Declaration

Adopted by the 40^th World Medical Assembly, Vienna, Austria, September 1988,
revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203^rd WMA Council Session, Buenos Aires, Argentina, April 2016

INTRODUCTION

The effective practice of medicine increasingly requires that physicians and their professional associations turn their attention to environmental issues that have a bearing on the health of individuals and populations.
More than ever, due to diminishing natural resources, these problems relate to the quality and protection of resources necessary to maintain health and indeed sustain life itself. In concrete terms, the key environmental issues are as follow:
1. The degradation of the environment, which must be halted as a matter of urgency so that resources essential to life and health – water and pure air – remain accessible to all.
2. The ongoing contamination of our reserves of fresh water with hydrocarbons and heavy metals, along with the contamination of ambient and indoor health by toxic agents, which have serious medical consequences, especially in the poorest segments of the globe. Moreover, the greenhouse effect with its concomitant proven rise in temperature should drive our discussions forward and prepare us for increasingly serious environmental and public health consequences.
3. The need to control the use of non-renewable resources such as topsoil, which should constantly be at the forefront of our minds, as should the importance of safeguarding this vital heritage so that it can be passed on to future generations.
4. The need to mobilise resources beyond national frontiers and to co-ordinate global solutions for the planet as a whole, so as to formulate a unified strategy to confront these worldwide medical and economic problems.
5. The foremost objective is to increase awareness of the vital balance between environmental resources on the one hand, and on the other, biological essentials for the health of everyone everywhere.
Our growing awareness of these issues today has, however, failed to prevent an increase in our societies’ negative impact on the environment, e.g., melting of glaciers and increasing desertification, nor has it halted the over-exploitation of natural resources, e.g. pollution of rivers and seas, air pollution, deforestation and diminishing arable land. In this context, the migration of people from disadvantaged or developing countries, together with the emergence of new diseases, exacerbates the lack of socioeconomic policies in many parts of the world. From a medical point of view, growth of the population and irresponsible destruction of the environment are unacceptable, and medical organisations throughout the world should redouble their efforts, not only to speak out about these problems, but also to suggest solutions.

PRINCIPLES

In their role as representatives of physicians, medical associations are duty bound to grapple with these environmental issues. They have a duty to produce analytical studies that include the identification of problems and current international regulations on environmental issues, as well as their impact on the field of health.
As physicians operate within the framework of ethics and medical deontology, the environmental regulations advocated should not seek to limit individual autonomy, but rather to enrich the quality of life for all and to perpetuate life-forms on the planet.
The WMA should therefore act as an international platform for research, education, and advocacy to help further sustain the environment and its potential to promote health.
Thus, when new environmental diseases or syndromes are identified, the WMA should help coordinate the scientific/medical discussions on the available data and their implications for human health. It should foster the development of consensus thinking within medicine, and help to stimulate preventive measures, accurate diagnosis and treatment of these emerging disorders.
The WMA should therefore provide a framework for the international co-ordination of medical associations, NGOs, research clinicians, international health organisations, decision-makers and funding providers, in their examination of the human health effects of environmental problems, their prevention, remediation and treatment for individuals and communities.

Adopted by the 43^rd World Medical Assembly, St. Julians, Malta, November 1991
and editorially revised by the 44^th World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68^th WMA General Assembly, Chicago, United States, October 2017

PREAMBLE

1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are usually a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, prisoners and detainees may hope to obtain certain goals by inflicting negative publicity on the authorities. Short-term food refusals rarely raise ethical problems. Prolonged fasting risks death or permanent damage for hunger strikers and can create a conflict of values for physicians. Hunger strikers rarely wish to die but some may be prepared to do so to achieve their aims.

2. Physicians need to ascertain the individual’s true intention, especially in collective strikes or situations where peer pressure may be a factor. An emotional challenge arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. This has been well worked through in many other clinical situations including refusal of life saving treatment. An added difficulty arises in custodial settings because it is not always clear whether the hunger striker’s advance instructions were made voluntarily and with appropriate information about the consequences.

PRINCIPLES

3. Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy. Whatever their role, physicians must try to prevent coercion or maltreatment of detainees and must protest if it occurs.

4. Respect for autonomy. Physicians should respect individuals’ autonomy. This can involve difficult assessments as hunger strikers’ true wishes may not be as clear as they appear. Any decisions lack moral force if made by use of threats, peer pressure or coercion. Hunger strikers should not forcibly be given treatment they refuse. Applying, instructing or assisting forced feeding contrary to an informed and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker’s explicit or necessarily implied consent is ethically acceptable.

5. ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to benefit those they treat. This is the concept of ‘beneficence’, which is complemented by that of ‘non-maleficence’ or primum non nocere. These two concepts need to be in balance. ‘Benefit’ includes respecting individuals’ wishes as well as promoting their welfare. Avoiding ‘harm’ means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other determinants.

Physicians must respect the autonomy of competent individuals, even where this will predictably lead to harm. The loss of competence does not mean that a previous competent refusal of treatment, including artificial feeding should be ignored.

6. Balancing dual loyalties. Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. In this situation, physicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient. They remain independent from their employer in regard to medical decisions.

7. Clinical independence. Physicians must remain objective in their assessments and not allow third parties to influence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non medical reasons.

8. Confidentiality. The duty of confidentiality is important in building trust but it is not absolute. It can be overridden if non-disclosure seriously and imminently harms others. As with other patients, hunger strikers’ confidentiality and privacy should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm. If individuals agree, their relatives and legal advisers should be kept informed of the situation.

9. Establishing trust. Fostering trust between physicians and hunger strikers is often the key to achieving a resolution that both respects the rights of the hunger strikers and minimises harm to them. Gaining trust can create opportunities to resolve difficult situations. Trust is dependent upon physicians providing accurate advice and being frank with hunger strikers about the limitations of what they can and cannot do, including situations in which the physician may not be able to maintain confidentiality.

