wmj_4_2018_WEB

WMA General Assembly
vol. 64
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 4, December 2018
Contents
Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Valedictory Address of WMA President Dr. Yoshitake Yokokura, October 2018 . . . . . . . . . . . 2
Inaugural Address of WMA President 2018–2019 Dr. Leonid Eidelman . . . . . . . . . . . . . . . . . 3
WMA 2018 General Assembly Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
WMA Statement on Avian and Pandemic Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
WMA Statement on Biosimilar Medicinal Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
WMA Declaration of Seoul on Professional Autonomy and Clinical Independence. . . . . 19
WMA Statement on Environmental Degradation and Sound Management of
Chemicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
WMA Statement on Gender Equality in Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
WMA Statement on Physicians Convicted of Genocide, War Crimes or Crimes
Against Humanity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
WMA Statement on the Development and Promotion of a Maternal and Child Health
Handbook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
WMA Statement on Medical Tourism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
WMA Statement on Medically-Indicated Termination of Pregnancy . . . . . . . . . . . . . . . . . 28
WMA Resolution on Migration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
WMA Council Resolution on the Prohibition of Nuclear Weapons. . . . . . . . . . . . . . . . . . . 30
WMA Statement on Sustainable Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
WMA Statement on the Ethics of Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Why Euthanasia is Unethical and Why We Should Name it as Such. . . . . . . . . . . . . . . . . . . . . 33
Ethics and Professional Autonomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Ten Reasons to “Go Green” in the Medical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Audit of Resident Doctors Attendance at Clinical Meeting in a Low Resource Setting. . . . . 41
Public-Private Partnership in Health Care: Case of Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Confederation of Medical Associations in Asia and Oceania (CMAAO) . . . . . . . . . . . . . . . . . 48
WMA General Assembly
WMA General Assembly
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Leonid EIDELMAN
WMA President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. René HÉMAN
WMA Chairperson of the Finance
and Planning Committee
P.O. Box 20051
3502 LB, Utrecht
Netherlands
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Yoshitake YOKOKURA
WMA Immediate Past-President
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Andrew DEARDEN
WMA Treasurer
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Miguel Roberto JORGE
WMA President-Elect,
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Heidi STENSMYREN
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE – 114 86 Stockholm
Sweden
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Editorial
Editor
In general, people are experts in three areas – educating their next-
door neighbour’s children,coaching their national football team and
treating patients,especially if it does not directly concern themselves
or their next of kin. Politicians, journalists and influencers (Internet
stakeholders) seem to possess this expertise best of all, regarding
health care in particular. Wherever they may be, these experts be-
lieve that medicine is no good at all, doctors should be wiser and
more industrious, and that health care needs a reform. Strange as
it may be, nearly in every country medical doctors, too, think that
a reform is needed in health care; however, their understanding of
this reform is quite different. Nonetheless, the numbers of advisers
in health care reform matters keep increasing: most probably, there
are billions of them.
Health care professionals and patients expect the reform to be a set
of actions making health care structure more compact and targeted
and capable of using human resources, material resources, technolo-
gies, facilities and transport etc. in a more efficient way. Policy mak-
ers and finance people associated with governments believe that re-
forms in health care mean cutting expenses in the health sector and
investing the spared money in technological advancement. Those
engaged in the system understand any reform as increase of collec-
tive and solidary financing from public budget or insurance.
In this aspect, it is similar all over the world – health care needs
more money due to ageing population, increasing numbers of pa-
tients with chronic diseases and growing costs of medical technolo-
gies and medication. However, the opinion of governments, global
associations, finance people and ministers for health is very dissimi-
lar.We could notice that in Astana.Nevertheless,the world was able
to agree that primary health care and universal coverage is the very
basis of global health care.
Our goal is health care in all policies; however, according to the As-
tana Conference, there is an impression that more often than not
it is rather policy in all healthcares. As to healthcare, the reality al-
ways is determined by the point of view from which we are look-
ing at health care. Nevertheless, the global document has been ad-
opted. The Global Conference on Primary Health Care in Astana,
Kazakhstan in October 2018 endorsed a new declaration emphasiz-
ing the critical role of primary health care around the world. The
declaration aims to refocus efforts on primary health care to ensure
that everyone everywhere is able to enjoy the highest possible at-
tainable standard of health.
My choice is to quote the part of the Astana Delaration that con-
cerns us, leaders of national medical associations – actual stakehold-
ers of global health care:
Align stakeholder support to national policies, strategies and plans.
We call on all stakeholders – health professionals, academia, pa-
tients, civil society, local and international partners, agencies and
funds, the private sector, faith-based organizations and others – to
align with national policies, strategies and plans across all sectors,
including through people-centred,gender-sensitive approaches,and
to take joint actions to build stronger and sustainable PHC towards
achieving UHC. Stakeholder support can assist countries to direct
sufficient human, technological, financial and information resources
to PHC. In implementing this Declaration, countries and stake-
holders will work together in a spirit of partnership and effective
development cooperation, sharing knowledge and good practices
while fully respecting national sovereignty and human rights.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
BACK TO CONTENTS
2
WMA General Assembly
One year has passed since October 2017
when I was inaugurated the 68th
WMA
President.
This picture was taken after the inauguration
ceremony. I feel that all these people coming
from the developing and advanced countries,
beyond race, are looking forward to the fu-
ture of global health care with a smile. I have
used it as the opening slide of my presenta-
tion to introduce the activities of WMA.
I visited various countries as WMA Presi-
dent and participated in many events in the
past year.
In the greetings and presentations in the
events I have suggested promotion of Uni-
versal Health Coverage (UHC). In the in-
augural speech, I mentioned that there was
a universal health insurance which pushed
Japan›s average life expectancy to the
world›s top level. I also advocated efforts in
the aged society in which with healthy life
expectancy extended,the society which sup-
ports the elderly is changed to the society
which the elderly supports.
This graph shows historical changes in mor-
tality rate in Japan by major five causes of
death in 1947–2016. Tuberculosis, which
marked 146,000 in death toll in 1947,sharp-
ly declined since 1951 when the TB control
law was enacted.It can be seen that this con-
tributed greatly to the achievement of uni-
versal health insurance in Japan in 1961.
Trends in medical expenses for TB have
been declining to 27.7% in 1954, 15.7% in
1961 and as low as 0.09% in 2009. This in-
dicates that TB control has achieved great
results.
This slide shows 5 year survival rate of can-
cer patients in Japan. The survival rate has
been improved by implementing the Can-
cer Basic Countermeasures Act with the
joint efforts among the central government,
local governments and medical community.
This graph shows the current average life
expectancy in Japan. It is 80.98 for males
and 87.14 for females in 2016. And for
healthy life expectancy, 72.14 for males and
74.79 for females.
The JMA has been doing various efforts to
extend healthy life expectancy. There are
health promotion activities for the pub-
lic. They are “Health Japan 21” led by the
government, the Japan Health Council in
which the private sector works together,and
the Diabetes Countermeasures Promotion
Council that the JMA is working for with
specialty societies. Through these efforts,
the Japanese average life expectancy stays in
the world top level in 2016.
I would like to talk about the promotion of
UHC.
To achieve UHC in Japan, it took about 40
years since the health insurance law was en-
acted in 1922.
It is clear that this system has contributed
greatly to Japanese health and longevity.
In September 2015, the UN General As-
sembly adopted the 2030 Agenda for Sus-
tainable Development that includes 17 Sus-
tainable Development Goals (SDGs), built
on the principle of “leaving no one behind”.
Goal 3 states to ensure healthy lives and
promote well-being for all at all ages.
The UHC Forum 2017 was jointly orga-
nized by the Japanese government, WHO,
World Bank, UNICEF and others in Tokyo.
At this occasion, we invited Dr. Tedros, Di-
rector General of WHO, to dinner which
was planned by the Japanese government,
Ministry of Health, Labor and Welfare and
Parliament members who are supporting me.
In the UHC Forum in Tokyo, the declara-
tion for UHC was supported by many global
leaders including Japanese Prime Minister
Shinzo Abe, UN Secretary General Antonio
Guterres,Heads of WHO,World Bank,UNI-
CEF,WMA and a remarkable array of leaders.
Through this forum, UHC became a global
goal for national health policy of the countries.
As WMA President, I stated that the
WMA will promote UHC together with
114 member associations.
The forum adopted the Tokyo Declaration
of UHC reaffirming Health for All.
In the declaration,we call for greater commit-
ment to accelerate progress towards UHC.
As WMA President,I exchanged the MOU
with Dr. Tedros at the WHO headquarters
in Geneva on April 5th
this year to promote
UHC and strengthen Emergency Disaster
Preparedness.
Lecture of promoting UHC was made by the
WHO senior advisor after the MOU exchange.
Yoshitake Yokokura
Valedictory Address of WMA President Dr. Yoshitake Yokokura,
October 2018
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3
WMA General Assembly
The National UHC road map was pre-
sented. He suggested the WHO supports
for the WMA engagement to contribute to
physician’s capacity building in countries,
national policy dialogue on health work-
force and global advocacy for workforce
investment, for example in the occasion of
G20 Osaka summit in June 2019.
It was planned to hold Health Professional
Meeting 20 or H20 to discuss UHC pro-
motion with the WHO leadership, the six
regional offices, and medical associations of
each region of WMA.
This plan was agreed by Japanese Prime Min-
ister Shinzo Abe,the Minister of Health,La-
bor and Welfare,and Parliament members.
I visited several International organizations
with Dr. Kloiber at the occasion of the ex-
changing MOU with WHO.
I would like to talk about the United Na-
tions General Assembly.
I attended the United Nations General As-
sembly held in New York last week.
I was invited to be a speaker as WMA Pres-
ident to the high level meeting on NCDs.
The theme given to me was about mental
health and well-being. I took up dementia
and mentioned the importance of school
health and food education in appealing
the necessity of control of obesity in chil-
dren.
I stressed that in order to address the is-
sue about NCDs, it is necessary to build
a strong health care system based on phy-
sician-led primary care and a cooperative
work of public and private sectors.
I was elected to JMA President for the
fourth term in this June. The term of office
is two years until June 2020. I will continue
to support the activities of WMA led by
Dr. Leonid Eidelman especially for promo-
tion of UHC.
I am grateful for the warm support of all
the member associations, Dr. Ardis Hoven,
Chair and the WMA secretariat led by
Dr. Otmar Kloiber.
I sincerely thank all of you that I was able to
spend such a fulfilling year as WMA Presi-
dent.
Inaugural Address of WMA President 2018–2019 Dr. Leonid Eidelman
When I attended the General Assem-
bly for the first time, 9 years ago in New
Delhi, I was overwhelmed by the presence
of so many prominent leaders of medicine
from all over the world. Since then, every
time I  participate in WMA events, I feel
deep appreciation and admire your sapient
leadership, vision and commitment to our
profession, its goals and values.
Dear distinguished delegates, your activity
within WMA and everyone›s participation in
his or her NMA, inspires and enlightens me.
I have had the great privilege of getting to
know you over the last years and I hope to
meet many more of you over the next year.
Each one of you is shaping the future of
healthcare and is furthering his or her na-
tion’s wellbeing. We all have great challeng-
es and together we can accomplish a great
deal on behalf of our patients.
It is my great honor to stand before you as
the President of the World Medical Associ-
ation. Before I continue, I want to acknowl-
edge our outgoing President, Dr. Yoshitake
Yokokura, who contributed greatly to the
physicians of the world.
Thank you, Dr.Yoshitake Yokokura for your
service to the WMA.
Over the years, I have come to realize that
the WMA is one of the most important or-
ganizations for physicians worldwide, with
unique strengths to meet the challenges of
our medical profession as well as to help
NMAs in need. In addition, the WMA
assists in instructing the individual physi-
cian, and guiding him or her in this rapidly
changing world.
We live in an extremely challenging period.
The changes we witness daily seem incom-
prehensible and the pace of these changes is
increasing constantly.
I believe that it is the time for WMA to take
a sophisticated,scientific and innovative look
to the future and to help both physicians
and patients become prepared for the huge
changes in medicine over the next decade.
Are we prepared for the future?
We can,and to my mind,we should,embark
on a critical venture to predict how medi-
cine will look in 2030, what will be the role
of a physician,physicians› organizations and
what can be done to spur significant posi-
tive changes.
I ask to dedicate my year of presidency to
this agenda.
It is our mandate as leaders, since an effec-
tive leader is one who creates an inspiring
vision of the future.
Working on this agenda I believe that three
kinds of scenarios are to be developed: one
that reflects maximal possible changes,
another one for minimal changes and the
third – the middle one.
The predictable societal changes, tech-
nological changes, changes in the role of
Leonid Eidelman
BACK TO CONTENTS
4
WMA General Assembly
a ­
physician, and in patients› preferences
should be addressed.
The goal will be to develop a report that can
help physicians and NMAs become pre-
pared for the future.
What will be the role of a physician in 2030?
In 1903, more than one hundred years ago,
the future for Thomas Edison as he predict-
ed was “The doctor … (who) will give no
medicine,but instruct his patient in the care
of the human frame,in diet and in the cause
and prevention of disease”
Today, we can predict that the future world
of medicine will be a world of electronic
health records, robots, artificial intelligence
and machine learning as well as highly de-
veloped communication means.
However, moving to a future of medicine is
probably like driving on a country road with
its ruts, convolutions and unexpected turns
rather than driving on a highway. Recent
problems with the Watson supercomputer
demonstrate that.
“A new study from MIT computer scien-
tists, suggests that human doctors provide a
dimension that, as yet, artificial intelligence
does not”. They have found that a physi-
cian’s “gut feeling” plays a significant role in
the intensive care unit. (Lagasse J. https://
www.healthcaref inancenews.com/news/
artificial-intelligence-cant-replace-doctors-
gut-instincts-mit-study-says). As researcher
Mohammad Ghassemi said: “there is some-
thing about a doctor›s experience and their
years of training and practice, that allows
them to know in a more comprehensive
sense, beyond just the list of symptoms,
whether you are doing well or you are not”.
We can predict that physicians will provide
integrated care as members of multidisci-
plinary teams and will perform more com-
plex tasks in an increasingly complex work
environment,although the question remains:
who will be the leaders of these teams?
But there is another factor that must be ad-
dressed in order to effectively propel medi-
cine into the next decades.
Today, at the time I am speaking on this
highly-respected podium, more than 10
million physicians all over the world take
care of those in need of medical help and
nearly half of them have symptoms of
burnout defined as emotional exhaustion,
interpersonal disengagement, and a low
sense of personal accomplishment. Besides
a physician›s well-being, burnout negatively
influences the quality of care and shortens
the life-time a physician is able to practice
medicine.
This is a great problem for society suffer-
ing from a shortage of physicians, which is
common in most countries of the world.
In the future of universal health coverage
there is a need for a growing number of
burnout-free physicians.
The pandemic of physician burnout, caused,
among other things, by very dynamic and
changing working conditions, is a subject
I believe we should address.
The quality and safety of patient care de-
pend on high-functioning physicians. This
is particularly challenging in our extremely
rapidly changing world.
The wellbeing of physicians, both mentally
and physically, has been on the agenda of
some NMAs for several decades. Some re-
sources have been invested to explore and
move things forward on this issue; however,
the real objective of combatting this blow
to modern medicine has yet to be achieved.
“Physicians are dealing with an incredible
amount of work stress as they confront
growing administrative burden, rising op-
erating costs, new technology and an in-
creasing patient demand for frontline care.
Physician burnout is a symptom of a larger
problem – a healthcare system that increas-
ingly overworks doctors and undervalues
their health needs.“ (Teresa Iafolla. https://
blog.evisit.com/prevent-physician-burnout)
That is why according to the new Decla-
ration of Geneva that was adopted by our
General Assembly in Chicago a year ago,
a physician pledges to attend to his own
health, well-being and abilities in order to
provide care of the highest standard.
While preparing for the future, there is a
place to develop recommendations for phy-
sicians all over the world to keep this im-
portant part of the pledge. Physicians are
an indispensable resource of every society;
burn out of this resource endangers the so-
ciety.
I believe we must draw from our combined
experiences and learn best practices.
An additional issue that cannot be sepa-
rated from planning the future is the role of
the physician in contemporary society.
Physicians have been traditionally conser-
vative. For years the practice of medicine
followed long-standing traditions. “A phy-
sician possessed a unique body of knowl-
edge to use in the care of patients. This
kind of the doctor-patient interaction was
paramount and served as the foundation
of a personal, caring relationship”. (Wart-
man S.A. http://www.aahcdc.org/Publi-
cations-Resources/Series/Nota-Bene/View/
ArticleId/20829/The-Role-of-the-Physician-
in-21st-Century-Healthcare). But the forces
changing 21st
century society and medicine
are transforming this tradition. Physicians
should be prepared both mentally and tech-
nologically to meet new demands.
I believe that WMA has a capacity to help
individual physicians in this challenging
process.
The role of NMAs is also under significant
pressure as a result of societal changes. The
WMA is the only body to explore this pro-
cess and develop recommendations that can
help NMAs to evolve their future strategies.
Notwithstanding any future changes, pa-
tients and physicians will continue to exist,
and we will continue to honor our social
contract.
“Every day, we are given the great privilege
of being invited into our patients’ lives. We
are with patients when they are born and
when they die; we provide advice and com-
fort; we prevent illness and treat and man-
age disease. Our patients trust us, and we
have always taken our advocacy role very
seriously. It is part of the essence of our pro-
fessionalism and we will keep our patients at
the center of everything we do.” (Dr. Chris
Simpson, inaugural speech, CMA 2014)
The support of WMA is essential and I am
sure, will be always provided.
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5
WMA General Assembly
Wednesday October 3
At the invitation of the Icelandic Medical
Association, delegates from more than 58
National Medical Associations and con-
stituent member associations met at the
award-winning Harpa Convention Cen-
tre, one of Reykjavik’s most distinguished
landmarks. The occasion was the WMA’s
69th
annual General Assembly to coincide
with the 100th
anniversary of the Icelandic
Medical Association. For the first time,
the General Assembly was combined with
a Medical Ethics conference organized by
the Icelandic Medical Association partly in
parallel with our Council Session.
Council
Dr. Ardis Hoven, Chair of Council, opened
the 210th
Council session, welcoming del-
egates to Reykjavik.
Dr. Otmar Kloiber, the Secretary General,
introduced several new Council members –
Dr.Tony Bartone from Australia, Dr. Grec-
co Aguer from Uruguay, Dr. Zion Hagay
from Israel, Dr. Hokuto Hoshi from Japan,
Dr. Barbara McAneny from America and
Dr. Jungyul Park from Korea.
President’s Report
The President,Dr.Yoshitake Yokokura,gave
a brief report on his activities over the pre-
ceding six months, when he had taken up
the theme of promoting Universal Health
Coverage through cooperation and col-
laboration based on the Memorandum of
Understanding between the WMA and the
World Health Organisation. He had spo-
ken at many meetings, including the High-
Level United Nations meeting on the pre-
vention and control of non-communicable
diseases and the 18th
MASEAN Confer-
ence, the confederation of medical asso-
ciations from the South-east Asian region
consisting of 10 ASEAN members. He had
also attended meetings of the German,Tai-
wan and American Medical Associations.
He said he had been re-elected as Presi-
dent of the Japan Medical Association for
a fourth term.
Secretary General’s Report
A comprehensive report was submitted to
the Assembly on the work of the Council
over the preceding six months.
Otmar Kloiber
Emergency Resolution
The Spanish Medical Association (Consejo
General de Médicos de España), with the
support of Confemel, submitted an emer-
gency resolution on migration, arguing that
this was a problem increasing around the
world.
The Council agreed that this was an issue
that should be considered by the Socio-
Medical Affairs Committee as a matter of
urgency.
Chair’s Report
Dr. Hoven spoke about the success of the
previous day’s medical ethics conference
organised in conjunction with the Icelandic
Medical Association.
Ardis Hoven
In her written report, she said she contin-
ued to be outraged by the atrocities imposed
upon physician colleagues throughout the
world who, when providing care for those
in need, were being injured, murdered or
imprisoned. The WMA had partnered with
the International Committee of the Red
Cross in the global project “Healthcare in
Danger”, which was aimed at identifying
the extent of this problem and proposing
interventions to mitigate the damage being
done. It was imperative they continued with
this activity.
In addition, the medical profession had
been under growing pressure around the
world from governments intent on under-
mining medical autonomy. In some parts
of the world, politicians appeared deter-
mined to curtail the power of the ­
medical
WMA 2018 General Assembly Report
Reykjavik, Iceland October 3–6
Nigel Duncan
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6
WMA General Assembly
profession and exercise more control over
their representative associations. The
WMA strongly opposed any attempt to
stifle the voices of physicians, because
in the end it was patients who suffered.
Professional self-governance was critical
to the delivery of healthcare across the
world.
Socio-Medical Affairs
Committee
Dr. Miguel Roberto Jorge (Brazil) took the
chair.
Miguel Roberto Jorge
Secretary General’s Monitoring
Report
Dr. Kloiber reported on the alarming dete-
rioration of the health system in Nicaragua
over the last few months. In response to
a request from the Royal Dutch Medical
Association, the WMA had issued a press
release in July, condemning violent attacks
on health personnel, medical vehicles and
hospitals.
Network on Disaster Medicine
The Japan Medical Association reported
on its proposal for a WMA Network on
Disaster Medicine. A discussion on this
had been held at the last Confederation of
Medical Associations in Asia and Oceania
(CMAAO) meeting, given the large num-
ber of natural disasters in this region. The
JMA said it would report further at the next
Council meeting.
Statement on Environmental Degradation
and Sound Management of Chemicals
The committee considered the proposed re-
vision of this Statement, which arose out of
a proposal for a specific policy on curbing
the consumption of plastic bags.The Swed-
ish Medical Association had been asked to
incorporate the issue of plastic pollution
into the WMA Statement on Environmen-
tal Degradation.
A revised policy, encouraging efforts to curb
the manufacture and use of plastic packag-
ing and plastic bags, had been circulated for
comment and the Committee recommend-
ed that the document be sent to the Council
for forwarding to the General Assembly for
adoption.
Declaration of Madrid on Professionally-Led
Regulation
A proposed revision to the Declaration of
Madrid was introduced, aimed at reaffirm-
ing the WMA’s view that the medical pro-
fession must regulate itself if public confi-
dence is to be maintained in the standards of
care.The Committee recommended that the
document should be referred back for further
work and considered at the next meeting.
Maternal and Child Health Handbook
The meeting considered a proposal from the
Japan Medical Association for a Statement
on the Development and Promotion of a
Maternal and Child Health Handbook.The
Japanese Handbook, tabled by the Japanese
at the previous meeting, was described as
a comprehensive home-based booklet de-
signed to provide relevant health informa-
tion and include integrated mother and
child health records.It covers health records
and information on pregnancy, delivery,
neonatal and childhood periods, and child
growth and immunizations. The Handbook
supports the integration of maternal, neo-
natal and child health services. The docu-
ment had been circulated for comments and
several amendments had been suggested
and included.
The Committee made several further
amendments to make it clear that the
WMA was supporting equivalent docu-
ments as well as the Japanese Handbook.
The Committee recommended that the
proposed Statement be sent to Council and
forwarded to the General Assembly for
adoption.
Proposed Declaration on Pseudoscience, Pseu-
dotherapies, Intrusion and Sects in the Field of
Health Pseudoscience
The proposed Declaration was submitted by
the Spanish Medical Association at the last
meeting, had been circulated for comment
and had prompted many amendments. The
meeting was told that the new draft was
trying to defend scientific medical profes-
sionals and to ensure the safety of patients
and the quality of health care. But several
speakers questioned the language used in
the document and said it was unfair to those
practicing different medicine.
After a brief debate, the Committee recom-
mended that a workgroup should be set up
with the mandate to work further on this
issue and develop a revised text to consider
at the next meeting.The Committee agreed
to recommend this to Council.
Access of Women and Children to Health Care
and the Role of Women in the Medical Profes-
sion
Under the WMA’s 10-year policy revision
rule, a major revision was considered to
the Resolution on Access of Women and
Children to Health Care and the Role of
Women in the Medical Profession. This re-
affirmed the WMA’s support for the rights
of women and children to full and adequate
medical care, especially where religious and
cultural restrictions hindered access to such
care. The revised document was submitted
by the Israeli Medical Association and the
Committee recommended that it be circu-
lated to members for comment.
Antimicrobial Resistance
Similarly, a major revision of the WMA
Statement on Antimicrobial Resistance was
submitted.It was explained that the purpose
of the revision was to recognize the impor-
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7
WMA General Assembly
tance of this issue for the future of medicine
and to break down the actions needed from
the WMA, NMAs and individual physi-
cians. The document warns of the growing
threat to global public health from antimi-
crobial resistance, threatening both the pre-
vention and treatment of infections.
