WMJ_3_2018 (1)

vol. 64
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 3, September 2018
Contents
“So, do you like being a treasurer? Yes. What, really??” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Regulating the Regulators? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Patient-reported Indicator Survey (PaRIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Physician Complicity in Capital Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Euthanasia in Canada: a Cautionary Tale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Telemedicine and its Ethical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Global Migration and the Health Workforce: the Experiences of Internationally
Educated Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Some Ethical Aspects of Aesthetic
Medicine in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Pseudosciences/Pseudotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
New IFPMA Code of Practice 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Interview with Dr. Otmar Kloiber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
World Federation for Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Yoshitake YOKOKURA
WMA President
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. René HÉMAN
WMA Chairperson of the Finance
and Planning Committee
P.O. Box 20051
3502 LB, Utrecht
Netherlands
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Ketan DESAI
WMA Immediate Past-President
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Andrew DEARDEN
WMA Treasurer
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Leonid EIDELMAN
WMA President-Elect
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Heidi STENSMYREN
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE – 114 86 Stockholm
Sweden
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
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Editorial
“So, do you like being a treasurer? Yes. What, really??”
At a recent medical dinner, I was asked why
I enjoyed being a treasurer so much. It was
an interesting question as I currently serve as
the treasurer of the British Medical Associa-
tion and the World Medical Association and
as the internal auditor for the CPME, the
Standing committee for doctors in Europe.
My answer (I was told) was so energetic and
enthusiastic that I was asked to write an ar-
ticle on the question. Nothing I am about to
say is new or, I suspect, original but seeks to
explain why I find money fascinating. I am
not a scholar or an academic,(so don’t expect
too much!) I’m a family practitioner with an
interest in finance.
I’ve always been fascinated by money, not so
much in the obtaining or keeping it but in
the way it acts, the way it reacts, the way it
responds to our activities and how it tells us so much about our-
selves.
In just the same way as a microbiologist is fascinated by the be-
haviour of bacteria – the way they live, the way they adapt, the
way they coexist with us and sometimes the profound effects they
could have on us as humans, so I am fascinated by the entity we
call money. I’m fascinated by the effect our creation can have on
us.
For example, in a recent article in the Independent (a UK broad-
sheet paper) commenting on a survey done by the law firm Slat-
er and Gordon, it was reported that “A poll of over 2,000 British
adults by legal firm Slater and Gordon found that money worries
top the list of reasons why married couples split up, with one in five
saying it was the biggest cause of marital strife”. Further it was
reported that “Over a third of those questioned said that financial
pressures were the biggest challenge to their marriage, while a fifth
said that most of their arguments were about money. One in five of
those polled blamed their partner for their money worries, ­
accusing
them of overspending or failing to budget
properly”.
The effect money can have on our happiness,
our families, our children and often on our
health makes me believe it is equally impor-
tant as a subject of study as any infectious
agent.
In very early human interactions, bartering
seemed to be the way that we exchanged
time, goods and skills. It wasn’t long be-
fore we began to use intermediary methods
to value those things and to then use this
as a method of exchange. This intermedi-
ary method has included not just notes and
coins but a whole host of objects, for exam-
ple, animals, beads, salt, shells and cigarettes,
a widely used and recognised “currency” in
many prison populations.
The importance is not the “thing” but the value we attach to it. For
example, in Christopher Columbus’s time the value of gold to the
Spanish was as a form of currency, the more gold you had the richer
you were, whereas it appears that the Aztecs used gold primarily
in jewellery and ornaments. They seemed to put greater “monetary”
value on feathers, jewels, cotton and they used cacao beans as a cur-
rency. (ThoughtCo. The Treasure of the Aztecs. Christopher Minster.
Sept. 2017).
Though we may smile at this,we do similar things today.For example,
we invest in paintings, wine, comics, antiquities, cars and an assort-
ment of other things.In one retirement seminar at which I spoke,one
person who attended told me proudly of how he had travelled Eu-
rope buying fine wines which would help fund his retirement. When
I asked him about his last purchase he told me he had bought a case
of 12 excellent bottles of wine. When I asked him how many he had
left,he smiled a bit shyly and said “eight”.I informed him this was not
so much retirement planning as much as enjoying life.
Andrew Dearden
2
Editorial
I find it fascinating that either we learn to control our money or it
controls us. In some Christian scriptures, for example, debt is de-
scribed as a form of bondage. It has been said that we either work
for money or we can get money to work for us and so I’m amazed
at the number of methods we have created to increase our money,
to make it grow. We have devised a multitude of ways with various
degrees of risk and, in some cases, legality, in an attempt to increase
the money that we have. Whole industries have been created with
this single purpose in mind and it has developed its own language
and culture. This whole culture around money can be a lifetime’s
study and pursuit. It can also become an obsession.
I believe it is possible to determine what is important to each of
us, what we value and what we feel is important by reviewing how
and where we spend our money. If you were to examine your own
budget you would see how much money you spend on your home,
your garden, your family, travelling, your hobby, etc. You would also
see how much of your money (and therefore your time) you give to
charitable causes important to you.
Again, when speaking about retirement planning, I often suggest
that we review our spending and saving patterns as if we were an
outside external person with no knowledge of us personally. I sug-
gest we look to where our money goes, what it is used for and spent
on and then form an opinion on what is important to that person,
us, and see if it matches our view of ourselves.
I find the way money responds to external factors, for example eco-
nomic ones, is really a reflection of how we are responding to those
things.When the news reports that the markets are nervous they re-
ally mean we are nervous, when we are told the markets are panick-
ing they really mean we are. So sometimes we see money as some-
thing different to us, something separate as if it had a mind and will
of its own, yet in a very basic way, it reflects how we think and how
we feel. Many people “stockpile money” feeling this is important,
until an impending hurricane, for example, makes them shift priori-
ties and they exchange that stockpile for food, water, batteries, etc.
So, when I look at the accounts of an organisation like the BMA
or the WMA, I hope to see what is important to the organisation,
by seeing where, and on what they spend their money. Or at least
I would hope to be able to do so. But like the person who claims to
love to spend time with the family, but who in reality, rarely does,
sometimes it is hard to match our aims, aspirations, our core values
and functions with what we spend our money on.
By listening to members of any organisation when they discuss fi-
nances you can often judge how members value the organisation by
the amount of the willing to pay into it, in terms of not just money
but time (personal and corporate), the value they feel they get from
membership and over the past few years the changing attitudes of
younger people towards organisations. Membership loyalty cannot
be assumed from the younger generation in the same way that it
could be expected from my generation,for example.One only has to
look at how often my children generation change banks compared
to mine. (I’ve had the same bank since I was 17 in case you were
wondering!)
Accounts can tell us what we think about risk, member services,
teaching, planning or interactions with external agencies. Accounts
can tell us how strongly we feel about the statement of the Charles
Dickens’character Mr Micawber who stated “annual income twenty
pounds,annual expenditure nineteen pounds,nineteen shillings and
six pence, result happiness. Annual income twenty pounds, annual
expenditure twenty pounds ought (nothing) and six (pence), result
misery”. For the record, I think the statement to be 100% accurate
and financially astute.
We often see money as some sort of external thing,something sepa-
rate to ourselves, yet it is, in a very real way, a method in which we
“express” ourselves. In the same way painters have different styles
and different ways to express what they see, I think the same applies
to people and organisations and their money and what they value.
But as a final thought,most studies show that money does not make
us personally happier in a consistent and constant way, but our re-
lationships do.
Dr. Andrew Dearden
MBCCh FRCGP
Treasurer of the BMA and WMA
adearden@bma.org.uk
3
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Health Care
The frequency and veracity questions relating to
who regulates the regulators seems to have been
increasing in recent years and is a topic of atten-
tion in many countries around the world. This
paper based on a presentation at the fifth World
Health Professions Regulation Conference in
Geneva Switzerland addresses this question.
Through the use of documentary analysis four
specific themes Motivation, Challenges, Tools,
and Measurement Dimensions emerged from a
diverse range of sources. It is clear that there is
a wide range of approaches being taken to the
regulation of regulators but unfortunately there
is paucity of evidence on the relative effectiveness
and efficiency of these methods. After comparing
the results from this study with already pub-
lished work it is appropriate to conclude that if
regulators are to live up to the changing require-
ments of acting in the public interest, they must
show leadership in this agenda. By designing
robust reliable and valid metrics, transparency
and accountability can be enhanced and vulner-
ability to political whims potentially reduced.
Introduction
This article is based on a paper presented at
the fifth World Health Professions Regu-
lation Conference in Geneva Switzerland,
2018. Questions like the one posed in the
title of this article have been around for two
millennia. Indeed, as noted by Uden [1],
the first and second century Roman poet
and satirist Juvenal posed a similar ques-
tion “Who guards the guards themselves?”
(Quis custodiet ipsos custodes?). However,
from a regulatory perspective, the frequency
and veracity of such questions seems to have
been increasing in recent years and is a topic
of attention in many countries around the
world [2-6]. The reason for this increased
interest seems to be multifactorial. In some
cases, such as in the case of the United
Kingdom, interest in scrutinizing the per-
formance of regulators has, at least in part,
been driven by high profile regulatory sys-
tems failures such as those identified in the
Shipman Inquiry [7]. Such interest is often
amplified by intense media coverage [8-10].
In Australia, commitment to a reduction of
regulatory burdens and a focus on best prac-
tice has played a major role in their reform
agenda. Whereas in the United States [11]
the need to address the tension that can arise
between pursuit of economic market mod-
els and public interest protections has acted
as a major stimulus.Irrespective of the cause
for this increased interest a more detailed
understanding of the topic is warranted if
efficient and effective public protection is to
be assured. After all, some authors such as
Baetjer [12] would have us believe that reg-
ulators are not subject to scrutiny, lack ac-
countability and view the existing political
processes, designed to hold regulators to ac-
count, as ineffective. Accordingly, the time
would seem right to more critically examine
the issue of who regulates the regulators and
more importantly to consider to what effect
and purpose they should be regulated.
Aim
To systematically examine using documen-
tary analysis the approaches taken to hold-
ing regulators to account.
Method
A structured review of the published and
grey literature using a variety of search terms
combined in a systematic way through the
application of logical operators was con-
ducted.To generate the search terms a small
group of nurse regulators from around the
world were asked to suggest terms that could
be used to identify relevant literature. The
terms generated were as follows,((Regulation
OR Regulator OR Licensure OR Licensing)
AND (Performance OR Accountability OR
Review OR Sunset OR Sunrise OR Inquiry
OR Evaluation OR Audit OR Governance)
AND (Nurse OR Nursing)). In addition, it
was suggested that both published and grey
literature be searched as it was noted that
many of the reviews that have been under-
taken by legislative and other bodies are not
indexed in the peer-reviewed bibliographic
databases. Accordingly, the search terms
were used to interrogate Pubmed, Scopus and
Google search engines. The Initial yields of
papers identified were then reviewed for rel-
evance through scrutiny of the title and ab-
stract. Remaining papers were then retrieved
for more detailed consideration.
Regulating the Regulators?
David C Benton Julie George
UNITED STATES OF AMERICA
4
Analysis of papers
All retrieved papers were initially read
and reviewed for specific relevance to the
study aim. Any papers whose substantive
content was written in any language other
than English was rejected along with those
that did not address the study aim. At this
stage all those remaining papers were then
uploaded to NVIVO 11plus for detailed
analysis. All content relating to the over-
sight, scrutiny and review of the regulatory
body, its powers and actions were coded us-
ing the general inductive coding method as
described by Thomas [13]. This approach is
said to offer efficient and defendable pro-
cedures for analyzing qualitative data. The
method according to Thomas [13] draws on
best practices from a range of experts in the
field of inductive qualitative analysis and
accommodates and condenses large quan-
tities of varied text into meaningful and
related themes and concepts. In this case
both authors read all the material several
times and independently identified con-
tent that addressed the aim of the study.
Both researchers then compared and con-
trasted their coded work so as to identify
and agree content that formed the basis for
the identification of specific interventions
and associated thematic categories. Wes-
ley [14] insists that the trustworthiness of
the analysis must apply the same degree of
rigor as those approaches dealing with the
reliability and validity of quantitative stud-
ies. To enhance the trustworthiness and
precision of the analysis the researchers
completed a series of cycles of independent
coding, comparing and contrasting their
work followed by consensus agreement.
However, Tashakkori and Teddie [15] pro-
posed that a triangulation of analysis by the
researchers may not be sufficient to assure
trustworthiness. Tashakkori and Teddie
[15] suggest that any analysis should be
augmented and objectified by reference to
existing literature. To this end, the results
of the analysis was further compared and
contrasted with existing literature as part of
the discussion section.
Ethical Approval
As this study did not involve human sub-
jects and was based upon an analysis of
publicly available documentary sources the
study did not require ethical or institutional
approval. Nevertheless, the design and ap-
proach used was reviewed by two indepen-
dent researchers experienced in regulatory
and policy analysis. This review confirmed
the appropriateness of the planned meth-
odological approaches and procedures to be
used.
Results
A total of 3723 papers were identified and
after review of the titles and associated ab-
stracts one hundred and fifty eight were
retained for retrieval and further analysis.
On closer consideration of these papers a
further eighty seven papers were rejected.
Of those rejected, nine were published in
a language other than English and the re-
mainder either did not focus specifically on
the study aim or were opinion pieces. This
left seventy one papers for detailed review
and analysis.
The papers fell into four categories.The most
frequently found (n=39) could be classified as
sunset or legislative reviews where the func-
tioning of the regulator was under scrutiny
by the establishing or accountable oversight
body. However, there was no consistency to
the topics addressed by these reviews. Nor
did the reviews follow any standard struc-
ture,analytical approach or reporting format.
The next most frequent type of publication
was independently funded reviews by policy
think-tanks or philanthropic organizations
(n=16). Most of these papers were propo-
nents of a market based model of regulation
and frequently advocated for deregulation. A
few research studies in peer reviewed journals
were identified (n=10).These covered a range
of relatively narrow aspects of performance
such as the efficiency of notification of the
National Practitioner Data Bank [16]. The
least frequently found papers (n=6) were col-
lations of suggested best practices produced
by inter-departmental or intergovernmental
bodies such as the Organization for Eco-
nomic Co-operation and Development [17].
Thematic Content
Four specific themes emerged from the
analysis, Motivation, Challenges, Tools, and
Measurement Dimensions. Each theme had
several sub-themes and accordingly these
are reported in detail. Figure 1 provides a
synopsis of the composition of each of the
themes.
Motivation
Irrespective of the type of publication, all
papers offered an explanation of why it was
necessary to undertake the review of the
regulatory body or its functions thereby
specifying the motivation behind the work.
Closer examination of this theme identi-
fied that the motivating factors could be
classified under three main topics – control,
alignment and operational improvements. In
the case of control, the motivation related
to ensuring there was no abuse of power
granted to the regulator and that they re-
mained within the bounds of the purpose
and responsibilities delegated to them by
their establishing legislation. Alignment was
more specific in ensuring that the actions of
the regulators were in step with their public
protection mandate. Operational Improve-
ments were far more narrowly defined and
addressed specific aspects of the perfor-
mance of various functions as well mecha-
nisms to improve efficiency, effectiveness
and quality of the services being delivered.
Challenges
Multiple references in the documents were
identified, which highlighted the challenges
associated with holding regulators to ac-
count. These challenges are classified under
the three sub-themes of complexity, temporal
Health Care UNITED STATES OF AMERICA
5
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components and clarity & capacity. Measur-
ing the performance of regulators can be
complex as it is only recently that robust
research into the topic has been conducted.
Also the fact that there can be both inter-
nal and external overlapping responsibilities
can make determining accountability more
challenging. For example, in the case of an
internal overlap where a board of nursing
is part of an umbrella structure and it does
not have control of some of its key resources
such as their investigators. Consequently,
it is difficult to attribute accountability for
both success and failure. Similarly, in the
case of educational program approval where
the Department of Education requires ac-
creditation to be conducted and the board
of nursing has overlapping program re-
sponsibilities determining how these dif-
fering approaches interact can be complex
to unpack. The temporal component refers
to the time taken to identify and resolve
issues. Sometimes there can be criminal
procedures taking place in parallel with the
investigation of conduct or performance
complaints. Ensuring a speedy resolution
can be a challenge. Finally, the difficulties
of precisely specifying clear measures that
are robust, reliable and valid can, along with
the relevant board and staff capacity to in-
terpret and respond to the findings, pres-
ent leadership of the organizations as well
as any oversight entities both operational
and strategic challenges. For example, in-
creasingly boards of nursing have enormous
amounts of digital data that relate to their
core purpose yet the analytical capacity to
interrogate and interpret such material may
be limited or in some cases entirely absent.
Measurement Dimensions
From consideration of the various reviews
conducted it is possible to identify that the
measures used to hold the regulators to
account are multidimensional. While the
studies do not frame the measures used as
a set of polar-opposites it is a useful way to
consider the evidence identified. As can be
seen from Figure 1 there is a framework of
four dimensions that can be used to classify
measures that can be used to hold the regu-
lator to account (Level, Frequency, Status,
and Methodological Approach).
A wide range of tools, techniques and pro-
cedures were identified as being used to
hold regulators to account. Some of these
are general in nature and amenable for use
across a range of responsibilities. Other
approaches were far more specific and ad-
dressed a single aspect of the board’s func-
tioning. Collectively these two aspects can
be used to delineate the coverage of the spe-
cific tools, techniques and procedures used
(Figure 2). In addition, the potential impact
of these approaches could be further classi-
fied as being either weak or strong.
Although it is not illustrated as part of Fig-
ure 2, it would also be possible to further
classify these interventions as either rou-
tine or ad-hoc, as well as being internally
or externally focused. These classifications
are congruent with the dimensions already
noted under the measurement theme.
Discussions
It has been reported by Baugas and Bose
[18] (2015) that 36 of the 50 US states have
some form of sunset legislation providing
regular scrutiny to the laws that govern
regulation and other controls on services
offered to citizens. In some cases, the sun-
set review is mandated on a regular cycle
whereas for other States it is an optional
power that the legislature can bring into
play when necessary either due to specific
performance problems or in some cases due
to political exigencies. It is clear from the
results presented in this paper and the find-
ings of Baugas and Bose [18] that this is a
common approach used to scrutinize the
performance of regulatory bodies. However,
Figure 1.  Themes from the Inductive Qualitative Analysis of Documents
Health Care
UNITED STATES OF AMERICA
6
the non-standardized methods used, the ir-
regularity of frequency, and inconsistency of
reporting means that it is difficult to track
improvements over time or provide oppor-
tunities for comparison between regulators.
These comparisons could be across regula-
tors in the same jurisdiction or for specific
regulators that regulate the same discipline
across jurisdictional boundaries. This vari-
ability, while in some cases addressing de-
fined concerns, denies legislators and the
regulators themselves an opportunity to
benchmark and learn from optimum prac-
tices.
One approach to address this problem
would be to attempt to generate a normative
movement through conducting an integra-
tive review of the sunset reports and their
associated guidance so as to identify best or
at least promising practices that could then
be followed.
An alternative way to address variability
would be to use the finding of this study
to design a set of regulatory metrics that
are cognizant of the challenges identified
and utilize sound measurement design ap-
proaches. The resulting, clearly defined
metrics can then be uniformly gathered so
comparisons both within and across juris-
dictions would be possible. The addition of
such metrics to the plethora of tools and
approaches already in place would poten-
tially add value to the many existing efforts
of holding regulators to account. Again,
the production of such measures, ideally
through a collaborative-based generative
approach would provide an opportunity to
take advantage of the normative impact of
developing standards of best practices. Ulti-
mately, based on the experience of the Na-
tional Council of State Boards of Nursing
Commitment to Regulatory Excellence[19]
(CORE) program, this approach should
provide opportunities for increasing effi-
ciency, effectiveness, transparency and ac-
countability of the regulator. A more radical
approach,but one that may be viewed by the
legislators as being more proactive, would
be for regulators themselves to develop and
implement an accreditation system where
peers provide expert commentary against a
set of well defined standards of best regula-
tory practices.
