Policy Type: Statement

Adopted by the 18th World Medical Assembly Helsinki, Finland, June 1964,
amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Santiago 2005

  1. Rural populations have the same entitlement to medical care as people living in urban areas. Although there may be economic and other factors affecting the quantity of medical services available in rural areas, there should be no disparity in the quality of medical services. Persistent efforts should be made to elevate the qualifications of all persons rendering medical service to the highest level in the nation.
  2. Studies and analysis of factual data are useful for rural communities and regions in providing information for planning and developing suitable health services in rural areas.
  3. Education and socio-economic levels in rural communities are mutually dependent. Health education of the public is most effectively achieved when agencies, organizations, the health professions and the community share in the development and maintenance of the highest level of health practices that can be mutually effected.
  4. The physician-patient relationship should be preserved in the development of health services in rural areas.
  5. It is the duty of the State to ensure that conditions offered in Public Health appointments are sufficiently attractive to enable rural health services to develop to the same extent as those in urban areas.
  6. Proper integration of the program and facilities for preventive and therapeutic medicine, sanitation and health education should be ensured in both rural and urban areas.
  7. Every effort should be made to ensure that only qualified physicians should have ultimate clinical responsibility in rural, as well as urban, health services. Medical auxiliaries should be employed only temporarily to perform the duties of qualified physicians. The number of rural health personnel should be adequate and should receive training well adapted to medical needs of the rural population. Their technical knowledge should be kept up to date.
  8. The training of medical auxiliaries especially nurses, male nurses and mid-wives should be based on and correspond to the cultural and educational level of the country in order that a sufficient number may be available for the rural areas. The medical profession should in every way possible assist in providing basic as well as post-graduate and refresher courses to this group.
  9. The special diseases of rural areas require cooperation of physicians with professionals of related fields.
  10. The medical profession should provide leadership in health education of rural populations. It is essential that there be cooperation between the physician and the rural population in order to achieve the highest possible standard of health education.
  11. National medical associations should do everything possible to ensure that rural physicians practice under conditions no less favourable than urban physicians.
  12. National medical associations should take an active part in the development of plans for improving health conditions in rural areas.

Adopted by the 42nd World Medical Assembly Rancho Mirage, CA., USA, October 1990
and rescinded at the WMA General Assembly, Santiago 2005

  • THE WORLD MEDICAL ASSOCIATION recognizes that tobacco products are hazardous to human health (See WMA Statement on Health Hazards of Tobacco Products, adopted September, 1988).
  • THE WORLD MEDICAL ASSOCIATION therefore urges all nations to protect the public health by adopting prohibitions or restrictions on the manufacture, import, export, sale or advertisement of tobacco products
  • THE WORLD MEDICAL ASSOCIATION further urges all national medical associations to take such actions as may be appropriate to advocate the adoption of prohibitions or restrictions on the manufacture, import, export, sale or advertisement of tobacco products by the governments of their respective nations.

Adopted by the 39th World Medical Assembly Madrid, Spain, October 1987
and rescinded at the WMA General Assembly, Santiago 2005

Preface

Recognizing the high infant mortality rate (IMR) in various areas of the world, the WMA and its national medical association members are embarked on a program to reduce unnecessary morbidity and mortality in developing countries.

The concept for the program was initiated by the AMA which collaborated with the Centers for Disease Control (CDC) in the development of what is now known as “WMA Infant Health Program”. The AMA is responsible for implementation of the program on behalf of WMA with CDC serving as the technical consultant.

The Indonesian Medical Association and the Medical Association of Thailand were selected to implement pilot projects in their respective countries. Funding for these projects has been provided by the United States Agency for International Development (USAID).

WMA’s Role

The World Medical Association (WMA) Infant Health Program, a private sector endeavor, involves the WMA in an initiative that is highly relevant to Third World countries. The hope is to contribute significantly to the overall goal of reducing unnecessary morbidity and mortality among children in Third World countries – a goal which is integral, as well, to efforts by other international and governmental bodies.

The main thrust of this initiative is to seek active involvement of physicians in Third World countries in measures such as the use of oral rehydration therapy (ORT), immunization, and nutrition programs which will significantly improve infant health. It recognizes the importance of mobilizing physicians, in their professional and private capacities and as influential citizens, around goals of improved infant health. The national medical association (NMA) is the ideal vehicle for such an approach.

The WMA and its member associations will work cooperatively with ministries of health and other governmental and private organizations in countries where the infant health program will be implemented. Private sector initiatives are increasingly being recognized as an essential force to accomplish national goals of improving the quality of health care and lowering infant mortality.

The WMA through its world-wide membership of NMAs representing more than two million physicians, will reach a wide audience with publications and information on interventions to enhance child survival. The WMA will be the catalyst to motivate NMAs in developing countries to participate in child survival programs focused on ORT immunization against the six vaccine-preventable diseases and other key interventions. NMAs in developed countries will join in the effort. Cooperating together under the auspices of the WMA, NMAs will develop the necessary resources to carry on the work into the future.

Goals and Objectives

The program components of the pilot projects, which will be developed fo replication in other countries, are as follows:

  • Full immunization of children against the six vaccine-preventable diseases
  • Use of ORT for the treatment of diarrhea
  • Immunization of all pregnant women with tetanus toxoid
  • Two-year interval between births
  • Exclusive breastfeeding of infants for at least four to six months and the introduction of weaning foods at an appropriate age
  • Prenatal examination of all pregnant women
  • Delivery of all newborns by trained personnel
  • Birthweight of at least 2500 grams

Strategies

The WMA joins with other private and public sector organizations in the battle to save lives and prevent the deaths each year of some 14 to 15 million children under five who die from disease and malnutrition. Millions of these children die needlessly since relatively low-cost disease prevention and life-saving interventions are available. The WMA Infant Health pilot programs will develop strategies for interventions that can be replicated and become selfsustaining and institutionalized within each country.

It is of paramount importance that physicians and their NMAs understand and support the delivery of relatively inexpensive vaccines for immunization against the six vaccine-preventable diseases (diphteria, pertussis, tetanus, measles, polio and tuberculosis). The WMA programs will be a part of the world-wide goal to immunize 80% of the world’s children by the end of this decade in countries where this is achievable and, shortly thereafter, in those countries with the most severe problems in accomplishing this goal.

In tandem with immunization, the WMA strategy will be to lower the IMR with the use of ORT in the treatment of diarrheal disease which kills five millions children every year. ORT is effective against dehydration – the complication of diarrhea which is most often lethal. If fluids and chemicals are not replenished, children who are already underweight or malnourished rapidly weaken and die.

Through lessons learned in the development of ORT, scientists determined the role of glucose in accelerating the absorption of salt and water through the wall of the intestine permitting rapid replacement of essential fluids. According to USAID:

It is now known that a simple combination of sugar, salts and water in specific ratios (along with bicarbonate or trisodium citrate), given by mouth in frequent small doses, will reverse dehydration in all but about 5 per cent of cases, usually within three to seven hours. Just sugar, salt and water, in the right proportions, will usually prevent dehydration if given soon enough. This ORT is not only far cheaper than the IVS and drugs it replaces, it is also better for the child and can be used in the home and outpatient clinic as well as in the hospital.

As a child’s most important health care provider, mothers must be taught how to mix fluids in the correct proportions, how to administer them, what other nourishment to provide the child, and when to seek outside help for a desperately ill child. In designing education and training programs, the cultural milieu prevailing in different societies must be taken into account.

In order to educate mothers to the need for ORT and to have the requisite knowledge to administer it, physicians must understand and support the therapy. Their acceptance will make ORT credible to health workers and to mothers. However, since many physicians have been trained to utilize anti-diarrheal drugs and IV therapy, NMAs can play a pivotal role in child survival by educating their physician members and non members to the efficacy of ORT in saving the lives of millions of children worldwide. Informed and trained physicians can educate health workers and most importantly, mothers, to use ORT in the home. It is clear from the continued high IMR in many countries that government programs cannot do the job alone. Governments, in turn, are increasingly aware of the need for more private sector involvement.

Conclusion

While recognizing that the battle against diseases is not easily nor quickly won, the WMA seizes the opportunity to save the lives of potentially millions of children through child survival action programs. WMA member NMAs in developed and developing countries have a shared responsibility to work for quality care for all people of the world, and in this spirit, to support efforts to reach child survival goals.

Adopted by the 37th World Medical Assembly Brussels, Belgium, October 1985,
amended by the 38th World Medical Assembly,Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

Those concerned with directing medical education programs in each country should communicate to their medical students the importance of obtaining actual experience in the practice of medicine in order to achieve basic medical competence, and the necessity for continuous experience to maintain such competence. Medical students should also be advised that the application of a medical education to alternative employment is extremely limited.

When it is doubtful that the medical student will have an opportunity to acquire the necessary experience to achieve basic medical competency, the medical student should be urged to reconsider the value of a medical education.

Adopted by the 36th World Medical Assembly Singapore, October 1984,
amended by the 38th World Medical Assembly Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

  • WHEREAS, the World Medical Association endeavors to serve humanity by seeking to achieve the highest international standards in medical education, and
  • WHEREAS, the World Medical Association and its National Medical Associations have always supported high quality medical education, and
  • WHEREAS, the quality of health care provided by physicians can be no better than the quality of medical education that physicians receive,
  • THEREFORE, the World Medical Association reaffirms its support for high standards of medical education that provide high quality educational experiences for all medical students, andThat only properly qualified candidates should be admitted to study medicine, andThat the number of students admitted to study medicine be no greater than the number which can be provided with high quality educational experience by the educational resources available.That the qualifications required of candidates to be admitted to medical schools be determined by the objective judgement of medical school faculties.

Adopted by the 35th World Medical Assembly Venice, Italy, October 1983
amended by the 38th World Medical Assembly Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

The Assembly of the World Medical Association meeting in Venice, this 28th day of October 1983, calls upon all National Medical Associations to work for a solution to the emerging problems related to medical manpower.

Recognizing the need:

  1. to provide access for all people to medical care of the highest quality, and
  2. to maintain those standards of medical care that result in the provision of quality medical care, as well as
  3. providing for the development of new knowledge, skills and techniques that will foster progress in medical science.

The Assembly urges all National Medical Associations to work with their governments within the provisions of their respective laws to accomplish these ends.

Quality medical care and the maintenance and development of a physician’s skills and techniques, as well as the discovery of new knowledge and information, are inseparably linked to the physician’s opportunity for patient care and clinical experience. This principle must be recognized in any solution to medical manpower problems, and economic and political concerns must be subordinated to this principle.

Most importantly, the foregoing principle must be recognized and applied to the laws and policies governing medical schools so that the high standards of quality medical care may be assured for future generations.

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Santiago 2005

In some countries medical malpractice claims are increasing, and National Medical Associations are seeking ways of coping with the problem. In other countries medical malpractice claims are rarely brought, but National Medical Associations in those countries should be alert to the issues and circumstances that could result in an increase in the number of claims asserted against physicians.

In this statement, the World Medical Association, Inc. seeks to inform National Medical Associations of some of the facts and issues related to medical malpractice claims. The laws and legal systems in each country, as well as the social traditions and the economic conditions of the country will affect the relevance of some portions of this statement to each National Medical Association. Nevertheless, the World Medical Association, Inc. believes that this statement should be of interest to all National Medical Associations.