The Committee recommended that the
proposed revision be circulated to members
for comments.
Statement on Reducing the Global Burden of
Mercury
The Committee agreed to a minor revision
to this Statement and recommended that it
be forwarded to the Council for adoption
by the General Assembly.
Statement on Reducing Dietary Sodium Intake
A major revision to the WMA Statement
on Reducing Dietary Sodium Intake was
introduced. The Committee decided to rec-
ommend that the document, warning that
the majority of the world consumed too
much sodium,should be circulated to mem-
bers for comment.
Resolution on Collaboration Between Human
and Veterinary Medicine
A minor revision to the Resolution was
agreed, and the Committee recommended
forwarding it to the Council for adoption
by the General Assembly.
Statement on Violence and health
Suggestions for major revisions to the
WMA’s Statement on Violence and Health
were submitted by the Nigerian Medical
Association. It was explained that the new
document, containing a series of measures
to combat violence in society, had merged
different WMA policy documents on vio-
lence in the workplace, violence against
women and children and family violence.
The document sets out measures to safe-
guard health institutions. Support for the
document came from the Indian Medi-
cal Association. The meeting was told that
72 per cent of Indian doctors had been sub-
jected to physical or oral abuse and 19 prov-
inces in the country had now enacted a law
against violence.
The Committee recommended that the
proposed document be circulated to mem-
bers for comments.
Statement on Artificial or Augmented Intelli-
gence in Medical Care
A draft policy Statement on artificial intel-
ligence was introduced by the American
Medical Association. The paper was based
on policy recently adopted by the AMA. It
was argued that AI was making significant
inroads into patient care and it was very
important that physicians became educated
about the issue and that the WMA had pol-
icy that would help shape the future of this
technology so that it worked for physicians
and for patients. AI offered the promise of
dramatically better patient care, but that
would only be accomplished if the medical
profession had policy and it could engage.
Several speakers said there was a sense of
urgency about developing policy on this is-
sue. They had an opportunity to influence
and shape the future. AI would have a ma-
jor impact on medicine and it was extremely
important to get the physicians’perspective.
There were a lot of dangers involved, but
also considerable opportunities. The need
to consider the risks to anonymisation and
confidentiality from AI was also mentioned.
The Committee recommended that the
proposed document be circulated to mem-
bers for comments.
Statement on Medical Age Assessment of Un-
accompanied Minor Asylum Seekers Minor
Asylum Seekers
The German Medical Association submit-
ted a draft Statement on what it argued was
an exceptionally pressing and timely matter,
namely, the methods employed to assess the
age of unaccompanied minor asylum seek-
ers for the purposes of determining their le-
gal status in the country in which they were
seeking asylum.It was argued that there was
a lack of definitive, internationally accepted
guidelines on this matter. Children ac-
counted for half of the world’s refugees and
unaccompanied minors who had fled their
countries of origin were especially vulner-
able when it came to means of age assess-
ment.The available methods of medical age
assessment – ranging from X-rays of the jaw,
hand, or wrist to examinations of secondary
sex characteristics – raised ethical concerns
because they could potentially endanger the
health of those being examined, as well as
violate the privacy and dignity of potentially
traumatized young people. It was essential
that physicians received clear guidance for
dealing with cases in which they were called
upon to perform medical age assessments.
The Committee recommended that the
proposed Statement be circulated to mem-
bers for comments.
Statement on Free Sugar Consumption and
Sugar-sweetened Beverages
A series of measures to combat the global
consumption of sugar was proposed by the
Kuwait Medical Association in a new pro-
posed Statement.
The Committee recommended that the
Statement be circulated to members for
comments.
Healthcare Information for All
A proposed new Statement to address the
lack of access to relevant, evidence-based
healthcare information was submitted by
the British Medical Association. It argued
that this lack of information was a major
contributor to unnecessary death and suf-
fering, especially in low- and middle-in-
come countries.
The Committee recommended that the
Statement be circulated to members for
comments.
Resolution on Migration
The Spanish Medical Association presented
its emergency motion on a situation that it
argued had been worsening over the last few
months. It said the WMA should reaffirm
the continued engagement of physicians in
caring for migrants. The voice of the medi-
cal profession should be raised now because
the most vulnerable people and those who
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WMA General Assembly
were in most need of support were suffering
from this difficult situation.
During a brief debate, speakers argued
that this was a global problem, and an
amendment was agreed to clarify this in
the Resolution. It was argued that every
opportunity should be taken to reaffirm
the human rights of refugees, as the po-
litical environment was getting more and
more difficult.
The Committee recommended that the
proposed Resolution be sent to the Council
for forwarding to the General Assembly for
adoption.
Medical Ethics Committee
Dr. Heidi Stensmyren (Swedish Medical
Association) took the chair.
Heidi Stensmyren
Monitoring Report
In his monitoring report, Dr. Kloiber raised
three topics whose developments could
have implications for the WMA and its
policy activities.
The first was artificial intelligence. He said
that advancements in this field would have
a strong impact on how physicians worked
and on the way medicine was regulated,
with significant ethical ramifications over
the long term. He advised the Committee
to be prepared to address these potential
challenges.
The second was on end of life issues. He
expressed concern that WMA discussions
and policies on numerous end of life topics,
such as patient autonomy, living wills, sub-
stitute decision making, terminal sedation,
and opioid use, had not reached large parts
of the global community of physicians. He
recommended that the WMA worked on
identifying possible barriers and explored
ways to better support physicians on these
issues, particularly where national regula-
tions did not exist.
The final issue was the Declaration of Hel-
sinki. He noted that there were a number of
issues being discussed in the international
community that had important connections
to and ramifications for the Declaration of
Helsinki.The WMA was currently working
on two of these issues – healthy volunteers
and vulnerable populations – as part of their
participation in the CIOMS (Council for
International Organizations of Medical
Sciences) working groups. Dr. Kloiber said
that at the next Council Session in Santiago
he would recommend reopening work on
the Declaration of Helsinki.
Licensing of Physicians Fleeing Prosecution for
Serious Criminal Offences
As part of the WMA’s annual policy review
process, it had been decided that the State-
ment on Licensing of Physicians Fleeing
Prosecution for Serious Criminal Offence
should undergo a major revision and the
French Medical Association (CNOM) vol-
unteered to undertake that work. An early
draft revision was sent round for comment,
was amended, further circulated and now
a second draft proposal was being submit-
ted.However,delegates were told that while
there was general agreement on what were
very serious offences, such as war crimes,
genocide and crimes against humanity,
there was less agreement on what were seri-
ous crimes.
This led to a lengthy debate and several
amendments were agreed about the scape
and definition of the paper.
The Committee agreed to change the title
of the document to Statement on Physi-
cians Convicted of Genocide, War Crimes
or Crimes Against Humanity and it recom-
mended that the revision be
approved by the Council and forwarded to
the General Assembly for adoption.
Genetics and Medicine
An oral report was received from the work
group in charge of revising the Statement
on Genetics and Medicine. A key goal of
the group was to update the WMA State-
ment regarding the increasing use of ge-
netic analyses and large-scale genome se-
quencing, both for treatment and research
purposes. Other central goals were to
provide recommendations regarding the
ethical sensitivity of genetic information,
the handling of secondary findings from
genetic testing and the cost of introducing
genetic analyses as standard procedure in
treatment. The workgroup reported that it
was not in a position to finalise a proposed
revision, but expected to have a draft ready
for the next meeting in Santiago. It had al-
ready reached one key conclusion – that the
revision should not aim to provide detailed
guidelines for every single ethical problem
in the medical use of genetics. Instead it
would try to provide general principles for
the use of genetics. Another workgroup
session was scheduled for December 2018
in Copenhagen.
The Committee unanimously agreed to a
proposal from the American Medical Asso-
ciation to name the future revised Statement
on Genetics and Medicine the ‘Declaration
of Reykjavik’, as an acknowledgement of
the essential involvement of the Icelandic
Medical Association.
Biosimilar Medicinal Products
A proposed Statement on Biosimilar Me-
dicinal Products was submitted by the Is-
raeli Medical Association. Its various rec-
ommendations result from the expiry of
patents for original biotherapeutics and
the subsequent development and approval
of copies, called ‘similar biological medici-
nal products’ or biosimilars that are highly
similar to a previously approved biological,
product. The document had been circulated
among members and amended where nec-
essary. It was explained that the paper was
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9
WMA General Assembly
principally designed to protect the autono-
my of the physician.However,the Commit-
tee agreed that this point should be backed
up in the document by adding the words
‘’There should be no substitution between
biosimilars and other drugs without the at-
tending physician’s permission’.
The Committee then recommended that
the proposed Statement, as amended, be
approved by the Council and forwarded to
the General Assembly for adoption.
International Code of Medical Ethics (ICoME)
The Committee received an oral report
from the workgroup on plans to prepare
a comprehensive revision of the ICoME,
engaging the entire WMA community as
well as external experts through open con-
sultation and public events, if possible. The
intention was for the workgroup to sub-
mit a concrete workplan and timeline to
the Committee at its next session in April
2019. The workgroup had met for the first
time the previous day to plan its major re-
vision to the document. Prof. Urban Wi-
esing, ethics advisor to the Committee,
presented a brief overview of the correla-
tions between the Declaration of Geneva
and the ICoME and possible options for
the revision of the latter. He reminded the
committee that the Code, adopted in 1949,
had been amended three times, in 1968,
1983 and 2006. It was in three parts – the
duties of physicians in general, their duty
to patients and their duty to colleagues.
There were many topics contained in the
Declaration of Geneva that were not men-
tioned in the Code, such as the well be-
ing of patients and physicians, and human
rights. Compared with the Declaration of
Geneva and Helsinki, the International
Code of Ethics was largely unknown. A re-
vised Code should be a coherent, extended
and additional document to the Declara-
tion of Geneva. It could also could become
a document on medical professionalism in
a globalized world.
The Committee received the report and
reaffirmed Prof. Wiesing’s appointment as
advisor.
Assisted Reproductive Technologies
A proposed major revision to the WMA
Statement on Assisted Reproductive Tech-
nologies was tabled with the suggestion
that a workgroup be established to continue
working on the document.
The Committee recommended that a work-
group be established.
Capital Punishment
The Committee considered a proposal to
merge two WMA policy documents on
capital punishment. It was agreed that the
new document should be entitled Resolu-
tion on Prohibition of Physician Participa-
tion in Capital Punishment. This reiterated
WMA policy that it was unethical for phy-
sicians to participate in capital punishment,
in any way, or during any step of the execu-
tion process, including its planning and the
instruction and/or training of persons to
perform executions.
This led to a debate about whether this un-
intentionally excluded prisoners on death
row from receiving good medical care and
attention.However,it was argued that other
WMA policy covered this area. There was
also a question about those countries where
capital punishment was part of the law of
the land and doctors employed by the state
were required to be present to certify a pris-
oner fit to be executed. Dr. Kloiber said that
in these circumstances, the NMA should
call on the WMA for support and a letter
could be sent to their government setting
out WMA policy.
The Committee recommended that the pro-
posed Resolution,as revised,be approved by
the Council and forwarded to the General
Assembly for information, and that the
2008 Resolution on Physician Participation
in Capital Punishment and the 2012 WMA
Resolution to Reaffirm WMA’s Prohibition
of Physician Participation in Capital Pun-
ishment be rescinded and archived.
Documentation of Torture
The Danish Medical Association reported
on its work undertaking a major revision
of the WMA Resolution on the Responsi-
bility of Physicians in the Documentation
and Denunciation of Acts of Torture and
Ill-treatment. The aim of the revision was
not to change the core recommendations,
but to make the document more accessible.
A new section had been added on protect-
ing physicians who acted in accordance
with WMA policy.
The Committee recommended that the
proposed revision be circulated to members
for comments.
Sex Selection and Female Foeticide
The Committee considered a proposed re-
vision of the WMA Statement on Female
Foeticide. This aimed to add to current
WMA policy, stating clearly that sex deter-
mination for reasons of gender preference
was unacceptable unless it was carried out
to avoid a severe sex-linked medical condi-
tion.
The Committee recommended that the
proposed revision be circulated to members
for comments.
Euthanasia and Physician Assisted Dying
The Committee was informed that the
Canadian and Royal Dutch Medical As-
sociations had decided to withdraw their
proposed Reconsideration of WMA
Statement, Resolution and Declaration
on Euthanasia and Physician Assisted
Dying, as a result of a new document
prepared by the German Medical As-
sociation. The new document, entitled
‘Proposed Statement on Euthanasia and
Physician-Assisted Dying’was a proposed
consolidation and revision of the WMA
Statement on Physician-Assisted Suicide
and WMA Resolution on Euthanasia.
Delegates were told that the new compro-
mise document did not represent a change
in WMA policy, but rather proposed a re-
finement of the language. It avoided using
the term ‘unethical’ to refer to physicians
who engaged in physician assisted suicide
in accordance with the legislation in their
countries. It reiterated that the WMA
was opposed to euthanasia and physician
assisted suicide.
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10
WMA General Assembly
A lengthy debate followed, during which a
number of Associate Members from Can-
ada outlined their opposition to changing
the WMA’s policy.
On a vote it was decided that the document
should be circulated to members for comment.
Finance and Planning Committee
Dr. René Héman (Royal Dutch Medical
Association) took the chair.
René Héman
Financial Statement
The Treasurer, Dr. Andrew Dearden, pre-
sented the Financial Statement for 2017.
He was pleased to report that the WMA
remained in a good financial position at
year-end, with a surplus for the fourth year
in a row.
The Committee recommended that the
Statement be approved by the Council and
forwarded to the General Assembly for ap-
proval and adoption.
Andrew Dearden
Dues for 2017 and 2018
The Committee received an oral report on
the 2017 Dues Arrears. The Treasurer said
that more than 99 per cent of contributions
had been received.
Budget 2019
The Committee considered the proposed
Budget for 2019 vs. actual 2017 expendi-
ture.
The Treasurer said that with the repeated
annual surpluses, the WMA was in a posi-
tion to move forward on projects that had
not been pursued due to lack of financial
resources.
The Committee recommended that the
Proposed Budget for 2019 be approved by
the Council and be forwarded to the Gen-
eral Assembly for adoption.
Membership Dues Payments for 2018
The Committee recommended that the
Treasurer’s report be forwarded to the Gen-
eral Assembly for information.
Associate Membership Dues Increase
The Committee considered a proposal for
a small dues increase for Associate Mem-
bership. Dr. Kloiber said that the benefits of
the WMA education platform could be of-
fered to Associate Members as a new ben-
efit when the dues were increased.He noted
that the Associate Members dues rate had
not been changed in many years.
The Committee recommended that the in-
crease be approved by the Council and be
forwarded to the General Assembly for
adoption.
Strategic Plan
Dr. Kloiber reported that he had begun
work on the Strategic Plan, following
the recommendations of the Governance
Workgroup. The work had been inter-
rupted by a number of extremely urgent
requirements emerging from the upcom-
ing Global Conference on Primary Health
Care to be held in Astana, Kazakhstan
on 25–26 October 2018. This conference
had considerable influence on policy that
was being made on the way to Universal
Health Care and the structure of prima-
ry health care and the role of physicians.
There was a very clear tendency, especial-
ly by the donors, to replace physicians in
primary health care by community health
workers or nurses.This was of considerable
concern and plans were being developed by
the WMA to co-operate with other organ-
isations to counteract these tendencies. He
said the WMA would be present in Astana,
led by WMA President Leonid Eidelman
and Immediate Past President Dr.  Yo-
kokura, and he thanked the Japan Medi-
cal Association for its critical assistance in
obtaining an invitation to the WMA. He
also noted that the WMA would have to
continue lobbying governments for proper
primary care structures long after the As-
tana conference.
He also reported that in 2019, Japan would
host the G20 Summit. This would provide
an opportunity to host an H20 meeting, as
proposed by Dr. Yokokura in Riga. An H20
meeting would create an important op-
portunity to lobby governments on physi-
cian-led primary health care and Universal
Health Coverage.
Dr. Kloiber added that the Governance
Workgroup had stressed the importance of
WMA outreach to ensure that it became
more active and worked to develop regional
representation in areas where it had not had
a strong presence. He was therefore propos-
ing that some of the WMA surplus be used
to support that outreach. In addition, there
would be a proposal later during the Com-
mittee discussion regarding the possibility
of establishing a new WMA region to at-
tract members from the Eastern Mediter-
ranean.
Statutory Meetings
The Committee considered proposed
themes for the Scientific Session at the 70th
General Assembly in Tbilisi, Georgia in
2019.
It recommended that the theme of ‘Pallia-
tive Care’ be recommended to the Council
for approval by the General Assembly,
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WMA General Assembly
The Committee considered invitations for
future meetings and recommended that:
• the invitation of the Spanish Medical
Association to host the 71st
General As-
sembly in Cordoba in October 2020 be
accepted;
• the invitation of the British Medical As-
sociation to host the 72nd
General As-
sembly in London in October 2021 be
accepted;
• the invitation of the Rwanda Medical
Association to host the 74th
General As-
sembly in Kigali in October 2023 be ac-
cepted;
• the meeting dates of the 73rd
General As-
sembly,Berlin 2022 be 5–8 October 2022.
Revision of WMA Articles and Bylaws/Rules
The Committee considered a proposal to
introduce a Self-declaration Statement to
the Nominating Process for WMA Presi-
dency with a revised nomination form.
The Committee recommended that the re-
vised nomination form be approved by the
Council and forwarded to the General As-
sembly for information.
Regional Structure
The Committee considered a proposal to set
up a sixth region to the WMA’s structure,
an Eastern Mediterranean region. Dr. Kloi-
ber explained that this would strengthen the
WMA’s outreach and would give this group
of countries a seat on the Council.
The Committee recommended that the
WMA Articles and Bylaws on a new
WMA Region Eastern Mediterranean be
approved by the Council and be forwarded
to the General Assembly for approval.
Thursday October 4
Associate Members
Dr.Joseph Heyman (America) took the Chair
Dr. Heyman reported that there were 1,115
associate members, 647 from Japan and 468
from the other regions.
Joseph Heyman
Junior Doctors Network
Dr. Caline Mattar, Immediate Past-Chair
of the JDN, reported on the activities of the
Network since October 2017. It had partici-
pated in several policy topics, including hu-
man resources for health and anti-microbial
resistance.It had also worked on a social me-
dia campaign and held a session on the Car-
ing Physicians of the World course.The JDN
had become a member of the World Forum
for Medical Education Council and was also
part of the young professionals’group on the
Alma Ata Declaration on Primary Care.
An informal meeting had taken place at the
WMA Secretariat for junior doctors attend-
ing the WHA, including those participating
as part of the WMA WHA delegation.They
had also held a meeting in Reykjavik on
Well-being and Post Graduate Education.
Dr. Mattar also introduced the new JDN
President, Dr. Chukwuma C. Oraegbunam
from Nigeria.
Report of Past Presidents and Chairs of Coun-
cil Network
A report from the Past Presidents and
Chairs of Council Network was received.
Dr. Kloiber reported on a key engagement
of the Network in support of the WMA
through the WMA Leadership Courses,
social media activities, and outreach to phy-
sicians in the African region.
Declaration of Geneva (Physicians’ Pledge)
A proposed Statement on Action to Stimu-
late use of the Physicians’ Pledge of the
Declaration of Geneva was presented by
Dr. Ankush Bansal (America). He argued
that the pledge was not used in a lot of
countries. It was not on people’s minds.
His resolution recommended that NMAs
encouraged use of the Pledge at their an-
nual meetings and at other medical meet-
ings and that the Pledge should be posted
in hospitals and clinics.
The meeting recommended that the pro-
posal be sent to the General Assembly for
consideration.
Policy Formulation and Consistency
Dr. Wunna Tun (Myanmar) proposed a
Statement on Policy Formulation and Con-
sistency among the World Medical Asso-
ciation and National Medical Associations.
He argued that NMAs should take WMA
policy into consideration when formulating
their own policy. However, speakers raised
doubts about the practicality of such a pro-
posal and on a vote, the meeting agreed to
delete the phrase that ‘When an NMA has
an ethical opinion that is not consistent with
WMA policy, but is consistent with the law
in its country and is clearly generated by be-
nevolence toward patients, WMA may al-
low for national and cultural differences in
formulating its own ethical policies’. How-
ever, the meeting voted to include a new
sentence: ‘When an NMA has an ethical
opinion that is not consistent with WMA
policy, it should inform the WMA about its
concern with existing WMA policy’.
The Committee recommended that the
Statement, as amended, be sent to the Gen-
eral Assembly for consideration.
Proposed Statement on Medically-Indicated
Termination of Pregnancy
An attempt was made to amend the pro-
posed Statement on Medically-Indicated
Termination of Pregnancy by including
provisions to allow physicians a right to
conscientious objection to ‘advising or per-
forming’ an abortion and that ‘in all cases,
‘proper informed consent must be provid-
ed’. But the proposed amendments were
defeated.
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WMA General Assembly
Freedom of Conscience
Dr. Sheila Harding (Canada) said that most
of the discussions at the previous day’s Eth-
ics Committee session related to freedom of
conscience and its protection. She said she
understood that it was too late to introduce
a statement at this meeting, but she in-
formed delegates that she would work on a
proposed policy statement with the Associ-
ates on the Google Group for introduction
at next year’s General Assembly.
Friday October 5
Resumed Council Session
Medical Ethics Committee Report
Biosimilar Medicinal Products
An amendment was proposed to the State-
ment on Biosimilar Medicinal Products to
change the sentence which read ‘Where
appropriate, national medical associations
should lobby against allowing insurers and
health funds to promote biosimilar and
originator product’s interchangeability’ to
read ‘Where appropriate, national medical
associations should lobby against allow-
ing insurers and health funds to require
biosimilar and originator product’s inter-
changeability, and for safe regulations of
interchanging biosimilar medicines where
this is allowed’.
The Council agreed the amendment and
recommended that the Statement be ad-
opted by the General Assembly.
Euthanasia and Physician Assisted Dying
The Council debated the Committee’s
recommendation to circulate to NMAs a
compromise Statement on WMA policy
relating to euthanasia and physician as-
sisted suicide. The Royal Dutch Medical
Associations proposed that a work group
should be set up to consider the responses
from NMAs. Several speakers opposed
this idea, arguing that the responses should
be considered first by the Medical Ethics
Committee. It was too early to establish a
work group. Following a debate, the Royal
Dutch Medical Association withdrew its
proposal.
The Canadian Medical Association ex-
plained to the Council the situation in
Canada where the law on this issue had
changed. Physicians were now concerned
at being called unethical and being con-
demned.That was the CMA’s issue with the
WMA.
The Council agreed that the compromise
Statement should be circulated to members
for comment.
The Council agreed that the following doc-
uments be forwarded to the General As-
sembly for adoption.
Statement on Physicians Convicted of
Genocide, War Crimes or Crimes Against
Humanity
Resolution on Prohibition of Physician
Participation in Capital Punishment
The Council agreed that further work be
carried out on the Statement on Genetics
and Medicine and that when adopted by
the Assembly it should be named the Dec-
laration of Reykjavik.
The Council agreed to recommend to the
Assembly that a workgroup be established
on Assisted Reproductive Technologies
The Council agreed to recommend to the
Assembly that the following documents be
circulated for comment:
• Resolution on the Responsibility of
Physicians in the Documentation and
Denunciation of Acts of Torture and Ill-
treatment
• Sex Selection and Female Foeticide
• Euthanasia and Physician Assisted Dy-
ing
The Council agreed that the following doc-
uments be forwarded to the General As-
sembly for adoption:
• Financial Statement for 2017
• Proposed Budget for 2019
• Associate Membership Dues Increase
• Revision of WMA Articles and Bylaws/
Rules on a Self-declaration Statement to
the Nominating Process for WMA Presi-
dency
• WMA Articles and Bylaws on a new
WMA Region Eastern Mediterranean
The Council agreed to recommend to the
Assembly that the theme for the Scientific
Session at the 70th
General Assembly in
Tbilisi, Georgia in 2019 be ‘Palliative Care’.
The Council agreed to recommend to the
General Assembly that:
• the invitation of the Spanish Medical
Association to host the 71st
General As-
sembly in Cordoba in October 2020 be
accepted;
• the invitation of the British Medical As-
sociation to host the 72nd
General As-
sembly in London in October 2021 be
accepted;
• the invitation of the Rwanda Medical
Association to host the 74th
General As-
sembly in Kigali in October 2023 be ac-
cepted;
• the meeting dates of the 73rd
General As-
sembly,Berlin 2022 be 5–8 October 2022.
Oral reports were given on the Associate
Members group, the Junior Doctors Net-
work, the World Medical Journal and Pub-
lic Relations.