10. Physicians must assess the mental capacity of individuals seeking to engage in a hunger strike. This involves verifying that an individual intending to fast is free of any mental conditions that would undermine the person’s ability to make informed health care decisions. Individuals with seriously impaired mental capacity may not be able to appreciate the consequences of their actions should they engage in a hunger strike. Those with treatable mental health problems should be directed towards appropriate care for their mental conditions and receive appropriate treatment. Those with untreatable conditions, including severe learning disability or advanced dementia should receive treatment and support to enable them to make such decisions as lie within their competence.

11. As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing conditions should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimised or delayed by, for example, increasing fluid and thiamine intake. Since the person’s decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences of fasting is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient what he or she understands.

12. A thorough examination of the hunger striker should be made at the start of the fast including measuring body weight. Management of future symptoms, including those unconnected to the fast, should be discussed with hunger strikers. Also, the person’s values and wishes regarding medical treatment in the event of a prolonged fast should be noted. If the hunger striker consents, medical examinations should be carried out regularly in order to determine necessary treatments. The physical environment should be evaluated in order to develop recommendations for preventing negative effects.

13. Continuing communication between the physician and hunger strikers is essential. Physicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. The clinician should identify whether the individual is willing, in the absence of their demands being met, to continue the fast even until death. These findings must be appropriately recorded.

14. Sometimes hunger strikers accept an intravenous solution transfusion or other forms of medical treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care, such as treatment of infections or of pain.

15. Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confidentiality.

16. Physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the authorities, the peer group, or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike. Any restraint or pressure including but not limited to hand-cuffing, isolation, tying the hunger striker to a bed or any kind of physical restraint due to the hunger strike is not acceptable.

17. If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or artificial feeding, the physician should make this clear at the outset, and must be sure to refer the hunger striker to another physician who is willing to abide by the hunger striker’s refusal.

18. When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual’s wishes regarding medical intervention to preserve life. Consideration and respect must be given to any advance instructions made by the hunger striker. Advance refusals of treatment must be followed if they reflect the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual’s intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because the situation in which the decision was made has changed radically since the individual lost competence.

19. If no discussion with the individual is possible and no advance instructions or any other evidence or note in the clinical records of a discussion exist, physicians have to act in what they judge to be in the person’s best interests. This means considering the hunger strikers’ previously expressed wishes, their personal and cultural values as well as their physical health. In the absence of any evidence of hunger strikers’ former wishes, physicians should decide whether or not to provide feeding, without interference from third parties.

20. Physicians may rarely and exceptionally consider it justifiable to go against advance instructions refusing treatment because, for example, the refusal is thought to have been made under duress. If, after resuscitation and having regained their mental faculties, hunger strikers continue to reiterate their intention to fast, that decision should be respected. It is ethical to allow a determined hunger striker to die with dignity rather than submit that person to repeated interventions against his or her will. Physicians acting against an advanced refusal of treatment must be prepared to justify that action to relevant authorities including professional regulators.

21. Artificial feeding, when used in the patient’s clinical interest, can be ethically appropriate if competent hunger strikers agree to it. However, in accordance with the WMA Declaration of Tokyo, where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a decision, he or she shall not be fed artificially. Artificial feeding can also be acceptable if incompetent individuals have left no unpressured advance instructions refusing it, in order to preserve the life of the hunger striker or to prevent severe irreversible disability. Rectal hydration is not and must never be used as a form of therapy for rehydratation or nutritional support in fasting patients.

22. When a patient is physically able to begin oral feeding, every caution must be taken to ensure implementation of the most up to date guidelines of refeeding.

23. All kinds of interventions for enteral or parenteral feeding against the will of the mentally competent hunger striker are “to be considered as “forced feeding”. Forced feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.

THE ROLE OF NATIONAL MEDICAL ASSOCIATIONS (NMAS) AND THE WMA

24. NMAs should organize and provide educational programmes highlighting the ethical dimensions of hunger strikes, appropriate medical approaches, treatments, and interventions. They shall make efforts to update physicians’ professional knowledge and skills.

NMAs should work to provide mechanisms for supporting physicians working in prisons/jails/immigration detention centers, who may often find themselves in conflict situations and, as stated in the WMA Declaration of Hamburg, shall support any physicians experiencing pressure to compromise their ethical principles.

NMAs have a responsibility to make efforts to prevent unethical practices, to take a position and speak out against ethical violations, and to investigate them properly.

25. The World Medical Association will support physicians and NMAs confronted with political pressures as a result of defending an ethically justifiable position, as stated in the WMA Declaration of Hamburg.

Portuguese translation

Adopted by the 42^nd World Medical Assembly, Rancho Mirage, CA., USA, October 1990
and revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67^th WMA General Assembly, Taipei, Taiwan, October 2016

Injuries are the leading cause of death and disability in children and young adults, destroying the health, livelihoods and lives of millions of people each year. Causes of injury include, among others, acts of violence against oneself or others, traffic crashes, falls, poisonings, drowning, and burns. Yet many injuries are preventable. Injury control should be recognized as a public health priority requiring coordination among health, transportation and social service agencies in each country. Physician participation and leadership through medicine, education and advocacy is necessary to ensure the success of such injury control programmes.

As the World Health Organization states in Injuries and Violence: The Facts, the rate of injury is far from uniform around the world. Indeed, about 90% of injury-related deaths occur in low- and middle-income countries. Within countries, injury rates vary by social class as well. The impoverished face more dangerous living and working conditions than the more affluent. For example, buildings in poorer communities are more likely to be older and in need of repair. Poor communities are also plagued by much higher rates of homicide. What’s more, people living in poverty also have less access to quality emergency care and rehabilitation services. Greater attention must be given to these root causes of injuries.

The World Medical Association urges National Medical Associations to work with appropriate public and private agencies to develop and implement programmes to prevent and treat injuries. Included in the programmes must be efforts to improve medical treatment and rehabilitation of injured patients. Research and education on injury control must be increased, and international cooperation is a vital and necessary component of successful programmes.

National Medical Associations should recommend that the following basic elements be incorporated in their countries’ programmes:

EPIDEMIOLOGY

The initial activity of such programmes must be the acquisition of more adequate data on which to base priorities, interventions and research. An effective injury surveillance system should be implemented in each country to gather and integrate information. A consistent and accurate system for coding injuries must be implemented by hospitals and health agencies. There should also be international uniformity in the coding of injury severity.