  1. An increase in medical malpractice claims may result, in part, from one or more of the following circumstances:
    1. The increase in medical knowledge and the increase in medical technology has allowed physicians to accomplish medical feats that were not possible in the past, but these accomplishments involve risks of greater severity in many instances.
    2. The obligation imposed on physicians to limit the costs of medical care.
    3. Confusing the right to health care, which is attainable, with the right to achieve and maintain health, which can not be guaranteed.
    4. The pernicious role often played by the media engendering mistrust in physician by questioning his ability, knowledge, behaviour and management of the patient, and by prompting patients to submit complaints against physicians.
    5. The indirect consequences of an upsurge of a defensive medicine engendered by the increase in the number of claims.
  2. A distinction must be made between medical malpractice and an untoward result occuring in the course of medical care and treatment that is not the fault of the physician.
    1. Medical malpractice involves the physician’s failure to conform to the standard of care for treatment of the patient’s condition, or a lack of skill, or negligence in providing care to the patient, which is the direct cause of an injury to the patient.
    2. An injury occuring in the course of medical treatment which could not be foreseen and was not the result of any lack of skill or knowledge on the part of the treating physician is an untoward result, for which the physician should not bear any liability.
  3. Compensation for patients suffering a medical injury could be determined to the extent that no national laws prohibit this, differently for medical malpractice claims than for the untoward results that occur during medical care and treatment.
    1. Where un untoward result occurs without fault on the part of the physician, society must determine if the patient should be compensated for the injuries suffered, and if so, the source from which the funds will be paid. The economic conditions of the country will determine if such solidarity funds are available to compensate the patient without being at the expense of the physician.
    2. The laws of each jurisdiction will provide the procedures for deciding liability for medical malpractice claims and for determining the amount of compensation owed to the patient in those cases where malpractice is proved.
  4. National Medical Associations should consider some or all of the following activities in an effort to provide fair and equitable treatment for both physicians and patients:
    1. Public education programs on the risks inherent in some of the new advances treatment modalities and surgery, and professional education programs on the need for obtaining the patient’s informed consent to such treatment and surgery.
    2. Public advocacy programs to demonstrate the problems in medicine and the delivery of health care resulting from strict cost containment limitations.
    3. Advocating general health education programs both in school and in social settings.
    4. Enhancing the level and quality of medical education for all physicians, including improved clinical training experiences.
    5. Develop and participate in programs for physicians designed to improve the quality of medical care and treatment.
    6. Develop appropriate policy positions on remedial training for physicians found to be deficient in knowledge or skills, including policy positions on limiting the physician’s medical practice until the deficiencies are corrected.
      Inform the public and government of the danger that various manifestations of defensive medicine may appear (the multiplication of medical acts or, on the contrary, the abstention of the doctors, or even the disaffection of young physicians for certain higher risk specialties).
    7. Educate the public on the possible occurence of injuries during medical treatment which could not be foreseen and are not the result of physician malpractice.
    8. Advocate for legal protection for physicians when patients are injured by untoward results not caused by any malpractice.
    9. Participate in the development of the laws and procedures applicable to medical malpractice claims.
    10. Develop active opposition to frivolous claims and to contingency billing by lawyers.
    11. Explore innovative procedures for handling medical malpractice claims, such as arbitration rather than court proceedings.
    12. Encourage self insurance by physicians against malpractice claims, paid by the practitioner himself or by the employer if the doctor is employed.
    13. Participate in decisions relating to the advisability of providing compensation for patients injured during medical treatment without any malpractice.

Adopted by the 41st World Medical Assembly Hong Kong, September 1989
and rescinded at the WMA General Assembly, Santiago 2005

Definition

Generic substitution is herein defined as the dispensing of a different brand or an unbranded drug product for the drug product prescribed; i.e., the exact same chemical entity in the same dosage form but distributed by a different company.

Preamble

If drug products are not bioequivalent because of different manufacturing processes and/or the presence of different biologically inactive excipients, anticipated therapeutic equivalence among such drug product may also change. Therefore, when substitution occurs among drug products that are not bioequivalent and chemically and therapeutically equivalent, the patient may be adversely affected; i.e, suffer an adverse drug reaction or a therapeutic failure. For these reasons, the physician should be assured by national regulatory authorities of the bioequivalence and the chemical and therapeutic equivalence of prescription drug products from multiple sources. This principle is also desirable in the case of single-source drug products. Quality assurance procedures should be in place to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equivalence.

In the drug selection process, many medical considerations should be addressed before prescribing the drug of choice for a particular indication in any given patient. Once these primary considerations are met, the physician should then consider comparative costs of similar drug products available to best serve all of the patient’s needs. The physician has both the right and the obligation to exercise his/her best judgment on behalf of the patient; therefore, the physician should select the type and quantity of drug product that he or she considers to be in the best medical and financial interest of the patient. Once the patient gives his consent on the drug selected that drug should not be changed without the consent of the patient and his or her physician. Even when third-party carriers mandate generic drug substitution, every effort must be made to preserve the prescribing authority of the physician. Failure to follow these principles can result in harm to patients, and physicians can be held liable for such harmful consequences. On behalf of patients and physicians alike, national medical associations should do everything possible to uphold these precepts.

Recommendations

  1. Physicians should become familiar with specific laws and/or regulations governing generic drug substitution in locals where they practice.
  2. On initiation of treatment, physicians should carefully determine the dose of any medication for optimum efficacy and safety, especially in patients with chronic disorders who require prolonged therapy or patients in special population groups not expected to respond to a drug in the normal manner.
  3. Once medication for chronic diseases has been prescribed and begun, no substitution of either generic or brand-name drug products should be made without the attending physician’s permission. If generic or brand-name substitution of a drug product occurs, the physician should carefully monitor and adjust the dose to ensure therapeutic equivalence of the drug products.
  4. The physician has the duty to report serious adverse drug reactions or therapeutic failures that may be related to drug substitution; the finding should be documented and reported to appropriate drug regulatory authorities, including the appropriate national medical association.
  5. National medical associations should regularly monitor generic drug substitution issues and keep their members advised on developments that have special relevance for patient’s care. When appropriate, information reports on significant developments should be made available to physicians.
  6. National medical associations, in collaboration with other appropriate drug regulatory bodies, should evaluate and ensure the bioequivalence and the chemical and therapeutic equivalence of all similar drug products, whether generic or brand-name manufactured, in order to ensure safe and effective treatment.
  7. National medical associations should oppose any action to restrict the freedom and the responsibility of the physician to prescribe in the best medical and financial interest of the patient.

Adopted by the 17th World Medical Assembly New York, USA, October 1963,
and amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

PREAMBLE

Medical care is organized throughout the world in many different ways, from the most complete laisser-faire, to medical services organized exclusively and completely by the State.

It would be impossible to describe all the systems in detail, but one may say that while some countries only help those in dire need, others have organized a system of health insurance, and others have gone even further in organizing complete medical care. Personal initiative is associated in varying degrees with government policies and action in the health care field, and this serves to multiply indefinitely the ways in which medical care is provided.

The ideal, in this field, is certainly the “provision of the most up-to-date medical care while entirely respecting the freedom of both physician and patient”.

A formula of this nature is however too imprecise to be of use in solving the problems which arise in the daily application of the various national systems (which exist whether one likes it or not).

The WMA has a duty to safeguard the basic principles of medical practice and defence of the freedom of the medical profession. In consequence it cannot be expected to produce valued judgement on the different systems, but has an overwhelming duty to decide as far as it is possible, upon what terms the medical profession can collaborate with State Health Services.

PRINCIPLES

  1. The conditions of medical practice in any system of health care shall be determined in consultation with the representatives of organizations of physicians.
  2. Any health care system should allow the patient to consult the physician of his choice, and the physician to treat only patients of his choice, without the rights of either being affected in any way. The principle of free choice also should be applied in cases where medical treatment or a part of it is provided in treatment centers. Physicians have a compelling professional and ethical duty to attend to a patient in an emergency.
  3. Any health care system should be open to all licensed physicians; neither the medical profession nor the individual physician should be forced to take part if they do not so wish.
  4. The physician should be free to practice his profession where he wishes and also to limit his practice to a given specialty in which he is qualified. The medical needs of the country concerned should be satisfied and the profession, wherever possible, should seek to orient young physicians toward the areas where they are most needed. In cases where these areas are less favorable than others, physicians who go there should be aided by appropriate incentives so that their equipment is satisfactory and their standard of living is in accordance with their professional responsibilities.
  5. The profession should be adequately represented on all official bodies dealing with problems concerning health or disease.
  6. The confidential nature of the physician-patient relationship must be recognized and must be observed by all those who collaborate at any stage of the patient’s treatment or in the control thereof. This should be duly respected by authority.
  7. The confidential nature of the physician-patient relationship must be recognized and must be observed by all those who collaborate at any stage of the patient’s treatment or in the control thereof. This should be duly respected by authority.
  8. When the remuneration for medical services in any national health care system is not fixed by direct agreement between physician and patient the remunerating authority must adequately compensate the physician.
  9. The remuneration of medical services should take into consideration the services rendered and should not entirely be fixed according to the financial status of the paying authority or as a result of unilateral government decisions and should be acceptable to the agency which represents the medical profession.
  10. The review of physician’s services for the purpose of quality safeguards or the utilization of services both as to the number and cost, should be carried out by physicians only and should be measured against local or regional rather than national standards.
  11. In the higher interest of the patient there should be no restriction of the physician’s right to prescribe drugs or any other treatment deemed appropriate by current medical standards.
  12. The physician should be encouraged to participate in any activity directed toward improving his knowledge and status in his professional life.

Adopted by the 49th WMA General Assembly Hamburg, Germany, November 1997
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

Preamble

Despite advances in therapeutics, tuberculosis (TB) is becoming an increasing cause of morbidity and mortality world-wide. Recent World Health Organisation estimates are that 30 million people could die from TB over the next ten years. While many patients with TB are not diagnosed many others are not treated effectively. There are many contributory reasons, including poor prescribing by doctors and poor patient compliance with treatment. TB is also a major threat to the health of HIV-positive persons and an increasingly common cause of death of persons with AIDS.

Furthermore, these factors also predispose to an increased likelihood of the development of drug resistant strains of M. Tuberculosis. In some closed communities, such as prisons, and amongst groups such as Hospitalised HIV-positive persons, the majority of new patients present with infection with multi-drug resistant strains.

Resolution

Therefore, and in accord with its Statement on Resistance to Antimicrobial Drugs (Doc. 10.120),

The World Medical Association calls on its national member associations to support the World Health Organisation in its “Directly Observed Treatment Short-Course” and “Strictly Supervised Treatment” projects, and in other work to promote the more effective management of tuberculosis.

Adopted by the 47th General Assembly Bali, Indonesia, September 1995
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

PREAMBLE

A large number of regions throughout the world currently are faced with the frequent tragedies generated by addicts to opiate drugs. These tragedies occur in the following four spheres:

  1. health: the physical and psychological condition of the addict; propagation of viral infections such as HIV and hepatitis B or C through the sharing of infected syringes and unprotected sexual intercourse;
  2. decay of the family, professional and social environment;
  3. degeneration of the individual: incitement of both sexes to prostitution to pay for the drug, hospitalization, imprisonment, etc…
  4. public safety: resorting to criminal behavior to obtain either the drug or the money to buy the drug.
    The World Medical Association, concerned by such a widespread medico-psycho-social calamity, must formulate recommendations for physicians involved in the treatment of addicts to opiate drugs. This subject has already been addressed briefly in the WMA Statement on the Use and Misuse of Psychotropic Drugs (Doc. 20.30). However, the current situation requires more specific and elaborate guidelines than those presented in that Statement.

POSITION

The addict to opiate drugs is a full citizen who has rights and duties. His/her drug dependence indicates suffering that leads to physical, psychological and social difficulties; even prolonged drug dependence should be considered a temporary situation. The help to which addicts should have access should respect their dignity. They must be cared for with the same consideration as any other patient. The objective of the treatment always should be to re-establish addicts in a free and responsible life.

Treating addiction to opiate drugs is often very difficult. Among the many programmes proposed in different countries concerned by the increase in the number of such addicts, two trends are revealed: “therapeutic communities” (external protection) and the prescription of substitute drugs (internal protection).

The use of substitute drugs in outpatient treatment is certainly not the ideal solution (which should be sought through further research and scientific evaluation) to the problem of drug dependence. However, this method as a “therapeutic tool” exists, is used in many places throughout the world, and may contribute in part – until a better solution is found – to containing the problem. The standard ambition of the method is the weaning of the patient and his/her reintegration into his/her family, professional, and social environment, without improper maintenance of his/her dependence. A decrease in dosage should always be sought by the prescribing physician.

Whatever we do, drug dependence is a phenomenon for which we know no “miracle solution”. The medical use of substitute products for heroin (diacetylmorphine), and opiate drugs of synthesis (and in particular but not only methadone, which has been known for about fifty years), creates fundamental problems (weaning, pharmacology, etc…), clinical problems (treatment programs, prescription, delivery, surveillance), legal problems (laws and regulations) and ethical problems.

Consequently, in outpatient treatment, substitute drugs should be subjected to a set of evidence-based guidelines, the formulation of which would stem from experience acquired during the last quarter of this century by those treating drug dependence, namely in North America and Europe. Many countries have established legal procedures for the treatment of addicts to opiate drugs. The National Medical Associations should seek, if necessary, to improve inadequate legal texts.