Socio-Medical Affairs
Committee Report
The Council agreed to forward the follow-
ing documents to the General Assembly for
adoption:
• Resolution on Migration
• Statement on Environmental Degrada-
tion and Sound Management of Chemi-
cals
• Statement on the Development and Pro-
motion of a Maternal and Child Health
Handbook
• Statement on Reducing the Global Bur-
den of Mercury
• Resolution on Collaboration Between
Human and Veterinary Medicine
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13
WMA General Assembly
The Council agreed to recommend that the
following documents be circulated for com-
ment:
• Access of Women and Children to
Health Care and the Role of Women in
the Medical Profession
• Statement on Antimicrobial Resistance
• Statement on Reducing Dietary Sodium
Intake
• Statement on Artificial or Augmented
Intelligence in Medical Care
• Statement on Medical Age Assessment
of Unaccompanied Minor Asylum Seek-
ers Minor Asylum Seekers
• Statement on Free Sugar Consumption
and Sugar-sweetened Beverages
• Healthcare Information for All
• Statement on Violence and Health
The Council agreed to recommend to the
General Assembly that a workgroup be
set up on Proposed Declaration on Pseu-
doscience, Pseudotherapies, Intrusion and
Sects in the Field of Health Pseudosci-
ence.
The Council agreed to recommend that the
Declaration of Madrid on Professionally-
Led Regulation should be referred back
for further work and considered at the next
meeting.
Advocacy Report
Dr. Ashok Paul, Chair of the Advocacy
and Communications Panel, reported on
the work of the group. He spoke about
the need for effective liaison between
the WMA and NMAs and the success
of regional meetings of smaller NMAs.
He thought that social media should be
used more effectively for putting forward
WMA statements on issues being dis-
cussed and said Council should consider
ways of making its discussions more trans-
parent.
Medical Ethics Conference
Dr. Jon Snædal (Iceland) reported on the
conference that had been held on the previ-
ous three days.
Nicaragua
Dr. Miguel Roberto Jorge (Brazil) proposed
a motion on the situation in Nicaragua.
He said there had been a massive wave of
violence in Nicaragua for several months,
due to government aggressive repression
towards street protests that started in rela-
tion to reform social security rules.The pro-
tests had been met with disproportionate
use of force by police resulting in hundreds
of deaths. The Government had also fired
hundreds of civil servants, including teach-
ers and health professionals, criminalizing
physicians who had delivered medical care
to protesters as well as to paramilitaries who
were also injured.There were also reports of
police and paramilitaries arresting patients
inside hospitals as well as blocking ambu-
lances in their attempts to provide emer-
gency care to anyone injured. The Brazilian
Medical Association and other NMAs from
the Confemel region proposed that a strong
public statement be issued by the WMA
Council, urging the Nicaraguan govern-
ment to stop its repression, not just against
medical doctors doing their due work but
also to stop using even harder violence
against protesters.
The Council agreed to the motion.
General Assembly Ceremonial
Session
The Session was called to order by the Pres-
ident, Dr. Yoshitake Yokokura.
Dr. Reynir Arngrímsson, President of the
Icelandic Medical Association, welcomed
delegates. He said it was an honour for the
Icelandic Medical Association to welcome
the WMA to Reykjavik for the General
Assembly. For Icelandic physicians it was
a historic moment, just as it was in 1947
when the Association that was barely able
to hold its own general meetings decided to
travel to Paris to join other medical associa-
tions to lay the foundations of the WMA.
The Icelandic Medical Association was
celebrating its 100th
anniversary this year
and the anniversary coincided with Ice-
land becoming a free and sovereign state in
1918. Then, the population of Iceland was
around 19,000. The founders of the Ice-
landic Medical Association were only 34.
Now the membership had grown to 1,400
and the population of Iceland was 350,000.
To be able to provide high quality health
care, Icelandic doctors realised very early
the importance of close communication
with the world outside the island and young
doctors were encouraged to go abroad for
specialisation in all fields of medicine. This
collaboration and educational opportunities
in many countries had enabled the Icelandic
medical profession to provide a high quality
medical service. Medical practice could not
be dissociated from the ethical implications
of medical procedures and they were very
proud to have organised the medical ethics
conference during the week.
Following a musical performance by an Ice-
landic choir, a welcome address was given
by the President of Iceland, Guðni Thorlacius
Jóhannesson. He said the people of Iceland
had long cherished and valued those who
tried to heal others. He spoke about the ad-
vances in science, saying that in today’s glo-
balised world of fake news and populism,
they should strive to defend the principles
of scientific method. If they lost the basis of
science, then they would be in trouble.
The Assembly then rose to recite the Decla-
ration in Geneva, after which the Secretary
General conducted the roll call of delegates.
Dr. Ardis Hoven, Chair of Council, paid
tribute to the retiring President, Dr. Yo-
kokura. She said he had presided with great
distinction over the WMA’s affairs. He had
done excellent work on universal health
care, leading the work on preparedness. He
had represented the WMA at many venues
and had been a caring and gracious Presi-
dent.
Dr. Yokokura then delivered his valedictory
address (see box).
This was followed by the installation of the
new President, Dr. Leonid Eidelman, who
delivered his inaugural address (see box).
The Assembly then adjourned.
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14
WMA General Assembly
Saturday October 6
General Assembly Plenary
Session
The Plenary Session of the General Assem-
bly was called to order by Dr. Frank-Ulrich
Montgomery, Vice Chair of the Council,
deputising for Dr. Ardis Hoven, the Chair
of Council, who had been taken ill.
Keynote Speaker
The Keynote Speaker for the morning was
Unnur Anna Valdimarsdottir, Professor of
Epidemiology, Faculty of Medicine, at the
University of Iceland.The title of her talk was
‘The human health response to major trauma
and life adversities’. She spoke about her re-
search on the effect of trauma on life expec-
tancy, and illustrated this by reference to the
national bankruptcy that hit Iceland 10 years
ago. This led to an increase of attendances
at emergency departments, particularly an
increase in stress levels among women. She
also looked at the effect of natural disasters
on health, as well as the loss of family mem-
bers. She said her data showed that there was
an opportunity for the medical profession to
intervene with people who had suffered se-
vere trauma,and the numbers were not small.
Eighty to 90% of people would experience
some sort of a trauma event in their lives and
this required co-operation across disciplines
in order to give appropriate intervention and
screening. Most people got over these trau-
mas with the help of friends and families.
But there was a considerable proportion who
needed treatment.
President’s Inaugural Address
Dr.Chris Simpson,Past President of the Ca-
nadian Medical Association and a member
of the Canadian Medical Association del-
egation, rose on a point of personal privilege.
He said he was shocked to hear the words
he had written for his 2014 inaugural speech
plagiarised by Dr. Eidelman in his inaugu-
ral address the previous day. Multiple other
parts of Dr. Eidelman’s speech had also been
taken word for word from various blogs and
websites. In the light of this, he called on Dr.
Eidelman to resign. The Canadian Medical
Association then formally moved a motion
demanding Dr. Eidelman’s resignation as he
had failed to meet the ethical standards ex-
pected of an elected officer of the WMA.
Dr. Montgomery suspended the Assembly
for a meeting of the Council executive com-
mittee to examine the allegation. This was
followed by an emergency meeting of the
Council, when Dr. Montgomery confirmed
that parts of Dr. Eidelman’s speech had
been taken from Dr. Simpson’s speech and
from other sources.
Dr. Eidelman then addressed the Council,
saying: ‘My speech was comprised from
many available sources. I worked for many
months on these remarks. I have reviewed
the literature in many journals, websites and
court cases. This specific remark that was
mentioned was based on a cornerstone case
in Supreme Court in Israel which specified
the trust between a patient and a doctor and
the idea was incorporated in my speech. My
speech was originally written in Hebrew
and was translated with a help of English
speech writers. I was totally unaware if any
English phrases were taken from other
sources. And I am really sorry.
‘Certainly if I would know, I would quote as
I did with Thomas Edison’s citation. If our
Canadian colleagues would mention it to
me, I would gladly have an opportunity to
check it with my speech writers and imme-
diately give required credits. I fully accept
the responsibility and express my sincere
regret and apology. I would like to stress
that everything that I said yesterday reflects
my views and beliefs in what I advocate and
struggle for years in Israel and outside’.
After a brief debate, the motion to demand
Dr. Eidelman’s resignation was defeated by
15 votes to one, with six abstentions.
When the Plenary Session of the General
Assembly resumed, Dr. Eidelman repeated
the statement he gave to Council.
Election of the President for 2019–20
Four candidates put their name forward for
election – Dr. Miguel Roberto Jorge (Bra-
zil), Dr. Peteris Apinis (Latvia), Dr. Louis
Francescutti (Canada) and Dr. Osahon En-
abulele (Nigeria).
However, the acting chair Dr. Montgom-
ery announced that the Secretary General
had just received an e mail from the Cana-
dian Medical Association announcing their
resignation from the WMA. As a result,
Dr.  Francescutti was no longer eligible to
stand for President.
The three remaining candidates each ad-
dressed the Assembly for five minutes.
Dr. Jorge said he was presenting his can-
didacy mainly based on the work he had
been developing with the WMA for about
10 years and to keep diversity present in the
Executive Committee. He went on: ‘Since
I became a physician, I have been involved
in many different organizations, always de-
voted to build conditions for excellence in
medical education and training, a continu-
ous updating of medical knowledge and
skills, a high standard on ethics, an inte-
grated work with other health profession-
als, and also promoting public campaigns
on health issues as well as fighting for gov-
ernmental policies that allow better access
to good health services. I am sure that all
these actions are fully coincident with the
objectives of the World Medical Associa-
tion’.
He went on: ‘I am seeking the Presidency
of our Association aiming to bring to its
higher leadership a strong voice coming
from our low and middle income coun-
tries’ physicians, and echoing medical issues
not always present in the World Medical
Association everyday agenda. I am very
confident that I  can help to enhance our
strengths when facing difficult challenges to
improve medical care and ethics worldwide.
I hope to count on your votes in order to
place the needs of every physician – and of
our most vulnerable people – higher in the
Association. You can be sure that will be re-
ally a pleasure and an honor for me to serve
the best interests of our membership’.
Dr. Apinis, in his speech, talked about the
issue of climate change, pollution and over
population. The WMA, together with its
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15
WMA General Assembly
NMAs, had the mandate and the ability
to champion the planet’s cause. He also re-
ferred to the restrictions being put on physi-
cians’ autonomy by bureaucrats around the
world and the need for the WMA to join
forces to resist this.
The final speaker, Dr. Enabulele, Past Presi-
dent of the Nigerian Medical Association,
said he had been attending WMA Assem-
blies since 2006. Since that time he had
been espousing the aspiration for better
health care across the globe and support-
ing patients’ rights and physicians’ rights. If
elected,he said he would harness the poten-
tial of the WMA to ensure that the Asso-
ciation was really about all national medical
associations.
In a vote, Dr. Jorge was elected in the first
round as President for 2019–20.
Dr. Jorge thanked the Assembly for its sup-
port.
Council Report
The Assembly then considered the report of
the Council.
Medical Ethics Committee
Medically-Indicated Termination of Preg-
nancy
Prof. Pablo Requena (Vatican) explained
why his association could not support this
document. He said the revised policy state-
ment had lost some important aspects from
the previous policy, namely the reference to
the value of all life, including the unborn,
and the possibility of conscientious objec-
tion, not only for carrying out abortion but
also for giving advice. He said they had lost
an opportunity in this document to recall
the importance of life, including unborn
life, as most abortions that took place were
on healthy foetuses and healthy women. If
doctors did not send out a clear message
about the value of human life and pre-natal
human life, no-one would.
The Assembly agreed to adopt the State-
ment on Medically-Indicated Termination
of Pregnancy. (see. p. 28)
The Assembly went on to adopt the follow-
ing documents from the Medical Ethics
Committee:
• Statement on Physicians Convicted
of Genocide, War Crimes, or Crimes
Against Humanity (revised) (see. p. 24)
• Statement on Biosimilar Medicinal
Products (see. p. 18)
• Statement on the Ethics of Telemedicine
(revised) (see. p. 31)
Socio-Medical Affairs Committee
The Assembly adopted the following docu-
ments from the Committee:
• Statement on Medical Tourism (see.p. 26)
• Statement on Gender Equality in Medi-
cine (see. p. 23)
• Declaration of Seoul on Professional Au-
tonomy and Clinical Independence (re-
vised) (see. p. 19)
• Statement on Sustainable Development
(see. p. 30)
• Statement on Avian and Pandemic Influ-
enza (revised) (see. p. 17)
• Statement on Nuclear Weapons (revised)
(see. p. 30)
• Statement on Environmental Degrada-
tion and Sound Management of Chemi-
cals (revised) (see. p. 20)
• Statement on the Development and Pro-
motion of a Maternal and Child Health
Handbook (see. p. 25)
• Resolution on Migration (see.p. 29)
The Assembly agreed that the following
policies be rescinded and archived:
• Resolution on Poppies for Medicine
Project for Afghanistan
• Resolution on the Economic Crisis: Im-
plications for Health
• Statement on Professional Responsibil-
ity for Standards of Medical Care be re-
scinded and archived.
The Assembly received for information two
revised policies:
• Statement on Reducing the Global Bur-
den of Mercury
• Resolution on Collaboration Between
Human and Veterinary Medicine
Finance and Planning
Committee
The Treasurer, Dr. Andrew Dearden, gave a
financial report and the Assembly adopted
the following documents:
• Audited Financial Statement for the year
ending 31 December 2017
• Budget for 2019
• Revision of WMA Articles and Bylaws/
Rules on a Self-declaration Statement to
the Nominating Process for WMA Presi-
dency
• WMA Articles and Bylaws on a new
WMA Region Eastern Mediterranean
• Associate Membership Dues Increase
The Assembly approved the following fu-
ture meetings:
• that the invitation of the Spanish Medi-
cal Association to host the 71st
General
Assembly in Cordoba in October 2020 be
accepted;
• that the invitation of the British Medi-
cal Association to host the 72nd
General
Assembly in London in October 2021 be
accepted;
• that the invitation of the Rwanda Medi-
cal Association to host the 74th
General
Assembly in Kigali in October 2023 be
accepted;
• that the meeting dates of the 73rd
General
Assembly, Berlin 2022 be 5–8 October
2022.
The Assembly agreed that the theme of the
scientific session of the 70th
General As-
sembly in Tbilisi, Georgia in 2019 be ‘Pal-
liative care’.
The Assembly received the following docu-
ments for information
• Membership Dues Payments for 2018
• Dues Categories 2019
Associate Members
Dr. Ankush Bansal gave a report from the
Associate Members meeting.
He presented two proposed Statements on
Action to Stimulate Use of the Physicians’
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16
WMA General Assembly
Pledge of the Declaration of Geneva and
on Policy Formulation and Consistency
among the World Medical Association and
National Medical Associations. The As-
sembly agreed to forward both proposed
Statements to the Council for consider-
ation.
Dr. Dainius Puras
Dr. Dainius Puras, UN Special Rappor-
teur on the Right to Health, Office of
the United Nations High Commissioner
for Human Rights, gave a talk entitled
‘Presentation on Opportunities and chal-
lenges on the way to realization of the
right to physical and mental health’. He
spoke about his work, which he said was
very challenging. He was the first medi-
cal doctor to become rapporteur. He said
that good primary care and the work of
GPs was absolutely crucial, although some
countries had tried to avoid primary care
and this was not good practice. He spoke
about mental health and said it needed
much more investment. He said this year
was the 70th
anniversary of the Declara-
tion of Human Rights and this coincided
with attacks on human rights globally. It
was important for the medical profession
to stand on the side of protecting and
promoting all human rights. But also the
evidence based approach was under attack
with fake news and post truth.This was an
important time for all in the health field to
unite to protect what was achieved in 1948
when people had a better understanding
of why the Declaration was needed. Now
the world was in danger of forgetting what
happened in the past and it was the medi-
cal profession’s duty to remind politicians
and the general public what human rights
were about.
Dr. Poonam Dhavan
Dr. Poonam Dhavan, Senior Migration
Health Policy Advisor at the International
Organization for Migration, gave a pre-
sentation on Health and Migration. She
said her organisation had 10,000 people
working around the world, 1,200 of them
on health. There were 60 health assess-
ment centres worldwide. She said that mi-
gration was a determinant of health. They
faced many challenges, among them the
issue of monitoring.There was a lack of evi-
dence on issues of financing and attacks on
health workers. She said there was a need
to change the perceptions about migration
and a need to bring out positive migration
stories. Migration health was about shared
responsibilities and about wanting to work
together. Migration was not about us and
them. It was about all of us.
Susannah Sirkin
The next presentation was given by Susan-
nah Sirkin, Director of International Pol-
icy and Partnerships, at the Physicians for
Human Rights. Her address was entitled
’The criminalization of healthcare’, which
she described as an ’alarming situation cry-
ing out for your attention and response’
and ‘a global emergency that threatens not
only health for many, but the preservation
and protection of the profession of medi-
cine altogether’. She said that the core eth-
ics of the medical profession were under
threat in dozens of countries in situations
of armed conflict and civil unrest and in
an undefined and unending and undefin-
able war on terrorism that had affected
the medical profession in a perverse and
threatening way.
The insecurity of access to health care in
these contexts was a fundamental threat to
the right to health. The neutrality of medi-
cal care had been violated over the years in
Somalia, El Salvador, in Kosovo, Iraq and
Chechnya, and in the past decade they had
witnessed the utter erosion of respect for
the duty of the doctor to treat the sick and
wounded without discrimination.
In the past 10 years, they had seen an
alarming increase in outright and appar-
ently intentional attacks on health facilities
and personnel in armed conflicts in direct
violation of the Geneva Convention protec-
tions.They were war crimes, and when they
were widespread and systematic, they were
crimes against humanity.
What they were seeing in Syria and Yemen
had virtually no precedent in the last half-
century. In Yemen there had been a horrific,
utter destruction of the health system and
in Syria deliberate, intentional attacks car-
ried out with total impunity.
People were calling this ‘the new normal’
but it was aberrant and should be highly ab-
normal, and it was up to the doctors of the
world to make sure this condition was com-
pletely unacceptable. They could not stand
by this outright assault on the practice of
medicine.
Dr. S.M. Johnson Chiang Dr. Johnson Chiang,
President of the World Veterinary Association,
spoke about the co-operation between the WVA
and the WMA over several years. Joint press
releases had been issued, most recently on the
elimination of rabies.
Open Session
Dr.Sinan Adiyaman,President of the Turk-
ish Medical Association, addressed the As-
sembly on the situation in his country. Fol-
lowing a press release issued by the Turkish
Medical Association stating that ‘War is a
Public Health Issue, members of the As-
sociation’s central committee had been de-
tained for eight days.The WMA had issued
a press release in their support. But TMA
members were still on trial for making pro-
paganda in favour of terrorist organisations.
Criminal action was still pending against
voluntary health workers and the TMA. He
thanked the WMA and NMAs for their
continued support.
The Assembly was then brought to a close
after the Secretary General thanked the
Icelandic Medical Association for their
hospitality.
Mr. Nigel Duncan
Public Relation Consultant,
WMA
E-mail: nduncan@ndcommunications.co.uk
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17
WMA General Assembly
WMA General Assembly
WMA Statement on Avian and
Pandemic Influenza
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa,
October 2006 and amended by the 69th
WMA General Assembly,
Reykjavik, Iceland, October 2018
Preamble
1. Pandemic influenza occurs approximately three or four times
every century. It usually occurs when a novel influenza A virus
emerges that can easily be transmitted from person-to-person,
to which humans have little or no immunity. Infection control
and social distancing practices can help slow down the spread of
the virus. Vaccine development can be challenging as the pan-
demic strain may not be accurately predicted. Adequate supplies
of antivirals are key for treatment of specific at-risk population
and controlling further spread of the outbreak.
2. Avian influenza is a zoonotic infection of birds and poultry, and
can cause sporadic human infections. Birds act as reservoir and
shed the virus in their feces, mucous and saliva. In addition, a
new pandemic virus could develop if a human became simul-
taneously infected with avian and human influenza viruses, re-
sulting in gene swapping and a new virus strain for which there
may be no immunity. Humans are infected if they are exposed
through the mouth, eyes, or from the inhalation of virus par-
ticles. Limited evidence of human to human transmission has
been reported as well.
3. This statement alongside with WMA Statement on Epidemics
and Pandemics provides guidance to National Medical Associa-
tions and physicians on how they should be involved in their
respective country’s pandemic influenza planning and how to
respond to Avian Influenza or pandemic influenza.
Recommendations
Avian Influenza
In the event of an avian influenza outbreak, the following measures
should be taken:
• Sources of exposure should be avoided when possible as this is the
most effective prevention measure.
• Personal protective equipment should be used and hand hygiene
practices emphasized for personnel handling poultry as well as
members of the healthcare team.
• All infected/exposed birds should be destroyed with proper dis-
posal of carcasses, and rigorous disinfection or quarantine of
farms.
• Stockpiles of vaccines and antivirals should be maintained for use
during an outbreak.
• Antiviral medications such as neuraminidase inhibitors may be
used for treatment.
Pandemic Influenza Preparedness
WHO and National Public Health Officials:
• The coordination of the international response to an influenza
pandemic is the responsibility of the World Health Organiza-
tion (WHO).The WHO currently uses an all-hazards risk based
approach, to allow for a coordinated response based on varying
degrees of severity of the pandemic.
The WHO should:
• Offer technical and laboratory assistance to affected countries if
needed and continuously monitor activity levels of potential pan-
demic influenza strains continuously, ensuring that the designa-
tion of “Public Health Emergency of International Concern” is
done in a timely manner if needed.
• Monitor and coordinate processes by which governments share
biological materials including virus strains, to facilitate the pro-
duction of and ensure access to vaccines globally.
• Communicate available information on influenza activity of con-
cern as early as possible to allow for a timely response.
• National governments are urged to develop National Action
plans to address the following points:
• Ensure that there is adequate local capacity for diagnosis and
surveillance to allow continuous monitoring of influenza activity
around the country.
• Consider the surge capacity of hospitals, laboratories, and public
health infrastructure and improve them if necessary.
• Identify legal and ethical frameworks as well as governance struc-
tures in relation to the pandemic planning.
• Identify the mechanisms and the relevant authorities to initiate
and escalate interventions to slow the spread of the virus in the
community such as school closures,quarantine,border closures etc.
• Prepare risk and crisis communication strategies and messages in
anticipation of public and media fear and anxiety.
• Governments are also urged to share biological materials namely
virus strains and others, to facilitate the production and ensure
access to vaccines globally.
• Ensure that diagnostics and surveillance efforts are continued and
that adequate vaccine and antiviral stockpiles are established.
• Establish protocols to manage patients in the community, carry
out triage in healthcare facilities, provide ventilation manage-
ment, and handle infectious waste.
• Allocation of vaccine doses, antivirals and hospital beds should be
coordinated with experts.
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18
WMA General Assembly
WMA General Assembly
• Priority for vaccination should be given to the highest risk groups
including those required to maintain essential services, including
health care services.
• Guidance and timely information to regional health departments,
health care organizations, and physicians.
• Preparation for an increase in demand for healthcare services
and absences of health care providers especially if clinical sever-
ity of the illness is high. In such cases prioritization and co-
ordination of available resources is essential. This may include
tapping into private sector capacity where state resources are
insufficient.
• Ensure adequate funding is allocated for pandemic preparedness
and response as well as its health and social consequences.
• Make sure that mechanisms are in place to ensure the safety of
healthcare facilities, personnel and the supply chains for vaccines
and antivirals
• Promote and fund research to develop vaccines and effective
treatments with lasting effects against influenza.
• Encourage collaboration between human and veterinary medi-
cine in the prevention, research and control of avian influenza.
• National Medical Associations are urged to:
• Delineate their involvement in the national pandemic influenza
preparedness plan, which may include increasing capacity build-
ing amongst physicians, participating in guideline development
and communication with healthcare professionals.
• Help educate the public about avian and pandemic influenza.
• When feasible, coordinate with other healthcare professionals’
organizations as well as other NMAs to identify common issues
and congruent policies related to pandemic influenza prepared-
ness and response.
• Consider implementing support strategies for members involved
in the response including mental health services, facilitation of
health emergency response teams, and locum relief.
• Advocate before and during a pandemic,for allocation of adequate
resources to meet foreseeable and emerging needs of healthcare,
patients and the general public.
• Encourage health personnel to protect themselves by vaccination.
• Develop their own organization-specific business contingency
plans to ensure continued support of their members.
• Physicians:
• Must be sufficiently knowledgeable about pandemic influenza
and transmission risks, including local, national and international
epidemiology.
• Should implement infection control practices and vaccination, to
protect themselves as well as other staff members during seasonal
and pandemic influenza outbreaks.
• Must participate in local/regional pandemic influenza prepared-
ness planning and training.
• Should develop contingency plans to deal with possible disrup-
tions in essential services and personnel shortages.
