wmj_3_2019_WEB

General Assembly Report
vol. 65
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 0049-8122
Nr. 3, November 2019
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Valedictory Address of WMA President Prof. Leonid Eidelman . . . . . . . . . . . . . . . . . . . . . . . . 2
Inaugural Speech of WMA President Dr. Miguel R. Jorge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
WMA 2019 General Assembly Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
WMA Statement on Sex Selection Abortion and Female Foeticide . . . . . . . . . . . . . . . . . . . . . . 22
WMA Declaration on Euthanasia and Physician-Assisted Suicide . . . . . . . . . . . . . . . . . . . . . . 22
WMA Declaration of Madrid on Professionally-led Regulation . . . . . . . . . . . . . . . . . . . . . . . . 22
WMA Declaration on the Relation of Law and Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
WMA Declaration of Reykjavik – Ethical Considerations Regarding the Use of Genetics
in Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
WMA Statement on Access of Women and Children to Health Care . . . . . . . . . . . . . . . . . . . . 28
WMA Statement on Antimicrobial Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
WMA Statement on Augmented Intelligence in Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . 31
WMA Statement on Free Sugar Consumption and Sugar-Sweetened Beverages . . . . . . . . . . 34
WMA Statement on Healthcare Information for All. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
WMA Statement on Medical Age Assessment of Unaccompanied Minor Asylum Seekers . . 36
WMA Statement on Reducing Dietary Sodium Intake. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
WMA Statement on Solitary Confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
WMA Resolution on Legislation Against Abortion in Nicaragua. . . . . . . . . . . . . . . . . . . . . . . 41
WMA Resolution on Climate Emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
WMA Resolution on the Revocation of Who Guidelines on Opioid Use. . . . . . . . . . . . . . . . . 42
WMA Statement on Violence and Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
United Nations Climate Action Summit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The Role of Physicians in Fighting Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
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
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Miguel Roberto JORGE
WMA President,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
Dr. David Barbe
WMA President-Elect,
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300
60611-5885 Chicago, Illinois
United States
Dr. Mari MICHINAGA
WMA Vice-Chairperson of Council
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Leonid EIDELMAN
WMA Immediate Past-President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
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
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Andreas RUDKJØBING
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
Kristianiagade 12
2100 Copenhagen 0
Denmark
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
Editorial
Editorial
Each doctor becomes a patient sooner or later.The opposite process
is possible theoretically. Consequently, sooner or later every doctor
stands in a patient’s shoes to face everything we talk about con-
cerning public health. In Public Health, the emphasis is somewhat
different. In each country Public Health focuses on slightly differ-
ent settings as priorities. It is determined by the country itself, its
geographical location, traditions, experience and medical schools.
However,globally the major challenges remain the previous ones: cli-
mate change, a sedentary lifestyle and overweight, smoking and alco-
hol abuse, malnutrition, population ageing and epidemics of chronic
diseases, including oncological, cardiovascular and mental diseases.
And all this applies to both – patients and doctors.Irrespective of that,
in the coffee pauses of the General Assembly of the World Medical
Association, a group of delegates smoked heavily in some corner.
Let us be honest, relations with overweight as well might be better
for our friendly global collective.
For many years, I have seen one or another delegate jogging in the
morning, the last time it was in Georgia; I have no need to run to-
gether with any of the delegates.
Doctors in the world differ the same way as patients do. In the
countries where the situation with Public Health is better, doctors
are healthier. In the countries that successfully fight against smok-
ing, doctors smoke significantly less than average population.
Tobacco use is one of four major risk factors for non-communicable
diseases. It is a huge threat to human health worldwide, and 8 mil-
lion people die each year, including more than 20% of cases world-
wide dying of cancer.
The global tobacco industry’s market value in 2017 was around
785 billion USD (excluding China). On the other hand, the global
loss caused by the tobacco industry to health care and productivity
was 1.4 trillion USD.
The tobacco industry is affecting governments and in different ways
is resisting tougher smoking restrictions and controls. And some-
times the doctor remains alone in the fight against smoking in their
country, among their patients and among their colleagues.
How to tackle the matter of low physical activity, how to reach the
situation that doctors move more, how to do more sports – at least
half an hour every day?
Once, when the overweight patient came to me, I started telling
them that they should start moving, and I usually asked them to go
to their physiotherapist twice a week, and after two months start
cycling, doing pilates or gymnastics, or go skiing. When I think
that my obese patient will start running for half an hour tomorrow,
I hear my colleagues reminding me about the knee injuries.
In the world, the number of female doctors is higher than that of
males. As regards sports and exercise, there is a great disproportion
and discrimination among men and women.
In the whole world, women’s and girls’ sports generally receive a
smaller contribution at the national level, including access to equip-
ment,transport and training,as well as safe and efficient sports spac-
es and facilities. Many women are restrained from serious physical
activity, they share concerns from stereotypes, the stigmatisation of
physically strong women, the insecurity of the image of their body,
or the sense limited by physical culture.
Girls of pre-school and school age are physically less active; they
have fewer sports available. Women’s sports are less paid and less
televised as men’s sports, and the gap (excluding tennis, beach vol-
leyball, skiing, skating, gymnastics and some more sports) is grow-
ing.
It means that doctors have to stand up for women’s sports. Wom-
en’s sports means women’s health, it means caring about the health
of women by doctors, nurses and health professionals. Doctors
in the world should help to bridge the gap in physical activity
between men and women, promote women’s sports and physical
activity.
What to start with? Every doctor with overweight and a sedentary
lifestyle should start with an hour at the physiotherapist doing exer-
cises that involve all the muscles, all joints and ligaments in physical
activity.The best vehicle for moving around is a bicycle.
Don’t believe that anyone else will take care of you even if you’re a
doctor.
Moreover, such a unique thing as the resettlement of residents in
London to the 2012 Olympic Village with great opportunities for
physical activity did not alter the sporting habits.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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General Assembly Report
Honorable Ilia Nakashidze,
Prof. Lobzhanidze,
Distinguished guests,
A warm thank you to our hosts here in
Georgia for your warm hospitality in this
wonderful city of Tbililsi.
My dear friends and colleagues, It is an
honour to address you here and to thank
you once again for the opportunity to serve
you, the World Medical Association and
physicians throughout the world. I am sure
that the WMA is an essential organization
in the modern world and should be visible,
active and presented in important forums.
The purpose of the WMA is to serve hu-
manity by endeavoring to achieve the high-
est international standards in Medical Edu-
cation, Medical Science, Medical Art and
Medical Ethics, and Health Care for all
people in the world.
Since having been inaugurated I have repre-
sented the WMA in different meetings.The
first one was the Global Conference on Pri-
mary Health Care in Astana, Kazakhstan.
Universal health coverage is absolutely nec-
essary to achieve sustainable development
goal number 3. Primary health care that
includes prevention, acute and chronic care
is an indispensable platform for Universal
Health Coverage.
There are many challenges for Primary
Health Care, the most important of them:
absence of strong political commitment;
difficulties in integration of health goals
into non-health sector planning; and lack of
intention for physician-led teamwork.
During the meeting, it was noticeable that
many participants didn’t think the Primary
Health Care model should have the physi-
cian at the helm of leadership. The confer-
ence focused on other health care providers,
traditional ones,such as,nurses,pharmacists
and social workers and new professions,like,
community health workers and healthcare
assistants. We should continue to promote
the team approach in Primary Health Care
and the leading role of physicians.
Universal Health Coverage was one of the
central issues at the Japan Medical Asso-
ciation Ceremony and Medical congress
and this was continued at The Health
Professional Meeting (H20) 2019 Road
to Universal Health Coverage in Tokyo,
Japan.
During his tenure as president of the World
Medical Association, Dr Yoshitake Yo-
kokura considerably promoted UHC.
I also stressed the importance of physician
leadership during the WHO Global Coor-
dination Mechanism meeting on Preven-
tion and Control of Noncommunicable
Diseases in Geneva. I took the opportunity
to visit the WMA headquarters and express
my appreciation to all the WMA staff.
During the ceremony of the German Medi-
cal Profession Marking the Withdrawal of
the Medical Licenses of Jewish German
Doctors 80 years ago, I emphasized the
physicians’moral responsibility according to
the WMA’s Declaration of Geneva,recently
updated due to the immense contribution
of the German Medical Association, which
states that physicians must never use their
medical knowledge to violate human rights
and civil liberties, even under threat.
Another opportunity to stress the impor-
tance of the physician’s professional obliga-
tion to the patient and the highest ethical
standards was at the CPME General As-
sembly, where the main topic was health
care in danger.
During the Swedish Medical Associa-
tion Annual Meeting, I learned about how
Swedish physicians tackle language limita-
tions and cultural differences when taking
care of the large number of refugees.
The global issue of violence in the health
sector that negatively impacts our ability to
treat patients was addressed at the meeting
in Mumbai, India.The future developments
in medicine was in center of our meeting at
the American Medical Association Head-
quarters. We discussed: augmented intel-
ligence; environmental intelligence; what
physicians want to know about technology;
healthcare economy and what is on the ho-
rizon.
In attempt to encourage the preparation for
the future changes and the new challenges of
a constantly evolving profession, the WMA
and Israeli Medical Association organised
the Physician 2030 meeting, that was at-
Valedictory Address of WMA President Prof. Leonid Eidelman,
October 2019
Leonid Eidelman
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General Assembly Report
tended by over 100 physicians worldwide. It
served as a platform for discussions in multi-
ple areas and dimensions of physicians’activ-
ity. Issues of the validity of models and pre-
dictors in health system, healthcare models
and medical workplace in 2030,patient-phy-
sician relationship,medical education-how it
should be changed and technology – where it
can take us, were addressed.
I believe that we must continue to look to
the future and be prepared.
Physician burnout is one of the most acute
challenges of contemporary medicine and
endangers physicians as well as the quality of
healthcare. There is a need for studying pre-
ventive and treatment solutions.The Interna-
tional College of Person-Centered Medicine
has decided to organize meetings on physi-
cian burnout and wellbeing every year.
During my presidency year, I visited many
physician meetings.You can see them in my
report but here I would like to give some
specific examples of such meetings.
At the British Medical Association Annual
Representative Meeting in Belfast, among
others, there were votes on the issue of as-
sisted dying and the BMA’s membership in
the WMA.The representatives endorsed the
continued membership of the BMA in the
World Medical Association, for the oppor-
tunity it provides to support and influence
the development of global health policy.
Dr. Chaand Nagpaul, BMA chair of coun-
cil, stated the BMA’s opposition to Brexit,
due to potential damage to the national
health service.
The other meeting was CONFEMEL the
Spain, Portugal, Latin American and Carib-
bean Medical Confederation.There were dis-
cussions about the specific challenges facing
doctors in their respective countries, some of
which demanded the WMA intervention.We
sent letters to the governments of Honduras,
Bolivia and others demanding a change of at-
titude towards physicians. Another example
was a letter that we sent to the Sudanese Gov-
ernment condemning the use of lethal force
against physicians and protesters.
During the European Forum Medical As-
sociation annual meeting in Montenegro,
one of the presentations was of particular
interest to me, because it reflected attitude
of young physicians that will definitely in-
fluence the workforce in healthcare in the
years to come.The European Junior doctors
presented the situation of part time em-
ployment of junior doctors in Europe and
stressed the importance of this possibility to
the new generation of doctors.
While attending the 34th
CMAAO Gener-
al Assembly we had the opportunity to visit
a palliative care centre supported by the In-
dian Medical Association. I was much very
impressed by great work undertaken by the
extremely dedicated staff in this facility.
The climate crisis is on the agenda of the
World Medical Association. The profes-
sional role of physicians in the fight against
climate change was suggested in our paper
in Fortune Journal.
The greatest media attention we received
was our position against the decision of the
International Association of Athletics Fed-
eration in the case of Caster Semenya. Our
position was based on strict ethical consider-
ations, that a medical treatment is only justi-
fied when there is a medical need. Medical
treatment for the sole purpose of altering the
performance in sports is not permissible.
Finally, I am glad to thank two chairs of
council I was privileged to work with, both
Dr. Ardis Hoven and Prof. Frank-Ulrich
Montgomery. I am grateful to the Secretary
General, Dr. Otmar Kloiber and his fantas-
tic team who have supported me through-
out my presidency. My deepest appreciation
to the leaders from more that one hundred
countries that make the WMA so important
and so influential across the globe.I am con-
fident that the WMA will continue to be a
beacon for doctors all over the world,to light
the way in medical ethics and continue to
serve as a voice of doctors, as well as, sup-
porting NMA’s and doctors in times of need.
I thank my predecessors and wish great success
to the incoming president Dr. Miguel Jorge.
Thank You
Dr. Miguel R. Jorge, World Medical Association 70th
President
Inaugural Speech, 25th
of October 2019
Dear Colleagues and Friends,
Ladies and Gentlemen,
Thank you for your presence and enduring
support to the World Medical Association.
It means a lot to the physicians we repre-
sent and, at this particular ceremony, it also
means a lot to me.
Those of you familiar with the World Medi-
cal Association know that our constituent
members include one hundred and twelve
national medical associations. I am here to-
day being inaugurated as the World Medi-
cal Association’s 70th
President not by my-
self but representing not just my colleagues
from the Brazilian Medical Association but
millions of physicians who practice in every
corner of the globe.
My home country, Brazil, is amongst the
10th
biggest economies but is also amongst
the 20th
most unequal countries in the
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General Assembly Report
world. And we know that wealth inequali-
ties within a country impact social determi-
nants of health and consequently the health
status of its population. It is not uncommon
to see, in unequal countries, two realities for
medical care: one with first world quality for
those who have more and the other of little
quality – if any – for the underprivileged.
The World Medical Association’s Declara-
tion of Geneva states in its opening remarks
that physicians pledge to dedicate their lives
to the service of humanity and have the
health and well being of their patients as
their first consideration. We, as physicians,
practice our commitment to these princi-
ples not just when attending to our patients
but also when we join our medical associa-
tions in their multiple activities, aiming, at
the end, to raise the health status and qual-
ity of life of the population we serve.
There are many and different factors influ-
encing the physicians’ role to promote the
health and quality of life of others, such
as a good and continuous medical educa-
tion, adequate resources and conditions for
work – particularly enough time with each
patient, a balanced professional and social
life, and – equally important – to take care
of their own physical and mental health.
As a psychiatrist, I was planning to empha-
size during my Presidential term that there
never will be health without mental health.
But I was challenged by myself to broaden
my concerns, and remind and highlight to
my fellow physicians one essential compo-
nent of the practice of Medicine: the great
value of the physician-patient relationship.
It is usually recognized that most of those
who are looking to enter medical school,
do so saying they want to help people in
their suffering related to illness. But studies
from different countries show that medi-
cal students usually are less sensitive to the
patient’s needs as a person when finishing
than they are when entering medical school.
What happened in between? One possible
reason is that students, during their medi-
cal education, are more and more exposed
to the biological nature of illnesses than to
the social environment surrounding their
patients and the development of diseases.
They also are not adequately taught to take
into consideration the emotional aspects of
those they are assisting.
To those who are being trained to be a
medical doctor, biology is an arena where
they feel more secure and comfortable to
act than they do when feeling incapable of
dealing with people’s social and psycho-
logical issues. Besides that, the physicians-
to-be were developing defences against
their own suffering when facing different
forms of pain in their patients. Physi-
cal pain, emotional pain, social pain. And
these defences reduce their sensibility to
others’ needs.
A good physician needs to be able to put
him/herself in the place of their patients,
trying to feel as they feel, in order to better
understand their needs and plan to provide
what they need more. But it is not a simple
task to put him/herself in the place of a pa-
tient and – at the same time – to avoid feel-
ing as helpless as the patient would be. In
medical care, it is as essential to have empa-
thy as it is to be able to examine the patient
from the outside.
A colleague from my Department in the
Federal University of São Paulo, Dr. Julio
Noto (personal communication), reported
to me that once he heard from one of his
Medical Psychology students: “How can
I talk to the patient if there is nothing that
I can do for him due to his condition?”Noto
considers that teaching Medical Psychology
to medical students sometimes is similar to
teaching someone “to do nothing”. There,
doing nothing can correspond to cathartic
listening, emotional continence, expectant
attitude, and even the use of countertrans-
ference in the physician-patient relation-
ship. A brilliant Brazilian novelist from the
later 19th
and early 20th
centuries, Machado
de Assis, once wrote: ”…there are things we
say better being quiet…”
We all hear that Medicine is both science
and art but, in the last decades, the prac-
tice of Medicine is more and more reflect-
ing an emphasis just on its scientific nature.
A competent physician is not a good me-
chanic of the human body but someone
who equally combines technical excellency
with being close to their patients,respecting
their dignity, and showing them empathy
and compassion.
Evidence-based guidelines containing stan-
dards of care are really of great importance.
They allow the organization of a fragment-
ed physician-patient care model, as differ-
ent physicians assisting the same patient
at different times can apply the same ob-
jective scientific knowledge. But an inter-
esting study published in 2016 by Lauren
Diamond-Brown suggested that goals of
standardization cannot rationalize all as-
pects of medical practice, and policy makers
must not forget the function of a positive
physician-patient relationship. We have to
recognize the importance of evidence-based
medical practice while not forgetting that
the decision-making process of care also in-
volves important subjective aspects.
Miguel R. Jorge
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General Assembly Report
Eric Cassel (2012), in his book The Na-
ture of Healing: The Modern Practice of
Medicine, states that “Respect for persons
has helped move the idea of persons and
knowledge about them to a more central
position in medicine. From this it follows
that healers and other clinicians should
know as much about persons as they know
about their pathophysiology.” According to
him, almost nothing about people is unaf-
fected by sickness.
Concepts like this one have led to a shift of
models of care from a disease-specific mod-
el to patient-centered collaborative care.
Results from reviews of the literature con-
ducted in 2000 by Mead and Brown and re-
peated in 2019 by Langberg et al. described
five dimensions of a patient-centered care:
sharing power and responsibility, therapeu-
tic alliance, patient-as-person, coordinated
care, and a biopsychosocial perspective.
Emanuel and Emanuel (1992) considered –
before the current digital era  – that the
role of physicians varies, in different mod-
els of physician-patient relationship, from
a guardian to a counsellor or advisor, from
a friend or a teacher to a technical expert.
Nevertheless, ethical considerations about
the rights of persons and the widespread ac-
cess to information brought by the Internet
to all, have a major impact on the physician-
patient relationship. Medical expertise con-
tinues to rely on the physicians’ knowledge,
but the decision-making process and adop-
tion of a treatment plan now need to include
and respect the patients’ preferred choices.
Taking just diagnostic imaging and indi-
vidual genetic tailoring for the treatment
of cancers as examples of the sophisticated
progress experienced by Medicine in the
last few decades, as well the development
of telemedicine, the use of artificial intelli-
gence and particularly of social media, we –
physicians – have to learn how to use these
tools for improving the physician-patient
relationship and not allow them to move us
from a focus on the patients themselves or
to create more difficulties in our communi-
cation with them.
Another interesting study, from Hitchsock
et al.(2005),involving primary care patients
with multimorbidity, showed that partici-
pants were willing to use technology for
monitoring or educational purposes if it did
not preclude human contact. When listen-
ing to patients’ expectations, humaneness
appears as equally or even more important
than medical competence. So, a recommen-
dation of major importance is that physi-
cians must be focused on building trust and
a strong therapeutic alliance early during
the first visit of a patient.
Last November, the European Council of
Medical Orders supported and adhered to
an initiative by the Forum of the Medi-
cal Profession of Spain and the Portu-
guese Medical Association to defend and
strengthen the physician-patient rela-
tionship by requesting its recognition by
UNESCO as an Intangible Cultural Heri-
tage of Humanity. That proposal considers
the physician-patient relationship a funda-
mental component of health care that can
be threatened by political, social, or eco-
nomic risks, and technological and commu-
nication changes, which makes it necessary
to protect and enhance the fundamental
elements of that relationship.
Physicians working under difficult cir-
cumstances such as those in Africa, Latin
America and Asia, often cannot do what
they consider to be the best plan of action
due to the scarcity of different resources.
But they can accomplish at least partially
their mission if they give a little more time
and show empathy and attention to their
patients. I am sure that we can always do
better for all if we keep in mind the reason
why we chose to be physicians earlier in our
lives: to help those who are suffering due to
their compromised health.
Finally, I would like to say something about
my background and this moment. My four
grandparents arrived in Brazil in 1912, af-
ter fleeing a difficult situation they were
facing in their mountain villages of Leba-
non. My parents were born in a small city
in the interior of the country and my father
became a merchant in his adult life. When
I was studying Medicine, his wish was to
see me as a general surgeon practicing and
making my life even in a deeper part of
Brazil, where everything was still waiting
to be built.
But, according to some of my colleagues
at the medical school, I – in a way – de-
clined to be a “real” physician by choosing
to become a psychiatrist. And, in the eyes
of many, the worst part of all: rather than
focusing on a money driven path, I chose
to follow an academic career and, early in
my professional life, I engaged in lifelong
actions for enhancing the quality of medical
care provided particularly to those that are
more in need.
After so many years, being here today, be-
coming the 70th
President of the World
Medical Association was not something
I ever dreamed of. It gives me great joy and
happiness, even though has not been pos-
sible to have some of my family members
with me at this moment. But, I want to spe-
cially thank them for their continuous and
enduring support.
I am sure that there are times when many
of you – like me now – are participating in
professional activities that divert you from
the company of your family. This is a kind
of side effect of being a physician but – re-
member – as I said before, a balanced pro-
fessional and social life is essential for tak-
ing care of others.
So, once again, on behalf of millions of phy-
sicians worldwide and of those they serve,
I want to recognize your efforts and dedi-
cation, ultimately aiming to provide better
health to all.
Thank you!
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6
General Assembly Report
Wednesday October 23
At the invitation of the Georgian Medical
Association, delegates from more than 50
National Medical Associations and constit-
uent member associations met at the Shera-
ton Grand Tbilisi Metechi Palace.
Council
Dr. Frank Ulrich Montgomery, Chair of
Council, opened the 213th
Council session,
welcoming delegates to Tbilisi.
Dr. Otmar Kloiber, the Secretary General,
introduced several new Council members
and gave apologies for absence.
President’s Report
Dr. Leonid Eidelman presented his written
and oral report about his work as President
during 2018/19. He said he had stated at
the start of his Presidency that he would
like to devote his tenure to evaluating future
challenges faced by physicians throughout
the world, as well as promoting prepared-
ness. This he had done at the many meet-
ings he had spoken at and attended. Among
them was the ‘Physician 2030’ meeting in
Herzliya, Israel in May, which addressed
healthcare models and the medical work-
place in 2030. He had also attended many
national medical association meetings.
