Global Refugee Crisis …………………………………………………………….
Resolution on the Protection of Health Care Facilities
and Personnel in Syria ……………………………………………………………………………
Resolution on Occupational and Environmental Health and Safety ………………….
Resolution on Refugees and Migrants ………………………………………………………….
Resolution on Zika Virus Infection ……………………………………………………………….
Resolution on Poland …………………………………………………………………………………
Resolution on Prohibition of Forced Anal Examinations
to Substantiate Same-Sex Sexual Activity …………………………………………………
Resolution on Migration …………………………………………………………………………….
Resolution on Prohibition of Physician Participation in Capital Punishment ………
R-2011-03-2011
R-2011-04-2011
R-2012-02-2012
R-2012-03-2012
R-2012-04-2012
R-2013-01-2013
R-2013-02-2013
R-2013-03-2013
R-2013-04-2013
R-2013-05-2013
R-2014-01-2014
R-2014-02-2014
R-2014-03-2014
R-2015-01-2015
R-2015-02-2015
R-2015-03-2015
R-2016-01-2016
R-2016-02-2016
R-2016-03-2016
R-2016-04-2016
R-2017-01-2017
R-2017-02-2017
R-2018-01-2018
R-2018-02-2018
* Code explanation (sorting criteria):
D-1948-01-2006
Year of last action
Serial number
Year of adoption
Document type
Handbook of WMA Policies
Order by Short Title
R-2002-05-2012
R-1988-01-2015
S-1988-01-2017
R-2011-01-2011
S-1991-01-2016
D-2002-04-2012
S-2014-01-2014
S-2016-01-2016
S-2014-02-2014
R-2006-01-2017
D-2015-01-2017
S-1992-01-2016
S-2005-01-2005
S-1989-01-2016
R-2003-01-2013
S-1996-01-2008
S-1956-01-2012
S-2017-02-2017
S-2006-01-2006
S-2006-02-2018
R-2011-02-2011
D-2002-01-2012
S-2018-01-2018
S-1993-01-2016
R-2015-02-2015
S-1983-01-2017
S-2017-01-2017
R-2018-02-2018
D-2017-01-2017
TABLE OF CONTENTS
– Order by Short Title –
[A]
Abuse of Psychiatry …………………………………………………………………………………………………..
Academic Sanctions or Boycotts …………………………………………………………………………………
Access to Health Care ………………………………………………………………………………………………..
Adequate Pain Treatment ………………………………………………………………………………………….
Adolescent Suicide ……………………………………………………………………………………………………
Advanced Technology …………………………………………………………………………………………………
Aesthetic Treatment ………………………………………………………………………………………………….
Ageing ……………………………………………………………………………………………………………………..
Air Pollution ……………………………………………………………………………………………………………..
Air Travel ………………………………………………………………………………………………………………….
Alcohol …………………………………………………………………………………………………………………….
Alcohol and Road Safety ……………………………………………………………………………………………
Alcohol on Health and Society ……………………………………………………………………………………
Animal Use in Biomedical Research …………………………………………………………………………….
Annual Medical Ethics Day …………………………………………………………………………………………
Antimicrobial Resistance ……………………………………………………………………………………………
Armed Conflict …………………………………………………………………………………………………………
Armed Conflicts …………………………………………………………………………………………………………
Assisted Reproductive Technologies ……………………………………………………………………………
Avian and Pandemic Influenza …………………………………………………………………………………….
[B]
Bahrain ……………………………………………………………………………………………………………………..
Biological Weapons (Washington) ……………………………………………………………………………….
Biosimilar Medicinal Products ……………………………………………………………………………………..
Body Searches of Prisoners ………………………………………………………………………………………..
Bombing on the Hospital of MSF in Kunduz …………………………………………………………………..
Boxing ……………………………………………………………………………………………………………………..
Bullying and Harassment within the Profession …………………………………………………………….
[C]
Capital Punishment …………………………………………………………………………………………………..
Chicago (Quality Assurance in Basic Medical Education) ………………………………………………….
Handbook of WMA Policies
Order by Short Title
S-1984-01-2017
D-1998-01-2009
R-2006-02-2016
S-2011-01-2011
D-2009-01-2017
S-2012-02-2012
S-2009-01-2015
S-2017-04-2017
S-1997-02-2007
R-2013-01-2013
R-1999-01-2015
S-2016-02-2016
S-2013-05-2013
D-2009-01-2017
R-2003-02-2007
D-1975-01-2016
D-1968-01-2016
S-2008-01-2008
D-2011-01-2011
S-1994-01-2017
S-2016-03-2016
R-2010-01-2010
S-2005-02-2015
R-2014-01-2014
R-2014-03-2014
R-1997-01-2017
R-2011-03-2011
D-2000-01-2011
D-1989-01-2015
S-2012-01-2012
S-2009-02-2009
D-2011-02-2011
S-2010-01-2018
S-1988-04-2016
Child Abuse and Neglect ……………………………………………………………………………………………
Child Health (Ottawa) ………………………………………………………………………………………………..
Child Safety in Airline Travel ………………………………………………………………………………………
Chronic Disease ………………………………………………………………………………………………………..
Climate Change (Delhi) ………………………………………………………………………………………………
Collective Action by Physicians …………………………………………………………………………………..
Conflict of Interest ……………………………………………………………………………………………………
Cooperation of NMAs during or in the Aftermath of Conflicts …………………………………………
Criminal Offences and Licensing …………………………………………………………………………………
Criminalisation of Medical Practice ……………………………………………………………………………..
Curriculum of Medical Schools World-wide ………………………………………………………………….
Cyber-Attacks on Health …………………………………………………………………………………………….
[D]
Death Penalty ……………………………………………………………………………………………………………
Delhi (Climate Change) ………………………………………………………………………………………………
Denunciation of Acts of Torture ………………………………………………………………………………….
Detention and Imprisonment (Tokyo) ………………………………………………………………………….
Determination of Death (Sydney) ………………………………………………………………………………..
Dietary Sodium Intake ……………………………………………………………………………………………….
Disaster Preparedness (Montevideo) …………………………………………………………………………..
Disasters ………………………………………………………………………………………………………………….
Divestment from Fossil Fuels ………………………………………………………………………………………
Drug Prescription ……………………………………………………………………………………………………..
Drug Substitution ……………………………………………………………………………………………………..
[E]
Ebola Viral Disease ……………………………………………………………………………………………………
Ebola Virus ………………………………………………………………………………………………………………
Economic Embargoes and Health ………………………………………………………………….. -02-2007
Economic Embargoes and Health [Revised] …………………………………………………………………..
Edinburgh (Prison Conditions on TB) ……………………………………………………………………………
Elderly Abuse (Hong Kong) ………………………………………………………………………………01-2005
Electronic Cigarettes ………………………………………………………………………………………………….
Embryonic Stem Cell Research ……………………………………………………………………… -02-2009
End-of-Life Medical Care …………………………………………………………………………………………….
Environmental Degradation …………………………………………………………………………. -01-2010
Environmental Issues ………………………………………………………………………………………………..
Handbook of WMA Policies
Order by Short Title
S-2017-05-2017
D-1987-01-2015
R-2002-01-2013
D-2017-02-2017
S-1996-02-2010
R-2002-02-2012
S-1993-02-2016
R-2017-02-2017
S-2012-03-2012
S-2003-01-2013
S-1984-02-1984
S-2013-01-2013
S-2005-03-2009
D-1948-01-2017
S-2018-03-2018
S-2016-04-2016
R-2015-03-2015
D-1997-02-2017
R-2016-01-2016
R-2015-01-2015
R-2013-02-2013
D-2002-02-2016
D-1964-01-2013
S-2006-03-2017
D-1989-01-2015
S-2013-02-2013
R-2007-01-2017
D-1991-01-2017
R-2011-04-2011
S-2009-03-2009
S-1990-01-2016
Epidemics and Pandemics …………………………………………………………………………………………..
Euthanasia ……………………………………………………………………………………………………01-2005
Euthanasia ……………………………………………………………………………………………………………….
[F]
Fair Medical Trade …………………………………………………………………………………………………….
Family Violence ………………………………………………………………………………………….. -02-2010
Female Foeticide ………………………………………………………………………………………… -02-2002
Female Genital Mutilation …………………………………………………………………………………………
Forced Anal Examinations …………………………………………………………………………………………..
Forced and Coerced Sterilisation ………………………………………………………………………………..
Forensic Investigations of the Missing …………………………………………………………… -01-2003
Freedom to Attend Medical Meetings ……………………………………………………….. 84-02-1984
Fungal Disease ………………………………………………………………………………………………………….
[G]
Genetics and Medicine …………………………………………………………………………………..03-2009
Geneva ……………………………………………………………………………………………………… -01-2006
Gender Equality in Medicine ……………………………………………………………………………………….
Global Medical Electives …………………………………………………………………………………………….
Global Refugee Crisis …………………………………………………………………………………………………
[H]
Hamburg (Refusing Torture) ……………………………………………………………………………………….
Health Care Facilities and Personnel in Syria …………………………………………………………………
Healthcare In Turkey ………………………………………………………………………………………………….
Healthcare Situation in Syria ……………………………………………………………………………………….
Health Databases ………………………………………………………………………………………….02-2002
Helsinki (Medical Research involving Human Subjects) …………………………………………………..
HIV/AIDS and the Medical Profession ……………………………………………………………. -03-2006
Hong Kong (Elderly Abuse) ………………………………………………………………………………………….
Human Papillomavirus Vaccination ……………………………………………………………………………..
Human Rights Abuses in Zimbabwe ………………………………………………………………. -01-2007
Hunger Strikers (Malta) ……………………………………………………………………………….D-01-2006
[ I ]
Independence of Medical Associations ………………………………………………………………………..
Inequalities in Health …………………………………………………………………………………..S03-2009
Injury Control …………………………………………………………………………………………………S-2006
Handbook of WMA Policies
Order by Short Title
S-2003-03-2014
R-1998-03-2009
R-2007-02-2017
R-2009-01-2009
D-2011-03-2011
D-1981-01-2015
S-2003-02-2013
D-2009-02-2009
D-1991-01-2017
S-2018-02-2018
S-2017-03-2017
S-2006-04-2017
D-1949-01-2006
S-2005-04-2015
D-1964-01-2013
S-2018-04-2018
R-1998-04-2009
S-2008-02-2018
R-2014-02-2014
R-2018-01-2018
S-2015-01-2015
S-2011-02-2011
D-2011-01-2011
S-2013-03-2013
S-1992-05-2017
R-2003-03-2014
S-1985-01-2015
R-2006-04-2016
S-1998-01-2018
S-2006-05-2016
S-2016-05-2016
International Migration of Health Workers …………………………………………………………………..
Investment in Public Health …………………………………………………………………………. -03-2009
[ L ]
Latin American and the Caribbean Medical Associations …………………………………. -02-2007
Legislation against Abortion in Nicaragua ………………………………………………………. -01-2009
Leprosy Control …………………………………………………………………………………………………………
Lisbon (Patient’s Rights) ……………………………………………………………………………………………..
Living Wills ………………………………………………………………………………………………… -02-2003
[M]
Madrid (Professionally-led Regulation) …………………………………………………………………………
Malta (Hunger Strikers) ………………………………………………………………………………………………
Maternal and Child Health Handbook ………………………………………………………………………….
Medical Cannabis ………………………………………………………………………………………………………
Medical Education ………………………………………………………………………………………. -01-2006
Medical Ethics ……………………………………………………………………………………………. -01-2006
Medical Liability Reform ……………………………………………………………………………… -04-2005
Medical Research involving Human Subjects (Helsinki) …………………………………………………..
Medical Tourism ……………………………………………………………………………………………………….
Medical Workforce ……………………………………………………………………………………… -04-2009
Mercury …………………………………………………………………………………………………….. -02-2008
Migrant Workers’ Health and Safety in Qatar ……………………………………………………………….
Migration …………………………………………………………………………………………………………………..
Mobile Health …………………………………………………………………………………………………………..
Monitoring Tokyo Declaration ……………………………………………………………………………………
Montevideo (Disaster Preparedness) …………………………………………………………………………..
[N]
Natural Variations of Human Sexuality ………………………………………………………………………..
Noise Pollution …………………………………………………………………………………………… -05-2007
Non-Commercialization of Human Reproductive Material ……………………………….. -03-2003
Non-Discrimination in Professional Membership ………………………………………………01-2005
Nuclear Testing in North Korea …………………………………………………………………….. -04-2006
Nuclear Weapons ……………………………………………………………………………………………..-2008
[O]
Obesity ……………………………………………………………………………………………………………………
Obesity in Children …………………………………………………………………………………………………….
Handbook of WMA Policies
Order by Short Title
R-2016-02-2016
S-2006-06-2016
S-2012-04-2017
D-1970-01-2006
D-1998-01-2009
R-1998-01-2018
S-1999-01-2019
S-1993-03-2016
D-2002-03-2012
D-1981-01-2015
S-1995-02-2015
S-2004-02-2009
S-1999-02-2010
S-1997-02-2018
S-2015-02-2015
R-2012-02-2012
R-2017-01-2017
S-2017-06-2017
S-2012-05-2012
D-2000-01-2011
D-2008-01-2018
D-2009-02-2009
R-2012-04-2012
R-2013-03-2013
S-2015-07-2015
S-2011-03-2011
D-2014-01-2014
S-1995-04-2016
D-1997-01-2009
D-2017-01-2017
S-1998-02-2010
R-2016-01-2016
D-1997-02-2017
Occupational and Environmental Health and Safety ………………………………………………………
Opiate and Psychotropic Drug Abuse …………………………………………………………….. -04-2006
Organ and Tissue Donation ………………………………………………………………………………………..
Oslo (Social Determinants of Health) …………………………………………………………………………….
Ottawa (Child Health) ………………………………………………………………………………………………..
Ottawa Convention …………………………………………………………………………………….. -05-2008
[P]
Patenting Medical Procedures ……………………………………………………………………… -01-2009
Patient Advocacy and Confidentiality …………………………………………………………….S-03-2006
Patient Safety …………………………………………………………………………………………….. -03-2002
Patient’s Rights (Lisbon) ………………………………………………………………………………D-01-2005
Patients with Mental Illness …………………………………………………………………………. -02-2006
Physicians and Commercial Enterprises …………………………………………………………S-02-2009
Physicians and Pharmacists in Medical Therapy ……………………………………………………………
Physicians convicted of Genocide or Crimes ………………………………………………………………….
Physicians Well-Being ………………………………………………………………………………………………..
Plain Packaging of Cigarettes ……………………………………………………………………………………..
Poland ……………………………………………………………………………………………………………………..
Preventing Exploitation in Adoption Practices ………………………………………………… R-02-2008
Prioritisation of Immunisation …………………………………………………………………………………….
Prison Conditions on TB (Edinburgh) ……………………………………………………………… -01-2000
Professional Autonomy and Clinical Independence (Seoul) …………………………………01-2008
Professionally-led Regulation (Madrid) …………………………………………………………………-2009
Professor Cyril Karabus ………………………………………………………………………………………………
Prohibition of Chemical Weapons ……………………………………………………………………………….
Promotional Mass Media Appearances by Physicians …………………………………………………….
Protection and integrity of Medical Personnel ………………………………………………………………
Protection of Healthcare Workers ……………………………………………………………………………….
Public Health ……………………………………………………………………………………………… -04-2006
[Q]
Quality Improvement in Health Care …………………………………………………………………………D
Quality Assurance in Basic Medical Education ……………………………………………………………….
[R]
Refugees’ Medical Care ……………………………………………………………………………………………..
Refugees and Migrants ……………………………………………………………………………………………..
Refusing Torture (Hamburg) …………………………………………………………………………. -02-2007
Handbook of WMA Policies
Order by Short Title
Right of Woman on Family Planning ……………………………………………………………..S-04-2007
Rights of Patients and Physicians in Iran ………………………………………………………………………
Riot Control Agents …………………………………………………………………………………………………..
[S]
Safe Injections in Health Care ………………………………………………………………………S-01-2002
Self-Medication …………………………………………………………………………………………… -02-2002
Seoul (Professional Autonomy and Clinical Independence) …………………………………………….
Social Determinants of Health ……………………………………………………………………………………
Social Media ……………………………………………………………………………………………………………..
Solitary Confinemnet …………………………………………………………………………………………………
Sports Medicine …………………………………………………………………………………………. -02-1999
Standardisation in Medical Practice and Patient Safety …………………………………………………
Street Children ………………………………………………………………………………………………………….
Suicide Physician-Assisted …………………………………………………………………………. 92-06-2005
Support of the AMB …………………………………………………………………………………………………..
Sustainable Development …………………………………………………………………………………………..
Sydney (Determination of Death) ………………………………………………………………………………..
[T]
Task Shifting ………………………………………………………………………………………………. -03-2009
Telehealth …………………………………………………………………………………………………S-04-2009
Telemedicine ……………………………………………………………………………………………… -02-2007
Terminal Illness (Venice) ………………………………………………………………………………. -01-2006
Therapeutic Abortion …………………………………………………………………………………….01-2006
Tobacco Products Health Hazards …………………………………………………………………. -05-2007
Tobacco-WHO FCTC ……………………………………………………………………………………. -05-2005
Tokyo (Detention and Imprisonment) ………………………………………………………………………….
Traffic Injury …………………………………………………………………………………………………………….
Transgender People …………………………………………………………………………………………………..
Tuberculosis …………………………………………………………………………………………………05-2006
[V]
Venice (Terminal Illness) …………………………………………………………………………………………….
Veterinary Medicine ………………………………………………………………………………………03-2008
Victims of Torture …………………………………………………………………………………………………….
Violence against Women and Girls ……………………………………………………………………..-2010
Violence and Health ……………………………………………………………………………………. -04-2003
Violence in the Health Sector ……………………………………………………………………………………..
S-1996-04-2017
R-2009-02-2009
S-2015-04-2015
S-2002-01-2012
S-2002-02-2012
D-2008-01-2018
S-2011-04-2015
S-2011-05-2011
S-2014-03-2014
D-1981-02-2010
R-2013-04-2013
S-2015-03-2015
S-1992-06-2015
R-2013-05-2013
S-2018-05-2018
D-1968-01-2016
R-2009-03-2019
S-2009-04-2009
S-2007-02-2018
D-1983-01-2006
D-1970-01-2006
S-1988-05-2011
R-2005-01-2016
D-1975-01-2016
S-1990-04-2016
S-2015-05-2015
R-2006-05-2017
D-1983-01-2006
R-2008-03-2018
S-2013-04-2013
R-2010-02-2010
S-2003-04-2008
S-2012-06-2012
Handbook of WMA Policies
Order by Short Title
Vitamin D Insufficiency ………………………………………………………………………………………………
[W]
Washington (Biological Weapons) ……………………………………………………………………………….
Water and Health ………………………………………………………………………………………..S03-2004
Weapons of Warfare …………………………………………………………………………………..S-05-2006
WFME ……………………………………………………………………………………………………… R-01-2004
Women and Children to Health Care …………………………………………………………………..-2008
Women’s Right to Health Care …………………………………………………………………………………….
[Z]
Zika Virus Infection …………………………………………………………………………………………………….
S-2015-06-2015
D-2002-01-2012
S-2004-03-2017
S-1996-05-2016
R-2004-01-2014
R-1997-03-2008
R-2002-06-2013
R-2016-02-2016
Handbook of WMA Policies
D-1948-01-2017 ⏐ World Medical Association
WMA DECLARATION OF GENEVA
Adopted by the 2nd
General Assembly of the World Medical Association,
Geneva, Switzerland, September 1948
and amended by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
and the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 46th
WMA General Assembly, Stockholm, Sweden, September 1994
and editorially revised by the 170th
WMA Council Session,
Divonne-les-Bains, France, May 2005
and the 173rd
WMA Council Session, Divonne-les-Bains, France, May 2006
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
The Physician’s Pledge
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, social standing or any other factor to
intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good
medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of
healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the
highest standard;
D-1948-01-2017 ⏐ Chicago
Geneva
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under
threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Handbook of WMA Policies
World Medical Association ⏐ D-1949-01-2006
WMA INTERNATIONAL CODE OF MEDICAL ETHICS
Adopted by the 3rd
General Assembly of the World Medical Association,
London, England, October 1949
and amended by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
and the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
DUTIES OF PHYSICIANS IN GENERAL
A PHYSICIAN SHALL always exercise his/her independent professional judgment and
maintain the highest standards of professional conduct.
A PHYSICIAN SHALL respect a competent patient’s right to accept or refuse treatment.
A PHYSICIAN SHALL not allow his/her judgment to be influenced by personal profit or
unfair discrimination.
A PHYSICIAN SHALL be dedicated to providing competent medical service in full pro-
fessional and moral independence, with compassion and respect for human dignity.
A PHYSICIAN SHALL deal honestly with patients and colleagues, and report to the
appropriate authorities those physicians who practice unethically or incompetently or who
engage in fraud or deception.
A PHYSICIAN SHALL not receive any financial benefits or other incentives solely for
referring patients or prescribing specific products.
A PHYSICIAN SHALL respect the rights and preferences of patients, colleagues, and
other health professionals.
A PHYSICIAN SHALL recognize his/her important role in educating the public but
should use due caution in divulging discoveries or new techniques or treatment through
non-professional channels.
A PHYSICIAN SHALL certify only that which he/she has personally verified.
A PHYSICIAN SHALL strive to use health care resources in the best way to benefit
patients and their community.
A PHYSICIAN SHALL seek appropriate care and attention if he/she suffers from mental
or physical illness.
A PHYSICIAN SHALL respect the local and national codes of ethics.
D-1949-01-2006 ⏐ Pilanesberg
Medical Ethics
DUTIES OF PHYSICIANS TO PATIENTS
A PHYSICIAN SHALL always bear in mind the obligation to respect human life.
A PHYSICIAN SHALL act in the patient’s best interest when providing medical care.
A PHYSICIAN SHALL owe his/her patients complete loyalty and all the scientific re-
sources available to him/her. Whenever an examination or treatment is beyond the physi-
cian’s capacity, he/she should consult with or refer to another physician who has the neces-
sary ability.
A PHYSICIAN SHALL respect a patient’s right to confidentiality. It is ethical to disclose
confidential information when the patient consents to it or when there is a real and im-
minent threat of harm to the patient or to others and this threat can be only removed by a
breach of confidentiality.
A PHYSICIAN SHALL give emergency care as a humanitarian duty unless he/she is
assured that others are willing and able to give such care.
A PHYSICIAN SHALL in situations when he/she is acting for a third party, ensure that
the patient has full knowledge of that situation.
A PHYSICIAN SHALL not enter into a sexual relationship with his/her current patient or
into any other abusive or exploitative relationship.
DUTIES OF PHYSICIANS TO COLLEAGUES
A PHYSICIAN SHALL behave towards colleagues as he/she would have them behave
towards him/her.
A PHYSICIAN SHALL NOT undermine the patient-physician relationship of colleagues
in order to attract patients.
A PHYSICIAN SHALL when medically necessary, communicate with colleagues who are
involved in the care of the same patient. This communication should respect patient confi-
dentiality and be confined to necessary information.
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
WMA DECLARATION OF HELSINKI
– ETHICAL PRINCIPLES FOR MEDICAL RESEARCH INVOLVING HUMAN SUBJECTS –
Adopted by the 18th
WMA General Assembly, Helsinki, Finland, June 1964
and amended by the:
29th
WMA General Assembly, Tokyo, Japan, October 1975
35th
WMA General Assembly, Venice, Italy, October 1983
41st
WMA General Assembly, Hong Kong, September 1989
48th
WMA General Assembly, Somerset West, Republic of South Africa, October 1996
52nd
WMA General Assembly, Edinburgh, Scotland, October 2000
53rd
WMA General Assembly, Washington DC, USA, October 2002
(Note of Clarification added)
55th
WMA General Assembly, Tokyo, Japan, October 2004
(Note of Clarification added)
59th
WMA General Assembly, Seoul, Republic of Korea, October 2008
64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
1. The World Medical Association (WMA) has developed the Declaration of Helsinki as
a statement of ethical principles for medical research involving human subjects,
including research on identifiable human material and data.
The Declaration is intended to be read as a whole and each of its constituent para-
graphs should be applied with consideration of all other relevant paragraphs.
2. Consistent with the mandate of the WMA, the Declaration is addressed primarily to
physicians. The WMA encourages others who are involved in medical research in-
volving human subjects to adopt these principles.
GENERAL PRINCIPLES
3. The Declaration of Geneva of the WMA binds the physician with the words, “The
health of my patient will be my first consideration,” and the International Code of
Medical Ethics declares that, “A physician shall act in the patient’s best interest when
providing medical care.”
4. It is the duty of the physician to promote and safeguard the health, well-being and
rights of patients, including those who are involved in medical research. The physi-
cian’s knowledge and conscience are dedicated to the fulfilment of this duty.
D-1964-01-2013 ⏐ Fortaleza
Medical Rsearch involving Human Subjects (Helsinki)
5. Medical progress is based on research that ultimately must include studies involving
human subjects.
6. The primary purpose of medical research involving human subjects is to understand
the causes, development and effects of diseases and improve preventive, diagnostic
and therapeutic interventions (methods, procedures and treatments). Even the best
proven interventions must be evaluated continually through research for their safety,
effectiveness, efficiency, accessibility and quality.
7. Medical research is subject to ethical standards that promote and ensure respect for all
human subjects and protect their health and rights.
8. While the primary purpose of medical research is to generate new knowledge, this
goal can never take precedence over the rights and interests of individual research
subjects.
9. It is the duty of physicians who are involved in medical research to protect the life,
health, dignity, integrity, right to self-determination, privacy, and confidentiality of
personal information of research subjects. The responsibility for the protection of
research subjects must always rest with the physician or other health care pro-
fessionals and never with the research subjects, even though they have given consent.
10. Physicians must consider the ethical, legal and regulatory norms and standards for
research involving human subjects in their own countries as well as applicable
international norms and standards. No national or international ethical, legal or
regulatory requirement should reduce or eliminate any of the protections for research
subjects set forth in this Declaration.
11. Medical research should be conducted in a manner that minimises possible harm to
the environment.
12. Medical research involving human subjects must be conducted only by individuals
with the appropriate ethics and scientific education, training and qualifications. Re-
search on patients or healthy volunteers requires the supervision of a competent and
appropriately qualified physician or other health care professional.
13. Groups that are underrepresented in medical research should be provided appropriate
access to participation in research.
14. Physicians who combine medical research with medical care should involve their
patients in research only to the extent that this is justified by its potential preventive,
diagnostic or therapeutic value and if the physician has good reason to believe that
participation in the research study will not adversely affect the health of the patients
who serve as research subjects.
15. Appropriate compensation and treatment for subjects who are harmed as a result of
participating in research must be ensured.
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
RISKS, BURDENS AND BENEFITS
16. In medical practice and in medical research, most interventions involve risks and
burdens.
Medical research involving human subjects may only be conducted if the importance
of the objective outweighs the risks and burdens to the research subjects.
17. All medical research involving human subjects must be preceded by careful assess-
ment of predictable risks and burdens to the individuals and groups involved in the
research in comparison with foreseeable benefits to them and to other individuals or
groups affected by the condition under investigation.
Measures to minimise the risks must be implemented. The risks must be continuously
monitored, assessed and documented by the researcher.
18. Physicians may not be involved in a research study involving human subjects unless
they are confident that the risks have been adequately assessed and can be satis-
factorily managed.
When the risks are found to outweigh the potential benefits or when there is con-
clusive proof of definitive outcomes, physicians must assess whether to continue,
modify or immediately stop the study.
VULNERABLE GROUPS AND INDIVIDUALS
19. Some groups and individuals are particularly vulnerable and may have an increased
likelihood of being wronged or of incurring additional harm.
All vulnerable groups and individuals should receive specifically considered protec-
tion.
20. Medical research with a vulnerable group is only justified if the research is responsive
to the health needs or priorities of this group and the research cannot be carried out in
a non-vulnerable group. In addition, this group should stand to benefit from the
knowledge, practices or interventions that result from the research.
SCIENTIFIC REQUIREMENTS AND RESEARCH PROTOCOLS
21. Medical research involving human subjects must conform to generally accepted
scientific principles, be based on a thorough knowledge of the scientific literature,
other relevant sources of information, and adequate laboratory and, as appropriate,
animal experimentation. The welfare of animals used for research must be respected.
22. The design and performance of each research study involving human subjects must be
clearly described and justified in a research protocol.
D-1964-01-2013 ⏐ Fortaleza
Medical Rsearch involving Human Subjects (Helsinki)
The protocol should contain a statement of the ethical considerations involved and
should indicate how the principles in this Declaration have been addressed. The pro-
tocol should include information regarding funding, sponsors, institutional affilia-
tions, potential conflicts of interest, incentives for subjects and information regarding
provisions for treating and/or compensating subjects who are harmed as a conse-
quence of participation in the research study.
In clinical trials, the protocol must also describe appropriate arrangements for post-
trial provisions.
RESEARCH ETHICS COMMITTEES
23. The research protocol must be submitted for consideration, comment, guidance and
approval to the concerned research ethics committee before the study begins. This
committee must be transparent in its functioning, must be independent of the
researcher, the sponsor and any other undue influence and must be duly qualified. It
must take into consideration the laws and regulations of the country or countries in
which the research is to be performed as well as applicable international norms and
standards but these must not be allowed to reduce or eliminate any of the protections
for research subjects set forth in this Declaration.
The committee must have the right to monitor ongoing studies. The researcher must
provide monitoring information to the committee, especially information about any
serious adverse events. No amendment to the protocol may be made without con-
sideration and approval by the committee. After the end of the study, the researchers
must submit a final report to the committee containing a summary of the study’s find-
ings and conclusions.
PRIVACY AND CONFIDENTIALITY
24. Every precaution must be taken to protect the privacy of research subjects and the
confidentiality of their personal information.
INFORMED CONSENT
25. Participation by individuals capable of giving informed consent as subjects in medical
research must be voluntary. Although it may be appropriate to consult family mem-
bers or community leaders, no individual capable of giving informed consent may be
enrolled in a research study unless he or she freely agrees.
26. In medical research involving human subjects capable of giving informed consent,
each potential subject must be adequately informed of the aims, methods, sources of
funding, any possible conflicts of interest, institutional affiliations of the researcher,
the anticipated benefits and potential risks of the study and the discomfort it may
entail, post-study provisions and any other relevant aspects of the study. The potential
subject must be informed of the right to refuse to participate in the study or to with-
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
draw consent to participate at any time without reprisal. Special attention should be
given to the specific information needs of individual potential subjects as well as to
the methods used to deliver the information.
After ensuring that the potential subject has understood the information, the physician
or another appropriately qualified individual must then seek the potential subject’s
freely-given informed consent, preferably in writing. If the consent cannot be expressed
in writing, the non-written consent must be formally documented and witnessed.
All medical research subjects should be given the option of being informed about the
general outcome and results of the study.
27. When seeking informed consent for participation in a research study the physician
must be particularly cautious if the potential subject is in a dependent relationship
with the physician or may consent under duress. In such situations the informed
consent must be sought by an appropriately qualified individual who is completely
independent of this relationship.
28. For a potential research subject who is incapable of giving informed consent, the
physician must seek informed consent from the legally authorised representative.
These individuals must not be included in a research study that has no likelihood of
benefit for them unless it is intended to promote the health of the group represented
by the potential subject, the research cannot instead be performed with persons
capable of providing informed consent, and the research entails only minimal risk and
minimal burden.
29. When a potential research subject who is deemed incapable of giving informed con-
sent is able to give assent to decisions about participation in research, the physician
must seek that assent in addition to the consent of the legally authorised representa-
tive. The potential subject’s dissent should be respected.
30. Research involving subjects who are physically or mentally incapable of giving con-
sent, for example, unconscious patients, may be done only if the physical or mental
condition that prevents giving informed consent is a necessary characteristic of the
research group. In such circumstances the physician must seek informed consent
from the legally authorised representative. If no such representative is available and if
the research cannot be delayed, the study may proceed without informed consent
provided that the specific reasons for involving subjects with a condition that renders
them unable to give informed consent have been stated in the research protocol and
the study has been approved by a research ethics committee. Consent to remain in the
research must be obtained as soon as possible from the subject or a legally authorised
representative.
31. The physician must fully inform the patient which aspects of their care are related to
the research. The refusal of a patient to participate in a study or the patient’s decision
to withdraw from the study must never adversely affect the patient-physician
relationship.
D-1964-01-2013 ⏐ Fortaleza
Medical Rsearch involving Human Subjects (Helsinki)
32. For medical research using identifiable human material or data, such as research on
material or data contained in biobanks or similar repositories, physicians must seek
informed consent for its collection, storage and/or reuse. There may be exceptional
situations where consent would be impossible or impracticable to obtain for such
research. In such situations the research may be done only after consideration and
approval of a research ethics committee.
USE OF PLACEBO
33. The benefits, risks, burdens and effectiveness of a new intervention must be tested
against those of the best proven intervention(s), except in the following circums-
tances:
Where no proven intervention exists, the use of placebo, or no intervention, is accept-
able; or
Where for compelling and scientifically sound methodological reasons the use of any
intervention less effective than the best proven one, the use of placebo, or no inter-
vention is necessary to determine the efficacy or safety of an intervention
and the patients who receive any intervention less effective than the best proven one,
placebo, or no intervention will not be subject to additional risks of serious or
irreversible harm as a result of not receiving the best proven intervention.
Extreme care must be taken to avoid abuse of this option.
POST-TRIAL PROVISIONS
34. In advance of a clinical trial, sponsors, researchers and host country governments
should make provisions for post-trial access for all participants who still need an
intervention identified as beneficial in the trial. This information must also be dis-
closed to participants during the informed consent process.
RESEARCH REGISTRATION AND PUBLICATION AND DISSEMINATION OF RESULTS
35. Every research study involving human subjects must be registered in a publicly
accessible database before recruitment of the first subject.
36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with
regard to the publication and dissemination of the results of research. Researchers
have a duty to make publicly available the results of their research on human subjects
and are accountable for the completeness and accuracy of their reports. All parties
should adhere to accepted guidelines for ethical reporting. Negative and inconclusive
as well as positive results must be published or otherwise made publicly available.
Sources of funding, institutional affiliations and conflicts of interest must be declared
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
in the publication. Reports of research not in accordance with the principles of this
Declaration should not be accepted for publication.
UNPROVEN INTERVENTIONS IN CLINICAL PRACTICE
37. In the treatment of an individual patient, where proven interventions do not exist or
other known interventions have been ineffective, the physician, after seeking expert
advice, with informed consent from the patient or a legally authorised representative,
may use an unproven intervention if in the physician’s judgement it offers hope of
saving life, re-establishing health or alleviating suffering. This intervention should
subsequently be made the object of research, designed to evaluate its safety and effi-
cacy. In all cases, new information must be recorded and, where appropriate, made
publicly available.
Handbook of WMA Policies
D-1968-01-2016 ⏐ World Medical Association
WMA DECLARATION OF SYDNEY
ON
THE DETERMINATION OF DEATH AND THE RECOVERY OF ORGANS
Adopted by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
and amended by the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
Determination of death can be made on the basis of the irreversible cessation of all functions
of the entire brain, including the brain stem, or the irreversible cessation of circulatory and
respiratory functions. This determination will be based on clinical judgment according to
accepted criteria, supplemented, if necessary, by standard diagnostic procedures, and it will
be made by a physician.
Even without intervention, cell, organ and tissue activity in the body may continue
temporarily after a determination of death. Cessation of all life at the cellular level is not a
necessary criterion for determination of death.
The use of deceased donor organs for transplantation has made it important for physicians to
be able to determine when mechanically-supported patients have died.
After death has occurred, it may be possible to maintain circulation to the organs and tissues
of the body mechanically. This may be done to preserve organs and tissues for
transplantation.
Prior to post-mortem transplantation, the determination that death has occurred shall be
made by a physician who is in no way immediately involved in the transplantation
procedure.
Following the determination of death, all treatment and resuscitation attempts may be ceased
and donor organs may be recovered, provided that prevailing requirements of consent and
other relevant ethical and legal requirements have been fulfilled. Physicians should follow
the protocol on organ donation for deceased donors as outlined in the WMA Statement on
Organ and Tissue Donation.
Handbook of WMA Policies
D-1975-01-2016 ⏐ World Medical Association
WMA DECLARATION OF TOKYO
– GUIDELINES FOR PHYSICIANS CONCERNING TORTURE AND OTHER CRUEL,
INHUMAN OR DEGRADING TREATMENT OR
PUNISHMENT IN RELATION TO DETENTION AND IMPRISONMENT –
Adopted by the 29th
World Medical Assembly, Tokyo, Japan, October 1975
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and the 173rd
WMA Council Session, Divonne-les-Bains, France, May 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
It is the privilege of the physician to practise medicine in the service of humanity, to
preserve and restore bodily and mental health without distinction as to persons, to comfort
and to ease the suffering of his or her patients. The utmost respect for human life is to be
maintained even under threat, and no use made of any medical knowledge contrary to the
laws of humanity.
For the purpose of this Declaration, torture is defined as the deliberate, systematic or
wanton infliction of physical or mental suffering by one or more persons acting alone or
on the orders of any authority, to force another person to yield information, to make a
confession, or for any other reason.
DECLARATION
1. The physician shall not countenance, condone or participate in the practice of torture
or other forms of cruel, inhuman or degrading procedures, whatever the offense of
which the victim of such procedures is suspected, accused or guilty, and whatever the
victim’s beliefs or motives, and in all situations, including armed conflict and civil
strife.
2. The physician shall not provide any premises, instruments, substances or knowledge to
facilitate the practice of torture or other forms of cruel, inhuman or degrading
treatment or to diminish the ability of the victim to resist such treatment.
3. When providing medical assistance to detainees or prisoners who are, or who could
later be, under interrogation, physicians should be particularly careful to ensure the
Detention and Imprisonment
D-1975-01-2006 ⏐ Divonne-les-Bains
confidentiality of all personal medical information. A breach of the Geneva
Conventions shall in any case be reported by the physician to relevant authorities.
4. As stated in WMA Resolution on the Responsibility of Physicians in the
Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or
Degrading Treatment and as an exception to professional confidentiality, physicians
have the ethical obligation to report abuses, where possible with the subject’s consent,
but in certain circumstances where the victim is unable to express him/herself freely,
without explicit consent.
5. The physician shall not use nor allow to be used, as far as he or she can, medical
knowledge or skills, or health information specific to individuals, to facilitate or
otherwise aid any interrogation, legal or illegal, of those individuals.
6. The physician shall not be present during any procedure during which torture or any
other forms of cruel, inhuman or degrading treatment is used or threatened.
7. A physician must have complete clinical independence in deciding upon the care of a
person for whom he or she is medically responsible. The physician’s fundamental role
is to alleviate the distress of his or her fellow human beings, and no motive, whether
personal, collective or political, shall prevail against this higher purpose.
8. Where a prisoner refuses nourishment and is considered by the physician as capable of
forming an unimpaired and rational judgment concerning the consequences of such a
voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in
WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the
prisoner to form such a judgment should be confirmed by at least one other
independent physician. The consequences of the refusal of nourishment shall be
explained by the physician to the prisoner.
9. Recalling the Declaration of Hamburg concerning Support for Medical Doctors
Refusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel,
Inhuman or Degrading Treatment, the World Medical Association supports, and
encourages the international community, the National Medical Associations and
fellow physicians to support, the physician and his or her family in the face of threats
or reprisals resulting from a refusal to condone the use of torture or other forms of
cruel, inhuman or degrading treatment.
10. The World Medical Association calls on National Medical Associations to encourage
physicians to continue their professional development training and education in human
rights.
Handbook of WMA Policies
D-1981-01-2015 ⏐ World Medical Association
WMA DECLARATION OF LISBON
ON
THE RIGHTS OF THE PATIENT
Adopted by the 34th
World Medical Assembly, Lisbon, Portugal,
September/October 1981
and amended by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and editorially revised by the 171st
WMA Council Session, Santiago, Chile, October 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
PREAMBLE
The relationship between physicians, their patients and broader society has undergone
significant changes in recent times. While a physician should always act according to his/
her conscience, and always in the best interests of the patient, equal effort must be made
to guarantee patient autonomy and justice. The following Declaration represents some of
the principal rights of the patient that the medical profession endorses and promotes.
Physicians and other persons or bodies involved in the provision of health care have a joint
responsibility to recognize and uphold these rights. Whenever legislation, government
action or any other administration or institution denies patients these rights, physicians
should pursue appropriate means to assure or to restore them.
PRINCIPLES
1. Right to medical care of good quality
a. Every person is entitled without discrimination to appropriate medical care.
b. Every patient has the right to be cared for by a physician whom he/she knows to
be free to make clinical and ethical judgements without any outside interference.
c. The patient shall always be treated in accordance with his/her best interests. The
treatment applied shall be in accordance with generally approved medical princi-
ples.
d. Quality assurance should always be a part of health care. Physicians, in parti-
cular, should accept responsibility for being guardians of the quality of medical
services.
e. In circumstances where a choice must be made between potential patients for a
particular treatment that is in limited supply, all such patients are entitled to a fair
selection procedure for that treatment. That choice must be based on medical cri-
teria and made without discrimination.
Handbook of WMA Policies
D-1981-01-2015 ⏐ World Medical Association
f. The patient has the right to continuity of health care. The physician has an obli-
gation to cooperate in the coordination of medically indicated care with other
health care providers treating the patient. The physician may not discontinue treat-
ment of a patient as long as further treatment is medically indicated, without
giving the patient reasonable assistance and sufficient opportunity to make alter-
native arrangements for care.
2. Right to freedom of choice
a. The patient has the right to choose freely and change his/her physician and hospi-
tal or health service institution, regardless of whether they are based in the private
or public sector.
b. The patient has the right to ask for the opinion of another physician at any stage.
3. Right to self-determination
a. The patient has the right to self-determination, to make free decisions regarding
himself/herself. The physician will inform the patient of the consequences of his/
her decisions.
b. A mentally competent adult patient has the right to give or withhold consent to
any diagnostic procedure or therapy. The patient has the right to the information
necessary to make his/her decisions. The patient should understand clearly what
is the purpose of any test or treatment, what the results would imply, and what
would be the implications of withholding consent.
c. The patient has the right to refuse to participate in research or the teaching of
medicine.
4. The unconscious patient
a. If the patient is unconscious or otherwise unable to express his/her will, informed
consent must be obtained whenever possible, from a legally entitled represen-
tative.
b. If a legally entitled representative is not available, but a medical intervention is
urgently needed, consent of the patient may be presumed, unless it is obvious and
beyond any doubt on the basis of the patient’s previous firm expression or con-
viction that he/she would refuse consent to the intervention in that situation.
c. However, physicians should always try to save the life of a patient unconscious
due to a suicide attempt.
5. The legally incompetent patient
a. If a patient is a minor or otherwise legally incompetent, the consent of a legally
entitled representative is required in some jurisdictions. Nevertheless the patient
must be involved in the decision-making to the fullest extent allowed by his/her
capacity.
Patient’s Right (Lisbon)
Oslo ⏐ D-1981-01-2015
b. If the legally incompetent patient can make rational decisions, his/her decisions
must be respected, and he/she has the right to forbid the disclosure of information
to his/her legally entitled representative.
c. If the patient’s legally entitled representative, or a person authorized by the pa-
tient, forbids treatment which is, in the opinion of the physician, in the patient’s
best interest, the physician should challenge this decision in the relevant legal or
other institution. In case of emergency, the physician will act in the patient’s best
interest.
6. Procedures against the patient’s will
Diagnostic procedures or treatment against the patient’s will can be carried out only in
exceptional cases, if specifically permitted by law and conforming to the principles of
medical ethics.
7. Right to information
a. The patient has the right to receive information about himself/herself recorded
in any of his/her medical records, and to be fully informed about his/her health
status including the medical facts about his/her condition. However,
confidential information in the patient’s records about a third party should not be
given to the patient without the consent of that third party.
b. Exceptionally, information may be withheld from the patient when there is good
reason to believe that this information would create a serious hazard to his/her
life or health.
c. Information should be given in a way appropriate to the patient’s culture and in
such a way that the patient can understand.
d. The patient has the right not to be informed on his/her explicit request, unless
required for the protection of another person’s life.
e. The patient has the right to choose who, if anyone, should be informed on his/
her behalf.
8. Right to confidentiality
a. All identifiable information about a patient’s health status, medical condition,
diagnosis, prognosis and treatment and all other information of a personal kind
must be kept confidential, even after death. Exceptionally, descendants may have
a right of access to information that would inform them of their health risks.
b. Confidential information can only be disclosed if the patient gives explicit con-
sent or if expressly provided for in the law. Information can be disclosed to other
health care providers only on a strictly «need to know» basis unless the patient
has given explicit consent.
Handbook of WMA Policies
D-1981-01-2015 ⏐ World Medical Association
c. All identifiable patient data must be protected. The protection of the data must be
appropriate to the manner of its storage. Human substances from which identifi-
able data can be derived must be likewise protected.
9. Right to health education
Every person has the right to health education that will assist him/her in making
informed choices about personal health and about the available health services. The
education should include information about healthy lifestyles and about methods of
prevention and early detection of illnesses. The personal responsibility of everybody
for his/her own health should be stressed. Physicians have an obligation to participate
actively in educational efforts.
10. Right to dignity
a. The patient’s dignity and right to privacy shall be respected at all times in medical
care and teaching, as shall his/her culture and values.
b. The patient is entitled to relief of his/her suffering according to the current state
of knowledge.
c. The patient is entitled to humane terminal care and to be provided with all avail-
able assistance in making dying as dignified and comfortable as possible.
11. Right to religious assistance
The patient has the right to receive or to decline spiritual and moral comfort including the
help of a minister of his/her chosen religion
Handbook of WMA Policies
D-1981-02-2010 ⏐ World Medical Association
WMA DECLARATION
ON
PRINCIPLES OF HEALTH CARE FOR SPORTS MEDICINE
Adopted by the 34th
World Medical Association General Assembly, Lisbon, Portugal,
September/October 1981
and revised by the 39th
World Medical Association General Assembly, Madrid, Spain,
October 1987
the 45th
World Medical Association General Assembly, Budapest, Hungary,
October 1993
and the 51st
World Medical Association General Assembly, Tel Aviv, Israel, October 1999
and reaffirmed by the 185th
WMA Council Session, Evian-les-Bains, France, May 2010
Considering the involvement of physicians in sports medicine, the WMA recommends the
following ethical guidelines for physicians in order to help meet the needs of athletes, rec-
ognizing special circumstances in which their medical care and health guidance is given.
Consequently,
1. The physician who cares for athletes has an ethical responsibility to recognize the
special physical and mental demands placed upon them by their performance in sports
activities.
2. When the sports participant is a child or an adolescent, the physician must give first
consideration to the participant’s growth and stage of development.
1. The physician must ensure that the child’s state of growth and development, as
well as his or her general condition of health can absorb the rigors of the training
and competition without jeopardizing the normal physical or mental development
of the child or adolescent.
2. The physician must oppose any sports or athletic activity that is not appropriate to
the child’s stage of growth and development or general condition of health. The
physician must act in the best interest of the health of the child or adolescent,
without regard to any other interest or pressure from any other source.
3. When the sports participant is a professional athlete and derives livelihood from that
activity, the physician should pay due regard to the occupational medical aspects
involved.
4. The physician should be aware that the use of doping practices1
by a physician is a
violation of the medical oath and the basic principles of the WMA’s Declaration of
D-1981-02-2010 ⏐ Evian-les-Bains
Sports Medicine
Geneva, which states: «My patient’s health will always be my first consideration.» The
WMA considers the problem of doping to be a threat to the health of athletes and
young people in general, as well as being in conflict with the principles of medical
ethics. The physician must thus oppose and refuse to administer or condone any such
means or method which is not in accordance with medical ethics, and/or which might
be harmful to the athlete using it, especially:
1. Procedures which artificially modify blood constituents or biochemistry.
2. The use of drugs or other substances whatever their nature and route of adminis-
tration, including central-nervous-system stimulants or depressants and procedures
which artificially modify reflexes.
3. Pharmacological interventions that may induce alterations of will or general men-
tal outlook.
4. Procedures to mask pain or other protective symptoms if used to enable the athlete
to take part in events when lesions or signs are present which make his participa-
tion inadvisable.
5. Measures which artificially change features appropriate to age and sex.
6. Training and taking part in events when to do so would not be compatible with
preservation of the individual’s fitness, health or safety.
7. Measures aimed at an unnatural increase or maintenance of performance during
competition. Doping to improve an athlete’s performance is unethical.
5. The physician should inform the athlete, those responsible for him or her, and other
interested parties, of the consequences of the procedures the physician is opposing,
guard against their use, enlist the support of other physicians and other organizations
with the same aim, protect the athlete against any pressures which might induce him
or her to use these methods and help with supervision against these procedures.
6. The sports physician has the duty to give his or her objective opinion on the athlete’s
fitness or unfitness clearly and precisely, leaving no doubt as to his or her conclu-
sions.
7. In competitive sports or professional sports events, it is the physician’s duty to decide
whether the athlete is medically fit to remain on the field or return to the game. This
decision cannot be delegated to other professionals or to other persons. In the physi-
cian’s absence these individuals must adhere strictly to the instructions he or she has
given them, with priority always being given to the best interests of the athlete’s
health and safety, and not the outcome of the competition.
8. In order to carry out his or her ethical obligations the sports physician must see his or
her authority fully recognized and upheld, particularly wherever it concerns the
health, safety and legitimate interests of the athlete, none of which can be prejudiced
Sports Medicine
Evian-les-Bains ⏐ D-1981-02-2010
to favour the interests of any third party whatsoever. These principles and obligations
should be supported by an agreement between the sports physician and the athletic
organization involved, recognizing that the physician is obligated to uphold the ethical
principles determined in national and international statements to which the medical
profession has subscribed and by which it is bound.
9. The sports physician should endeavour to keep the patient’s personal physician fully
informed of facts relevant to his or her treatment. If necessary the sports physician
should collaborate to ensure that the athlete does not exert himself or herself in ways
detrimental to his or her health and does not use potentially harmful techniques to im-
prove performance.
10. In sports medicine, as in all other branches of medicine, professional confidentiality
must be observed. The right to privacy over medical attention the athlete has received
must be protected, especially in the case of professional athletes.
11. The sports doctor must not be party to any contract which obliges him or her to re-
serve particular forms of therapy solely and exclusively for any one athlete or group
of athletes.
12. It is desirable that sports physicians from foreign countries, when accompanying a
team in another country, should enjoy the right to carry out their specific functions.
13. The participation of a sports physician is desirable when sports regulation are being
drawn up.
1
cf, The Olympic Charter Against Doping in Sport and the Lausanne Declaration on Dopping in
Sport adopted by the World Committee on Doping in Sport (February 1999)
Handbook of WMA Policies
World Medical Association ⏐ D-1983-01-2006
WMA DECLARATION OF VENICE
ON
TERMINAL ILLNESS
Adopted by the 35th
World Medical Assembly, Venice, Italy, October 1983
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
PREFACE
1. When addressing the ethical issues associated with end-of-life care, questions regard-
ing euthanasia and physician-assisted suicide inevitably arise. The World Medical
Association condemns as unethical both euthanasia and physician-assisted suicide. It
should be understood that WMA policy on these issues is fully applicable in the con-
text of this Statement on Terminal Illness.
PREAMBLE
1. When a patient’s medical diagnosis precludes the hope of health being restored or
maintained, and the death of the patient is inevitable, the physician and the patient are
often faced with a complex set of decisions regarding medical interventions. Ad-
vances in medical science have improved the ability of physicians to address many
issues associated with end-of-life care. However, it is an area of medicine that histori-
cally has not received the attention it deserves. While the priority of research to cure
disease should not be compromised, more attention must be paid to developing pallia-
tive treatments and improving the ability of physicians to assess and address the medi-
cal and psychological components of symptoms in terminal illness. The dying phase
must be recognized and respected as an important part of a person’s life. As public
pressure increases in many countries to consider physician assisted suicide and eutha-
nasia as acceptable options to end suffering in terminal patients, the ethical imperative
to improve palliative treatment in the terminal phase of life comes into sharp focus.
2. The World Medical Association recognizes that attitudes and beliefs toward death and
dying vary widely from culture to culture and among different religions. In addition,
many palliative and life-sustaining measures require technologies and/or financial
resources that are simply not available in many places. The approach to medical care
of the terminally ill will be influenced significantly by these factors, and thus at-
tempting to developing detailed guidelines on terminal care that can be universally
applied is neither practical nor wise. Therefore, the World Medical Association arti-
culates the following core principles to assist physicians and National Medical As-
sociations with decision-making related to terminal care.
Handbook of WMA Policies
World Medical Association ⏐ D-1983-01-2006
PRINCIPLES
1. The duty of physicians is to heal, where possible, to relieve suffering and to protect
the best interests of their patients. There shall be no exception to this principle even in
the case of incurable disease.
2. In the care of terminal patients, the primary responsibilities of the physician are to
assist the patient in maintaining an optimal quality of life through controlling symp-
toms and addressing psychosocial needs, and to enable the patient to die with dignity
and in comfort. Physicians should inform patients of the availability, benefits and
other potential effects of palliative care.
3. The patient’s right to autonomy in decision-making must be respected with regard to
decisions in the terminal phase of life. This includes the right to refuse treatment and
to request palliative measures to relieve suffering but which may have the additional
effect of accelerating the dying process. However, physicians are ethically prohibited
from actively assisting patients in suicide. This includes administering any treatments
whose palliative benefits, in the opinion of the physician, do not justify the additional
effects.
4. The physician must not employ any means that would provide no benefit for the pa-
tient.
5. Physicians should recognise the right of patients to develop written advance directives
that describe their wishes regarding care in the event that they are unable to commu-
nicate and that designate a substitute decision-maker to make decisions that are not
expressed in the advance directive. In particular, physicians should discuss the pa-
tient’s wishes regarding the approach to life-sustaining interventions as well as pal-
liative measures that might have the additional effect of accelerating death. When-
ever possible, the patient’s substitute decision-maker should be included in these con-
versations.
6. Physicians should endeavour to understand and address the psychosocial needs of
their patients, especially as they relate to patients’ physical symptoms. Physicians
should try to ensure that psychological and spiritual resources are available to patients
and their families to help them deal with the anxiety, fear and grief associated with
terminal illness.
7. The clinical management of pain in terminal patients is of paramount importance in
terms of alleviating suffering. Physicians and National Medical Associations should
promote the dissemination and sharing of information regarding pain management to
ensure that all physicians involved in terminal care have access to best practice guide-
lines and the most current treatments and methods available. Physicians should be
able to pursue clinically appropriate aggressive pain management without undue fear
of regulatory or legal repercussions.
8. National Medical Associations should encourage governments and research institu-
tions to invest additional resources in developing treatments to improve end-of-life
care. Medical school curricula should include the teaching of palliative medical care.
Where it does not exist, the establishment of palliative medicine as a medical special-
ty should be considered.
D-1983-01-2006 ⏐ Pilanesberg
Terminal Illness (Venice)
9. National Medical Associations should advocate for the development of networks
among institutions and organizations involved in palliative care in order to foster com-
munication and collaboration.
10. Physicians may, when the patient cannot reverse the final process of cessation of vital
functions, apply such artificial means as are necessary to keep organs active for trans-
plantation provided that they act in accordance with the ethical guidelines established
in the World Medical Association Declaration of Sydney on the Determination of Death
and the Recovery of Organs.
Handbook of WMA Policies
D-1987-01-2015 ⏐ World Medical Association
WMA DECLARATION
ON
EUTHANASIA
Adopted by the 39th
World Medical Assembly, Madrid, Spain, October 1987
and reaffirmed by the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s
own request or at the request of close relatives, is unethical. This does not prevent the phy-
sician from respecting the desire of a patient to allow the natural process of death to follow
its course in the terminal phase of sickness.
Handbook of WMA Policies
World Medical Association ⏐ D-1989-01-2015
WMA DECLARATION OF HONG KONG
ON
THE ABUSE OF THE ELDERLY
Adopted by the 41st
World Medical Assembly, Hong Kong, September 1989
and editorially revised by the 126th
WMA Council Session, Jerusalem, Israel, May 1990
and the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
Elderly people may suffer pathological problems such as motor disturbances and psychic
and orientation disorders. As a result of such problems, elderly patients may require assis-
tance with their daily activities that can lead to a state of dependence. This may cause their
families and the community to consider them to be a burden and to subsequently limit or
deny care and services.
Abuse or neglect of the elderly can be manifested in a variety of ways: physical, psycho-
logical, financial and/or material, and medical. Variations in the definition of elder abuse
present difficulties in comparing findings on the nature and causes of the problem. A num-
ber of preliminary hypotheses have been proposed on the etiology of elder abuse includ-
ing: dependency on others to provide services; lack of close family ties; family vio-
lence; lack of financial resources; psychopathology of the abuser; lack of community sup-
port, and institutional factors such as low pay and poor working conditions that contribute
to pessimistic attitudes of caretakers.
The phenomenon of elder abuse is becoming increasingly recognized by both medical
facilities and social agencies. The first step in preventing elder abuse and neglect is to in-
crease levels of awareness and knowledge among physicians and other health profes-
sionals. Once high-risk individuals and families have been identified, physicians can parti-
cipate in the primary prevention of maltreatment by making referrals to appropriate com-
munity and social service centres. Physicians may also participate by providing support
and information on high-risk situations directly to patients and their families. At the same
time, physicians should employ care and sensitivity to preserve patient trust and confiden-
tiality, particularly in the case of competent patients.
The World Medical Association therefore adopts the following general principles relating
to abuse of the elderly.
GENERAL PRINCIPLES
1. The elderly have the same rights to care, welfare and respect as other human beings.
2. Physicians have a responsibility to help prevent the physical and psychological abuse
of elderly patients.
Elderly Abuse
Oslo ⏐ D-1989-01-2015
3. Whether consulted by an aged person directly, a nursing home or the family, phy-
sicians should see that the patient receives the best possible care.
4. If physicians verify or suspect ill treatment, as defined in this statement, they should
discuss the situation with those in charge, be it the nursing home or the family. If ill
treatment is confirmed, or if death is considered to be suspicious, they should report
the findings to the appropriate authorities.
5. To guarantee protection of the elderly in any environment there should be no restric-
tions on their right of free choice of a physician. National Medical Associations should
strive to make certain that such free choice is preserved within the socio-medical sys-
tem.
The World Medical Association also makes the following recommendations to physicians
involved in treating the elderly, and urges all National Medical Associations to publicize
this Declaration to their members and the public.
RECOMMENDATIONS
Physicians involved in treating the elderly should:
• make increased attempts to establish an atmosphere of trust with elderly patients in
order to encourage them to seek medical care when necessary and to feel comfort-
able confiding in the physician;
• provide medical evaluation and treatment for injuries resulting from abuse and/or
neglect;
• attempt to establish or maintain a therapeutic alliance with the family (often the
physician is the only professional who maintains long-term contact with the patient
and the family), while preserving to the greatest extent possible the confidentiality
of the patient;
• report all suspected cases of elder abuse and/or neglect in accordance with local
legislation;
• utilize a multidisciplinary team of caretakers from the medical, social service,
mental health, and legal professions, whenever possible; and
• encourage the development and utilization of supportive community resources that
provide in-home services, respite care, and stress reduction with high-risk families.
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
WMA DECLARATION OF MALTA
ON
HUNGER STRIKERS
Adopted by the 43rd
World Medical Assembly, St. Julians, Malta, November 1991
and editorially revised by the 44th
World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in
settings where people are detained (prisons, jails and immigration detention
centres). They are usually a form of protest by people who lack other ways of
making their demands known. In refusing nutrition for a significant period,
prisoners and detainees may hope to obtain certain goals by inflicting negative
publicity on the authorities. Short-term food refusals rarely raise ethical problems.
Prolonged fasting risks death or permanent damage for hunger strikers and can
create a conflict of values for physicians. Hunger strikers rarely wish to die but
some may be prepared to do so to achieve their aims.
2. Physicians need to ascertain the individual’s true intention, especially in collective
strikes or situations where peer pressure may be a factor. An emotional challenge
arises when hunger strikers who have apparently issued clear instructions not to be
resuscitated reach a stage of cognitive impairment. The principle of beneficence
urges physicians to resuscitate them but respect for individual autonomy restrains
physicians from intervening when a valid and informed refusal has been made.
This has been well worked through in many other clinical situations including
refusal of life saving treatment. An added difficulty arises in custodial settings
because it is not always clear whether the hunger striker’s advance instructions
were made voluntarily and with appropriate information about the consequences.
PRINCIPLES
3. Duty to act ethically. All physicians are bound by medical ethics in their
professional contact with vulnerable people, even when not providing therapy.
Whatever their role, physicians must try to prevent coercion or maltreatment of
detainees and must protest if it occurs.
4. Respect for autonomy. Physicians should respect individuals’ autonomy. This can
involve difficult assessments as hunger strikers’ true wishes may not be as clear as
they appear. Any decisions lack moral force if made by use of threats, peer
pressure or coercion. Hunger strikers should not forcibly be given treatment they
refuse. Applying, instructing or assisting forced feeding contrary to an informed
and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker’s
explicit or necessarily implied consent is ethically acceptable.
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
5. ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to
benefit those they treat. This is the concept of ‘beneficence’, which is
complemented by that of ‘non-maleficence’ or primum non nocere. These two
concepts need to be in balance. ‘Benefit’ includes respecting individuals’ wishes as
well as promoting their welfare. Avoiding ‘harm’ means not only minimising
damage to health but also not forcing treatment upon competent people nor
coercing them to stop fasting. Beneficence does not necessarily involve prolonging
life at all costs, irrespective of other determinants.
Physicians must respect the autonomy of competent individuals, even where this
will predictably lead to harm. The loss of competence does not mean that a
previous competent refusal of treatment, including artificial feeding should be
ignored.
6. Balancing dual loyalties. Physicians attending hunger strikers can experience a
conflict between their loyalty to the employing authority (such as prison
management) and their loyalty to patients. In this situation, physicians with dual
loyalties are bound by the same ethical principles as other physicians, that is to say
that their primary obligation is to the individual patient. They remain independent
from their employer in regard to medical decisions.
7. Clinical independence. Physicians must remain objective in their assessments and
not allow third parties to influence their medical judgement. They must not allow
themselves to be pressured to breach ethical principles, such as intervening
medically for non medical reasons.
8. Confidentiality. The duty of confidentiality is important in building trust but it is
not absolute. It can be overridden if non-disclosure seriously and imminently
harms others. As with other patients, hunger strikers’ confidentiality and privacy
should be respected unless they agree to disclosure or unless information sharing is
necessary to prevent serious harm. If individuals agree, their relatives and legal
advisers should be kept informed of the situation.
9. Establishing trust. Fostering trust between physicians and hunger strikers is often
the key to achieving a resolution that both respects the rights of the hunger strikers
and minimises harm to them. Gaining trust can create opportunities to resolve
difficult situations. Trust is dependent upon physicians providing accurate advice
and being frank with hunger strikers about the limitations of what they can and
cannot do, including situations in which the physician may not be able to maintain
confidentiality.
10. Physicians must assess the mental capacity of individuals seeking to engage in a
hunger strike. This involves verifying that an individual intending to fast is free of
any mental conditions that would undermine the person’s ability to make informed
health care decisions. Individuals with seriously impaired mental capacity may not
be able to appreciate the consequences of their actions should they engage in a
hunger strike. Those with treatable mental health problems should be directed
towards appropriate care for their mental conditions and receive appropriate
treatment. Those with untreatable conditions, including severe learning disability
D-1991-01-2017 ⏐ Chicago
Hunger Strikers (Malta)
or advanced dementia should receive treatment and support to enable them to make
such decisions as lie within their competence.
11. As early as possible, physicians should acquire a detailed and accurate medical
history of the person who is intending to fast. The medical implications of any
existing conditions should be explained to the individual. Physicians should verify
that hunger strikers understand the potential health consequences of fasting and
forewarn them in plain language of the disadvantages. Physicians should also
explain how damage to health can be minimised or delayed by, for example,
increasing fluid and thiamine intake. Since the person’s decisions regarding a
hunger strike can be momentous, ensuring full patient understanding of the
medical consequences of fasting is critical. Consistent with best practices for
informed consent in health care, the physician should ensure that the patient
understands the information conveyed by asking the patient what he or she
understands.
12. A thorough examination of the hunger striker should be made at the start of the fast
including measuring body weight. Management of future symptoms, including
those unconnected to the fast, should be discussed with hunger strikers. Also, the
person’s values and wishes regarding medical treatment in the event of a prolonged
fast should be noted. If the hunger striker consents, medical examinations should
be carried out regularly in order to determine necessary treatments. The physical
environment should be evaluated in order to develop recommendations for
preventing negative effects.
13. Continuing communication between the physician and hunger strikers is essential.
Physicians should ascertain on a daily basis whether individuals wish to continue a
hunger strike and what they want to be done when they are no longer able to
communicate meaningfully. The clinician should identify whether the individual is
willing, in the absence of their demands being met, to continue the fast even until
death. These findings must be appropriately recorded.
14. Sometimes hunger strikers accept an intravenous solution transfusion or other
forms of medical treatment. A refusal to accept certain interventions must not
prejudice any other aspect of the medical care, such as treatment of infections or of
pain.
15. Physicians should talk to hunger strikers in privacy and out of earshot of all other
people, including other detainees. Clear communication is essential and, where
necessary, interpreters unconnected to the detaining authorities should be available
and they too must respect confidentiality.
16. Physicians need to satisfy themselves that food or treatment refusal is the
individual’s voluntary choice. Hunger strikers should be protected from coercion.
Physicians can often help to achieve this and should be aware that coercion may
come from the authorities, the peer group, or others, such as family members.
Physicians or other health care personnel may not apply undue pressure of any sort
on the hunger striker to suspend the strike. Treatment or care of the hunger striker
must not be conditional upon suspension of the hunger strike. Any restraint or
pressure including but not limited to hand-cuffing, isolation, tying the hunger
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
striker to a bed or any kind of physical restraint due to the hunger strike is not
acceptable.
17. If a physician is unable for reasons of conscience to abide by a hunger striker’s
refusal of treatment or artificial feeding, the physician should make this clear at the
outset, and must be sure to refer the hunger striker to another physician who is
willing to abide by the hunger striker’s refusal.
18. When a physician takes over the case, the hunger striker may have already lost
mental capacity so that there is no opportunity to discuss the individual’s wishes
regarding medical intervention to preserve life. Consideration and respect must be
given to any advance instructions made by the hunger striker. Advance refusals of
treatment must be followed if they reflect the voluntary wish of the individual
when competent. In custodial settings, the possibility of advance instructions
having been made under pressure needs to be considered. Where physicians have
serious doubts about the individual’s intention, any instructions must be treated
with great caution. If well informed and voluntarily made, however, advance
instructions can only generally be overridden if they become invalid because the
situation in which the decision was made has changed radically since the
individual lost competence.
19. If no discussion with the individual is possible and no advance instructions or any
other evidence or note in the clinical records of a discussion exist, physicians have
to act in what they judge to be in the person’s best interests. This means
considering the hunger strikers’ previously expressed wishes, their personal and
cultural values as well as their physical health. In the absence of any evidence of
hunger strikers’ former wishes, physicians should decide whether or not to provide
feeding, without interference from third parties.
20. Physicians may rarely and exceptionally consider it justifiable to go against
advance instructions refusing treatment because, for example, the refusal is thought
to have been made under duress. If, after resuscitation and having regained their
mental faculties, hunger strikers continue to reiterate their intention to fast, that
decision should be respected. It is ethical to allow a determined hunger striker to
die with dignity rather than submit that person to repeated interventions against his
or her will. Physicians acting against an advanced refusal of treatment must be
prepared to justify that action to relevant authorities including professional
regulators.
21. Artificial feeding, when used in the patient’s clinical interest, can be ethically
appropriate if competent hunger strikers agree to it. However, in accordance with
the WMA Declaration of Tokyo, where a prisoner refuses nourishment and is
considered by the physician as capable of forming an unimpaired and rational
judgment concerning the consequences of such a decision, he or she shall not be
fed artificially. Artificial feeding can also be acceptable if incompetent individuals
have left no unpressured advance instructions refusing it, in order to preserve the
life of the hunger striker or to prevent severe irreversible disability. Rectal
hydration is not and must never be used as a form of therapy for rehydratation or
nutritional support in fasting patients.
D-1991-01-2017 ⏐ Chicago
Hunger Strikers (Malta)
22. When a patient is physically able to begin oral feeding, every caution must be
taken to ensure implementation of the most up to date guidelines of refeeding.
23. All kinds of interventions for enteral or parenteral feeding against the will of the
mentally competent hunger striker are “to be considered as “forced feeding”.
Forced feeding is never ethically acceptable. Even if intended to benefit, feeding
accompanied by threats, coercion, force or use of physical restraints is a form of
inhuman and degrading treatment. Equally unacceptable is the forced feeding of
some detainees in order to intimidate or coerce other hunger strikers to stop
fasting.
THE ROLE OF NATIONAL MEDICAL ASSOCIATIONS (NMAS) AND THE WMA
24. NMAs should organize and provide educational programmes highlighting the
ethical dimensions of hunger strikes, appropriate medical approaches, treatments,
and interventions. They shall make efforts to update physicians’ professional
knowledge and skills.
NMAs should work to provide mechanisms for supporting physicians working in
prisons/jails/immigration detention centers, who may often find themselves in
conflict situations and, as stated in the WMA Declaration of Hamburg, shall
support any physicians experiencing pressure to compromise their ethical
principles.
NMAs have a responsibility to make efforts to prevent unethical practices, to take
a position and speak out against ethical violations, and to investigate them
properly.
25. The World Medical Association will support physicians and NMAs confronted
with political pressures as a result of defending an ethically justifiable position, as
stated in the WMA Declaration of Hamburg.
Handbook of WMA Policies
World Medical Association ⏐ D-1997-01-2009
WMA DECLARATION
ON
GUIDELINES FOR CONTINUOUS QUALITY IMPROVEMENT IN
HEALTH CARE
Adopted by the 49th
World Medical Assembly, Hamburg, Germany, November 1997
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
The purpose of health care is to prevent, diagnose and treat illness and to maintain and to
promote the health of the population. The goal of quality review in health care is conti-
nuous improvement of the quality of services provided for patients and the population, and
of the ways and means of producing these services. The ultimate goal is to improve both
individual patient outcomes and population health.
The obligation to continuously improve one’s professional ability and to rigorously eval-
uate the methods one uses has long been a fundamental tenet of the ethical codes of physi-
cians. According to these codes, a physician must always strive to maintain and increase
his/her knowledge and skills. The physician shall recommend only examinations and treat-
ments that are believed to be effective and appropriate according to the best available evi-
dence-based medicine.
Physicians and health care institutions have an ethical and professional obligation to strive
for continuous quality improvement of services and patient safety. These guidelines are in-
tended to articulate the ethical grounds for these obligations and to strengthen quality re-
view practices.
Ethical guidelines for health care quality improvement matter to all physicians, as well as
to institutions providing health care services for patients, those providing continuous
quality improvement services to assist physicians and organizations, health care payers
and regulators, patients, and every other stakeholder in the health care system.
THE OBLIGATION TO ESTABLISH STANDARDS FOR GOOD QUALITY WORK
Professionals, by definition, are responsible for specifying the standards that constitute
good quality in their work and the processes needed for the evaluation of that quality.
Health professionals, therefore, must define high quality health care and determine the
best methods of measuring the quality of care delivered.
D-1997-01-2009 ⏐ New Delhi
Quality Improvement in Health Care
THE OBLIGATION TO COLLECT DATA
In order to assess quality of care, it is necessary to obtain reliable data on the patients and
populations served as well as on care processes and outcomes. Patient records, whether
recorded on paper, digitally or in any other way, must be created written and preserved
with care and, with attention to confidentiality requirements. Procedures, decisions and
other matters connected with patients should be recorded in a format that will allow infor-
mation for measuring specific standards to be available on a timely basis when needed.
THE ROLE OF PROFESSIONAL EDUCATION
Health care professionals should have adequate opportunities to maintain and develop
their knowledge and skills by participating in continuing medical education and/or conti-
nuing professional development. Clinical guidelines based on professional standards for
high quality care should be created and made easily available to those requiring
them. Health care training should include specific instruction in quality improvement
techniques, including opportunities for hands-on practice in measuring and improving
quality. Health care institutions should create quality improvement systems for their own
use and to en-sure that instructions concerning such systems are followed.
Good quality work requires resources. Every effort should be made to make sure that ade-
quate time and economic means are available for quality work.
ATTENTION TO INAPPROPRIATE USE OF SERVICES
Inappropriate use of health care services includes overuse, underuse and misuse. Quality
measurement in health care should include a balanced set of measures in all three areas.
Overuse of services occurs when health care services are provided under circumstances in
which the potential for harm exceeds the possible benefit. Physicians can improve quality
by reducing overuse, thus sparing patients the unnecessary risk that results from inappro-
priate health services.
Underuse of services is the failure to provide health care services that would be likely to
produce a favourable outcome for the patient. Physicians should strive to expand the use
of beneficial health care services that are underused.
Misuse of services occurs when an incorrect diagnosis is made or when an appropriate
service has been selected for a correct diagnosis but the patient does not receive the full
potential benefit of the service because of a preventable adverse event. Misuse of services
can be greatly reduced by using risk management and error prevention strategies.
MONITORING QUALITY: CLINICAL AUDITS
Active participation in critical self-evaluation, usually through clinical audit programs, is a
useful mechanism for healthcare professionals, including healthcare administrators and
physicians, and the institutions in which they work, to improve the quality of their work.
External independent examination and accreditation of the institution can also be of use,
when carried out appropriately and with due attention to potential unintended effects.
Handbook of WMA Policies
World Medical Association ⏐ D-1997-01-2009
INTERNAL AND EXTERNAL QUALITY ASSESSMENT
At the individual level, a physician should continuously update their knowledge and skills
and subject their level of ability to critical self-appraisal.
In organizations, the quality of health care can be assessed by both internal and external
methods.
Health care institutions should create internal quality improvement systems for their own
use and ensure that instructions concerning such systems are followed. These systems
should include continuous conducting of internal clinical peer review, review examination
and treatment methods and their attendant results, tracking of the organization’s ability to
react to quality data, and monitoring of patient feedback.
External quality review initiatives, such as external peer review and audit, should be car-
ried out regularly and with a frequency corresponding to the evolution of the field or when
there is special reason for external assessment. Any review should take into account risk
adjustment of the patient population under consideration.
Whether internal or external, if the results of any quality assessment carry significant op-
portunities for benefit or threats of harms for the organization or individual being
assessed, special attention must be paid to potential unintended and dangerous
consequences of such quality assessments. It is especially important to monitor the results
of quality improve-ment measurement and intervention strategies over time, with attention
to their effects on especially vulnerable patient populations.
Protocols to be used for quality review should be replicable and transparent. Appeals me-
chanisms should be built into the protocols.
CONFIDENTIALITY OF PATIENT RECORDS
Patient records are an invaluable source of data for quality improvement. As with other uses
of individually-identifiable patient based information, consent is usually required from the
patient prior to use. If consent cannot reasonably be obtained, then all attempts should be
made to ensure that medical records are anonymised or pseudonimised for use in quality
improvement efforts. In every case, patient records used for quality improvement must
only be accessible to those who need to see them for the purposes of quality improvement.
CONFIDENTIALITY OF PEER REVIEW
For peer review to be most effective, all parties involved must participate and recognize its
importance. It is recommended that informed voluntary consent be obtained from those to
be reviewed. Within a healthcare team, the work of each physician must be able to be eval-
uated. Information regarding an individual physician’s evaluation should not be pu-blished
without the consent of the physician concerned. It is recommended that consent be ob-
tained prior to publishing information regarding an individual physician’s evaluation.
D-1997-01-2009 ⏐ New Delhi
Quality Improvement in Health Care
A provider of services may inform his/her patients about the results of quality review.
If reviews are made available to the public, careful monitoring must be undertaken to track
the effects, intended and unintended, of such public reporting of performance data.
ETHICAL REVIEW OF QUALITY IMPROVEMENT ACTIVITIES
National codes of medical ethics and ethical principles and guidelines that relate to conti-
nuous quality improvement, audit and clinical review must be followed.
Quality improvement should be an ongoing and integral part of the operations of every
health care organization. As such, the majority of quality improvement projects will not
require specific review by an ethics committee. If there are doubts about specific issues or
if a project poses more than minimal risk compared to the existing processes for care, then
the project should be referred to an appropriate ethics committee or institutional review
board. When such formal ethical review is needed, it should be undertaken by a commit-
tee with members who are knowledgeable about quality improvement techniques.
COMPETENCE AND IMPARTIALITY OF THE REVIEWER
Those who conduct performance reviews must be competent in quality improvement tech-
niques and in clinical audit as well as experienced in the clinical field relating to the re-
view. Where medical care is being reviewed, the reviewer should be a physician whose
knowledge and experience is accepted by those being reviewed.
The reviewer should be impartial and independent. Whilst he/she must be aware of the
activities under review, he/she must be objective in the report and base conclusions on
critical evaluation of observation and facts. Commercial or competitive matters should not
be allowed to influence the content of the reviewer’s report.
SEPARATION OF QUALITY REVIEWS AND SUPERVISION BY AUTHORITIES
Quality improvement of services and of health care systems is a requirement for every
physician and health care institution. It is not supervision of professional activities by au-
thorities and it must be kept independent of this. The results of performance reviews or au-
dits of physician activities should be used by supervising authorities only subject to a se-
parate agreement between them and the physicians concerned unless national legislation
mandates an alternative approach. These activities must be fully cognizant of the local le-
gal framework and must not expose participating physicians to litigation.
Handbook of WMA Policies
World Medical Association ⏐ D-1997-02-2017
WMA DECLARATION OF HAMBURG
CONCERNING SUPPORT FOR MEDICAL DOCTORS
REFUSING TO PARTICIPATE IN, OR TO CONDONE,
THE USE OF TORTURE OR OTHER FORMS OF CRUEL,
INHUMAN OR DEGRADING TREATMENT
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
PREAMBLE
1. On the basis of a number of international ethical declarations and guidelines subs-
cribed to by the medical profession, medical doctors throughout the world are
pro-hibited from countenancing, condoning or participating in the practice of
torture or other forms of cruel, inhuman or degrading procedures for any reason.
2. Primary among these declarations are the World Medical Association’s
International Code of Medical Ethics, Declaration of Geneva, Declaration of
Tokyo, and Resolu-tion on Physician Participation in Capital Punishment; the
Standing Committee of European Doctors’ Statement of Madrid; the Nordic
Resolution Concerning Physician Involvement in Capital Punishment; and, the
World Psychiatric Association’s Decla-ration of Hawaii.
3. However, none of these declarations or statements addresses explicitly the issue of
what protection should be extended to medical doctors if they are pressured, called
upon, or ordered to take part in torture or other forms of cruel, inhuman or
degrading treatment or punishment. Nor do these declarations or statements
express explicit sup-port for, or the obligation to protect, doctors who encounter or
become aware of such procedures.
RESOLUTION
4. The World Medical Association (WMA) hereby reiterates and reaffirms the
responsibility of the organised medical profession:
4.1 To encourage physicians to honour their commitment as physicians to serve
humanity and to resist any pressure to act contrary to the ethical principles
governing their dedication to this task;
4.2 To support physicians experiencing difficulties as a result of their resistance to
any such pressure or as a result of their attempts to speak out or to act against
such inhuman procedures; and,
D-1997-02-2017 ⏐ Chicago
Refusing Torture (Hamburg)
4.3 To extend its support and to encourage other international organisations, as
well as the constituent members of the World Medical Association (WMA), to
support physicians encountering difficulties as a result of their attempts to act
in accordance with the highest ethical principles of the profession.
4.4 To encourage physicians to report and document any acts of torture and other
cruel, inhuman or degrading treatment or punishment they are aware of.
5. Furthermore, in view of the continued employment of such inhumane procedures
in many countries throughout the world, and the documented incidents of pressure
upon physicians to act in contravention to the ethical principles subscribed to by
the profession, the WMA finds it necessary:
5.1 To protest internationally against any involvement of, or any pressure to
involve, physicians in acts of torture and or other forms of cruel, inhuman or
degrading treatment or punishment;
5.2 To support and protect, and to call upon its constituent members NMAs to
support and protect, physicians who are resisting involvement in such
inhuman procedures or who are documenting and reporting these procedures,
or who are working to treat and rehabilitate victims thereof, as well as to
secure the right to uphold the highest ethical principles including medical
confidentiality;
5.3 To publicize information about and to support physicians reporting evidence
of torture and to make known proven cases of attempts to involve physicians
in such procedures; and,
5.4 To encourage its constituent members to take action so that physicians are
held accountable before the law in case of complicity in acts of torture and
other cruel, inhuman or degrading treatment or punishment;
5.5 To encourage its constituent members to ask corresponding academic
authorities to teach and investigate in all schools of medicine and hospitals the
consequences of torture and its treatment, the rehabilitation of the survivors,
the documentation of torture, and the professional protection described in this
Declaration.
Handbook of WMA Policies
World Medical Association ⏐ D-1998-01-2009
WMA DECLARATION OF OTTAWA
ON
CHILD HEALTH
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
Science has now proven that to reach their potential, children need to grow up in a place
where they can thrive – spiritually, emotionally, mentally, physically and intellectually1
. That
place must have four fundamental elements:
• a safe and secure environment;
• the opportunity for optimal growth and development;
• health services when needed; and
• monitoring & research for evidence-based continual improvement into the future2
.
Physicians know that the future of our world depends on our children: their education,
their employability, their productivity, their innovation, and their love and care for one
another and for this planet. Early childhood experiences strongly influence future develop-
ment including basic learning, school success, economic participation, social citizenry,
and health3
. In most situations, parents and caregivers alone cannot provide strong nur-
turing environments without help from local, regional, national and international organi-
zations1
. Physicians therefore join with parents, and with world leaders to advocate for
healthy children.
The principles of this Declaration apply to all children in the world from birth to 18 years
of age, regardless of race, age, ethnicity, nationality, political affiliation, creed, language,
gender, disease or disability, physical ability, mental ability, sexual orientation, cultural
history, life experience or the social standing of the child or her/his parents or legal guard-
ian. In all countries of the world, regardless of resources, meeting these principles should
be a priority for parents, communities and governments. The United Nations Con-vention
on the Rights of Children (1989) sets out the wider rights of all children and young people,
but those rights cannot exist without health.
GENERAL PRINCIPLES
1. A place with a safe and secure environment includes:
a. Clean water, air and soil;
b. Protection from injury, exploitation, discrimination and from traditional practices
prejudicial to the health of the child, and
c. Healthy families, homes and communities
D-1998-01-2009 ⏐ New Delhi
Child Health (Ottawa)
2. A place where a child can have good health and development offers:
a. Prenatal and maternal care for the best possible health at birth
b. Nutrition for proper growth, development and long-term health
c. Early learning opportunities and high quality care at home and in the community
d. Opportunities and encouragement for physical activity
e. Affordable & accessible high quality primary & secondary education
3. A full range of health resources available to all means:
a. The best interests of the child shall be the primary consideration in the provision of
health care;
b. Those caring for children shall have the special training and skills necessary to
enable them to respond appropriately to the medical, physical, emotional and de-
velopmental needs of children & their families
c. Basic health care including health promotion, recommended immunization, drugs
& dental health
d. Mental health care and prompt referral to intervention when problems identified
e. Priority access to drugs for life- or limb-threatening conditions for all mothers and
children
f. Hospitalization only if the care and treatment required cannot be provided at home,
in the community or on an outpatient basis
g. Access to specialty diagnostic and treatment services when needed
h. Rehabilitation services and supports within community
i. Pain management and care and prevention (or minimization) of suffering
j. Informed consent is necessary before initiating any diagnostic, therapeutic, re-
habilitative, or research procedure on a child. In the majority of cases, the consent
shall be obtained from the parent(s) or legal guardian, or in some cases, by ex-
tended family, although the wishes of a competent child should be taken into ac-
count before consent is given.
4. Research4
& monitoring for continual improvement includes:
a. All infants will be officially registered within one month of birth
b. All children will be treated with dignity and respect
c. Quality care is ensured through on-going monitoring of services, including collec-
tion of data, and evaluation of outcomes
d. Children will share in the benefits from scientific research relevant to their needs
e. The privacy of a child patient will be respected
1
Irwin LG, Siddiqi A, Hertzman C. “Early Child Development: A Powerful Equalizer. Final Re-
port”. World Health Organization Commission on the Social Determinants of Health June 2007
2
WHO Commission on Social Determinants of Health (Closing the Gap in a Generation) 2008
3
Canadian Charter for Child and Youth Health
4
Proposed WMA statement on ethical principles for medical research on child subjects
* Please refer the background document for specific principles.
Handbook of WMA Policies
World Medical Association ⏐ D-2000-01-2011
WMA DECLARATION OF EDINBURGH
ON
PRISON CONDITIONS AND THE SPREAD OF TUBERCULOSIS AND
OTHER COMMUNICABLE DISEASES
Adopted by the 52nd
World Medical Association General Assembly, Edinburgh, Scotland,
October 2000
and revised by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
PREAMBLE
Prisoners enjoy the same health care rights as all other people. This includes the right to
humane treatment and appropriate medical care. The standards for the treatment of pri-
soners have been set down in a number of Declarations and Guidelines adopted by various
bodies of the United Nations.
The relationship between physician and prisoner is governed by the same ethical princi-
ples as that between the physician and any other patient. There are specific tensions within
the patient/physician relationship, which do not exist in other settings, in particular the
relationship of the physician with his/her employer, the prison service, and the general
attitude of society to prisoners.
There are also strong public health reasons for reinforcing the importance of these rules.
The high incidence of tuberculosis amongst prisoners in a number of countries reinforces
the need for considering public health as an important element when designing new prison
regimens, and for reforming existing penal and prison systems.
Individuals facing imprisonment are often from the most marginalised sections of society,
may have had limited access to health care before imprisonment, may suffer worse health
that many other citizens and may enter prison with undiagnosed, undetected and untreated
health problems.
Prisons can be breeding grounds for infection. Overcrowding, lengthy confinement within
tightly enclosed, poorly lit, badly heated and consequently poorly ventilated and often hu-
mid spaces are all conditions frequently associated with imprisonment and all of which
contribute to the spread of 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 prisoners in conditions, which expose them to substantial medical risk, poses a
humanitarian challenge. An infectious prisoner is a risk to other prisoners, prison person-
nel, relatives and other prison visitors and the wider community – not only when the pri-
soner is released, but also because prison bars do not keep Tuberculosis bacilli from
spreading into the outside world. The most effective and efficient way of reducing disease
D-2000-01-2011 ⏐ Montevideo
Prison Conditions on TB (Edinburgh)
transmission is to improve the prison environment, by putting together an efficient medi-
cal service that is capable of detecting and treating the disease, and by targeting prison
overcrowding as the most urgent action.
The increase in active Tuberculosis in prison populations and the development within
some of these populations of resistant and especially «multi-drug» and «extremely-drug»
resistant forms of TB, as recognised by the World Medical Association in its Statement on
Drug Treatment of Tuberculosis, is reaching very high prevalence and incidence rates in
prisons in some parts of the world.
Other conditions, such as Hepatitis C and HIV Disease, do not have as high a risk of per-
son-to- person communicability as TB but pose transmission risks from blood to blood
borne spread, or sharing and exchange of body fluids. Overcrowded prison conditions also
promote the spread of sexually transmitted diseases. Intravenous drug use will also contri-
bute to the spread of HIV as well as the more contagious Hepatitis B and C. These need
specific solutions that are not dealt with in this statement. However the principles set out
below will also be helpful in reducing the risk from such infective agents.
ACTIONS REQUIRED
The World Medical Association considers it essential both for public health and humani-
tarian reasons that careful attention is paid to:
1. Protecting the rights of prisoners according to the various UN instruments relating
to conditions of imprisonment. Prisoners should enjoy the same rights as other pa-
tients, as outlined in the WMA Declaration of Lisbon;
2. Not allowing the rights of prisoners to be ignored or invalidated because they have
an infectious illness;
3. Ensuring that the conditions in which detainees and prisoners are kept, whether
they are held during the investigation of a crime, whilst waiting for trial, or as pu-
nishment once sentenced, do not contribute to the development, worsening or trans-
mission of disease.
4. Ensuring that persons being held while going through immigration procedures, are
kept in conditions which do not encourage the spread of disease, although prisons
should not normally be used to house such persons;
5. Ensuring the coordination of health services within and outside prisons to facilitate
continuity of care and epidemiological monitoring of inmate patients when they
are released;
6. Ensuring that prisoners are not isolated, or placed in solitary confinement, as a res-
ponse to their infected status without adequate access to health care and the appro-
priate medical treatment of their infected status;
7. Ensuring that, upon admission to or transfer to a different prison, inmates’ health
status is reviewed within 24 hours of arrival to assure continuity of care;
Handbook of WMA Policies
World Medical Association ⏐ D-2000-01-2011
8. Ensuring the provision of follow-up treatment for prisoners who, on their release,
are still ill, particularly with TB or any other infectious disease. Because erratic treat-
ments or interruptions of treatment may be particularly hazardous epidemiolo-
gically and to the individual, planning for and providing continuing care are essen-
tial elements of prison health care provision;
9. Recognising that the public health mechanisms, which may in the rarest and most
exceptional cases involve the compulsory detention of individuals who pose a se-
rious risk of infection to the wider community must be efficacious, necessary and
justified, and proportional to the risks posed. Such steps should be exceptional and
must follow careful and critical questioning of the need for such constraints and
the absence of any effective alternative. In such circumstances detention should be
for as short a time as possible and be as limited in restrictions as feasible. There
must also be a system of independent appraisal and periodic review of any such
measures, including a mechanism for appeal by the patients themselves. Wherever
possible alternatives to such detention should be used;
10. This model should be used in considering all steps to prevent cross infection and to
treat existing infected persons within the prison environment.
11. Physicians working in prisons have a duty to report to the health authorities and
professional organisations of their country any deficiency in health care provided
to the inmates and any situation involving high epidemiological risk. NMAs are
obliged to attempt to protect those physicians against any possible reprisals.
12. Physicians working in prisons have a duty to follow national public health guide-
lines, where these are ethically appropriate, particularly concerning the mandatory
reporting of infectious and communicable diseases.
ANNEX
International texts relating to medical care in prisons:
Universal Declaration of Human Rights (Articles 4, 9, 10 and 11). Adopted by the United Nations
General Assembly on 16 December 1948.
Standard Minimum Rules for the Treatment of Prisoners (Rules 22-26). Approved by the United
Nations Economic and Social Council on 31 July 1957.
International Covenant on Economic, Social and Cultural Rights (Article 12). Adopted by the
United Nations General Assembly on 16 December 1966. Entry into force: 3 January 1976.
International Covenant on Civil and Political Rights (Articles 6, 7 and 10). Adopted by the United
Nations General Assembly on 16 December 1966. Entry into force: 23 March 1976.
Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture (Principle 1).
Adopted by the United Nations General Assembly on 18 December 1982.
D-2000-01-2011 ⏐ Montevideo
Prison Conditions on TB (Edinburgh)
Body of Principles for the Protection of All Persons Under Any Forms of Detention or
Imprisonment (Principle 24). Adopted by the United Nations General Assembly on 9 December
1988.
Basic Principles for the Treatment of Prisoners (Article 9). Adopted by the United Nations General
Assembly on 14 December 1990.
United Nations Rules for the Protection of Juveniles Deprived of Their Liberty (Principles 50-54).
Adopted by the United Nations General Assembly on 14 December 1990.
WHO Guidelines on HIV Infection and AIDS in Prison. Issued in March 1993, Geneva
(Document WHO/GPA/DIR/93.3).
Handbook of WMA Policies
World Medical Association ⏐ D-2002-01-2012
WMA DECLARATION OF WASHINGTON
ON
BIOLOGICAL WEAPONS
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and editorialiy revised by the 164th
WMA Council Session, Divonne-les-Bains, France,
May 2003
and reaffirmed by the 191st
WMA Council Session, Prague, Czech Republic, April 2012
A. INTRODUCTION
1. The World Medical Association recognizes the growing threat that biological wea-
pons might be used to cause devastating epidemics that could spread internationally.
All countries are potentially at risk. The release of organisms causing smallpox,
plague, anthrax or other diseases could prove catastrophic in terms of the resulting
illnesses and deaths compounded by the panic such outbreaks would generate. At
the same time, there is a growing potential for production of new microbial agents,
as expertise in biotechnology grows and methods for genetic manipulation of
organisms become simpler. These developments are of special concern to medical
and public health professionals because it is they who best know the potential
human suffering caused by epidemic disease and it is they who will bear primary
responsibility for dealing with the victims of biological weapons. Thus, the World
Medical Association believes that medical associations and all who are concerned
with health care bear a special responsibility to lead in educating the public and
policy makers about the implications of biological weapons and to mobilize uni-
versal support for condemning research, development, or use of such weapons as
morally and ethically unacceptable.