WMA Statement on Biosimilar
Medicinal Products
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Preamble
4. The expiry of patents for original biotherapeutics has led to the
development and approval of copies, called ‘similar biological
medicinal products’ or ‘biosimilars’ that are highly similar to a
previously approved biological,product,known as the originator
or reference product.
5. In light of the fact that biosimilars are made in living organ-
isms, there may be some minor differences from the reference
medicine, as minor variability is a characteristic attribute of all
biological medicines.The manufacture of biosimilars is generally
more complex than the manufacture of chemically derived mol-
ecules.Therefore, the active substance in the final biosimilar can
have an inherent degree of minor variability. Innovator biologics
also have inherent batch-to-batch variability,and for that reason
biosimilars are not always interchangeable with the reference
products, even after regulatory approval.
6. Biosimilars are not the same as generics. A generic drug is an
identical copy of a currently licenced pharmaceutical product
that has an expired patent protection and must contain the ‘same
active ingredients as the original formulation’. A biosimilar is a
different product with a similar, but not identical, structure that
elicits a similar clinical response. As a result, biosimilar medi-
cines have the potential to cause an unwanted immune response.
Whereas generics are interchangeable, biosimilars are not al-
ways interchangeable.
7. Biosimilars have been available in Europe for almost a decade fol-
lowing their approval by the European Medicines Agency (EMA)
in 2005. The first biosimilar was approved by the Food and Drug
Administration (FDA) for use in the United States in 2015.
8. Biosimilar medicines have transformed the outlook for patients
with chronic and debilitating conditions,as it is possible to obtain
similar efficacy as that of the reference product at a lower cost.
9. Biosimilars will also increase availability for patients without ac-
cess to the bio-originator. Greater global access to effective bio-
pharmaceuticals can reduce disability, morbidity, and mortality
associated with various chronic diseases.
10. Nonetheless, the potentially lower cost of biosimilars raises the
risk that insurers and health care providers may favor them over
the originator product, even when they may not be appropri-
ate for an individual patient or in situations when they have
not demonstrated adequate clinical equivalence to an original
biological product. The decision to prescribe biosimilars or to
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switch patients from reference medicine to a biosimilar must
be made by the attending physicians, not by health insurance
companies.
Recommendations
1. National medical associations should work with their govern-
ments to develop national guidance on safety of biosimilars.
2. National medical associations should advocate for delivering
biosimilar therapies that are as safe and effective as their refer-
ence products.
3. National medical associations should strive to ensure that physi-
cian autonomy is preserved in directing which biologic product
is dispensed.
4. Where appropriate, national medical associations should lobby
against allowing insurers and health funds to require biosimilar
and originator product’s interchangeability, and for safe regula-
tions of interchanging biosimilar medicines where this is allowed.
5. Physicians must ensure that patient medical records accurately
reflect the biosimilar medicine that is being prescribed and taken.
6. Physicians shouldn’t prescribe a biosimilar to patients already
showing success with the originator product, unless clinical
equivalence has been clearly demonstrated and established and
patients are adequately informed and have given consent. There
should be no substitution between biosimilars and other drugs
without the attending physcian’s permission.
7. Physicians should seek to improve their understanding of the dis-
tinctions between biosimilar products that are highly similar to or
are interchangeable with an originator product; raise awareness
of the issues surrounding biosimilars and interchangeability; and
promote clearly delineated labelling of biosimilar products.
8. Physicians should remain vigilant and report to the manufac-
turer, as well as through the designated regulatory pathways, any
adverse events suffered by patients using originator biological
products or biosimilars.
WMA Declaration of Seoul
on Professional Autonomy and
Clinical Independence
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October
2008 And amended by the 69th
WMA General Assembly, Reykjavik,
Iceland, October 2018
The WMA reaffirms the Declaration of Madrid on professionally-
led regulation.
The World Medical Association recognises the essential nature of
professional autonomy and physician clinical independence, and
states that:
1. Professional autonomy and clinical independence are essential
elements in providing quality health care to all patients and
populations. Professional autonomy and independence are es-
sential for the delivery of high quality health care and therefore
benefit patients and society.
2. Professional autonomy and clinical independence describes the
processes under which individual physicians have the freedom
to exercise their professional judgment in the care and treatment
of their patients without undue or inappropriate influence by
outside parties or individuals.
3. Medicine is highly complex. Through lengthy training and ex-
perience, physicians become medical experts weighing evidence
to formulate advice to patients. Whereas patients have the right
to self-determination, deciding within certain constraints which
medical interventions they will undergo,they expect their physi-
cians to be free to make clinically appropriate recommendations.
4. Physicians recognize that they must take into account the struc-
ture of the health system and available resources when mak-
ing treatment decisions. Unreasonable restraints on clinical
independence imposed by governments and administrators are
not in the best interests of patients because they may not be
evidence based and risk undermining trust which is an essential
component of the patient-physician relationship.
5. Professional autonomy is limited by adherence to professional
rules, standards and the evidence base.
6. Priority setting and limitations on health care coverage are
essential due to limited resources. Governments, health care
funders (third party payers), administrators and Managed Care
organisations may interfere with clinical autonomy by seeking
to impose rules and limitations.These may not reflect evidence-
based medicine principles, cost-effectiveness and the best inter-
est of patients. Economic evaluation studies may be undertaken
from a funder’s not a users’ perspective and emphasise cost-sav-
ings rather than health outcomes.
7. Priority setting, funding decision making and resource alloca-
tion/limitations processes are frequently not transparent. A lack
of transparency further perpetuates health inequities.
8. Some hospital administrators and third-party payers consider
physician professional autonomy to be incompatible with pru-
dent management of health care costs. Professional autonomy
allows physicians to help patients make informed choices, and
supports physicians if they refuse demands by patients and fam-
ily members for access to inappropriate treatments and services.
9. Care is given by teams of health care professionals, usually led by
physicians.No member of the care team should interfere with the
professional autonomy and clinical independence of the physi-
cian who assumes the ultimate responsibility for the care of the
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patient. In situations where another team member has clinical
concerns about the proposed course of treatment,a mechanism to
voice those concerns without fear of reprisal should exist.
10. The delivery of health care by physicians is governed by ethical
rules, professional norms and by applicable law. Physicians con-
tribute to the development of normative standards, recognizing
that this both regulates their work as professionals and provides
assurance to the public.
11. Ethics committees, credentials committees and other forms of
peer review have long been established, recognised and accepted
by organised medicine as ways of scrutinizing physicians’profes-
sional conduct and, where appropriate, may impose reasonable
restrictions on the absolute professional freedom of physicians.
12. The World Medical Association reaffirms that professional au-
tonomy and clinical independence are essential components of
high quality medical care and the patient-physician relationship
that must be preserved.The WMA also affirms that professional
autonomy and clinical independence are core elements of medi-
cal professionalism.
WMA Statement on Environ-
mental Degradation and Sound
Management of Chemicals
Adopted by the 61st
WMA General Assembly, Vancouver, Canada,
October 2010 and amended by the 69th
WMA General Assembly,
Reykjavik, Iceland, October 2018
Preamble
1. This Statement focuses on one important aspect of environ-
mental degradation, which is environmental contamination by
domestic and industrial substances. It emphasizes the harmful
chemical contribution to environmental degradation and physi-
cians’role in promoting sound management of chemicals as part
of sustainable development,especially in the healthcare environ-
ment.
2. Unsafe management of chemicals has potential adverse impacts
on human health and human rights,with vulnerable populations
being most at risk.
3. Most chemicals to which humans are exposed come from indus-
trial sources and include, toxic gases, food additives, household
consumer and cosmetic products, agrochemicals, and substances
used for therapeutic purposes, such as drugs and dietary supple-
ments. Recently, attention has been concentrated on the effects
of human engineered (or synthetic) chemicals on the environ-
ment, including specific industrial or agrochemicals and on new
patterns of distribution of natural substances due to human ac-
tivity. As the number of such compounds has multiplied, gov-
ernments and international organizations have begun to develop
a more comprehensive approach to their safe regulation.The in-
creasing amount of plastic waste in our environment is another
serious concern, that needs to be addressed.
4. While governments have the primary responsibility for estab-
lishing a framework to protect the public’s health from chemical
hazards, the World Medical Association, on behalf of its mem-
bers, emphasizes the need to highlight the human health risks
and make recommendations for further action.
Background
Chemicals of Concern
5. During the last half-century, the use of chemical pesticides and
fertilizers dominated agricultural practice and manufacturing
industries rapidly expanded their use of synthetic chemicals in
the production of consumer and industrial goods.
6. The greatest concern relates to chemicals, which persist in the
environment, have low rates of degradation, bio-accumulate
in human and animal tissue (concentrating as they move up
the food chain), and which have significant harmful impacts
on human health and the environment (particularly at low
concentrations). Some naturally occurring metals including
lead, mercury, and cadmium have industrial sources and are
also of concern. Advances in environmental health research
including environmental and human sampling and measuring
techniques, and better information about the potential of low
dose human health effects have helped to underscore emerging
concerns.
7. Health effects from chemical emissions can be direct (occur-
ring as an immediate effect of the emission) or indirect. Indirect
health effects are caused by the emissions’ effects on water, air
and food quality as well as the alterations in regional and global
systems, such as red tide in many oceans, and the ozone layer
and the climate, to which the emissions may contribute.
National and International Actions
8. The model of regulation of chemicals varies widely both within
and between countries, from voluntary controls to statutory leg-
islation. It is important that all countries move to a coherent,
standardized national legislated approach to regulatory control.
Furthermore, international regulations must be coherent such
that developing countries will not be forced by economic cir-
cumstances to accept elevated toxic exposure levels.
9. Synthetic chemicals include all substances that are produced by,
or result from, human activities including industrial and house-
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hold chemicals, fertilizers, pesticides, chemicals contained in
products and in wastes, prescription and over-the-counter drug
products and dietary supplements, and unintentionally pro-
duced byproducts of industrial processes or incineration, like di-
oxins. Furthermore, nanomaterials may need explicit regulation
beyond existing frameworks.
Strategic approach to international chemicals management
10. Worldwide hazardous environmental contamination persists
despite several international agreements on chemicals, making
a more comprehensive approach to chemicals essential. Reasons
for ongoing contamination include persistence of companies,
absolute lack of controls in some countries, lack of awareness
of the potential hazards, inability to apply the precautionary
principle, non-adherence to the various conventions and treaties
and lack of political will. The Strategic Approach to International
Chemicals Management (SAICM) was adopted in Dubai, on
February 6, 2006 by delegates from over 100 governments and
representatives of civil society. This is a voluntary global plan of
action designed to assure the sound management of chemicals
throughout their life cycle so that, by 2020, chemicals are used
and produced in ways that minimize significant adverse effects
on human health and the environment. The SAICM addresses
both agricultural and industrial chemicals, covers all stages of
the chemical life cycle of manufacture, use and disposal, and in-
cludes chemicals in products and in wastes.
Plastic waste
11. Plastic has been part of life for more than 100 years and is regu-
larly used in some form by nearly everyone. While some biode-
gradable varieties are being developed, most plastics break down
very slowly with the decomposition process taking hundreds of
years. This means that most plastics that have ever been manu-
factured are still on Earth, unless they have been burnt, thus
polluting the atmosphere with poisonous smoke.
12. Concerns about the use of plastic include accumulation of waste
in landfills and in natural habitats, terrestrial and marine, physi-
cal problems for wildlife resulting from ingestion or entangle-
ment in plastic, the leaching of chemicals from plastic products
and the potential for plastics to transfer chemicals to wildlife
and humans. Many plastics in use today are halogenated plastics
or contain other additives used in production, that have poten-
tially harmful effects on health (e.g. carcinogenic or promoting
endocrine disruption).
13. Our current usage of plastic is not sustainable, accumulating
waste and therefore contributing to environmental degradation
and potentially harmful effects on health. Specific regulation is
therefore needed to counter the harmful distribution of slowly
degradable plastic waste into the environment and the incinera-
tion of such waste which often creates toxic byproducts.
World Medical Association
(WMA) Recommendations
14. Despite national and international initiatives, chemical contam-
ination of the environment due to inadequately controlled pro-
duction and usage continues to exert harmful effects on global
public health. Evidence linking some chemicals to some health
issues is strong, but far from all chemicals have been tested for
their health or environmental impacts. This is especially true
for newer chemicals or nano materials, particularly at low doses
over long periods of time. Plastic contamination of our natural
environment, including in the sea where plastic decomposes to
minute particles, is an additional area of serious concern. Physi-
cians and the healthcare sector are frequently required to make
decisions concerning individual patients and the public as a
whole based on existing data. Physicians therefore recognize
that they, too, have a significant role to play in closing the gap
between policy formation and chemicals management and in
reducing risks to human health.
15. The World Medical Association reaffirms its commitment to
advocate for the environment in order to protect health and life,
and recommends that:
Advocacy
16. National Medical Associations (NMAs) advocate for legislation
that reduces chemical pollution, enhances the responsibities of
chemical manufacturers, reduces human exposure to chemicals,
detects and monitors harmful chemicals in both humans and
the environment, and mitigates the health effects of toxic expo-
sures with special attention to fertility for women and men and
vulnerability during pregnancy and early childhood.
17. NMAs urge their governments to support international efforts
to restrict chemical pollution through safe management, or phase
out and safer substitution when unmanageable (e.g. asbestos),
with particular attention to developed countries aiding developing
countries to achieve a safe environment and good health for all.
18. NMAs facilitate better inter-sectoral collaboration between
government ministries/departments responsible for the envi-
ronment and public health.
19. NMAs promote public awareness about hazards associated with
chemicals (including plastics) and what can be done about it.
20. Modern medical diagnosis and treatment relies heavily on the
single use of packaged clean or sterile materials with various
plastic components, whether the device itself or its packaging.
NMAs should encourage research and the dissemination of
practices that can reduce or eliminate this component of envi-
ronmental degradation.
21. Physicians and their medical associations advocate for environ-
mental protection, disclosure of product constituents, ­
sustainable
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development, green chemistry and green hospitals within their
communities, countries and regions.
22. Physicians and their medical associations should support the
phase out of mercury and persistent bioaccumulative and toxic
chemicals in health care devices and products and avoid incin-
eration of wastes from these products which may create further
toxic pollution.
23. Physicians and their medical associations should support the
Globally Harmonized System of Classification and Labelling of
Chemicals (GHS) and legislation to require an environmental
and health impact assessment prior to the introduction of a new
chemical or a new industrial facility.
24. Physicians should encourage the publication of evidence of the
effects of different chemicals and plastics, and dosages on human
health and the environment. These publications should be acces-
sible internationally and readily available to media, non-govern-
mental organizations (NGOs) and concerned citizens locally.
25. Physicians and their medical associations should advocate for
the development of effective and safe systems to collect and
dispose of pharmaceuticals that are not consumed. They should
also advocate for the introduction worldwide of efficient systems
to collect and dispose of plastic waste.
26. Physicians and their medical associations should encourage ef-
forts to curb the manufacture and use of plastic packaging and
plastic bags, to halt the introduction of plastic waste into the
environment, and to phase out and replace plastics with more
biocompatible materials. These efforts may include measures to
enhance recycling and specific regulations limiting the use of
plastic packaging and plastic bags.
27. Physicians and their medical associations should support efforts
to rehabilitate or clean areas of environmental degradation based
on a “polluter pays”and precautionary principles and ensure that
moving forward, such principles are built into legislation.
28. The WMA, NMAs and physicians should urge governments to
collaborate within and between departments to ensure coherent
regulations are developed.
Leadership
The WMA:
29. Supports the goals of the Strategic Approach to International
Chemicals Management (SAICM), which promotes best prac-
tices in the handling of chemicals by utilizing safer substitu-
tion, waste reduction, sustainable non-toxic building, recycling,
as well as safe and sustainable waste handling in the health care
sector.
30. Cautions that these chemical practices must be coordinated
with efforts to reduce greenhouse gas emissions from health care
and other sources to mitigate its contribution to global warming.
31. Urges physicians, medical associations and countries to work
collaboratively to develop systems for event alerts to ensure
that health care systems and physicians are aware of high-risk
industrial accidents as they occur, and receive timely and ac-
curate information regarding the management of these emer-
gencies.
32. Urges local, national and international organizations to focus
on sustainable production, safer substitution, green safe jobs,
and consultation with the health care community to ensure that
damaging health impacts of development are anticipated and
minimized.
33. Emphasizes the importance of the safe disposal of pharmaceuti-
cals as one aspect of health care’s responsibility and the need for
collaborative work in developing best practice models to reduce
this part of the chemical waste problem.
34. Encourages environmental classification of pharmaceuticals in
order to stimulate prescription of environmentally less harmful
pharmaceuticals.
35. Encourages local, national and international efforts to reduce
the use of plastic packaging and plastic bags.
36. Encourages ongoing outcomes research on the impact of regu-
lations and monitoring of chemicals on human health and the
environment.
The WMA recommends that Physicians:
37. Work to reduce toxic medical waste and exposures within their
professional settings as part of the World Health Professional
Alliance’s campaign for Positive Practice Environments.
38. Work to provide information on the health impacts associated
with exposure to toxic chemicals, how to reduce patient expo-
sure to specific agents and encourage behaviors that improve
overall health.
39. Inform patients about the importance of safe disposal of phar-
maceuticals that are not consumed.
40. Work with others to help address the gaps in research regarding
the environment and health (i.e., patterns and burden of dis-
ease attributed to environmental degradation; community and
household impacts of industrial chemicals; the effects, including
on health, of distribution of plastic and of plastic waste into our
natural environment; the most vulnerable populations and pro-
tections for such populations).
Professional Education & Capacity Building
The WMA recommends that:
41. Physicians and their professional associations assist in build-
ing professional and public awareness of the importance of
the environment and global chemical pollutants on personal
health.
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42. NMAs develop tools for physicians to help assess their patients’
risk from chemical exposures.
43. Physicians and their medical associations develop locally appro-
priate continuing medical education on the clinical signs, diag-
nosis, treatment and prevention of diseases that are introduced
into communities as a result of chemical pollution and exacer-
bated by climate change.
44. Environmental health and occupational medicine should be-
come a core theme in medical education.Medical schools should
encourage the training of sufficient specialists in environmental
health and occupational medicine.
WMA Statement on Gender
Equality in Medicine
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Preamble
1. The WMA notes the increasing trend around the world for
women to enter medical schools and the medical profession,
and believes that the study and the practice of medicine must
be transformed to a greater or lesser extent in order to sup-
port all people who study to become or practice as physicians,
of whatever gender. This is an essential process of moderniza-
tion by which inclusiveness is promoted by gender equality.This
statement proposes mechanisms to identify and address barriers
causing discrimination between genders.
2. In many countries around the world, the number of women
studying and practicing medicine has steadily risen over the past
decades, surpassing 50% in many places.
3. This development offers opportunities for action, including in
the following areas:
–
– Greater emphasis on a proper balance of work and family life,
while supporting the professional development of individual
physicians.
–
– Encouragement and actualization of women in academia, lead-
ership and managerial roles.
–
– Equalization of pay and employment opportunities for men
and women, the elimination of gender pay gaps in medicine,
and the removal of barriers negatively affecting the advance-
ment of female physicians.
4. The issue of women in medicine was previously recognized in
the WMA Resolution on Access of Women and Children to
Health Care and the Role of Women in the Medical Profession
which, among other things, called for increased representation
and participation in the medical profession, especially in light
of the growing enrolment of women in medical schools. It also
called for a higher growth rate of membership of women in Na-
tional Medical Associations (NMAs) through empowerment,
career development, training and other strategic initiatives.
Recommendations
Increased presence of women in academia, leadership and man-
agement roles.
5. National Medical Associations/Medical Schools/Employers are
urged to facilitate the establishment of mentoring programs,
sponsorship, and active recruitment to provide medical students
and physicians with the necessary guidance and encouragement
necessary to undertake leadership and management roles.
6. NMAs should explore opportunities and incentives to encour-
age both men and women to pursue diverse careers in medicine
and apply for fellowships, academic, senior leadership and man-
agement positions.
7. NMAs should lobby for gender equal medical education and
work policies.
8. NMAs should encourage the engagement of both men and
women in health policy organizations and professional medical
organizations.
Work-Life Balance
9. Physicians should recognize that an appropriate work-life bal-
ance is beneficial to all physicians, but that women may face
unique challenges to work-life balance imposed by societal ex-
pectations concerning gender roles that must be addressed to
solve the issue. Healthcare employers can show leadership and
help tackle this imbalance by:
–
– Ensuring women who go on maternity leave are able to access
all their rights and entitlements;
–
– Introducing programmes which encourage men as well as women
to take parental leave, so that women are able to pursue their ca-
reers and men are able to spend important time with their families.
10. Hospitals and other places of employment should strive to
provide and promote access to high quality, affordable, flexible
childcare for working parents, including the provision of onsite
housing and childcare where appropriate. These services should
be available to both male and female physicians, recognizing the
need for a better work-life balance. Employers should provide
information on available services which support the compatibil-
ity of work and family.
11. Hospitals and other places of employment should be receptive
to the possibility of flexible and family-friendly working hours,
including part-time residencies,posts,and professional appoint-
ments.
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12. There is a need for increased research on alternative work sched-
ules and telecommunication opportunities that will allow flex-
ibility in balancing work-life demands.
13. NMAs should advocate for the enforcement and, where nec-
essary, the introduction of policy mandating appropriate paid
parental leave and rights in their respective countries.
14. Medical workplaces and professional organisations should have
fair, impartial and transparent policies and practices to give all
physicians and medical students equal access to employment,
education and training opportunities in medicine.
Pregnancy and Parenthood
15. It should be illegal for employers to ask applicants about preg-
nancy and/or family planning in relation to work.
16. Employers should assess the risks to pregnant physicians and
their unborn children, when a physician has recently given
birth and when she is breastfeeding. Where it is found, or a
medical practitioner considers, that an employee or her child
would be at risk were she to continue with her normal du-
ties, the employer should provide suitable alternative work
for which the physician should receive her normal rate of
pay. Physician should have the right to not work night shifts
or on-call shifts during the later part of pregnancy, without
negative consequences on salary, employment or progression
in residency.
17. Pregnant physicians should have equal training opportunities in
post-graduate training.
18. Parents should have the right to take adequate parental leave
without negative consequences on their employment, training
or career opportunities.
19. Parents should have the right to return to the same position
after parental leave, without the fear of termination.
20. Employers and training bodies should provide necessary sup-
port to any physician returning after a prolonged period of ab-
sence including parental, maternity and elder-care leave.
21. Mothers should be able to breastfeed (or be given protected
time for breast pumping) during work hours, within the current
guidelines from the WHO.
22. Workplaces should provide adequate accommodation for wom-
en who are breastfeeding including designated areas for breast-
feeding, breast pumping, and milk storage, which are quiet, hy-
gienic, and private.
Changes in organisational culture
23. The medical profession and employers should work to eliminate
discrimination and harassment on the basis of gender and cre-
ate a supportive environment that allows equal opportunities for
training, employment and advancement.
24. Family friendliness should be part of the organizational culture
of hospitals and other places of employment.
Workforce planning and research
25. NMAs should encourage governments to take the increasing
number of women entering medicine into consideration in the
context of long-term workforce planning. A diverse workforce
is beneficial to the health care system and to patients. Organiza-
tions delivering healthcare should focus on ensuring systems are
appropriately resourced to ensure that all those working within
them are able to deliver safe care to patients and are appropri-
ately and equitably rewarded. Governments should also work to
counteract negative attitudes and behaviour, bias, and/or out-
dated norms and values from organizations and individuals.
26. NMAs should encourage governments to invest in research to
identify those factors that drive women and men to choose cer-
tain fields of specialization early on in their medical education
and training and strive to address any identified barriers in order
to achieve equal representation of men and women in all fields
of medicine.
27. NMAs should encourage governments and employers to ensure
that men and women receive equal compensation for commensu-
rate work and strive to eliminate the gender pay gap in medicine.
WMA Statement on Physicians
Convicted of Genocide, War
Crimes or Crimes Against
Humanity
Adopted by the 49th
WMA General Assembly, Hamburg, Germany,
November 1997 and reaffirmed by the WMA Council Session, Berlin,
Germany, May 2007 and amended by the 69th
WMA General
Assembly, Reykjavik, Iceland, October 2018
Scope and Definitions
The scope of this Statement includes the following specified crimes:
genocide,war crimes,and crimes against humanity,as defined by the
Rome Statute of the International Criminal Court.
Preamble
• Physicians are bound by medical ethics to dedicate themselves to
the good of their patients. Physicians who have been convicted of
genocide, war crimes or crimes against humanity1
, have violated
1  As defined by the Rome Statute of the International Criminal Court
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medical ethics, human rights and international law and are there-
fore unworthy of practising medicine.