Work by others have identified that the di-
mensions of regulatory accountability have
been changing. Some authors [20-22] have
explored and documented how professional
regulation has changed over the years. A
closer look at their work enables a synopsis
of key features of how the concept of act-
ing in the public interest, captured in the
three boxes, has evolved both in terms of
increased complexity and additional dimen-
sions (Figure 3). Identification of these di-
mensions potentially provides a useful basis
for augmenting the findings of this study in
developing evidence based approach to the
review of regulators.
In recent years, at least in the nurse regula-
tory space some attempts have been made
to identify and use more robust, reliable
and valid performance metrics. Benton et al
[23] in their global Delphi study identified
a multi-dimensional framework for the per-
formance assessment of nurse regulators. In-
deed, this framework was subsequently used
by Clarke et al [24] across five different disci-
plines (medicine, dentistry, midwifery, nurs-
ing and pharmacy) in Cambodia to bench-
mark and contrast their relative performance
as a means of seeking opportunities for qual-
ity improvement. More specific interest into
addressing the question of to what extent
are the administrative structures of regula-
tory boards having an impact of efficiency,
effectiveness and public safety is also being
addressed [25].The work of the Washington
State Care Quality Assurance Commission
[26], North Carolina General Assembly
[27], Benton et al [25], and Benton and Ra-
jwany [16] are all congruent with the wider
recommendations of the Organization for
Economic Co-operation and Development
[17] highlighting the advantages in terms of
effectiveness of assuring the independence of
regulatory bodies who advocate for a proac-
tive approach to performance review.
Conclusions
This study demonstrates that Baetjer [12]
view of regulators being unregulated is far
from the truth.There is already a wide range
Coverage
Specific
• 
Complaints
• 
Regulatory Impact
Assessment
• 
Peer Review
• 
Freedom of Information
Request
• 
Benchmarks with Best
Practices
• 
Judicial Reviews
• 
Media Reports
• 
Board Appointments/
Removals
• 
Audit Reports
• 
CEO Appointments
• 
Organizational Competence/
Scope
General
• 
Annual Reports
• 
Parliamentary Committees
• 
Lay Board Member
Appointments
• 
Consultation Requirements
• 
Giving Reasons for decisions
• 
Publishing Minutes
• 
Webcasting meetings
• 
Ministerial/Governor
Direction
• 
Funding Control
• 
Sunset Reviews
• 
Super-Regulators
Weak Strong
Impact
Figure 2.  Current Approaches to Holding Regulators to Account
Health Care UNITED STATES OF AMERICA
7
BACK TO CONTENTS
of tools being used. However, we agree with
Baetjer [12] in his contention that there is,
as yet, no robust and consistent approach to
regulatory performance review. Variabilities
in approach, frequency and measures re-
sult in a sub-optimum patchwork of find-
ings. Despite there being a wide range of
approaches to the regulation of regulators
there is currently a paucity of evidence on
the relative effectiveness and efficiency of
these methods. Regulators both within the
same discipline, across jurisdictions, as well
as those from different disciplines, within
the same jurisdiction, need to collaborate to
standardize performance metrics. Such col-
laborations could generate data collection
methods that subsequently could offer the
basis for the identification of best practices
to optimize and systemize the pursuit of
regulatory excellence. Accordingly, if regu-
lators are to live up to the changing require-
ments of acting in the public interest, they
must show leadership in this agenda. By
designing robust reliable and valid metrics,
transparency and accountability can be en-
hanced and vulnerability to political whims
potentially reduced.
The authors wish to thank Dr Máximo
González-Jurado and Dr. Juan Beniet-Mon-
tisinos for the helpful comments on the design
of this study.
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David C Benton PhD RGN FRCN FAAN
Chief Executive Officer
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of State Boards of Nursing
USA
Julie George MSN RN FRE
Executive Office
North Carolina Board
of Nursing &
President
National Council
of State Boards of Nursing
USA
E-mail: dbenton@ncsbn.org
Medical professionals and healthcare prac-
titioners are fundamentally motivated to
help patients improve their health and limit
the impact of their illness. Achieving this
in a way that respects the patient’s dignity,
as well as their preferences and values, is
Patient-reported Indicator Survey (PaRIS):
Aligning Practice and Policy for Better Health Outcomes
Luke Slawomirski Michael van den Berg Sunita Karmakar-Hore
9
BACK TO CONTENTS
Health Care
the underlying reason  – and the intrinsic
reward – for choosing a profession in the
challenging and demanding field of health-
care.
Given the global trend of increased ex-
penditure on health care as a share of na-
tional income, it is therefore surprising
that systematic, empirical measurement of
the outcomes and experiences of care from
the patient’s perspective is still the excep-
tion in most healthcare systems across the
world [1, 2]. This gap in knowledge limits
the ability for evidence-based policy mak-
ing and value-based health care, which
aims to maximise benefits of health care at
an acceptable cost (including opportunity
cost of alternative investment of these re-
sources).
This knowledge-gap impacts medical prac-
tice in two crucial and related ways. First,
healthcare providers lack information on
the effect of their work on factors valued by
their patients such as pain, function, inde-
pendence, and being treated with compas-
sion and respect. Second, this lack of in-
formation is a missed opportunity to frame
clinical activity around the person in front
of you – to ask ‘what matters to you’? rather
than ‘what’s the matter with you?’ [3] Bet-
ter information on outcomes and experi-
ences of care is also needed by policy mak-
ers trying to reorient the healthcare system
to meet the needs and expectations of the
communities it serves.
In this paper we seek to describe the cur-
rent shortcomings of measurement in
health care, what changing this means for
medical practitioners, and how the Patient-
Reported Indicator Survey (PaRIS) – a new
OECD initiative – can help health profes-
sionals measure what matters to their pa-
tients.
Outcome Measures
Miss a Very Important
Perspective: the patient’s
Medicine is fundamentally a scientific en-
deavour and, like all sciences, based on em-
pirical measurement and observation.Many
metrics are collected in health care but not
always those that tell us about of the impact
of care on patients’ lives.The problems with
traditional measurement in health can be
distilled to three concerns.
One: we confuse outputs with
outcomes
The number of procedures performed or
drugs prescribed are commonly measured.
But these describe outputs not outcomes.
While they have their use in some contexts,
they are inconsequential to the outcomes of
interventions.
For example, the age-adjusted rate of total
knee replacements in OECD countries has
more than doubled since the year 2000, ris-
ing from 55 to 119 per 100,000 population
(Figure 1). Rates vary more than 4-fold
between countries, and similar variation is
also observed within countries by hospital
or geographic region [4]. Such differences
provoke questions about the value gener-
ated for patients, and for communities that
pay for these procedures, which are expen-
sive, involve a lengthy and painful recovery
period, and are not without risk. Which
rates are justified by commensurate patient
outcomes compared to other treatment
modalities? What proportion of patients
experience an acceptable improvement in
their pain and symptoms? How many ex-
perience improved mobility, and to what
extent? In the majority of countries we
do not know. A recent US study of about
4,000 patients who underwent total knee
replacement suggests that most experience
no improvement in their symptoms [5].
But systematic data across entire healthcare
systems are rare.
Readmission and revision rates following
knee replacement – outcomes that most pa-
tients wish to avoid – are often measured
but shed little light on the other important
outcomes: less pain and better function.
These data can’t be harvested from admin-
istrative information systems but must be
Figure 1.  Total knee replacement rates per 100,000 population in selected OECD
countries and the all-OECD age-adjusted average, 2000–2015
Source: https://stats.oecd.org
Note: National average of 29 OECD countries adjusted for increased life expectancy (reference year: 2000)
10
collected from patients themselves, and
are needed to answer important questions
about effectiveness and value.
Two: ‘hard’ outcome metrics
have their limits
Certain outcome measures, while useful
and informative in some instances, are too
blunt to capture the subtle effects of many
medical interventions. For example, in ad-
dition to readmission and surgical revision
metrics, mortality outcomes are commonly
used in some sectors and specialties. Pa-
tient suicide is an important sentinel met-
ric, but only one of several indicators to
help us understand how well mental health
programs are working. Patient-reported
anxiety and depression, sleep quality and
social health status are softer but equally
important metrics that should be collected
systematically to inform practice and pol-
icy.
Survival or mortality rates are tradition-
ally deployed as the prevailing outcomes
for many pathologies. But these lack the
granularity and responsiveness to tell us
how well treatments are working at the
individual level. People diagnosed with
cancer highly value surviving the dis-
ease – but when these patients and their
families are asked, it is clear that thera-
peutic ‘success’ entails more: pain control,
retaining independence, ability to sleep
and perform normal activities of daily liv-
ing [6, 7]. Yet, measuring the effectiveness
and the value of cancer treatment rarely
extends beyond mortality [8], despite the
convergence on these measures in recent
years (Figure 2). In a growing number of
pathologies survival lacks sufficient sensi-
tivity to differentiate between therapies,
regions, hospitals or other units of mea-
surement – little separates the best from
the rest [9, 10, 11].
This evolution is also a cause for celebra-
tion  – modern medicine has become so
good at treating this disease that it now
limits how much we can learn from mortal-
ity statistics. To explore the full impact of
treatment on the patient, other outcomes
need to be considered. Men with prostate
cancer, for example, place high value in
preserving erectile function and avoiding
incontinence  – outcomes for which the
survival metric cannot capture and which
require direct input from the patient [12].
Other outcomes valued by patients re-
ceiving treatment for a range of acute and
chronic conditions include self-rated health
status, fatigue, limitations on daily activities
and bodily functions.
Three: the patient experience
matters more and more
The experience of care is important for all
patients, especially the growing cohort with
multiple chronic conditions who need to
manage their health over time and with the
help of a range of healthcare providers. The
care experience includes being treated with
respect and compassion, being supported,
listened to and involved in decision making;
it also means that care is integrated across
teams who communicate with each other
and with the patient. A good experience of
care is an important end in itself especially
for patients with complex health needs for
whom navigating a fragmented health sys-
tem is challenging, frustrating, time con-
suming and costly.
A positive care experience is also associ-
ated with better clinical outcomes, and is a
strong signal of a well-run healthcare prac-
tice or organisation [13, 14, 15]. While in
some sectors of care, such as palliative and
end of life care, dimensions of the care ex-
perience  – compassion, dignity, respect of
patient and family wishes – arguably com-
prise the most important, alongside pain
control, for patients and their loved ones.
While considerable progress has been made
in some places, the care experience is not
captured systematically or routinely com-
pared to other healthcare metrics.
Patient-reported measures
are an opportunity to
improve practice and
optimise results
Patient-reported outcomes and experience
measures  – PROMs and PREMs  – can
enable clinicians to improve their practice,
communication and outcomes in several
ways [16]. Nevertheless, many practioners
are anxious about collecting these data from
their patients and about the way in which
these data may be used. In our discussions
with providers, practical and professional
Figure 2.  Age-standardised mortality from cancer, 2013
Source: https://stats.oecd.org/
Health Care
11
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issues are often cited including additional
clinical and administrative burden, the va-
lidity and reliability of these metrics, their
use in pay-for-performance (P4P) schemes,
and the jettisoning of useful existing met-
rics.
Patient-reporting can
improve clinical practice
Collecting PREMs and PROMs may
seem like additional work for providers.
However, given the benefits, it should
not be viewed that way. Rather, collecting
these data should be seen as part of good
practice  – as routine as taking a sound
history and vital signs. PROMs especially
can add more structure and rigour to the
oral history during initial and subsequent
consultations, yielding valuable clinical
information that enables care tailored
to individual patient needs, especially in
complex cases. One randomised study
found that during chemotherapy, regu-
lar patient-reporting of symptoms such
as pain and nausea was associated with
significant reductions in emergency de-
partment visits, better quality of life and
longer survival [17, 18].
Shared clinical decision making can be dif-
ficult for providers and patients, even for
patients with higher socioeconomic sta-
tus [19]. PROMs and PREMs can enable
more effective partnering between pro-
viders and their patients, particularly for
preference-sensitive care [20, 21]. Deci-
sions may also be based on aggregated out-
comes and experiences of other patients.
As a result, clinical conversations change,
and care cycles pivot to what patients
need and prefer. Aggregated PREMs and
PROMs data are also an opportunity to
monitor and improve practice and policy
at a system level over time, through mean-
ingful benchmarking across organisations
[22]. The data can be used to develop and
update clinical guidelines and decision-
support tools.
Rather than increasing clinical workload,
jurisdictions implementing routine PREMs
and PROMs collection are reporting that
this can actually streamline clinical pro-
cesses and the flow of information [23, 24,
25]. Data submitted by the patient prior
to a consultation identifies in a structured
and consistent way their clinical status and
needs.This information is useful for triaging
patients, and better preparing the clinical
team. Using digital tools like smartphone
apps or web portals can further streamline
this process, and enable the patient to pro-
vide their data at their convenience. Link-
age with electronic health records means
that information is delivered directly to the
practitioner’s desktop with minimal delay
[26].
Nevertheless we do acknowledge that the
number of metrics collected by provid-
ers are has grown over the years. Calls
are heard to modernise data collection
methods, improve information feedback
to providers and patients in addition to
rationalising the amount of measurement
required and to focus on what truly mat-
ters [27]. However, we would argue that
PREMs and PROMs are indispensable
metrics that should be routinely collected.
Use of the right state-of-the-art technol-
ogy could greatly reduce administrative
burden, and with enough interest and
investment data collection could become
partly automated in the future. For exam-
ple, a patient’s mobility can be uploaded
from a wearable device or smartphone,
rather than manually reported in paper or
electronic form. This would not only re-
duce the burden but also boost the quality
of the data.
Patient-reported measures
are valid and robust
The validity and the sensitivity of PREMs
and PROMs is often questioned as is their
ability to discern the influence of a clini-
cal intervention from other factors that
influence outcomes. On the first point, the
development and validation of the various
tools to measure outcomes and experience
from patients is decades old. PROMs have
undergone rigorous psychometric test-
ing and statistical validation, with results
published in the peer-reviewed literature.
The evidence for disease-specific and ge-
neric tools measuring what is intended in
a valid and objective way is sound [28].
Data are collected at various time points
throughout a patient’s care, or pre- and
post-intervention, reducing recall bias by
eliciting responses for the various dimen-
sions and outcomes of interest at the time
of reporting. PROMs instruments for a
specific condition or intervention seek
scaled responses in the relevant dimensions
(e.g. pain, anxiety, function and mobility)
in a standardised, unambiguous way. Many
have been translated into various languages
and validated across a number of countries,
in order to take linguistic and culture nu-
ances into consideration.
PREMs also are now sophisticated and
sensitive, beyond the patient ‘satisfac-
tion’ surveys that many providers may
have encountered in the past. They elicit
scaled data across a range of dimensions
including accessibility, communication,
continuity and confidence. These data
are now used to inform assessment and
international comparisons of health sys-
tems [29].
Some factors that influence the outcomes of
care – patient behaviour, adherence to treat-
ment as well as age and comorbidities – are
beyond the clinician’s control. However,
this problem can be attributed to any met-
ric. Readmission, death and infections are
all subject to these confounding variables.
Singling out patient-reported measures
specifically in this manner is arbitrary. And
like any data that are reported and bench-
marked, confounders for patient-reported
indicators can and should be adjusted for
in order to make meaningful comparisons
[30]. This is also a way to correct for differ-
Health Care
12
ent response-tendencies between groups of
patients.
The goal is to facilitate
learning and improvement
On the question of P4P, collecting and re-
porting these data would help learning and
improvement. P4P is being tested in many
healthcare systems, but the evidence on
what financial incentives work best in im-
proving ‘performance’ is not clear-cut [31].
Numerous reasons exist for this. As previ-
ously noted, a fundamental motivation for
medical practitioners is the desire to im-
prove their patients’ lives. Financial incen-
tives are difficult because they often focus
on individual elements to be rewarded, and
may lead to clinicians focusing on certain
elements of their care only, while good care
is a product of individual, systemic and or-
ganisational factors.
With P4P, it is also difficult to reflect the
inherent complexities of modern medi-
cine which, in highly functioning systems,
is the product of an integrated healthcare
team involving numerous practitioners and
support staff working within and across
­
organisational boundaries and communities
over time. It has proved difficult to design a
scheme that effectively and equitably targets
financial rewards or penalties [32, 33]. Pro-
viding feedback and information on vari-
ous dimensions of ‘performance’ stimulates
continuous improvement across health care
teams [34]. This, of course, should include
information reported by the patients receiv-
ing care.
Patient-reported measures will
complement – not replace –
existing outcome indicators
While traditional outcome metrics such
as mortality or hospital readmission have
their limitations, they also have an impor-
tant place in informing policy and practice.
For many diseases and interventions, these
metrics remain valuable for making clini-
cal decisions and monitoring performance.
PREMs and PROMs are meant to comple-
ment – not replace – these important indi-
cators.
We also wish to point out that reporting
and benchmarking traditional outcome
metrics  – such as standardised mortality
rates – were also resisted when first intro-
duced. However, with time they have be-
come an accepted outcome measure. The
richness and granularity of health care
evaluation would be greatly enhanced by
also including information reported by pa-
tients.
How can an international
initiative like PaRIS
help practitioners?
In January 2017 OECD Health Minis-
ters met in Paris to discuss the next gen-
eration of health reforms. These discussions
revealed clear political momentum to pay
greater attention to what matters to pa-
tients. The resulting Ministerial Statement
[35] calls on health systems to become more
people-centred by developing international
benchmarks of health system performance
as reported by patients themselves. The
statement makes clear the nexus between
the core objective of medical professionals
and policy makers  – between policy and
practice.
Taking forward this mandate, the OECD
launched the Patient Reported Indictor
Survey (PaRIS) initiative. PaRIS aims to
build international capacity to measure and
compare care outcomes and experiences
as reported by patients, using indicators
that enable comparisons across countries.
It also aims to encourage patient-reported
measures to evolve in a common direction
internationally, to enable shared learning,
development and research.
PaRIS hopes to advance
by accelerating routine
adoption
Up to now, routine collection of patient-
reported measures has been predominantly
led by forward-thinking clinicians and
health services. Collection of PROMs in
specific conditions like cancer or osteo-
arthritis is growing in a number of coun-
tries. An objective of PaRIS is to support
countries where such initiatives already ex-
ist to accelerate the routine adoption and
reporting of validated, standardised, inter-
nationally-comparable patient-reported
measures, and to disseminate useful learn-
ings and insights to other countries wishing
implement PROMs. It is also to encourage
development of common metrics and in-
dicators that can enable comparisons and
learning at national and international levels.
OECD has established international work-
ing groups comprising clinicians, patients,
academics and policy makers to develop
patient-reported indicators suitable for in-
ternational comparisons in elective arthro-
plasty (hip and knee), breast cancer and
mental health, with the ambition to report
commence reporting in 2019.
An information gap needs
to be addressed
The proportion of people in OECD coun-
tries who suffer from one or more chronic
condition is growing. This cohort does not
fit neatly into one disease category and most
receive routine follow-up care in primary
care or other ambulatory settings. Often,
different providers are involved and people
must navigate fragmented, un-coordinated
care. The result is substandard care, and
systematic data for this group of patients is
virtually non-existent.
