Policy Type: Statement

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

The WMA Resolution on Physician Participation in Capital Punishment states that it is unethical for physicians to take part in capital punishment, and the WMA Declaration of Geneva obliges physicians to maintain the utmost respect for human life.

The WMA acknowledges that the views prevalent in the countries of some of its members prevent all members from unconditionally opposing the death penalty.

The WMA therefore supports the suspension of the use of the death penalty through a global moratorium.

The WMA has long recognized that it cannot hold its constituent members responsible for the actions and policies of their respective governments.

 

RECOMMENDATION

The World Medical Association supports the United Nations moratorium on the use of the death penalty.

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Individuals who identify as LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and other identities beyond these) represent a broad and fluid spectrum of natural sexual orientations, gender identities, gender expressions, and sex characteristics. While LGBTQIA+ people may share common cultural and social experiences and shared goals of justice and equity in the face of detrimental, discriminatory treatment and even violence, these are diverse communities facing distinct challenges and with specific needs in healthcare and beyond.

This statement is specifically focused on lesbian, gay, and bisexual people.

Healthcare professionals encounter many aspects of human diversity when providing care, including different natural variations of human sexuality.

A large body of scientific research indicates that being lesbian, gay, or bisexual constitute natural variations of human sexuality without any intrinsically harmful health effects. They do not constitute a disorder or illness that requires treatment or cure and any efforts to do so are contrary to the ethical practice of medicine.

Homosexuality and bisexuality are consequently not included in the World Health Organization’s (WHO) International Classification of Diseases (ICD 11).

However, direct and indirect discrimination, both interpersonally and at the institutional level, anti-homosexual or anti-bisexual legislation and human rights violations, stigmatisation, criminalisation of same-sex partnerships, peer rejection, and bullying continue to have a serious impact upon the psychological and physical health of lesbian, gay, or bisexual people. These negative experiences are perpetuated by a lack of education in society on the different natural variations of human sexuality. They lead to poorer health outcomes, including higher prevalence rates of depression, anxiety disorders, substance misuse, and suicidal ideations and attempts. As a result, the suicide rate among lesbian, gay, or bisexual adolescents and young adults significantly higher than that of their heterosexual peers.

These negative outcomes can be exacerbated by other intersectional factors, including but not limited to national origin, race, ethnicity, gender, age, religion, gender identity, socioeconomic status, or disabilities.

In addition, false and baseless pathologisation of lesbian, gay, or bisexual identities leaves such individuals at risk of being coerced into so-called “conversion” or “reparative” procedures. These harmful and unethical practices, also sometimes referred to as sexual orientation and gender identity change efforts (SOGICE), are intended to suppress or change a person’s natural sexual orientation or gender identity. These methods have no medical indication, lack any evidence of effectiveness, and represent a serious threat to the health and human rights of those subjected to these practices. They can lead to anxiety, depression, low self-esteem, substance abuse, problems with intimacy, and suicide.

Negative experiences in healthcare may affect the patient-physician relationship, leading lesbian, gay, and bisexual individuals to avoid accessing care where it is available. They may also withhold their sexual orientation from physicians due to the resulting lack of confidence that they will receive the appropriate treatment and concerns about the safety and confidentiality of their healthcare environment. Without this information, it may be more challenging for physicians to provide targeted care that takes into account the specific health needs of lesbian, gay, or bisexual patients.

Lesbian, gay, or bisexual physicians, medical students, and other health professionals also face discrimination, disadvantages, marginalisation and bullying in the workplace, in schools, in professional organisations, and beyond. Harmful working and learning environments can lead to stress and burnout, especially among marginalised individuals.

 

RECOMMENDATIONS

  1. The WMA strongly asserts that being lesbian, gay, or bisexual does not represent a disease, but rather natural variations within the range of human sexuality.
  2. The WMA condemns all forms of stigmatisation, criminalisation of and discrimination against people based on their sexual orientation.
  3. The WMA asserts that psychiatric or psychotherapeutic support, when needed, must not focus upon the variations of sexuality itself, but rather upon conflicts which arise between those variations and religious, social and internalised norms and prejudices, as well as the health needs of the individual patient.
  4. The WMA unequivocally condemns so-called “conversion” or “reparative” methods. These constitute violations of human rights and are unjustifiable practices that should be denounced and subject to sanctions and penalties. It is unethical for physicians to participate during any step of any such procedures.
  1. The WMA calls upon all physicians to:
    • classify physical and psychological diseases on the basis of clinically relevant symptoms according to ICD 11 criteria regardless of sexual orientation, and to provide quality, evidence-based care in accordance with internationally recognised treatments and protocols and in keeping with the principles set forth in the WMA International Code of Medical Ethics;
    • provide a safe, respectful, and inclusive healthcare setting for lesbian, gay, and bisexual patients;
    • foster safe, respectful, and inclusive work and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • engage in continuing education and professional development to better understand the specific health needs of lesbian, gay, and bisexual patients and the benefits of certain treatments;
    • where appropriate, involve patients’ same-sex partners and same-sex parents in healthcare discussions in keeping with the patient’s preferences, respecting their consent, and with due regard for patient confidentiality;
    • speak out against legislation and practices violating the human rights of lesbian, gay, and bisexual people, which may also negatively impact the healthcare system at large;
    • reject and refuse to participate in any step of so-called “conversion” or “reparative” methods.
  1. The WMA calls upon constituent members and professional associations to:
    • advocate for safe and inclusive working and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • establish and enforce non-discriminatory policies in keeping with the WMA Statement on Non-Discrimination in Professional Membership and Activities of Physicians;
    • create guidelines for physicians outlining the specific physical and mental health challenges facing lesbian, gay, and bisexual patients, where appropriate;
    • Where possible, promote changes to medical education, specialty training and CME/CPD curricula to create sensitivity and awareness of the specific health needs of lesbian, gay, and bisexual patients;
    • establish channels for lesbian, gay, and bisexual physicians to report incidents of discrimination or bias against themselves or lesbian, gay, or bisexual patients;
    • in environments where confidentiality and patient safety are guaranteed and data cannot be abused, encourage voluntary data collection in the clinical setting and regular reporting on the health outcomes of lesbian, gay, and bisexual patient groups, while also taking intersectionality into account, to ensure and further improve targeted and appropriate healthcare provision;
    • actively condemn so-called “conversion” or “reparative” methods as unethical.
  1. The WMA calls upon governments to:
    • reject and repeal anti-homosexual or anti-bisexual legislation;
    • condemn and ban so-called “conversion” or “reparative” methods;
    • promote policies that counteract health-related and other inequities caused by overt and implicit discrimination against lesbian, gay, and bisexual people;
    • encourage education from an early age on diverse natural variations of human sexuality to increase acceptance and with the ultimate aim of promoting better physical and mental health for all individuals.