2. Unlike the use of nuclear, chemical, and conventional weapons, the consequences
of a biological attack are likely to be insidious. Their impact might continue with
secondary and tertiary transmission of the agent, weeks or months after the initial
epidemic. The consequences of a successful biological attack, especially if the
infection were readily communicable, could far exceed those of a chemical or even
a nuclear event. Given the ease of travel and increasing globalization, an outbreak
anywhere in the world could be a threat to all nations.
3. A great many severe, acute illnesses occurring over a short span of time would
almost certainly overwhelm the capacities of most health systems in both the
developing and industrialized world. Health services throughout the world are
struggling to meet the demands created by HIV/AIDS and antimicrobial-resistant
organisms, the problems created by civil strife, refugees and crowded, unsanitary
urban environments as well as the increased health needs of aging populations.
Coping over a short period of time with large numbers of desperately ill persons
could overwhelm entire health systems.
D-2002-01-2012 ⏐ Prague
Biological Weapons (Washington)
4. Actions can be taken to diminish the risk of biological weapons as well as the
potentially harmful consequences of serious epidemics whatever their origin. Inter-
national collaboration is needed to build a universal consensus that condemns the
development, production, or use of biological weapons. Programs of surveillance
are needed in all countries for the early detection, identification, and response to
serious epidemic disease; health education and training is needed for professionals,
civic leaders, and the public alike; and collaborative programs of research are
needed to improve disease diagnosis, prevention, and treatment.
5. The proliferation of technology and scientific progress in biochemistry, biotech-
nology, and the life sciences provides the opportunity to create novel pathogens
and diseases and simplified production methods for bioweapons. The technology is
relatively inexpensive and, because production is similar to that used in biological
facilities such as vaccine manufacturing, it is easy to obtain. Capacity to produce
and effectively disperse biological weapons exists globally, allowing extremists
(acting collectively or individually) to threaten governments and endanger peoples
around the world. Nonproliferation and arms control measures can diminish but
cannot completely eliminate the threat of biological weapons. Thus, there is a need
for the creation of and adherence to a globally accepted ethos that rejects the
development and use of biological weapons.
B. STRENGTHENING PUBLIC HEALTH AND DISEASE SURVEILLANCE SYSTEMS
2.
1. A critical component in dealing with epidemic disease is a strong public health
infrastructure. Investment in public health systems will enhance capacity to detect
and to contain expeditiously, rare or unusual disease outbreaks, whether deli-
berately induced or naturally occurring. Core public health functions (disease sur-
veillance and supporting laboratory services) are needed as a foundation for detec-
tion, investigation, and response to all epidemic threats. A more effective global
surveillance program will improve response to naturally occurring infectious dis-
eases and will permit earlier detection and characterization of new or emerging
diseases.
2. It is especially important that physicians be alert to the occurrence of cases or
clusters of unusual infectious diseases, to seek help from infectious disease
specialists in diagnosis, and to report cases promptly to public health authorities.
Because any physician may see only one or a few cases and may not recognize that
an outbreak is occurring, cooperation between primary care physicians and public
health authorities is especially important.
3. Public health officials, dealing with an epidemic, will require the cooperation of
emergency management agencies, law enforcement officials, healthcare facilities,
and a variety of community service organizations. For these different groups to work
together effectively, advance planning will be important. In addition to developing
surveillance activities for early detection and reporting, public health efforts should
be directed toward educating primary caregivers and public health staff about
potential agents that might be used, building laboratory capacity for rapid identifi-
cation of biological agents, providing medical and hospital services as well as
vaccines and drugs to control the epidemic.
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4. C. ENHANCEMENT OF MEDICAL PREPAREDNESS AND RESPONSE CAPACITY
a.
1. The first indication that a biological weapon may have been disseminated is likely
to be the appearance of patients in the offices of practicing physicians, especially
those in acute care settings. Physicians thus play a critical role in early detection of
an outbreak and must be prepared to recognize and deal with diseases resulting
from the use of biological weapons as well as other infectious disease agents and to
promptly report suspicious illnesses and diseases to public health officials.
2. In the course of an epidemic, physicians will be directly involved with mass patient
care, with mass immunization and antibiotic prophylaxis, with providing informa-
tion to the public, and in a variety of hospital and community efforts to control the
epidemic. Thus, physicians should participate with local and national health
authorities to develop and implement disaster preparedness and response plans for
intentional and natural infectious disease outbreaks.
5. D. BIOWEAPONS RESEARCH AND MEDICAL ETHICS
a.
1. Rapid advances in microbiology, molecular biology, and genetic engineering have
created extraordinary opportunities for biomedical research and hold great promise
for improving human health and the quality of life. Better and more rapid diag-
nostic tools, novel vaccines, and therapeutic drugs can be foreseen. At the same
time, there is concern about the possible misuse of research for the development of
more potent biological weapons and the spread of new infectious diseases. It may
be difficult to distinguish legitimate biomedical research from research by un-
scrupulous scientists with the malign purpose of producing more effective biologi-
cal weapons.
2. All who participate in biomedical research have a moral and ethical obligation to
consider the implications of possible malicious use of their findings. Through
deliberate or inadvertent means, genetic modification of microorganisms could
create organisms that are more virulent, are antibiotic-resistant, or have greater
stability in the environment. Genetic modification of microorganisms could alter
their immunogenicity, allowing them to evade natural- and vaccine-induced im-
munity. Advances in genetic engineering and gene therapy may allow modification
of the immune response system of the target population to increase or decrease
susceptibility to a pathogen or disrupt the functioning of normal host genes.
3. Research specifically for the purposes of creating biological weapons is to be
condemned. As scientists and humanitarians, physicians have a societal respon-
sibility to decry scientific research for the development and use of biological wea-
pons and to express abhorrence for the use of biotechnology and information
technologies for potentially harmful purposes.
4. Physicians and medical organizations have important societal roles in demanding a
global prohibition on biological weapons and stigmatizing their use, guarding
against unethical and illicit research, and mitigating civilian harm from use of
biological weapons.
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Biological Weapons (Washington)
6. E. RECOMMENDATIONS
a.
1. That the World Medical Association and National Medical Associations world-
wide take an active role in promoting an international ethos condemning the
development, production, or use of toxins and biological agents that have no justi-
fycation for prophylactic, protective, or other peaceful purposes.
2. That the World Medical Association, National Medical Associations and health-
care workers worldwide promote, with the World Health Organization, the United
Nations, and other appropriate entities, the establishment of an international con-
sortium of medical and public health leaders to monitor the threat of biological
weapons, to identify actions likely to prevent bioweapons proliferation, and to
develop a coordinated plan for monitoring the worldwide emergence of infectious
diseases. This plan should address: (a) international monitoring and reporting sys-
tems so as to enhance the surveillance and control of infectious disease outbreaks
throughout the world; (b) the development of an effective verification protocol
under the UN Biological and Toxin Weapons Convention; (c) education of physi-
cians and public health workers about emerging infectious diseases and potential
biological weapons; (d) laboratory capacity to identify biological pathogens; (e)
availability of appropriate vaccines and pharmaceuticals; and (f) financial, tech-
nical, and research needs to reduce the risk of use of biological weapons and other
major infectious disease threats.
3. That the World Medical Association urge physicians to be alert to the occurrence
of unexplained illnesses and deaths in the community and knowledgeable of
disease surveillance and control capabilities for responding to unusual clusters of
diseases, symptoms, or presentations.
4. That the World Medical Association encourage physicians, National Medical
Associations and other medical societies to participate with local, national, and
international health authorities in developing and implementing disaster prepared-
ness and response protocols for acts of bioterrorism and natural infectious disease
outbreaks. These protocols should be used as the basis for physician and public
education.
5. That the World Medical Association urge all who participate in biomedical
research to consider the implications and possible applications of their work and to
weigh carefully in the balance the pursuit of scientific knowledge with their ethical
responsibilities to society.
Handbook of WMA Policies
World Medical Association ⏐ D-2002-02-2016
WMA DECLARATION
ON
ETHICAL CONSIDERATIONS REGARDING HEALTH DATABASES AND
BIOBANKS
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
1. The Declaration of Helsinki lays down ethical principles for medical research involving
human subjects, including the importance of protecting the dignity, autonomy, privacy
and confidentiality of research subjects, and obtaining informed consent for using
identifiable human biological material and data.
2. In health care provision, health information is gathered by physicians or other members
of the medical team to record health care events and to aid physicians in the on-going
care of their patient.
3. This Declaration is intended to cover the collection, storage and use of identifiable data
and biological material beyond the individual care of patients. In concordance with the
Declaration of Helsinki, it provides additional ethical principles for their use in Health
Databases and Biobanks.
This Declaration should be read as a whole and each of its constituent paragraphs should
be applied with consideration of all other relevant paragraphs.
4. A Health Database is a system for collecting, organizing and storing health information.
A Biobank is a collection of biological material and associated data. Biological material
refers to a sample obtained from an individual human being, living or deceased, which
can provide biological information, including genetic information, about that individual.
Health Databases and Biobanks are both collections on individuals and population, and
both give rise to the similar concerns about dignity, autonomy, privacy, confidentiality
and discrimination.
5. Research using Health Databases and Biobanks can often significantly accelerate the
improvement in the understanding of health, diseases, and the effectiveness, efficiency,
safety and quality of preventive, diagnostic and therapeutic interventions. Health
research represents a common good that is in the interest of individual patients, as well
D-2002-02-2016⏐ Taipei
Health Databases and Biobanks
as the population and the society.
6. Physicians must consider the ethical, legal and regulatory norms and standards for
Health Database and Biobanks in their own countries as well as applicable international
norms and standards. No national or international ethical, legal or regulatory
requirement should reduce or eliminate any of the protections for individuals and
population set forth in this Declaration.
When authorized by a national law adopted through a democratic process in respect of
human rights, other procedures could be adopted to protect the dignity, autonomy and
privacy of the individuals. Such procedures are only acceptable when strict rules on data
protection are implemented.
7. Consistent with the mandate of WMA, the Declaration is addressed primarily to
physicians. The WMA encourages others who are involved in using data or biological
material in Health Databases and Biobanks to adopt these principles.
ETHICAL PRINCIPLES
8. Research and other Health Databases and Biobanks related activities should contribute
to the benefit of society, in particular public health objectives.
9. Respecting the dignity, autonomy, privacy and confidentiality of individuals, physicians
have specific obligations, both ethical and legal, as stewards protecting information
provided by their patients. The rights to autonomy, privacy and confidentiality also
entitle individuals to exercise control over the use of their personal data and biological
material.
10. Confidentiality is essential for maintaining trust and integrity in Health Databases and
Biobanks. Knowing that their privacy will be respected gives patients and donors the
confidence to share sensitive personal data. Their privacy is protected by the duty of
confidentiality of all who are involved in handling data and biological material.
11. The collection, storage and use of data and biological material from individuals capable
of giving consent must be voluntary. If the data and biological material are collected for
a given research project, the specific, free and informed consent of the participants must
be obtained in accordance with the Declaration of Helsinki.
12. If the data or biological material are collected and stored in a Health Database or a
Biobank for multiple and indefinite uses, consent is only valid if the concerned
individuals have been adequately informed about:
• The purpose of the Health Database or Biobank;
• The risks and burdens associated with collection, storage and use of data and
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material;
• The nature of the data or material to be collected;
• The procedures for return of results including incidental findings;
• The rules of access to the Health Database or Biobank;
• How privacy is protected;
• The governance arrangements as stipulated in paragraph 21;
• That in case the data and material are made non-identifiable the individual may
not be able to know what is done with their data/material and that they will not
have the option of withdrawing their consent;
• Their fundamental rights and safeguards established in this Declaration; and
• When applicable, commercial use and benefit sharing, intellectual property
issues and the transfer of data or material to other institutions or third countries.
13. In addition to the requirements set forth in the Declaration of Helsinki, when persons
who were not able to consent, whose data and biological materials have been stored for
future research, attain or regain the capacity to consent, reasonable efforts should be
made to seek the consent of those persons for continued storage and research use of their
data and biological materials.
14. Individuals have the right to request for and be provided with information about their
data and its use as well as to request corrections of mistakes or omissions. Health
Databases and Biobanks should adopt adequate measures to inform the concerned
individuals about their activities.
15. Individuals have the right, at any time and without reprisal, to alter their consent or to
ask for their identifiable data to be withdrawn from the Health Database and their
biological material to be withdrawn from a Biobank. This applies to future use of the
data and biological materials.
16. In the event of a clearly identified, serious and immediate threat where anonymous data
will not suffice, the requirements for consent may be waived to protect the health of the
population. An independent ethics committee should confirm that each exceptional case
is justifiable.
17. The interests and rights of the communities concerned, in particular when vulnerable,
must be protected, especially in terms of benefit sharing.
18. Special considerations should be given to the possible exploitation of intellectual
property. Protections for ownership of materials, rights and privileges must be
considered and contractually defined before collecting and sharing the material.
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Health Databases and Biobanks
Intellectual property issues should be addressed in a policy, which covers the rights of all
stakeholders and communicated in a transparent manner.
19. An independent ethics committee must approve the establishment of Health Databases
and Biobanks used for research and other purposes. In addition the ethics committee
must approve use of data and biological material and check whether the consent given at
the time of collection is sufficient for the planned use or if other measures have to be
taken to protect the donor. The committee must have the right to monitor on-going
activities. Other ethical review mechanisms that are in accordance to par 6 can be
established.
GOVERNANCE
20. In order to foster trustworthiness, Health Databases and Biobanks must be governed by
internal and external mechanisms based on the following principles:
• Protection of individuals: Governance should be designed so the rights of
individuals prevail over the interests of other stakeholders and science;
• Transparency: any relevant information on Health Databases and Biobanks must
be made available to the public;
• Participation and inclusion: Custodians of Health Databases and Biobanks must
consult and engage with individuals and their communities.
• Accountability: Custodians of Health Databases and Biobanks must be accessible
and responsive to all stakeholders.
21. Governance arrangements must include the following elements:
• The purpose of the Health Database or Biobank;
• The nature of health data and biological material that will be contained in the
Health Database or Biobank;
• Arrangements for the length of time for which the data or material will be stored;
• Arrangements for regulations of the disposal and destruction of data or material;
• Arrangement for how the data and material will be documented and traceable in
accordance with the consent of the concerned persons;
• Arrangement for how the data and material will be dealt with in the event of
change of ownership or closure;
• Arrangement for obtaining appropriate consent or other legal basis for data or
material collection;
• Arrangements for protecting dignity, autonomy, privacy and preventing
discrimination;
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• Criteria and procedures concerning the access to and the sharing of the health
data or biological material including the systematic use of Material Transfer
Agreement (MTA) when necessary;
• The person or persons who are responsible for the governance;
• The security measures to prevent unauthorized access or inappropriate sharing;
• The procedures for re-contacting participants where relevant;
• The procedures for receiving and addressing enquiries and complaints.
22. Those professionals contributing to or working with Health Databases and Biobanks
must comply with the appropriate governance arrangements.
23. Health Databases and Biobanks must be operated under the responsibility of an
appropriately qualified professional assuring compliance with this Declaration.
24. The WMA urges relevant authorities to formulate policies and law that protect health
data and biological material on the basis of the principles set forth in this document.
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World Medical Association ⏐ D-2002-03-2012
WMA DECLARATION
ON
PATIENT SAFETY
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and reaffirmed by the 191st
WMA Council Session, Prague, Czech Republic, April 2012
PREAMBLE
1.
1. Physicians strive to provide the highest quality health and medical care to patients.
Patient safety is one of the core elements of quality in health and medical care.
2. Progress in medical and allied science and technology has transformed modern
medicine into an advanced and complex health system.
3. Inherent risks have always existed in clinical medicine. Developments in modern
medicine have resulted in new and sometimes greater risks – some avoidable, others
inherent.
4. Physicians should attempt to foresee these risks and manage them in the treatment of
patients.
PRINCIPLES
1.
1. Physicians must ensure that patient safety is always considered during medical
decision-making.
2. Individuals and processes are rarely solely responsible for producing 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 organi-
zation culpability.
3. A realistic understanding of the risks inherent in modern medicine requires that
physicians must go beyond the professional boundaries of health care and cooperate
with all relevant parties, including patients, to adopt a proactive systems approach to
patient safety.
4. To create such a systems 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 all relevant
parties, including the patient. However, patient confidentiality must be strictly pro-
tected.
Patient Safety
Washington, DC ⏐ D-2002-03-2002
RECOMMENDATIONS
1.
1. Hence, the WMA recommends the following to national medical associations:
1.
1. National medical associations should promote policies on patient safety to all
physicians in their countries;
2. National medical associations should encourage individual physicians, other
health care professionals, patients and other relevant individuals and organiza-
tions to work together to establish systems that secure patient safety;
3. National medical associations should encourage the development of effective
models to promote patient safety through continuing medical education/con-
tinuing professional development;
4. National medical associations should cooperate with one another and exchange
information about adverse events, including errors, their solutions, and «lessons
learned» to improve patient safety.
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World Medical Association ⏐ D-2002-04-2012
WMA DECLARATION
ON
MEDICAL ETHICS AND ADVANCED MEDICAL TECHNOLOGY
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
It is essential to balance the benefits and risks for persons inherent in the development and
application of advanced medical technology. Maintaining this balance is entrusted to the
judgment of the physician.
Therefore:
Medical technology should be used to promote health. Patient safety should be fully
considered by the physician in the development and application of medical technology.
In order to foster physicians’ ability to provide appropriate medical care and having
sufficient knowledge of medical technology efforts must be made to ensure the provision
of comprehensive medical education focusing on the safe and effective use and develop-
ment of medical technology.
Handbook of WMA Policies
D-2008-01-2018 ⏐ World Medical Association
WMA DECLARATION
OF SEOUL ON
PROFESSIONAL AUTONOMY
AND CLINICAL INDEPENDENCE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
And amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
The WMA reaffirms the Declaration of Madrid on professionally-led regulation.
The World Medical Association recognises the essential nature of professional autonomy
and physician clinical independence, and states that:
1. Professional autonomy and clinical independence are essential elements in
providing quality health care to all patients and populations. Professional
autonomy and independence are essential for the delivery of high quality health
care and therefore benefit patients and society.
2. Professional autonomy and clinical independence describes the processes under
which individual physicians have the freedom to exercise their professional
judgment in the care and treatment of their patients without undue or inappropriate
influence by outside parties or individuals.
3. Medicine is highly complex. Through lengthy training and experience, physicians
become medical experts weighing evidence to formulate advice to patients.
Whereas patients have the right to self-determination, deciding within certain
constraints which medical interventions they will undergo, they expect their
physicians to be free to make clinically appropriate recommendations.
4. Physicians recognize that they must take into account the structure of the health
system and available resources when making treatment decisions. Unreasonable
restraints on clinical independence imposed by governments and administrators are
not in the best interests of patients because they may not be evidence based and
risk undermining trust which is an essential component of the patient-physician
relationship.
5. Professional autonomy is limited by adherence to professional rules, standards and
the evidence base.
6. Priority setting and limitations on health care coverage are essential due to limited
resources. Governments, health care funders (third party payers), administrators
and Managed Care organisations may interfere with clinical autonomy by seeking
to impose rules and limitations. These may not reflect evidence-based medicine
principles, cost-effectiveness and the best interest of patients. Economic evaluation
studies may be undertaken from a funder’s not a users’ perspective and emphasise
cost-savings rather than health outcomes.
7. Priority setting, funding decision making and resource allocation/limitations
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processes are frequently not transparent. A lack of transparency further perpetuates
health inequities.
8. Some hospital administrators and third-party payers consider physician
professional autonomy to be incompatible with prudent management of health care
costs. Professional autonomy allows physicians to help patients make informed
choices, and supports physicians if they refuse demands by patients and family
members for access to inappropriate treatments and services.
9. Care is given by teams of health care professionals, usually led by physicians. No
member of the care team should interfere with the professional autonomy and
clinical independence of the physician who assumes the ultimate responsibility for
the care of the patient. In situations where another team member has clinical
concerns about the proposed course of treatment, a mechanism to voice those
concerns without fear of reprisal should exist.
10. The delivery of health care by physicians is governed by ethical rules, professional
norms and by applicable law. Physicians contribute to the development of
normative standards, recognizing that this both regulates their work as
professionals and provides assurance to the public.
11. Ethics committees, credentials committees and other forms of peer review have
long been established, recognised and accepted by organised medicine as ways of
scrutinizing physicians’ professional conduct and, where appropriate, may impose
reasonable restrictions on the absolute professional freedom of physicians.
12. The World Medical Association reaffirms that professional autonomy and clinical
independence are essential components of high quality medical care and the
patient-physician relationship that must be preserved. The WMA also affirms that
professional autonomy and clinical independence are core elements of medical
professionalism.
Handbook of WMA Policies
World Medical Association ⏐ D-2009-01-2017
WMA DECLARATION OF DELHI
ON
HEALTH AND CLIMATE CHANGE
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Human influence on the climate system is clear, and recent emissions of green-
house gases are the highest in history. Recent climate changes have had
widespread impacts on human and natural systems.
2. Compelling evidence substantiates the numerous health risks posed by climate
change, which threaten all countries. These include more frequent and potentially
more severe heatwaves, droughts, floods and other extreme weather events
including storms and bushfires. Climate change, especially warming, is already
leading to changes in the environment in which disease vectors flourish. There is
reduced availability and quality of potable water, and worsening food insecurity
leading to malnutrition and population displacement. Climate Change is universal
but its effects are uneven and many of the areas most affected are least able to
manage the challenges it poses.
3. Tackling climate change offers opportunities to improve health and wellbeing both
because of the health co-benefits of low carbon solutions and because mitigation
and adaptation may allow action on all the social determinants of health.
Transition to renewable energy, the use of active transport, and dietary change
including a reduction in consumption of beef and other animal products, may all
contribute to improving health and wellbeing.
4. The social determinants of health are those factors that correlate to health through
exposure before and after people are born and as they grow live, and work. They
vary between and within countries. Those with generally the poorest health and
lowest life and health expectancy will be least able to adapt to the adverse effects
of climate change thereby exacerbating adverse social determinants of health.
5. Climate change research and surveillance is important. The WMA supports studies
that describe the patterns of disease attributed to climate change, including the
impacts of climate change on communities and households; the burden of known
and emergent disease caused by climate change, and those diseases projected to
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Climate Change
occur with new development activities (Health Impacts Assessment). Such studies
should also define the most vulnerable populations.
6. The Paris Agreement highlights a transition to a new model of global collaboration
to address climate change and is an opportunity for the health sector to contribute
to climate action. It includes a series of actions to be undertaken by each party to
achieve a long-term goal of keeping the increase in global average temperature to
less than 1.5 C above pre-industrial levels. Whether or not individual states are
parties to the Paris agreement, NMAs have an obligation to consider the effects of
climate change on the planet and on human, animal, and environmental
sustainability and to take action as follows.
RECOMMENDATIONS
7. The World Medical Association and its Constituent Members:
• Urge national governments and non-state actors to recognize the serious health
consequences of climate change and to adopt strategies to adapt to and mitigate
its effects;
• Urge national governments to ensure the fulfilment of national commitments to
international agreements, including both mitigation and adaptation measures as
well as action on losses and damage;
• Urges national governments to provide climate financing that includes
designated funds to support the strengthening of health systems, and health and
climate co-benefit policies and, provide sufficient global, regional and local
financing for climate mitigation, adaptation measures, disaster risk reduction,
and the attainment of the Sustainable Development Goals (SDGs);
• Urge national governments to facilitate the active participation of health sector
representatives in the creation and implementation of climate change
preparedness plans and emergency planning and response on local, national
and international levels;
• Urge national governments to provide for the health and wellbeing of people
displaced by environmental causes including those becoming refugees due to
the consequences of climate change;
• Asks national governments to invest in public health and climate change
research to ensure of better understanding of adaptation needs and health co-
benefits at national level;
• Urge national governments to facilitate collaboration between Ministry of
Health and other ministries to ensure that health is considered in their national
commitments and sustainable strategies.
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8. National Medical Associations and their physician members should:
• Advocate for sustainable, environmentally responsible low-carbon practices
across the health sector to reduce the environmental impact of health care
facilities and practices;
• Prepare for the infrastructure disruptions that accompany health emergencies,
in particular by planning in advance for the delivery of services and increased
patient care demands during these crisis situations;
• Encourage and support advocacy for environmental protection and greenhouse
gas emissions reductions including through emissions trading systems and/or
carbon taxes;
• Become educated as to the health effects of climate change and be prepared to
treat and manage them in individual patients;
• Promote medical research into improved use of antibiotherapy to be able to
respond, in the future, to the new infectious diseases linked to climate change.
9. The WMA and its Constituent Members should:
• Encourage sustainable low-carbon living respectful of planetary limits
including active lifestyle and sustainable production and consumption patterns;
• Seek to build professional and public awareness of the importance of the
environment and climate change to personal, community and societal health;
• Work towards the integration of key climate change concepts and
competencies in undergraduate, graduate and continuing medical education
curricula;
• Collaborate with the WHO and other stakeholders as appropriate, to produce
educational and advocacy materials on climate change for national medical
associations, physicians, other health professionals, as well as the general
public;
• Advocate for their respective governments to finance, promote research into
the effects of climate change on health and collaborate with NGOs and other
health professionals;
• Work collaboratively with government, NGOs, businesses, civil societies and
others to create alert systems to ensure that health care systems and physicians
are aware of climate-related events as they unfold, and receive timely accurate
information regarding the management of emerging health events;
• Have climate change as a priority issue on their agendas and actively
participate in the creation of policies and initiatives that mitigate the effects of
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Climate Change
climate change on health.
10. The WMA urges National Medical Associations to:
• Work with health-care institutions, and individual physicians to adopt climate
policies and act as role models by reducing their carbon emissions;
• Recognize environmental factors as a key social determinants of health (SDH),
and encourage governments to foster collaboration between the health and non-
health sectors in addressing these determinants.
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D-2009-02-2009 ⏐ World Medical Association
WMA DECLARATION OF MADRID
ON
PROFESSIONALLY-LED REGULATION
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
The collective action by the medical profession seeking for the benefit of patients, in
assuming responsibility for implementing a system of professionally-led regulation will
enhance and assure the individual physician’s right to treat patients without interference,
based on his or her best clinical judgment. Therefore, the WMA urges the national medical
associations and all physicians to take the following actions.
1. Physicians have been granted by society a high degree of professional autonomy and
clinical independence, whereby they are able to make recommendations based on the
best interests of their patients without undue outside influence.
2. As a corollary to the right of professional autonomy and clinical independence, the
medical profession has a continuing responsibility to be self-regulating. Ultimate con-
trol and decision-making authority must rest with physicians, based on their specific
medical training, knowledge, experience and expertise.
3. Physicians in each country are urged to establish, maintain and actively participate in
a legitimate system of professionally-led regulation. This dedication is to ultimately
assure full clinical independence in patient care decisions.
4. To avoid being influenced by the inherent potential conflicts of interest that will arise
from assuming both representational and regulatory duties, National Medical Associa-
tions must do their utmost to promote and support the concept of professionally-led
regulation amongst their membership and the public.
5. Any system of professionally-led regulation must ensure
a) the quality of the care provided to patients,
b) the competence of the physician providing that care and
c) the professional conduct of physician.
To ensure the patient quality continuing care, physicians must participate actively in
the process of Continuing Professional Development in order to update and maintain
their clinical knowledge, skills and competence.
6. The professional conduct of physicians must always be within the bounds of the Code
of Ethics governing physicians in each country. National Medical Associations must
promote professional and ethical conduct among physicians for the benefit of their
patients. Ethical violations must be promptly recognized and reported. The physicians
who have erred must be appropriately disciplined and where possible be rehabilitated.
D-2009-01-2017 ⏐ Chicago
Climate Change
7. National Medical Associations are urged to assist each other in coping with new and
developing problems, including potential inappropriate threats to professionally-led
regulation. The ongoing exchange of information and experiences between National
Medical Associations is essential for the benefit of patients.
8. An effective and responsible system of professionally-led regulation by the medical
profession in each country must not be self serving or internally protective of the pro-
fession, and the process must be fair, reasonable and sufficiently transparent to ensure
this. National Medical Associations should assist their members in understanding that
self-regulation cannot only be perceived as being protective of physicians, but must
maintain the safety, support and confidence of the general public as well as the ho-
nour of the profession itself.
Handbook of WMA Policies
D-2011-01-2011 ⏐ World Medical Association
WMA DECLARATION OF MONTEVIDEO
ON
DISASTER PREPAREDNESS AND MEDICAL RESPONSE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
In the last decade, the attention of the world has been drawn to a number of severe events
which seriously tested and overwhelmed the capacity of local healthcare and emergency
medical response systems. Armed conflicts, terrorist attacks and natural distasters such as
earthquakes, floods and tsunamies in various parts of the world have not only affected the
health of people living in these areas but have also drawn the support and response of the
international community. Many National Medical Associations have sent groups to assist
in such disaster situations.
According to the World Health Organization (WHO) Center for Research on the Epide-
miology of Disasters (CRED), the frequency, magnitude, and toll of natural disasters and
terrorism have increased throughout the world. In the previous century, about 3.5 million
people were killed worldwide as a result of natural disasters; about 200 million were killed
as a result of human-caused disasters (e.g., wars, terrorism, genocides). Each year, dis-
asters cause hundreds of deaths and cost billions of dollars due to disruption of commerce
and destruction of homes and critical infrastructure.
Population vulnerability (e.g., due to increased population density, urbanization, aging)
has increased the risk of disasters and public health emergencies. Globalization, which
connects countries through economic interdependencies, has led to increased international
travel and commerce. Such activity has also led to increased population density in cities
around the world and increased movement of people to coastal areas and other disaster-
prone regions. Increases in international travel may speed the rate at which an emerging
infectious disease or bioterrorism agent spreads across the globe. Climate change and ter-
rorism have emerged as important global factors that can influence disaster trends and thus
require continued monitoring and attention.
The emergence of infectious diseases, such as H1N1 influenza A and severe acute respi-
ratory syndrome (SARS), and the recent arrival of West Nile virus and monkey pox in the
Western hemisphere, reinforces the need for constant vigilance and planning to prepare for
and respond to new and unexpected public health emergencies.
The growing likelihood of terrorist-related disasters affecting large civilian populations
affects all nations. Concern continues about the security of the worldwide arsenal of nu-
clear, chemical, and biological agents as well as the recruitment of people capable of manu-
facturing or deploying them. The potentially catastrophic nature of a «successful» terrorist
attack configures an event that may demand a disproportionate amount of resources and
healthcare professionals preparedness. Natural disasters such as tornadoes, hurricanes,
D-2009-01-2017 ⏐ Chicago
Climate Change
floods, and earthquakes, as well as industrial and transportation-related catastrophes, are
far more common and can also severely stress existing medical, public health, and emer-
gency response systems.
In light of recent world events, it is increasingly clear that all physicians need to become
more proficient in the recognition, diagnosis, and treatment of mass casualties under an
all-hazards approach to disaster management and response. They must be able to recog-
nize the general features of disasters and public health emergencies, and be knowledgeable
about how to report them and where to get more information should the need arise. Physi-
cians are on the front lines when dealing with injury and disease-whether caused by mi-
crobes, environmental hazards, natural disasters, highway collisions, terrorism, or other
calamities. Early detection and reporting are critical to minimize casualties through astute
teamwork by public- and private-sector health and emergency response personnel.
The WMA, representing the doctors of the world, calls upon its members to advocate for
the following:
• To promote a standard competency set to ensure consistency among disaster
training programs for physicians across all specialties. Many NMAs have dis-
aster courses and previous experiences in disaster response. These NMAs can
share this knowledge and advocate for the integration of some standardized
level of training for all physicians, regardless of specialty or nationality.
• To work with national and local governments to establish or update regional
databases and geographic mapping of information on health system assets, ca-
pacities, capabilities, and logistics to assist medical response efforts, domesti-
cally and worldwide, when needed. This could include information on local
response organizations, the condition of local hospitals and health system infra-
structures, endemic and emerging diseases, and other important public health
and clinical information to assist medical response in the event of a disaster. In
addition, systems for communicating directly with physicians and other front
line health care providers should be identified and strengthened.
• To work with national and local governments to ensure the developing and
testing of disaster management plans for clinical care and public health includ-
ing the ethical basis for delivering such plans.
• To encourage governments at national and local levels to work across normal
departmental and other boundaries in developing the necessary planning.
The WMA could serve as a channel of communication for NMAs during such times of
crisis, enabling them to coordinate activities and work together.
Handbook of WMA Policies
D-2011-02-2011 ⏐ World Medical Association
WMA DECLARATION
ON
END-OF-LIFE MEDICAL CARE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
INTRODUCTION
All people have the right to high-quality, scientifically-based, and humane healthcare.
Therefore, receiving appropriate end-of-life medical care must not be considered a pri-
vilege but a true right, independent of age or any other associated factors. The WMA reaf-
firms the principles articulated in the WMA Declaration on Terminal illness and the
WMA Declaration on Euthanasia. These Declarations support and complement the Decla-
ration on End of Life Medical Care.
Palliative care at the end of life is part of good medical care. The need for access to
improved quality palliative care is great, especially in resource-poor countries. The objec-
tive of palliative care is to achieve the best possible quality of life through appropriate
palliation of pain and other distressing physical symptoms, and attention to the social, psy-
chological and spiritual needs of the patient.
Palliative care may be provided at home as well as in various levels of health care insti-
tutions.
The physician must adopt an attitude to suffering that is compassionate and humane, and
act with empathy, respect and tact. Abandonment of the patient when he or she needs such
care is unacceptable medical practice.
RECOMMENDATIONS
1. Pain and symptom management
1.1 It is essential to identify patients approaching the end of life as early as possible so
that the physician can perform a detailed assessment of their needs. A care plan for
the patient must always be developed; whenever possible, this care plan will be de-
veloped in direct consultation with the patient.
For some this process may begin months or a year before death is anticipated. It
includes recognising and addressing the likelihood of pain and other distressing
symptoms and providing for patients’ social, psychological and spiritual needs in
the time remaining to them. The primary aim is to maintain patients’ dignity and
their freedom from distressing symptoms. Care plans pay attention to keeping them
as comfortable and in control as possible and recognise the importance of sup-
porting the family and treating the body with respect after death.
Handbook of WMA Policies
D-2011-02-2011 ⏐ World Medical Association
1.2 Important advances in the relief of pain and other distressing symptoms have been
made. The appropriate use of morphine, new analgesics, and other measures can
suppress or relieve pain and other distressing symptoms in the majority of cases.
The appropriate health authorities must make necessary medications accessible and
available to physicians and their patients. Physician groups should develop guide-
lines on their appropriate use, including dose escalation and the possibility of unin-
tended secondary effects.
1.3 In a very limited number of cases, generally in the very advanced stages of a phy-
sical illness, some symptoms may arise that are refractory to standard therapy. In
such cases, palliative sedation to unconsciousness may be offered when life ex-
pectancy is a few days, as an extraordinary measure in response to suffering which
the patient and clinician agree is intolerable. Palliative sedation must never be used
to intentionally cause a patient’s death or without the agreement of a patient who
remains mentally competent. The degree and timing of palliative sedation must be
proportionate to the situation. The dosage must be carefully calculated to relieve
symptoms but should still be the lowest possible to achieve a benefit.
2. Communication and consent; ethics and values
2.1 Information and communication among the patient, their family and members of
the health care team is one of the fundamental pillars of quality care at the end of
life. The patient should be encouraged to express his or her preferences regarding
care, and his or her emotions and existential angst must be taken into considera-
tion.
2.2 Ethically-appropriate care at the end of life should routinely promote patient auto-
nomy and shared decision-making, and be respectful of the values of the patient
and his or her family.
2.3 Physicians should directly discuss a patient’s preferences with the patient and/or
the patient’s substitute health care decision maker, as appropriate. These discus-
sions should be initiated early and routinely offered to all patients and should be
revisited regularly to explore any changes patients may have in their wishes, espe-
cially as their clinical conditions change. Physicians should encourage their pa-
tients 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. Patients who are
in denial about the implications of their condition may not want to engage in such
discussion at some stages of their illness, but should know that they can change
their minds. Because documented advance directives are often 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.
2.4 If a patient is capable of giving consent, care should be based on the patient’s wishes
as long as preferences can be justified medically, ethically and legally. Consent
needs to be based on sufficient information and dialogue, and it is the physician’s
Montevideo ⏐ D-2011-02-2011
End-of-Life Medical Care
obligation to make sure that the patient is adequately treated for pain and dis-
comfort before consent is obtained in order to assure that unnecessary physical and
mental suffering do not interfere with the decision-making process.
2.5 The patient’s next-of-kin or family should be informed and involved in the deci-
sion-making process, provided the patient is not opposed to this. If the patient is
unable to express consent and an advance directive is not available, the views of
the health care substitute decision maker, appointed by the patient on care and
treatment, must be considered.
3. Medical records and medico-legal aspects
3.1 Physicians caring for a patient in the final stages of life must carefully document
treatment decisions and the reasons for choosing particular procedures, including
the patient’s and family’s wishes and consent, in the progress notes of the medical
records. An adequate medical record is of the utmost importance for continuity and
quality of medical care in general and palliative care in particular.
3.2 The physician must also take into account that these notes may serve a medico-
legal purpose, e.g., in determining the patient’s decision-making capacity.
4. Family members
It is necessary to acknowledge the importance of the family and the emotional environ-
ment of the patient. The needs of the family and other close caregivers throughout the
course of the illness must be recognized and attended to. The heath care team should pro-
mote collaboration in the care of the patient and provide bereavement support, when re-
quired, after the patient’s death. Children’s and families’ needs may require special atten-
tion and competence, both when children are patients and dependents.
5. Teamwork
Palliative care is usually provided by multiprofessional and interdisciplinary teams of
healthcare and non-healthcare professions. The physician must be the leader of the team,
being responsible, amongst other obligations, for diagnosis and medical treatment. Conti-
nuity of care is very important. The team should do all it can to facilitate a patient’s wish
to die at home, if applicable and possible.
6. Physician training
The increasing number of people who require palliative care and the increased availability
of effective treatment options mean that end-of-life care issues should be an important part
of undergraduate and postgraduate medical training.
7. Research and education
More research is needed to improve palliative care. This includes, but is not limited to, ge-
neral medical care, specific treatments, psychological implications and organization. The
WMA will support efforts to better educate physicians in the skills necessary to increase
the prevalence and quality of meaningful advance care planning.
Handbook of WMA Policies
D-2011-02-2011 ⏐ World Medical Association
CONCLUSION
The care that a people give to dying patients, within available resources, is an indication of
their degree of civilisation. As physicians representing the best humanitarian tradition, we
should always commit ourselves to delivering the best possible end-of-life care.
The WMA recommends that all National Medical Associations develop a national policy
on palliative care and palliative sedation based on the recommendations in this declara-
tion.
Handbook of WMA Policies
D-2011-03-2011 ⏐ World Medical Association
WMA DECLARATION
ON
LEPROSY CONTROL AROUND THE WORLD AND
ELIMINATION OF DISCRIMINATION
AGAINST PERSONS AFFECTED BY LEPROSY
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
Leprosy is a widespread public health problem, with approximately 250,000 new cases
diagnosed annually worldwide. It is a curable disease and after starting treatment, the
chain of transmission is interrupted. Leprosy is a disease that have been inadequately ad-
dressed from the point of view of investments in research and medical treatment.
The World Medical Association recommends to all National Medical Associations to de-
fend the right of the people affected with leprosy and members of their families, that they
should be treated with dignity and free from any kind of prejudice or discrimination. Phy-
sicians, health professionals and civil society should be engaged in combating all forms of
prejudice and discrimination. Research centers should acknowledge leprosy as a major
public health problem, and continue to research this disease since there are still gaps in
understanding its patho-physiological mechanisms. These gaps in knowledge may be over-
come through the allocation of resources to new research, which will contribute to more
efficient control worldwide. Medical schools, especially in countries with high preval-
ence of leprosy, should enhance its importance in the curriculum. The public, private, and
civil sectors should unify their best efforts in order to disseminate information that would
counteract prejudice towards leprosy and that acknowledges its curability.
Handbook of WMA Policies
D-2011-04-2015 ⏐ World Medical Association
WMA DECLARATION OF OSLO
ON
SOCIAL DETERMINANTS OF HEALTH
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and the title (Statement to Declaration) changed by the 66th
WMA General Assembly,
Moscow, Russia, October 2015
The social determinants of health are: the conditions in which people are born, grow, live,
work and age; and the societal influences on these conditions. The social determinants of
health are major influences on both quality of life, including good health, and length of
disability-free life expectancy. While health care will attempt to pick up the pieces and
repair the damage caused by premature ill health, it is these social, cultural, environ-
mental, economic and other factors that are the major causes of rates of illness and, in
particular, the magnitude of health inequalities.
Historically, the primary role of doctors and other health care professionals has been to
treat the sick – a vital and much cherished role in all societies. To a lesser extent, health
care professionals have dealt with individual exposures to the causes of disease – smoking,
obesity, and alcohol in chronic disease, for example. These familiar aspects of life style
can be thought of as ‘proximate’ causes of disease.
The work on social determinants goes far beyond this focus on proximate causes and
considers the «causes of the causes». For example, smoking, obesity, alcohol, sedentary
life style are all causes of illness. A social determinants approach addresses the causes of
these causes; and in particular how they contribute to social inequalities in health. It
focuses not only on individual behaviours but seeks to address the social and economic
circumstances that give rise to premature ill health, throughout the life course: early child
development, education, work and living conditions, and the structural causes that give
rise to these living and working conditions. In many societies, unhealthy behaviours fol-
low the social gradient: the lower people are in the socioeconomic hierarchy, the more
they smoke, the worse their diet, and the less physical activity they engage in. A major,
but not the only, cause of the social distribution of these causes is level of education.
Other specific examples of addressing the causes of the causes: price and availability,
which are key drivers of alcohol consumption; taxation, package labeling, bans on
advertising, and smoking in public places, which have had demonstrable effects on
tobacco consumption. The voice of the medical profession has been most important in
these examples of tackling the causes of the causes.
There is a growing movement, globally, that seeks to address gross inequalities in health
and length of life through action on the social determinants of health. This movement has
involved the World Health Organisation, several national governments, civil society organi-
zation, and academics. Solutions are being sought and learning shared. Doctors should be
Moscou ⏐ D-2011-04-2015
Social Determinants of Health
well informed participants in this debate. There is much that can happen within the prac-
tice of medicine that can contribute directly and through working with other sectors. The
medical profession can be advocates for action on those social conditions that have im-
portant effects on health.
The WMA could add significant value to the global efforts to address these social deter-
minants by helping doctors, other health professionals and National Medical Associations
understand what the emerging evidence shows and what works, in different
circumstances. It could help doctors to lobby more effectively within their countries and
across interna-tional borders, and ensure that medical knowledge and skills are shared.
The WMA should help to gather data of examples that are working, and help to engage
doctors and other health professionals in trying new and innovative solutions. It should
work with national associations to educate and inform their members and put pressure on
national governments to take the appropriate steps to try to minimise these root causes of
premature ill health. In Britain, for example, the national government has issued a public
health white paper that has at its heart reduction of health inequalities through action on
the social determinants of health; several local areas have drawn up plans of action; there
are good examples of general practice that work across sectors improve the quality of
people’s lives and hence reduce health inequalities. The WMA should gather examples of
good practice from its members and promote further work in this area.
Handbook of WMA Policies
World Medical Association ⏐ D-2014-01-2014
WMA DECLARATION
ON
THE PROTECTION OF HEALTH CARE WORKERS
IN SITUATION OF VIOLENCE
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
The right to health is a fundamental element of human rights which does not change in
situations of conflict and violence. Access to medical assistance for the sick and wounded,
whether they have been engaged in active combat or not, is guaranteed through various
international agreements, including the Geneva Convention and the Basic Principles on
the Use of Force and Firearms by Law Enforcement Officials of the United Nations.
The primary obligation of physicians is always to their patients, and physicians have the
same ethical responsibilities to preserve health and save life in situations of violence or
armed conflicts as in peacetime. These are as set out in the WMA Regulations in Times of
Armed Conflict and Other Situations of Violence.
It is essential to ensure the safety and personal security of healthcare workers in order to
enable the provision of the highest standard of care to patients. If healthcare workers are
not safe, they might not be able to provide care, and patients will suffer.
In situations of violence, the delivery of healthcare is frequently obstructed and the sick
and wounded deprived of essential treatment through:
1. Medical workers being prevented from attending to the injured;
2. Interference by the state or others in positions of power through intimidation, de-
tention or other legal measures;
3. Patients being denied access to medical facilities;
4. Targeted attacks upon medical facilities and medical transport;
5. Targeted attacks upon medical personnel, including kidnapping;
6. Non-targeted violent acts which result in the damage to or destruction of facilities
or vehicles, or cause injury or death to medical personnel.
Such actions have serious humanitarian implications and violate international standards of
medical neutrality as set out in the provisions of international human rights and human-
itarian law and codes of medical ethics.
Durban⏐ D-2014-01-2014
Protection of Healthcare Workers
Attacks on the fundamental ethical principles of the medical profession, such as attempts
to coerce medical professionals into providing details regarding those under their care, can
undermine the confidence of patients and discourage injured people from seeking neces-
sary treatment.
RECOMMENDATIONS
The WMA calls upon governments and all parties involved in situations of violence to:
1. Ensure the safety, independence and personal security of healthcare personnel at
all times, including during armed conflicts and other situations of violence, in ac-
cordance with the Geneva Conventions and their additional protocols;
2. Enable healthcare personnel to attend to 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 punish-
ment or intimidation;
3. Safe access to adequate medical facilities for the injured and others in need of
medical aid should not be unduly impeded;
4. Protect medical facilities, medical transport and the people being treated in them
and provide the safest possible working environment for healthcare workers and
protect them from interference and attack;
5. Respect and promote the principles of international humanitarian and human rights
law which safeguard medical neutrality in situations of conflict;
6. Establish reporting mechanisms to document violence against medical personnel
and facilities as set out in the WMA Statement on the Protection and Integrity of
Medical Personnel in Armed Conflicts and Other Situations of Violence.
7. Raise awareness of international norms on the protection of healthcare workers and
cooperate with different actors to identify strategies to tackle threats to healthcare.
The collaboration between the WMA and the International Committee of the Red
Cross on the Health Care in Danger project provides one example of this.
Handbook of WMA Policies
World Medical Association ⏐ D-2015-01-2017
WMA DECLARATION
ON
ALCOHOL
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. The burden of disease and injury associated with alcohol consumption is a critical
challenge to global public health and development around the world. The World
Medical Association offers this declaration on alcohol as its commitment to
reducing excessive alcohol consumption and as a means to support its members in
promulgating harm-reduction policies and other measures.
2. There are significant health, social and economic problems associated with
excessive alcohol use. Overall, there are causal relationships between alcohol
consumption and more than 200 types of disease and injury including traffic
fatalities. The harmful use of alcohol kills approximately 3.3 million people every
year (5.9 % of all deaths worldwide), and is the third leading risk factor for poor
health globally, accounting for 5.1 % of disability-adjusted life years lost. Beyond
the numerous chronic and acute health effects, alcohol use is associated with
widespread social, mental and emotional consequences. The problem has a special
magnitude among young people and adolescents who are beginning to consume
alcohol at earlier ages, and the risk to their physical, mental and social health is of
concern.
3. Although alcohol consumption is deeply rooted in many societies, alcohol cannot
be considered an ordinary beverage or consumer commodity. It is a substance that
causes extensive medical, psychological and social harm by means of physical
toxicity, intoxication and dependence.
There is increasing evidence that genetic vulnerability to alcohol dependence is a
risk factor for some individuals. Foetal alcohol syndrome and foetal alcohol
effects, preventable causes of intellectual disability, result from alcohol
consumption during pregnancy.
Adolescence is a stage of significant vulnerability because the neurological
development is not complete and alcohol has a negative impact on it. Growing
scientific evidence has demonstrated the harmful effects of consumption prior to
adulthood on the brains, mental, cognitive and social functioning of youth and
increased likelihood of adult alcohol dependence and alcohol related problems
among those who drink before full physiological maturity. Regular alcohol
Handbook of WMA Policies
World Medical Association ⏐ D-2015-01-2017
consumption and binge drinking in adolescents can negatively affect school
performance, increase participation in crime and adversely affect sexual
performance and behaviour.
4. Effective alcohol harm-reduction policies and measures will include legal and
regulatory measures that target overall alcohol consumption in the population, as
well as health and social policy interventions that specifically target high-risk
drinkers, vulnerable groups and harms to people affected by those who consume
alcohol, e.g. domestic violence.
When developing policies it should be taken into account that the majority of
alcohol-related problems in a population are associated with harmful or hazardous
drinking by non-dependent ‘social’ drinkers, particularly when intoxicated. This is
particularly a problem of young people in many regions of the world who drink
with the intent of becoming intoxicated.
5. There are many evidence-based alcohol policies and prevention programmes that
are effective in reducing the health, safety and socioeconomic problems
attributable to harmful use of alcohol. International public health advocacy and
partnerships are needed to strengthen and support the ability of governments and
civil society worldwide to commit to, and deliver on, reducing the harmful use of
alcohol through effective interventions, including action on social determinants of
health.
Health professionals in general and physicians in particular have an important role
to play in preventing, treating and mitigating alcohol-related harm, and in using
effective preventive and therapeutic interventions.
The World Medical Association encourages and supports the development and
implementation of evidence-based national alcohol policies by promoting and
facilitating partnerships, information exchange and health policy capacity building.
POLICY OBJECTIVES
In developing alcohol policies, the WMA recommends the following broad objectives:
6. Strengthen health systems to identify and improve a country’s capacity to develop
policy and lead actions that target excessive alcohol consumption.
7. Promote the development and evaluation in all countries of national alcohol
strategies which are comprehensive, evidence-based and include measures to
address the supply, distribution, sale, advertising, sponsorship and promotion of
alcohol. The WHO ‘best buys’ cost effective policies should be particularly
promoted, such as (i) increasing alcoholic beverage taxes, (ii) regulating the
availability of alcoholic beverages, (iii) restricting marketing of alcoholic
beverages and (iv) drink-driving countermeasures. Strategies should be routinely
reviewed and updated.
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Alcohol
8. Through government health departments, accurately measure the health burden
associated with alcohol consumption through the collection of sales data,
epidemiological data, and per capita consumption figures.
9. Support and promote the role of health and medical professionals in early
identification, screening and treatment of harmful alcohol use.
10. Dispel myths and dispute alcohol control strategies that are not evidence-based.
11. Reduce the impact of harmful alcohol consumption in at risk populations.
12. Foster multi-disciplinary collaboration and coordinated inter-sectoral action.
13. Raise awareness of alcohol-related harm through public education and information
campaigns.
14. Promote social determinants of health approach in fighting harmful alcohol
consumption.
REOMMENDATIONS
he following priorities are suggested for WMA members, National Medical Associations
and governments when developing integrated and comprehensive policy and legislative
responses.
15. Regulate affordability, accessibility and availability
15.1 Pricing policies
Evidence from epidemiological and other research demonstrates a clear link between the
price of alcohol and levels of consumption, especially amongst young drinkers and those
who are heavy alcohol users.
Therefore, action is needed to increase alcohol prices, through volumetric taxation of
products based on their alcohol strength, and other proven pricing mechanisms, to reduce
alcohol consumption, particularly in heavy drinkers and high risk groups.
Setting a minimum unit price at a level that will reduce alcohol consumption is a strong
public health measure, which will both reduce average alcohol consumption throughout
the population and be especially effective in heavy drinkers and young drinkers.
15.2 Accessibility and availability
Regulate access to, and availability of, alcohol by limiting the hours and days of sale, the
number and location of alcohol outlets and licensed premises, and the imposition of a
minimum legal drinking age. Governments should tax and control the production and
Handbook of WMA Policies
World Medical Association ⏐ D-2015-01-2017
consumption of alcohol, with licensing that emphasises public health and safety and
empowers licensing authorities to control the total availability of alcohol in their
jurisdictions. Governments should also control importation and sale of illegal alcohol
across borders.
Public authorities must strengthen the prohibition of selling to and by minors and must
systematically request proof of age before alcohol can be purchased in shops or bars.
16. Regulation of non-commercial alcohol
The production and consumption of non-commercial forms of alcohol, such as home
brewing, illicit distillation, and illegal diversion alcohol to avoid taxes, should be curtailed
using appropriate taxing and pricing mechanisms.
17. Regulation of alcohol marketing
Alcohol marketing should be restricted to prevent the early adoption of drinking by young
people and to minimise their alcohol consumption. Regulatory measures range from
wholesale bans and restrictions on measures that promote excessive consumption, to
restrictions on the placement and content of alcohol advertising and sponsorship that are
attractive to young people. There is evidence that industry self-regulation and voluntary
codes are ineffective at protecting vulnerable populations from exposure to alcohol
marketing and promotion.
Increase public awareness of harmful alcohol consumption through mandatory product
labelling that clearly states alcoholic content in units, advice on recommended drinking
levels and a health warning, supported by public awareness campaigns.
In conjunction with other measures, social marketing campaigns should be implemented
together with the media to educate the public about harmful alcohol use, to adopt driving
while intoxicated policies, and to target the behaviour of specific populations at high risks
of harm.
18. The role of health and medical services in prevention
Health, medical and social services professionals should be provided with the training,
resources and support necessary to prevent harmful use of alcohol and treat people with
alcohol dependence, including routinely providing brief interventions to motivate high-
risk drinkers to moderate their consumption. Health professionals also play a key role in
education, advocacy and research.
Specialised treatment and rehabilitation services should be available in due time and
affordable for alcohol dependent individuals and their families.
Together with national and local medical societies, specialty medical organizations,
concerned social, religious and economic groups (including governmental, scientific,
professional, nongovernmental and voluntary bodies, the private sector, and civil society)
physicians and other health and social professionals can work to:
D-2015-01-2017 ⏐ Chicago
Alcohol
18.1 Reduce harmful use of alcohol, especially among young people and pregnant
women, in the workplace, and when driving;
18.2 Increase the likelihood that everyone will be free of pressures to consume alcohol
and free from the harmful and unhealthy effects of drinking by others;
18.3 Promote evidence-based prevention strategies in schools and communities;
18.4 Assist in informing the public of alcohol related harm and demystifying the myth of
health enhancing properties of alcohol.
Physicians have an important role in facilitating epidemiologic and health service data
collection on the impact of alcohol with the aim of prevention and promotion of public
health. Data collection must respect the confidentiality of health data of individual
patients.
19. Driving while intoxicated measures
Key deterrents should be implemented for driving while intoxicated, which include a
strictly enforced legal maximum blood alcohol concentration for drivers of no more than
50mg/100ml, supported by social marketing campaigns and the power of authorities to
impose immediate sanctions.
These measures should also include active enforcement of traffic safety measures, random
breath testing, and legal and medical interventions for repeat intoxicated drivers.
20. Limit the role of the alcohol industry in alcohol policy development
The commercial priorities of the alcohol industry are in direct conflict with the public
health objective of reducing overall alcohol consumption. Internationally, the alcohol
industry is frequently included in alcohol policy development by national authorities, but
the industry is often active in opposing and weakening effective alcohol policies.
Ineffective and non-evidence-based alcohol control strategies promoted by the alcohol
industry and the social organisations that the industry sponsors should be countered. The
role of the alcohol industry in the reduction of alcohol-related harm should be confined to
their roles as producers, distributors and marketers of alcohol, and not include alcohol
policy development or health promotion.
21. Convention on Alcohol Control
Promote consideration of a Framework Convention on Alcohol Control similar to that of
the WHO Framework Convention on Tobacco Control.
22. Exclude alcohol from trade agreements
Furthermore, in order to protect current and future alcohol control measures, advocate for
alcohol to be classified as an extra-ordinary commodity and that measures affecting the
Handbook of WMA Policies
World Medical Association ⏐ D-2015-01-2017
supply, distribution, sale, advertising, sponsorship, promotion of or investment in
alcoholic beverages be excluded from international trade agreements.
23. Action against positive media messaging
It is important to act on the impact of media messages on beliefs, intentions, attitudes and
social norms. Well-designed media campaigns can have direct effects on behavior. The
media also influence the social conception of a problem, and indirectly influence political
decision-making on measures for intervention on alcohol.
Handbook of WMA Policies
World Medical Association ⏐ D-2017-01-2017
WMA DECLARATION
OF CHICAGO ON
QUALITY ASSURANCE IN MEDICAL EDUCATION
Adopted by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
he goals of medical education are to prepare practitioners to apply the latest scientific
knowledge to promote health, to prevent and cure human diseases, and to impart the
ethical standards governing the thought and behavior of physicians. All physicians have a
responsibility to themselves, the profession, and their patients to maintain high standards
for basic medical education.
Well-planned and well-executed quality assurance programs are essential to ensuring that
medical schools meet these goals and expectations. There are many threats to the quality
of basic medical education. The ability to deliver a high standard of education can be
affected by the availability of infrastructure, clinical resources, faculty, and finances. Also,
the growth of basic medical education globally, with a rapid increase in the number of
medical schools in some countries, raises concerns about the quality of graduates. A well-
developed quality assurance program allows schools to identify and address conditions
that threaten the quality of their basic medical education. Such programs need to be
implemented as far as possible at medical schools around the world.
BACKGROUND
Standards developed by and for a medical school are designed to reflect what the school
believes to be important quality measures. Institutional reviews using such internally-
developed standards can ensure that the school’s missions are being met and that students
are being prepared to achieve the desired outcomes. The presence of an institutional
quality assurance program that uses its own defined criteria and is supported by
knowledgeable personnel can be important to ensure educational program quality over
time.
However, a better outcome will more likely be achieved by also including a second
dimension of review that includes an external perspective. A national quality assurance
system includes the use of standards of quality that are developed and approved at the
national or regional level. Evaluating a medical school based on what a country or region
expects of its basic medical educational programs leads to a higher and more consistent
level of student preparation.
Handbook of WMA Policies
World Medical Association ⏐ D-2017-01-2017
Unless compliance with standards set by a national evaluation system is required of
medical schools, there is no guarantee that schools will undertake an internal evaluation or
correct problems that interfere with educational quality. The World Medical Association
(WMA) recognises the need for and importance of sound global standards for assuring the
quality of basic medical education programs.
An accreditation/recognition system is a quality assurance mechanism that is increasingly
common around the world. Accreditation/recognition systems are based on standards of
educational quality that are developed to meet national needs and that use valid, reliable,
and widely-accepted processes to assess the attainment of these standards by schools.
After evaluating compliance with standards, cooperation and coordination among various
stakeholder groups within and external to a medical school is needed to implement
solutions to the problems identified.
PRINCIPLES FOR ACCREDITATION SYSTEMS
An accreditation system reviews educational programs or institutions using a pre-
determined (typically national) set of process and outcome standards. The accreditation
systems that exist around the world differ in several ways. In some countries,
accreditation of medical schools has been occurring for decades; in other countries,
accreditation is relatively new. Participation in accreditation is either mandatory or
voluntary for medical schools and reviews take place over different intervals.
Accreditation is defined as the evaluation of educational programs or institutions based on
a clear and specific set of standards. Accreditation guidelines should be articulated as
standards that have been created with national needs in mind and with the input of relevant
stakeholder groups within the country.
Certain general principles should form the basis for an accreditation system to ensure that
the process is valid and decisions related to educational program quality are trustworthy.
These principles include transparency, absence of conflict of interest, and
reliability/consistency. Transparency means that the accreditation standards and processes
are known to and understood by schools, evaluators, and decision-makers. To reduce the
potential for conflict of interest, evaluators and decision-makers should have no ties to the
institution being evaluated or to other institutions that may affect their ability to make a
judgment free from positive or negative bias. Reliability and consistency require a
common understanding of what constitutes compliance with standards and that, as far as
possible, this understanding is applied consistently in reviews and decisions across
schools.
Accreditation standards are measurable, but need not be quantitative. Standards are
normally developed for both the process and the outcomes of a medical education
program. Specific information should be identified to evaluate compliance. For example,
the standards related to process could address the objectives for and structure of the
curriculum; the qualifications of entering students and teaching faculty; and the
availability of resources for program support, including adequate finances, sufficient
faculty, and an appropriate educational infrastructure for the scientific and clinical phases
of training. The outcomes of the medical education program are then evaluated to
D-2017-01-2017 ⏐ Chicago
Quality Assurance in Basic Medical Education
determine if graduates have been adequately prepared based on the school’s objectives.
In order to be most effective, standards used in accreditation need to be widely
disseminated and thoroughly explicated so that medical schools, evaluators, and decision-
makers share a common understanding of their meaning and the expectations for
compliance. For the sake of process effectiveness and transparency, the medical school
faculty, the evaluators who review the medical schools’ compliance with accreditation
standards, and the decision-makers who determine accreditation status will require
training.
Institutions will have achieved their objectives if they have continually complied with
accreditation standards and when internal monitoring becomes a formal responsibility for
one or more individuals within the medical school who have access to relevant quality-
linked information (e.g., the results of student satisfaction surveys and student
performance data). Ongoing review of some or all accreditation standards allows schools
to correct problem areas before they are identified as part of the formal accreditation
review and ensures that educational program quality remains high.
If an accreditation review identifies areas where improvement is needed, a medical school
should promptly correct the deficiencies. The accreditation/recognition body normally sets
a timeline for follow-up by the end of which the educational program should be able to
demonstrate the actions that have been taken and the outcomes that have been achieved.
This may require the medical school/university to provide financial resources and to
provide faculty time, effort, and adequate infrastructure, to make the needed corrections.
To assist schools in addressing identified deficiencies, support and consultation could be
provided by the staff of the accrediting body or other trained individuals. To avoid
conflict of interest, those who provide consultation should not take part in accreditation
reviews or in decisions about accreditation status.
RESPONSIBILITIES OF STAKEHOLDERS GROUPS WITHIN AND EXTERNAL TO MEDICAL
SCHOOLS
The creation of an accreditation system that meets the principles for validity and
trustworthiness requires actions by a variety of stakeholder groups, such as:
• Entities that sponsor accrediting bodies (e.g., governments, medical associations)
need to ensure that the accrediting body is appropriately funded and staffed for its
activities. Funding may come from the sponsors and/or from the accrediting
body’s ability to generate its own funding from accreditation review fees.
Accrediting bodies in certain countries may require additional funding and staffing
to address the increase in the number of medical schools.
• It is advisable for school leadership to encourage an environment that values
educational quality assurance activities. Faculty should be given time and
recognition for their participation in program evaluation and accreditation
activities, and medical students should be prepared and encouraged to provide
feedback on all relevant aspects of the medical education program.
Handbook of WMA Policies
World Medical Association ⏐ D-2017-01-2017
RECOMMENDATIONS
The WMA calls upon National Medical Associations (NMAs)to encourage medical
schools to develop quality assurance programs regarding ongoing review of educational
program quality.
The WMA urges NMAs to support and promote the ongoing development of national and
regional accreditation/recognition systems for medical schools. These systems should be
designed and led by physicians in collaboration with experienced medical educators and
with input from other relevant experts.
The WMA calls upon NMAs to urge national governmental and private-sector policy-
makers to ensure that the national accreditation system has adequate and appropriate
resources for its activities. This includes sufficient and consistent funding to support the
infrastructure and staffing of the accrediting body.
The WMA recommends that accreditation systems use nationally-relevant standards
applied consistently by trained evaluators and decision-makers when reviewing medical
schools.
The WMA encourages NMAs to advocate to policy-makers that participation in the
national accreditation system should be required for all medical schools within a country.
The WMA calls upon NMA’s to urge national accreditation systems to participate in
external reviews of their policies, practices, and standards. This may include seeking
recognition by the World Federation for Medical Education (WFME). Recognised
accrediting bodies and similar organisations are urged to establish a forum for discussion
and collaboration among national accrediting bodies to share best practices and
mechanisms to overcome challenges.
Physicians should be encouraged to lead and actively participate in national accreditation
activities as evaluators and decision-makers and in quality assurance activities at their own
medical schools.
Handbook of WMA Policies
World Medical Association ⏐ D-2017-02-2017
WMA DECLARATION
ON
FAIR TRADE IN MEDICAL PRODUCTS AND DEVICES
Adopted by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Every year trillions of dollars are spent on medical supplies globally. Little
consideration is given to the conditions in which they are made, nor to the impact on
the people who make them.
2. Abuses of labour standards, evidence of modern slavery, and unethical working
conditions have been uncovered in the manufacture of many medical products bound
for health systems around the world. Evidence shows that many supplies used in the
healthcare sector are produced in unhealthy, unsafe and unfair working conditions.
Widescale abuses have been reported in numerous manufacturing sites – from
uniforms, to latex gloves, to disposable surgical instruments – international labour core
conventions are persistently disregarded, and the use of child labour is widespread.
3. The global healthcare community should not condone unethical trade practices that are
detrimental to global health and encourage modern slavery. Healthcare organisations
and professionals around the world must insist that the goods they use are not
produced at the expense of the health of workers in the global community.
4. It is important to maintain trading with developing countries to ensure jobs and
livelihoods, and commitment to the UN sustainable development goals. These goals
provide an overarching opportunity for sustained action to be taken by health
professionals in protecting human health globally.
5. As enshrined in the UN Guiding Principles on Business and Human rights (June 2011)
– applicable to all States- businesses have a responsibility to minimise human rights
violations in their supply and procurement chains, irrespective of whether the business
contributed directly to the violation, and a duty to adequately address any abuses that
do occur.
6. Introduction of fair and ethical trade in health service purchasing should be used to
secure improvement in the health system supply chains. Modern approaches to
addressing labour rights abuses focus on models of ‘ethical procurement’.
7. Ethical procurement refers to the steps that purchasing organisations, such as hospitals,
take to improve the pay and conditions of people involved in the supply of goods and
services. It asks purchasers to systematically assess the risk of labour rights abuses in
the goods they procure, and to push for improvement where necessary. This includes
D-2017-02-2017 ⏐ Chicago
Fair Medical Trade
working with companies throughout the supply chain to help workers exercise
fundamental rights such as the right to safe and decent working conditions. This model
aims to make international trade work better for poor and otherwise disadvantaged
people.
RECOMMANDATIONS
8. Recognizing this, the World Medical Association and its national medical association
members on behalf of their physician members, support and commit to the following
actions:
• Call upon purchasing bodies, to develop a fair and ethical purchasing policy for
medical goods to promote good working conditions and eradicate modern
slavery throughout the supply chains of the products purchased within the
health sector.
• Promote multiple health product production sources throughout the world.
National medical associations
9. National medical associations should advocate for labour/ human rights to be protected
throughout the global supply chains of products used in their healthcare systems.
10. National medical associations should work with their members to promote fair and
ethical trade in the health sector.
11. National medical associations should support community action and initiatives with to
promote ethical working conditions across the health sector as a whole.
12. National medical associations should harness government support to formulate
national guidance and/or policy on fair and ethical trade in healthcare purchasing.
Physicians
13. Physicians should play a leadership role in integrating considerations of labour
standards into purchasing decisions within healthcare organisations.
14. Physicians should raise awareness of the issues, and promote the development of fair
and ethically produced medical goods, amongst colleagues and those working with
health systems.
Handbook of WMA Policies
World Medical Association ⏐ S-1956-01-2012
WMA REGULATIONS
IN
TIMES OF ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
Adopted by the 10th
World Medical Assembly, Havana, Cuba, October 1956
and edited by the 11th
World Medical Assembly, Istanbul, Turkey, October 1957
and revised by the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and editorially revised by the 173rd
WMA Council Session, Divonne-les-Bains, France,
May 2006
and revised by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
GENERAL GUIDELINES
Medical ethics in times of armed conflict is identical to medical ethics in times of peace,
as stated in the International Code of Medical Ethics of the WMA. If, in performing their
professional duty, physicians have conflicting loyalties, their primary obligation is to their
patients; in all their professional activities, physicians should adhere to international con-
ventions on human rights, international humanitarian law and WMA declarations on medi-
cal ethics.
The primary task of the medical profession is to preserve health and save life. Hence it is
deemed unethical for physicians to:
• Give advice or perform prophylactic, diagnostic or therapeutic procedures that are
not justifiable for the patient’s health care;
• Weaken the physical or mental strength of a human being without therapeutic
justification;
• Employ scientific knowledge to imperil health or destroy life;
• Employ personal health information to facilitate interrogation;
• Condone, facilitate or participate in the practice of torture or any form of cruel, in-
human or degrading treatment.
During times of armed conflict and other situations of violence, standard ethical norms
apply, not only in regard to treatment but also to all other interventions, such as research.
Research involving experimentation on human subjects is strictly forbidden on all persons
deprived of their liberty, especially civilian and military prisoners and the population of
occupied countries.
The medical duty to treat people with humanity and respect applies to all patients. The
physician must always give the necessary care impartially and without discrimination on
the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political af-
filiation, race, sexual orientation, or social standing or any other similar criterion.
S-1956-01-2012 ⏐ Bangkok
Armed Conflict
Governments, armed forces and others in positions of power should comply with the
Geneva Conventions to ensure that physicians and other health care professionals can
provide care to everyone in need in situations of armed conflict and other situations of
violence. This obligation includes a requirement to protect health care personnel and
facilities.
Whatever the context, medical confidentiality must be preserved by the physician. However,
in armed conflict or other situations of violence, and in peacetime, there may be cir-
cumstances in which a patient poses a significant risk to other people and physicians will
need to weigh their obligation to the patient against their obligation to other individuals
threatened.
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 other than for health
care purposes.
Physicians have a clear duty to care for the sick and injured. Physicians should recognise
the special vulnerability of some groups, including women and children. Provision of such
care should not be impeded or regarded as any kind of offence. Physicians must never be
prosecuted or punished for complying with any of their ethical obligations.
Physicians have a duty to press governments and other authorities for the provision of the
infrastructure that is a prerequisite to health, including potable water, adequate food and
shelter.
Where conflict appears to be imminent and inevitable, physicians should, as far as they are
able, ensure that authorities are planning for the protection of the public health infra-
structure and for any necessary repair in the immediate post-conflict period.
In emergencies, physicians are required to render immediate attention to the best of their
ability. Whether civilian or combatant, the sick and wounded must receive promptly the
care they need. No distinction shall be made between patients except those based upon
clinical need.
Physicians must be granted access to patients, medical facilities and equipment and the
protection needed to carry out their professional activities freely. Such access must include
patients in detention centres and prisons. Necessary assistance, including unimpeded
passage and complete professional independence, must be granted.
In fulfilling their duties and where they have the legal right, physicians and other health
care professionals shall be identified and protected by internationally recognized symbols
such as the Red Cross, Red Crescent or Red Crystal.
Hospitals and health care facilities situated in areas where there is either armed conflict or
other situations of violence must be respected by all combatants and media personnel.
Health care given to the sick and wounded, civilians or combatants, cannot be used for
publicity or propaganda. The privacy of the sick, wounded and dead must always be res-
Handbook of WMA Policies
World Medical Association ⏐ S-1956-01-2012
pected. This includes visits from important political figures for media purposes and also
when important political figures are among the wounded and the sick.
Physicians must be aware that, during armed conflict or other situations of violence, health
care becomes increasingly susceptible to unscrupulous practice and the distribution of
poor quality / counterfeit materials and medicines, and attempt to take action on such
practices.
The WMA supports the collection and dissemination of data related to assaults on phy-
sicians, other health care personnel and medical facilities, by an international body. Such
data are important to understand the nature of such attacks and to set up mechanisms to
prevent them. Assaults against medical personnel must be investigated and those res-
ponsible must be brought to justice.
CODE OF CONDUCT: DUTIES OF PHYSICIANS WORKING IN ARMED CONFLICT AND
OTHER SITUATIONS OF VIOLENCE
Physicians must in all circumstances:
• Neither commit nor assist violations of international law (international humanitarian
law or human rights law);
• Not abandon the wounded and sick;
• Not take part in any act of hostility;
• Remind authorities of their obligation to search for the wounded and sick and to
ensure access to health care without unfair discrimination;
• Advocate and provide effective and impartial care to the wounded and sick
(without reference to any ground of unfair discrimination, including whether they
are the «enemy»);
• Recognise that security of individuals, patients and institutions are a major
constraint to ethical behaviour and not take undue risk in the discharge of their
duties;
• Respect the individual wounded or sick person, his / her will, confidence and his /
her dignity;
• Not take advantage of the situation and the vulnerability of the wounded and sick
for personal financial gain;
• Not undertake any kind of experimentation on the wounded and sick without their
real and valid consent and never where they are deprived of liberty;
• Give special consideration to the greater vulnerability of women and children in
armed conflict and other situations of violence and to their specific health-care
needs;
• Respect the right of a family to know the fate and whereabouts of a missing family
member whether or not that person is dead or receiving health care;
• Provide health care for anyone taken prisoner;
• Advocate for regular visits to prisons and prisoners by physicians, if such a me-
chanism is not already in place;
• Denounce and act, where possible, to put an end to any unscrupulous practices or
distribution of poor quality/counterfeit materials and medicines;
S-1956-01-2012 ⏐ Bangkok
Armed Conflict
• Encourage authorities to recognise their obligations under international humani-
tarian law and other pertinent bodies of international law with respect to protection
of health care personnel and infrastructure in armed conflict and other situations of
violence;
• Be aware of the legal obligations to report to authorities the outbreak of any noti-
fiable disease or trauma;
• Do anything within their power to prevent reprisals against the wounded and sick
or health care;
• Recognise that there are other situations where health care might be compromised
but in which there are dilemmas.
Physicians should to the degree possible:
• Refuse to obey an illegal or unethical order;
• Give careful consideration to any dual loyalties that the physician may be bound
by and discuss these dual loyalties with colleagues and anyone in authority;
• As an exception to professional confidentiality, and in line with WMA Resolution
on the Responsibility of Physicians in the Documentation and Denunciation of
Acts of Torture or Cruel or Inhuman or Degrading Treatment and the Istanbul Pro-
tocol1
, denounce acts of torture or cruel, inhuman or degrading treatment of which
physicians are aware, where possible with the subject’s consent, but in certain
circumstances where the victim is unable to express him/herself freely, without
explicit consent;
• Listen to and respect the opinions of colleagues;
• Reflect on and try to improve the standards of care appropriate to the situation;
• Report unethical behaviour of a colleague to the appropriate superior;
• Keep adequate health care records;
• Support sustainability of civilian health care disrupted by the context;
• Report to a commander or to other appropriate authorities if health care needs are
not met;
• Give consideration to how health care personnel might shorten or mitigate the
effects of the violence in question, for example by reacting to violations of interna-
tional humanitarian law or human rights law.
1
Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment, OHCHR, 1999
Handbook of WMA Policies
World Medical Association ⏐ S-1970-01-2018
WMA STATEMENT
ON
MEDICALLY-INDICATED TERMINATION OF PREGNANCY
Adopted by the 24th
World Medical Assembly, Oslo, Norway, August 1970
and amended by the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. Medically-indicated termination of pregnancy refers only to interruption of pregnancy
due to health reasons, in accordance with principles of evidence-based medicine and
good clinical practice. This Declaration does not include or imply any views on
termination of pregnancy carried out for any reason other than medical indication.
2. Termination of pregnancy is a medical matter between the patient and the physician.
Attitudes toward termination of pregnancy are a matter of individual conviction and
conscience that should be respected.
3. A circumstance where the patient may be harmed by carrying the pregnancy to term
presents a conflict between the life of the foetus and the health of the pregnant woman.
Diverse responses to resolve this dilemma reflect the diverse cultural, legal, traditional,
and regional standards of medical care throughout the world.
RECOMMENDATIONS
1. Physicians should be aware of local termination of pregnancy laws, regulations and
reporting requirements. National laws, norms, standards, and clinical practice related
to termination of pregnancy should promote and protect women’s health, dignity and
their human rights, voluntary informed consent, and autonomy in decision-making,
confidentiality and privacy. National medical associations should advocate that
national health policy upholds these principles.
2. Where the law allows medically-indicated termination of pregnancy to be performed,
the procedure should be performed by a competent physician and only in extreme
cases by another qualified health care worker, in accordance with evidence-based
medicine principles and good medical practice in an approved facility that meets
required medical standards.
3. The convictions of both the physician and the patient should be respected.
4. Patients must be supported appropriately and provided with necessary medical and
psychological treatment along with appropriate counselling if desired.
S-1970-01-2018 ⏐ Reykjavik
Medically-Indicated Termination of Pregnancy
5. Physicians have a right to conscientious objection to performing an abortion;
therefore, they may withdraw while ensuring the continuity of medical care by a
qualified colleague. In all cases, physician must perform those procedures necessary to
save the woman’s life and to prevent serious injury to her health.
6. Physicians must work with relevant institutions and authorities to ensure that no
woman is harmed because medically-indicated termination of pregnancy services are
unavailable.
Handbook of WMA Policies
World Medical Association ⏐ S-1983-01-2017
WMA STATEMENT
ON
BOXING
Adopted by the 35th
World Medical Assembly, Venice, Italy, October 1983
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
1. Boxing is a dangerous sport. Unlike other sports, its basic intent is to produce
bodily harm by specifically targeting the head. The main medical argument against
boxing is the risk of chronic traumatic encephalopathy (CTE), also known as
chronic traumatic brain injury (CTBI), and dementia pugilistica or “punch-drunk”
syndrome. Other injuries caused by boxing can lead to loss of sight, loss of
hearing, and fractures. Studies show that boxing is associated with devastating
short-term injuries and chronic neurological damage on the participants in the long
term.
2. The past few decades have witnessed vigorous campaigns by national medical
bodies to have all forms of boxing abolished. In the absence of such a ban, a series
of boxing tragedies worldwide has pressured various sports regulatory bodies to
adopt a variety of rules and standards to enhance the safety of boxers.
3. Despite regulation of boxing in various countries, injuries and death still occur as a
result of boxing related head trauma, indicating that regulation does not provide
adequate protection to participants.
4. In addition to regulated boxing, unchecked and unsupervised boxing competitions
(bareknuckle battles or “street fights”) still take place in many parts of the world.
This underground boxing puts at risk the lives and health of a significant number
of persons who participate in these fights.
5. Health and safety concerns in boxing extend to other professional sports where
boxing is a component, such as mixed martial arts (MMA), kickboxing etc. For
this reason, the recommendations in this statement should be applied to these
sports as well.
6. The WMA believes that boxing is qualitatively different from other sports because
of the injuries it causes and that it should be banned.
7. Until a full ban is achieved the WMA urges that the following measures be
implemented:
S-1983-01-2017 ⏐ Chicago
Boxing
7.1 Boxing must be regulated and all boxers licensed. Boxers should be provided
with written information on the risks of participating in boxing.
7.2 No children (as per country-specific definition) should be permitted to
participate in boxing.
7.3 A national registry of all amateur and professional boxers, including sparring
partners, should be established in each country where boxing is allowed. The
registry should record the results of all matches, including technical
knockouts, knockouts, and other boxing injuries, and compile injury records
for individual boxers. All boxers should be followed up for a period of at least
twenty years to document long-term outcomes.
7.4 All boxers should undergo a baseline medical examination, which should
include neurological assessment, including brain imaging, at the beginning of
their careers. Medical and neurological assessments should also be performed
before and after each event. Boxers who do not pass the examination must be
reported to the national registry and must not be allowed to participate in
future matches.
7.5 Personal protective equipment recommendations (such as size and weight of
gloves, head gear and gum shields) should take into consideration medical
recommendations.
7.6 A physician serving at a boxing match has a professional responsibility to
protect the health and safety of the contestants. To that end, the physician
should receive specialized training in athlete evaluation, especially traumatic
brain injury assessment. The physician’s judgment should be governed only by
medical considerations, and the physician must be allowed to stop any match
in progress to examine a contestant and to terminate a match that, in the
physician´s opinion, could result in serious injury.
7.7 Funding and sponsorship of boxing should be discouraged, and TV coverage of
boxing events should be age restricted and include a warning statement on the
risks of boxing.
Handbook of WMA Policies
World Medical Association ⏐ S-1984-01-2017
WMA STATEMENT
ON
CHILD ABUSE AND NEGLECT
Adopted by the 36th
World Medical Assembly, Singapore, October 1984
and amended by the 41st
World Medical Assembly, Hong Kong, September 1989
42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
44th
World Medical Assembly, Marbella, Spain, September 1992
47th
WMA General Assembly, Bali, Indonesia, September 1995
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and 67th
WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. The welfare of children[1] is of paramount importance. Health professionals should
put the welfare of children at the centre of all decision-making related to the child and
act in the best interests of children in all of their interactions with children, young
people, families, policy-makers and other professionals.
INTRODUCTION
2. One of the most destructive manifestations of family violence and upheaval is child
abuse[2] in all its forms. Prevention, protection, early identification, suitable
interventions and comprehensive treatment of child abuse victims remain challenging
for the world medical community. The World Medical Association (WMA) has called
for increased health support of children living on the streets in its Statement on
Supporting Health Support to Street Children, but it is also important to address the
root causes of child abuse in all its forms.[3]
3. Definitions of child abuse vary from culture to culture. Unfortunately, cultural
rationalizations for harmful behaviour toward children may be accepted all too readily
as proof that the treatment of children is neither abusive nor harmful. For instance, the
work contribution of children in the everyday lives of families and in society should be
recognized and encouraged only as long as it also contributes to the child’s own
development. In contrast, exploitation of children in the labour market deprives them
of their childhood and of educational opportunities and endangers their present and
future health. The WMA considers such exploitation of children a serious form of
child abuse in all its forms.
4. For the purposes of this Statement, the various forms of child abuse include emotional
abuse, physical abuse, sexual abuse, child trafficking, child exploitation and child
neglect. Child neglect represents a failure of a parent, or other person legally
responsible for a child’s welfare, to provide for the child’s basic needs and an adequate
level of care.
S-1984-01-2017 ⏐ Chicago
Child Abuse and Neglect
RECOMMENDATIONS
The WMA recognizes that child abuse in all its forms is a world health problem and
recommends that National Medical Associations adopt the following guidelines for
physicians:
5. Physicians have both a unique and special role in identifying and helping abused
children and their families.
6. All physicians should be educated about the paramount importance of the welfare of
children.
7. Physicians must be aware of and observe local laws regarding consent to undertake
examinations of children. Physicians must act in the best interests of children in all of
their interactions with children, young people, families, policy-makers and other
professionals.
8. Collaboration with an experienced multidisciplinary team is strongly recommended for
the physician. Such a team is likely to include physicians, social workers, child and
adult psychiatrists, developmental specialists, psychologists and attorneys. When
participation in a team is not possible or such a team is not available, the physician
must consult with other medical, social, law enforcement and mental health personnel
as appropriate.
9. Primary care physicians, family practitioners, internists, paediatricians, emergency
medicine specialists, surgeons, psychiatrists and other specialists who treat children
must acquire knowledge and skills in the physical, psychological and emotional
assessment of child abuse in all its forms, the assessment of child development and
parenting skills, the utilization of community resources, and the physician’s legal
responsibilities.
10. All physicians who treat children, and those adults with caring responsibilities for
children, should be aware of the principles of the UN Convention on the Rights of the
Child as well as relevant national protective legal provisions applying to children and
young people.
11. The medical evaluation of children who are suspected of having been abused should
be performed by physicians skilled in both paediatrics and abuse evaluation. The
medical evaluation needs to be tailored to the child’s age, injuries, and condition and
may include blood testing, a trauma radiographic survey, and developmental and
behavioural screenings. Follow up radiographs are strongly urged in some children
who present with serious, apparently abusive injuries.
12. The medical assessment and management of sexually abused children includes a
complete history and physical examination, as physical and sexual abuses often occur
together; examination of the genitalia and anus; the collection and processing of
evidence, including photographs; and the treatment and/or prevention of pregnancy
and venereal disease. Specific attention should be paid to the child’s right to privacy.
13. It is essential for the physician to understand and be sensitive to the following: the
quality of relationships between care-givers; disciplinary actions or styles used within
the child’s home; economic stresses on the family; emotional stresses or issued
Handbook of WMA Policies
World Medical Association ⏐ S-1984-01-2017
experienced by members of the family; mental health problems exhibited by any
members of the family; violence between the care-givers or other members of the
family; substance use and abuse, including alcohol and legal and illegal drugs; and any
other forms of stress that could relate to child abuse in all its forms.
14. All physicians need to be aware that all forms of abuse of children by other children
can occur. Recognition that this may be a result of prior or current abuse of the
alleged abuser must be at the forefront of the physician’s mind when such situations
are suspected or encountered.
15. The signs of abuse are often subtle, and the diagnosis may require comprehensive,
careful interviews with the child, parent(s), care-givers, and siblings. Inconsistencies
among explanation(s) and characteristics of the injury(s), such as the severity, type and
age, should be documented and further investigated.
16. In any child presenting to a medical facility, the emergent medical and mental health
needs should be addressed first. If abuse is suspected, safety needs must be addressed
prior to discharge from the facility. These measures should include:
• Reporting all suspected cases to child protective services;
• Hospitalizing any abused child needing protection during the initial evaluation
period;
• Informing the parents of the suspicion of abuse or diagnosis of abuse if it is
safe to do so; and
• Reporting the child’s injuries to child protective services or other relevant
authorities.
17. If hospitalization is required, a prompt evaluation of the child’s physical, emotional
and developmental problems is necessary. This comprehensive assessment should be
conducted by physicians with expertise or through a multidisciplinary team of experts
with specialized training in child abuse.
18. If child abuse is suspected, the physician should discuss with the parent(s) the fact that
child abuse is in the differential diagnosis of their child’s problem. Advice may be
required from child protective services.
19. During discussions with the parent(s), guardians, or care-givers it is essential that the
physician maintain objectivity and avoid accusatory or judgmental statements in
interactions with the parent(s) or individual(s) responsible for the child’s care.
20. It is essential that the physician record the history and examination findings in the
medical chart contemporaneously during the evaluation process. Injuries should be
documented using photographs, illustrations, and detailed descriptions. The medical
record often provides critical evidence in court proceedings.
21. Physicians should participate at all levels of prevention by providing prenatal and
postnatal family counselling, identifying problems in child rearing and parenting, and
advising about family planning and birth control.
22. Public health measures such as home visits by nurses and other health professionals,
anticipatory guidance by parents, and well-infant and well-child examinations should
be encouraged by physicians. Programs that improve the child’s general health also
tend to prevent child abuse in all its forms and should be supported by physicians and
S-1984-01-2017 ⏐ Chicago
Child Abuse and Neglect
their representative bodies.
23. Physicians should recognize that child abuse and neglect is a complex problem and
more than one type of treatment or service may be needed to help abused children and
their families. The development of appropriate treatment requires contributions from
many professions, including medicine, law, nursing, education, psychology and social
work.
24. Physicians should promote the development of innovative programs that will advance
medical knowledge and competence in the field of child abuse and neglect. Inclusion
of on-going reviews of knowledge, skills and competency in relation to protecting the
rights of children and young people, promoting their health and well-being and the
recognition of and response to suspected cases of child abuse and neglect is crucial in
professional educational programs. Physicians should obtain education on child
neglect and abuse in all its forms during training as medical students.
25. In the interests of the child, patient confidentiality may be waived in cases of child
abuse. The first duty of a doctor is to protect his or her patient if victimization is
suspected. No matter what the type of abuse (including physical abuse, emotional
abuse, sexual abuse, trafficking, exploitation or neglect), an official report must be
made to the appropriate authorities.
26. Inclusion of on-going reviews of knowledge, skills and competency in relation to
protecting the rights of children and young people, promoting their health and well-
being and the recognition of and response to suspected cases of child abuse in all its
forms and neglect is crucial in professional educational programmes.
27. The undergraduate medical curriculum must include a mandatory course on child
abuse, in all its forms, within the paediatrics program, that can be developed within
postgraduate and continuing medical education for those intending to work within this
field.
[1] The United Nations Convention on the Rights of the Child defines a child as anyone who
has not reached their 18th birthday.
[2] Child abuse and Child maltreatment are used synonymously in this Statement.
[3] Neglect is the persistent failure to meet a child’s basic needs, likely to result in the serious
impairment of a child’s health, well-being or development.
Handbook of WMA Policies
S-1984-02-1984 ⏐ World Medical Association
WMA STATEMENT
ON
FREEDOM TO ATTEND MEDICAL MEETINGS
Adopted by the 36th
World Medical Assembly, Singapore, October 1984
Professional independence and professional freedom are indispensable to physicians to
enable them to give appropriate health care to their patients. Therefore, there should be no
barriers, whether philosophical, religious, racial, political, geographic, physical or of any
other nature to prevent physicians from participating in professional activities that will
enable them to acquire the information, knowledge, skills and techniques required to pro-
vide appropriate health care to their patients.
In as much as the purpose of 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 of the world, there should accordingly be no
barriers which will prevent physicians from attending meetings of the WMA, or other
medical meetings, wherever such meetings are convened.
Handbook of WMA Policies
World Medical Association ⏐ S-1985-01-2015
WMA STATEMENT
ON
NON-DISCRIMINATION IN PROFESSIONAL MEMBERSHIP
AND ACTIVITIES OF PHYSICIANS
Adopted by the 37th
World Medical Assembly, Brussels, Belgium, October 1985
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 66th
WMA General Assembly, Moscow, Russia, October 2015
The World Medical Association is in favour of equality of opportunity in medical associa-
tion activities, medical education and training, employment, and all other medical profess-
sional endeavours regardless of any factors of discrimination.
The World Medical Association is unalterably opposed to the denial of membership pri-
vileges and responsibilities in National Medical Associations to any duly registered physi-
cian because of any factors of discrimination.
The World Medical Association calls upon the medical profession and all individual
members of National Medical Associations to exert every effort to prevent any instance in
which such equal rights, privileges or responsibilities are denied.
Handbook of WMA Policies
S-1988-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
ACCESS TO HEALTH CARE
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Health is not simply the absence of illness, but is also more than a state of physical,
psychological and social flourishing, and includes an individual’s ability to adapt to
physical, social and mental adversity. It is affected by many factors, including
access to health care and especially the Social Determinants of Health (SDH), and
its restoration is similarly multidimensional. Society has an obligation to make
access to an adequate level of care available to all its members, regardless of ability
to pay.
2. Health care professionals regularly confront the effects of lack of access to adequate
care and health inequality and have a corresponding responsibility to contribute their
expertise to work with governments at local, regional and national levels to ensure
they understand the Social Determinants of Health and integrate reduction of factors
leading to inequality into all policies. Health care policies should suggest ways to
eliminate health inequality.
3. Access to health care is an important factor in reducing the short, medium and long
term consequences of poor health, caused by adverse social and other conditions.
Access is itself multidimensional, and is constrained by factors including health
human resources, training, finance, transportation, geographical availability,
freedom of choice, public education, quality assurance and technology.
GUIDELINES
Health Human Resources
4. The delivery of health care is highly dependent upon the availability of trained
health care workers. The training should not only include socio-medical
competencies, but particularly emphasize an understanding of how the social
determinants of health affect people’s health outcomes.
The distribution of health care workers varies widely as do the demographics in
most countries, where an ageing population forms a huge challenge for the years to
come. There is global mal-distribution. While all countries train health care workers,
global movement, especially from less to better developed countries, is leading to
continuing shortages. The development of ethical recruitment codes may help to
reduce inappropriate recruitment activities by states. Ethical recruitment codes
should also be applied to commercial recruitment agencies.
S-1988-01-2017 ⏐ Chicago
Access to Health Care
5. Research is needed to determine the best mix of different health care workers for
different clinical settings to meet the needs of populations. Mal-distribution within
countries should be addressed by seeking methods of attracting health care workers
to rural and remote areas, or other underserved regions, at least for a part of their
careers. Innovative concepts should be explored to make working in underserved
areas interesting; punitive and coercive recruiting methods must not be used.
Recruiting students who express a wish to return to their home area may help to
alleviate this problem.
Training
6. Primary training of health care workers has to be appropriate, accessible and of good
quality, which makes the training costly, with the country of origin meeting this
cost. Workers move to continue with secondary training, including higher
professional training and specialisation for physicians, and also to earn more money
that may be remitted home to support the family and community.
7. The ambition for self-improvement is understandable; efforts to increase retention of
health care workers should include consideration of encouraging a return to the
home country, with use of the new skills and knowledge to improve health care
access.
8. Countries should not actively recruit from other states. Even when they do so
passively, this recruitment should take place in accordance with ethical standards
and the WMA Statement on Ethical Guidelines for the International Migration of
Health Care workers.
Finance
9. Access to care is essential for the whole population. Methods of financing care are
for each country to decide, according to their own resources, health and social
priorities, and health needs. Countries should develop revenue systems that reduce
reliance on out-of-pocket payments and private health insurance as these increase
inequalities between population groups.