PREVENTION

Injury prevention requires education and training to teach and persuade people to alter their behaviour in order to reduce their risk of injury. Laws and regulations based on scientifically sound methods of preventing injuries may be appropriate for effecting changes in behaviour (for example, the use of seatbelts and protective helmets). These laws must in turn be strictly enforced. An effective injury surveillance system as mentioned above will help determine how to target further preventive efforts. Urban and traffic planning should support safe environments for the residents.

BIOMECHANICS

A better understanding of the biomechanics of injury and disability could inform the development of improved safety standards and regulations of products and their designs.

TREATMENT

Injury management at the scene of the occurrence must be enhanced by an effective system of communication between first responders and health professionals at hospitals to facilitate decision-making. Rapid and safe transportation to the hospital should be provided. An experienced team of trauma practitioners should be available at the hospital. There should also be adequate equipment and supplies available for the care of the injured patient, including immediate access to a blood bank. Education and training of medical practitioners in trauma care must be encouraged to assure optimal technique by an adequate number of physicians at all times.

REHABILITATION

Trauma victims need continuity of care emphasizing not only survival but also the identification and preservation of residual functions. Rehabilitation to restore biological, psychological and social functions must be undertaken in an effort to allow the injured person to achieve maximal personal autonomy and an independent lifestyle. Where feasible, community integration is a desirable goal for people chronically disabled by injury. Rehabilitation may also require changes in the patient’s physical and social environment.

Adopted by the 29^th World Medical Assembly, Tokyo, Japan, October 1975
Editorially revised by the 170^th WMA Council Session, Divonne-les-Bains, France, May 2005
and the 173^rd WMA Council Session, Divonne-les-Bains, France, May 2006
and revised by the 67^th WMA General Assembly, Taipei, Taiwan, October 2016

PREAMBLE

It is the privilege of the physician to practise medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, and to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use is to be made of any medical knowledge contrary to the laws of humanity.

For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.

1. The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives, and in all situations, including armed conflict and civil strife.

2. The physician shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment.

3. When providing medical assistance to detainees or prisoners who are, or who could later be, under interrogation, physicians should be particularly careful to ensure the confidentiality of all personal medical information. A breach of the Geneva Conventions shall in any case be reported by the physician to relevant authorities.

4. As stated in WMA Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment and as an exception to professional confidentiality, physicians have the ethical obligation to report abuses, where possible with the subject’s consent, but in certain circumstances where the victim is unable to express him/herself freely, without explicit consent.

5. The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.

6. The physician shall not be present during any procedure during which torture or any other forms of cruel, inhuman or degrading treatment is used or threatened.

7. A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose.

8. Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.

9. Recalling the Declaration of Hamburg concerning Support for Medical Doctors Refusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman or Degrading Treatment, the World Medical Association supports, and encourages the international community, the National Medical Associations and fellow physicians to support, the physician and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

10. The World Medical Association calls on National Medical Associations to encourage physicians to continue their professional development training and education in human rights.

Adopted by the 41^st World Medical Assembly, Hong Kong, September 1989,
editorially revised by the 126^th WMA Council Session, Jerusalem, Israel, May 1990,
and by the 170^th WMA Council Session, Divonne-les-Bains, France,May 2005,
reaffirmed the 200^th WMA Council Session, Oslo, Norway, April 2015 and
with minor revisions by the 227^th WMA Council, Helsinki, Finland, October 2024

PREAMBLE

Older people may suffer pathological problems such as motor disturbances and psychic and orientation disorders. As a result of such problems, older patients may require assistance with their daily activities that can lead to a state of dependence. This may cause their families and the community to consider them to be a burden and to subsequently limit or deny care and services.

Abuse or neglect of older people can manifest in a variety of ways: physical, psychological, emotional, financial and/or material, and medical. Variations in the definition of elder abuse present difficulties in comparing findings on the nature and causes of the problem. A number of preliminary hypotheses have been proposed on the etiology of elder abuse including: dependency on others to provide care and services; lack of close family ties; family violence; lack of financial resources; psychopathology of the abuser; lack of community support, and institutional factors such as low pay and poor working conditions that contribute to pessimistic attitudes of caretakers.

The phenomenon of elder abuse is becoming increasingly recognized by both medical facilities and social agencies. The first step in preventing elder abuse and neglect is to increase levels of awareness and knowledge among physicians and other health professionals. Once high-risk individuals and families have been identified, physicians can participate in the primary prevention of maltreatment by making referrals to appropriate community and social service centres. Physicians may also participate by providing support and information on high-risk situations directly to patients and their families. At the same time, physicians should employ care and sensitivity to preserve patient trust and confidentiality, particularly in the case of competent patients.

The World Medical Association therefore adopts the following general principles relating to abuse of older people.

General principles

Older people have the same rights to care, welfare and respect as other human beings.
Physicians have a responsibility to help prevent all forms of abuse of older patients.
Whether consulted by an older person directly, a nursing home or the family, physicians should see that the patient receives the best possible care.
If physicians verify or suspect ill treatment, as defined in this declaration, they should discuss the situation with those in charge, be it the nursing home or the family. If ill treatment is confirmed, or if death is suspicious, they should report the findings to the appropriate authorities.
To guarantee protection of older people in any environment, there should be no restrictions on their right of free choice of a physician. Medical Associations should strive to make certain that such free choice is preserved within the socio-medical system.
The World Medical Association also makes the following recommendations to physicians involved in treating older people, and urges all its constituent members to publicize this declaration to their members and the public.

RECOMMENDATIONS

Physicians involved in treating older people should:

make increased attempts to establish an atmosphere of trust with their patients in order to encourage them to seek medical care when necessary and to feel comfortable confiding in the physician;
provide medical evaluation and treatment for injuries resulting from abuse and/or neglect;
attempt to establish or maintain a therapeutic alliance with the family (often the physician is the only professional who maintains long-term contact with the patient and the family), while preserving to the greatest extent possible the confidentiality of the patient;
report all suspected cases of elder abuse and/or neglect in accordance with local legislation;
utilize a multidisciplinary team of caretakers from the medical, social service, mental health, and legal professions, whenever possible, and
encourage the development and utilization of supportive community resources that provide in-home services, respite care, and stress reduction for high-risk families.