PaRIS is therefore developing a new in-
ternational survey on outcomes and ex-
periences of patients with one or more
chronic conditions. This new survey will
Health Care
13
BACK TO CONTENTS
measure both PROMs and PREMs in-
cluding health status, pain, fatigue, func-
tion, anxiety and depression, access, com-
munication and care continuity. Indicators
will be selected on the basis of criteria such
as reliability, validity, relevance, feasibility
and fitness for use. The survey will make
variation within countries visible.Together
with other data, this will help shed light
on variations in care and how successful
healthcare systems and organisations are in
responding to the needs of this important
group of patients.
A rising tide can lift all boats
How can country-level reporting and
benchmarking of patient-reported indica-
tors influence grass roots clinical practice?
OECD collects a range of indicators, many
of which concern the quality and outcomes
of care. Some of these – cancer survival and
hospital readmissions – have been discussed
above. The aim of international reporting
of these, like any other indicator, is not to
create league-based tables but to flag areas
of care that may need greater examination
and drive quality improvement strategies.
Each country runs its health system in a
unique context, based on its own priori-
ties, values and resourcing constraints. The
value of international reporting lies in the
provision of accurate, timely and consistent
information on a range of structural,process
and outcome measures that is critical to the
effective governance and functioning of any
healthcare system.
Practice and policy should be based on solid
evidence and continuous measurement.
OECD provides a forum for countries to
learn and to improve the way these data are
collected and indicators are generated. Nu-
merous examples exist where improved data
collection at the country level has generated
tangible benefits.
The objective of PaRIS is no different. Its
aim is to help participating countries build
their internal capacity to reliably measure
this very important dimension of health
care, and to deploy this information for
continuous learning and improvement in
clinical practice to policy. Countries are
at very different stages of implementing
patient-reported measures, and PaRIS pro-
vides a platform and a set of tools to achieve
the necessary transformation – a rising tide
that can lift all boats.
Many outputs are measured and reported in
health care. However, metrics on improv-
ing health, limiting the impact of disease
and experience of care are currently lack-
ing. The systematic collection of this infor-
mation through PROMS and PREMS is
an important lever to meet the needs and
expectations of patients in an increasingly
complex and challenging environment. The
OECD PaRIS initiative aims to help coun-
tries institute consistent and reliable col-
lection of patient-reported measures across
their health systems.
Healthcare practitioners and providers
have much to gain from collecting and
using patient-reported measures if imple-
mented in concert and with proper sup-
port from administrators, health system
managers and policy makers. PROMs and
PREMs can and should be part of routine
patient care, as a robust way to gather in-
formation from patients to better inform
their clinical care and improve the health
system for the benefit of patients, providers
and societies.
Disclaimer: The opinions expressed and ar-
guments employed herein are those of the
author and do not necessarily reflect the of-
ficial views of the OECD, CIHI, or of the
governments of OECD’s member coun-
tries.
References
1. OECD. Health at a Glance. OECD Publish-
ing, Paris. 2017 www.oecd.org/health/health-
systems/health-at-a-glance-19991312.htm
2. OECD. Recommendations to OECD Min-
isters of Health from the High-Level Reflec-
tion Group on the Future of Health Statistics.
OECD Publishing, Paris. 2017 www.oecd.org/
els/health-systems/Recommendations-from-
high-level-reflection-group-on-the-future-of-
health-statistics.pdf
3. Don Berwick, OECD Policy Forum on the Fu-
ture of Health, 16 Jan 2017 http://www.oecd.
org/health/ministerial/policy-forum/
4. OECD. Geographic Variations in Health
Care: What Do We Know and What Can
Be Done to Improve Health System Perfor-
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5. Ferket BS, et al. Impact of total knee replace-
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6. Abahussin AA; West RM; Wong DC; Ziegler
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7. Msaouel P; Gralla RJ; Jones RA; Hollen
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with initial psychometric assessment of
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tent/7/3/308.long
8. Allemani C, et al. Global surveillance of
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37 513 025 patients diagnosed with one of 18
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1023 – 1075
9. Hamdy F et al. 10-Year Outcomes after Moni-
toring, Surgery, or Radiotherapy for Localized
Prostate Cancer. NEJM 2017; 375:1415-1424.
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11. Gurria, A and Porter, M. Putting people at the
centre of health care. HuffPost 2017 https://
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and Bosco III, J. A. Patients’ perceptions of
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zarelli, A. J. Association between Medicare
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ing patient-centered care: a qualitative study
of facilitators and barriers in healthcare or-
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intqhc/mzr024
16. Agency for Clinical Innovation. Evidence for
Patient-reported measures. ACI, Sydney. 2017
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assets/pdf_file/0005/389453/Evidence-for-
PRMs-August-11-2017.pdf [accessed 1 Aug
2018]
17. Basch, E ‘Patient-Reported Outcomes—Har-
nessing Patients’ Voices to Improve Clinical
Care’, NEJM 2017; 376, no. 2, pp. 105-108.
18. Basch E, Deal A, Kris M et al., Symptom moni-
toring with patient-reported outcomes during
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19. Adams JR, Elwyn G, Légaré F, Frosch DL.
Communicating With Physicians About
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doi:10.1001/archinternmed.2012.2360
20. Veroff D, Marr A and Wennberg D, En-
hanced Support For Shared Decision Making
Reduced Costs Of Care For Patients With
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Preference-Sensitive Conditions, Health Affairs
2013;32(2):285–293 10.1377/hlthaff.2011.0941
32, NO. 2 (2013): 285–293
21. Dartmouth Atlas of Health Care. Preference-
sensitive care. http://www.dartmouthatlas.org/
keyissues/issue.aspx?con=2938 [accessed 7 Aug
2018]
22. Canadian Institute for Health Information,
Statistics Canada. Health Outcomes of Care:
An Idea Whose Time Has Come – A Frame-
work for Health Outcomes. 2012 https://secure.
cihi.ca/free_products/HealthOutcomes2012_
EN.pdf
23. Agency for Clinical Innovation. Patient-report-
ed measures: Formative evaluation.ACI,Sydney.
2017
24. NHS Digital. Benefits case study: Patient-Re-
ported Outcome Measures (PROMs) outputs.
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uk/20180307185757/http:/content.digital.nhs.
uk/media/16547/full-PROMs-benefits-case-
study/pdf/promscasestudy.pdf
25. Devlin, NJ et al, Getting the Most out of
PROMs: Putting Health Outcomes at the
Heart of NHS Decision-Making, 2010 The
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fault/files/Getting-the-most-out-of-PROMs-
Nancy-Devlin-John-Appleby-Kings-Fund-
March-2010.pdf
26. Wagle NW. Implementing Patient-Reported
Outcome Measures. NEJM Catalyst. October
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ures/
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Care.  JAMA. 2016;315(13):1329–1330.
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could help transform healthcare BMJ 2013;
346:f167
29. Schneider W et al. Mirror Mirror 2017: Inter-
national Comparison Reflects Flaws and Op-
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mirror/
30. Nuttall D, Parkin D, Devlin N. Inter-provider
comparison of patient-reported outcomes: de-
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pay-for-performance schemes. BMJ Qual Saf.
Online First: 30 July 2018. doi: 10.1136/bm-
jqs-2018-008088
33. OECD. Better ways to pay for health care.
OECD Health Policy Studies 2016. Paris
34. C Cashin, Y-L Chi, PC Smith, M Borowitz,
S Thomson: Paying for performance in health
care: implications for health system perfor-
mance and accountability, European Observa-
tory on Health Systems and Policies Series 2014
http://www.euro.who.int/__data/assets/pdf_
file/0020/271073/Paying-for-Performance-in-
Health-Care.pdf
35. OECD Health Ministerial Meeting, January
2017.Minsters’Statement http://www.oecd.org/
health/ministerial/ministerial-statement-2017.
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Luke Slawomirski
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Co-operation and Development
(OECD), Paris
Michael van den Berg
Organisation for Economic Co-operation
and Development (OECD), Paris
Sunita Karmakar-Hore
Canadian Institute for Health
Information (CIHI), Toronto
E-mail: luke.slawomirski@oecd.org
Following the violations of medical ethics
committed by physicians during the Nazi
regime and immediately after the Nurem-
berg revelations, the World Medical As-
sociation adopted two documents that em-
bodied the Hippocratic Oath and asserted
the prohibition of physician complicity in
antihumanitarian acts.
The Declaration of Geneva affirms the
medical professional’s pledge “to dedicate
their lives to the service of humanity”and “to
not use medical knowledge to violate human
rights and civil liberties, even under threat”.1
The International Code of Medical Ethics
sustains the physician’s duty to provide “com-
petent medical service in full professional
1 
WMA Declaration of Geneva, 2017. Retrieved
from https://www.wma.net/policies-post/wma-
declaration-of-geneva/ on August 17, 2018.
Physician Complicity in Capital Punishment
Violating the ethical obligation to do no harm
Ethical Aspects of Health Care UNITED STATES OF AMERICA
15
BACK TO CONTENTS
and moral independence, with compassion
and respect for human dignity”.2
These documents not only make it explicit
that medicine is a therapeutic and com-
passionate field but also that the medical
professional has a duty to uphold medical
ethics in the face of contravening laws or
regulations. This idea is portrayed clearly in
the WMA Council Resolution in the Re-
lation of Law and Ethics.3
It follows then
that physician involvement in the admin-
istration of capital punishment is ethically
proscribed because it violates the ethical
principles of the profession.
In the Islamic Republic of Iran, physicians
have been implicated as complicit in the
sentencing of persons convicted of crimes
committed as juveniles (below the age of
18) to the death penalty. In June 2018, a
2 
WMA International Code of Medical Eth-
ics, 2006. Retrieved from https://www.wma.net/
policies-post/wma-international-code-of-medical-
ethics/ on August 17, 2018.
3 
WMA Council Resolution on the Relation of
Law and Ethics, 2003. Retrieved from https://
www.wma.net/policies-post/wma-council-resolu-
tion-on-the-relation-of-law-and-ethics/ on August
17, 2018.
19‑year old Iranian teenager was executed.
His sentence had been issued based on an
official medical opinion that he was “men-
tally mature” at the age of 14 when the
crime of which he was convicted had taken
place.In its verdict,the court cited an expert
medical opinion from the Legal Medicine
Organization of Iran, which stated without
explanation that he had gained “full matu-
rity” at the age of 14.4
Most crucially, this teenager is the fourth
individual since the beginning of 2018 to
be executed after being convicted of crime
committed when under the age of 18.There
are at least 85 other juvenile offenders who
currently remain on death row based on
medical maturity assessments.5
The issue of concern is twofold. Firstly, such
physicians are complicit in the administra-
tion of capital punishment, which as men-
tioned is a direct violation of their ethical
duties as medical professionals.
Secondly, it is a matter of violating the
rights of a child, by both physicians and the
Iranian government.
Under international law and in accordance
with international principles of juvenile jus-
tice, including articles 17.1 and 17.2 of the
United Nations Minimum Rules for the
Administration of Juvenile Justice (“The
Beijing Rules”) [6] and the International
Covenant on Civil and Political Rights6
to
which Iran is a State Party, the use of the
4 
Iran: Teenager’s execution exposes complicity
of courts, parliament and doctors in assault on
children’s rights. Amnesty International Pub-
lic Statement, 29 June 2018. Retrieved from
https://www.amnesty.org/download/Documents/
MDE1386962018ENGLISH.PDF on August
17, 2018.
5 Ibid.
6 
International Covenant on Civil and Political
Rights, 1966. Office of the High Commissioner
of Human Rights, United Nations. Retrieved
from https://www.ohchr.org/en/professionalinter-
est/pages/ccpr.aspx August 17, 2018.
death penalty against people who were be-
low the age of 18 at the time of the crime
they are convicted of committing is abso-
lutely prohibited.
The decision of countries such as Iran to
continue to administer the death penalty
among persons who committed crimes as
juveniles is also in direct opposition to the
Convention on the Rights of the Child,7
which Iran has ratified. This Convention
writes: State parties shall ensure that: No
child shall be subjected to torture or other
cruel, inhuman or degrading treatment or
punishment.
It should be noted that this interpretation
depends on what one considers capital
punishment to be. If we are to consider the
death penalty as torture or inhuman treat-
ment, then it is not only in violation of the
Rights of the Child, but it is also in viola-
tion of the Universal Declaration of Hu-
man Rights, which explicitly dictates under
Article 5 that “no person shall be subjected
to torture or to cruel, inhuman or degrading
treatment or punishment”.8
Nevertheless, the Universal Declaration of
Human Rights is non-binding. Countries
are not internationally mandated to abide
by the provisions of this declaration.
In fact, the Iranian Penal Code in many
ways is abiding by the tenets of human
rights. In relation to juvenile crimes for
example, children who commit crimes are
not immediately subject to execution or the
death penalty; rather, they are sentenced to
7 
Convention on the Rights of the Child, 1990.
Office of the High Commissioner for Human
Rights, United Nations. Retrieved from https://
www.ohchr.org/en/professionalinterest/pages/crc.
aspx on August 17, 2018.
8 
The Universal Declaration of Human Rights,
1948. United Nations General Assembly. http://
www.un.org/en/ga/search/view_doc.asp?symbol=A/
RES/217(III).
Rania Mansour
Ethical Aspects of Health Care
UNITED STATES OF AMERICA
16
correctional and rehabilitation measures.9
However, the age of criminal responsibility
for a child is associated with age of men-
tal maturity or puberty under Shari’a Law
(and consequently the Iranian Penal Code),
which is around 9 years of age for girls and
15 years for boys. A judge must therefore
decide a juvenile’s sentence based on wheth-
er the child was mentally mature at the time
the crime was committed.This maturity as-
sessment is made by physicians of the Legal
Medicine Organization of Iran.
Physician contribution to this decision by
providing a medical opinion is effectively
facilitating the execution of individuals and
consequently violating international hu-
man rights law and their ethical duties as
physicians. As stated in the WMA Resolu-
tion on Physician Participation in Capital
Punishment10
, it is unethical for physicians
to participate in capital punishment, in any
way, or during any step of the execution
process.
The World Medical Association, as a rep-
resentative of physicians worldwide, has
­
continuously published Resolutions and
Declarations pertaining to physician in-
volvement in capital punishment.
In 1975, the WMA Declaration of To-
kyo11
defined torture as the deliberate,
9 
Islamic Penal Code of the Islamic Republic of
Iran – Book Five,2013.Iran Human Rights Doc-
umentation Center. Retrieved from http://www.
iranhrdc.org/english/human-rights-documents/
iranian-codes/1000000351-islamic-penal-code-
of-the-islamic-republic-of-iran-book-five.html on
August 17, 2018.
10 
WMA Resolution on Physician Participation in
Capital Punishment, 2008. World Medical As-
sociation. Retrieved from https://www.wma.net/
policies-post/wma-resolution-on-physician-partic-
ipation-in-capital-punishment/ August 17, 2018.
11 
WMA Declaration of Tokyo – Guidelines for
Physicians Concerning Torture and other Cruel,
systematic, or wanton infliction of suffer-
ing by one or more persons acting alone or
on the orders of any authority. It called on
National Medical Associations to encour-
age physicians to continue their profes-
sional development training and education
in human rights.
In 1997, the WMA Declaration of Ham-
burg12
encouraged its constituent members
to take action so that physicians are held
accountable before the law in case of com-
plicity in acts of torture, and to protest in-
ternationally against any pressure to involve
physicians in acts of torture.
Following global reports in 2009 regarding
practices by health professionals indicating
their direct involvement in the infliction
or ill-treatment and participation in inter-
rogation processes, the WMA published
the Council Resolution on Prohibition of
Physician Participation in Torture13
.
Inhuman or Degrading Treatment or Punish-
ment in Relation to Detention and Imprison-
ment, 2016. World Medical Association. Re-
trieved from https://www.wma.net/policies-post/
wma-declaration-of-tokyo-guidelines-for-physi-
cians-concerning-torture-and-other-cruel-inhu-
man-or-degrading-treatment-or-punishment-in-
relation-to-detention-and-imprisonment/ August
17, 2018.
12 
WMA Declaration of Hamburg Concerning
Support for Medical Doctors Refusing to Par-
ticipate in, or to Condone, the use of Torture
and other Cruel, Inhuman or Degrading Treat-
ment, 2017. World Medical Association. Re-
trieved from https://www.wma.net/policies-post/
wma-declaration-of-hamburg-concerning-sup-
port-for-medical-doctors-refusing-to-participate-
in-or-to-condone-the-use-of-torture-or-other-
forms-of-cruel-inhuman-or-degrading-treatment/
August 17, 2018.
13 
WMA Council Resolution on Prohibition of
Physician Participation in Torture, 2009. World
Medical Association. Retrieved from https://
www.wma.net/policies-post/wma-council-resolu-
tion-on-prohibition-of-physician-participation-
in-torture/ August 17, 2018.
Although the WMA cannot hold its na-
tional medical association members respon-
sible for the actions, policies, and laws of
their respective governments,the WMA re-
leased a Statement on the United Nations
Resolution14
in 2013 recommending and
supporting the UN GA Resolution 65/206
calling for a moratorium on the use of the
death penalty.
However, National Medical Associations
must also work towards guaranteeing that
physicians are complying with the fun-
damental principles of medical ethics by
prohibiting physician involvement in the
preparation, facilitation, or participation in
executions of persons who commit crimes
as juveniles.
Moving forward, the international commu-
nity of physicians and medical professionals
must continue to collectively call upon their
Iranian colleagues and their organizations
to acknowledge a physician’s duty to do no
harm. The medical maturity assessments as
described in this article and as provided by
the Legal Medicine Organization of Iran,
whereby physicians are using their medical
knowledge to violate ethical duties, human
rights, and civil liberties, are both: unethical
and illegal.
Rania Mansour BSc MPH Candidate,
University of Pennsylvania
2018 Intern,
World Medical Association
Philadelphia, USA
E-mail: mrania@pennmedicine.upenn.edu
14 
WMA Statement on the United Nations Reso-
lution for a Moratorium on the Use of the Death
Penalty, 2013. World Medical Association. Re-
trieved from https://www.wma.net/policies-post/
wma-statement-on-the-united-nations-resolu-
tion-for-a-moratorium-on-the-use-of-the-death-
penalty/ August 17, 2018.
Ethical Aspects of Health Care UNITED STATES OF AMERICA
17
BACK TO CONTENTS
We are Canadian physicians who are dis-
mayed and concerned by the impact – on
patients, on doctors, on medical practice –
of the universal implementation, in our
country, of euthanasia defined as medical
“care”to which all citizens are entitled (sub-
ject to the satisfaction of ambiguous and
arbitrary qualifying criteria). Many of us
feel so strongly about the difficulty of prac-
ticing under newly prescribed constraints
that we may be forced, for reasons of per-
sonal integrity and professional conscience,
to emigrate or to withdraw from practice
altogether. All of us are deeply worried
about the future of medicine in Canada.
We believe this transformation will not
only be detrimental to patient safety, but
also damaging to that all-important per-
ception by the public – and by physicians
themselves – that we are truly a profession
dedicated to healing alone. Thus, we are
alarmed by attempts to convince the World
Medical Association (WMA) to change its
policies against physician participation in
euthanasia and assisted suicide.
Notwithstanding the disavowals of those
promoting change of the WMA policies,
such a change would encourage legalization
of the procedures in other countries, and it
is certain that this would have a major ad-
verse impact on our patients and colleagues
around the world. Hence, we believe it is
important for them to reflect upon our per-
spective: that of Canadian physicians who
refuse to kill our patients or to help them
commit suicide, who refuse to facilitate eu-
thanasia or assisted suicide by others, and
who practise in a country where such refus-
als are widely thought to reflect unaccept-
ably extreme and unprofessional views. Our
perspective has been missing in WMA dis-
cussions until now.