10. No single system of finance is ideal for every country; the exact balance needs to be
locally decided. In making decision about financing systems governments must
understand the essential nature of health care, the absolute requirement that it be
available to all, based upon clinical need and not on the ability to pay, and that
access can be constrained by financial fears. Eligibility for care does not ensure
access, especially if co-payment schemes exclude those with the fewest financial
resources.
11. Innovative means should be used to provide comprehensive health care, including
partnerships with private providers and commercial entities, who may be able to
provide elements of specialised care. In doing so states must ensure that this does
not limit specialised care to the wealthiest proportion of their population nor should
this be seen as a preference for a private health care model.
12. Decisions to limit access to elements of health care should be done on the basis of
objective information, based on the best available scientific data about the efficacy
Chicago⏐ S-1988-01-2017
Access to Health Care
and safety of health care services. It must include public debate about, and
acceptance of, the concepts involved. Nothing should be introduced which
discriminates against the elderly or vulnerable populations.
13. The public should have access to clear information on the health care resources
available to them and how they may be accessed. Specific processes should be
established to ensure that poverty or illiteracy will never be a barrier to access care.
Vulnerable and hard to reach people
14. There are groups of people in every country who are hard to reach with health care
messages, and who often seek health care late in the progress of disease.
15. A variety of methods should be used to ensure hard to reach people are aware of the
availability of health care, without direct cost, including methods to reduce fear and
other barriers to access.
16. Where specific vulnerabilities such as learning disabilities or sensory impairments
exist, solutions should include identifying and dealing with those vulnerabilities.
17. Health care workers have a duty to provide care that is free from any form of unfair
discrimination.
Transportation
18. Health care facilities should be situated in locations that are easy to access. This may
mean working with local transportation providers to ensure formal and informal
public transport routes pass the facilities. Consideration should be made to making
health care facilities more accessible by active transport methods. Especially in rural
and remote locations, patients may travel considerable distances to attend the
facilities.
19. Patients who need referral to secondary and specialized care should be provided
with access to transportation. Those needing help with accessing primary care
should also receive support. Transportation should also be offered to isolated rural
patients who require a level of care that can be found only in metropolitan medical
centres. Telemedicine can sometimes be an acceptable substitute for transportation
of patients.
Geographical availability
20. Working with other health providers, including traditional birth attendants, may
provide assistance. They should be integrated into the health care system, offered
training, and be assisted to offer care that is safe and effective and that includes
referral where necessary. This does not extend to the state health care system
providing or funding care which is not evidence based, including so-called
complementary therapies.
Freedom of choice
21. The freedom to choose care providers, and the options of care they offer is an
essential element of care in every system. It requires the ability to understand that
S-1988-01-2017 ⏐ Chicago
Access to Health Care
choice, and the freedom to choose a provider from among alternatives.
22. Barriers to freedom of choice may lie in access to financial resources, understanding
of the options, and in cultural geographic, or other factors. Access to information
about the available options is crucial in making an appropriately informed choice.
23. The health authorities should ensure that all populations understand how to access
care, and should seek to ensure that populations have access to objective information
about the availability of different health care suppliers.
24. Once individuals access care through a particular provider or physician they should
be given opportunities to consider the clinical options open to them; access to
systematically available information resources is an essential element supporting
choice.
Public education
25. General education is a determinant of health; the better educated a person is,
generally the better their health likelihood. When ill-health presents, prior education
may be a determinant of the speed at which the person accesses health care.
Education also aids individuals to make appropriate choices about the care options
they access.
26. Specific education about health matters can be an important adjunct to lifestyle
planning. While education alone does not, for example, stop people from smoking,
using drugs or alcohol, it can aid in decision making about risk behaviour.
27. A general level of health literacy assists patients to make choices among different
options for treatment, and to comply or co-operate with the requirements of that
treatment. It will also improve self-care and the appropriateness of self-referral.
28. Educational programs that assist people in making informed choices about their
personal health and about the appropriate uses of both self-care and professional
care should be established. These programs should include information about the
costs and benefits associated with alternative courses of treatment within the context
of modern medicine; the use of professional services that permit early detection and
treatment or prevention of illnesses; personal responsibilities in preventing illnesses;
and the effective use of the health care system. Physicians should actively
participate, wherever appropriate, in such educational efforts and must be provided
with adequate resources to enable them to undertake such education.
29. Public education also assists governments by increasing understanding of public
health measures, including taxation of tobacco, banning of human consumption of
some products, and restrictions on individual freedoms because of health concerns.
When legislative or other regulatory mechanisms are to be imposed by governments,
a campaign of public education and explanation must be undertaken to gain public
understanding and voluntary compliance.
Quality assurance
30. Quality assurance mechanisms should be part of every system of health care
Chicago⏐ S-1988-01-2017
Access to Health Care
delivery. Physicians share responsibility for assuring the quality of health care and
must not allow other considerations to jeopardize the quality of care provided.
Technology
31. Technology is playing an increasing role in the provision of health care services.
Capital purchase prices are high because of the need for specific logistical services,
including skilled technicians and adequate facilities. Advanced technologies are not
available in all locales; access to their benefits must be well planned to ensure they
benefit all patients in need, not simply those local to advanced technology centres.
Extraordinary circumstances
32. In extraordinary circumstances, including armed conflicts and major natural events
such as earthquakes, physicians have a specific duty to ensure that policy makers
protect access to care, especially for those most vulnerable and least able to move to
more secure areas.
RECOMMENDATIONS
33. Social Determinants of Health greatly affect access to health care as well as directly
impacting on health. Physicians should work with governments to ensure they are
able to take effective action on SDH.
34. Access to health care requires systematic consideration to ensure appropriate
conditions are met. These include:
34.1 Having an appropriate, universal, solidaristic and equitable health system,
adequately resourced facilities, being available throughout a country, providing
health centers and their professional staff with sufficient and sustainable
financing, with individuals being treated on the basis of need and not on the
ability to pay.
34.2 Patient choice should include which facility to access.
34.3 Access to adequate information for all is essential for making choices and for co-
operating with health care providers.
34.4 Education is both a social determinant and a key factor in co-operation with
health care provision, fostering responsible self-care with accessible support.
34.5 Health care professionals should be free to move around the world, especially to
access educational and professional opportunities. This mobility must not
damage resource availability, especially in resource poor countries.
34.6 Physicians must be provided with transparent and efficient ethical criteria for
working in overcrowded or underserved areas.
34.7 Provision of health care requires action by government at all levels, working
with populations to ensure that people understand the benefit of this care and are
able to access it.
S-1988-01-2017 ⏐ Chicago
Access to Health Care
34.8 Physicians have an important role in ensuring that health care planning makes
clinical sense, is communicated well to the population being served, and that
patients are not endangered by inadequate resources, poor planning or other
system flaws.
34.9 Physicians are aware of the health system and this forces them to play a socially
conscious role regarding the social determinants of health and access to health
care by themselves or through their representative medical associations.
34.10 Medical associations should work with their members to promote access to
health care systems that equitably support the needs of populations.
Handbook of WMA Policies
World Medical Association ⏐ S-1988-04-2016
WMA STATEMENT
ON
THE ROLE OF PHYSICIANS IN ENVIRONMENTAL ISSUES
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
INTRODUCTION
1. The effective practice of medicine increasingly requires that physicians and their pro-
fessional associations turn their attention to environmental issues that have a bearing
on the health of individuals and populations.
2. More than ever, due to diminishing natural resources, these problems relate to the
quality and protection of resources necessary to maintain health and indeed sustain
life itself. In concrete terms, the key environmental issues are as follow:
a. The degradation of the environment, which must be halted as a matter of urgency
so that resources essential to life and health – water and pure air – remain accessi-
ble to all.
b. The ongoing contamination of our reserves of fresh water with hydrocarbons and
heavy metals, along with the contamination of ambient and indoor health by
toxic agents, which have serious medical consequences, especially in the poorest
segments of the globe. Moreover, the greenhouse effect with its concomitant pro-
ven rise in temperature should drive our discussions forward and prepare us for
increasingly serious environmental and public health consequences.
c. The need to control the use of non-renewable resources such as topsoil, which
should constantly be at the forefront of our minds, as should the importance of
safeguarding this vital heritage so that it can be passed on to future generations.
d. The need to mobilise resources beyond national frontiers and to co-ordinate
global solutions for the planet as a whole, so as to formulate a unified strategy to
confront these worldwide medical and economic problems.
e. The foremost objective is to increase awareness of the vital balance between
environmental resources on the one hand, and on the other, biological essentials
for the health of everyone everywhere.
3. Our growing awareness of these issues today has, however, failed to prevent an in-
S-1988-04-2016 ⏐ Buenos Aires
Environmental Issues
crease in our societies’ negative impact on the environment, e.g., melting of glaciers
and increasing desertification, nor has it halted the over-exploitation of natural re-
sources, e.g. pollution of rivers and seas, air pollution, deforestation and diminishing
arable land. In this context, the migration of people from disadvantaged or developing
countries, together with the emergence of new diseases, exacerbates the lack of socio-
economic policies in many parts of the world. From a medical point of view, growth
of the population and irresponsible destruction of the environment are unacceptable,
and medical organisations throughout the world should redouble their efforts, not only
to speak out about these problems, but also to suggest solutions.
PRINCIPLES
1. In their role as representatives of physicians, medical associations are duty bound to
grapple with these environmental issues. They have a duty to produce analytical stu-
dies that include the identification of problems and current international regulations
on environmental issues, as well as their impact on the field of health.
2. As physicians operate within the framework of ethics and medical deontology, the
environmental regulations advocated should not seek to limit individual autonomy,
but rather to enrich the quality of life for all and to perpetuate life-forms on the planet.
3. The WMA should therefore act as an international platform for research, education,
and advocacy to help further sustain the environment and its potential to promote
health.
4. Thus, when new environmental diseases or syndromes are identified, the WMA
should help coordinate the scientific/medical discussions on the available data and
their implications for human health. It should foster the development of consensus
thinking within medicine, and help to stimulate preventive measures, accurate diagno-
sis and treatment of these emerging disorders.
5. The WMA should therefore provide a framework for the international co-ordination
of medical associations, NGOs, research clinicians, international health organisations,
decision-makers and funding providers, in their examination of the human health ef-
fects of environmental problems, their prevention, remediation and treatment for indi-
viduals and communities.
Handbook of WMA Policies
World Medical Association ⏐ S-1988-05-2011
WMA STATEMENT
ON
HEALTH HAZARDS OF TOBACCO PRODUCTS AND
TOBACCO-DERIVED PRODUCTS
Adopted by the 40th
WMA General Assembly, Vienna, Austria, September 1988
and amended by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
PREAMBLE
More than one in three adults worldwide (more than 1.1 billion people) smokes, 80 per-
cent of whom live in low- and middle-income countries. Smoking and other forms of
tobacco use 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 con-
ditions. Five million deaths occur worldwide each year due to tobacco use. If current
smoking patterns continue, it will cause some 10 million deaths each year by 2020 and 70
percent of these will occur in developing countries. Tobacco use was responsible for 100
million deaths in the 20th century and will kill one billion people in the 21st century unless
effective interventions are implemented. Furthermore, secondhand smoke – which contains
more than 4000 chemicals, including more than 50 carcinogens and many other toxins –
causes lung cancer, heart disease, and other illnesses in nonsmokers.
The global public health community, through the World Health Organization (WHO), has
expressed increasing concern about the alarming trends in tobacco use and tobacco-
attributable disease. As of 20 September 2007, 150 countries had ratified the Framework
Convention on Tobacco Control (FCTC), whose provisions call for ratifying countries to
take strong action against tobacco use by increasing tobacco taxation, banning tobacco
advertising and promotion, prohibiting smoking in public places and worksites, imple-
menting effective health warnings on tobacco packaging, improving access to tobacco
cessation treatment services and medications, regulating the contents and emissions of
tobacco products, and eliminating illegal trade in tobacco products.
Exposure to secondhand smoke occurs anywhere smoking is permitted: homes, work-
places, and other public places. According to the WHO, some 200,000 workers die each
year due to exposure to smoke at work, while about 700 million children, around half the
world’s total, breathe air polluted by tobacco smoke, particularly in the home. Based on the
evidence of three recent comprehensive reports (the International Agency for Research on
Cancer’s Monograph 83, Tobacco Smoke and Involuntary Smoking; the United States
Surgeon General’s Report on The Health Consequences of Involuntary Exposure to
Tobacco Smoke; and the California Environmental Protection Agency’s Proposed Identifi-
S-1988-05-2011 ⏐ Montevideo
Tobacco Products Health Hazards
cation of Environmental Tobacco Smoke as a Toxic Air Contaminant), on May 29, 2007,
the WHO called for a global ban on smoking at work and in enclosed public places.
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. For many years the industry claimed that there was no conclusive proof that
smoking tobacco causes diseases such as cancer and heart disease. It has also claimed that
nicotine is not addictive. These claims have been repeatedly refuted by the global medical
profession, which because of this is also resolutely opposed to the massive advertising
campaigns mounted by the industry and believes strongly that the medical associations
themselves must provide a firm leadership role in the campaign against tobacco.
The tobacco industry and its subsidiaries have for many years supported research and the
preparation of reports on various aspects of tobacco and health. By being involved in such
activities, individual researchers and/or their organizations give the tobacco industry an
appearance of credibility even in cases where the industry is not able to use the results
directly in its marketing. Such involvement also raises major conflicts of interest with the
goals of health promotion.
RECOMMENDATIONS
The WMA urges the national medical associations and all physicians to take the following
actions to help reduce the health hazards related to tobacco use:
1. Adopt a policy position opposing smoking and the use of tobacco products, and
publicize the policy so adopted.
2. Prohibit smoking, including use of smokeless tobacco, at all business, social,
scientific, and ceremonial meetings of the National Medical Association, in line
with the decision of the World Medical Association to impose a similar ban at all
its own such meetings.
3. 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. Programs aimed at convincing and helping smokers and
smokeless tobacco users to cease the use of tobacco products and programs for
non-smokers and non-users of smokeless tobacco products aimed at avoidance are
both important.
4. Encourage individual physicians to be role models (by not using tobacco products)
and spokespersons for the campaign to educate the public about the deleterious
health effects of tobacco use and the benefits of tobacco-use cessation. Ask all
medical schools, biomedical research institutions, hospitals, and other health care
facilities to prohibit smoking, use of smokeless tobacco on their premises.
Handbook of WMA Policies
World Medical Association ⏐ S-1988-05-2011
5. Introduce or strengthen educational programs for medical students and physicians
to prepare them to identify and treat tobacco dependence in their patients.
6. Support widespread access to evidence-based treatment for tobacco dependence –
including counseling and pharmacotherapy – through individual patient encounters,
cessation classes, telephone quit-lines, web-based cessation services, and other ap-
propriate means.
7. Develop or endorse a clinical practice guideline on the treatment of tobacco use
and dependence.
8. Join the WMA in urging the World Health Organization to add tobacco cessation
medications with established efficacy to the WHO’s Model List of Essential Medi-
cines.
9. Refrain from accepting any funding or educational materials from the tobacco
industry, and to urge medical schools, research institutions, and individual re-
searchers to do the same, in order to avoid giving any credibility to that industry.
10. Urge national governments to ratify and fully implement the Framework Conven-
tion on Tobacco Control in order to protect public health.
11. Speak out against the shift in focus of tobacco marketing from developed to less
developed nations and urge national governments to do the same.
12. Advocate the enactment and enforcement of laws that:
• provide for comprehensive regulation of the manufacture, sale, distribution,
and promotion of tobacco and tobacco-derived products, including the specific
pro-visions listed below.
• require written and pictorial warnings about health hazards to be printed on all
packages in which tobacco products are sold and in all advertising and pro-
motional materials for tobacco products. Such warnings should be prominent
and should refer those interested in quitting to available telephone quit-lines,
websites, or other sources of assistance.
• prohibit smoking in all enclosed public places (including health care facilities,
schools, and education facilities), workplaces (including restaurants, bars and
nightclubs) and public transport. Mental health and chemical dependence treat-
ment centers should also be smoke-free. Smoking in prisons should not be per-
mitted.
• ban all advertising and promotion of tobacco and tobacco-derived products.
• encourage the development of plain packaging legislation
• 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.
• prohibit smoking on all commercial airline flights within national borders and
on all international commercial airline flights, and prohibit the sale of tax-free
tobacco products at airports and all other locations.
S-1988-05-2011 ⏐ Montevideo
Tobacco Products Health Hazards
prohibit all government subsidies for tobacco and tobacco-derived products.
provide for research into the prevalence of tobacco use and the effects of tobac-co
products on the health status of the population.
prohibit the promotion, distribution, and sale of any new forms of tobacco pro-
ducts that are not currently available.
increase taxation of tobacco products, using the increased revenues for preven-tion
programs, evidence-based cessation programs and services, and other health care
measures.
curtail or eliminate illegal trade in tobacco products and the sale of smuggled
tobacco products.
help tobacco farmers switch to alternative crops.
urge governments to exclude tobacco products from international trade agree-
ments.
13. Recognize that tobacco use may lead to pediatric disease because of the harm done
to children caused by tobacco use and second-hand smoke exposure, the relation-
ship of tobacco use by children and exposure to adult tobacco use, and the existence
of effective interventions to reduce tobacco use. Special efforts should be made by
physicians to:
• provide tobacco-free environments for children
• target parents who smoke for tobacco cessation interventions
• promote programs that contribute to the prevention and decrease of tobacco use
by youth
• control access to and marketing of tobacco products, and
• make pediatric tobacco-control research a high priority
14. Refuse to invest in companies or firms producing or promoting the use or sale of
tobacco.
Handbook of WMA Policies
World Medical Association ⏐ S-1989-01-2016
WMA STATEMENT
ON
ANIMAL USE IN BIOMEDICAL RESEARCH
Adopted by the 41st
World Medical Assembly, Hong Kong, September 1989
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
PREAMBLE
1. Biomedical research is essential to the health and well-being of our society. Advances
in biomedical research have dramatically improved the quality and prolonged the
duration of life throughout the world. However, the ability of the scientific commu-
nity to continue its efforts to improve personal and public health is being threatened
by a movement to eliminate the use of animals in biomedical research. This move-
ment is spearheaded by groups of radical animal rights activists whose views are
considered to be far outside mainstream public attitudes and whose tactics range from
sophisticated lobbying, fund-raising, propaganda and misinformation campaigns to
violent attacks on biomedical research facilities and individual scientists. These violent
attacks are carried out by a relatively small number of activists compared with those
who use peaceful means of protest, but they have profound and wide-ranging effects.
2. The magnitude of violent animal rights activities is staggering, and these activities
take place in many different parts of the world. Various animal rights groups have
claimed responsibility for the bombing of cars, institutions, stores, and the private
homes of researchers.
3. Animal rights violence has had a chilling effect on the scientific community inter-
nationally. Scientists, research organizations, and universities have been intimidated
into altering or even terminating important research efforts that depend on the use of
animals. Laboratories have been forced to divert thousands of research dollars for the
purchase of sophisticated security equipment. Young people who might otherwise
pursue a career in biomedical research are turning their sights to alternative profes-
sions.
4. Despite the efforts of many groups striving to protect biomedical research from
radical animal activism, the response to the animal rights movement has been frag-
mented, underfunded, and primarily defensive. Many groups within the biomedical
community are hesitant to take a public stand about animal activism because of fear of
reprisal. As a result, the research establishment has been backed into a defensive pos-
ture. Its motivations are questioned, and the need for using animals in research is re-
S-1989-01-2016 ⏐ Buenos Aires
Animal Use in Biomedical Research
peatedly challenged.
5. While properly designed and executed research involving animals is necessary to
enhance the medical care of all persons, we recognize also that humane treatment of
research animals must be ensured. Appropriate training for all research personnel
should be prescribed and adequate veterinary care should be available. Experiments
must comply with any rules or regulations promulgated to govern humane handling,
housing, care, treatment and transportation of animals.
6. International medical and scientific organizations must develop a stronger and more
cohesive campaign to counter the growing threat to public health posed by animal
activists. Leadership and coordination must be provided. In addition, there must be a
clear understanding of the rights of animals who are part of medical research, and the
obligations of those who undertake it.
The World Medical Association therefore affirms the following principles:
1. Animal use in biomedical research is essential for continued medical progress.
2. The WMA Declaration of Helsinki requires that biomedical research involving human
subjects should be based, where appropriate, on animal experimentation, but also re-
quires that the welfare of animals used for research be respected.
3. Humane treatment of animals used in biomedical research is essential and research
facilities should be required to comply with all guiding principles for humane treat-
ment. Education about these principles should be provided to all researchers in train-
ing.
4. Animals should only be used in biomedical research when it is clear that their use is
required to achieve an important outcome, and where no other feasible method is
available.
5. Duplication of animal experiments should not occur unless scientifically justified.
6. The use of animals for the futile testing of cosmetic products and their ingredients,
alcohol and tobacco should not be supported.
7. Although rights to free speech should not be compromised, the anarchistic element
among animal right activists should be condemned.
8. The use of threats, intimidation, violence, and personal harassment of scientists and
their families should be condemned internationally.
9. A maximum coordinated effort from international law enforcement agencies should
be sought to protect researchers and research facilities from activities of a terrorist
nature.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-01-2016
WMA STATEMENT
ON
INJURY CONTROL
Adopted by the 42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
njuries are the leading cause of death and disability in children and young adults,
destroying the health, livelihoods and lives of millions of people each year. Causes of
injury include, among others, acts of violence against oneself or others, traffic crashes,
falls, poisonings, drowning, and burns. Yet many injuries are preventable. Injury control
should be recognized as a public health priority requiring coordination among health,
transportation and social service agencies in each country. Physician participation and
leadership through medicine, education and advocacy is necessary to ensure the success of
such injury control programmes.
As the World Health Organization states in Injuries and Violence: The Facts, the rate of
injury is far from uniform around the world. Indeed, about 90% of injury-related deaths
occur in low- and middle-income countries. Within countries, injury rates vary by social
class as well. The impoverished face more dangerous living and working conditions than
the more affluent. For example, buildings in poorer communities are more likely to be
older and in need of repair. Poor communities are also plagued by much higher rates of
homicide. What’s more, people living in poverty also have less access to quality
emergency care and rehabilitation services. Greater attention must be given to these root
causes of injuries.
The World Medical Association urges National Medical Associations to work with
appropriate public and private agencies to develop and implement programmes to prevent
and treat injuries. Included in the programmes must be efforts to improve medical
treatment and rehabilitation of injured patients. Research and education on injury control
must be increased, and international cooperation is a vital and necessary component of
successful programmes.
National Medical Associations should recommend that the following basic elements be
incorporated in their countries’ programmes:
EPIDEMIOLOGY
The initial activity of such programmes must be the acquisition of more adequate data on
which to base priorities, interventions and research. An effective injury surveillance
system should be implemented in each country to gather and integrate information. A
consistent and accurate system for coding injuries must be implemented by hospitals and
health agencies. There should also be international uniformity in the coding of injury
severity.
S-1990-01-2006 ⏐ Pilanesberg
Injury Control
PREVENTION
Injury prevention requires education and training to teach and persuade people to alter
their behaviour in order to reduce their risk of injury. Laws and regulations based on
scientifically sound methods of preventing injuries may be appropriate for effecting
changes in behaviour (for example, the use of seatbelts and protective helmets). These
laws must in turn be strictly enforced. An effective injury surveillance system as
mentioned above will help determine how to target further preventive efforts. Urban and
traffic planning should support safe environments for the residents.
BIOMECHANICS
A better understanding of the biomechanics of injury and disability could inform the
development of improved safety standards and regulations of products and their designs.
TREATMENT
Injury management at the scene of the occurrence must be enhanced by an effective
system of communication between first responders and health professionals at hospitals to
facilitate decision-making. Rapid and safe transportation to the hospital should be
provided. An experienced team of trauma practitioners should be available at the hospital.
There should also be adequate equipment and supplies available for the care of the injured
patient, including immediate access to a blood bank. Education and training of medical
practitioners in trauma care must be encouraged to assure optimal technique by an
adequate number of physicians at all times.
REHABILITATION
Trauma victims need continuity of care emphasizing not only survival but also the
identification and preservation of residual functions. Rehabilitation to restore biological,
psychological and social functions must be undertaken in an effort to allow the injured
person to achieve maximal personal autonomy and an independent lifestyle. Where
feasible, community integration is a desirable goal for people chronically disabled by
injury. Rehabilitation may also require changes in the patient’s physical and social
environment.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-04-2016
WMA STATEMENT
ON
TRAFFIC INJURY
Adopted by the 42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Serious injuries and mortality in road collisions are a public health problem with
consequences similar to those of major diseases such as cancer and cardiovascular disease.
Worldwide, about 1.2 million persons are killed each year on the roads, and an additional
20-50 million are injured. By 2020, road traffic injuries are expected to be the third largest
contributor to the global burden of disease and injury.
In addition to the immeasurable personal and social price paid by road crash victims and
their relatives, traffic injury has a significant economic impact. The economic costs of
traffic injury and disability, including emergency and rehabilitative health care, costs of
disability and disability adjusted life years (DALYs), amount to 1% of the GDP of poorer
countries and 1.5-2% of wealthier countries. Much of this burden is borne by the health
sector.
Road injuries continue to increase in many countries, particularly in low- and middle-
income nations which currently account for 85% of all road traffic deaths, and are the
second leading cause of death among youth worldwide.
Most traffic injuries could be prevented by better countermeasures. Combating traffic
injury is the shared responsibility of groups and individuals at the international, national,
and community levels, including governments, NGOs, industry, public health
professionals, engineers and law enforcement personnel.
Speed is widely recognized as the most important determinant of road safety, affecting
both the likelihood that a crash will occur and the severity of a crash. On average, an
increase in speed of 1 km/h is associated with a 3% higher risk of a crash involving injury
and a 5% higher risk of serious or fatal injury.
However, efforts to decrease road crashes and injury also require a “systems approach”
that recognizes and addresses the many factors that contribute to the risk of traffic crashes
and resulting injury, including human, vehicle and road design variables.
Preventing traffic injury requires addressing the social determinants of health—the social,
economic, environmental, and political factors in society that influence a population’s
S-1990-04-2016 ⏐ Taipei
Traffic Injury
health. Low- and middle-income countries, where there is less safe infrastructure, fewer
minimum standards on vehicle safety, and poorer quality emergency care, experience the
greatest number of traffic injuries. In this way, human, vehicular and environmental
factors interact before, during and after a collision. Intervention at each of these stages will
help reduce crashes and injury. Effective intervention requires public education as well as
professional involvement in the fields of engineering, law enforcement and medical care.
Pre-collision intervention is aimed at preventing crashes and reducing risk factors.
Examples include preventing drivers from driving when fatigued (especially drivers of
heavy vehicles), distracted or under the influence of drugs or alcohol. Necessary policies
may include prohibiting the use of hand-held cellular phones and night curfews or
graduated licensing for young drivers. Pre-collision intervention also includes setting
vehicle design standards that ensure that vehicles are roadworthy and cannot be driven at
excessive speeds. Other interventions include setting and enforcing appropriate speed
limits, installing speed cameras, and optimizing road design and layout to prevent crashes.
A second level of intervention is aimed at preventing or reducing injury during the crash.
Such interventions include: enforcing the use of seat belts and child restraints; requiring
helmets for cyclists; manufacturing vehicles equipped with safety devices and crash-
protective design; lowering and enforcing speed limits; and removing heavy, rigid objects
such as concrete or metal dividers, light posts and abutments from the sides of roads.
Post-crash intervention is aimed at maximizing life-saving and injury-reducing treatment
and includes improved pre-hospital and emergency trauma care and rehabilitation.
RECOMMENDATIONS
1. The WMA supports the findings and key recommendations of the WHO’s 2015
Report on road traffic injury prevention and calls for their implementation by its
member National Medical Associations and their governments and relevant bodies.
2. Physicians must view traffic injury as a public health problem and recognize their
responsibility in fighting this global problem.
3. National Medical Associations and their member physicians should work to
persuade governments and policy makers of the importance of this issue and
should assist in adapting empirical and scientific information into workable
policies.
4. National Medical Associations and physicians should be key players in public
education and should include road safety in health promotion activities.
5. Physicians should be involved in the collection and analysis of data regarding road
crashes and concomitant injuries, including injury surveillance systems.
6. Physicians should work toward changing the public attitude of road travel,
including pressing for improved public transportation, bicycle paths and proper
sidewalks to encourage less car use and the adoption of healthier options such as
walking and cycling.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-04-2016
7. Physicians should address the human factor and medical reasons for road crashes,
including, but not limited to, the use of prescription drugs or medical conditions
that may impair driving ability, and explore ways to prevent and reduce the
severity of injuries.
8. Physicians should lobby for the implementation and enforcement of the measures
listed above, which have been shown to decrease the risk and severity of vehicle
crashes, and the evaluation of their impact.
9. National Medical Associations and their member physicians should encourage the
research and development of improved training systems and medical care at all
stages, including effective communication and transport systems to locate and
evacuate the victims, emergency medical care systems to provide life-saving first
aid services, and expert trauma and rehabilitative care, and should lobby for
increased resources to help provide these services.
Handbook of WMA Policies
S-1991-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ADOLESCENT SUICIDE
Adopted by the 43rd
World Medical Assembly, Malta, November 1991
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
The past several decades have witnessed a dramatic change in causes of adolescent
mortality. Previously, adolescents mostly died of natural causes, whereas they now more
likely die from preventable causes. Part of this change has been a worldwide rise in
adolescent suicide rates in both developed and developing countries. In the adolescent
population, suicide is currently one of the leading causes of death. Suicides are probably
under-reported due to cultural and religious stigma attached to self-destruction and to an
unwillingness to recognize certain traumas, such as some automobile accidents, as self-
inflicted.
Adolescent suicide is a tragedy that affects not only the individual but also the family,
peers and larger community in which the adolescent lived. Suicide is often experienced as
a personal failure by parents, friends and physicians who blame themselves for not
detecting warning signs. It is also viewed as a failure by the community, serving as a vivid
reminder that modern society often does not provide a nurturing, supportive and healthy
environment in which children can grow and develop.
Factors contributing to adolescent suicide are varied and include: affective disorders,
trauma, emotional isolation, low self-esteem, excessive emotional stress, eating disorders,
harassment (school bullying, cyber bullying and sexual harassment), romantic fantasies,
thrill-seeking, drug and alcohol abuse, the availability of firearms and other agents of self-
destruction, and media reports of other adolescent suicides, which may inspire copycat
acts. In addition, the prolonged exposure to electronic media, which predominantly affects
adolescents through their use of computer games and social media, can contribute to social
isolation, school failure and malaise amongst young people.
Youth within correctional facilities are at a higher risk for suicide than the general
population, yet they have fewer resources available to them. The lack of resources makes
it difficult to identify those at risk for suicide.
The incidence of adolescent suicide is observed to be greater in the “first peoples” of some
nations. The reasons for this are complex.
The health care of adolescents is best achieved when physicians provide comprehensive
Taipei⏐ S-1991-01-2016
Adolescent Suicide
services, including both medical and psychosocial evaluation and treatment. Continuous,
comprehensive care provides the physician the opportunity to obtain the information
necessary to detect adolescents at risk for suicide or other self-destructive behaviour. This
service model also helps to build a socially supportive patient-physician relationship that
may moderate adverse influences adolescents experience in their environment.
In working to prevent adolescent suicide, the World Medical Association recognizes the
complex nature of adolescent bio-psycho-social development; the changing social world
faced by adolescents; and the introduction of new, more lethal, agents of self-destruction.
In response to these concerns, the World Medical Association recommends that National
Medical Associations adopt the following guidelines for physicians. In doing so, we
recognise that many other players – parents, governmental agencies, schools,
communities, social services – also have important roles in this area.
RECOMMENDATIONS
1. All physicians should receive, during medical school and postgraduate training,
education in child psychiatry and adolescent bio-psycho-social development,
including education in the risk factors for suicide.
2. Physicians should be trained to identify early signs and symptoms of physical,
emotional, and social distress of adolescent patients. They should also be trained to
identify the signs and symptoms of psychiatric disorders, like depression, bipolar
disorder and substance use disorders, that may contribute to suicide as well as
other self-destructive behaviours.
3. Physicians should be taught how and when to assess suicidal risk in their
adolescent patients.
4. Physicians should be taught and keep up-to-date on the treatment and referral
options appropriate for all levels of self-destructive behaviours of their adolescent
patients. The physicians with the most significant training in adolescent suicide are
child and adolescent psychiatrists, so the patient should be referred to one if
available.
5. Physicians should also collaborate with other relevant stakeholders, such as social
workers, school officials, and psychologists who bear expertise in child and
adolescent behavior.
6. When caring for adolescents with any type of trauma, physicians should consider
the possibility that the injuries might have been self-inflicted.
7. When caring for adolescents who demonstrate deterioration in thinking, feeling or
behaviour, the possibility of substance abuse and addiction should be considered,
and the threshold should be low for urine toxicology assessment.
8. Health care systems should facilitate the establishment of mental health
consultation services aimed at preventing suicide and should pay for the socio-
medical care given to patients who have attempted suicide. Services should be
tailored to the specific needs of adolescent patients.
Adolescent Suicide
S-1991-01-2016 ⏐ Taipei
9. Epidemiological studies on suicide, its risk factors and methods of prevention
should be conducted, and physicians should keep up-to-date with such studies.
10. When caring for adolescents with psychiatric disorders or risk factors for suicide,
physicians should educate parents or guardians to watch for the signs of suicide
and educate them about the options for evaluation.
11. Physicians should advocate for the identification of at risk groups of adolescents
with the mobilization of specifically targeted resources directed at prevention and
risk reduction.
Handbook of WMA Policies
S-1992-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ALCOHOL AND ROAD SAFETY
Adopted by the 44th
World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General ssembky, Taipei, Taiwan, October 2016
INTRODUCTION
Deaths and injuries resulting from road crashes and collisions are a major public health
problem. The World Health Organization’s 2015 Global status report on road safety
indicates that the total number of road traffic deaths per year has reached 1.25 million
worldwide, with the highest road traffic fatality rates in low-income countries.
Driving while under the influence of alcohol has caused a large number of the deaths and
injuries resulting from road crashes. The prevalence of drinking and driving is increasing
worldwide each year.
A change in the behaviour of road users with regard to alcohol consumption would appear
to be the most promising approach to preventing traffic deaths and injuries. Measures
forbidding driving while under the influence of alcohol will lead to a considerable
improvement in road safety and an appreciable reduction in the number of dead and
injured.
CONSEQUENCES OF DRINKING AND DRIVING
Driving a vehicle implies the acceptance of a certain number of risks. The careful driver
will always be aware of the risks but also ensure that the level of risk never rises to an
unacceptable level. Alcohol not only impairs one’s ability to drive, but it also alters a
driver’s subjective assessment of risk so that he or she drives more recklessly.
Irrespective of the amount of alcohol consumed, the maximum concentration of alcohol in
the body is reached:After half an hour when taken
• on an empty stomach;
• After an hour when taken with a meal.
On the other hand, it takes the body a long time to eliminate alcohol. An individual in
good health eliminates alcohol at a rate that reduces blood alcohol concentration by 0.1 to
0.15 gram/litre/hour. Thus, one’s driving ability remains impaired long after he or she has
stopped drinking.
Alcohol abuse has both short- and long-term neurological and psychiatric consequences
that can endanger road safety.
Handbook of WMA Policies
S-1992-01-2016 ⏐ World Medical Association
Certain drugs interact negatively with alcohol, and in particular some combinations are
known to reduce alertness. When drugs, whether legal or illegal, are taken with alcohol,
the effect of the latter is intensified. This mixture can trigger mental dysfunctions that are
extremely dangerous for road users. Physicians should be educated and informed about
these pharmacological facts.
RECOMMENDATIONS
1. The WMA reaffirms its commitments to work for reducing excessive alcohol
consumption and for fostering harm-reduction policies and other measures (WMA
Declaration on Alcohol, October 2015.)
2. Physicians and National Medical Associations should play an active role in promoting
and advocating for the development of evidence-based government policies to reduce
alcohol use and driving:
Policy interventions
3. At the present time, permitted blood alcohol levels while driving vary from country to
country. Even small amounts of alcohol have a direct effect on the brain, with
disturbances noted at levels as low as 0.3 grams per litre. Therefore, it would be
desirable to lower the maximum permissible level of blood alcohol to a minimum, but
not above 0.5 grams per litre, which is low enough to allow the average driver to retain
the ability to assess risk.
4. The especially high prevalence in certain countries of driving while under the
influence of alcohol may justify more coercive policies, which physicians and
National Medical Associations should play an active role in supporting. For example,
the driver may be declared unfit to drive for a period of time sufficient to ensure he or
she will no longer be a threat to road safety in the future.
5. Government officials should consider implementing restrictions on the sale or
affordability of alcohol, perhaps through taxation, licensing systems, and/or limits on
the days and hours of sale. Restrictions on the promotion of alcoholic beverages,
including advertising and event sponsorship, should also be considered.
6. A minimum legal age for alcohol purchase and consumption should be adopted in each
country. Government officials should consider implementing a separate, lower or zero
blood alcohol content law for young drivers.
7. There should be strict consequences to selling alcoholic beverages to individuals under
the age to purchase and consume alcohol. These laws should be properly enforced.
8. Any driver who has been in a road traffic crash must undergo a blood alcohol
concentration test or a breath test.
9. The practice of random driver testing for breath alcohol levels should become more
widespread, and there should be further research into other ways to test urine, breath
Taipei ⏐ S-1992-01-2016
Alcohol and Road Safety
and saliva to identify impaired drivers and prevent subsequent operation of motor
vehicles.
10. Devices that prevent individuals with an unauthorised level of blood alcohol from
starting the engine of or operating the vehicle should be developed and experimented
with.
Educational interventions
11. Educational interventions should promote moderation and responsibility in the
consumption of alcohol and seek to reduce the likelihood that someone will consume
alcohol and drive afterwards.
12. The information dispensed by physicians and other health professionals should be
aimed at making everyone aware of the dangers of driving under the influence of
alcohol. When physicians and other health professionals issue fitness-to-drive
certificates, they can use this opportunity to educate road users and pass on a message
of prevention and personal responsibility.
13. In most countries, road crashes linked to alcohol consumption affect adolescents and
young adults to a disproportionately high degree, and every available resource should
be mobilised to reduce their consumption of alcohol. The problem of alcohol
consumption in adolescents and young adults and its relation to road safety should be
addressed in the school curricula so that a responsible attitude becomes the norm.
Clinical and rehabilitative interventions
14. Physicians should also be involved in reducing the likelihood of impaired driving by
participating in the detoxification and rehabilitation of drunk drivers. These initiatives
should be based on a detailed analysis of the problem as it manifests itself within each
country or culture. Generally speaking, however, alcoholism is a medical condition
with concomitant psychological or social and interpersonal difficulties that affect the
family, work or social environment.
15. Alcoholic subjects should be given access to rehabilitation services. When drivers are
found to have excess alcohol in their blood (or their breath), other factors linked to
their excessive drinking should be examined and included in a rehabilitation
programme. These rehabilitation programmes should be publicly funded.
16. Road crashes linked to the consumption of alcohol can be considered as possible
predictors of other addictive and violent behaviours. This should be taken into
consideration in the medical treatment of the patient.
Community interventions
17. Strategies should be developed by relevant stakeholders to ensure safe transportation
home in situations where alcohol consumption occurs.
18. Eliminating alcohol from the workplace and in situations where consumers must drive
should be a goal of organizational policies. The promotion of non-alcoholic drinks is
an important tool to facilitate these policies.
Handbook of WMA Policies
S-1992-05-2017 ⏐ World Medical Association
WMA STATEMENT
ON
NOISE POLLUTION
Adopted by the 44th
World Medical Assembly, Marbella, Spain, September 1992
amended by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
PREAMBLE
Given growing environmental awareness and knowledge of the impact of noise on health,
the psyche, performance and well-being, environmental noise is becoming a serious public
health threat. The World Health Organization (WHO) describes noise as the principal
environmental nuisance in industrial nations.
Noise affects people in various ways. Its effects relate to hearing, the vegetative nervous
system, the psyche, spoken communication, sleep and performance. Since noise acts as a
stressor, an increased burden on the body leads to higher energy consumption and greater
wear. It is thus suspected that noise can primarily favour diseases in which stress plays a
contributory role, such as cardiovascular diseases, which can then be manifested in the
form of hypertension, myocardial infarction, angina pectoris, or even apoplexy.
The effects in the psychosocial field are likewise dramatic. The stress caused by
environmental noise is a central concern, not only in the industrial nations, but
increasingly also in the developing countries. Owing to the continuous and massive
growth of traffic volumes, both on the roads and in the air, the stress caused by
environmental noise has increased steadily in terms of both its duration and the area
affected.
Similarly, occupational noise generates increasingly work-related hearing impairment.
Damage to hearing caused by leisure-time noise is also of growing concern. The most
common source of noise in this context is music, to which the ear is exposed by different
audio media at different places (portable music players, stereo systems, discotheques,
concerts). The risk of suffering hearing damage is underestimated by most people, or even
consciously denied. The greatest issue (or aspect) lies in creating awareness of the
problem in the high-risk group – which generally means young people. In this respect, the
legislature is called upon to intervene and reduce the potential for damage by introducing
sound level limiters in audio playback units and maximum permissible sound levels at
music events, or by banning children’s toys that are excessively loud or produce excessive
noise levels.
In keeping with its socio-medical commitment, the World Medical Association is issuing a
statement on the problem of noise pollution with the aim of making a contribution to the
fight against environmental noise through more extensive information and more acute
awareness.
Chicago ⏐ S-1992-05-2017
Noise Pollution
RECOMMENDATIONS
The World Medical Association calls upon the National Medical Associations to:
1. Inform the public, especially persons affected by environmental noise, as well as poli-
cy and decision makers, of the dangers of noise pollution.
2. Call upon ministers of transport and urban planners to develop alternative concepts
that are capable of countering the growing level of environmental noise pollution.
3. Advocate appropriate statutory regulations for combating environmental noise pollu-
tion.
4. Support enforcement of noise pollution legislation and monitor the effectiveness of
control measures.
5. Inform young people of the risks associated with listening to excessively loud music,
such as that which emanates, for example, from portable music players, use of stereo
systems with earphones, audio systems in cars, and attendance at rock concerts and
discotheques.
6. Prompt the educational authorities to inform pupils at an early stage regarding the
effects of noise on people, how stress due to environmental noise can be counteracted,
the role of the individual in contributing to noise pollution, and the risks associated
with listening to excessively loud music.
7. Provide information about risks of damage to hearing that arise in the private sector as
a result of working with power tools or operating excessively loud motor vehicles.
8. Emphasize to those individuals who are exposed to excessive levels of noise in the
workplace the importance of protecting themselves against irreducible noise.
9. Call upon the persons responsible for occupational safety and health in businesses to
take further action to reduce noise emission, in order to ensure protection of the health
of employees at the workplace.
Handbook of WMA Policies
S-1992-06-2015 ⏐ World Medical Association
WMA STATEMENT
ON
PHYSICIAN-ASSISTED SUICIDE
Adopted by the 44th
World Medical Assembly, Marbella, Spain, September 1992
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the
medical profession. Where the assistance of the physician is intentionally and deliberately
directed at enabling an individual to end his or her own life, the physician acts unethically.
However the right to decline medical treatment is a basic right of the patient and the phy-
sician does not act unethically even if respecting such a wish results in the death of the
patient.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-01-2016
WMA STATEMENT
ON
BODY SEARCHES OF PRISONERS
Adopted by the 45th
World Medical Assembly, Budapest, Hungary, October 1993
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 67th
WMA General Assembky, Taipei, Taiwan, October 2016
1. The World Medical Association adopts this statement for the purpose of providing
guidance for National Medical Associations as they develop guidelines for their
members.
2. Physician participation in body cavity searches for purposes of law enforcement or
public safety involves complex issues of patient rights, informed consent,
physicians’ fiduciary obligations (dual loyalty matters) and their responsibilities to
contribute to public health. A request to conduct a body cavity search puts the
physician in the untenable position of potentially violating the ethical standards of
his/her profession. Physician participation should be in exceptional cases only.
3. There are several types of searches of prisoners carried out within the detention
system. These will include searches for contraband and searches for items
immediately dangerous to the prisoner and those around him/her. Searches range
from the least invasive “pat-down” searches to the most invasive strip searches
(including examination of the mouth) and body cavity searches.
4. The prison systems in many countries mandate body cavity searches of prisoners.
Such searches, which include rectal and pelvic (vaginal) examination, may be
performed when an individual initially enters the prison population and thereafter
whenever the individual is permitted to have direct personal contact with someone
outside the prison population. They may also be undertaken when there is a reason
to believe a breach of security or of prison regulations has occurred. For example,
when a prisoner is taken to Court for a hearing, or to the hospital for treatment, or
to work outside the prison, the prisoner, upon returning to the institution, may be
subjected to a body cavity search that will include all body orifices. Where
prisoners have direct contact with visitors – family members or otherwise – prison
rules may also require body cavity searches. The purpose of the search is primarily
security-related, to prevent contraband, such as weapons or drugs, from entering
the prison.
5. These searches are performed for security reasons and not for medical or health-
S-1993-01-2016 ⏐ Taipei
Body Searches of Prisoners
related reasons. They should only be done by someone with appropriate training.
In most cases this will mean someone working within the detention system who
has been trained to perform safely such searches. This person should not be a
physician except under unusual and specific circumstances.
6. A physician’s obligation to provide medical care to the prisoner can be
compromised by an obligation to participate in the prison’s security system. A
physician should seek to be as far removed from performing body searches as
possible. Any directive to search should be separated from the physician’s broad
general medical care duties in order to protect the patient/physician relationship.
7. In exceptional cases the detaining authority, may indicate that a search be
performed by a physician. The physician, will decide whether medical
participation is necessary, and act accordingly and ethically.
8. If the search could, if carried out by someone with lesser skills, cause harm, for
example if the prisoner is a pregnant, or has severe haemorrhoids, then this non-
medical procedure may be performed by a physician to protect the prisoner from
harm. In such a case the physician should explain this to the prisoner. The
physician should also explain to the prisoner that s/he is performing this search not
as a physician caring for the patient, but for patient safety and as required by the
detention authorities for which the normal patient/doctor relationship does not
exist. The physician should inform the prisoner that the usual conditions of
medical confidentiality do not apply during this procedure and the results of the
search will be revealed to the authorities. If a physician is properly mandated by an
authority and agrees to perform a body cavity search on a prisoner for reasons of
patient safety, the authority should be informed that it is necessary for this
procedure to be done in a humane manner.
9. If the search is conducted by a physician, it should not be done by any physician
who will subsequently provide medical care to the prisoner.
10. Forced examinations are not ethically acceptable, and physicians must not perform
them. If the prisoner acquiesces to a search, the doctor, or other individual carrying
out the body cavity search, should ensure that the prisoner is fully aware of what
will be done, including the facilities in which the search will be performed.
11. Searches should be performed humanely, and, where possible, in a private,
confidential setting respecting the prisoner. The person performing the search
should be of the same gender as the prisoner being searched. When applicable,
transgender persons should be asked first with which gender they identify.
12. The World Medical Association urges all governments and public officials with
responsibility for public safety to recognize that invasive searches are serious
assaults on a person’s privacy and dignity, and they also carry some risk of
physical and psychological injury. The World Medical Association urges that, to
Body Searches of Prisoners
Taipei ⏐ S-1993-01-2016
the extent feasible without compromising public security, the following
recommendations be followed:
• Alternate methods be used for routine screening of prisoners, including
ultrasound and other scans, and body cavity searches be used only as a last
resort;
• Squatting over mirrors to examine the anus while making the prisoner bear
down, a degrading procedure with questionable reliability, must be banned;
• If a body cavity search must be conducted, the responsible public official must
ensure that the search is conducted humanely by personnel who are of the same
gender as the prisoner and who possess sufficient medical and skills to safely
perform the search;
• The same responsible authority must ensure that the individual’s privacy and
dignity be guaranteed.
• Physician participation in body cavity searches should be in exceptional cases
only. In these cases, the duty to search should be separated from the
physician’s delivery of medical care.
13. Finally, the World Medical Association urges all governments and responsible
public officials to provide body searches that are performed by a qualified
physician whenever warranted by the individual’s physical condition. A specific
request by a prisoner for a physician shall be respected, so far as possible.
14. In specific cases, it may be the detaining authority, which requires a search be
performed by a physician, for the well-being of this prisoner. The physician, in
such a case, will decide whether medical participation is indeed necessary, and act
accordingly and ethically.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-02-2016
WMA STATEMENT
ON
FEMALE GENITAL MUTILATION
Adopted by the 45th
World Medical Assembly, Budapest, Hungary, October 1993
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
The World Medical Association joins with other international agencies in condemning the
practice of genital mutilation or cutting of women and girls, regardless of the level of
mutilation, and opposes the participation of physicians in these practices.
Stopping female genital mutilations (FGM) requires action on strict enforcement of laws
prohibiting the practice, medical and psychological care for women who are victims and
prevention of FGM by education, risk assessment, early detection and engagement with
community leaders.
FGM is a common practice in more than 30 countries of the world, including some in
Africa, Asia and the Middle East. The phrase FGM is used to convey a number of
different forms of surgery, mutilation or cutting of the female external genitalia. The term
female circumcision is no longer used as it suggests equivalence with male circumcision,
which is both inaccurate and counterproductive. Most girls undergo FGM/C between the
ages of 7 and 10. There is no medical necessity for any such cutting, which is often
performed by an unqualified individual in un-hygienic surroundings.
FGM of any type is a violation of the human rights of girls and women, as it is a harmful
procedure performed on a child who cannot give valid consent. As a result of migration a
growing number of girls living outside countries where the practice is common are being
affected.
Respecting the social norms of immigrants is increasingly posing problems for physicians
and the wider community.
Because of its impact on the physical and mental health of women and children, and
because it is a violation of human rights, FGM is a matter of concern to physicians.
Physicians worldwide are confronted with the effects of this traditional practice. They
may be asked to perform this mutilating procedure or to restore the result of mutilating
“surgery” on women after childbirth has reopened the introitus.
Female Genital Mutilation
Taipei ⏐ S-1993-02-2016
There are various forms of FGM, classified by WHO.[1] It can be a primary procedure for
young girls, usually between 5 and 12 years of age, or a secondary one, e.g., after
childbirth. The extent of a primary procedure may vary: from an incision in the foreskin of
the clitoris, up to the maximally mutilating so-called pharaonic infibulation which
involves partly removing the clitoris and labia minora and stitching up of the labia majora
so that only a small opening remains to allow the passage of urine and menstrual blood.
The majority of procedures performed are somewhere in between these two extremes.
While the term female circumcision is no longer used it remains useful, familiar and
readily accessible in the context of physician/patient consultations in some cases.
FGM has no health benefits and harms girls and women in many ways, regardless of
which procedure is performed. Research shows grave permanent damage to health,
including: haemorrhage, infections, urinary retention, injury to adjacent organs, shock and
very severe pain. Long-term complications include severe scarring, chronic bladder and
urinary tract infections, urologic and obstetric complications, and psychological and social
problems. FGM has serious consequences for sexuality and how it is experienced,
including the loss of capacity for orgasm. There are also many complications during
childbirth including expulsion disturbances, formation of fistulae, and traumatic tears of
vulvar tissue.
There are a number of reasons given for the continuation of the practice of FGM: custom,
community tradition (preserving the virginity of young girls and limiting the sexual
expression of women) and as part of a girl’s initiation into womanhood. These reasons do
not justify the considerable damages to physical and mental health.
None of the major religions supports this practice, which is otherwise often wrongly
linked to religious beliefs. FGM is a form of violence usually perpetuated on young
women and girls and represents a lack of respect for their individuality, freedom and
autonomy.
Physicians may be faced with parents seeking a physician to perform FGM, or they may
become aware of parents who seek to take girls to places where the practice is commonly
available. They must be prepared to intervene to protect the girl.
Medical associations should prepare guidance on how to manage these requests which
may include invoking local laws that protect children from harm and may include
involving police and other agencies.
When patients who have undergone FGM give birth, physicians may receive requests to
restore the results of the FGM. They should be confident in handling such requests and
supported with appropriate educational material that will enable them to discuss with the
patient the medically approved option of repairing the damage done by FGM and by
childbirth. Physicians also have a responsibility to have a discussion with the spouse of the
patient, with the consent of the patient, who might otherwise seek “restoration” of the
FGM, if not given a full explanation of the harm that is done by FGM.
There is a growing tendency for physicians and other health care professionals in some
S-1993-02-2016 ⏐ Taipei
Female Genital Mutilation
countries to perform FGM because of a wish to reduce the risks involved. Some
practitioners may believe that medicalization of the procedure is a step towards its
eradication. Performing FGM is a breach of medical ethics and human rights, and
involvement by physicians may give it credibility. In most countries performing this
procedure is a violation of the law.
Governments in several countries have developed legislation, such as prohibiting FGM in
their criminal codes.
RECOMMENDATIONS
1. Taking into account the psychological needs and ‘cultural identity’ of the people
involved, physicians should explain the dangers and consequences of FGM and
discourage performing or promoting FGM. Physicians should integrate women’s
health promotion and counselling against FGM into their work.
2. Physicians should assist in educating health professionals and work with local
community, cultural and social leaders to educate them about the adverse
consequences of FGM. They should support persons who want to end FGM and
the establishment of community programmes designed to outlaw the practice,
offering medical information about its damaging effects as necessary.
3. There are active campaigns against FGM that are led by women leaders and heads
of state in Africa and elsewhere. These campaigns have issued strong statements
against the practice.
4. Physicians should work with groups such as these and others who manage
pregnant women including midwives, nurses and traditional birth attendants, to
ensure all practitioners have standardized and sensitive information about FGM.
5. Physicians should cooperate with any preventive legal strategy when a child is at
risk of undergoing FGM.
6. National Medical Associations should stimulate public and professional awareness
of the damaging effects of FGM.
7. National Medical Associations should ensure that FGM education and awareness
are part of its advocacy to prevent violence against women and girls.
8. National Medical Associations should work with opinion leaders, encouraging
them to become active advocates against FGM.
9. National Medical Associations should stimulate government action in preventing
the practice of FGM. This should include sustained advocacy programmes and the
development of legislation prohibiting FGM.
10. NMAs must prohibit involvement by physicians in the practice of FGM, including
re-infibulation after childbirth. Physicians should be encouraged to perform
reconstructive surgery on women who have undergone FGM. Physicians should
seek to ensure the provision of adequate (and non-judgemental) medical and
psychological care for women who have undergone FGM.
Female Genital Mutilation
Taipei ⏐ S-1993-02-2016
11. Physicians should be aware that the risk of FGM might be a justification for
overriding patient confidentiality, and allow disclosure to social or other relevant
services to protect a child from serious harm.
[1] FGM can be classified into four types: clitoridectomy, excision, infibulation and other
harmful procedures such as pricking, piercing, incising, scraping and cauterizing the
genital area.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-03-2016
WMA STATEMENT
ON
PATIENT ADVOCACY AND CONFIDENTIALITY
Adopted by the 45th
World Medical Assembly, Budapest, Hungary, October 1993
revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006 and
reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
PREAMBLE
Medical practitioners have an ethical duty and a professional responsibility to act in the
best interests of their patients without regard to age, gender, sexual orientation, physical
ability or disability, race, religion, culture, beliefs, political affiliation, financial means or
nationality.
This duty includes advocating for patients, both as a group (such as advocating on public
health issues) and as individuals.
Occasionally, this duty may conflict with a physician’s other legal, ethical and/or pro-
fessional duties, creating social, professional and ethical dilemmas for the physician.
Potential conflicts with the physician’s obligation of advocacy on behalf of his or her pa-
tient may arise in a number of contexts:
1. Conflict between the obligation of advocacy and confidentiality – A physician is
ethically and often legally obligated to preserve in confidence a patient’s personal
health information and any information conveyed to the physician by the patient
in the course of his or her professional duties. This may conflict with the
physician’s obligation to advocate for and protect patients where the patients may
be incapable of doing so themselves.
2. Conflict between the best interest of the patient and employer or insurer dictates –
Often there exists potential for conflict between a physician’s duty to act in the best
interest of his or her patients, and the dictates of the physician’s employer or the in-
surance body, whose decision may be shaped by economic or administrative factors
unrelated to the patient’s health. Examples of such might be an insurer’s instructions
to prescribe a specific drug only, where the physician believes a different drug
would better suit a particular patient, or an insurer’s denial of coverage for
treatment that a physician believes is necessary.
3. Conflict between the best interests of the individual patient and society – Although
the physician’s primary obligation is to his or her patient, the physician may, in
certain circumstances, have responsibilities to a patient’s family and/or to society
Handbook of WMA Policies
World Medical Association ⏐ S-1993-03-2016
as well. This may arise in cases of conflict between the patient and his or her
family, in the case of minor or incapacitated patients, or in the context of limited
resources.
4. Conflict between the patient’s wishes and the physician’s professional judgment or
moral values – Patients are presumed to be the best arbiters of their best interests
and, in general, a physician should advocate for and accede to the wishes of his or
her pa-tient. However, in certain instances such wishes may be contrary to the
physician’s professional judgment or personal values.
RECOMMENDATION
1. The duty of confidentiality must be paramount except in cases where the physician
is legally or ethically obligated to disclose such information in order to protect the
wel-fare of the individual patient, third parties or society. In such cases, the
physician must make a reasonable effort to notify the patient of the obligation to
breach confi-dentiality, and explain the reasons for doing so, unless this is clearly
inadvisable (such as where telling the patient would exacerbate a threat). In certain
cases, such as gene-tic or HIV testing, physicians should discuss with their
patients, prior to performing the test, instances in which confidentiality might need
to be breached.
A physician should breach confidentiality in order to protect the individual patient
only in cases of minor or incompetent patients (such as certain cases of child or
elder abuse) and only where alternative measures are not available. In all other
cases, confidentiality may be breached only with the specific consent of the patient
or his/ her legal representative or where necessary for the treatment of the patient,
such as in consultations between medical practitioners.
Whenever confidentiality must be breached, it should be done so only to the extent
necessary and only to the relevant party or authority.
2. In all cases where a physician’s obligation to his or her patient conflicts with the
administrative dictates of the employer or the insurer, a physician must strive to
change the decision of the employing/insuring body. His or her ultimate obligation
must be to the patient.
Mechanisms should be in place to protect physicians who wish to challenge
decisions of employers/insurers without jeopardizing their jobs, and to resolve
disagreements between medical professionals and administrators with regard to
allocation of re-sources.
Such mechanisms should be embodied in medical practitioners’ employment con-
tracts. These employment contracts should acknowledge that medical practitioners’
ethical obligations override purely contractual obligations related to employment.
3. A physician should be aware of and take into account economic and other factors
before making a decision regarding treatment. Nonetheless, a physician has an
obliga-tion to advocate on behalf of his or her patient for access to the best
S-1993-03-2016 ⏐ Buenos Aires
Patient Advocacy and Confidentiality
available treat-ment.
In all cases of conflict between a physician’s obligation to the individual patient
and the obligation to the patient’s family or to society, the obligation to the
individual pa-tient should typically take precedence.
4. Competent patients have the right to determine, on the basis of their needs, values
and preferences, what constitutes for them the best course of treatment in any given
situa-tion. Unless it is an emergency situation, physicians should not be required to
participate in any procedures that conflict with their personal values or professional
judgment. In such non-emergency cases, the physician should explain to the patient
his or her in-ability to carry out the patient’s wishes, and the patient should be
referred to another physician, if required.
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
MEDICAL ETHICS IN THE EVENT OF DISASTERS
Adopted by the 46th
WMA Gener al Assembly, Stockholm, Sweden, September 1994
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. According to International Federation of Red Cross and Red Crescent Societies (IFRC)
a disaster is a sudden, calamitous event that seriously disrupts the functioning of a
community or society and causes human, material, and economic or environmental
losses that exceed the community’s or society’s ability to cope using its own resources.
Though often caused by nature, disasters can have human origins.
This definition excludes situations arising from conflicts and wars, whether international
or internal, which give rise to other problems in addition to those considered in this
paper.
2. Disasters often result in substantial material damage, considerable displacement of
people, many victims and significant social disruptions. Adequate preparation would
make major consequences less likely and less severe and protect people especially the
most vulnerable.
This document will focus particularly on the medical aspects of disasters. From a
medical standpoint, disaster situations are characterized by an acute and unforeseen
imbalance between resources and the capacity of medical professionals, and the needs of
survivors who are injured whose health is threatened, over a given period of time.
3. Disasters, irrespective of cause, share several common features:
3.1. Their sudden and unexpected but often predictable occurrence, demanding prompt
action;
3.2. Material or natural damage making access to the survivors difficult and/or
dangerous;
3.3. Displacement or movement of often large numbers of people;
3.4. Adverse effects on health due to various reasons such as physical injuries and high
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
energy trauma, direct and indirect consequences of pollution, the risks of epidemics and
emotional and psychological factors as well as factors such as reduced access to food,
potable water, shelter, health care and other health determinants;
3.5. A context of insecurity sometimes requiring police or military measures to maintain
order; and
3.6. Media coverage, and the use of social media.
4. Disasters require multifaceted responses involving many different types of relief ranging
from transportation and food supplies to medical services. Physicians are likely to be
part of coordinated operations involving other responders such as law enforcement
personnel. These operations require an effective and centralized authority to coordinate
public and private efforts.
Rescue workers and physicians are confronted with exceptional circumstances, which
require the continued need of a professional and ethical standard of care. This is to
ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not
influenced by other motivations. Inadequate and/or disrupted medical resources on site
and a large number of people injured in a short time present specific ethical challenges.
RECOMMENDATIONS
5. Medical profession is at the service of the patients and society at all times and in all
circumstances. Therefore, the physicians should be firmly committed to addressing the
health consequences of disasters, without excuse or delay.
6. The World Medical Association (WMA) reaffirms its Declaration of Montevideo on
Disaster Preparedness and Medical Response (2011) recommending the development of
adequate training of physicians, accurate mapping of information on health system
assets and advocacy towards governments to ensure planning for clinical care.
7. The WMA recalls the primary necessity to ensure the personal safety of physicians and
other responders during the event of disasters (Declaration on the Protection of Health
Care Workers in situation of Violence, 2014).
Physicians and other responders must have access to appropriate and functional
equipment, both medical and protective.
8. Furthermore, the WMA recommends the following ethical principles and procedures
with regard to the physician’s role in disaster situations:
8.1 A system of triage may be necessary to determine treatment priorities. Despite triage
often leading to some of the most seriously injured receiving only symptom control
Chicago ⏐ S-1994-01-2017
Disasters
such as analgesia, such systems are ethical provided they adhere to normative
standards. Demonstrating care and compassion despite the need to allocate limited
resources is an essential aspect of triage.
Ideally, triage should be entrusted to authorized, experienced physicians or to
physician teams, assisted by a competent staff. Since cases may evolve and thus
change category, it is essential that the official in charge of the triage regularly
assesses the situation.
8.2 The following statements apply to treatment beyond emergency care:
8.2.1 It is ethical for a physician not to persist, at all costs, in treating individuals
“beyond emergency care”, thereby wasting scarce resources needed else-
where. The decision not to treat an injured person on account of priorities
dictated by the disaster situation cannot be considered an ethical or medical
failure to come to the assistance of a person in mortal danger. It is justified
when it is intended to save the maximum number of individuals. However, the
physician must show such patients compassion and respect for their dignity,
for example by separating them from others and administering appropriate
pain relief and sedatives, and if possible ask somebody to stay with the patient
and not to leave him/her alone.
8.2.2 The physician must act according to the needs of patients and the resources
available. He/she should attempt to set an order of priorities for treatment that
will save the greatest number of lives and restrict morbidity to a minimum.
8.3 Relation with the patients
8.3.1 In selecting the patients who may be saved, the physician should consider only
their medical status and predicted response to the treatment, and should
exclude any other consideration based on non-medical criteria.
8.3.2 Survivors of a disaster are entitled to the same respect as other patients, and the
most appropriate treatment available should be administered with the patient’s
consent.
8.4 Aftermath of disaster
8.4.1 In the post-disaster period the needs of survivors must be considered. Many
may have lost family members and may be suffering psychological distress.
The dignity of survivors and their families must be respected.
8.4.2 The physician must make every effort to respect the customs, rites and
religions of the patients and act in impartiality.
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
8.4.3 As far as possible, detailed records should be kept, including details of any
difficulties encountered. Identification of patients, including the deceased
should be recorded.
8.5 Media and other third parties
Physicians should take into consideration that in any disaster media is present. The work
of the media should be respected and facilitated as appropriate in the circumstances. If
needed, physicians should be empowered to restrict the entrance of reporters and other
media representatives to the medical premises. Appropriately trained personnel should
handle media relations.
The physician has a duty to each patient to exercise discretion and to seek to ensure
confidentiality when dealing with third parties. The physician must also exercise caution
and objectivity and respect the often emotional and politicized atmosphere surrounding
disaster situations. Any and all media especially filming must only occur with the
explicit consent of each patient who is filmed. With regard to social media use,
physicians must adhere to these same standards of discretion and respect for patient
privacy.
8.6 Duties of paramedical personnel
The ethical principles that apply to physicians in disaster situations should also apply to
other health care workers.
8.7 Training
The World Medical Association recommends that disaster medicine training be included
in the curricula of university and post-graduate courses in medicine.
8.8 Responsibility
8.8.1 The World Medical Association calls upon governments and insurance
companies to cover both civil liability and any personal damages to which
physicians might be subject when working in disaster or emergency situations.
This should also include life and disability coverage for physicians who die or
are harmed in the line of duty.
8.8.2 The WMA requests that governments:
• Ensure the preparedness of healthcare system to serve in disaster settings.
• Share all information related to public health timely and accurately.
• Accept the participation of demonstrably qualified foreign physicians, where
Chicago ⏐ S-1994-01-2017
Disasters
needed, without discrimination on the basis of factors such as affiliation (e.g.
Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or
religion.
• Give priority to the rendering of medical services over anything else that
might delay necessary treatment of patients.
Handbook of WMA Policies
S-1995-02-2015 ⏐ World Medical Association
WMA STATEMENT
ON
ETHICAL ISSUES CONCERNING PATIENTS WITH MENTAL ILLNESS
Adopted by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Historically, many societies have regarded patients with mental illness as a threat to those
around them rather than as people in need of support and care. In the absence of effective
treatment, to prevent self-destructive behaviour or harm to others, many persons with
mental illness were confined to asylums for all or part of their lives.
Today, progress in psychiatric treatment allows for better care of patients with mental ill-
ness. Efficacious drugs and psychosocial interventions offer outcomes ranging from
complete recovery to remission for varying lengths of time.
The adoption in 2006 of the United Nations Convention on the Rights of Persons with
Disabilities constituted a major step towards viewing them as full members of society with
the same rights as everyone else. It is the first comprehensive human rights treaty of the
21st
century. It aims to promote, protect and reinforce the human rights and dignity of all
persons with disabilities, including those with mental impairments.
Persons with major mental illnesses and those with learning disability have the same right
to preventive services and interventions to promote health as others members of the com-
munity, for which they often have greater need because they are more likely to live
unhealthy lifestyles.
Patients with psychiatric morbidity may also experience non- psychiatric illness. Persons
with mental illness have the same right to health care as any other patient. Psychiatrists
and health care professionals who provide mental health services should refer patients to
other appropriate professionals when patients need medical care. Health care professionals
should never decline to provide needed medical care solely because the patient has a
mental illness.
Physicians have the same obligations to all patients, including patients with mental illness.
Psychiatrists or other physicians who treat patients with mental illness must adhere to the
same ethical standards as any physician.
The physician’s primary obligation is to the patient and not to serve as agents of society,
Moscow ⏐ S-1995-02-2015
Patients with Mental Illness
except in circumstances when a patient presents clear danger to himself/ herself or others
due to mental illness.
PHYSICIANS’ ETHICAL PRINCIPLES
The stigma and discrimination associated with psychiatry and the mentally ill should be
eliminated. Stigma and discrimination may discourage people in need from seeking
medical care, thereby aggravating their situation and placing them at risk of emotional or
physical harm.
Physicians have a responsibility to respect the autonomy of all patients. When patients
who are being treated for mental illness have decision-making capacity, they have the
same right to make decisions about their care as any other patient. Because decision-
making capacity is specific to the decision to be made and can vary over time, including as
a result of treatment, physicians must continually evaluate the patient’s capacity. When a
patient lacks decision-making capacity, physicians should seek consent from an
appropriate surrogate in accordance with applicable law.
The therapeutic relationship between physician and patient is founded on mutual trust, and
physicians have a responsibility to seek patients’ informed consent to treatment, including
patients who are being treated for mental illness. Physicians should inform all patients of
the nature of the psychiatric or other medical condition, and the expected benefits,
outcomes and risks of treatment alternatives.
Physicians should always base treatment recommendations on their best professional
judgment and treat all patients with solicitude and respect, regardless of the setting of care.
Physicians who practice in mental health facilities, the military, or correctional institutions
may have concurrent responsibilities to society that create conflicts with the physician’s
primary obligation to the patient. In such situations, physicians should disclose the conflict
of interest to minimize possible feelings of betrayal on the patient’s part.
Involuntary treatment or hospitalization of persons with mental illness is ethically
controversial. While laws regarding involuntary hospitalization and treatment vary
worldwide, it is generally acknowledged that this treatment decision without the patient’s
informed consent or against the patient’s will is ethically justifiable only when: (a) a
severe mental disorder prevents the individual from making autonomous treatment
decisions; and/or (b) There is significant likelihood that the patient may harm him/her self
or others. Involuntary treatment or hospitalization should be exceptional and physicians
should utilize it only when there is good evidence that it is medically appropriate and
necessary and should ensure that the individual is hospitalized for the shortest duration
feasible under the circumstances. Wherever possible and in accordance with local laws,
physicians should include an advocate for the rights of that patient in the decision process.
Physicians must protect the confidentiality and privacy of all patients. When legally
required to disclose patient information, the physician should disclose only the minimum
relevant information necessary and only to an entity legally authorized to request or
require the information. When databanks allow access to or transfer of information from
Patients with Mental Illness
S-1995-02-2015 ⏐ Moscow
one authority to another confidentiality must be respected and such access or transfer must
comply fully with applicable law.
The participation of individuals with psychiatric illness in research needs to be in full
accordance with the Declaration of Helsinki’s recommendations.
Physicians must never use their professional position to violate the dignity or human rights
of any individual or group, and should never allow their personal desires, needs, feelings,
prejudices or beliefs to interfere with a patient’s treatment. Physicians must never abuse
their authority or take advantage of a patient’s vulnerability.
RECOMMENDATION
The World Medical Association and National Medical Associations are encouraged to:
• Publicize this Statement and affirm the ethical foundations for treatment of patients
with mental illness;
• While doing so, call for full respect – at all times – of the dignity and human rights
of patients with mental illness;
• Raise awareness of physicians’ responsibilities to support the well-being and rights
of patients with mental illness;
• Promote recognition of the privileged relationship between patient and physician
based on trust, professionalism and confidentiality;
• Advocate for appropriate resources to meet the needs of persons with mental
illness.
Handbook of WMA Policies
S-1995-04-2016 ⏐ World Medical Association
WMA STATEMENT
ON
PHYSICIANS AND PUBLIC HEALTH
Adopted by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
The health of a community or population is determined by several factors that go beyond
traditionally understood causes of disease. Social determinants of health include factors
that affect behavioural lifestyle choices; the physical, psychosocial and economic
environments in which individuals live; and the health services available to people. Public
health involves monitoring, assessing and planning a variety of programs and activities
targeted to the identified needs of the population, and the public health sector should have
the capacity to carry out those functions effectively to optimise community health. A key
tenet of public health policy should be inclusivity and health equity; public health agencies
must pay specific attention to populations and communities whose social, economic, and
political conditions put them at greater risk of poor health than the general population.
Physicians and their professional associations have an ethical and professional
responsibility to act in the best interests of patients at all times. This involves collaboration
with public health agencies to integrate medical care of individual patients with a broader
promotion of the health of the public.
The key functions of public health agencies are:
1. Health promotion:
• Working with health care providers to inform and enable the general public to take
an active role in preventing and controlling disease, adopting healthful lifestyles,
and using medical services appropriately;
• Assuring that conditions contributing to good health, including high-quality
medical services, safe water supplies, good nutrition, an unpolluted atmosphere,
and opportunities for exercise and recreation are accessible for the entire
population;
• Working with the responsible public authorities to create healthy public policy and
supportive environments in which healthy behavioural choices are the easy
choices, and to develop human and social capital.
• Prevention: assuring access to screening and other preventive services and curative
care to the entire population.
2. Protection: monitoring and protecting the health of communities against
communicable diseases and exposure to toxic environmental pollutants, occupational
S-1995-04-2016 ⏐ Taipei
Public Health
hazards, harmful products, and poor quality health services. This function includes the
need to set priorities, establish essential programs, obtain requisite resources and
assure the availability of necessary public health laboratory services.
3. Surveillance: identifying outbreaks of infectious disease and patterns of chronic
disease and injury and establishing appropriate control or prevention programs;
4. Population Health Assessment: assessing community health needs and marshalling the
resources for responding to them, and developing health policy in response to specific
community and national health needs.
The specific programs and activities carried out in each jurisdiction (local or national)
will depend on the problems and needs identified, the organization of the health care
delivery system, the types and scope of the partnerships developed and the resources
available to address the identified needs.
Public health agencies benefit greatly from the support and close cooperation of
physicians and their professional associations. The health of a community or a nation
is measured by the health of all its residents, and the preventable health problems that
affect an individual person affect the health and resources of the community. The
effectiveness of many public health programs, therefore, depends on the active
collaboration of physicians and their professional associations with public health
agencies and other governmental and nongovernmental agencies.
The medical sector and the public health sector should effectively co-operate on the
dissemination of public health information and education programs that promote
healthful lifestyles and reduce preventable risks to health, including those from the use
of tobacco, alcohol and other drugs; sexual activities that increase the risk of HIV
transmission and sexually transmitted diseases; poor diet and physical inactivity; and
inadequate childhood immunization levels. For example, health education can
substantially reduce infant morbidity and mortality (e.g. through the promotion of
breast-feeding and providing nutrition education to parents together with providing
supportive conditions, both at work and in the community).
The formal responsibility of public health agencies is primarily disease surveillance,
investigation and control. These activities cannot be conducted effectively, however,
without the active cooperation and support of physicians at the community level who
are aware of individual and community illness patterns and can notify health
authorities promptly of problems that might require further investigation and action.
For example, physicians can help identify populations at high risk for particular
diseases, such as tuberculosis, and report cases of communicable diseases such as
measles, whooping cough, or infectious causes of diarrhoea, as well as cases of
exposure to lead or other toxic chemicals and substances in the community or work
place. Close collaboration between public health agencies and physicians as well as
other health professionals is critical for an efficient disease monitoring system.
Regardless of the effectiveness of existing public health programs in a jurisdiction,
professional medical associations should be aware of unmet health needs in their
Taipei ⏐ S-1995-04-2016
Public Health
communities and nations and advocate for activities, programs and resources to meet
those needs. These efforts might be in areas of public education for health promotion
and disease prevention; monitoring and controlling environmental hazards; identifying
and publicising adverse health effects resulting from social problems, such as
interpersonal violence or social practices that affect health; or identifying and
advocating for services such as improvements in emergency treatment preparedness.
In jurisdictions in which basic public health services are not being provided
adequately, medical associations must work with other health agencies and groups to
establish priorities for advocacy and action. For example, in a country or area with
limited resources in which potable water and sewage facilities are not available to
most residents, these needs should be given priority over medical technologies that
would provide service to only a small portion of the population.
Some health-related issues are extremely complex and involve multiple levels of
response. For example, those diagnosed with high blood lead levels need not only
appropriate medical treatment, but the source of contamination must also be
determined, and measures need to be taken to eliminate the danger. At times policies
that promote public health create concern because of their potential economic impact.
For example, strong opposition to the potential economic impact of tobacco control
policies could come from regions or groups that derive significant revenue from
growing or processing tobacco. However, economic concerns should not deter a strong
public health advocacy program against the use of tobacco products. The promotion of
tobacco products should be rigorously opposed, and every effort should be made to
reduce tobacco consumption in both developed and developing countries.
Physicians and their associations should collaborate with political authorities and other
organizations to encourage the media to send positive messages for health education
regarding diet, drug use, sexually transmitted diseases, cardiovascular risk, etc.
Medical associations should ask their members to educate their patients on the
availability of public health services.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-01-2008
WMA STATEMENT
ON
RESISTANCE TO ANTIMICROBIAL DRUGS
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
PREAMBLE
The global increase in resistance to antimicrobial drugs, including the emergence of bac-
terial strains resistant to all available antibacterial agents, has created a multi-faceted
public health problem of crisis proportions with significant economic and human implica-
tions. The development of resistant microorganisms is a problem whenever antimicrobial
agents are used. The increase in high-risk populations who frequently require antimicro-
bial therapy, including immunocompromised patients, those undergoing invasive medical
interventions, those with implanted medical devices and patients with chronic debilitating
diseases, has amplified the problem. The fact that certain infectious diseases have been
linked to the development of chronic disease and cancer adds another dimension to the
problem.
A renewed effort to increase awareness of antimicrobial resistance is needed in order to
contain and slow its development. International cooperation is essential in accomplishing
this objective, including global, national, and local components. In particular, implement-
tation of national and global efforts to contain the development and spread of antimicro-
bial resistance is vital; policy statements without international will to accomplish results
are not enough. Given the dynamics of antimicrobial resistance, the need for continuing
development of new antimicrobials by the pharmaceutical industry can be anticipated.
Substantial misuse and overuse of antimicrobial agents have exacerbated the problem by
adding selection pressures to microbial populations that favor mutation to antibiotic resist-
ance. These include inappropriate prescribing of antibacterial prophylactics and/or treat-
ment of bacterial infections by physicians and poor compliance with antimicrobial regi-
mens by patients. Thus, there is a need for enhanced training and education to improve the
appropriate clinical use of antimicrobials and prevent the development of resistance. There
is a need at every level to educate the public about the appropriate use of antimicrobials
and the problem of antimicrobial resistance.
The availability of antimicrobial agents without a prescription in many developing coun-
tries is escalating antibiotic resistance, and this practice must be discontinued. The in-
creasing prevalence of counterfeit medications is another critical and expanding risk fac-
tor. Successfully addressing this problem will require substantial cooperation among
nations and the development and use of better technologies to verify the authenticity of
pharmaceutical products and assure the security of deployment from point of manufacture
to the point of need. Similarly, the inappropriate use of antibiotics in veterinary medicine
and livestock production in many countries needs to be controlled.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-01-2008
RECOMMENDATIONS
Global
Individual governments should work to create cross-sectional national task forces to col-
lect national data on the use of antibiotics and antimicrobial resistance and to prioritize
regulation, intervention, and other measures to reduce antimicrobial resistance.
The World Medical Association and its member national medical associations should
advocate for:
• Individual governments to cooperate with the World Health Organization (WHO)
to enhance the effectiveness of the WHO’s global network of antimicrobial resist-
ance surveillance. This will foster the collection, quality and sharing of data; the
monitoring of progress in combating antimicrobial resistance; the establishment of
appropriate formularies; and scientific support for interventions.
• The WHO to examine the role of international travel and trade agreements on the
development of antimicrobial resistance.
• The widespread application of verifiable technology to ensure the authenticity of
pharmaceutical products.
The World Medical Association and its national medical associations should encourage
their governments to:
• Fund more basic and applied research directed toward the development of inno-
vative antimicrobial agents and vaccines, and on the appropriate and safe use of
such therapeutic tools.
• Create incentives for the pharmaceutical industry to pursue research and develop-
ment programs leading to the availability of innovative antimicrobial agents, vac-
cines, and rapid diagnostic methods.
National
National medical associations should:
• urge their governments to require that antimicrobial agents be available only
through a prescription provided by licensed and qualified health care and/or veteri-
nary professionals.
• urge their governments to initiate a national media campaign explaining to the pu-
blic the harmful consequences of overuse and misuse of antibiotics.
• actively pursue the development of a national surveillance system for antimicrobial
resistance that will provide physicians with the information necessary to deliver
timely, evidence-based, high-quality care. Data from this system should be linked
with, or at minimum, fed into, the WHO’s global network of antimicrobial resist-
ance surveillance.
• create guidelines on the appropriate use of antibiotics for common medical con-
ditions, such as respiratory infections, tonsillitis, pneumonia and urinary tract in-
fection; pursue the development of a national surveillance system for sales of anti-
microbials.
S-1996-01-2008 ⏐ Seoul
Antimicrobial Resistance
• encourage medical schools and continuing medical education programs to renew
their efforts to educate physicians about the appropriate use of antimicrobial agents
and appropriate infection control practices, including antibiotic use in the out-
patient setting.
• in collaboration with veterinary authorities, encourage their governments to restrict
the use of antimicrobial agents as feed additives for animals strictly to those anti-
microbials that do not have a human public health impact.
Local
Physicians should:
• assume leadership roles in their local hospitals, clinics, and communities regarding
appropriate antiseptic habits, antimicrobial agent usage, and antimicrobial resist-
ance prevention and control programs. This applies especially to those trained in
infectious diseases and clinical microbiology.
• raise awareness amongst their patients about antimicrobial therapy, its risks and
benefits, the importance of compliance with the prescribed regimen, optimal hy-
gienic practices, and the problem of antimicrobial drug resistance.
• herever possible, explore strategies for reducing the use of antibiotics that do not
compromise the quality of patient care, such as «wait-and-see» prescriptions for the
treatment of acute otitis media.
Handbook of WMA Policies
S-1996-02-2010 ⏐ World Medical Association
WMA STATEMENT
ON
FAMILY VIOLENCE
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
editorially revised by the 174th
WMA Council Session, Pilanesberg, South Africa,
October 2006
and amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
PREAMBLE
Recalling the World Medical Association Declaration of Hong Kong on the Abuse of the
Elderly and the World Medical Association Statement on Child Abuse and Neglect, and
profoundly concerned with violence as a public health issue, the World Medical Associa-
tion calls upon National Medical Associations to intensify and broaden their efforts to
address the universal problem of family violence.
Family violence is a term applied to physical and/or emotional mistreatment of a person
by someone in an intimate relationship with the victim. The term includes domestic vio-
lence (sometimes referred to as partner, spouse, or wife battering), child physical abuse
and neglect, child sexual abuse, maltreatment of older people, and many cases of sexual
assault. Family violence can be found in every country in the world, cutting across gender
and all racial, ethnic, religious and socio-economic lines. Although case definitions vary
from culture to culture, family violence represents a major public health problem by virtue
of the many deaths, injuries, and adverse psychological consequences that it causes. The
physical and emotional harm may represent chronic or even lifetime disabilities for many
victims. Family violence is associated with increased risk of depression, anxiety, sub-
stance abuse, and self-injurious behaviour, including suicide. Victims often become per-
petrators or become involved in violent relationships later on. Although the focus of this
document is the welfare of the victim, the needs of the perpetrator should not be over-
looked.
Although the causes of family violence are complex, a number of contributing factors are
known. These include poverty, unemployment, other exogenous stresses, attitudes of ac-
ceptance of violence for dispute resolution, substance abuse (particularly alcohol), rigid
gender roles, poor parenting skills, ambiguous family roles, unrealistic expectations of
other family members, interpersonal conflicts within the family, actual or perceived physi-
cal or psychological vulnerability of victims by perpetrators, perpetrator pre-occupation
with power and control, and familial social isolation, among others.
POSITION
There is a growing awareness of the need to think about and take action against family
S-1996-02-2010 ⏐ Vancouver
Family Violence
violence in a unified way, rather than focusing on the particular type of victim or com-
munity affected. In many families where partner battering occurs, for example, there may
be abuse of children and/or of older people as well, often carried out by a single perpe-
trator. In addition, there is substantial evidence that children who are victimized or who
witness violence against others in the family are later at increased risk as adolescents or
adults of being re-victimized and/or becoming perpetrators of violence themselves. Final-
ly, more recent data suggest that victims of family violence are more likely to become
perpetrators of violence against non-intimates as well. All of this suggests that each in-
stance of family violence may have implications not only for further family violence, but
also for the broader spread of violence throughout a society.
Physicians and NMAs should oppose violent practices such as dowry killings and honour
killings.
Physicians and NMAs should oppose the practice of child marriage.
Physicians have important roles to play in the prevention and treatment of family violence.
Of course they will manage injuries, illnesses, and psychiatric problems deriving from the
abuse. The therapeutic relationships physicians have with patients may allow victims to
confide in them about current or past victimization. Physicians should inquire about vio-
lence routinely, as well as when they see particular clinical presentations that may be as-
sociated with abuse. They can help patients to find methods of achieving safety and access
to community resources that will allow protection and/or intervention in the abusive rela-
tionship. They can educate patients about the progression and adverse consequences of
family violence, stress management and availability of relevant mental health treatment,
and parenting skills as ways of preventing the violence before it occurs. Finally, physi-
cians as citizens and as community leaders and medical experts can become involved in
local and national activities designed to decrease family violence.
Physicians recognise that victims of violence may find it difficult to trust their physician at
first. Physicians must be prepared to develop a trusting relationship with their patient over
time until s/he is ready to accept advice, help and intervention.
RECOMMENDATION
The World Medical Association recommends that National Medical Associations adopt
the following guidelines for physicians:
• All physicians should receive adequate training in the medical, sociological, psy-
chological and preventive aspects of all types of family violence. This would in-
clude medical school training in the general principles, specialty-specific infor-
mation during postgraduate training, and continuing medical education about
family violence. Trainees must receive adequate instruction in the role of gender,
power and other issues of family dynamics in contributing to family violence. The
training should also include adequate collecting of evidence, documentation and
reporting in cases of abuse.
• Physicians should know how to take an appropriate and culturally sensitive history
of current and past victimization.
Vancouver ⏐ S-1996-02-2010
Family Violence
• Physicians should routinely consider and be sensitive to signs indicating the need
for further evaluations about current or past victimization as part of their general
health screen or in response to suggestive clinical findings.
• Physicians should be encouraged to provide pocket cards, booklets, videotapes,
and/or other educational materials in reception rooms and emergency departments
to offer patients general information about family violence as well as to inform
them about local help and services.
• Physicians should be aware of social, community and other services of use to vic-
tims of violence, and refer to and use these routinely.
• Physicians have the obligation to consider reporting to appropriate protection
services suspected violence against children and other family members without
legal capacity.
• Physicians should be acutely aware of the need for maintaining confidentiality in
cases of family violence.
• Physicians should be encouraged to participate in coordinated community acti-
vities that seek to reduce the amount and impact of family violence.
• Physicians should be encouraged to develop non-judgemental attitudes toward
those involved in family violence so their ability to influence victims, survivors
and perpetrators is enhanced. For example, the behaviour should be judged but not
the person.
• National Medical Associations should encourage and facilitate coordination of
action against family violence between and among components of the health care
system, criminal justice systems, law enforcement authorities, family and juvenile
courts, and victims’ services organizations. They should also support public aware-
ness and community education.
• National Medical Associations should encourage and facilitate research to under-
stand the prevalence, risk factors, outcomes and optimal care for victims of family
violence.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-04-2017
WMA STATEMENT
ON
FAMILY PLANNING AND THE RIGHT OF A WOMAN
TO CONTRACEPTION
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
amended by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed with minor revision by the 207th WMA Council session, Chicago, United
States, October 2017
PREAMBLE
The WMA recognizes that unwanted pregnancies and pregnancies that are too closely
spaced can have a serious adverse effect on the health of a woman and of her children.
These adverse effects can include the premature deaths of women. Existing children in the
family can also suffer starvation, neglect or abandonment resulting in their death or
impaired health, when families are unable to provide for all their children. Social
functioning and the ability to reach their full potential can also be impaired.
The WMA recalls its Declaration of Ottawa on Child Health, and supports the universal
health rights of all children worldwide.
The WMA recognizes the benefits for women who are able to control their fertility. They
should be helped to make such choices themselves, as well as in discussion with their
partners. The ability to do so by choice and not chance is a principal component of
women’s physical and mental health and social well-being.
Access to adequate fertility control methods is not universal; many of the poorest women
in the world have the least access. Knowledge about how their bodies work, information
on how to control their fertility and the materials necessary to make those choices are
universal and basic human rights for all women.
The Sustainable Development Goals 5, target 6 calls for the “universal access to sexual
and reproductive health and reproductive rights…”.
RECOMMENDATIONS
The WMA recommends that National Medical Associations:
• Promote family planning education by working with governments, NGOs and others
to provide secure and high-quality services and assistance;
• Demand from governments to ensure that such information, materials, products and
services are available without regard to nationality, creed, race, religion or
socioeconomic status.
Handbook of WMA Policies
S-1996-05-2016 ⏐ World Medical Association
WMA STATEMENT
ON
WEAPONS OF WARFARE AND
THEIR RELATION TO LIFE AND HEALTH
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
and editorially revised by the 174th
WMA Council Session, Pilanesberg, South Africa,
October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Recalling its Declaration of Washington on Biological Weapons, its Resolution on the
Prohibition of chemical weapons and its Statement on Nuclear Weapons, the World
Medical Association condemns the use of any forms of weapons – conventional,
biological, chemicals and nuclear weapons – which has the potential to bring immense
human suffering and substantial death together with catastrophic effects on the earth’s
ecosystem, a reduction of the world food supply and increased poverty. The use of such
weapons against human beings is in opposition with physicians’ duties and responsibilities
to preserve life.
When nations enter into warfare or into weapons development, they do not usually
consider the effects of the use of weapons on the health of individual non-combatants and
on public health in general, either in the short or in the longer term.
Nevertheless the medical profession is required to deal with both the immediate and long
term health effects of warfare, and in particular with the effects of different forms of
weaponry including the threat of nuclear, chemical and biological warfare.
The potential for scientific and medical knowledge to contribute to the development of
new weapons systems, targeted against specific individuals, specific populations or
against body systems, is considerable. This includes the development of weapons designed
to target anatomical or physiological systems, including vision, or which use knowledge
of human genetic similarities and differences to target weapons.
There are no current and commonly used criteria to measure weapons effects on health.
International Humanitarian Law states that weapons that cause injuries, which would
constitute “unnecessary suffering or superfluous injury”, are illegal. These terms are not
defined and require interpretation against objective criteria for the law to be effective.
Physicians can aid in developing criteria for weapons that cause injury or suffering so
extreme as to invoke the terms of International Humanitarian Law.
Such criteria could aid lawyers in the use of International Humanitarian Law, allow
assessment of the legality of new weapons currently in development against an agreed,
Weapons of Warfare and Their Relation to Life and Health
S-1996-05-2006 ⏐ Pilanesberg
objective system of assessment of their medical effects, and identify breaches of the Law
once it is developed.
Physician involvement in the delineation of such objective criteria is essential if it is to
become part of the legal process. However, it must be recognised that physicians are
firmly opposed to any use of weapons against human beings.
RECOMMENDATIONS
The WMA believes that the development, manufacture and sale of weapons for use
against human beings are abhorrent. To support the prevention and reduction of weapons
injuries, the WMA:
• Supports international efforts to define objective criteria to measure the effects of
current and future weapons, which could be used to stop the development,
manufacture, sale and use of those weapons;
• Calls on National Medical Associations to urge national governments to cooperate
with the collection of such data as are necessary for establishing objective criteria;
• Calls on National Medical Associations to support and encourage research into the
global public health effects of weapons use, and to publicise the results of that
research, both nationally and internationally. This will ensure that both governments
and the public are aware of the long-term health consequences of weapons use on
non-combatant individuals and populations.
Handbook of WMA Policies
S-1997-01-2007 ⏐ World Medical Association
WMA PROPOSAL
FOR
A UNITED NATIONS RAPPORTEUR ON THE INDEPENDENCE
AND INTEGRITY OF HEALTH PROFESSIONALS
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
The British Medical Association (BMA) requests that the World Medical Association
(WMA) supports a proposal, put forward by a network of medical organizations*
con-
cerned with human rights issues, for the establishment of a new UN post of rapporteur on
the independence and integrity of health professionals.
It is envisaged that the role of the rapporteur will supplement the work already done by a
series of existing UN rapporteurs on issues such as torture, arbitrary execution, violence
against women, etc. The new rapporteur would be charged with the task of monitoring that
doctors are allowed to move freely and that patients have access to medical treatment,
without discrimination as to nationality or ethnic origin, in war zones or in situations of
political tension. The role of the proposed rapporteur is detailed on pages two, three and
four of this submission.
The original proposal was drawn up by a lawyer, Cees Flinterman, who is a professor of
constitutional and international law at the University of Limburg, Maastricht, in The
Netherlands. It has the support of a range of doctors’ organizations listed below*
, whose
interests are in protection of human rights and protection of doctors who act impartially in
conflict situations. This group will be consulting widely and acting with the help of the
International Commission of Jurists to interest the United Nations in this proposal.