RECOMMENDATIONS

  1. The physician shall abstain from prescribing at the sole request of the patient any drug that is not medically justified by his/her condition.
  2. In the outpatient treatment of addicts to opiate drugs, substitute drugs shall be prescribed according to evidence-based guidelines.
  3. The ultimate goal of the treatment always shall be the weaning of the patient, which may be achieved only after a long period of time.
  4. The use of substitute drugs will allow the patient to be medically, psychologically or socially stabilized and therefore reintegrated without delay into his/her family and professional environments. It will also serve to reduce the risk of contracting viruses such as HIV or hepatitis B or C through the use of infected syringes. In addition, the crime induced by the use of heroin can only diminish.
  5. Any treatment using substitution drugs shall be prescribed only after accurate diagnosis. It should be supervised by a competent and trained physician with an appropriate support team.
  6. The physician shall limit the number of patients addicted to opiate drugs that he/she will treat, with a view to ensuring attentive and conscientious care to each of them. In every case, he will keep a detailed medical record concerning the treatment provided to the patient, and audit the results.
  7. The prescription and administration of substitute drugs should be organized in such a way as to avoid any stocking by the patient, resale or other illicit usage.
  8. Subject to the provisions of national law, the patient, in order to receive drug substitution must agree to comply regularly with unscheduled, supervised biological tests, (urine for instance) to ensure that he/she is not taking other drugs simultaneously and/or accepting simultaneous treatment from another physician, without the knowledge of both practitioners.

Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975
and amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

  1. The use of psychotropic drugs is a complex social phenomenon and not simply a medical problem.
  2. Within society generally there is urgent need for intensive public education, presented in non-moralizing, non-punitive manner, and the development and demonstration of practical alternatives to drug use. Physicians, as knowledgeable, concerned citizens, should participate in such programs.
  3. Physicians should prescribe psychotropic drugs with the greatest restraint and observing the strictest possible medical indication ensuring that all prescribing of psychotropic drugs reflects accurate diagnosis, appropriate non-pharmacologic advice, and careful utilization of precise pharmacotherapeutic materials, mindful of the potential dangers of misuse and abuse.
  4. Physicians should accept the responsibility for collating and providing factual information regarding the health hazards of the non-medical use of all psychotropic material, including alcohol.
  5. In cooperation with governments and relevant agencies, the medical profession should ensure that such information is disseminated as widely as possible; especially within those age groups most likely to experiment with drugs to counteract peer group pressure and other factors which lead to misuse and abuse, and in order to maintain for each individual the right and the responsibility of free exercise of informed personal choice.

Adopted by the 42nd World Medical Assembly Rancho Mirage, CA., USA, October 1990
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

 

PREFACE

The care of terminally ill patients with severe chronic pain should provide treatment that permits these patients to close their lives with dignity and purpose. Analgesics, both opioid and nonopioid, are available and when properly used, can provide effective relief of pain for most terminally ill patients. It is incumbent on the physician and on all others who care for the dying patient with severe chronic pain to understand clearly the dynamics of the pain experience, the clinical pharmacology of analgesics, and the needs of the patient, family and friends. It also is imperative that governments assure that medically necessary quantities of opioid analgesics are available for appropriate application in the management of severe chronic pain.

PRINCIPLES OF THE CLINICAL MANAGEMENT OF SEVERE CHRONIC PAIN

When a patient is terminally ill, the physician must focus efforts on the relief of suffering. Pain is only one component of the patient’s suffering. However, the impact that pain can have on a patient’s life can range from tolerable discomfort to the production of a sense of crushing and exhausting defeat.

Clinical experience has demonstrated that, in general, it is not so much which opioid is used to achieve the relief of severe chronic pain in the terminally ill patient, rather it is the manner in which the drug is used that is critical.

It is imperative, however, that the physician distinguish between acute pain and pain that can be expected to be chronic, as this distinction can carry important implications for the use of opioid analgesics. The following are general principles that should guide the treatment of severe chronic pain particularly through the use of analgesic medication.

  1. Treatment must be individualized to satisfy the patient’s needs and keep him or her as comfortable as possible;
  2. It must be understood that the needs of the patient with chronic pain often differ from those of patients with acute pain.
  3. The physician must know the potency, duration of action and side effects of available analgesics to select the appropriate drug, as well as the dose, route, and schedule that will ensure delivery of optimum pain relief for the patient.
  4. Combinations of opioid and nonopioid analgesics can provide greater relief of pain to patients in whom nonopioid analgesics are no longer sufficient. This can be achieved without producing a concomitantly greater potential for undesirable side effects.
  5. The development of tolerance to the analgesic effects of an opioid agonist can be surmounted by switching the patient to an alternative opioid agonist. This is based on the lack of complete cross-tolerance among different opioid analgesics.
  6. Iatrogenic dependence should not be considered a primary problem in treating the severe pain of neoplastic disease and must never be a reason to withhold strong analgesics from patients who may benefit from them.
  7. Governments should examine the extent to which their health care systems and laws and regulations permit the use of opioids for medical purposes, identify possible impediments to such use and develop plans of action to facilitate the supply and availability of opioids for all appropriate medical indications.

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

Modern medical technologies and therapies have led to the treatment and control (but not cure) of many potentially fatal illnesses. Such medical successes worldwide have, in turn, led to a rapidly growing population of chronically ill and disabled people of all ages. The problem facing the world health care community is how to best care for his chronically ill and disabled population (including the need to develop new technologies and social/medical organizations).

The goal of medical care in these cases is to control the disease processes and to help the patients maintain their independence and maximum level of function within their own homes and communities.

The scope of medical care includes not only diagnosis and medical treatment but also patient education in self-care and prolonged medical monitoring and supervision.

Patients must learn to perform a wide variety of medical tasks that have only been performed by trained medical personnel in the past. Such tasks can range from that of a diabetic patient who checks his/her blood glucose level 2-4 times a day and adjusts the insulin dose appropriately, to the patient with a pacemaker who learns to use the equipment to send a electrocardiographic rhythm strip over the telephone lines to the local physician’s office or to a distant monitoring center.

Telecommunication technology has made possible new ways for physicians to collect information and manage the medical needs of their patients from a distance. A wide range of medical information can now be transmitted via telephone including electrocardiograms, encephalograms, x-rays, photographs and medical documents of all kinds. Such information can be collected and sent from a patient’s home or physician’s office to a major medical center for interpretation and advice on treatment. The rapid exchange of medical information enables the patient to remain in his/her own home and community and receive the most comprehensive and up-to-date medical care.

The World Medical Association recognizes that “tele-medicine” will undoubtedly play an increasingly important role in the practice of medicine in the future.

Developing tele-surveillance systems need to address the following issues:

  • A central station needs to be able to receive and respond to calls coming from different bio-televigilance systems.
  • There is a need for an interactive system, such as an “interphone system” which allows for dialogue and intervention.
  • The tele-medicine network must establish a medical link from the patient’s home to the most sophisticated medical center. Implementation of tele-surveillance systems includes:
  1. The utilization of communications systems (telephone, television, satellites) for visual consultation and cooperation between doctors at a distance, and for connecting facilities in high quality medical establishments to:
    1. modest medical centers
    2. private homes
    3. convalescent clinics
    4. in those areas that are geographically isolated and distant, or that are not readily accessible in case of an emergency.
  2. Transmission of documents: electrocardiographs, encephalograms, photographs, radiographies, scanners, biological analysis, echograms, magnetic resonance imaging, and a history of the patient, etc.
    • description of symptoms
    • therapeutic and medico-surgical advice
  3. Assistance to homecare (tele-vigilance network): control in cardiology, obstetrics, renal dialysis, respiratory problems, serious physical disorders, etc.

The World Medical Association recognizes that in addition to the technological difficulties involved in developing and implementing tele-medicine systems, there are many ethical and legal issues raised by these new practices. Therefore, the World Medical Association recommends that physicians utilize the following guidelines as key elements in establishing an effective “tele-medicine” network/system.

  1. The physician must determine that the patient or family are competent and well-informed before initiating a tele-medicine system. Those systems that rely on the patient or the family to collect and send the data will not be effective if patients do not understand the significance of the tests and the importance of completing them. Patient compliance psychologically as well as physically is essential.
  2. There must be close collaboration and trust between the patient and the physician who is responsible for his/her medical care. The organizations providing “tele-medicine” services should respect the right of the patient to choose his/her personal doctor.
  3. Close collaboration between the patient’s personal physician and the staff at the “tele-medicine” center is essential to ensure humane, individualized, quality care.
  4. Confidentiality of all patients records must be ensured. There must be strict control of access to records, technological safeguards and heavy legal penalties for infringement.
  5. Control of the quality of the equipment used and the information sent is essential to ensure adequacy of care. Strict monitoring systems for calibration and maintenance of equipment are necessary for patient safety.

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

The World Medical Association, Inc. previously adopted strategies to cope with the HIV epidemic, including physician’s avoidance of discrimination toward HIV infected patients, provision of care to those infected, an HIV-infected physician’s responsibility to avoid infection to a patient, issuing no false certificates, compliance with infection control procedures, cooperation with public authorities in prevention programs, development of national policies and programs, counseling patients to avoid HIV infection or, if infected, to avoid infecting others, wide availability of HIV testing especially for those likely to be infected, mandatory testing in certain circumstances such as blood donations, reporting cases of AIDS and HIV infection, balancing the rights of the infected patient with the rights of the uninfected, confidentiality of patient medical information, and research to establish the prevalence and incidence of HIV.

The number of persons with HIV infection and those who have progressed to AIDS has grown steadily. By the year 2000 an estimated 40 million persons worldwide will be infected with HIV. The World Medical Association therefore expresses a continuing concern that National Medical Associations take an active role in policy and programs of prevention, treatment and research. The World Medical Association adds the following to its previous recommendations:

  1. That the National Medical Associations, in cooperation with all segments of society and government, develop and implement a comprehensive program of HIV prevention, treatment, and research.
  2. That the National Medical Associations work with all media and forms of communication to assure a coordinated program of prevention, treatment awareness, and public compassion toward the infected.
  3. That National Medical Associations advise physicians of their responsibility to inform their patients as thoroughly as possible of the consequences of testing positive. In so informing their patients, physicians should use tact and delicacy, and have due consideration for the patients psychological condition.
  4. That the National Medical Associations assist in the training and education of physicians in the current medical treatments available for all stages of HIV infection and in the use of proper infection control procedures and universal precautions as outlined by the centers for disease control.
  5. That the National Medical Associations insist on the need for biological, clinical and psychological medical education relating to HIV-infected patients, to help physicians give effective care to their patients.
  6. That the National Medical Associations encourage physicians to help their patients assess the risks of HIV infection and to take appropriate prevention measures.
  7. That the National Medical Associations review and encourage improved infection control procedures in hospitals and other medical facilities.
  8. That the National Medical Associations review and encourage improvement in HIV diagnosis and treatment for women and children.
  9. That the National Medical Associations encourage the use of those public health techniques which have been successful in the past in dealing with infection epidemics especially those of sexually transmissible diseases.
  10. That the link of drug abuse to HIV transmission is an additional ground for National Medical Associations to further encourage drug abuse treatment.
  11. That the National Medical Associations seek to join with other medical, professional and health organizations to develop worldwide strategies for cooperation in prevention, treatment and research on HIV especially those that may be carried out by professional societies.

Adopted by the 40th World Medical Assembly Vienna, Austria, September 1988
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

The World Medical Association, Inc. has previously adopted guidelines to assist National Medical Associations in developing strategies to cope with a growing AIDS epidemic. This statement provides the individual physician with direction as to his or her professional responsibilities with reference to the treatment of AIDS patients, and also as to the physician’s responsibility to his or her patients in the event the physician is seropositive.

The WMA Interim Statement on AIDS, adopted in October 1987, states in part:
“Patients with AIDS and those who test positively for the antibody to the AIDS virus must be provided with appropriate medical care and should not be treated unfairly or suffer from arbitrary or irrational discrimination in their daily lives. Physicians have a long and honored tradition of tending to patients afflicted with infectious diseases with compassion and courage. That tradition must be continued throughout the AIDS epidemic.”

AIDS patients are entitled to competent medical care with compassion and respect for human dignity. A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence, solely because the patient is seropositive. Medical ethics do not permit categorical discrimination against a patient based solely on his or her seropositivity. A person who is afflicted with AIDS needs competent, compassionate treatment. A physician who is not able to provide the care and services required by persons with AIDS should make an appropriate referral to those physicians or facilities that are equipped to provide such services. Until the referral can be accomplished, the physician must care for the patient to the best of his or her ability.

The rights and interests of those who are infected with the AIDS virus, as well as those who are not, are entitled to protection. A physician who knows that he or she has an infectious disease should not engage in any activity that creates a risk of transmission of the disease to others. In the context of possible exposure to AIDS, the activity in which the physician wishes to engage will be the controlling factor.

In the provision of medical care, if a risk of transmission of an infectious disease from a physician to a patient exists, disclosure of that risk to patients is not enough; patients are entitled to expect that their physicians will not increase their exposure to the risk of contracting an infectious disease.

If no risk exists, disclosure of the physician’s medical condition to his or her patients will serve no rational purpose; if a risk does exists, the physician should not engage in that activity.