The Law
In Canada, the federal government is re-
sponsible for criminal law and the prov-
inces have jurisdiction over health care and
enforcement of criminal law. In 2014, the
Province of Quebec exploited this consti-
tutional arrangement by legally redefining
end-of-life medical care to include eutha-
nasia [1]. The law came into force in De-
cember 2015.
In February 2015, the Supreme Court of
Canada ruled in Carter v. Canada that phy-
sicians may provide euthanasia or assisted
suicide for competent adults who clearly
consent, who have a grievous and irreme-
diable medical condition (including illness,
disease, or disability) that causes enduring
and intolerable physical or psychological
suffering, and that cannot be relieved by
means acceptable to the individual [2]. The
criteria are broader than those specified in
the Quebec statute.
The Criminal Code was amended in June
2016 to give effect to the ruling throughout
the country [3]. Quebec law allows only eu-
thanasia, and only for someone “at the end
of life” who is in an “advanced state of irre-
versible decline in capability” [1]. Similarly,
the Criminal Code states that the natural
death of the candidate must be “reasonably
foreseeable” (an undefined term) and repli-
cates Quebec’s requirement of an advanced
state of decline. It also specifies that the
candidate’s illness, disease or disability be
incurable [3].
Determined patients who do not meet
these requirements because of natural dis-
ease processes can opt to starve themselves
to the point of qualifying for the procedures
[4]. This has been denounced as “cruel” and
suggested as a reason to abolish the require-
ments [5]. Lawsuits underway in British
Columbia [6] and Quebec [7] assert the
requirements are unconstitutional.
Expanding Access
to Euthanasia and
Assisted Suicide
If current lawsuits are successful, euthana-
sia and assisted suicide will be available as
a supposed “treatment” for mental illness,
since not all mental illnesses permanently
impair decisional capacity. Moreover, the
Supreme Court did not rule out allowing
euthanasia and assisted suicide for reasons
beyond those identified in Carter [2].
Euthanasia in Canada: a Cautionary Tale
Rene Leiva Margaret
M Cottle
Catherine Ferrier Sheila Rutledge
Harding
Timothy Lau Terence
McQuiston
John F Scott
Ethical Aspects of Health Care
CANADA
18
Within a year of the ruling, the pressure
for “Carter Plus” had become so great that
the federal government legally commit-
ted itself to consider allowing euthanasia
and assisted suicide for adolescents and
children, for indications caused by mental
illness alone, and by advance directive (for
those who lack capacity, like patients with
dementia) [8].
In sum, while the WMA regional meetings
demonstrate there is no appetite for eutha-
nasia outside some parts of Europe and the
European diaspora, in Canada we have ob-
served that even the prospect of legalization
whets the appetite for it, and the appetite is
not satisfied by legalization alone.
The unreliability of
Legal “Safeguards”
The Supreme Court of Canada believed that
“a carefully designed and monitored system
of safeguards” would limit risks associated
with allowing physicians to kill patients or
help them commit suicide [2].However,the
Vulnerable Persons Standard, developed to
assist in establishing such safeguards, finds
current Canadian law seriously deficient
[9]. Even supplemented by provincial and
professional guidelines, current criteria are
so broad as to have permitted lethal injec-
tion of an elderly couple who preferred to
die together by euthanasia rather than at
different times by natural causes [10].
Despite this, only a year after legalization,
Canadian Euthanasia and Assisted Suicide
(EAS) practitioners were already complain-
ing about having to meet with patients
(perhaps more than once), review their
often “lengthy and complicated” medical
histories, counsel and overcome resistance
from family members [11], refer patients
to psychiatrists or social workers [12], find
two independent witnesses to verify the
voluntariness of a patient’s request [13],
and manage the “paperwork and bureau-
cracy involved,”[14] such as having to com-
plete forms and fax reports to the coroner
[13;15].What others see as safeguards, they
characterized as “disincentives” to physician
participation that were creating “barriers”to
access.
Demand for Collaboration
EAS practitioners also claimed that there
was “a crisis”because so few physicians were
willing to provide euthanasia or assisted
suicide [16]. Their alarm seems to have
been triggered by a 46.8% increase in EAS
deaths in the second half of the first year of
legalization.Canada’s EAS death rate in the
first year – about 0.9% of all deaths [17] –
was not reached by Belgium for seven to
eight years [18].
However, inter-jurisdictional comparisons
indicate that, even in the first year of legal-
ization, more than enough Canadian EAS
practitioners were available to meet the
demand [19]. This ought to make coercion
of unwilling physicians unnecessary, but
prominent, influential and powerful people
in Canada disagree.
It is true that nothing in the Criminal
Code requires physicians to personally kill
patients or help them commit suicide [3].
However, nothing in the Criminal Code
prevents compulsion by other laws or poli-
cies. Thus, for example, Canada’s largest
medical regulator demands that physicians
who are unwilling to personally provide eu-
thanasia or assisted suicide must collaborate
in homicide and suicide by referring pa-
tients to colleagues who are willing to do
so [20].
We categorically refuse. Such collabora-
tion would make us morally responsible
for killing our patients; if not for the Carter
decision, it would make us criminally re-
sponsible and liable to conviction for mur-
der, just as it still does in most parts of the
world. For refusing to collaborate in killing
our patients, many of us now risk discipline
and expulsion from the medical profession.
How has this come about?
Access to Euthanasia and
Assisted Suicide as Entitlements
Part of the explanation is that Canada’s
state-run health insurance system pays for
“medically necessary hospital and physician
services” from public funds. Most Canadian
physicians are independent contractors paid
only for services we provide, but many Ca-
nadians now believe we are state employees,
and we face an entrenched attitude of en-
titlement. Since taxpayers pay for “medical-
ly necessary” health services, many people
think it is unacceptable for physicians to
refuse to provide those [21].
And what counts as a “medically necessary”
service? In brief, anything declared to be
so by the state. As we have seen, in 2014
the Quebec government redefined medi-
cal practice to include euthanasia. Indeed,
Quebec deliberately restricted the practice
of euthanasia to physicians [1].
Access to Euthanasia
and Assisted Suicide
as Human Rights
The sponsor of Quebec’s law claimed that
euthanasia would remain “very exceptional”
[24]. However, the law also said qualified
patients had a right to euthanasia, and the
exercise of a right cannot be exceptional.
Thus, all public health care institutions
(residences, long term care facilities, com-
munity health centres and hospitals  – in-
cluding palliative care units) are required to
provide or arrange for euthanasia [1]. Even
this, however, has not been enough.
McGill University Health Centre complied
with Quebec law by arranging to transfer
patients from the palliative care unit to be
lethally injected elsewhere in the facility.
Ethical Aspects of Health Care CANADA
19
BACK TO CONTENTS
The Quebec Minister of Health forced eu-
thanasia into the palliative care unit, citing
“patients’ lawful right to receive end-of-life
care” [23; 24].
Quebec law allows hospices to opt out of
providing euthanasia [1], but when Quebec
hospices opted out, the Minister of Health
denounced them for “administrative funda-
mentalism,” declaring their refusal “incom-
prehensible.” Notwithstanding the law, a
prominent Quebec lawyer urged that their
public subsidies be withdrawn, accused
them of compromising the right of access
to care, and warned that allowing refusal
was a slippery slope [25]. A similar situa-
tion is also being faced by the hospices in
other provinces such as British Columbia
[26].
Quebec physicians and health care practi-
tioners now work in environments charac-
terized by an emphasis on a purported ‘right’
to euthanasia. The notion that access to eu-
thanasia and assisted suicide is a fundamen-
tal human right has spread across Canada
since the Supreme Court of Canada ruling
in Carter. We are accused of violating hu-
man rights – even called bigots – because
we refuse to kill or collaborate in killing our
patients [27].
Providing Euthanasia as an
Ethical/Professional Obligation
Leaders of the medical profession contrib-
uted substantially to the legal redefinition of
euthanasia as a medical act and to the le-
galization of physician assisted suicide and
euthanasia.
The Collège des médecins du Québec
(CMQ) told Quebec legislators that ac-
tively causing the death of a patient is “a
medical procedure” for which physicians
must be completely responsible, insisting
that physician assume “the moral burden”
of killing patients [28]. The Federation of
General Practitioners of Quebec was ada-
mant that only physicians should provide
euthanasia [29].
The Canadian Medical Association (CMA)
secured approval of an apparently neutral
resolution on euthanasia and assisted sui-
cide, supporting both physicians willing to
provide the services and those unwilling
to do so [30]. The CMA later told the Su-
preme Court of Canada those positions for
and against physician participation in eu-
thanasia/assisted suicide were both ethically
defensible, and that its long-standing policy
against physician participation would be re-
vised to reflect support for both views [31].
However, in 2014, prior to the 2015 Su-
preme Court ruling its legalization, the
CMA formally approved physician assist-
ed suicide and euthanasia (subject to legal
constraints) as responses to “the suffering
of persons with incurable diseases.” It clas-
sified both practices as “end of life care,”
and promised to ensure access to “the full
spectrum” of end of life care (i.e., including
euthanasia and assisted suicide) [32]. The
Supreme Court cited the CMA’s new policy
when it struck down the law two months
later [2].
By redefining euthanasia and assisted sui-
cide as therapeutic medical services [33],
the CMA made physician participation
normative for the medical profession; refus-
ing to provide them in the circumstances set
out by law became an exception requiring
justification or excuse. That is why public
discourse in Canada has since centred large-
ly on whether or under what circumstances
physicians and institutions should be al-
lowed to refuse to provide or collaborate in
homicide and suicide: hence the “long de-
bate” about conscientious objection at the
CMA’s 2015 annual meeting to which the
CMA Vice-President, Medical Profession-
alism referred in his World Medical Journal
article [34].
The CMA Vice-President, Medical Profes-
sionalism elsewhere noted that, for years,
physicians opposed to euthanasia and as-
sisted suicide have lobbied the CMA to
support their right to refuse to participate
in the procedures. “They have made tear-
ful pleas at several CMA General Council
meetings, asking their non-objecting col-
leagues to support them and to defend their
rights”[35]. We have had to do this precise-
ly because of the reversal of CMA policy
against physician participation in euthaniz-
ing patients, the reclassification of euthana-
sia and assisted suicide as medical services,
and the insistence that there should be no
“undue delay” in providing them [36].
To be fair,our pleading has not been in vain.
The CMA does support physicians who re-
fuse to provide or refer for euthanasia and
assisted suicide, asserts that the state should
develop mechanisms to allow patients di-
rect access to the services without violating
physicians’ moral commitments, and rejects
discrimination against objecting practitio-
ners [36]. But this advice can be ignored
and, when it is, Hippocratic practitioners
face the state in court and foot the bill for
expensive constitutional challenges [37].
Further, public calls from influential voices
have been heard for those medical students
who are personally opposed to the euthana-
sia imperative, to either abandon, or refrain
from applying for, medical training [38].
Canada’s Euthanasia/
Assisted Suicide Regime
The CMA is sincerely convinced that it “did
the right thing” in shaping the debate and
law in Canada and that it is on the right
side of history.It is urging the WMA to fol-
low its lead [34]. Our colleagues in other
countries thus need to be aware that the
EAS regime in Canada is one of the most
radical in the world.
Patients do not have a ‘right to euthanasia’
in the Netherlands [39] or in Belgium [40],
though long practice inclines the public to
the contrary view [41]. Euthanasia is not
Ethical Aspects of Health Care
CANADA
20
permitted in either country unless a phy-
sician is personally convinced there is no
reasonable alternative [42; 43]. Similarly,
Dutch and Belgian physicians must be per-
sonally convinced that a patient’s suffering
is intolerable and enduring [42, 43], and
Belgian physicians may insist upon criteria
beyond those set by law [42].
In Canada, however, access to euthanasia
and assisted suicide is seen as a tax-paid en-
titlement, is described as a “constitutionally
protected civil and human right” [44], and
homicide and suicide are legally and profes-
sionally defined to be therapeutic medical
services. Moreover, a physician’s conviction
that there are other reasonable and effica-
cious alternatives is irrelevant; patients can
insist upon lethal injection. Finally, the
criterion of intolerable suffering is entirely
subjective, established unilaterally by the
patient.
Small wonder, then, that the onus seems
increasingly to lie on physicians to show
why euthanasia should be refused, and that
health care administrators may be more
anxious about being accused of “obstructing
access” [45] than about “killing people who
really ought not to be killed” [46].
Only a year after legalization,Dr.Yves Rob-
ert, Secretary of the CMQ was alarmed by
“the rapidity with which public opinion
seems to have judged [the new law] insuf-
ficient.”
“If anything has become apparent over the
past year, it is this paradoxical discourse
that calls for safeguards to avoid abuse,” he
wrote, “while asking the doctor to act as if
there were none. … [W]e sees the emer-
gence of pressure demanding a form of
death à la carte,” he warned [47].
Patients and Palliative Care
As Hippocratic practitioners, our focus is
on the good of our patients, avoiding thera-
peutic obstinacy and responding to their
suffering with compassion,competence,and
palliative care. We are disturbed that the
number of Quebec practitioners entering
palliative care dropped after legalization of
euthanasia, and the CMQ and the Quebec
Society for Palliative Care are concerned
that patients are choosing euthanasia be-
cause adequate palliative care is unavailable
[48].
We are disturbed and grieved by the story
of a 25-year-old disabled woman in acute
crisis in an Emergency ward, pressured to
consider assisted suicide by an attending
physician, who called her mother “selfish”
for protecting her [49].
We are disturbed and angered to hear that
hospital authorities denied a chronically ill,
severely disabled patient the care he needed,
suggesting euthanasia or assisted suicide in-
stead [50].
And we were astonished to hear that some
emergency physicians in Quebec were, for a
time,letting suicide victims die even though
they could have saved their lives. The inci-
dents came to light at about the time the
Quebec euthanasia law came into force, and
the president of the Association of Quebec
Emergency Physicians speculated that the
law and accompanying publicity may have
‘confused’ the physicians about their role
[51].
These incidents are entirely consistent with
the acceptance of euthanasia and physician
assisted suicide and they illustrate grave vio-
lations of traditional medical ethics. This is
not coincidental.
Euthanasia and the
Transformation of
Medical Culture
Canadian medical leaders learned that, in
other jurisdictions, legalizing assisted sui-
cide and euthanasia caused “changes in the
medical culture” leading to “general, overall
comfort” with the law [52].
However, when emergency physicians re-
fuse to resuscitate patients who attempt
suicide and urge disabled patients in crisis
to request euthanasia, such “changes in the
medical culture”are not, in our view, consis-
tent with ensuring patient safety, nor with
maintaining the trust essential to preserving
the Hippocratic physician-patient relation-
ship.
And when physicians are told to write ‘natu-
ral death’instead of ‘euthanasia’on the death
certificates [53,54] – and, by extension, to
misrepresent facts – “changes in the medical
culture” may make physicians comfortable,
but we do not believe that they will sustain
trust in the medical profession. Even newly
released federal guidelines for monitoring
euthanasia lack any emphasis on prevention
of EAS, in favour of merely regulating these
practices [55; 56; 57].
Finally, when a Jewish nursing home for-
bids euthanasia and assisted suicide on its
premises out of respect for Jewish beliefs
and concern for its residents (who include
Holocaust survivors),“changes in the medi-
cal culture” may encourage applause for the
EAS practitioner who crept in at night to
lethally inject someone [58], but we do not
applaud; we are aghast.
Our observations and personal experiences
over the last two years confirm our belief
that the practice of Hippocratic medicine is
fundamentally incompatible with euthana-
sia and assisted suicide. Mandating system-
wide provision and physician involvement
in the practices can be expected to trans-
form medical culture, ultimately making
Hippocratic medical practice impossible.
The WMA regional conferences demon-
strate that the great majority of physicians
worldwide agree with us. Nonetheless, it is
true that some physicians and patients seek
Ethical Aspects of Health Care CANADA
21
BACK TO CONTENTS
euthanasia or assisted suicide where the
procedures are legal. Supposing that killing
people or helping them to commit suicide
might sometimes be an acceptable response
to human suffering (something we do not
concede), how might these demands be ac-
commodated?
The answer is intuitively obvious: with the
least possible disruption of existing long-
standing medical practice. And from this
perspective a completely non-medical
solution would be best. Where this is no
longer practicable, law and policy should
allow medical practice to remain largely
unchanged. Patients have no entitlement;
practitioners and institutions have no duty;
medical associations respectfully continue
unresolved ethical debates; the amplitude
of the phenomena remains proportional to
minority demands. The introduction of eu-
thanasia in Canada has caused doubt, con-
flict and crisis. In our view, new disciplines,
new professions and new methods may
arise to satisfy new social goals; but not
in the name of Medicine. We believe that
doctors, and medical associations, should
vigorously defend the successful model
inherited from our past. Euthanasia is not
medicine.
As Canadians, we are saddened by this situ-
ation, but we hope that our experience and
observations will serve as a warning for our
colleagues in other countries, and their pa-
tients. Most important: The World Medical
Association must recognize that accommo-
dating the kind of radical change in medical
culture underway in Canada is ill-advised.
Mindful of the legacy of past WMA lead-
ers, such as former Secretary General, Dr.
Andre Wynen, who, based on his personal
experience, stood courageously against any
minimization of the dangers of euthanasia
to patients and physicians [59], we advise
against any compromising additions or
modifications to existing WMA declara-
tions, and strongly support a full defence
of established policy against euthanasia and
assisted suicide.
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Physicians’ Alliance against Euthanasia. Avail-
able from: https://collectifmedecins.org/en/dr-
roberts-regrets/
48. http://www.cmq.org/nouvelle/fr/vers-la-mort-
a-la-carte.aspx
Ethical Aspects of Health Care CANADA
23
BACK TO CONTENTS
49. CBC News. Lack of palliative care pushing
Quebecers toward medically assisted death,
College of Physicians says. 31 May 2018 [cited
2018 Sep 01]. Available from: https://www.
cbc.ca/news/canada/montreal/lack-of-palli-
ative-care-pushing-quebecers-toward-med-
ically-assisted-death-college-of-physicians-
says-1.4685470
50. Fatal Flaws Film Clip : “They wanted me to do
an assisted suicide death on her” [Video]. You-
Tube; 2017 Oct 10 [cited 2018 Sep 01]. Avail-
able from: https://youtu.be/hB6zt43iCs8
51. Chronically ill man releases audio of hospital
staff offering assisted death [Internet]. CTV
News; 2018 Aug 02 [cited 2018 Sep 01]. Avail-
able from: https://www.ctvnews.ca/health/
chronically-ill-man-releases-audio-of-hospital-
staff-offering-assisted-death-1.4038841
52. Hamilton G. Some Quebec doctors let suicide
victims die though treatment was available:
college [Internet]. National Post; 2016 Mar 17
[cited 2018 Sep 01]. Available from: https://
nationalpost.com/news/canada/some-quebec-
doctors-let-suicide-victims-die-though-treat-
ment-was-available-college
53. Geddes J. Interview: The CMA’s president on
assisted dying [Internet]. Macleans; 2015 Feb
06 [cited 2018 Sep 01]. Available from: http://
www.macleans.ca/politics/ottawa/interview-
the-cmas-president-on-assisted-dying/). This
part of the interview is not included in the edit-
ed published transcript, but can be heard on the
linked audio file (02:43-03:25) [cited 2018 Sep
01] Available from: https://soundcloud.com/
macleans-magazine/john-geddes-in-conversa-
tion-with-cma-president-chris-simpson
54. Murphy S. A bureaucracy of medical decep-
tion: Quebec physicians told to falsify eutha-
nasia death certificates [Internet]. Protection of
Conscience Project; 2015 [cited 2018 Sep 01].