Secretary General’s Report
Dr. Kloiber said that a comprehensive writ-
ten report had been submitted to the As-
sembly on the work of the Council over the
preceding six months.
Emergency Resolutions
Two emergency resolutions were submitted
for consideration.
Opioids
The first Proposed Emergency Resolution
on the Revocation of WHO Guidelines
on Opioid Use concerned the decision by
the World Health Organisation to abruptly
withdraw its guidelines on controlled medi-
cines. The Council was told that this had
made it much more difficult for patients
suffering pain to get access to opioids. The
emergency resolution called on the WHO
to reinstate its guidelines urgently until they
were replaced by new or amended ones.
The Council agreed that this was a matter of
urgency and the Resolution should be sent to
the Social Affairs Committee for discussion.
Climate Emergency
A second proposed Resolution on Climate
Emergency was submitted by the Brit-
ish Medical Association. The Council was
told that the resolution followed the recent
United Nations summit on climate change
which recognised that controlling climate
change was necessary for achieving sig-
nificant health gains. In order to take full
advantage of this political momentum now,
the BMA said it was proposing this reso-
lution to help co-ordinated action globally
through the voice of doctors. The summit
was instrumental in galvanizing support
from the private sector and securing na-
tional commitment. Radical change was
needed. Climate action was an opportunity
and a call to action to fundamentally trans-
form economies, systems of production and
trade. It was an issue that went far beyond
the environment to affect every aspect of
society and development, and climate ac-
tion was necessary for achieving the sus-
tainable development goals and controlling
disease. The WMA was in a unique posi-
tion, as the voice of doctors, to ensure that
the significant implications for health that
climate change posed were recognised and
appropriately mitigated.
The Council agreed that this was also an
emergency and the Resolution should be
discussed in the Social Affairs Commit-
tee.
Chair’s Report
Dr. Montgomery, in his written report,
said that since his election in Santiago in
April many big health issues had ‘stormed
over’ them  – Universal Health Coverage,
Ebola returning to Africa, and the measles
returning in many countries, either due to
people having no access to vaccines, or to
the shameful fact that a growing vaccine
hesitancy in richer societies had led to a loss
of immunity.There was also climate change,
with heatwaves in Europe, typhoons and
hurricanes in tropical and subtropical re-
gions, and the dangerous melting of polar
ice on both sides of the planet This was cast-
ing long shadows over the future of their
children’s generation.
WMA 2019 General Assembly Report
Tbilisi, Georgia October 23–26
Nigel Duncan
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7
General Assembly Report
The Council meeting was then adjourned
until Friday.
Finance and Planning Committee
Dr. Jung Yul Park (South Korea) took the
chair and called the committee to order.
Financial Statement for 2018
The committee considered the Audited Fi-
nancial Statement for 2018. The Treasurer,
Dr. Ravindra Sitaram Wankhedkar, stated
that the WMA finished 2018 with a sur-
plus and he thanked the secretariat, which
regulated, monitored and controlled the ex-
penses.
The committee agreed that the Statement
be approved by the Council and forwarded
to the General Assembly for approval and
adoption.
Budget
The committee considered the proposed
WMA Budget for 2020 vs. the actual 2018
Expenditures. The Treasurer noted the ex-
cess of income over expenses.
The committee recommended that the pro-
posed Budget for 2020 be approved by the
Council and forwarded to the General As-
sembly for adoption.
Membership Dues Payments and Arrears
The committee received the report on
membership dues payments for 2019 to be
forwarded to the General Assembly for in-
formation.
It also considered the report on member-
ship dues arrears and the proposed dues in-
crease for 2020.
The committee received dues categories for
2020 to be forwarded to the General As-
sembly for information.
WMA Strategic Plan
Dr. Kloiber reported that the Strategic Plan
for 2020-2025 had been forwarded to the
General Assembly for a decision. Some
of the items in the strategic plan, such as
Universal Health Coverage, had already
been taken up for action as described in the
Council Report.
WMA Statutory Meetings
The committee considered planning and ar-
rangements for future WMA Meetings.
It recommended that the Council with-
draw its recommendation to hold the
224th
Council Session in 2023 in Baku,
Azerbaijan, because of visa problems and
the membership status of the Azerbaijan
Medical Association. It recommended
that the venue be switched to Nairobi, Ke-
nya.
WMA Special Meetings
Dr. Kloiber gave an oral report about the
following meetings planned in 2020:
• International Conference on Bioethics in
Philadelphia, 18-21 June 2020
• UNESCO Bioethics Conference in Por-
to, 11-14 May 2020
• International Code of Medical Ethics
Regional Conferences
–
– East Mediterranean Region in Kuwait,
6-7 February 2020
–
– Latin American Region in Sao Paulo,
5-6 March 2020
–
– Further regional conferences were
planned for the second half of the
year
• Global Forum on Vaccination in Vatican,
4-5 May 2020
Review Committee
The committee received an oral report from
the Chair of the Review Committee, Ms
Robin Menes. She reported that the man-
date of the committee as a pilot project had
been extended through to April 2020. She
hoped that this committee could be estab-
lished as a permanent fixture.
Dr. Montgomery thanked Ms Menes for
her contributions and hard work during her
term.Since this meeting was her last, he ap-
pointed Ms Mervi Kattelus (Finnish Medi-
cal Association) in her place.
Council Resolutions
The committee considered the proposed
classification of old council resolutions.
It recommended that the following Council
resolutions be revised for the next meeting
in Porto, April 2020 for forwarding to the
General Assembly:
• Trade Agreements and Public Health
• Threats to Professional Autonomy and Self-
Regulation in Turkey
• Support of Dr Serdar Küni
The proposal to revise the Resolution on
Observer Status for Taiwan to the World
Health Organisation and Inclusion as
Participating Party to the International
Health Regulations prompted opposi-
tion from the Chinese Medical Associa-
tion. The CMA said the UN General As-
sembly and World Health Assembly had
provided legal foundation for the WHO
to follow the One-China Policy and con-
firmed the legal status of Taiwan as part
of the Chinese Territory to participate in
the WHA. The mainland had consistent-
ly attached great importance to the health
and welfare of compatriots in the Taiwan
region. Taiwan region’s participation in
global health affairs, including WHO
technical activities and information ac-
cess, was unimpeded. But the CMA’s
motion to withdraw the proposal was not
seconded.
A further proposal on how to deal with the
Council Resolution on Organ Donation in
China also led to criticism from the Chinese
Medical Association.
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8
General Assembly Report
Dr. Kloiber reported that the WMA had
strict policy that organs from executed pris-
oners must not be used for organ transplan-
tation. They had learned that in 2015 there
was a change in the legal situation in China
and that it was planned to phase out trans-
plantation.The WMA was not in a position
to do any research or fact-finding missions
to discover what was now happening. The
Chinese Medical Association had written
to say there had been significant change and
the use of organs from executed prisoners
no longer took place.
The Chinese Medical Association appealed
to the committee to withdraw the proposal
to revise the resolution. Since July 2015
China had completely stopped using or-
gans from executed prisoners.Therefore, the
resolution was already irrelevant.
At the suggestion of the Chair of Council,
the committee agreed to forward this issue
to the Medical Ethics Committee for con-
sideration in Porto. Law and Ethics see p. 23.
The committee agreed to recommend that
the Council Resolution on the Relation of Law
and Ethics be approved by the Council as a
Declaration and be forwarded to the Gen-
eral Assembly for adoption.
It was agreed that the following Council
resolutions be filed for no further action:
• Legislation Banning Smoking in Public
Places
• Supporting the Preservation of Internation-
al Standards of Medical Neutrality
• Prohibition of Physician Participation in
Torture
• Autonomy of Professional Orders in West
Africa
• Professor Cyril Karabus
• Prohibition of Nuclear Weapons
• Danger in Health Care in Syria and Bah-
rain
On the final policy on Syria, Dr. Kloiber ex-
plained that work continued on monitoring
the situation in Syria.
Socio-Medical Affairs Committee
Dr. Osahon Enabulele (Nigeria) took the
chair and called the committee to order.
Dr. Kloiber, in his monitoring report, spoke
about events related to physicians in primary
health care.The WMA had been working on
a study about this issue,in the light of the fact
that major funding donor groups in develop-
ing countries tended to be critical about the
role and availability of physicians in primary
health care. The WMA had worries about
various studies that set out to support the
replacement of physicians by nurse practitio-
ners, but did not prove this. He had asked
NMAs to send in evidence on the situation
relating to the substitution, replacement
and delegation of the role of physicians. He
thanked those NMAs that had done so and
a WMA report would soon be available to
counteract arguments from other professions
and international organisations. This would
not be a document against any other health
profession.Modern health care was based on
a team approach. But at the same time there
had to be clearly defined roles,
Network on Disaster Medicine
An oral report was given by the Japan Med-
ical Association
on the initiative to set up a World Platform
for Disaster Medicine involving the WMA,
WHO and other United Nations agencies,
governments, NGOs, academic institutions,
enterprises and public service organisations.
Given the increasing number of natural di-
sasters related to climate change, such as
the typhoon ‘Hagibis’ earlier in October in
Japan, the need to develop a robust interna-
tional framework for emergency medicine
was becoming urgent.
Pseudoscience and Pseudotherapies in the Field
of Health
The chair of the workgroup from the Span-
ish Medical Association presented a pro-
posed Declaration on Pseudoscience and
Pseudotherapies in the Field of Health. He
explained that this was not a declaration
against traditional medicine nor against
indigenous medicine. It was a commitment
to scientific proven methods to quality of
medical care, medical values, and profes-
sional good practice. It was against intru-
sion and in favour of patient safety. He pro-
posed that the document should be sent to
the Assembly for adoption.
This led to a debate, during which several
delegates said this was a very topical is-
sue, but argued that more time was needed
to consider the various amendments that
had been suggested by NMAs. References
were made to pseudoscientific journals in
the United States and Europe and to fake
news.
The committee recommended that the pro-
posed Declaration be recirculated with the
suggested amendments and that further
discussion be postponed until the next com-
mittee meeting in Porto.
Violence and Health
The committee considered the proposed
revision of the WMA Statement on Vio-
lence and Health submitted by the Nigerian
Medical Association.
After a brief debate, during which two edi-
torial amendments were agreed, the com-
mittee decided to recommend that the
Statement, as amended, be approved by the
Council and forwarded to the General As-
sembly for adoption.
Medical Liability and Defensive Medicine
The Israel Medical Association introduced
a proposed revision to the WMA State-
ment on Medical Liability. The document
entitled, Medical Liability Reform and De-
fensive Medicine, defined defensive medi-
cine as ‘the practice of ordering medical
tests, procedures, or consultations of doubt-
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9
General Assembly Report
ful clinical value in order to protect the pre-
scribing physician from malpractice suits.’
In the brief debate that followed, several
speakers argued that that further consid-
eration should be given to the paper. One
speaker argued that it focused on personal
physician culpability,when the vast majority
of errors that occurred were about systems.
Had the WMA ever looked at whether na-
tions that had no fault compensation had
less defensive practice than nations which
had personal liability? Dr. Kloiber replied
that the WMA did not have such informa-
tion, but it was very important and perti-
nent.
The committee decided to recommend that
the document be recirculated to NMAs for
comment.
Declaration of Ottawa on Child Health
The committee considered a proposed ma-
jor revision of the WMA Declaration of
Ottawa on Child Health submitted by the
South African Medical Association. The
paper emphasised the importance for chil-
dren to grow up in an environment where
they could strive. Delegates were told that
the health and prosperity of a nation were
measured by the state of their health and
education systems. That started with chil-
dren. If children could fulfil their potential
there would be a lot less poverty across the
world.
The committee recommended that in view
of the number of amendments submitted
the document should be recirculated to
NMAs for comment.
Inequalities in Health
A proposed revision of the WMA Decla-
ration of Oslo on social determinants of
health was presented by the Swedish Medi-
cal Association. The meeting was reminded
that this involved a major revision of the
2009 Statement on Inequalities in Health
statement, integrating relevant parts of the
Statement in the Declaration of Oslo on Social
Determinants of Health. This new consoli-
dated policy on social determinants would
refer to Universal Health Coverage and the
Sustainable Development Goals, especially
on ensuring ensure healthy lives and pro-
moting well-being for all ages and the SDG
on reducing inequality within and among
countries. The Statement on Inequalities in
health would then be rescinded.
The committee recommended that the re-
vised Declaration be recirculated to NMAs
for comments.
Use of Telehealth for the Provision of Health
Care
As part of the 10-year revision process, the
Indian Medical Association proposed a
major revision of the WMA Statement on
Guiding Principles for the Use ofTelehealth
for the Provision of Health Care.This com-
bined the Statements on Telemedicine and
Mobile Health.
In a brief debate, it was pointed out that
there was nothing in the paper about in-
equalities, yet telemedicine should reduce
inequalities. It was also argued that there
should be more about safety and efficacy.
The committee recommended that the doc-
ument be recirculated to NMAs for com-
ments.
Legislation Against Abortion in Nicaragua
A proposed revision of the WMA Resolu-
tion on the Legislation Against Abortion in
Nicaragua was submitted following com-
ments at the last meeting that there was a
need for a more global document.The Reso-
lution had been amended to broadly address
the threats to women’s reproductive health
care and the criminalization of reproductive
health care provided by physicians that was
occurring globally. It called on the Nicara-
guan Government to repeal its penal code
criminalising abortion and to develop in its
place legislation promoting and protecting
women’s human rights. An amendment was
agreed, inserting a reference to the need for
medical confidentiality.
The committee recommended that the
document, as amended, be approved by the
Council and forwarded to the General As-
sembly for adoption.
Rights of Patients and Physicians in the Is-
lamic Republic of Iran
At the last Council meeting in April, it was
decided that the Resolution Supporting the
Rights of Patients and Physicians in the
Islamic Republic of Iran should undergo a
major revision, but there was no volunteer
to undertake the revision.
The committee recommended that the Ku-
wait Medical Association be appointed as
rapporteur for the revision of the Resolu-
tion.
Continuous Quality Improvement in Health
Care
A minor revision was proposed to the
WMA Declaration on Guidelines for Con-
tinuous Quality Improvement in Health
Care, including references to new WMA
policies.
The committee recommended that the
document be approved by the Council and
forwarded to the General Assembly for in-
formation.
Relationship between Physicians and Com-
mercial Enterprises
A proposal was submitted for a minor revi-
sion to the WMA Statement Concerning
the Relationship between Physicians and
Commercial Enterprises.
Several speakers said this was a major
problem. In the United States commercial
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10
General Assembly Report
­
relationships were changing rapidly, with
private equity and other commercial enti-
ties purchasing medical practices.
The committee recommended that the
document be approved by the Council and
forwarded to the General Assembly for in-
formation.
Hypertension and Cardiovascular Disease
The American Medical Association pre-
sented a proposed Statement on Hyper-
tension and Cardiovascular Disease as a
basis for further discussion. The State-
ment called for national governments to
recognize hypertension as the single most
important risk factor for cardiovascular
disease and death and said that hyperten-
sion control should be declared a national
health priority.
The committee recommended that the doc-
ument be circulated for comment.
Protecting the Future Generation’s Right to
Live in a Healthy Environment
A proposed Resolution on Protecting the
Future Generation’s Right to Live in a
Healthy Environment was submitted by the
Turkish Medical Association.
The committee recommended that the doc-
ument be circulated for comment.
Climate Emergency
The British Medical Association presented
its emergency resolution on climate change,
calling on the WMA to declare a climate
emergency and for the international health
community to join doctors’ mobilisation on
the issue.
Several speakers said the resolution should
be stronger, and a number of amendments
were proposed. The committee agreed that
the resolution should be simplified and that
proposed amendments should be consid-
ered as part of the discussion on the pre-
vious document on Protecting the Future
Generation’s Right to Live in a Healthy
Environment.
Several amendments were agreed to sim-
plify the resolution.
The committee recommended that the
resolution, as amended, be approved by the
Council and forwarded to the General As-
sembly for adoption.
Opioid use
The committee considered the second
emergency resolution on the Revocation of
the WHO Guidelines on Opioid Use. The
Secretary General said this represented a
call to the WHO to rectify the situation and
to do so transparently.
The committee recommended that the reso-
lution be approved by the Council and for-
warded to the General Assembly for adop-
tion.
Medical Ethics Committee
Dr. Andreas Rudkjoebind (Denmark) took
the chair and called the committee to order.
Monitoring Report
The Secretary General, in his monitoring
report, informed the committee in rela-
tion to the Declaration of Helsinki that
the secretariat was interested in collecting
information from NMAs related to medi-
cal experimentation, and the development
of clinical testing. He was interested in ex-
amples of good practice and challenges, as
well as trends or changes observed.
Genetics and Medicine
The Iceland Medical Association presented
a proposed revision of the WMA Declara-
tion of Reykjavik on Ethical Consideration
Regarding the Use of Genetics in Medicine.
The committee was told there had been
rapid changes in this field and the revised
document set out updated guidance on the
use of genetics and genetic testing in health
care.
The committee recommended that the pro-
posed revision be approved by the Council
and forwarded to the General Assembly for
adoption.
International Code of Medical Ethics
The committee received an oral report
from the Chair of the workgroup, Dr. Ra-
min Parsa-Parsi (German Medical Asso-
ciation). He presented an update on the
workgroup’s progress and a timeline of the
ICoME revision process for the coming
months. He said regional expert meetings
had been scheduled for 2020, starting with
Kuwait (6-7 February) and Brazil (5-6
March).
The oral report was received.The committee
agreed that the proposed revision process be
approved so that the workgroup could pro-
ceed with the regional expert meetings. It
was also agreed that the preliminary draft of
the International Code of Medical Ethics
be shared to serve as a basis for discussion
in the regional meetings.
Reproductive Technologies
The chair of the workgroup from the South
African Medical Association gave an oral
report on a proposed revision of the WMA
Statement on Reproductive Technologies
and said that further work was needed on
many important issues. The workgroup
had coordinated with the workgroup on
genetics, as there were some reproduction-
related aspects that could be considered for
incorporation in this paper. The workgroup
would prepare a list of priority issues and
a proposed revision was planned to be sub-
mitted to the next Council meeting in April
2020.
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11
General Assembly Report
Documentation of Torture
The committee received an oral report
from the Chair of the workgroup. It was
explained that a new draft was not being
considered as the workgroup was seeking to
find a balance between ethical obligations
to report and denounce torture without be-
ing too demanding. A proposed revised ver-
sion of the Resolution on the Responsibility
of  Physicians in the Documentation and
Denunciation of Acts of Torture and  Ill-
treatment was planned to be submitted to
the next Council meeting in April 2020.
Euthanasia and Physician Assisted Suicide
The proposed revision of the WMA State-
ment Euthanasia and Physician Assisted
Suicide was presented by the German
Medical Association. The committee was
reminded that the draft compromise docu-
ment was intended to replace the WMA
Resolution on Euthanasia, the Declaration
on Euthanasia and the Statement on Physi-
cian Assisted Suicide.
This led to the first of three lengthy debates
held during the meeting on the issue of eu-
thanasia and physician assisted suicide.
A number of speakers argued against
changing current WMA policy. Concern
was expressed about the attempt to com-
promise. It was argued that this was erod-
ing ethics and was the beginning of the
end for an ethical stance. It would become
a slippery slope.
Others supported the draft document, say-
ing that it was right to remove the policy
condemning doctors who participated in
euthanasia in those countries where it was
legal.
Several amendments were proposed. The
first referred to the opening paragraph of the
document which stated: ‘For the purpose of
this declaration, euthanasia is defined as the
voluntary act of a physician deliberately ad-
ministering a lethal substance or carrying
out an intervention to cause the death of
a patient with decision-making capacity at
the patient’s own voluntary request.’
An amendment was proposed to delete the
words ‘the voluntary act of.’ It was argued
that by including these words it ruled out
dealing with physicians being forced to par-
ticipate in euthanasia. The amendment was
agreed.
A further debate took place about the sen-
tence which read: ‘It is not the role of the
physician to participate in euthanasia or
deliberately enable a patient to end his or
her own life.’ It was felt that the already
expressed opposition to physician assisted
suicide and euthanasia was strong and clear
and should not be confused. Others argued
that this was taking policy backwards and
some wanted to add that it was contrary to
medical ethics.
An amendment to delete the sentence was
agreed.
The committee recommended that the
document, as amended, be forwarded to the
Council for adoption by the Assembly. It
also recommended that the WMA Resolu-
tion on Euthanasia, the WMA Declaration
on Euthanasia, and the WMA Statement
on Physician-Assisted Suicide be rescinded
and archived.
During the whole debate on this issue, no
delegate spoke in favour of physician as-
sisted suicide and/or euthanasia
Action on the WMA Physician’s Pledge
The Associate Members proposed a revi-
sion of the WMA Statement on Action to
Stimulate use of the Physicians’ Pledge of
the Declaration of Geneva, by making the
wording less prescriptive. They proposed
using the word ’encourage’ rather than
‘require’ the pledge to be used at medical
meetings.
After speakers said that this change was not
necessary, the proposal to amend the State-
ment was rejected.
Solitary Confinement
The committee considered a proposed revi-
sion of the WMA Statement on Solitary
Confinement submitted by the British
Medical Association. This advised physi-
cians not to participate in the decision-
making process resulting in the solitary
confinement of prisoners. The BMA talked
about the need to exclude children and
young people from this practice.
The committee recommended that the pro-
posed revision be approved by the Council
and forwarded to the General Assembly for
adoption.
Physicians Treating Relatives and Friends
The South African Medical Association
presented a proposed revision of the WMA
Statement on Physicians Treating Relatives
and Friends, stating that wherever possible,
physicians should avoid providing medical
treatment to family.
Speakers argued that the document ad-
dressed an important issue but needed fur-
ther consideration and editing.
The committee recommended that the pro-
posed revision be recirculated for comments.
Physician Patient Relationship
The committee received an oral report
from the Chair of the workgroup from the
Spanish Medical Association. The commit-
tee was told that a revised Declaration was
planned to be submitted to the Council ses-
sion in Porto in April 2020.
Ethics in Sports Medicine
A proposed revision of the Council Reso-
lution on Ethics in Sports Medicine was
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12
General Assembly Report
submitted by the South African Medical
Association. This was largely related to the
issue of the gender rules for classifying fe-
male athletes issued by the International
Association of Athletics Federation.
Speakers argued that this issue had been
well publicised following the last meeting.
However, there was a need for more general
policy to be drawn up.