If a patient is fully informed of the physician’s condition and the risks that condition presents, and the patient elects to continue care and treatment with the seropositive physician, great care must be exercised to assure that true informed consent is obtained.

The duty of all physicians is to refrain from issuing false certificates even if the intention of such is to help the patients to stay within his regular environment.

The duty of the physician is to comply with and make comply the sanitary and protective rules established for health personnel because they are known, simple and effective.

The duty of all physicians is to participate fully in preventive programs initiated by public authorities to stop the spread of AIDS.

Adopted by the 39th World Medical Assembly Madrid, Spain, October 1987
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

In-Vitro Fertilization and Embryo Transplantation is a medical technique which is available for the treatment of infertility in many parts of the world. It has the potential to benefit both individual patients and society generally, not only by the alleviation of infertility, but also by the possible avoidance of genetic disorders and by enhancing fundamental studies of human reproduction and contraception.

The WMA urges physicians to act ethically and with appropriate respect for the health of the prospective mother and for the embryo from the beginning of life. To assist physicians in recognizing and following their ethical obligations, the WMA has promulgated this statement.

From the ethical and scientific viewpoint, medical assistance in human reproduction is justified in all cases of infertility which do not respond to classical drug or surgical treatment with specific reference to:

  1. immunological incompatibility
  2. irreversible obstacle to contact between male and female gametes
  3. infertility for unknown cause

In all these cases, the physician can only act with the full informed consent of donors and recipients. The physician must always act in the best interest of the child to be born of the procedure.

It is the physician’s responsibility to provide the patients, at their own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences and disappointments of the procedure, and to obtain from the patients their informed consent to the procedure. As in any type of elective procedure, the physician must have adequate specialized training before undertaking the responsibility of performing the procedure. The physician must always comply with all applicable laws and regulations as well as the ethical requirements and the professional standards established by the National Medical Association and other appropriate medical organizations in the community. The patients are entitled to the same confidentiality and privacy as is required with any medical treatment.

When IVF techniques produce excess ova which will not be utilized for the immediate treatment of sterility, their use must be determined in agreement with the donors; excess ova can be:

  1. destroyed
  2. cryopreserved
  3. fertilized and cryopreserved

Scientific knowledge concerning maturation, fertilization and first stages of pluricellular development processes is still in an early stage. It is therefore appropriate to continue study and experimentation of the physical and chemical phenomena in this field strictly in accordance with the Declaration of Helsinki, and with the written consent of the donors.

RESEARCH

The technique of in vitro fertilization and embryo transplantation can also be useful in research directed towards a better understanding of how genetic defects arise and are transmitted, and how they might be prevented or treated. Profound moral and ethical implications may arise for both the physician and the patient. The physician should not violate his personally held moral principles and must be sensitive to, and respect, the moral and ethical principles held by patients. The physician has a greater responsibility to communicate fully with the patients who will participate in the research effort and the informed consent of those patients must meet the requirements of law as well as the special level of professional responsibility dictated by ethical standards. The principles of the World Medical Association’s Declaration of Helsinki will apply to all clinical research in respect to in-vitro fertilization and embryo transplantation, as well as all problems that arise out of such clinical research.

The World Medical Association recommends that physicians refrain from intervening in the reproduction process for the purpose of making a choice as to the foetus’ sex, unless it is to avoid the transmission of serious sex-linked disease.

DONATION

The technique of in-vitro fertilization and embryo transplantation creates the possibility of donation of ova, sperm, and embryo, so that the biological donors may not be the parents of the child produced by this procedure. Such use of donated gametes or embryo may present serious legal, moral, and ethical issues for both patients and physicians involved in such in-vitro fertilization and embryo transplantation procedures. The physician must observe all applicable laws and ethical restrictions imposed by the National Medical Association or other appropriate medical organizations. The physician must also be sensitive to, and respect, the moral and ethical principles of patients, and refrain from the use of donated gametes or embryos when it would conflict with legal or ethical restrictions or the moral principles of the patients. The physician has the right to refuse any intervention he or she deems unacceptable.

The technique of cryo-preservation increases the availability of gametes and embryos for donation. Where permitted, if one or more donors of gametes, or the donors of an embryo, will not be the functional parent(s) of the prospective child, the physician must obtain assurance that the recipients will accept full responsibility for the unborn child and that the donors will renounce all rights or claims to the unborn child without prejudice to the rights of the child when born.

In the case of an adult woman who is without a uterus, the use of the so-called method of substitute or surrogate motherhood may be used unless prohibited by applicable laws or the ethical rules of the National Medical Association or other appropriate medical organizations. Free and informed consent must be obtained from the parties who are participating in any way in such substitute or surrogate method. There are legal, ethical and moral implications in the use of such method of substitute or surrogate motherhood and the physician must recognize them and consider them as part of any decision to use such method.

The preceding paragraph is not intended to endorse the so-called “Surrogate Parenting” arrangement by which a woman agrees, for a fee, to be artificially inseminated with the sperm of a man for the purpose of conceiving a child who will be adopted by the man and his wife.

Any commercialization by which ova, sperm, or embryo are offered for purchase or sale is expressly condemned by the World Medical Association.

Adopted by the 67th World Medical Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

  • Advancements in modern information technology (IT) pave the way for improvements in healthcare delivery and help streamline physician workflow, from medical record keeping to patient care. At the same time, implementing new and more sophisticated IT infrastructure is not without its challenges and risks, including cyber-attacks and data breaches.
  • Cyber security threats are an unfortunate reality in an age of digital information and communication. Attacks on critical infrastructure and vital assets of public interest, including those used in the fields of energy, food and water supply, telecommunications, transportation and healthcare, are on the rise and pose a serious threat to the health and well-being of the general public.
  • With the proliferation of electronic medical records and billing systems, the healthcare sector is especially susceptible to cyber intrusions and has become a prime soft target for cyber criminals. Healthcare institutions and business partners, from the smallest of private practices to the largest of hospitals, are vulnerable not only to the theft, alteration and manipulation of patients’ electronic medical and financial records, but also to increasingly sophisticated system breaches that could jeopardise their ability to provide care for patients and respond to health emergencies. Especially disconcerting is the threat posed to a patient’s fundamental right to data privacy and safety. In addition, repairing the damage caused by successful cyber-attacks can entail significant costs.
  • Patient data also demands protection because it often contains sensitive personal information that can be used by criminals to access bank accounts, steal identities, or obtain prescriptions illegally. For this reason, it is worth far more on the black market than credit card information alone. Alterations to or abuse of patient data in the case of a breach can be detrimental to the health, safety and material situation of patients. In some cases, breaches can even have life-threatening consequences.
  • Current security procedures and strategies in the healthcare sector have generally not kept pace with the volume and magnitude of cyber-attacks. If not adequately protected, hospital information systems, practice management systems or control systems for medical devices can become gateways for cybercriminals. Radiology imaging software, video conferencing systems, surveillance cameras, mobile devices, printers, routers and digital video systems used for online health monitoring and remote procedures are just some of the many IT structures at risk of being compromised.
  • Despite this danger, many healthcare organisations and institutions lack the financial resources (or the will to provide them) and the administrative or technical skills and personnel required to detect and prevent cyber-attacks. They may also fail to adequately communicate the seriousness of cyber threats both internally and to patients and external business partners.

RECOMMENDATIONS

  1. The WMA recognises that cyber-attacks on healthcare systems and other critical infrastructure represent a cross-border issue and a threat to public health. It therefore calls upon governments, policy makers and operators of health and other vital infrastructure throughout the world to work with the competent authorities for cyber security in their respective countries and to collaborate internationally in order to anticipate and defend against such attacks.
  2. The WMA urges national medical associations to raise awareness among their members, health care institutions and other industry stakeholders about the threat of cyber-attacks and to support an effective, consistent healthcare IT strategy to protect sensitive medical data and to assure patient privacy and safety.
  3. The WMA underscores the heightened risk of cyber intrusions and other data breaches faced by the healthcare sector and urges medical institutions to implement and maintain comprehensive systems for preventing security breaches, including but not limited to providing training to ensure employee compliance with optimal data handling practices and to maintain security of computing devices. 
  4. In the event of a data security breach, healthcare institutions should have proven response systems in place, including but not limited to notifying and offering protection services to victims and implementing processes to correct errors in medical records that result from malicious use of stolen data. Data breach insurance policies could be considered as a precautionary measure for defraying the costs associated with a potential cyber intrusion.
  5. The WMA calls upon physicians, as guardians of patient safety and data confidentiality, to remain aware of the unique challenge cyber-attacks could pose to their ability to practice their profession and to take all necessary measures that have been shown to safeguard patient data, patient safety and other vital information.
  6. The WMA recommends that undergraduate and postgraduate medical education curricula include comprehensive information on how physicians can use modern IT and electronic communications systems to full advantage, while still ensuring data protection and maintaining the highest standards of professional conduct.
  7. The WMA acknowledges that physicians and healthcare providers may not always have access to the resources (including financial), infrastructure and expertise required to establish fail-safe defence systems and stresses the need for the appropriate public as well as private bodies to support them in overcoming these limitations.

Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016

PREAMBLE

  • As noted by the 65th World Medical Assembly in Durban in 2014, physicians around the world are aware that fossil fuel air pollution reduces quality of life for millions of people worldwide, causing a substantial burden of disease, economic loss, and costs to health care systems.
  • According to World Health Organization data, in 2012, approximately “7 million people died, one in eight of total global deaths, as a result of air pollution” (WHO, 2014).
  • The United Nations’ Intergovernmental Panel on Climate Change (IPCC) notes that global economic and population growth, relying on an increased use of coal, continues to be the most important driver of increases in Carbon Dioxide emissions.  These emissions are the major component of an accelerating the amount of human fossil fuel Greenhouse Gas (GHG) emissions despite the adoption of climate change mitigation policies (IPCC, 2014).
  • The burden of disease arising from Climate Change will be differentially distributed across the globe and, while it will affect everyone, the most marginal populations will be the most vulnerable to the impacts of climate change and have the least capacity for adaptation.

BACKGROUND

  • In many densely settled populated cities around the world, the fine dust measurable in the air is up to 50 times higher than the WHO recommendations. A high volume of transport, power generated from coal, and pollution caused by construction equipment are among the contributing factors (WMA, SMAC 197, Air Pollution WMA Statement on the Prevention of Air pollution due to Vehicle Emissions 2014).
  • Evidence from around the world shows that the effects of climate change and its extreme weather are having significant and sometimes devastating impacts on human health.   Fourteen of the 15 warmest years on record have occurred in the first 15 years of this century (World Meteorological Organization 2014).  The vulnerable among us including children, older adults, people with heart or lung disease, and people living in poverty are most at risk from these changes.
  • The WMA notes the Lancet Commission’s description of Climate Change as “the greatest threat to human health of the 21st century”, and that the Paris agreement at COP21 on Climate calls upon governments “when taking action on climate change” to “respect, promote and consider their respective obligations on human rights (and) the right to health”.
  • As the WMA states in its Delhi Declaration on Health and Climate Change, “Although governments and international organizations have the main responsibility for creating regulations and legislation to mitigate the effects of climate change and to help their populations adapt to it, the World Medical Association, on behalf of (…) its physician members, feels an obligation to highlight the health consequences of climate change and to suggest solutions. (…) The WMA and NMAs should develop concrete actionable plans/practical steps” to both mitigate and adapt to climate change (WMA 2009).

RECOMMENDATIONS

The WMA recommends that its national medical associations and all health organizations:

  1. Continue to educate health scientists, businesses, civil society, and governments concerning the benefits to health of reducing greenhouse gas emissions and advocate for the incorporation of health impact assessments into economic policy.
  2. Encourage governments to adopt strategies that emphasize strict environmental regulations and standards that encourage energy companies to move toward renewable fuel sources.
  3. Begin a process of transferring their investments, when feasible without damage, from energy companies whose primary business relies upon extraction of, or energy generation from, fossil fuels to those generating energy from renewable energy sources.
  4. Strive to invest in companies upholding the environmental principles consistent with the United Nations Global Compact (www.unglobalcompact.org), and refrain from investing in companies that do not adhere to applicable legislation and conventions regarding environmental responsibility.
Within the framework of the Health Care in Danger project, the World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) were consulted by the ICRC with the aim of these organizations agreeing on a common denominator of ethical principles of health care applicable in times of armed conflict and other emergencies. These principles, which are the result of these consultations, are without prejudice to existing policy documents adopted by these organizations. 

The “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies” were adopted by the 65th General Assembly of the WMA, Durban (South Africa), October 2014 and officially launched by all partners in June 2015.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015
and rescinded and archived by the 73rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Mobile health (mHealth) is a form of electronic health (eHealth) for which there is no fixed definition. It has been described as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other devices intended to be used in connection with mobile devices. It includes voice and short messaging services (SMS), applications (apps), and the use of the global positioning system (GPS).