Available from: http://www.consciencelaws.org/
background/procedures/assist012.aspx
55. Michael Swan. Can a doctor-assisted death be
‘natural’ and ‘suicide’? [Internet]. The Catho-
lic Register; 2018 Aug 08 [cited 2018 Sep 01].
Available from: https://www.catholicregister.
org/item/27790-can-a-doctor-assisted-death-
be-natural-and-suicide
56. Globe editorial: Ottawa should do more to ex-
amine how medically-assisted death is working
[Internet]. The Globe and Mail; 2018 Aug 16
[cited 2018 Sep 01]. Available from: https://
www.theglobeandmail.com/opinion/editorials/
article-globe-editorial-ottawa-should-do-more-
to-examine-how-medically/
57. Regulations for the Monitoring of Medical As-
sistance in Dying: SOR/2018-166 [Internet].
Government of Canada; 2018 Jul 27 [cited 2018
Sep 01]. Available from: http://www.gazette.
gc.ca/rp-pr/p2/2018/2018-08-08/html/sor-
dors166-eng.html
58. Frazee C. Medically assisted dying needs
more monitoring [Internet]. The Star; 2018
Aug 29 [cited 2018 Sep 01]. Available from:
https://www.thestar.com/opinion/contribu-
tors/2018/08/29/medically-assisted-dying-
needs-more-monitoring.html
59. Lazaruk S. Jewish care home accuses doctor of
‘sneaking in and killing someone’ [Internet].
Vancouver Sun; 2018 Jan 05 [cited 2018 Sep
01]. Available from: https://vancouversun.com/
news/local-news/jewish-care-home-accuses-
doctor-of-sneaking-in-and-killing-someone
60. World Medical Association issues Madrid Dec-
laration against euthanasia [Internet]. 1987
Nov 20 [cited 2018 Sep 01]. Available from:
https://larouchepub.com/eiw/public/1987/eir-
v14n46-19871120/eirv14n46-19871120_014-
dr_andre_wynen.pdf
(Institutional affiliations are provided for
identification purposes only and do not imply
endorsement by the institutions. See below
for list of professional designation abbrevia-
tions.)
Rene Leiva, MDCM, CCFP
(COE/PC), FCFC
Family Medicine, Palliative
Care, Care of the Elderly
Bruyere Continuing Care
Ottawa, Ontario, Canada
Margaret M Cottle, MD, CCFP (PC)
Palliative Care
Assistant Professor, University
of British Columbia
Vancouver, British Columbia, Canada
Catherine Ferrier, MD,
CCFP (COE), FCFP
Family Medicine, Care of the Elderly
McGill University Health Centre
Assistant Professor of Family
Medicine, McGill University
Montreal, Quebec, Canada
Sheila Rutledge Harding, MD, MA, FRCPC
Hematology
Saskatchewan Health Authority
Professor, University of Saskatchewan
Saskatoon, Saskatchewan, Canada
Timothy Lau, MD, MSc, FRCPC
Geriatric Psychiatry
Royal Ottawa Hospital
Associate Professor, University of Ottawa
Ottawa, Ontario, Canada
Terence McQuiston, MD
Family Medicine (special
interest in Geriatrics)
Donway Place Retirement Residence
Toronto, Ontario, Canada
John F Scott, MD, MDiv
Palliative Care
Associate Professor, University of Ottawa
The Ottawa Hospital
Ottawa, Ontario, Canada
Acknowledgements and Endorsements
The authors want to express our deepest thanks
for insights, edits and support received from
many of our colleagues. The final article has
been explicitly endorsed by the following Ca-
nadian physicians:
Balfour M Mount, Anita Au,
Sasha Bernatsky, Thomas Bouchard,
Julia Bright, Myra Butler, Luigi Castagna,
Julia Cataudella, Cyril Chan, Luke Chen,
Joyce Choi, Andre Constantin, Alana Cormier,
MD, David D’Souza, Ed Dubland,
Abraham Fuks, Dominique Garrel,
Richard Haber, Ronald E Hiller,
Neil Hilliard, Todd C Howlett,
Evelyne Huglo, K. Issigonis,
Andre Jakubow, Will Johnston, Lynn Kealey,
Nuala P Kenny, Anthony T Kerigan,
Edmond Kyrillos, Joseph M Lam,
Renata Leong, Constant H. Leung,
Henry Lew, Andrea H. S. Loewen,
Jean-Noel Mahy, François Mai,
Karen MacDonald, Karen Mason,
John R McLeod, J Stephen Mitchinson,
Ibrahim Mohamed, José A. Morais,
Louis Morissette, Laurence Normand‑Rivest,
Liette Pilon, Roger Roberge,
Cameron Ross, Paul Saba, Kevin Sclater,
William F. Sullivan, Vanessa Sweet,
Sephora Tang, Mark Tsai, Stephen Tsai,
James Warkentin, Maria Wolfs, Paul Yong
Ethical Aspects of Health Care
CANADA
24
Telemedicine entered the scene during the
early 19th century and has been steadily
growing and further developing in the
background. Dr Hugo Gernsback featured
his ‘teledactyl’ device in the 1925 edition
of the Science and Invention Magazine,
with the hope that the device would be
a medical breakthrough whereby physi-
cians would be able to examine patients
from a distance using radio technology.
This ‘failed’ invention paved the way for
telemedicine, and was shortly followed by
studies at the University of Nebraska in
1959 where physicians were able to trans-
mit neurological examinations to medical
students across the campus via a two-way
interactive television. Within ten years,
physicians were able to use a telemedicine
link to provide health services at a Norfolk
State Hospital over a distance of 180 kilo-
metres [1].
In general, telemedicine is defined as the
remote diagnosis and treatment of pa-
tients via telecommunications technology.
The World Medical Association (WMA)
describes telemedicine as “the practice of
medicine over a distance, in which inter-
ventions, diagnostic and treatment deci-
sions and recommendations are based on
data, documents and other information
transmitted through telecommunication
systems”[2].Telemedicine can refer to con-
sultation between a physician and a patient
or between two physicians/health profes-
sionals, with a primary physician/health
professional being in the same location as
the patient.Telehealth services may be pro-
vided through two types of communication
platforms: (i) asynchronous communica-
tions, which is known more commonly as
“store and forward” (e.g. X-rays, CT scan
reports, video-recorded symptoms) and (ii)
synchronous communication, described as
“real-time” communication (e.g. video con-
sultation) [3].
The definition of telemedicine can differ
across different jurisdictions, and what is
legal in one jurisdiction may be illegal in
the other. Some jurisdictions recognise
telemedicine as an interaction between
the physicians and their patients and some
jurisdictions limit telemedicine between
health professionals [4]. It is therefore
important for physicians to understand
definitions of telemedicine in their juris-
dictions” [5].
Top fields in telemedicine include Tele-
radiology, Telepathology, Teledermatol-
ogy, Telepsychiatry, Teleophthalmology,
Telenephrnology, Teleobstetrics, Teleon-
cology, and Telerehabilitation, Telesurgery
and telemonitoring (or remote surgery).
Telemedicine can also be used for patient
education and follow-up [5-7].
Benefits of Telemedicine
Telemedicine can be used to improve ac-
cess to healthcare services in remote and
underserved areas. [8] Telemedicine can be
used as a direct link to patients or to enable
remote facilities to obtain specialised sup-
port from major centres [8,9].Telemedicine
can also be used for learning and develop-
ment of junior physicians, resident officers,
nurses and general practitioners. Increas-
ingly,telemedicine is being used for patients
with barriers to access outside geographical
limitations; these include physical disability,
employment, family commitments (includ-
ing caring for others), patients’ cost and
physician schedules.
Telemedicine can allow for frequent follow-
up of chronic patients, therefore, increasing
contact time at low costs. Patient tele-edu-
cation also assists in providing patients with
individualised health promotion messages
and may improve empowerment [9].
Potential Risks in
Telemedicine
Quality of care: The ultimate purpose of
any medical care is to maintain or im-
prove health and well-being. Like all clini-
cal interventions, telemedicine should be
subjected to the evaluation of efficiency,
effectiveness and cost-effectiveness. Argu-
ments in favour of the use and expansion
of telemedicine include, amongst others,
Salaelo Mametja
Telemedicine and its Ethical Aspects
Jolene Hattingh
Telemedicine SOUTH AFRICA
25
BACK TO CONTENTS
increased access and affordability. This
should, however, not be done at the ex-
pense of quality of care, and in fact should
not replace access to essential clinical ser-
vices and face-to-face consultations, as not
all clinical conditions can be treated using
telemedicine.
Telemedicine can result in three types of
quality problems: [10] (i) Overuse of medi-
cal care due to unnecessary consultations
and investigations, (ii) under-use of medical
care through failure to conduct appropriate
clinical examination and referral appropri-
ate/referral delayed referral and (iii) poor
technical or interpersonal performance
(e.g. incorrect interpretation of pathology
specimen or inattention to patient con-
cerns) [11].Telemedicine should be used as
an adjunct to health services and not as a
standalone intervention.
The effectiveness of telemedicine: Studies
of effectiveness in telemedicine are incon-
sistent. Compared to usual care, telemedi-
cine did not result in the improvement in
outcomes in heart failure [12, 13]. In one
systematic review, telemedicine was found
to be associated with decreased hospi-
talisation and mortality, and resulted in
lower patient satisfaction12. In another
randomised control trial, telemedicine was
reported to reduce HBA1C but had no ef-
fect on health outcomes such as mortal-
ity [14]. The inconsistency in findings can
be due to variable telemedicine platforms,
settings and to the extent to which usual
care is replaced or complemented by tele-
medicine. It is therefore, important that
physicians test effectiveness, efficiency,
safety and feasibility of telemedicine plat-
forms in their setting before wide-scale
rollout.
Ethics andTelemedicine
Some of the most prominent ethical con-
cerns include the effect on patient-physi-
cian relationships, and threats to patient
privacy[14]. Properly informed written
consent requires that all necessary infor-
mation regarding the telemedicine visit be
explained fully to patients, including ex-
plaining how telemedicine works, how to
schedule appointments, privacy concerns,
the possibility of technological failure, pro-
tocols for contact during virtual visits, pre-
scribing policies,and coordinating care with
other health professionals in a clear and un-
derstandable language, without influencing
the patient’s choices [15].
Telemedicine involves the use of an in-
formation technology platform, which
can result in unintended confidentiality
bridges by hacking and unauthorised ac-
cess. IT staff responsible for telemedicine
platforms may not have similar ethical
rules as the medical professionals.This risk
is even higher when secular telemedicine
platforms such as Skype or WhatsApp are
used. Therefore, a physician needs to use
appropriate, accredited, secure and compli-
ant IT platforms for telecommunication
where applicable.
Generally, the patient needs to have an ex-
isting relationship with the medical profes-
sional performing the telemedicine con-
sultation. There is a therapeutic value of
face-to-face encounters with a physician
that helps to build a relationship of mutual
trust and rapport building[16].Face-to-face
consultation allows the physician to obtain
an appropriate history as well as conduct
general and symptomatic examinations. For
these reasons, telemedicine should only be
implemented for existing patients, where
the physician has an intimate knowledge of
the patient’s history.
In providing telemedicine, physicians must
be aware of its benefits and harms. Tele-
medicine should not replace face-to-face
consultation.There are circumstances where
telemedicine is inappropriate and physi-
cians must, therefore, retain their autonomy
in deciding on the appropriate use of tele-
medicine.The standards of care provided in
telemedicine should be similar to face-to-
face consultations.
Telemedicine can be harmful as the physi-
cians’ ability to clinically examine the pa-
tients is limited. Physician-only relies on
two (visual and audio) senses instead of four
(visual, audio, smell and touch) to complete
a clinical exam.
Justice: The healthcare system has a duty to
distribute social benefits and burdens equal-
ly.Telemedicine can widen the gap in health
outcomes if people are treated differently
based on their ability to access telecommu-
nication or denial of necessary face-to-face
consultation in lieu of telemedicine.
Furthermore, reimbursement for telemedi-
cine should be proportionate to the bur-
dens. Physicians should be careful of per-
verse incentives geared to promote uptake
of telemedicine as this can erode the ethics
in medicine [15, 17].
Barriers to Implementation
of Telemedicine
Infrastructure remains a huge barrier to ex-
pansion and access to telemedicine. Ironi-
cally, this affects remote and rural societ-
ies who are believed to be beneficiaries of
telemedicine. Instead, telemedicine is ex-
panding rapidly in urban areas and metro-
politans. Barriers that physicians, in general,
experience with the implementation of tele-
medicine in their practices include a lack
of access to infrastructure, requirements of
complex systems, absences of standards in
telemedicine, and a lack of direction from
regulatory bodies and national departments
of health [8].
Legal Considerations
The regulations for telemedicine vary from
country to country and within countries.
Generally, there is also a lack of harmony
Telemedicine
SOUTH AFRICA
26
within and between countries legal frame-
works. For, examples, in the US, physicians
are required to be licensed or registered with
the relevant regulator to practise telemedi-
cine. However, regulators in other countries
are often silent on consultations across ju-
risdictions [18].This can threaten a patient’s
safety and lead to abuse by unscrupulous
fraudsters. Physicians should be cognisant
that in the absence of guidance on cross-
jurisdictional regulations, long-arm laws
may grant the court’s jurisdiction over out-
of-state individuals.
Whilst there are telecommunication laws,
telemedicine requires a special type of
regulation due to the sensitivity of medi-
cal information, and the requirements for
regulation of physicians and medical in-
terventions. This requires harmonisation of
both medical and telecommunication legal
frameworks.
Telemedicine can increase the potential for
litigation due to an inability to assess symp-
toms and signs appropriately through elec-
tronic consultation media.
Conclusion
Telemedicine can provide access to health-
care in under-resourced areas. However,
physicians must adhere to biomedical ethics
and be cognisant of the unintended adverse
effects both at individual and population
level. Face-to-face medicine remains the
gold standard of care. Telemedicine should
not be used for any medical emergencies
(unless justified by lack of access) or condi-
tions where physical examination is required.
Physicians should use their professional
judgment, along with available legislation
and guidelines,to decide when telemedicine
is appropriate. Prescribing medicine virtu-
ally is generally acceptable; however, physi-
cians should only prescribe medicine when
there is a pre-existing relationship with the
patient and guard against potential abuse
and fraudulent use of prescribed medicine.
Physicians need to be aware of medicines
that cannot be prescribed via telemedicine
consultations. Physicians should only prac-
tise telemedicine in countries or jurisdic-
tions where they are licenced to practice.
Cross-jurisdictional consultations should
only be allowed between two physicians.
References
1. Bashur, R. and G. Shannon, History of Tele-
medicine: Evolution. Context, and Transforma-
tion Mary Anne Liebert, New Rochelle, 2009.
2. Association, WM,Statement on the Ethics of
Telemedicine. adopted by the 58th WMA Gen-
eral Assembly, Copenhagen, Denmark, 2007.
3. Marcoux,RM and FR Vogenberg,Telehealth: ap-
plications from a legal and regulatory perspective.
Pharmacy and Therapeutics, 2016. 41(9): p. 567.
4. Health Professions Council for South Africa,
General Ethical Guidelines for Good PRactice
in Telemedicine. 2010.
5. Smith Y, Types of telemedicine. News Medical
Life Science, 2015.
6. Wikipedia,Telemedicine. 2017.
7. Smith R, Research in Lag Time set to Deter-
mine the Future of Telesurgery. TechChurch,
2015.
8. Parajuli, R. and P. Doneys, Exploring the role
of telemedicine in improving access to health-
care services by women and girls in rural Ne-
pal. Telematics and Informatics, 2017. 34(7): p.
1166-1176.
9. Anderson, JG, Social, ethical and legal barriers
to e-health. International journal of medical in-
formatics, 2007. 76(5-6): p. 480-483.
10. Institute of Medicine (US) Committee on Eval-
uating Clinical Applications of Telemedicine,
Telemedicine: A Guide to Assessing Telecom-
munications in Health Care. 1996.
11. Field, MJ and I.o.M.C.o.E.C.A.o. Telemedi-
cine, Evaluating the effects of telemedicine on
quality, access, and cost. 1996.
12. Scherr, D, et al., Effect of home-based telem-
onitoring using mobile phone technology on the
outcome of heart failure patients after an epi-
sode of acute decompensation: randomized con-
trolled trial.Journal of medical Internet research,
2009. 11(3).
13. Lee, SWH, et al., Comparative effectiveness
of telemedicine strategies on type 2 diabetes
management: A systematic review and network
meta-analysis. Scientific Reports, 2017. 7(1): p.
12680.
14. Jack,C,Telemedicine a need for ethical and legal
guidelines in South Africa. South African Fam-
ily Practice, 2008. 50(2): p. 60-60.
15. Beauchamp, TL and JF Childress, Principles
of biomedical ethics. 2001: Oxford University
Press, USA.
16. Hewitt, H, J Gafaranga, and B McKinstry,
Comparison of face-to-face and telephone
consultations in primary care: qualitative anal-
ysis. Br J Gen Pract, 2010. 60(574): p. e201-
e212.
17. EL,Z,Electronic Health Records raise new eth-
ical concerns.The National Psychologist, 2014.
18. European Health Telematics Association,
ETHICAL Principles for eHealth: Briefing Pa-
per. 2012: p. 7-10.
Dr. Salaelo Mametja, MBBCh, MMed (PH),
FCPHM, PGD (Health Management)
Jolene Hattingh, BA (Psychology), CCSA
Registered (Counsellor), MPH student
Knowledge Management and Research, the
South African Medical Association (SAMA)
E-mail: SelaeloM@Samedical.org
Telemedicine SOUTH AFRICA
27
BACK TO CONTENTS
Migration has been a constant of human
life for centuries [1]. In our own time, the
movement of individuals between cities,
countries, and cultures has accelerated due
to ease of transportation and communica-
tion, yet the fundamental issues faced by
people uprooting themselves and their fam-
ilies for new opportunities remain similar
[2]. Issues related to the alignment of ex-
pectations with realities, integration in new
communities,cultural understanding within
new societies, and a psychological sense of
loss are all common experiences that con-
tinue to occur [3]. More recently, especially
within many Western countries, increased
scrutiny on migrants and migration policies
have created new challenges for individuals
who may simply want a better life for their
families [4].
Internationally educated health profession-
als (IEHPs) are generally defined as indi-
viduals who received their primary educa-
tion and training in a health care field in a
different country than the one they current-
ly reside within. In some cases (for example
the movement of physicians between Aus-
tralia and New Zealand) [2] there may be
minimal regulatory, cultural, or social bar-
riers to professional practice. In other cases
(for example the movement of nurses be-
tween sub-Saharan Africa and the United
States) there may be significant barriers and
obstacles to overcome [3].
While political debate around migration
and its benefits continues to swirl, the un-
deniable reality in many Western countries
is that reliance upon IEHPs to comple-
ment the domestic workforce continues
to increase [4, 5]. In some professions and
in some jurisdictions, this reliance can be
significant; for example, in the Canadian
province of Ontario, upwards of 50% of all
pharmacists registered to practice each year
come from outside Canada or the United
States, and without their contributions to
the workforce, the practice of the phar-
macy profession in Ontario would be over-
whelmed [6].
Despite increasing reliance on IEHPs for
an aging population and health care sys-
tems under stress, relatively little is known
about their experiences in navigating
the personal and professional transitions
required by all migrants [6]. In our cur-
rent time in which migration in general
has become a political issue, and actions
to reduce all forms of migration currently
seize the public agenda, policy makers may
lack an understanding of the real, impor-
tant, and invaluable contributions made by
IEHPs in allowing health care systems to
continue to function safely and effectively
[7].