• In accordance with the principle of the presumption of innocence,
only physicians who have been convicted of the specified crimes
should be declared unworthy of practising medicine.
Discussion
1. Physicians seeking to work in any country are subject to the
regulations of that country’s relevant authorities or jurisdiction.
The duty to demonstrate suitability to practice medicine rests
with the person seeking licensure.
2. Physicians who have been convicted of genocide, war crimes or
crimes against humanity must not be allowed to practise in an-
other country or jurisdiction.
3. The relevant licensing authorities must ensure both that physi-
cians have the required qualifications and that they have not
been convicted of genocide, war crimes or crimes against hu-
manity.
4. Physicians who have been convicted of the specified crimes have
sometimes been able to leave the country in which these crimes
were committed and obtain a licence to practise medicine from
the relevant licensing authority in another country.
5. This practice is contrary to the public interest, damaging to the
reputation of the medical profession, and may be detrimental to
patient safety.
Recommendations
1. The WMA recommends that physicians who have been con-
victed of the specified crimes be denied a license to practice
medicine and membership to national medical associations by
the relevant regulatory and licensing authority of that jurisdic-
tion.
2. The WMA recommends that relevant regulatory and licens-
ing authorities use their own authority to inform themselves,
in so far as is possible, if verifiable allegations of participation
in genocide, war crimes or crimes against humanity have been
made against physicians, while at the same time respecting the
presumption of innocence.
3. National Medical Associations must be sure that a thorough in-
vestigation into those allegations is performed by an appropriate
authority.
4. The WMA recommends that national medical associations
ensure that there is efficient communication amongst them-
selves and that where possible and appropriate they inform
relevant national regulatory and licensing authorities of physi-
cians’ convictions of genocide, war crimes, or crimes against
humanity.
WMA Statement on the
Development and Promotion
of a Maternal and Child Health
Handbook
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Preamble
• The WMA believes that both a continuum of care and family
empowerment is necessary to improve the health and wellbeing
of the mother and child.The reduction of maternal mortality ratio
and infant deaths was an important objective of the Millennium
Development Goals (MDGs). The reductions of the maternal
mortality ratio,neonatal mortality rate and the under-five mortal-
ity rate are important targets to be achieved under the Sustainable
Development Goals (SDGs).
• The maternal and child health (MCH) handbook is a compre-
hensive home-based booklet designed to provide relevant health
information and include integrated mother and child health re-
cords. The MCH handbook covers health records and informa-
tion on pregnancy, delivery, neonatal and childhood periods, and
child growth and immunizations. The MCH handbook supports
the integration of maternal, neonatal and child health services.
The MCH handbook is not only about health education, but
about creating ownership with women and families.
• In 1948, Japan became the first country in the world to create
and distribute a maternal and child health (MCH) handbook,
in order to protect and improve the health and wellbeing of the
mother and child.
• There are now approximately 40-country versions of the MCH
handbook, all adapted to the local culture and socio-economic
context. There are a variety of handbooks and educational ma-
terials concerned to MCH in many countries. The use of MCH
handbooks has helped improve the knowledge of mothers on
maternal and child health issues, and has contributed to chang-
ing behaviors during pregnancy, delivery and post-delivery pe-
riod.
• The MCH handbook can promote the health of pregnant wom-
en, neonates and children by using it as a tool for strengthening a
continuum of care. Physicians can make better care decisions, by
referring to the patient’s medical history and health-check data
recorded in the MCH handbook. The MCH handbook alone
has not been shown to improve health indicators. The benefits
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are maximized when women and children have access to relevant
healthcare services based on information recorded in the hand-
book. Such benefits of the handbook could be shared globally.
• In Japan, a digital handbook is spreading progressively. The dig-
ital handbook is expected to be utilized in a way that protects
confidentiality of the patient’s health information. Some private
kindergarten and primary schools request access to the MCH as
part of their admission process, placing pressure on parents and
physicians to modify the answers to questions in the handbook.
Recommendations
1. The WMA recommends that the constituent member asso-
ciations encourage their health authorities and health institu-
tions to provide accessible and easy to understand information
regarding maternal and child health. The MCH handbook, or
equivalents, can be an important tool to improve continuity of
care and benefit health promotion for mothers, neonates and
children.
2. The WMA recommends that the constituent member associa-
tions and medical professionals promote the adaptation to local
setting and the utilization of MCH handbooks, or equivalents,
in order to leave no one behind with respect to SDGs, especially
for non-literate people, migrant families, refugees, minorities,
people in underserved and remote areas.
3. When using a MCH handbook or similar documentation, in
either digital or print form, the confidentiality of the individual
health information and the privacy of mothers and children
should be strictly protected. It should be used exclusively to im-
prove health and wellbeing of mothers, neonates, and children.
It should not be used in the admission procedures of schools.
4. The constituent member associations should promote local re-
search to evaluate the utilization of the MCH handbooks, or
equivalents, and make recommendations to improve the quality
of care in the local setting.
WMA Statement on Medical
Tourism
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Preamble
1. Medical tourism is an expanding phenomenon,although to date
it has no agreed upon definition and, as a result, practices and
protocols in different countries can vary substantially. For pur-
poses of this statement, medical tourism is defined as a situation
where patients travel voluntarily across international borders to
receive medical treatment, most often at their own cost. Treat-
ments span a range of medical services, and commonly include:
dental care, cosmetic surgery, elective surgery, and fertility treat-
ment (OECD, 2011).
2. This statement does not cover cases where a national health care
system or treating hospital sends a patient abroad to receive
treatment at its own cost or where, as in the European Union,
patients are allowed to seek care in another EU Member State
according to legally defined criteria, and their home health sys-
tem bears the costs. Also not covered is a situation in which
people are in a foreign country when they become ill and need
medical care.
3. If not regulated appropriately, medical tourism may have
medico-legal and ethical ramifications and negative implica-
tions, including but not limited to: internal brain drain, es-
tablishment of a two-tiered health system, and the spread of
antimicrobial resistance. Therefore, it is imperative that there
are clear rules and regulation to govern this growing phenom-
enon.
4. Medical tourism is an emerging global industry,with health ser-
vice providers in many countries competing for foreign patients,
whose treatment represents a significant potential source of in-
come. The awareness of health as a potential economic benefit
and the willingness to invest in it rise with the economic wel-
fare of countries, and billions of dollars are invested each year in
medical tourism all over the world.The key stakeholders within
this industry include patients, brokers, governments, health care
providers, insurance providers, and travel agencies. The prolif-
eration of medical tourism websites and related content raise
concerns about unregulated and inaccurate on-line health in-
formation.
5. A medical tourist is in a more fragile and vulnerable situation
than that of a patient in his or her home country.Therefore, ex-
tra sensitivity on the part of caretakers is needed at every stage of
treatment and throughout the patient’s care, including linguistic
and cultural accommodation wherever possible. When medical
treatment is sought abroad, the normal continuum of care may
be interrupted and additional precautions should therefore be
taken.
6. Medical tourism bears many ethical implications that should be
considered by all stakeholders. Medical tourists receive care in
both state-funded and private medical institutions and regula-
tions must be in place in both scenarios. These recommenda-
tions are addressed primarily to physicians. The WMA encour-
ages others who are involved in medical tourism to adopt these
principles.
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Recommendations
General
7. The WMA emphasises the importance of developing health care
systems in each country in order to prevent excessive medical
tourism resulting from limited treatment options in a patient´s
home country. Financial incentives to travel outside a patient’s
home country for medical care should not inappropriately limit
diagnostic and therapeutic alternatives in the patient’s home
country, or restrict treatment or referral options.
8. The WMA calls on governments to carefully consider all the
implications of medical tourism to the healthcare system of a
country by developing comprehensive, coordinated national
protocols and legislation for medical tourism in consultation
and cooperation with all relevant stakeholders. These protocols
should assess the possibilities of each country to receive medical
tourists, to agree on necessary procedures, and to prevent nega-
tive impacts to the country´s health care system.
9. The WMA calls on governments and service providers to ensure
that medical tourism does not negatively affect the proper use
of limited health care resources or the availability of appropri-
ate care for local residents in hosting countries. Special atten-
tion should be paid to treatments with long waiting times or
involving scarce medical resources. Medical tourism must not
promote unethical or illegal practices, such as organ trafficking.
Authorities, including government, should be able to stop elec-
tive medical tourism where it is endangering the ability to treat
the local population.
10. The acceptance of medical tourists should never be allowed to
distort the normal assessment of clinical need and, where ap-
propriate, the development of waiting lists, or priority lists for
treatment. Once accepted to treatment by a health care provider,
medical tourists should be treated in accordance with the ur-
gency of their medical condition. Whenever possible patients
should be referred to institutions that have been approved by
national authorities or accredited by appropriately recognised
accreditation bodies.
Prior to travel
11. Patients should be made aware that treatment practices and
health care laws may be different than in their home country
and that treatment is provided according to the laws and prac-
tices of the host country. Patients should be informed by the
physician/service provider of their rights and legal recourse
prior to travelling outside their home country for medical care,
including information regarding legal recourse in case of patient
injury and possible compensation mechanisms.
12. The physician in the host country should establish a treatment
plan, including a cost estimate and payment plan, prior to the
medical tourist’s travel to the host country. In addition, the
physician and the medical tourism company (if any) should
collaborate in order to ensure that all arrangements are made
in accordance with the patient´s medical needs. Patients
should be provided with information about the potential risks
of combining surgical procedures with long flights and vaca-
tion activities.
13. Medical tourists should be informed that privacy laws are not
the same in all countries and, in the context of the supplemen-
tary services they receive, it is possible that their medical infor-
mation will be exposed to individuals who are not medical pro-
fessionals (such as interpreters). If a medical tourist nonetheless
decides to avail him or herself of these services, he or she should
be provided with documentation specifying the services pro-
vided by non-medical practitioners (including interpreters) and
an explanation as to who will have access to his or her medical
information, and the medical tourist should be asked to consent
to the necessary disclosure.
14. All stakeholders (clinical and administrative) involved in the
care of medical tourists must be made aware of their ethical ob-
ligations to protect confidentiality. Interpreters, and other ad-
ministrative staff with access to health information of the medi-
cal tourist should sign confidentiality agreements.
15. The medical tourist should be informed that a change in his or
her clinical condition might result in a change in the cost esti-
mate and in associated travel plans and visa requirements.
16. If the treatment plan is altered because of a medical need that
becomes clear after the initial plan has been established, the
medical tourist should be notified of the change and why it was
necessary. Consent should be obtained from the patient for any
changes to the treatment plan.
17. When a patient is suffering from an incurable condition, the
physician in the host country shall provide the patient with ac-
curate information about his or her medical treatment options,
including the limitations of the treatment, the ability of the
treatment to alter the course of the disease in an appreciable
manner,to increase life expectancy and to improve the quality of
life. If, after examining all the data, the physician concludes that
it is not possible to improve the patient’s medical condition, the
physician should advise the patient of this and discourage the
patient from travelling.
Treatment
18. Physicians are obligated to treat every individual accepted for
treatment, both local and foreigner, without discrimination. All
the obligations detailed in law and international medical ethical
codes apply equally to the physician in his or her encounter with
medical tourists.
19. Medical decisions concerning the medical tourist should be
made by physicians, in cooperation with the patient, and not by
non-medical personnel.
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20. At the discretion of the treating physicians, and where informa-
tion is available and of good quality, the patient should not be
required to undergo tests previously performed, unless there is a
clinical need to repeat tests.
21. The patient should receive information about his or her treat-
ment in a language he or she understands. This includes the
right to receive a summary of the treatment progress and termi-
nation by the treating physician and a translation of the docu-
ments, as needed.
22. Agreement should be reached before treatment begins, on the
transfer of test results and diagnostic images, back to the home
country of the patient.
23. Where possible, communication between the physicians in the
host and home country should be established in order to en-
sure appropriate aftercare and clinical follow-up of the medical
problems for which the patient was treated.
24. The physician who prepares the treatment plan for the patient
should confirm the diagnosis, the prognosis and the treatments
that the medical tourist has received.
25. The patient should receive a copy of his or her medical documents
for the purpose of continuity of care and follow-up in his or her
home country.Where necessary,the patient should be given a de-
tailed list of medical instructions and recommendations for the
period following his or her departure. This information should
include a description of the expected recovery time and the time
required before travelling back to his or her home is possible.
Advertising
26. Advertising for medical tourism services, whether via the in-
ternet or in any other manner, should comply with accepted
principles of medical ethics and include detailed information
regarding the services provided. Information should address the
service provider’s areas of specialty,the physicians to whom it re-
fers the benefits of its services,and the risks that may accompany
medical tourism.Access to licensing/accreditation status of phy-
sicians and facilities and the facility’s outcomes data should be
made readily available. Advertising material should note that all
medical treatment carries risks and specific additional risks may
apply in the context of medical tourism.
27. National Medical Associations should do everything in their
power to prevent improper advertising or advertising that is in
violation of medical ethical principles,including advertising that
contains incorrect or partial information and/or any informa-
tion that is liable to mislead patients, such as overstatement of
potential benefits.
28. Advertising that notes the positive attributes of a specific medi-
cal treatment should also present the risks inherent in such
treatment and should not guarantee treatment results or foster
unrealistic expectations of benefits or treatment results.
Transparency and the prevention of conflicts of interest
29. Possible conflicts of interest may be inevitable for physicians
treating medical tourists, including at the behest of their em-
ploying institution. It is essential that all clinical circumstances
and relationships are managed in an open and transparent man-
ner.
30. A physician shall exercise transparency and shall disclose to the
medical tourist any personal, financial, professional or other
conflict of interest, whether real or perceived, that may be con-
nected to his or her treatment.
31. A physician should not accept any benefit,other than remunera-
tion for the treatment, in the context of the medical treatment,
and should not offer the medical tourist nor accept from him
or her any business or personal offer, as long as the physician-
patient relationship exists. Where the physician is treating the
medical tourist as another fee paying patient, the same rules
should apply as with his/her other fee paying patients.
32. A physician should ensure that any contract with a medical tour-
ism company or medical tourist does not constitute a conflict of
interest with his or her current employment, or with his or her
ethical and professional obligations towards other patients.
Transparency in payment and in the physician’s fees
33. A treatment plan and estimate should include a detailed report
of all costs, including a breakdown of physician’s fees, such as:
consultancy and surgery and additional fees the patient might
incur, such as: hospital costs, surgical assistance, prosthesis (if
separate), and costs for post-operative care.
34. The cost estimate may be changed after the treatment plan has
been given only in the event that the clinical condition of the
patient has changed, or where circumstances have changed in a
way that it was impossible to anticipate or prevent.If the pricing
was thus changed, the patient must be informed as to the reason
for the change in costs in as timely a fashion as possible.
WMA Statement on
Medically-Indicated Termination
of Pregnancy
Adopted by the 24th
World Medical Assembly, Oslo, Norway, August
1970 and amended by the 35th
World Medical Assembly, Venice, Italy,
October 1983, the 57th
WMA General Assembly, Pilanesberg, South
Africa, October 2006, and the 69th
WMA General Assembly, Reykjavik,
Iceland, October 2018
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Preamble
1. Medically-indicated termination of pregnancy refers only to
interruption of pregnancy due to health reasons, in accordance
with principles of evidence-based medicine and good clinical
practice. This Declaration does not include or imply any views
on termination of pregnancy carried out for any reason other
than medical indication.
2. Termination of pregnancy is a medical matter between the pa-
tient and the physician. Attitudes toward termination of preg-
nancy are a matter of individual conviction and conscience that
should be respected.
3. A circumstance where the patient may be harmed by carrying
the pregnancy to term presents a conflict between the life of the
foetus and the health of the pregnant woman. Diverse responses
to resolve this dilemma reflect the diverse cultural, legal, tradi-
tional, and regional standards of medical care throughout the
world.
Recommendations
4. Physicians should be aware of local termination of pregnancy
laws, regulations and reporting requirements. National laws,
norms, standards, and clinical practice related to termination of
pregnancy should promote and protect women’s health, dignity
and their human rights, voluntary informed consent, and auton-
omy in decision-making, confidentiality and privacy. National
medical associations should advocate that national health policy
upholds these principles.
5. Where the law allows medically-indicated termination of preg-
nancy to be performed, the procedure should be performed by
a competent physician and only in extreme cases by another
qualified health care worker, in accordance with evidence-based
medicine principles and good medical practice in an approved
facility that meets required medical standards.
6. The convictions of both the physician and the patient should be
respected.
7. Patients must be supported appropriately and provided with
necessary medical and psychological treatment along with ap-
propriate counselling if desired.
8. Physicians have a right to conscientious objection to perform-
ing an abortion; therefore, they may withdraw while ensur-
ing the continuity of medical care by a qualified colleague. In
all cases, physician must perform those procedures necessary
to save the woman’s life and to prevent serious injury to her
health.
9. Physicians must work with relevant institutions and authorities
to ensure that no woman is harmed because medically-indicated
termination of pregnancy services are unavailable.
WMA Resolution
on Migration
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Nowadays, we are facing increased migration trends globally.
This situation, far from being resolved, has worsened over the last
months, exacerbated by political, social and economic events, with
serious impacts on the population deteriorating the quality of life
and in some cases putting people in mortal danger. This violates
their fundamental right to health and in many cases forces them to
abandon their countries to search for a better life.
International migration is a global phenomenon, caused by multiple
factors, including demographic and economic inequalities among
countries, in addition to war, hunger and natural disasters. Migra-
tion policies adopted by the majority of receiving countries are be-
coming more and more restrictive towards economic migrants.
The World Medical Association (WMA) considers that health is a
basic need, a human right and one of the essential drivers of eco-
nomic and social development. Increased migration is a phenom-
enon linked to progress and to the trends of the 21st
century.
The WMA reaffirms its Resolution on Refugees and Migrants ad-
opted in October 2016.
The WMA, its constituent members and the international health
community should advocate for:
1. Strong continued engagement of physicians in the defense of
human rights and dignity of all people worldwide, as well as
combatting suffering, pain and illness;
2. The prioritization of the care of human beings above any other
consideration or interest;
3. Providing the necessary healthcare, through international co-
operation, directed to countries that welcome and receive large
number of migrants.
4. Governments to reach political agreements to obtain the neces-
sary health resources to deliver care in an adequate and coordi-
nated manner to the migrant population.
The WMA emphasizes the role of physicians to actively support
and promote the rights of all people to medical care based solely
on clinical necessity, and protest against legislation and practices
contrary to this fundamental right.
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WMA Council Resolution on the
Prohibition of Nuclear Weapons
Adopted by the 209th
Session of the Council, Riga, April 2018
The duties of physicians are to preserve life and safeguard the health
of the patient and to dedicate themselves to the service of humanity.
Concerned about current global discussions on nuclear proliferation
and given the catastrophic consequences of these weapons on hu-
man health and the environment, the World Medical Association
(WMA) and its Constituent Members consider that they have a re-
sponsibility to work for the elimination of nuclear weapons world-
wide.
The WMA is deeply concerned by plans to retain indefinitely and
modernize nuclear arsenals; the absence of progress in nuclear
disarmament by nuclear-armed states; and the growing threat of
nuclear war.
The WMA welcomes the Treaty on the Prohibition of Nuclear
Weapons, and joins with others in the international community,
including the Red Cross and Red Crescent movement, Interna-
tional Physicians for the Prevention of Nuclear War, the Interna-
tional Campaign to Abolish Nuclear Weapons, and a large majority
of UN member states. Consistent with our mission as physicians,
the WMA calls on all states to promptly sign, ratify or accede to,
and faithfully implement the Treaty on the Prohibition of Nuclear
Weapons;
Emphasizing the devastating long-term health consequences, the
WMA and its Constituent Members urge governments to work
immediately to prohibit and eliminate nuclear weapons.
WMA Statement on Sustainable
Development
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland,
October 2018
Preamble
1. The WMA believes that health and well-being are dependent
upon social determinants of health (SDHs), the conditions in
which people are born, grow, live, work and age.These social de-
terminants will directly influence the achievement of the United
Nations Sustainable Development Goals (SDGs). Many of the
SDG goals, targets and indicators that have been developed to
measure progress towards them, will also be useful measures of
the impact of action is having on improving the SDH and, in
particular, on reducing health inequities.
2. This statement builds upon WMA policy on Social Determi-
nants of Health as set out in the Declaration of Oslo, and upon
the basic principles of medical ethics set out in the Declaration
of Geneva.
3. The WMA recognizes the important efforts undertaken by the
United Nations with the adoption on 25 September 2015 of
the resolution “Transforming our world: the 2030 Agenda for Sus-
tainable Development”. The Sustainable Development Agenda
is based upon five key themes: people, planet, prosperity, peace
and partnership and the principle of leaving no one behind.The
WMA affirms the importance of global efforts on sustainable
development and the impact that they can bring to humanity.
4. SDGs are built on the lessons learned from successes and
failures in achieving the Millennium Development Goals
(MDGs), including inequity in many areas of life. While there
is no overarching concept unifying the SDGs, the WMA be-
lieves that inequity in health and wellbeing encapsulates much
of the 2030 Agenda. The WMA notes that while only SDG
3 is overtly about health, many of the goals have major health
components.
5. The WMA recognizes all governments must commit and invest
to fully implement the goals by 2030,in alignment with the Ad-
dis Ababa Action Agenda. The WMA also recognizes the risk
that the SDGs might be considered unaffordable due to their
estimated potential cost of between US$ 3.3 and US$ 4.5 tril-
lion a year.
6. The WMA emphasises the need for cross and inter-sectoral
work to achieve the goals and believes that health must be ad-
dressed in all SDGs and not only under health specific SDG 3.
Policy priorities:
7. Recognition of Health in All Policies and the Social Determi-
nants of Health / Whole of Society approach.
8. Policy areas that are essential to achieving the SDG 3:
–
– Patient Empowerment and Patient Safety
–
– Continuous Quality Improvement in Health Care
–
– Overcoming the Impact of Aging on Health Care
–
– Addressing Antimicrobial Resistance
–
– The safety and welfare of Health care staff
9. Ensuring policy alignment among all the UN Agencies and the
work of regional governmental organizations such as EU, Afri-
can Union,Arab League,ASEAN,and Organization of Ameri-
can States.
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10. The WMA commits to support implementation of the other
three global agreements regarding the sustainable development
process:
–
– The Addis Ababa Action Agenda as the mechanism that will
provide the financial support for the 2030 Agenda.
–
– The Paris Agreement is the binding mechanism of the sustain-
able development process that sets out a global action plan to
put the world on track to avoid dangerous climate change by
limiting global warming to well below 2°C above pre-industrial
levels.
–
– The Sendai Framework for Disaster Risk Reduction as the
agreement which recognizes that the State has the primary role
to reduce disaster risk but that responsibility should be shared
with local government, the private sector and other stakehold-
ers.
Recommendations and Commitments
11. The WMA commits to work with other intergovernmental or-
ganizations, including the UN, the WHO, healthcare profes-
sionals’organizations and other stakeholders, for the implemen-
tation and follow-up of this Agenda and related international
agreements, and for policy and advocacy alignment.
12. The WMA commits to collaborate with its constituent mem-
ber Associations to support their work at regional and national
levels, and with their governments on the 2030 Agenda imple-
mentation.
13. The WMA recommends that NMAs create strategies regarding
data collection,implementation,capacity building and advocacy,
to enhance policy coherence and to maximise the 2030 Agenda
implementation at national and global levels.
14. The WMA also recommends that NMAs collaborate with de-
velopment banks, NGOs, intergovernmental organisations and
other stakeholders who are also working to implement of the
2030 Agenda, especially in their own countries.
15. The WMA encourages the UN and the WHO to develop guide-
lines on how financing for health will be implemented to reach
the targets established by the 2030 Agenda and the economic
implications of NCDs, aging and antimicrobial resistance.
WMA Statement on the Ethics of
Telemedicine
Adopted by the 58th
WMA General Assembly, Copenhagen, Denmark,
October 2007 And amended by the 69th
WMA General Assembly,
Reykjavik, Iceland, October 2018
Definition
Telemedicine is the practice of medicine over a distance, in which
interventions, diagnoses, therapeutic decisions, and subsequent
treatment recommendations are based on patient data, documents
and other information transmitted through telecommunication sys-
tems.
Telemedicine can take place between a physician and a patient or
between two or more physicians including other healthcare profes-
sionals.
Preamble
• The development and implementation of information and com-
munication technology are creating new and different ways for of
practicing medicine.Telemedicine is used for patients who cannot
see an appropriate physician timeously because of inaccessibility
due to distance, physical disability, employment, family commit-
ments (including caring for others), patients’ cost and physician
schedules. It has capacity to reach patients with limited access
to medical assistance and have potential to improve health care.
• Face-to-face consultation between physician and patient remains
the gold standard of clinical care.