The committee noted that the WMA Decla-
ration on Principles of Health Care for Sports
Medicine was scheduled to be revised next
April as part of the annual policy review
process. This revision would provide an op-
portunity to incorporate the main policy el-
ements of the proposed Council Resolution
on Ethics in Sports Medicine into the re-
vised Declaration in an effort to consolidate
WMA policy.
The committee decided not to approve
the revised Resolution, but to circulate the
document and a paper from the American
Medical Association, and to work on an-
other more general statement on ethics and
sports medicine.
Embryonic Stem Cell Research
The committee considered a major revi-
sion of the WMA Statement on Embry-
onic Stem Cell Research submitted by the
American Medical Association and recom-
mended that the document be circulated for
comments.
Declaration of Geneva
A proposed revision of the WMA Declara-
tion of Geneva was submitted by the Brit-
ish Medical Association. It suggested add-
ing one sentence to the Declaration: ‘I shall
strive to practise fairly and justly through-
out my professional life’.
The committee welcomed the proposal as
a positive one and noted that it was being
actively examined as part of the current re-
vision process of the International Code of
Medical Ethics. The issue was also consid-
ered during the most recent revision process
of the Declaration of Geneva and would be
kept in mind for the next revision.
The committee recommended that the pro-
posed revision be rejected.
WMA Human Rights
Clarisse Delorme, WMA Advocacy Advi-
sor, referred to the relevant human rights
section of the Report of the Council to the
WMA General Assembly.
Thursday October 24
Associate Members Group
The meeting was called to order by the
Chair Dr. Joseph Heyman.
Membership
Dr. Heyman reported that there were 613
Associate Members from Japan, 775 other
members, 31 life members, 192 junior doc-
tors and 96 medical students.
Junior Doctors’ Network
Dr. Audrey Fontaine, newly elected Chair
of the JDN, reported on the Network’s ac-
tivities since the last Associate Members
meeting in October 2018. Membership had
increased considerably due to increasing
support from the Constituent Members.
The JDN’s participation in the World
Health Assembly meeting had produced
reports on the various issues discussed,
namely health workforce, universal health
coverage, health emergencies, air pollution
and antimicrobial resistance.
Dr. Fontaine thanked all those who had
supported the JDN. She introduced the
new JDN leadership team and reminded
the meeting that 2020 would mark the 10th
anniversary of the Network, an event which
would be marked with special activities.
Past Presidents and Chairs of Council Net-
work
Dr. Jon Snaedal reported on the activities
of the Network. He spoke about Dr Yoram
Blachar’s continued liaison with the UNES-
CO World Conference on Bioethics, Medi-
cal Ethics and Health Law, which was last
held in Jerusalem,Israel,from 27-29 Novem-
ber 2018. Dr Mukesh Haikerwal was con-
tinuing to raise the WMA’s profile in social
media networks.He had attended the Health
Professional Meeting (H20) – The Road to
Universal Health Coverage, as a keynote
speaker, in June 2019, in Tokyo, Japan.
Dr. Snaedal expressed his regret on the
passing of Dr J. Blahos from the Czech Re-
public.
Dr. Heyman reported that the Associates
now had a lively Google group of 228 mem-
bers
Access to Surgery and Anesthesia Care
The JDN presented a proposed Statement
on Access to Surgery and Anesthesia Care.
It was agreed to send this to the General
Assembly for consideration.
Scientific Session on “Palliative
care – For the implementation
of international standards
of palliative care
Zaza Bokhua, Vice-Minister of Ministry of
Internally Displaced Persons from the Oc-
cupied Territories, Labor, Health and Social
Affairs of Georgia welcomed delegates.
The first speaker, Professor Robert
Twycross, Emeritus Clinical Reader in Pal-
liative Medicine from Oxford, UK entitled
his speech ‘Palliative Care: What, Who,
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General Assembly Report
When, and How?’ He spoke about the his-
tory of the hospice movement and the way
in which palliative care had broadened out.
He said palliative care focused on quality of
life, and was based on need, not limited by
diagnosis or prognosis. It was care beyond
cure. He said patients’ top four priorities
were expert care, effective communication
and shared decision-making, respectful and
compassionate care, and trust and confi-
dence in clinicians.
Professor Julia Downing,Chief Executive of
the International Children’s Palliative Care
Network (ICPCN),King’s College London,
spoke on ‘Palliative care for children’ and
particularly in Uganda where she works.She
said the ICPCN was the global network of
individuals and organisations working to-
gether to reach the estimated 21 million
children with life-limiting conditions and
life-threatening illnesses. Yet only five per
cent of them had any access to palliative
care. The Network believed that all children
and young people and their families had
the right of access to palliative care and this
should begin at diagnosis until bereavement.
Dr. Fiona Rawlinson (Johansen), Director
of the Cardiff University School of Medi-
cine Centre for Medical Education, Col-
lege of Biomedical and Life Sciences in the
UK talked about ‘Postgraduate education
programmes – correct planning and imple-
mentation.’ She said that there needed to be
undergraduate palliative care training for
all.Palliative care was something that would
affect everybody. But there were not enough
health care professionals with expertise in
the area. Palliative care needed to be includ-
ed as an integral part of ongoing education
and training to care providers. She went on
to talk about what should be taught and the
core competencies needed.
Professor Xavier Gomez-Batiste, Professor
of Palliative Care at the Faculty of Medicine,
University of Vic, Catalonia entitled his
speech ‘Adapting palliative care programs to
advanced chronic care epidemics’. He spoke
about how to extend palliative care to non-
cancer patients, and about ’the tsunami of
needs’they were facing in Catalonia.
The next speaker was Professor Julia Verne,
Head of Clinical Epidemiology, at Public
Health England’s National End of Life
Care Intelligence Network, who spoke on
‘Using a Human Rights approach to evalu-
ate Palliative and End of Life Care in Eng-
land.’ She said that a human rights frame-
work was useful to judge the progress of
implementation of comprehensive palliative
and end of life care. Human rights legisla-
tion could also be a useful adjunct to the ar-
guments made for implementing palliative
and end of life care to relieve suffering and
respect the dignity of human beings.
‘Palliative Care Development Globally and
in Post-Soviet Countries’ was the subject of
the next speaker, Professor Stephen Con-
nor, Executive Director of the Worldwide
Hospice Palliative Care Alliance. He spoke
about palliative care development in the
former Soviet Republics. He talked of the
global need for palliative care and looked at
the impact of palliative care on the cost of
health care.The challenge for the future was
how to integrate specialised palliative care
into existing healthcare delivery structures
and primary care, to get better continuity of
care and more community involvement and
ownership.
Dr. Katalin Muzsbek, Medical Director of
the Hungarian Hospice Foundation, talk-
ed about ‘Psychological issues in palliative
care’. Cancer, death and dying were still ta-
boos subjects in eastern European countries.
Advanced cancer and incurability caused
fear,distress and depression.Therefore,early
recognition and treatment of psychological
symptoms were crucial, and the education
of professionals and the public were of great
importance.
Professor Ging-Long Wang, Adjunct Clini-
cal Professor of Psychiatry National Yang-
Ming University School of Medicine, Tai-
pei, Taiwan talked about the integration of
psycho-oncology services and palliative care
in Taiwan. The aim was to improve quality
of care for all patients and families in every
stage of their medical care. There was satis-
factory coverage in the stage of diagnosis and
curative treatment and at end of life. They
had tried to extend psycho-oncology services
to all cancer patients and palliative care to
all patients in stage 4 disease who needed it.
‘Care development across Europe: les-
sons from the Atlas 2013-Atlas 2019’ was
the title of the speech by Professor Carlos
Centeno, Professor, Palliative Medicine and
Symptom Control Faculty of Medicine,
University of Navarra, Spain. He said that
little by little palliative care was becoming
the conscience and responsibility of society.
Volunteers and the community were play-
ing a leading role in many countries. He
said that society involvement would be the
key to the future.
Dr. Eduardo Garralda, from the University
of Navarra, Spain talked about the current
status of palliative care development in
Georgia in comparison with benchmark-
ing countries. He looked at socio economic
data. Globally there were 60 million people
needing palliative care, with 44,000 people
in Georgia in need. He compared Geor-
gia’s palliative care services to neighbouring
countries. There was a low use of opioids,
below the European average. He said that
the situation in Georgia had slightly im-
proved recently, but coverage was still insuf-
ficient and there was still a need to focus on
access to medicines and speciality services.
Friday October 25
Resumed Council Session. Medical
Ethics Committee Report
With the exception of the issue of physi-
cian-assisted suicide,the Council passed the
full report of the Medical Ethics Commit-
tee.
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14
General Assembly Report
This included forwarding to the General
Assembly for adoption the Declaration of
Reykjavik on Ethical Consideration Re-
garding the Use of Genetics in Medicine
and the revised Statement on Solitary Con-
finement.
It also agreed to circulate for comment the
Statement on Physicians Treating Relatives
and Friends and the Statement on Embry-
onic Stem Cell Research.
It agreed that the revision of the Interna-
tional Code of Medical Ethics should con-
tinue with a draft proposal being shared at
regional expert meetings.
Declaration on Euthanasia and Physician-
Assisted Suicide (see p. 22)
On the proposed Declaration on Euthana-
sia and Physician-Assisted Suicide,a further
debate took place, when several delegates
called for the document to be recirculated
and for further debate to be postponed until
the next meeting in Porto in April. It was
pointed out that the proposed Declaration
did not mention either palliative care or
mental health of children. However, there
was opposition to any delay, and in a vote
the committee rejected a motion to recircu-
late the document.
The committee then approved the Declara-
tion for forwarding to the General Assem-
bly for adoption.
Socio-Medical Affairs Report
With the exception of three items, the re-
port from the
Socio- Medical Affairs Committee was ap-
proved.
It was agreed that the following documents
be forwarded to the General Assembly for
adoption:
Violence and Health, Legislation Against
Abortion in Nicaragua, Climate Emergen-
cy and Opioid Use.
It was agreed that the following documents
be circulated for comment – Pseudoscience
and Pseudotherapies in the Field of Health,
Medical Liability & Defensive Medicine,
Child Health,Inequalities in Health,Use of
Telehealth for the Provision of Health Care,
Hypertension and Cardiovascular Disease,
and Protecting the Future Generation’s
Right to Live in a Healthy Environment
Continuous Quality Improvement
An amendment was proposed by the Brit-
ish Medical Association to add a new para-
graph to the proposed revision of the WMA
Declaration on Guidelines for Continuous
Quality Improvement in Healthcare. The
paragraph read: ‘Healthcare professionals
and institutions should systematically re-
cord and reflect on adverse incidents and
medical error for the purposes of learning
and quality improvement. This should oc-
cur in an environment of trust (and confi-
dentiality when appropriate) and to actively
avoid a blame culture.’
The amendment was accepted and the
Council agreed that the document as
amended should be forwarded to the Gen-
eral Assembly for adoption.
Relationship Between Physicians and Com-
mercial Enterprises
The American Medical Association sug-
gested recirculating the proposed revi-
sion of the WMA Statement Concerning
the Relationship Between Physicians and
Commercial Enterprises. It was argued
that significant changes were occurring in
relations between physicians, hospitals and
other economic institutions, such as private
equity groups, venture capital and insurance
companies. This required more discussion
on the policy.
A motion to recirculate the document was
agreed.
Climate Emergency (see p. 41)
The British Medical Association proposed
an amendment to add to its emergency
resolution the sentence: ‘The WMA and
its constituent members and the interna-
tional health community must acknowledge
the environmental footprint of the global
healthcare sector, and act to reduce waste
and prevent pollution to ensure healthcare
sustainability.‘
The amendment was supported and the
Council agreed to forward the Resolution,
as amended, to the General Assembly for
adoption.
Finance and Planning
Committee Report
The Council approved the report from the
Finance and Planning Committee, includ-
ing the Audited Financial Statement for
2018 and the proposed Budget for 2020,
both of which were forwarded to the Gen-
eral Assembly for adoption.
The Council agreed to withdraw the rec-
ommendation on the venue for the 224th
Council Session in 2023 in Baku, Azer-
baijan, and approve Nairobi, Kenya, as
the venue for the 224th
Council Session in
2023.
The Council agreed the proposed Classifi-
cation of Old Council Resolutions as rec-
ommended by the committee.
Associates Members
A report was presented from the Chair of
the Associate Members, Dr. Joseph Hey-
man. He said the membership had become
much more efficient,engaged and meaning-
ful.
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General Assembly Report
Two webinars were being planned, on social
determinants of health and on the Interna-
tional Code of Medical Ethics.
Past President and Chairs Network
Dr. Jon Snaedal said the Network had been
active with past Presidents and Chairs act-
ing individually on behalf of the WMA.
Junior Doctors Network
A report on the work of the Network was
presented by the Chair. A growing number
of junior doctors had been attracted to the
Network and plans were being prepared to
celebrate the 10th
anniversary of the Net-
work next year.
World Medical Journal
The Editor referred to his written report,
which stressed that the Journal was his-
torical evidence which enabled them to re-
member all presidents, key members of the
Council, chairs of committees and opin-
ion leaders. His task was to collate, as far
as possible, everything that WMA leaders
thought, did and wrote. He said he would
like to see more activity from the leaders of
national medical associations writing about
social determinants, public health and med-
ical ethics.
Public Relations
The meeting heard a report on public re-
lations and the need to publicise the vari-
ous policy statements to be adopted by the
General Assembly. Press releases and social
media were used to achieve this. However,
national medical associations could also
help by issuing their own press releases and
contacting their own governments about
new policy statements.
Environment Caucus
An oral report was presented on the Envi-
ronment Caucus which had met the previ-
ous day. The Caucus had heard about the
results of the recent UN Climate Action
Summit. It was now preparing for the next
climate conference COP 25 in December
where the WMA would be co-hosting a
global climate and health summit. Consid-
eration was being given to having sustain-
able climate for WMA meetings and how
WMA delegates would promote and sup-
port green conduct at international meet-
ings, reducing WMA delegates’ contribu-
tions to climate change.
Advocacy and Communications Panel
The Chair of the Advocacy and Commu-
nications Advisory Panel, Dr. Angelique
Coetzee gave an oral report. She referred to
a small survey of NMAs that had been car-
ried out about communications and advo-
cacy, which emphasised the importance of
the WMA website and e mail communica-
tion with the office in France. At a meeting
of the Panel earlier in the week there had
been a discussion about the need to support
smaller NMAs, possibly by having larger
NMAs in the region acting as mentors,how
to foster media visibility by reaching the
unreached, the role of social media and the
possibility of having open consultation on
key issues under consideration .
General Assembly Ceremonial Session
The Ceremonial Session was called to order
by the WMA President, Dr. Leonid Eidel-
man
Following welcoming speeches, delegates
stood to recite the Declaration of Geneva.
A Roll Call and Introduction of Delegates
and Observers was carried out by the Secre-
tary General, Dr. Otmar Kloiber
The Chair of the WMA Council Dr.Mont-
gomery then paid tribute to the outgoing
President Dr. Eidelman and thanked him
for his work during his Presidential year.He
said he had highlighted the issue of physi-
cians of the future, questioning how they
were going to carry out their profession in
the years to come. And he had never forgot-
ten patients during his work.
Dr.Eidelman then delivered his Valedictory
Address.
Dr. Miguel Roberto Jorge, then took the
oath of office as President of the WMA
for 2019/20. He was officially installed as
President and presented with the Presiden-
tial Medal.
Dr. Jorge then gave his Inaugural Address.
The Assembly then adjourned.
Saturday October 26
General Assembly Plenary Session
The day began with a brief orientation
session, when the Chair of Council Dr.
Montgomery explained to delegates the
procedure of the Assembly. He reminded
delegates that any vote on changing ethical
policy required a three-quarters majority.
He then called the Assembly to order.
Credentials Committee
The Credentials Committee reported that
there were 52 WMA constituent members
present and registered, with a total number
of 145 votes. A three-quarters majority was
109. A two-thirds majority, required for
changing the bylaws, would be 97 votes.
Election of President for 2020-2021
The first item on the agenda was the elec-
tion of a President for 2020-21.
The only nomination was that of Dr. David
Barbe, former President of the American
Medical Association. Dr. Barbe was elected
unopposed as President-elect.
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General Assembly Report
He thanked the meeting for its support
with these words:
‘Our physician colleagues and our patients
depend on our wisdom and leadership to
make healthcare better. Only by relying
on strong core principles can we adapt to
the changes and seize the opportunities
that face us. I promise I will rely on WMA
policy and our core values of promoting hu-
man rights, ethical medical practice and the
primacy of the patient physician relation-
ship to make decisions and statements that
reflect the will of this Assembly.
‘The WMA will continue to form partner-
ships and collaborative efforts to accomplish
our many strategic objectives. But most of
all, critical to our success, will be your ac-
tive participation. So I sincerely hope you
will join me in boldly moving the WMA
forward into the future, while at same time
upholding our best ideals from past and as
always providing the best patient care for
the patients that we serve.’
Universal Health Coverage
An oral report was given by Dr. Yoshitake
Yokokura, Past President of the WMA and
President of the Japan Medical Association.
He talked about the WMA’s engagement
on the issue of universal health coverage.He
reported on the UHC Forum held in De-
cember 2017 in Tokyo, which had adopted
the Memorandum of Tokyo ‘Affirming
health for all’ and about the Memorandum
of Understanding signed with the World
Health Organisation.
He had participated in the United Nations
High Level meeting in New York in Sep-
tember where world leaders adopted a high-
level declaration.
Report of the Council
The Assembly approved the written report
from Council that had been tabled.
The Assembly then considered actions rec-
ommended by the Council from the Medi-
cal Ethics Committee.
Female Foeticide (see p. 22)
Dr.Jürg Schlup (Switzerland) presented the
proposed Revision of the WMA Statement
on Female Foeticide. He said the policy
had been amended to add the following
sentence: ‘The WMA holds that sex selec-
tion abortion for reasons of gender prefer-
ence is discriminatory, where it is solely
due to parental preference and where there
are no health implications for the foetus or
the woman.’ He said the goal was to avoid
female foeticide with all its social conse-
quences.
The Assembly agreed to adopt the revised
Statement.
Genetics in Medicine (see p. 26)
Dr. Reynir Arngrimsson (Iceland) present-
ed the Declaration of Reykjavik – Ethical
Consideration Regarding the Use of Ge-
netics in Medicine. He said the Declara-
tion was a response to the rapid progress
taking place with genetics in medicine and
the need to put ethical considerations at the
forefront of these developments.
The Assembly agreed to adopt the Declara-
tion.
Solitary Confinement (see p. 39)
The proposed revision of the WMA State-
ment on Solitary Confinement was present-
ed by Dr.Chaand Nagpaul (British Medical
Association).
The Assembly agreed to adopt the State-
ment.
The Assembly then moved on to consider
actions recommended by the Council from
the Socio-Medical Affairs Committee.
Declaration of Madrid on Professionally-led
Regulation (see p. 22)
Dr. Nagpaul presented the proposed revi-
sion of the WMA Declaration of Madrid
on Professionally-led Regulation
The Assembly agreed to adopt the Declara-
tion.
Antimicrobial Resistance (see p. 29)
Dr. Nagpaul also introduced the proposed
revision of the WMA Statement on Anti-
microbial Resistance. He said this was an
issue of huge importance and was central to
the work of the WMA globally.
The Assembly agreed to adopt the State-
ment.
Reducing Dietary Sodium Intake (see p. 37)
Th South African Medical Association pre-
sented the proposed revision of the WMA
Statement on Reducing Dietary Sodium
Intake, recognising the prevalence of hyper-
tension associated with sodium intake.
The Assembly agreed to adopt the Statement.
Sugar (see p. 34)
The proposed WMA Statement on Free Sug-
ar Consumption and Sugar-sweetened Bev-
erages was introduced by Dr. Lujain Alqod-
mani (Kuwait Medical Association). She said
that given the rise of NCDs and child health
obesity and nutritional challenges all over the
world,it was important for the WMA to have
a strong statement on the issue.
The Assembly agreed to adopt the State-
ment.
Healthcare Information for All (see p. 35)
Dr. Nagpaul introduced the proposed
WMA Statement on Healthcare Informa-
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General Assembly Report
tion for All. He said it was well recognised
that a lack of access to health care informa-
tion was a major contributor to morbidity
and mortality, especially in low and middle
income countries and also among vulner-
able groups. He said this was a really im-
portant statement because it was essentially
about equity, empowerment and allowing
every single citizen to fulfil their fullest po-
tential in achieving their maximum health.
The Assembly agreed to adopt the State-
ment.
Access of Women and Children to Health Care
(see p. 28)
Leah Wapner (Israel) presented the pro-
posed WMA Statement on Access of
Women and Children to Health Care.
The Assembly agreed to adopt the State-
ment.
Augmented Intelligence (see p. 31)
Dr. Patrice Harris (American Medical As-
sociation) presented the proposed WMA
Statement on Augmented Intelligence in
Medical Care. She said the AMA had pro-
posed this because machine learning tech-
nology innovation was going to continue to
impact on how they cared for their patients.
It was important for NMAs to be educated
on the issue.
The Assembly agreed to adopt the State-
ment.
Medical Age Assessment of Unaccompanied
Minor Asylum Seekers (see p. 36)
Dr. Ramin Parsa-Parsi (German Medi-
cal Association) introduced the proposed
WMA Statement on Medical Age Assess-
ment of Unaccompanied Minor Asylum
Seekers. He said the document emerged
from what was perceived to be an exception-
ally pressing and timely matter, namely the
methods employed to assess the age of un-
accompanied minor asylum seekers for the
purposes of determining their legal status in
the country in which they were seeking asy-
lum. Given the global implications of this
issue, it was important that physicians the
world over were given guidance for dealing
with cases they were called upon to perform
medical age assessments.
Dr. Marit Hermansen (Norway) referred
to the WMA statement earlier in the year
on new eligibility regulations for classifying
female athletes which said ‘It is in general
considered as unethical for physicians to
prescribe treatment for excessive endoge-
nous testosterone if the condition is not rec-
ognized as pathological’ and went on to call
on physicians to refuse to perform any test
or administer any treatment or medicine
which was not in accordance with medi-
cal ethics. In that case, she said, the WMA
was opposing treatment for non-medical
reasons. Radiological examination without
medical indication or examination that in-
fringed on the dignity and privacy of asylum
seekers,that was genital examination,was in
the same category.
So she proposed inserting in the asylum
seekers Statement a new paragraph saying
‘The WMA advises doctors not to partici-
pate in the age assessment of minor asylum
seekers in all cases but where it is demon-
strably of interest of the individual.’
Dr. Andreas Rudkjoebin (Denmark) spoke
against the amendment. He said it was not
consistent with an earlier paragraph in the
Statement which stated that the patient
must be informed that the procedure was
not done to provide health care. In addi-
tion, the Statement already referred to any
infringement of dignity and privacy.