The Council of the BMA supported this proposal after debate in 1996. It would lend con-
siderable weight to the campaign if the WMA would also support this concept whose
fundamental aim is to protect doctors and their patients in war situations and other cases
where medical independence may come under threat from political or military factions.
PROPOSAL FOR A RAPPORTEUR
ON THE INDEPENDENCE AND INTEGRITY OF HEALTH PROFESSIONALS
Goals
accepting that in many situations of political conflict (such as civil or international war) or
political tension (such as during suspension of civil rights in a government-declared state
of emergency), health professionals are often the first people outside military of govern-
ment circles to have detailed knowledge of human rights violations, including viola-tions
of the right of populations to access medical treatment, a network of physicians is anxious
that a range of national and international reporting mechanisms be established to achieve
the following goals:
Handbook of WMA Policies
S-1997-01-2007 ⏐ World Medical Association
1. To monitor the role of health professionals working in situations where either their
rights to give, or the rights of their patients to receive, treatment are threatened;
2. To make appeals for the protection of health professionals when they are in danger
solely because of their professional or human rights activities;
3. To defend patients who are in danger of suffering human rights violations solely be-
cause of seeking medical treatment;
4. To encourage reporting of human rights violations by health professionals;
5. To analyse information about health professionals voluntarily adopting discriminatory
practices. The group consider that existing UN reporting mechanisms need expansion.
Key among proposals for new mechanisms is the development of a new UN rap-
porteur’s post which would link together relevant information emerging from other
existing UN mechanisms and also suggest where other useful local and national
reporting networks could be developed in the long-term. Therefore, on the basis of
materials prepared by the Law Department at the University of Limburg, Maastricht
and circulated by the Dutch medical group, the Johannes Wier Foundation, the group
is campaigning for a new post of UN Rapporteur of the Independence and Integrity of
Health Professionals.
Defining the Role
The potential role of a UN Rapporteur need not be exhaustively defined in advance since
the experience of the individual and the practical applicability of the goals must have an
influence.
It should include the following:
• Receive, evaluate, investigate and report allegations of repression directed at health
professionals or intended to prevent individuals receiving medical care. The rap-
porteur should be a clearing house for reports from individuals, groups of doctors,
NGOs etc. and as well as simply receiving information, should pro-actively seek
our information, including on-site visits.
• To build upon existing principles as found in humanitarian lay and the codes of
medical ethics applicable in armed conflicts to develop specific guidelines on the
subject of medical impartiality in relation to the treatment of patients in situations
of political or armed conflict.
The World Medical Association and national medical association should be en-
couraged to disseminate such information to health professionals during their train-
ing. Arising also form such guidance should be the institution of mechanisms to
help health professionals protect themselves in situations where human rights are
at risk.
• The rapporteur should also have a consultative role, seeking the views of interna-
tional and national professional associations, human rights bodies and humani-
tarian organizations with regards to the protection of health professionals and the
defence of the right to treat patients impartially.
• The rapporteur should investigate reports of health professionals voluntarily trans-
gressing guidelines about impartiality and non-discrimination.
Berlin ⏐ S-1997-01-2007
UN Rapporteur on the Independence and Integrity of Health Professionals
Issues within the Remit
• The fundamental concern is to protect the nature of the doctor-patient relationship
from unjustified external interference although it will also include voluntary trans-
gressing of impartiality by health professionals. The rapporteur’s role will be to en-
sure the independence, integrity and impartiality of health professionals.
Ensuring these aims requires analysis of whether:
• the treatment decisions of health professionals can be carried out without coming
into conflict with improper pressure from authorities;
• the physical integrity and ability of health professionals to act in accordance
with their professional principles are both protected;
• health professionals are able to provide treatment on the basis of patient need;
• people in need of medical treatment are able to access it safely;
• health professionals are ensured their freedom of movement, in the capacity as
medical care providers, and be able to have access to people in need of medical
services.
Monitoring the degree to which external pressures influence negatively the provision
of medical treatment will be within the remit of the rapporteur.
• The remit will be global.
• For lack of a reporting mechanism, health professionals are often disempowered
form taking action on violations of patient rights. One of the issues of the rap-
porteur to monitor would be the introduction of national or local legislation, civil
or military regulations or other rules prohibiting or limiting the provision of medi-
cal or nursing care to certain categories of patient.
• It will be within the remit of the rapporteur to bring the evidence or reports of viola-
tions of medical impartiality, including those in health professionals cooperating
voluntarily, to responsible bodies in the medical field and to the governments
concerned.
• Blanket restrictions on the medical or nursing services to be provided to members
of vulnerable groups, such as refugees, asylum seekers, prisoners, minority ethnic
groups, should be among the issues monitored by the rapporteur. The rapporteur
should contribute to the empowerment of the health professionals to resist col-
lectively the erosion of such patients’ rights.
• Threats, intimidation or pressures on health professionals to discriminate against
patients on the basis solely of non-medical related considerations such as ethics,
religious or racial affiliation should be investigated even if the threats do not ma-
terialize into action.
• Reports of health professionals being harassed or detained simply because of their
profession or because of the exercise of professional skills will be investigated by
the rapporteur. Similarly repressive measures designed to prevent health profes-
sionals reporting infringements of medical integrity will be investigated. Measures
to encourage health professionals actively to document and report such violations
should be put forward by the rapporteur in consultation with other bodies.
• Reports of patients being impeded or discouraged from gaining access to the avail-
able medical treatment will be investigated.
Handbook of WMA Policies
S-1997-01-2007 ⏐ World Medical Association
Issues Outside the Remit
Just as important as defining what is within the rapporteur’s remit is the matter of
clarifying those issues which fall outside it. We anticipate that this too will become clearer
as practice and experience develop. In the meantime, however, we suggest that:
• health professionals in every country should be educated about the ethical res-
ponsibilities they owe to patients and potential patients. Whereas such education is
not within the remit of the rapproteur, acting as a resource for advice about medi-
cal impartiality would be within the rapporteur’s remit. In the long term this func-
tion should ideally be dealt with by delegation through medical schools, profes-
sional bodies and voluntary national networks;
• while government measures to regulate aspects of care, (such as the equitable dis-
tribution of medical resources of the prioritizing of treatment on basis of need)
would not generally be a matter for monitoring for the rapporteur, extreme meas-
ures likely to result in the disenfranchising of groups of patients from medical or
nursing services would be monitored and investigated;
• governments’ indiscriminate failure to provide health promotion or treatment to
many or all sectors of the community does not fall within the remit of the rappor-
teur;
• since a principal concern is to ensure access to medical treatment by patients who
need and want it, the voluntary decision of some individuals or patient groups to
exclude themselves (for example on religious or cultural grounds) from orthodox
medicine does not fall within the remit of the rapporteur.
*
organizations participating in the network include: Amnesty International; British Medical Asso-
ciation; Centre for Enquiry into Health & Allied Themes (Bombay); Graza Community Mental
Health; International Committee of the Red Cross; Physicians for Human Rights (in Denmark,
Israel, South Africa, the UK, & the USA); Turkish Medical Association; and, the Johannes Weir
Foundation.
Handbook of WMA Policies
S-1997-02-2018 ⏐ World Medical Association
WMA STATEMENT
ON
PHYSICIANS CONVICTED OF GENOCIDE, WAR CRIMES OR CRIMES
AGAINST HUMANITY
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
SCOPE AND DEFINITIONS
The scope of this Statement includes the following specified crimes: genocide, war
crimes, and crimes against humanity, as defined by the Rome Statute of the International
Criminal Court.
PREAMBLE
• Physicians are bound by medical ethics to dedicate themselves to the good of their
patients. Physicians who have been convicted of genocide, war crimes or crimes
against humanity1, have violated medical ethics, human rights and international
law and are therefore unworthy of practising medicine.
• In accordance with the principle of the presumption of innocence, only physicians
who have been convicted of the specified crimes should be declared unworthy of
practising medicine.
DISCUSSION
1. Physicians seeking to work in any country are subject to the regulations of that
country’s relevant authorities or jurisdiction. The duty to demonstrate suitability to
practice medicine rests with the person seeking licensure.
2. Physicians who have been convicted of genocide, war crimes or crimes against
humanity must not be allowed to practise in another country or jurisdiction.
3. The relevant licensing authorities must ensure both that physicians have the
required qualifications and that they have not been convicted of genocide, war
crimes or crimes against humanity.
4. Physicians who have been convicted of the specified crimes have sometimes been
able to leave the country in which these crimes were committed and obtain a
licence to practise medicine from the relevant licensing authority in another
Physicians convicted of Genocide or Crimes
S-1997-02-2018 ⏐ Reykjavik
country.
5. This practice is contrary to the public interest, damaging to the reputation of the
medical profession, and may be detrimental to patient safety.
RECOMMENDATIONS
1. The WMA recommends that physicians who have been convicted of the specified
crimes be denied a license to practice medicine and membership to national
medical associations by the relevant regulatory and licensing authority of that
jurisdiction.
2. The WMA recommends that relevant regulatory and licensing authorities use their
own authority to inform themselves, in so far as is possible, if verifiable allegations
of participation in genocide, war crimes or crimes against humanity have been
made against physicians, while at the same time respecting the presumption of
innocence.
3. National Medical Associations must be sure that a thorough investigation into
those allegations is performed by an appropriate authority.
4. The WMA recommends that national medical associations ensure that there is
efficient communication amongst themselves and that where possible and
appropriate they inform relevant national regulatory and licensing authorities of
physicians’ convictions of genocide, war crimes, or crimes against humanity.
1 As defined by the Rome Statute of the International Criminal Court.
Handbook of WMA Policies
S-1998-01-2018 ⏐ World Medical Association
WMA STATEMENT
ON
NUCLEAR WEAPONS
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and revised by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
The WMA Declarations of Geneva, of Helsinki and of Tokyo make clear the duties and
responsibilities of the medical profession to preserve and safeguard the health of the
patient and to dedicate itself to the service of humanity. Therefore, and in light of the
catastrophic humanitarian consequences that any use of nuclear weapons would have, and
the impossibility of a meaningful health and humanitarian response, the WMA considers
that it has a duty to work for the elimination of nuclear weapons. To achieve a world free
of nuclear weapons is a necessity.
RECOMMENDATIONS
Therefore, the WMA:
1. Condemns the development, testing, production, stockpiling, transfer, deployment,
threat and use of nuclear weapons;
2. Requests all governments to refrain from the development, testing, production,
stockpiling, transfer, deployment, threat and use of nuclear weapons and to work in
good faith towards the elimination of nuclear weapons;
3. Advises all governments that even a limited nuclear war would bring about immense
human suffering and substantial death toll together with catastrophic effects on the
earth’s ecosystem, which could subsequently decrease the worlds food supply and
would put a significant portion of the world’s population at risk of famine;
4. Is deeply concerned by plans to retain indefinitely and modernize nuclear arsenals; the
absence of progress in nuclear disarmament by nuclear-armed states; and the growing
dangers of nuclear war, whether by intent, including cyberattack, inadvertence or
accident;
5. Welcomes the Treaty on the Prohibition of Nuclear Weapons, and joins with others in
Nuclear Weapons
S-1998-01-2018 ⏐ Reykjavik
the international community, including the Red Cross and Red Crescent movement,
International Physicians for the Prevention of Nuclear War, the International
Campaign to Abolish Nuclear Weapons, and a large majority of UN member states, in
calling, as a mission of physicians, on all states to promptly sign, ratify or accede to,
and faithfully implement the Treaty on the Prohibition of Nuclear Weapons; and
6. Requests that all National Medical Associations join the WMA in supporting this
Declaration, use available educational resources to educate the general public and to
urge their respective governments to work urgently to prohibit and eliminate nuclear
weapons, including by joining and implementing the UN Treaty on the Prohibition of
Nuclear Weapons.
Handbook of WMA Policies
World Medical Association ⏐ S-1998-02-2010
WMA STATEMENT
ON
MEDICAL CARE FOR REFUGEES, INCLUDING ASYLUM SEEKERS,
REFUSED ASYLUM SEEKERS AND UNDOCUMENTED MIGRANTS,
AND INTERNALLY DISPLACED PERSONS
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
reaffirmed by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
PREAMBLE
International and civil conflicts as well as poverty and hunger result in large numbers of
refugees, including asylum seekers, refused asylum seekers and undocumented migrants,
as well as internally displaced persons (IDPs) in all regions. These persons are among the
most vulnerable in society.
International codes of human rights and medical ethics, including the WMA Declaration
of Lisbon on the Rights of the Patient, declare that all people are entitled without discrimi-
nation to appropriate medical care. However, national legislation varies and is often not in
accordance with this important principle.
STATEMENT
Physicians have a duty to provide appropriate medical care regardless of the civil or poli-
tical status of the patient, and governments should not deny patients the right to receive
such care, nor should they interfere with physicians’ obligation to administer treatment on
the basis of clinical need alone.
Physicians cannot be compelled to participate in any punitive or judicial action involving
refugees, including asylum seekers, refused asylum seekers and undocumented migrants,
or IDPs or to administer any non-medically justified diagnostic measure or treatment, such
as sedatives to facilitate easy deportation from the country or relocation.
Physicians must be allowed adequate time and sufficient resources to assess the physical
and psychological condition of refugees who are seeking asylum.
National Medical Associations and physicians should actively support and promote the
right of all people to receive medical care on the basis of clinical need alone and speak out
against legislation and practices that are in opposition to this fundamental right.
Handbook of WMA Policies
S-1999-01-2019 ⏐ World Medical Association
WMA STATEMENT
ON
PATENTING MEDICAL PROCEDURES
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212th
WMA Council Session, Santiago, Chile, April 2019
PREAMBLE
1. Under the law of some jurisdictions medical procedures are patentable. Patents on
medical procedures are often called medical procedure patents. A medical procedure
patent or patent claim is one that only confers rights over procedural steps and does
not confer rights over any new devices.
2. Over 80 countries prohibit medical procedure patents. The practice of excluding
medical procedures from patentability is consistent with the Uruguay Round of
Amendments to the General Agreements on Tariffs and Trade Agreement on Trade
Related Aspects of International Property Rights (GATT-TRIPs), which states:
«Members may also exclude from patentability: (a) diagnostic, therapeutic and surgical
methods for the treatment of humans or animals» (Article 27).
3. The purpose of patents is to encourage private investment in research and
development. However, physicians, particularly those who work in research
institutions, already have incentives to innovate and improve their skills. These
incentives include professional reputation, professional advancement, and ethical and
legal obligations to provide competent medical care (International Code of Medical
Ethics, 17.A). Physicians are already paid for these activities, and public funding is
sometimes available for medical research. The argument that patents are necessary to
spur invention of medical procedures, and that without procedure there would be fewer
beneficial medical procedures for patients, is not particularly persuasive when these
other incentives and financing mechanisms are available.
4. Another argument is that patents are necessary, not so much for invention but for
product development. This argument also is not persuasive in the case of medical
procedure patents. Unlike device development, which requires investment in
engineers, production processes, and factories, development of medical procedures
consists of physicians attain-ing and perfecting manual and intellectual skills. As
discussed above, physicians already have both obligations to engage in these
professional activities as well as rewards for doing so.
5. Whether or not it is ethical to patent medical devices does not bear directly on whether
it is ethical for physicians to patent medical procedures. Devices are manufactured and
disseminated by companies, whereas medical procedures are «produced and
disseminated» by physicians. Physicians have ethical or legal obligations to patients
and professional obligetions towards each other, which companies do not have.
Having particular ethical obliga-tions is part of what defines medicine as a profession.
Santiago ⏐ S-1999-01-2019
Patenting Medical Procedures
6. There is no a priori reason to believe that those holding medical procedure patents
would make patented medical procedures widely available. Patentees might attempt to
maximize their profits by making the procedure widely available through
nonexclusive licensing with low fees. Alternatively, they might attempt to maximize
profits by limiting avail-ability of the procedure and charging higher prices to those
for whom the procedure is extremely important and who have the means to pay.
7. Competition between organizations providing health care could provide incentives
for some organizations to negotiate exclusive licenses, or licenses which sharply limit
who else could practice the procedure. Such a license might provide the organization
with an advantage in attracting patients, if the organization could advertise that it was
the only organization in a region which could provide a particularly desirable service.
Thus, at least some of the time patentees will probably limit access to patented medical
procedures.
8. Medical procedure patents may negatively affect patient care. If medical procedure
patents are obtained, then patients’ access to necessary medical treatments might
diminish and thereby undermine the quality of medical care. Access could diminish for
the following reasons:
• the cost of medical practice would likely increase because of licensing and royalty
fees, and because the cost of physicians’ insurance would likely increase to cover
patent litigation expenses.
• some physicians capable of performing the patented procedure might not obtain
licenses to perform it. The number of licensed physicians might be restricted be-
cause certain physicians cannot or will not pay the licensing fees or royalties, or
because the patentee refuses to make the license widely available. Limiting the
number of licenses would, in some circumstances, limit patients’ choice of physi-
cians.
• The presence of patents may prevent physicians from undertaking even those pro-
cedures which do not infringe. It may also deter a physician from introducing new
or modified procedures into his or her practice. Devices can be labelled if they are
patented, but procedures cannot, and therefore it is not immediately obvious
whether what one is doing infringes somebody else’s medical procedure patent.
However, lack of knowledge is no defence against patent infringement, so if a
physician is uncertain he or she may simply refrain from performing the procedure.
9. Enforcement of medical procedure patents can also result in invasion of patients’
privacy or in the undermining of physicians’ ethical obligation to maintain the
confidentiality of patients’ medical information. Where physicians practice in small
groups or as sole practi-tioners, the most expedient methods for a patentee to identify
instances of infringement might be to look through patients’ medical records or to
interview patients. Removing obvious identifiers for the record review would not
guarantee confidentiality, because identity can often be «reconstructed» with very few
pieces of information. This would be parti-cularly true in small towns or small
practices.
10. Physicians have ethical obligations both to teach skills and techniques to their
S-1999-01-2019 ⏐ Santiago
Patenting Medical Procedures
colleagues, and to continuously learn and update their own skills. Medical procedure
patents can undermine these obligations. Once a patent has issued on a procedure,
the procedure would be fully disclosed (this is one requirement for obtaining a patent);
however, those without licenses would not be able to practice it. Limiting who can
practice the procedure undermines the spirit of the ethical mandate to teach and
disseminate knowledge. It also undermines the obligation to update one’s skills,
because it does not do much good to acquire skills which cannot be used legally.
11. The obligation to teach and impart skills may also be impaired if the possibility of
patents causes physicians to delay publishing new results or presenting them at
conferences. Physicians may be inclined to keep new techniques secret while waiting
to complete a patent application. This is because public use of a procedure, or
publication of a description of the procedure, prior to applying for a patent may
invalidate the application.
12. Physicians also have an ethical obligation not to permit profit motives to influence
their free and independent medical judgment (International Code of Medical Ethics,
17.A). For physicians to pursue, obtain, or enforce medical procedure patents could
violate this requirement. Physicians holding patents or licenses for procedures might
advocate for the use of those procedures even when they are not indicated, or not the
best procedure under the circumstances. Physicians who are not licensed to perform a
particular procedure might advocate against that procedure, even when it is the best
procedure under the circumstances.
13. Finally, physicians’ professional obligations to practice their profession with
conscience and dignity (Declaration of Geneva) might be violated by the enforcement
of medical procedure patents. The spectacle of physicians suing each other on a
regular basis is unlikely to enhance the standing of the profession.
POSITION
14. The World Medical Association
• states that physicians have an ethical responsibility to make relevant scientific in-
formation available to colleagues and the public, when possible.
• states that the patenting of medical procedures poses serious risks to the effective
practice of medicine by potentially limiting the availability of new procedures to
patients.
• considers that the patenting of medical procedures is unethical and contrary to the
values of the medical profession that should guide physicians’ service to their pa-
tients and relations with their colleagues.
• encourages national medical associations to make every effort to protect physi-
cians’ incentives to advance medical knowledge and develop new medical proce-
dures.
Handbook of WMA Policies
World Medical Association ⏐ S-1999-02-2010
WMA STATEMENT
ON
THE RELATIONSHIP BETWEEN PHYSICIANS AND PHARMACISTS
IN MEDICINAL THERAPY
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
INTRODUCTION
The goal of pharmacological treatment is to improve patients´ health and quality of life.
Optimal pharmacological treatment should be safe, effective and efficient. There should
be equity of access to this kind of treatment and an accurate and up-to-date information
base that meets the needs of patients and practitioners.
Pharmacological treatment has become increasingly complex, often requiring the input of
a multi-disciplinary team to administer and monitor the chosen therapy. In the hospital set-
ting the inclusion of a clinical pharmacist in such a team is increasingly common and help-
ful. The right to prescribe medicine should be competency based and ideally the responsi-
bility of the physician.
Physicians and pharmacists have complementary and supportive responsibilities in
achieving the goal of providing optimal pharmacological treatment. This requires com-
munication, respect, trust and mutual recognition of each other’s professional competence.
Access by both physicians and pharmacists to the same accurate and up-to-date informa-
tion base is important to avoid providing patients with conflicting information.
Physicians and pharmacists must provide quality service to their patients and ensure safe
use of drugs. Therefore collaboration between these professions is imperative, including
with respect to the development of training and in terms of information sharing with one
another and with patients. It is necessary to keep an open and continued dialogue between
physicians’ and pharmacists’ representative organizations in order to define each profes-
sion’s respective functions and promote the optimal use of drugs within a framework of
transparency and cooperation, all in the best interests of patients.
THE PHYSICIAN’S RESPONSIBILITIES
Diagnosing diseases on the basis of the physician’s education and specialized skills and
competence.
Assessing the need for pharmacological treatment and prescribing the corresponding medi-
cines in consultation with patients, pharmacists and other health care professionals, when
appropriate.
S-1999-02-2010 ⏐ Vancouver
Physicians and Pharmacists in Medical Therapy
Providing information to patients about diagnosis, indications and treatment goals, as well
as action, benefits, risks and potential side effects of pharmacological treatment. In the
case of off-label prescriptions the patient must be informed about the character of the pre-
scription.
Monitoring and assessing response to pharmacological treatment, progress toward thera-
peutic goals, and, as necessary, revising the therapeutic plan in collaboration with pharma-
cists, other health professionals and, when appropriate, caregivers.
Providing and sharing information in relation to pharmacological treatment with other
health care practitioners.
Leading the multi-disciplinary team of health professionals responsible for managing
com-plex pharmacological treatment.
Maintaining adequate records for each patient, according to the need for therapy and in
compliance with legislation respecting confidentiality and protecting the patient’s data.
Where practically possible, actively participating in establishing electronic drug delivery
systems within their workplace and supporting those systems with their professional
knowledge.
Maintaining a high level of knowledge of pharmacological treatment through continuing
professional development.
Ensuring safe procurement and storage of medicines that the physician is required to
supply or permitted to dispense.
Reviewing prescription orders to identify interactions, allergic reactions, contra-indica-
tions and therapeutic duplications.
Reporting adverse reactions to medicines to health authorities, in accordance with national
legislation.
Monitoring and limiting, where appropriate, prescriptions of medications that may have
addictive properties.
Documenting adverse reactions to medicines in the patient’s medical record.
THE PHARMACIST’S RESPONSIBILITIES
Ensuring safe procurement, adequate storage and dispensing of medicines in compliance
with the relevant regulations.
Providing information to patients, which may include the information leaflet, name of the
medicine, its purpose, potential interactions and side effects, as well as correct usage and
storage.
Handbook of WMA Policies
World Medical Association ⏐ S-1999-02-2010
Reviewing prescription orders to identify interactions, allergic reactions, contra-indica-
tions and therapeutic duplications. Concerns should be discussed with the prescribing phy-
sician but the pharmacist should not change the prescription without consulting the
prescriber.
Discussing medicine-related problems or concerns with regard to the prescribed medicines
when appropriate and when requested by the patient.
Advising patients, when appropriate, on the selection and the use of non-prescription
medicines and the patient’s management of minor symptoms or ailments. Where self-
medication is not appropriate, advising patients to consult their physician for diagnosis
and treatment.
Participating in multi-disciplinary teams concerning complex pharmacological treatment
in collaboration with physicians and other health care providers, typically in a hospital
setting.
Reporting adverse reactions to medicines to the prescribing physician and to health au-
thorities in accordance with national legislation.
Providing and sharing general as well as specific medicine-related information and advice
with the public and health care practitioners.
Maintaining a high level of knowledge of pharmacological treatment through continuing
professional development.
CONCLUSION
The patient will best be served when pharmacists and physicians collaborate, recognizing
and respecting each other’s roles, to ensure that medicines are used safely and appropriately
to achieve the best outcome for the patient’s health.
Handbook of WMA Policies
S-2002-01-2012 ⏐ World Medical Association
WMA STATEMENT
ON
SAFE INJECTIONS IN HEALTH CARE
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and amended with minor resivion by the 192nd
WMA Council Session,
Bangkok, Thailand, October 2012
PREAMBLE
According to the World Health Organization, billions of injections are administered world-
wide each year in health care. Of these injections, many millions are unsafe, especially
those that are administered with a re-used syringe and/or needle.
The most common diseases acquired from unsafe injections are hepatitis B, hepatitis C
and HIV.
In many countries disposable equipment is always used in health care settings, and the
major problem is the safe use and disposal of sharps.
Physicians are involved in the prescription and/or administration of injections. Therefore,
they are in a prime position to bring about changes in behaviour, which could lead to the
appropriate and safe use of injections.
Safe and appropriate use of injections is a necessary component of HIV prevention. Safe
practices to prevent HIV infection also yield substantial spin-off benefits outside the HIV
prevention area, such as hepatitis B and C infections.
BASIC CONSIDERATIONS
Unsafe injections result from the overuse of therapeutic injections and unsafe injection
practices. These practices include the use of unsterilized or inadequately sterilized needles,
the re-use of syringes and the inappropriate and unsafe disposal of syringes and needles.
Safe injection practices prevent harm to the recipient, the provider and the community.
Unsafe injections cause widespread harm by spreading pathogens on a large scale.
Physician attitudes and inappropriate practice standards may be important determinants in
the overuse of «therapeutic» injections in certain countries. These are a result of the as-
sumption that some patients only feel satisfied with a treatment if it includes an injection.
Scientific evidence has shown that this assumption is incorrect. Patients prefer good
Bangkok ⏐ S-2002-01-2012
Safe Injections in Health Care
communication with physicians to receiving injections. Furthermore, the payment schemes
in some health care systems may be structured in a way that they provide perverse in-
centives for unnecessary use of injections.
Most non-injectable medications are equivalent in action and efficacy to those which are
injectable.
Unsafe injections are a waste of precious healthcare resources and can easily be prevented
through integrated interventions. For an effective national, regional or local strategy to
promote safe injections, the following primary elements are necessary:
• The use of injections should be limited to suitably trained health care professionals
and trained lay persons;
• Behaviour change among patients and health care professionals to decrease injec-
tion overuse and achieve injection safety;
• The availability of necessary equipment and supplies, preferably disposable;
• The use of auto-disable syringes where appropriate;
• The appropriate management of sharps waste.
Increased availability of appropriate injection equipment and supplies, preferably dis-
posable, increases the safety of injections without necessarily increasing the number of
unnecessary injections.
RECOMMENDATIONS
That National Medical Associations cooperate with their national governments or other
appropriate authorities to develop effective policies on the safe and appropriate use of
injections. These policies would demand appropriate financing and include the assessment
of current injection practices and the development of an integrated plan. Such a plan
should support the provision of adequate supplies of injection equipment, measures to
enforce proper standards of sterilisation where needed, the management of sharps waste
and training programs to deter the overuse of injections and promote safe injection prac-
tices.
That physicians worldwide are urged to:
• Prescribe non-injectable medication rather than injectable medication whenever
possible and promote the use of non-injectable medication with patients and their
colleagues;
• Use injectable medications only if safe and appropriate and administer injections in
a way that does not harm the recipient, the provider and the community;
S-2002-01-2012 ⏐ Bangkok
Safe Injections in Health Care
• Ensure that only waste disposal containers for sharp objects be used to safely dis-
pose of used surgical material (e.g. needles, blades, etc.), and that the covers of
sharp instruments not be re-utilised.
Raise awareness regarding the risks involved with unsafe injections and help bring about
behaviour changes in patients and health professionals to promote safe and appropriate
injections. Training in this area should emphasise that needles should not be re-sheathed
Handbook of WMA Policies
World Medical Association ⏐ S-2002-02-2012
WMA STATEMENT
ON
SELF-MEDICATION
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and reaffirmed by the 191st
WMA Council Session, Prague, Czech Republic, April 2012
PREAMBLE
The World Medical Association has developed this statement to provide guidance to phy-
sicians and their patients regarding responsible self-medication.
1. Distinction between Self-Medication and Prescription Medicine
1. Medicinal products can generally be divided into two separate categories: pre-
scription and non-prescription medicines. This classification may differ from
country to country. The national authorities must assure that medicines, cate-
gorized as non-prescription medicines, are sufficiently safe not to be harmful
to health.
2. Prescription medicines are those which are only available to individuals on
prescription from a physician following a consultation. Prescription medicines
are not safe for use except under the supervision of a physician because of
toxicity, other potential or harmful effects (e.g. addictiveness), the method of
use, or the collateral measures necessary for use.
3. Responsible self-medication, as used in this document, is the use of a re-
gistered or monographed medicine legally available without a physician’s pre-
scription, either on an individual’s own initiative or following advice of a
healthcare professional. The use of prescription medicines without a prior me-
dical prescription is not part of responsible self-medication.
4. The safety, efficacy and quality of non-prescription medicines must be proved
according to the same principles as prescription medicines.
2. Use of Self-Medication in conjunction with Prescription Medication A course of
treatment may combine self-medication and prescription medication, either con-
currently or sequentially. The patient must be informed about possible interactions
between prescription medicines and non-prescription medicines. For this reason
the patient should be encouraged to inform the physician about his / her self-
medication.
3. Roles & Responsibilities in Self-Medication
1. In self-medication the individual bears primary responsibility for the use of
self-medication products. Special caution must be exercised when vulnerable
groups such as children, elderly people or pregnant women use self-medication.
S-2002-02-2012 ⏐ Prague
Self-Medication
2. If individuals choose to use self-medication, they should be able:
1. to recognize the symptoms they are treating;
2. to determine that their condition is suitable for self-medication;
3. to choose an appropriate self-medication product;
4. to follow the directions for use of the product as provided in the product
labelling.
3.
3. In order to limit the potential risks involved in self-medication it is important
that all health professionals who look after patients should provide:
1. Education regarding the non-prescription medicine and its appropriate use,
and instructions to seek further advice from a physician if they are unsure.
This is particularly important where self-medication is inappropriate for
certain conditions the patient may suffer from;
2. Encouragement to read carefully a product’s label and leaflet (if provided),
to seek further advice if necessary, and to recognize circumstances in which
self-medication is not, or is no longer, appropriate.
4. All parties involved in self-medication should be aware of the benefits and
risks of any self-medication product. The benefit-risk balance should be com-
municated in a fair, rational manner without overemphasizing either the risks
or the benefits.
5. Manufacturers in particular are obliged to follow the various codes or regula-
tions already in place to ensure that information provided to consumers is
appropriate in style and content. This refers in particular to the labelling, ad-
vertising and all notices concerning non-prescription medicines.
6. The pharmacist has a professional responsibility to recommend, in appropriate
circumstances, that medical advice be sought.
4. Role of Governments in Self-Medication Governments should recognize and en-
force the distinction between prescription and non-prescription medicines, and
ensure that the users of self-medication are well informed and protected from
possible harm or negative long-term effects.
5. The Promotion and Marketing of Self-Medication Products
1. Advertising and marketing of non-prescription medicines should be responsi-
ble, provide clear and accurate information and exhibit a fair balance between
benefit and risk information. Promotion and marketing should not encourage
irresponsible self-medication, purchase of medicines that are inappropriate, or
purchases of larger quantities of medicines than are necessary.
2. People must be encouraged to treat medicines (prescription and non-prescrip-
tion) as special products and that standard precautions should be followed in
terms of safe storage and usage, in accordance with professional advice.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-01-2013
WMA STATEMENT
ON
FORENSIC INVESTIGATIONS OF THE MISSING
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and amended by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Over the last three decades, forensic investigations into the whereabouts and fate of people
killed and missing as a result of armed conflict, other situations of violence and catas-
trophes, have made an important contribution to humanitarian action on behalf of victims,
including [the deceased and] bereaved families. Forensic investigations have also helped
in achieving justice and reparations for victims.
In 2003 the International Conference on The Missing and their Families, organized by the
International Committee of the Red Cross (ICRC), adopted a set of recommendations to
help prevent people going missing, and resolve the cases of those already missing, as a
result of armed conflicts and other situations of violence. The recommendations include
ethical, scientific and legal principles that must apply to forensic investigations in the
search, recovery, management and identification of human remains. These principles have
since been further developed by the ICRC’s forensic services and they provide a frame-
work for humanitarian forensic action in situations of armed conflicts, other situations of
violence and catastrophes.1
The principles also ensure the proper and dignified manage-
ment and identification of the dead, and help provide answers to the bereaved.
National Medical Associations have a role in promoting these principles and encouraging
compliance with them, and for ensuring the highest possible ethical, scientific and legal
standards in forensic investigations aimed at addressing the humanitarian consequences of
armed conflicts, other situations of violence and catastrophes.
In many countries NMAs will not have a role in certifying the qualifications and experi-
ence of forensic medical practitioners. NMAs should draw the attention of practitioners to
the best practice guidelines produced by the ICRC, the United Nations and Interpol, and
recommend or, where possible, require compliance with those standards.
RECOMMENDATIONS
The WMA calls upon all NMAs to help ensure that, when its members take part in
forensic investigations for humanitarian and human rights purposes, such investigations
are established with a clear mandate based upon the highest ethical, scientific and legal
S-2003-01-2013 ⏐ Fortaleza
Forensic Investigations of the Missing
standards, and conform with the principles and practice of humanitarian forensic action
developed by the ICRC.
The WMA calls upon NMAs to develop expertise in the principles collated by the dif-
ferent authorities on forensic investigations for humanitarian and human rights purposes,
including those developed by the ICRC to prevent new cases and resolve those of existing
missing persons, and to assist their members in applying these principles to forensic
investigations worldwide.
The WMA calls upon NMAs to disseminate the principles that should apply to such
investigations, including those developed by the ICRC, and to attempt to ensure that phy-
sicians refuse to take part in investigations that are ethically or otherwise unacceptable.
The WMA calls upon NMAs to help ensure compliance by forensic medical practitioners
with the principles enshrined in international humanitarian law for the dignified and
proper management, documentation and identification of the dead, and, where possible,
providing answers to the bereaved.
The WMA invites NMAs to be mindful of academic qualifications and ethical under-
standing, ensuring that forensic doctors practice with competence and independence.
1
The ICRC defines catastrophes as disasters beyond expectations. See: M. Tidball-Binz, Man-
aging the dead in catastrophes: guiding principles and practical recommendations for first
responders. International review of the Red Cross, Vol 89 Number 866 June 2007; 421- 442
Handbook of WMA Policies
World Medical Association ⏐ S-2003-02-2013
WMA STATEMENT
ON
ADVANCE DIRECTIVES («LIVING WILLS»)
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and reaffirmed by the 194th
WMA Council Session, Bali, Indonesia, April 2013
A. PREAMBLE
1. An advance directive is a written and signed document or a witnessed verbal
statement whereby persons record their wishes regarding the medical care they
wish to receive, or not receive, if they become unconscious or otherwise unable to
express their will.
2. This type of document may have different names in different countries (e.g.,
«living will» or «biological wills»). The acceptability and legal status of such
directives may differ from one country to another, depending on social, cultural
and religious and other factors.
3. The majority of persons who draw up such directives are particularly concerned
about excessive, ineffective or prolonged therapeutic interventions in the terminal
phases of life, in situations where there is clear and irreversible physical or mental
degeneration.
4. The WMA Declaration of Lisbon on the Rights of the Patient states that «If the
patient is unconscious and if a legally entitled representative is not available but a
medical intervention is urgently needed, consent of the patient may be presumed
unless it is obvious and beyond any doubt on the basis of the patient’s previous
firm expression or conviction that he/she would refuse consent to the intervention
in that situation.»
B. RECOMMENDATIONS
1. A patient’s duly executed advance directive should be honoured unless there are
reasonable grounds to suppose that it is not valid because it no longer represents
the wishes of the patient or that the patient’s understanding was incomplete at the
time the directive was prepared. If the advance directive is contrary to the physi-
cian’s convictions, provisions should be made to transfer the care of the patient to
another consenting physician.
2. If the physician is uncertain about the validity of an advance directive to terminate
life-prolonging treatment, he/she should consult family members or legal
guardians of the patient concerned and should seek advice from at least one other
S-2003-02-2013 ⏐ Bali
Living Wills
physician or the relevant ethics committee. The family members or legal guardians
should be designated in the advance directive, be trustworthy and willing to testify
as to the intention(s) expressed in the advance directive by the signatory. The
physician should consider any relevant legislation concerning substitute decision
making for incompetent patients.
3. Patients should be advised to review their advance directives periodically.
4. In the absence of an advance directive or a legally designated substitute decision
maker, physicians should render such treatment as they believe to be in the pa-
tient’s best interests.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-03-2014
WMA STATEMENT
ON
ETHICAL GUIDELINES FOR
THE INTERNATIONAL MIGRATION OF HEALTH WORKERS
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and revised by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
The WMA acknowledges that temporary stays of physicians in other countries help both
the receiving and the sending countries to exchange medical knowledge, skills and atti-
tudes. The exchange of medical professionals is therefore beneficial for the development
of medicine and healthcare systems and in general deserves the support of national medi-
cal associations as well as governments.
The WMA Statement on Medical Manpower – 1 (1983, 1986) called upon all National
Medical Associations to work with their governments towards solutions to the emerging
problems related to the medical workforce.
The WMA Resolution on the Medical Workforce (1998) identified the major components
of the medical workforce situation that need to be taken into account when developing a
national workforce policy.
For several decades many governments, employers and medical associations have mis-
interpreted demographical data regarding the number of physicians that are required.
Young people seeing employment as physicians have often been seriously affected by
poor medical workforce planning.
In many countries, including the wealthiest ones, there is a shortage of physicians. A
major reason for the shortage is a failure to educate enough physicians to meet the needs
of the country. Other reasons for the net loss of physicians are the recruitment of physi-
cians to other professions, early retirement and emigration, and the problems of combining
professional and family responsibilities, all of which are often due to poor working con-
ditions for physicians.
Some countries have traditionally solved their need for physicians by recruiting medical
graduates from other countries. This practice continues today.
The flow of international migration of physicians is generally from poorer to wealthier
countries. The poorer countries bear the expense of educating the migrating physicians
and receive no recompense when they enter other countries. The receiving countries gain a
valuable resource without paying for it, and in the process they save the cost of educating
their own physicians.
Physicians do have valid reasons for migrating, for example, to seek better career oppor-
tunities and to escape poor working and living conditions, which may include the pursuit
of more political and personal freedoms and other benefits.
S-2003-03-2014 ⏐ Durban
International Migration of Health Workers
RECOMMENDATIONS
1.
1. National medical associations, governments and employers should exercise utmost
care in utilizing demographic data to make projections about future requirements
for physicians and in communicating these projections to young people contem-
plating a medical career.
2. Every country should do its utmost to educate an adequate number of physicians,
taking into account its needs and resources. A country should not rely on immi-
gration from other countries to meet its need for physicians.
3. Every country should do its utmost to retain its physicians in the profession as well
as in the country by providing them with the support they need to meet their
personal and professional goals, taking into account the country’s needs and re-
sources.
4. Countries that wish to recruit physicians from another country should only do so in
terms of and in accordance with the provisions of a Memorandum of Under-
standing entered into between the countries.
5. Physicians should not be prevented from leaving their home or adopted country to
pursue career opportunities in another country.
6. Countries that recruit physicians from other countries should ensure that recruiters
provide full and accurate information to potential recruits on the nature and re-
quirements of the position to be filled, on immigration, administrative and con-
tractual requirements, and on the legal and regulatory conditions for the practice of
medicine in the recruiting country, including language skills.
7. Physicians who are working, either permanently or temporarily, in a country other
than their home country should be treated fairly in relation to other physicians in
that country (for example, equal opportunity career options and equal payment for
the same work).
8. Nothing should prevent countries from entering into bilateral agreements and
agreements of understanding, as provided for in international law and with due
cognizance of international human rights law, so as to effect meaningful co-
operation on health care delivery, including the exchange of physicians.
9. The WHO Global Code of Practice on the International Recruitment of Health
Personnel (May 2010) was established to promote voluntary principles and prac-
tices for the ethical international recruitment of health professionals and to facilitate
the strengthening of health systems. The Code takes into account the rights, obliga-
tions and expectations of source countries and migrant health professionals. The
WMA was involved in the drafting of the Code and supports its implementation.
10. The WHO Code states that international recruitment should be “conducted in ac-
cordance with the principles of transparency, fairness and promotion of sustain-
ability of health systems in developing countries.”
11. The monitoring and information-sharing system established by the WHO should be
robustly supported with the goal of international cooperation. Stakeholders should
regularly collate and share data, which should be monitored and anlaysed by the
WHO. The WHO should provide substantive critical feedback to governments.
Information should be shared about how to overcome challenges encountered.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-04-2008
WMA STATEMENT
ON
VIOLENCE AND HEALTH
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and reaffirmed by the 59th
WMA General Assembly, Seoul, Korea, October 2008
INTRODUCTION
In the year 2000 there were over 1.6 million people who lost their lives to violence –
meaning that every day more than 4,000 people around the world die a violent death.
Roughly half of these deaths are due to suicide, almost a third due to homicide, and the
remainder arise from conflict-related violence. These fatalities are only the tip of the ice-
berg – available data tends to come from higher income countries with established re-
porting systems and it is known that many forms of violence are more prevalent in lower
income settings that may not provide data to the World Health Organization. In addition to
potential data collection problems, a variety of different forms of violence, child abuse and
neglect, intimate partner violence and elder abuse, to name a few, are systematically under-
reported, owing to fear, shame, or cultural norms.
For every young person killed by homicide, at least 20-40 other youth receive hospital
treatment for violence-related injuries. One in five females and 5-10% of males report
being sexually abused during childhood. International population-based studies indicate
that between 10 and 69 percent of women report having been physically assaulted by an
intimate partner. In addition to the direct effects of injury arising from violence there are a
wide range of health effects, including mental and reproductive health problems, sexually
transmitted diseases, and other health problems. Health effects arising from violence can
last for years, and may include permanent mental or physical disability. From a societal
perspective, the economic costs associated with violence are substantial, with direct costs
for health services alone amounting to 5.0% of GDP in some countries.
No single factor drives violence, either at the level of the community or the individual.
Violence arises out of a complex interplay of individual, relationship, community, societal
and political factors.
In 1996 the World Health Assembly adopted resolution WHA49.25, which declared vio-
lence a global public health priority. One year later, resolution WHA50.19 was adopted,
which endorsed the World Health Organization’s integrated plan of action for a science-
based public health approach to the prevention of violence and called for further work in
this field.
S-2003-04-2008 ⏐ Seoul
Violence and Health
INVOLVEMENT OF THE INTERNATIONAL MEDICAL COMMUNITY
Irrespective of the diversity of factors that give rise to violence, there is one feature com-
mon to all forms of violence: the health effects suffered are a direct concern for the medi-
cal community.
Doctors can be victims of violence in the workplace or in other settings. In some cases
doctors can be involved in committing acts of violence or neglect. Doctors of every
description also deal with the victims of violence on a daily basis. They make decisions
regarding referral and coordinated care across specialties and health sectors, they plan for
long-term follow-up and care of disabilities, and in some settings they have contributed as
a profession to the prevention of violence. Whether as a pediatrician assessing if a child is
a victim of abuse, an emergency physician or surgeon tending to a shooting victim, a psy-
chiatrist dealing with the psychosocial impacts of intimate partner violence or any number
of other possible encounters, the reality is that more than any other profession the medical
community is absolutely central in terms of responding to the health effects of violence.
The manner in which the medical community can respond is varied and will depend as
much as anything else upon contextual features and realities. In some settings more struc-
tured forms of data collection are of paramount concern and doctors may be the only
group within such settings with the ability to lobby for health systems to adequately inte-
grate systematic data collection related to violent injury. In other settings that are more
advanced, clinicians and public health practitioners can play a major role in facilitating or
conducting focused studies that examine an aspect of violence or violence prevention. The
provision of such data to policy-makers in a timely and appropriate fashion can contribute
to further development of evidence-based policies to reduce violence.
RECOMMENDATIONS
National Medical Associations are encouraged to contribute to more systematic appro-
aches to dealing with violence, including:
Advocacy – violence is a global health problem and its victims are frequently among the
poorest, most powerless or otherwise most vulnerable within society. The medical profes-
sion should advocate at local, national and international levels for effective strategies to
prevent violence and limit its impact on health. Moreover, the medical profession should
denounce all depictions or uses of violent behaviour as solutions for personal, societal or
political problems.
Data collection – the medical profession should play a central role in ensuring that routine
data collection occurs and is of a sufficient standard and comprehensive enough to be a
valuable tool to guide public health policy. Research has shown that a large proportion of
victims of violence are not reported in police statistics because they are not the victims of
a crime (e.g. forms of family violence, bullying, etc.) or have avoided being reported to
the police.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-04-2008
Medical training – in recognition of the substantial burden of global morbidity and mor-
tality that is related to violence and the fact that violence and injury as a threat to health is
largely absent from medical training, the medical profession should take steps to ensure
the integration of injury and violence prevention into medical school curricula.
Prevention – the medical profession should use the unique opportunity during clinical en-
counters, where appropriate, to counsel patients and families with respect to creating safer,
less violent household environments. They can also use their clinical judgment to detect
victims of violence or those at potential risk for violence and make arrangements for ap-
propriate care.
Coordination of victim assistance – whether through detecting victims that may suffer
from violence but do not know how to bring themselves to medical attention, or through
appropriate referral to deal with the related health conditions or the physical, psychosocial
or long-term disability associated with injury, doctors can play a vital role in enhancing
the quality and comprehensiveness of victim assistance.
Research – violence is an under-documented global public health problem. Better under-
standing of causes and consequences of violence is necessary, along with an enhanced
understanding of the effectiveness of various strategies to prevent violence.
Social example – the medical profession should contribute to the creation and reinforce-
ment of social norms by not participating in or tolerating various forms of violence, such
as torture or mistreatment or neglect of certain populations such as prisoners, and actively
opposing such violence.
Policy-making – many countries still lack comprehensive national or local violence pre-
vention policies and plans of action. The medical profession should encourage the develop-
ment of such policies and in some cases take a leading role in developing them.
Handbook of WMA Policies
S-2004-02-2009 ⏐ World Medical Association
WMA STATEMENT
CONCERNING THE RELATIONSHIP
BETWEEN PHYSICIANS AND COMMERCIAL ENTERPRISES
Adopted by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
In the treatment of their patients, physicians use drugs, instruments, diagnostic tools,
equipment and materials developed and produced by commercial enterprises. Industry
possesses resources to finance expensive research and development programmes, for
which the knowledge and experience of physicians are essential. Moreover, industry sup-
port enables the furtherance of medical research, scientific conferences and continuing
medical education that can be of benefit to patients and the entire health care system. The
combination of financial resources and product knowledge contributed by industry and the
medical knowledge possessed by physicians enables the development of new diagnostic
procedures, drugs, therapies, and treatments and can lead to great advances in medicine.
However, conflicts of interest between commercial enterprises and physicians occur that
can affect the care of patients and the reputation of the medical profession. The duty of the
physician is to objectively evaluate what is best for the patient, while commercial enter-
prises are expected to bring profit to owners by selling their own products and competing
for customers. Commercial considerations can affect the physician’s objectivity, especially
if the physician is in any way dependent on the enterprise.
Rather than forbidding any relationships between physicians and industry, it is preferable
to establish guidelines for such relationships. These guidelines must incorporate the key
principles of disclosure, avoidance of obvious conflicts of interest and the physician’s cli-
nical autonomy to act in the best interests of patients.
These guidelines should serve as the basis for the review of existing guidelines and the de-
velopment of any future guidelines.
MEDICAL CONFERENCES
Physicians may attend medical conferences sponsored in whole or in part by a commercial
entity if these conform to the following principles:
1. The main purpose of the conference is the exchange of professional or scientific infor-
mation.
New Delhi ⏐ S-2004-02-2009
Physicians and Commercial Enterprises
2. Hospitality during the conference is secondary to the professional exchange of infor-
mation and does not exceed what is locally customary and generally acceptable.
3. Physicians do not receive payment directly from a commercial entity to cover travel-
ling expenses, room and board at the conference or compensation for their time unless
provided for by law and/or the policy of their National Medical Association.
4. Physicians may not accept unjustified hospitality and may not receive payment from a
commercial entity to cover room and board for accompanying persons.
5. The name of a commercial entity providing financial support is publicly disclosed in
order to allow the medical community and the public to assess the information pre-
sented in light of the source of funding. In addition, conference organizers and lec-
turers disclose to conference participants any financial affiliations they may have with
manufacturers of products mentioned at the event or with manufacturers of competing
products.
6. Presentation of material by a physician is scientifically accurate, gives a balanced
review of possible treatment options, and is not influenced by the sponsoring organi-
zation.
7. A conference can be recognised for purposes of continuing medical education / conti-
nuing professional development (CME/CPD) only if it conforms to the following
principles:
7.1. The commercial entities acting as sponsors, such as pharmaceutical companies,
have no influence on the content, presentation, choice of lecturers, or publica-
tion of results.
7.2. Funding for the conference is accepted only as a contribution to the general
costs of the meeting.
GIFTS
Physicians may not receive a gift from a commercial entity unless this is permitted by law
and/or by the policy of their National Medical Association and it conforms to the fol-
lowing conditions:
1. Physicians may not receive payments in cash or cash equivalents from a commercial
entity.
2. Physicians may not receive gifts for their personal benefit.
3. Gifts designed to influence clinical practice are always unacceptable. Promotional
aids may be accepted provided that the gift is of minimal value and is not connected
to any stipulation that the physician prescribes a certain medication, uses certain
instruments or materials or refers patients to a certain facility.
4. Cultural courtesy gifts may be received on an infrequent basis according to local
standards if the gift is inexpensive and not related to the practice of medicine.
S-2004-02-2009 ⏐ New Delhi
Physicians and Commercial Enterprises
RESEARCH
A physician may carry out research funded by a commercial entity, whether individually
or in an institutional setting, if it conforms to the following principles:
1. The physician is subject only to the law, the ethical principles and guidelines of the
Declaration of Helsinki, and clinical judgment in performing research and does not
allow himself or herself to be subject to external pressure regarding the results of his
or her research or their publication.
2. If possible, a physician or institution wishing to undertake research approaches more
than one company to request funding for the research.
3. Identifiable information about research patients or voluntary participants is not passed
to the sponsoring company without the consent of the individuals concerned.
4. A physician’s compensation for research is based on his or her time and effort and
such compensation is in no way connected to the results of the research.
5. The results of research are made public with the name of the sponsoring entity
disclosed, along with a statement disclosing who requested the research. This applies
whether the sponsorship is direct or indirect, full or partial.
6. Commercial entities do not suppress the publication of research results. If results of
research are not made public, especially if they are negative, the research may be re-
peated unnecessarily and thereby expose future participants to potential harm.
AFFILIATIONS WITH COMMERCIAL ENTITIES
A physician may not enter into an affiliation with a commercial entity such as consulting
or membership on an advisory board unless the affiliation conforms to the following prin-
ciples:
1. The affiliation does not compromise the physician’s integrity.
2. The affiliation does not conflict with the physician’s obligations to his or her patients.
3. Affiliations and/or other relationships with commercial entities are fully disclosed in
all relevant situations such as lectures, articles and reports.
Handbook of WMA Policies
World Medical Association ⏐ S-2004-03-2017
WMA STATEMENT
ON
WATER AND HEALTH
Approved by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and revised by the 65th
WMA General Assembly, Durban, South Africa, October 2014
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. An adequate supply of fresh (i.e. clean potable and uncontaminated) water is
essential for individual and public health, as well as being a social determinant of
health. It is central to living a life in dignity and health and upholding human
rights. Many individuals, families and communities do not have access to such a
supply, and even in those places where there is an abundance of fresh water, it is
threatened by pollution, activities such as industry and waste, inadequate or
ineffective sanitation and other negative forces.
2. A recent review of the evidence demonstrates that inadequate access to clean
water, sanitation and soap for hand washing is the norm in many healthcare
facilities worldwide, even in normal operating conditions. Natural and manmade
major events, including war, reduce access to clean water still further.
3. In keeping with its mission to serve humanity by endeavouring to achieve the
highest international standards in health care for all people in the world, the World
Medical Association has developed this statement to encourage all those
responsible for health to consider the importance and work towards achieving
universal access to of water, sanitation and hygiene for individual and public
health
4. Hygiene, sanitation and water (HSW) are important determinants of health. And
key intervention strategies for reducing preventable morbidity, mortality and health
care costs. The health sector, and physicians in particular, play a key role in
ensuring such determinants are properly managed.
CONSIDERATIONS
5. Water-borne diseases account for a large proportion of mortality and morbidity,
especially in developing countries. These problems are accentuated in times of
disasters such as conflicts nuclear and man-made accidents with oil and/or
chemicals, earthquakes, epidemics, droughts and floods.
6. Anthropogenic changes to ecosystems, lowered retention by the earth’s surface,
and the limitation of the inherent capacity of nature to filter dirt from the water are
causing increasing damage to the natural environment, especially the water
S-2004-03-2017 ⏐ Chicago
Water and Health
environment. Fracking for fossil fuels may have a significant effect on ground
water as does the accumulation of micropollutant substances including
pharmaceuticals and pesticides.
7. The commodification of water, whereby it is provided for profit rather than as a
public service, has potentially significant negative implications for access to an
adequate supply of drinking water.
8. The development of sustainable infrastructure for the provision of safe water and
adequate sanitation contributes greatly to sound public health and national well-
being. Curtailing infectious diseases and other ailments that are caused by unsafe
water lowers the burden of health care costs and improves productivity. This
creates a positive ripple effect on national economies
9. Water as a vital and necessary resource for life has become scarce in many parts of
the world and therefore must be used reasonably and with care.
10. Water and effective sanitation are assets that are shared by humanity and the earth.
Thus, water-related issues should be addressed collaboratively by the global
community.
11. Water, sanitation and hygiene are essential to the safe and effective provision of
health care services, and are fundamental to public health.
RECOMMENDATIONS
12. The WMA encourages National Medical Associations, health authorities and
physicians to support all measures related to improving access to adequate, safe
water and health including:
12.1. International and national programmes to provide ready access to safe
drinking water at low cost, or free, to every human on the planet and to prevent the
pollution of water supplies.
12.2. International, national, local and regional programmes to provide access to
sanitation and to prevent the degradation of water resources.
12.3. Research on the relationship between water pollution, water supply systems,
including wastewater treatment, and health.
12.4. The development of plans for providing potable water and proper wastewater
disposal during emergencies. These will vary according to the nature of the
emergency, but may include on-site water disinfection, identifying sources of
water, and back-up power to run pumps.
12.5. Preventive measures to secure safe water, sanitation and good hygiene for all
health care institutions, including after the occurrence of natural disasters,
especially earthquakes. Such measures should include the development of
Chicago ⏐ S-2004-03-2017
Water and Health
infrastructure and training programs to help health care institutions cope with such
crises. The implementation of continued emergency water supply programs should
be done in conjunction with regional authorities and with community involvement.
12.6. More efficient use of water resources by each nation. The WMA especially
urges hospitals and health institutions to examine their impact on sustainable water
resources and to adhere to the highest safety standards for drug and medical waste
disposal from healthcare settings.
12.7. Preventive measures and emergency preparedness to save water from
pollution.
12.8. The promotion of the universal access to clean and affordable water and
sanitation as a human right[1] and as a common good of humanity.
12.9. Instruction on the link between hygiene supported by hand washing, and ill
health prevention are health promotion and health education measures and requires
work by government and health agencies, especially where access to water has
previously been too limited for persons to exploit it for hygiene purposes.
12.10. The establishment of a real-time alert system accessible to both the local
population and to tourists providing information about the risks of contamination
of water in a particular area.
1
In 2010, the United Nations General Assembly and the Human Rights Council explicitly recog-
nized the human right to water and sanitation, derived from the right to an adequate standard of
living as stipulated in article 11 of the International Covenant on Economic, Social and Cultural
Rights and other international human rights treaties. Hence, it is part of international human
rights law.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-02-2015
WMA STATEMENT
ON
DRUG SUBSTITUTION
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
INTRODUCTION
1. The prescription of a drug represents the culmination of a careful deliberative process
between physician and patient aimed at the prevention, amelioration or cure of a
disease or problem. This deliberative process requires that the physician evaluate a
variety of scientific and other data including costs and make an individualized choice
of therapy for the patient. Sometimes, however, a pharmacist is required to substitute
a different drug for the one prescribed by the physician. The World Medical Associa-
tion has serious concerns about this practice.
2. Drug substitution can take two forms: generic substitution and therapeutic substitu-
tion.
3. In generic substitution, a generic drug is substituted for a brand name drug. However,
both drugs have the same active chemical ingredient, same dosage strength, and same
dosage form.
4. Therapeutic substitution occurs when a pharmacist substitutes a chemically different
drug for the drug that the physician prescribed. The drug substituted by the pharmacist
belongs to the same pharmacologic class and/or to the same therapeutic class. How-
ever since the two drugs have different chemical structures, adverse outcomes for the
patient can occur.
5. The respective roles of physicians and pharmacists in serving the patient’s need for
optimal drug therapy are outlined in the WMA Statement on the Working Relation-
ship between Physicians and Pharmacists in Medicinal Therapy.
6. The physician should be assured by national regulatory authorities of the bioequi-
valence and the chemical and therapeutic equivalence of prescription drug products
from both multiple and single sources. Quality assurance procedures should be in
place to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equi-
valence.
7. Many considerations should be addressed before prescribing the drug of choice for a
particular indication in any given patient. Drug therapy should be individualized
based on a complete clinical patient history, current physical findings, all relevant
laboratory data, and psychosocial factors. Once these primary considerations are met,
the physician should then consider comparative costs of similar drug products avail-
able to best serve the patient’s needs. The physician should select the type and quan-
tity of drug product that he or she considers to be in the best medical and financial
interest of the patient.
Santiago ⏐ S-2005-02-2005
Drug Substitution
8. Once the patient gives his or her consent to the drug selected, that drug should not be
changed without the consent of the patient and his or her physician. Failure to follow
this principle can result in harm to patients. On behalf of patients and physicians alike,
National Medical Associations should do everything possible to ensure the imple-
mentation of the following recommendations:
RECOMMENDATIONS
1. Physicians should become familiar with specific laws and/or regulations governing
drug substitution where they practise.
2. Pharmacists should be required to dispense the exact chemical, dose, and dosage form
prescribed by the physician. Once medication has been prescribed and begun, no drug
substitution should be made without the prescribing physician’s permission.
3. If substitution of a drug product occurs, the physician should carefully monitor and
adjust the dose to ensure therapeutic equivalence of the drug products.
4. If drug substitution leads to serious adverse drug reaction or therapeutic failure, the
physician should document this finding and report it to appropriate drug regulatory
authorities.
5. National Medical Associations should regularly monitor drug substitution issues and
keep their members advised on developments that have special relevance for patient
care. Collection and evaluation of information reports on significant developments in
this area is encouraged.
6. Appropriate drug regulatory bodies should evaluate and ensure the bioequivalence
and the chemical and therapeutic equivalence of all similar drug products, whether
generic or brand-name, in order to ensure safe and effective treatment.
7. National Medical Associations should oppose any action to restrict the freedom and
the responsibility of the physician to prescribe in the best medical and financial
interest of the patient.
8. National Medical Associations should urge national regulatory authorities to declare
therapeutic substitution illegal, unless such substitution has the immediate prior con-
sent of the prescribing physician.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-03-2009
WMA STATEMENT
ON
GENETICS AND MEDICINE
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
1. In recent years, the field of genetics has undergone rapid change and development.
The areas of gene therapy and genetic engineering and the development of new tech-
nology have presented possibilities inconceivable only decades ago.
2. The Human Genome Project opened new spheres of research. Its applications also
proved useful to clinical care, by allowing physicians to utilize knowledge of the
human genome in order to diagnose future disease as well as to individualize drug
therapy (pharmacogenomics).
3. Because of this, genetics has become an integral part of primary care medicine.
Whereas at one time, medical genetics was devoted to the study of relatively rare
genetic disorders, the Human Genome Project has established a genetic contribution to
a variety of common diseases. It is therefore incumbent upon all physicians to have a
working knowledge of the field.
4. Genetics is an area of medicine with enormous medical, social, ethical and legal
implications. The WMA has developed this statement in order to address some of
these concerns and provide guidance to physicians. These guidelines should be up-
dated in accordance with developments in the field of genetics.
MAJOR ISSUES:
Genetic testing
5. The identification of disease-related genes has led to an increase in the number of
available genetic tests that detect disease or an individual’s risk of disease. As the
number and types of such tests and the diseases they detect increases, there is concern
about the reliability and limitations of such tests, as well as the implications of testing
and disclosure. The ability of physicians to interpret test results and counsel their pa-
tients has also been challenged by the proliferation of knowledge.
6. Genetic testing may be undergone prior to marriage or childbearing to detect the pre-
sence of carrier genes that might affect the health of future offspring. Physicians
should actively inform those from populations with high incidence of certain genetic
Handbook of WMA Policies
World Medical Association ⏐ S-2005-03-2009
diseases about the possibility of pre-marital and pre-pregnancy testing, and genetic
counselling should be made available to those individuals or couples who are consi-
dering such testing.
7. Genetic counselling and testing during pregnancy should be offered as an option. In
cases where no medical intervention is possible following diagnosis, this should be
explained to the couple prior to their decision to test.
8. In recent years, with the advent of IVF, genetic testing has been extended to pre-
implantation genetic diagnosis of embryos (PGD). This can be a useful tool in cases
where a couple has a high chance of conceiving a child with genetic disease.
9. Since the purpose of medicine is to treat, in cases where no sickness or disability is
involved, genetic screening should not be employed as a means of producing children
with pre-determined characteristics. For example, genetic screening should not be
used to enable sex selection unless there is a gender-based illness involved. Similarly,
physicians should not countenance the use of such screening to promote non-health
related personal attributes.
10. Genetic testing should be done only with informed consent of the individual or his/her
legal guardian. Genetic testing for predisposition to disease should be performed only
on consenting adults, unless there is treatment available for the condition and the test
results would facilitate earlier instigation of this treatment.
11. Valid consent to genetic testing should include the following factors:
• The limitations of genetic testing, including the fact that the presence of a specific
gene may denote predisposition to disease rather than the disease itself and does
not definitively predict the likelihood of developing a certain disease, particularly
in multi-factorial disorders.
• The fact that a disease may manifest itself in one of several forms and in varying
degrees. Information about the nature and predictability of information received
from the tests.
• The benefits of testing including the relief of uncertainty and the ability to make
informed choices, including the possible need to increase or reduce regular screen-
ings and checkups and to implement risk reduction measures.
• The implications of a positive result and the prevention, screening and/or
treatment possibilities.
• The possible implications for the family members of the patient involved.
12. In the case of a positive test result that may have implications for third parties such as
close relatives, the individual tested should be encouraged to discuss the results of the
test with such third parties. In cases where not disclosing the results involves a direct
and imminent threat to the life or health of an individual, the physician may reveal the
results to such third parties, but should usually discuss this with the patient first. If the
physician has access to an ethics committee, it is preferable to consult such a com-
mittee prior to revealing results to third parties.
S-2005-03-2009 ⏐ New Delhi
Genetics and Medicine
Genetic counselling
13. Genetic counselling is generally offered prior to marriage or conception, in order to
predict the likelihood of conceiving an affected child, during pregnancy, in order to
determine the condition of the fetus, or to an adult, in order to determine susceptibility
to a certain disease.
14. Individuals at higher risk for conceiving a child with a specific disease should be
offered genetic counselling prior to conception or during pregnancy. In addition,
adults at higher risk for various diseases such as cancer, mental illness or neuro-
degenerative diseases in which the risk can be tested for, should be made aware of the
availability of genetic counselling.
15. Because of the scientific complexity involved in genetic testing as well as the prac-
tical and emotional implications of the results, the WMA sees great importance in
educating and training medical students and physicians in genetic counselling, parti-
cularly counselling related to pre-symptomatic diagnosis of disease. Independent ge-
netic counsellors also have an important role to play. The WMA acknowledges that
there can be very complex situations requiring the involvement of medical genetics
specialists.
16. In all cases where genetic counselling is offered, it should be non-directive and
protect the individual’s right not to be tested.
17. In cases of counselling prior to or during pregnancy, the prospective parents should be
given information to provide the basis for an informed decision regarding child-
bearing, but should not be influenced by the physicians’ personal views in this matter
and physicians should be careful not to substitute their own moral judgment for that
of the prospective parents. In cases where a physician is morally opposed to
contracep-tion or abortion, he/she may choose not to provide these services but should
alert pro-spective parents that a potential genetic problem exists and make note of the
option of contraception or abortion as well as treatment alternatives, relevant genetic
tests, and the availability of genetic counselling.
Confidentiality of results
18. Like all medical records, the results of genetic testing should be kept strictly
confidential, and should not be revealed to outside parties without the consent of the
individual tested. Third parties to whom results may in certain circumstances be
released are identified in paragraph 12.
19. Physicians should support the passage of laws guaranteeing that no individual shall be
discriminated against on the basis of genetic makeup in the fields of human rights,
employment and insurance.
Gene therapy and genetic research
20. Gene therapy represents a combination of techniques used to correct defective genes
that cause disease, especially in the fields of oncology, hematology and immune dis-
orders. Gene therapy is not yet an active current therapy but is still in a stage of clini-
Handbook of WMA Policies
World Medical Association ⏐ S-2005-03-2009
cal investigation. However, with the continued development of this field, it should
proceed according to the following guidelines:
• Gene therapy performed in a research context should conform to the requirements
of the Declaration of Helsinki while therapy performed in a treatment context
should conform to standards of medical practice and professional responsibility.
• Informed consent should always be obtained from the patient undergoing the
therapy. This informed consent should include disclosure of the risks of gene
therapy, including the fact that the patient may have to undergo multiple rounds of
gene therapy, the risk of an immune response, and the potential problems arising
from the use of viral vectors.
• Gene therapy should only be undertaken after a careful analysis of the risks and
benefits involved and an evaluation of the perceived effectiveness of the therapy,
as compared to the risks, side effects, availability and effectiveness of other treat-
ments.
21. It is currently possible to undertake screening of an embryo in order to provide stem
cell or other therapies for an existing sibling with a genetic disorder. This may be
considered acceptable medical practice where no evidence exists that the embryo is
being created exclusively for this purpose.
22. Genetic discoveries should be shared as much as possible between countries so as to
benefit humankind and reduce duplication of research and the risk inherent in research
in this area.
23. The mapping of human genomes must be anonymous but the information acquired
will apply to every human being. The genetic information should be general property.
Therefore, no patents should be given for the human genome or parts of it.
24. In the case of genetic research performed on large, defined population groups, efforts
should be made to avoid potential stigmatization.
Cloning
25. Recent developments in science have led to the cloning of a mammal and raise the
possibility of such cloning techniques being used in humans.
26. Cloning includes both therapeutic cloning, namely the cloning of individual stem cells
in order to produce a healthy copy of a diseased tissue or organ for transplant, and re-
productive cloning, namely the cloning of an existing mammal to produce a duplicate
of such mammal. The WMA currently opposes reproductive cloning, and in many
countries it is considered to pose more of an ethical problem than therapeutic cloning.
27. Physicians should act in accordance with the codes of medical ethics in their countries
regarding the use of cloning and be mindful of the law governing this activity
Handbook of WMA Policies
World Medical Association ⏐ S-2005-04-2015
WMA STATEMENT
ON
MEDICAL LIABILITY REFORM
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
1. A culture of litigation is growing around the world that is adversely affecting the
practice of medicine and eroding the availability and quality of health care services.
Some National Medical Associations report a medical liability crisis whereby the
lawsuit culture is increasing health care costs, restraining access to health care ser-
vices, and hindering efforts to improve patient safety and quality. In other countries,
medical liability claims are less rampant, but National Medical Associations in those
countries should be alert to the issues and circumstances that could result in an in-
crease in the frequency and severity of medical liability claims brought against physi-
cians.
2. Medical liability claims have greatly increased health care costs, diverting scarce
health care resources to the legal system and away from direct patient care, research,
and physician training. The lawsuit culture has also blurred the distinction between
negligence and unavoidable adverse outcomes, often resulting in a random determi-
nation of the standard of care. This has led to the broad perception that anyone can
sue for almost anything, betting on a chance to win a big award. Such a culture breeds
cynicism and distrust in both the medical and legal systems with damaging conse-
quences to the patient-physician relationship.
3. In adopting this Statement, the World Medical Association makes an urgent call to all
National Medical Associations to demand the establishment of a reliable system of
medical justice in their respective countries. Legal systems should ensure that patients
are protected against harmful practices, physicians are protected against unmeritorious
lawsuits, and standard of care determinations are consistent and reliable so that all
parties know where they stand.
4. In this Statement the World Medical Association wishes to inform National Medical
Associations of some of the facts and issues related to medical liability claims. The
laws and legal systems in each country, as well as the social traditions and the econo-
mic conditions of the country, will affect the relevance of some portions of this State-
ment to each National Medical Association but do not detract from the fundamental
importance of such a Statement.
5. An increase in the frequency and severity of medical liability claims may result, in
part, from one or more of the following circumstances:
a. Increases in medical knowledge and medical technology that have enabled phy-
sicians to accomplish medical feats that were not possible in the past, but that
involve considerable risks in many instances.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-04-2015
b. Pressures on physicians by private managed care organizations or government-
managed health care systems to limit the costs of medical care.
c. Confusing the right to access to health care, which is attainable, with the right to
achieve and maintain health, which cannot be guaranteed.
d. The role of the media in fostering mistrust of physicians by questioning their
ability, knowledge, behaviour, and management of patients, and by prompting pa-
tients to submit complaints against physicians.
6. A distinction must be made between harm caused by medical negligence and an un-
toward result occurring in the course of medical care and treatment that is not the fault
of the physician.
a. Injury caused by negligence is the direct result of the physician’s failure to con-
form to the standard of care for treatment of the patient’s condition, or the physi-
cian’s lack of skill in providing care to the patient.
b. An untoward result is an injury occurring in the course of medical treatment that
was not the result of any lack of skill or knowledge on the part of the treating
physician, and for which the physician should not bear any liability.
7. Compensation for patients suffering a medical injury should be determined differently
for medical liability claims than for the untoward results that occur during medical
care and treatment, unless there is an alternative system in place such as a no-fault
system or alternate resolution system.
a. Where an untoward result occurs without fault on the part of the physician, each
country must determine if the patient should be compensated for the injuries suf-
fered, and if so, the source from which the funds will be paid. The economic con-
ditions of the country will determine if such solidarity funds are available to com-
pensate the patient without being at the expense of the physician.
b. The laws of each jurisdiction should provide the procedures for deciding liability
for medical liability claims and for determining the amount of compensation
owed to the patient in those cases where negligence is proven.
8. National Medical Associations should consider some or all of the following activities
in an effort to provide fair and equitable treatment for both physicians and patients:
a. Establish public education programs on the risks inherent in some of the new
advances in treatment modalities and surgery, and professional education pro-
grams on the need for obtaining the patient’s informed consent to such treatment
and surgery.
b. Implement public advocacy programs to demonstrate the problems in medicine
and health care delivery resulting from strict cost containment limitations.
S-2005-04-2015 ⏐ Oslo
Medical Liability Reform
c. Enhance the level and quality of medical education for all physicians, including
improved clinical training experiences.
d. Develop and participate in programs for physicians to improve the quality of
medical care and treatment.
e. Develop appropriate policy positions on remedial training for physicians found to
be deficient in knowledge or skills, including policy positions on limiting the
physician’s medical practice until the deficiencies are corrected.
f. Inform the public and government of the dangers that various manifestations of
defensive medicine may pose (the multiplication of medical acts or, on the con-
trary, the abstention of the physicians, the disaffection of young physicians for
certain higher risk specialties or the reluctance by physicians or hospitals to treat
higher-risk patients).
g. Educate the public on the possible occurrence of injuries during medical treat-
ment that are not the result of physician negligence, and establish simple proce-
dures to allow patients to receive explanations in the case of adverse events and
to be informed of the steps that must be taken to obtain compensation, if avail-
able.
h. Advocate for legal protection for physicians when patients are injured by un-
toward results not caused by any negligence, and participate in decisions relating
to the advisability of providing compensation for patients injured during medical
treatment without any negligence.
i. Participate in the development of the laws and procedures applicable to medical
liability claims.
j. Develop active opposition to meritless or frivolous claims and to contingency
billing by lawyers.
k. Explore innovative alternative dispute resolution procedures for handling medical
liability claims, such as arbitration, rather than court proceedings.
l. Encourage self-insurance by physicians against medical liability claims, paid by
the practitioners themselves or by the employer if the physician is employed.
m. Encourage the development of voluntary, confidential, and legally protected sys-
tems for reporting untoward outcomes or medical errors for the purpose of analy-
sis and for making recommendations on reducing untoward outcomes and im-
proving patient safety and health care quality.
n. Advocate against the increasing criminalization or penal liability of medical acts
by the courts.
Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
WMA STATEMENT
ON
ASSISTED REPRODUCTIVE TECHNOLOGIES
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
PREAMBLE
1. Assisted reproductive technology encompasses a wide range of techniques designed
primarily to aid couples unable to conceive without medical assistance. Since the birth
of the first so-called ‘test-tube baby’ in 1978, more than 1.5 million children world-
wide have been born following IVF treatment.
2. The term ‘assisted reproductive technology’ includes techniques such as in-vitro fer-
tilisation (IVF) and intra-cytoplasmic sperm injection (ICSI). It can be defined as in-
cluding all treatments that include medical and scientific manipulation of human gam-
etes and embryos in order to produce a term pregnancy. Although some legislatures
have considered artificial insemination, whether using donor semen or semen from the
patient’s partner, as different, many of the issues about regulation in relation to obtain-
ing, storing, using and disposing of gametes and embryos are closely inter-linked. In
this statement treatments such as artificial insemination are excluded.
3. Assisted reproductive technologies raise profound moral issues. Views and beliefs
about the moral status of the embryo, which are central to much of the debate in this
area, vary both within and among countries. Assisted conception is also regulated dif-
ferently in various countries. Whilst consensus can be reached on some issues, there
remain fundamental differences of opinion that cannot be resolved. This statement
identifies areas of agreement and also highlights those matters on which agreement
cannot be reached. Physicians faced with such situations should comply with applica-
ble laws and regulations as well as the ethical requirements and professional standards
established by their National Medical Association and other appropriate organisations
in the community.
4. Physicians involved in providing assisted reproductive technologies should always
consider their ethical responsibilities towards any child who may be born as a result of
the treatment. If there is evidence that a future child would be exposed to serious
harm, treatment should not be provided.
5. As with all other medical procedures, physicians also have an ethical obligation to
limit their practice to areas in which they have relevant expertise and experience and
to respect the rights of patients. These rights include that of personal bodily integrity
and freedom from coercion. In practice this means that valid or real consent is re-
quired 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 to decide in a parti-
cular way.
Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
6. Assisted conception differs from the treatment of illness in that the inability to be-
come a parent without medical intervention is not always regarded as an illness.
While it may have profound psychosocial, and thus medical, consequences, it is not in
itself life limiting. It is, however, a significant cause of major psychological illness
and its treatment is clearly medical.
7. Obtaining informed consent from those considering undertaking treatment must in-
clude consideration of the alternatives, including accepting childlessness or pursuing
adoption, the risks associated with the various techniques, and the possibility of failure.
In many jurisdictions the process of obtaining consent must follow a process of infor-
mation 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.
8. Patients seeking assisted reproductive technologies are entitled to the same level of
confidentiality and privacy as for any other medical treatment.
9. Assisted reproductive technology always involves handling and manipulation of hu-
man gametes and embryos. Different individuals regard this with different levels of
concern but there is general agreement that these special concerns should be met by
specific safeguards to protect from abuse. In some jurisdictions all centres handling
such materials require a licence and must demonstrate compliance with high norma-
tive standards.
SUCCESS OF THE TECHNIQUES
1. The success of different techniques may differ widely from centre to centre. Physi-
cians have an obligation to give realistic information about success rates to potential
patients. If their success rates are widely different from the current norm they should
disclose this fact to patients. They also have an obligation to consider the reasons for
this as they might relate to poor practice, and if so, to correct their deficiencies.
MULTIPLE PREGNANCIES
1. Replacement of more than one embryo may raise the likelihood of at least one embryo
implanting. This is offset by the increased risk, especially of premature labour, in
multiple pregnancies. The risk of twin pregnancies, while higher than that of singleton
pregnancies, is considered acceptable by most people. Practitioners should follow pro-
fessional guidance on the maximum number of embryos to be transferred per treat-
ment cycle. If multiple pregnancies occur, selective termination might be considered
on medical grounds to increase the chances of the pregnancy proceeding to term
where this is compatible with the national law and code of ethics.
DONATION
1. Some patients are unable to produce usable gametes. They require ova or sperm from
donors. Donation should follow counselling and be carefully controlled to avoid
abuses, including coercion of potential donors. It is inappropriate to offer money or
benefits in kind (for example free or lower cost treatment cycles) to encourage dona-
tion but donors may be reimbursed for reasonable expenses.
Pilanesberg ⏐ S-2006-01-2006
Assisted Reproductive Technologies
2. Where a child is born following donation, families should be encouraged to be open
with him/her about this, irrespective of whether domestic law entitles the child to
information about the donor. Keeping secrets within families is difficult and can be
harmful to children if information about donor conception is disclosed inadvertently
and without appropriate support.
PRE-IMPLANTATION GENETIC DIAGNOSIS (PGD)
1. Pre-implantation genetic diagnosis (PGD) 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 reasons, includ-
ing identifying those embryos most likely to implant successfully in women who have
had multiple spontaneous abortions. Embryos carrying the abnormality are discarded;
only embryos with apparently normal genetic and chromosomal complements are im-
planted.
2. Neither this powerful technique nor simpler means should be used for trivial reasons
such as sex selection for reasons of gender preference. The WMA holds that physi-
cians should only be involved with sex selection where it is used to avoid a serious
sex-chromosome related condition such as Duchenne’s Muscular Dystrophy.
3. PGD can also be combined with HLA matching to select embryos on the basis that
stem cells from the resulting child’s umbilical cord blood could be used to treat a
seriously ill sibling. Views on the acceptability of this practice vary and physicians
should follow national laws and local ethical and professional standards if confronted
with such requests.
USE OF SPARE GAMETES AND EMBRYOS
AND DISPOSAL OF UNUSED GAMETES AND EMBRYOS
1. In most cases, assisted conception results in the production of gametes and embryos
that will not be used to treat those from whom they are procured. Such so-called spare
gametes and embryos may be stored, cryo-preserved for future use, donated to other
patients or disposed of. One alternative to disposal, in countries that permit embryo
research, is donation to a research facility. The available options must be explained
clearly and precisely to individuals before donations are made or retrievals performed.
SURROGACY
1. Where a woman is unable, for medical reasons, to carry a child to term, surrogacy
may be used to overcome childlessness, unless prohibited by national law or the ethi-
cal rules of the National Medical Association or other relevant organisation. Where
surrogacy is practised, great care must be taken to protect the interests of all parties
involved.
Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
RESEARCH
1. Physicians should promote the importance of research using tissues obtained during
assisted conception procedures. Because of the special status of the material being
used, research on human gametes and especially on human embryos is, in many juris-
dictions, specifically regulated. Physicians have an ethical duty to comply with such
regulation and to help inform public debate and understanding of the issues.
2. Due to the special nature of human embryos, research should be carefully controlled
and should be limited to areas in which the use of alternative materials will not pro-
vide an adequate alternative.
3. Views, and legislation, differ on whether embryos may be created specifically for, or
in the course of, research. Physicians should act in accordance with national legisla-
tion and local ethical advice.
CELL NUCLEAR REPLACEMENT
1. The WMA opposes the use of cell nuclear replacement with the aim of cloning human
beings.
2. Cell nuclear replacement may also be used to develop embryonic stem cells for
research and ultimately, it is hoped, for therapy for many serious diseases. Views on
the acceptability of such research differ and physicians wishing to participate in such
research should ensure that they are acting in accordance with national laws and local
ethical guidance.
RECOMMENDATIONS
1. Assisted reproductive technology is a dynamic, rapidly developing field of medical
practice. Developments should be subject to careful ethical consideration alongside
the scientific monitoring.
2. Human gametes and embryos are accorded a special status. Their use, including for
research, donation to others and disposal, should be carefully explained to potential
donors and subject to local regulation.
3. Embryo research should only be carried out if local law and ethical standards permit it
and should be limited to areas where the use of alternative materials or computer
modelling does not provide an adequate alternative.
4. Physicians should follow professional guidance on the maximum number of embryos
to transfer in any treatment cycle.
5. It is inappropriate to offer money or benefits in kind (for example free or lower cost
treatment cycles) to encourage donation but donors may be reimbursed for reasonable
expenses.
Pilanesberg ⏐ S-2006-01-2006
Assisted Reproductive Technologies
6. Families using donated embryos or gametes should be encouraged and supported to
be open with the child about this.
7. Sex selection should only be carried out to avoid serious, including life threatening,
medical conditions.
8. Physicians have an important role in ensuring that public debate about the
possibilities of assisted conception, and the limits to be applied to its practice, is
informed.
9. Physicians should comply with national legislation and should demonstrate com-
pliance with high normative standards.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2018
WMA STATEMENT
ON
AVIAN AND PANDEMIC INFLUENZA
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
Pandemic influenza occurs approximately three or four times every century. It usually
occurs when a novel influenza A virus emerges that can easily be transmitted from person-
to-person, to which humans have little or no immunity. Infection control and social
distancing practices can help slow down the spread of the virus. Vaccine development can
be challenging as the pandemic strain may not be accurately predicted. Adequate supplies
of antivirals are key for treatment of specific at-risk population and controlling further
spread of the outbreak.
Avian influenza is a zoonotic infection of birds and poultry, and can cause sporadic human
infections. Birds act as reservoir and shed the virus in their feces, mucous and saliva. In
addition, a new pandemic virus could develop if a human became simultaneously infected
with avian and human influenza viruses, resulting in gene swapping and a new virus strain
for which there may be no immunity. Humans are infected if they are exposed through the
mouth, eyes, or from the inhalation of virus particles. Limited evidence of human to
human transmission has been reported as well.
This statement alongside with WMA Statement on Epidemics and Pandemics provides
guidance to National Medical Associations and physicians on how they should be
involved in their respective country’s pandemic influenza planning and how to respond to
Avian Influenza or pandemic influenza.
RECOMMENDATIONS
Avian Influenza
• In the event of an avian influenza outbreak, the following measures should be
taken:
• Sources of exposure should be avoided when possible as this is the most effective
prevention measure.
• Personal protective equipment should be used and hand hygiene practices
emphasized for personnel handling poultry as well as members of the healthcare
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team.
• All infected/exposed birds should be destroyed with proper disposal of carcasses,
and rigorous disinfection or quarantine of farms.
• Stockpiles of vaccines and antivirals should be maintained for use during an
outbreak.
• Antiviral medications such as neuraminidase inhibitors may be used for treatment.
Pandemic Influenza Preparedness
WHO and National Public Health Officials:
• The coordination of the international response to an influenza pandemic is the
responsibility of the World Health Organization (WHO). The WHO currently uses
an all-hazards risk based approach, to allow for a coordinated response based on
varying degrees of severity of the pandemic.
The WHO should:
• Offer technical and laboratory assistance to affected countries if needed and
continuously monitor activity levels of potential pandemic influenza strains
continuously, ensuring that the designation of “Public Health Emergency of
International Concern” is done in a timely manner if needed.
• Monitor and coordinate processes by which governments share biological
materials including virus strains, to facilitate the production of and ensure access to
vaccines globally.
• Communicate available information on influenza activity of concern as early as
possible to allow for a timely response.
National governments are urged to develop National Action plans to address the following
points:
• Ensure that there is adequate local capacity for diagnosis and surveillance to allow
continuous monitoring of influenza activity around the country.
• Consider the surge capacity of hospitals, laboratories, and public health
infrastructure and improve them if necessary.
• Identify legal and ethical frameworks as well as governance structures in relation
to the pandemic planning.
• Identify the mechanisms and the relevant authorities to initiate and escalate
interventions to slow the spread of the virus in the community such as school
closures, quarantine, border closures etc.
• Prepare risk and crisis communication strategies and messages in anticipation of
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Avian and Pandemic Influenza
public and media fear and anxiety.
• Governments are also urged to share biological materials namely virus strains and
others, to facilitate the production and ensure access to vaccines globally.
• Ensure that diagnostics and surveillance efforts are continued and that adequate
vaccine and antiviral stockpiles are established.
• Establish protocols to manage patients in the community, carry out triage in
healthcare facilities, provide ventilation management, and handle infectious waste.
• Allocation of vaccine doses, antivirals and hospital beds should be coordinated
with experts.
• Priority for vaccination should be given to the highest risk groups including those
required to maintain essential services, including health care services.
• Guidance and timely information to regional health departments, health care
organizations, and physicians.
• Preparation for an increase in demand for healthcare services and absences of
health care providers especially if clinical severity of the illness is high. In such
cases prioritization and coordination of available resources is essential. This may
include tapping into private sector capacity where state resources are insufficient.
• Ensure adequate funding is allocated for pandemic preparedness and response as
well as its health and social consequences.
• Make sure that mechanisms are in place to ensure the safety of healthcare facilities,
personnel and the supply chains for vaccines and antivirals
• Promote and fund research to develop vaccines and effective treatments with
lasting effects against influenza.
• Encourage collaboration between human and veterinary medicine in the
prevention, research and control of avian influenza.
National Medical Associations are urged to:
• Delineate their involvement in the national pandemic influenza preparedness plan,
which may include increasing capacity building amongst physicians, participating
in guideline development and communication with healthcare professionals.
• Help educate the public about avian and pandemic influenza.
• When feasible, coordinate with other healthcare professionals’ organizations as
well as other NMAs to identify common issues and congruent policies related to
pandemic influenza preparedness and response.
• Consider implementing support strategies for members involved in the response
including mental health services, facilitation of health emergency response teams,
and locum relief.
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• Advocate before and during a pandemic, for allocation of adequate resources to
meet foreseeable and emerging needs of healthcare, patients and the general
public.
• Encourage health personnel to protect themselves by vaccination.
• Develop their own organization-specific business contingency plans to ensure
continued support of their members.
Physicians:
• Must be sufficiently knowledgeable about pandemic influenza and transmission
risks, including local, national and international epidemiology.
• Should implement infection control practices and vaccination, to protect
themselves as well as other staff members during seasonal and pandemic influenza
outbreaks.
• Must participate in local/regional pandemic influenza preparedness planning and
training.
• Should develop contingency plans to deal with possible disruptions in essential
services and personnel shortages.
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WMA STATEMENT
ON
HIV/AIDS AND THE MEDICAL PROFESSION
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
INTRODUCTION
1. HIV/AIDS, a chronic manageable disease, is a global pandemic that has created
unprecedented challenges for physicians and health infrastructures.
In addition to representing a staggering public health crisis, HIV/AIDS is also
fundamentally a human rights issue.
Many factors drive the spread of the disease, such as poverty, homelessness, illiteracy,
prostitution, human trafficking, drug (substance) abuse, stigma, discrimination and
gender-based inequality.
These social, economic, legal and human rights factors affect not only the public
health dimension of HIV/AIDS but also individual physicians/health workers and
patients, their decisions and relationships.
Efforts to tackle the disease are also constrained by the lack of human and financial
resources available in health care systems.
2. Discrimination against HIV / AIDS patients by physicians is unacceptable and must be
eliminated completely from the practice of medicine.
2.1 All persons with HIV/AIDS are entitled to adequate and timely support,
treatment and care with compassion and respect for human dignity.
2.2 It is unethical for a physician to refuse to treat a patient whose condition is
within his or her current realm of competence, solely because the patient is
seropositive.
2.3 National Medical Associations should work with respective governments,
patient groups and relevant national and international organizations to ensure
that national health policies clearly and explicitly prohibit discrimination
against people infected with or affected by HIV/AIDS, including vulnerable
groups such as males having sex with males and transgender persons.
2.4 Woman and man having sex with same sex partners are at a higher risk of
discrimination at all levels. National Medical organizations shall work with
Government, Non-Governmental Organizations, and Community based
organizations to remove the discrimination for these under-privileged
disadvantaged groups.
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APPROPRIATE / COMPETENT MEDICAL CARE
3. Patients with HIV/AIDS must be provided with competent and appropriate medical
care at all stages of the disease.
4. A physician who is not able to provide the care and services required by patients with
HIV/AIDS must make an appropriate timely referral to those physicians or facilities
that are equipped to provide such services. Unless or until the referral can be
accomplished, the physician must take care for the patient.
5. All physicians should be able to timely suspect and identify common opportunistic
infections such as tuberculosis, fungal infections in HIV-AIDs patients and also
suspect HIV-AIDS in presence of these infections especially in high risk individuals
like IV drug users.
They must timely counsel these patient about the nexus of these infections with HIV
infection.
6. Physicians and other appropriate professional bodies must ensure that patients have
accurate information regarding transmission of HIV/AIDS and strategies to protect
themselves against infection.
Proactive measures should be taken to ensure that all members of the population,
particularly at-risk groups, are educated to this effect.
Public information and related strategies should recognise that everyone is at risk, and
attempt to spell out methods of risk reduction.
7. Physicians must effectively counsel all seropositive patients regarding responsible
behaviour to prevent the spread of the infection to their partners and prevention of
opportunistic infections.
8. Physicians must recognize that many people still believe HIV/AIDS to be an
automatic and immediate death sentence and therefore will not seek testing.
Physicians must ensure that patients have accurate information regarding the treatment
options available to them.
Patients should understand the potential and need of starting early antiretroviral
treatment (ART) to improve not only their medical condition but also the quality of
their lives. The new strategy is test and treat strategy.
Effective ART can greatly extend the period that patients are able to lead healthy
productive lives, functioning socially and in the workplace and maintaining their
independence.
HIV/AIDS is now manageable chronic condition.
For ART country – specific WHO evidence based practice guidelines should be
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HIV/AIDS and the Medical Profession
followed and promoted by all NMAs.
9. Physicians should be aware that misinformation regarding the negative aspects of ART
has created resistance toward treatment by patients in some areas. Where
misinformation is being spread about ART, physicians and medical associations must
make it an immediate priority to publicly challenge the source of the misinformation
and to work with the HIV/AIDS community to counteract the negative effects of the
misinformation.
10. Physicians should encourage the involvement of support networks to assist patients in
adhering to ART regimens. With the patient’s consent, counselling and training should
be available to family members to assist them in providing care.
11. Physicians must be aware of the discriminatory attitudes toward HIV/AIDS that are
prevalent in society and local culture. Because physicians are the first, and sometimes
the only, people who are informed of their patients’ HIV status, physicians should be
able to counsel them about their basic social and legal rights and responsibilities or
should refer them to counsellors who specialize in the rights of persons living with
HIV/AIDS.
12. Physicians should be aware of the current availability and prescribing guidelines for
pre-exposure and post-exposure prophylaxis for any patient and health care providers
who may have been exposed to HIV.
TESTING
13. Mandatory testing for HIV must be required of donated blood and blood fractions
collected for donation or to be used in the manufacture of blood products; organs and
other tissues intended for transplantation; and semen or ova collected for assisted
reproduction procedures.
Newer technologies which are more sensitive, specific, and reduce the window period
of HIV detection, such as nuclear acid testing (NAT), should be encouraged for such
screening.
14. Mandatory HIV testing of an individual against his or her will is a violation of medical
ethics and human rights.
15. Physicians must clearly explain the purpose of an HIV test, the reasons it is
recommended and the implications of a positive test result.
Before a test is administered, the physician should have an action plan in place in case
of a positive test result. Informed consent must be obtained from the patient prior to
testing.
16. While certain groups are labeled “high risk”, anyone who has had unprotected sex
should be considered at risk.
Physicians must become increasingly proactive about recommending testing to
patients, based on a mutual understanding of the level of risk and the potential to
benefit from testing. Pregnant women and her partner should routinely be offered
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testing for HIV, and those pregnant women found to be HIV positive should be offered
immediate counseling and offered timely ART (at diagnosis) in order to prevent
transmission of the virus to the fetus and treatment of the fetus if seropositive.