• The delivery of telemedicine services must be consistent with in-
person services and supported by evidence.
• The principles of medical ethics that are mandatory for the pro-
fession must also be respected in the practice of telemedicine.
Principles
Physicians must respect the following ethical guidelines when
practicing telemedicine:
1. The patient-physician relationship should be based on a per-
sonal examination and sufficient knowledge of the patient’s
medical history. Telemedicine should be employed primarily
in situations in which a physician cannot be physically present
within a safe and acceptable time period. It could also be used
in management of chronic conditions or follow-up after initial
treatment where it has been proven to be safe and effective.
2. The patient-physician relationship must be based on mutual
trust and respect. It is therefore essential that the physician and
patient be able to identify each other reliably when telemedicine
is employed. In case of consultation between two or more pro-
fessionals within or between different jurisdictions, the primary
physician remains responsible for the care and coordination of
the patient with the distant medical team.
3. The physician must aim to ensure that patient confidentiality,
privacy and data integrity are not compromised. Data obtained
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during a telemedicine consultation must be secured to prevent
unauthorized access and breaches of identifiable patient infor-
mation through appropriate and up to date security measures
in accordance with local legislation. Electronic transmission of
information must also be safeguarded against unauthorized ac-
cess.
4. Proper informed consent requires that all necessary informa-
tion regarding the distinctive features of telemedicine visit be
explained fully to patients including, but not limited to:
–
– explaining how telemedicine works,
–
– how to schedule appointments,
–
– privacy concerns,
–
– the possibility of technological failure including confidentiality
breaches,
–
– protocols for contact during virtual visits,
–
– prescribing policies and coordinating care with other health
professionals in a clear and understandable manner, without
influencing the patient’s choices.
5. Physicians must be aware that certain telemedicine technolo-
gies could be unaffordable to patients and hence impede access.
Inequitable access to telemedicine can further widen the health
outcomes gap between the poor and the rich.
Autonomy and privacy of the Physician
6. A physician should not to participate in telemedicine if it vio-
lates the legal or ethical framework of the country.
7. Telemedicine can potentially infringe on the physician privacy
due to 24/7 virtual availability. The physician needs to inform
patients about availability and recommend services such as
emergency when inaccessible.
8. The physician should exercise their professional autonomy in
deciding whether a telemedicine versus face-to-face consulta-
tion is appropriate.
9. A physician should exercise autonomy and discretion in select-
ing the telemedicine platform to be used.
Responsibilities of the Physician
10. A physician whose advice is sought through the use of telemedi-
cine should keep a detailed record of the advice he/she delivers
as well as the information he/she received and on which the
advice was based in order to ensure traceability.
11. If a decision is made to use telemedicine it is necessary to ensure
that the users (patients and healthcare professionals) are able to
use the necessary telecommunication system.
12. The physician must seek to ensure that the patient has under-
stood the advice and treatment suggestions given and take steps
in so far as possible to promote continuity of care.
13. The physician asking for another physician’s advice or second
opinion remains responsible for treatment and other decisions
and recommendations given to the patient.
14. The physician should be aware of and respect the special difficul-
ties and uncertainties that may arise when he/she is in contact
with the patient through means of tele-communication. A phy-
sician must be prepared to recommend direct patient-doctor
contact when he/she believes it is in the patient’s best interests.
15. Physicians should only practise telemedicine in countries/juris-
dictions where they are licenced to practise. Cross-jurisdiction
consultations should only be allowed between two physicians.
16. Physicians should ensure that their medical indemnity cover in-
clude cover for telemedicine.
Quality of Care
17. Healthcare quality assessment measures must be used regularly
to ensure patient security and the best possible diagnostic and
treatment practices during telemedicine procedures. The deliv-
ery of telemedicine services must follow evidence-based prac-
tice guidelines to the degree they are available, to ensure pa-
tient safety, quality of care and positive health outcomes. Like
all health care interventions, telemedicine must be tested for its
effectiveness, efficiency, safety, feasibility and cost-effectiveness.
18. The possibilities and weaknesses of telemedicine in emergencies
must be duly identified. If it is necessary to use telemedicine in
an emergency situation, the advice and treatment suggestions
are influenced by the severity of the patient´s medical condition
and the competency of the persons who are with the patient.
Entities that deliver telemedicine services must establish proto-
cols for referrals for emergency services.
Recommendations
1. Telemedicine should be appropriately adapted to local regula-
tory frameworks, which may include licencing of telemedicine
platforms in the best interest of patients.
2. Where appropriate the WMA and National Medical Associa-
tions should encourage the development of ethical norms, prac-
tice guidelines,national legislation and international agreements
on subjects related to the practice of telemedicine, while pro-
tecting the patient-physician relationship, confidentiality, and
quality of medical care.
3. Telemedicine should not be viewed as equal to face-to-face
healthcare and should not be introduced solely to cut costs or
as a perverse incentive to over-service and increase earnings for
physicians.
4. Use of telemedicine requires the profession to explicitly identify
and manage adverse consequences on collegial relationships and
referral patterns.
5. New technologies and styles of practice integration may require
new guidelines and standards.
6. Physicians should lobby for ethical telemedicine practices that
are in the best interests of patients.
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33
Euthanasia
‘Unanimously, a declaration was adopted which
simply says that euthanasia is unethical.’
Thus read a brief initial note in the World
Medical Journal of 1987 with reference to
the key passage of a new WMA Declara-
tion on Euthanasia adopted in the Madrid
General Assembly of that year [1]. Concise
as this message was, it announced the affir-
mation of a powerful,enduring medical dic-
tum, and we believe it to be essential for us,
today, to understand the context in which it
came about.
The WMA was founded in 1947, in part
to work for the highest possible standards
of ethical behaviour and care among phy-
sicians. This was considered particularly
important after the gross ethical violations
observed, by physicians themselves during
the Second World War (1939-45) [2]. In
1987, several members of the WMA, who
had had personal experience with these
atrocities, were still alive. One of them,
Dr. Andre Wynen, who was then Secretary
General, and a Nazi camp survivor himself,
was a strong advocate of the formulation
of the Declaration ‘because protection of
life was very important for him’ [3]. These
sentiments were echoed in a 1989 essay by
then WMA President Ram Ishay from the
Israeli Medical Association [4]. Dr.  Ishay
explained that the WMA had not seen the
need to pass such a Declaration earlier, be-
cause it had already adopted policies laying
out what it considered to be appropriate and
ethical end of life care. However, given new
positions emerging within some countries,
it felt the need to break this silence, and
passed the present Declaration unanimous-
ly. This robust vehicle was subsequently re-
affirmed in 2005 and again in 2015.
The authors of this article are three Canadi-
ans – two are practicing physicians and the
other a severely disabled individual – who
have combined their efforts, here, in the
hope of preserving, once again, the deep and
timely precautions WMA has maintained all
these years. We ask that the full language of
the original Declaration – explicitly stating
that euthanasia “is unethical” – be preserved.
The nature of euthanasia
Voluntary euthanasia, simply put, is the
medicalization of suicide.The use of euphe-
misms such as Physician Assisted Death or
Medical Assistance in Dying are misguided
attempts to rebrand a practice which doc-
tors have renounced for close to 2500 years.
These terms should be rejected as linguistic
deceptions.
The objective judgement of whether any
suicide or assisted suicide is warranted is
impossible because of the subjective nature
of suffering. What is grievous, irremediable,
or intolerable to one person, may not be so
for another. And, unfortunately, the physi-
cian’s opinion is no less subjective than that
of the patient. An illustration of this comes
from the review of psychiatric euthanasia in
the Netherlands which demonstrated that,
in 24% of cases, there was disagreement
amongst consultants [5]. Having doctors
validate and assist in suicide, therefore, is a
distortion of our role as healers and makes
us both accomplices and supporters – if not
encouragers – of suicide.
We believe doctors should never be open to
euthanasia and assisted suicide as solutions
to our patients’ suffering. It is our personal
experience, backed up by multiple studies,
that the majority number of requests for
Why Euthanasia is Unethical and Why We Should Name it as Such
Rene Leiva Gordon Friesen Timothy Lau
CANADA
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34
Euthanasia
the hastening of death are based on what
we call ‘existential suffering’ which includes
social, psychological and spiritual reasons
such as loss of autonomy, wish to avoid bur-
dening others or losing dignity and the in-
tolerability of not being able to enjoy one’s
life [6,7]. Moreover, it is our position that,
behind the fears caused by that existential
suffering, there is also a call for help, to find
meaning, even in the midst of such suffer-
ing. Hopelessness and the wish for death
naturally arise in the course of human expe-
rience, but it should not be our role, as phy-
sicians, to judge of their validity (regardless
of personal opinion), nor is it our role to
give them satisfaction.
The scope of euthanasia
in theory and practice:
a stark contrast
Euthanasia was purportedly introduced
as a solution for ‘rare cases’ involving the
very end of life where unbearable suffer-
ing could, supposedly, be ended only with
death. But euthanasia is not only employed
for such cases.
In Canada,physicians may provide euthana-
sia or assisted suicide for competent adults
who clearly consent, who have a grievous
and irremediable medical condition (in-
cluding illness, disease, or disability) that
causes enduring and intolerable physical or
psychological suffering that cannot be re-
lieved by means acceptable to the individual
[8]. But as stated earlier, these are entirely
subjective and elastic concepts. In practice,
Canadian criteria are already so broad as to
have permitted the administration of lethal
injections to an elderly couple who pre-
ferred to die together by euthanasia rather
than at different times by natural causes [9].
Moreover,court challenges and government
studies are presently underway which could
soon open euthanasia access to competent
minors; to people who are non-terminal
(death not “reasonably foreseeable”); to de-
mentia patients by advance directive; and to
those with psychiatric disorders only [10].
In Ontario,only 15% of patients euthanized
had a previous relationship with the eutha-
nasia provider [11].
Economic pressure
towards euthanasia
Economics and resource management al-
ways play a critical role in health services.
Dr. Wynen, as we know from his writings,
definitely feared that legalised euthanasia
would eventually be used to ration health
care [3]. But even then, warning about the
risks of abuse from euthanasia, due to fi-
nancial reasons, was not new. Dr. Leo Al-
exander, who served as a medical consul-
tant to the Allied prosecutors during the
Nuremberg trials, wrote in his historic essay
“Medical Science under Dictatorship”, New
England Journal of Medicine (1949):
“Hospitals like to limit themselves to the care
of patients who can be fully rehabilitated, and
the patient whose full rehabilitation is unlike-
ly finds himself, at least in the best and most
advanced centers of healing, as a second-class
patient faced with a reluctance on the part of
both the visiting and the house staff to suggest
and apply therapeutic procedures that are not
likely to bring about immediately striking re-
sults in terms of recovery. I wish to emphasize
that this point of view did not arise primar-
ily within the medical profession, which has
always been outstanding in a highly com-
petitive economic society for giving freely and
unstintingly of its time and efforts, but was
imposed by the shortage of funds available,
both private and public. From the attitude
of easing patients with chronic diseases away
from the doors of the best types of treatment
facilities available to the actual dispatching of
such patients to killing centers is a long but
nevertheless logical step. Resources for the so-
called incurable patient have recently become
practically unavailable ”[12].
In Canada, a recent cost analysis concluded
that ‘providing medical assistance in dying
should not result in any excess financial
burden to the health care system and could
result in substantial savings [13]. It is obvi-
ous that those patients who opt for eutha-
nasia do provide a saving to the health care
system. Therefore, the danger of exerting
a hidden pressure on vulnerable people is
very real. For example, hospital authorities
recently denied a chronically ill, severely
disabled patient the care he needed, and –
faced with his inability to pay – suggested
euthanasia or assisted suicide instead [14].
On another occasion, a 25-year-old dis-
abled woman in acute crisis in a Canadian
Emergency ward, was pressured to consider
assisted suicide by an attending physician,
who called her mother “selfish” for protect-
ing her [15].
Private financial interests are also impor-
tant. Colleagues have voiced case reports
where family members may be taking ad-
vantage of the law and creating vulnerable
victims [16]. Elder abuse is endemic – in
Canada as elsewhere – and one of the main
forms of that abuse is financial.The conflict
is obvious, and so is the potential for abuse.
Breaking the promise: how
euthanasia destroys trust in
the medical profession
At the root of euthanasia lies an assumption
that some lives are not worth living. But ra-
tional people disagree, both on the principle
and on the application to each individual
case. Severely disabled and chronically ill
individuals disagree, also, on the value of
their own lives. Some become suicidal; a
greater number do not. But a critical factor
in the choices they make results from the
attitudes of friends, family, medical profes-
sionals and society at large. As philosopher
Daniel Callahan has stated, “Euthanasia is
not a private matter of self-determination.
It is an act that requires two people to make
it possible, and a complicit society to make
it acceptable” [17].
CANADA
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35
Euthanasia
Again, both Wynan and Ishay were con-
cerned that people caring for patients would
personally side with the logic of euthana-
sia, thus creating new risks for the abuse of
patients, and especially the most vulnerable.
It is our experience that in several cases
the troubles of human relationships within
families become accentuated, and problems
of physician error and abuse in an already
stressed medical system become exacer-
bated. In the words of President Ishay, “The
main problem is to differentiate between
what is really done for the benefit of the pa-
tient, and what is done out of comfort for
the family or for the caring team. Killing
can occur, not because the patient is suffer-
ing, but because the person caring for the
patient can not take it any more” [4].
No wonder, then, that many doctors remain
unsure of correct practice. Some emergency
physicians in Quebec were, for a time, ac-
tually allowing suicide victims to die even
though they could have saved their lives.
President of the Association of Quebec
Emergency Physicians later speculated that
the law, and accompanying publicity, may
have ‘confused’ the physicians about their
role [18]. Dr. Damiaan Denys, President of
the Dutch Society of Psychiatrists, has also
recently voiced the possibility that euthana-
sia is causing a frustrating new therapeutic
atmosphere in psychiatric treatment, lower-
ing many people’s threshold for ending their
lives and causing increased moral distress on
the part of the doctor [19]. Canada’s largest
children’s hospital has drafted a policy in
preparation for the day when children could
decide for themselves to be euthanized. On
it, they entertain the possibility of not in-
forming the parents until after the minor
has been euthanatized [20].
We do not deny, therefore, that doctors per-
forming euthanasia may sincerely believe
themselves to be acting virtuously. But trust
between doctor and patient depends, in
the end, on public perception of the whole
medical profession. When some doctors
perform euthanasia, patients begin to worry
about the attitudes of all doctors, and trust
is lost. In Canada, for example, we are per-
sonally aware that many patients,out of fear,
are now directly asking for doctors who will
not practice euthanasia. Already in 2005, it
became apparent that some elderly Dutch
were afraid that those around them would
take advantage of their vulnerable state to
shorten their lives. Having lost confidence
in Dutch practitioners, they either went to
German doctors or they settled in Germa-
ny, as reported in the 2008 French govern-
ment report to the National Assembly [21];
or they carry cards with them stating that
they don’t want to be euthanatized when
seriously ill [22]. In a recent survey among
Quebec physicians caring for patients with
dementia, between 14% to 43% of doctors
would provide access to euthanasia to pa-
tients with advanced or terminal stage de-
mentia respectively even if no a prior writ-
ten request existed [23].
The true physician’s role
At the heart of modern medical practice,
we expect to find the survival, welfare and
comfort of the patient. It is this conscious
devotion to life which is so urgently re-
quired from physicians by the vast majority
of patients,whether they are suicidal or not.
The declaration of Geneva holds as the first
consideration, the health and well-being of
our patients. The respect for the autonomy
and dignity of our patients which is the
next line of the declaration, should not ig-
nore the first consideration, nor the third
line of the declaration which includes the
utmost respect for human life. Properly
understood there should be no conflict at
all [24].
One of us (Friesen) knows, first hand, the
mental strain of suddenly being presented,
as a young man,with serious post-traumatic
disabilities which took months to fully un-
derstand, years to accommodate, and de-
cades to accept. In his own words, “it is an
illusion to believe that education, family re-
lations, economic status, or present health
and happiness,can effectively protect people
such as myself from the risk of euthanasia,
because the most ordinary chances of life –
the slightest relaxation of discipline in the
maintenance of my physical state – would
immediately (within months at most) place
me in the intended category for that lethal
procedure. And so, it is, for all surviving dis-
abled and chronically ill.”
The good doctor, we believe, does not judge
the value of such lives. Doctors are — doc-
tors must be unconditionally devoted to
supporting every life, through all the phases
of therapy and palliation.
And to conclude: “If I had not had such
doctors to guide me through the first critical
weeks of Intensive Care (and the long years
of recovery which followed), I would not be
here to write these lines today.”
Euthanasia policy: a unique
responsibility of the World
Medical Association
Objectively speaking, nothing has changed
in the facts of euthanasia since 1945. Our
current debate has not been caused by real
changes in the internal logic of medical eth-
ics and practice. It is actually the result of
those same political, social, and economic
factors, which civilized medicine has reject-
ed time and again: the attraction of econom-
ic savings,feared by Wynen and described at
first hand by Alexander; the terrible possi-
bility that doctors and families might choose
their own convenience over the survival of
the patient, as voiced by Ishay; the horrible
notion that certain lives are objectively less
valuable. When death becomes the answer,
we as human beings  – as doctors  – have
failed in our duty to sustain trust and hope.
Amid the larger pressures we have described,
a free, autonomous decision about euthana-
sia becomes impossible. Patient choice be-
comes a cruel illusion.
CANADA
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36
On the positive side, it is evident that most
doctors will never be willing to ­
personally
practice euthanasia. This conclusion has
emerged clearly from the four regional
WMA symposia, held recently on the sub-
ject in Brazil, Japan, Rome and Nigeria
[25]. From the records of these seminars,
we are reminded that a majority of doctors,
everywhere, wish only to foster the will to
live, not to lay the seeds of suicidal despair.
In those countries where it unfortunately
becomes legal, law and policy should al-
low medical practice to remain largely
unchanged. Those who support medi-
cal involvement should thus embrace the
liberation of relinquishing such a painful
technical monopoly for doctors and allow
other ‘experts’ to do it.
Unwavering ethical guidance from the
World Medical Association is of crucial im-
portance in preserving this positive climate
in global medical practice. Any compromis-
ing additions or modifications to existing
WMA declarations can only bring harm to
our patients and to our profession. A firm
WMA refusal to accept euthanasia, on the
other hand, will stand as a powerful aid to
all doctors.
We hope the WMA will take this opportu-
nity to make it clear that what is legal is not
necessarily ethical. It is useful to note, that
the WMA was recently willing to make this
distinction by condemning the participation
of physicians in capital punishment, even
in jurisdictions where that practice is legal
[26].We believe that the WMA should also
remain consistent in this principle with re-
gard to euthanasia, and not confuse political
expediency with medical ethics.
WMA policy, we hope, will continue to
stand as a beacon to the world, bringing
comfort to patients and physicians around
the globe, proclaiming that – regardless of
changing opinions from place to place  –
true medicine’s first value is human life.
Similarly, even if some particular society
may devalue human life by promoting sui-
cide, medicine and medical practitioners
should not.
We believe that euthanasia is, was, and will
always be, unethical. The World Medical
Association was right to say this in the past,
and must continue for the future, firmly on
the same path.
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Euthanasia CANADA
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Medical Ethics
ajp.psychiatryonline.org/doi/10.1176/appi.
ajp.2018.18060725
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23. Bravo G, Rodrigue C, Arcand M, Downie
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physician-participation-in-capital-punishment/
Rene Leiva, MDCM, CCFP
(COE/PC), FCFP
Family Medicine, Palliative Care, Care of the
Elderly, Bruyere Continuing Care, Assistant
Professor, Department of Family Medicine
University of Ottawa
Ottawa, Ontario, Canada
Gordon Friesen, Advisory Assistant
Physicians’ Alliance Against Euthanasia
Montreal, Quebec, Canada
Timothy Lau, MD, MSc, FRCPC
Geriatric Psychiatry
Royal Ottawa Hospital
Associate Professor, University of Ottawa
Ottawa, Ontario, Canada
E-mail: rene.leiva@mail.mcgill.ca
The concept of professional autonomy is core to
most health professions understanding of their
role, and any perceived diminution of that au-
tonomy is always perceived and portrayed by
health professionals as inimical to their status
as professionals. Examples of trends that are
sometimes characterised in this way include the
growing use (portrayed as an imposition) of
clinical practice guidelines by insurers or gov-
ernments, the growing role of managers in the
health system (often not medically-qualified,
but with considerable power to direct how care
is delivered), and the oversight mechanisms
that measure the delivery of care against a pre-
determined set of process indicators or quality
standards. In this sense, the concept of “autono-
my”is complementary to,but also different from
the well-known Beauchamp-Childress concept
of respect for the autonomy of persons [1]. These
principles are uniquely applicable to medical
(or more broadly, health professional) practice,
but the concept of professional autonomy is far
more widely applied and appealed for, not al-
ways successfully.
Tracking the Concept Through
WMA Declarations
The ways in which the concept of profes-
sional autonomy has evolved can be tracked
when considering the evolving World Med-
ical Association (WMA) policy positions,
as expressed in a series of Declarations.
The Declaration of Madrid on Professional
Autonomy and Self-Regulation was adopt-
ed by the WMA in 1987 [2].The key state-
ment here was that “the central element of
professional autonomy is the assurance that
individual physicians have the freedom to
exercise their professional judgement in the
care and treatment of their patients.” This
Declaration was subsequently rescinded
and replaced by the Declaration of Seoul on
Professional Autonomy and Clinical Inde-
pendence, in 2009 [3]. The new WMA po-
sition emphasised the circumstances which
might lead to an assault on professional au-
tonomy, and in particular on clinical inde-
pendence, stating:
“The central element of professional au-
tonomy and clinical independence is the
assurance that individual physicians have
the freedom to exercise their professional
judgment in the care and treatment of their
patients without undue influence by outside
parties or individuals.”
In particular, the Declaration went on to
outline, briefly, who might be implied by
such “undue influence”. Point 3 targeted
Andy Gray
Ethics and Professional Autonomy
BACK TO CONTENTS
38
Medical Ethics
“governments and administrators: “Al-
though physicians recognize that they must
take into account the structure of the health
system and available resources, unreason-
able restraints on clinical independence
imposed by governments and administra-
tors are not in the best interests of patients,
not least because they can damage the trust
which is an essential component of the
patient-physician relationship.” Point 4
aimed at hospital administrators and third-
party payers: “Hospital administrators and
third-party payers may consider physician
professional autonomy to be incompatible
with prudent management of health care
costs. However, the restraints that admin-
istrators and third-party payers attempt to
place on clinical independence may not be
in the best interests of patients. Further-
more, restraints on the ability of physicians
to refuse demands by patients or their fam-
ilies for inappropriate medical services are
not in the best interests of either patients
or society.”
However, the pendulum is also swinging in
the other direction, with recognition that
patients and their families have a greater
need for, and right to, access to sufficient
information to decide whether their phy-
sicians are subject to undue influence. For
example, Bauchner et al. have argued that
“[a]s increased transparency reveals many
aspects of medicine that have formerly
been hidden from patients (such as con-
flicts of interest and costs of care), as more
physicians are employed, as the economic
stakes for patients and their families are
greater, and as the belief that medicine
should be more personalized becomes in-
tegrated into practice, it is incumbent on
the leaders of medicine to re-examine the
organizational, governance, and self-regu-
latory structure of the profession” [4]. The
key statement here is about the nature of
the physician as an employee, not an inde-
pendent practitioner.
The 2008 Declaration of Seoul was accom-
panied by the 2009 Declaration of Madrid
on Professionally-led Regulation [5]. This
Declaration claimed that “[a]s a corollary
to the right of professional autonomy and
clinical independence, the medical pro-
fession has a continuing responsibility to
be self-regulating. Ultimate control and
decision-making authority must rest with
physicians, based on their specific medical
training, knowledge, experience and exper-
tise.”This right would include, for example,
the right to define professional competen-
cies, and thus exercise control of entry into
the profession through the accreditation of
educational providers and qualifications,
and the requirement for continued com-
petence. It would also include the right to
exercise disciplinary powers, whereby prac-
titioners would be subject to the judgment
by their peers and no-one else. That set of
rights is also under attack. Collier has writ-
ten that “granting doctors complete control
over their own ship is becoming a tougher
sell” [6].