Adopted by the 34^th World Medical Assembly, Lisbon, Portugal, September/October 1981
and amended by the 47^th WMA General Assembly, Bali, Indonesia, September 1995
and editorially revised by the 171^st WMA Council Session, Santiago, Chile, October 2005
and reaffirmed by the 200^th WMA Council Session, Oslo, Norway, April 2015

PREAMBLE

The relationship between physicians, their patients and broader society has undergone significant changes in recent times. While a physician should always act according to his/her conscience, and always in the best interests of the patient, equal effort must be made to guarantee patient autonomy and justice. The following Declaration represents some of the principal rights of the patient that the medical profession endorses and promotes. Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.

PRINCIPLES

Right to medical care of good quality
1. Every person is entitled without discrimination to appropriate medical care.
2. Every patient has the right to be cared for by a physician whom he/she knows to be free to make clinical and ethical judgements without any outside interference.
3. The patient shall always be treated in accordance with his/her best interests. The treatment applied shall be in accordance with generally approved medical principles.
4. Quality assurance should always be a part of health care. Physicians, in particular, should accept responsibility for being guardians of the quality of medical services.
5. In circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.
6. The patient has the right to continuity of health care. The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.
Right to freedom of choice
1. The patient has the right to choose freely and change his/her physician and hospital or health service institution, regardless of whether they are based in the private or public sector.
2. The patient has the right to ask for the opinion of another physician at any stage.
Right to self-determination
1. The patient has the right to self-determination, to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decisions.
2. A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. The patient should understand clearly what is the purpose of any test or treatment, what the results would imply, and what would be the implications of withholding consent.
3. The patient has the right to refuse to participate in research or the teaching of medicine.
The unconscious patient
1. If the patient is unconscious or otherwise unable to express his/her will, informed consent must be obtained whenever possible, from a legally entitled representative.
2. If a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed, unless it is obvious and beyond any doubt on the basis of the patient’s previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.
3. However, physicians should always try to save the life of a patient unconscious due to a suicide attempt.
The legally incompetent patient
1. If a patient is a minor or otherwise legally incompetent, the consent of a legally entitled representative is required in some jurisdictions. Nevertheless the patient must be involved in the decision-making to the fullest extent allowed by his/her capacity.
2. If the legally incompetent patient can make rational decisions, his/her decisions must be respected, and he/she has the right to forbid the disclosure of information to his/her legally entitled representative.
3. If the patient’s legally entitled representative, or a person authorized by the patient, forbids treatment which is, in the opinion of the physician, in the patient’s best interest, the physician should challenge this decision in the relevant legal or other institution. In case of emergency, the physician will act in the patient’s best interest.
Procedures against the patient’s will
Diagnostic procedures or treatment against the patient’s will can be carried out only in exceptional cases, if specifically permitted by law and conforming to the principles of medical ethics.
Right to information
1. The patient has the right to receive information about himself/herself recorded in any of his/her medical records, and to be fully informed about his/her health status including the medical facts about his/her condition. However, confidential information in the patient’s records about a third party should not be given to the patient without the consent of that third party.
2. Exceptionally, information may be withheld from the patient when there is good reason to believe that this information would create a serious hazard to his/her life or health.
3. Information should be given in a way appropriate to the patient’s culture and in such a way that the patient can understand.
4. The patient has the right not to be informed on his/her explicit request, unless required for the protection of another person’s life.
5. The patient has the right to choose who, if anyone, should be informed on his/her behalf.
Right to confidentiality
1. All identifiable information about a patient’s health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential, even after death. Exceptionally, descendants may have a right of access to information that would inform them of their health risks.
2. Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law. Information can be disclosed to other health care providers only on a strictly “need to know” basis unless the patient has given explicit consent.
3. All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected.
Right to Health Education
Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his/her own health should be stressed. Physicians have an obligation to participate actively in educational efforts.
Right to dignity
1. The patient’s dignity and right to privacy shall be respected at all times in medical care and teaching, as shall his/her culture and values.
2. The patient is entitled to relief of his/her suffering according to the current state of knowledge.
3. The patient is entitled to humane terminal care and to be provided with all available assistance in making dying as dignified and comfortable as possible.
Right to religious assistanceThe patient has the right to receive or to decline spiritual and moral comfort including the help of a minister of his/her chosen religion.

Portuguese translation

Adopted by the 164^th WMA Council Session, Divonne-les-Bains, France, May 2003
and adopted as a Declaration by the 70^th WMA General Assembly, Tbilisi, Georgia, October 2019

Ethical Values and legal principles are usually closely related, but ethical obligations typically exceed legal duties. In some cases, the law mandates unethical conduct. The fact that a physician has complied with the law does not necessarily mean that the physician acted ethically.

When law is in conflict with medical ethics, physicians should work to change the law. In circumstances of such conflict, ethical responsibilities supersede legal obligations.

Adopted by the 39^th World Medical Assembly, Madrid, Spain, October 1987,
and reaffirmed by the 170^th WMA Council Session, Divonne-les-Bains, France, May 2005 and by the 200^th WMA Council Session, Oslo, Norway, April 2015,
and rescinded and archived by the 70^th WMA General Assembly, Tbilisi, October 2019
* This document has been replaced by the completely rewritten “WMA Declaration on Euthanasia and Physician-Assisted Suicide” (2019)

Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.

Adopted by the 53^rd WMA General Assembly, Washington, DC, USA, October 2002,
editorially revised by the 164^th WMA Council Session, Divonne-les-Bains, France, May 2003,
reaffirmed by the 191^st WMA Council Session, Prague, Czech Republic, April 2012, and
revised by the 74^th WMA General Assembly, Kigali, Rwanda, October 2023

PREAMBLE

Rapid advances in microbiology, molecular biology, and genetic engineering have created extraordinary opportunities for biomedical research and hold great promise for improving human health and the quality of life. However, the proliferation of these technologies provides the opportunity to create novel pathogens and diseases and simplified production methods for biological weapons. The technologies are relatively inexpensive and, because production is similar to that used in biological facilities such as vaccine manufacturing, they are easy to obtain. Capacity to produce and effectively disperse biological weapons exists globally, threatening governments and endangering people around the world.