Sufficient policies and safeguards to regulate and secure the collection, storage, protection and processing of data of mHealth users, especially health data, must be implemented. Users of mHealth services must be informed about how their personal data is collected, stored, protected and processed and their consent must be obtained prior to any disclosure of data to third parties, e.g. researchers, governments or insurance companies.

The monitoring and evaluation of mHealth should be implemented carefully to avoid inequity of access to these technologies. Where appropriate, social or healthcare services should facilitate access to mHealth technologies as part of basic benefit packages, while taking all the required precautions to guarantee data security and privacy. Access to mHealth technologies should not be denied to anyone on the basis of financial status or a lack of technical expertise.

mHealth technologies cover a wide spectrum of functions. They may be used for:

  • Health promotional (lifestyle) purposes, such as apps into which users input their calorie intake or motion sensors which track exercise.
  • Services which require the medical expertise of physicians, such as SMS services providing advice to pregnant women or wearable sensors to monitor chronic conditions such as diabetes. mHealth technologies of this nature frequently meet the definition of a medical device and should be subject to risk-based oversight and regulation with all its implications.

mHealth may also be used to expedite the transfer of information between health professionals, e.g. providing physicians with free, cross network mobile phone access in resource poor settings.

Technological developments and the increasing prevalence and affordability of mobile devices have led to an exponential increase in the number and variety of mHealth services in use in both developed and developing countries. At the same time, this relatively new and rapidly evolving sector remains largely unregulated, a fact which could have potential patient safety implications.

mHealth has the potential to supplement and further develop existing healthcare services by leveraging the increasing prevalence of mobile devices to facilitate access to healthcare, improve patient self-management, enable electronic interactions between patients and their physicians and potentially reduce healthcare costs. There are significant regional and demographic variations in the potential use and benefits of mHealth. The use of certain mHealth services may be more appropriate in some settings than others.

mHealth technologies generally involve the measurement or manual input of medical, physiological, lifestyle, activity and environmental data in order to fulfil their primary purpose. The large amount of data generated in this way also offers huge scope for research into effective healthcare delivery and disease prevention. However, this secondary use of personal data also has great potential for misuse and abuse, of which many users of mHealth services are unaware.

The expansion of mHealth services has been largely market driven and many technologies have been developed in an uncoordinated, experimental fashion and without appropriate consideration of data protection and security or patient safety aspects. It is often impossible for users to know whether the information provided via mHealth stems from a reliable medical source. Major challenges faced by the mHealth market are the quality of mHealth technologies and whether their use ultimately helps patients or physicians achieve the intended purpose.

Comprehensive regulation and evaluation of the effectiveness, quality and cost effectiveness of mHealth technologies and services is currently lacking, which has implications for patient safety. These factors are crucial to the integration of mHealth services into regular healthcare provision.

RECOMMENDATIONS

The WMA recognises the potential of mHealth to supplement traditional ways of managing health and delivering healthcare. While mHealth may offer advantages to patients otherwise unable to access services from physicians, it is not universally appropriate, nor is it always an ideal form of diagnosis and treatment option. Where face-to-face treatment is available this is almost always advantageous to the patient.

The driving force behind mHealth must be the need to eliminate deficiencies in the provision of care or to improve the quality of care.

The WMA urges patients and physicians to be extremely discerning in their use of mHealth and to be mindful of potential risks and implications.

A clear distinction must be made between mHealth technologies used for lifestyle purposes and those which require the medical expertise of physicians and meet the definition of medical devices. The latter must be appropriately regulated and users must be able to verify the source of information provided. The information provided must be clear, reliable and non-technical, and therefore comprehensible to lay people.

Concerted work must go into improving the interoperability, reliability, functionality and safety of mHealth technologies, e.g. through the development of standards and certification schemes.

Comprehensive and independent evaluations must be carried out by competent authorities with appropriate medical expertise on a regular basis in order to assess the functionality, limitations, data integrity, security and privacy of mHealth technologies. This information must be made publicly available.

mHealth can only make a positive contribution towards improvements in care if services are based on sound medical rationale. As evidence of clinical usefulness is developed, findings should be published in peer reviewed journals and be reproducible.

Suitable reimbursement models must be set up in consultation with national medical associations and healthcare providers to ensure that physicians receive appropriate reimbursement for their involvement in mHealth activities

A clear legal framework must be drawn up to address the question of identifying potential liability arising from the use of mHealth technologies.

Physicians who use mHealth technologies to deliver healthcare services should heed the ethical guidelines set out in the WMA Statement on Guiding Principles for the Use of Telehealth for the Provision of Health Care.

It is important to take into account the risks of excessive or inappropriate use of mHealth technologies and the potential psychological impact this can have on patients.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

In most cultures, an individual’s sex is assigned at birth according to primary physical sex characteristics. Individuals are expected to identify with their assigned sex (gender identity) and behave according to specific cultural norms strongly associated with this (gender expression). Gender identity and gender expression make up the concept of “gender” itself.

There are individuals who experience different manifestations of gender that do not conform to those typically associated with their sex assigned at birth. The term “transgender” refers to people who experience gender incongruence, which is defined as a marked mismatch between one’s gender and the sex assigned at birth.

While conceding that this is a complex ethical issue, the WMA would like to acknowledge the crucial role played by physicians in advising and consulting with transgender people and their families about desired treatments. The WMA intends this statement to serve as a guideline for patient-physician relations and to foster better training to enable physicians to increase their knowledge and sensitivity toward transgender people and the unique health issues they face.

Along the transgender spectrum, there are people who, despite having a distinct anatomically identifiable sex, seek to change their primary and secondary sex characteristics and gender role completely in order to live as a member of the opposite sex (transsexual). Others choose to identify their gender as falling outside the sex/gender binary of either male or female (genderqueer). The generic term “transgender” represents an attempt to describe these groups without stigmatisation or pathological characterisation. It is also used as a term of positive self-identification. This statement does not explicitly address individuals who solely dress in a style or manner traditionally associated with the opposite sex (e.g. transvestites) or individuals who are born with physical aspects of both sexes, with many variations (intersex). However, there are transvestites and intersex individuals who identify as transgender. Being transvestite or intersex does not exclude an individual from being transgender. Finally, it is important to point out that transgender relates to gender identity, and must be considered independently from an individual’s sexual orientation.

Although being transgender does not in itself imply any mental impairment, transgender people may require counseling to help them understand their gender and to address the complex social and relational issues that are affected by it. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5) uses the term “gender dysphoria” to classify people who experience clinically significant distress resulting from gender incongruence.

Evidence suggests that treatment with sex hormones or surgical interventions can be beneficial to people with pronounced and long-lasting gender dysphoria who seek gender transition. However, transgender people are often denied access to appropriate and affordable transgender healthcare (e.g. sex hormones, surgeries, mental healthcare) due to, among other things, the policies of health insurers and national social security benefit schemes, or to a lack of relevant clinical and cultural competence among healthcare providers. Transgender persons may be more likely to forego healthcare due to fear of discrimination.

Transgender people are often professionally and socially disadvantaged, and experience direct and indirect discrimination, as well as physical violence. In addition to being denied equal civil rights, anti-discrimination legislation, which protects other minority groups, may not extend to transgender people. Experiencing disadvantage and discrimination may have a negative impact upon physical and mental health.

RECOMMENDATIONS

  1. The WMA emphasises that everyone has the right to determine one’s own gender and recognises the diversity of possibilities in this respect. The WMA calls for physicians to uphold each individual’s right to self-identification with regards to gender.
  2.  The WMA asserts that gender incongruence is not in itself a mental disorder; however it can lead to discomfort or distress, which is referred to as gender dysphoria (DSM-5). 
  3. The WMA affirms that, in general, any health-related procedure or treatment related to an individual’s transgender status, e.g. surgical interventions, hormone therapy or psychotherapy, requires the freely given informed and explicit consent of the patient. 
  4. The WMA urges that every effort be made to make individualised, multi-professional, interdisciplinary and affordable transgender healthcare (including speech therapy, hormonal treatment, surgical interventions and mental healthcare) available to all people who experience gender incongruence in order to reduce or to prevent pronounced gender dysphoria.
  5.  The WMA explicitly rejects any form of coercive treatment or forced behaviour modification. Transgender healthcare aims to enable transgender people to have the best possible quality of life. National Medical Associations should take action to identify and combat barriers to care.
  6.  The WMA calls for the provision of appropriate expert training for physicians at all stages of their career to enable them to recognise and avoid discriminatory practises, and to provide appropriate and sensitive transgender healthcare.
  7. The WMA condemns all forms of discrimination, stigmatisation and violence against transgender people and calls for appropriate legal measures to protect their equal civil rights. As role models, individual physicians should use their medical knowledge to combat prejudice in this respect.
  8.  The WMA reaffirms its position that no person, regardless of gender, ethnicity, socio-economic status, medical condition or disability, should be subjected to forced or coerced permanent sterilisation (WMA Statement on Forced and Coerced Sterilisation). This also includes sterilisation as a condition for rectifying the recorded sex on official documents following gender reassignment.
  9.  The WMA recommends that national governments maintain continued interest in the healthcare rights of transgender people by conducting health services research at the national level and using these results in the development of health and medical policies. The objective should be a responsive healthcare system that works with each transgender person to identify the best treatment options for that individual.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

 The WMA recognises that having children in living on the streets is unacceptable in a society even though this phenomenon is difficult to avoid in many communities around the world.

The WMA intends to raise awareness within civil and medical society about the fundamental role played by medical contact in improving the situation of street children. In this regard, it is important that the initial contact with street children be based on trust. Therefore, together with other healthcare professionals and social workers, medical contact should be viewed as the first step towards resocialising street children by building trust between the physician and the street child. Once achieved, a more global multidisciplinary and multidimensional approach can follow to improve the well-being of street children.

Childhood and adolescence are the beginnings of a long physical, mental, cultural and social growth process;

The health of young people shapes the health of tomorrow’s population;

Young people play a part in social cohesion and they are an asset to any country;

Addressing the social determinants of health is essential to achieving equity in healthcare. The social determinants leading to the appearance and growth of the phenomenon of “street children” are varied and complex;

The negative health impact of living on the streets for children, both in terms of the additional health risks to which these children are exposed and their lack of access to healthcare and prevention; street children are, in particular, more vulnerable to acute illnesses and traumatic injuries. In addition, preventive care and continuity of care are non-existent for street children due to frequent relocation;

The health of street children remains critical and has been exacerbated by the global financial and economic crisis, which has contributed to family break-ups, social upheaval and disruptions in healthcare and education;

Children may be victims of discrimination arising from their gender, ethnic origin, language, religion, political opinion, handicap, social status or population migration; Street children are especially vulnerable to abuse, violence, exploitation and manipulation, including trafficking;

Child homelessness often goes unrecognised at a national and international level since it is difficult to quantify and assess.

RECOMMENDATIONS

  1. The WMA strongly condemns any violations of the rights of children living on the streets and any infringements of these rights, in particular discrimination and stigmatisation and their exposure to abuse, violence, exploitation and manipulation, including trafficking.
  2. The WMA calls upon governments to address the factors, which lead to children living on the streets and to take action to implement all applicable legislation and systems of protection to reduce the health implications for street children. National authorities have an obligation to provide care for all children and, where necessary, to support their return to a living environment appropriate for a child. Reducing health implications includes not only direct treatment of health issues but also protection of Street Children from health risks such as exposure to drugs, HIV infection, smoking and drinking.
  3. The WMA calls upon governments, national medical associations and healthcare professionals to acknowledge the scale of this phenomenon and to instigate prevention and awareness campaigns. These children must be able to access the full range of necessary health and social protection.
  4. The WMA urges all national medical associations to work with legal counterparts, governments, health care professionals and public authorities to ensure the fundamental rights of children, who are a particularly vulnerable population in need of protection, particularly access to healthcare and education. The right to food and housing should be guaranteed, and any form of discrimination or exploitation should be forbidden.
  5. The WMA condemns any improper age-assessment practices that make use of insufficiently reliable clinical or paraclinical investigations. Until they reach adulthood, adolescents must be able to enjoy their status as minors, as recognised by the UN International Convention on the Rights of the Child.
  6. The WMA urges physicians to remain vigilant in terms of delivering all the support required to provide suitable and comprehensive care for ‘street children’. Physicians should be aware that homelessness is a pervasive problem. They should be knowledgeable about the existence of homelessness in their own communities and are encouraged to establish a relationship of trust between the physician and the street child to become involved in local relief and advocacy programs.
  7. The WMA maintains that every effort should be made to provide all children, and particularly those that are homeless, with access to a suitable and balanced psycho-social environment, in which their rights, including the right to health, are respected.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

There has been a long-standing concern regarding the use of chemical weapons. Despite this concern, poison gas was used fairly extensively during World War I, leading to a call from the International Committee of the Red Cross (ICRC) in February 1918 for cessation of its use.