Concerns around professional autonomy
have not been reserved to medicine. In
pharmacy, one of the key schisms has been
between those jurisdictions that have al-
lowed the entry of non-pharmacists owners
of community pharmacies (usually in the
form of chain stores) and those that have
resisted this change. In 2009, the European
Court of Justice weighed in on this debate,
noting: “a Member State may take the view
that there is a risk that legislative rules
designed to ensure the professional inde-
pendence of pharmacists would not be ob-
served in practice, given that the interest of
a non-pharmacist in making a profit would
not be tempered in a manner equivalent to
that of self-employed pharmacists and that
the fact that pharmacists, when employees,
work under an operator could make it dif-
ficult for them to oppose instructions given
by him. [7]”
However, the core principle cannot just be
reduced to one of ownership. As the work-
ing environment has changed for many
health professionals, with fewer being
self-employed solo practitioners, so profes-
sional autonomy has been seen to be under
threat. Another way to consider this, is to
see professional autonomy as important,
but subject to change. The same challenges
can be seen in government service and not
only in the for-profit environment. Calnan
and Williams identified “market principles
and the new “managerialism” into the Na-
tional Health Service by the government”
as threats to autonomy in the United King-
dom, but also added “the emergence of
complementary medicine and the role of
the “articulate” consumer” [8]. One of their
respondents cited being “put upon from
above and below”.
Dual Loyalty Issues
Any time of radical change is unsettling to
old perceptions and assumptions. So, when
the Affordable Care Act was passed in the
United States (more commonly referred
to as “Obamacare”), some saw the risk of
restrictions on professional autonomy  [9].
Times of political strife can also pose
threats to autonomy, as have been identified
in the Middle East, as it was buffeted by the
“Arab Spring” [10]. In combat zones, many
health professionals may perceive a tussle
between dual loyalties, to the the objectives
of the armed forces, compared to the needs
of their individual patients, who may be
combatants or civilians [11].
The concept of dual loyalty has particular
resonance for anyone who has served in a
conscripted role, especially in a civil war
setting [12]. In analysing the dual loyalties
at play in the military tribunals at Guan-
tanamo Bay, Singh pointed to the lessons
from apartheid South Africa, where profes-
sional associations did not always stand up
for their members,but were “acquiescent”to
the security policies of the day [13]. How-
ever, dual loyalties are not confined to areas
of conflict or the military. They have been
identified in the prison health service, for
example, with the advice that “Profession-
BACK TO CONTENTS
39
Medical Ethics
als caring for prisoners should strictly and
exclusively adhere to their role as caregivers
to their inmate patients, acting in complete
and undivided loyalty to them, and should
firmly refuse to take over any professional
obligation that is outside the interest of
their prisoner patients. [14]” Similar chal-
lenges have been identified in immigrant
detention centres [15].
Collaborative Practice –
the new Normal
The concept of the solo practitioner, ac-
countable only to himself (and yes, there
is probably a gendered element to the con-
cept), is not only untenable in the light of
the demand of respect for patient auton-
omy, it also runs headlong into the more
compelling demand for truly collaborative
practice.
In 2013, the World Health Professions
Alliance issued a joint statement on in-
terprofessional collaborative practice. The
Statement defines collaborative practice as
follows: “Collaborative practice happens
when multiple health workers from differ-
ent professional backgrounds work together
with patients, families, carers and commu-
nities to deliver the highest quality of care
across settings.” In particular, professional
regulatory systems and processes including
professional competencies, practice stan-
dards, and scopes of practice should permit
and facilitate effective collaborative practice.
Collaborative practice should be the norm,
not an exception, just as active involvement
of the patient and caregivers in all decisions
is imperative. Pellegrino, in outlining the
linkages between the elements of medical
ethics, underscored the centrality of respect
for autonomy:
“Do good and avoid evil is the primum
principium of all ethics. All ethical systems,
medical ethics included, must begin with
this dictum, which means that the good
must be the focal point and the end of any
theory or professional action claiming to be
morally justifiable. … The good of the per-
son served is linked ontologically to the end
of the professional activity. It is not subject
to change at will. With the good as the end
of professional activity, autonomy becomes
mandatory since to violate autonomy is to
violate the dignity and humanity of the per-
son. [16]”
Just as the working environment has
changed for many health professionals, so
professional autonomy has also been seen as
under threat or at least subject to change.
However, on the positive side, collaborative
practice has blurred the boundaries between
professions and between professionals.
Although health professionals need to
guard against the negative consequences of
dual and divided loyalties,they should never
lose sight of their primary obligation, to re-
spect the autonomy of persons, and thus to
serve.
Disclosure: At the time of the presenta-
tion, the author was a Vice-President of
the International Pharmaceutical Federa-
tion (FIP). He is currently a member of the
World Health Organization’s Expert Panel
on Drug Policies and Management,a mem-
ber of the South African National Essential
Medicines List Committee (NEMLC),and
a member of three expert advisory com-
mittees of the successor to South African
Medicines Control Council (MCC), the
South African Health Products Regulatory
Authority (SAHPRA).
References
1. Beauchamp TL, Childress JF. Principles of
Biomedical Ethics (5th ed). Oxford University
Press, 2001.
2. World Medical Association. Declaration of
Madrid on Professional Autonomy and Self-
Regulation, 1987. https://www.wma.net/
policies-post/wma-declaration-of-madrid-on-
professional-autonomy-and-self-regulation/
3. World Medical Association. Declaration of
Seoul on Professional Autonomy and Clini-
cal Independence, 2008. https://www.wma.
net/policies-post/wma-declaration-of-seoul-
on-professional-autonomy-and-clinical-inde-
pendence/
4. Bauchner H, Fontanarosa PB, Thompson AE.
Professionalism, governance, and self-regulation
of medicine. JAMA 2015; 313(18): 1831-1836.
5. World Medical Association. Declaration of
Madrid on Professionally-led Regulation, 2009.
https://www.wma.net/policies-post/wma-
declaration-of-madrid-on-professionally-led-
regulation/
6. Collier R. Professionalism: The privilege and
burden of self-regulation. CMAJ 2012; 184(14):
1559-1560.
7. European Court of Justice. Joined Cases
C‑171/07 and C‑172/07, 19 May 2009.
8. Calnan M, Williams S. Challenges to profes-
sional autonomy in the United Kingdom? The
perceptions of general practitioners. Int J Health
Serv 1995; 25(2): 219-241.
9. Emanuel EJ, Pearson SD. Physician autonomy
and health care reform. JAMA 2012; 307(4):
367-368.
10. Hathout L.The right to practice medicine with-
out repercussions: ethical issues in times of po-
litical strife.Philos Ethics Humanit Med 2012;
7: 11.
11. Lundberg K, Kjellström S, Sandman L. Dual
loyalties: Everyday ethical problems of registered
nurses and physicians in combat zones. Nurs
Ethics 2017: 969733017718394.
12. Moodley K, Kling S. Dual loyalties, human
rights violations, and physician complicity in
apartheid South Africa. AMA J Ethics 2015;
17(10): 966-972.
13. Singh JA. Military tribunals at Guantan-
amo Bay: dual loyalty conflicts. Lancet 2003;
362(9383): 573.
14. Pont J, Stöver H, Wolff H. Dual loyalty in
prison health care. Am J Public Health 2012;
102(3):475-480.
15. Essex R. Human rights, dual loyalties, and
clinical independence: challenges facing mental
health professionals working in Australia’s im-
migration detention network. J Bioeth Inq 2014;
11(1): 75-83.
16. Pellegrino ED. The internal morality of clinical
medicine: a paradigm for the ethics of the help-
ing and healing professions. J Med Philos 2001;
26(6): 559-579.
Andy Gray, Senior Lecturer
Division of Pharmacology
Discipline of Pharmaceutical Sciences
University of KwaZulu-Natal
Durban, South Africa
E-mail: graya1@ukzn.ac.za
BACK TO CONTENTS
40
WMA General Assembly
The World Medical Association now of-
fers to its members a free online service, My
Green Doctor, which helps health profes-
sionals to add wise environmental prac-
tices and climate change awareness to their
medical practices. WMA members in 34
countries are using My Green Doctor.They
find this to be an easy way to save money
as they adopt environmental sustainability.
One medical group in the United States
began saving money in the first month and
continues to save more than $2000 US per
doctor annually.
My Green Doctor is located on the web at
www.mygreendoctor.org. It is a complete,
simple-to-follow program that can be used in
any outpatient health facility. It is peer-writ-
ten, peer-reviewed, non-partisan, science-
based, and uses language that can be under-
stood by anyone working in a medical office.
The office teaches how to make changes
that help build healthier and more efficient
workplaces. My Green Doctor offers ways to
teach healthy environmental choices to the
patients as well.This is another way in which
your practice improves community health
outcomes. My Green Doctor will make your
colleagues and you truly proud!
Share My Green Doctor with your members,
free from the World Medical Association.
Contact the WMA (secretbariat@wma.net)
to receive a short announcement that you can
include in your organization’s newsletter or
email.
The Ten Reasons
“Going Green”means to achieve My Green
Doctor’s well-defined benchmarks in man-
aging your environmental impact and teach-
ing your patients. There are at least ten rea-
sons why your medical practice should try
this. But the most important is the tenth:
to “help make environmental sustainability
and climate change awareness part of every-
one’s life.”
Ten Reasons to “Go Green”:
1. Leads to wiser and more responsible use
of resources.
2. Saves money by lowering office expens-
es.
3. Creates a healthier work environment.
4. Green Teams encourage team-work and
finding better ways to do things.
5. Green Teams generate ideas from every
member of the office or clinic.
6. Improves job satisfaction.
7. Enhances the office’s public image and
the trust of patients.
8. Decreases air pollution,water consump-
tion and waste.
9. Builds a healthier community.
10. Helps to make environmental sustain-
ability and climate change awareness
part of everyone’s life!
Five-to-Ten Minutes Weekly
The key principle of My Green Doctor is
the Green Team, a management tool that
has found success in many types of com-
panies. My Green Doctor’s “Quick Start,
Now!” page (reading time: ten minutes)
explains simple steps for how the office
manager or director begins the Green Team
process. Green Team meetings take place
for 5-10 minutes as a part of your prac-
tice’s usual weekly or monthly staff meet-
ing. There is nothing to plan in advance of
your Team meetings because the website’s
“Meeting-by-Meeting Guide” directs what
to say and what to do at each meeting.There
is one topic for each meeting, such as “En-
ergy Efficiency”, “Chemicals in the Office
and Home”, “Recycling”, “Healthy Foods”,
or “Patient Education”. The “Meeting-by-
Meeting Guide” lists for each meeting two
or three specific actions that the office can
choose from on that topic. In this manner,
your practice will make gradual improve-
ments. By six months, you will qualify for
the World Medical Association’s Green
Doctor Office Certificate that can be dis-
played in your patient waiting room and
staff lunch room.
The benefits are real and nearly immediate.
Your office is likely to save electricity and
water, which is real money. For example, a
five-office practice in Pensacola, Florida, is
saving more than $14,000 US each year on
its electric bill. In addition, your office col-
leagues are likely to enjoy contributing to
making their workplace safer, cleaner and
healthier. This builds office morale and a
team approach to problem-solving.
Your patients will see the improvements:
recycling bins in your waiting room, bro-
chures or posters for them to read, a “Green
Doctor Recognition” certificate from the
World Medical Association on your wall,
and likely other measures showing them
that yours is a modern, progressive office
with a broad interest in their health.
Todd Sack
Ten Reasons to “Go Green” in the Medical
Practice
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41
Health Care
Getting Started
Start by talking with your practice’s manag-
ing physicians,owners or Board of Directors.
They should agree to adopt environmental
sustainability as a core value for your compa-
ny and to choose My Green Doctor to guide
the process.You may not need these, but My
Green Doctor provides a sample company
environmental sustainability policy and a
ten-minute Power Point talk to introduce
these ideas. If you are a large practice, your
company might appoint an Environmen-
tal Sustainability Committee that will meet
quarterly to coordinate your progress.
My Green Doctor is free for members of the
World Medical Association and National
Medical Associations.
A key early step is to find someone to be
the Green Team Leader. This might be a
physician, an office manager, or anyone
who wants to help. The leader will sched-
ule the Team meetings, send reminders to
members, and manage the meetings to be
sure that each Action Step has a Champion
who takes responsibility for reporting back
at the next Team meeting. The position of
Team leader can rotate every few months.
In an organization with several offices, each
Green Team will report its progress quar-
terly to your Environmental Sustainability
Committee or to the Director.
Education Steps: Your
Biggest Impact
An important purpose of My Green Doc-
tor is to help health professionals to share
wise environmental practices and climate
change awareness with the patients. The
program offers dozens of ideas for teaching:
waiting room brochures, posters, blogs and
ideas for office handouts. The “Tip-of-the-
Week” section suggests a simple but power-
ful theme for each week that can be taught
easily across the practice.
My Green Doctor teaches climate change
awareness.
Green Team members often take ideas home
to their families and neighbors.These include
ideas about energy efficiency, wise water and
chemicals uses, healthy food choices, and
healthy transportation decisions. Patients
look to their health providers for role mod-
els; when we recycle, keep organic gardens,
bicycle to work or drive energy-efficient cars,
our patients and neighbors pay attention.
Green Doctor Office
Recognition
We suggest that your office allocate five to
ten minutes of each regular staff meeting for
the Green Team. Doing so will qualify you
for the World Medical Association’s Green
Doctor Office Recognition certificate in six
months or less. The criteria for qualifying
are found at www.mygrendoctor.org. They
include completing five Green Team Meet-
ings, implementing five Action Steps, and
completing five Education Steps.
Going Green, For Good
Businesses large and small have been “going
green” for decades. Their motivations are as
diverse as their business plans and profit mar-
gins. Like doctor offices, most start because
they want to save money and most accom-
plish that. But many businesses report that
the non-monetary advantages are the most
rewarding and are gained when a business
not only “goes green”but also stays green “for
good”. These offices have used the greening
process to foster a culture of teamwork, re-
sources conservation and mutual respect.
The World Medical Association is proud
to offer My Green Doctor to its members
without a fee. The WMA urges you both to
register your office today at www.mygreen-
doctor.org and to share this idea with your
national organization’s members.
Dr. Todd Sack, Associate Member of
the World Medical Association,
edits My Green Doctor for the WMA.
E-mail: tsack8@gmail.com
Audit of Resident Doctors Attendance at
Clinical Meeting in a Low Resource Setting
Doctors choose from a range of many spe-
cialties after qualification for further training.
This further training takes different forms
such as residency, masters and PhD aca-
demic programmes; postgraduate diploma,
certificate and refresher (update) courses.
There has been a threefold increase in the
number of training facilities for Nigerian
doctors in the last twenty years.This is an ex-
cellent marker of progress in Nigerian health
education [1]. The primary objective of the
residency-training programme in Nigeria as
conceptualised by the founding fathers is to
provide highly trained doctors who have ac-
quired competence in the current practice of
a given branch of medicine in a manner rel-
evant to the healthcare needs of Nigeria [2].
Consultants as leaders, teachers, role models,
and mentors are to guide, train and impact
knowledge to residents.
The most competent doctor needs to assess
him/herself periodically and make improve-
ments on his/her performance [1]. Con-
tinuing education is a term used to describe
the process of continuing to learn once a
career has begun.
Continuous medical education (CME) has
long been recognised as the key to updating
and maintaining the knowledge and skill of
BACK TO CONTENTS
42
Health Care
health professional [3] continuous medical
education also known as continuous pro-
fessional development is a process of con-
tinuous learning that begins ones the person
starts practicing as a doctor as it is a way
of updating the knowledge of the doctor o
new developments [4–7]. Most of what is
taught in medical school becomes obsolete
about a decade after graduation [3; 7–8].
In-hospital continuous medical education
takes different forms. One of which is clini-
cal meeting also known as clinical confer-
ence or Grand round where health work-
ers organise meetings, selected topics are
presented and discussed, giving each par-
ticipant a chance to contribute [5]. Some-
times case presentations are done. Clinical
meetings play a vital role in the education
and training of doctors as it provides an
opportunity for patient centered clinical
discussion, integration of research and best
practice literature with contemporary clini-
cal cases, demonstration of clinical leader-
ship poor delivery of formal education [8].
Attendance at clinical meetings includes
doctors, medical students, nurses and some-
times other healthcare workers such as
physiotherapists and medical technicians.
The clinical meeting is intended to keep the
doctors abreast with current knowledge and
competent and should be part of the hos-
pital schedule of activities [9–10]. World-
wide, the number of medical graduates are
increasing, it is important that hospitals
ensure that clinical meetings remain a pri-
ority [8]. Attendance at continuous medical
education is a requirement for certification
and dictated by certain regulatory authori-
ties in some countries.
This is a 29-months retrospective study
from March 2009 to July 2011 at a Nige-
rian hospital. Names of attendees at the in-
hospital continuous medical education are
entered into a registers during each clinical
meeting.
It is a tertiary hospital, the in-hospital con-
tinuous medical education available at the
hospital studied are weekly journal club,
morning review and clinical meeting in
all the departments and a monthly general
hospital clinical meeting
The audit was conducted in the department
of anaesthesiology. The hospital is a tertiary
hospital with training for residency that
is specialist doctors in raining. The cadre
of doctors at the hospital are consultants,
medical officers, registrars, senior registrars
and house-officers (interns).
Data was extracted from the clinical meet-
ing register of the department of anaesthe-
siology. Residents from other departments
having posting in the department of anaes-
thesiology when the study was conducted
were included in the survey.
During this 29 months when the audit was
conducted, the department held 76 sessions
of clinical meetings, which was attended by
1695 doctors made up of 11.27% consul-
tants, 24.78% senior registrars, 54.93% reg-
istrars,7.61% doctors on posting from other
departments and 1.42% visitors. Residents
absent from the 76 sessions of clinical meet-
ings were 1107. The percentages of those
present, absent against the total number
of residents that is supposed to attend the
clinical meeting are shown in Table 1. The
residents are made of registrars and senior
registrars.
Continuous describes those educational ac-
tivities undertaken by physicians after com-
pletion of the basic formal undergraduate
training [11]. Clinical meetings are neces-
sary in improving and updating the doctor’s
knowledge of the current trends in medi-
cine. It helps doctors and other healthcare
professionals keep up to date in important
evolving areas which may be outside of their
core practice. It also helps those preparing
for professional examinations and learns
how difficult cases were managed especially
in low resource centres where there is lack
of current modern sophisticated equipment.
Residents on posting from other depart-
ments had the least attendance at clinical
meetings.They should be encouraged to at-
tend these academic sessions. All residents
should be advised to attend these academic
sessions as no knowledge is ever wasted.
Attendance by visitors made up 1.42% of
attendees. These visitors are made up of
doctors from another hospital and depart-
ments. One visitor was from the obstetrics
and gynaecology department when obstet-
ric haemorrhage was discussed and another
from the department of surgery when deep
venous thrombosis was discussed. Doctors
still absent themselves from this crucial and
very important meeting, which does not
have a course fee.
Table 1. Showing number of residents absent and present at the clinical meeting
Cadre of resident Senior registrar Registrar
Residents on posting from
other departmentsv
Attended
Absent
total
60.09% (420)
39.9% (279)
100% (699)
60.42%(931)
39.58%(610)
100%(1541)
9.92%(24)
90.08%(218)
100%(242)
Yvonne Dabota Buowari
NIGERIA
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43
Health Care
In a study conducted in the United States
of America, continuous medical educa-
tion consisted of 41% conference’s/lectures,
20% Grand rounds, 17% online, 7% tumour
boards, 4% projects, 4% case/peer reviews,
2% journal club, 2% participation in com-
mittee, 2% collaborates and 1% simulation/
skill lab [12].
Continuous medical education helps in-
crease the chances of the most positive out-
come for patient care. Continuous medical
education is aimed at educating practising
physicians through the provision of up-to-
date clinical information. Grand rounds
require much effort in preparation and
prolonged attention by their audience, but
their purpose and effectiveness are rarely
investigated or even questioned by physi-
cians [4]. Healthcare leaders and medical
educators often rely on Grand rounds to
change physician behaviour and improve
patient outcomes [3]. Non-medical observ-
ers have reached the conclusion that Grand
rounds are used in
continuous medical
education as an in-
structional method
for maintaining and
improving clinical
skills of practising
physicians [10].
Health care is a field
with constant new
developments hence
continuous medical
education prepares
health staff for these
changes. There is
need to learn the
latest in health care
technology. Doctors
should continually
educate themselves
to keep up to date
otherwise; they
would only have the
education received
before graduation.
Doctors have a duty to maintain personal
knowledge and skills. In-hospital academic
programmes are important to upgrade the
knowledge of doctors. These clinical meet-
ings are beneficial to the residents that is why
it is been instituted by the consultants and se-
nior doctors. All residents should be encour-
aged to attend all academic programmes of
their departments and hospitals. Attendance
registers should be provided at such meetings
instead of using sheets of papers, which can
easily be lost. All doctors should be encour-
aged to put down their names whether it is
there hospital or primary department as this
may be used for research in future.Topics to
be discussed should be discussed should be
advertised at conspicuous places to the hos-
pital community so that it can be attended
by doctors, nurses and other paramedical
medical staff from other departments es-
pecially if the topic is related to their disci-
pline. Where resources are available in larger
hospitals, a notice board can be dedicated to
the advertisements of clinical meetings top-
ics and other in-hospital continuous medical
education where that of various departments
is kept. A library of all presentations of the
various departments can be made for refer-
ence purposes to those who cannot attend
the meeting. Interesting topics can be sub-
mitted as review articles to journals.
References
1. Fafowora OF. Continuing medical education for
Nigerian doctors. Nig J Med. 1997. 6(3): 61-62.
2. Akinyemi RO.Improving the quality of residen-
cy training in Nigeria. Annals Ibadan Postgrad
Med. 2006, 4(1): 7-8.
3. Ogbaini-Emovon E. Continuing medical educa-
tion closing the gap between medical research and
practice, Benin J Postgrad Med, 2009, 11, 43-49.
4. Kulatunga GGAK, Marasunghe RB, Karuthilake
IM, Dissanayake VHW. Introduction of web
based continuous professional development to Sri
Lanka, Sri Lanka J Bio-Med Informatics, 2012,
3 (4), 127-131.
5. Haruna L. Continuing medical education: les-
sons from Butambala health Sub-District,
Health Policy Dev, 2004, 2 (2), 161-167.
6. Alhejji A, Aramadan M, Aljasim M, Alran-
madham B. Barriers to practicing continuous
medical education among primary healthcare
physicians in Alhasa, Kingdom of Saudi Arabia,
J Health Edu Res Dev, 2015, 3:3, http://dx.doi.
org/10.4172/2380-5939.1000147
7. Anshu MG,Tejinder S. Continuing professional
development of doctors, Natl Med J India, 2017,
30 (2), 88-92.
8. AMA junior doctor training, education and su-
pervision survey, report of findings, AMA, www.
ama.com.au, assessed January 2018.
9. Van-Hoof TJ, Morison RJ, Majdalany GT, Gi-
annotti TE,Meehan TP.A case study of medical
Grand rounds: are we using effective methods?
Acad Med. 2009. 84(8): 1144-51.
10. Lewkonia RM, Murray FR. Grand rounds:
paradox in medical education. Can Med Assoc
J. 1995. 152 (3): 371-376.
11. Eguma SE. Continuing medical education:
what do African anaesthetists need? Anaesthesia
News. 2002, 6(2): 6-7.
12. Combes JR. Continuing medical education as
a strategic resource, American hospital associa-
tion’s physician leadership forum, Chicago, IL,
2014, September 2014.
Dr. Yvonne Dabota Buowari,
Dr. Longinus N. Ebirim,
Department Of Anaesthesiology, University
Of Port Harcourt Teaching Hospital, Nigeria.
E-mail: dabotabuowari@yahoo.com
Figure 1.  Showing attendance at the clinical meeting
  Attended clinical conference    Absent from clinical conference
SR: Senior Registrar; Reg: Registrar; PO: Resident doctor on posting from
another department
NIGERIA
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44
Health Care
The nature of neoliberal health reforms that
brings market orientation to health and
making it a new area of profit maximization
for capital has, within the last three decades,
deeply affected public hospitals in Turkey
in terms of organization, financing and em-
ployment. The financing structure of pub-
lic hospitals has radically changed in this
process. While citizens have already taken
up the burden through direct and indirect
taxation, hospitals are forced to seek funds
from extra budgetary resources and conse-
quently it became necessary to have citizens
to contribute to the financing of health ser-
vices through social/private security contri-
butions, cost-sharing/user fees and out-of-
pocket costs.
Changing the financial and organizational
structure of public hospitals is the princi-
pal approach in widening the operational
sphere of capital in the field of health. In
this context, the building of and service
delivery by public hospitals on the basis of
the model called public-private partnership
(PPP) is brought to the fore in Turkey.
Historical Background
The first arrangement in Turkey relating to
the building of health facilities under the
public sector through “leasing” was made in
2005 by adding an article (Additional Ar-
ticle 7) to the Fundamental Law on Health
Services No. 3359 dated 1987. Then, a new
regulation (2006) and legislation (2013)
established in detail the scope and content
of leasing. These arrangements were first
referred to as “Integrated Health Campus”,
followed by other terms including “Health
Campus”, “Public-Private Partnership” and
“Public-Private Cooperation.” Finally, hos-
pitals built through public-private partner-
ship were introduced to the public as “City
Hospitals”. Presently there are 6 active city
hospitals in Turkey (Yozgat, Mersin, Adana,
Isparta, Kayseri and Elazig).