In a vote, the amendment was rejected.
The Assembly then agreed to adopt the
Statement.
The Assembly agreed that the WMA Resolu-
tion on Improved Investment in Public Health
be rescinded and archived.
Violence and Health (see p. 42)
The Nigerian Medical Association intro-
duced the proposed revision of the WMA
Statement on Violence and Health.
The meeting was told that this covered all
forms of violence at the work place and
against physicians. The Assembly agreed to
adopt the Statement.
Abortion in Nicaragua (see p. 41)
Dr. Gustavo Grecco (Uruguay) proposed
the revised Resolution on Legislation
Against Abortion in Nicaragua
The Assembly agreed to adopt the revised
Resolution.
Climate Emergency (see p. 41)
Dr. Helena Mc Keown (British Medical
Association) introduced the emergency
Resolution on Climate Emergency. She
said she recognised the previous work un-
dertaken by the WMA on this issue,but the
BMA believed it was time to express the
view that action on climate change should
be accelerated.
The Assembly agreed to adopt the emer-
gency Resolution.
Opioid Use (see p. 42)
Dr. Ravindra Wankhedkar (India) intro-
duced the emergency Resolution on the
Revocation of WHO Guidelines on Opi-
oid Use. He said the resolution had been
introduced because the WHO, without
any discussion with any stakeholder, had
rescinded its guidelines on opioids, causing
a lot of difficulties for health care providers
and patients.
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General Assembly Report
The Assembly agreed to adopt the emer-
gency Resolution.
The Assembly then referred back to the re-
port from the Medical Ethics Committee
to discuss one additional item.
Physician-Assisted Suicide
On a motion to adopt the proposed Dec-
laration on Euthanasia and Physician-As-
sisted Suicide as amended by the Council,
Dr. Ramin Parsa-Parsi (Germany) said that
discussions had been continuing for some
time about merging three WMA policies
into a new document. Following further
collaboration, he proposed an amendment
adding wording at the beginning of the
document to read: ‘The WMA reiterates
its strong commitment to the principles of
medical ethics and that utmost respect has
to be maintained for human life. Therefore,
the WMA is firmly opposed to euthanasia
and physician-assisted suicide.’
This led to a lengthy debate, with speakers
arguing for and against the amendment.
Dr. Helena McKeown (British Medical
Association) supported the amendment.
She said the BMA was concerned by the
shortcomings in current and applied care
and was working to ensure that those cared
for at home had access to needed pain re-
lief at any time during the day or night.
The BMA did not believe that physician
assisted suicide should be made legal in
Britain. It did not believe either voluntary
or involuntary euthanasia should be legal-
ised. The BMA was currently polling its
members on the position of the BMA and
neutrality.
Prof. Pablo Requena Meana (Vatican
Medical Association) said the draft policy
submitted was not a bad document. But
without doubt it weakened the WMA’s
position on euthanasia. He said it would
not be appropriate to adopt this document
because many countries were discussing
laws on euthanasia and it might give the
impression that the WMA in some way
recognised this social pressure and had low-
ered its standards on this issue. The Vatican
Medical Association was not in a position
to adopt this document if it did not include
at the beginning a reference saying that eu-
thanasia and physician assisted suicide were
contrary to medical ethics.
Prof. Yang Yang (Chinese Medical Asso-
ciation) supported adopting the document,
but Dr. Kgosi Letlape, a Past President of
the WMA, said that current WMA policy
was a beacon of medical ethics. He argued
against adopting a document that might
give governments that did not want to pro-
vide health services an option of allowing
citizens to die that might have tacit support
from the WMA.
He received support from the New Zea-
land and Romanian Medical Associations.
Delegates heard that New Zealand was
going through a big social debate on phy-
sician-assisted suicide at the moment and
the medical association there had used the
WMA’s strong policy position. Dr. Gheor-
ghe Borcean (Rumania) asked the meeting
to consider what message it wanted to send
the world and whether it would still be rep-
resentative of the profession.
Dr. Yoshitake Yokokura (Japan) said that
in Japan and in Asia there were very strong
religious conceptions about death and eu-
thanasia. Two years ago, a symposium had
been held in Japan on this issue, and Asian
countries were unanimously against the
idea of euthanasia. The other day the state-
run broadcaster in Japan had reported on
a lady who had travelled to Switzerland to
receive physician-assisted suicide because
she could not do so in Japan. Since then in
Japan this topic had attracted much atten-
tion. Under such circumstances it was high
time the WMA came out with a very clear
message that it was opposed to euthanasia
and physician-assisted suicide. Physicians
should not be forced into being any part of
that. He therefore suggested that the pro-
posed Declaration be adopted.
Dr. Jaques de Haller, an Associate Member
from Switzerland
and former President of the Standing Com-
mittee of European Doctors, thanked the
Germans for their compromise document.
It reaffirmed the position of the majority of
members of the WMA,being firmly against
euthanasia and physician assisted-suicide.
At same time it avoided stigmatising col-
leagues in different situations. This was a
positive point. He said the document fos-
tered respect and reconciliation and they
should be thankful for it.
Dr. Barbara McAneny (American Medi-
cal Association) said that ethics over time
did change.The document carefully defined
euthanasia and physician-assisted suicide as
two very different things. She said she was
a cancer doctor and had been present at the
end of life for many patients.The cancer,not
the patient decided when that patient would
die. The only thing the patient had in their
control was the manner and the comfort of
their passing. The WMA had decided that
with palliative care and terminal sedation
it was acceptable for her to sedate a patent
in the last two hours of their life. But two
hours was different from two weeks. There
was a grey zone of what was acceptable and
what it meant to relieve pain and suffering
at the end of life. She said she supported
the amendment because the words allowed
physicians to use their own judgement.
Prof. Zion Hagay (Israel) said he fully sup-
ported palliative care but not euthanasia. It
was against his ethics.It was also against the
position of the Israeli medical ethics com-
mittee which was against euthanasia.There-
fore, he would vote against the proposed
Declaration and the amendment.
The Brazilian Medical Association said
it would support the document, while Dr.
Serafin Romero (Spain) said it was im-
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19
General Assembly Report
portant to reach a consensus. He said that
they should all made clear that everyone
was against euthanasia. Dr. Gana Baskaran
Nadason, President of the Malaysian Medi-
cal Association, said his association strongly
opposed euthanasia. Physicians were sup-
posed to save life, not to take away life.
Dr. Francis Faduyile (Nigeria) said that at
the regional meeting held in Africa two
years it was agreed that euthanasia and phy-
sician-assisted suicide were unethical and
they should go the way of palliative care.
The physician pledge stated that physicians
would maintain the utmost respect for hu-
man life. In Nigeria, they believed that any
physician who participated in euthanasia or
physician-assisted death was actually un-
ethical. He said he wanted to plead with
colleagues they should state that the WMA
reiterated its strong commitment to the
principle of medical ethics. He proposed a
further amendment to add the words ‘The
WMA considers involvement in physician-
assisted suicide and euthanasia as being un-
ethical’.
Discussion then focused on the Nigerian
amendment, which was seconded. Dr. Jac-
queline Kitula (Kenya) said that medical
ethics was their bedrock. The amendment
would be in line with this. In Kenya eutha-
nasia and physician-assisted suicide were
not permissible. But any statement that be-
gan to waiver might open up a leeway for
governments to deliver a cheaper way to take
care of those who were chronically ill. She
therefore supported issuing a strong state-
ment as set out in the Nigerian amendment.
After further debate, a vote was taken and
the Nigerian amendment was defeated by
84 votes to 36 with 17 abstentions.
The debate then continued on the original
amendment from the German Medical As-
sociation.
Dr.Tony Bartone (Australia) said that society
changed and ethics evolved. He did not be-
lieve the language of the amendment and the
proposed Declaration weakened the position
of the WMA.The AMA had a firm position
on euthanasia and physician-assisted suicide.
He read one sentence from the AMA policy
‘The AMA believes doctors should not be
involved in interventions that have as their
primary intent the ending of a person’s life.
This does not include the discontinuation of
treatment of no medical benefit’. He said in
Australia some of the states had started the
process of allowing the legalisation of vol-
untary assisted dying. He said he did not
believe there was anything in the proposed
Declaration that lessened the opposition to
euthanasia and physician-assisted suicide.
He would therefore be voting in favour.
Dr. Jean-Francois Rault (France) said that
the French Medical Association was op-
posed to active euthanasia and assisted sui-
cide. Like many colleagues, he was pleased
that a compromise text had been found in
which all opinions could be reflected. Fur-
ther support came from speakers from the
Hungarian and Indian Medical Associa-
tions, both of whom welcomed the strength
of the document.
Before the next vote was taken, Dr. Andy
Gurman, an Associate Member, asked for
clarification about how abstaining votes
would be treated as part of the rule for
three-quarters or two-thirds majorities.
This led to an examination of the bylaws
and a ruling from the Chair that in the As-
sembly abstentions counted.
A vote then took place on the original
amendment to add at the start of the docu-
ment two sentences: ‘The WMA reiterates
its strong commitment to the principles of
medical ethics and that utmost respect has
to be maintained for human life. Therefore,
the WMA is firmly opposed to euthanasia
and physician-assisted suicide.’
The amendment was carried by 115 votes to
0, with 12 abstentions.
The debate continued on the proposed Dec-
laration, as amended.
The Ghana Medical Association proposed
adding the words ‘No physician should
participate in euthanasia or assisted suicide
whether voluntary or under compulsion,
nor should any physician make, refer deci-
sions to this end even if obliged or coerced.’
But the proposal failed to find a seconder.
Before the final vote on whether to adopt
the final Declaration as amended, Leah
Wapner (Israel) said that voting on this did
not mean that participating in euthanasia or
assisted suicide was unethical. It was clear
that what they were going to vote on was
weaker than what they were saying before,
that it was unethical. She said they needed
to reach a consensus on this,but she thought
there were large parts of the room that felt
very uncomfortable with the document.
Dr. Kenji Matsubara (Japan) said the pro-
posed Declaration was a softening of the
WMA’s policy and he proposed an amend-
ment to add the words ‘Euthanasia and
physician-assisted suicide are not compat-
ible with medical ethics.’
The amendment was defeated by 70 votes to
45 with 21 abstentions.
In a final vote to adopt the amended Dec-
laration, which required a three-quarters
majority, 110 voted for, 10 against with four
abstentions.
The Declaration was adopted and the As-
sembly agreed to rescind three previous
WMA policy statements.
Declaration of Geneva
Prof. Raanan Gillon, President of the Brit-
ish Medical Association, returned to the is-
sue of revising the Declaration of Geneva
by adding the words ‘I shall strive to practise
fairly and justly’, an amendment that failed
to find a seconder earlier in the week. He
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said he should have sought a seconder for
his motion before proposing it and he in-
vited those who supported it to contact him
so that the matter could be raised again at
the next meeting.
Report of the Treasurer
The Treasurer, Dr. Ravindra Sitaram
Wankhedkar gave a comprehensive report
on the financial statement for 2018. He said
there was a surplus, and expenses were well
regulated, monitored and controlled.
Membership dues had increased and the
Association had a low risk investment strat-
egy. It relied heavily on membership sub-
scriptions for its income.
He said the volume, structure and quality of
the finances were solid,and savings were safe.
He reported detailed expenditure and in-
come statistics.
The Audited Financial Statement for the
year ending 31 December 2018 was ap-
proved.
Dr. Wankhedkar then presented the pro-
posed Budget for 2020 and the Report on
Membership Dues Payments for 2019.
Both reports were adopted.
The Assembly received for information the
WMA Dues Categories 2020.
The Assembly approved the proposed Dues
Increase starting in 2021.
Future Meetings
The Assembly agreed that the 224th
Council
Session in 2023 be held in Nairobi, Kenya.
Law and Ethics (see p. 23)
The Assembly adopted the 2003 Resolution
on Law and Ethics as a Declaration.
The Assembly received for information the
list of policy documents to be rescinded.
Scientific Session 2020
The Assembly agreed that ‘Transplants and
donation/organ trafficking: International
scenario’ be the theme of the Scientific Ses-
sion of the 71st
General Assembly, in Cor-
doba 2020.
General Assembly 2023
The Assembly agreed that 4-7 October
2023 be the dates for the 74th
General As-
sembly in Kigali, Rwanda.
Membership
The application for membership from Doc-
tors 4 Doctors, Seychelles was approved.
Strategic Plan 2020-25
The draft WMA Strategic Plan 2020-2025
was approved.
Associate Members
Dr. Audrey Fontaine gave a report of the
Associate Members meeting and proposed
a Statement on Access to Surgery and An-
esthesia Care, which she said had been very
much neglected in the objectives towards
universal health coverage. She said it was
important to have a position on this.
The Assembly agreed to send the document
to Council for consideration.
Presentations from International Organisa-
tions
Dr. Patricia Turner, President-Elect of the
World Veterinary Association, spoke about
collaboration between the WMA and the
WVA. She gave a brief history of the WVA
and its structure.The Association represent-
ed more than half a million members and
put great emphasis on public health.
She talked about the ongoing African swine
fever, which was highly infectious and was
spreading throughout south east Asia. This
was a massive animal welfare issue.
There had been an increased feminisation in
veterinary practice and a change in work-
ing practices, such as increased technology
and the use of telemedicine. She referred to
the issue of antimicrobial misuse and spoke
about the health benefits of keeping pets.
Finally, Dr. Turner talked about the collab-
oration between the WVA and the WMA
that had been going on since 2012. This
had involved joint press releases and host-
ing joint conferences. It was bringing to-
gether the strength of the two professions,
capitalising on their joint knowledge base
for educating people about issues impact-
ing humans, animals and the environment
and applying pressure on governments and
non-governmental organisations.The WVA
highly valued this partnership.
Istanbul Protocol
Mariam Jishkariani from the Rehabilitation
Centre for Victims of Torture spoke about
revisions to the Istanbul Protocol for the
investigation and documentation of torture
in relation to the various WMA policies on
the issue.
WMA Open Session
This session gave delegates an opportunity
to present to the Assembly any profession-
specific problem, policy or project they
believed the WMA should know about or
help address.
British Medical Association
Dr. Helena McKeown spoke about plans
for the WMA Council meeting in Porto.
The BMA had presented its climate emer-
gency resolution this week and she thought
it was time they looked to extend this to at-
tendees at the Porto meeting to try to use
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General Assembly Report
a green travel plan and reduce air travel. If
they were not able to reduce air travel, she
would suggest they should be trying to off-
set their carbon. She would like to see the
Porto conference be as green as possible,
with the use of single use plastic, recycle
bins and the avoidance of generating waste.
Venezuela Medical Association
Dr. Douglas Leon-Natera, President of the
Venezuelan Medical Association, said they
were fighting for the health of the Venezue-
lan people because the Government was ne-
glecting it.There was no way that physicians
could provide the health service that was
required, save lives and provide medicines.
Regrettably, patients were paying the price
for this. Physicians could not do anything
to stop the diseases that were killing people.
There was no epidemiological data available
to allow them to do their job. The medical
profession was doing its best, but many of
them were fleeing the country as it was not
safe and they were not being paid. Inflation
was rampant,4,500 per cent this year,and as
a result people could not live. The situation
was a terrible crisis and he wanted the world
to be aware of this.
Uruguay Medical Association
Dr. Gustavo Grecco also spoke about the
situation that the medical communities in
Latin America were facing. At the moment
they had countries with different political
situations from both the left and the right
that were suffering from a dilapidation of
health services.
In Chile there was a serious situation, in
Venezuela the situation was terrible, in
Honduras doctors were being persecuted
trying to protect the health of their people.
In Nicaragua doctors were suffering from
violence and being forced not to help op-
ponents of the regime.
He said the World Health Organisation
was fighting for universal health coverage,
but in his region many countries were actu-
ally going in the wrong direction
Bangladesh Medical Association
Dr. Ehteshamul Huq Choudhury said that
in his country doctors were also being as-
saulted by miscreants and patients’ relatives.
The police and law enforcement authorities
took the side of the miscreants. In India one
doctor had died. He would like to urge the
Assembly to take a decision that govern-
ments should be asked to formulate a law
to protect doctors in their working environ-
ments.
The Chair of Council, Dr. Montgomery,
said this was a very important issue and was
also a problem in Germany, where legisla-
tion was being discussed to protect physi-
cians and other health care workers from
assaults by patients.
The Assembly ended with a presentation
to the outgoing President of the WMA,
Dr. Leonid Eidelman, and a short film of
Cordoba, the venue for the next Assembly
in 2020.
The Chair of Council then brought the
Assembly to a close, after a very successful
week.
Mr. Nigel Duncan
Public Relation Consultant,
WMA
E-mail: nduncan@ndcommunications.co.uk
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WMA Statement on Sex Selection
Abortion and Female Foeticide
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA,
October 2002, reaffirmed by the 191st
WMA Council Session, Prague,
Czech Republic, April 2012 And revised by the 70th
WMA General As-
sembly, Tbilisi, Georgia, October 2019
The WMA is gravely concerned that female foeticide and sex selec-
tion abortion is commonly practiced in certain countries.
The WMA denounces female foeticide and sex selection abortion as
a totally unacceptable example form of gender discrimination.
The WMA holds that sex selection abortion for reasons of gender
preference is discriminatory, where it is solely due to parental pref-
erence and where there are no health implications for the foetus or
the woman.
The World Medical Association calls on National Medical Associa-
tions:
• To denounce the practice of female foeticide and the use of sex
selection abortion for gender preference and;
• To advise their governments accordingly.
WMA Declaration on Euthanasia
and Physician-Assisted Suicide
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
The WMA reiterates its strong commitment to the principles of
medical ethics and that utmost respect has to be maintained for hu-
man life. Therefore, the WMA is firmly opposed to euthanasia and
physician-assisted suicide.
For the purpose of this declaration, euthanasia is defined as a physi-
cian deliberately administering a lethal substance or carrying out an
intervention to cause the death of a patient with decision-making
capacity at the patient’s own voluntary request. Physician-assisted
suicide refers to cases in which, at the voluntary request of a patient
with decision-making capacity, a physician deliberately enables a
patient to end his or her own life by prescribing or providing medi-
cal substances with the intent to bring about death.
No physician should be forced to participate in euthanasia or as-
sisted suicide, nor should any physician be obliged to make referral
decisions to this end.
Separately, the physician who respects the basic right of the patient
to decline medical treatment does not act unethically in forgoing or
withholding unwanted care, even if respecting such a wish results in
the death of the patient.
WMA Declaration of Madrid on
Professionally-led Regulation
Adopted by the 60th
WMA General Assembly, New Delhi, India, October
2009 and revised by the 70th
WMA General Assembly, Tbilisi, Georgia,
October 2019
The WMA reaffirms the Declaration of Seoul on professional autono-
my and clinical independence of physicians.
The medical profession must play a central role in regulating the
conduct and professional activities of its members, ensuring that
their professional practice is in the best interests of citizens.
The regulation of the medical profession plays an essential role in
ensuring and maintaining public confidence in the standards of care
and of behaviour that they can expect from medical professionals.
That regulation requires very strong independent professional in-
volvement.
Physicians aspire to the development or maintenance of systems
of regulation that will best protect the highest possible stan-
dards of care for all patients. Professionally led models can pro-
vide an environment that enhances and assures the individual
physician’s right to treat patients without interference, based on
his or her best clinical judgment. Therefore, the WMA urges its
constituent members and all physicians to work with regulatory
bodies and take appropriate actions to ensure effective systems
are in place. These actions should be informed by the following
principles:
1. Physicians are accorded a high degree of professional autono-
my and clinical independence, whereby they are able to make
recommendations based on their knowledge and experience,
clinical evidence and their holistic understanding of the patient
including his/her best interests without undue or inappropriate
outside influence. This is expounded in more detail in the Dec-
laration of Seoul.
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2. The regulation of the profession must be proportionate and
facilitative and not be burdensome, and be based on a model
that applies to every physician equally and that protects and
benefits patients and is based upon an ethical code. The plan-
ning and delivery of all types of health care is based upon an
ethical model and current evidence-based medical knowledge
by which all physicians are governed. This is a core element of
professionalism and protects patients. Physicians are best quali-
fied to judge the actions of their peers against such normative
standards, bearing in mind relevant local circumstances.
3. The medical profession has a continuing responsibility to be
strongly involved in regulation or self-regulating. Ultimate con-
trol and decision-making authority must include physicians,
based on their specific medical training, knowledge, experience
and expertise. In countries where Professionally led regulation is
in place physicians must ensure that this retains the confidence
of the public. In countries that have a mixed regulation system
physicians must seek to ensure that it maintains professional
and public confidence.
4. Physicians in each country are urged to consider establishing,
maintaining and actively participating in a proportionate, fair,
rigorous and transparent system of professionally-led regulation.
Such systems are intended to balance physicians’ rights to exer-
cise medical judgment freely with the obligation to do so wisely
and temperately.
5. National Medical Associations must do their utmost to promote
and support the concept of well-informed and effective regula-
tion amongst their membership and the public. To ensure that
any potential conflicts of interest between their representative
and regulatory roles are avoided they must ensure separation of
the two processes and pay rigorous attention to a transparent
and fair system of regulation that will assure the public of its
independence and fairness.
6. Any system of professionally-led regulation must enhance and
ensure:
–
– the delivery of high quality safe and competent healthcare to
patients,
–
– the competence of the physician providing that care
–
– the professional, including ethical, conduct of all physicians
–
– the protection of society and the rights of patients
–
– the promotion of trust and confidence of patients,their families
and the public
–
– the quality assurance of the regulation system
–
– the maintenance of trust by patients and society
–
– the development of solutions to potential conflicts of interest
–
– a commitment to wide professional responsibilities
7. To ensure that the patient is offered quality continuing care,
physicians should participate actively in the process of Continu-
ing Professional Development, including reflective practice, in
order to update and maintain their clinical knowledge,skills and
competence. Employers and management have a responsibility
to enable physicians to meet this requirement.
8. The professional conduct of physicians must always be within
the bounds of the Code of Ethics governing physicians in each
country. National Medical Associations must promote profes-
sional and ethical conduct among physicians for the benefit of
patients,and ethical violations must be promptly recognized, re-
ported to the relevant regulatory authority and acted upon.Phy-
sicians are obligated to intervene in a timely manner to ensure
that impaired colleagues do not put patients or colleagues at risk
and receive appropriate assistance from a physician health pro-
gram or appropriate training enabling a return to active practice.
9. The regulatory body should, when the judicial or quasi-judicial
processes are complete,and assuming that a case is found against
the physician, publish their findings and include details of the
remedial action taken. Lessons learned from every case should,
to the extent possible,be extracted and used in professional edu-
cation processes. The regulation process should ensure that the
incorporation of such lessons is, as far as possible, seamless.