This led to the Geneva Protocol of 1925, the Biological and Toxin Weapons Convention of 1972 (BTWC) and the Chemical Weapons Convention of 1993 (CWC).

All but six countries in the world have signed and ratified the CWC; two more have signed but not yet ratified, making it a nearly universally accepted Convention.

The conventions prohibit the development, production and stockpiling of chemical weapons in addition to their usage in warfare and call for measures to decommission or destroy existing stores. However, the CWC allows the use of specific chemicals in domestic law enforcement including riot control situations, which means that governments might hold stockpiles of certain agents. Even so, riot control agents cannot be used in warfare; the exclusion has reached the status of customary law, which allows their use only in domestic or national jurisdictions.

Although there is academic and military interest in what is often called non-lethal weapons, the incidence of morbidity and mortality caused by weapons are not criteria used in prohibition. A tiered approach based upon degrees of lethality of specific weapons is contrary to the ethos of both conventions.

In situations of widespread public unrest and political or other uprisings governments unfortunately may choose to deploy riot control agents in a domestic setting. Although this is not in conflict with the principles of the CWC their use may still give rise to specific medical, legal and ethical challenges.

While riot control agents are designed to make remaining within the riot unpleasant and impractical, they are not expected to directly cause any injuries or deaths. As with all other agents, how they are used determines the concentration to which individuals are exposed. The ability to take evasive actions, such as leaving the area, to reduce exposure may also have an impact. It is recognised that individual determinants including general health and age will affect an individual’s response to chemical agent.

Release of chemical agents such as tear gas in a small enclosed space exposes individuals to concentrations far higher than those expected in normal deployment in riot situations, causing higher levels of serious morbidity and potentially death.

Misuse of riot control agents, leading to serious harms or deaths of demonstrators, exposing individuals excessively or using them for oppressing non-violent peaceful demonstrations, may lead to a breach of the human rights of the individuals concerned, in particular the right to life (article 3), the right to freedom of expression (article 19) and of peaceful assembly (article 20) of the Universal Declaration of Human Rights.

Governments, who authorize the stockpiling and use of such agents by their police and security forces, are urged to consider that there might be fatal results of their usage. Governments are required to ensure that they are used in a manner, which minimise their likelihood of causing serious morbidity and mortality.

RECOMMENDATION

The WMA recognises that the inappropriate use of riot control agents risks the lives of those targeted and exposes people around, amounting to a potential breach of human rights standards, in particular the right to life, the right to freedom of expression and of peaceful assembly as stated in the Universal Declaration of Human Rights.

In case of use of riot control agents, the WMA urges States to do so in a manner designed to minimise the risk of serious harm to individuals, and to prohibit its use in the presence of vulnerable populations, such as children, older people or pregnant women;

The WMA insists that riot control agents should never be used in enclosed spaces where chemical concentrations may reach dangerous levels, and where people cannot move away from areas with high concentrations of the agent;

The WMA insists that governments train police and other security forces in the safe and legal use of riot control agents, in order to minimise the risk of harm when they are deployed. This must include the rapid evacuation of any individual who is apparently suffering from a high level of exposure, not aiming people, and not using the agent excessively;

The WMA insists that States penalise individuals who misuse riot control agents and who deliberately endanger human life and safety by using the agents. Such misuse leading to serious physical harms or death of individuals should be investigated by independent experts.

The WMA calls for unimpeded and protected access of healthcare personnel to allow them to fulfil their duty of attending to the injured as set forth in the “WMA Declaration on the protection of healthcare workers in situations of violence”.

The WMA recommends that, because of the significant difficulties and risks to health and life associated with the use of such riot control agents, States should refrain from using them in any circumstances.

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

Physician well-being refers to the optimization of all factors affecting biological, psychological and social health and preventing or treating acute or chronic diseases experienced by physicians including mental illness, disabilities and injuries resulting from work hazards, occupational stress and burnout.

Physician’s well-being could have positive impact on patient care, but more research is needed. The profession should therefore encourage and support on-going research on physician’s health. Evidence that already exists should be implemented in policy and practice. While physicians tend to have healthy habits, it is essential to enhance their health as a way to improve health for the whole population.

Physicians and medical students at all career stages are exposed to both positive experiences as well as a variety of stressors and work injuries The medical profession should seek to identify and revise policies and practices that contribute to these stressors and collaborate with NMA’s in order to develop policies and practices that have protective effects. Like all human beings, physicians experience illness, and they also have family obligations and other commitments outside their professional lives that should be taken into account.

One reason physicians delay seeking help is their concern about confidentiality and feeling ill at ease in the patient role. They experience feelings of responsibility towards their patients and are sensitive to external expectations on their health. Therefore, physicians must be assured of the same right of confidentiality as any other patient when seeking and undergoing treatment. The health care system may need to provide special arrangements for the care of physician-patients in order to uphold its duty to provide privacy and confidentiality. Prevention, early assistance and intervention should be available separately from any disciplinary process.

THREATS, BARRIERS AND OPPORTUNITIES FOR PHYSICIAN WELL-BEING

Professional Roles and Expectations

The medical profession often attracts highly driven individuals with a strong sense of duty. Successfully completing the long and intense educational requirements often confers upon physicians a high degree of respect and responsibility in their communities.

With these high levels of respect and responsibility, physicians are subject to high expectations from patients and the public.  These expectations can contribute to prioritizing the care of others over care of self and feelings of guilt and selfishness for managing their own well-being.

There is a direct relationship between physicians’ and patients’ preventive health practices. This relationship should encourage healthcare systems to better support and evaluate the effects on patients of improving physician and medical student health.

Work Environment

Working conditions, including workload and working hours, affect physicians’ motivation, job satisfaction, personal life and psychological health during their careers.

Physicians are often perceived as being immune to injury and diseases as they care for their patients, and workplace health and safety programs may be overlooked. Physician who are employed by small organizations or who are self-employed may be at even a higher risk for occupational diseases and may not have access to health and safety programs provided by large health care establishments.

As a consequence of their professional duties, physicians and physicians in postgraduate education often confront emotionally challenging and traumatic situations including patients’ suffering, injury and death. Physicians may also be exposed to physical hazards like radiation, noise, poor ergonomics, and biological hazards like HIV, TB and hepatitis.

Some healthcare systems may exacerbate stress because of the hierarchies and competition inherent in them. Physicians in postgraduate education and medical students can be victims of harassment and discrimination during their medical education. Due to their position within the medical hierarchy, they may feel powerless to confront these behaviours.

Physician autonomy is one of the strongest predictors of physician satisfaction. Increasing external regulatory pressures such as undue emphasis on cost efficiencies and concerns about consequences of reporting medical errors may unduly influence medical decision-making and diminish a physician’s autonomy.

Illness

Even though medical professionals recognize that it is preferable to identify and treat illness early, physicians are often adept at hiding their own illnesses and may continue to function without seeking help until they become incapable of carrying out their duties. There are many potential obstacles to an ill physician seeking care including: denial, confidentiality issues, aversion to the patient role, practice coverage, fear of disciplinary action, potential loss of practice privileges, loss of performance based payment and the efficiencies of self-care. Because of these obstacles doctors are often reluctant to refer themselves or their colleagues for treatment.

Illnesses can include mental and behavioural health problems, burnout, communication and interpersonal issues, physical and cognitive problems and substance use disorders. These illnesses and problems can overlap and can occur throughout the professional life cycle from basic medical education to retirement. It is important to acknowledge the continuum of physician well-being, ranging from optimal health, to minor illness, to debilitating illness.

Substance abuse may disrupt a physician’s personal life and may also significantly affect his or her ability to care for patients. Easy access to medications may contribute to physicians’ risk for abuse of recreational drugs and prescription medications.  Assistance prior to impairment in the workplace is protective for physicians, their professional credentials and their patients.

Improved wellness promotion, prevention strategies and earlier intervention can help mitigate the severity of mental and physical illnesses and help reduce incidence of suicide in physicians, physicians in postgraduate education and medical students.

RECOMMENDATIONS

The World Medical Association recommends that National Medical Associations (NMAs) recognize and, where possible, actively address the following:

  1. In partnership with medical schools and workplaces, NMAs recognize their obligation to provide education at all levels about physician well-being. NMAs should collaboratively promote research to establish best practices that promote physician health and to determine the impact of physician well-being on patient care.
  2. Physician well-being should be supported and provided within and outside the workplace. Support may include but is not limited to referral to medical treatment, counselling, support networks, recognized physician health programs, occupational rehabilitation and primary prevention programs including resiliency training, healthy lifestyles and case management.
  3. NMA’s should recognize the strong and consistent link between physicians’ and patients’ personal health practices, providing yet another critically important reason for health systems to promote physician health.
  4. Physician health programs can help all physicians to proactively help themselves via prevention strategies and can assist physicians who are ill via assessment, referral to treatment and follow-up.  Programs and resources to help promote positive psychological health should be available to all physicians. Early identification, intervention and special arrangements for the care of physician-patients should be available to protect the health of physicians. Fostering a supportive and accepting culture is critical to successful early referral and intervention.
  5. Physicians at risk for abuse of alcohol or drugs should have access to appropriate confidential medical treatment and comprehensive professional support. NMAs should promote programs that help physicians re-enter medical practice with appropriate ongoing supervision at the completion of their treatment programs. More research should be conducted to determine best practices in preventing substance abuse among physicians and physicians in postgraduate education.
  6. Physicians have the right to working conditions that help limit the risk of burnout and empower them to care for their personal health by balancing their professional medical commitments and their private lives and responsibilities. Optimal working conditions include a safe and reasonable maximum number of consecutive and total working hours, adequate rest between shifts and appropriate number of non-working days. Relevant organizations should constructively address professional autonomy and work-life balance problems and involve physicians in making decisions about their work lives. Working conditions must not put the safety of patients or physicians at risk, and ultimately physicians should be engaged in establishing optimal workplace conditions.
  7. Workplaces should promote conditions conducive to healthy lifestyles, including access to healthy food choices, exercise, nutrition counselling and support for smoking cessation.
  8. Physicians, physicians in postgraduate education and medical students have the right to work in a harassment and violence-free workplace. This includes freedom from verbal, sexual and physical abuse.
  9. Physicians, physicians in postgraduate education and medical students have the right to a collaborative safe workplace. Workplaces should promote interdisciplinary teamwork, and communication between physicians and all other professionals in the workplace should be offered in a spirit of cooperation and respect. Education on communications skills, self-awareness and team-work should be considered.
  10. Medical staff should undergo training in recognizing, handling and communicating with potentially violent persons. Health care facilities should safeguard against violence including routine violence risk audits, especially in mental health treatment facilities and emergency departments. Staff members who are victims of violence or who report violence should be supported by management and offered medical, psychological and legal counselling.
  11. Medical schools and teaching hospitals should develop and maintain confidential services for physicians in postgraduate education and medical students and to raise awareness of and access to such programs. Workplaces should consider offering medical consultations to physicians in postgraduate education in order to identify any health issues at the outset of medical education.
  12. Workplace support for all physicians should be easily accessible and confidential. Physicians evaluating and treating their medical colleagues should not be required to report any aspects of their physician-patients’ care in any manner not required for their non-physician patients.

Adopted by the 200th WMA Council Session, Oslo, April 2015,
and adopted, with amendments by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

Trade agreements are treaties between two or more countries which include provisions addressing trade in goods and/or services. Trade agreements are tools of globalization and typically seek to promote global wealth through trade liberalization. They can have significant implications for the social, commercial, political and ecological determinants of health as well as the delivery of health care. 

International trade contributes significantly to increases in national wealth which is a key factor in building strong health care systems.  

While trade agreements are designed to produce economic benefits and global wealth, it is fundamental to identify public health implications that may arise from these agreements.  

Negotiations should take into account broad impact to ensure that the right to health and to a healthy natural and social environment are well-prioritized. Trade agreements should be directed at contributing to global health and equity. 

Trade agreements may have the ability to promote the health and wellbeing of all people when they are well-designed to protect health and preserve the ability of governments to legislate, regulate and plan for health promotion, health care delivery and health equity. 

Recent trade agreement negotiations have sought to establish a new global governance framework for trade and have been unprecedented in their size, scope and secrecy. A lack of transparency and the selective sharing of information with a limited set of stakeholders are anti-democratic. 