Opinions of neither the Turkish Medical
Association (TMA) nor trade unions were
solicited during arrangements related to the
drafting of the law in 2015, regulation on
the enforcement of the law and in estab-
lishment of the Ministry of Health Depart-
ment of Public-Private Partnership.
On land allocated free by the public for city
hospitals, the Ministry of Health goes out
to tender for buildings whose projects were
developed by the Ministry and these tenders
are generally won by group of companies
active in the fields of medical equipment/
technology, construction and financing. Ac-
cording to tender specifications, winning
companies have to finish hospital buildings
within three years (in many contracts this
condition is not met; for instance, the con-
struction of Kayseri City Hospital tendered
out in 2009 was completed only recently),
and to undertake care/maintenance works
throughout the leasing period (25 years).
Information available about tenders is kept
limited since it is considered as “business
secret.”
Contracts acted by the Ministry of Health
and companies are subject to private law
provisions and related disputes are to be
settled by arbitration. At this point it must
be recalled that Prof Alfred de Zayas, Unit-
ed Nations Special Rapporteur for Human
Rights warned that the privatization of
public services through public-private part-
nerships would lead to human rights viola-
tions and it would harm citizens in longer
term since arbitration is but a mechanism
making the powerful also rightful [1].
Decisions related to the building of city
hospitals used to be taken by the High
Planning Board under the Ministry of
Development comprising relevant Min-
isters under the chair of Prime Minister.
The Ministry of Development was closed
with the new government system in Turkey.
The decision making authority of the High
Planning Board was withdrawn and at pres-
ent the building of city hospitals is to be de-
cided by the President as the sole authority.
Until recently, the Board used to decide on
building city hospitals on the condition that
the number of beds in existing hospitals is
reduced by the same amount as needed by
prospective hospital or the closure of exist-
ing hospitals. Following the completion of
a city hospital, state hospitals move to their
new buildings, old buildings remaining
Kayihan Pala Ozgur Erbas Eris Bilaloglu Bayazit Ilhan Rasit Tukel Sinan Adiyaman
Public-Private Partnership in Health Care: Case of Turkey
TURKEY
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45
Health Care
within the city are closed, and consequently
no inpatient beds are added to Ministry of
Health hospitals in provinces where city
hospitals are built.For example,while public
hospitals in Adana used to deliver services
with bed capacity of 3,011,this number rose
to only 3,025 after the opening of the city
hospital with bed capacity of 1,550. In An-
kara, the capital city of the country, the plan
for the closure of 13 deep-seated hospitals
of the Ministry of Health located at central
town and delivery of health services by two
city hospitals will radically transform health
services and urban structure.
It was revealed upon lawsuits brought by
the Turkish Medical Association that ten-
der specifications prepared by the Ministry
of Health also included the free transfer of
land once occupied by closed public hospi-
tals to tender winning companies for their
business enterprises such as hotels, luxury
housing or shopping malls though not en-
visaged either in Board decisions or legisla-
tive arrangements. Upon this, the Council
of State decided to suspend tenders relat-
ed to Ankara-Etlik, Ankara-Bilkent and
Elazig city hospitals. Then a legislative ar-
rangement was introduced to the effect
“tender specifications envisaging the trans-
fer of hospital land to companies are not to
be complied with.”In order to stand against
any possible decision of annulment by the
Council of State, the clause “decisions of
annulment by the administrative jurisdic-
tion are not enforced; but relevant revisions
are made according to justifications given
for annulment” was introduced.
“Commercial revenues” in city hospitals
are left to tender winning companies and
both “Clinical Support Services” and “Sup-
port Services” are also delivered by these
companies. Throughout the period of con-
tract (25  years) companies are to be paid
“Availability payment” as rental and repair/
maintenance, and volume based “Service
payments” for clinical support services
(Laboratory, imaging, sterilization and dis-
infection, rehabilitation, etc.) and other
support services (Linen and laundry, cater-
ing, waste management, etc.). Companies
that undertake city hospital tenders in Tur-
key are guaranteed that hospitals will be op-
erated by rate of occupancy of 70% in terms
of volume-based care. This rate is 80% for
high security forensic psychiatry hospitals.
The definition of “clinical support services”
included in tender specifications is not suf-
ficiently clear. Due to this lack of clarity
branches such as physical treatment and
rehabilitation and radiation oncology to-
gether with medical imaging and labora-
tory services are included in “clinical sup-
port services” and left to private companies.
Upon an amendment made later, ambigu-
ity went further and it was accepted that
“services requiring advanced technology
and high funding” may be handed over to
companies.This means that all services with
high rates of return may be transferred to
companies upon their request.
It is agreed that availability and service pay-
ments for city hospitals is to be paid by the
Ministry of Health or from revolving fund
budgets of its affiliate facilities and/or by
central government budget. But it is un-
certain whether revolving funds can cover
very high service costs. Due to neoliberal
health policies, base salaries of doctors and
other health workers are low in Turkey and
the system of performance-based additional
payment is adopted on the condition that
that it is covered by revolving fund. Since
priority in the use of revolving fund is given
to payments due to companies, there are
cuts in additional payments of doctors and
other health workers.
As can be understood clearly from what has
been said above, public-private partnership
is a model of investment and service deliv-
ery that is based on State’s long-term con-
tractual relationship with a group of private
companies. In this model, hospitals are built
by private companies and leased to the State
for long-term (i.e. 25 years) while the State,
on its part, both pays rent and transfers all
services other than “core services” to these
companies.
Public-private partnership is a privatiza-
tion method and cases from many countries
clearly show that public-private partnership
initiatives serve not to the interest of pa-
tients but financiers.There are many studies
confirming that investments in infrastruc-
ture made through public-private partner-
ships are costlier than others made through
routine tendering procedures.In public-pri-
vate partnership model, risks and costs rest
with public whereas private companies en-
joy means of financing through rental and
income guaranteed on the basis of service
transfer.
Problems Coming to
the Fore in Turkey
The major problem related to city hospitals
in Turkey is the high cost of hospital build-
ings and equipment to the public. Exam-
ining the amount of fixed investment and
annual rentals in tenders arranged by the
Ministry of Health we come across signifi-
cantly high costs. According to a report by
the Ministry of Development, for 18 city
hospitals whose contract price amounts to
10.6 billion USD, an amount of 30.3 billion
USD is to be paid in 25 years to compa-
nies building and operating these hospitals
[2]. Given that the number of city hospitals
planned is 31 (for the time being) we can
foresee that Turkey will undertake a debt
burden of over 50 billion USD for a period
running until 2050 only as availability pay-
ments. Considering that the total invest-
ment budget of the Ministry of Health is
1.5 billion USD for the year 2018, it is un-
derstood better how high the cost of public-
private partnership is in the field of health.
In case the State has its investments within
the framework of a plan there will be no
need to resort to methods like PPP by going
into long-term debt or paying rental. Such
methods are too costly and paid through
TURKEY
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46
taxes collected from people. For instance, it
is figured out that with 2.6 billion TL allo-
cated from the 2018 budget of the Ministry
of Health to presently operating hospitals
it is possible to build 64 full-fledged hos-
pitals each with 150 bed capacity [3]. The
extremely high cost burden can be seen
more clearly if it is considered that rent-
als will be paid for a period of 25 years and
it will further increase with each new city
hospital. While the exchange rate was set
as 1 USD=1.5 TL in preliminary feasibility
reports for hospitals, the present exchange
rate is well over 1 USD=6 TL. Given that
the Turkish lira is recently losing value
against foreign currencies including dol-
lar and euro in the first place, it is a great
risk for the country that rentals have to be
paid based on USD. Economists warn that
initiatives in public-private partnership will
further deepen the present economic crisis
faced by Turkey.
Worldwide, suppositions that once laid
the basis of arguments about the “ratio-
nality” and “legitimacy” of privatizations
through public-private partnerships and
other methods are collapsing while argu-
ments and struggle for the delivery of pub-
lic services publicly and for the benefit of
public are getting stronger. The call made
by more than 150 organizations throughout
the world with a Manifesto addressed to
the World Bank and IMF was an impor-
tant stage in this process. Upon reactions,
the World Bank had to update its criteria
related to Environmental and Social Im-
pact Assessment [4]. In the same vein, a
revised text related to counselling services
in initiatives supported by the International
Bank for Reconstruction and Development
(IBRD) and International Development
Association (IDA) was issued in July 2014.
The point that is emphasized in modifica-
tions made is that relevant reports should go
into the essence beyond what is formal and
include realistic assessments. A statement
made by the World Bank openly admits the
presence of manipulations in environmental
and social impact assessment reports com-
ing from the field in relation to projects that
it will fund and concedes that its local units
have to be more meticulous on such mat-
ters.
The first one being in April 2011, tenders
based on the PPP method and their legis-
lative basis was carried out in a way closed
to all relevant stakeholders. Infractions and
irregularities in the process include the fol-
lowing: Change in companies involved in
tendering process; continuation of price re-
lated discussions even after the completion
of tenders; failure in making deliveries on
committed dates; revision of contracts over
and over again; and deeming the procedure
of tendering practically non-functional
through transfer of shares of the main com-
pany as a method having no place either in
legislation or in relevant regulation. The es-
sential point in any tender is to find a com-
pany best suited to perform a specific work
in compliance with some specifications and
award it in a way to uphold public benefit.
In the method mentioned above, however,
even companies not participating to tender
process were awarded by moving out of the
inspection of tender commissions. This is
openly in contrast with the Law on Public
Tendering and the Law No. 6428 on Build-
ing and Renewal of Facilities and Delivery
of Services through Public-Private Partner-
ship Model by the Ministry of Health.
In relation to PPP practices known as “city
hospitals” tendered in Turkey since 2011,
various consulting firms solicited the opin-
ion of the Turkish Medical Association in
the context of environmental and social
impact assessment. Resulting opinions were
placed on internet pages of the organiza-
tion. Retrospective visits to World Bank’s
project evaluation and promotion pages
showed that opinions of the TMA were
not incorporated into reports and the only
mention of the TMA was about its lawsuit
requesting the nullification of tenders.
Yet, opinions forwarded by the TMA had
pointed out to many defects and irregulari-
ties in relevant procedures and processes in-
cluding the following: practices, including
those under the relevant legislation in the
first place, totally out of public informa-
tion and scrutiny; absence of Environmen-
tal Impact Assessment (EIA) in any project
though it is compulsory under the existing
Environment Law; development of projects
out of international criteria related to effi-
ciency; existence of building projects leading
to implicit incremental costs; threat to peace
in working life as a result of status differ-
ences of personnel to be employed in hospi-
tals; negative implications on education for
specialty in medicine as a result of arrange-
ments not considering the requirements of
this education; threats to medical autonomy
in the absence of rules on doctor-private
company relations; increased possibility of
companies shifting risks to public and pub-
lic employees as a result of ambiguities in
risk sharing; non-compliance of preliminary
feasibility reports on projects with criteria
set by the World Bank, OECD, European
Bank for Reconstruction and Development
(EBRD) and European Investment Bank;
absence of any value for money (VfM) anal-
ysis complying with international standards;
and neither including nor taking the opin-
ion of trade unions and professional orga-
nizations at any stage in the process. Hence,
the process operating so far in Turkey as a
whole runs counter to all environmental and
social impact assessment criteria.
In Turkey there are also some technical
problems associated with city hospitals such
as high number of beds and large size of in-
door space per bed.
The average number of beds in a city hos-
pital in Turkey is 1,311. This number, how-
ever, may be as high as 3,704 in the case of
Ankara-Bilkent City Hospital for instance.
The number of beds in a hospital is accepted
as an important indicator with respect to ef-
ficiency.The outcomes of a systematic study
on the efficiency and optimal size of hos-
pitals show that hospitals with bed capac-
ity under 200 and over 600 are inefficient
Health Care TURKEY
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47
[5]. The high number of beds preferred for
city hospitals confronts Turkey as a source
of inefficiency as proven by past experience
and scientific studies. While large hospitals
are being abandoned throughout the world
for their inefficiency,the Ministry of Health
targets launching such hospitals with thou-
sands of beds.
In city hospitals in Turkey, the average in-
door space per bed is 287 m2
than can be
as high as 350 m2
in some hospitals. It is
observed that this space is generally around
150-200 m2
in new hospitals built in de-
veloped countries. This means that indoor
space per bed in city hospitals in Turkey
is larger by about 40 per cent than what is
recently preferred in modern hospitals. The
point is that larger the indoor space per bed
is, higher the costs of energy, cleaning, re-
pair and maintenance are.
As far as health workers are concerned, city
hospitals first of all created problems related
to their employment.While it is accepted to
transfer sub-contracted workers in Ministry
of Health hospitals to permanent employ-
ment status, those working in city hospitals
as well as workers in public hospitals to be
closed for these hospitals are excluded from
this arrangement.
The practice of city hospitals that under-
went auditing by the Court of Accounts for
the first time in 2018 since 2005 presents a
dire picture.The report by the Court of Ac-
counts observes the following: Hospitals are
delivered with yet uncompleted construc-
tion and equipment; operations favouring
companies in payment schedules even when
guarantees are given for changes in foreign
exchange and inflation rates; deletion of
records of flaws by companies that are also
awarded hospital information management
systems; or administrations that have to
conduct inspection only on databases pro-
vided by companies; possibility of revising
all contracts to the benefit of companies
upon the request of companies and credit
institutions; and while in legislative terms
it is only the Treasury that can undertake
debts on behalf of public, top staff in the
Ministry of Health committing to com-
pensate companies in cases of termination
of contracts even when companies are the
breaching party and undertake the repay-
ment of debts incurred by companies [6].
To sum up, the major problem areas related
to “City Hospitals” in Turkey can be listed
as follows:
• Method of financing (extremely high cost
to the public, payment difficulties faced
by public hospitals to move, ways to be
pursued in relation to treasury guarantee
and cases like bankruptcy),
• Site selection (opening of farmland to
development and constructions on sites
under the threat of floods),
• Problems of physical access resulting
from the closure of hospitals located at
city centres (geographical/economical ac-
cessibility),
• Status of sites to be vacated by public
hospitals moving elsewhere (their trans-
fer to contracting companies is at issue),
• Concessions for the delivery of both
health and support services in public hos-
pitals to move and
• Issues related to the employment and
rights of health workers [7].
Stance of Turkish
Medical Association
It is known that the PPP is a method of
privatization creating new market opportu-
nities in countries where it is implemented
in the field of health and that its purpose is
not public benefit. Hospitals operating in
the context of PPP deliver private and profit
seeking services that erode the system of
healthcare. The focal point of service here is
not human health but what accrues as profit.
The Turkish Medical Association closely
follows the process of city hospitals and
wages a struggle in both organizational and
legal terms against public-private partner-
ship initiatives in the field of health up-
holding the interests of health workers and
public benefit. In 2012, the TMA carried
the issue of public-private partnership/city
hospitals to the top of its agenda and de-
fined it as a strategic work given that the
process will eventually lead to the full priva-
tization of healthcare and leave doctors and
health workers with no other option but be-
ing employees of international consortiums.
The TMA Central Council established its
City Hospitals Monitoring Group in April
to steers efforts and initiatives in this area.
Despite the promotion of city hospitals as
new and modern buildings that public hos-
pitals will finally enjoy, it is clear that such
campuses built through public-private part-
nerships have in fact no ties with what is
actually public. It appears that city hospitals
will be the means of transferring new and
large resources to global capital under the
pretext of “public”.The people of Turkey are
now confronted in the field of health a form
of privatization even more destructive than
what has been experienced so far.
References
1. Current Concerns, accessed August 8, 2018,
https://www.zeit-fragen.ch/en/numbers/2016/
no-12-28-may-2016/ttip-international-arbitra-
tion-courts-an-assault-on-democracy-and-the-
state-of-law.html .
2. Ministry of Development (2017), Report on
Developments Related to Public-Private Part-
nership Practices in the World and in Turkey
2016, General Directorate of Investment Pro-
gramming, Monitoring and Evaluation, 2017.
3. Northern Anatolia Development Agency Pri-
vate Hospital Preliminary Feasibility Report
(2016), accessed April 22, 2018, https://www.
kuzka.gov.tr/paylasim/01_ozel_hastane_(on_
fizibilite).pdf
4. WORLD BANK Environmental and Social
Framework Setting Environmental and So-
cial Standards for Investment Project Financ-
ing, 2016, accessed August 8, 2018, http://
consultations.worldbank.org/Data/hub/files/
consultation-template/review-and-update-
world-bank-safeguard-policies/en/materials/
third_draft_esf_for_disclosure_july_20_2016.pdf
5. Giancotti, M., Guglielmo, A. and Mauro, M.
(2017), “Efficiency and Optimal Size of Hos-
Health Care
TURKEY
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48
pitals: Results of a Systematic Search”, PLoS
ONE, 12 (3): e0174533.
6. Court of Accounts, 2017 Inspection Report on
Public Hospitals in Turkey.
7. Pala, K. High Cost of City Hospitals is Con-
cealed, Bianet; 2017, accessed April 15, 2018,
https://bianet.org/bianet/siyaset/183006-sehir-
hastanelerinin-yuksek-maliyeti-gizleniyor .
Kayihan Pala, Professor of Public Health,
Turkish Medical Association, member
of City Hospitals Monitoring Group
Ozgur Erbas, Lawyer,
Turkish Medical Association,
member of City Hospitals
Monitoring Group
Eris Bilaloglu, Biochemistry specialist,
Turkish Medical Association President
of Central Council (2010–2012),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Bayazit Ilhan, Ophthalmologist,
Turkish Medical Association President
of Central Council (2014–2016),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Rasit Tukel, Professor of Psychiatry,
Turkish Medical Association President
of Central Council (2016–2018),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Sinan Adiyaman, Professor of
Orthopaedics and Traumatology,
Turkish Medical Association President
of Central Council (2018-2020),
Turkish Medical Association, member
of City Hospitals Monitoring Group
E-mail: ttb@ttb.org.tr
Welcome speech by
Dr. ­Ravindran R. Naidu –
president oftheCmaao2018–2019
“Friends, it is an absolute honour and privi-
lege to stand before you on this graceful oc-
casion and utter the most awaited words“Yes,
I accept to be the President of CMAAO for
the year 2018–2019, an organisation with a
proud past and an exciting future. A single
head achieves nothing, so I am counting on
your support to achieve the growth and goals
of CMAAO. This is truly a moment to be
honoured and cherished. I accept this ap-
pointment with pride and will give my best
efforts to make you proud.With the grace of
god and the cooperation of fellow members,
I will devote my time and myself to the obli-
gations and duties of this post.
Currently comprised of 19-member Na-
tional Medical Associations (NMAs), the
Confederation of Medical Associations in
Asia and Oceania (CMAAO) has more
than 50 years of history. Its establishment
was proposed in 1956 by Dr.  Rodolfo
P.  Gonzalez, then President of the Phil-
ippine Medical Association at the third
meeting of the Southeast Asian Medical
Confederation. In 1959, CMAAO was in-
augurated at the first Congress and Council
Meeting held at the Imperial Hotel in To-
kyo. There were 11-member NMAs at the
time of inauguration, of which 6 were pres-
ent at the first congress.
The Secretariat, which was originally in the
Philippine Medical Association, moved
to Malaysia (1993), Thailand (1997), New
Zealand (1999), and since 2000 it has been
in Japan. The role of CMAAO Secretary
General was also passed to the JMA.
This is a history that should never be forgot-
ten,and we,the current generation of mem-
bers, owe it to all the organisation’s past
members to keep this great organisation
strong and vibrant as we face the challenges
of the medical profession that confront us
now and into the future.
Over the next one year we will continue to
build on our strengths, but also take on new
directions.
We will continue our programs that
strengthen our professionalism. We will also
retain our commitment to solidarity, ensur-
ing that our members that are less resourced
can have more opportunities and assistance
to be part of this organisation and promot-
ing exchange of information and activities
aimed at improving the health of all in the
Asia Pacific region. To ensure that all of us
can perform our critical role and be a part of:
• CMAAO Resolution on Ensuring Food
Safety,
• CMAAO Resolution on Ethical Frame-
works for Health Databases and Health
genetic databases,
• CMAAO Delhi Resolution on the Pre-
vention of Child Abuse,
Ravindran R Naidu
Confederation of Medical Associations in
Asia and Oceania (CMAAO)
NMA News MALAYSIA
BACK TO CONTENTS
• CMAAOTaipei Resolution on Strength-
ening of Primary Healthcare in Asia and
Oceania,
• CMAAO Statement on Task Shifting,
• CMAAO Resolution in Economic Crisis
and Health,
• CMAAO Declaration on Tobacco Con-
trol in Asia and Oceania,
And this year in this General Assembly, the
Malaysia Statement on Pathway to Univer-
sal Health Coverage.
For the first time this year, we have organ-
ised a concurrent JDN meeting whereby a
discussion on Bullying at Workplace and
Sexual Harassment will be deliberated by
the Junior Doctors. This will be presented
as the JDN-SCHOMOS-MMA Penang
Declaration to the Ministry of Health, Ma-
laysia and the World Medical Association.
But let’s not forget we are an organisation –
united by our values and rich with talent.
If each of us puts in what we can, we will
become an organisation to be reckoned with
andsecureaplaceofrecognitionintheworld.
I have noted that I will be the 36th
President
of CMAAO over this 59-year period, an
amazing statistic that further highlights to
me the great responsibility I have taken on.
For those who know me well, you will know
that I will always do the very best I can for
the organisation and will hopefully lead the
team to continue the great work done by the
people before me. I will always strive to con-
tinue the development of CMAAO,through
leadership, co-operation and hard work.
I want to take this opportunity to thank the
outgoing President Dr. Yoshitake Yokokura
for his immense contribution to CMAAO.”
NMA News
MALAYSIA
The 33rd
CMAAO General Assembly and 54th
Council meeting was held in Shangri-La Rasa
Sayang Resort and SPA, Penang, Malaysia on
12–14 September 2018. The countries repre-
sented were Malaysia, Australia, Bangladesh,
Hong Kong, India, Indonesia, Japan, Korea,
Myanmar, Nepal, Pakistan, Philippines, Sin-
gapore,Taiwan andThailand.We had 120 del-
egates attending this event. The special guests
were Dr.  Otmar Kloiber,Secretary General of
the World Medical Association, Dr. Miguel
Jorge of the Brazilian Medical Association,
Dr. Peteris Apinis and Ms Maira Sudraba of
the Latvian Medical Association.
Dr.  Ravindran R. Naidu, Immediate Past
President of the MMA, was installed as
the 36th
President of CMAAO for the
year 2018-2019. The outgoing President
of CMAAO was Dr. Yoshitake Yokokura,
President of the World Medical Associa-
tion and President of the Japan Medical
Association. Dr.  K.  K.  Aggarwal was ap-
pointed as President Elect 2018–2019.
The Director General of Health of the Min-
istry of Health, Malaysia, Datuk Dr. Noor
Hisham was the orator at the 16th
Takemi
Memorial Oration and hie presentation
was on “Global Surgery as part of Universal
Health Coverage”. This was then followed
by a symposium on “Path to Universal
Health Coverage”which was attended by all
the National Medical Associations present.
The CMAAO Council passed and adopted
theCMAAOResolution,namely,”“CMAAO
Penang Resolution on Universal Health Cov-
erage”, which will be presented to the World
Medical Association.
For the first time in the history of CMAAO,
the Junior Doctors Network (JDN) togeth-
er with the SCHOMOS MMA had a con-
current meeting with the CMAAO Coun-
cil Meeting represented by 7 countries. The
JDN themed discussion was “Leading the
way towards mutual respect – The Role of
Junior Doctors in preventing Workplace
Bullying & Sexual Harassment”. This ses-
sion was graced by the Deputy Director of
the Medical Development Division, Min-
istry of Health, Dr. Mohd Fikri Bin Ujang.
A proposal has been submitted to the Com-
mittee of the CMAAO to involve the JDN
as part of the CMAAO General Assembly
and Council Meeting. After a serious dis-
cussion the following resolution has been
presented by the JDN – “Junior Doctors
Network-SCHOMOS MMA Penang
Declaration 2018” on workplace bullying
and sexual harassment which will be sub-
mitted to the Ministry of Health and the
World Medical Association.
Dr. Ravindran R Naidu
KMN, PJK, CMAAO
Immediate Past President
Malaysian Medical Association,
Vice President, Commonwealth
Medical Association
E-mail: flynaidumma@gmail.com
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IV
WMA General Assembly
WMA General Assembly
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