10. National Medical Associations are urged to assist each other in
coping with new and developing challenges including potential
threats to professionally-led regulation. The ongoing exchange
of information and experiences between National Medical As-
sociations is essential for the benefit of patients.
11. Whatever judicial or regulatory process a country has estab-
lished, any judgment on a physician’s professional conduct or
performance must incorporate evaluation by the physician’s pro-
fessional peers who,by their training,knowledge and experience,
understand the complexity of the medical issues involved.
12. An effective and responsible system of professionally-led regu-
lation must not be self-serving or internally protective of the
profession. National Medical Associations should assist their
members in understanding that professionally-led regulation, in
countries where that system exists,must maintain the safety,sup-
port and confidence of the general public,including their health-
related rights, as well as the honour of the profession itself.
WMA Declaration on the
Relation of Law and Ethics
Adopted by the 164th
WMA Council Session,Divonne-les-Bains,France,
May 2003 and adopted as a Declaration by the 70th WMA General As-
sembly, Tbilisi, Georgia, October 2019
Ethical Values and legal principles are usually closely related, but
ethical obligations typically exceed legal duties. In some cases, the
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law mandates unethical conduct.The fact that a physician has com-
plied with the law does not necessarily mean that the physician
acted ethically.
When law is in conflict with medical ethics, physicians should work
to change the law. In circumstances of such conflict, ethical respon-
sibilities supersede legal obligations.
WMA Declaration of Reykjavik –
Ethical Considerations Regarding
the Use of Genetics in Health Care
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October
2005, Revised by the 60th
WMA General Assembly, New Delhi, India,
October 2009 and by the 70th
WMA General Assembly,Tbilisi, Georgia,
October 2019
Preamble
Genetics contributes to the growing understanding of the causes,
developments, classifications and treatments of diseases. The use
of genetics is increasing, moving from the identification of mono-
genic diseases and use in cancer treatment towards predicting risks
of multifactorial diseases and manipulation of individual genes. In
these ways,the use of genetics does and increasingly will create great
value at an individual as well as at a societal level. However, the use
of genetic information about individuals also raises issues concern-
ing confidentiality, privacy and the risk of psychological distress,
stigmatization, and discrimination.
This declaration provides recommendations for the use of medical
genetics that respects the ethical challenges that such use entails. It
is primarily aimed at the use of genetics in the provision of health
care.The collection,storage and use of genetic data beyond the indi-
vidual care of patients should adhere to the principles put forward in
the WMA Declaration of Taipei on Ethical Considerations regard-
ing Health Databases and Biobanks.The use of genetics in medical
research involving human subjects, including research on identifi-
able human material and data, should adhere to the principles put
forward in the WMA Declaration of Helsinki Ethical Principles
for Medical Research Involving Human Subjects.
This Declaration should be read as a whole and each of its constitu-
ent paragraphs should be applied with consideration of all other rel-
evant paragraphs. The declaration should be updated in accordance
with developments in the field of genetics.
Genetic information has characteristics that are ethically significant.
Individually, these characteristics can also be found in other types of
health care information. However, the combination of these charac-
teristics makes genetic information particularly sensitive. This sensi-
tivity – combined with the intense interest in genetic information
from many different stakeholders – underscores the importance of
respecting the fundamental principles of medical ethics, particularly
the patient’s right to autonomy, confidentiality, privacy and benefit in
relation to generating, storing, using or sharing genetic information.
Central among the ethically significant characteristics are:
• Genetic information is identifying for an individual.
• Genetic analysis can generate extensive and detailed information
about an
• Genetic analysis may generate additional findings.
• The full significance of the information generated by genetic
analysis is not yet known.
• Genetic information about an individual cannot be fully anony-
mized, and de-identified genetic information may be re-identi-
fied.
• Genetic data contains information not only about the individual
who has undergone testing, but also about individuals who are
genetically related to the tested individual.
• Genetic testing of one individual may entail that the phycisian
asks for access to health care information about – or genetic test-
ing of – genetically related persons (family members).
Ethical principles
1. Benefit
Genetic testing in the context of healthcare provision should pri-
marily be done for the benefit of the patient being tested.
2. Relevance
Genetics test should not be wider in scope than what is relevant for
the purpose of the test.
3. Informed consent
a.Genetic testing should only be done with the informed consent of
the individual or his/her legal guardian. Genetic testing for predis-
position to disease should be performed on children only if there are
clear clinical indications and being aware of the test results would be
in the best interests of the child.
b. The consent process must include providing the patient with un-
derstandable, accurate and adequate information about the follow-
ing:
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• The purpose, nature and benefits of the test.
• The risks, burdens and limitations of the test.
• The nature and significance of the information to be generated
by the test.
• The procedures for return of results including additional findings
and future discoveries.
• The options for responding to the results, including possible
treatments.
• How, where, and for how long the test results, data and biological
samples will be stored, and who can gain access to current and
future results.
• The possible secondary uses of the information generated by the
test
• The measures protecting confidentiality, privacy and autonomy,
including data security measures
• The procedures for managing results that have implications for
genetically related persons
• When applicable,commercial use and benefit sharing,intellectual
property issues and the transfer of data or material to third par-
ties.
4. Additional findings (secondary and incidental findings)
a. A genetic test may generate additional findings that are not related
to the primary purpose of the test, also referred to as secondary or
incidental findings. Procedures for handling such findings should be
determined before the test, and information about these procedures
should be communicated to the patient as part of the consent process.
b. The principles for managing additional findings must include
consideration for:
• The patient’s preferences regarding the management of additional
findings.
• The significance of the additional findings for the patient’s health
and other interests.
• The significance of the findings for the health and other interests
of persons who are genetically related to the patient.
• The scientific validity of the additional findings.
• The strengths of the evidence for the correlation between the ad-
ditional findings and health related risks for the patient.
• The degree to which the additional findings are actionable, medi-
cally or otherwise.
5. Genetic counselling
a. Appropriate genetic counselling should always be offered when
genetic tests or genetics-based treatments are offered or performed
and for the interpretation of results. Counselling should enable the
patient to make informed decisions according to their own values
and interests. Counselling must not be biased by the personal values
of the counsellor. The individual’s right not to be tested should be
protected, and if the individual has been tested, there should be no
obligation for the individual to act on the results of the test.
b. Medical students and physicians should receive education and
training in genetic counselling, particularly counselling related to
pre-symptomatic diagnosis of disease.
6. Confidentiality
Like all medical records, information from genetic testing or ge-
netic therapy must be kept strictly confidential and must not be
revealed to third parties in identifiable form without the consent of
the individual tested. Third parties, to whom results may in certain
circumstances be released, are identified in paragraph 15.
7. Informing third parties
In the case of a test result that may have implications for third par-
ties such as close relatives, the individual tested should be encour-
aged to discuss the results of the test with such third parties.In cases
where not disclosing the results involves an expected harm that is
serious and unavoidable except by disclosure, and clearly greater
than the harm likely to result from disclosure, the physician may re-
veal necessary information to such third parties without the consent
of the patient but should usually discuss this with the patient first.
If the physician has access to an ethics committee, it is preferable
to consult such a committee prior to revealing information to third
parties.
8. Data protection
The collection, storage and use of genetic data requires the highest
level of data protection.
9. Discrimination
No individual or group must be discriminated against in any way
based on genetic makeup, including the fields of human rights,
employment and insurance. This protection should apply to those
individuals who have undergone genetic testing or genetic therapy
as well as those individuals about whom genetic information can
be inferred. Particular care should be taken to protect vulnerable
individuals and groups.
10. Cost of testing
The decision to include genetic analysis as part of medical care can
introduce significant cost for the patient and the health care system.
Therefore, such a decision should always be based on the expecta-
tion that the costs of the analysis are justified by the benefits for the
patient.
11. Reliability and limitations
a. The identification of disease-related genes has led to an increase
in the number of available genetic tests, analyses and treatments.
As the number, types and complexity of these increase, great care
must be taken to ensure their reliability, accuracy and quality and to
inform patients about their limitations.
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b.The benefit of a genetic test for an individual may depend on the
availability of information about the relevant background popula-
tion. Medical professionals should be aware of the scope and the
limitations of genetic background data and health information
stored in databases used in providing clinical genetic testing ser-
vices.
12. Direct-to-consumer tests
If genetic tests are offered directly to consumers for medical pur-
poses, they must meet the same technical, professional, legal and
ethical standards as tests offered by certified laboratories and must
be in accordance with the recommendations put forward in this
statement. In particular, providers of direct-to-consumer tests must
provide understandable, accurate and adequate information about
the reliability and limitations of their services.
13. Clinical use of data from research
For research projects that involve genetic testing,and where the par-
ticipant can be identified,the research participant must be informed
about the possibility of findings that indicate a serious threat to the
health of the participant. If there are such findings, the participant
should be offered a referral to genetic counseling and appropriate
medical intervention.
14. Gene therapy and editing
Gene therapy and editing represents a combination of techniques
used to manipulate disease related genes. The use of these tech-
niques should adhere to the following guidelines:
• The use of gene therapy and somatic genome editing should con-
form to standards of medical ethics and professional responsibility.
• Patient autonomy should be respected,and informed consent should
always be obtained. This informed consent process should include
disclosure of the risks of gene therapy and editing, including the
fact that the patient may have to undergo multiple rounds of gene
therapy, the risk of an immune response, the potential problems
arising from the use of viral vectors and off-target genome effects.
• Gene therapy and editing should only be undertaken after a care-
ful analysis of the risks and benefits involved and an evaluation
of the perceived effectiveness of the therapy, as compared to the
risks,side effects,availability and effectiveness of other treatments.
• Gene editing of germline cells has scientifically unresolved risks
and should not be clinically applied. This does not preclude test-
ing gene editing or other similar research.
15. Cloning
Cloning includes both therapeutic cloning, namely the cloning of
individual stem cells to produce a healthy copy of a diseased tissue
or organ for transplant, and reproductive cloning, namely the clon-
ing of an existing human to produce a genetic duplicate of that hu-
man.The WMA opposes reproductive cloning of humans.
WMA Statement on Access of
Women and Children to Health
Care
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, No-
vember 1997 and revised by the 59th
WMA General Assembly, Seoul,
Korea, October 2008 and by the 70th
WMA General Assembly, Tbilisi,
Georgia, October 2019
Preamble
For centuries, women and girls worldwide have suffered from gen-
der inequality and an uneven balance of power between men and
women. Historically based gender bias has led to women and girls
being restricted in their access to, inter alia, employment, education
and health care. Gender inequality may lead to health risks, subop-
timal health behaviors and inferior health outcomes for women and
girls1
1.
In addition, in some countries, female doctors and nurses have been
prevented from, or face barriers to practicing their profession due to
religious and/or cultural convictions, or discrimination based on the
intersecting grounds of sex and religion/ethnicity. A lack of gender
representation and diversity within the medical profession may lead
to female patients and their children not having equitable access to
health care.
Gender is a social determinant of health and health problems may
manifest themselves differently in men and women.There is a need
to address the differences in health and health care between men
and women, including both the biological and socio-cultural di-
mensions.
Discrimination against girls and women damages their health ex-
pectation. For example, the education of girls positively affects their
health and well-being as adults.Education also improves the chanc-
es of their children surviving infancy and contributes to the overall
well-being of their families. Conversely, secondary discrimination
due to social, religious and cultural practices – which diminishes
women’s freedom to make decisions for themselves and to access
employment and healthcare opportunities – has a negative impact
on health expectation.
1 
Men et al, “Gender as a social determinant of health: Gender analysis of the
health sector in Cambodia in Cambodia”.World Conference on Social Deter-
minants of Health. World Health Organization. October 2011.
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The WMA has several policies that focus on women and children’s
health. They include: WMA Resolution on Women’s Rights to Health
Care and How That Relates to the Prevention of Mother-to-Child HIV
Infection, WMA Resolution on Violence against Women and Girls and
WMA Declaration of Ottawa on Child Health.This statement stresses
the importance of equal access to health care and the effects of dis-
crimination against women and children.
Recommendations
Therefore, the World Medical Association urges its constituent
members to:
• Categorically condemn violations of the basic human rights of
women and children, including violations stemming from social,
political, religious, economic and cultural practices;
• Insist on the rights of all women and children to full and adequate
medical care,especially where religious,social and cultural restric-
tions or discrimination may hinder access to such medical care;
• Advocate for parity of health insurance premiums and coverage to
ensure that women’s access to care is not impeded by prohibitively
high expenses;
• Promote the provision of pre-conception, prenatal and maternal
care, and post-natal care including immunization, nutrition for
proper growth and health-care development for children;
• Ensure universal access to sexual and reproductive health;
• Promote women’s and children’s health as human rights;
• Advocate for educational, employment and economic opportuni-
ties for women and for their access to information about health-
care and health services;
• Work towards the achievement of the human right to equality of
opportunity and equality of treatment, regardless of gender.
WMA Statement on
Antimicrobial Resistance
Adopted by the 48th
WMA General Assembly, Somerset West, South Afri-
ca, October 1996 and revised by the 59th
WMA General Assembly, Seoul,
Korea, October 2008 and by the 70th
WMA General Assembly, Tbilisi,
Georgia, October 2019
Preamble
AMR is a growing threat to global public health that transcends
national boundaries and socioeconomic divisions. AMR affects hu-
man, animal and environmental health. It is a multi-faceted prob-
lem of crisis proportions with significant economic, health, and hu-
man implications.
Addressing the threat of antimicrobial resistance is a fundamental
global health priority, and the responsibility of all countries.
Antimicrobial drugs form an essential component of modern medi-
cine, ensuring that complex procedures, such as surgery and chemo-
therapy, can be performed with lower risk.
AMR threatens the effective prevention and treatment of an in-
creasing range of infections caused by bacteria, parasites, viruses and
fungi.
AMR occurs when microorganisms develop the ability to resist the
actions of antimicrobial drugs (such as antibiotics, antifungals, anti-
virals, antimalarials, and anthelmintics).
Infections caused by bacteria that are resistant to multiple classes of
antibiotic are increasingly being documented.
While AMR is a natural evolutionary phenomenon, it is exacer-
bated by the overuse and misuse of antimicrobials in medicine, as
well as in veterinary practice and agriculture,and can be exacerbated
when antimicrobials are given as growth promoters in animals or
used to prevent diseases in healthy animals.
The emergence and spread of AMR is further enhanced by lack of
access to effective drugs, access to antibiotics “over the counter” in
some countries, the availability of substandard and falsified prod-
ucts, misuse of antibiotics in food production, increased global trav-
el, medical tourism and trade, and the poor application of infection
control measures.
Another major cause of AMR is the release of antibiotics into the
environment. This can occur as either as a result of poor manufac-
turing practices, the improper disposal of unused medication, hu-
man and animal excretion, and the inadequate disposal of human
and animal corpses.
In many countries, particularly in low-and middle-income coun-
tries, access to effective antimicrobials as well as complementary
technologies including vaccines and diagnostics continues to re-
main a significant challenge, furthering AMR.
The ramifications of resistance manifest themselves not just in the
impact on human health, but also in potentially heavy economic
costs. The World Health Organization (WHO) has warned that
resistance has reached alarming levels in many parts of the world,
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and that a continued increase in resistance could lead to 10 million
people dying per year and a reduction of 2-3.5% in global gross
domestic product by 2050.
At the rate at which resistance is growing globally, it poses a sig-
nificant threat to successfully achieving the UN Sustainable De-
velopment Goals and undermines efforts to reduce health inequali-
ties. Without harmonized and coordinated cross-sector action on a
global, scale, the world is heading towards a post-antibiotic era in
which common infections and minor injuries can once again kill.
AMR has reached great prominence at the highest political levels
including the UN General Assembly, and the agenda of the G7 and
G20.
There is a need for an effective ‘one health’ approach to minimize
unnecessary or inappropriate use of antimicrobials and to prevent
and control the transmission of existing resistance. A ‘one health’
approach recognizes that action is required across human medicine,
veterinary practice and agriculture.
Recommendations
1. Global
a. The primary prevention of community and healthcare associated
infections is necessary to reduce the demand for antibiotics. Ad-
dressing the social determinants of infectious disease, such as poor
living conditions and sanitation, will have co-benefits of reducing
health inequalities and tackling AMR.
b. Nations have varying resources available to combat antimicrobial
resistance, and must cooperate with the WHO, Food and Agricul-
ture Organization and World Organization for Animal Health that
support the WHO Global Action Plan on AMR which provides
the framework for national action plans.
c. The World Medical Association and its constituent members
should advocate for:
• investment in the surveillance of drug resistant infections across
human health, veterinary medicine, agriculture, fishing industry,
and food production, and international cooperation for data-
sharing procedures to improve global responses;
• the WHO and other UN agencies should examine the role of
international travel and trade agreements on the development of
antimicrobial resistance, and promote measures in those agree-
ments to act as safeguards against the globalisation of drug resis-
tant pathogens in our food supply;
• the WHO should continue to encourage the use of Trade Related
Aspects of Intellectual Property Rights (TRIPS) flexibilities to
help ensure affordable access to quality medicines and oppose the
proliferation of ‘TRIPS-plus’provisions within trade agreements,
which restrict the use of TRIPS flexibilities and limit their ef-
fectiveness;
• the widespread application of verifiable technology such as track-
and-trace systems to ensure the authenticity of pharmaceutical
products;
• equitable access to, and appropriate use of, existing and new
quality-assured antimicrobial medicines. This requires effectively
applying the Access, Watch and Reserve lists of the WHO Es-
sential Medicines program. For the WHO global action plan and
national action plans to be effective, access to health facilities,
health care professionals, veterinarians, knowledge, education and
information are vital;
• greater use of vaccinations which will reduce the burden of in-
fectious disease, reducing the need for antibiotics and therefore
limiting the emergence of resistance;
• for global health organisations and governments to scale up their
action and coordination in promoting appropriate antibiotic use
and work together to reduce AMR using a One Health approach,
which recognises that human,animal and environmental health is
inextricably linked. to reduce the spread of resistance.
d. The World Medical Association and its constituent members
should encourage their governments to:
• fund more basic and applied research directed toward the devel-
opment of innovative antimicrobial agents, diagnostic tools and
vaccines (innovative antimicrobial vaccines), and on the appropri-
ate and safe use of such therapeutic tools;
• ensure parity between financial and technical resources towards
the development of innovative antimicrobial medicines, vaccines,
and diagnostics as well as innovative infection control and pre-
vention methods across human health, veterinary, and agricultural
sectors;
• support Research and Development efforts for novel antimi-
crobial agents, vaccines, and rapid diagnostic methods that are
needs-driven and guided by the principles outlined in the UN
Declaration on AMR, adopted in September 2016, including af-
fordability, effectiveness, efficiency, and equity [1];
• initiate regulatory measures to control the environmental pollu-
tion that allows the spread of antibiotic- resistant genes across
soil, water and air;
• educate a sufficient number of clinical infectious disease special-
ists in every country, which is a fundamental requirement for
tackling antimicrobial resistance and hospital-acquired infections.
2. National
a. National medical associations should urge their governments to:
• require that antimicrobial agents be available only through a pre-
scription provided by healthcare professionals and/or veterinary
professionals and dispersed or sold by professionals;
• to initiate national campaigns to raise awareness among the public
of the harmful consequences of overuse and misuse of antibiotics.
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This should be supported through the introduction of national
targets to raise public awareness;
• to support professional societies, civil society, and healthcare de-
livery systems to pilot and adopt proven behaviour change strate-
gies to ensure appropriate use of antibiotics;
• to ensure access to appropriate and fit-for-purpose point-of-care
diagnostics in hospitals and clinics to support decision making
and prevent inappropriate prescribing of antibiotic;
• to mandate the collection of data on antibiotic use, prescriptions,
prices, resistance patterns, and trade in both the healthcare and
agricultural sectors.This data should be made publicly accessible;
• promote effective programs of antimicrobial stewardship and
training on the appropriate use of antimicrobials agents, and in-
fection control;
• actively pursue the development of a national surveillance system
for the provision of antimicrobials and for antimicrobial resis-
tance.Data from this system should be linked with or contributed
to the WHO’s global surveillance network;
• monitoring of antimicrobial use in food producing animals must
be sufficiently granular to ensure accountability.
b. National medical associations should:
• encourage medical schools and continuing medical education
programs to renew their efforts to educate physicians, who can in
turn inform their patients, about the appropriate use of antimi-
crobial agents and appropriate infection control practices, includ-
ing antibiotic use in the outpatient setting;
• support the education of their members in areas of AMR, includ-
ing antimicrobial stewardship, rational use of antimicrobials, and
infection control measures including hand hygiene;
• advocate for the publishing and communication of local informa-
tion relating to resistance patterns, clinical guidelines and recom-
mended treatment options for physicians;
• in collaboration with veterinary authorities, encourage their gov-
ernments to introduce regulations to reduce the use of antimi-
crobials in agriculture, in particular food producing animals, in-
cluding restrictions on the routine use of antimicrobials for both
prophylaxis and growth promotion, and on the use of classes of
antimicrobial that are critically important in human medicine;
• support regulation that prevents conflicts of interest among vet-
erinarians, such as roles where veterinarians both prescribe and
sell antibiotics;
• consider the use of social media to educate and promote the prop-
er use and disposal of antibiotic medications;
• encourage parents to comply with the national recommended immu-
nization schedules for children.Adults should also have easy access to
vaccines against influenza and pneumococcal infections among others.
3. Local
a. Health professionals and health systems have a vital role in pre-
serving antimicrobial medicines.
b. Physicians should:
• have access to high-quality and reliable, evidence-based informa-
tion free of conflict of interest and actively participate in and lead
antimicrobial stewardship programs in their hospitals, clinics and
communities to optimise antibiotic use;
• raise awareness amongst their patients about antimicrobial ther-
apy, its risks and benefits, the importance of adherence with the
prescribed regimen, infection prevention practices, and the prob-
lem of AMR;
• promote and ensure adherence hygiene measures (especially hand
hygiene) and other infection prevention practices.
WMA Statement on Augmented
Intelligence in Medical Care
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
Preamble
Artificial Intelligence (AI) is the ability of a machine to simulate in-
telligent behavior,a quality that enables an entity to function appro-
priately and with foresight in its environment. The term AI covers
a range of methods, techniques and systems. Common examples of
AI systems include, but are not limited to, natural language process-
ing (NLP), computer vision and machine learning. In health care,
as in other sectors, AI solutions may include a combination of these
systems and methods.
(Note: A glossary of terms appears as an appendix to this statement.)