The consequences of a biological attack would be insidious and devastating. Their impact might continue with secondary and tertiary transmission of the agent, weeks, months or years after the initial epidemic. Given the ease of travel and increasing globalization, an outbreak anywhere in the world could be a threat to all nations. A great many severe, acute illnesses occurring over a short span of time could overwhelm the capacities of health systems worldwide.

Physicians and other health personnel are on the frontline in alleviating human suffering caused by epidemic disease and will bear primary responsibility for dealing with the victims of biological weapons.

Participants in biomedical research have a moral and ethical obligation to consider the implications of possible malicious use of their findings. Through deliberate or inadvertent means, genetic modification of microorganisms could create organisms that are more virulent, are antibiotic-resistant, or have greater stability in the environment. Genetic modification of microorganisms could alter their immunogenicity, allowing them to evade natural and vaccine-induced immunity. Advances in genetic engineering and gene therapy may allow modification of the immune response system of the target population to increase or decrease susceptibility to a pathogen or disrupt the functioning of normal host genes.

Nonproliferation and arms control measures can diminish but cannot completely eliminate the threat of biological weapons. Thus, there is a need for the creation of and adherence to a globally accepted ethos that rejects the development, production, possession and use of biological weapons. International collaboration is critical to build such a universal consensus.

The United Nations Biological Weapons Convention (BWC) prohibits the development, production, acquisition, transfer, stockpiling and use of biological and toxin weapons. Having reached almost universal membership, the BWC constitutes a key element in the international community’s efforts to address the proliferation of weapons of mass destruction and has established a strong norm against biological weapons.

Medical associations and physicians have a responsibility in educating the public and policy makers about the implications of biological weapons and to mobilize universal support for condemning research, development, or use of such weapons as morally and ethically unacceptable. They have important societal and ethical roles in demanding the full respect of the BWC, stigmatizing the use of biological weapons, guarding against unethical and illicit research, and mitigating harm from use of biological weapons.

RECOMMENDATIONS

Recognizing the growing threat of biological weapons, the WMA and its constituent members condemn the development, production, or use of toxins and biological agents that have no justification for prophylactic, protective, therapeutic or other peaceful purposes, and makes the following recommendations:

Strengthening global preparedness and response to health emergencies

Governments and national health authorities:

To develop a strategy for the effective coordinated and timely access to vital protective measures for new pathogens, whatever their origin, for all populations at risk. The strategy should assure surge capacity to address mass casualty care.
In line with the WMA Statement on Epidemics and Pandemics, to meet the critical needs for:

Adequate investment in public health systems, including resources and supplies, to enhance capacity to effectively detect, investigate and contain rare or unusual disease outbreaks.
An operative global surveillance program to improve response to naturally occurring infectious diseases and to permit earlier detection and characterization of new or emerging diseases.

To provide to WHO adequate means to fulfill its leadership role in ensuring appropriate international cooperation and coordination for surveillance and action on emerging infectious diseases.
To support the development of a WHO legally binding instrument on pandemic prevention, preparedness and response, integrating principles of equity and human rights.
To develop adequate and targeted health education and training for health professionals, civic leaders, and the public alike, as well as collaborative programs of research to improve disease diagnosis, prevention, and treatment.
To develop communications strategies to inform health care professionals and the public about acts of bioterrorism and infectious disease outbreaks, including local information on available medical services.
To fund research and development to counteract biological weapons, including:

to improve understanding of the epidemiology, pathogenesis, and treatment of diseases caused by potential bioweapon agents and the immune response to such agents;
for new and more effective vaccines, pharmaceuticals, and antidotes against biological weapons; and
for improving biological agent detection and defense capabilities.

Physicians, Medical Associations and other health entities:

To participate with local, national, and international health authorities in developing and implementing disaster preparedness and response protocols for acts of bioterrorism and natural infectious disease outbreaks. These protocols should be used as the basis for physician and public education.
To support and fulfill the critical role of physicians in early detection of unusual clusters of diseases or symptoms, potentially resulting from the use of biological weapons, so that they can promptly report it to the appropriate institutions.
Physicians in relevant specialties should:

be alert to the occurrence of unexplained illness and death in the community;
be knowledgeable of disease surveillance and control capabilities for responding to unusual clusters of diseases, symptoms, or presentations;
be familiar with the clinical manifestations, diagnostic techniques, isolation precautions, decontamination protocols, and therapy/prophylaxis of biological agents likely to be used in an attack;
utilize appropriate procedures to prevent exposure to themselves and others; and
understand the essentials of risk communication so that they can communicate clearly and nonthreateningly about issues such as exposure risks and potential preventive measures.

Counteracting biological weapons research

Governments and national health authorities:

To develop and implement national and global raising awareness strategies on the potential development of biological weapons among researchers and practitioners, with comprehensive information on the reporting system to be used if needed.
To reinforce accountable and transparent supervision mechanisms and regulation of biological and toxin laboratory work with the potential for weaponized applications.

Physicians:

Recognizing the societal responsibility of physicians as scientists and humanitarians, to decry scientific research for the development and use of biological weapons and to advocate against the use of biotechnology and information technologies for potentially harmful purposes.

Researchers:

To consider the implications and possible applications of their work and carefully balance the pursuit of scientific knowledge with their ethical responsibilities to society.

Fostering global mechanisms monitoring the threat of biological weapons

Governments:

To take necessary measures to guarantee the respect and implementation of the BWC and to reinforce its implementation with appropriate means, ensuring transparency and adequate accountability mechanisms for Member State Parties.