There must be recognition of the importance of innovation sharing in public health. This is particularly important during health emergencies. Access to medicines and medical supplies is essential to address the major public health problems such as pandemics and trade agreements must not act as a barrier to that access. 

Investor-state dispute settlement (ISDS) provides a mechanism for investors to bring claims against governments and seek compensation, operating outside existing systems of accountability and transparency. ISDS in existing trade agreements has been used to challenge evidence-based public health measures including tobacco plain packaging. Inclusion of a broad ISDS mechanism could threaten public health actions designed to support evidence-based tobacco control, alcohol control, healthy and safe food consumption including regulation of obesogenic foods and beverages, access to medicines, health care services, environmental protection/climate change and occupational / environmental health protections. Efforts by industry to challenge domestic public health laws and regulation have targeted nations with limited access to legal resources and some of the world’s most vulnerable populations. 

Access to affordable medicines is critical to controlling the global burdens of communicable and non-communicable diseases. The World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) established a set of common international rules governing the protection of intellectual property including the patenting of pharmaceuticals. TRIPS safeguards and flexibilities including compulsory licensing seek to ensure that patent protection does not supersede public health. 

The WMA Statement on Patenting Medical Procedures states that patenting of diagnostic, therapeutic and surgical techniques is unethical and “poses serious risks to the effective practice of medicine by potentially limiting the availability of new procedures to patients.” 

Trade agreements should not pose a new difficulty in accessing medicines, especially for developing countries and for the most vulnerable populations. 

There must be a fair balance established between the prices of medicines and the protection of intellectual property through patents. 

The WMA considers that patenting on medicines/vaccines must be regulated in accordance with the ethical principles and values of the medical profession in order to ensure effective and global action for public health and therefore recognizes that it may be necessary to temporarily waive patents in times of public health emergencies.  Moreover, to produce fast and comprehensive results, sustainable solutions for patent issues must be supplemented by the transfer of technology, knowledge, and manufacturing expertise, global investment in manufacturing sites, training of personnel, and quality control. 

The WMA Resolution on Medical Workforce states that the WMA has recognized the need for investment in medical education and has called on governments to “…allocate sufficient financial resources for the education, training, development, recruitment and retention of physicians to meet the medical needs of the entire population…” 

The WMA Declaration of Delhi on Health and Climate Change states that global climate change has had and will continue to have serious consequences for health and demands comprehensive action. 

The WMA Declaration on Fair Trade in Medical Products and Devices states that purchasing policies for medical goods should be fair and ethical, working conditions should be safe and modern slavery should be eradicated throughout supply chains. Health product manufacturers should establish a plan for continuity of supply of vital and life-sustaining products to avoid production shortages whenever possible. This plan should include establishing the necessary resiliency and redundancy in manufacturing capability to minimize disruptions of supplies. 

 

RECOMMENDATIONS 

 Therefore, the WMA calls on national governments and constituent member associations to: 

1.Call for transparency and openness in all trade agreement negotiations including public access to negotiating texts and meaningful opportunities for stakeholder engagement. 

2. Call for a proactive assessment of anticipated effects on health, human rights, and the environment for all trade agreements. 

3. Advocate for trade agreements that protect, promote and prioritize public health over commercial or political interests, and secure services in the public interest, especially those affecting individual and public health. This should include new modalities of health care provision including eHealth. 

4. Ensure that trade agreements do not have negative impacts on health systems, human resources for health and universal health coverage (UHC). Ensure trade agreements do not interfere with governments’ ability to protect and regulate health and health care, or to guarantee a right to health for all. Government action to protect and promote health should not be subject to challenge through an investor-state dispute settlement (ISDS) or similar mechanism.

5. Work to ensure that patents on medicines and vaccines are regulated in accordance with the principles of medical ethics, in order to protect public health in global emergency situations.  

6. Therefore, urge NMAs to promote the possibility of temporarily waiving patents on medicines and vaccines to protect public health in global emergency situations while ensuring fair compensation for the intellectual property of the patent holders, global investment in manufacturing sites, and knowledge transfer. Promote public health, equity, solidarity and social justice and protect countries and people who are weaker economically and health-wise, and therefore most vulnerable. 

7. Oppose any trade agreement provisions which would compromise access to health care services or medicines including but not limited to: 

  • Patenting (or patent enforcement) of diagnostic, therapeutic and surgical techniques; 
  • “Evergreening”, or patent protection for minor modifications of existing drugs; 
  • Patent linkage or other patent term adjustments that serve as a barrier to generic entry into the market; 
  • Data exclusivity for biologics; 
  • Any effort to undermine TRIPS safeguards or restrict TRIPS flexibilities including compulsory licensing; 
  • Limits on clinical trial data transparency. 

8. Oppose any trade agreement provision which would reduce public support for or facilitate commercialization of medical education. 

9. Oppose any trade agreement which would facilitate the inappropriate privatization of public services in areas such as conservation of natural environment, education, healthcare, and daily necessities such as energy and water. 

10. Ensure that trade agreements promote environmental protection and support efforts to reduce activities that cause climate change. 

 11. Ensure that trade agreements promote equity and human rights and include mechanisms for accountability following implementation. 

 

 

Adopted by the 65th World Medical Assembly, Durban, South Africa, Otober 2014

Preamble

Aesthetic treatments have become increasingly common in recent years as society appears to have become more preoccupied with physical appearance. These treatments are performed by practitioners with widely differing clinical and educational backgrounds.

For the purpose of this statement, aesthetic treatment is defined as an intervention that is performed not to treat an injury, a disease or a deformity, but for non-therapeutic reasons, with the sole purpose of enhancing or changing the physical appearance of the individual concerned. In this statement, the individual undergoing treatment is referred to as the patient. The treatments available include a great variety of interventions, ranging from surgical procedures to injections and different kinds of skin treatments. This statement focuses on interventions that are methodologically similar to those performed in conventional health care. Tattooing, scarring and similar interventions are therefore not considered in this statement.

Body image affects a person’s self-esteem and mental health and is an integral part of a person’s overall health and well-being. However, media images of “perfect bodies” have become the norm, causing some people, to develop unrealistic and unhealthy body images.

Many aesthetic treatments involve risks and may potentially harm the health of the patient. Minors[1] are particularly vulnerable, as their bodies are often not fully developed. In order to protect persons considering or undergoing aesthetic treatment the WMA has developed the following basic principles regarding aesthetic treatments.

Reaffirming the medical ethics principles laid out in the WMA Declaration of Geneva, the WMA Declaration of Lisbon on the Rights of the Patient and the WMA International Code of Medical Ethics, and consistent with the mandate of the WMA, this statement is addressed primarily to physicians. However, the WMA encourages other practitioners performing aesthetic treatments to adopt these principles.

PRINCIPLES

1. The patient´s dignity, integrity and confidentiality must always be respected.

2. Physicians have a role in helping to identify unhealthy body images and to address and treat disorders when these exist.

3. Aesthetic treatments must only be performed by practitioners with sufficient knowledge, skills and experience of the interventions performed.

4. All practitioners providing aesthetic treatments must be registered with and/or licensed by the appropriate regulatory authority. Ideally, the practitioner should also be authorized by this authority to provide these specific aesthetic treatments.

5. All aesthetic treatments must be preceded by a thorough examination of the patient. The practitioner should consider all circumstances, physical and psychological, that may cause an increased risk of harm for the individual patient and should refuse to perform the treatment if the risk is unacceptable. This is especially true in the case of minors. Practitioners should always choose the most appropriate treatment option, rather than the most lucrative one.

6. Minors may need or benefit from plastic medical treatments but pure aesthetic procedures should not be performed on minors. If, in exceptional cases, aesthetic treatment is performed on a minors, it should only be done with special care and consideration and only if the aim of the treatment is to avoid negative attention rather than gain positive attention. All relevant medical factors, such as whether the minor is still growing or whether the treatment will need to be repeated at a later date, must be considered.

7. The patient must consent explicitly to any aesthetic treatment, preferably in writing. Before seeking consent the practitioner should inform the patient of all relevant aspects of the treatment, including how the procedure is performed, possible risks and the fact that many of these treatments may be irreversible. The patient should be given sufficient time to consider the information before the treatment starts. Where the patient requesting the treatment is a minor, the informed consent of his or her parents or legally authorized representative should be obtained.

8. All aesthetic treatments performed should be carefully documented by the practitioner. The documentation should include a detailed description of the treatment performed, information on medications used, if any, and all other relevant aspects of the treatment.

9. Aesthetic treatments must only be performed under strictly hygienic and medically safe conditions on premises that are adequately staffed and equipped. This must include equipment for treating life-threatening allergic reactions and other potential complications.

10. Advertising and marketing of aesthetic treatments should be responsible and should not foster unrealistic expectations of treatment results. Unrealistic or altered photographs showing patients before and after treatments must not be used in advertising.

11. Advertising and marketing of aesthetic treatments should never be targeted to minors.

12. Practitioners should never offer or promote financial loans as a means of paying for aesthetic treatment.

 

[1] For the purpose of this statement minor is defined as a person who, according to applicable national legislation, is not an adult.

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003
and revised by the 65th WMA General Assembly, Durban, South Africa, October 2014

PREAMBLE

The WMA acknowledges that temporary stays of physicians in other countries help both the receiving and the sending countries to exchange medical knowledge, skills and attitudes. The exchange of medical professionals is therefore beneficial for the development of medicine and healthcare systems and in general deserves the support of national medical associations as well as governments.

The WMA Statement on Medical Manpower – 1 (1983, 1986) called upon all National Medical Associations to work with their governments towards solutions to the emerging problems related to the medical workforce.

The WMA Resolution on the Medical Workforce (1998) identified the major components of the medical workforce situation that need to be taken into account when developing a national workforce policy.

For several decades many governments, employers and medical associations have misinterpreted demographical data regarding the number of physicians that are required. Young people seeing employment as physicians have often been seriously affected by poor medical workforce planning.

In many countries, including the wealthiest ones, there is a shortage of physicians. A major reason for the shortage is a failure to educate enough physicians to meet the needs of the country. Other reasons for the net loss of physicians are the recruitment of physicians to other professions, early retirement and emigration, and the problems of combining professional and family responsibilities, all of which are often due to poor working conditions for physicians.

Some countries have traditionally solved their need for physicians by recruiting medical graduates from other countries. This practice continues today.

The flow of international migration of physicians is generally from poorer to wealthier countries. The poorer countries bear the expense of educating the migrating physicians and receive no recompense when they enter other countries. The receiving countries gain a valuable resource without paying for it, and in the process they save the cost of educating their own physicians.

Physicians do have valid reasons for migrating, for example, to seek better career opportunities and to escape poor working and living conditions, which may include the pursuit of more political and personal freedoms and other benefits.

RECOMMENDATIONS

  1. National medical associations, governments and employers should exercise utmost care in utilizing demographic data to make projections about future requirements for physicians and in communicating these projections to young people contemplating a medical career.
  2. Every country should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians.
  3. Every country should do its utmost to retain its physicians in the profession as well as in the country by providing them with the support they need to meet their personal and professional goals, taking into account the country’s needs and resources.
  4. Countries that wish to recruit physicians from another country should only do so in terms of and in accordance with the provisions of a Memorandum of Understanding entered into between the countries.
  5. Physicians should not be prevented from leaving their home or adopted country to pursue career opportunities in another country.
  6. Countries that recruit physicians from other countries should ensure that recruiters provide full and accurate information to potential recruits on the nature and requirements of the position to be filled, on immigration, administrative and contractual requirements, and on the legal and regulatory conditions for the practice of medicine in the recruiting country, including language skills.
  7. Physicians who are working, either permanently or temporarily, in a country other than their home country should be treated fairly in relation to other physicians in that country (for example, equal opportunity career options and equal payment for the same work).
  8. Nothing should prevent countries from entering into bilateral agreements and agreements of understanding, as provided for in international law and with due cognizance of international human rights law, so as to effect meaningful co-operation on health care delivery, including the exchange of physicians.
  9. The WHO Global Code of Practice on the International Recruitment of Health Personnel (May 2010) was established to promote voluntary principles and practices for the ethical international recruitment of health professionals and to facilitate the strengthening of health systems. The Code takes into account the rights, obligations and expectations of source countries and migrant health professionals. The WMA was involved in the drafting of the Code and supports its implementation.
  10. The WHO Code states that international recruitment should be “conducted in accordance with the principles of transparency, fairness and promotion of sustainability of health systems in developing countries.”
  11. The monitoring and information-sharing system established by the WHO should be robustly supported with the goal of international cooperation. Stakeholders should regularly collate and share data, which should be monitored and anlaysed by the WHO. The WHO should provide substantive critical feedback to governments. Information should be shared about how to overcome challenges encountered.