17. Counselling and voluntary anonymous testing for HIV should be available to all
persons who request it, along with adequate post-testing support mechanisms.
PROTECTION FROM HIV IN THE HEALTH CARE ENVIRONMENT
18. Physicians and all health care workers have the right to a safe work environment.
Especially in developing countries, the problem of occupational exposure to HIV has
contributed to high attrition rates of the health labour force. In some cases, employees
become infected with HIV, and in other cases fear of infection causes health care
workers to leave their jobs voluntarily. Fear of infection among health workers can
also lead to refusal to treat HIV/AIDS patients. Likewise, patients have the right to be
protected to the greatest degree possible from transmission of HIV from health
professionals and in health care institutions.
18.1 Proper infection control procedures and universal precautions consistent with
the most current national or international standards, as appropriate, should be
implemented in all health care facilities. This includes procedures for the use
of preventive and timely bART for health professionals who have been
exposed to HIV.
18.2 If the appropriate safeguards for protecting physicians or patients against
infection are not in place, physicians and National Medical Associations
should take action to correct the situation.
18.3 Physicians who are infected with HIV should not engage in any activity that
creates a risk of transmission of the disease to others.
In the context of possible exposure to HIV, the activity in which the physician
wishes to engage will be the determining factor.
There may be nationally agreed standards but if not a determination should be
made by a suitable expert panel or committee of health workers.
18.4 In the provision of medical care, if a risk of transmission of an infectious
disease from a physician to a patient exists, disclosure of that risk to patients is
not enough; patients are entitled to expect that their physicians will not
increase their exposure to the risk of contracting an infectious disease.
18.5 If no risk exists, disclosure of the physician’s medical condition to his or her
patients will serve no rational purpose.
18.6 Physicians should be aware of current professional guidelines for post-
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exposure prophylaxis of health care workers in case of any accidental
exposure to HIV.
PROTECTING PATIENT PRIVACY AND ISSUES RELATED TO NOTIFICATION
19. Fear of stigma and discrimination is a driving force behind the spread of HIV/AIDS.
The social and economic repercussions of being identified as infected can be
devastating and can include violence, rejection by family and community members,
loss of housing and loss of employment.
Normalizing the presence of HIV/AIDS in society through public education is the only
way to reduce discriminatory attitudes and practices. Until that can be universally
achieved, or a cure is developed, potentially infected individuals may refuse testing to
avoid these consequences.
The result of individuals not knowing their HIV status is not only disastrous on a
personal level in terms of not receiving treatment, but may also lead to high rates of
avoidable transmission of the disease. Fear of unauthorized disclosure of information
also provides a disincentive to participate in HIV/AIDS research and generally thwarts
the efficacy of prevention programs. Lack of confidence in protection of personal
medical information regarding HIV status is a threat to public health globally and a
core factor in the continued spread of HIV/AIDS. At the same time, in certain
circumstances, the right to privacy must be balanced with the right of partners (sexual
and injection drug) of persons with HIV/AIDS to be informed of their potential
infection. Failure to inform partners not only violates their rights but also leads to the
health problems of avoidable transmission and delay in treatment.
20. All standard ethical principles and duties related to confidentiality and protection of
patients’ health information, as articulated in the WMA Declaration of Lisbon on the
Rights of the Patient, apply equally in the context of HIV/AIDS. In addition, National
Medical Associations and physicians should take note of the special circumstances and
obligations (outlined below) associated with the treatment of HIV/AIDS patients.
20.1 National Medical Associations and physicians must, as a matter of priority,
ensure that HIV/AIDS public education, prevention and counselling programs
contain explicit information related to protection of patient information as a
matter not only of medical ethics but of their human right to privacy.
20.2 Special safeguards are required when HIV/AIDS care involves a physically
dispersed care team that includes home-based service providers, family
members, counsellors, case workers or others who require medical information
to provide comprehensive care and assist in adherence to treatment regimens. In
addition to implementing protection mechanisms regarding transfer of
information, ethics training regarding patient privacy should be given to all
team members.
Many countries have specific legislation to protect the privacy of those who are
HIV positive. Others may consider the same.
20.3 Physicians must make all efforts to convince HIV/AIDS patients to take action
to notify all partners (sexual and/or injection drug) about their exposure and
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potential infection. Physicians must be competent to counsel patients about the
options for notifying partners. These options should include:
20.3.1 Notification of the partner(s) by the patient. In this case, the patient should
receive counselling regarding the information that must be provided to the
partner and strategies for delivering it with sensitivity and in a manner that
is easily understood. A timetable for notification should be established and
the physician should follow-up with the patient to ensure that notification
has occurred.
20.3.2 Notification of the partner(s) by a third party. In this case, the third party
must make every effort to protect the identity of the patient.
20.4 When all strategies to convince the patient to take such action have been
exhausted, and if the physician knows the identity of the patient’s partner(s), the
physician is compelled, either by law or by moral obligation, to take action to
notify the partner(s) of their potential infection. Depending on the system in
place, the physician will either notify directly the person at risk or report the
information to a designated authority responsible for notification. Physicians
must be aware of the laws and regulations in the jurisdiction in which they are
practicing. In cases where a physician must disclose the information regarding
exposure, the physician must:
20.4.1 inform the patient of his or her intentions,
20.4.2 to the extent possible, ensure that the identity of the patient is protected,
20.4.3 take the appropriate measures to protect the safety of the patient, especially
in the case of a female patient vulnerable to domestic violence.
20.5 Regardless of whether it is the patient, the physician or a third party who
undertakes notification, the person learning of his or her potential infection
should be offered support and assistance in order to access testing and
treatment.
20.6 National Medical Associations should develop guidelines to assist physicians in
decision-making related to notification. These guidelines should help physicians
understand the legal requirements and consequences of notification decisions as
well as the medical, psychological, social and ethical considerations.
20.7 As per local and national laws and guidelines requiring the reporting of new
HIV infections, sexually transmitted diseases, and opportunistic infections,
physicians must protect the privacy and confidentiality of all patients and
maintain the highest ethical standards.
20.8 National Medical Associations should work with governments to ensure that
physicians who carry out their ethical obligation to notify individuals at risk,
and who take precautions to protect the identity of their patient, are afforded
adequate legal protection.
MEDICAL EDUCATION
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HIV/AIDS and the Medical Profession
21. National Medical Associations should assist in ensuring that there is training and
education of physicians in the most current prevention strategies and medical
treatments available for all stages of HIV/AIDS and associated infections, including
prevention and support.
22. National Medical Associations should, when appropriate, collaborate with NGOs and
community based organizations, insist upon, and when possible assist with, the
education of physicians in the relevant psychological, legal, cultural and social
dimensions of HIV/AIDS.
23. National Medical Associations should fully support the efforts of physicians wishing
to concentrate their expertise in HIV/AIDS care, even where HIV/AIDS is not
recognized as an official specialty or sub-specialty within the medical education
system.
24. The WMA encourages its national medical associations to promote the inclusion of
designated, comprehensive courses on HIV/AIDS in undergraduate and postgraduate
medical education programs, as well as continuing medical education.
INTEGRATION of HIV/AIDS SERVICES with other STDs MANAGEMENT ACTIVITES
25. The National Medical Associations should support governments to integrate
HIV/AIDS preventive and curative services with other STD management activities in
a comprehensive manner.
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WMA STATEMENT
ON
MEDICAL EDUCATION
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Medical education consists of basic medical education, postgraduate medical
education, and continuing professional development. Medical education is a dynamic
process that commences at the start of basic medical education (medical school) and
continues until a physician retires from active practice. Its goal is to prepare physicians
to apply the latest scientific knowledge to promote health, prevent and cure human
disease and mitigate symptoms. All physicians have a responsibility to themselves, the
profession and their patients to maintain a high standard for medical education.
BASIC PRINCIPLES OF MEDICAL EDUCATION
2. Medical education consists of training aimed at ensuring physicians acquire the
competencies, skills and aptitudes that that allow them to practice professionally and
ethically at the highest level. All physicians, the profession as a whole, medical
faculties, educational institutions, and governments share the responsibility for
guaranteeing that medical education meets a high quality standard throughout the
medical education continuum.
I. BASIC MEDICAL EDUCATION
3. The goal of basic medical education is to ensure that medical students have acquired
the knowledge, skills, and professional behaviors that prepare them for a spectrum of
career choices, including, but not limited to, patient care, public health, clinical or
basic research, leadership and management, or medical education. Each of these career
choices will require additional education beyond the first professional degree.
4. At a medical school, the knowledge, skills and professional behavior that students
should acquire should be based on the professional judgment of the faculty and
accreditation councils, and be responsive to the healthcare needs of the region and/or
the country. These decisions will inform the selection of students, the curriculum
design and content, the student assessment system, and the evaluation of whether the
school has achieved its goals. Such decisions should also be subject to relevant
standards, the needs of fairness and accessibility, and diversity and inclusion in the
medical workforce.
II. SELECTION OF STUDENTS
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Medical Education
5. Prior to their entry to medical school, medical students should have acquired a broad
education, ideally including background in the arts, humanities, and social sciences, as
well as biological and physical sciences. Students should be chosen for the study of
medicine based on their intellectual ability, motivation for medicine, previous relevant
experiences, and character and integrity. The selection process for students must not
be discriminatory and should reflect the importance of increasing diversity in the
medical workforce. A medical school should also consider its mission when
developing admission requirements.
6. Within a given country or region, there should be enough medical students to meet
local and regional needs. National medical associations (NMAs) and national
governments should collaborate to mitigate the economic barriers that prevent
qualified individuals from entering and completing medical school.
7. Curriculum and Assessment
7.1 A medical school’s educational program should be based on educational program
objectives developed in response to the healthcare needs of the region and/or
country. These educational program objectives must be used in the selection of
curriculum content, the development of the system for student assessment, and the
evaluations of whether the school has achieved its educational goals, subject to
relevant regulatory and educational standards.
7.2 The medical curriculum should equip the student with a broad base of general
medical knowledge. This includes the biological and behavioral sciences, as well
as the socio-economics of health care, the social determinants of health, and
population and public health. These disciplines, together with basic medical
science, are central to an understanding and practice of clinical medicine. The
WMA recommends that content related to medical ethics and human rights should
be a core requirement in the medical curriculum.1 The student should also be
introduced to the principles and methodology of medical research and how the
results of research are used in clinical practice. Students should have opportunities,
if desired or required by the medical school, to participate in research. The
cognitive skills of self-directed learning, critical thinking, and medical problem
solving should be introduced early in the medical curriculum to prepare students for
clinical training.
7.3 Before beginning independent practice, every physician should complete a formal
program of supervised clinical education. Within basic medical education, clinical
experiences should range from primary to tertiary care in a variety of inpatient and
outpatient settings, such as university hospitals, community hospitals, clinics,
physician practices, and other health care facilities. The clinical component of
basic medical education should use an apprenticeship model of teaching using
defined objectives and must involve direct experiences in the diagnosis and
treatment of disease, with a gradual increase in the student’s responsibility based on
his/her demonstration of the relevant knowledge and skills. Experiences and
training in interprofessional teams providing collaborative care to patients is
important in preparing medical students for practice.
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7.4 The medical school faculty have the responsibility to ensure that students who have
graduated and received the first professional degree have acquired a basic
understanding of clinical medicine, have the basic skills needed to evaluate clinical
problems and take appropriate action, and exhibit the attitudes and character to be
an ethical physician. The assessment system within a medical school should
include appropriate and valid methods to ensure that all graduates have met each of
these expectations. It would be useful for medical schools to have access to
individuals with expertise in student assessment, either from within the medical
school or from external sources.
8. Sudent Support
8.1 Medical students should receive academic and social support, such as counselling
for personal problems and programs to support well-being, to assist them in meeting
the demands of medical school. Academic support includes tutoring and advice for
study and time management skills. Social support includes access to activities to
promote their physical and mental well-being, as well as access to general and
mental health services. Mentors and advisors to assist students in specialty choice
and career planning also should be available.
9. Faculty and Institutional Resources
9.1 Basic medical education must be taught by appropriate staff including faculty who
possess the appropriate qualifications that can only be achieved through formal
training and experience. There should be a sufficient number of faculty to meet the
educational, research, and other missions of the medical school. The selection
process for faculty must be not be discriminatory. The faculty should have a formal
commitment to the medical school, such as a faculty appointment, and be part of
and subject to the medical school’s governance and departmental structures.
9.2 The faculty of a medical school are accountable for developing the medical
curriculum and the student assessment system. As such, the educational program
objectives, curriculum content and format, and evaluation of the curriculum are the
responsibility of the faculty. The faculty should review the curriculum frequently,
ideally utilizing statistics on student achievement and input from students,
graduates, and the practicing community. Furthermore, the faculty must regularly
evaluate the quality of each component of the educational program and the program
as a whole through the utilization of student and peer feedback. Medical schools
should provide opportunities for faculty development to support the acquisition and
maintenance of teaching and assessment, and curriculum development skills so that
they can meet their responsibilities for the medical education program and
curriculum design skills.
9.3 Medical schools must provide an academic environment which encourages learning
and inquiry by faculty including an active institutional research program to advance
the body of medical knowledge and the quality of care. Medical schools should
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Medical Education
provide support for faculty to acquire research skills and to engage in independent
or collaborative research.
9.4 In addition to sufficient numbers of well-prepared faculty, medical schools must
ensure that there are adequate library and information technology resources,
classrooms, research laboratories, clinical facilities, and study areas for students in
sufficient quantity to meet the needs of all learners. There must be an administrative
support structure for things such as academic records maintenance and registrar
functions.
10. Financing Medical Education
10.1 National governments and medical schools should collaborate to develop financing
mechanisms to support basic medical education. Support is needed for individual
students and for the medical schools themselves. There should be sufficient financial
resources for medical schools to educate the number of medical students required to
meet national or regional health care system needs.
III. POSTGRADUATE MEDICAL EDUCATION
11. A graduate from a basic medical education institution must participate in a clinically-
based advanced training program prior to being legally authorized to enter independent
medical practice and, if required, obtaining a license to practice. Postgraduate medical
education, the second phase of medical education continuum, prepares physicians for
practice in a medical discipline or specialty and focuses on specific competencies
needed for practice in that specialty area.
12. Postgraduate medical education programs, also termed residency programs, include
educational experiences that support the resident’s acquisition of the knowledge and
skills characteristic of the specialty area. Depending on the specialty, postgraduate
programs will use a variety of inpatient and ambulatory clinical settings, including
community-based clinics, hospitals or other health care institutions. The education of
residents should combine a structured didactic curriculum with clinical activity that
includes the diagnosis and management of patients under appropriate and supportive
levels of supervision. A residency program must ensure that each resident has
opportunities to care for an adequate number of patients in order to gain experience in
the range of conditions that characterize the specialty. These clinical experiences
should occur in settings where high quality care is delivered, since educational quality
and patient care quality are interdependent and must be pursued in a manner so that
they enhance one another.
13. A proper balance must be maintained so that residents are not required to meet clinical
service needs at the expense of their education. The residency program should further
the resident’s teaching and leadership skills and ability to contribute to continuous
improvement. The program should also provide opportunities for scholarly activity
aimed at enhancing scientific and critical thinking, clinical problem-solving, and life-
long learning skills. These opportunities will have been introduced during basic
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medical education and should be reinforced during residency to prepare and motivate
the resident to exercise these skills during practice. Additionally, a proper balance
must be maintained among clinical work, education, and personal life.
14. During the residency program, a resident takes on progressively greater responsibility
for patient care based on his or her individual growth in clinical experience,
knowledge, and skill. Allowing the resident to assume increased responsibility
requires a system of assessment to monitor the resident’s increase in knowledge and
skills over time. There also needs to be a process in place to conclusively determine
that the resident is prepared to undertake independent medical practice.
15. Postgraduate medical education should take place in institutions that are accredited or
have been reviewed for quality.
IV. CONTINUING PROFESSIONAL DEVELOPMENT
16. Continuing professional development* (CPD) is defined as the activities that maintain,
develop, or increase the knowledge, skills, and professional performance and
relationships a physician uses on a daily basis to provide services for patients, the
public, or the profession. CPD can include activities such as involvement in national or
regional medical associations; committee work in hospitals or group practices; and
teaching, mentoring and participating in education within his or her chosen specialty
or more broadly within medicine.
17. One of the components of CPD is continuing medical education (CME), in which the
physician participates in medically-related educational activities. Physicians should
further their medical education throughout their careers, including acquiring new
knowledge and skills in response to scientific discoveries and the introduction of new
treatments. Such educational experiences are essential to for the physician to keep
abreast of developments in clinical medicine and the health care delivery environment,
and to continue to maintain the knowledge and skills necessary to provide high quality
care. In many jurisdictions, CME is specialty-defined and may be required for
maintaining a medical license.
18. The goal of continuing professional development is to broadly sustain and enhance the
competent physician. Medical schools, hospitals and professional societies all share a
responsibility for developing and making available to all physicians effective
opportunities for continuing professional development, including continuing medical
education.
RECOMMENDATIONS
19. The demand for physicians to provide medical care, prevent disease, and give advice
in health matters to patients, the public, and policy-makers calls for the highest
standards of basic, postgraduate, and continuing professional development.
Recommendations are as follows:
S-2006-04-2017 ⏐ Chicago
Medical Education
19.1 That the WMA encourage NMAs, governments, and other relevant stakeholder
groups to engage in planning for a high quality continuum of medical education
within countries that is informed by and supports the health care needs of the
population.
19.2 That the WMA encourage NMAs to work with medical schools to plan and deliver
faculty development that enhances the skills of medical school faculty as teachers
and researchers.
19.3 That the WMA encourage NMAs and governments to engage in dialogue related to
medical school and postgraduate program funding so that adequate numbers of
well-trained physicians are available to meet national health care needs.
19.4 That NMAs and national governments collaborate to mitigate the economic barriers
that prevent qualified individuals from entering and completing medical school.
19.5 That the WMA encourage NMAs to individually or collaboratively provide
opportunities for continuing physician professional development and continuing
medical education.
* Note on terminology
There are different uses of the term ‘Continuing Professional Development’ (CPD). One way to
describe it is all those activities that contribute to the professional development of a physician
including involvement in organized medicine, committee work in hospitals or group practices,
teaching, mentoring and reading, to name just a few. One of the components of CPD should be
Continuing Medical Education, which in many jurisdictions is specially defined and possibly
required for licensure.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-05-2016
WMA STATEMENT
ON
THE PHYSICIAN’S ROLE IN OBESITY
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Obesity is one of the single most important health issues facing the world in the twenty-
first century, affecting all countries and socio-economic groups and representing a serious
drain on health care resources.
Obesity in children is of increasing concern and is emerging as a growing epidemic in
itself.
Obesity has complex origins linked to economic and social changes in society including
the obeso-genic environment within which much of the population lives.
Therefore the WMA urges physicians to use their roles as leaders to advocate for
recognition by national health authorities that reduction in obesity should be a priority,
with culturally and age appropriate policies involving physicians and other key
stakeholders.
THE WMA RECOMMENDS THAT PHYSICIANS:
• Lead the development of societal changes that emphasize environments which
support healthy food choices and regular exercise or physical activity for all
people, with a specific focus on children;
• Individually and through medical associations, express concern that excessive
television viewing and video game playing are impediments to physical activity
among children and adolescents in many countries;
• Encourage individuals to make healthy choices and guide parents in helping their
children to do so;
• Recognise the role of personal decision making and the adverse influences exerted
by current environments;
• Recognise that collection and evaluation of data can contribute to evidence based
S-2006-05-2016 ⏐ Taipei
Obesity
management, and should be part of routine medical screening and evaluation
throughout life;
• Encourage the development of life skills that contribute to a healthy lifestyle in all
persons and to better public knowledge of healthy diets, exercise and the dangers
of smoking and excess alcohol consumption;
• Advocate for appropriately trained professionals to be placed in educational
facilities, highlighting the importance of education on healthy lifestyles from an
early age;
• Contribute to the development of better assessment tools and databases to enable
better targeted and evaluated interventions;
• Ensure that obesity, its causes and management remain part of continuing
professional development programmes for health care workers, including
physicians;
• Use pharmacotherapy and bariatric surgery consistent with evidence-based
guidelines and an assessment of the risks and benefits associated with such
therapies.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-06-2016
WMA STATEMENT
ON
THE RESPONSIBILITIES OF PHYSICIANS IN PREVENTING
AND TREATING OPIATE AND PSYCHOTROPIC DRUG ABUSE
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Opiate and psychotropic drugs are valuable therapeutic tools when used as medically
indicated for a variety of symptoms and conditions. Indeed, the WMA has called for the
greater provision of pain management treatment in its Resolution on the Access to
Adequate Pain Treatment (Montevideo, Uruguay, October 2011). Unfortunately, non-
clinical misuse of these addictive substances is an enormous problem worldwide. Drug
addiction is a complex social, economic and legal issue as well as a threat to public health
and safety globally. It affects people from all demographic and social groups and
economic spheres. In addition to exposing themselves to the direct health risks related to
the inappropriate use of these substances, persons addicted to drugs may engage in high
risk behaviour, such as needle-sharing and unprotected sex, and many resort to criminal
activity to finance their expensive addiction. These factors increase transmission of viral
infections, such as Hepatitis B and C and HIV/AIDS, among both users and non-users
alike. Other results of addiction include failure to maintain employment or to function in
social and family life.
The legal ramifications of non-medical drug use, which is illegal in most countries,
generally do little to assist users in breaking free from their addiction. Despite the
presence of drug programs in many correctional facilities, illegal substances are very often
available to inmates and, in fact, some users begin their addiction in these institutions.
Addressing addiction therefore falls largely to society and the health profession.
The World Medical Association, concerned by the widespread misuse of psychotropic and
opiate drugs, urges physicians to prioritize this problem in the practice of medicine and to
adhere to the following guidelines.
PRINCIPLES
Responsible prescribing practices
Physicians should be aware of the addictive properties of certain psychotropic and opiate
drugs. Such drugs should be prescribed with the greatest restraint, observing the strictest
possible generally accepted medical indications. Physicians must take all necessary
measures to ensure that they are fully informed of the effects of these drugs. This includes
reviewing up-to-date research regarding dosage, potential effectiveness for the specific
S-2006-06-2016 ⏐ Taipei
Opiate and Psychotropic Drug Abuse
condition, potential side effects and pharmacological interactions and prevalence of
misuse.
When such drugs are medically indicated, their use must be carefully monitored to ensure
that the patient is following strict dosage instructions, timing and any other factors
associated with the safe use of the particular drug. All appropriate measures must be taken
to prevent the stockpiling, resale or other illicit usage of the drug.
Patients must be fully informed of all potential therapeutic and non-therapeutic effects of
psychotropic and opiate drugs, including potential for addiction, and be fully involved in
the decision to take them. No competent patient should be forced to take any psychotropic
drug against his or her will.
Physicians should be aware of non-medical factors that may predispose patients to
addiction. These may include, among others, family history, past addiction, emotional
trauma, depression or other mental health conditions and peer pressure, especially among
young persons.
Physicians should learn to recognize ‘drug seekers’, addicted patients who attempt to
obtain psychotropic and opiate drugs under false medical pretenses. Drug seekers often
consult more than one physician in an effort to obtain multiple prescriptions. In extreme
cases, drug seekers may harm themselves to create symptoms to obtain a prescription. All
patient conditions and symptoms should be clinically verified, to the extent possible, and
meticulous records maintained regarding the patient’s drug history. If databases containing
patient drug records and prescribing histories are available, they should be consulted.
When prescribing any psychotropic or opiate substance to minors, physicians must ensure
that the parents or guardians of the patient are fully informed of the potential misuse of the
drug and encouraged to monitor the child carefully to ensure adherence to the physician’s
instructions. Parents or guardians should be informed that, in some countries, it is
increasingly common for children to sell prescription drugs to their peers.
Non-drug therapy for addicts to opiate and psychotropic drugs
Physicians should be aware of all non-drug treatment options for addicts to opiate and
psychotropic drugs, including inpatient and outpatient programs and therapeutic
communities, in which recovering addicts live in a supportive, drug-free environment.
Most treatment programs are focused on breaking the cycle of drug dependence through
detoxification, counselling – including ongoing peer support – and permanent abstinence
from the use of any addictive opiate or psychotropic substance, including alcohol. Some
offer educational and/or vocational programs to facilitate successful reintegration into
community life.
Physicians should encourage their patients to participate in drug treatment programs at the
earliest possible stage of addiction.
All efforts should be made to respect the dignity and autonomy of addicted patients.
Involuntary inpatient treatment of addicted persons should be a last resort, according to
established guidelines and, where applicable, legal requirements.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-06-2016
Drug therapy for addicts to opiate drugs
In some cases, persons addicted to opiate drugs may be treated using medications that
relieve withdrawal symptoms and cravings for the addictive substance without producing
the ‘high’ associated with opiates. These medications also provide cross tolerance to other
opioids. The objective of drug treatment is the immediate cessation of the use of opiate
drugs.
Drug therapy can assist the opiate-dependent patient to function in his or her normal
environment and activities while working to overcome the opiate addiction. However, it
should always be part of a multi-disciplinary approach that includes proven non-drug
treatment elements, such as counselling and peer support.
Drug therapy should be administered according to established evidence-based guidelines
and supervised by specially trained physicians with an appropriate support team.
Awareness raising and policy development
National Medical Associations (NMAs) should engage in cross-sectoral national efforts to
raise awareness of the risks associated with the abuse of opiate and psychotropic drugs and
to ensure the availability of appropriate treatment options for addicted persons. NMAs
should encourage their members to participate in similar programs at the community level.
NMAs should promote appropriate drug prevention programming at all levels of the
educational system, recognizing that experimentation with drugs is increasingly prevalent
among younger age groups.
NMAs and physicians should participate in the development of evidence-based guidelines
that support a multi-disciplinary approach to the treatment of drug addiction, including
harm reduction strategies such as needle exchange programmes.
NMAs should participate in the development of legal procedures relating to illegal drug
use to ensure that addicted persons are recognized as entitled to receive appropriate
medical and rehabilitative care, including in correctional institutions.
CONCLUSION
Physicians have an important role to play in the treatment of drug addiction, both as
clinicians and as advocates for the treatment, rights and dignity of persons addicted to
these harmful substances. Treatment of addiction, like treatment for any disease or
condition, should be undertaken in the best interests of the patient and according to
established principles of medical ethics.
Handbook of WMA Policies
S-2007-02-2018 ⏐ World Medical Association
WMA STATEMENT
ON
THE ETHICS OF TELEMEDICINE
Adopted by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
DEFINITION
Telemedicine is the practice of medicine over a distance, in which interventions,
diagnoses, therapeutic decisions, and subsequent treatment recommendations are based on
patient data, documents and other information transmitted through telecommunication
systems.
Telemedicine can take place between a physician and a patient or between two or more
physicians including other healthcare professionals.
PREAMBLE
• The development and implementation of information and communication
technology are creating new and different ways for of practicing medicine.
Telemedicine is used for patients who cannot see an appropriate physician
timeously because of inaccessibility due to distance, physical disability,
employment, family commitments (including caring for others), patients’ cost and
physician schedules. It has capacity to reach patients with limited access to
medical assistance and have potential to improve health care.
• Face-to-face consultation between physician and patient remains the gold standard
of clinical care.
• The delivery of telemedicine services must be consistent with in-person services
and supported by evidence.
• The principles of medical ethics that are mandatory for the profession must also be
respected in the practice of telemedicine.
PRINCIPLES
Physicians must respect the following ethical guidelines when practicing telemedicine:
1. The patient-physician relationship should be based on a personal examination and
sufficient knowledge of the patient’s medical history. Telemedicine should be
employed primarily in situations in which a physician cannot be physically present
within a safe and acceptable time period. It could also be used in management of
chronic conditions or follow-up after initial treatment where it has been proven to
be safe and effective.
Reykjavik ⏐ S-2007-02-2018
Telemedicine
2. The patient-physician relationship must be based on mutual trust and respect. It is
therefore essential that the physician and patient be able to identify each other
reliably when telemedicine is employed. In case of consultation between two or
more professionals within or between different jurisdictions, the primary physician
remains responsible for the care and coordination of the patient with the distant
medical team.
3. The physician must aim to ensure that patient confidentiality, privacy and data
integrity are not compromised. Data obtained during a telemedicine consultation
must be secured to prevent unauthorized access and breaches of identifiable patient
information through appropriate and up to date security measures in accordance
with local legislation. Electronic transmission of information must also be
safeguarded against unauthorized access.
4. Proper informed consent requires that all necessary information regarding the
distinctive features of telemedicine visit be explained fully to patients including,
but not limited to:
• explaining how telemedicine works,
• how to schedule appointments,
• privacy concerns,
• the possibility of technological failure including confidentiality breaches,
• protocols for contact during virtual visits,
• prescribing policies and coordinating care with other health professionals in a
clear and understandable manner, without influencing the patient’s choices.
5. Physicians must be aware that certain telemedicine technologies could be
unaffordable to patients and hence impede access. Inequitable access to
telemedicine can further widen the health outcomes gap between the poor and the
rich.
Autonomy and privacy of the Physician
6. A physician should not to participate in telemedicine if it violates the legal or
ethical framework of the country.
7. Telemedicine can potentially infringe on the physician privacy due to 24/7 virtual
availability. The physician needs to inform patients about availability and
recommend services such as emergency when inaccessible.
8. The physician should exercise their professional autonomy in deciding whether a
telemedicine versus face-to-face consultation is appropriate.
9. A physician should exercise autonomy and discretion in selecting the telemedicine
platform to be used.
S-2007-02-2018 ⏐ Reykjavik
Telemedicine
Responsibilities of the Physician
10. A physician whose advice is sought through the use of telemedicine should keep a
detailed record of the advice he/she delivers as well as the information he/she
received and on which the advice was based in order to ensure traceability.
11. If a decision is made to use telemedicine it is necessary to ensure that the users
(patients and healthcare professionals) are able to use the necessary
telecommunication system.
12. The physician must seek to ensure that the patient has understood the advice and
treatment suggestions given and take steps in so far as possible to promote
continuity of care.
13. The physician asking for another physician’s advice or second opinion remains
responsible for treatment and other decisions and recommendations given to the
patient.
14. The physician should be aware of and respect the special difficulties and
uncertainties that may arise when he/she is in contact with the patient through
means of tele-communication. A physician must be prepared to recommend direct
patient-doctor contact when he/she believes it is in the patient’s best interests.
15. Physicians should only practise telemedicine in countries/jurisdictions where they
are licenced to practise. Cross-jurisdiction consultations should only be allowed
between two physicians.
16. Physicians should ensure that their medical indemnity cover include cover for
telemedicine.
Quality of Care
17. Healthcare quality assessment measures must be used regularly to ensure patient
security and the best possible diagnostic and treatment practices during
telemedicine procedures. The delivery of telemedicine services must follow
evidence-based practice guidelines to the degree they are available, to ensure
patient safety, quality of care and positive health outcomes. Like all health care
interventions, telemedicine must be tested for its effectiveness, efficiency, safety,
feasibility and cost-effectiveness.
18. The possibilities and weaknesses of telemedicine in emergencies must be duly
identified. If it is necessary to use telemedicine in an emergency situation, the
advice and treatment suggestions are influenced by the severity of the patient´s
medical condition and the competency of the persons who are with the patient.
Entities that deliver telemedicine services must establish protocols for referrals for
emergency services.
Reykjavik ⏐ S-2007-02-2018
Telemedicine
RECOMMENDATION
1. Telemedicine should be appropriately adapted to local regulatory frameworks,
which may include licencing of telemedicine platforms in the best interest of
patients.
2. Where appropriate the WMA and National Medical Associations should encourage
the development of ethical norms, practice guidelines, national legislation and
international agreements on subjects related to the practice of telemedicine, while
protecting the patient-physician relationship, confidentiality, and quality of medical
care.
3. Telemedicine should not be viewed as equal to face-to-face healthcare and should
not be introduced solely to cut costs or as a perverse incentive to over-service and
increase earnings for physicians.
4. Use of telemedicine requires the profession to explicitly identify and manage
adverse consequences on collegial relationships and referral patterns.
5. New technologies and styles of practice integration may require new guidelines
and standards.
6. Physicians should lobby for ethical telemedicine practices that are in the best
interests of patients.
Handbook of WMA Policies
S-2008-01-2008 ⏐ World Medical Association
WMA STATEMENT
ON
REDUCING DIETARY SODIUM INTAKE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
INTRODUCTION
Cardiovascular diseases (CVD) remain a leading cause of mortality throughout the world.
Risk factors include high blood cholesterol, hypertension, cigarette smoking, physical
inactivity, obesity, and diabetes. These risk factors are largely preventable and modifiable.
Globally, about 25% of all deaths from cardiovascular diseases are due to hypertension.
This figure may underestimate the true impact of elevated blood pressure since the blood
pressure cardiovascular risk continuum begins at 115/75 mm Hg. There is overwhelming
evidence that excessive sodium intake is a risk factor for the development, or worsening of
hypertension, and it may also be an independent risk factor for cardiovascular diseases as
well as all-cause mortality.
Substantial overall benefits can accrue from even small reductions in the population’s
blood pressure. Depending upon an individual’s salt sensitivity, sodium may cause great
damage to both normotensive and hypertensive populations. Therefore, population-wide
efforts to reduce dietary sodium intake are a cost-effective way to reduce overall hyper-
tension levels and subsequent cardiovascular disease.
BACKGROUND
In acculturated populations, the level of blood pressure, the incremental rise in blood pres-
sure with age, and the prevalence of hypertension are related to salt intake. Observational
studies and randomized controlled trials document a clear and consistent effect of salt con-
sumption on increased blood pressure. Blood pressure is also affected by other foods and
nutrients, and a reduced salt intake should be only one component of a comprehensive
strategy to lower blood pressure. Increasing physical activity, consuming a diet high in
fruits and vegetables and low in saturated and total fats, maintenance of optimal body
weight, and moderation in alcohol intake are also recommended lifestyle approaches to
preventing and managing hypertension and reducing its impact on cardiovascular disease.
The World Health Organization recommends that average daily sodium consumption in
adults should be less than 2000 mg (5 g salt). Epidemiologic evidence, including the
marked reduction of either hypertension or of a progressive rise in blood pressure with
advancing age in populations with an average sodium ingestion <1500 mg (3.8 g salt) per
day, supports the concept of such a threshold, above which the risk for harmful cardio-
vascular disease consequences begins to increase.
Seoul ⏐ S-2008-01-2008
Dietary Sodium Intake
The world's population consumes 2300-4600 mg of sodium (5.8 – 11.5 g salt) per day per
2000 calories. In developed countries, it is estimated that 75% to 80% of the daily intake
of sodium comes from processed foods and foods that are prepared outside of the home
(e.g., fast food or restaurant meals). Therefore, any meaningful strategy to reduce popula-
tion salt intake must rely on food manufacturers and preparers to reduce the amount added
during preparation as well as on nutritional education programs. The largest impact on
sodium in the food supply of developed countries may derive from the stepwise lowering
of sodium in foods that are most commonly eaten and are large contributors to sodium
intake. In less developed countries, reductions in sodium are more likely to be achieved by
adding less salt during cooking inside the home.
RECOMMENDATIONS
National Medical Associations should:
• In cooperation with national and international health organizations, work to
educate consumers about the effects of sodium intake on hypertension and cardio-
vascular disease, the benefits of long-term reductions in sodium intake, and about
the dietary sources of salt/sodium and how these can be reduced.
• Call for a stepwise 50% reduction in the sodium content of processed foods, "fast"
food products, and restaurant meals over the next decade.
• Urge physicians to counsel patients about the major sources of sodium in their
diets and how to reduce sodium intake, including reducing the amount of salt used
in cooking at home.
• In cooperation with the food industry and government regulators, discuss ways to
improve labeling of food products and develop label markings and warnings for
foods high in sodium.
• Encourage government authorities to create national laws and regulations that
enforce the reduction of sodium in processed foods to acceptable levels. Establish
a deadline for industries to comply with new laws and regulations.
• Stimulate debate on the issue at conferences, symposia, and teleconferences in an
effort to promote awareness among the medical profession regarding sodium in
food and its consequences. Doctors who are well-informed will transmit the infor-
mation to their patients and may be able to prescribe fewer antihypertensive medi-
cations.
Handbook of WMA Policies
S-2008-02-2018 ⏐ World Medical Association
WMA STATEMENT
ON
REDUCING THE GLOBAL BURDEN OF MERCURY
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed with minor revision by the 210th
WMA Council Session, Reykjavik, Iceland,
October 2018
PREAMBLE
Mercury is a naturally occurring heavy metal that is a potent neurotoxin. The most likely
routes of human exposure on a population basis are ingestion of methylmercury from
contaminated fish. Less commonly, individuals are exposed via inhalation of inorganic
mercury vapor after a spill or during a manufacturing process.
Mercury has been the ideal choice for use in medical devices that measure temperature
and pressure. Therefore, a typical large hospital may have more than a hundred pounds of
mercury onsite incorporated into various devices in separate locations.
Hospitals and clinics can avoid the occupational or environmental risk of mercury by
using products that don’t rely on mercury-based technology. Major healthcare institutions
around the world have demonstrated that safe, effective alternative products exist, and can
be safely used for most situations, such as electronic thermometers, recently calibrated
aneroid devices and mercury-free batteries.
Although the rationale for instituting voluntary mercury replacement initiatives is
compelling from both occupational and environmental perspectives, financial
considerations may ultimately motivate hospitals to undertake a mercury replacement
program. Hazardous waste clean-up costs, reporting requirements for spills, disruptions in
services, and staff training are costly. The cost of cleaning up one significant
contamination can be substantially higher than the cost of converting to mercury-free
alternatives.
By implementing a “best practices” management method for mercury use, the need for
increased government regulations in the future, may be avoided. Such regulations may
create costly burdens that some facilities may not be able to meet.
The World Medical Association (WMA) recalls its statement on Environmental
Degradation and Sound Management of Chemicals that provides recommendations for
advocacy measures and capacity building in order to tackle this issue.
Reykjavik ⏐ S-2008-02-2018
Mercury
RECOMMENDATIONS
The following recommendations are based on the urgent need to reduce both the supply
and demand of mercury in the health care sector:
Global
The World Medical Association and its member national medical associations should:
• Advocate for the United Nations and individual governments to voluntarily
cooperate to implement key features of the United Nations Environment
Programme (UNEP) Mercury Programme, which provides a framework for
reducing the use, release, trade and risk related to mercury.
• Enhance the activity of existing partnerships.
Regional/National
National medical associations should advocate that their governments work to reduce risks
related to mercury in the environment by:
• Reducing reliance on mercury mining in favor of environmentally-friendly sources
of mercury, such as recycled mercury.
• Developing options and scientifically sound plans for the long term safe storage of
excess mercury supplies.
• Urging Member States to ratify and implement the United Nations Minamata
Convention on Mercury adopted in 2013 and designed to protect human health and
the environment from anthropogenic emissions and releases of mercury and
mercury compounds.
• Encouraging a phase-out of mercury use in the health care sector
• Designing and implementing regulations and/or requirements designed to
significantly reduce mercury emissions from coal combustion and cement
production by using specific mercury emission controls.
Local
Physicians should:
• Explore eliminating mercury-containing products in their offices and clinical
practices, including thermometers, sphygmomanometers, gastrointestinal tubes,
batteries, lamps, electrical supplies, thermostats, pressure gauges, and other
laboratory reagents and devices.
• Ensure that local hospitals and medical facilities have a plan to identify sources of
mercury in their workplace, a commitment to mercury reduction, and a mercury
management policy regarding recycling, disposal and education.
• Encourage local hospitals and medical facilities to phase out mercury-containing
products and switch to non-mercury equivalents.
• Counsel patients about local and national advisories related to fish consumption
designed to limit exposure to mercury in children and women of childbearing age.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
WMA STATEMENT
ON
CONFLICT OF INTEREST
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
This policy is intended to identify areas where a conflict of interest might occur during the
day-to-day practice of medicine, and to assist physicians in resolving such conflicts in the
best interests of their patients. A conflict of interest is understood to exist when profes-
sional judgement concerning direct patient care might be unduly influenced by a second-
ary interest.
In some cases, it may be enough to acknowledge that a potential or perceived conflict
exists. In others, specific steps to resolve the conflict may be required. Some conflicts of
interest are inevitable and there is nothing inherently unethical in the occurrence of con-
flicts of interest in medicine but it is the manner in which they are addressed that is cru-
cial.
In addition to the clinical practice of medicine and direct patient care, physicians have
traditionally served in several different roles and pursued various other interests, such as
participation in research, the education of future physicians and physicians in training and
the occupation of administrative or managerial positions. As private interests within medi-
cine have expanded in many locales, physicians have occasionally provided their expertise
to these endeavours as well, acting as consultants (and sometimes employees) for private
enterprise.
Although the participation of physicians in many of these activities will ultimately serve
the greater public good, the primary obligation of the individual physician continues to be
the health and well-being of his or her patients. Other interests must not be allowed to
influence clinical decision-making (or even have the potential to do so).
Each doctor has a moral duty to scrutinise his or her own behaviour for potential conflicts
of interest, even if the conflicts fall outside the kinds of examples or situations addressed
in this document. If unacknowledged, conflicts of interest can seriously undermine patient
trust in the medical profession as well as in the individual practitioner.
Physicians may also wish to avail themselves of additional resources such as specialty
societies, national medical associations or regulatory authorities, and should be aware of
applicable national regulations and laws.
New Delhi ⏐ S-2009-01-2009
Conflict of Interest
RECOMMENDATION
Research
The interests of the clinician and the researcher may not be the same. If the same indivi-
dual is assuming both roles, as is often the case, the potential conflict should be addressed
by ensuring that appropriate steps are put in place to protect the patient, including dis-
closure of the potential conflict to the patient.
As stated in the Declaration of Helsinki:
• The Declaration of Geneva of the World Medical Association states that, "The
health of my patient will be my first consideration," and the International Code of
Medical Ethics declares that, "A physician shall act only in the patient's interest
when providing medical care which might have the effect of weakening the phy-
sical and mental condition of the patient."
• The Declaration of Helsinki states that “In medical research involving human
subjects, the well-being of the individual research subject must take precedence
over all other interests.”
Research should be conducted primarily for the advancement of medical science. A
physician should never place his or her financial interests above the welfare of his or her
patient. Patient interests and scientific integrity must be paramount.
All relevant and material physician-researcher relationships and interests must be dis-
closed to potential research participants, research ethics boards, appropriate regulatory
oversight bodies, medical journals, conference participants and the medical centre where
the research is conducted.
All hypothesis-testing research trials should be registered with a publicly-accessible re-
search registry.
A clear contract should be signed by all parties, including sponsors, investigators and
program participants, clarifying terms relating to, at a minimum:
• financial compensation for the physician-researcher (which should approximate
lost clinical earnings)
• ownership of research results (which should rest with the investigator)
• the right of the investigator to publish negative results
• the right of the investigator to release relevant information to trial participants at
any point during the study.
Physician-researchers should retain control of and should have full access to all trial data,
and should decline non-disclosure clauses.
Physician-researchers should ensure that, regardless of the trial results, the presentation or
publication of the results of hypothesis-testing trials will not be unduly delayed or other-
wise obstructed.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
Referral fees should not be accepted for providing the names of potential trial participants,
and patient information should not be released without the consent of the patient, except
where required by legislation or regulatory authorities.
Any compensation received from trial sponsors should approximately replace lost clinical
income and should be commensurate with the efforts and responsibilities of the physician
performing the research. When enrolment is particularly challenging and time-consuming,
reasonable additional payments may be made to compensate the clinical investigator or
institution specifically for time and effort spent on extra recruiting efforts to enrol appro-
priate research participants. Escalating bonuses designed to increase trial enrolment should
not be accepted.
Physician-researchers should decline requests to review grant applications or research
paper submissions from colleagues or competitors where their relationship would have the
potential to influence their judgment on the matter.
Payments or compensation of any sort should not be tied to the outcome of clinical trials.
Physician-researchers should not have a financial interest in a company sponsoring a trial
or a product being studied in a clinical trial if this financial interest could be affected
positively or negatively by the results of the trial; they should have no direct financial
stake in the results of the trial. They should not purchase, buy or sell stock (shares) in the
company while the trial is ongoing and until the results have been made public. This
might not apply for those physicians who have developed a medication but are not part of
the enrolment process.
Physician-researchers should only participate in clinical trials when they relate to their
area of medical expertise and they should have adequate training in the conduct of re-
search and the principles of research ethics.
Authorship should be determined prior to the start of the trial and should be based on
substantive scientific contribution.
Education
The educational needs of students and the quality of their training experience must be
balanced with the best interests of patients. Where these are in conflict, the interests of
patients will take precedence.
While recognizing that medical trainees require experience with real patients, physician-
educators must ensure that these trainees receive supervision commensurate with their
level of training.
Patients should be made aware that their medical care may be performed in part by stu-
dents and physicians in training, including the performance of procedures and surgery, and
where possible should give appropriate informed consent to this effect.
Patients should be made aware of the identity and qualifications of the individuals in-
volved in their care.
Refusal by a patient to involve trainees in their care should not affect the amount or
quality of care they subsequently receive.
New Delhi ⏐ S-2009-01-2009
Conflict of Interest
Self-referrals and fee-splitting
All referrals and prescriptions (whether for specific goods or services) should be based on
an objective assessment of the quality of the service or of the physician to whom the pa-
tient has been referred.
Referral by physicians to health care facilities (such as laboratories) where they do not
engage in professional activities but in which they have a financial interest is called self-
referral. This practice has the potential to significantly influence clinical decision-making
and is not generally considered acceptable unless there is a need in that particular com-
munity for the facility and other ownership is not a possibility (for example, in small rural
communities). The physician in this situation should receive no more financial interest
than would an ordinary investor.
Kickbacks (or fee-splitting) occur when a physician receives financial consideration for
referring a patient to a specific practitioner or for a specific service for which a fee is
charged. This practice is not acceptable.
Physician offices
For reasons of patient convenience, many physician offices are located in close geographic
proximity to other medical services such as laboratories, pharmacies and opticians. The
physician should not receive any financial compensation or other consideration either for
referring a patient to these services, or for being located in close geographical proximity to
them. Physician-owned buildings should not charge above-market or below-market rates
to tenants.
Non-medical products (those having nothing to do with patient health or the practice of
medicine) and scientifically non-validated medical products should not be sold out of the
physician’s office. If scientifically validated medical products are sold out of the physi-
cian’s office charges should be limited to the costs incurred in making them available and
the products should be offered in such a way that the patient does not feel pressured to
purchase them.
Organizational/institutional conflicts
Health care institutions in particular are increasingly subject to a number of pressures that
threaten several of their roles, and many academic medical centres have begun to identify
alternate sources of revenue. Policies should be in place to ensure that these new sources
are not in conflict with the values and mission of the institution (for example, tobacco
funding in medical schools).
Individual medical organizations and institutions (including, but not limited to, medical
schools, hospitals, national medical associations, official/state regulators and research in-
stitutions) should develop and, where possible, enforce conflict of interest guidelines for
their employees and members.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
Physician-researchers and others will benefit from the development of institutional con-
flict of interest guidelines to assist them in making appropriate disclosure and clearly
identifying situations where a conflict would preclude them from participating in a re-
search study or other activity.
Academic health care institutions should have a clear demarcation between investment
decision-making committees, technology transfer and the research arm of the institution.
Written policies should provide guidelines for disclosure requirements, or for disconti-
nuing participation in the decision-making process, for those individuals who are con-
flicted due to sponsored research, consulting agreements, private holdings or licensing
agreements.
Handbook of WMA Policies
World Medical Association ⏐ S-2009-02-2009
WMA STATEMENT
ON
EMBRYONIC STEM CELL RESEARCH
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
The field of stem cell research has been developing during the last decade and is now one
of the fastest growing areas of biotechnology.
Stem cells can be harvested from an established tissue (adult stem cell) or from the blood
of the umbilical cord and these sources, for many, create no specific ethical dilemma.
Stem cells can also be obtained from the embryo (embryonic stem cells). Obtaining and
using these stem cells raises specific ethical questions and is, for some, problematic.
Some legislatures have prohibited obtaining and using embryonic stem cells. Others have
allowed using so-called spare or excess embryos from assisted reproduction cycles for re-
search purposes, but often the production of embryos solely for research purposes is prohi-
bited. Many jurisdictions have no specific legislative provisions with respect to embryonic
stem cells.
The basis of legal and ethical consideration is that human embryos have a specific and
special ethical status. This has generated debate amongst ethicists, philosophers, clini-
cians, scientists, health workers, the public and legislators.
Some assisted reproductive technology, specifically in vitro fertilisation, involves the pro-
duction of embryos outside of the human body. In many cases not all of these are needed
to achieve pregnancies. Those not used, so called “spare or excess embryos”, may be do-
nated for the treatment of others or for research or stored for some time and then des-
troyed.
The differing legislative approaches to the use of embryos for research, may be reflected
in law prohibiting the public funding of such research.
Stem cells can be used to conduct research into human disease and basic developmental
biology. There are many current research programs investigating the use of stem cells to
treat human disease. Although clinical studies have not yet validated the use of stem cells
in therapy, the potential for therapeutic use in the future has been widely acknowledged by
members of the medical and scientific community.
It is too early to assess the likelihood of success in any specific therapy and the place of
stem cells amongst a variety of forms of treatments.
S-2009-02-2009 ⏐ New Delhi
Embryonic Stem Cell Research
Public views of stem cell research are at least as varied as those of doctors and scientists.
Much public debate centres on concerns of abuse of the technology as well as specific
concerns about the use of embryos.
Regulation according to established ethical principles is likely to alleviate concerns for
many members of the public, especially if associated with careful and credible policing of
the regulations.
RECOMMENDATION
Whenever possible research should be carried out using stem cells that are not of embryo-
nic origin. However, there will be circumstances where only embryonic stem cells will be
suitable for the research model.
All research on stem cells, regardless of their origin, must be carried out according to
agreed ethical principles. Regulation and legislation must also accord with these principles
to avoid confusion or conflicts between law and ethics.
The ethical principles should, where possible, follow international agreement. Recogni-
sing that different groups have widely varying views on the use, especially, of embryonic
stem cells, these principles should be drafted to allow different jurisdictions to limit their
allowed levels of research as locally appropriate.
All and any research using embryos must only occur when written informed consent has
been obtained from both donors of the genetic material that created the embryo.
Handbook of WMA Policies
World Medical Association ⏐ S-2009-03-2009
WMA STATEMENT
ON
INEQUALITIES IN HEALTH
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
For over 150 years, the existence of health inequality has been acknowledged worldwide.
The recently published Final Report of the WHO Commission on Social Determinants of
Health has highlighted the critical importance of health equity to the health, economy and
social cohesiveness of all countries. It is clear that while there are major differences be-
tween countries, especially between the developing and developed countries, there are also
substantial disparities within countries with respect to various measures of socio-economic
and cultural diversity. Disparities in health can be defined as either disparities in access to
healthcare, disparities in quality of care received, or both. The differences manifest them-
selves in a wide variety of health measures, such as life expectancy, infant mortality, and
childhood mortality. Particularly disturbing is evidence of the gradual and ongoing widen-
ing of specific disparities.
At the core of this issue is the healthcare provided by physicians. National medical asso-
ciations should take an active role in combating social and health inequalities in order to
allow their physician members the ability to provide equal, quality service to all.
The Role of the Health Care System:
While the major causes of health disparities lie in the socio-economic and cultural di-
versity of population groups, there is a very significant role for the health care system in
their prevention and reduction. This role can be summarized as follows:
• To prevent the health effects of socio-economic and cultural inequality and in-
equity – especially by health promotion and disease prevention activities (Primary
Prevention)
• To Identify, treat and reduce existing health inequality, e.g. early diagnosis of
disease, quality management of chronic disease, rehabilitation (Secondary and Ter-
tiary Prevention).
RECOMMENDATIONS
The members of the medical profession, faced with treating the results of this inequity,
have a major responsibility and call on their national medical associations to:
• Recognize the importance of health inequality and the need to influence national
policy and action for its prevention and reduction
S-2009-03-2009 ⏐ New Delhi
Inequalities in Health
• Identify the social and cultural risk factors to which patients and families are ex-
posed and to plan clinical activities (diagnostic and treatment) to counter their con-
sequences.
• Advocate for the abolishment of financial barriers to obtaining needed medical
care.
• Advocate for equal access for all to health care services irrespective of geographic,
social, age, gender, religious, ethnic and economic differences or sexual orienta-
tion.
• Require the inclusion of health inequality studies (including the scope, severity,
causes, health, economic and social implications) as well as the provision of cul-
tural competence tools, at all levels of academic medical training, including further
training for those already in clinical practice.
Handbook of WMA Policies
World Medical Association ⏐ S-2009-04-2009
WMA STATEMENT
ON
GUIDING PRINCIPLES FOR THE USE OF TELEHEALTH
FOR THE PROVISION OF HEALTH CARE
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
DEFINITION
Telehealth is the use of information and communications technology to deliver health and
healthcare services and information over large and small distances.
PREAMBLE
The prevalence of telemedicine and telehealth in most countries in the world has led the
World Medical Association (WMA) to develop ethical guidelines for physicians who use
this modality to provide health care services. The WMA defines telemedicine as “the prac-
tice of medicine over a distance, in which interventions, diagnostics and treatment deci-
sions and recommendations are based on data, including voice and images, documents and
other information transmitted through telecommunication systems”. This could include
telephone and internet.
A broader telehealth definition brings into play the entire range of activities that support
the patient and the public in being healthy: prevention, promotion, diagnostics self-care
and treatment are all areas where physicians play an important role. It is this broader defi-
nition that the WMA endorses.
Telehealth/telemedicine helps eliminate distance barriers and improve equity of access to
services that otherwise often would not be available in remote, rural and increasingly ur-
ban communities. It is about transmitting voice, data, images, and information rather than
physically moving patients, health professionals and educators – thereby improving ac-
cess, timeliness and convenience and reducing travel costs. It also has the added benefit
that the patients more easily can become active participants in their own health and well-
being and are able to engage in educational programs aimed at fostering wellness from the
comfort, convenience and safety of their own homes. While this statement focuses mainly
on telehealth encounters between patients and health professionals, it should be noted that
another important aspect of telehealth is the use of tele-communication between health
professionals when providing health care.
The telemedicine/telehealth agenda will become an integral part of the larger eHealth
programs that most countries in the developed world are pursuing, as are many countries
in the developing world. More and more solutions are being introduced that provide the
ability to deliver care through an e-channel and therefore more physicians will have access
to this capability to provide care to their patients.
S-2009-04-2009 ⏐ New Delhi
Telehealth
GUIDING PRINCIPLES
Duty of Care
While the practice of telehealth challenges the conventional perception of the physician-
patient relationship, there is a “duty of care” established in all telehealth encounters be-
tween the physician and the patient as in any healthcare encounter.
The physician needs to give clear and explicit direction to the patient during the telehealth
encounter as to who has ongoing responsibility for any required follow-up and ongoing
health care. Physician supervision regarding protocols, conferencing and medical record
review is required in all settings and circumstances. Physicians should have the capability
to immediately contact nonphysician providers and technicians as well as patients.
The physician needs to clarify ongoing responsibility for the patient with any other health
care providers who are involved in the patient’s care.
The legal responsibility of health professionals providing health care through means of
telehealth must be clearly defined by the appropriate jurisdiction.
Communication with Patients
The physician will take steps to ensure that quality of communication during a telehealth
encounter is maximized. Any significant technical deficiencies should be noted in the
documentation of the consultation.
The physician providing telehealth services should be familiar with the technology.
The physician should be aware of and accommodate the limitations of video/audio in the
provision of telehealth health care services.
The physician should receive education/orientation in telehealth communication skills prior
to the initial telehealth encounter.
The physician needs to determine to the best of his or her ability each patient’s appropria-
teness for, and level of comfort with, telehealth prior to or at the encounter, while recog-
nizing that this will not be possible in all situations.
The physician, to the extent possible, should ensure that the patient receives sufficient
education/orientation to the telehealth process and communication issues prior to their ini-
tial telehealth encounter.
Standards of Practice/Quality of Clinical Care
The physician must be satisfied that the standard of care delivered via telehealth is
“reasonable” and at least equivalent to any other type of care that can be delivered to the
patient/client, considering the specific context, location and timing, and relative avail-
ability of traditional care. If the “reasonable” standard cannot be satisfied via telehealth,
the physician should inform the patient and suggest an alternative type of health care
delivery/service.
The physician should use existing clinical practice guidelines, whenever possible, to guide
the delivery of care in the telehealth setting, recognizing that certain modifications may
need to be made to accommodate specific circumstances.
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World Medical Association ⏐ S-2009-04-2009
The physician should ensure that any modifications to clinical practice guidelines for the
telehealth setting are approved by the discipline's clinical governing body or association.
The physician providing telehealth services should follow all relevant protocols and pro-
cedures related to: informed consent (verbal, written, and recorded); privacy and confi-
dentiality; documentation; ownership of patient/client record; and appropriate video/tele-
phone behaviours.
The physician providing telehealth services ensures compliance with the relevant legisla-
tion and professional guidelines of the jurisdiction from which the services are provided as
well as the jurisdiction from which the service is administered.
The physician providing telehealth services should possess the following: required skills
expected in the professional's field of practice; competent communication skills; an under-
standing of the scope of service being provided via telehealth; orientation to and ability to
navigate the technology system and environment; an understanding of the telehealth
operational protocols and procedures; and an understanding of any limitations of the tech-
nology being used.
Clinical Outcomes
Organizations providing telehealth programs should monitor and continuously strive to
improve the quality of services in order to achieve the best possible outcomes.
Organizations providing telehealth programs should have in place a systematic method of
collecting, evaluating and reporting meaningful health care outcome data and clinical ef-
fectiveness. Quality indicators should be identified and utilized.
Patient Confidentiality
The confidentiality of patient information should be protected.
The health care organization and physician providing telehealth services should be aware
of, and ensure compliance with, relevant legislation and regulations designed to protect the
confidentiality of patient/client information and have its own confidentiality guidelines.
The health care organizations and the physician are encouraged to consult with legal
counsel and relevant professional licensing/regulatory bodies when determining confi-
dentiality policy.
Informed Consent
Relevant legislation and regulations that relate to patient decision-making and consent
should be applied.
To the extent possible, informed consent shall be obtained by the physician before starting
any service or intervention. Where appropriate the patient’s consent should be noted in the
documentation of the consultation.
Consent for telehealth should follow similar principles and processes as those used for
other health services.
Handbook of WMA Policies
S-2010-01-2018 ⏐ World Medical Association
WMA STATEMENT
ON
ENVIRONMENTAL DEGRADATION
AND SOUND MANAGEMENT OF CHEMICALS
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. This Statement focuses on one important aspect of environmental degradation, which
is environmental contamination by domestic and industrial substances. It emphasizes
the harmful chemical contribution to environmental degradation and physicians’ role
in promoting sound management of chemicals as part of sustainable development,
especially in the healthcare environment.
2. Unsafe management of chemicals has potential adverse impacts on human health and
human rights, with vulnerable populations being most at risk.
3. Most chemicals to which humans are exposed come from industrial sources and
include, toxic gases, food additives, household consumer and cosmetic products,
agrochemicals, and substances used for therapeutic purposes, such as drugs and dietary
supplements. Recently, attention has been concentrated on the effects of human
engineered (or synthetic) chemicals on the environment, including specific industrial
or agrochemicals and on new patterns of distribution of natural substances due to
human activity. As the number of such compounds has multiplied, governments and
international organizations have begun to develop a more comprehensive approach to
their safe regulation. The increasing amount of plastic waste in our environment is
another serious concern, that needs to be addressed.
4. While governments have the primary responsibility for establishing a framework to
protect the public’s health from chemical hazards, the World Medical Association, on
behalf of its members, emphasizes the need to highlight the human health risks and
make recommendations for further action.
BACKGROUND
Chemicals of Concern
5. During the last half-century, the use of chemical pesticides and fertilizers dominated
agricultural practice and manufacturing industries rapidly expanded their use of
synthetic chemicals in the production of consumer and industrial goods.
6. The greatest concern relates to chemicals, which persist in the environment, have low
rates of degradation, bio-accumulate in human and animal tissue (concentrating as they
move up the food chain), and which have significant harmful impacts on human health
and the environment (particularly at low concentrations). Some naturally occurring
Reykjavik ⏐ S-2010-01-2018
Environmental Degradation
metals including lead, mercury, and cadmium have industrial sources and are also of
concern. Advances in environmental health research including environmental and
human sampling and measuring techniques, and better information about the potential
of low dose human health effects have helped to underscore emerging concerns.
7. Health effects from chemical emissions can be direct (occurring as an immediate effect
of the emission) or indirect. Indirect health effects are caused by the emissions’ effects
on water, air and food quality as well as the alterations in regional and global systems,
such as red tide in many oceans, and the ozone layer and the climate, to which the
emissions may contribute.
National and International Actions
8. The model of regulation of chemicals varies widely both within and between
countries, from voluntary controls to statutory legislation. It is important that all
countries move to a coherent, standardized national legislated approach to regulatory
control. Furthermore, international regulations must be coherent such that developing
countries will not be forced by economic circumstances to accept elevated toxic
exposure levels.
9. Synthetic chemicals include all substances that are produced by, or result from, human
activities including industrial and household chemicals, fertilizers, pesticides,
chemicals contained in products and in wastes, prescription and over-the-counter drug
products and dietary supplements, and unintentionally produced byproducts of
industrial processes or incineration, like dioxins. Furthermore, nanomaterials may need
explicit regulation beyond existing frameworks.
Strategic approach to international chemicals management
10. Worldwide hazardous environmental contamination persists despite several
international agreements on chemicals, making a more comprehensive approach to
chemicals essential. Reasons for ongoing contamination include persistence of
companies, absolute lack of controls in some countries, lack of awareness of the
potential hazards, inability to apply the precautionary principle, non-adherence to the
various conventions and treaties and lack of political will. The Strategic Approach to
International Chemicals Management (SAICM) was adopted in Dubai, on February 6,
2006 by delegates from over 100 governments and representatives of civil society.
This is a voluntary global plan of action designed to assure the sound management of
chemicals throughout their life cycle so that, by 2020, chemicals are used and
produced in ways that minimize significant adverse effects on human health and the
environment. The SAICM addresses both agricultural and industrial chemicals, covers
all stages of the chemical life cycle of manufacture, use and disposal, and includes
chemicals in products and in wastes.
Plastic waste
11. Plastic has been part of life for more than 100 years and is regularly used in some form
by nearly everyone. While some biodegradable varieties are being developed, most
plastics break down very slowly with the decomposition process taking hundreds of
years. This means that most plastics that have ever been manufactured are still on
Earth, unless they have been burnt, thus polluting the atmosphere with poisonous
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S-2010-01-2018 ⏐ World Medical Association
smoke.
12. Concerns about the use of plastic include accumulation of waste in landfills and in
natural habitats, terrestrial and marine, physical problems for wildlife resulting from
ingestion or entanglement in plastic, the leaching of chemicals from plastic products
and the potential for plastics to transfer chemicals to wildlife and humans. Many
plastics in use today are halogenated plastics or contain other additives used in
production, that have potentially harmful effects on health (e.g. carcinogenic or
promoting endocrine disruption).
13. Our current usage of plastic is not sustainable, accumulating waste and therefore
contributing to environmental degradation and potentially harmful effects on health.
Specific regulation is therefore needed to counter the harmful distribution of slowly
degradable plastic waste into the environment and the incineration of such waste
which often creates toxic byproducts.
WORLD MEDICAL ASSOCIATION (WMA) RECOMMENDATIONS
14. Despite national and international initiatives, chemical contamination of the
environment due to inadequately controlled production and usage continues to exert
harmful effects on global public health. Evidence linking some chemicals to some
health issues is strong, but far from all chemicals have been tested for their health or
environmental impacts. This is especially true for newer chemicals or nano materials,
particularly at low doses over long periods of time. Plastic contamination of our
natural environment, including in the sea where plastic decomposes to minute
particles, is an additional area of serious concern. Physicians and the healthcare sector
are frequently required to make decisions concerning individual patients and the public
as a whole based on existing data. Physicians therefore recognize that they, too, have a
significant role to play in closing the gap between policy formation and chemicals
management and in reducing risks to human health.
15. The World Medical Association reaffirms its commitment to advocate for the
environment in order to protect health and life, and recommends that:
ADVOCACY
16. National Medical Associations (NMAs) advocate for legislation that reduces chemical
pollution, enhances the responsibities of chemical manufacturers, reduces human
exposure to chemicals, detects and monitors harmful chemicals in both humans and
the environment, and mitigates the health effects of toxic exposures with special
attention to fertility for women and men and vulnerability during pregnancy and early
childhood.
17. NMAs urge their governments to support international efforts to restrict chemical
pollution through safe management, or phase out and safer substitution when
unmanageable (e.g. asbestos), with particular attention to developed countries aiding
developing countries to achieve a safe environment and good health for all.
18. NMAs facilitate better inter-sectoral collaboration between government
ministries/departments responsible for the environment and public health.
19. NMAs promote public awareness about hazards associated with chemicals (including
plastics) and what can be done about it.
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Environmental Degradation
20. Modern medical diagnosis and treatment relies heavily on the single use of packaged
clean or sterile materials with various plastic components, whether the device itself or
its packaging. NMAs should encourage research and the dissemination of practices
that can reduce or eliminate this component of environmental degradation.
21. Physicians and their medical associations advocate for environmental protection,
disclosure of product constituents, sustainable development, green chemistry and
green hospitals within their communities, countries and regions.
22. Physicians and their medical associations should support the phase out of mercury and
persistent bioaccumulative and toxic chemicals in health care devices and products and
avoid incineration of wastes from these products which may create further toxic
pollution.
23. Physicians and their medical associations should support the Globally Harmonized
System of Classification and Labelling of Chemicals (GHS) and legislation to require
an environmental and health impact assessment prior to the introduction of a new
chemical or a new industrial facility.
24. Physicians should encourage the publication of evidence of the effects of different
chemicals and plastics, and dosages on human health and the environment. These
publications should be accessible internationally and readily available to media, non-
governmental organizations (NGOs) and concerned citizens locally.
25. Physicians and their medical associations should advocate for the development of
effective and safe systems to collect and dispose of pharmaceuticals that are not
consumed. They should also advocate for the introduction worldwide of efficient
systems to collect and dispose of plastic waste.
26. Physicians and their medical associations should encourage efforts to curb the
manufacture and use of plastic packaging and plastic bags, to halt the introduction of
plastic waste into the environment, and to phase out and replace plastics with more
biocompatible materials. These efforts may include measures to enhance recycling and
specific regulations limiting the use of plastic packaging and plastic bags.
27. Physicians and their medical associations should support efforts to rehabilitate or clean
areas of environmental degradation based on a “polluter pays” and precautionary
principles and ensure that moving forward, such principles are built into legislation.
28. The WMA, NMAs and physicians should urge governments to collaborate within and
between departments to ensure coherent regulations are developed.
LEADERSHIP
The WMA:
29. Supports the goals of the Strategic Approach to International Chemicals Management
(SAICM), which promotes best practices in the handling of chemicals by utilizing
safer substitution, waste reduction, sustainable non-toxic building, recycling, as well as
safe and sustainable waste handling in the health care sector.
30. Cautions that these chemical practices must be coordinated with efforts to reduce
greenhouse gas emissions from health care and other sources to mitigate its
contribution to global warming.
31. Urges physicians, medical associations and countries to work collaboratively to
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S-2010-01-2018 ⏐ World Medical Association
develop systems for event alerts to ensure that health care systems and physicians are
aware of high-risk industrial accidents as they occur, and receive timely and accurate
information regarding the management of these emergencies.
32. Urges local, national and international organizations to focus on sustainable
production, safer substitution, green safe jobs, and consultation with the health care
community to ensure that damaging health impacts of development are anticipated and
minimized.
33. Emphasizes the importance of the safe disposal of pharmaceuticals as one aspect of
health care’s responsibility and the need for collaborative work in developing best
practice models to reduce this part of the chemical waste problem.
34. Encourages environmental classification of pharmaceuticals in order to stimulate
prescription of environmentally less harmful pharmaceuticals.
35. Encourages local, national and international efforts to reduce the use of plastic
packaging and plastic bags.
36. Encourages ongoing outcomes research on the impact of regulations and monitoring of
chemicals on human health and the environment.
The WMA recommends that Physicians:
37. Work to reduce toxic medical waste and exposures within their professional settings as
part of the World Health Professional Alliance’s campaign for Positive Practice
Environments.
38. Work to provide information on the health impacts associated with exposure to toxic
chemicals, how to reduce patient exposure to specific agents and encourage behaviors
that improve overall health.
39. Inform patients about the importance of safe disposal of pharmaceuticals that are not
consumed.
40. Work with others to help address the gaps in research regarding the environment and
health (i.e., patterns and burden of disease attributed to environmental degradation;
community and household impacts of industrial chemicals; the effects, including on
health, of distribution of plastic and of plastic waste into our natural environment; the
most vulnerable populations and protections for such populations).
PROFESSIONAL EDUCATION & CAPACITY BUILDING
The WMA recommends that:
41. Physicians and their professional associations assist in building professional and public
awareness of the importance of the environment and global chemical pollutants on
personal health.
42. NMAs develop tools for physicians to help assess their patients’ risk from chemical
exposures.
43. Physicians and their medical associations develop locally appropriate continuing
medical education on the clinical signs, diagnosis, treatment and prevention of
diseases that are introduced into communities as a result of chemical pollution and
exacerbated by climate change.
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Environmental Degradation
44. Environmental health and occupational medicine should become a core theme in
medical education. Medical schools should encourage the training of sufficient
specialists in environmental health and occupational medicine.
Handbook of WMA Policies
World Medical Association ⏐ S-2011-01-2011
WMA STATEMENT
ON
THE GLOBAL BURDEN OF CHRONIC DISEASE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
INTRODUCTION
Chronic diseases, including cardiovascular and circulatory diseases, diabetes, cancer, and
chronic lung disease are the leading cause of death and disability in both the developed
and developing world. Chronic diseases are not replacing existing causes of disease and
disability (infectious disease and trauma), but are adding to the disease burden. Develop-
ing countries now face the triple burden of infectious disease, trauma and chronic disease.
This increased burden is straining the capacity of many countries to provide adequate
health care services. This burden is also undermining these nations' efforts to increase life
expectancy and spur economic growth.
Ongoing and anticipated global trends that will lead to more chronic disease problems in
the future include an aging population, urbanization and community planning,
increasingly sedentary lifestyles, climate change and the rapidly increasing cost of medical
technology to treat chronic disease. 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.
POSSIBLE SOLUTIONS
The primary solution is disease prevention. National policies that help people achieve
healthy lifestyles and behaviors are the foundation for all possible solutions.
Increased access to primary care combined with well designed and affordable disease –
control programs can greatly improve health care. Partnerships of national ministries of
health with institutions in developed countries may overcome many barriers in the poorest
settings. Effective partnerships currently exist in rural Malawi, Rwanda and Haiti. In these
settings where no oncologists are available, care is provided by local physicians and nurse
teams. These teams deliver chemotherapy to patients with a variety of treatable malig-
nancies.
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,
Handbook of WMA Policies
World Medical Association ⏐ S-2011-01-2011
health professionals and the public. There is an urgent need to adopt accreditation stand-
ards and norms that support social accountability. Educating physicians and other health
care professionals to deliver health care that is concordant with the resources of the coun-
try 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 princi-ples of
quality, equity, relevance and effectiveness. [see WMA Resolution on Medical Work-
force]
Strengthening the health care infrastructure is important in caring for the increasing num-
bers of people with chronic disease. Components of this infrastructure include training the
primary health care team, improved facilities, chronic disease surveillance, public health
promotion campaigns, quality assurance and establishment of national and local standards
of care. One of the most important components of health care infrastructure is human re-
sources; well-trained and motivated health care professionals led by primary care physi-
cians 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.
For World Governments:
1. Support global immunization strategies;
2. Support global tobacco and alcohol control strategies;
3. Promote healthy living and implement policies that support prevention and healthy
lifestyle behaviors;
4. Set aside a fixed percentage of national budget for health infrastructure develop-
ment and promotion of healthy lifestyles.
5. Promote trade policy that protects public health;
6. Promote research for prevention and treatment of chronic disease;
7. Develop global strategies for the prevention of obesity.
For National Medical Associations:
1. Work to create communities that promote healthy lifestyles and prevention beha-
viors and to increase physician awareness of optimal disease prevention behaviors;
2. Offer patients smoking cessation, weight control strategies, substance abuse coun-
seling, self-management education and support, and nutritional counseling;
3. Promote a team-based approach to chronic disease management;
4. Advocate for integration of chronic disease prevention and control strategies in
government-wide policies;
5. Invest in high quality training for more primary care physicians and an equitable
distribution of them among populations;
S-2011-01-2011 ⏐ Montevideo
Chronic Disease
6. Provide high quality accessible resources for continuing medical education;
7. Support establishing evidence-based standards of care for chronic disease;
8. Establish, support and strengthen professional associations for primary care physi-
cians
9. Promote medical education that is responsive to societal needs;
10. Promote an environment of support for continuity of care for chronic disease, in-
cluding patient education and self-management;
11. Advocate for policies and regulations to reduce factors that promote chronic dis-
ease such as smoking cessation and blood pressure control;
12. Support strong public health infrastructure; and
13. Support the concept that social determinants are part of prevention and health care.
For Medical Schools:
1. Develop curriculum objectives that meet societal needs; e.g., social accountability;
2. Focus on providing primary care training opportunities that highlight the integra-
tive and continuity elements of the primary care specialties including family medi-
cine;
3. Provide community-oriented and community-based primary care educational ve-
nues so that students become acquainted with the basic elements of chronic care
infrastructure and continuity care provision;
4. Create departments of family medicine that are of equal academic standing in the
university; and
5. Promote the use of interdisciplinary and other collaborative training methodologies
within primary and continuing education programs.
6. Include instruction in prevention of chronic diseases in the general curriculum.
For Individual Physicians:
1. Work to create communities that promote healthy lifestyles and prevention beha-
viors;
2. Offer patients smoking cessation, weight control strategies, substance abuse coun-
seling, self-management education and support, and nutritional counseling;
3. Promote a team-based approach to chronic disease management;
4. Ensure continuity of care for patients with chronic disease;
Handbook of WMA Policies
World Medical Association ⏐ S-2011-01-2011
5. Model prevention behaviors to patients by maintaining personal health;
6. Become community advocates for positive social determinants of health and for
best prevention methods;
7. Work with parents and the community to ensure that the parents have the best
advice on maintaining the health of their children.
8. Physicians should collaborate with patients' associations in designing and deliver-
ing prevention education.
Note: Depending on the country, different stakeholders will assume greater or lesser responsibility
for change.
Handbook of WMA Policies
World Medical Association ⏐ S-2011-02-2011
WMA RECOMMENDATION
ON
THE DEVELOPMENT OF A MONITORING AND
REPORTING MECHANISM TO PERMIT AUDIT OF
ADHERENCE OF STATES TO THE DECLARATION OF TOKYO
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
The WMA recommends that
1.
1. Where physicians are working in situations of dual loyalties, support must be
offered to ensure they are not put in positions that might lead to violations of
fundamental professional ethics, whether by active breaches of medical ethics or
omission of ethical conduct, and/or of human rights, as laid out in the Declaration
of Tokyo.
2. National Medical Associations (NMA's) should offer support for physicians in
difficult situations, including, as feasible and without endangering either patients
or doctors, helping individuals to report violations of patients' health rights and
physicians' professional ethics in custodial settings.
3. The WMA should review the evidence available, in cases brought to it by its mem-
bers, of the violation of human rights codes by states and/or the forcing of physi-
cians to violate the Declaration of Tokyo, and refer as appropriate such cases to the
relevant national and international authorities.
4. The WMA should contact member associations and encourage them to investigate
accusations of physician involvement in torture and similar abuses of human rights
reported to it from reputable sources, and to report back in particular on whether
physicians are at risk and in need of support. The WMA should provide support to
the NMAs and their members to resist such violations, and as far as realistically
possible, stand firm in their ethical convictions.
5. The WMA shall encourage and support NMAs in their calls for investigations by
the relevant special rapporteur (or other individual or organization) when NMAs
and their members raise valid concerns.
Handbook of WMA Policies
S-2011-03-2011 ⏐ World Medical Association
WMA STATEMENT
ON
THE PROTECTION AND INTEGRITY OF MEDICAL PERSONNEL
IN ARMED CONFLICTS AND OTHER SITUATIONS OF VIOLENCE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
PREAMBLE
During wars and armed conflicts hospitals and other medical facilities have often been
attacked and misused and patients and medical personnel have been killed or wounded.
Such attacks are a violation of the Geneva Conventions (1949), Additional Protocols to
the Geneva Conventions (1977) and WMA regulations in times of war (2006).
The World Medical Association (WMA) has been active in condemning documented at-
tacks on medical personnel and facilities in armed conflicts. The International Committee
of the Red Cross (ICRC) Geneva Conventions and their Additional Protocols shall protect
medical personnel in international and non-international armed conflicts. The warring
parties have duty not to interfere with medical care for wounded or sick combatants and
civilians, and not attack, threaten or impede medical functions. Physicians and other health
care personnel must be considered as neutral and must not be prevented from fulfilling
their duties.
The lack of systematic reporting and documentation of violence against medical personnel
and facilities creates threats to both civilians and military personnel. The development of
strategies for protection and efforts to improve compliance with the laws of war are im-
peded as long as such information is not available.
STATEMENT
The World Medical Association condemns all attacks on and misuse of medical personnel,
facilities and vehicles in armed conflicts. These attacks put people in need of help in great
danger and can lead to the flight of physicians and other health personnel from the conflict
areas with a lack of available medical personnel as a result.
Currently no party is responsible for collecting data regarding assaults on medical person-
nel and facilities. Data collection after attacks is vital to identify the reasons why medical
personnel and facilities are attacked. Such data are important in order to understand the
nature of the attacks and to take necessary steps to prevent attacks in the future. All attacks
must also be properly investigated and those responsible for the violations of the Geneva
Conventions and Protocols must be brought to justice.
S-2011-03-2011 ⏐ Montevideo
Protection and Integrity of Medical Personnel
The WMA requests that appropriate international bodies establish mechanisms with the
necessary resources to collect and disseminate data regarding assaults on physicians, other
health care personnel and medical facilities in armed conflicts. Such mechanisms could in-
clude the establishment of a new United Nations post of Rapporteur on the independence
and integrity of health professionals. As stated in the WMA proposal for a United Nations
Rapporteur on the Independence and Integrity of Health Professionals (1997), "The new
rapporteur would be charged with the task of monitoring that doctors are allowed to move
freely and that patients have access to medical treatment, without discrimination as to na-
tionality or ethnic origin, in war zones or in situations of political tension".
When a reporting system is established the WMA will recommend to their member or-
ganisations reporting armed conflicts which they become aware of.
Handbook of WMA Policies
D-2011-04-2015 ⏐ World Medical Association
WMA DECLARATION OF OSLO
ON
SOCIAL DETERMINANTS OF HEALTH
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and the title (Statement to Declaration) changed by the 66th
WMA General Assembly,
Moscow, Russia, October 2015
The social determinants of health are: the conditions in which people are born, grow, live,
work and age; and the societal influences on these conditions. The social determinants of
health are major influences on both quality of life, including good health, and length of
disability-free life expectancy. While health care will attempt to pick up the pieces and
repair the damage caused by premature ill health, it is these social, cultural, environ-
mental, economic and other factors that are the major causes of rates of illness and, in
particular, the magnitude of health inequalities.
Historically, the primary role of doctors and other health care professionals has been to
treat the sick – a vital and much cherished role in all societies. To a lesser extent, health
care professionals have dealt with individual exposures to the causes of disease – smoking,
obesity, and alcohol in chronic disease, for example. These familiar aspects of life style
can be thought of as ‘proximate' causes of disease.
The work on social determinants goes far beyond this focus on proximate causes and
considers the "causes of the causes". For example, smoking, obesity, alcohol, sedentary
life style are all causes of illness. A social determinants approach addresses the causes of
these causes; and in particular how they contribute to social inequalities in health. It
focuses not only on individual behaviours but seeks to address the social and economic
circumstances that give rise to premature ill health, throughout the life course: early child
development, education, work and living conditions, and the structural causes that give
rise to these living and working conditions. In many societies, unhealthy behaviours fol-
low the social gradient: the lower people are in the socioeconomic hierarchy, the more
they smoke, the worse their diet, and the less physical activity they engage in. A major,
but not the only, cause of the social distribution of these causes is level of education.
Other specific examples of addressing the causes of the causes: price and availability,
which are key drivers of alcohol consumption; taxation, package labeling, bans on
advertising, and smoking in public places, which have had demonstrable effects on
tobacco consumption. The voice of the medical profession has been most important in
these examples of tackling the causes of the causes.
There is a growing movement, globally, that seeks to address gross inequalities in health
and length of life through action on the social determinants of health. This movement has
involved the World Health Organisation, several national governments, civil society organi-
zation, and academics. Solutions are being sought and learning shared. Doctors should be
S-2011-04-2011 ⏐ Montevideo
Social Determinants of Health
well informed participants in this debate. There is much that can happen within the prac-
tice of medicine that can contribute directly and through working with other sectors. The
medical profession can be advocates for action on those social conditions that have im-
portant effects on health.
The WMA could add significant value to the global efforts to address these social deter-
minants by helping doctors, other health professionals and National Medical Associations
understand what the emerging evidence shows and what works, in different circumstances.
It could help doctors to lobby more effectively within their countries and across interna-
tional borders, and ensure that medical knowledge and skills are shared.
The WMA should help to gather data of examples that are working, and help to engage
doctors and other health professionals in trying new and innovative solutions. It should
work with national associations to educate and inform their members and put pressure on
national governments to take the appropriate steps to try to minimise these root causes of
premature ill health. In Britain, for example, the national government has issued a public
health white paper that has at its heart reduction of health inequalities through action on
the social determinants of health; several local areas have drawn up plans of action; there
are good examples of general practice that work across sectors improve the quality of
people's lives and hence reduce health inequalities. The WMA should gather examples of
good practice from its members and promote further work in this area.
Handbook of WMA Policies
S-2011-05-2011 ⏐ World Medical Association
WMA STATEMENT
ON
THE PROFESSIONAL AND ETHICAL USE OF SOCIAL MEDIA
Adopted by the 62nd
WMA General Assembly, Montevideo, Urugay, October 2011
DEFINITION
Social Media is generally understood to be a collective term for the different platforms and
applications that allow user-generated content to be created and shared electronically.
PREAMBLE
The objectives of the proposed 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.
The use of social media has become a fact of life for many millions of people world wide
including physicians, medical students and patients.
Interactive, collaborative tools such as wikis, social networks, chat rooms and blogs have
transformed passive Internet users into active participants. They are means for gathering,
sharing and disseminating personal information, including health information, socializing
and connecting with friends, relatives, professionals etc. They can be used to seek medical
advice, and patients with chronic diseases can share their experiences with each other.
They can also been used in research, public health, education and direct or indirect pro-
fessional promotion.
The positive aspects of social media should be recognized such as in promoting healthy
life style, in empowering patients and in reducing patients' isolation.
Areas, which may require special attention:
• Sensitive content, photographs, other personal materials posted on online social
forums often exists in the public domain and have the capacity to remain on the
internet permanently. Individuals may not have control over the ultimate distribu-
tion 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
S-2011-05-2011 ⏐ Montevideo
Social Media
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 in the absence of adequate and con-
servative 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.
•
Interested stakeholders such as current/prospective employers, insurance companies and
commercial entities may monitor these Internet web sites for various purposes such as to
better understand their customer's needs and expectations, to profile job candidates or to
improve a product or a service.
RECOMMENDATIONS
The WMA urges their NMA´s to establish guidelines for their physicians addressing the
following issues:
1.
1. To maintain appropriate boundaries of the patient-physician relationship in accor-
dance with professional ethical guidelines just as they would in any other context.
2. To study carefully and understand the privacy provisions of social networking
sites, bearing in mind their limitations.
3. For physicians to routinely monitor their own Internet presence to ensure that the
personal and professional information on their own sites and, to the extent possi-
ble, content posted about them by others is accurate and appropriate.
4. To consider the intended audience and assess whether it is technically feasible to
restrict access to the content to pre-defined individuals or groups.
5. To adopt a conservative approach when disclosing personal information as patients
can access the profile. The professional boundaries that should exist between the
physician and the patient can thereby be blurred. Physicians should acknowledge
the potential associated risks of social media and accept them, and carefully select
the recipients and privacy settings.
6. To provide factual and concise information, declare any conflicts of interest and
adopt a sober tone when discussing professional matters.
7. To ensure that no identifiable patient information be posted in any social media by
their physician. Breaching confidentiality undermines the public's trust in the medi-
cal profession, impairing the ability to treat patients effectively.
8. To draw the attention of medical students and physicians to the fact that online
posting may contribute also to the public perception of the profession.
Montevideo ⏐ S-2011-05-2011
Social Media
9. To consider the inclusion of educational programs with relevant case studies and
appropriate guidelines in medical curricula and continuing medical education.
10. To bring their concerns to a colleague when observing his or her clearly inappro-
priate behavior. If the behaviour significantly violates professional norms and the
individual does not take appropriate action to resolve the situation, physicians should
report the conduct to appropriate authorities.
•
Handbook of WMA Policies
World Medical Association ⏐ S-2012-01-2012
WMA STATEMENT
ON
ELECTRONIC CIGARETTES AND
OTHER ELECTRONIC NICOTINE DELIVERY SYSTEMS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
INTRODUCTION
Electronic cigarettes (e-cigarettes) are products designed to deliver nicotine to a user in the
form of a vapor. They are usually composed of a rechargeable battery-operated heating
element, a replaceable cartridge that contains nicotine and/or other chemicals, and an
atomizer that, when heated, turns the contents of the cartridge into a vapor (not smoke).
This vapor is then inhaled by the user. These products are often made to look like other
tobacco-derived products like cigarettes, cigars, and pipes. They can also be made to look
like everyday items such as pens and USB memory sticks.
No standard definition of e-cigarettes exists and different manufacturers use different
designs and different ingredients. Quality control processes used to manufacture these
products are substandard or non-existent. Few studies have been done to analyze the level
of nicotine delivered to the user and the composition of the vapor produced.
Manufacturers and marketers of e-cigarettes often claim that use of their products is a safe
alternative to smoking, particularly since they do not produce carcinogenic smoke.
However, no studies have been conducted to determine that the vapor is not carcinogenic,
and there are other potential risks associated with these devices: Appeal to children,
especially when flavors like strawberry or chocolate are added to the cartridges. E-
cigarettes can increase nicotine addiction among young people and their use may lead to
experimenting with other tobacco products.
Manufacturers and distributors mislead people into believing these devices are acceptable
alternatives to scientifically proven cessation techniques, thus delaying actual smoking
cessation. E-cigarettes are not comparable to scientifically-proven methods of smoking
cessation. Their dosage, manufacture, and ingredients are not consistent or clearly la-
belled. Brand stretching by using known cigarette logos is to be deplored.
Unknown amounts of nicotine are delivered to the user, and the level of absorption is
unclear, leading to potentially toxic levels of nicotine in the system. These products may
also contain other ingredients toxic to humans.
High potential of toxic exposure to nicotine by children, either by ingestion or dermal
absorption, because the nicotine cartridges and refill liquid are readily available over the
Internet and are not sold in child resistant packaging.
S-2012-01-2012 ⏐ Bangkok
Electronic Cigarettes
Due to the lack of rigorous chemical and animal studies, as well as clinical trials on com-
mercially available e-cigarettes, neither their value as therapeutic aids for smoking ces-
sation nor their safety as cigarette replacements is established. Lack of product testing
does not permit the conclusion that e-cigarettes do not produce any harmful products even
if they produce fewer dangerous substances than conventional cigarettes.
Clinical testing, large population studies and full analyses of e-cigarette ingredients and
manufacturing processes need to be conducted before their safety, viability and impacts
can be determined as either clinical tools or as widely available effective alternatives to
tobacco use.
RECOMMENDATIONS
That the manufacture and sale of e-cigarettes and other electronic nicotine delivery sys-
tems be subject to national regulatory bodies prior approval based on testing and research
as either a new form of tobacco product or as a drug delivery device.
That the marketing of e-cigarettes and other electronic nicotine delivery systems as a valid
method for smoking cessation must be based on evidence and must be approved by ap-
propriate regulatory bodies based on safety and efficacy data.
That e-cigarettes and other electronic nicotine delivery systems be included in smoke free
laws.
Physicians should inform their patients of the risks of using e-cigarettes even if regulatory
authorities have not taken a position on the efficacy and safety of these products.
Handbook of WMA Policies
World Medical Association ⏐ S-2012-02-2012
WMA STATEMENT
ON
THE ETHICAL IMPLICATIONS OF COLLECTIVE ACTION BY PHYSICIANS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
PREAMBLE
In recent years, in countries where physicians' satisfaction with their working conditions
has decreased, collective action by physicians has become increasingly common.
Physicians may carry out protest action and sanctions in order to improve direct and
indirect working conditions that also may affect patient care. Physicians must consider not
only their duty to individual patients, but also their responsibility to improve the system
such that it meets the requirements of accessibility and quality.
In addition to their professional obligations, physicians are often also employees. There
may be tension between physicians' duty not to cause harm, and their rights as employees.
Therefore, physicians' strikes or other forms of collective action often give rise to public
debate on ethical and moral issues. This statement attempts to address these issues.
RECOMMENDATIONS
The World Medical Association recommends that National Medical Associations (NMAs)
adopt the following guidelines for physicians with regard to collective action:
Physicians who take part in collective action are not exempt from their ethical or pro-
fessional obligations to patients.
Even when the action taken is not organized by or associated with the National Medical
Association, the NMA should ensure that the individual physician is aware of and abides
by his or her ethical obligations.
Whenever possible, physicians should press for reforms through non-violent public de-
monstrations, lobbying and publicity or informational campaigns or negotiation or media-
tion.
If involved in collective action, NMAs should act to minimize the harm to the public and
ensure that essential and emergency health services, and the continuity of care, are pro-
vided throughout a strike. Further, NMAs should advocate for measures to review excep-
tional cases.If involved in collective action, NMAs should provide continuous and up-to-
date information to their patients and the general public with regard to the demands of the
conflict and the actions being undertaken. The general public must be kept informed in a
timely manner about any strike actions and the restrictions they may have on health care.
Handbook of WMA Policies
S-2012-03-2012 ⏐ World Medical Association
WMA STATEMENT
ON
FORCED AND COERCED STERILISATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
The WMA recognises that no person, regardless of gender, ethnicity, socio-economic
status, medical condition or disability, should be subjected to forced or coerced permanent
sterilisation.
A full range of contraceptive services, including sterilisation, should be accessible and
affordable to every individual. The state may have a role to play in ensuring that such ser-
vices are available, along with private, charitable and third sector organisations. The
decision to undergo contraception, including sterilisation, must be the sole decision of the
individual concerned.
As with all other medical treatments, sterilisation should only be performed on a com-
petent patient after an informed choice has been made and the free and valid consent of the
individual has been obtained. Where a patient is incompetent, a valid decision about treat-
ment must be made in accordance with relevant legal requirements and the ethical
standards of the WMA before the procedure is carried out. Sterilization of those unable to
give consent would be extremely rare and done only with the consent of the surrogate
decision maker.
Such consent should be obtained when the patient is not facing a medical emergency, or
other major stressor.
The WMA condemns practices where a state or any other actor attempts to bypass ethical
requirements necessary for obtaining free and valid consent.
Consent to sterilisation should be free from material or social incentives which might
distort freedom of choice and should not be a condition of other medical care (including
safe abortion), social, insurance, institutional or other benefits.
The WMA calls on national medical associations to advocate against forced and coerced
sterilisation in their own countries and globally.
Handbook of WMA Policies
World Medical Association ⏐ S-2012-04-2017
WMA STATEMENT
ON
ORGAN AND TISSUE DONATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Advances in medical sciences, especially surgical techniques, tissue typing and
immuno-suppressive drugs, have made possible a significant increase in the rates of
successful transplantation of human organs and tissue. Yet, in all countries, a shortage
of organ donors results in potentially avoidable loss of life. National medical
associations should support attempts to maximise the number of donor organs
available in their countries and to ensure that the highest ethical standards are
maintained. The World Medical Association has developed this policy to assist
medical associations, physicians, other health care providers and policy makers to
achieve this.
This policy is based on a number of core ethical principles: altruism, autonomy,
beneficence, equity and justice. These principles should guide those developing
national policies and those operating within it, both in relation to organ procurement
and to the distribution and transplantation of donor organs. All systems and processes
should be transparent and open to scrutiny.