Physicians, Medical Associations and other health entities:

To advocate, in cooperation with the United Nations, including the WHO, and other appropriate entities, for strengthening of the Implementation Support Unit under the BWC, including medical and public health leaders in order to monitor the threat of biological weapons, to identify actions likely to prevent biological weapons proliferation, and to develop a coordinated plan for scrutinizing the worldwide emergence of infectious diseases. This plan should address:

international monitoring and reporting systems so as to enhance the surveillance and control of infectious disease outbreaks throughout the world;
the development of an effective verification protocol under the BWC;
education of physicians and public health personnel about emerging infectious diseases and potential biological weapons;
laboratory capacity to identify biological pathogens;
availability of appropriate vaccines and pharmaceuticals; and
financial, technical, and research needs to reduce the risk of use of biological weapons and other major infectious disease threats.

Adopted by the 53^rd WMA General Assembly, Washington, DC, USA, October 2002,
reaffirmed by the 191^st WMA Council Session, Prague, Czech Republic, April 2012,
and revised by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

preamble

Physicians strive to provide safe, high-quality health and medical care to patients.

Progress in medical and allied science and technology has transformed how modern medicine is delivered in advanced and complex health systems.

Inherent risks always exist in clinical medicine. Developments in modern medicine often reduce risk but may also introduce new or increased risks – some avoidable, others inherent.

Physicians and healthcare organisations should attempt to foresee these risks and manage them to the best of their ability.

Many health services continue to struggle with demand exceeding capacity, often with an inadequate infrastructure due to underinvestment by governments or other providers of healthcare. Patient safety is at risk where physicians work in systems under pressure.

Patient safety is affected by the working culture that physicians operate within. In many healthcare systems there is often a culture of blame, where individuals are targeted rather than examining wider organisational causes of error (such as resource constraints, workforce shortages, or systemic failures).

Many physicians fear being unfairly blamed for medical errors which may have been caused or exacerbated by systemic factors, and often feel unable to be open or raise concerns.

A workplace culture of learning assures and improves patient safety. Embedding a just and learning culture approach can be an antidote to cultures of blame and fear.

In a just and learning culture, the initial focus is on what went wrong when patient safety incidents took place, rather than seeking to determine who may individually be responsible.

Medical regulation and a fear of litigation can compromise physicians’ ability to be open about medical error. A system where physicians feel unable to speak up, due to fear of personal recrimination, will compromise the identification of systemic causes of error or poor care and imped measures to improve patient safety.

Working in a system under pressure that has a culture of fear and blame can erode physician wellbeing. Physicians’ performance in stressful working environments may be impaired, potentially leading to error or poor patient outcomes.

Improving physician wellbeing significantly improves productivity, care quality, patient safety and the sustainability of health services.

Positive cultures within workplaces are vital to minimize medical error, improve physician wellbeing and assure patient safety.

Principles

Physicians must ensure that patient safety is always considered during their medical decision-making.
Individuals and processes are rarely solely responsible for errors. Rather, separate elements combine and together produce a high-risk situation. Therefore, there should be a non-punitive culture for confidential reporting healthcare errors that focuses on preventing and correcting systems failures and not on individual or organization culpability.
A realistic understanding of the risks inherent in modern medicine requires physicians to cooperate with all relevant parties, including patients, to adopt a proactive systems approach to patient safety.
To create such an approach, physicians must continuously absorb a wide range of advanced scientific knowledge and continuously strive to improve medical practice.
All information that concerns a patient’s safety must be shared with the patient and all relevant parties. However, patient confidentiality must be strictly protected.
When medical error or a patient safety incident occurs, investigations should always begin by fully reviewing the wider environment that the physician operates within to identify systemic factors and pressures that may have contributed to the error.
Where medical error is found to have been caused fully or partly by systemic factors, any judgement by the regulator(s) should also hold the healthcare providing organisation to account.
Regulators of healthcare providing organisations must promote and ensure positive, just, and learning workplace cultures, where physicians and patients feel supported and empowered to learn when adverse events occur.
Regulators have a responsibility to identify systemic and contextual constraints that impact on patient safety, including a lack of resources and infrastructure.

RECOMMENDATIONS

Recognizing the importance of system pressures, workplace culture, physician wellbeing, and healthcare regulation on patient safety, the WMA recommends that its Constituent members:

promote policies on patient safety to all physicians in their countries;
encourage individual physicians, other health care professionals, patients and other relevant individuals and organizations to work together to establish systems that secure patient safety;
encourage the development of effective models to promote patient safety through continuing medical education/continuing professional development;
cooperate with one another and exchange information about adverse events, including errors, their solutions, and “lessons learned” to improve patient safety;
demand that the investigation of medical error and patient safety incidents always consider wider contextual and systemic factors or pressures;
demand that healthcare providing organisations foster a culture of learning, support and improvement that facilitates patient safety;
work to ensure that the regulation of the medical profession encourages and supports patient safety;
support regulation that works to prevent medical error, promoting good practice and learning among individuals and organisations providing healthcare;
work to ensure healthcare environments have the necessary resources, infrastructure, and workforce to support patient safety.

Adopted by the 52^nd WMA General Assembly, Edinburgh, Scotland, October 2000
Revised by the 62^nd WMA General Assembly, Montevideo, Uruguay, October 2011
and by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

The WMA Declaration of Lisbon on the Rights of the Patient states ‘Every person is entitled without discrimination to appropriate medical care’.

The Constitution of the World Health Organization states that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”.

Persons deprived of liberty (“prisoners”) should receive the same standard of health care as people outside prisons. They have the same rights as all other people. This includes the right to humane treatment and appropriate medical care. The standards for the treatment of prisoners have been set down in a number of United Nations Declarations and Guidelines, in particular the Standard Minimum Rules for the Treatment of Prisoners – known as the Nelson Mandela Rules in its 2015 revised version, they are supplemented by the UN Bangkok Rules on women.

The term “persons deprived of liberty” refers to all regardless of the reason for their detention as well as of their legal status, from pre-trial detainees to sentenced persons.

It is the responsibility of the states to guarantee the right to life and health of persons deprived of liberty. This implies caring for them with the aim that prison does not become a determining factor of communicable disease.