In health care, a more appropriate term is “augmented intelligence”,
an alternative conceptualization that more accurately reflects the
purpose of such systems because they are intended to coexist with
human decision-making [1]. Therefore, in the remainder of this
statement, AI refers to augmented intelligence.
An AI system utilizing machine learning employs an algorithm
programmed to learn (“learner algorithm”) from data referred to as
“training data.”The learner algorithm will then automatically adjust
the machine learning model based on the training data. A “continu-
ous learning system” updates the model without human oversight
as new data is presented, whereas “locked learners” will not auto-
matically update the model with new data. In health care, it is im-
portant to know whether the learner algorithm is eventually locked
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or whether the learner algorithm continues to learn once deployed
into clinical practice in order to assess the systems for quality, safety,
and bias. Being able to trace the source of training data is critical
to understanding the risk associated with applying a health care AI
system to individuals whose personal characteristics are significantly
different than those in the training data set.
Health care AI generally describes methods, tools and solutions
whose applications are focused on health care settings and patient
care. In addition to clinical applications, there are many other appli-
cations of AI systems in health care including business operations,
research, health care administration, and population health.
The concepts of AI and machine learning have quickly become at-
tractive to health care organizations, but there is often no clear defi-
nition of terminology used.Many see AI as a technological panacea;
however,realizing the promise of AI may have its challenges,since it
might be hampered by evolving regulatory oversight to ensure safety
and clinical efficacy, lack of widely accepted standards, liability is-
sues, need for clear laws and regulations governing data uses, and a
lack of shared understanding of terminology and definitions.
Some of the most promising uses for health care AI systems include
predictive analytics, precision medicine, diagnostic imaging of dis-
eases, and clinical decision support. Development in these areas is
underway, and investments in AI have grown over the past several
years [2]. Currently, health care AI systems have started to provide
value in the realm of pattern recognition, NLP, and deep learning.
Machine learning systems are designed to identify data errors with-
out perpetuating them. However, health care AI systems do not re-
place the need for the patient-physician relationship. Such systems
augment physician-provided medical care and do not replace it.
Health care AI systems must be, transparent, reproducible, and be
trusted by both health care providers and patients. Systems must
focus on users’ needs. Usability should be tested by participants
who reflect similar needs and practice patterns of the end user, and
systems must work effectively with people. Physicians will be more
likely to accept AI systems that can be integrated into or improve
their existing practice patterns, and also improve patient care.
Opportunities
Health care AI can offer a transformative set of tools to physicians
and patients and has the potential to make health care safer and more
efficient. By automating hospital and office processes, physician pro-
ductivity would improve.The use of data mining to produce accurate
useful data at the right time may improve electronic health records.
and access to relevant patient information.Results of data mining may
also provide evidence for trends that may serve to inform resource al-
location and utilization decisions. New insights into diagnosis and
best practices for treatment may be produced because of analyzing all
known data about a patient. The potential also exists to improve the
patient experience, patient safety, and treatment adherence.
Applications of health care AI to medical education include con-
tinuing medical education, training simulations, learning assistance,
coaching for medical students and residents,and may provide objec-
tive assessment tools to evaluate competencies. These applications
would help customize the medical education experience and facili-
tate independent individual or group learning.
There are a number of stakeholders and policy makers involved in
shaping the evolution of AI in health care besides physicians.These
include medical associations, businesses, governments, and those in
the technology industry. Physicians have an unprecedented oppor-
tunity to positively inform and influence the discussions and debates
currently taking place around AI. Physicians should proactively en-
gage in these conversations in order to ensure that their perspectives
are heard and incorporated into this rapidly developing technology.
Challenges
Developers and regulators of health care AI systems must ensure
proper disclosure and note the benefits, limitations, and scope of
appropriate use of such systems. In turn, physicians will need to
understand AI methods and systems in order to rely upon clinical
recommendations. Instruction in the opportunities and limitations
of health care AI systems must take place both with medical stu-
dents and practicing physicians, as physician involvement is critical
to successful evolution of the field. AI systems must always adhere
to professional values and ethics of the medical profession.
Protecting confidentiality,control and ownership of patient data is a
central tenet of the patient-physician relationship. Anonymization
of data does not provide enough protection to a patient’s informa-
tion when machine-learning algorithms can identify an individual
from among large complex data sets when provided with as few as
three data points, which could put patient data privacy at risk. Cur-
rent expectations patients have for confidentiality of their personal
information must be addressed, and new models that include con-
sent and data stewardship developed. Viable technical solutions to
mitigate these risks are being explored and will be critical to wide-
spread adoption of health care AI systems.
Data structure, and integrity are major challenges that need to be
addressed when designing health care AI systems. The data sets on
which machine learning systems are trained are created by humans
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General Assembly Report
and may reflect bias and contain errors. Because of this, these data
sets will normalize errors and the biases inherent in their data sets.
Minorities may be disadvantaged because there is less data available
about minority populations. Another design consideration is how a
model will be evaluated for accuracy and involves very careful analy-
sis of the training data set and its relationship to the data set used to
evaluate the algorithms.
Liability concerns present significant challenges to adoption. As ex-
isting and new oversight models develop health care AI systems, the
developers of such systems will typically have the most knowledge of
risks and be best positioned to mitigate the risk.As a result,develop-
ers of health care AI systems and those who mandate use of such
systems must be accountable and liable for adverse events resulting
from malfunction(s) or inaccuracy in output. Physicians are often
frustrated with the usability of electronic health records.Systems de-
signed to support team-based care and other workflow patterns but
often fall short. In addition to human factors in the design and de-
velopment of health care AI systems, significant consideration must
be given to appropriate system deployment. Not every system can be
deployed to every setting due to data source variations.
Work is already underway to advance governance and oversight of
health care AI, including standards for medical care, intellectual
property rights, certification procedures or government regulation,
and ethical and legal considerations.
Recommendations
1.That the WMA:
–
– Recognize the potential for improving patient outcomes and
physicians’ professional satisfaction through the use of health
care AI, provided they conform to the principles of medical
ethics, confidentiality of patient data, and non-discrimination.
–
– Support the process of setting priorities for health care AI.
–
– Encourage the review of medical curricula and educational op-
portunities for patients, physicians, medical students, health
administrators and other health care professionals to promote
greater understanding of the many aspects, both positive and
negative, of health care AI.
2.The WMA urges its member organizations to:
–
– Find opportunities to bring the practicing physician’s perspec-
tive to the development, design, validation and implementation
of health care AI.
–
– Advocate for direct physician involvement in the development
and management of health care AI and appropriate govern-
ment and professional oversight for safe, effective, equitable,
ethical, and accessible AI products and services.
–
– Advocate that all healthcare AI systems be transparent, repro-
ducible,and be trusted by both health care providers and patients.
–
– Advocate for the primacy of the patient-physician relationship
when developing and implementing health care AI systems.
Appendix
Glossary of Terms Used in Health
Care Augmented Intelligence
Algorithm is a set of detailed,ordered instructions that are followed
by a computer to solve a mathematical problem or to complete a
computer process.
Artificial intelligence consists of a host of computational methods
used to produce systems that perform tasks which exhibit intelligent
behavior that is indistinguishable from human behavior.
Augmented intelligence (AI) is a conceptualization of artificial intel-
ligence that focuses on artificial intelligence’s assistive role, emphasiz-
ing that its design enhances human intelligence rather than replaces it.
Computer vision is an interdisciplinary scientific field that deals
with how computers can be made to gain high-level understanding
from digital images or videos and seeks to automate tasks that the
human visual system can do.
Data mining is an interdisciplinary subfield of computer science
and statistics whose overall goal is to extract information (with in-
telligent methods) from a data set and transform the information
into a comprehensible structure for further use.
Machine learning (ML) is the scientific study of algorithms and sta-
tistical models that computer systems use to effectively perform spe-
cific tasks with minimal human interaction and without using explicit
instructions, by learning from data and identification of patterns.
Natural language processing (NLP) is a subfield of computer sci-
ence, information engineering, and artificial intelligence concerned
with the interactions between computers and human (natural) lan-
guages, in particular how to program computers to process and ana-
lyze large amounts of natural language data.
Training data is used to train an algorithm; it generally consists of a
certain percentage of an overall dataset along with a testing set. As a
rule, the better the training data, the better the algorithm performs.
Once an algorithm is trained on a training set, it’s usually evaluated
on a test set. The training set should be labelled or enriched to in-
crease an algorithm’s confidence and accuracy.
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References:
1. For purposes of this statement, the term “health care AI”will be used to refer
to systems that augment, not replace, the work of clinicians.
2. CB Insights. The Race for AI: Google, Baidu, Intel, Apple in a Rush to Grab Ar-
tificial Intelligence Startups. https://www.cbinsights.com/research/top-acquirers-
ai-startups-ma-timeline/.
WMA Statement on Free
Sugar Consumption and Sugar-
Sweetened Beverages
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
Preamble
Non-communicable diseases (NCDs) are the leading causes of
death worldwide. Every year 40 million people die from NCDs [1].
The most common causes of these diseases are poorly balanced diet
and physical inactivity. A high level of free sugar consumption has
been associated with NCDs because of its association with obesity
and poor dietary quality.
According to the World Health Organization (WHO), free sugar
is sugar that is added to foods and beverages by the manufacturer,
cook or consumer that results in excess energy intake which in turn
may lead to parallel changes in body weight.
WHO defines free sugar as ‘all sugars that are added during food
manufacturing and preparation as well as sugars that are naturally
present in honey, syrups, fruit juices, and fruit concentrates.’
Sugar has become widely available and its global consumption has
grown from about 130 to 178 million tonnes over the last decade.
Excess free sugar intake,particularly in the form of sugar-sweetened
beverages, threatens the nutrient quality of the diet by contribut-
ing to the overall energy density but without adding specific nutri-
ents. This can lead to unhealthy weight gain and increases the risk
of dental disease, obesity and NCDs. Sugar-sweetened beverages
are defined as all types of beverages containing free sugars (include
monosaccharides and disaccharide) including soft drinks, fruit/veg-
etables juices and drinks, liquid and powder concentrates, flavored
water, energy and sports drinks, ready-to-drink tea, ready-to-drink
coffee and flavored milk drinks.
The World Health Organization recommends reducing sugar in-
take to a level that comprises 5% of total energy intake (that is
around 6 teaspoons per day) and not to exceed 10% of total energy
intake [2].
The price elasticity of sugar-sweetened beverages according to a
meta-analysis published in USA, is –1.21. This means that for each
10% increase in the price of sugar-sweetened beverages, there is a
–12.1% decrease in consumption. Successful examples of price elas-
ticity were seen in Mexico as the consumption of sugar-sweetened
beverages decreased after imposing the sugar tax.
Data and experience from across the world demonstrate that a tax
on sugar works best as part of a comprehensive set of interventions
to address obesity and related chronic diseases. Such interventions
include food advertising regulations, food labelling, educational
campaigns, and subsidy on healthy foods.
Recommendations
3. The World Medical Association (WMA) and its constituent
members should:
–
– call upon the national governments to reduce the affordabil-
ity of free sugar and sugar-sweetened beverages through sugar
taxation. The tax revenue collected should be used for health
promotion and public health preventive programs aimed at re-
ducing obesity and NCDs in their countries;
–
– encourage food manufacturers to clearly label sugar, if present,
in their products and urge governments to mandate such label-
ing;
–
– urge governments to strictly regulate the advertising of sugar
containing food and beverages targeted especially at children;
–
– urge national governments to restrict availability of sugar-
sweetened beverages and products that are highly concentrated
with free sugar from educational and healthcare institutions
and replace with healthier alternatives.
4. Constituent members of the WMA and their physician mem-
bers should work with national stakeholders to:
–
– advocate for healthy sustainable food with limited free sugar
intake that is less than 5% of total energy intake;
–
– encourage nutrition education and skills programs toward pre-
paring healthy meals from foods without added sugar;
–
– initiate and/or support campaigns focused on healthy diets to
reduce sugars intake;
–
– advocate for an inter-sectoral, multidisciplinary and compre-
hensive approach to reducing free sugar intake.
References
1. http://www.who.int/fr/news-room/fact-sheets/detail/noncommunicable-diseases
2. WHO Guideline: Sugars Intake for Adults and Children 2015
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WMA Statement on Healthcare
Information for All
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
Preamble
The WHO constitution states that “the extension to all people of
the benefits of medical, psychological and related knowledge is es-
sential to the fullest attainment of health”. Access to relevant, reli-
able, unbiased, up-to-date and evidence-based healthcare informa-
tion is crucial for the public, patients and health personnel for every
aspect of health, including (but not limited to) health education,
informed choice, professional development, safety and efficacy of
health services, and public health policy.
Lack of access to healthcare information is a major contributor
to morbidity and mortality, especially in low- and middle-income
countries, and among vulnerable groups in all countries.
Healthcare information is only useful if it is relevant, appropriate,
timely,updated,understandable and accurate.It covers a broad spec-
trum of issues and refers to diseases, treatments, services, as well as
the promotion and preservation of health.
Health literacy is a key factor in understanding how health services
work and how to use them. Health professionals need access to
adequate training and support to communicate with patients with
low health literacy or with those who have difficulty understanding
healthcare information, for example because of a disability.
Globally, thousands of children and adults die needlessly because
they do not receive basic life-saving interventions. Some interven-
tions may be available locally but are simply not provided due to
indecision, delays, misdiagnosis and incorrect treatment. Failure to
provide basic life-saving interventions more commonly affects those
who are socioeconomically disadvantaged.
In the case of children with acute diarrhea, for example, the wide-
spread misconception among parents that they should withhold
fluids, and among health workers that they should give antibiotics
rather than oral rehydration, contributes to thousands of unneces-
sary deaths every day worldwide.
Governments have a moral obligation to ensure that the public,
patients and health workers have access to the healthcare informa-
tion they need to protect their own health and the health of those
for whom they are responsible. This obligation includes providing
adequate education, in form and content, to identify and use such
information effectively.
The public, patients and healthcare workers need easy, reliable ac-
cess to evidence-based, relevant healthcare information as part of
a learning process throughout the life-course to enhance under-
standing, and to make informed and conscious decisions about
their health, healthcare options and the health care they receive.
These groups need information in the right language, and in a
format and technical level that is understandable to them, with
relevant services signposted as appropriate. This should take into
account the characteristics, customs and beliefs of the popula-
tion to which it is directed, and a feedback process should be
established. The public, patients and families need information
that is appropriate to their specific context and situation, which
may change over time. They need guidance on when and how to
make important health decisions, which are usually best made
when there is time to consider, understand and discuss the issue
at hand.
Meeting the information needs of the public, patients and health-
care providers is a prerequisite for the realisation of quality univer-
sal health coverage and the UN Sustainable Development Goals
(SDGs).” UN SDG Target 3.8 on universal health coverage spe-
cifically aims to deliver ‘quality essential health-care services and
access to safe, effective, quality and affordable essential medicines
and vaccines for all’. Achieving this requires empowerment of the
public and patients, as well as health workers, with the healthcare
information they need to recognize and assume their rights and re-
sponsibilities to access, use and provide appropriate services and to
prevent, diagnose and manage disease.
The development and availability of evidence-based,relevant health-
care information depends on the integrity of the global healthcare
information system. This system comprises researchers, publishers,
systematic reviewers, producers of end-user content (including aca-
demic publishers, health education, journalists and others), infor-
mation professionals, policymakers, frontline health professionals
and patient representatives, among others.
Recommendations
Recognizing this, the World Medical Association and its constitu-
ent members on behalf of their physician members,will support and
commit to the following actions:
1. Promote initiatives to improve access to timely, current, evi-
dence-based healthcare information for health professionals,
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patients and the public to support appropriate decision-making,
lifestyle changes, care-seeking behaviour and improved quality
of care – thereby upholding the right to health.
2. Promote standards of good practice and ethics to be met by in-
formation providers, guaranteeing reliable and quality informa-
tion that is produced with the participation of physicians, other
health professionals, and patient representatives.
3. Support research to identify enablers and barriers to the avail-
ability of healthcare information, including how to improve the
production and dissemination of evidence-based information
for the public, patients and health professionals, and measures
to increase health literacy and the ability to find and interpret
such information.
4. Ensure that health professionals have access to evidence-based
information on diagnosis and treatment of diseases, including
unbiased information on medicines. Particular attention should
be paid to those working in primary care in low- and middle-
income countries.
5. Combat myths and misinformation around healthcare through
validated scientific and clinical evidence, and by urging the me-
dia to report responsibly on health issues.This includes the study
of health-related beliefs stemming from cultural or sociological
differences.This will improve the effectiveness of health promo-
tion activities and allow the dissemination of healthcare infor-
mation to be adequately targeted to different segments of the
population.
6. Urge governments to recognize their moral obligation to take
measures to improve the availability and use of evidence-based
healthcare information.This includes:
–
– resources to select, compile, integrate and channel scientifically
validated information and knowledge. This should be adapted
to target various different recipients;
–
– measures to increase availability of healthcare information for
healthcare workers and patients at health centres;
–
– leveraging modern communication technology and social me-
dia;
–
– policies that support efforts to increase the availability and use
of reliable healthcare information.
7. Urge governments to provide the political and financial sup-
port needed for ‘WHO’s function to ensure access to authori-
tative and strategic information on matters that affect peoples’
health’, based on the WHO General Programme of Work
2019-23.
WMA Statement on Medical Age
Assessment of Unaccompanied
Minor Asylum Seekers
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
Preamble
Population displacement resulting from war, violence or persecu-
tion has wide-ranging implications for the entire global community.
Refugees – that is, individuals who have been forced to flee their
respective countries of origin for these reasons – generally must
undergo rigorous procedures for determining their legal status ac-
cording to the national legislation of the country in which they are
seeking asylum.
An increasing number of refugees fall under the category of unac-
companied minors, which are defined as people under the age of 18
who have been separated from or who have fled their countries of
origin without their families. In light of their unique vulnerability,
unaccompanied minor refugees are eligible for special protections,
as outlined in the United Nations’ Convention on the Rights of the
Child, which states that the best interests of the child must be the
primary consideration in all stages of the displacement cycle.
Given the differences in how adults and unaccompanied minors are
processed and protected when seeking asylum, recipient countries
have an interest in verifying the age of applicants outside the context
of criminal proceedings. However, some asylum seekers either do
not have access to documentation confirming their age or originate
from countries in which there is no central birth registry. In cases
where there is doubt as to whether an asylum seeker is a child or an
adult, e.g. if the authenticity of available documentation is called
into question or if there is reason to believe the applicant’s physical
appearance suggests a discrepancy between the reported age and the
actual age, the competent authorities may resort to medical and/or
non-medical methods for assessing the applicant’s age.
Medical age assessments carried out by medical professionals may
take the form of X-ray scans of the jaw, hand or wrist; CT scans
of the collarbone; MRI scans of the knee; or the examination of
secondary sex characteristics to determine the applicant’s stage of
puberty.However,ethical concerns have been raised about these and
other forms of examination, as they can potentially endanger the
health of those being examined and violate the privacy and dig-
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nity of young people who may already be severely traumatized. [1]
Furthermore, there is conflicting evidence about the accuracy and
reliability of the available methods of medical age assessment,which
may generate significant margins of error. [2] For example, some
available studies do not appear to take into account potential delays
in skeletal maturation caused by malnutrition, which is just one fac-
tor that could translate into a risk of age misclassification among
asylum seekers. [3] Comparative assessments are further impeded
by a lack of standard images from certain world regions and limited
representation in age assessment reference data, much of which was
compiled on the basis of European and North American popula-
tions. [4] An imprecise assessment of an individual’s age can have
far-reaching administrative, ethical, psychological and other signifi-
cant consequences, including potential breaches of children’s rights.
The following recommendations apply explicitly and exclusively to
cases outside the context of the criminal justice system.
Recommendations
1. The WMA recognizes that there is sometimes a need to assess
the age of asylum seekers to ensure that all unaccompanied mi-
nors receive the protections afforded them under international
and national law.
2. The WMA recommends that medical age assessments only be
carried out in exceptional cases and only after all non-medical
methods have been exhausted.The WMA recognizes that non-
medical methods, e.g. questioning children about traumatic
events, may also have a negative impact and must therefore be
carried out with great care. Each case must be evaluated care-
fully based on the totality of circumstances and the preponder-
ance of available evidence.
3. The WMA asserts that,in cases where medical age assessment is
unavoidable, the health and safety and dignity of the young asy-
lum seeker must be the highest priority. Physical examinations
must be carried out by a qualified physician with appropriate
pediatric examination experience in accordance with the highest
medical and ethical standards, in observance of the principles of
proportionality, in adherence to the standards of prior informed
consent and with consideration of cultural and religious sensi-
tivities and potential language barriers. The asylum seeker must
always be made aware that the examination is carried out as part
of the age assessment procedure and not to provide healthcare.
4. The WMA underscores that any medical methods that could
involve a health risk for the applicant, e.g. radiological exami-
nations without medical indication, or that infringe upon the
dignity or privacy of an already potentially traumatized asylum
seeker, e.g. genital examinations, must be avoided.
5. The WMA stresses that medical certificates indicating the re-
sults of medical age assessment examinations should include in-
formation concerning the accuracy and reliability of the meth-
ods used and the relevant margins of error.
6. The WMA urges constituent members to develop or promote
the development of internationally accepted interdisciplinary
guidelines which outline the scientific basis, as well as ethical
and legal or regulatory principles of medical age assessment of
asylum seekers, including the potential health risks and psycho-
logical impact of specific procedures.
7. The WMA emphasizes that, in cases where doubts regarding
the age of an asylum seeker cannot be resolved or confirmed
with absolute certainty, any remaining uncertainty should be in-
terpreted in favor of the asylum seeker.
References:
1. Zentrale Ethikkommission der Bundesärztekammer (2016): Stellungnahme
“Medizinische Altersschätzung bei unbegleiteten jungen Flüchtlingen.
Deutsches Ärzteblatt 2016; A1-A6./German Medical Association’s Central
Ethics Committee: Statement on Medical Age Assessment of Unaccompa-
nied Minor Refugees.
2. Separated Children in Europe Programme (2012): Position Paper on Age
Assessment in the Context of Separated Children in Europe. Online http://
www.separated-children-europe-programme.org/separated_children/good_prac-
tice/index.html. Last accessed 03.07.2018.
3. Sauer PJJ, Nicholson A, Neubauer D, On behalf of the Advocacy and Ethics
Group of the European Academy of Paediatrics (2016): Age determination
in asylum seekers: physicians should not be implicated. European Journal of
Pediatrics 175, (3): 299-303.