These contributions, however important,
must also be balanced against perceptions
related to integration of newcomers into
the social and cultural fabric of their ad-
opted societies. Integration of IEHPs into
the community and into the health care
system may be more complicated today
due to the patterns of migration, particu-
larly the movement of peoples across large
geographic – and cultural – distances.
Well-publicized cases of (for example)
foreign-trained physicians refusing service
to gay and lesbian patients due to religious
differences can sometimes create the im-
pression for the public – and for policy
makers – that IEHPs are more bother-
some than helpful. The reality, of course,
is that in many Western countries, reliance
on IEHPs to complement the domestic
workforce will only increase over time [1,
4, 6].
Given this reality, it is important to under-
stand the experiences and diverse trajecto-
ries of IEHPs as they become a more im-
portant part of our communities and health
care systems for several reasons. First, it is
imperative that policy makers understand
both the value IEHPs bring to domestic
health care systems as well as the barri-
ers and facilitators to fuller integration in
the workforce [5]. Second, regulators need
greater clarity around how their policies
and practices may create inadvertent ac-
cess barriers that ultimately may result in
unfairness to potential registrants or inef-
ficiencies that adversely impact patient care
by inappropriately reducing the number of
health care providers available. Third, pub-
lic awareness of the contributions of, and
struggles faced by, IEHPs is essential: while
health care personnel shortages are an issue
across the globe, few members of the public
understand the importance of global migra-
tion as a health human resources planning
tool to forestall staffing problems. Fourth,
Zubin Austin
Global Migration and the Health
Workforce: the Experiences of
Internationally Educated Health
Professionals
Migration and Health Care
CANADA
28
educators and those involved in skills up-
grading and immigration settlement require
further research to support their curricular
efforts to enhance professional and com-
munity integration of IEHPs as efficiently
and ­
effectively as possible. Finally, IEHPs
themselves need access to better informa-
tion about the personal and professional
implications of migration; in cases of eco-
nomic or voluntary migration, IEHPs may
have unfounded or unrealistic expectations
regarding the ease and speed with which
their qualifications may be recognized and
respected in their adopted country of choice
[6].
Healthforce Integration
Research and Education
for Internationally Educated
Health Professionals
(HIRE IEHPs)
From 2012–2017, the Canadian govern-
ment (like many national governments)
recognized the importance of greater un-
derstanding of the experiences of IEHPs
in Canada, especially given the large and
growing reliance of the Canadian health
care system for foreign-trained doctors,
nurses, pharmacists, and other health
professionals [6] As part of a menu of
initiatives designed to address needs of
multiple stakeholders across the country,
the HIRE IEHPs initiative was funded to
support integration of IEHPs in the Ca-
nadian health workforce.The ultimate ob-
jective was to use research to guide curric-
ulum design for educators and to provide
supports for employers and community
agencies to more effectively and efficiently
support full integration of IEHPs into
Canadian health care practices and set-
tings.
Over the course of this project, several key
insights have emerged, which may be of
relevance to jurisdictions similar to Canada
working to support and enhance integration
of IEHPs to alleviate domestic health care
workforce shortages:
1.  Personal and Professional
Migration Needs Differ
During the course of the project, we
worked with literally thousands of foreign
trained health professionals from all over
the world, representing over a dozen regu-
lated and recognized health professions
including medicine, dentistry, midwifery,
nursing, and pharmacy. Across these in-
teractions – and regardless of profession,
country of origin, gender, or age – a strik-
ingly common theme emerged amongst
voluntary/economic migrants to Canada.
Almost without exception, health profes-
sionals who decided to leave “home” and
move to Canada did so with the express
purpose of enhancing prospects and im-
proving life for their children, rather than
for themselves [6]. In some cases, this same
sentiment was expressed by IEHPs even if
they were currently childless. IEHPs rec-
ognized that “back home” they had social
status, good jobs, good incomes, and a rea-
sonable or good quality of life – but that
they expected that migration to Canada
would be of primary benefit for their chil-
dren rather than for themselves. Their pro-
fessional degree/designation was merely of
instrumental use to meet Canada’s immi-
gration requirements; virtually no IEHPs
in our project said they had undertaken the
stressful migration process to Canada be-
cause of professional opportunities or the
chance to practice their profession. Indeed,
the vast majority described how they would
personally be less well-off, less profession-
ally satisfied, and less personally happy be-
cause of the migration experience but in
the longer term it would be a sacrifice that
was rewarded by the happiness and future
prosperity of their children [8].
This is a crucial insight for regulators,
educators, and employers: professional
satisfaction and practice are secondary to
parental responsibilities for the vast major-
ity of IEHPs, yet the existing literature on
IEHPs rarely discusses this issue. It is easy
to overlook the reality that health profes-
sionals are also people who must juggle
multiple roles and multiple responsibili-
ties; for the IEHPs in this project, their
professional integration was merely a tool
to support personal/social integration to
support their children. This underlying
motivation was frequently ignored or over-
looked throughout their registration and
employment experiences yet it is crucial
to understanding who they were as indi-
viduals. Perhaps most importantly when
viewed from this perspective, failure to be-
come licensed as a professional or delays
in finding suitable employment are not
simply “personal” issues – they have enor-
mous implications for a family network, a
sense of self-worth and self-identity, and
can therefore provoke strong emotional
responses.
2.  Domestic professional
and regulatory cultures can
appear cold and indifferent to
outsiders
A second common theme across all pro-
fessions was the interactions experienced
with profession-specific regulators, edu-
cators, professional associations, and em-
ployers. IEHPs in this project spoke of the
difficulties they had simply understanding
what they needed to do in order to get reg-
istered and gain employment. Bureaucratic
indifference or complexity was frequently
experienced as hostility or discrimination
due to country of origin. While very few
IEHPs in this project reported blatant rac-
ism or outright discrimination, a subtle
level of systemic barriers was omnipresent,
blocking progress through the licensing
system and frustrating attempts at gain-
ing Canadian experience or employment.
This was interpreted as the system being
“rigged” to favour Canadian graduates
over non-Canadian graduates; while most
Migration and Health Care CANADA
29
BACK TO CONTENTS
IEHPs did not necessarily object to this
type of favouritism per se, they did ob-
ject to the lack of transparency and clarity
about what they needed to do in order to
continue to progress in the system. While
official policy and practice amongst regula-
tors, educators, and employers in Canada
clearly emphasizes non-discrimination
and treating all applicants fairly regardless
of country of origin, the lived experiences
of many IEHPs suggest improvements are
needed in systems to achieve this policy
objective.
3.  Technical/procedural skills
are less important than
social/contextual ones
Many IEHPs – regardless of their profes-
sional background – expressed surprise at
the extent to which the Canadian health
care system prioritized social competencies
over technical competencies, particularly
in fields such as medicine. In most cases,
IEHPs were expecting greater challenges
in mastering the technical nuances of
Canadian health practice than they expe-
rienced; indeed many project participants
noted that the actual practice of their
profession from a technical perspective
was not that dissimilar in Canada to their
experience in another country. What was
completely different – and in many cases
very overwhelming – were the multiple
social interactions and interpersonal nice-
ties that characterize professional practice
in Canada. The conversational burden
amongst health care professionals, and
the “small talk” demanded by patients was
frequently challenging for IEHPs to mas-
ter, which in turn may have led Canadian
patients and providers to label IEHPs as
“cold”, “aloof ” or “not personable enough
to work here”. Most IEHPs reported man-
aging to pass requirements related to the
technical aspects of their professional work
(e.g. licensing exams), but struggling to
master the application of this learning in
a Canadian health care context.The impli-
cations for Canadian regulators, educators,
and employers are significant – greater sup-
port for “soft skills”upgrading and training
is needed to more fully engage IEHPs and
help them better integrate in the Canadian
system.
4.  Communication is more
than just language skills
In all regulated health professions in
Canada, there are mandatory English or
French language fluency requirements that
must be demonstrated prior to registration
in the field. Standardized widely available
international tests such as the TOEFL or
IELTs are used by regulators, educators,
and employers to establish communication
readiness for practice. IEHPs in this proj-
ect were virtually unanimous in describing
how passing standardized language tests
was not the same as being able to com-
municate in a Canadian context. First,
standardized language tests are frequent-
ly general in nature, and do not focus on
complex medical terminology or nuances.
Second, while the vast majority of IEHPs
coming to Canada speak some English or
French, there are many different kinds of
“englishes” and “frenches” spoken in differ-
ent parts of the world. Specific local idioms
or dialects are rarely tested in standardized
tests, yet are crucial for establishing social
bonds with patients or other health care
professionals.Third, standardized language
tests only test verbal, written, or aural com-
munication and as noted by many IEHPs
in this project much of “communication”in
health care is non-verbal in nature. Many
non-verbal cues and gestures (for example,
eye contact, handshakes, physical distance
while speaking) are just as (if not more)
important than the specific word choices
and verbal communication used, yet for
some IEHPs their non-verbal commu-
nication patterns were misinterpreted or
misunderstood by others in a negative way.
Educators, regulators and employers need
to be aware that communication is not
simply about verbal skills, but instead cover
a constellation of issues for which further
education and support may be required to
truly support integration of IEHPs in the
workforce.
5.  Patient Centeredness
The Canadian health care system – like the
system of many other countries – is based
upon the notion of patient autonomy, pa-
tient rights and patient centeredness. The
central role of patients in decision making
is instilled in health professional students
from the first day of their studies. Inter-
estingly, IEHPs in this project highlighted
how their interpretations and understand-
ings of patient centeredness were at times
misaligned with Canadian expectations,
particularly with respect to the patient’s
role in clinical decision making. While
many IEHPs in this project recognized
and acknowledged that their views of pa-
tient centeredness may appear patriarchal
or professionally-focused by Canadian
standards, they equally expressed discom-
fort regarding how a truly patient-centred
health care system could actually function.
Many of them noted that by definition
there is knowledge and skills gap between
most patients and most professionals and
that one of the primary responsibilities
of professionals was sometimes to lever-
age their higher levels of knowledge in
positive ways to overcome patients’ misap-
prehensions. While at times this may give
the appearance of being overly directive or
paternalistic in care delivery, many IEHPs
– and in particular physicians – struggled
with the overly idealistic notion of a pa-
tient-centred health care model that did
not suitably value their privileged knowl-
edge base and skill set. Many framed it
in terms of responsibility to and for the
patient, even if the patient him/herself
was not behaving responsibly or choosing
wisely. Particularly for physicians there
was significant discomfort in the notion of
a patient-led care team or decision making
Migration and Health Care
CANADA
30
process that was at odds with a physician’s
recommendations, and a sense of helpless-
ness in terms of how to better communi-
cate or better negotiate in such situations.
For educators, regulators, and employers,
this introduces challenges and opportu-
nities around integration. First, there is a
need to provide IEHPs with both back-
ground knowledge but also advanced in-
terpersonal and communication skills to
work within the patient centred world-
view that is integral to Canadian health
practice. Second, there may be a need for
not only greater education but more ro-
bust assessment of such competencies to
ensure that those entering professional
practice are well equipped to deal with
the realities of working with diverse Ca-
nadian populations. Third, finding ways of
honouring the personal and professional
traditions of IEHPs while still meeting
the expectations of Canadian patients is
essential – pride in one’s profession and
professional role is an important part of
being a professional, but of course cannot
be used as an excuse for inappropriately
paternalistic behaviours. Finding ways of
reconciling these issues is essential to sup-
port greater integration of IEHPs in the
workforce, and require collaboration from
all parts of a profession.
6. Interprofessionalism
The delivery of health care in Canada (as
in many countries) is rapidly evolving to-
wards more highly integrated interprofes-
sional teams where professionals with dif-
ferent designations can perform different
non-traditional roles.For example,in many
parts of Canada,pharmacists may prescribe
medications or physical therapists may di-
rectly order and interpret x-rays without a
physician being involved. Canadian gradu-
ates of these fields are trained for these
sorts of responsibilities, but those from
other countries where more traditional
professional silos exist may struggle with
advanced practice responsibilities. Further,
in the Canadian system, it is both expected
and desired that health care professionals
fully discuss and debate patient care deci-
sions with one another as a way of ensur-
ing best possible care. At times, this may
mean questioning physicians’ orders in a
collaborative, non-hierarchical way. Again,
in many parts of the world, medical team
hierarchy may be stronger than in Canada,
and non-physicians may have little expe-
rience and no comfort in questioning or
disagreeing with a doctor. Models of inter-
professional practice require a diverse array
of skill sets related to conflict management,
negotiation, interpersonal communication
and other soft skills, and these were identi-
fied by many IEHPs as a significant bar-
rier to their full integration in the health
care workforce. Simply stating that health
care professionals work together is very
different than actually working together
in practice; those IEHPs (physician and
non-physician alike) who come from more
traditional hierarchical health care systems
found themselves struggling with the real-
ity of interprofessional practice in Canada.
For educators, regulators, and employers, it
is clear that further education, in-service
training, and summative and formative as-
sessment are needed to ensure interprofes-
sional competencies are met or exceeded to
facilitate greater integration in the work-
force.
While the six primary themes noted above
were consistent and expressed by IEHPs
regardless of their profession or demo-
graphic background, they all point to the
central importance of non-technical or
“soft skills” in the daily practice of any
profession. The real barrier to registration,
licensure, employment, and meaningful
integration in the Canadian health care
system does not appear to be technical or
procedural skills – as reported by IEHPs
in this project, the main issues are those
related to interpersonal, communication,
interprofessional, and socio-cultural skills
that are much more challenging to teach
and assess.
Enhancing Integration
of IEHPs in the
Workforcev
One of the outcomes of the HIRE IEHPs
project was the development of a reposi-
tory of online resources aimed at both
IEHPs themselves and employers/regula-
tors of IEHPs to support development of
the “soft skills” that are so crucial to suc-
cess in the workforce. These resources are
freely available on-line at www.hireiehps.
com and are meant to be a set of tools that
can be accessed before or after migration.
While the focus and context of this work
is the Canadian health care system, many
of the modules contained in this program
will have applicability to other jurisdic-
tions. The repository was explicitly de-
signed to be patient focused and interpro-
fessional in its orientation, to reinforce the
structure of health care delivery and prac-
tice in Canada. Any professional – physi-
cian, nurse, midwife, physical therapist
etc – who is internationally educated can
access the repository and benefit from its
content.The repository is rich in video and
patient simulations, provides opportunities
for self-assessment and formative evalua-
tion, provides links for onward readings,
and uses a variety of teaching and learning
strategies to convey complex content in an
engaging manner that is aligned with their
learning needs.
Conclusions
Global migration continues to be an im-
portant public policy and personal issue
that affects all individuals in society. In
many Western countries, reliance upon in-
ternationally educated health professionals
is growing and health care systems would
struggle to cope with increasing demands
without the contributions and talents of
IEHPs. The experience in Canada suggests
that key issues related to better workplace
integration for IEHPs include “soft skills”
Migration and Health Care CANADA
31
BACK TO CONTENTS
related to interprofessionalism and patient-
centred care, and those specific strategies to
support learning and assessment in these
soft-skills areas is necessary and valuable,
and will ultimately lead to better quality
care for patients.
References
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2. Zurn P and Dumont JC. Health workforce and
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3. International Organization for Migration,
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5. Walton-Roberts, M, Runnels V, Rajan S et al.
Causes, consequences, and policy responses
to the migration of health workers: key find-
ings from India. Human Resources for Health
2017;15:28. Accessed at: https://human-
resources-health.biomedcentral.com/arti-
cles/10.1186/s12960-017-0199-y
6. Paul R, Martimianakis M, Johnstone J, Mc-
Naughton N and Austin Z. Internationally edu-
cated health professionals in Canada: navigating
three policy subsystems along the pathway to
practice. Acad Med 2017;92(5):635-640.
7. Chen L, Evans T, Anand S et al. Human re-
sources for health: overcoming the crisis. The
Lancet 364(9449):1984-1990.
8. Arah O, Ogbu and Okeke C. Too poor to leave,
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Zubin Austin, BScPhm, MBA,
MISc, PhD, FCAHS
Professor and Koffler Chair in Management,
Leslie Dan Faculty of Pharmacy,
University of Toronto Canada
E-mail: zubin.austin@utoronto.ca
Paul AM Gregory, BA, MLS
Research Associate, Leslie Dan Faculty of
Pharmacy, University of Toronto Canada
Medicine is the “science or practice of
the diagnosis, treatment, and preven-
tion of disease” [1]. Another widely ac-
cepted definition is “science and art that
deals with the maintenance of health and
the prevention, alleviation or cure of dis-
eases” [2]. Considering these two defini-
tions of medicine, it is clear that aesthetic
medicine, as a new developing branch, has
some features distinguishing it from con-
ventional medicine.
Aesthetic medicine encompasses special-
ties that are aimed at improving the ap-
pearance by treating certain conditions.
Traditionally, aesthetic medicine includes
aesthetic dermatology, reconstructive
plastic surgery and cosmetic (aesthetic)
plastic surgery [3, 4]. A wide range of
professionals are involved in the field of
aesthetic medicine – dermatologists, plas-
tic surgeons, medical cosmetologists. In
some cases, the medical team includes
psychiatrists, psychologists and dietitians.
The training of different professionals on
Bioethics and communication skills also
differs.
According to the American Academy of
Aesthetic Medicine (AAAM), the term
“aesthetic medicine” includes only mini-
mally invasive procedures and is quite dif-
ferent from plastic surgery, which includes
face lift, breast implants, liposuction,
etc [5].
Some Ethical Aspects of Aesthetic
Medicine in Adolescents
Radka Goranova-Spasova Andrey Kehayov
Ethical Aspects of Health Care
BULGARIA
32
In this paper, we discuss all procedures that
are designed to improve the appearance,
not just the minimally invasive. Conven-
tional medicine has a thousand-year his-
tory and the conditions it treats justify its
means, ­
including violating the integrity
of the human body in surgical operations
[5, 6]. When a person is ill, the only pur-
pose is to cure or at least improve the con-
dition of the patient. In aesthetic medicine,
the goal is not to restore impaired health
but to improve the aesthetic appearance.
However, if we refer to the broad defini-
tion of the World Health Organization
(WHO), “health is a state of complete
physical, mental and social well-being and
not merely the absence of disease or infir-
mity” [7]. In this sense, cosmetic proce-
dures are justified because they create the
psycho-physical balance necessary for the
healthy human being. In addition, they can
significantly improve the quality of life and
social well-being of the individual.
Importance of the topic
Western cultures (also Eastern ones) idol-
ize the perfection of the human body. This
is not new in human history because the
beautiful appearance is associated with
good health, well-being and prosperity [8].
Never before, however, improving appear-
ance with the contibution of medical pro-
fession has been so significant. Following
literature review we have formulated the
following reasons, which make the topic
relevant, important and requiring increased
attention by the medical community and in
particularly by the physicians involved in
cosmetic procedures.
• Aesthetic procedures (dermatological and
surgical) are becoming more and more
popular as a result of media, social net-
works and aggressive marketing, promot-
ing a particular appearance as attractive,
desirable and accessible [9].
• The contemporary values of Western so-
cieties, focused on beauty and perfection,
are a source of profits for those involved
in aesthetic medicine. According to the
economy laws demand and supply are
interrelated. And the orientation of the
medical professionals to a purely eco-
nomic benefit is in contradiction with
medical ethics values.
• Improving economic, social and cultural
status is a prerequisite for easier access to
cosmetic procedures [10, 11].