This statement applies to organ and tissue donation from both deceased and living
donors. It does not apply to blood donation.
RAISING PUBLIC AWARENESS
2. It is important that individuals are aware of the option of donation and have the
opportunity to choose whether or not to donate organs and/or tissue before and after
their death. Awareness and choice should be facilitated in a coordinated multi-faceted
approach by a variety of stakeholders and means, including media awareness and
public campaigns. In designing such campaigns account needs to be taken of any
religious or cultural sensitivities of the target audience.
3. Through awareness raising campaigns, individuals should be informed of the benefits
of transplantation, the impact on the lives of those who are waiting for a transplant and
the shortage of donors available. They should be encouraged to think about their own
wishes about donation, to discuss their wishes with their family and friends and to use
established mechanisms to formally record them by opting into, or out of, donation.
4. The WMA advocates informed donor choice. National medical associations in
Handbook of WMA Policies
World Medical Association ⏐ S-2012-04-2017
countries that have adopted or are considering a policy of “presumed consent” (or opt-
out), in which there is an assumption that the individual wishes to donate unless there
is evidence to the contrary, or “mandated choice”, in which all persons would be
required to declare whether they wish to donate, should make every effort to ensure
that these policies have been adequately publicised and do not diminish informed
donor choice, including the patient’s right not to donate.
5. Consideration should be given to the establishment of national donor registries to
collect and maintain a list of citizens who have chosen either to donate or not to donate
their organs and/or tissue. Any such registry must protect individual privacy and the
individual’s ability to control the collection, use, disclosure of, and access to, his or
her health information for other purposes. Provisions must be in place to ensure that
the decision to sign up to a register is adequately informed and that registrants can
withdraw from the registry easily and quickly and without prejudice.
6. Living organ donation is becoming an increasingly important component of
transplantation programmes in many countries. Most living donation is between
related or emotionally close individuals and small but increasing numbers are donating
to people they do not know. Given that there are health risks associated with living
organ donation, proper controls and safeguards are essential. Information aimed at
informing people about the possibility of donating organs as a living donor should be
carefully designed so as not to put pressure on them to donate and to minimise the risk
of financial or other coercion. Potential donors should know where to obtain detailed
information about what is involved, should be informed of the inherent risks and
should know that there are safeguards in place to protect those offering to donate.
PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM DECEASED DONORS
7. The WMA encourages its members to support the development of comprehensive,
coordinated national protocols for deceased (also referred to as cadaveric) organ and
tissue procurement in consultation and cooperation with all relevant stakeholders.
Ethical, cultural and societal issues arising in connection with donation and
transplantation should be resolved, wherever possible, in an open process involving
public debate informed by sound evidence.
8. National and local protocols should provide detailed information about the
identification, referral and management of potential donors as well as communication
with those close to people who have died. They should encourage the procurement of
organs and tissues consistent with this statement. Protocols should uphold the
following key principles:
• Decisions to withhold or withdraw life-prolonging treatment should be based on an
assessment of whether the treatment is able to benefit the patient. Such decisions
must be, and must be seen to be, completely separate from any decisions about
donation.
• The diagnosis of death should be made according to national guidelines and as
S-2012-04-2017 ⏐ Chicago
Organ and Tissue Donation
outlined in the WMA’s Declaration of Sydney on the Determination of Death and
Recovery of Organs.
• There should be a clear separation between the treating team and the transplant
team. In particular, the physician who declares or certifies the death of a potential
donor should not be involved in the transplantation procedure. Nor should he/she
be responsible for the care of the organ recipient.
• Countries that carry out donation following circulatory/cardiac death should have
specific and detailed protocols for this practice.
• Where an individual has expressed a clear and voluntary wish to donate organs
and/or tissue after death, steps should be taken to facilitate that wish wherever
possible. This is part of the treating team’s responsibility to the dying patient.
• The WMA considers that the potential donor’s wishes are paramount. Relatives
and those close to the patient should be strongly encouraged to support a deceased
person’s previously expressed wish to donate organs and/or tissues. Whenever
possible, these conversations should occur prior to the death of the patient.
• Those charged with approaching the patient, family members or other designated
decision maker about organ and tissue donation should possess the appropriate
combination of knowledge, skill and sensitivity for engaging in such discussions.
Medical students and practising physicians should seek the necessary training for
this task, and the appropriate authorities should provide the resources necessary to
secure that training.
• Donation must be unconditional. In exceptional cases, requests by potential
donors, or their substitute decision makers, for the organ or tissue to be given to a
particular recipient may be considered if permitted by national law. Donors
seeking to apply conditions that could be seen as discriminatory against certain
groups, however, should be declined.
9. Hospitals and other institutions where donation occurs should ensure that donation
protocols are publicised amongst those likely to use them and that adequate resources
are available for their implementation. They should also foster a pro-donation culture
within the institution in which consideration of donation is the norm, rather than the
exception, when a patient dies.
10. The role of transplant coordination is critical to organ donation. Those performing
coordination act as the key point of contact between the bereaved family and the
donation team and usually also undertake the complex logistical arrangements to make
donation happen. Their role must be recognised and supported.
11. Deceased organ donation must be based on the notion of a gift, freely and voluntarily
given. It should involve the voluntary and unpressured consent of the individual
provided before death (by opting in or opting out of donation depending upon the
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World Medical Association ⏐ S-2012-04-2017
jurisdiction) or the voluntary authorisation of those close to the deceased patient if that
person’s wishes are unknown. The WMA is strongly opposed to the commercialisation
of donation and transplantation.
12. Prospective donors or their substitute health care decision makers should have access
to accurate and relevant information, including through their general practitioners.
Normally, this will include information about:
• the procedures and definitions involved in the determination of death,
• the testing that is undertaken to determine the suitability of the organs and/or tissue
for transplantation and that this may reveal previously unsuspected health risks in
prospective donors and their families,
• measures that may be required to preserve organ function until death is determined
and transplantation can occur,
• what will happen to the body once death has been declared,
• what organs and tissues can be donated,
• The protocol that will be followed in the event that the family objects to donation,
and
• the possibility of withdrawing consent.
13. Prospective donors or their substitute health care decision makers should be given the
opportunity to ask questions about donation and should have their questions answered
sensitively and intelligibly.
14. Where both organs and tissues are to be donated, information should be provided, and
consent obtained, for both together in order to minimise distress and disruption to
those close to the deceased.
15. In some parts of the world a contribution towards funeral costs is given to the family
of those who donate. This can be viewed either as appropriate recognition of their
altruistic act or as a payment that compromises the voluntariness of the choice and the
altruistic basis for donation. The interpretation may depend, in part, on the way it is set
up and managed. When considering the introduction of such a system, care needs to
be taken to ensure that the core principles of altruism, autonomy, beneficence, equity
and justice are met.
16. Free and informed decision making requires not only the provision of information but
also the absence of coercion. Any concerns about pressure or coercion must be
resolved before the decision to donate organs or tissue is made.
17. Prisoners and other people who are effectively detained in institutions should be
eligible to donate after death where checks have been made to ensure that donation is
in line with the individual’s prior, un-coerced wishes and, where the individual is
S-2012-04-2017 ⏐ Chicago
Organ and Tissue Donation
incapable of giving consent, authorisation has been provided by a family member or
other authorized decision-maker. Such authorisation may not override advance
withholding or refusal of consent.
18. Their death is from natural causes and this is verifiable.
19. In jurisdictions where the death penalty is practised, executed prisoners must not be
considered as organ and/or tissue donors. While there may be individual cases where
prisoners are acting voluntarily and free from pressure, it is impossible to put in place
adequate safeguards to protect against coercion in all cases.
ALLOCATION OF ORGANS FROM DECEASED DONORS
20. The WMA considers there should be explicit policies, open to public scrutiny,
governing all aspects of organ and tissue donation and transplantation, including the
management of waiting lists for organs to ensure fair and appropriate access.
21. Policies governing the management of waiting lists should ensure efficiency and
fairness. Criteria that should be considered in allocating organs or tissue include:
• Severity and urgency of medical need,
• Length of time on the waiting list,
• Medical probability of success measured by such factors as age, type of disease,
likely improvements in quality of life, other complications, and histocompatibility.
22. There must be no discrimination based on social status, lifestyle or behaviour. Non-
medical criteria must not be considered.
PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM LIVING DONORS
23. Living donation is becoming increasingly common as a way to overcome the shortage
of organs from deceased donors. In most cases donors provide organs to relatives or
people to whom they are emotionally close. A small number of individuals choose to
donate an organ altruistically to a stranger. Another scenario is where one or more
donor and recipient pairs are incompatible with each other but donate in the form of a
cross-over or pooled donation system (for example, donor A donates to recipient B,
donor B donates to recipient C and donor C donates to recipient A).
24. All potential donors should be given accurate and up to date information about the
procedure and the risks of donation and have the opportunity to discuss the issue
privately with a member of the healthcare team or a counsellor. Normally this
information will include:
• The risks of becoming a living donor,
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• The tests that are undertaken to assess suitability for donation and that this may
reveal previously unsuspected health problems,
• What will happen before, during and after donation takes place, and
• In the case of solid organs, the long-term implications of living without the
donated organ.
25. Prospective donors should be given the opportunity to ask questions about donation
and should have their questions answered sensitively and intelligibly.
26. Procedures should be in place to ensure that living donors are acting voluntarily and
free from pressure or coercion. In order to avoid donors being paid and then posing as
a known donor, independent checks should also be undertaken to verify the claimed
relationship and, where this cannot be proven, the donation should not proceed. Such
checks should be independent of the transplant team and those who are caring for the
potential recipient.
27. Additional safeguards should be in place for vulnerable donors, including but not
limited to, people who are dependent in some way (such as competent minors donating
to a parent or sibling).
28. Prisoners should be eligible to be living donors only in exceptional circumstances, to
first or second degree family members; evidence should be provided of any claimed
relationship before the donation may proceed. Where prisoners are to be considered as
living donors, extra safeguards are required to ensure they are acting voluntarily and
are not subject to coercion.
29. Those who lack the capacity to consent should not be considered as living organ
donors because of their inability to understand and decide voluntarily. Exceptions may
be made in very limited circumstances, following legal and ethical review.
30. Donors should not lose out financially as a result of their donation and so should be
reimbursed for general and medical expenses and any loss of earnings incurred.
31. In some parts of the world individuals are paid for donating a kidney, although in
virtually all countries the sale of organs is unlawful. The WMA is strongly opposed to
a market in organs.
PROTOCOLS FOR RECIPIENTS
32. Protocols for free and informed decision making should be followed in the case of
recipients of organs or tissue. Normally, this will include providing information about:
The risks of the procedure,
The likely short, medium and long-term survival, morbidity, and quality-of-life
S-2012-04-2017 ⏐ Chicago
Organ and Tissue Donation
prospects,
Alternatives to transplantation, and
How organs and tissues are obtained.
33. In the case of a delayed diagnosis for infection, disease or malignancy in the donor,
there should be a strong presumption that the recipient will be informed of any risk to
which they may have been exposed. Individual decisions about disclosure need to take
account of the particular circumstances, including the level and severity of risk. In
most cases disclosure will be appropriate and should be managed carefully and
sensitively.
COSTS AND ORIGIN OF ORGANS AND TISSUES
34. Organs or tissue suspected to have been obtained through unlawful means must not be
accepted for transplantation.
35. Organs and tissues must not be sold for profit. In calculating the cost of
transplantation, charges related to the organ or tissue itself should be restricted to those
costs directly associated with its retrieval, storage, allocation and transplantation.
36. Transplant surgeons should seek to ensure that the organs and tissues they transplant
have been obtained in accordance with the provisions of this policy and should refrain
from transplanting organs and tissues that they know, or suspect, have not been
procured in a legal and ethical manner.
TRANSPARENCY AND ACCOUNTABILITY
37. National Medical Associations should work with governments and relevant institutions
to ensure that appropriate, effective structures and processes are in place to:
• support relevant traceability and follow-up of all transplant recipients and living
donors including those who require ongoing medical management receive care and
support;
• record information on donation and transplantation rates and outcomes;
• assess the short and long-term outcomes, quality, safety and efficacy of organ
donation and transplantation activities;
• assess the adherence to ethical and clinical protocols of organ donation and
transplantation activities;
38. The data arising from these activities should be publicly accessible and open to
scrutiny (notwithstanding appropriate protection of donor and recipient
confidentiality).
FUTURE OPTIONS
39. Public health measures to reduce the demand for donated organs should be seen as a
priority, alongside initiatives to increase the effectiveness and success of organ
Handbook of WMA Policies
World Medical Association ⏐ S-2012-04-2017
donation systems.
40. New developments and possibilities, such as xenotransplantation and the use of stem
cell technology to repair damaged organs, should be monitored. Before their
introduction into clinical practice such technologies should be subject to scientific
review and robust safety checks as well as ethical review. Where, as with
xenotransplantation, there are potential risks that go beyond individual recipients, this
process must also involve public debate.
Handbook of WMA Policies
S-2012-05-2012 ⏐ World Medical Association
WMA STATEMENT
ON
THE PRIORITISATION OF IMMUNISATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
PREAMBLE
Vaccination use to prevent against disease was first done successfully by Jenner in 1796
when he used cowpox material for vaccination against smallpox. Since then, vaccination
and immunisation have been acknowledged as an effective preventive strategy for several
communicable diseases and are now being developed for the control of some non-
communicable diseases.
Vaccine development and administration are some of the most significant interventions to
influence global health in modern times. It is estimated that immunisation currently pre-
vents approximately 2.5 million deaths every year, saving lives from diseases such as
diphtheria, tetanus, whooping cough (pertussis) and measles. Approximately 109 million
children under the age of one are fully vaccinated with the diphtheria-tetanus-pertussis
(DTP3) vaccine alone.
Mostly the ultimate goal of immunisation is the total eradication of a communicable
disease. This was achieved for smallpox in 1980 and there is a realistic goal for the eradi-
cation of polio within the next few years.
The Global Immunisation Vision Strategy (GIVS) 2006-2015 was developed by the WHO
and UNICEF in the hope of reaching target populations who currently do not have im-
munisation services or who do not have an adequate level of coverage.
The four strategies promoted in this vision are:
• Protecting more people in a changing world
• Introducing new vaccines and technologies
• Integrating immunisation, other linked health interventions and
• Surveillance in the health systems context
• Immunizing in the context of global interdependence1
Vaccine research is constantly revealing new possibilities to protect populations from
serious health threats. Additionally, new strains of diseases emerge requiring the adapta-
tion of vaccines in order to offer protection.
The process of immunisation requires an environment that is resourced with appropriate
materials and health workers to ensure the safe and effective administration of vaccines.
Bangkok ⏐ S-2012-05-2012
Prioritisation of Immunisation
Administration of vaccines often requires injections, and safety procedures for injections
must always be followed.
Immunisation schedules can vary according to the type of vaccine, with some requiring
multiple administrations to be effective. It is vitally important that the full schedule is
followed otherwise the effectiveness of the vaccine may be compromised.
The benefits of immunisation have had a profound effect on populations, not only in terms
of preventing ill health but also in permitting resources previously required to treat the
diseases to be redirected to other health priorities. Healthier populations are economically
beneficial and can contribute more to society.
Reducing child mortality is the fourth of the United Nation's Millennium Development
Goals, with immunisation of children having a significant impact on mortality rates on
children aged under five. According to the WHO, there are still more than 19 million
children who have not received the DTP3 vaccine. In addition, basic health care services
for maternal health with qualified health care personnel must be established.
Immunisation of adults for diseases such as influenza and pneumococcal infections has
been shown to be effective, not only in decreasing the number of cases amongst those that
have received immunisation but also in decreasing the disease burden in society.
The medical profession denounce any claims that are unfounded and inaccurate with res-
pect to the possible dangers of vaccine administration. Claims such as these have resulted
in diminished immunisation rates in some countries. The result is that the incidences of the
diseases to be prevented have increased with serious consequences for a number of
persons.
Countries differ in immunisation priorities, with the prevalence and risk of diseases
varying among populations. Not all countries have the same coverage rates, nor do they
have the resources to acquire, coordinate, distribute or effectively administer vaccines to
their populations, often relying on non-governmental organizations to support immuni-
sation programmes. These organizations in turn often rely on external funding that may
not be secure. In times of global financial crisis, funding for such programmes is under
considerable pressure.
The risk of health complications from vaccine-preventable diseases is greatest in those
who experience barriers in accessing immunisation services. These barriers could be cost,
location, lack of awareness of immunisation services and their health benefits or other
limiting factors.
Those with chronic diseases, underlying health issues or other risk factors such as age are
at particular risk of major complications due to vaccine-preventable diseases and therefore
should be targeted to ensure adequate immunisation.
Supply chains can be difficult to secure, particularly in countries that lack coordination or
support of their immunisation programmes. Securing the appropriate resources, such as
qualified health professionals, equipment and administrative support can present signifi-
cant challenges.
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S-2012-05-2012 ⏐ World Medical Association
Data collection on vaccine administration rates, side effects of vaccines and disease sur-
veillance can often be difficult to achieve, particularly in isolated and under-resourced
areas. Nevertheless, reporting incidents and monitoring disease spread are vital tools in
combating global health threats.
RECOMMENDATIONS
The WMA supports the recommendations of the Global Immunisation Vision Strategy
(GIVS) 2006-2015, and calls on the international community to:
• Encourage governments to commit resources to immunisation programmes targeted
to meet country specific needs.
• Recognise the importance of vaccination/immunisation through the continued sup-
port and adoption of measures to achieve global vaccination targets and to meet the
Millennium Development Goals, especially four (reduce child mortality), five (im-
prove maternal health) and six (combat HIV/AIDS, malaria and other diseases).
• Recognise the global responsibility of immunisation against preventable diseases
and support work in countries that have difficulties in meeting the 2012 targets in
the Global Polio Eradication Initiative2
.
• Support national governments with vulnerable populations at risk of vaccine-pre-
ventable diseases, and the local agencies that work to deliver immunisation services
and to work with them to alleviate retrictions in accessing services.
• Support vaccine research and development and ensure commitment through the ade-
quate funding of vital vaccine research.
• Promote vaccination and the benefits of immunisation, particularly targeting those
at-risk and those who are difficult to reach. Comply with monitoring activities
undertaken by WHO and other health authorities. Promote high standards in the
research, development and administration of vaccines to ensure patient safety. Vac-
cines need to be thoroughly tested before implemented on a large scale and subse-
quently monitored in order to identify possible complications and untoward side
effects. In order to be successful, immunisation programmes need public trust which
depends on safety.
In delivering vaccination programmes, the WMA recommends that:
• The full immunisation schedule is delivered to provide optimum coverage. Where
possible, the schedule should be managed and monitored by suitably trained indi-
viduals to ensure consistent delivery and prompt appropriate management of adverse
reactions to vaccines.
• Strategies are employed to reach populations that may be isolated because of loca-
tion, race, religion, economic status, social marginalization, gender and/or age.
• Ensure that qualified health professionals receive comprehensive training to safely
deliver vaccinations and immunisations, and that vaccination/immunisations are tar-
geted to those whose need is greatest.
• Educate people on the benefits of immunisation and how to access immunisation
services.
Bangkok ⏐ S-2012-05-2012
Prioritisation of Immunisation
• Maintain accurate medical records to ensure that valid data on vaccine admin-
istration and coverage rates are available, enabling immunisation policies to be
based upon sound and reliable evidence.
• Healthcare professionals should be seen as a priority population for the receipt of
immunisation services due to their exposure to patients and to diseases.
The WMA calls upon its members to advocate the following:
• To increase awareness of national immunisation schedules and of their own (and
their dependents) personal immunisation history.
• To work with national and local governments to ensure that immunisation pro-
grammes are resourced and implemented.
• To ensure that health personnel delivering vaccines and immunisation services re-
ceive proper education and training.
• To promote the evidence base and increase awareness about the benefits of im-
munisation amongst physicians and the public.
1
World Health Organization and United Nations Children's Fund. Global Immunisation Vision and
Strategy, 2006-2015. Geneva, Switzerland: World Health Organization and United Nations Child-
ren's Fund; 2005. Available at: http://www.who.int/immunisation/givs/related_docs/en/index.html
2
World Health Organization. Global Polio Eradication Initiative: Strategic Plan 2010-2012.
Geneva, Switzerland: World Health Organization; 2010. Available at:
http://www.polioeradication.org/Portals/0/Document/StrategicPlan/StratPlan2010_2012_ENG.pdf
Handbook of WMA Policies
S-2012-06-2012 ⏐ World Medical Association
WMA STATEMENT
ON
VIOLENCE IN THE HEALTH SECTOR BY PATIENTS AND
THOSE CLOSE TO THEM
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
PREAMBLE
All persons have the right to work in a safe environment without the threat of violence.
Workplace violence includes both physical and non-physical (psychological) violence.
Given that non-physical abuse, such as harassment and threats, can have severe psy-
chological consequences, a broad definition of workplace violence should be used. For
the purposes of this statement we will use the widely accepted definition of workplace
violence, as used by the WHO: "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".
Violence, apart from the numerous health effects it can have on its victims, also has
potentially destructive social effects. Violence against health workers, including physi-
cians, not only affects the individuals directly involved, but also impacts the entire health-
care system and its delivery. Such acts of violence affect the quality of the working
environment, which has the potential to detrimentally impact the quality of patient care.
Further, violence can affect the availability of 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
constitutes violence and what specific forms of workplace violence are most likely to
occur. Threats and other forms of psychological violence are widely recognized to be
more prevalent than physical violence. Reasons and causes of violence in the healthcare
setting are extremely complex.
Several studies have identified common triggers for acts of violence in the health sector to
be delays in receiving treatment and dissatisfaction with the treatment provided1
.
Moreover, patients may act aggressively as a result of their medical condition, the medi-
cation they take or the use of alcohol and other drugs. Another important example is that
individuals may threaten or perpetrate physical violence against healthcare workers
because they oppose, on the basis of their social, political or religious beliefs, a specific
area of medical practice.
A multi-faceted approach encompassing the areas of legislation, security, data collection,
training, environmental factors, public awareness and financial incentives is required in
order to successfully address the issue of violence in the health sector.
Bangkok ⏐ S-2012-06-2012
Violence in the Health Sector
In addition, collaboration among various stakeholders (including governments, National
Medical Associations (NMAs), hospitals, general health services, management, insurance
companies, trainers, preceptors, researchers, police and legal authorities) is more effective
than the individual efforts of any one party. As the representatives of physicians, NMAs
should take an active role in combating violence in the health sector and also encourage
other key stakeholders to act, thus further protecting the quality of the working environ-
ment for healthcare employees and the quality of patient care.
This collaborative approach to addressing violence in the health sector must be promoted
throughout the world.
RECOMMENDATIONS
The WMA encourages National Medical Associations (NMAs) to act in the following areas:
Strategy – NMAs should encourage healthcare institutions to develop and implement a
protocol to deal with acts of violence. The protocol should include the following:
• A zero-tolerance policy towards workplace violence.
• A universal definition of workplace violence.
• A predetermined plan for maintaining security in the workplace.
• A designated plan of action for healthcare professionals to take when violence
takes place.
• 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.
In order for this protocol to be effective, it is necessary for the management and admin-
istration of healthcare institutions to communicate and take the necessary steps to ensure
that all staff are aware of the strategy.
Policymaking – In order to help increase patient satisfaction, national priorities and limita-
tions on medical care should be clearly addressed by government institutions.
The state has obligations to ensure the safety and security of patients, physicians, and
other healthcare workers. This includes providing an appropriate physical environment.
Hence, healthcare systems should be designed to promote the safety of healthcare staff and
patients. An institution which has experienced an act of violence by a patient may require
the provision of extra security, as all healthcare workers have the right to be protected in
their work place.
In some jurisdictions, physicians might have the right to refuse to treat a violent patient.
In such cases, they must ensure that adequate alternative arrangements are made by the
relevant authorities in order to safeguard the patient's health and treatment.
Patients with acute, chronic or illness-induced mental health disturbances may act
violently toward caregivers; those offering care to these patients must be adequately pro-
tected.
Training – A well-trained and vigilant staff supported by management can be a key
deterrent of violent acts. NMAs should work with undergraduate and postgraduate edu-
cation providers to ensure that healthcare professionals are trained in the following: com-
Handbook of WMA Policies
S-2012-06-2012 ⏐ World Medical Association
munication skills and recognising and handling potentially violent persons and high risk
situations in order to prevent incidents of violence. The cultivation of physician-patient
relationships based on respect and mutual trust will not only improve the quality of patient
care, but will also foster feelings of security resulting in a reduced risk of violence.
Communication – NMAs should work with other key stakeholders to increase awareness
of violence in the health sector. When appropriate, they should inform healthcare workers
and the public when acts of violence occur and encourage physicians to report acts of
violence through the appropriate channels.
Further, once an act of violence has taken place, the victim should be informed about the
procedures undertaken thereafter.
Support to victims – Medical, psychological and legal counselling and support should be
provided to staff members who have been the victims of threats and/or acts of violence
while at work.
Data Collection – NMAs should lobby their governments and/or hospital boards to
establish appropriate reporting systems enabling all healthcare workers to report anony-
mously 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 pre-
ventative strategies. Aggregated data and analyses should be made available to NMAs.
Investigation – In all cases of violence there should be some form of investigation to
better understand the causes and to aid in prevention of future violence. In some cases, the
investigation may lead to prosecution under civil or criminal codes. The procedure should
be, as much as possible, authoritative-led and uncomplicated for the victim.
Security – NMAs should work to ensure that appropriate security measures are in place in
all healthcare institutions and that acts of violence in the healthcare sector are given a high
priority by law-enforcement institutions. A routine violence risk audit should be imple-
mented in order to identify which jobs and locations are at highest risk for violence.
Examples of high risk areas include general practice premises, mental health treatment
facilities and high traffic areas of hospitals including the emergency department.
The risk of violence may be ameliorated by a variety of means which could include
placing security guards in these high risk areas and at the entrance of buildings, by the
installation of security cameras and alarm devices for use by health professionals, and by
maintaining sufficient lighting in work areas, contributing to an environment conducive to
vigilance and safety.
Financial – NMAs should encourage their governments to allocate appropriate funds in
order to effectively tackle violence in the health sector.
1
Carmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence towards hospital-
and community- based physicians in the Negev: an observational study BMC Health Service
Research 2005; 5: 54
Derazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department
(Article in Hebrew) Harefuah. 1999 Aug; 137(3-4): 95-101, 175
Landua SF. Violence against medical and non-medical personnel in hospital emergency wards
in Israel Research Report, Submitted to the Israel National Institute for Health Policyand Health
Services Research, December 2004
Handbook of WMA Policies
World Medical Association ⏐ S-2013-01-2013
WMA STATEMENT
ON
FUNGAL DISEASE DIAGNOSIS AND MANAGEMENT
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
Annual WHO Global Burden of Disease estimates recognize that fungal diseases account
for a significant proportion of health problems worldwide. These include cutaneous fungal
infections which affect up to a billion persons and vulvovaginal candidiasis which affects
tens of millions of women, often multiple times annually.
Even more serious are invasive and chronic fungal diseases that lead to estimated annual
morbidity rates that are similar to those caused by commonly recognized global health
concerns such as malaria and tuberculosis. In addition to death, these fungal diseases
commonly lead to chronic ill health, including blindness with keratitis, respiratory distress
with allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensiti-
sation (SAFS) and chronic pulmunary aspergillosis (CPA), weight loss and nutritional
deficiency with oesophageal candidiasis and CPA, and inability to engage in healthy
sexual activity with vulvovaginal candidiasis.
Serious fungal diseases are often opportunistic, occurring as a consequence of other condi-
tions that suppress the immune system, such as asthma, AIDS, cancer, post-transplant im-
munosuppressive drugs and corticosteroid therapies. Some occur in critically ill patients.
Despite the fact that many fungal diseases can be treated relatively simply, in many cases,
these diseases go untreated. Fungal infections alone are often not distinctive enough to
allow a clinical diagnosis, and as cultures are frequently falsely negative, missed diagnosis
is common. In addition, a relatively narrow diagnostic window to cure the patient is fre-
quently missed, resulting in prolonged expensive hospital stays, often with a fatal out-
come. Despite the existence of effective medicine to treat fungal infections, these are often
not available when and where they are needed.
STATEMENT
The WMA stresses the need to support the diagnosis and management of fungal diseases
and urges national governments to ensure that both diagnostic tests and antifungal ther-
apies are available for their populations. Depending on the prevalence of fungal diseases
and their underlying conditions, specific antigen testing or microscopy and culture are
essential. These tests, and personnel trained to administer and interpret the tests, should be
available in all countries where systemic fungal infections occur. This will likely include
developing at least one diagnostic centre of excellence with a sufficient staff of trained
diagnostic personnel. Monitoring for antifungal toxicities should be available.
S-2013-01-2013 ⏐ Fortaleza
Fungal Disease
Physicians will be the first point of contact for most patients with a fungal infection and
should be sufficiently educated about the topic in order to ensure an effective diagnostic
approach.
The WMA encourages its members to undertake and support epidemiologic studies on the
burden of fungal disease in their country and to inform the national government of the
results.
Handbook of WMA Policies
World Medical Association ⏐ S-2013-02-2013
WMA STATEMENT
ON
HUMAN PAPILLOMAVIRUS VACCINATION
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Human papillomavirus (HPV) vaccination presents a unique and valuable opportunity for
physicians to substantially prevent morbidity and mortality from certain cancers in all
populations, and to improve maternal health. The HPV vaccine therefore merits considera-
tion by the World Medical Association (WMA) separately from other vaccines.
HPV is a sexually transmitted virus and is so common that most sexually active adults
become infected at some point in their lives. Most infections are asymptomatic and
resolve without medical intervention. However, some of the 40 types of HPV can cause
cervical cancer. HPV is the cause of nearly 100% of cervical cancer cases and may also
cause cancer of the vagina, vulva, anus, penis and the head and neck. Cervical cancer
accounts for more than 10% of all female cancers, and the majority of cervical cancer
deaths are in developing countries.
Vaccines can protect against infection by the most common HPV types and afford pro-
tection against cancer. The U.S. Advisory Committee on Immunization Practices recom-
mends HPV vaccination for both females and males starting at age 11 years up to age 26
years. Benefits of vaccinating young men include protection against genital warts and
cancer in addition to preventing transmission of HPV to sexual partners. The additional
protection afforded by the quadrivalent vaccine against genital warts as well as cervical
and other cancers should be taken into consideration when developing HPV vaccination
programmes. The HPV vaccines are effective; post-marketing studies have shown decreases
in HPV prevalence and HPV related disorders such as genital warts and abnormal cervical
cytology. Studies concerning the safety of HPV vaccines have been reassuring.
These vaccines should be made widely available and should be promoted by physicians as
a matter of individual patient wellbeing and public health.
RECOMMANDATIONS
The WMA urges physicians to educate themselves and their patients about HPV and
associated diseases, HPV vaccination and routine cervical cancer screening; and encourages
the development and funding of programs to make HPV vaccine available and to provide
cervical cancer screening in countries without organized cervical cancer screening pro-
grams.
S-2013-02-2013 ⏐ Fortaleza
Human Papillomavirus Vaccination
National medical associations (NMAs) are encouraged to carry out intensive education of
and advocacy efforts toward their members to:
• Improve awareness and understanding of HPV and associated diseases;
• Understand the availability and efficacy of HPV vaccines;
• Understand the desirability of including HPV vaccines in national immunization
programs;
• Understand the need for routine cervical cancer screening; and
• Integrate HPV cancer prevention methods, early detection and screening, diagnosis,
treatment and palliative care into existing continuing professional development pro-
grams and pre-service training. Such training will leverage existing support for HPV
programs and help in capacity building and quality assurance efforts.
NMAs are also encouraged to:
• Integrate HPV vaccination for all adolescents and routine cervical cancer screening
for young women into all appropriate health care settings and visits;
• Support the availability of the HPV vaccine and routine cervical cancer screening
for appropriate populations that benefit most from preventive measures, including
but not limited to at-risk patients such as low-income, disadvantaged and popula-
tions that are not yet sexually active;
• Recommend HPV vaccination for all appropriate populations;
• Promote member advocacy for HPV prevention, care and treatment; and
• Create a network of physicians and practitioners who are willing and able to mentor
and support one another and establish linkages to existing HPV vaccine and cancer
prevention networks.
Handbook of WMA Policies
World Medical Association ⏐ S-2013-03-2013
WMA STATEMENT
ON
NATURAL VARIATIONS OF HUMAN SEXUALITY
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Healthcare professionals encounter many aspects of human diversity when providing care,
including different variations of human sexuality.
A large body of scientific research indicates that homosexuality is a natural variation of
human sexuality without any intrinsically harmful health effects.
As a consequence homosexuality was removed from the American Psychiatric Associa-
tion’s official diagnostic manual in 1973. The World Health Organisation (WHO) removed
it from the ICD in 1990 following a similar process of scientific review. The Pan
American Health Organization (WHO) states: “In none of its individual manifestations
does homosexuality constitute a disorder or an illness, and therefore it requires no cure.”
Direct and indirect discrimination, stigmatisation, peer rejection, and bullying continue to
have a serious impact upon the psychological and physical health of people with a homo-
sexual or bisexual orientation. These negative experiences lead to higher prevalence rates
of depression, anxiety disorders, substance misuse, and suicidal ideations and attempts.
The suicide rate among adolescents and young adults with a homosexual or bisexual
orientation is, consequently, three times higher than that of their peers.
This can be exacerbated by so-called “conversion” or “reparative” procedures, which
claim to be able to convert homosexuality into asexual or heterosexual behaviour and give
the impression that homosexuality is a disease. These methods have been rejected by
many professional organisations due to a lack of evidence of their effectiveness. They
have no medical indication and represent a serious threat to the health and human rights of
those so treated.
RECOMMENDATIONS
The WMA strongly asserts that homosexuality does not represent a disease, but rather a
natural variation within the range of human sexuality.
The WMA condemns all forms of stigmatisation, criminalisation and discrimination of
people based on their sexual orientation.
S-2013-03-2013 ⏐ Fortaleza
Natural Variations of Human Sexuality
The WMA calls upon all physicians to classify physical and psychological diseases on the
basis of clinically relevant symptoms according to ICD-10 criteria regardless of sexual
orientation, and to provide therapy in accordance with internationally recognised treat-
ments and protocols.
The WMA asserts that psychiatric or psychotherapeutic approaches to treatment must not
focus upon homosexuality itself, but rather upon conflicts, which arise between homo-
sexuality, and religious, social and internalised norms and prejudices.
The WMA condemns so-called “conversion” or “reparative” methods. These constitute
violations of human rights and are unjustifiable practices that should be denounced and
subject to sanctions and penalties. It is unethical for physicians to participate during any
step of such procedures.
Handbook of WMA Policies
World Medical Association ⏐ S-2013-04-2013
WMA STATEMENT
ON
THE RIGHT OF REHABILITATION OF VICTIMS OF TORTURE
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
The World Medical Association notes with grave concern the continued use of torture in
many countries throughout the world.
The WMA reaffirms its total condemnation of all form of torture, and other cruel, in-
human or degrading treatment or punishment, as defined by the UN Convention Against
Torture (CAT, 1984). Torture is one of the gravest violations of international human rights
law and has devastating consequences for victims, their families and society as a whole.
Torture causes severe physical and mental injuries and is a crime absolutely prohibited
under international law.
The WMA reaffirms its policies adopted previously, namely:
• The Declaration of Tokyo laying down Guidelines for Physicians Concerning Tor-
ture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to
Detention and Imprisonment (1975)
• The Declaration of Hamburg concerning Support for Medical Doctors Refusing to
Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman
or Degrading Treatment (1997)
• The Resolution on the Responsibility of Physicians in the Documentation and De-
nunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment (2003).
The medical evaluation is an essential factor in pursuing the documentation of torture and
the reparation of victims of torture. Physicians have a critical role to play in gathering
information about torture, documenting evidence of torture for legal purposes, as well as
supporting and rehabilitating victims.
The WMA recognizes the adoption, in December 2012, by the UN Committee Against
Torture of the General Comment on the Implementation of article 14 of Convention
against Torture relating to the right to reparation of victims of torture.
The General Comment outlines the right of rehabilitation as an obligation on States and
specifies the scope of these services. The WMA welcomes in particular:
• The obligation of State parties to adopt a “long-term and integrated approach and
S-2013-04-2013 ⏐ Fortaleza
Victims of Torture
ensure that specialized services for the victim of torture or ill treatment are available,
appropriate and promptly accessible” (paragraph 13), without making access to these
services dependent on the victim pursuing judicial remedies.
• The recognition of the right of victims to choose a rehabilitation service provider, be
it a State institution, or a non-State service provider, which is funded by the State.
• The recognition that State parties should provide torture victims with access to
rehabilitation programs as soon as possible following an assessment by qualified
independent healthcare professionals.
• The references in paragraph 18 to measures aimed at protecting health and legal
professionals who assist torture victims, developing specific training on the Istanbul
Protocol for health professionals, and promoting the observance of international
standards and codes of conduct by public servants, including medical, psychological
and social service personnel.
RECOMMENDATIONS
The WMA emphasizes the vital function of reparation for victims of torture and their
families in rebuilding their lives and achieve redress and the important role of physicians
in rehabilitation.
The WMA encourages its member associations to work with relevant agencies – govern-
mental and non-governmental – acting for the reparation of victims of torture, in particular
in the areas of documentation and rehabilitation, as well as prevention.
The WMA encourages its members to support agencies that are under threat of – or
subjected to – reprisals from state parties due to their involvement in the documentation of
torture, rehabilitation and reparation of torture victims.
The WMA calls on its members to use their medical experience to support torture victims
in accordance with article 14 of the UN Convention against Torture.
The WMA calls on its member associations to support and facilitate data collection at the
national level in order to monitor the implementation of the State’s obligation to provide
rehabilitation services.
Handbook of WMA Policies
World Medical Association ⏐ S-2013-05-2013
WMA STATEMENT
ON
THE UNITED NATIONS RESOLUTION FOR A MORATORIUM ON
THE USE OF THE DEATH PENALTY
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
The WMA Resolution on Physician Participation in Capital Punishment states that it is
unethical for physicians to take part in capital punishment, and the WMA Declaration of
Geneva obliges physicians to maintain the utmost respect for human life.
The WMA acknowledges that the views prevalent in the countries of some of its members
prevent all members unconditionally opposing the death penalty.
The WMA therefore supports the suspension of the use of the death penalty through a
global moratorium.
The WMA has long recognized that it cannot hold its national medical association mem-
bers responsible for the actions and policies of their respective governments.
RECOMMANDATIONS
The World Medical Association supports United Nations General Assembly Resolution
65/206 calling for a moratorium on the use of the death penalty.
Handbook of WMA Policies
S-2014-01-2014 ⏐ World Medical Association
WMA STATEMENT
ON
AESTHETIC TREATMENT
Adopted by the 65th
WMA General Assembly, Durban, South Africa, Otober 2014
PREAMBLE
Aesthetic treatments have become increasingly common in recent years as society appears
to have become more preoccupied with physical appearance. These treatments are per-
formed by practitioners with widely differing clinical and educational backgrounds.
For the purpose of this statement, aesthetic treatment is defined as an intervention that is
performed not to treat an injury, a disease or a deformity, but for non-therapeutic reasons,
with the sole purpose of enhancing or changing the physical appearance of the individual
concerned. In this statement, the individual undergoing treatment is referred to as the
patient. The treatments available include a great variety of interventions, ranging from
surgical procedures to injections and different kinds of skin treatments. This statement
focuses on interventions that are methodologically similar to those performed in con-
ventional health care. Tattooing, scarring and similar interventions are therefore not con-
sidered in this statement.
Body image affects a person's self-esteem and mental health and is an integral part of a
person's overall health and well-being. However, media images of “perfect bodies” have
become the norm, causing some people, to develop unrealistic and unhealthy body images.
Many aesthetic treatments involve risks and may potentially harm the health of the patient.
Minors1
are particularly vulnerable, as their bodies are often not fully developed. In order
to protect persons considering or undergoing aesthetic treatment the WMA has developed
the following basic principles regarding aesthetic treatments.
Reaffirming the medical ethics principles laid out in the WMA Declaration of Geneva, the
WMA Declaration of Lisbon on the Rights of the Patient and the WMA International
Code of Medical Ethics, and consistent with the mandate of the WMA, this statement is
addressed primarily to physicians. However, the WMA encourages other practitioners per-
forming aesthetic treatments to adopt these principles.
PRINCIPLES
1. The patient´s dignity, integrity and confidentiality must always be respected.
2. Physicians have a role in helping to identify unhealthy body images and to address
and treat disorders when these exist.
Durban ⏐ S-2014-01-2014
Aesthetic Treatment
3. Aesthetic treatments must only be performed by practitioners with sufficient knowl-
edge, skills and experience of the interventions performed.
4. All practitioners providing aesthetic treatments must be registered with and/or li-
censed by the appropriate regulatory authority. Ideally, the practitioner should also
be authorized by this authority to provide these specific aesthetic treatments.
5. All aesthetic treatments must be preceded by a thorough examination of the patient.
The practitioner should consider all circumstances, physical and psychological,
that may cause an increased risk of harm for the individual patient and should
refuse to perform the treatment if the risk is unacceptable. This is especially true in
the case of minors. Practitioners should always choose the most appropriate treat-
ment option, rather than the most lucrative one.
6. Minors may need or benefit from plastic medical treatments but pure aesthetic
procedures should not be performed on minors. If, in exceptional cases, aesthetic
treatment is performed on a minors, it should only be done with special care and
consideration and only if the aim of the treatment is to avoid negative attention
rather than gain positive attention. All relevant medical factors, such as whether
the minor is still growing or whether the treatment will need to be repeated at a
later date, must be considered.
7. The patient must consent explicitly to any aesthetic treatment, preferably in writing.
Before seeking consent the practitioner should inform the patient of all relevant
aspects of the treatment, including how the procedure is performed, possible risks
and the fact that many of these treatments may be irreversible. The patient should
be given sufficient time to consider the information before the treatment starts.
Where the patient requesting the treatment is a minor, the informed consent of his
or her parents or legally authorized representative should be obtained.
8. All aesthetic treatments performed should be carefully documented by the practi-
tioner. The documentation should include a detailed description of the treatment
performed, information on medications used, if any, and all other relevant aspects
of the treatment.
9. Aesthetic treatments must only be performed under strictly hygienic and medically
safe conditions on premises that are adequately staffed and equipped. This must
include equipment for treating life-threatening allergic reactions and other poten-
tial complications.
10. Advertising and marketing of aesthetic treatments should be responsible and should
not foster unrealistic expectations of treatment results. Unrealistic or altered pho-
tographs showing patients before and after treatments must not be used in adver-
tising.
11. Advertising and marketing of aesthetic treatments should never be targeted to
minors.
12. Practitioners should never offer or promote financial loans as a means of paying
for aesthetic treatment.
1
For the purpose of this statement minor is defined as a person who, according to applicable
national legislation, is not an adult.
Handbook of WMA Policies
S-2014-02-2014 ⏐ World Medical Association
WMA STATEMENT
ON
THE PREVENTION OF AIR POLLUTION DUE TO VEHICLE EMISSIONS
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
There are a number of ways in which the volume of harmful emissions can be reduced.
These include encouraging fewer road traffic journeys, active transport for individuals
undertaking relatively short journeys, the use of mass public transit in preference to
individual vehicles, and alternative energy sources for vehicles, including electric and
hybrid technologies. Where vehicle use is essential, means of reducing harmful emissions
should be used.
Physicians around the world are aware of air pollution. It impacts the quality of life for
hundreds of millions of people worldwide, causing both, a large burden of disease as well
as economic losses and increased health care costs. According to WHO estimates, in 2012,
urban outdoor air pollution was responsible for 3.7 million annual deaths, representing
6.7% of the total deaths (WHO, 2014).
Especially, diesel soot is acknowledged as a proven carcinogen (IARC, 07/2012). Further-
more, it has many other toxic effects, most prominently in the cardiovascular (Brook et al.,
2010) and respiratory systems (ERS, 2010). Moreover, in the context of global warming,
soot, along with methane, is identified as the second most important greenhouse driving
force substance after CO2 (Kerr, 2013).
Despite the fact that new vehicles will have to comply with stricter emission standards
which take into account most harmful ultra fine particles too, a high-polluting in-use fleet,
including off-road vehicles such as construction engines and ships, will continue polluting
for many more years.
BACKGROUND
In many densely populated cities around the world, fine dust concentrations measurable as
aerosols exceed up to 50 times the maximum WHO recommendation. High volumes of
transport, power generated from coal, and pollution caused by construction machinery are
among the contributing factors. People living and working near major (high density
volume traffic) streets are most affected by pollutants. For fighting the health risks men-
tioned above, there exist a variety of highly efficient and reliable filter systems on the
market (Best Available Technology (BAT) filters1
). They are applicable to all internal
combustion engines and they reduce even most harmful ultra-fine particles by a factor of
Durban ⏐ S-2014-02-2014
Air Pollution
over one hundred. As soon as 90% of heavy duty vehicles, both, new and upgraded ones,
satisfy this standard, health problems attributable to emissions of heavy duty traffic will be
greatly reduced, and no further tightening of emission standards will be possible or even
needed at all because of an almost total elimination of the pollutant as such.
In a variety of countries on different continents and under varying conditions retrofit or
upgrading programs have been successfully performed. The UN’s Working Party on Pol-
lution Prevention and Energy in Geneva has just proposed a technical standard for
regulation in their member states, which will be applicable worldwide.
The WMA supports these efforts and calls on policy makers in all countries, especially in
urban regions, to introduce regulatory restrictions of access for vehicles without filter,
and/or to provide financial assistance to support the retrofitting of in-use vehicles.
RECOMMENDATIONS
The WMA therefore recommends that all NMAs should encourage their respective govern-
ments to:
1. Introduce BAT standards for all new diesel vehicles (on road and off-road)
2. Incentivise retrofitting with BAT filters for all in-use engines
3. Monitor and limit the concentration of nanosize soot particles in the urban breathing
air
4. Conduct epidemiological studies detecting and differentiating the health effects of
ultrafine particles
5. Build professional and public awareness of the importance of diesel soot and the
existing methods of eliminating the particles
6. Contribute to developing strategies to protect people from soot particles in aircraft
passenger cabins, trains, homes and in the general environment. These strategies
should include plans to develop and increase use of public transportation systems.
ABBREVIATIONS:
EPA: Environmental Protection Agency (US)
ERS: European Respiratory Society
IARC: International Agency for Research of Cancer
BAT Standards: Emission standards for passenger cars, heavy-duty vehicles and off-road
machinery, based on count of ultrafine particles rather than mass and aimed at the
protection of human health from the most hazardous soot particles, the lung and even cell
membrane penetrating ultra-fines.
Handbook of WMA Policies
S-2014-02-2014 ⏐ World Medical Association
REFERENCES:
• Brook, Robert D. et al. (2010): AHA Scientific Statement: Particulate Matter Air
Pollution and Cardiovascular Disease. An Update to the Scientific Statement from
the American Heart Association. Circulation 121: 2331-2378.
• ERS (2010): The ERS report on air pollution and public health. European
Respiratory Society, Lausanne, Switzerland. ISBN: 978-1-84984-008-8
• IARC (2012): “IARC: Diesel Engine Exhaust Carcinogenic”. Press Release No.
213.http://www.iarc.fr/en/media-centre/pr/2012/pdfs/pr213_E.pdf. (access: 14/02/14)
• Kerr, Richard R. (2013): “Soot is Warming the World Even More Than Thought”.
In: Science 339(6118), p. 382.
• WHO (2014): “Burden of disease from Ambient Air Pollution for 2012.” http://
www.who.int/phe/health_topics/outdoorair/databases/AAP_BoD_results_March20
14.pdf?ua=1 (access: 26/08/14)
1
Euro 6/VI, US/EPA/CARB, Chinese and equivalent standards.
Handbook of WMA Policies
World Medical Association ⏐ S-2014-03-2014
WMA STATEMENT
ON
SOLITARY CONFINEMENT
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
In many countries substantial numbers of prisoners are held at times in solitary confine-
ment. Prisoners are typically kept in isolation for most of the day, and are allowed out of
their cells only a short period of time of solitary exercise. Meaningful contact with other
people (prisoners, prison staff, outside world) is kept to a minimum. Some countries have
strict provisions on how long and how often prisoners can be kept in solitary confinement,
but many countries lack clear rules on this.
The reasons for the use of solitary confinement vary in different jurisdictions. It may be
used as a disciplinary measure when a prisoner does not respond to other sanctions in-
tended to address his or her behaviour, for example, in response to seriously disruptive
behaviour, threats of violence or suspected acts of violence.
The legal authorities in some nations allow individuals to be held in solitary confinement
during an on-going criminal investigation or to be sentenced to solitary confinement, even
when the individual poses no threat to others. Individuals with mental illness may be
kept in high-security or super-maximum security (supermax) units or prisons. Solitary con-
finement can be imposed for hours to days or even years.
Reliable data on the use of solitary confinement are lacking. Various studies estimate that
tens of thousands or even hundreds of thousands of prisoners are currently held in soli-
tary confinement worldwide.
People react to isolation in different ways. For a significant number of prisoners, solitary
confinement has been documented to cause serious psychological, psychiatric, and some-
times physiological effects, including insomnia, confusion, hallucinations and psycho-
sis. Solitary confinement is also associated with a high rate of suicidal behaviour. Nega-
tive health effects can occur after only a few days, and may in some cases persist when
isolation ends.
Certain populations are particularly vulnerable to the negative health effects of solitary
confinement. For example, persons with psychotic disorders, major depression, or post-
traumatic stress disorder or people with severe personality disorders may find isolation
unbearable and suffer health harms. Solitary confinement may complicate treating such
individuals and their associated health problems successfully later in the prison environ-
ment or when they are released back into the community.
S-2014-03-2014 ⏐ Durban
Solitary Confinement
Human rights conventions prohibit the use of torture, cruel, inhuman or degrading treat-
ment or punishment. The use of pronged solitary confinement against a prisoner´s own
will or the use of solitary confinement during pre-trial detention or against minors can
be regarded as a breach of international human rights law, and must be avoided.
RECOMMENDATIONS
The WMA urges National Medical Associations and governments to promote the follow-
ing principles:
1. Solitary confinement should be imposed only as a last resort whether to protect
others or the individual prisoner, and only for the shortest period of time pos-
sible. The human dignity of prisoners confined in isolation must always be res-
pected.
2. Authorities responsible for overseeing solitary confinement should take account of
the individual’s health and medical condition and regularly re-evaluate and docu-
ment the individual’s status. Adverse health consequences should lead to the im-
mediate cessation of solitary confinement.
3. All decisions on solitary confinement must be transparent and regulated by law.
The use of solitary confinement should be time-limited by law. Prisoners sub-
ject to solitary confinement should have a right of appeal.
4. Prolonged solitary confinement, against the will of the prisoner, must be avoided.
Where prisoners seek prolonged solitary confinement, for whatever reason, they
should be medically and psychologically assessed to ensure it is unlikely to lead to
harm.
5. Solitary confinement should not be imposed when it would adversely affect the
medical condition of prisoners with a mental illness. If it is essential to provide
safety for the prisoner or other prisoners then especially careful and frequent
monitoring must occur, and an alternative found as soon as possible.
6. Prisoners in isolation should be allowed a reasonable amount of regular human
contact. As with all prisoners, they must not be subjected to extreme physical
and mentally taxing conditions.
7. The health of prisoners in solitary confinement must be monitored regularly by a
qualified physician. For this purpose, a physician should be allowed to check both
the documentation of solitary confinement decisions in the institution and the
actual health of the confined prisoners on a regular basis.
8. Prisoners who have been in solitary confinement should have an adjustment period
before they are released from prison. This must never extend their period of in-
carceration.
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9. Physician´s role is to protect, advocate for, and improve prisoners´ physical and
mental health, not to inflict punishment. Therefore, physicians should never parti-
cipate in any part of the decision-making process resulting in solitary confine-
ment.
10. Doctors have a duty to consider the conditions in solitary confinement and to pro-
test to the authorities if they believe that they are unacceptable or might amount to
inhumane or degrading treatment.
Handbook of WMA Policies
World Medical Association ⏐ S-2015-01-2015
WMA STATEMENT
ON
MOBILE HEALTH
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
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).
Sufficient policies and safeguards to regulate and secure the collection, storage, protection
and processing of data of mHealth users, especially health data, must be implemented.
Users of mHealth services must be informed about how their personal data is collected,
stored, protected and processed and their consent must be obtained prior to any disclosure
of data to third parties, e.g. researchers, governments or insurance companies.
The monitoring and evaluation of mHealth should be implemented carefully to avoid
inequity of access to these technologies. Where appropriate, social or healthcare services
should facilitate access to mHealth technologies as part of basic benefit packages, while
taking all the required precautions to guarantee data security and privacy. Access to
mHealth technologies should not be denied to anyone on the basis of financial status or a
lack of technical expertise.
mHealth technologies cover a wide spectrum of functions. They may be used for:
Health promotional (lifestyle) purposes, such as apps into which users input their calorie
intake or motion sensors which track exercise.
Services which require the medical expertise of physicians, such as SMS services
providing advice to pregnant women or wearable sensors to monitor chronic conditions
such as diabetes. mHealth technologies of this nature frequently meet the definition of a
medical device and should be subject to risk-based oversight and regulation with all its
implications.
mHealth may also be used to expedite the transfer of information between health
professionals, e.g. providing physicians with free, cross network mobile phone access in
resource poor settings.
Technological developments and the increasing prevalence and affordability of mobile
devices have led to an exponential increase in the number and variety of mHealth services
S-2015-01-2015 ⏐ Moscow
Mobile Health
in use in both developed and developing countries. At the same time, this relatively new
and rapidly evolving sector remains largely unregulated, a fact which could have potential
patient safety implications.
mHealth has the potential to supplement and further develop existing healthcare services
by leveraging the increasing prevalence of mobile devices to facilitate access to
healthcare, improve patient self-management, enable electronic interactions between
patients and their physicians and potentially reduce healthcare costs. There are significant
regional and demographic variations in the potential use and benefits of mHealth. The use
of certain mHealth services may be more appropriate in some settings than others.
mHealth technologies generally involve the measurement or manual input of medical,
physiological, lifestyle, activity and environmental data in order to fulfil their primary
purpose. The large amount of data generated in this way also offers huge scope for
research into effective healthcare delivery and disease prevention. However, this
secondary use of personal data also has great potential for misuse and abuse, of which
many users of mHealth services are unaware.
The expansion of mHealth services has been largely market driven and many technologies
have been developed in an uncoordinated, experimental fashion and without appropriate
consideration of data protection and security or patient safety aspects. It is often
impossible for users to know whether the information provided via mHealth stems from a
reliable medical source. Major challenges faced by the mHealth market are the quality of
mHealth technologies and whether their use ultimately helps patients or physicians
achieve the intended purpose.
Comprehensive regulation and evaluation of the effectiveness, quality and cost
effectiveness of mHealth technologies and services is currently lacking, which has
implications for patient safety. These factors are crucial to the integration of mHealth
services into regular healthcare provision.
RECOMMENDATIONS
The WMA recognises the potential of mHealth to supplement traditional ways of
managing health and delivering healthcare. While mHealth may offer advantages to
patients otherwise unable to access services from physicians, it is not universally
appropriate, nor is it always an ideal form of diagnosis and treatment option. Where face-
to-face treatment is available this is almost always advantageous to the patient.
The driving force behind mHealth must be the need to eliminate deficiencies in the
provision of care or to improve the quality of care.
The WMA urges patients and physicians to be extremely discerning in their use of
mHealth and to be mindful of potential risks and implications.
A clear distinction must be made between mHealth technologies used for lifestyle
purposes and those which require the medical expertise of physicians and meet the
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World Medical Association ⏐ S-2015-01-2015
definition of medical devices. The latter must be appropriately regulated and users must be
able to verify the source of information provided. The information provided must be clear,
reliable and non-technical, and therefore comprehensible to lay people.
Concerted work must go into improving the interoperability, reliability, functionality and
safety of mHealth technologies, e.g. through the development of standards and
certification schemes.
Comprehensive and independent evaluations must be carried out by competent authorities
with appropriate medical expertise on a regular basis in order to assess the functionality,
limitations, data integrity, security and privacy of mHealth technologies. This information
must be made publicly available.
mHealth can only make a positive contribution towards 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.
Suitable reimbursement models must be set up in consultation with national medical
associations and healthcare providers to ensure that physicians receive appropriate
reimbursement for their involvement in mHealth activities
A clear legal framework must be drawn up to address the question of identifying potential
liability arising from the use of mHealth technologies.
Physicians who use mHealth technologies to deliver healthcare services should heed the
ethical guidelines set out in the WMA Statement on Guiding Principles for the Use of
Telehealth for the Provision of Health Care.
It is important to take into account the risks of excessive or inappropriate use of mHealth
technologies and the potential psychological impact this can have on patients.
Handbook of WMA Policies
World Medical Association ⏐ S-2015-02-2015
WMA STATEMENT
ON
PHYSICIANS WELL-BEING
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Physician well-being refers to the optimization of all factors affecting biological,
psychological and social health and preventing or treating acute or chronic diseases
experienced by physicians including mental illness, disabilities and injuries resulting from
work hazards, occupational stress and burnout.
Physician’s well-being could have positive impact on patient care, but more research is
needed. The profession should therefore encourage and support on-going research on
physician’s health. Evidence that already exists should be implemented in policy and
practice. While physicians tend to have healthy habits, it is essential to enhance their
health as a way to improve health for the whole population.
Physicians and medical students at all career stages are exposed to both positive
experiences as well as a variety of stressors and work injuries The medical profession
should seek to identify and revise policies and practices that contribute to these stressors
and collaborate with NMA’s in order to develop policies and practices that have protective
effects. Like all human beings, physicians experience illness, and they also have family
obligations and other commitments outside their professional lives that should be taken
into account.
One reason physicians delay seeking help is their concern about confidentiality and feeling
ill at ease in the patient role. They experience feelings of responsibility towards their
patients and are sensitive to external expectations on their health. Therefore, physicians
must be assured of the same right of confidentiality as any other patient when seeking and
undergoing treatment. The health care system may need to provide special arrangements
for the care of physician-patients in order to uphold its duty to provide privacy and
confidentiality. Prevention, early assistance and intervention should be available
separately from any disciplinary process.
THREATS, BARRIERS AND OPPORTUNITIES FOR PHYSICIAN WELL-BEING
Professional Roles and Expectations
The medical profession often attracts highly driven individuals with a strong sense of
duty. Successfully completing the long and intense educational requirements often confers
S-2015-02-2015 ⏐ Moscow
Physicians Well-Being
upon physicians a high degree of respect and responsibility in their communities.
With these high levels of respect and responsibility, physicians are subject to high
expectations from patients and the public. These expectations can contribute to
prioritizing the care of others over care of self and feelings of guilt and selfishness for
managing their own well-being.
There is a direct relationship between physicians’ and patients’ preventive health
practices. This relationship should encourage healthcare systems to better support and
evaluate the effects on patients of improving physician and medical student health.
Work Environment
Working conditions, including workload and working hours, affect physicians’
motivation, job satisfaction, personal life and psychological health during their careers.
Physicians are often perceived as being immune to injury and diseases as they care for
their patients, and workplace health and safety programs may be overlooked. Physician
who are employed by small organizations or who are self-employed may be at even a
higher risk for occupational diseases and may not have access to health and safety
programs provided by large health care establishments.
As a consequence of their professional duties, physicians and physicians in postgraduate
education often confront emotionally challenging and traumatic situations including
patients’ suffering, injury and death. Physicians may also be exposed to physical hazards
like radiation, noise, poor ergonomics, and biological hazards like HIV, TB and hepatitis.
Some healthcare systems may exacerbate stress because of the hierarchies and competition
inherent in them. Physicians in postgraduate education and medical students can be
victims of harassment and discrimination during their medical education. Due to their
position within the medical hierarchy, they may feel powerless to confront these
behaviours.
Physician autonomy is one of the strongest predictors of physician satisfaction. Increasing
external regulatory pressures such as undue emphasis on cost efficiencies and concerns
about consequences of reporting medical errors may unduly influence medical decision-
making and diminish a physician’s autonomy.
Illness
Even though medical professionals recognize that it is preferable to identify and treat
illness early, physicians are often adept at hiding their own illnesses and may continue to
function without seeking help until they become incapable of carrying out their duties.
There are many potential obstacles to an ill physician seeking care including: denial,
confidentiality issues, aversion to the patient role, practice coverage, fear of disciplinary
action, potential loss of practice privileges, loss of performance based payment and the
efficiencies of self-care. Because of these obstacles doctors are often reluctant to refer
themselves or their colleagues for treatment.
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Illnesses can include mental and behavioural health problems, burnout, communication
and interpersonal issues, physical and cognitive problems and substance use disorders.
These illnesses and problems can overlap and can occur throughout the professional life
cycle from basic medical education to retirement. It is important to acknowledge the
continuum of physician well-being, ranging from optimal health, to minor illness, to
debilitating illness.
Substance abuse may disrupt a physician’s personal life and may also significantly affect
his or her ability to care for patients. Easy access to medications may contribute to
physicians’ risk for abuse of recreational drugs and prescription medications. Assistance
prior to impairment in the workplace is protective for physicians, their professional
credentials and their patients.
Improved wellness promotion, prevention strategies and earlier intervention can help
mitigate the severity of mental and physical illnesses and help reduce incidence of suicide
in physicians, physicians in postgraduate education and medical students.
RECOMMENDATIONS
The World Medical Association recommends that National Medical Associations (NMAs)
recognize and, where possible, actively address the following:
1. In partnership with medical schools and workplaces, NMAs recognize their obligation
to provide education at all levels about physician well-being. NMAs should
collaboratively promote research to establish best practices that promote physician
health and to determine the impact of physician well-being on patient care.
2. Physician well-being should be supported and provided within and outside the
workplace. Support may include but is not limited to referral to medical treatment,
counselling, support networks, recognized physician health programs, occupational
rehabilitation and primary prevention programs including resiliency training, healthy
lifestyles and case management.
3. NMA’s should recognize the strong and consistent link between physicians’ and
patients’ personal health practices, providing yet another critically important reason
for health systems to promote physician health.
4. Physician health programs can help all physicians to proactively help themselves via
prevention strategies and can assist physicians who are ill via assessment, referral to
treatment and follow-up. Programs and resources to help promote positive
psychological health should be available to all physicians. Early identification,
intervention and special arrangements for the care of physician-patients should be
available to protect the health of physicians. Fostering a supportive and accepting
culture is critical to successful early referral and intervention.
5. Physicians at risk for abuse of alcohol or drugs should have access to appropriate
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Physicians Well-Being
confidential medical treatment and comprehensive professional support. NMAs
should promote programs that help physicians re-enter medical practice with
appropriate ongoing supervision at the completion of their treatment programs. More
research should be conducted to determine best practices in preventing substance
abuse among physicians and physicians in postgraduate education.
6. Physicians have the right to working conditions that help limit the risk of burnout and
empower them to care for their personal health by balancing their professional
medical commitments and their private lives and responsibilities. Optimal working
conditions include a safe and reasonable maximum number of consecutive and total
working hours, adequate rest between shifts and appropriate number of non-working
days. Relevant organizations should constructively address professional autonomy
and work-life balance problems and involve physicians in making decisions about
their work lives. Working conditions must not put the safety of patients or physicians
at risk, and ultimately physicians should be engaged in establishing optimal
workplace conditions.
7. Workplaces should promote conditions conducive to healthy lifestyles, including
access to healthy food choices, exercise, nutrition counselling and support for
smoking cessation.
8. Physicians, physicians in postgraduate education and medical students have the right
to work in a harassment and violence-free workplace. This includes freedom from
verbal, sexual and physical abuse.
9. Physicians, physicians in postgraduate education and medical students have the right
to a collaborative safe workplace. Workplaces should promote interdisciplinary
teamwork, and communication between physicians and all other professionals in the
workplace should be offered in a spirit of cooperation and respect. Education on
communications skills, self-awareness and team-work should be considered.
10. Medical staff should undergo training in recognizing, handling and communicating
with potentially violent persons. Health care facilities should safeguard against
violence including routine violence risk audits, especially in mental health treatment
facilities and emergency departments. Staff members who are victims of violence or
who report violence should be supported by management and offered medical,
psychological and legal counselling.
11. Medical schools and teaching hospitals should develop and maintain confidential
services for physicians in postgraduate education and medical students and to raise
awareness of and access to such programs. Workplaces should consider offering
medical consultations to physicians in postgraduate education in order to identify any
health issues at the outset of medical education.
12. Workplace support for all physicians should be easily accessible and confidential.
Physicians evaluating and treating their medical colleagues should not be required to
report any aspects of their physician-patients’ care in any manner not required for
their non-physician patients.
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WMA STATEMENT
ON
SUPPORTING HEALTH SUPPORT TO STREET CHILDREN
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
The WMA recognises that having children in living on the streets is unacceptable in a
society even though this phenomenon is difficult to avoid in many communities around
the world.
The WMA intends to raise awareness within civil and medical society about the
fundamental role played by medical contact in improving the situation of street children.
In this regard, it is important that the initial contact with street children be based on trust.
Therefore, together with other healthcare professionals and social workers, medical
contact should be viewed as the first step towards resocialising street children by building
trust between the physician and the street child. Once achieved, a more global
multidisciplinary and multidimensional approach can follow to improve the well-being of
street children.
Childhood and adolescence are the beginnings of a long physical, mental, cultural and
social growth process;
The health of young people shapes the health of tomorrow's population;
Young people play a part in social cohesion and they are an asset to any country;
Addressing the social determinants of health is essential to achieving equity in healthcare.
The social determinants leading to the appearance and growth of the phenomenon of
“street children” are varied and complex;
The negative health impact of living on the streets for children, both in terms of the
additional health risks to which these children are exposed and their lack of access to
healthcare and prevention; street children are, in particular, more vulnerable to acute
illnesses and traumatic injuries. In addition, preventive care and continuity of care are
non-existent for street children due to frequent relocation;
The health of street children remains critical and has been exacerbated by the global
financial and economic crisis, which has contributed to family break-ups, social upheaval
and disruptions in healthcare and education;
Children may be victims of discrimination arising from their gender, ethnic origin,
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Health Support to Street Children
language, religion, political opinion, handicap, social status or population migration;
Street children are especially vulnerable to abuse, violence, exploitation and manipulation,
including trafficking;
Child homelessness often goes unrecognised at a national and international level since it is
difficult to quantify and assess.
RECOMMENDATIONS
1. The WMA strongly condemns any violations of the rights of children living on the
streets and any infringements of these rights, in particular discrimination and
stigmatisation and their exposure to abuse, violence, exploitation and manipulation,
including trafficking.
2. The WMA calls upon governments to address the factors, which lead to children living
on the streets and to take action to implement all applicable legislation and systems of
protection to reduce the health implications for street children. National authorities
have an obligation to provide care for all children and, where necessary, to support
their return to a living environment appropriate for a child.
3. Reducing health implications includes not only direct treatment of health issues but
also protection of Street Children from health risks such as exposure to drugs, HIV
infection, smoking and drinking.
4. The WMA calls upon governments, national medical associations and healthcare
professionals to acknowledge the scale of this phenomenon and to instigate prevention
and awareness campaigns. These children must be able to access the full range of
necessary health and social protection.
5. The WMA urges all national medical associations to work with legal counterparts,
governments, health care professionals and public authorities to ensure the
fundamental rights of children, who are a particularly vulnerable population in need of
protection, particularly access to healthcare and education. The right to food and
housing should be guaranteed, and any form of discrimination or exploitation should
be forbidden.
6. The WMA condemns any improper age-assessment practices that make use of
insufficiently reliable clinical or paraclinical investigations. Until they reach
adulthood, adolescents must be able to enjoy their status as minors, as recognised by
the UN International Convention on the Rights of the Child.
7. The WMA urges physicians to remain vigilant in terms of delivering all the support
required to provide suitable and comprehensive care for 'street children'. Physicians
should be aware that homelessness is a pervasive problem. They should be
knowledgeable about the existence of homelessness in their own communities and are
encouraged to establish a relationship of trust between the physician and the street
child to become involved in local relief and advocacy programs.
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8. The WMA maintains that every effort should be made to provide all children, and
particularly those that are homeless, with access to a suitable and balanced psycho-
social environment, in which their rights, including the right to health, are respected.
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WMA STATEMENT
ON
RIOT CONTROL AGENTS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
There has been a long-standing concern regarding the use of chemical weapons. Despite
this concern, poison gas was used fairly extensively during World War I, leading to a call
from the International Committee of the Red Cross (ICRC) in February 1918 for cessation
of its use.
This led to the Geneva Protocol of 1925, the Biological and Toxin Weapons Convention
of 1972 (BTWC) and the Chemical Weapons Convention of 1993 (CWC).
All but six countries in the world have signed and ratified the CWC; two more have
signed but not yet ratified, making it a nearly universally accepted Convention.
The conventions prohibit the development, production and stockpiling of chemical
weapons in addition to their usage in warfare and call for measures to decommission or
destroy existing stores. However, the CWC allows the use of specific chemicals in
domestic law enforcement including riot control situations, which means that governments
might hold stockpiles of certain agents. Even so, riot control agents cannot be used in
warfare; the exclusion has reached the status of customary law, which allows their use
only in domestic or national jurisdictions.
Although there is academic and military interest in what is often called non-lethal
weapons, the incidence of morbidity and mortality caused by weapons are not criteria used
in prohibition. A tiered approach based upon degrees of lethality of specific weapons is
contrary to the ethos of both conventions.
In situations of widespread public unrest and political or other uprisings governments
unfortunately may choose to deploy riot control agents in a domestic setting. Although
this is not in conflict with the principles of the CWC their use may still give rise to
specific medical, legal and ethical challenges.
While riot control agents are designed to make remaining within the riot unpleasant and
impractical, they are not expected to directly cause any injuries or deaths. As with all other
agents, how they are used determines the concentration to which individuals are exposed.
The ability to take evasive actions, such as leaving the area, to reduce exposure may also
have an impact. It is recognised that individual determinants including general health and
age will affect an individual’s response to chemical agent.
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Riot Control Agents
Release of chemical agents such as tear gas in a small enclosed space exposes individuals
to concentrations far higher than those expected in normal deployment in riot situations,
causing higher levels of serious morbidity and potentially death.
Misuse of riot control agents, leading to serious harms or deaths of demonstrators,
exposing individuals excessively or using them for oppressing non-violent peaceful
demonstrations, may lead to a breach of the human rights of the individuals concerned, in
particular the right to life (article 3), the right to freedom of expression (article 19) and of
peaceful assembly (article 20) of the Universal Declaration of Human Rights.
Governments, who authorize the stockpiling and use of such agents by their police and
security forces, are urged to consider that there might be fatal results of their usage.
Governments are required to ensure that they are used in a manner, which minimise their
likelihood of causing serious morbidity and mortality.
RECOMMENDATION
The WMA recognises that the inappropriate use of riot control agents risks the lives of
those targeted and exposes people around, amounting to a potential breach of human rights
standards, in particular the right to life, the right to freedom of expression and of peaceful
assembly as stated in the Universal Declaration of Human Rights.
In case of use of riot control agents, the WMA urges States to do so in a manner designed
to minimise the risk of serious harm to individuals, and to prohibit its use in the presence
of vulnerable populations, such as children, older people or pregnant women;
The WMA insists that riot control agents should never be used in enclosed spaces where
chemical concentrations may reach dangerous levels, and where people cannot move away
from areas with high concentrations of the agent;
The WMA insists that governments train police and other security forces in the safe and
legal use of riot control agents, in order to minimise the risk of harm when they are
deployed. This must include the rapid evacuation of any individual who is apparently
suffering from a high level of exposure, not aiming people, and not using the agent
excessively;
The WMA insists that States penalise individuals who misuse riot control agents and who
deliberately endanger human life and safety by using the agents. Such misuse leading to
serious physical harms or death of individuals should be investigated by independent
experts.
The WMA calls for unimpeded and protected access of healthcare personnel to allow them
to fulfil their duty of attending to the injured as set forth in the “WMA Declaration on the
protection of healthcare workers in situations of violence”.
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The WMA recommends that, because of the significant difficulties and risks to health and
life associated with the use of such riot control agents, States should refrain from using
them in any circumstances.
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WMA STATEMENT
ON
TRANSGENDER PEOPLE
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
In most cultures, an individual’s sex is assigned at birth according to primary physical sex
characteristics. Individuals are expected to identify with their assigned sex (gender
identity) and behave according to specific cultural norms strongly associated with this
(gender expression). Gender identity and gender expression make up the concept of
“gender” itself.
There are individuals who experience different manifestations of gender that do not
conform to those typically associated with their sex assigned at birth. The term
“transgender” refers to people who experience gender incongruence, which is defined as a
marked mismatch between one’s gender and the sex assigned at birth.
While conceding that this is a complex ethical issue, the WMA would like to acknowledge
the crucial role played by physicians in advising and consulting with transgender people
and their families about desired treatments. The WMA intends this statement to serve as a
guideline for patient-physician relations and to foster better training to enable physicians
to increase their knowledge and sensitivity toward transgender people and the unique
health issues they face.
Along the transgender spectrum, there are people who, despite having a distinct
anatomically identifiable sex, seek to change their primary and secondary sex
characteristics and gender role completely in order to live as a member of the opposite sex
(transsexual). Others choose to identify their gender as falling outside the sex/gender
binary of either male or female (genderqueer). The generic term “transgender” represents
an attempt to describe these groups without stigmatisation or pathological characterisation.
It is also used as a term of positive self-identification. This statement does not explicitly
address individuals who solely dress in a style or manner traditionally associated with the
opposite sex (e.g. transvestites) or individuals who are born with physical aspects of both
sexes, with many variations (intersex). However, there are transvestites and intersex
individuals who identify as transgender. Being transvestite or intersex does not exclude an
individual from being transgender. Finally, it is important to point out that transgender
relates to gender identity, and must be considered independently from an individual’s
sexual orientation.
Although being transgender does not in itself imply any mental impairment,
transgender people may require counseling to help them understand their gender
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Transgender People
and to address the complex social and relational issues that are affected by it. The
Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association (DSM-5) uses the term “gender dysphoria” to classify people who experience
clinically significant distress resulting from gender incongruence.
Evidence suggests that treatment with sex hormones or surgical interventions can be
beneficial to people with pronounced and long-lasting gender dysphoria who seek gender
transition. However, transgender people are often denied access to appropriate and
affordable transgender healthcare (e.g. sex hormones, surgeries, mental healthcare) due to,
among other things, the policies of health insurers and national social security benefit
schemes, or to a lack of relevant clinical and cultural competence among healthcare
providers. Transgender persons may be more likely to forego healthcare due to fear of
discrimination.
Transgender people are often professionally and socially disadvantaged, and experience
direct and indirect discrimination, as well as physical violence. In addition to being denied
equal civil rights, anti-discrimination legislation, which protects other minority groups,
may not extend to transgender people. Experiencing disadvantage and discrimination may
have a negative impact upon physical and mental health.
RECOMMENDATION
1. The WMA emphasises that everyone has the right to determine one’s own gender
and recognises the diversity of possibilities in this respect. The WMA calls for
physicians to uphold each individual’s right to self-identification with regards to
gender.
2. The WMA asserts that gender incongruence is not in itself a mental disorder;
however it can lead to discomfort or distress, which is referred to as gender
dysphoria (DSM-5).
3. The WMA affirms that, in general, any health-related procedure or treatment
related to an individual’s transgender status, e.g. surgical interventions, hormone
therapy or psychotherapy, requires the freely given informed and explicit consent
of the patient.
4. The WMA urges that every effort be made to make individualised, multi-
professional, interdisciplinary and affordable transgender healthcare (including
speech therapy, hormonal treatment, surgical interventions and mental healthcare)
available to all people who experience gender incongruence in order to reduce or to
prevent pronounced gender dysphoria.
5. The WMA explicitly rejects any form of coercive treatment or forced behaviour
modification. Transgender healthcare aims to enable transgender people to have
the best possible quality of life. National Medical Associations should take action
to identify and combat barriers to care.
6. The WMA calls for the provision of appropriate expert training for physicians at
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all stages of their career to enable them to recognise and avoid discriminatory
practises, and to provide appropriate and sensitive transgender healthcare.
7. The WMA condemns all forms of discrimination, stigmatisation and violence
against transgender people and calls for appropriate legal measures to protect their
equal civil rights. As role models, individual physicians should use their medical
knowledge to combat prejudice in this respect.
8. The WMA reaffirms its position that no person, regardless of gender, ethnicity,
socio-economic status, medical condition or disability, should be subjected to
forced or coerced permanent sterilisation (WMA Statement on Forced and Coerced
Sterilisation). This also includes sterilisation as a condition for rectifying the
recorded sex on official documents following gender reassignment.
9. The WMA recommends that national governments maintain continued interest in
the healthcare rights of transgender people by conducting health services research
at the national level and using these results in the development of health and
medical policies. The objective should be a responsive healthcare system that
works with each transgender person to identify the best treatment options for that
individual.
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World Medical Association ⏐ S-2015-06-2015
WMA STATEMENT
ON
VITAMIN D INSUFFICIENCY
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Vitamin D has major role in calcium and bone metabolism. Normal values are 75-100
nmol/L (30-40 ng/ml). Vitamin D deficiency is defined if serum hydroxyvitamin D levels
are less than 50nmol/L (20 ng/ml), insufficiency as 50-75 nmol/L (20-30 ng/ml).
Studies demonstrate that vitamin D is essential also for overall health and well-being. In
the body vitamin D is produced during exposure to sunlight and in lesser degree by food
intake.
Vitamin D exists in two forms: vitamin D3 (cholecalciferol in humans and other
mammals) and vitamin D2(ergocalciferol in plants), but both are similarly metabolized.
Vitamin D3 is more active than vitamin D2.
The serum concentration of the hepatic metabolite of vitamin D3, the 25-hydroxyvitamin
D, is consideredas the best biomarker of vitamin D status.
Vitamin D deficiency is an important health issue globally. About one third of the
population is estimated to have lower serum concentration of vitamin D.
Many studies have shown that vitamin D deficiency is linked to impaired growth and
development. Because vitamin D receptors are broadly distributed in tissues, vitamin D
deficiency is associated with musculoskeletal disorders (osteoporosis), falls, fractures,
autoimmune disorders, chronic inflammatory diseases, type 2 diabetes mellitus, and
cardiovascular, neurologic and psychiatric disorders. High risk groups are young children,
the elderly and pregnant women. Primary factors, contributing to vitamin D deficiency,
include reduced sunshine exposure, poor quality diet, availability of fortified foods and
supplement use.
RECOMMANDATIONS
Because of widespread occurrence of vitamin D deficiency/insufficiency it is desirable to
focus attention on adequate preventive actions in populations at risk. Determining vitamin
D levels requires only a blood test, and oral supplementation is a simple treatment method.
Sun exposure is not generally recommended because it can increase the risk of skin
cancer.
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Vitamin D Insufficiency
The World Medical Association recommends that national medical associations:
• Support continued research in vitamin D and its metabolites
• Educate physicians about the evolving science of vitamin D and its impact on
health (documents, brochures, posters)
• Encourage physicians to consider measuring the serum concentrations of 25-
hydroxyvitamin D in the patients at risk of vitamin D deficiency
• Monitor development of dietary recommendations for vitamin D.
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WMA GUIDELINES
ON PROMOTIONAL MASS MEDIA
APPEARANCES BY PHYSICIANS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Mass media can effectively play diverse roles in medical communication. Physicians, as
professionals and experts can contribute to improved public health by providing the public
with accurate health related information. Mass media provides a channel through which
physicians may contribute to society by leveraging mass media appearances in positive
ways.
However, the increase in instances of physicians’ frequent appearances on mass media to
recommend unproven treatments or products and to use such appearances for marketing
purposes is posing a serious concern. The public may readily accept groundless
recommendations by physicians and may develop unrealistic expectations. The subsequent
confusion and disappointment can damage the patient-physician-relationship.
This issue is more serious in some countries where there are different systems of
medicine, including alternative medicine.
RECOMMANDATIONS
The WMA recommends the following guidelines regarding mass media appearances by
physicians to prevent them from being involved in commercial activities that may
compromise professional ethics and to contribute to patient safety by ensuring physicians
providing accurate, timely, and objective information.
Accurate and Objective Delivery of Scientifically Proven Medical Information
When appearing in media, physicians shall provide objective and evidence-based
information and shall not recommend medical procedures or products that are not
medically proven or justified.
A physician shall not use expressions that may promote unrealistic patient expectations or
mislead viewers about the function and effect of medical procedures, drugs or other
products.
Physicians shall include important information including possible adverse effects and risks
when explaining medical procedures, drugs, or other products.
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Promotional Mass Media Appearances by Physicians
Not Abusing Mass Media as a Means of Advertisement
Physicians should not recommend specific products by either specifically introducing or
intentionally highlighting the name or trademark of a product.
Physicians shall practice prudence regarding personal appearances on home shopping
programs.. The physician should have no financial stake in the products being sold.
Physicians shall not be a part of mass media advertisement on any product, which is
harmful to human, and/or environment.
Maintaining Professional Integrity
Physicians shall not require or receive economic benefits for mass media appearances
other than a customary appearance fee.
Physicians shall not provide economic benefits to broadcasting personnel in order to
secure mass media appearances.
Physicians shall not engage in the promotion, sale or advertising of commercial products
and shall not introduce false or exaggerated statements regarding their qualifications such
as academic background, professional experience, medical specialty and licensure as a
specialist, for the benefit of the economic interests of any commercial entity.
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S-2016-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON AGEING
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
The world is undergoing a longevity extension at an unprecedentedly rapid pace. Over the
last century, some 30 years have been added to global average Life Expectancy at Birth
(LEB) – with more gains expected in the future. By 2050, LEB is projected to reach 74
years with an ever-increasing number of countries reaching 80 years and beyond. In 1950
the total number of people aged 80+ was 14 million – by 2050 the estimated number is
384 million, a 26-fold increase. The proportion of elderly will more than double from 10%
in 2015 to 22% of the total population in 2050. These improvements are very variable;
many of the poorest communities in all countries and a larger percentage of the population
in the poorest countries have gained little in terms of life expectancy over this period of
time.
The increase in longevity has been paired with a decreasing number of children,
adolescents and younger adults as more and more countries experience Total Fertility
Rates below replacement level, raising the average age in these countries.
The challenges of aging in developing countries are complicated by the fact that basic
infrastructure is not always in place. In some cases, populations in developing countries
are aging more quickly than infrastructure is being developed.
Longevity is arguably the greatest societal achievement of the 20th century but it could
turn into a major problem during the 21st century. The World Health Organization (WHO)
defines Active Ageing as “the process of optimizing opportunities for Health, Lifelong
learning, Participation and Security in order of enhancing quality of life as individuals
age”. This definition presupposes a life course perspective as the determinants that
influence active ageing operates throughout the life course of an individual. These are
social determinants of health and include behavioral determinants (life-styles), personal
determinants (not only hereditary factors which are, overall, responsible for no more than
25% of the chances of ageing well but also psychological characteristics), the physical
environment where one lives as well as broad social and economic determinants. All of
these act individually on the prospects of active ageing but also interact among
themselves: the more they interact and overlap, the higher the chance of an individual
ageing actively. Gender and culture are crosscutting determinants, influencing all the
others.
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Ageing
GENERAL PRINCIPLES
Medical Expenses
There is strong evidence that chronic diseases increase the use (and costs) of health
services rather than age per se.
However, chronic conditions and disabilities become more prevalent with advancing age –
therefore health care use and spending rise in tandem with age.
In many countries health care spending for older persons has increased over the years as
more interventions and new technologies have become available for problems common in
older age.
Effect of Ageing on Health Systems
Health care systems face two major challenges in the longevity revolution: preventing
chronic disease and disability and delivering high quality and cost-effective care that is
appropriate for individuals regardless of age.
In less developed regions the disease burden in old age is higher than in more developed
regions.
Special Health Care Considerations
The leading diseases contributing to disability in all regions are cardiovascular diseases,
cancers, chronic respiratory diseases, musculoskeletal disorders, and neurological and
mental diseases, including the dementias. Some common conditions in older age are
especially disabling and require early detection and management.
Chronic diseases common among older people include diseases preventable through
healthy behaviors and/or lifestyle interventions and effective preventive health services –
typically cardiovascular disease, diabetes, chronic obstructive pulmonary disease and
many types of cancer. Other diseases are more closely linked to ageing processes and are
not understood well enough to prevent them – such as dementia, depression and some
musculoskeletal and neurological disorders.
While research may eventually lead to effective disability prevention or treatment, early
management is key to controlling disability and/or maintaining quality of life.
Older persons may be more vulnerable to the effects of accidents within and outside the
home. This will include risks when operating machinery such as road vehicles, but also
risks from handling other potentially dangerous equipment. As older people continue to
work these risks must be assessed and managed. Those who suffer injuries may have their
recovery complicated by other medical vulnerabilities and comorbidities.
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Considerations for Health Care Professionals
Health care for elderly people usually requires a variety of professionals working as an
articulated team.
Education and training of health professionals to treat and manage the conditions common
in the elderly are generally not sufficiently emphasized in undergraduate curricula.
Reducing Impact on Health Care
A comprehensive continuum of health services needs to be adopted urgently as population
age. It should include health promotion, disease prevention, curative treatments,
rehabilitation, management and prevention of decline, and palliative care.
Different types of health care providers offer these services, from self and family/informal
care – sometimes in a voluntary capacity – to community-based providers and institutions.
Establishing Optimal Health Care Systems
Universal Health Care coverage ideally should be provided to all, including elderly
people.
The vast majority of health problems can and should be dealt with at the community level.
In order to provide optimal community care and ensure care coordination over time it is
critical to strengthen Primary Health Care (PHC) services.
In order to strengthen PHC to promote active ageing, WHO advanced evidence-based
principles for age-friendly PHC in three areas which should be considered:
information/education/communication/ training, health management systems and the
physical environment.
The health sector should encourage health systems to support all such dimensions of care
provided to individuals as they age given the importance of health to ensure quality of life.
Specificities of Health Care
Many formal systems of health care have been developed with an emphasis on “acute or
catastrophic care” of a much younger population, often focused on communicable diseases
and/or injuries. Health systems should emphasize other needs, especially chronic diseases
management and cognitive decline, when treating the elderly.
While acute care services are essential for people of all ages, but they are not focused on
keeping people healthy or providing the ongoing support and care required to manage
chronic conditions. A paradigm shift is needed to avoid treating chronic diseases as if they
were acute conditions.
Medical conditions in older age often occur simultaneously with social problems and both
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Ageing
need to be considered by health professionals when providing health care. Doctors,
particularly specialists, should bear in mind that elderly patients may have other
concurrent chronic diseases or comorbidities that interact with each other and that their
treatment should not lead to inadvertent and preventable induction of complications.
When initiating a pharmacologic treatment for chronic disease in an elderly patient,
prescribers should generally start low (doses) and go slow (increasing the doses) to
accommodate the specific needs of the patient.
If the patient cannot decide for him/herself, due to the high prevalence of memory and
cognitive problems in old age, physicians treating elderly patients should actively
communicate with the family, and frequently with the formal caretaker, to better educate
them about the patient’s health condition and about medication administration, in order to
avoid complications.
When considering different therapeutic options, physicians should always seek to find out
the wishes of the patient and recognize that for some patients quality of life will be more
important than the potential results of more aggressive treatment options.
Education and Training for Physicians
All physicians should be appropriately trained to diagnose and treat the health problems of
older people, which means mainstreaming ageing in the medical curriculum.
Secondary health care for the elderly should be provided as necessary. It should be
holistic, including taking into consideration psychosocial as well as environmental
aspects. Physicians should also be aware of the risks of elder abuse and measures to be
taken when abuse is identified or suspected. (See the WMA Declaration of Hong Kong on
the Abuse of the Elderly.)
Every doctor, particularly general practitioners, should have access to information and
undergo training to identify and prevent polypharmacy and adverse drugs interactions that
may be more common in elderly patients.
Continuing medical education on topics relevant to the ageing patient should be
emphasized in order to help physicians adequately diagnose, treat, and manage the
complexities of caring for an ageing population.
Handbook of WMA Policies
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WMA STATEMENT
ON
CYBER-ATTACKS ON HEALTH AND OTHER CRITICAL
INFRASTRUCTURE
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
• Advancements in modern information technology (IT) pave the way for
improvements in healthcare delivery and help streamline physician workflow,
from medical record keeping to patient care. At the same time, implementing new
and more sophisticated IT infrastructure is not without its challenges and risks,
including cyber-attacks and data breaches.
• Cyber security threats are an unfortunate reality in an age of digital information
and communication. Attacks on critical infrastructure and vital assets of public
interest, including those used in the fields of energy, food and water supply,
telecommunications, transportation and healthcare, are on the rise and pose a
serious threat to the health and well-being of the general public.
• With the proliferation of electronic medical records and billing systems, the
healthcare sector is especially susceptible to cyber intrusions and has become a
prime soft target for cyber criminals. Healthcare institutions and business partners,
from the smallest of private practices to the largest of hospitals, are vulnerable not
only to the theft, alteration and manipulation of patients’ electronic medical and
financial records, but also to increasingly sophisticated system breaches that could
jeopardise their ability to provide care for patients and respond to health
emergencies. Especially disconcerting is the threat posed to a patient’s
fundamental right to data privacy and safety. In addition, repairing the damage
caused by successful cyber-attacks can entail significant costs.
• Patient data also demands protection because it often contains sensitive personal
information that can be used by criminals to access bank accounts, steal identities,
or obtain prescriptions illegally. For this reason, it is worth far more on the black
market than credit card information alone. Alterations to or abuse of patient data in
the case of a breach can be detrimental to the health, safety and material situation
of patients. In some cases, breaches can even have life-threatening consequences.
• Current security procedures and strategies in the healthcare sector have generally
not kept pace with the volume and magnitude of cyber-attacks. If not adequately
protected, hospital information systems, practice management systems or control
systems for medical devices can become gateways for cybercriminals. Radiology
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Cyber-Attacks on Health
imaging software, video conferencing systems, surveillance cameras, mobile
devices, printers, routers and digital video systems used for online health
monitoring and remote procedures are just some of the many IT structures at risk
of being compromised.
• Despite this danger, many healthcare organisations and institutions lack the
financial resources (or the will to provide them) and the administrative or technical
skills and personnel required to detect and prevent cyber-attacks. They may also
fail to adequately communicate the seriousness of cyber threats both internally and
to patients and external business partners.
RECOMMENDATIONS
1. The WMA recognises that cyber-attacks on healthcare systems and other critical
infrastructure represent a cross-border issue and a threat to public health. It
therefore calls upon governments, policy makers and operators of health and other
vital infrastructure throughout the world to work with the competent authorities for
cyber security in their respective countries and to collaborate internationally in
order to anticipate and defend against such attacks.
2. The WMA urges national medical associations to raise awareness among their
members, health care institutions and other industry stakeholders about the threat
of cyber-attacks and to support an effective, consistent healthcare IT strategy to
protect sensitive medical data and to assure patient privacy and safety.
3. The WMA underscores the heightened risk of cyber intrusions and other data
breaches faced by the healthcare sector and urges medical institutions to
implement and maintain comprehensive systems for preventing security breaches,
including but not limited to providing training to ensure employee compliance with
optimal data handling practices and to maintain security of computing devices.
4. In the event of a data security breach, healthcare institutions should have proven
response systems in place, including but not limited to notifying and offering
protection services to victims and implementing processes to correct errors in
medical records that result from malicious use of stolen data. Data breach
insurance policies could be considered as a precautionary measure for defraying
the costs associated with a potential cyber intrusion.
5. The WMA calls upon physicians, as guardians of patient safety and data
confidentiality, to remain aware of the unique challenge cyber-attacks could pose
to their ability to practice their profession and to take all necessary measures that
have been shown to safeguard patient data, patient safety and other vital
information.
6. The WMA recommends that undergraduate and postgraduate medical education
curricula include comprehensive information on how physicians can use modern
IT and electronic communications systems to full advantage, while still ensuring
data protection and maintaining the highest standards of professional conduct.
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7. The WMA acknowledges that physicians and healthcare providers may not always
have access to the resources (including financial), infrastructure and expertise
required to establish fail-safe defence systems and stresses the need for the
appropriate public as well as private bodies to support them in overcoming these
limitations.
Handbook of WMA Policies
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WMA STATEMENT
ON
DIVESTMENT FROM FOSSIL FUELS
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
• As noted by the 65th World Medical Assembly in Durban in 2014, physicians
around the world are aware that fossil fuel air pollution reduces quality of life
for millions of people worldwide, causing a substantial burden of disease,
economic loss, and costs to health care systems.
• According to World Health Organization data, in 2012, approximately “7
million people died, one in eight of total global deaths, as a result of air
pollution” (WHO, 2014).