Adopted by the 65th World Medical Assembly, Durban, South Africa, October 2014
and rescinded and archived by the 75th WMA General Assembly, Helsinki, Finland, October 2024

Preamble

There are a number of ways in which the volume of harmful emissions can be reduced. These include encouraging fewer road traffic journeys, active transport for individuals undertaking relatively short journeys, the use of mass public transit in preference to individual vehicles, and alternative energy sources for vehicles, including electric and hybrid technologies. Where vehicle use is essential, means of reducing harmful emissions should be used.

Physicians around the world are aware of air pollution. It impacts the quality of life for hundreds of millions of people worldwide, causing both, a large burden of disease as well as economic losses and increased health care costs. According to WHO estimates, in 2012, urban outdoor air pollution was responsible for 3.7 million annual deaths, representing 6.7% of the total deaths (WHO, 2014).

Especially, diesel soot is acknowledged as a proven carcinogen (IARC, 07/2012). Furthermore, it has many other toxic effects, most prominently in the cardiovascular (Brook et al., 2010) and respiratory systems (ERS, 2010). Moreover, in the context of global warming, soot, along with methane, is identified as the second most important greenhouse driving force substance after CO2 (Kerr, 2013).

Despite the fact that new vehicles will have to comply with stricter emission standards which take into account most harmful ultra fine particles too, a high-polluting in-use fleet, including off-road vehicles such as construction engines and ships, will continue polluting for many more years.

Background

In many densely populated cities around the world, fine dust concentrations measurable as aerosols exceed up to 50 times the maximum WHO recommendation. High volumes of transport, power generated from coal, and pollution caused by construction machinery are among the contributing factors. People living and working near major (high density volume traffic) streets are most affected by pollutants.
For fighting the health risks mentioned above, there exist a variety of highly efficient and reliable filter systems on the market (Best Available Technology (BAT) filters[1]). They are applicable to all internal combustion engines and they reduce even most harmful ultra-fine particles by a factor of over one hundred.
As soon as 90% of heavy duty vehicles, both, new and upgraded ones, satisfy this standard, health problems attributable to emissions of heavy duty traffic will be greatly reduced, and no further tightening of emission standards will be possible or even needed at all because of an almost total elimination of the pollutant as such.

In a variety of countries on different continents and under varying conditions retrofit or upgrading programs have been successfully performed. The UN’s Working Party on Pollution Prevention and Energy in Geneva has just proposed a technical standard for regulation in their member states, which will be applicable worldwide.

The WMA supports these efforts and calls on policy makers in all countries, especially in urban regions, to introduce regulatory restrictions of access for vehicles without filter, and/or to provide financial assistance to support the retrofitting of in-use vehicles.

Recommendations

The WMA therefore recommends that all NMAs should encourage their respective governments to:

  1. Introduce BAT standards for all new diesel vehicles (on road and off-road)
  2. Incentivise retrofitting with BAT filters for all in-use engines
  3. Monitor and limit the concentration of nanosize soot particles in the urban breathing air
  4. Conduct epidemiological studies detecting and differentiating the health effects of ultrafine particles
  5. Build professional and public awareness of the importance of diesel soot and the existing methods of eliminating the particles
  6. Contribute to developing strategies to protect people from soot particles in aircraft passenger cabins, trains, homes and in the general environment. These strategies should include plans to develop and increase use of public transportation systems.

 

Abbreviations:

EPA: Environmental Protection Agency (US)

ERS: European Respiratory Society

IARC: International Agency for Research of Cancer

BAT Standards: Emission standards for passenger cars, heavy-duty vehicles and off-road machinery, based on count of ultrafine particles rather than mass and aimed at the protection of human health from the most hazardous soot particles, the lung and even cell membrane penetrating ultra-fines.

References:

  • Brook, Robert D. et al. (2010): AHA Scientific Statement: Particulate Matter Air Pollution and Cardiovascular Disease. An Update to the Scientific Statement from the American Heart Association. Circulation 121: 2331-2378.
  • ERS (2010): The ERS report on air pollution and public health. European Respiratory Society, Lausanne, Switzerland. ISBN: 978-1-84984-008-8
  • IARC (2012): “IARC: Diesel Engine Exhaust Carcinogenic”. Press Release No. 213. http://www.iarc.fr/en/media-centre/pr/2012/pdfs/pr213_E.pdf .
    (access: 14/02/14)
  • Kerr, Richard R. (2013): “Soot is Warming the World Even More Than Thought”. In: Science 339(6118), p. 382.
  • WHO (2014): “Burden of disease from Ambient Air Pollution for 2012.” http://www.who.int/phe/health_topics/outdoorair/databases/AAP_BoD_results_March2014.pdf?ua=1   (access: 26/08/14)

[1] Euro 6/VI, US/EPA/CARB, Chinese and equivalent standards.

Adopted by the 65th WMA General Assembly, Durban, South Africa, October 2014
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE 

In many countries, a substantial number of prisoners are held in solitary confinement. Solitary confinement is a form of confinement used in detention settings where individuals are separated from the general detained population and held alone in a separate cell or room for upwards of 22 hours a day. Jurisdictions may use a range of different terms to refer to the process (such as segregation, separation, isolation or removal from association) and the conditions and environment can vary from place to place. However, it may be defined or implemented, solitary confinement is characterised by complete social isolation; a lack of meaningful contact; and reduced activity and environmental stimuli. Some countries have strict provisions on how long and how often prisoners can be kept in solitary confinement, but many countries lack clear rules on this.

Solitary confinement can be distinguished from other brief interventions when individuals must be separated as an immediate response to violent or disruptive behaviour or where a person must be isolated to protect themselves or others. These interventions should take place in a non-solitary confinement environment.

The reasons for the use of solitary confinement vary in different jurisdictions and it can be used at various stages of the criminal justice process. It may be used as a disciplinary measure for the maintenance of order or security; as an administrative measure, for the purposes of investigation or questioning; as a preventive measure against future harm (either to the individual or to others); or it may be the consequence of a restrictive regime that limits contact with others. It can be imposed for hours to days or even years. 

Medical impacts of solitary confinement

People react to isolation in different ways. For a significant number of prisoners, solitary confinement has been documented to cause serious psychological, psychiatric, and sometimes physiological effects. These include insomnia, confusion, hallucinations, psychosis, and aggravation of pre-existing health problems. Solitary confinement is also associated with a high rate of suicidal behaviour. Negative health effects can occur after only a few days and may in some cases persist when isolation ends.

Certain populations are particularly vulnerable to the negative health effects of solitary confinement. Persons with psychotic disorders, major depression, or post-traumatic stress disorder or people with severe personality disorders may find isolation unbearable and suffer considerable health harms. Solitary confinement may complicate treating such individuals and their associated health problems successfully later in the prison environment or when they are released back into the community. Prisoners with physical disabilities or other medical conditions often have their conditions aggravated, not only as a result of the physical conditions of isolation, but also as the particular health requirements linked to their disability or condition are often not accommodated.

For children and young people, who are in the crucial stages of developing socially, psychologically, and neurologically, there are serious risks of solitary confinement causing long-term mental and physical harm. A growing international consensus about the harms of solitary confinement on children and young people has resulted in some jurisdictions abolishing the practice completely.

International norms on solitary confinement

The increasing documentation on the harmful impact of solitary confinement on the health of prisoners led to the development of a range of international norms and recommendations seeking to mitigate the use and the harmful effect of solitary confinement.

The United Nations Standard Minimum Rules for the Treatment of Prisoners (SMR) were first adopted in 1957, and revised in 2015 as the Nelson Mandela Rules unanimously adopted by the United Nations Assembly. The SMR constitute the key international framework for the treatment of prisoners.

Other international standards and recommendations, such as the United Nations Rules for the Treatment of Women Prisoners and Non-Custodial Sanctions for Women Offenders (the Bangkok Rules), the United Nations Rules for the Protection of Juveniles Deprived of their Liberty and the observations of the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, support and complete the Nelson Mandela Rules.

The misuse of solitary confinement can include indefinite or prolonged solitary confinement (defined as a period of solitary confinement in excess of 15 days), but can also include corporal or collective punishment, the reduction of a prisoner’s diet or drinking water, or the placement of a prisoner in a dark or constantly lit cell. Misuse of solitary confinement in these ways can constitute a form of torture or ill-treatment and as such must be prohibited in line with international human rights law and medical ethics.

The WMA and its members reiterate their firm and long-standing position condemning any forms of torture and other cruel, inhuman or degrading treatment or punishment and reaffirm the basic principle that doctors should never participate in or condone torture or other cruel, inhuman or degrading treatment.

 

RECOMMENDATIONS

1. Given the harmful impact of solitary confinement, which can on occasion result in a form of torture or ill-treatment, the WMA and its members call for the implementation of the Nelson Mandela Rules and other associated international standards and recommendations, with a view to protect the human rights and the dignity of the prisoners.

2. The WMA and its members emphasize in particular the respect of the following principles:

  • In light of the serious consequences solitary confinement can have on physical and mental health (including an increased risk of suicide or self-harm), it should be imposed only in exceptional cases as a last resort and subject to independent review, and for the shortest period of time possible. The authority imposing the solitary confinement must be acting in line with clear rules and regulations as to its use.
  • All decisions on solitary confinement must be transparent and regulated by law. The use of solitary confinement should be time-limited by law. The detainee should be informed of the duration of the isolation, and the period of duration should be determined before the measure takes place. Prisoners subject to solitary confinement should have a right of appeal.
  • Solitary confinement should not exceed a time period of 15 consecutive days. Releasing the prisoner from solitary confinement for a very limited period of time, with the intention that the individual will be placed in solitary confinement immediately again to get around the rules on length of stay must also be prohibited.

Prohibitions of the use of solitary confinement

3. The indefinite or prolonged solitary confinement should be prohibited as amounting to torture or other cruel, inhuman or degrading treatment or punishment [1].

4. Solitary confinement should be prohibited for children and young people (as defined by domestic law), pregnant women, women up to six months post-partum, women with infants and breastfeeding mothers as well as for prisoners with mental health problems given that isolation often results in severe exacerbation of pre-existing mental health conditions.

5. The use of solitary confinement should be prohibited in the case of prisoners with physical disabilities or other medical conditions where their conditions would be exacerbated by such measures.

6. Where children and young people must be separated, in order to ensure their safety or the safety of others, this should be carried out in a non-solitary confinement setting with adequate resources to meet their needs, including ensuring regular human contact and purposeful activity.

Conditions of solitary confinement

7. The human dignity of prisoners confined in isolation must always be respected.

8. Prisoners in isolation should be allowed a reasonable amount of meaningful regular human contact, activity, and environmental stimuli, including daily outside exercise. As with all prisoners, they must not be subjected to extreme physically and/or mentally taxing conditions.

9. Prisoners who have been in solitary confinement should have an adjustment period, including a medical examination, before they are released from prison. This must never extend their period of incarceration.

Role of physician

10. The physician’s role is to protect, advocate for, and improve prisoners’ physical and mental health, not to inflict punishment. Therefore, physicians should never participate in any part of the decision-making process resulting in solitary confinement, which includes declaring an individual as “fit” to withstand solitary confinement or participating in any way in its administration. This does not prevent physicians from carrying out regular visits to those in solitary confinement to assess health and provide care and treatment where necessary, or from raising concerns where they identify a deterioration in an individual’s health.

11. The provision of medical care should take place upon medical need or the request of the prisoner. Physicians should be guaranteed daily access to prisoners in solitary confinement, upon their own initiative. More frequent access should be granted if physicians deem this to be necessary.

12. Physicians working in prisons must be able to practice with complete clinical independence from the prison administration. In order to maintain that independence, physicians working in prisons should be employed and managed by a body separate from the prison or criminal justice system.

13. Physicians should only provide drugs or treatment that are medically necessary and should never prescribe drugs or treatment with the intention of enabling a longer period of solitary confinement.

14. Healthcare should always be provided in a setting that respects the privacy and dignity of prisoners. Physicians working in the prison setting are bound by the same codes and principles of medical ethics as they would be in any other setting.

15. Physicians should report any concerns about the impact solitary confinement is having on the health and wellbeing of an individual prisoner to those responsible for reviewing solitary confinement decisions. If necessary, they should make a clear recommendation that the person be removed from solitary confinement, and this recommendation should be respected and acted upon by the prison authorities.

16. Physicians have a duty to consider the conditions in solitary confinement and to raise concerns with the authorities if they believe that they are unacceptable or might amount to inhumane or degrading treatment. There should be clear mechanisms in place in each system to allow physicians to report such concerns.

 

Reference

[1] Rule 43 SMR