The relationship between physician and persons deprived of liberty is governed by the same ethical principles as that between the physician and any other patient. However, the particular prison setting can lead to tensions within the patient/physician relationship as a result of the physician potentially being subject to pressure from authorities and seeming to be hierarchically subordinate to his/her employer, the prison service, and of the general attitude of society towards persons deprived of liberty.

Beyond the States responsibilities to treat all persons deprived of liberty with respect for their inherent dignity and value as human beings, there are strong public health reasons for ensuring the adequate implementation of the Nelson Mandela Rules. The high incidence of tuberculosis and other communicable diseases amongst prisoners in a number of countries reinforces the urgent need to consider public health as a critical element when designing new prison regimens, and for reforming existing penal and prison systems.

Individuals facing imprisonment are often from the most vulnerable sections of society. They may have had limited access to health care before imprisonment, may suffer worse health conditions that many other citizens and as a result may have a high risk of entering prison with undiagnosed, undetected and untreated health problems.

Overcrowding, lengthy confinement within tightly enclosed, poorly lit, badly heated and consequently poorly ventilated and often humid spaces are all conditions frequently associated with imprisonment and all of which contribute to the spread of communicable disease and ill-health. Where these factors are combined with poor hygiene, inadequate nutrition and limited access to adequate health care, prisons can represent a major public health challenge.

Keeping persons deprived of liberty in conditions that expose them to substantial medical risk, poses a serious humanitarian challenge. The most effective and efficient way to reduce disease transmission is to improve the prison environment.

It is the responsibility of states to dedicate sufficient resources to ensure adequate prison conditions, that prison health care is appropriate in relation to the size and needs of the prison population, and to define and implement sustainable health strategies to prevent communicable diseases transmission. The organization of health care in prison requires a suitable team of health personnel capable of detecting and treating communicable diseases as part of its essential mission to provide care and treatment to their patients in detention.

The increase in active tuberculosis in prison populations and the development of resistant, especially “multi–drug” and “extensively-drug” resistant forms of TB, as recognised by the World Medical Association in its Resolution on Tuberculosis, is reaching very high prevalence and incidence rates in prisons in some parts of the world. Likewise, the Covid-19 pandemic has severely impacted prisons with outbreaks reported around the world. Other conditions, such as hepatitis C and HIV disease, pose transmission risks from blood-borne spread, exchange of body fluids. Overcrowded prison conditions also promote the spread of sexually transmitted diseases, while intravenous drug use contributes to the spread of HIV as well as hepatitis B and C.

RECOMMENDATIONS

Recalling its Declaration of Lisbon on the Rights of the Patient, the World Medical Association calls on all relevant actors to take the necessary measures to guarantee the highest attainable standard of health for persons deprived of liberty, in particular:

Governments, prison and health authorities

1. To protect the rights of persons deprived of liberty according to the various United Nations instruments relating to conditions of imprisonment, in particular the Nelson Mandela Rules for the Treatment of Prisoners.

2. To allocate the necessary resources to health care in prisons, proportionate to the number and needs of the persons deprived of liberty and including adequate funding for health personnel and appropriate level of staffing of such personnel.

3. To define and implement robust health strategies that ensure a safe and healthy prison environment, through vaccination, hygiene, surveillance and other measures to prevent transmission of communicable diseases.

4. To guarantee that persons deprived of liberty with an infectious illness are treated with dignity and that their rights to health care are respected, in particular that they are not isolated, or placed in solitary confinement, as a response to their infected status, without adequate access to health care and the appropriate medical treatment.

5. To ensure that the conditions of detention, at any stage from arrest to sentencing or once sentenced, do not contribute to the development, worsening or transmission of diseases.

6. To ensure that diagnosis and treatment of non-communicable chronic disease and acute non-communicable illness and/or injury is reasonably and adequately treated so as to not cause undue burden on health personnel or increase risk of communicable disease spread due to prisoners with decompensated illness or injury.

7. To ensure the appropriate planning for and provision of continuing care as essential elements of prison health care, coordination of health services within and outside prisons facilitates, including continuity of care and epidemiological monitoring of prisoner patients when they are released.

8. To ensure that, upon admission to or transfer to a different prison, individuals’ health status is reviewed within 24 hours of arrival to ensure continuity of care.

9. To avoid disruption of care within the institution, particularly when the prisoner is receiving opiate substitution treatment by continuing the prescribed treatment.

10. Imprisonment is unacceptable in cases where infection or the risk of transmission is the cause of deprivation of liberty. Imprisonment is not an effective way to prevent the transmission of infectious diseases, and further, it is a cause of concealment of the diagnosis due to fear, leading to greater aggregate dissemination.

11. To respect autonomy and responsibilities of physicians working in prisons who must observe principles of medical ethics to protect health of persons deprived of liberty.

12. To conduct independent and transparent investigations to prevent denial of health care to inmates in prison.

WMA constituent members and the medical profession

13. To work with national and local governments, and health and prison authorities to prioritize health and health care, including that for mental health issues, in prisons and to adopt strategies that ensure a safe and healthy prison environment.

14. In accordance with the ethical principles of the medical profession, to encourage physicians to report and document any deficiency in health care provision, leading to ill-treatments of persons deprived of liberty.

15. To support and protect physicians encountering difficulties as a result of their attempts to denounce deficiencies in prison health care provision.

16. To support improving prison conditions and prison systems from a viewpoint of health of persons deprived of liberty.

Physicians working in prisons

17. To report duly to the health authorities and professional organisations of their country any deficiency in health care, including that for mental health issues, provided to the persons deprived of liberty and any situation involving high epidemiological risk.

18. To follow national public health guidelines, where these are ethically appropriate, particularly concerning the mandatory reporting of infectious and communicable diseases.

Adopted by the 34^thWorld Medical Association General Assembly, Lisbon, Portugal, September/October 1981,
revised by the 39^th World Medical Association General Assembly, Madrid, Spain, October 1987,
by the 45^thWorld Medical Association General Assembly, Budapest, Hungary, October 1993,
by the 51^stWorld Medical Association General Assembly, Tel Aviv, Israel, October 1999,
reaffirmed by the 185^th WMA Council Session, Evian-les-Bains, France, May 2010,
and revised by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

PREAMBLE

Sports medicine physicians are physicians concerned with the prevention and treatment of injuries and disorders that are related to participation in sports. In some countries, sports medicine physicians are recognized as medical specialists. They are trained to address issues associated with nutrition, sports psychology and substance misuse, and may also counsel athletes on injury prevention.