• The United Nations’ Intergovernmental Panel on Climate Change (IPCC) notes
that global economic and population growth, relying on an increased use of
coal, continues to be the most important driver of increases in Carbon Dioxide
emissions. These emissions are the major component of an accelerating the
amount of human fossil fuel Greenhouse Gas (GHG) emissions despite the
adoption of climate change mitigation policies (IPCC, 2014).
• The burden of disease arising from Climate Change will be differentially
distributed across the globe and, while it will affect everyone, the most
marginal populations will be the most vulnerable to the impacts of climate
change and have the least capacity for adaptation.
BACKGROUND
• In many densely settled populated cities around the world, the fine dust measurable
in the air is up to 50 times higher than the WHO recommendations. A high volume
of transport, power generated from coal, and pollution caused by construction
equipment are among the contributing factors (WMA, SMAC 197, Air Pollution
WMA Statement on the Prevention of Air pollution due to Vehicle Emissions
2014).
• Evidence from around the world shows that the effects of climate change and its
extreme weather are having significant and sometimes devastating impacts on
human health. Fourteen of the 15 warmest years on record have occurred in the
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Divestment from Fossil Fuels
first 15 years of this century (World Meteorological Organization 2014). The
vulnerable among us including children, older adults, people with heart or lung
disease, and people living in poverty are most at risk from these changes.
• The WMA notes the Lancet Commission’s description of Climate Change as “the
greatest threat to human health of the 21st century”, and that the Paris agreement at
COP21 on Climate calls upon governments “when taking action on climate
change” to “respect, promote and consider their respective obligations on human
rights (and) the right to health”.
• As the WMA states in its Delhi Declaration on Health and Climate Change,
“Although governments and international organizations have the main
responsibility for creating regulations and legislation to mitigate the effects of
climate change and to help their populations adapt to it, the World Medical
Association, on behalf of (…) its physician members, feels an obligation to
highlight the health consequences of climate change and to suggest solutions. (…)
The WMA and NMAs should develop concrete actionable plans/practical steps” to
both mitigate and adapt to climate change (WMA 2009).
RECOMMENDATIONS
The WMA recommends that its national medical associations and all health organizations:
• Continue to educate health scientists, businesses, civil society, and governments
concerning the benefits to health of reducing greenhouse gas emissions and
advocate for the incorporation of health impact assessments into economic policy.
• Encourage governments to adopt strategies that emphasize strict environmental
regulations and standards that encourage energy companies to move toward
renewable fuel sources.
• Begin a process of transferring their investments, when feasible without damage,
from energy companies whose primary business relies upon extraction of, or
energy generation from, fossil fuels to those generating energy from renewable
energy sources.
• Strive to invest in companies upholding the environmental principles consistent
with the United Nations Global Compact (www.unglobalcompact.org), and refrain
from investing in companies that do not adhere to applicable legislation and
conventions regarding environmental responsibility.
Handbook of WMA Policies
S-2016-04-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ETHICAL CONSIDERATIONS IN GLOBAL MEDICAL ELECTIVES
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
• Medical trainees are increasingly participating in global educational and service
experiences, commonly referred to as ‘international medical electives’ (IMEs).
These experiences are normally short term, i.e., less than 12 months, and are often
undertaken in resource-limited settings in low-and middle-income countries.
• Although IMEs can provide valuable learning experience, this must be weighed
against the potential risks to the host community, the sponsor organization and the
visiting trainee. Successful placements help to ensure that there are mutual benefits
for all parties and are built upon an agreed understanding of concepts including
non-maleficence and justice.
• Published ethical guidelines, such as the Ethics and Best Practice Guidelines for
Training Experiences in Global Health by the Working Group on Ethics
Guidelines for Global Health Training (WEIGHT), call on sponsor institutions
(i.e., universities and organizations facilitating electives) to commit to sustainable
partnerships with host institutions and local communities. All parties are also
called upon to work collaboratively in creating professional guidelines and
standards for medical electives.
• In turn, trainees undertaking IMEs must adhere to relevant ethical principles
outlined in WMA ethical documents, including the WMA’s Declaration of
Geneva, the WMA International Code of Medical Ethics and the WMA Statement
on the Professional and Ethical Use of Social Media.
RECOMMENDATIONS
Therefore the WMA recommends that:
1. Sponsor institutions work closely with host institutions and local communities to
create professional and ethical guidelines on best practices for international
medical electives. Both institutions should be actively engaged in guideline
development. The sponsor organization should evaluate the proposed elective
using such standards prior to approval.
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Global Medical Electives
2. Guidelines should be appropriate to local context and endorse the development of
sustainable, mutually-beneficial and just partnerships between institutions and the
patients and the local community, with their health as the first consideration. These
must take account of best practice guidelines, already available in many countries.
3. Guidelines must hold patient and community safety as paramount, and outline
processes to ensure informed consent, patient confidentiality, privacy, and
continuity of care as outlined in the WMA International Code of Medical Ethics.
4. Guidelines should also outline processes to protect the safety and health of the
trainee, and highlight the obligations of the sponsor and host institutions to ensure
adequate supervision of the trainee at all times. Institutions should consider means
of addressing possible natural disasters, political instability, and exposure to
disease. Emergency care should be available.
5. Sponsor and host institutions have a responsibility to ensure that IMEs are well
planned, including, at a minimum, appropriate pre-departure briefings, which
should include training in culture and language competency and explicit avoidance
of any activity which could be exploitative, provision of language services as
required, and sufficient introduction and guidance at the host institution. Post-
departure debriefing should be planned on return of the trainee, including
reviewing ethical situations encountered and providing appropriate emotional and
medical support needed.
6. It is expected that the trainee will receive feedback and assessment for the
experience so that he/she can receive academic credit. The trainee should have the
opportunity to evaluate the quality and utility of the experience.
7. Trainees must be fully informed of their responsibility to follow instructions given
by local supervisors, and to treat local host staff and patients with respect.
8. These guidelines and processes should be reviewed and updated on a regular basis
as sponsor and host institutions develop more experience with one another.
9. National Medical Associations should develop best practices for international
medical electives, and encourage their adoption as standards by national or
regional accrediting bodies, as feasible, and their implementation by sponsor and
host institutions.
Handbook of WMA Policies
S-2016-05-2016 ⏐ World Medical Association
WMA STATEMENT
ON
OBESITY IN CHILDREN
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Childhood obesity is a serious medical condition and a major public health concern
affecting many children. Childhood obesity is emerging as a growing epidemic and is a
challenge in both developed and developing countries. Due to its increasing prevalence
and its immediate and long-term impact on health, including predisposition to diabetes and
cardiovascular abnormalities, childhood obesity should be viewed as a serious concern for
public health. The increase in childhood obesity may be attributed to many factors:
• Recent studies show that marketing targeted at children has a wide influence on the
shopping trends and food preferences of households all over the world. Special
offers, short-term price reductions and other price promotions and advertising on
social as well as traditional media all play a role in increasing product demand.
• Many advertisements are in conflict with nutritional recommendations of medical
and scientific bodies. TV advertisements for food and drink products with little or
no nutritional value are often scheduled for broadcast hours with a large
concentration of child viewers and are intended to promote the desire to consume
these products regardless of hunger. Advertisements increase children’s emotional
response to food and exploit their trust. These methods and techniques are also
used in non-traditional media, such as social networks, video games and websites
aimed at children.
• Unhealthy dietary patterns, together with a sedentary lifestyle and lack of exercise,
contribute to childhood obesity. The sedentary lifestyle is the most predominant
one in the developed world today. Many children typically spend more time than
ever in front of screens, rarely engaging in physical activities.
• International corporations and conglomerates that manufacture foods and
beverages are not always subject to regional regulations that govern food labeling.
Concern for profits may come at the expense of corporate responsibility for
environmental and public health issues.
• Products containing large amounts of added sugar, fat, and salt can be addictive,
especially when combined with flavor enhancers. In some countries, not all
ingredients are required to be listed on food labels and manufacturers often refuse
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Obesity in Children
to release data on methods employed to maximize consumption of their products.
Governments should require that all ingredients in food and beverages be clearly
labeled, including those proprietary ingredients intended to increase consumption
of the product.
• Socioeconomic disparities also correlate with increasing rates of childhood
obesity. The link between living in poverty and early childhood obesity continues
to negatively affect health in adult life.[1] Exposure to environmental
contaminants, sporadic medical checkups, insufficient access to nutritious foods
and limited physical activity lead to obesity and other chronic illnesses that are all
more prevalent among children living in poverty.
RECOMMENDATIONS
1. A comprehensive program is needed to prevent and address obesity in all segments
of the population, with a specific focus on children. The approach must include
initiatives on price and availability of nutritious foods, access to education,
advertising and marketing, information, labeling and other areas specific to regions
and countries. An approach similar to that on tobacco in the WHO Framework
Convention on Tobacco Control is advocated.
2. International studies stress the importance of adopting an integrated approach to
education and health promotion. Investment in education is key to minimizing
poverty, improving health and providing economic benefits.
3. Quality education offered in formal settings to children aged 2 to 3 years,
combined with enrichment activities for parents, and sufficient supply of nutritious
food and beverages may help to reduce the rate of adolescent obesity and reduce its
health implications throughout the life course. Developing early healthy eating
practices and experiencing flavors of healthy food when very young appear to be
positive factors in prevention of childhood obesity.
4. Governments should invest in education related to menu design, food shopping
including budget setting, storage and preparation so that people are better equipped
to plan their food intake.
5. Governments should seek to regulate the availability of food and beverages of poor
nutritional value, by a range of methods including price. Attention should be paid
to the availability close to schools of establishments selling products of poor
nutritional quality. Governments should seek to persuade manufacturers to
reformulate products to reduce their obesogenic effects. Where possible
government and local authorities should seek to manage the density of such
establishments in the area.
6. Governments should consider imposing a tax on non-nutritious foods and sugary
drinks and use the additional revenue to fund research and epidemiological studies
aimed at preventing childhood obesity and reducing the resulting disease risk.
7. Ministries of health and education should regulate food and beverages that are sold
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S-2016-05-2016 ⏐ World Medical Association
and served at educational and healthcare facilities.
8. Given the scientifically proven link between the extent of media consumption and
adverse effects on body weight in children, the WMA recommends that the
advertising of non-nutritious products be restricted during television programming
and other forms of media that appeal to children. Regulators should be aware that
children access television programs designed for adults and ensure that legislation
and regulation also limits marketing associated with such programs.
9. Governments should work with independent health experts to produce sound
guidance on food and nutrition, with no involvement of the food and drink
industry.
10. Governments and local authorities should subsidize and encourage activities that
promote good health among their residents, including providing safe spaces for
walking, bike riding and other forms of physical activity.
11. Parents have a crucial role in fostering physical activity in their children. Schools
should incorporate daily physical activity into their daily routine. Participation in
sport activities should be possible for everyone regardless of their economic
situation.
12. National Medical Associations should support or develop guidelines and
recommendations to ensure that they reflect current knowledge of prevention and
treatment of childhood obesity.
13. National Medical Associations should work to raise public awareness on the issue
of childhood obesity and highlight the need to tackle the rising prevalence of
obesity and its health and economic burden.
14. Clinics and Health Maintenance Organizations should employ appropriately
trained professionals to offer classes and consultation in selecting appropriate
amounts of nutritious foods and beverages and attaining optimal levels of physical
activity for children. They should also ensure that their premises are exemplars in
the provision of healthy food options.
15. Educational facilities should employ appropriately trained professionals who
educate for healthy lifestyles from an early age and allow all children, whatever
their social environment, to practice regular physical activities.
16. Physicians should guide parents and children in how to live healthy lives and
emphasize the importance of doing so, and must identify as soon as possible
obesity in their patients, particularly children. They should direct patients suffering
from obesity to the appropriate services at the earliest possible stage, and conduct
regular follow-ups.
17. Physicians and health professionals should be educated in nutrition assessment,
obesity prevention and treatment. This could be accomplished by strengthening
CME activities focused on nutritional medicine.
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Obesity in Children
[1] WHO Commission on Social Determinants of Health (Closing the Gap in a
Generation) 2008.
Handbook of WMA Policies
S-2017-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
BULLYING AND HARASSMENT WITHIN THE PROFESSION
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Workplace bullying has been recognised as a major occupational stressor since the
early 1980s.
2. Workplace bullying is unreasonable and inappropriate behaviour directed towards a
worker or a group of workers that creates a risk to health and safety. By definition,
bullying is behaviour that is repeated over time or occurs as part of a pattern of
behaviour, rather than a single episode. Unreasonable behaviour is what a reasonable
person in the same circumstances would see as unreasonable. It includes behaviour
that intimidates, offends, victimises, threatens, degrades, insults or humiliates.
Bullying can take psychological, social and physical forms. It is not the perpetrator’s
intention, but the victim’s perception, that is key to determining whether bullying has
occurred.
3. Harassment is unwanted, unwelcome or uninvited behaviour that makes a person feel
humiliated, intimidated or offended. Harassment can be related to a person’s ethnicity,
gender, sexual orientation, disability or other factors such as whether a person has
made a complaint.
4. Employers generally have a legal duty to ensure the health, safety and welfare of their
employees. This includes identifying bullying and harassment and taking steps to
eliminate and prevent it. Employees are generally required to take reasonable care for
their own health and safety as well as for the health and safety of others who may be
affected by their acts in the workplace.
5. In recent years, bullying and harassment have become more recognised in the medical
profession; there is good evidence that disruptive behaviour, inappropriate behaviour
and harassment occurs in the medical workplace. International research has shown that
bullying in the healthcare profession is not associated with specialty or sex. It appears
that bullying is widespread and occurs across all specialties and at all levels of
seniority, although it is fair to say that where bullying occurs it is more common to be
inflicted by a more senior employee upon a more junior one. The hierarchical nature of
medicine and the inherent power imbalance associated with this can however create a
culture of bullying and harassment which, in some cases, becomes pervasive and
institutionalized.
6. Workplace bullying can have detrimental effects such as decreased job satisfaction,
depression, anxiety, and absenteeism, all of which impact adversely on staff retention
and quality of patient care.
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Bullying and Harassment within the Profession
RECOMMENDATIONS
7. The WMA condemns bullying or harassment under any circumstances. It further
believes that raising awareness of inappropriate behaviour, disruptive behaviour and
harassment in the medical profession is an important step in the process of eliminating
the problem. The WMA is of the view that this is an issue of professionalism and it
encourages National Medical Associations (NMAs), medical schools, employers, and
medical colleges to establish and implement anti-bullying and harassment policies.
8. The WMA recommends that NMAs recognise and, where possible, actively address
the following:
8.1 Bullying in the health workplace is an entirely unprofessional and destructive
behaviour and should not be tolerated.
8.2 Steps should be taken to prevent, confront, report and eliminate bullying at any
level.
8.3 Bystanders also have a responsibility to take action.
8.4 There can be significant barriers for junior doctors to speak out about bullying by
senior colleagues, for example fear of career retribution.
8.5 Professionalism is not just how we treat our patients, but how we treat each other
as professional colleagues. Acting professionally means also being vigilant and
stepping in to intervene, for the good of all.
8.6 Bullying is unprofessional, contradicts the fundamentals of the profession and
raises fitness to medical practise concerns.
8.7 Healthcare needs good teams. Eliminating bullying ensures a safer team
environment and a safer healthcare environment for patients.
8.8 It is the responsibility of the management to maintain a good working
environment and address all signs of harassment and bullying. There should be
zero tolerance of bullying and harassment
Handbook of WMA Policies
S-2017-02-2017 ⏐ World Medical Association
WMA STATEMENT
ON
ARMED CONFLICTS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. The duties of physicians in times of armed conflict are set out in the WMA Statement
on Ethical Principles of Health Care in Times of Armed Conflict and Other
Emergencies and WMA Regulations in Times of Armed Conflict and Other Situations
of Violence.
2. Physicians should encourage politicians, governments, and others in positions of
power to be more aware of the consequences, including the impact on health, of their
decisions on the commencement or continuation of armed conflict.
3. Armed conflict damages the health of individuals and of populations as well as critical
infrastructure including health care facilities, housing, potable-water supplies and
sewerage. It also leads to environmental degradation. Such destruction of critical
infrastructure may lead to adverse health consequences including malnutrition, and
infectious or waterborne diseases, such as cholera and typhoid. Warfare also destroys
work-related infrastructure, including factories and manufacturing centres as well as
agriculture. Repair to damaged infrastructure cannot proceed until cessation of the
conflict.
4. Wars start for many different reasons. Efforts to avoid conflicts are often insufficient
and inadequate and country leaders may not seek all alternatives. Avoiding war and
seeking constructive alternatives is always desirable.
5. It is essential that those claiming that a war us a “just war” understand that this is a
rare and extreme circumstance, which must not be overcited. The concept of a “just”
war must not be used to legitimize violence.
6. Warfare and other forms of armed conflict are likely to worsen the suffering of the
poorest and to contribute to the development of large numbers of Internally Displaced
Persons and refugees.
7. Physicians should seek, during conflicts, to influence parties in order to alleviate the
suffering of populations.
RECOMMENDATIONS
8. The WMA believes that armed conflict should always be a last resort. Physicians and
NMAs should alert governments and non-state actors of the human consequence of
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Armed Conflicts
warfare.
9. Physicians should encourage politicians, governments, and others in positions of
power to be more aware of the consequence of their decisions related to armed
conflict.
10. The WMA recognizes that armed conflict always produces enormous human suffering.
States and other authorities, including non-state actors, who enter into armed conflict
must accept responsibility for the consequences of their actions, and be prepared to
answer for their consequences including to international courts and tribunals and
recommends that authorities recognize and cooperate to ensure this occurs.
11. The WMA recognizes that the impact of armed conflict will be most significant upon
women and vulnerable populations, including children, the young, the elderly and the
poorest members of society. Physicians should seek to ensure that allocation of
medical care resources does not have a discriminatory impact.
12. Physicians must continually remind those in power of the need to provide essential
services to those within areas damaged and disrupted by conflict.
13. After a 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.
14. The WMA demands that parties to a conflict respect relevant Humanitarian Law and
do not use health facilities as military quarters, nor target health institutions, workers
and vehicles, and respect established International Humanitarian Law (IHL) and do not
use health facilities as military quarters, nor initiate attacks against 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.
15. Physicians should work with aid and other agencies to seek to ensure that parties
protect family integrity and, wherever possible, remove people from direct and
immediate danger.
16. Physicians should be aware of the likely prevalence of Post-Traumatic Stress Disorder
(PTSD) and other post-conflict psychosocial and psychosomatic problems and provide
appropriate care and treatment to combatants and civilians.
17. Physicians, including forensic medicine specialists, should help families ensure that
efforts to identify the missing and the dead are not subverted by security forces.
Handbook of WMA Policies
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WMA STATEMENT
ON
MEDICAL CANNABIS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Cannabis is the generic term used to denote psychoactive preparations of the plant
Cannabis sativa, which grows wild in many parts of the world and is known by
numerous other names, such as: “marijuana”, “dagga”, “weed”, “pot”, “hashish”, or
“hemp”.
2. Cannabis for medical use refers to the use of cannabis and its constituents, natural or
synthetic, to treat disease or alleviate symptoms under professional supervision;
however, there is no single agreed upon definition.
3. Recreational cannabis refers to the use of cannabis to alter one’s mental state in a way
that modifies emotions, perceptions, and feelings regardless of medical need.
4. This WMA statement is intended to provide a position on legalisation of cannabis for
medical use and highlight the adverse effects associated with recreational use.
5. Recreational cannabis use is an important health and social issue across the world.
Cannabis is the most commonly used illicit drug in the world. The World Health
Organisation estimates that about 147 million people, 2.5% of the world population,
use cannabis compared with 0.2% using cocaine and 0.2% using opiates.
6. The WMA opposes recreational cannabis use due to serious adverse health effects
such as increased risk of psychosis, fatal motor vehicle accidents, dependency, as well
as deficits in verbal learning, memory and attention. Use of cannabis before the age
of 18 doubles the risk of psychotic disorder. The ominously growing availability of
cannabis or its forms in foodstuffs such as sweets and “concentrates”, which have
enormous appeal to children and adolescent, requires intensive vigilance and policing.
7. National Medical Associations should support strategies to prevent and reduce
recreational cannabis use.
8. Evidence for use of cannabis for medical use
8.1 Cannabinoids are chemical constituents of Cannabis sativa that contain similar
structural features; some of the chemical constituents act on human cannabinoid
receptor cells. Conceptually, cannabinoids that activate these receptors (1) occur
naturally in the human body like other endogenous neurotransmitters
(endocannabinoids); (2) occur naturally in the cannabis plant
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(phytocannabinoids); or (3) are pharmaceutical preparations containing either
synthetic cannabinoids, (e.g. delta9-tetrahydrocannabinol [dronabinol,
Marinol™], or a related compound, nabilone [Cesamet™], or extracts of
phytocannabinoids (nabiximols [Sativex™]).
8.2 Amongst phytocannabinoids is naturally occurring Cannabis sativa, delta-9-
tetrahydrocannabinol (THC), the main bioactive cannabinoid and the principal
psychoactive constituent, while cannabidiol (CBD) is the second most
abundant. CBD lacks significant psychoactive properties but may possess
analgesic and antiseizure properties.
8.3 The human endocannabinoid system is believed to mediate the psychoactive
effects of cannabis and is involved in a variety of physiologic processes
including appetite, pain-sensation, mood, and memory. The significant medical
and pharmacological therapeutic potential of influencing the endocannabinoid
system has been widely recognized.
8.4 The medical benefits of cannabis reported in scientific literature are widely
debated globally. Cannabis has been used for the treatment of severe spasticity
in multiple sclerosis, chronic pain, nausea and vomiting due to cytotoxics, and
loss of appetite and cachexia associated with AIDS. Evidence suggest that
certain cannabinoids are effective in the treatment of chronic pain, particularly
as an alternative or adjunct to the use of opiates when the development of opiate
tolerance and withdrawal can be avoided. Evidence supporting use of cannabis
for medicinal purposes is of low to moderate quality, and inconsistent. The
inconsistency can be partially attributable to the prohibition of cannabis. Its
classification as an illegal substance in some countries has constrained safe and
high-quality clinical research.
8.5 The short-term adverse effects of cannabis use are well documented. However,
the long-term adverse effects are less well understood, particularly the risk of
dependence and cardiovascular disease. There are also significant public health
concerns for vulnerable populations such as adolescents, and pregnant or
breastfeeding women.
8.6 Despite weak evidence of its medical benefits, cannabis for medical use has
been legalised in some countries. In other countries medical cannabis is
forbidden or under debate.
9. Medical professionals may find themselves in a medico-legal dilemma as they try to
balance their ethical responsibility to patients for whom cannabis may be an effective
therapy and compliance with applicable legislation. This dilemma can manifest itself
both with patients who may medically benefit from the use of cannabis, and those
who are not likely to do so, but pressure the medical professionals to prescribe it.
RECOMMENDATIONS
10. Cannabis Research
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Medical Cannabis
10.1 In the light of the low-quality scientific evidence on the health effects and
therapeutic effectiveness of cannabis, more rigorous research involving larger
samples is necessary before governments decide whether or not to legalise
medical cannabis for medical purposes. Comparators must include the existing
standards of treatment. Expansion of such research should be supported.
Research should also examine the public health, social and economic
consequences of cannabis use.
10.2 Governments may consider reviewing laws governing access to and possession
of research-grade cannabis for the purpose of allowing well-designed scientific
research studies to broaden the evidence base on the health effects and
therapeutic benefits of cannabis.
11. In countries where cannabis is legalised for medicinal purposes, the following
requirements should apply:
11.1 Requirements for producers and products:
11.1.1 Provision of cannabis plant products for treatment must be in accordance
with the UN Single Convention on Narcotic Drugs from 30 March 1961,
including the Convention’s rules on production, trade, and distribution.
Thus, it is essential that the cannabis included in the products delivered for
medical treatment must be provided and handled in accordance with the
requirements of the Convention.
11.1.2 Requirements must include that the cannabis plants meet appropriate
quality demands for growing and standardization. The produced cannabis
plant products must have a specific indication (interval) of ingredients,
including the content of delta-9-tetrahydrocannabinol (THC) and
cannabidiol (CBD) and strength indication of these.
11.2 Requirements for prescription and dispensing of cannabis for medical
purposes:
11.2.1 Cannabis must be prescribed by an authorised physician/prescriber in
accordance with the best level of evidence and the country’s regulatory
frameworks.
11.2.2 It is recommended that treatment with approved conventional drugs is
undertaken before cannabis products are used for treatment.
11.2.3 Each individual physician must take responsibility for and make a decision
regarding treatment with cannabis products, in accordance with the best
available evidence and country specific registered indications.
11.2.4 Cannabis for medical purposes must only be dispensed at pharmacies or by
authorised dispensers in accordance with the country´s regulatory
frameworks.
11.2.5 Effective control measures must be put in place to impede illicit use of
medical cannabis.
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11.2.6 Public health surveillance systems to monitor prevalence of cannabis use
and trends in utilisation patterns are necessary.
12. In considering policy and legislation on cannabis, governments, NMAs,
policymakers, and other health stakeholders, should emphasize and examine the
health effects and therapeutic benefits based on the available evidence, while also
recognizing various contextual factors such as regulatory capacity, cost-effectiveness,
societal values, social circumstances of the country, and the public health and safety
impact on the wider population.
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WMA STATEMENT
ON
THE COOPERATION OF NATIONAL MEDICAL ASSOCIATIONS
DURING OR IN THE AFTERMATH OF CONFLICTS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Throughout history, there have been cases of political conflict in which physicians and
the professional bodies that represent them have adopted and reinforced the policies of
their respective governments in violation of medical ethical standards. There have also
been cases of physicians themselves deliberately engaging in criminal activities and
embracing unethical ideologies. Even today, on-going moral and political conflicts can
lead physicians and their representative organisations to overstep ethical boundaries.
2. To prevent such breaches of ethical conduct from occurring, physicians and their
representative organisations have a responsibility to rise above national conflicts, to
foster mutual professional support and to base their actions on the highest medical
ethical standards, including the physician’s primary obligation to the health of
individual patients.
3. All national medical associations and their members have an obligation to uphold the
ethos of medicine, to demonstrate absolute forthrightness and honesty in confronting
historical and ongoing national conflicts, as well as to preserve the lessons gleaned
from all forms of unethical behaviour. This includes maintaining a clear commitment
to human rights, explicitly rejecting racial, religious, gender, sexual orientation and
any other forms of discrimination and actively confronting moral failures of the
medical profession.
4. Physicians have professional and ethical obligations that go beyond ethnic and
national interests. Medical associations have a role to play in bridging the gap between
different groups based on their common medical ethical codes, regardless of political,
religious, ethnic and social background. Medical expertise as represented in the
medical associations could be a powerful agent for re-establishing respect for human
rights in general at times of war and other conflicts.
RECOMMENDATIONS
5. The World Medical Association urges National Medical Associations to:
5.1 Meet regularly in the spirit of enduring friendship and cooperation;
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Cooperation of NMAs during or in the Aftermath of Conflicts
5.2 Take initiative to invite colleagues from medical associations from nations in
conflict to meetings with the intention of re-establishing the contact and
cooperation between the associations;
5.3 Engage in a meaningful exchange of experience and knowledge with the regional
and global medical community in order to maintain the highest levels of ethical
standards and care;
5.4 Ensure that all generations of physicians, including those who have not been
involved in any wrongdoing, are made aware of the vital importance of medical
ethics and the dire consequences of any departure therefrom. This can be
accomplished by including these principles as part of basic medical training (see
WMA Resolution on the Inclusion of Medical Ethics and Human Rights in the
Curriculum of Medical Schools Worldwide) and continuing throughout
physicians’ careers;
5.5 Recognise their obligation to work with each other and with other competent
authorities to keep the memory of any deviations from medical ethics or
violations of human rights alive, in order to prevent them from happening again;
5.6 Promote the preservation and growth of constructive relations in the medical
profession, even in the aftermath of regretful pasts or on-going conflicts. To
achieve this, it is particularly important to engage in continuous communication
in an atmosphere of professional collegiality.
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WMA STATEMENT
ON
EPIDEMICS AND PANDEMICS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. History demonstrates that new diseases may emerge and old diseases re-emerge,
unpredictably. The rapid global movement of people and goods now means that
infections spread globally at unprecedented rates, challenging health systems to
respond in a timely manner. Therefore, quickly recognizing and reacting appropriately
to such epidemics or pandemics must be an international concern, with effective
communication and collaboration between nations.
2. Epidemics may be caused by a variety of infectious agents with different methods of
transmission. These diseases may be self-limiting, may lead to few obvious symptoms
or may cause short or long term, sometimes serious, effects. Relatively minor illnesses
may become life threatening in some vulnerable individuals. This may include the
elderly and the very young as well as those with some degree of compromised
immunity.
3. Investment in public health systems will enhance capacity to effectively detect and to
contain rare or unusual disease outbreaks. Core public health functions are needed as a
foundation for detection, investigation and response to all epidemics. A more effective
global surveillance program will improve response to infectious diseases and will
allow earlier detection and identification of new or emerging diseases. Epidemics and
pandemics have the potential to spread more rapidly in countries with systematically
underfunded and underdeveloped public health systems.
RECOMMENDATIONS
WHO and National Governments
4. The World Health Organization (WHO) has the responsibility for coordinating the
international response to epidemics and pandemics. It has defined phases that allow an
escalating approach to preparedness planning and response as an epidemic evolves.
The WMA recommends:
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4.1 WHO should ensure that all relevant data on the development of infectious
diseases and their spread is collected, including working with voluntary bodies or
non-state actors as well as national and local governments who observe
developments in areas where documentation may be limited. A global system of
data capture and surveillance is essential for tracking infectious diseases and their
consequences.
4.2 WHO should work closely with the Centers for Disease Control in Atlanta and
Europe (CDC and ECDC), National Centres for Disease Control and other
applicable regional public health agencies to examine reports of disease pattern
changes and to declare epidemics and pandemics as soon as they are identified.
Emergence and identification may be on different time scales.
4.3 WHO and others should work with national governments and international
government groups to coordinate responses to emerging and reemerging infectious
diseases.
4.4 WHO should collaborate with national medical associations and other health
authorities to ensure that accurate and timely clinical care guidelines are made
available to physicians and health care providers.
4.5 As infections emerge or reemerge WHO and other UN agencies must ensure that
easy-to-understand information is made available to all people in the affected zone
in local languages, working with governments and other partners. This should
include information on disease prevention, including appropriate information on
optimal hygiene and infection control practices.
4.6 Where diseases lead to the development of birth defects, governments must
provide support to families that are affected.
4.7 A cadre of public health specialists who can offer support during a developing
health emergency should be developed and supported by all national governments.
They and other physicians should be prepared to make themselves available to assist in
epidemic control, according to their relevant skill set.
National Medical Associations (NMAs)
5.1 NMAs should clearly identify their responsibilities during an epidemic including
the extent of their participation in the national epidemic planning process. These
responsibilities should include communicating vital information to the public and
especially to health care professionals.
5.2 Where applicable, NMAs should offer training, information and clinical support
tools to physicians and regional medical associations, working with public health
and educational institutions.
5.3 NMAs should be prepared to advocate for adequate government funding for
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Epidemics and Pandemics
supporting the health care workforce and preparing for an epidemic.
Physicians
6.1 Physicians should be sufficiently educated about transmission risks, infection
control, and concurrent chronic illness management during an epidemic.
6.2 Since physicians will be the first responders, they must remain involved in planning
for epidemics and all stages of epidemic response at the local level.
6.3 Physicians should take all measures necessary to protect their own health and the
health of their staff and co-workers.
6.4 Physicians should assist in primary data collection to monitor epidemics with due
regard to confidentiality and protecting the vulnerable.
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WMA STATEMENT
ON
THE ROLE OF PHYSICIANS IN PREVENTING EXPLOITATION IN
ADOPTION PRACTICES
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. UNICEF’s Convention on the Rights of the Child calls in article 21 for a transparent
and proper adoption process in which the best interests of the child are the principal
concern.
2. The Hague Convention on the Protection of Children and Co-operation in Respect of
Inter-Country Adoption (Hague Adoption Convention) establishes safeguards to
ensure that intercountry adoptions take place in the best interests of the child. Its
principles should form the basis for global intercountry adoption practices.
3. Physicians may be in touch with children who are going to be adopted, with parents
and/or legal guardians of those children, and with parents who are going to adopt a
child. Because physicians may confront the consequences of exploitation in adoptive
practices, their role is crucial in seeking to ensure adherence to children’s’ rights, and
in particular to article 21 of UNICEF´s Convention on the Rights of the Child.
Professional awareness of the legal adoption process is necessary to protect the rights
and health of the child.
RECOMMENDATIONS
4. The WMA condemns all forms of exploitation in child adoption practices.
Unacceptable practices may include criminal acts, including trafficking and sexual
crimes.
5. WMA calls on National Medical Associations and physicians to actively participate in
preventing exploitation in adoption practices.
6. Physicians should be educated about the nature and importance of their role during the
adoption process. Physicians should become knowledgeable about exploitative
adoption practices and should be aware of resources to help them identify and address
the needs of victims.
7. Physicians having contact with families who are adopting minors, should strongly
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Preventing Exploitation in Adoption Practices
encourage them to verify that the adoption practices meet all legal and regulatory
requirements in their jurisdiction.
8. The WMA supports providing information to families who are considering adoption
about the existence of networks that may engage in exploitation in adoption practices,
especially when adoption will take place across legal jurisdictions.
9. Physicians who have justifiable reason to suspect that a child or adult patient may be
involved in exploitative adoption practices should, according to national regulations,
notify appropriate authorities.
10. Physicians should be educated about the existence of tools that may help identify
family members of adopted children, including DNA identification testing.
11. The WMA encourages scientific and professional activities that could support local
authorities’ efforts to deter exploitation in adoption practices.
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WMA STATEMENT
ON
BIOSIMILAR MEDICINAL PRODUCTS
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. he expiry of patents for original biotherapeutics has led to the development and
approval of copies, called ‘similar biological medicinal products’ or ‘biosimilars’
that are highly similar to a previously approved biological product, known as the
originator or reference product.
2. In light of the fact that biosimilars are made in living organisms, there may be
some minor differences from the reference medicine, as minor variability is a
characteristic attribute of all biological medicines. The manufacture of biosimilars
is generally more complex than the manufacture of chemically derived molecules.
Therefore, the active substance in the final biosimilar can have an inherent degree
of minor variability. Innovator biologics also have inherent batch-to-batch
variability, and for that reason biosimilars are not always interchangeable with the
reference products, even after regulatory approval.
3. Biosimilars are not the same as generics. A generic drug is an identical copy of a
currently licenced pharmaceutical product that has an expired patent protection and
must contain the ‘same active ingredients as the original formulation’. A biosimilar
is a different product with a similar, but not identical, structure that elicits a similar
clinical response. As a result, biosimilar medicines have the potential to cause an
unwanted immune response. Whereas generics are interchangeable, biosimilars are
not always interchangeable.
4. Biosimilars have been available in Europe for almost a decade following their
approval by the European Medicines Agency (EMA) in 2005. The first biosimilar
was approved by the Food and Drug Administration (FDA) for use in the United
States in 2015.
5. Biosimilar medicines have transformed the outlook for patients with chronic and
debilitating conditions, as it is possible to obtain similar efficacy as that of the
reference product at a lower cost.
6. Biosimilars will also increase availability for patients without access to the bio-
originator. Greater global access to effective biopharmaceuticals can reduce
disability, morbidity, and mortality associated with various chronic diseases.
7. Nonetheless, the potentially lower cost of biosimilars raises the risk that insurers
and health care providers may favor them over the originator product, even when
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Biosimilar Medicinal Products
they may not be appropriate for an individual patient or in situations when they
have not demonstrated adequate clinical equivalence to an original biological
product. The decision to prescribe biosimilars or to switch patients from reference
medicine to a biosimilar must be made by the attending physicians, not by health
insurance companies.
RECOMMENDATIONS
1. National medical associations should work with their governments to develop
national guidance on safety of biosimilars.
2. National medical associations should advocate for delivering biosimilar therapies
that are as safe and effective as their reference products.
3. National medical associations should strive to ensure that physician autonomy is
preserved in directing which biologic product is dispensed.
4. Where appropriate, national medical associations should lobby against allowing
insurers and health funds to require biosimilar and originator product’s
interchangeability, and for safe regulations of interchanging biosimilar medicines
where this is allowed.
5. Physicians must ensure that patient medical records accurately reflect the
biosimilar medicine that is being prescribed and taken.
6. Physicians shouldn’t prescribe a biosimilar to patients already showing success
with the originator product, unless clinical equivalence has been clearly
demonstrated and established and patients are adequately informed and have given
consent. There should be no substitution between biosimilars and other drugs
without the attending physcian’s permission.
7. Physicians should seek to improve their understanding of the distinctions between
biosimilar products that are highly similar to or are interchangeable with an
originator product; raise awareness of the issues surrounding biosimilars and
interchangeability; and promote clearly delineated labelling of biosimilar products.
8. Physicians should remain vigilant and report to the manufacturer, as well as
through the designated regulatory pathways, any adverse events suffered by
patients using originator biological products or biosimilars.
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WMA STATEMENT
ON
THE DEVELOPMENT AND PROMOTION OF A MATERNAL AND
CHILD HEALTH HANDBOOK
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
The WMA believes that both a continuum of care and family empowerment is necessary
to improve the health and wellbeing of the mother and child. The reduction of maternal
mortality ratio and infant deaths was an important objective of the Millennium
Development Goals (MDGs). The reductions of the maternal mortality ratio, neonatal
mortality rate and the under-five mortality rate are important targets to be achieved under
the Sustainable Development Goals (SDGs).
The maternal and child health (MCH) handbook is a comprehensive home-based booklet
designed to provide relevant health information and include integrated mother and child
health records. The MCH handbook covers health records and information on pregnancy,
delivery, neonatal and childhood periods, and child growth and immunizations. The MCH
handbook supports the integration of maternal, neonatal and child health services. The
MCH handbook is not only about health education, but about creating ownership with
women and families.
In 1948, Japan became the first country in the world to create and distribute a maternal
and child health (MCH) handbook, in order to protect and improve the health and
wellbeing of the mother and child.
There are now approximately 40-country versions of the MCH handbook, all adapted to
the local culture and socio-economic context. There are a variety of handbooks and
educational materials concerned to MCH in many countries. The use of MCH handbooks
has helped improve the knowledge of mothers on maternal and child health issues, and has
contributed to changing behaviors during pregnancy, delivery and post-delivery period.
The MCH handbook can promote the health of pregnant women, neonates and children by
using it as a tool for strengthening a continuum of care. Physicians can make better care
decisions, by referring to the patient’s medical history and health-check data recorded in
the MCH handbook. The MCH handbook alone has not been shown to improve health
indicators. The benefits are maximized when women and children have access to relevant
healthcare services based on information recorded in the handbook. Such benefits of the
handbook could be shared globally.
In Japan, a digital handbook is spreading progressively. The digital handbook is expected
to be utilized in a way that protects confidentiality of the patient’s health information.
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Maternal and Child Health Handbook
Some private kindergarten and primary schools request access to the MCH as part of their
admission process, placing pressure on parents and physicians to modify the answers to
questions in the handbook.
RECOMMENDATIONS
1. The WMA recommends that the constituent member associations encourage their
health authorities and health institutions to provide accessible and easy to
understand information regarding maternal and child health. The MCH handbook,
or equivalents, can be an important tool to improve continuity of care and benefit
health promotion for mothers, neonates and children.
2. The WMA recommends that the constituent member associations and medical
professionals promote the adaptation to local setting and the utilization of MCH
handbooks, or equivalents, in order to leave no one behind with respect to SDGs,
especially for non-literate people, migrant families, refugees, minorities, people in
underserved and remote areas.
3. When using a MCH handbook or similar documentation, in either digital or print
form, the confidentiality of the individual health information and the privacy of
mothers and children should be strictly protected. It should be used exclusively to
improve health and wellbeing of mothers, neonates, and children. It should not be
used in the admission procedures of schools.
4. The constituent member associations should promote local research to evaluate the
utilization of the MCH handbooks, or equivalents, and make recommendations to
improve the quality of care in the local setting.
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WMA STATEMENT
ON
GENDER EQUALITY IN MEDICINE
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. The WMA notes the increasing trend around the world for women to enter medical
schools and the medical profession, and believes that the study and the practice of
medicine must be transformed to a greater or lesser extent in order to support all
people who study to become or practice as physicians, of whatever gender. This is an
essential process of modernization by which inclusiveness is promoted by gender
equality. This statement proposes mechanisms to identify and address barriers causing
discrimination between genders.
2. In many countries around the world, the number of women studying and practicing
medicine has steadily risen over the past decades, surpassing 50% in many places.
3. This development offers opportunities for action, including in the following areas:
• Greater emphasis on a proper balance of work and family life, while supporting
the professional development of individual physicians.
• Encouragement and actualization of women in academia, leadership and
managerial roles.
• Equalization of pay and employment opportunities for men and women, the
elimination of gender pay gaps in medicine, and the removal of barriers
negatively affecting the advancement of female physicians.
4. The issue of women in medicine was previously recognized in the WMA Resolution
on Access of Women and Children to Health Care and the Role of Women in the
Medical Profession which, among other things, called for increased representation and
participation in the medical profession, especially in light of the growing enrolment of
women in medical schools. It also called for a higher growth rate of membership of
women in National Medical Associations (NMAs) through empowerment, career
development, training and other strategic initiatives.
RECOMMENDATIONS
Increased presence of women in academia, leadership and management roles.
5. National Medical Associations/Medical Schools/Employers are urged to facilitate the
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Gender Equality in Medicine
establishment of mentoring programs, sponsorship, and active recruitment to provide
medical students and physicians with the necessary guidance and encouragement
necessary to undertake leadership and management roles.
6. NMAs should explore opportunities and incentives to encourage both men and women
to pursue diverse careers in medicine and apply for fellowships, academic, senior
leadership and management positions.
7. NMAs should lobby for gender equal medical education and work policies.
8. NMAs should encourage the engagement of both men and women in health policy
organizations and professional medical organizations.
Work-Life Balance
9. Physicians should recognize that an appropriate work-life balance is beneficial to all
physicians, but that women may face unique challenges to work-life balance imposed
by societal expectations concerning gender roles that must be addressed to solve the
issue. Healthcare employers can show leadership and help tackle this imbalance by:
• Ensuring women who go on maternity leave are able to access all their rights
and entitlements;
• Introducing programmes which encourage men as well as women to take
parental leave, so that women are able to pursue their careers and men are able
to spend important time with their families.
10. Hospitals and other places of employment should strive to provide and promote access
to high quality, affordable, flexible childcare for working parents, including the
provision of onsite housing and childcare where appropriate. These services should be
available to both male and female physicians, recognizing the need for a better work-
life balance. Employers should provide information on available services which
support the compatibility of work and family.
11. Hospitals and other places of employment should be receptive to the possibility of
flexible and family-friendly working hours, including part-time residencies, posts, and
professional appointments.
12. There is a need for increased research on alternative work schedules and
telecommunication opportunities that will allow flexibility in balancing work-life
demands.
13. NMAs should advocate for the enforcement and, where necessary, the introduction of
policy mandating appropriate paid parental leave and rights in their respective
countries.
14. Medical workplaces and professional organisations should have fair, impartial and
transparent policies and practices to give all physicians and medical students equal
access to employment, education and training opportunities in medicine.
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Pregnancy and Parenthood
15. It should be illegal for employers to ask applicants about pregnancy and/or family
planning in relation to work.
16. Employers should assess the risks to pregnant physicians and their unborn children,
when a physician has recently given birth and when she is breastfeeding. Where it is
found, or a medical practitioner considers, that an employee or her child would be at
risk were she to continue with her normal duties, the employer should provide suitable
alternative work for which the physician should receive her normal rate of pay.
Physician should have the right to not work night shifts or on-call shifts during the
later part of pregnancy, without negative consequences on salary, employment or
progression in residency.
17. Pregnant physicians should have equal training opportunities in post-graduate training.
18. Parents should have the right to take adequate parental leave without negative
consequences on their employment, training or career opportunities.
19. Parents should have the right to return to the same position after parental leave,
without the fear of termination.
20. Employers and training bodies should provide necessary support to any physician
returning after a prolonged period of absence including parental, maternity and elder-
care leave.
21. Mothers should be able to breastfeed (or be given protected time for breast pumping)
during work hours, within the current guidelines from the WHO.
22. Workplaces should provide adequate accommodation for women who are
breastfeeding including designated areas for breastfeeding, breast pumping, and milk
storage, which are quiet, hygienic, and private.
Changes in organisational culture
23. The medical profession and employers should work to eliminate discrimination and
harassment on the basis of gender and create a supportive environment that allows
equal opportunities for training, employment and advancement.
24. Family friendliness should be part of the organizational culture of hospitals and other
places of employment.
Workforce planning and research
25. NMAs should encourage governments to take the increasing number of women
entering medicine into consideration in the context of long-term workforce planning.
A diverse workforce is beneficial to the health care system and to patients.
Organizations delivering healthcare should focus on ensuring systems are
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Gender Equality in Medicine
appropriately resourced to ensure that all those working within them are able to deliver
safe care to patients and are appropriately and equitably rewarded. Governments
should also work to counteract negative attitudes and behaviour, bias, and/or outdated
norms and values from organizations and individuals.
26. NMAs should encourage governments to invest in research to identify those factors
that drive women and men to choose certain fields of specialization early on in their
medical education and training and strive to address any identified barriers in order to
achieve equal representation of men and women in all fields of medicine.
27. NMAs should encourage governments and employers to ensure that men and women
receive equal compensation for commensurate work and strive to eliminate the gender
pay gap in medicine.
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WMA STATEMENT
ON
MEDICAL TOURISM
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. Medical tourism is an expanding phenomenon, although to date it has no agreed upon
definition and, as a result, practices and protocols in different countries can vary
substantially. For purposes of this statement, medical tourism is defined as a situation
where patients travel voluntarily across international borders to receive medical
treatment, most often at their own cost. Treatments span a range of medical services,
and commonly include: dental care, cosmetic surgery, elective surgery, and fertility
treatment (OECD, 2011).
2. This statement does not cover cases where a national health care system or treating
hospital sends a patient abroad to receive treatment at its own cost or where, as in the
European Union, patients are allowed to seek care in another EU Member State
according to legally defined criteria, and their home health system bears the costs.
Also not covered is a situation in which people are in a foreign country when they
become ill and need medical care.
3. If not regulated appropriately, medical tourism may have medico-legal and ethical
ramifications and negative implications, including but not limited to: internal brain
drain, establishment of a two-tiered health system, and the spread of antimicrobial
resistance. Therefore, it is imperative that there are clear rules and regulation to govern
this growing phenomenon.
4. Medical tourism is an emerging global industry, with health service providers in many
countries competing for foreign patients, whose treatment represents a significant
potential source of income. The awareness of health as a potential economic benefit
and the willingness to invest in it rise with the economic welfare of countries, and
billions of dollars are invested each year in medical tourism all over the world. The
key stakeholders within this industry include patients, brokers, governments, health
care providers, insurance providers, and travel agencies. The proliferation of medical
tourism websites and related content raise concerns about unregulated and inaccurate
on-line health information.
5. A medical tourist is in a more fragile and vulnerable situation than that of a patient in
his or her home country. Therefore, extra sensitivity on the part of caretakers is needed
at every stage of treatment and throughout the patient’s care, including linguistic and
cultural accommodation wherever possible. When medical treatment is sought abroad,
the normal continuum of care may be interrupted and additional precautions should
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Medical Tourism
therefore be taken.
6. Medical tourism bears many ethical implications that should be considered by all
stakeholders. Medical tourists receive care in both state-funded and private medical
institutions and regulations must be in place in both scenarios. These
recommendations are addressed primarily to physicians. The WMA encourages others
who are involved in medical tourism to adopt these principles.
RECOMMENDATIONS
General
7. The WMA emphasises the importance of developing health care systems in each
country in order to prevent excessive medical tourism resulting from limited treatment
options in a patient´s home country. Financial incentives to travel outside a patient’s
home country for medical care should not inappropriately limit diagnostic and
therapeutic alternatives in the patient’s home country, or restrict treatment or referral
options.
8. The WMA calls on governments to carefully consider all the implications of medical
tourism to the healthcare system of a country by developing comprehensive,
coordinated national protocols and legislation for medical tourism in consultation and
cooperation with all relevant stakeholders. These protocols should assess the
possibilities of each country to receive medical tourists, to agree on necessary
procedures, and to prevent negative impacts to the country´s health care system.
9. The WMA calls on governments and service providers to ensure that medical tourism
does not negatively affect the proper use of limited health care resources or the
availability of appropriate care for local residents in hosting countries. Special
attention should be paid to treatments with long waiting times or involving scarce
medical resources. Medical tourism must not promote unethical or illegal practices,
such as organ trafficking. Authorities, including government, should be able to stop
elective medical tourism where it is endangering the ability to treat the local
population.
10. The acceptance of medical tourists should never be allowed to distort the normal
assessment of clinical need and, where appropriate, the development of waiting lists,
or priority lists for treatment. Once accepted to treatment by a health care provider,
medical tourists should be treated in accordance with the urgency of their medical
condition. Whenever possible patients should be referred to institutions that have been
approved by national authorities or accredited by appropriately recognised
accreditation bodies.
Prior to travel
11. Patients should be made aware that treatment practices and health care laws may be
different than in their home country and that treatment is provided according to the
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laws and practices of the host country. Patients should be informed by the
physician/service provider of their rights and legal recourse prior to travelling outside
their home country for medical care, including information regarding legal recourse in
case of patient injury and possible compensation mechanisms.
12. The physician in the host country should establish a treatment plan, including a cost
estimate and payment plan, prior to the medical tourist’s travel to the host country. In
addition, the physician and the medical tourism company (if any) should collaborate in
order to ensure that all arrangements are made in accordance with the patient´s
medical needs. Patients should be provided with information about the potential risks
of combining surgical procedures with long flights and vacation activities.
13. Medical tourists should be informed that privacy laws are not the same in all countries
and, in the context of the supplementary services they receive, it is possible that their
medical information will be exposed to individuals who are not medical professionals
(such as interpreters). If a medical tourist nonetheless decides to avail him or herself of
these services, he or she should be provided with documentation specifying the
services provided by non-medical practitioners (including interpreters) and an
explanation as to who will have access to his or her medical information, and the
medical tourist should be asked to consent to the necessary disclosure.
14. All stakeholders (clinical and administrative) involved in the care of medical tourists
must be made aware of their ethical obligations to protect confidentiality. Interpreters,
and other administrative staff with access to health information of the medical tourist
should sign confidentiality agreements.
15. The medical tourist should be informed that a change in his or her clinical condition
might result in a change in the cost estimate and in associated travel plans and visa
requirements.
16. If the treatment plan is altered because of a medical need that becomes clear after the
initial plan has been established, the medical tourist should be notified of the change
and why it was necessary. Consent should be obtained from the patient for any
changes to the treatment plan.
17. When a patient is suffering from an incurable condition, the physician in the host
country shall provide the patient with accurate information about his or her medical
treatment options, including the limitations of the treatment, the ability of the
treatment to alter the course of the disease in an appreciable manner, to increase life
expectancy and to improve the quality of life. If, after examining all the data, the
physician concludes that it is not possible to improve the patient’s medical condition,
the physician should advise the patient of this and discourage the patient from
travelling.
Treatment
18. Physicians are obligated to treat every individual accepted for treatment, both local
and foreigner, without discrimination. All the obligations detailed in law and
international medical ethical codes apply equally to the physician in his or her
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Medical Tourism
encounter with medical tourists.
19. Medical decisions concerning the medical tourist should be made by physicians, in
cooperation with the patient, and not by non-medical personnel.
20. At the discretion of the treating physicians, and where information is available and of
good quality, the patient should not be required to undergo tests previously performed,
unless there is a clinical need to repeat tests.
21. The patient should receive information about his or her treatment in a language he or
she understands. This includes the right to receive a summary of the treatment
progress and termination by the treating physician and a translation of the documents,
as needed.
22. Agreement should be reached before treatment begins, on the transfer of test results
and diagnostic images, back to the home country of the patient.
23. Where possible, communication between the physicians in the host and home country
should be established in order to ensure appropriate aftercare and clinical follow-up of
the medical problems for which the patient was treated.
24. The physician who prepares the treatment plan for the patient should confirm the
diagnosis, the prognosis and the treatments that the medical tourist has received.
25. The patient should receive a copy of his or her medical documents for the purpose of
continuity of care and follow-up in his or her home country. Where necessary, the
patient should be given a detailed list of medical instructions and recommendations for
the period following his or her departure. This information should include a
description of the expected recovery time and the time required before travelling back
to his or her home is possible.
Advertising
26. Advertising for medical tourism services, whether via the internet or in any other
manner, should comply with accepted principles of medical ethics and include detailed
information regarding the services provided. Information should address the service
provider’s areas of specialty, the physicians to whom it refers the benefits of its
services, and the risks that may accompany medical tourism. Access to
licensing/accreditation status of physicians and facilities and the facility’s outcomes
data should be made readily available. Advertising material should note that all
medical treatment carries risks and specific additional risks may apply in the context
of medical tourism.
27. National Medical Associations should do everything in their power to prevent
improper advertising or advertising that is in violation of medical ethical principles,
including advertising that contains incorrect or partial information and/or any
information that is liable to mislead patients, such as overstatement of potential
benefits.
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28. Advertising that notes the positive attributes of a specific medical treatment should
also present the risks inherent in such treatment and should not guarantee treatment
results or foster unrealistic expectations of benefits or treatment results.
Transparency and the prevention of conflicts of interest
29. Possible conflicts of interest may be inevitable for physicians treating medical tourists,
including at the behest of their employing institution. It is essential that all clinical
circumstances and relationships are managed in an open and transparent manner.
30. A physician shall exercise transparency and shall disclose to the medical tourist any
personal, financial, professional or other conflict of interest, whether real or perceived,
that may be connected to his or her treatment.
31. A physician should not accept any benefit, other than remuneration for the treatment,
in the context of the medical treatment, and should not offer the medical tourist nor
accept from him or her any business or personal offer, as long as the physician-patient
relationship exists. Where the physician is treating the medical tourist as another fee
paying patient, the same rules should apply as with his/her other fee paying patients.
32. A physician should ensure that any contract with a medical tourism company or
medical tourist does not constitute a conflict of interest with his or her current
employment, or with his or her ethical and professional obligations towards other
patients.
Transparency in payment and in the physician’s fees
33. A treatment plan and estimate should include a detailed report of all costs, including a
breakdown of physician’s fees, such as: consultancy and surgery and additional fees
the patient might incur, such as: hospital costs, surgical assistance, prosthesis (if
separate), and costs for post-operative care.
34. The cost estimate may be changed after the treatment plan has been given only in the
event that the clinical condition of the patient has changed, or where circumstances
have changed in a way that it was impossible to anticipate or prevent. If the pricing
was thus changed, the patient must be informed as to the reason for the change in costs
in as timely a fashion as possible.
Handbook of WMA Policies
S-2018-05-2018 ⏐ World Medical Association
WMA STATEMENT
ON
SUSTAINABLE DEVELOPMENT
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. The WMA believes that health and well-being are dependent upon social determinants
of health (SDHs), the conditions in which people are born, grow, live, work and age.
These social determinants will directly influence the achievement of the United
Nations Sustainable Development Goals (SDGs). Many of the SDG goals, targets and
indicators that have been developed to measure progress towards them, will also be
useful measures of the impact of action is having on improving the SDH and, in
particular, on reducing health inequities.
2. This statement builds upon WMA policy on Social Determinants of Health as set out
in the Declaration of Oslo, and upon the basic principles of medical ethics set out in
the Declaration of Geneva.
3. The WMA recognizes the important efforts undertaken by the United Nations with the
adoption on 25 September 2015 of the resolution “Transforming our world: the 2030
Agenda for Sustainable Development”. The Sustainable Development Agenda is based
upon five key themes: people, planet, prosperity, peace and partnership and the
principle of leaving no one behind. The WMA affirms the importance of global efforts
on sustainable development and the impact that they can bring to humanity.
4. SDGs are built on the lessons learned from successes and failures in achieving the
Millennium Development Goals (MDGs), including inequity in many areas of life.
While there is no overarching concept unifying the SDGs, the WMA believes that
inequity in health and wellbeing encapsulates much of the 2030 Agenda. The WMA
notes that while only SDG 3 is overtly about health, many of the goals have major
health components.
5. The WMA recognizes all governments must commit and invest to fully implement the
goals by 2030, in alignment with the Addis Ababa Action Agenda. The WMA also
recognizes the risk that the SDGs might be considered unaffordable due to their
estimated potential cost of between US$ 3.3 and US$ 4.5 trillion a year.
6. The WMA emphasises the need for cross and inter-sectoral work to achieve the goals
and believes that health must be addressed in all SDGs and not only under health
specific SDG 3.
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Sustainable Devlopment
Policy priorities:
7. Recognition of Health in All Policies and the Social Determinants of Health / Whole
of Society approach.
8. Policy areas that are essential to achieving the SDG 3:
• Patient Empowerment and Patient Safety
• Continuous Quality Improvement in Health Care
• Overcoming the Impact of Aging on Health Care
• Addressing Antimicrobial Resistance
• The safety and welfare of Health care staff
9. Ensuring policy alignment among all the UN Agencies and the work of regional
governmental organizations such as EU, African Union, Arab League, ASEAN, and
Organization of American States.
10. The WMA commits to support implementation of the other three global agreements
regarding the sustainable development process:
• The Addis Ababa Action Agenda as the mechanism that will provide the
financial support for the 2030 Agenda.
• The Paris Agreement is the binding mechanism of the sustainable development
process that sets out a global action plan to put the world on track to avoid
dangerous climate change by limiting global warming to well below 2°C above
pre-industrial levels.
• The Sendai Framework for Disaster Risk Reduction as the agreement which
recognizes that the State has the primary role to reduce disaster risk but that
responsibility should be shared with local government, the private sector and
other stakeholders.
Recommendations and Commitments
11. The WMA commits to work with other intergovernmental organizations, including the
UN, the WHO, healthcare professionals’ organizations and other stakeholders, for the
implementation and follow-up of this Agenda and related international agreements,
and for policy and advocacy alignment.
12. The WMA commits to collaborate with its constituent member Associations to support
their work at regional and national levels, and with their governments on the 2030
Agenda implementation.
13. The WMA recommends that NMAs create strategies regarding data collection,
implementation, capacity building and advocacy, to enhance policy coherence and to
maximise the 2030 Agenda implementation at national and global levels.
Handbook of WMA Policies
S-2018-05-2018 ⏐ World Medical Association
14. The WMA also recommends that NMAs collaborate with development banks, NGOs,
intergovernmental organisations and other stakeholders who are also working to
implement of the 2030 Agenda, especially in their own countries.
15. The WMA encourages the UN and the WHO to develop guidelines on how financing
for health will be implemented to reach the targets established by the 2030 Agenda and
the economic implications of NCDs, aging and antimicrobial resistance.
Handbook of WMA Policies
World Medical Association ⏐ R-1988-01-2015
WMA RESOLUTION
ON
ACADEMIC SANCTIONS OR BOYCOTTS
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
WHEREAS
academic sanctions or boycotts are discriminatory restrictions on academic, professional
and scientific freedoms that deny or exclude physicians and others from educational, cul-
tural and scientific meetings and other opportunities for the exchange of information and
knowledge, the purpose of such restrictions being to protest the social and political poli-
cies of governments, and
WHEREAS
such restrictions are in direct conflict with the major objectives of the WMA, viz., to
achieve the highest international standards in medical education, medical science, medical
art and medical ethics, and
WHEREAS
such restrictions adversely affect health care, particularly of the disadvantaged, and there-
fore thwart the WMA's objective of obtaining the best possible health care for all people
of the world, and
WHEREAS
such restrictions discriminate against physicians and patients on grounds of political per-
suasion or of political decisions taken by governments and are therefore in conflict with
the WMA's Declaration of Geneva, Statement on Non-Discrimination in Professional Mem-
bership and Activities of Physicians and Statement on Freedom to Attend Medical Meet-
ings, and
WHEREAS
a basic rule of medical practice is "primum non nocere", i.e. first, do no harm,
THEREFORE BE IT RESOLVED,
that the WMA regards the application of such restrictions as arbitrary political decisions
designed to deny international scholarly exchange and to blacklist particular physicians or
R-1988-01-2015 ⏐Oslo
Academic Sanctions Boycotts
bodies of physicians because of their nationality or because of the political policies of
their governments. The WMA is unalterably opposed to such restrictions and calls on all
Na-tional Medical Associations to resist the imposition of such restrictions by every
means at their disposal and to heed the WMA's Statement on Non-Discrimination in
Professional Membership and Activities of Physicians and the WMA Statement on
Freedom to Attend Medical Meetings.
Handbook of WMA Policies
World Medical Association ⏐ R-1997-01-2017
WMA RESOLUTION
ON
ECONOMIC EMBARGOES AND HEALTH
Adopted by the 49th WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
And reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
RECOGNISING THAT:
all people have the right to the preservation of health; and,
the Geneva Convention (Article 23, Number IV, 1949) requires the free passage of
medical supplies intended for civilians;
Recalling the standards of international human rights law, specifically the Universal
Declaration of Human Rights and the International Covenant on Economic, Social and
Cultural Rights guarantees in its article 12 “the right of everyone to the enjoyment of the
highest attainable standard of physical and mental health”;
The WMA urges national medical associations to ensure that Governments employing
economic sanctions against other States respect the agreed exemptions for medicines,
medical supplies and basic food items. Exemptions should not be exploited for
inappropriate purposes.
Handbook of WMA Policies
R-1997-03-2008 ⏐ World Medical Association
WMA RESOLUTION
ON
ACCESS OF WOMEN AND CHILDREN TO HEALTH CARE
AND THE ROLE OF WOMEN IN THE MEDICAL PROFESSION
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
PREAMBLE
For years women and girls worldwide have been suffering increasing violations of their
human rights. These violations often arise from historically based gender bias where
women and girls are restricted in their access to, inter alia, employment, education and
health care.
In many countries, due to, inter alia, religious and cultural convictions, female doctors and
nurses have been prevented from exercising their profession, which may lead to female
patients and their children not having access to health care.
Girls have the same rights as boys, and women have the same rights as men. Discrimina-
ting against girls and women damages their health expectation. Education of girl children
is a major factor affecting their likelihood of experiencing health and well-being as adults.
It also improves the chances of their children surviving infancy. Secondary discrimination
due to social, religious and cultural practices – which diminishes women's freedom to
make decisions for themselves and to access work and healthcare – should be condemned.
RECOMMANDATIONS:
Therefore, the World Medical Association urges its constituent members to:
• Categorically condemn violations of the basic human rights of women and child-
ren, including violations stemming from social, religious and cultural practices;
• Insist on the rights of women and children to full and adequate medical care, espe-
cially where religious and cultural restrictions hinder access to such medical care;
• Promote women's and children's health rights as human rights;
• Sensitize their membership on issues of gender equality and on participation of
women in decision-making and health related activities;
• Increase broad-based representation and effective participation of women in the
medical profession, especially in light of the increased enrolment of women in
medical schools;
New Delhi ⏐ R-1997-03-2008
Woman and Children to Health Care
• Promote the achievement of the human right to equality of opportunity, equality of
treatment and non-sexism;
• Promote a higher growth rate of membership in National Medical Associations
amongst women through empowerment, career development, appropriate training to
improve knowledge and skills, and other strategic initiatives.
Handbook of WMA Policies
R-1998-01-2018 ⏐ World Medical Association
WMA RESOLUTION
SUPPORTING THE OTTAWA CONVENTION
(Convention on the prohibition of the use, stockpiling, production
and transfer of anti-personnel mines and on their destruction)
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed by the 209th
WMA Council Session, Riga, April 2018
The World Medical Association:
• expresses its support for the Ottawa Convention (also known as the landmine ban
convention); and
• urges its member National Medical Associations to press their governments to sign
and ratify the Convention.
• urges its member National Medical Associations to press their governments to
cease manufacture, sale, deployment and use of landmines.
Handbook of WMA Policies
R-1998-03-2009 ⏐ World Medical Association
WMA RESOLUTION
ON
IMPROVED INVESTMENT IN PUBLIC HEALTH
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
INTRODUCTION
Each country should have a health system with enough resources to attend to the needs of
its population. However today, many countries across the world are suffering wide in-
equities and inequalities in health care and this is causing problems of access to health ser-
vices for the poorer segments of society [the weak or underprivileged]. The situation is
especially serious in low-income countries.
The international community has attempted to improve the situation. The 20/20 initiative
of 1995, the 1996 Initiative for Heavily Indebted Poor Countries (HIPC), and Objectives
for Millennium 2000 Development (MDGs) are all initiatives aimed at reducing poverty
and dealing with poor health, inequities and inequalities between the sexes, education,
insufficient access to drinking water and environmental contamination.
The objectives are formed as an agreement with acknowledgement of the contributions
which developed countries can make, in the shape of trade relations, development assis-
tance, reduction of the burden of debt, improving access to essential medication and the
transfer of technology. Three of the eight objectives are directly related to health, which
has a considerable influence on various other objectives that interact to support each of the
others within a structural framework, these are designed to increase human development
globally. The eight Millennium Development Objectives (MDO) foresee a development
vision based on health and education, thus affirming that development does not only refer
(allude) to economic growth.
Various reports from the World Health Organization have underlined the opportunities
and skills [or techniques] which are currently involved in bringing about significant im-
provements in health, as well as helping to reduce poverty and encourage growth. Addi-
tionally, the reports highlight the fact that it is of fundamental importance to reduce limita-
tions on human resources, in order to increase the achievements of the public health sys-
tem, a situation which requires urgent attention. These limitations are related to work, train-
ing and payment conditions, and play a substantial role in determining capacity for sus-
tained growth of access to health services.
RECOMMENDATIONS
The World Medical Association urges National Medical Associations to:
R-1998-03-2009 ⏐ New Delhi
Investment in Public Health
1. Advocate that their governments should adhere to and promote the proposals to in-
crease investment in the health sector; and to adhere to and promote initiatives to re-
duce the debt burden for the poorest countries on the planet.
2. Advocate [defend] the inclusion of public health factors in all fields of policy pro-
vision, since health is mostly determined by factors that are external to the area of
healthcare, for example, housing and education. [Health is not only medicine, it also
depends on living standards].
3. Encourage and support countries in the planning and implementation of investment
plans, which invest in health for the poor; guarantee that more resources be used for
health in general, with greater efficiency and impact; and reduce limitations for the
most effective use of the additional investments.
4. Maintain vigilance to ensure that the investment plans focus maximum attention on
generating capacity, that they promote leadership skills and promote incentives to
retain and place qualified personnel, whilst it is taken into consideration that the limi-
tations in relation to the previous matter currently constitute the greatest obstacle for
progress.
5. Urge international financial institutions and other important donors to: i) Adopt the
necessary measures to help the countries that have already organised mechanisms to
prepare their investment plans, and provide assistance to those countries that have be-
gun to take the necessary steps, with the support and participation of the international
community; ii) Help countries to obtain funds to develop and implement their invest-
ment plans; iii) Continue providing technical assistance to the countries for their plans.
6. Exchange information in order to coordinate efforts to change policies in these areas.
Handbook of WMA Policies
R-1998-04-2009 ⏐ World Medical Association
WMA RESOLUTION
ON
MEDICAL WORKFORCE
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
The health of our countries depends upon keeping the population healthy. Health care is a
key right of individuals. This care is dependent upon access to highly-trained medical and
other healthcare professionals. Well-functioning health care systems depend upon these
sufficient human resources. Comprehensive and extensive planning on a national level is
required in order to ensure that a country has a medical workforce in all fields of medicine
that meets the present and future health needs of the entire population of that country.
There are currently significant shortages in the area of health human resources. These
shortages are present in all countries but are especially pronounced in developing coun-
tries where health human resources are more limited.
The problem is made more severe by the fact that many countries have not invested ade-
quately in the education, training, recruitment and retention of their medical workforce.
The ageing population in developed countries has also been reflected by an ageing medi-
cal workforce. Many developed countries address their medical workforce shortages by
employing health care professionals from developing countries to bolster their own health
care systems.
The migration of health care professionals from developing countries to developed coun-
tries has, over the past ten years, impaired the performance of health systems in develop-
ing countries. Economic realities of insufficient investments in health care and inadequate
facilities and support for health care professionals have continued to be responsible for
this migration.
The World Health Organization has recognized that the crisis of health workforce short-
ages is impeding the provision of essential, life-saving interventions. It has therefore esta-
blished structures such as the Global Health Workforce Alliance, a partnership dedicated
to identifying and implementing solutions to the health workforce problems. The WHO is
promoting the development of a cadre of medical/clinical assistants who propose to join
the medical workforce to partially address these shortages.
RECOMMENDATIONS
Recognizing that health care systems require adequate numbers of qualified and com-
petent health care professionals, the World Medical Association asks all National Medical
Associations to participate and be active in addressing these requirements and to:
R-1999-01-2015 ⏐ Moscow
Medical Workforce
1. Call on their respective governments to allocate sufficient financial resources for the
education, training, development, recruitment and retention of physicians to meet the
medical needs of the entire population in their countries.
2. Call on their respective governments to ensure that the education, training and develop-
ment of healthcare professionals meets the highest possible standards including:
• The training and development of medical/clinical assistants where this is applica-
ble and appropriate and
• Ensuring clear definitions of scope of practice and conditions for adequate support
and supervision;
3. Call on governments to ensure that appropriate ratios are maintained between popula-
tion and the medical workforce at all levels, including mechanisms to address reduced
access to care in rural and remote areas, based on accepted international norms and
standards where these are available;
4. Take measures to attract and support individuals within their countries to enter the
medical profession and also call on their respective governments to take such action;
5. Actively advocate for programs that will ensure the retention of physicians within
their respective countries and ensure governments’ recognition of this need;
6. Call on governments to improve the health care working environment (including ac-
cess to appropriate facilities, equipment, treatment modalities and professional sup-
port), physician remuneration, physician living environment and career development
of the medical workforce at all levels;
7. Advocate for the development of transparent memoranda of understanding between
countries where migration of trained health care professionals is an issue of concern
and enlist where possible the NMA of origin and receiving NMA’s to support these
physicians.
Handbook of WMA Policies
World Medical Association ⏐ R-1999-01-2015
WMA RESOLUTION
ON
THE INCLUSION OF MEDICAL ETHICS AND HUMAN RIGHTS
IN THE CURRICULUM OF MEDICAL SCHOOLS WORLD-WIDE
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and revised by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Medical School curricula are designed to prepare medical students to enter the profession
of medicine. Increasingly, in addition to core biomedical and clinical knowledge, they
teach skills including critical appraisal and reflective practice. These additional skills help
to enable future doctors to understand and assess the importance of published research
evidence, and how to evaluate their own practice against norms and standards set nation-
ally and internationally.
In much the way same that anatomy, physiology and biochemistry are a solid base for
understanding the human body, how it works, how it can fail or otherwise go wrong, and
how different mechanisms can be used to repair damaged structure and functions, there is
a clear need for physicians in training to understand the social, cultural and environmental
contexts within which they will practice. This includes a solid understanding of the social
determinants of health.
Medical ethics includes the social contract made between the health care professions and
the societies they serve, based upon established principles, on the limits that apply to
medical practice It also establishes a system or set of principles through which new
treatments or other clinical interventions will be sieved before decisions are made on
whether elements are acceptable within medical practice. There is a complex intermingl-
ing of medical ethics and the duties of physicians to patients, and the rights patients enjoy
as citizens.
At the same time physicians face challenges and opportunities in relation to the human
rights of their patients and of populations, for example occasions for imposing treatments
without consent, and will also often be the first to observe and to itemize the infringement
of these rights by others, including the state. This places very specific responsibilities
upon the observing physician.
Physicians have a duty to use their knowledge to improve the wellbeing and health of
patients and the population. This will mean considering social and societal change,
including legislation and regulation, and can only be done well if doctors can take a
holistic view within clinical and ethical parameters.
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Medical Workforce
Physicians should press government to ensure legislation supports principled medical
practice.
Given the core nature of health care ethics in establishing medical practice in a manner
that is acceptable to society and that does not violate civil, political and other human
rights, it is essential that all physicians are trained to perform an ethics evaluation of every
clinical scenario they may encounter, while simultaneously understanding their role in
protecting the rights of individuals.
Physicians’ ability to act and communicate in a way that respects the values of the
individual patient is a prerequisite for successful treatment. Physicians must also be able to
work effectively in teams with other health care professionals including other physicians.
Failures of individual physicians to recognize the ethical obligations they owe patients and
communities can damage the reputation of doctors both locally and globally. Therefore it
is essential that all doctors are taught to understand and respect medical ethics and human
rights from the beginning of their medical school careers.
In many countries ethics and human rights are an integral part of the medical curriculum,
but this is not universal. Too often teaching is undertaken by volunteers, and can fail if
those volunteers are unable or unavailable to teach, or if that teaching is unduly idiosync-
ratic or inadequately based upon clinical scenarios.
The teaching of medical ethics should become an obligatory and examined part of the
medical curriculum within every medical school.
RECOMMENDATIONS
1. The WMA urges that medical ethics and human rights be taught at every medical
school as obligatory and examined parts of the curriculum, and should continue at all
stages of post graduate medical education and continuing professional development.
2. The WMA believes that medical schools should seek to ensure that they have
sufficient faculty skilled at teaching ethical enquiry and human rights to make these
courses sustainable.
3. The WMA commends the inclusion of medical ethics and human rights within post
graduate and continuing medical education.
Handbook of WMA Policies
R-2002-01-2013 ⏐ World Medical Association
WMA RESOLUTION
ON
EUTHANASIA
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and reaffirmed with minor revision by the 194th
WMA Council Session,
Bali, Indonesia, April 2013
The World Medical Association's Declaration on Euthanasia, adopted by the 38th
World
Medical Assembly, Madrid, Spain, October 1987 and reaffirmed by the 170th
WMA
Council Session, Divonne-les-Bains, France, May 2005 states:
"Euthanasia, that is the act of deliberately ending the life of a patient, even at the
patient's own request or at the request of close relatives, is unethical. This does not
prevent the physician from respecting the desire of a patient to allow the natural pro-
cess of death to follow its course in the terminal phase of sickness."
The WMA Statement on Physician-Assisted Suicide, adopted by the 44th
World Medical
Assembly, Marbella, Spain, September 1992 and editorially revised by the 170th
WMA
Council Session, Divonne-les-Bains, France, May 2005 likewise states:
"Physicians-assisted suicide, like euthanasia, is unethical and must be condemned by
the medical profession. Where the assistance of the physician is intentionally and
deliberately directed at enabling an individual to end his or her own life, the physi-
cian acts unethically. However the right to decline medical treatment is a basic right
of the patient and the physician does not act unethically even if respecting such a
wish results in the death of the patient."
The World Medical Association has noted that the practice of active euthanasia with
physician assistance, has been adopted into law in some countries.
BE IT RESOLVED that:
The World Medical Association reaffirms its strong belief that euthanasia is in conflict
with basic ethical principles of medical practice, and
The World Medical Association strongly encourages all National Medical Associations
and physicians to refrain from participating in euthanasia, even if national law allows it or
decriminalizes it under certain conditions.
Handbook of WMA Policies
World Medical Association ⏐ R-2002-02-2012
WMA RESOLUTION
ON
FEMALE FOETICIDE
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and reaffirmed by the 191st
WMA Council Session, Prague, Czech Republic, April 2012
1. Whereas there is grave concern that in certain countries female foeticide is commonly
practised.
2. The WMA denounces female foeticide as a totally unacceptable example of gender
discrimination.
3. The World Medical Association calls on National Medical Associations:
1. To denounce the practice of female foeticide and the use of selective sex
determination for that purpose and;
2. To advise their governments accordingly.
Handbook of WMA Policies
R-2002-05-2012 ⏐ World Medical Association
WMA RESOLUTION
ON
THE ABUSE OF PSYCHIATRY
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 63rd
WMA General Assembly, Bangkok, Thiland, October 2012
The World Medical Association (WMA) notes with concern evidence from a number of
countries that political dissidents, practitioners of various religions and social activists
have been detained in psychiatric institutions and subjected to unnecessary psychiatric
treatment as a punishment and not to treat a substantiated psychiatric illness.
The WMA:
• Declares that such detention and unwarranted treatment is abusive, unethical and
unacceptable;
• Calls on physicians and psychiatrists to resist involvement in these abusive prac-
tices;
• Calls on member NMAs to support their physician members who resist involve-
ment in these abuses, and
• Calls on governments to stop abusing medicine and psychiatry in this manner, and
on non-governmental organizations and the World Health Organization to work to
end these abuses; and
• Calls on governments to uphold the United Nations International Covenant on
Civil and Political Rights, which states that "all persons are equal before the law
and are entitled without any discrimination to the equal protection of the law."
Handbook of WMA Policies
World Medical Association ⏐ R-2002-06-2013
WMA RESOLUTION
ON
WOMEN'S RIGHTS TO HEALTH CARE
AND HOW THAT RELATES TO THE PREVENTION
OF MOTHER-TO-CHILD HIV INFECTION
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and amended by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
In many parts of the world the prevalence of HIV infection continues to increase. One of
the Millennium Development Goals (MDG 6), specifically targets combating HIV/AIDS,
malaria and other diseases, with 2015 being its target year to halt HIV/AIDS infection and
to begin reversing the spread of HIV/AIDS. In addition, it was hoped that by 2010
universal access to treatment for HIV/AIDS for all those requiring it would be achieved. A
December 2012 UN resolution declared that countries must develop programmes for
Universal Health Access after 2015 when the MDGs end.
HIV/AIDS is a disease that disproportionately affects people in their reproductive years
although today, due to better management of the condition, there are also many older
people who are infected. In addition, many who were infected as infants are now reaching
reproductive maturity.
In developed countries men who have sex with men and injection drug users constitute
significant risk groups for contracting HIV. In many developing countries, women are at
risk due to heterosexual contact with HIV infected partners. In 2011 approximately 58
percent of people living with HIV in sub-Saharan Africa were women, equating to about
13.6 million women living with HIV and AIDS, compared to about 9.9 million men
(UNAIDS 'Global Fact Sheet 2012: World AIDS Day 2012).
In the absence of HIV, maternal mortality worldwide would be significantly (20% ) lower
(Murray et al. Maternal mortality for 181 countries, 1980~2008: a systematic analysis of
progress towards Millennium Development Goal 5).
HIV infection increases the risk of invasive cervical cancer 2 to 22 fold. Some evidence
exists that the use of antiretroviral therapy may decrease this risk. Hence, the appropriate
management of patients infected with HIV may have a long-term impact on other aspects
of women’s health.
The WMA believes that access to healthcare, including both therapeutic and preventative
strategies, is a fundamental human right. This imposes an obligation on government to
Washington, DC ⏐ R-2002-06-2002
Women’s Right to Health Care
ensure that these human rights are fully respected and protected. Gender inequalities must
be addressed and eradicated. This should impact every aspect of healthcare.
The promotion and protection of the reproductive rights of women are critical to the
ultimate success of confronting and resolving the HIV/AIDS pandemic.
Many of the MDGs address empowering women and promoting their role in society and
specifically in healthcare. MDG 5B, in particular, promotes universal access to repro-
ductive health including contraceptive access, reduction in adolescent birth rate, antenatal
care coverage and addressing unmet needs for family planning. In addition, MDG 3
which promotes gender equality and empowers women, and MDGs 1 and 2 will influence
women’s status in society and therefore their access to healthcare and health promotion.
RECOMMENDATIONS
The WMA requests all national member associations to encourage their governments to
undertake and promote the following actions:
• Develop empowerment programs for women of all ages to ensure that women are
free from discrimination and enjoy universal and free access to reproductive health
education and life skills training. It is recommended that campaigns be initiated and
activated in the media, including social media and popular programmes on radio and
television in order to eradicate myths, stigma and stereotypes that might degrade or
dehumanise women. This must include campaigns against genital mutilation and
forced adolescent marriages and unwanted pregnancies. In addition, promoting the
availability and choice of contraception for women, without necessarily having to
get input from their partners, and promoting the availability of HIV testing and treat-
ment are essential for reproductive health. It is also important to provide for the eco-
nomic means for the infected populations in terms of prevention, treatment and
medical follow-up.
• Women must have the same access as men, without discrimination to education,
employment, economic independence, information about healthcare and health ser-
vices.
• Laws, policies and practices that facilitate the full recognition and respect of human
rights and the fundamental freedom of women should be initiated or reviewed and
revised where appropriate. It is essential that women are empowered to make deci-
sions regarding their children, their financial status and their future.
• All governments should develop programmes to provide prophylactic treatment in
the form of antiretrovirals to women who have been raped or sexually assaulted.
Universal and free access to antiretroviral therapy must also be provided to all HIV
infected women.
• HIV infected women who are pregnant should receive counselling and access to
anti-retroviral prophylaxis or treatment in order to prevent mother to child trans-
mission of HIV.
Handbook of WMA Policies
World Medical Association ⏐ R-2003-01-2013
WMA RESOLUTION
ON
THE DESIGNATION OF AN ANNUAL MEDICAL ETHICS DAY
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and reaffirmed by the 194th
WMA Council Session, Bali, Indonesia, April 2013
Whereas the World Medical Association has a specific focus and function in the field of
medical ethics, and came into being on 18 September 1947 during the first General
Assembly, it is resolved that NMAs are encouraged to annually observe the 18th
September as "Medical Ethics Day".
Handbook of WMA Policies
R-2003-02-2007 ⏐ World Medical Association
WMA RESOLUTION
ON
THE RESPONSIBILITY OF PHYSICIANS IN THE DOCUMENTATION
AND DENUNCIATION OF ACTS OF TORTURE OR CRUEL
OR INHUMAN OR DEGRADING TREATMENT
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and amended by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
The World Medical Association,
1. Considering the Preamble to the United Nations Charter of 26 June 1945 solemnly
proclaiming the faith of the people of the United Nations in the fundamental human
rights, the dignity and value of the human person,
2. Considering the Preamble to the Universal Declaration of Human Rights of 10 De-
cember 1948 which states that disregard and contempt for human rights have re-
sulted in barbarous acts which have outraged the conscience of mankind,
3. Considering Article 5 of that Declaration which proclaims that no one shall be sub-
jected to torture or cruel, inhuman or degrading treatment,
4. Considering the American Convention on Human Rights, which was adopted by the
Organization of American States on 22 November 1969 and entered into force on 18
July 1978, and the Inter-American Convention to Prevent and Punish Torture, which
entered into force on 28 February 1987,
5. Considering the Declaration of Tokyo, adopted by the World Medical Association in
1975, which reaffirms the prohibition of any form of medical involvement or presence
of a physician during torture or inhuman or degrading treatment,
6. Considering the Declaration of Hawaii, adopted by the World Psychiatric Association
in 1977,
7. Considering the Declaration of Kuwait, adopted by the International Conference of
Islamic Medical Associations in 1981,
8. Considering the Principles of Medical Ethics Relevant to the Role of Health Person-
nel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Tor-
ture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by
the United Nations General Assembly on 18 December 1982, and particularly Princi-
ple 2, which states: "It is a gross contravention of medical ethics… for health person-
nel, particularly physicians, to engage, actively or passively, in acts which constitute
participation in, complicity in, incitement to or attempts to commit torture or other
cruel, inhuman or degrading treatment…",
Handbook of WMA Policies
R-2003-03-2014 ⏐ World Medical Association
9. Considering the Convention Against Torture and Other Cruel, Inhuman or Degrading
Treatment or Punishment, which was adopted by the United Nations General Assem-
bly on December 1984 and entered into force on 26 June, 1987,
10. Considering the European Convention for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment, which was adopted by the Council of Europe on
26 June 1987 and entered into force on 1 February 1989,
11. Considering the Resolution on Human Rights adopted by the World Medical Asso-
ciation in Rancho Mirage, in October 1990 during the 42nd
General Assembly and
amended by the 45th
, 46th
and 47th
General Assemblies,
12. Considering the Declaration of Hamburg, adopted by the World Medical Association
in November 1997 during the 49th
General Assembly, calling on physicians to protest
individually against ill-treatment and on national and international medical organiza-
tions to support physicians in such actions,
13. Considering the Istanbul Protocol (Manual on the Effective Investigation and Docu-
mentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punish-
ment), adopted by the United Nations General Assembly on 4 December 2000,
14. Considering the Convention on the Rights of the Child, which was adopted by the
United Nations on 20 November 1989 and entered into force on 2 September 1990,
and
15. Considering the World Medical Association Declaration of Malta on Hunger Strikers,
adopted by the 43rd
World Medical Assembly Malta, November 1991and amended by
the WMA General Assembly, Pilanesberg, South Africa, October, 2006,
RECOGNIZING
1. That careful and consistent documentation and denunciation by physicians of cases of
torture and of those responsible contributes to the protection of the physical and men-
tal integrity of victims and in a general way to the struggle against a major affront to
human dignity,
2. That physicians, by ascertaining the sequelae and treating the victims of torture, either
early or late after the event, are privileged witnesses of this violation of human rights,
3. That the victims, because of the psychological sequelae from which they suffer or the
pressures brought on them, are often unable to formulate by themselves complaints
against those responsible for the ill-treatment they have undergone,
4. That the absence of documenting and denouncing acts of torture may be considered as
a form of tolerance thereof and of non-assistance to the victims,
5. That nevertheless there is no consistent and explicit reference in the professional
codes of medical ethics and legislative texts of the obligation upon physicians to
document, report or denounce acts of torture or inhuman or degrading treatment of
which they are aware,
Copenhagen ⏐ R-2003-02-2007
Denunciation of Acts of Torture
RECOMMENDS THAT NATIONAL MEDICAL ASSOCIATIONS
1. Attempt to ensure that detainees or victims of torture or cruelty or mistreatment have
access to immediate and independent health care. Attempt to ensure that physicians
include assessment and documentation of symptoms of torture or ill-treatment in the
medical records using the necessary procedural safeguards to prevent endangering
detainees.
2. Promote awareness of the Istanbul Protocol and its Principles on the Effective Investi-
gation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treat-
ment. This should be done at country level using different methods of information
dis-semination; including trainings, publications and web documents.
3. Disseminate to physicians the Istanbul Protocol.
4. Promote training of physicians on the identification of different modes of torture, in
recognizing physical and psychological symptoms following specific forms of torture
and in using the documentation techniques foreseen in the Istanbul Protocol to create
documentation that can be used as evidence in legal or administrative proceedings.
5. Promote awareness of the correlation between the examination findings, under-
standing torture methods and the patients' allegations of abuse;
6. Facilitate the production of high-quality medical reports on torture victims for sub-
mission to judicial and administrative bodies;
7. Attempt to ensure that physicians observe informed consent and avoid putting indi-
viduals in danger while assessing or documenting signs of torture and ill-treatment;
8. Attempt to ensure that physicians include assessment and documentation of
symptoms of torture or ill-treatment in the medical records using the necessary
procedural safe-guards to prevent endangering detainees.
9. Support the adoption in their country of ethical rules and legislative provisions:
1. aimed at affirming the ethical obligation on physicians to report or denounce acts
of torture or cruel, inhuman or degrading treatment of which they are aware; de-
pending on the circumstances, the report or denunciation would be addressed to
medical, legal, national or international authorities, to non-governmental organiza-
tions or to the International Criminal Court. Doctors should use their discretion in
this matter, bearing in mind paragraph 68 of the Istanbul Protocol.
2. establishing, to that effect, an ethical and legislative exception to professional con-
fidentiality that allows the physician to report abuses, where possible with the sub-
ject's consent, but in certain circumstances where the victim is unable to express
him/herself freely, without explicit consent.
3. cautioning physicians to avoid putting individuals in danger by reporting on a
named basis a victim who is deprived of freedom, subjected to constraint or threat
or in a compromised psychological situation
Handbook of WMA Policies
R-2003-03-2014 ⏐ World Medical Association
10. Place at their disposal all useful information on reporting procedures, particularly to
the national authorities, nongovernmental organizations and the International Crimi-
nal Court.
Istanbul Protocol, paragraph 68: "In some cases, two ethical obligations are in conflict.
International codes and ethical principles require the reporting of information concerning
torture or maltreatment to a responsible body. In some jurisdictions, this is also a legal re-
quirement. In some cases, however, patients may refuse to give consent to being exa-
mined for such purposes or to having the information gained from examination disclosed
to others. They may be fearful of the risks of reprisals for themselves or their families. In
such situations, health professionals have dual responsibilities: to the patient and to society
at large, which has an interest in ensuring that justice is done and perpetrators of abuse are
brought to justice. The fundamental principle of avoiding harm must feature prominently
in consideration of such dilemmas. Health professionals should seek solutions that pro-
mote justice without breaking the individual's right to confidentiality. Advice should be
sought from reliable agencies; in some cases this may be the national medical association
or non-governmental agencies. Alternatively, with supportive encouragement, some reluc-
tant patients may agree to disclosure within agreed parameters."
Handbook of WMA Policies
R-2003-03-2014 ⏐ World Medical Association
WMA RESOLUTION
ON
THE NON-COMMERCIALISATION OF
HUMAN REPRODUCTIVE MATERIAL
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and revised by 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
The rapid advances in biomedical technologies have led to growth of the reproductive
assistance industry, which tends to be poorly regulated. Despite the fact that many govern-
ments have laws prohibiting commercial transactions of reproductive material, most have
not been successful in universally preventing the sale of human ova, sperm and embryos
on the internet and elsewhere. The market value of human material, including cells, tis-
sues, and cellular tissue can be lucrative, creating a potential conflict for physicians and
others between economic interests and professional ethical obligations.
For the purposes of this resolution human reproductive material is defined as human
gametes and embryos.
According to the WHO, transplant commercialism “is a policy or practice in which cells,
tissues or organs are treated as a commodity, including by being bought or sold or used for
material gain.”1
The principle that the “human body and its parts shall not, as such, give rise to financial
gain”2
is laid down in numerous international declarations and recommendations.3
The
2006 WMA Statement on Human Organ Donation and Transplantation and the 2012
WMA Statement on Organ and Tissue Donation call for the prohibition of the sale of or-
gans and tissues for transplantation. The WMA Statement on Assisted Reproductive
Technologies (2006) also states that it is inappropriate to offer financial benefits to en-
courage donation of human reproductive material.
The same principles should be in place for the use of human reproductive material in the
area of medical research. The International Bioethics Committee of the United Nations
Educational, Scientific and Cultural Organization (UNESCO IBC) in its report on the
ethical aspects of human embryonic stem cell research states that the transfer of human
embryos must not be a commercial transaction and that measures should be taken to
discourage any financial incentive.
It is important to distinguish between the sale of clinical assisted reproductive services,
which is legal, and the sale of the human reproductive materials, which is usually illegal.
Due to the special nature of human embryos, the commercialization of gametes is unlike
that of other cells and tissues as sperm and eggs may develop into a child if fertilization is
successful.
Handbook of WMA Policies
R-2003-03-2014 ⏐ World Medical Association
Before human reproductive material is donated, the donor must give informed consent that
is free of duress. This requires that the individual donor is deemed fully competent and has
been given all the available information regarding the procedure and its outcome. If re-
search is to be conducted on the material, it is subject to a separate consent process that
must be consistent with the provisions in the WMA's Declaration of Helsinki. There must
not be any inducement or other undue pressure to donate or offers of compensation.
Monetary compensation given to individuals for economic losses, expenses or incon-
veniences associated with the retrieval of donated reproductive materials should be dis-
tinguished from payment for the purchase of reproductive materials.
RECOMMENDATIONS
1.
1. National Medical Associations (NMAs) should urge their governments to prohibit
commercial transactions in human ova, sperm and embryos and any human material
for reproductive purpose.
2. Physicians involved in the procurement and use of human ova, sperm, and em-
bryos should implement protocol to ensure that materials have been acquired ap-
propriately with the consent and authorization of the source individuals. In doing
so, they can uphold the ethical principle of non-commercialization of human repro-
ductive material.
3. Physicians should consult with potential donors prior to donation in order to ensure
free and informed consent.
4. Physicians should adhere to the WMA Statement on Conflict of Interest when
treating patients who seek reproductive services.