Worldwide statistics show an increase in
cosmetic procedures. According to the lat-
est published data of The International So-
ciety of Aesthetic Plastic Surgery for the year
2016, 31,610 million plastic surgeries were
performed worldwide, and the total in-
crease in surgical and non-surgical cosmet-
ic procedures in one year was 9%. The ten
leading countries in cosmetic procedures
are the United States, Brazil, Japan, Italy,
and Mexico, where approximately 41.4%
of all worldwide cosmetic procedures are
performed. These are followed by Russia,
India, Turkey, Germany, and France [12].
• Adolescents are a specific group that
needs legal protection. The number of
minors willing to undergo aesthetic in-
tervention is also rising [9].
Aim of the study
We set our aim to study and analyze some
ethical aspects of aesthetic procedures in
adolescents. To achieve the aim, we used
common and private scientific methods, in-
cluding a documentary method and a litera-
ture review, analysis, synthesis, and a com-
parative method.
Results and discussion
First we reviewed the classification of aes-
thetic procedures (dermatological and sur-
gical) to assess their relevance to adoles-
cents and the ethical acceptability of each.
Anti-aging and rejuvenating procedures are
Table 1.  Types of aesthetic procedures and degree of ethical acceptability
Type of procedure Procedure Ethical acceptability
Reparative plastic surgery
Surgical treatment Cleft
lips/ palates and other
congenital malformations
Ethically acceptable at a
reasonable risk
Reconstructive plastic
surgery
In case of major injuries,
burns, accidents and
diseases of the face and
body
Ethically acceptable at a
reasonable risk
Aesthetic plastic surgery
Breast augmentation/
reduction
Otoplasty
Rhinoplasty
Liposuction
Blefaroplasty
Hymenorrhaphy
Different degrees of ethical
acceptability in individual
cases.
Increased attention: general
anesthesia; allergic reactions;
failed surgery; dissatisfying
effect; complications.
Non-surgical cosmetic
procedures
(face and body)
Botulinum Toxin
Facial fillers
Lip augmentation
Laser for acne treatment
Laser hair removal
Different degrees of ethical
acceptability in individual
cases.
Increased attention: local
anesthesia; allergic reactions;
failed procedure; dissatisfying
effect; complications.
Ethical Aspects of Health Care BULGARIA
33
BACK TO CONTENTS
not used by minors, thus they are not in-
cluded [13].
Plastic surgery is usually divided into two
categories  – reconstructive and cosmetic
(aesthetic) surgery. The most commonly
used procedures on minors are presented by
type on the following table.
Reparative and reconstructive surgery is
associated with pathology or major disfig-
urements. As these surgeries are most com-
monly considered ethically acceptable, we
will not put emphasis on them later in this
paper.
Breast augmentation is the most common
aesthetic surgical intervention that is par-
ticularly discussable in adolescents. Other
frequent interventions include otoplasty,
rhinoplasty, lip augmentation with fill-
ers and laser treatments. The ethical ac-
ceptability of each procedure depends on
a number of factors – the severity of the
condition, patient age, the risks of inter-
vention, etc.
Application of the
Principles of Biomedical
Ethics in Aesthetic
Medicine
In 1979, Beauchamp & Childress pub-
lished the Principles of Biomedical Ethics,
which are now widely accepted as the ethi-
cal basis of medical practice.The Principal-
ism is an ethical theory, based on the four
fundamental principles (autonomy, benefi-
cience, non- maleficience, and justice), and
is suitable for practical purpuses. In many
cases, solving ethical dilemmas is based on
intuitive professional knowledge [6].The
emergence of a moral case in which there
is a collision of value systems imposes a
higher level of rules and guidelines to be
invoked by medical professionals. Ethical
principles provide the abstract frames of
ethical norms and outline the morally ac-
ceptable limits of moral relationships [15,
18].
The principle of respect for autonomy is
expressed in the right of each individual
to make their own choices for themselves,
following their own plan of life [6, 16]. In
general, competent adults have the right
to decide whether or not they want to
undergo invasive manipulation. For that
purpuse, they receive complete informa-
tion on the need for the procedure and the
potential risks and give informed consent.
Information should include, in addition to
procedure risks, the probability of failure
and possible alternatives. One of the pre-
requisites for informed consent is patient’s
competence, i.e. the patient is able to un-
derstand the implications of informed con-
sent and the ability to freely give their con-
sent [17, 18] Adolescents have a different
degree of autonomy and decision-making
ability. Informed consent is given by their
legal guardians – parents or other guardians.
However, it is considered that the physician
should provide sufficient and accessible in-
formation on the procedure – its type, com-
plications, price and risks, both to parents
and minor patients [17, 18].
The principle of beneficience requires that
medical professionals act in favor of and for
the benefit of the patient or what will fur-
therer the patient’s interest. This principle
has been fundamental to the medical pro-
fession since its beginning.
The principle of non-maleficience requires
medical professionals to limit the harm to
the patient or what will be against his/her
best interest. Patient’s unrealistic expecta-
tions can raise ethical issues and, in order
for a healthcare professional to comply with
the principle of non-maleficience, he must
explain the expected results and the pos-
sibility of failure. The physician should as-
sess both the physical and the psychological
state of the patient in order to minimize the
possible risk, especially when it is not a per-
son with a disease [10].The registration of a
form of psychosomatic disorder is essential
for the success of the procedure and for pa-
tient’s satisfaction.
It should be borne in mind that the risks
of different aesthetic interventions vary de-
pending on the type of procedure, health
status, age of the patient, etc. Some proce-
dures do not require anesthesia,while others
are under local or general anesthesia. If the
patient’s expectations are unrealistic and the
risks unjustified, the physician has a duty to
assume moral responsibility and to refuse to
perform an aesthetic procedure. Physician’s
duty should be put in front of the financial
interest in line with the maxim Primum non
nocere” (First, to do no harm).
Both principles (of beneficience and non-
maleficience) rest on the fundamental im-
portance of the interest of and benefit to the
patient [19]. In the first the focus is on the
positive requirement to affirm the interest
of the patient and in the second – on the
abstinence from actions that will disrupt the
patient’s interest. It is sometimes difficult to
judge whether an action has benefit or harm
to the patient. Because the medical benefit
may be accompanied by moral harm and
vice versa.
The principle of justice in medicine is pri-
marily seen in the context of distributed
justice and means honest, impartial and
appropriate action on the person [6].This
principle requires medical professionals to
provide medical care to all those in need.
Healthcare systems, despite the variety of
funding sources and payment methods,
would rarely cover the cost of cosmetic pro-
cedures. So these procedures remain in the
private sector at the expense of consumers.
Those who can afford to pay undergo cos-
metic procedure.Even in countries with low
economic growth, the demand for aesthetic
medicine is rising [20]. Aesthetic medicine
can be referred to as a client – user of health
services – rather than a patient.But the pro-
vider of these medical services should not
be just a profit-driven dealer.
Ethical Aspects of Health Care
BULGARIA Ethical Aspects of Health Care
BULGARIA
34
Factors for Increased
Demand for Aesthetic
Medicine in Adolescents
We tried to summarize and systematize
the main motives of adolescents to search
for the services of aesthetic medicine. The
demand for cosmetic surgery is usually mo-
tivated by psychosocial factors.
• Psychological problems: The search for
plastic surgery is most often provoked
by psychological factors. In some cases,
it may be psychiatric disorders (for ex-
ample, Body Dysmorphic Disorders  –
BDD). Typical of these patients is that
the aesthetic problems they are looking
for cosmetic services are not real. Often
after a procedure, they are looking for
more new interventions to improve their
appearance. Patients with such pathology
should be consulted with a psychiatrist.
The role of the aesthetic physician is to
record the likelihood of such disorder and
to redirect the patient,following the prin-
ciple of harmlessness [21].
• Low self-esteem, provoked by numerous
factors  – beauty standards promoted in
the media and social networks; bullying at
school; social exclusion. Each of these rea-
sons is real and in the specific cases the real
need for the procedure must be assessed.
• Real serious physical problem (severe
acne, congenital malformations, disabili-
ties, etc.)
• Aggressive advertising [22] and media
induced perceptions [8].
• Public acceptability and complicity of
parents (for example,in 2008,over 10,000
teenagers in Italy have corrected their
breasts, most of whom have received the
surgery as a gift from their parents).
Adolescent Patient –
Features And Rights
Some characteristics of adolescents that
distinguish them from adults undergoing
aesthetic procedures are as follows:
• Adolescent patients may be considered as
a specific vulnerable group. They do not
have complete autonomy and their health
decisions are often taken by their parents
and legal guardians [18]. Even more deli-
cate are cases in procedures that do not
aim at restoring the health of the indi-
vidual and, as in aesthetic medicine, are
applied to healthy individuals [9].
• Adolescents are still developing physi-
cally, mentally and emotionally. Unreal-
istic expectations and underestimation of
medical risks are characteristic of them
because of their social immaturity.
• In any case, besides the medical assess-
ment, the physician should also assess
the emotional maturity of the patient-
customer.
The “Doctor-Patient”
Relationship and the Specific
Role of the Physician in
Aesthetic Medicine
The “doctor-patient” relationship is funda-
mental to medical ethics. The health and
interest of the patient are leading for the
physician. The Declaration of Geneva of
the World Medical Association states “The
health of my patient will be my first consid-
eration” [23]. In the present case, this rela-
tionship has two distinctions: 1/ the patient
is more like a client, as discussed above; and
2/ the patient is a minor and cannot declare
their own interest by themselves due to lack
of autonomy.
Aesthetic medicine can be referred to as a
client-user of health services rather than
a patient. As we mentioned earlier, con-
sidering fairly distribution of resources in
healthcare, aesthetic services are in the pri-
vate sector.
Adolescents cannot give informed consent
on their own. Although they have no legal
capacity, many are able to relate cause and
effect and to cover different tests that assess
their competence. In the case of cosmetic
procedures, adolescents play an essential
role in the decision-making process and the
discussion with them is just as important
as the one with the parent. Minor patients
may have acquired autonomous capacity,
which is not always directly dependent on
the age of the patient. The relationship be-
tween the parent’s authority and the youth’s
freedom is dynamic. In the event of a dis-
crepancy between the wishes and expecta-
tions of parents and children, the physician
must always act in the best interests of the
child; to reduce the potential adverse conse-
quences, including physical suffering, pain,
stress and death; to respect the spiritual and
cultural values ​​
of the family and the child. 18
In the case of a significant risk for small aes-
thetic benefits,procedures should be refused
even with the consent of the parents.
Adequate communication with the patient
is a mandatory professional characteristic
of the physician [6]. Communicative skills
are not simply granted, they are subject to
improvement. Working with healthy indi-
viduals with certain expectations and wishes
poses new challenges for medical profes-
sionals. The patient-client is not dependent
and vulnerable, but demanding.
Professionalism and
Legal Framework
According to the definition of Epstein and
Hundert professional competence is the
“habitual and judicious use of communi-
cation, knowledge, technical skills, clinical
reasoning, emotions, values, and reflection
in daily practice for the benefit of the indi-
vidual and community being served” [24].
Professionalism in medicine is guaranteed
by professional codes, ethical frameworks
and rules of good medical practice. This
happens in the context of a more compre-
hensive legal framework [6].
Many European countries are introducing
tougher rules to protect adolescents under-
Ethical Aspects of Health Care BULGARIA
35
BACK TO CONTENTS
going aesthetic medicine. In Austria and
Germany, adolescents under the age of 16
cannot undergo aesthetic surgery. Future
patients between 16 and 18 years of age
undergo a mandatory psychological assess-
ment and need the consent of their par-
ents [9].Legislators in Italy have introduced
a ban on breast plastic surgery in minors [8].
In the field of aesthetic medicine there are
ethical dilemmas which, given the increase in
these procedures worldwide,require increased
attention. Therefore, the scientific commu-
nity develops relevant professional codes and
ethical frameworks.The International Society
of Plastic Surgery, for example, introduces a
code that guarantees the preservation of hu-
man dignity, academic and practical skills
of involved professionals. Adolescents are a
specific vulnerable group with varying com-
petence degrees, but without the necessary
autonomy for self-informed consent. In each
particular case, the physician should consult
the adolescent, evaluate their expectations,
seek a balance between risks and benefits,and
act in the best interests of the patient.
Professionals, beyond knowledge of the legal
framework of their country, must know the
basic principles and rules of medical profes-
sion, the ethical codes and the rules of good
medical practice in the specific field.The in-
troduction of such rules in aesthetic medi-
cine is necessary and a guarantor of the qual-
ity of medical services. Continuing training
in communication skills is a prerequisite for
better coping with ethical problems in the
practice of aesthetic medicine where patients
have client characteristics.
References
1. Definition of Medicine, Oxford Dictionaries
Online. Oxford University Press. Available at:
https://en.oxforddictionaries.com/definition/
medicine
2. Definition of Medicine, Merriam-Webster
Medical Dictionary. Available at: https://www.
merriam-webster.com/dictionary/medicine
3. American Academy of Anti-Aging Medicine,
“What is Aesthetic Medicine?”, Available at:
https://www.a4m.com/the-aesthetic-anti-ag-
ing-fellowship.html
4. Definition of aesthetic medicine, International
Association for Physicians in Aesthetic Medi-
cine, IAPAM. Available at: https://iapam.com/
aboutiapam.
5. American Academy of Aesthetic Medicine,
“Difference with Conventional Medicine”.
Available at: https://www.aaamed.org/past_pre-
sent_future.php.
6. Vodenicharov, T., S. Popova, Medical Eth-
ics, EcoPrint Printing Workshop, Sofia, 2010.
[Trasnlated from Bulgarian]
7. World Health Organization. (2006). Constitu-
tion of the World Health Organization – Basic
Documents, Forty-fifth edition, Supplement,
October 2006. Available at: http://www.who.
int/governance/eb/who_constitution_en.pdf
8. Del Rio A, Rinaldi R, Napoletano S, di Luca
NM. Cosmetic surgery for children and ado-
lescents. Deontological and bioethical re-
marks. Clin Ter. 2017 Nov-Dec;168(6):e415-
e420.
9. Vergallo GM, Marinelli E, Napoletano S,
Di Luca NM, Zaami S. Ethics and/or Aes-
thetics? Reflections on Cosmetic Surgery
for Adolescents. Cuad Bioet. 2018 May-
Aug;29(96):177-189.
10. Spear M. The ethical dilemmas of aesthetic
medicine: what every provider should consider.
Plast Surg Nurs. 2010 Jul-Sep; 30 (3): 152-5.
11. Hyman DA. Aesthetics and ethics: the implica-
tions of cosmetic surgery. Perspect Biol Med.
1990 Winter;33(2):190-202. PubMed PMID:
2304820.
12. International society of Aesthetic Plastic Sur-
gery.ISAPS Global Survey, 2017. Available at:

Medical Professionals

isaps-global-statistics/
13. IASPS International Study on Aesthetic/Cos-
metic Precedures Performed in 2016. Avail-
able at: https://www.isaps.org/wp-content/
uploads/2017/10/GlobalStatistics.WorldWide.
Summary2016s-1.pdf
14. Rakesh K.,Sandhir M.Ch,Definition and Clas-
sification of Plastic Surgery. Plastic and Recon-
structive Surgery: November 1997; Volume 100;
Issue 6; ppg 1599-1600.
15. Beauchamp,Tom L; Childress, James F., Princi-
ples of biomedical ethics. Seventh edition New
York : Oxford University Press, c2013.
16. F‐C Tsai D. The WMA Medical Ethics Man-
ual. Journal of Medical Ethics. 2006;32(3):163.
doi:10.1136/jme.2005.013623.
17. Shtereva- Nikolova, N., Informed consent. In:
Guidance on Medical Ethics, Ed. ID Print,
Sofia, 2014, pp. 24-33. [Trasnlated from Bul-
garian]
18. Shtereva-Nikolova, N., Informed Consent- Na-
ture, Importance and Application in Ambula-
tory Practice, RA “Euromedia” Ltd., Sofia 2015.
[Trasnlated from Bulgarian]
19. Mousavi S. The Ethics of Aesthetic Surgery.
Journal of Cutaneous and Aesthetic Sur-
gery. 2010;3(1):38-40. doi:10.4103/0974-
2077.63396.
20. Nejadsarvari N, Ebrahimi A, Ebrahimi A,
Hashem-Zade H. Medical Ethics in Plastic
Surgery: A Mini Review. World Journal of Plas-
tic Surgery. 2016;5(3):207-212.
21. Spriggs, M., Gillam, L. Body Dysmorphic Dis-
order: Contraindication or Ethical Justification
for Female Genital Cosmetic Surgery. Adoles-
cents Bioethics. 2016;30(9):706-713.
22. Maio G. (2011) Ethical Considerations in Aes-
thetic Medicine. In: Raulin C., Karsai S. (eds)
Laser and IPL Technology in Dermatology and
Aesthetic Medicine. Springer, Berlin, Heidel-
berg.
23. Declaration of Geneve. Available at https://
www.wma.net/what-we-do/medical-ethics/
declaration-of-geneva/
24. Epstein RM, Hundert EM. Defining and as-
sessing professional competence. JAMA.
2002;287(2):226–235.
Radka Goranova-Spasova, MD, PhD
Asst. prof. at Department of medical
ethics and law, Faculty of Public
Health, Medical University-Sofia
E-mail: r.goranova@foz.mu-sofia.bg
Andrey Kehayov, MD, PhD
Assoc. Prof. at Department of health
policy and management, Faculty of Public
Health, Medical University- Sofia
President of SEEMF
Ethical Aspects of Health Care
BULGARIA Ethical Aspects of Health Care
BULGARIA
36
For Karl Popper, Austrian philosopher and
father of critical rationalism, the bound-
ary between science and non-science was
in the way that scientific theories make
verifiable and therefore falsifiable state-
ments and predictions and are discarded or
refuted when those checks do not pass.The
character of pseudo-science is not given
by the subject itself, but by the statements
on the basis of which their study is con-
structed.
The concept of pseudoscience brings to-
gether beliefs or practices that are consid-
ered as based on a scientific method without
this being true; these beliefs or practices do
not follow a valid and recognized scientific
method although they are falsely presented
as scientific, hence their simplest definition
of “false science”.
Pseudotherapy is defined in a broad sense
“as a proposal for cure of diseases, relief of
symptoms or improvement of health, based
on criteria without the support of available
evidence”.
It cannot be doubted that current medicine
based on the experimental scientific meth-
od and forming the basis of our National
Health Systems has achieved great mile-
stones and benefits and manages to cure
many diseases, unthinkable a few years ago,
although it has serious financing problems,
is aggressive in many cases and is accom-
panied by a series of non negligible adverse
events and effects. Furthermore, it cannot
always meet the expectations of citizens.
These are perhaps two problems of current
medicine, the adverse effects /events and
uncertainty of results in the case of some
serious diseases, which create the breeding
ground for the offer of pseudotherapies.
The vast credulity and lack of critical
thinking has always had a subscription in
the most vulnerable population groups, i.e.,
especially patients with serious pathologies
(although anyone can be vulnerable due
to lack of academic preparation in a con-
crete aspect, relying on inadequate sources
of information, going through a period of
physical or mental weakness, etc.). In the
collective imagination there is the figure
of the “snake oil salesman” or “hair-growth
vendor”. The mechanisms and strategies
are exactly the same as those of these clas-
sic figures, only adapted to modern times
by accelerating their dissemination with
the tools provided by the Internet and so-
cial networks.
Indeed, in this spurious offer, current tech-
nological tools that can be introduced in
any field play a fundamental role. Yes, there
are groups or organizations interested in
the dissemination of pseudotherapies, but
any citizen with a computer can break into
the privacy of a citizen who is sick and in a
situation of extreme vulnerability, dissatis-
faction or emotional disorder making them
an easy target of any unscrupulous charlatan
with pseudoscientific theories.