Considering the involvement of physicians in sports medicine, the World Medical Association (WMA) recommends ethical guidelines for sports medicine physicians, recognizing the special circumstances in which their medical care and health guidance is given.

Anabolic Agents and Performance Enhancing Drugs and Methods

The use of anabolic agents, performance enhancing drugs, pain killers and performance enhancing methods by athletes is contrary to the rules and ethical principles of athletic competition as set forth by most sports governing bodies. Performance enhancing drugs and methods have been associated with adverse health effects.

The sports medicine physician should be aware that methods, drugs or interventions which artificially modify blood constituents, biochemistry, genome sequence, gene expression or hormone levels and do not benefit patients, violate the basic principles of the WMA’s Declaration of Geneva, which states: “the health and wellbeing of my patient will be my first consideration.”

The WMA believes that the use of anabolic agents and performance enhancing drugs and methods is a threat to the health of athletes and is in conflict with the principles of medical ethics. The physician must oppose and refuse to administer or condone any means or method which is not in accordance with medical ethics, or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.

Examples of these drugs and methods include, but are not limited to:

The use of drugs or other substances whatever their nature and route of administration, including central-nervous-system stimulants or depressants and procedures which artificially modify reflexes, alter a sense of well-being and/or general mental outlook.
Procedures or therapeutics to mask pain or other protective symptoms if used to enable the athlete to take part in events or training activities when clinical signs make his or her participation inadvisable. This includes allowing participation in athletic activity when doing so would be dangerous to the athlete.
Procedures or therapeutics used to mask the presence of other performance enhancing drugs or to induce rapid water or weight loss.
Measures aimed at an unnatural improvement in or maintenance of endurance or oxygen carrying capacity during competition. This includes the manipulation of blood and/or blood components defined as the administration or reintroduction of blood or red blood cell products of any origin into the circulatory system, artificially enhancing the uptake, transport, or delivery of oxygen using chemicals such as erythropoietin, or other forms of intravascular manipulation to artificially increase red blood cell mass, unless medically indicated for the treatment of a documented disease or medical condition. Blood doping also exposes the athlete to unwarranted and potentially serious health risks.
Use of anabolic agents including “designer steroids”, which are substances that are undetectable through the use of standard testing methods.
Use of anabolic steroid precursors, including dietary supplements, that claim to provide “safe” steroid equivalents, but that metabolize in the body into anabolic steroids.
Use of non-approved substances which have no current approval by any governmental regulatory health authority for human therapeutic use, for example, drugs under pre-clinical or clinical development, discontinued drugs, designer drugs or substances approved only for veterinary use.
Use of peptide hormones, growth factors and related substances to increase red blood cell count, blood oxygenation or oxygen-carrying capacity.
Use of hormone and metabolic modulators, which are substances to modify hormone activity by blocking the action or increasing the activity of a hormone.

Of special concern is the use of anabolic agents and steroid precursors in adolescents. Young users are considered particularly susceptible to potentially serious health problems during this physically and emotionally vulnerable period when their own hormonal cycles are changing. In females, anabolic agents have been associated with a number of adverse effects, some of which appear to be permanent even when drug use is stopped. Physicians should strongly discourage using these products.

World Athletics Gender Rules for Classifying Female Athletes

World Athletics 2018 Eligibility Regulations for Female Classification^[1] imposes an upper hormonal limit for athletes wishing to compete in the female category in certain disciplines of international athletics competitions.

The WMA opposes World Athletics’ rules^[2] requiring female athletes with differences in sex development to take drugs to reduce and maintain their natural level of blood testosterone in order to compete. The mere existence of a condition caused by a difference in sex development, in a person who has not expressed a desire to change that condition, does not constitute a medical indication for treatment. Medical treatment solely to alter athletic performance is unethical.

RECOMMENDATIONS

Sports medicine physicians have an obligation and duty to respect and comply with the ethical standards of the medical profession.
The sports medicine physician who cares for athletes has an ethical responsibility to recognize the special physical and mental demands placed upon athletes by their participation in athletic activities. The physician’s duty is to preserve the athlete’s mental and physical health and not solely to increase athletic performance.
When the sports participant is a professional athlete and derives livelihood from that activity, the physician should understand the occupational health aspects involved.
The sports physician should give his or her objective opinion about the athlete’s state of fitness clearly and precisely, leaving no doubt as to his or her conclusions.
In all sporting events, it is the physician’s duty to decide whether the athlete is medically fit to compete in an event. This decision cannot be delegated to other non-physician professionals.
In order to carry out his or her ethical obligations, the sports medicine physician’s authority must be fully recognized and upheld, particularly when it concerns the health and safety of the athlete. Concern for the athlete’s health and safety must override the interests of any third party.
The sports medicine physician is obligated to uphold the ethical principles of the medical profession. This includes the right to privacy and respect for the confidential nature of the patient-physician relationship. These principles and obligations should be supported by an agreement between the sports medicine physician and the athletic organization involved.
The sports medicine physician must oppose and refuse to administer any substance or condone any means or treatment method which is not in accordance with medical ethics and/or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.
The sports medicine physician should be invited to participate in the design and modification of a sport’s rules and regulations in order to protect the health and safety of athletes.
The sports medicine physician, with patient consent, should work cooperatively with the patient’s personal physician, and keep him or her fully informed of the patient’s current condition.
All physicians should recognize that the desire to enhance performance, appearance, and/or well-being is not limited to elite athletes. Amateur and recreational athletes, as well as adolescents, are also at risk of and subject to sociocultural pressures to misuse anabolic agents and performance enhancing drugs and methods. A harm-reduction approach with discussions focused on risks, harm minimization, prevention strategies, and health promotion is recommended.

[1] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”

[2] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”