1
Global Glossary of Terms and Definitions on Donation and Transplantation, WHO, November
2009
2
European convention of human rights and biomedicine – Article 21 – Prohibition of financial
gain
3
Declaration of Istanbul guiding principle 5
Handbook of WMA Policies
R-2004-01-2014 ⏐ World Medical Association
WMA RESOLUTION
ON
WFME GLOBAL STANDARDS FOR QUALITY IMPROVEMENT OF
MEDICAL EDUCATION
Approved by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and reaffirmed by the 197th
WMA Council Session, Tokyo, Japan, April 2014
Whereas the WMA:
1. Recognizes the need and importance for sound global standards for quality improve-
ment of medical education;
2. Acknowledges the WMA's special relationship with the World Federation for Medical
Education (WFME) as one of the founders of the Federation;
3. Recognizes that it is represented in the WFME Executive Council and in this capacity
is co-responsible for the WFME Project on International Standards in Medical Educa-
tion, conducted since 1997 1
;
4. Acknowledges the recent development of the WFME Trilogy of Documents of Global
Standards in Medical Education for Quality Improvement, covering Basic Medical
Education2
, Postgraduate Medical Education3
and the Continuing Professional De-
velopment (CPD) of Medical Doctors4
;
5. Recognizes the endorsement5
of the WFME Global Standards at the World Confer-
ence in Medical Education: Global Standards in Medical Education for Better Health
Care, in Copenhagen, Denmark, March 20036
;
It hereby:
1. Expresses its encouragement and support of the ongoing work of implementing the
Trilogy of WFME Documents on Global Standards in Medical Education.
1
The Executive Council, The World Federation for Medical Education: International standards in
medical education: assessment and accreditation of medical schools´ educational programmes. A
WFME position paper. Med Ed 1998; 32: 549-558.
2
World Federation for Medical Education: Basic Medical Education. WFME Global Standards for
Quality Improvement. WFME, Copenhagen 2003. http://www.wfme.org
3
World Federation for Medical Education. Postgraduate Medical Education. WFME Global
Standards for Quality Improvement. WFME, Copenhagen 2003. http://www.wfme.org
4
World Federation for Medical Education: Continuing Professional Development (CPD) of Me-
dical Doctors. WFME Global Standards for Quality Improvement. WFME Copenhagen 2003.
5
J.P. de V. van Niekerk. WFME Global Standards receive ringing endorsement. Med Ed, 2003;
37: 586-587.
6
WFME website: http://www.wfme.org
Handbook of WMA Policies
World Medical Association ⏐ R-2005-05-2016
WMA RESOLUTION
ON
IMPLEMENTATION OF THE WHO FRAMEWORK CONVENTION
ON TOBACCO CONTROL
Adopted by the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
And revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
The World Medical Association
1. Acknowledges the essential role of health professionals in tobacco control and
urges National Medical Associations to use World No Tobacco Day each year to
advocate for tobacco control measures;
2. Recognises the importance of the WHO Framework Convention on Tobacco
Control (FCTC) as a mechanism to protect people from exposure and addiction to
tobacco;
3. Encourages Member States to the Convention to recognize (ratify, accept, approve,
confirm or accede) the Protocol to Eliminate Trade in Tobacco Products;
4. Encourages National Medical Associations to work assiduously and energetically
to get their governments to implement the measures set out in the FCTC as a
minimum;
5. Urges governments to introduce regulations and other measures as described in the
FCTC. Governments should also ban smoking in public places and work places as
an urgent public health intervention. Governments should also consider additional
measures, especially those tobacco control measures that have been proven to be
successful in other countries;
6. Strongly encourages governments to set a distinct method to ensure adequate
funding for tobacco control and research;
7. Urges governments to promote ready access to smoking cessation advice and
services to all smokers, including children;
8. Recognises the vital role of health professionals in public health education and in
promoting smoking cessation;
9. Follows up the tactics of the tobacco industry very closely to prevent individuals
and communities from any threat;
10. Contributes to the improvements and updating of international tobacco control
regulations as needed.
Handbook of WMA Policies
World Medical Association ⏐ R-2006-01-2017
WMA RESOLUTION
ON
MEDICAL ASSISTANCE IN AIR TRAVEL
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Air travel is the preferred mode of long distance transportation for people across the
world. The growing convenience and affordability of air travel has led to an increase in
the number of air passengers. In addition, long-duration flights are becoming
increasingly common, increasing the risk of in-flight medical emergencies.
2. The environment in normal passenger planes is not conducive to delivering quality
medical care, especially in medical emergencies. Noise and movement of the plane, the
very confined space, the presence of other passengers who may be experiencing stress or
fear as a result of the situation, the insufficiency or complete lack of diagnostic and
therapeutic materials and other factors often create extremely difficult conditions for
diagnosis and treatment. Even the most experienced medical professional is likely to be
challenged by these circumstances.
3. Most airlines require flight personnel to be trained in basic first aid. In addition, many
provide some degree of training beyond this minimum level and may also carry certain
emergency medicines and equipment on board. Some carriers even have the capacity to
provide remote ECG reading and medical counselling services. The ICAO (International
Civil Aviation Organization) standard requires medical supplies to be carried on
airplanes, but the detailed quantity and contents are in non-mandatory recommended
practices. Requirements for individual airlines are determined by the national aviation
regulatory authority. Detailed requirements of the cabin crew training program are also
determined by the national aviation regulatory authority as ICAO standards states that
“An operator (airline) shall establish and maintain a training program approved by the
State of the operator.”
4. Even well-trained flight personnel are often limited in their knowledge and experience
and cannot offer the same assistance as a physician or other certified health professional.
Currently, continuing medical education courses are available to physicians in some
locales to train them specifically for in-flight emergencies.
5. Physicians are often concerned about providing assistance due to uncertainty regarding
legal liability, especially on international flights or flights within the airspace of the
United States. While many airlines provide some liability insurance for medical
R-2006-01-2017 ⏐ Chicago
Air travel
professionals and lay persons who will provide voluntary assistance during a flight, this
is not always the case and even where it does exist, the terms of the insurance cannot
always be adequately explained and understood in an acute medical crisis. The financial
and professional consequences of litigation against physicians who offer assistance can
be very costly, though actual examples of this appear to be quite limited. “Good
Samaritan” legislation should be adopted in all jurisdictions to allow physicians to
provide emergency care during flights without fear of legal reprisals.
6. Some important steps have been taken to protect the life and health of airline passengers,
yet the situation is far from ideal and still needs improvement. Many of the major
problems could be mitigated by simple actions taken by both airlines and national
legislatures, ideally in cooperation with one another and with the International Air
Transport Association (IATA) to arrive at coordinated and consensus-based
international policies and programs.
7. National Medical Associations have an important leadership role to play in promoting
measures to improve the availability and efficacy of in-flight medical care. Physicians
should decide whether or not to make the flight crew aware of their availability to
provide medical assistance if needed.
RECOMMENDATIONS
8. Therefore the World Medical Association calls on its members to encourage national
airlines, especially those providing medium and long range passenger flights, to take the
following actions:
8.1 Equip their airplanes with a sufficient and standardised set of medical
emergency materials and drugs that:
8.1.1 Are packaged in a standardised and easy to identify manner;
8.1.2 Are accompanied by information and instructions in English as well the main
languages of the countries of departure; and
8.1.3 Include Automated External Defibrillators, which are considered essential
equipment in non-professional settings and ensure that at least one crew
member is competent in the use of that particular AED.
8.2 Provide stand-by medical assistance that can be contacted by radio or
telephone to help either the flight attendants or to support a volunteering health
professional, if one is on board and willing to assist.
8.3 Develop medical emergency plans to guide airline personnel in responding to
the medical needs of passengers.
8.4 Provide sufficient medical and organisational instruction to flight personnel,
beyond basic first aid training, to enable them to better attend to passenger
needs and to assist medical professionals who volunteer their services during
Chicago ⏐ R-2006-01-2017
Air Travel
emergencies.
8.5 Provide sufficiently comprehensive insurance for medical professionals and
assisting lay personnel to protect them from damages and liabilities (material
and non-material) resulting from in-flight diagnosis and treatment.
8.6 Lobby for Good Samaritan laws.
9. The World Medical Association calls on its members to encourage their national aviation
authorities to provide yearly summarised reports of in-flight medical incidents based on
mandatory standardised incident reports for every medical incident requiring the
administration of first aid or other medical assistance and/or causing a change in flight
plans.
10. The World Medical Association calls on its members to encourage their legislators to
enact legislation to provide immunity from legal action to physicians who provide
appropriate emergency assistance during in-flight medical incidents.
11. In the absence of legal immunity for physicians, the airline must accept all legal and
financial consequences of any assistance provided by a physician.
12. The World Medical Association calls on its members to:
12.1 Advocate so that potential challenges of in-flight medical emergencies are
included in the ordinary emergency training courses for physicians;
12.2 Inform physicians of training opportunities or provide or promote the
development of training programs where they do not exist;
12.3 Encourage physicians to consider whether they wish to identify themselves prior
to departure as being willing to help in the event of a medical emergency, and
12.4 Encourage physicians to discuss potential problems with their own patients who
are at high risk for requiring in-flight medical attention prior to their flight.
12.5 Encourage medical physicians to determine if their liability insurance includes
cover for Samaritan deeds.
12.6 Inform and encourage physicians to attend appropriate training programs so they
can make informed decisions when declaring their patients fit to travel by air.
13. The World Medical Association calls on IATA to further develop precise standards in
the following areas and, where appropriate, work with governments to implement these
standards as legal requirements:
13.1 Medical equipment and drugs on board medium and long range flights;
13.2 Packaging and information materials standards, including multilingual
descriptions and instructions in appropriate languages;
R-2006-01-2017 ⏐ Chicago
Air travel
13.3 Medical emergency procedures and training programs for medical personnel.
Handbook of WMA Policies
World Medical Association ⏐ R-2006-02-2016
WMA RESOLUTION
ON
CHILD SAFETY IN AIR TRAVEL
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
1. Whereas air travel is a common mode of transportation and is used by people of all
ages every day;
2. Whereas high standards of safety for adult passengers in air travel have been
achieved;
3. Whereas strict safety procedures are being followed in air travel that greatly increase
the chance of survival during emergency situations for properly secured adults;
4. Whereas infants and children are not always guaranteed adequate and appropriate
safety measures during emergency situations in aircraft;
5. Whereas restraint and safety systems for infants and children have been successfully
tested to reduce the risk of suffering injuries during emergency situations in aircraft;
6. Whereas child restraint systems have been approved for usage in standard passenger
aircrafts and successfully introduced by several airlines;
Therefore, the World Medical Association
1. Expresses grave concern regarding the fact that adequate safety systems for infants
and children have not been generally implemented;
2. Calls on all airline companies to take immediate steps to introduce safe, thoroughly
tested and standardized child restraint systems;
3. Calls on all airline companies to train their staff in the appropriate handling and usage
of child restraint systems;
4. Calls for the establishment of a universal standard or specification for the testing and
manufacturing of child restraint systems; and
5. Calls on national legislators and air transportation safety authorities to:
a. require for infants and children, as a matter of law, safe individual child restraint
systems that are approved for use in standard passenger aircraft;
b. ensure that airlines provide child restraint systems or welcome passengers using their
own systems, if the equipment is qualified and approved for the specific aircraft;
R-2006-02-2016 ⏐ Buenos Aires
Child Safety in Air Travel
c. ban the usage of inappropriate "Loop Belts" frequently used to secure infants and
children in passenger aircraft;
d. provide appropriate information about infant and child safety on board of aircraft
to all airline passengers.
Handbook of WMA Policies
World Medical Association ⏐ R-2006-04-2016
WMA RESOLUTION
ON
NORTH KOREAN NUCLEAR TESTING
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
RECALLING the WMA Declaration on Nuclear Weapons that was adopted at the WMA
General Assembly in Ottawa, Canada, in October 1998;
The WMA:
1. Denounces North Korean nuclear testing conducted at a time of heightened global
vigilance on nuclear testing and arsenals;
2. Calls for the immediate abandonment of the testing of nuclear weapons; and
3. Requests all member National Medical Associations to urge their governments to
understand the adverse health and environmental consequences of the testing and use
of nuclear weapons.
Handbook of WMA Policies
R-2006-05-2017 ⏐ World Medical Association
WMA RESOLUTION
ON
TUBERCULOSIS
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. According to the World Health Organization, tuberculosis is a significant global public
health problem. South East Asian and African countries are most affected.
2. In developing countries, the incidence of tuberculosis has risen dramatically because
of high prevalence of HIV/AIDS, increasing migration of populations, urbanisation
and over-crowding. The incidence and severity of the disease is closely associated
with the social and economic living conditions within a population.
3. The emergence of strains of tuberculosis bacteria resistant to first line drugs have
become a major public health threat in the forms of multidrug-resistant tuberculosis
(MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). MDR-TB and
XDR-TB are indicators of the growing antimicrobial resistance whose drivers are
multifactorial and complex and require a multisectoral approach. MDR-TB and XDR-
TB is a significant threat to development and the safety of global health.
4. Community awareness and public health education and promotion are essential
elements of tuberculosis prevention.
5. Screening of high risk groups including PLHIV (people living with HIV) and
vulnerable populations including migrants, prisoners, and the homeless should be
considered within each national epidemiological context as a component of
tuberculosis prevention. Systematic screening of contacts of infected persons is also
recommended.
6. Rapid diagnosis with molecular tests and supervised daily treatment started early
should help arrest the spread of disease.
7. BCG (Bacille Calmette-Guérin) vaccination as early as possible after birth should
continue, in line with International Union against Tuberculosis and Lung Disease
(IUATLD) criteria, until a new more effective vaccine is available.
8. Intensified research and innovation is also considered imperative if attempts to address
the epidemic and emerging resistance are to be successful.
Chicago ⏐ R-2006-05-2017
Tuberculosis
RECOMMANDATIONS
9. The World Medical Association, in consultation with WHO and national and
international health authorities and organizations, will continue its work to generate
community awareness about symptoms of TB and increase capacity building of health
care providers in early identification and diagnosis of TB cases and to ensure complete
treatment utilizing Directly Observed Treatment Short course or other appropriate
therapy.
10. The WMA supports the WHO “End TB Strategy” and its visions, goals and
milestones.
11. The WMA supports calls for adequate financial, material and human resources for
tuberculosis and HIV/AIDS research and prevention, including adequately trained
health care providers and adequate public health infrastructure, and will participate
with health professionals in providing information on tuberculosis and its treatment.
12. Health care professionals should have access to all required medical and protective
equipment to guard against the risk of infection and spread of the disease.
13. The WMA encourages continuing efforts to build up the capacity of health care
professionals in the use of rapid diagnostics methods, their availability in the public
and private sector and in the management of all forms of TB, including MDR and
XDR.
14. The WMA calls on National Medical Associations to support their National TB
Programmes by generating awareness among healthcare professionals about TB
management and early reporting of cases in the community.
15. The WMA calls on National Medical Associations to promote methods of TB
prevention including respiratory hygiene, cough etiquettes, and safe sputum disposal.
16. National Medical Associations should encourage their members to notify in a timely
manner to relevant authorities, about all patients diagnosed with TB or put on TB
treatment for initiation of contact screening and adequate follow up till the completion
of treatment.
17. In addition, National Member Associations should encourage the development of
strong pharmacovigilance and active TB drug-safety monitoring and management, to
detect, manage and report suspected or confirmed drug toxicities, and encourage all
their members to contribute actively to these systems.
18. National Medical Associations should co-ordinate with their TB National Programme
and promote the adopted guidelines to all members.
R-2006-05-2017 ⏐ Chicago
Tuberculosis
19. The WMA supports WHO’s efforts and calls upon all governments, communities, civil
society and the private sector to act together to end tuberculosis world-wide.
Handbook of WMA Policies
R-2007-01-2017 ⏐ World Medical Association
WMA RESOLUTION
ON
HEALTH AND HUMAN RIGHTS ABUSES IN ZIMBABWE
Adopted by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed by the 206th
WMA Council Session, Livingstone, Zambia, April 2017
PREAMBLE
Noting information and reports of systematic and repeated violations of human rights,
interference with the right to health in Zimbabwe, failure to provide resources essential for
provision of basic health care, declining health status of Zimbabweans, dual loyalties and
threats to health care workers striving to maintain clinical independence, denial of access
to health care for persons deemed to be associated with opposition political parties and
escalating state torture, the WMA wishes to confirm its support of, and commitment to:
• Attaining the World Health Organization principle that the "enjoyment of the
highest attainable standard of health is one of the fundamental rights of every
human being"
• Defending the fundamental purpose of physicians to alleviate distress of patients
and not to let personal, collective or political will prevail against such purpose
• Supporting the role of physicians in upholding the human rights of their patients as
central to their professional obligations
• Supporting physicians who are persecuted because of their adherence to medical
ethics
RECOMMENDATION
Therefore, the World Medical Association, recognizing the collapsing health care system
and public health crisis in Zimbabwe, calls on its affiliated national medical associations to:
1. Publicly denounce all human rights abuses and violations of the right to health in
Zimbabwe
2. Actively protect physicians who are threatened or intimidated for actions which are
part of their ethical and professional obligations
3. Engage with the Zimbabwean Medical Association (ZiMA) to ensure the autonomy of
the medical profession in Zimbabwe
4. Urge and support ZiMA to invite an international fact finding mission to Zimbabwe
as a means for urgent action to address the health and health needs of Zimbabweans
R-2007-01-2007 ⏐ Copenhagen
Human Right Abuse in Zimbabwe
In addition, the WMA encourages ZiMA, as a member organization of the WMA, to:
1. Uphold its commitment to the WMA Declarations of Tokyo, Hamburg and Madrid as
well as the WMA Statement on Access to Health Care
2. Facilitate an environment where all Zimbabweans have equal access to quality health
care and medical treatment, irrespective of their political affiliations
3. Commit to eradicating torture and inhumane, degrading treatment of citizens in Zim-
babwe
4. Reaffirm their support for the clinical independence of physicians treating any citizen
of Zimbabwe
5. Obtain and publicize accurate and necessary information on the state of health ser-
vices in Zimbabwe
6. Advocate for inclusion in medical curricula, teachings on human rights and the ethical
obligations of physicians to maintain full and clinical independence when dealing
with patients in vulnerable situations
The WMA encourages ZiMA to seek assistance in achieving the above by engaging with
the WMA, the Commonwealth Medical Association and the NMAs of neighboring coun-
tries and to report on its progress from time to time.
Handbook of WMA Policies
R-2007-02-2017 ⏐ World Medical Association
RESOLUTION
IN
SUPPORT OF THE MEDICAL ASSOCIATIONS
IN LATIN AMERICA AND THE CARIBBEAN
Adopted by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
There are credible reports that arrangements between the Cuban government and certain
Latin American and Caribbean governments to supply Cuban health workers as physicians
to these countries are bypassing systems, established to protect patients, that have been set
up to verify physicians’ credentials and competence.
The World Medical Association (WMA) is significantly concerned that patients are put at
risk by unregulated medical practices and recalls its Statement on Ethical Guidelines for
the International Migration of Health workers, whereby “Physicians who are working,
either permanently or temporarily, in a country other than their home country should be
treated fairly in relation to other physicians in that country” (Parag.7) and that bilateral
agreements require “due cognizance of international human rights law, so as to effect
meaningful co-operation on health care delivery” (parag. 8).
There exist already duly constituted and legally authorized medical associations within
this region that are charged with the registration of physicians and which should be
consulted by their respective Ministries of Health.
Therefore, the WMA:
1. Condemns any actions by governments in policies and practices that subvert or bypass
the accepted standards of medical credentialing and medical care;
2. Calls upon the governments in Latin America and the Caribbean to work with the
medical associations on all matters related to physician certification and the practice of
medicine and to respect the role and rights of these medical associations and the
autonomy of the medical profession.
3. Urges, as a matter of utmost concern, that the governments in Latin America and the
Caribbean respect the WMA International Code of Medical Ethics, the Declarations of
Madrid on Professionally-led Regulation, and of Seoul on Professional Autonomy and
Clinical Independence as well as the Statement on Ethical Guidelines for the
International Migration of Health workers that guide the medical practice of
physicians all over the world..
Handbook of WMA Policies
World Medical Association ⏐ R-2008-01-2018
WMA RESOLUTION
ON
COLLABORATION BETWEEN HUMAN AND VETERINARY MEDICINE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed with minor revision by the 210th
WMA Council Session, Reykjavik, Iceland,
October 2018
PREAMBLE
The majority of the existing human infectious diseases, including the bioterrorist agents,
are zoonoses. Zoonoses can, by definition, infect both animals and humans. By their
very nature, the fields of human medicine and veterinary medicine are complementary
and synergistic in confronting, controlling and preventing zoonotic diseases from
infecting across species.
Collaboration and communication between human medicine and veterinary medicine
have been limited in recent decades, yet the challenges of the 21st Century demand that
these two professions work together in times when there is an increased risk of zoonotic
diseases due to globalization and climate change, in addition to changes in human
behavior.
An initiative, often called the “One Health” initiative, is being developed to improve the
lives of all species through the integration of human and veterinary medicine. “One
Health” aims to promote and implement close meaningful collaboration and
communication between human medicine, veterinary medicine and all allied health
scientists with the goal of hastening human public health efficacy as well as advanced
health care options for humans (and animals) via comparative biomedical research.
The World Medical Association (WMA) recognizes the ways in which animals and
animal care may affect human health and disease through its own current policies,
particularly its statements on Animal Use in Biomedical Research, Resistance to
Antimicrobial Drugs and Avian and Pandemic Influenza. The WMA also recognized the
impact that climate change has on health, through the WMA Declaration on Health and
Climate Change. The WMA already works with other health professions including
dentists, nurses and pharmacists though the World Health Professions Alliance.
RECOMMENDATIONS
That the World Medical Association:
• Support collaboration between human and veterinary medicine.
Reykjavik⏐ R-2008-03-2018
Veterinary Medicine
• Support the concept of joint educational efforts between human medical and
veterinary medical schools.
• Encourage joint efforts in clinical care through the assessment, treatment, and
prevention of cross-species disease transmission.
• Support cross-species disease surveillance and control efforts in public health,
particularly the identification of early disease and outbreak trends.
• Support the need for joint efforts in the development, integration and evaluation
of screening tools, diagnostic methods, medicines, vaccines, surveillance systems
and policies for the prevention, management and control of zoonotic diseases.
• Engage in a dialogue with the World Veterinary Association to discuss strategies
for enhancing collaboration between human and veterinary medical professions
in medical education, clinical care, public health, and biomedical research.
• Encourage National Medical Associations to engage in a dialogue with their
veterinary counterparts to discuss strategies for enhancing collaboration between
human and veterinary medical professions within their own countries.
Handbook of WMA Policies
World Medical Association ⏐ R-2009-01-2009
WMA EMERGENCY RESOLUTION
ON
LEGISLATION AGAINST ABORTION IN NICARAGUA
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
WHEREAS,
Legislative changes in Nicaragua (Articles 143, 145, 148 and 149 Law No. 641, revised
Penal Code) criminalise abortion in all circumstances; including any medical treatment of
a pregnant woman which results in the death of or injury to an embryo or fetus; and
This legislation
• may have a negative impact on the health of women in Nicaragua country.
• could result in preventable deaths of women and the embryo or fetus they are
carrying.
• places physicians at risk of imprisonment if they break this law, and at risk of sus-
pension from medical practice if they fail to follow the Nicaraguan Ministry of
Health’s 2006 Obstetric Protocols, which sometimes requires treatment of a preg-
nant woman that is contrary to the legislation.
THEREFORE, the World Medical Association urges the Nicaraguan government to repeal
the above legislation.
Handbook of WMA Policies
R-2009-02-2009 ⏐ World Medical Association
WMA RESOLUTION
SUPPORTING THE RIGHTS OF PATIENTS AND PHYSICIANS
IN THE ISLAMIC REPUBLIC OF IRAN
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
WHEREAS,
Physicians in the Islamic Republic of Iran have reported:
Unsettling practices of injured persons being taken to prisons, without adequate medical
treatment or the consensus of the attending physicians;
Physicians being hindered from treating patients;
Concern about the veracity of documentation related to the death of patients and physi-
cians being forced to clinically inaccurate documentation; and
Corpses and badly injured political and religious prisoners who were admitted to hospitals
with signs of brutal torture, including sexual abuse.
THEREFORE, the World Medical Association
1. Reaffirms its Declaration of Lisbon: Declaration on the Rights of the Patient, which
states that whenever legislation, government action or any other administration or
institution denies patients the right to medical care, physicians should pursue appro-
priate means to assure or to restore it.
2. Reaffirms its Declaration of Hamburg: Declaration Concerning Support for Medical
Doctors Refusing to Participate in, or to Condone, the Use of Torture or Other Forms
of Cruel, Inhuman or Degrading Treatment, which encourages doctors to honor their
commitment as physicians to serve humanity and to resist any pressure to act contrary
to the ethical principles governing their dedication to this task.
3. Reaffirms its Declaration of Tokyo: Guidelines for Physicians Concerning Torture
and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to De-
tention and Imprisonment, which:
• prohibits physicians from participating in, or even being present during the
practice of torture or other forms of cruel or inhuman or degrading procedures;
• requires that physicians maintain utmost respect for human life even under
threat, and prohibits them from using any medical knowledge contrary to the
laws of humanity.
R-2009-02-2009 ⏐ New Delhi
Rights of Patients and Physicians in Iran
4. Reaffirms its Resolution on the Responsibility of Physicians in the Documentation
and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment;
which states that physicians should attempt to:
• ensure that detainees or victims of torture or cruelty or mistreatment have ac-
cess to immediate and independent health care;
• ensure that physicians include assessment and documentation of symptoms of
torture or ill-treatment in the medical records using the necessary procedural
safeguards to prevent endangering detainees.
5. Refers to the WMA International Code of Medical Ethics, which states that physi-
cians shall be dedicated to providing competent medical service in full professional
and moral independence, with compassion and respect for human dignity.
6. Urges the government of the Islamic Republic of Iran to respect the International
Code of Medical Ethics and the standards included in the aforementioned declarations
to which physicians are committed.
7. Urges National Medical Associations to speak out in support of this resolution.
Handbook of WMA Policies
R-2009-03-2019 ⏐ World Medical Association
WMA RESOLUTION
ON
TASK SHIFTING FROM THE MEDICAL PROFESSION
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212th
WMA Council Session, Santiago, Chile, April 2019
1. In health care, the term “Task Shifting” is used to describe a situation where a task
normally performed by a physician is transferred to a health professional with a
different or lower level of education and training, or to a person specifically trained to
perform a limited task only, without having a formal health education. Task shifting
occurs both in countries facing shortages of physicians and those not facing shortages.
2. A major factor leading to task shifting is the shortage of qualified workers resulting
from migration or other factors. In countries facing a critical shortage of physicians,
task shifting may be used to train alternate health care workers or laypersons to
perform tasks generally considered to be within the purview of the medical profession.
The rationale behind the transferring of these tasks is that the alternative would be no
service to those in need. In such countries, task shifting is aimed at improving the
health of extremely vulnerable populations, mostly to address current shortages of
healthcare professionals or tackle specific health issues such as HIV. In countries with
the most extreme shortage of physicians, new cadres of health care workers have been
established. However, those persons taking over physicians’ tasks lack the broad
education and training of physicians and must perform their tasks according to
protocols, but without the knowledge, experience and professional judgement required
to make proper decisions when complications arise or other deviations occur. This
may be appropriate in countries where the alternative to task shifting is no care at all
but should not be extended to countries with different circumstances.
3. In countries not facing a critical shortage of physicians, task shifting may occur for
various reasons: social, economic, and professional, sometimes under the guise of
efficiency, savings or other unproven claims. It may be spurred, or, conversely,
impeded, by professions seeking to expand or protect their traditional domain. It may
be initiated by health authorities, by alternate health care workers and sometimes by
physicians themselves. It may be facilitated by the advancement of medical
technology, which standardizes the performance and interpretation of certain tasks,
therefore allowing them to be performed by non-physicians or technical assistants
instead of physicians. This has typically been done in close collaboration with the
medical profession. However, it must be recognized that medicine can never be
viewed solely as a technical discipline.
4. Task shifting may occur within an already existing medical team, resulting in a
reshuffling of the roles and functions performed by the members of such a team. It
may also create new types of personnel whose function is to assist other health
professionals, specifically physicians, as well as personnel trained to independently
perform specific tasks.
R-2009-03-2019 ⏐ Santiago
Task Shifting
5. Although task shifting may be useful in certain situations, and may sometimes
improve the level of patient care, it carries with it significant risks. First and foremost
among these is the risk of decreased quality of patient care, particularly if medical
judgment and decision making is transferred. In addition to the fact that the patient
may be cared for by a lesser trained health care worker, there are specific quality
issues involved, including reduced patient-physician contact, fragmented and
inefficient service, lack of proper follow up, incorrect diagnosis and treatment and
inability to deal with complications.
6. In addition, task shifting which deploys assistive personnel may actually increase the
demand on physicians. Physicians will have increasing responsibilities as trainers and
supervisors, diverting scarce time from their many other tasks such as direct patient
care. They may also have increased professional and/or legal responsibility for the care
given by health care workers under their supervision.
7. The World Medical Association expresses particular apprehension over the fact that
task shifting is often initiated by health authorities, without consultation with
physicians and their professional representative associations.
RECOMMENDATIONS
8. Therefore, the World Medical Association recommends the following guidelines:
8.1 Quality and continuity of care and patient safety must never be compromised and
should be the basis for all reforms and legislation dealing with task shifting.
8.2 When tasks are shifted away from physicians, physicians and their professional
representative associations should be consulted and closely involved from the
beginning in all aspects concerning the implementation of task shifting,
especially in the reform of legislations and regulations. Physicians might
themselves consider initiating and training a new cadre of assistants under their
supervision and in accordance with principles of safety and proper patient care.
8.3 Quality assurance standards and treatment protocols must be defined, developed
and supervised by physicians. Credentialing systems should be devised and
implemented alongside the implementation of task shifting in order to ensure
quality of care. Tasks that should be performed only by physicians must be
clearly defined. Specifically, the role of diagnosis and prescribing should be
carefully studied.
8.4 In countries with a critical shortage of physicians, task shifting should be viewed
as an interim strategy with a clearly formulated exit strategy. However, where
conditions in a specific country make it likely that it will be implemented for the
longer term, a strategy of sustainability must be implemented.
8.5 Task shifting should not replace the development of sustainable, fully functioning
health care systems. Assistive workers should not be employed at the expense of
unemployed and underemployed health care professionals. Task shifting also
Santiago ⏐ R-2009-03-2019
Task Shifting
should not replace the education and training of physicians and other health care
professionals. The aspiration should be to train and employ more skilled workers
rather than shifting tasks to less skilled workers.
8.6 Task shifting should not be undertaken or viewed solely as a cost saving measure
as the economic benefits of task shifting remain unsubstantiated and because cost
driven measures are unlikely to produce quality results in the best interest of
patients. Credible analysis of the economic benefits of task shifting should be
conducted in order to measure health outcomes, cost effectiveness and
productivity.
8.7 Task shifting should be complemented with incentives for the retention of health
professionals such as an increase of health professionals’ salaries and
improvement of working conditions.
8.8 The reasons underlying the need for task shifting differ from country to country
and therefore solutions appropriate for one country cannot be automatically
adopted by others.
8.9 The effect of task shifting on the overall functioning of health systems remains
unclear. Assessments should be made of the impact of task shifting on patient and
health outcomes as well as on efficiency and effectiveness of health care delivery.
In particular, when task shifting occurs in response to specific health issues, such
as HIV, regular assessment and monitoring should be conducted of the entire
health system. Such work is essential in order to ensure that these programs are
improving the health of patients.
8.10 Task shifting must be studied and assessed independently and not under the
auspices of those designated to perform or finance task shifting measures.
8.11 Task shifting is only one response to the health workforce shortage. Other
methods, such as collaborative practice or a team/partner approach, should be
developed in parallel and viewed as the gold standard. Task shifting should not
replace the development of mutually supportive, interactive health care teams,
coordinated by a physician, where each member can make his or her unique
contribution to the care being provided.
8.12 In order for collaborative practice to succeed, training in leadership and
teamwork must be improved. There must also be a clear understanding of what
each person is trained for and capable of doing, clear understanding of
responsibilities and a defined, uniformly accepted use of terminology.
8.13 Task shifting should be preceded by a systematic review, analysis and discussion
of the potential needs, costs and benefits. It should not be instituted solely as a
reaction to other developments in the health care system.
8.14 Research must be conducted in order to identify successful training models.
Work will need to be aligned to various models currently in existence. Research
should also focus on the collection and sharing of information, evidence and
R-2009-03-2019 ⏐ Santiago
Task Shifting
outcomes. Research and analysis must be comprehensive and physicians must be
part of the process.
8.15 When appropriate, National Medical Associations should collaborate with
associations of other health care professionals in setting the framework for task
shifting. The WMA shall consider establishing a framework for the sharing of
information on this topic where members can discuss developments in their
countries and their effects on patient care and outcomes.
Handbook of WMA Policies
World Medical Association ⏐ R-2010-01-2010
WMA RESOLUTION
ON
DRUG PRECSRIPTION
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
PREAMBLE
From the beginning of their studies and throughout their professional careers, doctors ac-
quire the knowledge, training and competence required to treat their patients with the ut-
most skill and care.
Physicians determine the most accurate diagnosis and the most effective treatment to cure
illness, or alleviate its effects, taking into consideration the overall condition of the
patient.
Pharmaceutical products are often an essential part of the treatment approach. In order to
make the right decisions in accordance with the ethical and professional principles of me-
dical practice, the doctor must have a thorough knowledge and understanding of the prin-
ciples of pharmacology and possible interactions among different drugs and their effects
on the health of the patient.
The prescribing of medication is a significant clinical intervention, which should be pre-
ceded by multiple, integrated processes to assess the patient and determine the correct cli-
nical diagnosis. These processes include:
• Taking a history of the current condition and past medical history;
• The ability to make differential diagnosis;
• Understanding any multiple chronic and complex illnesses involved;
• Taking a history of the medications currently being administered successfully or
previously withdrawn and also being aware of possible interactions.
Inappropriate drug prescription without proper knowledge and accurate diagnosis may
cause serious adverse effects on the patient’s health. In view of the possible serious conse-
quences that may result from an inappropriate therapeutic decision, the WMA affirms the
following principles on high quality treatment and ensuring patient safety:
PRINCIPLES
Prescription of drugs should be based on a correct diagnosis of the patient’s condition and
should be performed by those who have successfully completed a curriculum on disease
R-2010-01-2010 ⏐ Vancouver
Drug Prescription
mechanisms, diagnostic methods and medical treatment of the condition in question.
Prescriptions issued by physicians are vital for ensuring patient safety, which in turn is
critical for maintaining the relationship of trust between patients and their physicians.
Although nurses and other healthcare workers cooperate in the overall treatment of
patients, the physician is the best qualified individuals to prescribe independently. In some
countries, laws may allow for other professionals to prescribe drugs under specific circum-
stances, generally with extra training and education and most often under medical super-
vision. In all cases, the responsibility for the patient’s treatment must remain with the phy-
sician. Each country’s medical system should ensure the protection of public interest and
safety in the diagnosis and treatment of patients. If a system fails to comply with this basic
framework due to social, economical or other compelling reasons, it should make every
effort to improve the situation and to protect the safety of the patients.
Handbook of WMA Policies
World Medical Association ⏐ R-2010-02-2010
WMA RESOLUTION
ON
VIOLENCE AGAINST WOMEN AND GIRLS
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
Violence is a worldwide, institutionalised phenomenon, and a complex issue, which in-
cludes many manifestations. The nature of the violence experienced by victims is at least
partly dependent upon the social, cultural, political and economic contexts within which
the victims and their abusers live. Some violence is deliberate, systematic and widespread
while others will experience it in covert circumstances; this is especially true of domestic
violence in settings where women enjoy legislated equal and protected rights to those of
men but culturally still have an increased likelihood of experiencing life-threatening do-
mestic violence.
There is clear evidence in most countries that men can be and are often the victims of
violence, including intimate partner violence. They are also statistically far more likely to
be the victims of random violence on the streets. Research shows that while men fre-
quently experience such events, they are not associated with systemic abuse in terms of
denial of rights, which makes the experience of women so much worse in many cul-
tures. Nothing in this paper suggests that violence against men including boys should be
condoned. Actions to protect women and girls are likely to reduce everyone’s experience
of violence.
DEFINING VIOLENCE
Definitions of violence vary (see footnote), but it is essential that the various forms vio-
lence may take are recognised by policy makers. Violence against women and girls in-
cludes violence within the family, within the community and violence perpetrated by (or
condoned by) the state. Many excuses are given for violence generally and specifically; in
cultural and societal terms these include tradition, beliefs, customs, values and religion.
Although rarely cited the traditional power differential between men and women is also a
major cause.
Within the family and domestic settings violence includes the denial of rights and free-
doms enjoyed by boys and men. This includes female feticide and infanticide, systematic
and deliberate neglect of girls, including poor nutrition and denial of educational oppor-
tunities1
as well as direct physical, psychological and sexual violence. Specific cultural
practices that harm women, including female genital mutilation, forced marriages, dowry
attacks and so-called “honour” killings are all practices that may occur within the family
setting.
R-2010-02-2010 ⏐ Vancouver
Violence against Women and Girls
Within society, attitudes towards rape, sexual abuse and harassment, intimidation at work
or in education, modern slavery, trafficking and forced prostitution, are all forms of vio-
lence condoned by some societies. One extreme form of such violence is sexual violence
used as a weapon of war. In several recent conflicts (e.g. the Balkans, Rwanda) rape was
both associated with ethnic cleansing and specifically, in some cases, used to introduce
widespread AIDS into a community. The ICRC has examined this issue, and recognises
that sexual violence of this sort may be commonly perpetrated against women and girls.2
Sexual violence or the threat of it can also be used against men, but culturally, women are
more vulnerable and more likely to be targeted. Current conflicts are not based upon
battles fought in far away places, but are increasingly concentrated around dense centres
of population increasing the exposure of women to soldiers and armed groups. In war and
in immediate post-conflict situations, societal fabric can collapse, making women in-
creasingly vulnerable to group attacks.
Lack of economic independence, and of basic education, also mean that women who sur-
vive abuse are more likely to be or to become more dependent upon the state or society
and less able to support themselves and contribute to that society. Biologically and beha-
viourally, women are likely to outlive men; denial of the opportunity to be economically
independent leaves society with a cohort of older, economically dependent women.
All these forms of violence may be condoned by the state, or it may remain silent on them,
refusing to condemn or act against them. In some cases the state may legislate to allow
violent practices (for example rape within marriage) and itself become a perpetrator.
All human beings enjoy certain fundamental human rights; the examples listed above of
violence against women and girls involve denial of many of those rights, and each abuse
can be examined against the UN convention on human rights (and for children the Con-
vention on the Rights of the Child).3
In health terms, the denial of rights and the violence itself have health consequences to the
girls and women and to the society of which they are a part. In addition to the specific and
direct physical and health consequences, the general way in which girls and women are
treated can lead to an excess of mental health problems; suicide is the second leading cause
of premature death in women.
CONSEQUENCES OF VIOLENCE
The direct health consequence of the violence depends upon the nature of the act. Female
genital mutilation for example may kill the woman at the time of infliction, may lead to
difficulty in voiding the body of waste products including those of menses, and will give
rise to difficulties in childbearing. It also reinforces the ideological concept of women as
the possessions of men (on its own, a form of abuse) who control their sexuality. Gang
rape or other forms of sexual violence may result in long-term gynaecological, urological
and intestinal difficulties including the development of fistulae and incontinence, which
further diminishes societal support for the abused female.
Handbook of WMA Policies
World Medical Association ⏐ R-2010-02-2010
The short and long term mental health consequences of violence may severely influence
later wellbeing, enjoyment of life, function in society and the ability to provide appropri-
ate care for dependants.
Gathering evidence is an important role for doctors. Currently many countries do not have
mandatory registration of all births, making evidence about infanticide or the effects of
neglect difficult to document. Equally, some countries allow marriage at any age, ex-
posing girls to the high risks associated with childbearing before their own bodies are fully
mature, let alone the mental health risks involved. The health consequences of such poli-
cies and their relationship to other health costs must be better documented.
Denial of good nutritional opportunities leads to generations of women with poorer health,
poorer growth and development leading to women who are less fit to survive pregnancy
and childbirth or to rear their families. Denial of educational opportunities leads to poorer
health for all the family members; good education is a major factor in the mother provi-
ding optimal care for all her family. In addition to being wrong in and of itself, violence
against women is also socially and economically damaging to the family and to society.
There are direct and indirect economic consequences to violence against women that are
far greater than the direct health sector costs.
The costs and consequences of violence, including neglect, against women have been
reported in many fora including by WHO4
. The health consequences to the women, their
children and thus to society are clear and need to be made explicit to policy makers.
WHAT CAN THE WMA DO?
The WMA has a number of policies on violence including the WMA Statement on
Violence and Health and the WMA Statement on Family Violence. This current (State-
ment/resolution/ declaration) brings some of these policies together with a coordinated set
of action points for the WMA, NMAs and individual physicians.
As most human beings look first for the advantages to themselves, their families and their
societies in enabling change, making the benefits of change obvious from the beginning
creates a “win:win” solution. Concentrating first on the health aspects, for women, their
children, and the broad family is therefore a useful way to enter the debate.
Doctors have a unique insight into the combined effects upon wellbeing of social, cultural,
economic and political environments. If all persons are to achieve health and wellbeing,
all these factors need to operate positively. The holistic view from doctors can be used to
influence society and politicians. Gaining societal support for improving the rights, free-
dom and status of women is essential.
ACTIONS
The WMA:
• Asserts that violence is not only about physical, psychological and sexual violence
but includes abuses such as harmful cultural and traditional practices, and actions
such as complicity in trafficking of women, and is a major public health crisis.
R-2010-02-2010 ⏐ Vancouver
Violence against Women and Girls
• Recognizes the linkage between better education and other rights for women with
family and societal health and wellbeing and emphasizes that equality in civil li-
berties and human rights is a health issue.
• Will prepare briefing and advocacy materials for NMAs to use with national
governments and intergovernmental groups addressing the health and wellbeing
implications of discrimination against women and girls, including adolescents.
This material will include relevant references about the impact of violence on
family wellbeing and on societal financial sustainability.
• Will work with others to prepare and distribute to physicians and other health
workers briefing and advocacy materials dealing with harmful traditional and cul-
tural practices, including female genital mutilation, dowry, and honour killings,
and emphasizing the health impact as well as the violations of human rights.
• Prepare practical examples of the impact of violence and strategies for reducing it,
such as consensus guidelines that are based upon the best available evidence.
• Will advocate at WHO, other UN agencies and elsewhere for ending discrimina-
tion and violence against women.
• Will work with others to prepare templates of educational materials for use by
individual practitioners for documenting and reporting individual cases of abuse.
• Encourages others to develop free educational materials online to provide guidance
to front line health care workers on abuse and its effects, and on prevention strate-
gies.
• Encourage legislation that classifies gang rape used as a weapon of war as a crime
against humanity that is eligible for litigation through the jurisdiction of the Inter-
national Criminal Court system.
NMAs should:
• Use and promote the available materials on preventing and treating the conse-
quences of violence against women and girls and act as advocates within their own
country.
• Seek to ensure that those devising and delivering education to doctors and other
health care workers are aware of the likelihood of exposure to violence, its conse-
quences, and the evidence on preventative strategies that work, and place appro-
priate emphasis on this in undergraduate, graduate and continuing education of
health care workers.
• Recognise the importance of more complete reporting of the sequelae of violence
and encourage the development of training that emphasises violence awareness and
prevention, in addition to using better reporting and research into incidence, pre-
valence and health impact of all forms of violence.
• Encourage medical journals to publish more of the research on the complex inter-
actions in this area, thus keeping it in the professions’ awareness and contributing
to the development of a solid research base and ongoing documentation of types
and incidence of violence.
• Encourage medical journals to consider publishing theme issues on violence in-
cluding neglect of women and girls.
• Advocate for universal registration of births, and a higher age limit for marriage.
• Advocate for effective implementation of universal human rights.
• Advocate for parental education and support on the care, nurturing, development,
education and protection of children, especially girls.
Handbook of WMA Policies
World Medical Association ⏐ R-2010-02-2010
• Advocate for the monitoring of statistics on children, including both positive and
negative indicators of health and well-being, and social determinants of health.
• Advocate for legislation against specific harmful practices including female feti-
cide, female genital mutilation, forced marriage, and corporal punishment.
• Advocate for the criminalisation of rape in all circumstances including within mar-
riage.
• Condemn the use of gang rape as a weapon of war and work with others to docu-
ment and report it.
• Advocate for the development of research data on the impact of violence and
neglect upon primary and secondary victims and upon society, and for increased
funding for such research.
• Advocate for the protection of those who speak out against abuse, including physi-
cians and other health workers.
Physicians should:
• Use the material developed for their education to better inform themselves about
the effects of abuse and the successful strategies for prevention.
• Provide health care and protection to children, (especially in times of crisis) and
document and report all cases of violence against children, taking care to safeguard
the patient’s privacy as much as possible.
• Treat and reverse, where possible, the complications and adverse effects of female
genital mutilation and refer the patient for social support services.
• Oppose the publication or broadcast of victims’ names, addresses or likenesses
without the explicit permission of the victim.
• Assess for risk of family violence in the context of taking a routine social history.
• Be alert to the association between current alcohol or drug dependence among
women and a history of abuse.
• Support colleagues who become personally involved in work to end abuse.
• Work to establish the necessary relationship of trust with abused women and child-
ren including respect for confidentiality.
• Support global and local action to better understand the health consequences both
of abuse and of the denial of rights, and advocate for increased services for vic-
tims.
1
At first glance neglect does not seem to equate with violence. But the acceptance of neglect and
the lesser rights given to women and girls are major factors in reinforcing an acceptance of causal
and systematic violence. In that it denies basic rights, many would classify neglect as a form of
violence in and of itself.
2
Rape is considered to be a method of warfare when armed forces or groups use it to torture, in-
jure, extract information, degrade, displace, intimidate, punish or simply to destroy the fabric of the
community, The mere threat of sexual violence can cause entire communities to flee their homes.
from Women and War, ICRC 2008
3
Women’s Health and Human Rights: the Promotion and Protection of Women’s Health through
International Human Rights Law. Rebecca Cook. Presented at the 1999 Adapting to Change
Core Course
4
Women and Health: Today’s Evidence, Tomorrow’s Agenda. WHO November 2009. ISBN 978
92 4 156385 7
Handbook of WMA Policies
R-2011-01-2011 ⏐ World Medical Association
WMA RESOLUTION
ON
THE ACCESS TO ADEQUATE PAIN TREATMENT
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
PREAMBLE
Around the world, tens of millions of people with cancer and other diseases and conditions
experience moderate to severe pain without access to adequate treatment. These people
face severe suffering, often for months on end, and many eventually die in pain, which is
unnecessary and almost always preventable and treatable. People who may not be able to
adequately express their pain – such as children and people with intellectual disabilities or
with consciousness impairments – are especially at risk of receiving inadequate pain treat-
ment.
It is important to acknowledge the indirect consequences of inadequate pain treatment,
such as a negative economic impact, as well as the individual human suffering directly
resulting from untreated pain.
In most cases, pain can be stopped or relieved with inexpensive and relatively simple
treatment interventions, which can dramatically improve the quality of life for patients.
It is accepted that some pain is particularly difficult to treat and requires the application of
complex techniques by, for example, multidisciplinary teams. Sometimes, especially in
cases of severe chronic pain, psycho-emotional factors are even more important than bio-
logical factors.
Lack of education for health professionals in the assessment and treatment of pain and
other symptoms, and unnecessarily restrictive government regulations (including limiting
access to opioid pain medications) are two major reasons for this treatment gap.
PRINCIPLES
The right to access to pain treatment for all people without discrimination, as laid down in
professional standards and guidelines and in international law, should be respected and
effectively implemented.
Physicians and other health care professionals have an ethical duty to offer proper clinical
assessments to patients with pain and to offer appropriate treatment, which may require
prescribing medications – including opioid analgesics – as medically indicated. This also
applies to children and other patients who cannot always adequately express their pain.
Montevideo ⏐ R-2011-01-2011
Adequate Pain Treatment
Instruction on pain management, including clinical training lectures and practical cases,
should be included in mandatory curricula and continuing education for physicians and
other health professionals. Such education should include evidence-based therapies effec-
tive for pain, both pharmacological and non-pharmacological. Education about opioid
therapy for pain should include the benefits and risks of the therapy. Safety concerns re-
garding opioid therapy should be emphasized to allow the use of adequate doses of analge-
sia while mitigating detrimental effects of the therapy. Training should also include recog-
nition of pain in those who may not be able to adequately express their pain, including
children, and cognitively impaired and mentally challenged individuals.
Governments must ensure the adequate availability of controlled medicines, including opi-
oids, for the relief of pain and suffering. Governmental drug control agencies should re-
cognize severe and/or chronic pain as a serious and common health care issue and appro-
priately balance the need to relieve suffering with the potential for the illegal use of anal-
gesic drugs. Under the right to health, people facing pain have a right to appropriate pain
management, including effective medications such as morphine. Denial of pain treatment
violates the right to health and may be medically unethical.
Many countries lack necessary economic, human and logistic resources to provide optimal
pain treatment to their population. The reasons for not providing adequate pain relief must
therefore be fully clarified and made public before accusations of violating the right to
health are made.
International and national drug control policies should balance the need for adequate avail-
ability and accessibility of controlled medicines like morphine and other opioids for the
relief of pain and suffering with efforts to prevent the misuse of these controlled sub-
stances. Countries should review their drug control policies and regulations to ensure that
they do not contain provisions that unnecessarily restrict the availability and accessibility
of controlled medicines for the treatment of pain. Where unnecessarily or disproportion-
ately restrictive policies exist, they should be revised to ensure the adequate availability of
controlled medicines.
Each government should provide the necessary resources for the development and imple-
mentation of a national pain treatment plan, including a responsive monitoring mechanism
and process for receiving complaints when pain is inadequately treated.
Handbook of WMA Policies
R-2011-02-2011 ⏐ World Medical Association
WMA RESOLUTION
ON
BAHRAIN
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
The WMA General Assembly notes that
A number of doctors, nurses and other health care professionals in the Kingdom of
Bahrain were arrested in March 2011 after the civil unrest in that country and tried under
emergency powers before a special court, led by a military judge. Twenty of this group
were found guilty of a number of charges, on 29 September 2011 and sentenced to fifteen,
ten or five years imprisonment.
These trials failed to meet international standards for fair trials, including the accused not
being allowed to make statements in their own defence, and their lawyers not being
allowed to question all the witnesses. Allegations from the accused and their lawyers of
mistreatment, abuse and other human right violations during arrest and while in detention
have not been investigated.
While various criminal charges were brought it appears that the major offence was treating
all the patients who presented for care, including leaders and members of the rebellion.
Other charges appear to be closely related to providing such treatment and were, in any
case, not proven to the standard expected in court proceedings. In treating patients without
considering the circumstances of their injury these health care professionals were honour-
ing their ethical duty as set out in the Declaration of Geneva.
The WMA welcomes the announcement by the government of Bahrain of 6 October 2011
that all twenty will be re-tried before a full civil court.
Therefore, the WMA requires that no doctor or other health care professional be arrested,
accused or tried for treating patients, regardless of the origins of the patient's injury or
illness.
The WMA demands that all states understand, respect and honour the concept of medical
neutrality. This includes providing working conditions which are as safe as possible, even
under difficult circumstances, including armed conflict or civil unrest.
The WMA expects that if any individual, including health care professionals, are subject
to trial that there is due process of law including during arrest, questioning and trial in
accordance with the highest standards of international law.
The WMA demands that states investigate any allegations of torture or cruel and inhu-
mane treatment by prisoners against its agents, and act quickly to stop such abuses.
Montevideo ⏐ R-2011-02-2011
Bahrain
The WMA recommends that independent international assessors are allowed to observe
the trials and meet privately with the accused, so that the state of Bahrain can prove to the
watching world that the future legal proceedings follow fair process.
The WMA recognises that health care workers and health care facilities are increasingly
under attack during wars, conflicts and civil unrest. We demand that states throughout the
world recognise, respect and honour principles of medical neutrality and their duty to pro-
tect health care institutions and facilities for humanitarian reasons.
Handbook of WMA Policies
R-2011-03-2011 ⏐ World Medical Association
WMA RESOLUTION REAFFIRMING THE WMA RESOLUTION
ON
ECONOMIC EMBARGOES AND HEALTH
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
The World Medical Association is deeply concerned about reports of potential serious
health impacts resulting from economic sanctions imposed by the European Union against
Ivory Coast leader, Laurent Gbagbo, and numerous individuals and entities associated
with his regime, including two major ports linked to Gbagbo's government. The sanctions
aim to severely restrict EU-registered vessels from transacting business with these ports,
which could inhibit the delivery of necessary and life-saving medicines.
The WMA General Assembly reiterates the following position from the WMA Resolution
on Economic Embargoes and Health:
• All people have the right to the preservation of health; and,
• the Geneva Convention (Article 23, Number IV, 1949) requires the free passage
of medical supplies intended for civilians;
1.
The WMA therefore urges the European Union to take steps immediately to ensure the
delivery of medical supplies to the Ivory Coast, in order to protect the life and health of
the population.
Handbook of WMA Policies
World Medical Association ⏐ R-2011-04-2011
WMA RESOLUTION
ON
THE INDEPENDENCE OF NATIONAL MEDICAL ASSOCIATIONS
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
National medical associations are established to act as representatives of their physicians,
and to negotiate on their behalf, sometimes as a trade union or regulatory body but also as
a professional association, representing the expertise of medical doctors in relation to mat-
ters of public health and wellbeing.
They represent the views of the medical profession, including attempting to ensure the
practice of ethical medicine, the provision of good quality medical care, and the adherence
to high standards by all practitioners.
These associations may also campaign or advocate on behalf of their members, often in
the field of public health. Such advocacy is not always welcomed by governments who
may consider the advocacy to have oppositional politics attached, when in reality it is
based upon an understanding of the medical evidence and the needs of patients and popu-
lations.
The WMA is aware that because of those advocacy efforts some governments attempt to
silence the medical association by placing it's own nominated representatives into posi-
tions of authority, to subvert the message into one they are better able to tolerate.
The WMA denounces such action and demands that no government interferes with the
independent functioning of national medical associations. It encourages governments to
understand better the reasons behind the work of their national medical association, to
consider the medical evidence and to work with physicians to improve the health and well
being of their populations.
Handbook of WMA Policies
World Medical Association ⏐ R-2012-02-2012
WMA RESOLUTION
ON
PLAIN PACKAGING OF CIGARETTES
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
The WMA recognises that:
• Cigarettes offer a serious threat to the life and health of individuals that use them,
and a considerable cost to the health care services of every country;
• Those who smoke predominantly start to do so while adolescents;
• There is a proven link between brand recognition and likelihood of starting to
smoke;
• Brand recognition is strongly linked to cigarette packaging;
• Plain packaging reduces the impact of branding, promotion and marketing of
cigarettes.
The WMA encourages national governments to support moves to introduce plain packaging
of cigarettes, initially by the Federal Government of Australia, to break the brand recog-
nition/ smoking cycle and commends adoption of this policy to other national govern-
ments and deplores the legal moves being taken by the tobacco industry to oppose this
policy.
Handbook of WMA Policies
R-2012-03-2012 ⏐ World Medical Association
WMA RESOLUTION
TO REAFFIRM
THE WMA’S PROHIBITION OF PHYSICIAN PARTICIPATION
IN CAPITAL PUNISHMENT
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
There is universal agreement that physicians must not participate in executions because
such participation is incompatible with the physician's role as healer. The use of a
physician's knowledge and clinical skill for purposes other than promoting health,
wellbeing and welfare undermines a basic ethical foundation of medicine—first, do no
harm.
The WMA Declaration of Geneva states: "I will maintain the utmost respect for human
life"; and, "I will not use my medical knowledge to violate human rights and civil
liberties, even under threat."
As citizens, physicians have the right to form views about capital punishment based on
their individual moral beliefs. As members of the medical profession, they must uphold
the prohibition against participation in capital punishment.
Therefore, be it RESOLVED that:
• Physicians will not facilitate the importation or prescription of drugs for execution.
• The WMA reaffirms: "that it is unethical for physicians to participate in capital
punishment, in any way, or during any step of the execution process, including its
planning and the instruction and/or training of persons to perform executions", and
• The WMA reaffirms: that physicians "will maintain the utmost respect for human
life and will not use [my] medical knowledge to violate human rights and civil
liberties, even under threat."
Handbook of WMA Policies
World Medical Association ⏐ R-2012-04-2012
WMA RESOLUTION
IN
SUPPORT OF PROFESSOR CYRIL KARABUS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
The WMA welcomes the bail granted on the 11th
of October to the retired South African
paediatric haematologist, 78-year-old Professor Cyril Karabus, as a positive step given his
state of health; he has cardiac disease. Dr Karabus had been detained in an Abu Dhabi,
UAE prison since August 18th
2012. He was arrested in Dubai, whilst in transit to South
Africa, owing to alleged charges emanating from a brief period that he worked in the UAE
in 2002.
Professor Karabus was neither informed of the charges leveled against him nor the subse-
quent trial that was held in absentia relating to the unfortunate death of a child with acute
leukemia under his care during his tenure in the UAE in 2002. His defense lawyer has also
been unable to access any documents or files relating to the case that may assist in
providing a fair defense.
Therefore,
The WMA General Assembly urgently calls on the authorities of the United Arab
Emirates to ensure that Professor Karabus:
• Is guaranteed a fair trial according to international standards;
• Has access to the relevant documents or information he may require to prepare his
defense.
Handbook of WMA Policies
R-2013-01-2013 ⏐ World Medical Association
WMA RESOLUTION
ON
CRIMINALISATION OF MEDICAL PRACTICE
Adopted as a Council Reolution by the 194th
WMA Council Session, Bali, Indonesia,
April 2013
and adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Doctors who commit criminal acts which are not part of patient care must remain as liable
to sanctions as all other members of society. Serious abuses of medical practice must be
subject to sanctions, usually through professional regulatory processes.
Numerous attempts are made by governments to control physicians’ practice of medicine
at local, regional and national levels worldwide. Physicians have seen attempts to:
• Prevent medically indicated procedures;
• Mandate medical procedures that are not indicated; and
• Mandate certain drug prescribing practices.
Criminal penalties have been imposed on physicians for various aspects of medical prac-
tice, including medical errors, despite the availability of adequate non-criminal redress.
Criminalizing medical decision making is a disservice to patients.
In times of war and civil strife, there have also been attempts to criminalize compassionate
medical care to those injured as a result of these conflicts.
RECOMMENDATIONS
Therefore, the WMA recommends that its members:
1. Oppose government intrusions into the practice of medicine and in healthcare
decision making, including the government’s ability to define appropriate medical
practice through imposition of criminal penalties.
2. Oppose criminalizing medical judgment.
3. Oppose criminalizing healthcare decisions, including physician variance from
guidelines and standards.
4. Oppose criminalizing medical care provided to patients injured in civil conflicts.
Fortaleza ⏐ R-2013-01-2013
Criminalisation of Medical Practice
5. Implement action plans to alert opinion leaders, elected officials and the media
about the detrimental effects on healthcare that result from criminalizing healthcare
decision making.
6. Support the principles set forth in the WMA’s Declaration of Madrid on Profes-
sional Autonomy and Self-Regulation.
7. Support the guidance set forth in the WMA’s Regulations in Times of Armed
Conflict and Other Situations of Violence.
Handbook of WMA Policies
R-2013-02-2013 ⏐ World Medical Association
WMA RESOLUTION
ON
THE HEALTHCARE SITUATION IN SYRIA
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
During wars and armed conflicts, hospitals and other medical facilities have often been
attacked and misused and patients and medical personnel have been killed or wounded.
Such attacks are a violation of the Geneva Conventions (1949), Additional Protocols to
the Geneva Conventions (1977) and WMA policies, in particular, the WMA Statement on
the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations
of Violence (Montevideo 2011) as well as WMA Regulations in Times of Armed
Conflicts and Other Situations of Violence (Bangkok 2012).
The World Medical Association (WMA) has been active in condemning documented
attacks on medical personnel and facilities in armed conflicts, including civil wars. The
Geneva Conventions and their Additional Protocols are designed to protect medical
personnel, medical facilities and their patients in international and non-international armed
conflicts. The parties on both sides of the conflict have legal and moral duties not to inter-
fere with medical care for wounded or sick combatants and civilians, and to not attack,
threaten or impede medical functions. Physicians and other health care personnel must act
as and be considered neutral and must not be prevented from fulfilling their duties.
RECOMMENDATIONS
•
• The WMA calls upon all parties in the Syrian conflict to ensure the safety of
healthcare personnel and their patients, as well as medical facilities and medical
transport.
• The WMA calls upon its members to approach local governments in order to
facilitate international cooperation in the United Nations, the European Union or
other international body with the aim of ensuring the safe provision of health care
to the Syrian people.
Handbook of WMA Policies
World Medical Association ⏐ R-2013-03-2013
WMA RESOLUTION
ON
THE PROHIBITION OF CHEMICAL WEAPONS
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
It has been recognised for centuries that certain chemical agents can affect consciousness,
or other factors influencing the ability of an individual to take part in fighting, predomi-
nantly during warfare. More recently some agents have been used to temporarily disable
participants in civil unrest, protests or riots. In warfare such agents have, historically, had
a significant morbidity and mortality and included nerve gases and related agents.
Despite widespread condemnation such weapons were extensively used in the early 20th
century. A global movement to outlaw the use of such weapons led to the development of
the Chemical Weapons Convention (CWC), which entered into force in 1997 having been
opened to signature in 1993. Currently only six countries have not ratified or acceded to
the CWC.
The production, stockpiling and use of CW is prohibited. Despite this, such weapons have
been used by state forces and by non-state actors in a number of countries. By their nature
such weapons are indiscriminate. This use has led to deaths, injuries and human suffering
in those countries.
Chemical agents used in policing actions, including by the military acting in a policing
role, are allowed under the CWC. There is a significant international dialogue underway
on the definition of such agents and the situations in which they can be used. It should be
noted that the CWC appears to assume such agents will not be lethal, but the use of any
agent might have fatal consequences. Those using them, or authorising their use, must
seek to ensure that they are not used in a manner which risks death or serious injury to
targeted persons.
RECOMMENDATIONS
The WMA notes that the development, production, stockpiling and use of Chemical
Weapons is banned under the CWC, and that use of such weapons is regarded by some to
be a crime against humanity, regardless of whether the target populations are civilian or
military.
The WMA urges all relevant parties to make active efforts to abide by the CWC ban on
the development, production, stockpiling and use of Chemical Weapons.
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Prohibition of Chemical Weapons
The WMA urges support from all states party to the CWC for the safe destruction of all
stockpiles of Chemical weapons.
The WMA supports UN initiatives to identify anyone who is responsible for the use of
Chemical Weapons and to bring them to justice.
The WMA urges states using chemical agents in riot control and related situations to
carefully consider and minimise the risks and to, wherever possible, refrain from such
use. Any use must follow the establishment of the necessary procedures to reduce the risk
of death or serious injury. They should not be used in a manner, which deliberately
increases the risk of injury, harm or death to their targets.
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World Medical Association ⏐ R-2013-04-2013
WMA RESOLUTION
ON
STANDARDISATION IN MEDICAL PRACTICE
AND PATIENT SAFETY
Adopted as a Council Resolution by the 194th
WMA Council Session, Bali, Indonesia,
April 2013
and adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
Ensuring patient safety and quality of care is at the core of medical practice. For patients, a
high level of performance can be a matter of life or death. Therefore, guidance and stand-
ardisation in healthcare must be based on solid medical evidence and has to take ethical
considerations into account.
Currently, trends in the European Union can be observed to introduce standards in clinical,
medical care developed by non-medical standardisation bodies, which neither have the
necessary professional ethical and technical competencies nor a public mandate.
The WMA has major concerns about such tendencies which are likely to reduce the
quality of care offered, and calls upon governments and other institutions not to leave
standardisation of medical care up to non-medical self selected bodies.
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WMA RESOLUTION
IN
SUPPORT OF THE BRAZILIAN MEDICAL ASSOCIATION
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
There are credible reports that the Brazilian Government program “Mais Médicos” to
create more medical schools, extend the duration of the medical course, compulsorily
place last years medical students to work in public services and attract foreign physicians
to work in remote areas of the country and in the poorest outskirts of big cities, was
proposed without the appropriate consultation to the medical community and medical
schools, and departs from a wrong diagnosis about the causes of the insufficient health
care provided to the Brazilian population. The program as proposed bypass systems
established to verify physicians' credentials, medical competence and language skills in
order to protect patients.
The World Medical Association is concerned that patients are put at risk by unregulated
medical license, inadequate medical competence and potential misunderstanding of patient
communication and of drugs and medical supplies labels.
Therefore, the WMA:
• Condemns any policy and practice that disrupt the accepted standards of medical
credentialing and medical care;
• Calls upon the Brazilian government to work with the medical community and
medical schools on all matters related to medical education, physician certification
and the practice of medicine, and to respect the role of the Brazilian Medical
Association on behalf of the Brazilian physicians and population;
• Urges, as a matter of utmost concern, that the Brazilian government respect the
WMA International Code of Medical Ethics that guides the medical practice of
physicians all over the world.
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WMA RESOLUTION
ON
EBOLA VIRAL DISEASE
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
BACKGROUND
A number of viral diseases have caused occasional health emergencies in parts of Africa,
with local or wider spread epidemics. These include Lassa, Marburg and Ebola Viral
Diseases (EVD). The 2013-14 outbreak of EVD in West Africa has proven far more dif-
ficult to control than previous epidemics and is now present in Sierra Leone, Liberia and
Guinea with more than 2000 deaths. This epidemic appears to have a case related mor-
tality of approximately 55% against a range for EVD of 50~95%.
Following infection, patients remain asymptomatic for a period of 2~21 days, and during
this time tests for the virus will be negative, and patients are not infectious, posing no
public health risk. Once the patient becomes symptomatic, EVD is spread through contact
with body fluids including blood. Symptoms include diarrhea, vomiting and bleeding, and
all these body fluids are potentially sources of infection.
Management is primarily through infection control, the use of personal protective equip-
ment (PPE) by health care workers and those disposing of body fluids and of bodies, and
supportive care for sick patients including using IV fluids and inotropes. Contact tracing is
also important but may be difficult in many of the communities currently affected. Vac-
cines are in development as are some antivirals, but they will arrive late in this epidemic if
they are proven successful.
Evidence from those treating patients in affected communities is that a shortage of re-
sources, including health care workers and PPE, as well as poor infection control training
of health care workers, caregivers and others at risk are making epidemic control difficult.
Some governments have indicated that they will build new treatment centres in affected
areas as a matter of urgency, while others are directly providing personal protective equip-
ment and other supplies.
RECOMMENDATIONS
1. The WMA honours those working in these exceptional circumstances, and strongly
recommends that national governments and international agencies work with health
care providers on the ground and offer stakeholders training and support to reduce
the risks that they face in treating patients and in seeking to control the epidemic.
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Ebola Viral Disease
2. The WMA commends those countries that have committed resources for the urgent
establishment of new treatment and isolation centres in the most heavily burdened
countries and regions. The WMA calls upon all nations to commit enhanced sup-
port for combatting the EVD epidemic.
3. The WMA calls on the international community, acting through the United
Nations and its agencies as well as aid agencies, to immediately provide the
necessary sup-plies of PPE to protect health care workers and ancillary staff and
reduce the risk of cross infection. This must include adequate supplies of gloves,
masks and gowns, and distribution must include treatment centres at all levels.
4. The WMA calls on all those managing the epidemic, including local and national
governments and agencies such as WHO, to commit to adequate training in infec-
tion control measures, including PPE for all staff and caregivers who might come
into contact with infective materials.
5. The WMA calls on national and local governments to increase public communica-
tion about basic infection control practices.
6. The WMA calls upon WHO to facilitate research into the timeliness and effective-
ness of international interventions, so that planning and interventions in future health
emergencies can be better informed.
7. The WMA strongly urges all countries, especially those not yet affected, to educate
health care providers about the current case definition in addition to strengthening
infection control methodologies and contact tracing in order to prevent transmis-
sion within their countries.
8. The WMA calls for NMAs to contact their national governments to act as des-
cribed in this document.
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WMA RESOLUTION
ON
MIGRANT WORKERS' HEALTH AND SAFETY IN QATAR
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
Reliable reports indicate that migrant workers in Qatar suffer from exploitation and viola-
tion of their rights. Workers basic needs, e.g. access to sufficient water and food, are not
met. Less than half of the workers are entitled to health care. Hundreds of workers have
already died in the construction sites since 2010 as the country prepares to host the 2022
FIFA1 World Cup. Workers are not free to leave when they see their situation hopeless or
health endangered since their passports are confiscated.
Despite the pleas of international labour and human rights organizations, such as ITUC
(International Trade Union Confederation) and Amnesty International, the response of the
Qatar government to solve the situation has not been adequate. FIFA has been inefficient
and has not taken the full responsibility to facilitate the improvements to the worker´s
living and working conditions.
The World Medical Association reminds that health is a human right that should be safe-
guarded in all situations.
The World Medical Association is concerned that migrant workers are continuously put at
risk in construction sites in Qatar, and their right to freedom of movement and right to
health care and safe working conditions are not respected.
RECOMMENDATIONS
1. The WMA calls upon the Qatar government and construction companies to ensure
the health and safety of migrant workers;
2. The WMA demands the FIFA as the responsible organization of the World Cup to
take immediate action by changing the venue as soon as possible;
3. The WMA calls upon its members to approach local governments in order to fa-
cilitate international cooperation with the aim of ensuring the health and safety of
migrant workers in Qatar.
1
Fédération Internationale de Football Association
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WMA RESOLUTION
ON
UNPROVEN THERAPY AND THE EBOLA VIRUS
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
In the case of Ebola virus, the WMA strongly supports the intention of Paragraph 37 of the
2013 revision of the Declaration of Helsinki, which reads:
In the treatment of an individual patient, where proven interventions do not exist or other
known interventions have been ineffective, the physician, after seeking expert advice, with
informed consent from the patient or a legally authorized representative, may use an un-
proven intervention if in the physician’s judgement it offers hope of saving life, re-
establishing health or alleviating suffering. This intervention should subsequently be made
the object of research, designed to evaluate its safety and efficacy. In all cases, new in-
formation must be recorded and, where appropriate, made publicly available.
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WMA RESOLUTION
TO STOP ATTACKS AGAINST
HEALTHCARE WORKERS AND FACILITIES IN TURKEY
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Several media report that over the last two months of conflict in Turkey, healthcare
workers have been killed, wounded or threatened with guns. Some physicians have been
taken out of ambulances and beaten. Access to wounded people is prevented by security
forces, and ambulances as well as health facilities are regularly targeted. A rather
comprehensive study conducted by the Turkish Medical Association confirms these facts.
There are indications that attacks on healthcare workers and the obstructions of service
delivery are used as a deliberate political instrument to intimidate people, depriving them
of their democratic rights.
Parties in armed conflict have the obligation to protect health care provision to wounded
and sick and to prevent attack on or threat to medical activities, healthcare workers and
facilities. Physicians and other healthcare workers should not be impeded to perform their
duties. Such attacks constitute blatant violation of international human rights law, in
particular the inherent right to life that shall be protected by law, and the right to enjoy the
highest attainable standard of health[1].
These attacks undermine gravely as well fundamental medical ethics principles, in
particular WMA international Code of Medical Ethics and the Ethical Principles of Health
Care in Times of Armed Conflict and Other Emergencies endorsed by civilian and
military health-care organisations[2], stating that: “Health-care personnel, as well as
health-care facilities and medical transports, whether military or civilian, must be
respected by all. They are protected while performing their duties and the safest possible
working environment shall be provided to them » (article 10).
RECOMMENDATIONS
The WMA urges all parties to:
Stop attacks on healthcare workers and patients, health care facilities, and ambulances and
ensure their safety,
Respect the professional autonomy and impartiality of healthcare workers,
Comply fully with international human rights law as well as other relevant international
regulations that Turkey is a State Party to, and
Document and record all violations and duly prosecute their perpetrators.
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[1] International Covenant on Economic, Social and Cultural Rights, article 12 – December 1966
[2] Adopted by the ICRC, the WMA, the International Committee of Military Medicine (ICMM),
the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) –
June 2015
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WMA RESOLUTION
ABOUT THE BOMBING ON THE HOSPITAL
OF MSF IN KUNDUZ
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
After the events of October 3 in Kunduz (Afghanistan), the WMA:
• Extends its deepest condolences to families, colleagues and friends of doctors,
healthcare workers and patients killed in the bombing
• Deeply regrets and condemns the bombing of the Hospital of MSF , considering it
a violation of human rights.
• Reaffirms its positional statements on “Healthcare in Danger” and calls on all
countries to respect healthcare personnel in conflict situations
• Demands an immediate enquiry into the attack by an independent body and the
assumption of responsibilities.
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WMA RESOLUTION
ON
REFUGEE CRISIS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
The WMA recognises that mass movement of people often follows disasters that flow
from armed conflict or natural phenomena as populations seek to escape danger and
deprivation. The current mass movement of the populations, to escape the effects of
armed conflict including bombing, lack of access to utilities, clean water, and the
destruction of homes, schools and hospitals, has been numerically larger than any mass
movement of populations in over 70 years.
While the WMA recognises that countries may have concerns about their ability to absorb
significant numbers of new migrants, we recognise that people fleeing warfare, or natural
phenomena are doing so because they are desperate and often face life-threatening
conditions. They are afraid for their health, safety and welfare, and that of the family
members who accompany them.
Most countries have signed international treaties giving them binding obligations to offer
aid and assistance to refugees and asylum seekers. The WMA believes that, when there
are events, including on-going events such as conflict, which generate refugee crises,
governments must increase their efforts to provide assistance to those in need.
This should include ensuring safe passage for refugees, and appropriate support after they
enter countries offering refuge. Recognising that the disaster from which they have fled,
and the vicissitudes of the journey, may have led to health problems it is essential that
receiving countries establish systems to provide health care to refugees.
Governments should seek to ensure that refugees and asylum seekers are able to live in
dignity within their country of refuge and make all efforts to enable their integration into
their new society. The international community should seek to obtain a peaceful solution
in Syria under which the population can either stay at home safely or, if they have already
left, safely return home.
The WMA recognises that mass population movement cause significant stress on existing
populations of countries as well on those who become refugees. We believe that
governments and international agencies including the United Nations must make more
concerted efforts to reduce the pressures that lead to such movements, including rapidly
providing extensive relief after natural phenomena, and making more efforts to avert or
stop armed conflict. Re-establishing security of food, water, housing, sewerage, education
and health care, and improving public safety, should make a significant impact and reduce
the numbers of refugees.
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The WMA:
• Recognises that the process of becoming a refugee is damaging to physical and
mental health;
• Commends those countries that have welcomed and cared for refugees, especially
those currently fleeing Syria;
• Calls on other countries to improve their willingness to receive refugees and
asylum seekers;
• Calls on national governments to ensure that refugees and asylum seekers are
enabled to live in dignity by providing access to essential services;
• Calls on all governments to work together to seek to end local, regional, and
international conflicts, and to protect the health, safety and welfare of populations;
• Calls on all governments to cooperate in providing immediate help to countries
facing the effects of natural phenomena, remembering that those already the most
socio-economically disadvantaged will face the most challenges;
• Calls upon global media to report on the refugee crisis in a manner that respects
the dignity of refugees and displaced persons, and to avoid bigotry and racial or
other bias in reporting.
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WMA RESOLUTION
ON
THE PROTECTION OF HEALTH CARE FACILITIES AND PERSONNEL
IN SYRIA
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
The World Medical Association (WMA) notes with great concern the recent and repeated
attacks on health care facilities, health care workers and patients in Syria, especially in
Aleppo. These attacks have killed and injured civilian people, and the most vulnerable
among them, children and patients. Since the beginning of the war in Syria in 2011, an
estimated 270 health care facilities have been attacked and 760 health care workers have
been killed. The WMA is profoundly concerned by this development, as health care
facilities and personnel should, according to the international law, be protected by the
parties of the conflict.
Therefore the WMA
• Deeply regrets and condemns the recent and recurring bombings of the hospitals in
Aleppo, considering these as a violation of human rights;
• Reaffirms its statements on “Healthcare in Danger” and demands all countries to
ensure the safety of healthcare personnel and patients in conflict situations;
• Calls on all countries to fully implement the UN Resolution 2286 (2016) which
demands all parties to armed conflicts to fully comply with their obligations under
international law, to ensure the respect and protection of all medical personnel and
humanitarian personnel exclusively engaged in medical duties, of their means of
transport and equipment, as well as hospitals and other medical facilities;
• Demands an immediate and impartial enquiry into the attacks against health care
facilities and personnel, and actions taken against those responsible in accordance
with domestic and international law.
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WMA RESOLUTION
ON
OCCUPATIONAL AND ENVIRONMENTAL HEALTH AND SAFETY
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
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.[1]
Workers represent at least half of the world’s population and are the backbone of many
economies, but may have inadequate access to occupational and environmental health
services[2]. Decent work sums up the aspirations of people in their working lives. It
involves opportunities for work that is productive and delivers a fair income, security in
the workplace and social protection for families, better prospects for personal development
and social integration, freedom for people to express their concerns, organize and
participate in the decisions that affect their lives and equality of opportunity and treatment
for all women and men (ILO).
Every 15 seconds, a worker dies from a work-related accident or disease,[3] and each year
there are 160 million cases of work-related/occupational diseases; 313 million work
accidents occur annually and over 2.3 million people die as a result of work accidents and
occupational diseases.[4]
Despite this, the proportion of work accidents and occupational diseases that are recorded
and reported is incredibly extremely small. It estimated that only less than 1% of
occupational diseases are recorded.[5]
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
impact positively within the work place on all the above mentioned sustainable
development goals.
Physicians have a critical role in preventing and protecting from, diagnosing, treating and
reporting work accidents and occupational diseases. Information, skills and functions of
physicians form the basis of service models that vary by countries and constitute key
elements in addressing OEHS. In addition, physicians should strive for inclusive working
life so that even employees with disabilities are given opportunities to stay integrated in
decent working life.
Despite many governments and employers’ and workers’ organizations place greater
emphasis on the prevention of occupational diseases. Prevention is not receiving the
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priority warranted by the scale and severity of the occupational disease epidemic.
Physicians and National 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, in their turn, a cause of mortality among
working population. Women bear the brunt of the work-related burden which often makes
them a more vulnerable group in working life.
RECOMMENDATIONS
1. Physicians should play a pivotal role in the development of a workforce that is
trained in the social determinants of health, and raise workplace awareness about
the social determinants of health.
2. The field of OEHS should be accorded the necessary importance in both graduate
and post-graduate medical studies.
3. 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.
4. National Medical Associations should act proactively and encourage the expansion
of the scope of OEHS services, prevent and reduce occupational diseases, and
injuries, reproductive health and protect the environment. They should also
promote workplace gender equality, and improve recording and reporting systems.
In addition, they should focus on capacity building, teaching and training,
collaborative research and improving the qualifications of their members in this
field.
5. National Medical Associations, together with governments, should take an active
role, where appropriate, in the formulation and development of national systems
that facilitate OEHS prevention, and recording and reporting occupational diseases
in their respective countries and lead their member physicians in efforts to be made
in this area.
6. Occupational diseases and injuries are often addressed in the context of insurance
and compensation. Where these mechanisms are not in place, national medical
associations should advocate for the protection of workers through by means of
insurance or social security.
7. NMAs should engage in establishing “medical causality” in the context of
reporting accidents and diseases, and inform the public that the health impacts of
hazards and risk factors inherent to working life can be established and recorded
only through a well-developed reporting system.
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Occupational and Environmental Health and Safety
8. As part of medical care, physicians who are evaluating workers’ compensation
patients should be accredited in occupational and environmental medicine. The
first contact may be with the patient’s regular physician who should routinely
obtain history on patient’s occupation and environmental exposures. If the
physician establishes a relationship between the diagnosis and these exposures,
he/she must report it to the relavent authority and ideally refer the patient for an
evaluation by a accreddited occupational and environmental medicine physician.
9. National Medical Associations should consider forming an internal body for
addressing the problems of physicians working in this area and encourage them to
contribute to related scientific studies
10. National Medical Associations should promote opportunities for physicians to
benefit, in their daily professional practice, from systems identifying
environmental/occupational risks and hazards having an impact on workers’,
including pregnant workers, health and safety. In this context, apart from the lists
of WHO International Classification of Diseases and the International Labour
Organisation (ILO), they should promote an easy-to-use system for “exploring,
recording and reporting environmental risks and factors” that physicians can use
easily.
11. Governments should collaborate in setting up an international system to assess
occupational hazards and develop strategies to protect the health of workers.
12. Governments should establish legislative frameworks that protect the rights and
health of workers, including reproductive health and health effects of work at
home.
13. The active participation of employers’ and workers’ organizations is essential for
the development of national policies and programmes for the prevention of
occupational diseases.
14. Employers should provide a safe working environment, recognising and
addressing the impact of adverse working conditions on individuals and society.
15. When rendering services for an employer, physicians should advocate that
employers fulfil minimum requirements set in the International Labour
Organization’s (ILO) occupational standards, especially when such requirements
are not set by national legislation. Physicians must maintain their autonomy and
independence from employer.
[1] World Health Organization. Declaration of Alma-Ata: International Conference on
Primary Health Care, Alma-Ata, USSR, 6-12 September 1978.
[2] World Health Organization. Workers’ health: Global plan of action. WHA 60.26.
[3] International Labour Organization [internet]. Safety and health at work. ILO; [updated
2016; cited 2016 January 19]. Available from: http://www.ilo.org/global/topics/safety-and-
health-at-work/lang–en/index.htm
[4] Safety and health at work, ILO The Prevention of Occupational Diseases. World Day for
safety and health at work 28 April 2013.
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[5] The Prevention of Occupational Diseases. World Day for safety and health at work 28
April 2013.
National System for Recording and Notification of Occupational Diseases Practical guide
International Statistical Classification of Diseases and Related Health Problems (ICD-10) In
Occupational Health.
World Health Organization Geneva 1999.
Improving Workers’ Health Worldwide: Implementing the WHO Global Plan of Action on
Workers’ Health. GOHNET NEWSLETTER NO. 22. November 2013 Edition.
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WMA RESOLUTION
ON
REFUGEES AND MIGRANTS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and adopted by the 67th
World Medical Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Currently, a very large number of people are seeking refuge and/or asylum; some are
fleeing war zones or other conflicts, others are fleeing from desperate poverty, violence,
and other injustices and abuses with potentially very harmful effects to mental and
physical health.
The global community has been ill prepared for handling the refugee crisis, including
addressing the health needs of those seeking refuge.
The WMA recognizes that mass migration will continue unless people are content to stay
in their birth countries because they see opportunities to live their lives in relative peace
and security and to offer themselves and their families the ability to live lives with
opportunities for fulfilment of various sorts, including economic improvement. The
global community has a responsibility to seek to improve the lot of all populations,
including those in countries currently with the poorest economies and other key factors.
Sustainable development will give all populations improved security, and economic
options.
The WMA recognizes that warfare and other armed conflict, including continuous civil
strife, unrest and violence, will inevitably lead to people movement. The worse the
conflict the higher the percentage of people who will want to leave the conflict zone.
There is a responsibility for the global community, especially its political leaders, to seek
to support peace making and conflict resolution.
The WMA recognizes and condemns the phenomenon of forced migration, which is
inhumane and must be stopped. Such cases should be considered for referral to the
International Criminal Court.
PRINCIPLES
1. The WMA reiterates the WMA Statement on Medical Care for Refugees originally
adopted in Ottawa, Canada in 1998 which states:
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Refugees and Migrants
• Physicians have a duty to provide appropriate medical care regardless of the
civil or political status of the patient, and governments should not deny patients
the right to receive such care, nor should they interfere with physicians’
obligation to administer treatment on the basis of clinical need alone.
• Physicians cannot be compelled to participate in any punitive or judicial action
involving refugees, including asylum seekers, refused asylum seekers and
undocumented migrants, or Internally Displaced Persons or to administer any
non-medically justified diagnostic measure or treatment, such as sedatives to
facilitate easy deportation from the country or relocation.
• Physicians must be allowed adequate time and sufficient resources to assess the
physical and psychological condition of refugees who are seeking asylum.
• National Medical Associations and physicians should actively support and
promote the right of all people to receive medical care on the basis of clinical
need alone and speak out against legislation and practices that are in opposition
to this fundamental right.
2. WMA urges governments and local authorities to ensure access to adequate
healthcare as well as safe and adequate living conditions for all regardless of their
legal status. healthcare as well as safe and adequate living conditions for all
regardless of their legal status.
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WMA RESOLUTION
ON
ZIKA VIRUS INFECTION
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
Recognizing that the WHO has designated the Zika virus infection a global health
emergency, the WMA provides the following recommendations:
• WHO should work with ECDC, CDC and other disease control organisations to
better understand the natural history and current epidemiology of Zika virus
infection.
• Information should be disseminated widely to advise and protect all women and
men who live in or must travel to Zika-affected areas and who are considering
becoming parents. Advice should also include recommendations for women who
are already pregnant who may have been directly exposed to the Zika virus or
whose partners live in or have travelled to Zika-affected areas.
• Relevant agencies, including WHO, should gather data on the efficacy of different
mosquito control methodologies, including the potentially harmful or teratogenic
effects of the use of various insecticides.
• Work on diagnostic tests, antivirals, and vaccines should continue with an
emphasis on producing a product that is safe for use in pregnant women and public
funding should be assured for this research. When such products are developed
states should ensure that they are available to, and affordable by, those most at
risk.
• States which have witnessed the delivery of a number of babies with microcephaly
and other fetal brain abnormalities must ensure that these infants are properly
followed up by health and other services, and provide support to families seeking
to cope with a child with developmental abnormalities. Wherever possible
research on the consequences of microcephaly should be published, to better
inform future parents, and to allow the development of optimal service provision.
Handbook of WMA Policies
R-2017-01-2017 ⏐ World Medical Association
WMA RESOLUTION
ON
POLAND
Adopted as a Council Resolution by the 207th Council Session, Chicago, October 2017
and adopted by the 68th
General Assembly, Chicago, United States, October 2017
BACKGROUND
Doctors in specialist education in Poland are protesting against underfunding of the health
services, resulting in poor access to health care for the population, and very low salaries
for doctors in specialist training. Currently health expenditure in Poland is 6.1% of GDP
(Global average around 9.8%) Doctors in specialist education have salaries of around 510-
580 Euro per month after tax, and many are working several jobs to afford housing and
other living expenses.
For over 8 days a number of doctor have been on hunger strike in Warsaw while
negotiations with the Health Minister were underway. Those negotiations have now
broken down.
RESOLUTION
The World Medical Association notes with serious concern the dispute between
physicians in specialist education and the government of Poland, in relation to health
sector funding and the salaries of junior doctors, many of whom are having to work
several jobs to achieve a living wage.
We note that a number of these doctors have been on hunger strike for some days, and also
that negotiations with the Health Minister have broken down.
It is essential that a resolution is found before these physicians suffer irreversible harm, or
die, as they seek to improve working conditions for their colleagues and a better financial
basis for health care provision for the population.
We urge the Prime Minister to step in and negotiate an acceptable solution to protect the
lives of physicians in specialist education, especially those currently on hunger strike, as
well as taking the opportunity to better fund health services for all the population.
We, the physicians of the World Medical Association, stand in solidarity with the
physicians in Poland.
Handbook of WMA Policies
R-2017-02-2017 ⏐ World Medical Association
WMA RESOLUTION
ON
PROHIBITION OF FORCED ANAL EXAMINATIONS TO
SUBSTANTIATE SAME-SEX SEXUAL ACTIVITY
Adopted by the 68th
General Assembly, Chicago, United States, October 2017
PREAMBLE
1. The World Medical Association’s 1975 Declaration of Tokyo strictly forbids medical
personnel from engaging in acts of torture or other forms of cruel, inhuman or
degrading treatment and requires them to respect the confidentiality of medical
information.
2. In addition, the United Nations’ “Principles of Medical Ethics Relevant to the Role of
Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees
Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment”
prohibits health personnel from “participation in, complicity in, incitement to or
attempts to commit torture or other cruel, inhuman or degrading treatment or
punishment”.
3. Since 2011, in at least eight countries, medical personnel have participated in forced
anal examinations of men and transgender women who are charged with consensual
same-sex conduct.
4. The UN Special Rapporteur on Torture and other forms of Cruel, Inhuman and
Degrading Treatment has described forced anal examinations as a form of torture or
cruel, inhuman and degrading treatment that is “medically worthless”.
5. Furthermore, the Independent Forensic Experts Group, composed of forensic medicine
specialists from around the world, has determined that “the examination has no value
in detecting abnormalities in anal sphincter tone that can be reliably attributed to
consensual anal intercourse”.
6. The WMA is deeply disturbed by the complicity of medical personnel in these non-
voluntary and unscientific examinations, including the preparation of medical reports
that are used in trials to convict men and transgender women of consensual same-sex
conduct.
7. Although some medical personnel argue that accused persons provide “consent” for
such exams, the ability of persons in custody to provide free and informed consent is
limited. Even when consent is given freely, medical personnel should refrain from
Chicago ⏐ R-2017-02-2017
Forced Anal Examinations
undertaking procedures that are medically worthless, discriminatory and potentially
incriminating.
RECOMMENDATIONS
8. Recognizing that persons who have undergone forced anal exams have described them
as painful, humiliating, and amounting to sexual assault, the WMA:
9. Calls on its members, and other medical professionals, to abstain from participation in
forced anal examinations;
10. Urges national medical associations (NMA’s) to issue written communications
prohibiting their members from participating in such examinations.
11. Urges national medical associations to educate doctors and health professionals about
the unscientific and futile nature of forced anal exams and the fact that they are a form
of torture or cruel, inhuman and degrading treatment.
12. Calls on the World Health Organization to make an official statement opposing forced
anal examinations to prove same-sex sexual activity as unscientific and unethical in
violation of medical ethics.
Handbook of WMA Policies
R-2018-01-2018 ⏐ World Medical Association
WMA RESOLUTION
ON
MIGRATION
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
Nowadays, we are facing increased migration trends globally. This situation, far from
being resolved, has worsened over the last months, exacerbated by political, social and
economic events, with serious impacts on the population deteriorating the quality of life
and in some cases putting people in mortal danger. This violates their fundamental right to
health and in many cases forces them to abandon their countries to search for a better life.
International migration is a global phenomenon, caused by multiple factors, including
demographic and economic inequalities among countries, in addition to war, hunger and
natural disasters. Migration policies adopted by the majority of receiving countries are
becoming more and more restrictive towards economic migrants.
The World Medical Association (WMA) considers that health is a basic need, a human
right and one of the essential drivers of economic and social development. Increased
migration is a phenomenon linked to progress and to the trends of the 21st century.
The WMA reaffirms its Resolution on Refugees and Migrants adopted in October 2016.
The WMA, its constituent members and the international health community should
advocate for:
1. Strong continued engagement of physicians in the defense of human rights and
dignity of all people worldwide, as well as combatting suffering, pain and illness;
2. The prioritization of the care of human beings above any other consideration or
interest;
3. Providing the necessary healthcare, through international cooperation, directed to
countries that welcome and receive large number of migrants.
4. Governments to reach political agreements to obtain the necessary health resources
to deliver care in an adequate and coordinated manner to the migrant population.
The WMA emphasizes the role of physicians to actively support and promote the rights of
all people to medical care based solely on clinical necessity, and protest against legislation
and practices contrary to this fundamental right.
Handbook of WMA Policies
R-2018-02-2018 ⏐ World Medical Association
WMA RESOLUTION
ON
PROHIBITION OF PHYSICIAN PARTICIPATION IN CAPITAL
PUNISHMENT
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
There is universal agreement that physicians must not participate in executions because
such participation is incompatible with the physician’s role as healer. The use of a
physician’s knowledge and clinical skill for purposes other than promoting health,
wellbeing and welfare undermines a basic ethical foundation of medicine. The WMA
Declaration of Geneva states: “I will maintain the utmost respect for human life”, and “I
will not use my medical knowledge to violate human rights and civil liberties, even under
threat”.
As citizens, physicians have the right to form views about capital punishment based on
their individual moral beliefs. As members of the medical profession, they must uphold
the prohibition against participation in capital punishment.
Therefore, the World Medical Association
AFFIRMS that it is unethical for physicians to participate in capital punishment, in any
way, or during any step of the execution process, including its planning and the instruction
and/or training of persons to perform executions.
REQUESTS firmly its constituent members to advise all physicians that any participation
in capital punishment as stated above is unethical.
URGES its constituent members to lobby actively national governments and legislators
against any participation of physicians in capital punishment.
*The WMA Resolution on Prohibition of Physician Participation in Capital Punishment is
a minor revision that merges two existing WMA policies, the Resolution on Physician
Participation in Capital Punishment (2008) and the WMA Resolution to Reaffirm WMA’s
Prohibition of Physician Participation in Capital Punishment (2012). As a result of the
new merged document, these two policies have been rescinded and archived.