4. Aynsley-Green et al. (2012): Medical, statistical, ethical and human rights
considerations in the assessment of age in children and young people subject
to immigration control. British Medical Bulletin 2012; 102: 39.
WMA Statement on Reducing
Dietary Sodium Intake
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October
2008 and amended by the 70th
WMA General Assembly, Tbilisi, Geor-
gia, October 2019
Preamble
Dietary table salt is an ionic compound comprising of sodium chlo-
ride, which is 40% sodium (Na+
) and 60% chloride (Cl–
). There is
overwhelming evidence that excessive sodium intake is a risk factor
for the development, or worsening of hypertension, which is one
of the main cardiovascular risk factors. Hypertension may also be
an independent risk factor for cardiovascular diseases as well as all-
cause mortality. The effect of dietary sodium on blood pressure is
influenced by various demographic factors such as age and ethnicity.
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Salt intake is also a risk factor for gastric cancer [1].
The World Health Organization (WHO) recommends that average
daily sodium consumption in adults (≥16 years of age) should be less
than 2000 mg (5 g salt). For children (2–15 years of age), the adult
intake limit of 2 g/day sodium should be adjusted downward based
on the energy requirements of children relative to those of adults [2].
The majority of the world’s population consumes too much sodi-
um – 3.95 (3.89–4.01) g/day, equivalent to table salt level of 10.06
(9.88–10.21) g/day.These consumption levels are far above the rec-
ommended limit [3].
The main source of sodium is dietary consumption, 90% of it in the
form of salt [4], as added salt during cooking or eating, or in pro-
cessed foods such as canned soups, condiments, commercial meals,
baking soda, processed meats (such as ham, bacon, bologna), cheese,
snacks, and instant noodles, among others. In higher-income coun-
tries sodium added during food processing can be as high as 75%-
80% of total salt intake [5].
The Global Action Plan for the Prevention and Control of Non-
Communicable Disease (NCDs) 2013-2020 is made up of 9 global
targets, including a 30 % relative reduction in mean population in-
take of sodium. The WHO has created the S.H.A.K.E technical
package to assist Member States with the development, implemen-
tation and monitoring of salt reduction strategies.
The WHO recognises that while salt reduction is recommended
globally, there is concern that iodine deficiency disorders (IDD)
may re-emerge as iodized salt is the main vehicle for dietary iodine
intake through fortification.Therefore the WHO, in recognition of
the importance of both sodium reduction and iodine fortification,
urges that efforts of the two programs be coordinated [6].
Substantial overall benefits can result from even small reductions in
the population’s blood pressure. Population-wide efforts to reduce
dietary sodium intake are a cost-effective way to reduce overall hy-
pertension levels and subsequent cardiovascular disease. Evidence
shows that keeping sodium consumption within the reference level
could prevent an estimated premature 2.5 million deaths each year
globally [7].
Recommendations
WMA and its Constituent Members should:
1. Urge governments to recognise that salt consumption is a seri-
ous public health problem and prioritise prevention as an equi-
table, cost effective and lifesaving population-wide approach to
address high sodium intake and the associated high burden of
cardiovascular diseases.
2. Work in cooperation with national and international health
organisations to educate consumers from childhood about the
effects of excessive sodium intake on hypertension and cardio-
vascular disease, the benefits of long-term reductions in sodium
intake, and about the dietary sources of salt/sodium and how
these can be reduced.
3. Urge the governments and other stakeholders work together to
achieve the targets set in the Global Action Plan for the Preven-
tion and Control of NCDs 2013-2020.
4. Recognise the critical role of the food processing and food ser-
vices industry in reducing dietary sodium, and support regu-
latory efforts involving mandatory targets in food processing,
sodium content of foodstuffs, and clear labelling. Food reformu-
lation efforts must target food products that are most commonly
consumed in the population.
Constituent members of WMA should:
1. Encourage their governments strictly to enforce laws regulating
the sodium content in processed foods.
2. Embrace a multi stakeholder approach in working towards re-
ducing the consumption of excessive sodium by the population,
including active promotion of physician awareness regarding the
effects of excessive dietary sodium.
3. Recognise that sodium reduction and salt iodization programmes
need to be compatible and support sodium reduction strategies
that do not compromise dietary iodine content,orincrease or wors-
en iodine deficiency disorders, especially in low income settings.
4. Contribute to making the public aware of the potential conse-
quences of low iodine levels as a result of restricted iodized salt
intake.
5. Encourage their members to contribute to scientific research on
sodium reduction strategies.
6. Encourage the initiation of food labeling, media campaigns and
population-wide policies such as mandatory reformulation to
achieve larger reductions in population-wide salt consumption
than individually focused interventions.
Individual physicians should:
1. Counsel patients about the major sources of sodium in their di-
ets and how to reduce sodium intake, including reducing the
amount of salt used in cooking at home, use of salt substitutes,
and addressing any relevant local practices and beliefs that con-
tribute to high sodium intake.
References:
1. World Cancer Research Fund/American Institute for Cancer Research.
Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global
Perspective. Washington DC: AICR, 2007
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General Assembly Report
2. Guideline: Sodium intake for adults and children. Geneva, World Health
Organization (WHO), 2012.
3. Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata,
Khatibzadeh, Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz,
Ezzati, Majid and Powles, John (2014) Global sodium consumption and
death from cardiovascular causes. New England Journal of Medicine, 371 7:
624-634. doi:10.1056/NEJMoa1304127
4. J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent
hypertension and cardiovascular disease. Rev. Panam. Salud Publica, 32 (4)
(2012), pp. 293-300
5. World Health Organization Regional Office for Europe Mapping salt re-
duction initiatives in the WHO European Region (Web. 10 May 2014.)
http://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping-
salt-reduction-initiatives-in-the-WHO-European-Region.pdf (2013)
6. Salt reduction and iodine fortification strategies in public health. 2014.
http://www.who.int/nutrition/publications/publichealth_saltreduc_iodine_
fortification/en/
7. McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V,
Webster J, Campbell NRC.Population-level interventions in government
jurisdictions for dietary sodium reduction. Cochrane Database of System-
atic Reviews 2016, Issue 9. Art. No.: CD010166.DOI: 10.1002/14651858.
CD010166.pub2.
WMA Statement on Solitary
Confinement
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014 and amended by the 70th
WMA General Assembly,Tbilisi,
Georgia, October 2019
Preamble
1. In many countries, a substantial number of prisoners are held in
solitary confinement. Solitary confinement is a form of confine-
ment used in detention settings where individuals are separated
from the general detained population and held alone in a sepa-
rate cell or room for upwards of 22 hours a day. Jurisdictions
may use a range of different terms to refer to the process (such
as segregation, separation, isolation or removal from associa-
tion) and the conditions and environment can vary from place
to place. However, it may be defined or implemented, solitary
confinement is characterised by complete social isolation; a lack
of meaningful contact; and reduced activity and environmental
stimuli. Some countries have strict provisions on how long and
how often prisoners can be kept in solitary confinement, but
many countries lack clear rules on this.
2. Solitary confinement can be distinguished from other brief inter-
ventions when individuals must be separated as an immediate re-
sponse to violent or disruptive behaviour or where a person must
be isolated to protect themselves or others. These interventions
should take place in a non-solitary confinement environment.
3. The reasons for the use of solitary confinement vary in different
jurisdictions and it can be used at various stages of the criminal
justice process. It may be used as a disciplinary measure for the
maintenance of order or security; as an administrative measure,for
the purposes of investigation or questioning; as a preventive mea-
sure against future harm (either to the individual or to others); or it
may be the consequence of a restrictive regime that limits contact
with others. It can be imposed for hours to days or even years.
Medical impacts of solitary confinement
4. People react to isolation in different ways.For a significant num-
ber of prisoners, solitary confinement has been documented to
cause serious psychological, psychiatric, and sometimes physi-
ological effects. These include insomnia, confusion, hallucina-
tions, psychosis, and aggravation of pre-existing health prob-
lems. Solitary confinement is also associated with a high rate of
suicidal behaviour. Negative health effects can occur after only
a few days and may in some cases persist when isolation ends.
5. Certain populations are particularly vulnerable to the negative
health effects of solitary confinement. Persons with psychotic
disorders, major depression, or post-traumatic stress disorder
or people with severe personality disorders may find isolation
unbearable and suffer considerable health harms. Solitary con-
finement may complicate treating such individuals and their
associated health problems successfully later in the prison en-
vironment or when they are released back into the community.
Prisoners with physical disabilities or other medical conditions
often have their conditions aggravated,not only as a result of the
physical conditions of isolation, but also as the particular health
requirements linked to their disability or condition are often not
accommodated.
6. For children and young people, who are in the crucial stages of
developing socially, psychologically, and neurologically, there are
serious risks of solitary confinement causing long-term mental
and physical harm.A growing international consensus about the
harms of solitary confinement on children and young people has
resulted in some jurisdictions abolishing the practice completely.
International norms on solitary confinement
7. The increasing documentation on the harmful impact of solitary
confinement on the health of prisoners led to the development of
a range of international norms and recommendations seeking to
mitigate the use and the harmful effect of solitary confinement.
8. The United Nations Standard Minimum Rules for the Treat-
ment of Prisoners (SMR) were first adopted in 1957, and re-
vised in 2015 as the Nelson Mandela Rules unanimously adopted
by the United Nations Assembly. The SMR constitute the key
international framework for the treatment of prisoners.
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9. Other international standards and recommendations, such as
the United Nations Rules for theTreatment of Women Prisoners and
Non-Custodial Sanctions for Women Offenders (the Bangkok Rules),
the United Nations Rules for the Protection of Juveniles Deprived
of their Liberty and the observations of the Special Rapporteur
on Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment, support and complete the Nelson Mandela Rules.
10. The misuse of solitary confinement can include indefinite or pro-
longed solitary confinement (defined as a period of solitary con-
finement in excess of 15 days), but can also include corporal or
collective punishment, the reduction of a prisoner’s diet or drink-
ing water,or the placement of a prisoner in a dark or constantly lit
cell. Misuse of solitary confinement in these ways can constitute
a form of torture or ill-treatment and as such must be prohibited
in line with international human rights law and medical ethics.
11. The WMA and its members reiterate their firm and long-stand-
ing position condemning any forms of torture and other cruel,
inhuman or degrading treatment or punishment and reaffirm
the basic principle that doctors should never participate in or
condone torture or other cruel,inhuman or degrading treatment.
Recommendations
12. Given the harmful impact of solitary confinement,which can on
occasion result in a form of torture or ill-treatment, the WMA
and its members call for the implementation of the Nelson
Mandela Rules and other associated international standards and
recommendations, with a view to protect the human rights and
the dignity of the prisoners.
13. The WMA and its members emphasize in particular the respect
of the following principles:
14. In light of the serious consequences solitary confinement can
have on physical and mental health (including an increased risk
of suicide or self-harm), it should be imposed only in exception-
al cases as a last resort and subject to independent review, and
for the shortest period of time possible.The authority imposing
the solitary confinement must be acting in line with clear rules
and regulations as to its use.
15. All decisions on solitary confinement must be transparent and
regulated by law. The use of solitary confinement should be
time-limited by law. The detainee should be informed of the
duration of the isolation, and the period of duration should be
determined before the measure takes place. Prisoners subject to
solitary confinement should have a right of appeal.
16. Solitary confinement should not exceed a time period of 15 con-
secutive days. Releasing the prisoner from solitary confinement
for a very limited period of time, with the intention that the
individual will be placed in solitary confinement immediately
again to get around the rules on length of stay must also be
prohibited.
Prohibitions of the use of solitary confinement
17. The indefinite or prolonged solitary confinement should be pro-
hibited as amounting to torture or other cruel, inhuman or de-
grading treatment or punishment [1].
18. Solitary confinement should be prohibited for children and
young people (as defined by domestic law), pregnant women,
women up to six months post-partum, women with infants
and breastfeeding mothers as well as for prisoners with mental
health problems given that isolation often results in severe exac-
erbation of pre-existing mental health conditions.
19. The use of solitary confinement should be prohibited in the case
of prisoners with physical disabilities or other medical conditions
where their conditions would be exacerbated by such measures.
20. Where children and young people must be separated, in order
to ensure their safety or the safety of others, this should be car-
ried out in a non-solitary confinement setting with adequate re-
sources to meet their needs, including ensuring regular human
contact and purposeful activity.
Conditions of solitary confinement
21. The human dignity of prisoners confined in isolation must al-
ways be respected.
22. Prisoners in isolation should be allowed a reasonable amount of
meaningful regular human contact, activity, and environmental
stimuli, including daily outside exercise. As with all prisoners,
they must not be subjected to extreme physically and/or men-
tally taxing conditions.
23. Prisoners who have been in solitary confinement should have an
adjustment period,including a medical examination,before they
are released from prison.This must never extend their period of
incarceration.
Role of physician
24. The physician’s role is to protect, advocate for, and improve pris-
oners’ physical and mental health, not to inflict punishment.
Therefore, physicians should never participate in any part of the
decision-making process resulting in solitary confinement,which
includes declaring an individual as “fit”to withstand solitary con-
finement or participating in any way in its administration. This
does not prevent physicians from carrying out regular visits to
those in solitary confinement to assess health and provide care
and treatment where necessary, or from raising concerns where
they identify a deterioration in an individual’s health.
25. The provision of medical care should take place upon medical
need or the request of the prisoner. Physicians should be guar-
anteed daily access to prisoners in solitary confinement, upon
their own initiative. More frequent access should be granted if
physicians deem this to be necessary.
26. Physicians working in prisons must be able to practice with
complete clinical independence from the prison administration.
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In order to maintain that independence, physicians working in
prisons should be employed and managed by a body separate
from the prison or criminal justice system.
27. Physicians should only provide drugs or treatment that are
medically necessary and should never prescribe drugs or treat-
ment with the intention of enabling a longer period of solitary
confinement.
28. Healthcare should always be provided in a setting that respects
the privacy and dignity of prisoners. Physicians working in the
prison setting are bound by the sample codes and principles of
medical ethics as they would be in any other setting.
29. Physicians should report any concerns about the impact soli-
tary confinement is having on the health and wellbeing of an
individual prisoner to those responsible for reviewing solitary
confinement decisions. If necessary, they should make a clear
recommendation that the person be removed from solitary con-
finement, and this recommendation should be respected and
acted upon by the prison authorities.
30. Physicians have a duty to consider the conditions in solitary
confinement and to raise concerns with the authorities if they
believe that they are unacceptable or might amount to inhumane
or degrading treatment. There should be clear mechanisms in
place in each system to allow physicians to report such concerns.
Reference.
1. Rule 43 SMR
WMA Resolution on Legislation
Against Abortion in Nicaragua
Adopted by the 60th
WMA General Assembly, New Delhi, India, October
2009, and amended by the 70th
WMA General Assembly, Tbilisi, Geor-
gia, October 2019
Whereas
In 2006, Nicaragua adopted a penal code that criminalises abortion
in all circumstances, including any medical treatment of a pregnant
woman which results in the death of or injury to an embryo or fetus.
According to the UN Population Fund (UNFPA), despite improve-
ment of national sexual and reproductive health indicators, Nica-
ragua continues to have one of the highest teenage pregnancy and
maternal mortality rates in the Americas region, in particular in
lower income rural population groups.
This legislation:
• Has a negative impact on the health of women in Nicaragua re-
sulting in preventable deaths of women and the embryo or fetus
they are carrying.
• Places physicians at risk of imprisonment if they carry out abor-
tions, even to save a pregnant woman’s life, unless they follow the
Nicaraguan Ministry of Health’s (MINSA) 2006 Obstetric Pro-
tocols designed for high emergency care alone.
• Requires physicians to report to police, women and girls for sus-
pected abortions, in breach of their duty of confidentiality to-
wards patients and placing them in a conflict between the law
and medical ethics.
The WMA Statement on Medically-IndicatedTermination of Pregnancy­
(October 2018) provides that: “National laws, norms, standards, and
clinical practice related to termination of pregnancy should promote and
protect women’s health, dignity and their human rights, voluntary in-
formed consent, and autonomy in decision-making, confidentiality and
privacy. National medical associations should advocate that national
health policy upholds these principles.”
The WMA reiterates its Resolution on Criminalisation of Medical
Practice (October 2013) recommending that its members “oppose
government intrusions into the practice of medicine and in healthcare
decision making, including the government’s ability to define appropriate
medical practice through imposition of criminal penalties.”
THEREFORE,the World Medical Association and its constituent
members urge the Nicaraguan government to repeal its penal code
criminalizing abortion and develop in its place a legislation that
promotes and protects women’s human rights, dignity and health,
including adequate access to reproductive healthcare, and that al-
lows physicians to perform their duties in line with medical ethics
and particularly medical confidentiality.
WMA Resolution on Climate
Emergency
Adopted by the 70th
WMA General Assembly,Tbilisi,Georgia,October 2019
Health professionals have an important role in advocating to protect
the health of citizens around the world,and therefore have a respon-
sibility to demand greater action on climate change.
The UN summit on climate action that took place in September
2019 further demonstrated the growing recognition that climate
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change action must be accelerated, with many countries making
commitments to achieving net zero emissions by 2050 and others
committing to boost national action plans by 2020.
There is emerging consensus within the medical profession globally
that action on climate change must be accelerated.
The WMA and its constituent members and the international
health community:
• declare a climate emergency and call the international health
community to join their mobilisation;
• commit to advocate to protect the health of citizens across the
globe in relation to climate change;
• urge national government to rapidly work to deliver carbon neu-
trality by 2030, so as to minimise the life-threatening impacts of
climate change on health;
• must acknowledge the environmental footprint of the global
healthcare sector,and act to reduce waste and prevent pollution to
ensure healthcare sustainability.
WMA Resolution on the
Revocation of Who Guidelines
on Opioid Use
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October
2019
The World Medical Association expresses concern about the abrupt
discontinuation of WHO 2011 guidance “Ensuring balance in na-
tional policies on controlled substances: Guidance for availability and ac-
cessibility of controlled medicines”, as well as its 2012 “WHO guidelines
on the pharmacological treatment of persisting pain in children with
medical illnesses”.
This revocation, which took place last Summer without consulting
the medical community, will deprive many physicians of support
and regulation in countries without related national legislation, thus
endangering their medically justified use of such substances. Ulti-
mately, suffering patients will not have access to proper medication.
The WMA notes that the withdrawal was decided unilaterally,with-
out providing any supporting evidence and without including any
replacement or substitution. Moreover, the discontinued guidelines
were fully removed from WHO online publications portal, thus im-
peding the ability of physicians to justify and validate retrospectively
the use of controlled substances,exposing them potentially to crimi-
nal prosecution.
Without further information, the WMA considers it necessary to
reinstate the mentioned guidelines until they are replaced by new or
amended ones.
The WMA demands the adherence to the principle of evidence-
based development of treatment guidelines. This should apply to
the definition, amendment and discontinuation of such guidance in
addition to the application of a precautionary principle. Evidence
supporting the revocation of the opioid-guidelines must be pub-
lished and made available for scientific scrutiny.
The WMA welcomes the efforts to assemble a new team of experts
and strongly recommends an open and transparent process, includ-
ing a reliable mechanism to ensure the disqualification of experts
with conflicts of interest.
WMA Statement on Violence
and Health
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, Sptem-
ber 2003 and reaffirmed by the 59th
WMA General Assembly, Seoul,
Korea, October 2008 and revised by the 70th WMA General Assembly,
Tbilisi, Georgia, October 2019
Preamble
Violence is defined as “the intentional use of physical force or pow-
er, threatened or actual, against oneself, or against a group or com-
munity that either results in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment or deprivation.’’
Violence is multi-dimensional, has multiple driving factors, and can
be physical,sexual,psychological or exerted through acts of depriva-
tion or neglect.
The World Medical Association (WMA) has developed policies
condemning different forms of violence.These include statements on
Violence Against Women and Girls, Family Violence, Child Abuse
and Neglect, Abuse of the Elderly, Adolescent Suicide, Violence in
the Health Sector by Patients and those close to them,Protection of
Health Care Workers in Situation of Violence, WMA Declaration
on Alcohol and the WMA Statement on Armed-Conflicts.
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43
General Assembly Report
Violence is a manifestation of the health, socio-economic, policy,
legal, and political conditions of a country. It occurs in all social
classes and is strongly associated with leadership failure and poor
governance, and social determinants such as unemployment, pov-
erty, health and gender inequality, and poor access to educational
opportunities.
Despite regional and country-wide disparities in the scale and bur-
den of violence, along with the under reporting of data, it is evident
that violence results in fatal and non-fatal consequences. These in-
clude the devastation of individual, family, and community life, as
well as disruption of the social,economic,and political development
of nations.
Violence impacts the economy because of increased health and ad-
ministrative expenditures by the criminal justice, law enforcement,
and social welfare systems. It also has negative impact on a nation’s
productivity because of a loss in human capital and the productivity
of the workforce.
Impact on Health
The effects of violence on health vary and can be life-long. Health
consequences include physical disability, depression, post-traumatic
stress disorder and other mental health challenges, unwanted preg-
nancies, miscarriages, and sexually transmitted infections.
Behavioral risk factors such as substance use, which can give rise to
violent behaviour, are also risk factors for cancer, cardiovascular and
cerebrovascular diseases.
Direct victims of violence are prone to traumatizing experienc-
es such as physical, sexual and psychological abuse, and may be
unwilling or unable to disclose or report their experiences to ap-
propriate authorities due to shame, cultural taboo, fear of societal
stigma or reprisal, and the justice system’s undue delay in dispens-
ing justice.
In institutions such as healthcare facilities, violence is often in-
terpersonal in nature, and may be perpetrated against patients by
healthcare workers, or against health care workers by patients and
their caregivers, or among healthcare personnel in the form of bul-
lying, intimidation, and harassment.
Additionally, healthcare professionals and healthcare facilities are
increasingly subjected to violent attacks. Such violence and targeted
attacks on healthcare facilities, healthcare personnel, and the sick
and wounded are in direct breach of medical ethics, international
humanitarian and human rights laws.
Though many countries are increasingly accepting the need to insti-
tute violence prevention programs in their respective jurisdictions,
the field of violence prevention and management still faces many
challenges. Challenges include inadequate or non-existent report-
ing of data, inadequate investment in violence prevention programs
and support services for victims of violence, and failure to enforce
existing laws against violence, including measures to restrict access
to alcohol.
Recognizing that violence remains a significant public health chal-
lenge which is multi-dimensional and preventable in nature, and af-
firming the pre-eminent role of physicians as role models,and in the
care and support of victims of violence, the WMA commits itself to
act against this global scourge.
Recommendations
WMA encourages its constituent members to:
1. Educate and advise political and public office holders at all levels
of government with appropriate and adequate knowledge and
scientific evidence on the benefits of investing more resources in
violence prevention.