Therefore, the first step of the General
Medical Council of Spain has been the
creation of an Observatory that includes an
interpretative analysis of 139 non-conven-
tional therapies and techniques, almost all
referenced in the Ministry of Health, So-
cial Services and Equality document since
2011. http://www.cgcom.es/observatorio-
omc-contra-las-pseudociencias-intrusismo-y-
sectas-sanitarias
Among the most dangerous pseudothera-
pies this Observatory analyzes are those
related to the area of ​​
the so-called new
Germanic medicine, a method created by
Ryke Geerd Hamer, and the two variants of
biodecoding and bioneuroemotion which
have attracted many followers and deceive
people with false hopes of healing all kinds
of diseases, from cancer to malaria, AIDS
or autism.
Among adherents are also well-known
people who practice impunity with sanitary
intrusion and profit,taking advantage of the
weakness of patients and selling products
that are prohibited by the Medicines Agen-
cies in Spain and Europe, such as Sodium
Chloride – MMS, industrial-use bleach di-
luted to 28%, with the false message that it
can be used to cure cancer and other serious
processes.
We can remember the case of Hamer, who
in 1994 deceived around 3,000 cancer pa-
tients in Spain who stopped chemotherapy
and many of them died. He was sued and
fled to Germany, Italy and later France,
countries in which he was jailed; later he
returned to Spain where he was also con-
victed and jailed. In 2007 he settled down
with several of his clinics in Norway.
“The funny thing is that, after two decades,
these events are repeated and we have well-
known personalities, some of them doctors,
who are sued, who proselytize this pseudo-
therapy/pseudoscience,” the so-called new
Germanic medicine, that “is neither medi-
cine, nor is it new; it is deception that also
Pseudosciences/Pseudotherapies
Jerónimo Fernández-
Torrente
Ethical Aspects of Health Care SPAIN
37
BACK TO CONTENTS
IFPMA News
has a sectarian element to it because the pa-
tient abandons their treatment and departs
from their relational environment because
they tell them that this makes healing more
difficult”.
One of the main problems is the legal vacu-
um and the lack of information, something
that many unscrupulous people take advan-
tage of. Although there are health profes-
sionals and non-professionals who use these
techniques/therapies as experimentation
with good intention, there are many others
who really “deceive people saying they will
cure important diseases when there is no
evidence of this cure”.
All our Medical Deontology Codes and
legislation on public health advertise-
ments in many of their issues prohibit
deception of citizens and patients; they
also prohibit medicines and procedures
that have no proven evidence and their
use through deception, and public admin-
istrations are responsible for it, sharing
responsibility with our professional cor-
porations.
We must highlight the issue of minors and
the responsibility of parents /guardians who
act, very often, on the basis of misinforma-
tion, and also the responsibility of the au-
thorities and professionals who do this and
who are completely outside the Law.
These pseudotherapies “must be subjected
to scientific rigor and evidence, something
that is not currently happening”.“The strat-
egy that the person against pseudotherapies
must prove why they are against them, is
fallacious and deceptive; it is used when
there are no credible arguments, neither sci-
entific,nor experimental,nor security of any
practice or technique.”
We must defend conventional scientific
medicine and experimental scientific med-
icine, which are based on public health
systems in the European environment,
Spain including, of course, and which is
our obligation and responsibility to de-
fend because it is an essential part of our
professional and ethical commitment with
the medical profession and with society as
a whole.
On the part of professional, academic, ad-
ministrative and also scientific organiza-
tions “we must know how to respond with
force to the challenge of this parascientific
and paramedical universe that is very harm-
ful to the health of citizens, for the security
and the rights of our citizens and patients
and for our welfare state.”
Dr. Jerónimo Fernández-Torrente, Treasurer
General Medical Council of Spain
IFPMA (International Federation of Phar-
maceutical Manufacturers & Associations)
represents the research-based pharmaceuti-
cal companies and associations across the
globe. The research-based pharmaceutical
industry’s 2 million employees discover, de-
velop, and deliver medicines and vaccines
that improve the life of patients worldwide.
Based in Geneva, IFPMA has official rela-
tions with the United Nations and contrib-
utes industry expertise to help the global
health community find solutions that im-
prove global health.
Thomas B. Cueni is Director General of
IFPMA since 1 February 2017. Prior to
joining IFPMA he was Secretary General
of Interpharma, the association of pharma-
ceutical research companies in Switzerland.
For many years Thomas Cueni has been in-
volved in the work of the European Federa-
tion of Pharmaceutical Industries and As-
sociations, EFPIA, where he most recently
served as Vice-Chair of the European Mar-
kets Committee and association represen-
tative on the Board. He represented the
industry on the EU High Level Pharma-
ceutical Forum, was Chairman of EFPIA’s
Economic and Social Policy Committee
and Chairman of the EFPIA Task Force
on the EU Commission’s Pharmaceutical
Sector Inquiry. Thomas Cueni also repre-
sented Interpharma, which he successfully
transformed from the association of Swiss
Rx companies to the association of pharma-
ceutical research companies in Switzerland,
on the Council of IFPMA.
Prior to his appointment with Interpharma,
Thomas Cueni had a career as a journalist,
inter alia as London correspondent for the
“Basler Zeitung” and “Der Bund”, and he
served as a Swiss career diplomat with post-
ings in Paris (OECD) and Vienna (IAEA,
UNIDO). He studied at the University of
Basle, the London School of Economics,
and the Geneva Graduate Institute for In-
ternational Studies, and has Master degrees
in economics (University of Basel) and poli-
tics (London School of Economics, LSE).
New IFPMA Code of Practice 2019
Thomas Cueni
38
IFPMA News
An efficient healthcare system depends on
mutual trust between all parties – but how
should that translate concretely into the day
to day reality of whether a healthcare pro-
fessional should be given a subscription to
a journal or a box of chocolates by a phar-
maceutical company? So while the most
important part of the R&D-based pharma-
ceutical industry’s work is the discovery of
new medicines and vaccines, it also needs to
develop, promote, sell and distribute them
in an ethical manner and in accordance with
all the rules and regulations for medicines
and healthcare. It’s not just what we achieve
that matters, but also how we achieve it.
In today’s fast-changing world, what might
have been considered normal business prac-
tice a few years ago may no longer be ac-
ceptable. For our industry, what is essential
is to constantly try to live up to the trust
that so many – patients, healthcare profes-
sionals, regulators, policy makers from all
over the world – have in the medicines and
vaccines we make.
Our R&D-based pharmaceutical industry
Code of Practice was first drawn up in 1981,
and it was the first one of its kind for any
business sector.Indeed,it set a precedent for
many other global self-regulation initiatives
of industry practices that were to follow.
Initially, correct information on the effects
and side effects of medicines were at the
core of the Code and was necessary to build
trust among patients,healthcare profession-
als, and other stakeholders for the innova-
tions we would bring to the market. Today,
through periodic updates of the Code, ex-
pectations regarding compliance are much
more comprehensive.
The last IFPMA Code revision in 2012
(current version, in force until 31st
Decem-
ber 2018) saw its scope expanded beyond
just focusing on our promotional practices
to cover all our company members’ interac-
tions with healthcare professionals, medical
institutions and patient organizations. Over
the past two years, we have been revising
this Code by consulting with our members
from all over the world. Our members are
now getting ready to implement a new ver-
sion of the global Code, which will be effec-
tive from 1st
January 20191
.
With this sixth edition of our IFPMA Code
of Practice , we are again setting the bar
higher than with previous Codes. The 2019
Code is marked by two important changes.
First, several sections have been updated,
including the introduction of a ban on
gifts and promotional aids (for prescription
medicines). Second, we have developed our
“Ethos”, the ethical foundation of IFPMA.
This addition aims to shift the approach to
changing behaviors from a rules-based to a
values-based Code. The intention is to en-
sure our members embrace the values and
principles that underpin the requirements
of the Code.
The new global Code has been aligned with
current European and US guidance and re-
sulted in a global ban on gifts and promo-
tional aids for prescription-only medicines.
Any exceptions based on the custom of gifts
to mark significant national, cultural or re-
ligious events (for example, mooncakes or
condolence payments) have been removed.
IFPMA members are also banning all pro-
motional items for healthcare professionals
for use in their offices (including post-its,
calendars, diaries, etc.). The only items that
can be provided to healthcare profession-
als – in the context of company organized
events – are company-branded pens or
notepads in order to take notes during the
meeting.
We have also added the new category of
Informational or Educational items. These
are things like scientific books, journal sub-
scriptions or memory sticks with educa-
tional data that may be provided to health-
care professionals for their own education
or for the education of patients, provided
1  https://www.ifpma.org/subtopics/new-ifpma-code-
of-practice-2019
that the items do not have independent
value. Product branding is not allowed, in
the same way as for items of medical utility
(such as inhalers, or devices to learn how to
self-inject).
As R&D-based pharmaceutical companies
are the innovators behind most new medi-
cines and vaccines, they are best equipped
to share much of the information on medi-
cines and their application, and have the
responsibility to share this scientific knowl-
edge with healthcare practitioners. Today’s
fast pace of medical innovation requires a
continuous dialogue to ensure that patients
have access to the treatments they need, and
that healthcare professionals have up-to-
date, comprehensive information about the
medicines they prescribe. We think that the
so called “goodies” or “promotional aids”,
even if they are of minimal value, send the
wrong message, as they trivialize the im-
portant, professional relationship that must
exist between our representatives and the
healthcare professionals. This relationship
is based on a mutual exchange where both
sides win by sharing expertise and scientific
knowledge, enabling the development and
effective use of new medicines.
The latest IFPMA Code emphasizes the
educational nature of these important inter-
actions and supports high-quality, patient-
centered health services and further focuses
on the value we bring to patients, and to
society as a whole.
Trust remains the crucial bedrock of these
exchanges and IFPMA encourages doctors,
pharmacists, nurses and patients to become
aware of our updated ethical standards.
The better our stakeholders understand our
standards and hold us to account, the easier
it will be for us to live-up to our commit-
ments.
By Thomas Cueni, IFPMA Director
General and co-chair of the APEC
Biopharmaceutical Working Group on Ethics
E-mail: info@ifpma.org
39
BACK TO CONTENTS
WMA News
In September 1978, the WHO staged the
first International Conference on Primary
Health Care in Alma-Ata, Kazakhstan (at
that time a part of the Soviet Union). The
outcome was a document widely known
as the Alma-Ata Declaration on Primary
Health Care. The conference also started a
program called “Health for All in the Year
2000” setting targets that should improve
the health status of all nations.
Forty years later, the WHO has called
for a second Global Conference on Pri-
mary Health Care, hosted this time by the
government of Kazakhstan, along with
WHO and UNICEF, in its new capital
Astana. Peteris Apinis, editor of the World
Medical Journal talked to Otmar Kloiber,
Secretary General of the World Medical
Association about the significance of this
conference.
Apinis: Next month health ministers, rep-
resentatives of WHO, UNICEF, the World
Bank and the International Monetary Fund
will meet in Kazakhstan for the 2nd
Confer-
ence on Primary Care.Will it be as success-
ful as the first conference?
Kloiber: I hope it will be a much bigger
success than the Alma-Ata conference.
Apinis: You sound as if you were not sat-
isfied with the outcome of the Alma-Ata
conference. Why is that?
Kloiber: Alma-Ata was the biggest WHO
event ever, however the results where
patchy or mixed, to put it kindly. The Al-
ma-Ata Declaration reads well, but what
many countries took away from it was no
more than a minimalist approach. Primary
Health Care be-
came a cheap sub-
stitute for real care.
This has led to dis-
appointments and
misunderstandings,
and sometimes to
a rejection of the
concept of Primary
Care. This must not
happen again. Pri-
mary Health Care
should be at the
core of every health
care system, even
of the most advanced and comprehen-
sive health care systems. Primary Health
should not be a dead-end road and should
not be seen as a second-class concept for
poor people.
Apinis: Do you mean that Primary Health
Care is only for affluent countries?
Kloiber: No, no it is truly for everyone.
Health care systems should be organised
around a solid core of Primary Health
Care providing prevention, medical treat-
ment, dental care, rehabilitation and pal-
liative care. This should offer pathways
to secondary and tertiary care. But when
starting up a health care system, your focus
will have to be on Primary Health Care as
this provides care options for most health
needs. But again: it must not be a dead-
end road. When serious conditions and
trauma cannot be dealt with, frustrations
will rise. Comprehensive health care sys-
tems have to be built around the core of
Primary Care.
Apinis: Why now after 40 years?
Kloiber: Yes, this is late. In fact the
WHO issued a remarkable report in 2008
entitled “Primary Care – Now more than
ever”, but obviously this advice was not
taken. Now the WHO is looking into
Universal Health Coverage. This is the
most ambitious WHO program ever: the
desire to bring affordable health care to
everybody, not sectorial, siloed programs,
not episodic care – real health care for all
people. If you want to achieve this, Pri-
mary Health Care is the first step on the
delivery side.
Apinis: What is on the other side?
Kloiber: Aiming for Universal Health
Coverage means, in the first instance, tack-
ling the Social Determinants of Health.
Without bringing justice  – some people
call it “social justice” – to people Univer-
sal Health Coverage will remain wishful
thinking. And yes, this must include pro-
viding the necessary financial resources. If
countries don’t understand that health care
is an investment and not an expense they
will not get this done.
Interview with Dr. Otmar Kloiber, WMA Secretary General, on the
Upcoming WHO Global Conference on Primary Health Care in
Astana, Kazakhstan, 22–23 October 2018
40
WMA News
Apinis: What mistakes should be avoided
this time?
Kloiber: It needs a comprehensive ap-
proach, starting with the Social Determi-
nants of Health, and it must not end with
a high-quality Primary Care service  – al-
though establishing this first is a sound
idea. After Alma-Ata, countries reduced
their ambitions to a minimum of care – they
thought the cheaper the better. In some
places where health targets were aimed at
everything else got forgotten. The typical
“window-dressing” problem: Fulfil the tar-
gets to look good, drop the rest. This can
easily turn into a fatal concept.
Apinis: What is the role of medical doctors
in Primary Health Care?
Kloiber: Everybody who needs a doctor
should be seen by a doctor. Medical doctors
have the highest level of competency and
they should lead the primary care team.This
doesn’t mean that doctors have to direct and
command everything. There are other pro-
fessionals that can contribute with their ex-
pertise, but in the end this is about health
and medicine. Medical doctors should be in
charge wherever this is possible.
Apinis: This sounds very logical, why are
you stressing it?
Kloiber: Firstly, doctors are a scarce re-
source in many countries. We must under-
stand that in the short run a doctor will not
be available everywhere. Secondly, there are
groups and donors who again want to “save
money”. At the World Health Assembly
this year we heard all too often that doctors
are too expensive. Some want to focus only
on Community Health Workers; others
such as the OECD prefer nurses as leaders
of Primary Care teams, giving physicians
more of a bystander’s role. In my opinion
these are perfect recipes for repeating the
mistakes of 1978. Investment in human re-
sources for health must include investment
in the education and employment of physi-
cians.
Apinis: Is there no role for nurses and
Community Health Care Workers?
Kloiber: There definitely is. Nurses are
desperately needed, for nursing care.
Community Health Care workers can
support health professionals through out-
reach work, especially in rural communi-
ties. And this again is no simple task. A
lot can be done right now by well-trained
Community Health Care workers, and
more will be possible in the future with
better and more intelligent e-health tools.
But this will not replace a nurse, it will
not replace a dentist, it will not replace a
physiotherapist, a pharmacist or a physi-
cian.
Apinis: What do you expect from the As-
tana Conference – or more specifically from
the participants?
Kloiber: From the WHO: keep aspira-
tions high and do not settle for second
best. From politicians: go for Univer-
sal Health Coverage, even if it will be a
long journey. The Social Determinants of
Health have to be on the agenda of every
minister in every government and quality
Primary Health Care is a sound delivery
concept to start with. From donors: sup-
port sustainable solutions and not quick
fixes that don’t last. From doctors: engage
for the Social Determinants of Health, for
equitable access to health, health care and
medical care.
Apinis: Dr Kloiber thank you for your in-
sights.
III
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World Federation for Medical
Education. World Conference
Seoul, Korea, April 2019
In April 2019, WFME will hold a World Conference under the
common theme of “Quality Assurance in Medical Education in the
21st
Century”.
In medical education, as in other fields, to attempt to achieve higher
quality on a global scale is a difficult endeavour.The needs of societies
vary considerably from region to region,even from country to country,
while migration of health care professionals creates the need to achieve
a degree of global comparability: to find a balance is challenging.
The World Conference is a chance to bring knowledge and expe-
rience together and find common ways to enhance the quality of
medical education both on the global and on the local scale.
In the past, the WFME Conference brought significant steps to-
wards improvement.
• In 1988, 30 years ago, the WFME World Conference resulted in
the Edinburgh Declaration which set out to alter the character of
medical education so that it truly meets the defined needs of the
society in which it is situated.
• In 2003, the WFME Conference was devoted to the WFME Tril-
ogy of Global Standards for Quality Improvement,which gained in-
ternational endorsement.Since then,the Standards have been widely
used and adapted for the needs of particular regions and societies.
For 2019, the focus remains on the quality of medical education
world-wide: its current state, its challenges and progress, and the
view of the future. The Conference will attempt to answer several
crucial questions:
Are your practices in accreditation the right ones?
It is widely understood that accreditation of medical education
ensures the quality of education. However, the mere existence an
accreditation system in a country or a region does not guarantee
that the system will result in trustworthy decisions; this requires the
accreditation system itself to operate in a robust, transparent and
norm-referenced way.WFME attempts to promote quality accredi-
tation through its Recognition of Accreditation Programme.
What is happening in the WFME Recognition of Accreditation
programme,and how should an accrediting agency prepare for it?
The Recognition of Accreditation sessions will present the system of
assessing the quality accrediting agencies, as WFME has developed
and implemented it,and the lessons we have learned from the agen-
cies we have already visited, experiencing various contexts, systems
and solutions, the differences – but also many unifying aspects.
How should you develop standards for education that are right for
the context of your medical school,your country or your region?
The Global Standards for Quality Improvement will once again be
a prominent topic; in the dedicated sessions, participants will hear
about the experience of developing standards for medical education
in particular context and learn how they should be used. There is a
common misconception that the WFME Standards are to be used
as a prescriptive tool. WFME regularly tries to dispel this notion,
as the Standards always need to be adjusted to the needs of the par-
ticular context and society.
How can we help to make the transition from medical school, to
postgraduate education, and on to a fully-established medical
career while maintaining a lifetime of learning and quality im-
provement?
Medicine is a dynamic art and science, and lifelong education of
professionals is a vital requirement. There needs to be a discussion
on how to train future doctors to approach and tackle this compo-
nent of their work, and how medical education should be structured
to account for the variability of the profession.
What are the questions to be answered in developing accredita-
tion of postgraduate medical education?
While the accreditation of basic medical education is demonstrably
in progress – although, of course, there is still a long way to go to
achieve an ideal state – the accreditation of postgraduate medical
education is a very complex process that works well in some ju-
risdictions, but is yet to be addressed in a constructive way on the
global level. The sessions dedicated to this theme will attempt to
map out the field of postgraduate medical education and lay out a
plan how quality of such a diverse field can be assured in a system-
atic way.
We invite all interested parties – representatives of physicians, edu-
cators, researchers and students from all over the world – to come
and join us in discussion about the challenges we are facing world-
wide and opportunities we have to improve the quality of medical
education.
Date of the Conference: 7–10 April 2019
Abstract Submission Due: 31 October 2018
Notification of Acceptance: 14 December 2018
Early Registration Due: 31 January 2019
On-line Registration Due: 29 March 2019
Please follow the conference website www.wfme2019.org for the
upcoming details about the programme and more.
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