2. Advocate for and support good governance based on the rule of
law, transparency, and accountability.
3. Conduct and support effective media campaigns to inform and
raise the public’s awareness on the burden and consequences of
violence and the need to prevent it.
4. Raise public awareness of international laws, norms, and ethical
codes that mandate the protection of healthcare workers and
facilities in times of peace and conflict.
5. Advocate for and promote the inclusion of courses on violence
and its prevention in academic curricula,including those for un-
dergraduate and postgraduate medical training and Continuing
Medical Education (CME).
6. Consider organizing capacity building and CME programs for
physicians on violence prevention, caring for victims of violence,
emergency preparedness and response, and early recognition of
signs of interpersonal and sexual violence.
The WMA urges governments to:
1. Work towards achieving a zero-tolerance for violence, through
prevention programs, establishment of violence prevention and
victim support clinics, establishment of safe domestic violence
shelters,increased public and private investment in public safety,
security, and strengthening of health and educational institu-
tions.
2. Encourage collaborative action on violence prevention, with in-
tegrated violence prevention and victim support in health care
institutions.
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44
Climate Changes
3. Promote social justice and equity by eliminating inequities and
inequalities that may create the conditions for violence.
4. Focus on addressing social determinants of health through
the creation and improvement of socio-economic, educational
and health infrastructure and opportunities, and elimination
of adverse and oppressive cultural attitudes and practices and
all forms of inequality or discrimination on the basis of gender,
creed, ethnic origin, nationality, political affiliation, race, sexual
orientation, social standing, disease or disability.
5. Secure the enactment and enforcement of policies and laws on
violence prevention, protection and support of victims of vio-
lence, and punishment of offenders.
6. Strengthen institutions concerned with public safety and security.
7. Develop policies and enforce legislations that regulate access to
alcohol.
8. Develop and implement effective legal frameworks that protect
individuals and entities that deliver healthcare. Such frame-
works should guarantee the protection of physicians and other
healthcare professionals, as well as the free and safe access of
healthcare personnel and patients to health care facilities.
9. Support comprehensive research studies on the nature and
character of the various forms of violence, including the effec-
tiveness of response strategies, to assist them in the preparation
and implementation of policies, laws and strategies on violence
prevention, protection and support of victims, and punishment
of perpetrators.
10.
Initiate and foster multi-stakeholder involvement and col-
laboration among relevant bodies and organizations at global,
national, state and local levels, in the development, implemen-
tation and promotion of violence prevention and management
strategies, including engagement of traditional, religious, and
political leaders.
11.
Develop robust multi-sectoral partnerships at local, state and
national levels with violence prevention made a priority concern
in all government ministries,including health,education,labour,
and defense ministries.
12.
Institute a Safe Care Initiative that guarantees the safety and
security of physicians and other healthcare workers, patients,
healthcare facilities, and the uninterrupted delivery of health-
care services in times of peace and conflict.
13. The initiative should include the following components:
–
– Routine violence risk audit.
–
– Efficient and effective violence surveillance and reporting
mechanisms.
–
– Transparent and timely investigation of all reported cases of
violence.
–
– A system for protecting patients and healthcare personnel who
report cases of violence.
–
– Legal support for physicians and other healthcare workers sub-
jected to violence in the workplace.
–
– Establishment of security posts in healthcare facilities as
deemed necessary.
–
– Financial coverage for injured medical personnel and other
healthcare workers.
–
– Compensated time off for injured medical personnel and other
healthcare workers.
The United Nations Climate Action Sum-
mit was held in New York at UN Headquar-
ters on 21–22 September 2019. This week-
end prefaced the high-level meetings by
heads of state and government officials from
around the world that started on 23 Sep-
tember. Representatives from governmental
and non-governmental organizations from
around the world attended. World Medical
Association was represented at the Climate
Action Summit by Dr.Mike Kalmus-Eliasz
from the Junior Doctors Network and Dr.
Yoshitake Yokokura, past president of the
WMA. Additionally, a few other WMA
members were present representing other
organizations at the coalition meetings pre-
ceding the summit. I was present as a rep-
resentative of Physicians for Social Respon-
sibility (PSR), the United States chapter of
International Physicians for the Prevention
of Nuclear War (IPPNW). PSR has two
primary national aims – the prevention of
nuclear war and climate change.
One of the tracks was on air pollution, en-
titled, “Climate Action for Health: Cut
Emissions, Clean our Air, and Save Lives”
moderated by Lucia Ruiz Ostoic, the Min-
ister of Environment for Peru. There was
also a special appearance, speech, and plea
by Dr. Tedros Ghebreyesus, Director-Gen-
eral of the World Health Organization. Ankush K. Bansal
United Nations Climate Action Summit
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45
Climate Changes
An informative and sobering presentation,a
call to action, was given by Dr. Arvind Ku-
mar, a leading pulmonologist in New Delhi,
India. New Delhi has one of the highest
levels of air pollution globally, a fact that
I can personally attest to, with PM2.5 levels
consistently many times over the maximum
safe limit. In 2018, the average PM2.5 lev-
el was 14.3 times over the safe limit. This
was equivalent to smoking 6.5 cigarettes
per day. In fact, a teenager living his/her
whole life in the Delhi Metropolitan Area
(DMA) had the level of pollution and par-
ticulate matter in his/her lungs as a lifelong
smoker, even if this teenager never smoked
a single cigarette. Furthermore, from 1988
to 2018, the rate of lung cancer among
non-smokers in the DMA rose from 10%
to 50%, with the average age of diagnosis
dropping from 50–60 to 30–40, even fac-
toring in earlier diagnosis during this same
time period, and increase in diagnosis in
women rising from almost non-existent to
40%. The sobering statistic for populations
is that based on previous studies, breath-
ing polluted air was equivalent to smoking
at a rate of 22 mcg/m3
of pollutants, equal
to 1 cigarette. This included newborns and
children which has been found to result in
neuroinflammation and reduced cognitive
development. In adults, it increases the risk
of stroke by at least 5 times.Additionally,air
pollution results in infertility, miscarriage,
preterm and low-birth-weight infants, and
congenital abnormalities. Up to 7 million
premature deaths per year worldwide have
been attributed to air pollution according to
the WHO. This is the reason that reducing
air pollution and mitigating its effects is so
critical and emergent.
Leaders from government and non-govern-
mental organizations then provided exam-
ples of solutions, trials, and collaborations
to tackle this. While the DMA may be one
of the most extreme examples in the world,
air pollution affects all of us. The mayors of
Accra and Seville; the Ministers of Health,
Environment/Climate, or Energy from the
United Arab Emirates, Finland, and Nor-
way; the European Union Commissioner
for Environment; and the Directors of
Healthcare Without Harm and the Clean
Air Fund made presentations on work be-
ing done. Cities in Spain and in South
America are working together to reduce
air pollution by redesigning cities through
decentralization of services, increasing bi-
cycle and pedestrian lanes with improve-
ment in access to social, occupational, and
retail services through decentralization.
Furthermore, some cities are utilizing pol-
lution sensors with less expensive versions
being developed so that the population can
be notified accordingly. While these mea-
sures will result in some improvement in lo-
cal pollution levels and future city planning/
development, the causes of air pollution on
a larger scale need to be addressed fully and
urgently. Here, the national ministers pro-
vided examples of how their governments
are committed to solutions. However, no
specific examples beyond voluntary interna-
tional agreements were provided. Partially
because of this, the Clean Air Fund was
created and was formally introduced to the
world in the subsequent days at the United
Nations to bring awareness and encourage
pressure on governments to act.
It is of note that recent research has shown
that air pollution, particularly among the
wealthiest nations, is increasing, contrary to
what scientific consensus strongly recom-
mends occur as soon as possible. For ex-
ample, in the United States, in 2018, there
were an additional 10,000 deaths attributed
to air pollution, specifically PM2.5 pollu-
tion, compared to 2 years prior. This was
after a decline to almost half from 2000 lev-
els. Even if the increase in wildfires in the
western United States during the preceding
3 years were considered, the rise in air pol-
lution would continue.
Therefore, as physicians of the world who
encounter the effects of climate change
regularly, including air pollution, it is our
responsibility to advocate for our patients’
health to our respective governments.
Decentralization, pedestrian and bicycle-
friendly cities, and pollution sensors are
a start but even as the mayors and minis-
ters present at the Summit stated, it is not
enough or comprehensive.
The Environmental Caucus at the World
Medical Association meets during the
council sessions and is open to all WMA
members. The Caucus discusses measures
being taken in participant’s respective coun-
tries, news from recent international meet-
ings, upcoming meeting announcements,
and drafts documents for the Council to
consider regarding the environment and
climate change.
Ankush K. Bansal, MD, FACP,
FACPM, SFHM
Associate Member and Representative to the
General Assembly – World Medical Association
Board Member – Florida Chapter,
Physicians for Social Responsibility
Co-Chair and Co-Founder – Florida
Clinicians for Climate Action
Co-Chair and Co-Founder – Palm Beach
Chapter, Climate Reality Project
United States of Americav
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46
Climate Changes
In 1958,a team of researchers installed their
equipment on the top of the Mauna Loa,
one of the five volcanoes on the island of
Hawaii.Led by Charles David Keeling,they
started monitoring the level of atmospheric
CO₂ concentration. Since then, the verdict
is unequivocal: the CO₂ concentration in
the atmosphere is consistently increasing
from year to year. This is now known as the
Keeling curve.
At that time, only a handful of individuals
were starting to worry about climate change.
However, greenhouse gases (GHGs) have
increased in such a way that effects of cli-
mate change have already started being
felt by people around the globe, increasing
as consistently as the Keeling curve. What
was once a scientific matter is now a public
health matter.
Climate change has been called the great-
est threat to global health in the 21st cen-
tury [1]. We could lose decades of global
health advancement [2] and face about 250
000 additional deaths each year between
2030 and 2050 [3]. This article aims to
explain key impacts of climate change on
health and what physicians can do about
it, specifically focusing on the global pro-
test movements that have started occurring
globally.
Health Impacts of
Climate Change
Heat waves
“July has re-written climate history, with
dozens of new temperature records at local,
national and global level,” recently com-
mented Petteri Taalas, Secretary-General
of the World Meteorological Organization
[4]. Indeed, many cities in Europe saw their
thermometers reach temperatures as high as
45 ºC in July.
Each decade since the 1980s has been hot-
ter than the previous [5]. We expect that
hot days and nights will be warmer and
more frequent and that periods of intense
heat will occur more frequently and will be
longer in parts of Europe, Asia, the Ameri-
cas and Australia [6]. This will affect the
health of our communities, particularly the
most vulnerable (older populations, people
living with chronic diseases, such as cardio-
vascular,respiratory or renal diseases,people
dealing with psychiatric issues and people
living in urban areas, particularly those in
neighborhoods with lower socioeconomic
status). According to the 2018 report of The
Lancet countdown on health and climate
change, there were 18 million more heat
wave exposure affecting vulnerable people
in 2017 than in 2016, and over 157 mil-
lion more than the 2000s baseline [7]. The
healthcare system and its workers must be
ready to address the challenges related to
this important exposure.
Air pollution
Climate change and air pollution are closely
related, both driven by fossil fuel burning,
and because of the impact of the former
on the latter. Indeed, climate change could
worsen air quality with increased levels of
tropospheric ozone, a lengthened pollen
season and an increased number of forest
wildfires [8].
For example, in urban areas, tropospheric
ozone can increase in response to high tem-
peratures. It is hence predicted that there
would be more ozone-related mortality
with a global warming of 2 ºC than with
warming of 1.5 ºC [9].
Currently, over 90% of the urban popula-
tion of the world breathes air containing
levels of outdoor air pollutants that exceed
WHO’s guidelines [10].This can contribute
to strokes, ischaemic heart disease, chronic
obstructive pulmonary disease and lung
cancer. Estimates say that 7 million people
die each year from outdoor and indoor air
pollution; one in eight deaths annually [11].
Reducing fossil fuel burning would have
an impact on both climate change and air
pollution-related diseases.
Anne-Sara Briand Alice McGushin Claudel Pétrin-Desrosiers Amro Aglan
The Role of Physicians in Fighting Climate Change
Yassen Tcholakov
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47
Climate Changes
Extreme weather events
In November last year, the state of Cali-
fornia had to deal with the Camp Fire,
the largest and the deadliest wildfire in its
history as 153,336 acres were progressively
burned [12]. 85 people died, many were in-
jured, and the smoke from the fire caused
widespread air pollution. A few weeks later,
a United States report underlined that cli-
mate change would increase the quantity of
wildfires and their size in the country [13].
Globally, from 1979 to 2013, fire seasons
have lengthened in time by almost 19% and
across 25.3% of the vegetated surface of the
Earth [14]. Forest fires are expected to con-
tinue to increase in many parts of the world
because of climate change [15].
This increase is also observed in other ex-
treme weather events (EWE): droughts,
heavy rains, violent tropical cyclones and
floods [16]. While EWE cause direct im-
pacts such as trauma and increases in diar-
rheal diseases, many people also experience
stress and serious mental health consequenc-
es. For example, among a population sample
affected by Hurricane Katrina, suicide and
suicidal ideation more than doubled, one
in six people met the diagnostic criteria for
post-traumatic stress disorder (PTSD), and
49% of people living in an affected area de-
veloped an anxiety or mood disorder such as
depression [17]. With a changing climate,
we will have to face the added stress from
increased EWE on the healthcare system.
Infectious diseases
The National Institute of Public Health of
Quebec in Canada is currently working on
a public education campaign on Lyme’s dis-
ease. This disease, transmitted by a tick, has
been in Quebec for only a few years, but it
is now constantly gaining ground with the
climate becoming more favorable [18].This
is the case for many vector-borne diseases
around the world that will cover new areas
as the climate change. Aedes aegypti and Ae-
des albopictus are two kinds of mosquitoes
that can transmit viruses like dengue,yellow
fever, chikungunya and zika. It is expected
that the geographical distribution of these
mosquitoes will grow with climate change,
but also that their ability to act as a vector
and transmit diseases will increase [19].
The case of malaria is particularly worrisome.
The WHO predicts that climate change
could result in 60,000 additional malaria
deaths by 2030, even with improvements in
our control methods [20]. During the next
century, the geographical reach of malaria
and the period of transmission could both
increase, exposing ever-growing numbers of
people to this deadly disease [21].
It is also predicted that climate change will
increase morbidity and mortality from vari-
ous diarrheal illnesses such as vibrio cholera
cases which have been linked to high tem-
peratures and heavy rainfalls [22, 23].
These changes in the pattern of infectious
diseases related to climate change will need
to be dealt with globally and are in certain
cases linked to global health security.
Food security
A recent analysis from the World Resources
Institute, identified that nearly a quarter of
the world’s population, in just 17 countries,
are in severe water shortage [24]. At this
moment, drinking water levels are decreas-
ing; food yields from ocean are waning; and
crops yields are declining as they are im-
pacted by rising temperatures and extreme
weather events. Climate stress represents
62.5% of all stressors accelerating soil deg-
radation in Africa [25]. All aspects of food
security could be affected by climate change
according to the IPCC [26].The progress of
recent decades in the fight to end hunger in
developing countries and the access to food
globally are at stake.
Climate change could push 3 to 16 mil-
lion people into extreme poverty [27] and it
could force people to flee their homes in or-
der to survive. The Red Cross believes that
environmental crises are already generat-
ing more refugee flows than armed conflict
[28]. In 2010, more than 42 million people
worldwide were displaced due to sudden
natural disasters, and it is that 90% of those
were due to climate change [29].
The Role of Physicians
Climate change is already affecting the
health of people around the world and its
impacts are expected to grow. Even if all
emissions of greenhouse gas (GHG) were
reduced to zero tomorrow,we would still feel
the impact, due to the effects of the cumu-
lative GHG emissions [30]. As physicians
caring for the health of our communities, we
have a role to play in fighting climate change.
The Canadian Association of Physicians for
the Environment dedicated an entire chapter
of its Climate Change Toolkit for Health Pro-
fessionals as to what we can do [31].
Physicians hold a privileged position in so-
ciety as trusted health authorities. We can
be powerful messengers, informing our pa-
tients and the public about the health im-
pacts of climate change and give ideas for
action. We also have a responsibility to en-
sure that the health co-benefits of environ-
mental policies are well understood by the
public and by policymakers.
Engaged doctors can, for example, carry
messages on a wide range of health benefits
that result from “healthy transport”measures
such as active transport (walking and cy-
cling) and better urban planning based upon
low-emissions public transport systems.
Physical activity from walking and cycling
can help prevent heart disease, type 2 diabe-
tes,and some obesity-related risks.Increased
use of non-vehicular transport also leads to
lower rates of traffic injuries and less noise
pollution. Active transport systems along
with better urban land use can help improve
healthcare access for vulnerable groups, en-
hancing health equity [32].
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48
Climate Changes
We can also help our hospitals and clinics
to adapt to climate change, making sure we
are prepared, and contribute to making the
healthcare system greener. Indeed, GHG
emissions from the health sector are grow-
ing and currently represent 5 to 8% of the
total emissions in high-income countries
[33]. Many solutions exist, and physicians
can help implement them. According to a
new report published by Healthcare With-
out Harm, if the global healthcare system
was a country, it would be the fifth largest
emitter on the planet [32]. Physicians are
well placed to initiate changes in their insti-
tution and to reduce greenhouse gas emis-
sions from the healthcare sector.
This is also true at an international level. The
involvement of the health community dur-
ing the previous UN Framework Convention
on Climate Change Conferences of Par-
ties (COPs) have led to the insertion of “the
right to health”in the Paris Agreement.It was
specified that “parties should,when taking ac-
tion to address climate change, respect, pro-
mote and consider their respective obligations
on the right to health”[34]. At the COP24, a
call to action on climate and health was issued
by organizations representing over 5 million
doctors, nurses and health professionals in
over 120 countries [35]. By pushing govern-
ments to meet the targets of the Paris Agree-
ment, we could save over one million lives a
year from air pollution alone by 2050 [36].
Climate Health Education
Climate change has various and serious
implications for human health and as such
are of fundamental relevance to future and
current doctors [37]. Since July 2017, the
accreditation process of the Association of
Faculties of Medicine of Canada (AFMC)
requires all medical schools to have a social
accountability mandate. Social accountabil-
ity has been defined by the World Health
Organization as “the obligation to direct
their education, research and service activi-
ties towards addressing the priority health
concerns of the community, region, and/or
nation they have a mandate to serve” [38].
Additionally,ASPIRE,an international pro-
gram that recognises excellence in medical
education, has now outlined specific criteria
on environmental accountability, including
the obligation for medical schools to ensure
they actively develop, promote, and protect
environmentally sustainable solutions to ad-
dress the health concerns of the community,
region, and the nation they serve [39].
However, there is a worrisome gap in educa-
tion of medical students and health profes-
sionals on this topic, leaving healthcare pro-
fessionals with insufficient knowledge and
skills to address climate change.As an exam-
ple,presently,there is no climate change cur-
riculum within any Canadian medical school
programs [40]. The preliminary results from
a survey done by the Canadian Federation
of Medical Students (CFMS) suggest that
students are concerned about the health
impacts of climate change and believe their
current teaching is insufficient [41].A survey
done by the Québec National Public Health
Institute (INSPQ) in 2016 has also shown
that 65% of family physicians in the province
believed they lacked the required training on
climate change and health issues [42].
The Canadian Medical Association
(CMA), the Canadian Association of Phy-
sicians for the Environment (CAPE) and
The Lancet have unanimously recommended
that climate change be integrated into all
medical and health science curricula [43].
They argue that a well-trained workforce
is required to respond to the enormous
challenges posed by climate change. The
International Federation of Medical Stu-
dents Associations (IFMSA), the world’s
largest and oldest medical students’ group,
representing over 1.3 million medical stu-
dents in 123 countries,is also advocating for
the inclusion of climate change in medical
curricula around the world [44]. The Fed-
eration has collaborated with the World
Health Organization (WHO) and the
United Nations Framework Convention on
Climate Change (UNFCCC) to create a
manual for future health professionals [45].
There is an urgent need to integrate climate
change related issues within the medical
curricula. Medical teachers can play a cru-
cial role in supporting their respective facul-
ties to develop such curricula.
Global Protest Movements
School strikes for the climate is a move-
ment started by Greta Thunberg, a student,
who, on 20 August 2018, stopped attend-
ing school until the Swedish elections three
weeks later calling for more action on cli-
mate change from Swedish politicians [46].
The strikes then continued every Friday and
were given the name Fridays for Future as
students from all parts of the world joined
in the movement [47]. Through 2018 and
2019, the global protest movements have
increased in size and diversity of popula-
tions reached with more than 4500 climate
strikes taking place in over 150 countries
during the month of September 2019 [48]
and bringing the estimated total number of
people to an impressive 6 million [49]. This
is estimated to have been the largest global
protest movement [50].
Doctors and healthcare professionals have
been joining the protest movement, lending
their voices and those of their patients suffer-
ing from the consequences of climate change
to support increase action on this emergency
[51, 52]. Organizations such as Doctors for
Extinction Rebellion have also formed and
are calling for three simple things: telling the
truth, acting now; and going beyond politics
to create a citizens’assembly [53, 54].
Climate change poses a threat to people’s
health now and in the future.It is one of the
most defining issues on which the genera-
tions that currently have the power to act
will be judged by their successors. Knowing
that each degree of warming will have a sig-
nificant impact on the health of our patients
and of people around the world, addressing
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Climate Changes
climate change might be the most powerful
way we can improve health. Doctors around
the world have a role to play in the political
decisions that will shape our environment.
As Rudolf Virchow said: “Medicine is a so-
cial science and politics is nothing else but
medicine on a large scale.”
References
1. Costello, Anthony, et al. (2009). Managing the
Health Effects of Climate Change. The Lancet, vol.
373, no. 9676, pp. 1693–1733., doi:10.1016/s0140-
6736(09)60935-1
2. World Health Organization. (2018). Global Re-
port on Health and Climate Change. Geneva,
Switzerland. p.10
3. Ibid., p.24
4. World Meteorological Organization. (2019). July
matched, and maybe broke, the record for the hot-
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Anne-Sara Briand, Resident in Public
Health and Preventive Medicine,
University of Montreal, Canada
Alice McGushin, University College
London, United Kingdom.
Claudel Pétrin-Desrosiers, Resident in Family
Medicine, University of Montreal, Canada
Amro Aglan, Medical intern,
Tanta University, Egypt
Yassen Tcholakov, Resident in Public
Health and Preventive Medicine,
McGill University, Canada
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IV
General Assembly Report
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