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

The World Medical Association notes with grave concern the continued use of torture in many countries throughout the world.

The WMA reaffirms its total condemnation of all form of torture, and other cruel, inhuman or degrading treatment or punishment, as defined by the United Nations Convention Against Torture (CAT, 1984). Torture is one of the gravest violations of international human rights law and has devastating consequences for victims, their families and society as a whole. Torture causes severe physical and mental injuries and is a crime absolutely prohibited under international law.

The WMA reaffirms its policies adopted previously, namely:

The medical evaluation is an essential factor in pursuing the documentation of torture and the reparation of victims of torture. Physicians have a critical role to play in gathering information about torture, documenting evidence of torture for legal purposes, as well as supporting and rehabilitating victims.

The WMA recognizes the adoption, in December 2012, by the UN Committee Against Torture of the General Comment on the Implementation of article 14 of Convention against Torture relating to the right to reparation of victims of torture. The General Comment outlines the right of rehabilitation as an obligation on States and specifies the scope of these services. The WMA welcomes in particular:

  • The obligation of State parties to adopt a “long-term and integrated approach and ensure that specialized services for the victim of torture or ill treatment are available, appropriate and promptly accessible”, without making access to these services dependent on the victim pursuing judicial remedies [1].
  • The recognition of the right of victims to choose a rehabilitation service provider, be it a State institution, or a non-State service provider, which is funded by the State.
  • The recognition that State parties should provide torture victims with access to rehabilitation programs as soon as possible following an assessment by qualified independent healthcare professionals.
  • The references to measures aimed at protecting health and legal professionals who assist torture victims, developing specific training on the Istanbul Protocol for health professionals, and promoting the observance of international standards and codes of conduct by public servants, including medical, psychological and social service personnel [2].

The WMA notes that since the adoption of the General Comment on the Implementation of article 14, important developments have taken place in the practice of rehabilitation and in monitoring State compliance with their obligations:

 

RECOMMENDATIONS

  1. The WMA emphasizes the vital function of reparation for victims of torture and their families in rebuilding their lives and achieve redress and the important role of physicians in rehabilitation.
  2. The WMA encourages its member associations to work with relevant agencies – governmental and non-governmental – acting for the reparation of victims of torture, in particular in the areas of documentation and rehabilitation, as well as prevention, and to use the revised Istanbul Protocol and the global rehabilitations standards in doing so.
  3. The WMA encourages its members to support agencies that are under threat of – or subjected to – reprisals from state parties due to their involvement in the documentation of torture, rehabilitation and reparation of torture victims.
  4. The WMA calls on its members to use their medical experience to support torture victims in accordance with article 14 of the UN Convention against Torture, including by helping them to become active agents in their own rehabilitation process through survivor explicit programs.
  5. The WMA calls on its member associations to support and facilitate data collection at the national level, using established indicators for the right to rehabilitation, to monitor the implementation of the State’s obligation to provide rehabilitation services.

 

[1] Paragraph 13 of the General Comment
[2] Paragraph 18 of the General Comment
[3] Global Impact Data – IRCT

Adopted by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

According to WHO Fungal Priority Pathogens List (WHO FPPL), fungal pathogens are a major threat to public health as they are becoming increasingly common and resistant to treatment. Moreover, emerging evidence suggest that global warming and the rise in international travel and trade are contributing to the worldwide expansion of fungal diseases, in both incidence and geographic range.

Invasive and chronic fungal diseases lead to estimated annual morbidity rates that are similar to those caused by commonly recognized global health concerns such as malaria and tuberculosis. In addition to death, these fungal diseases commonly lead to chronic ill health, including blindness with keratitis, respiratory distress with allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensitisation (SAFS) and chronic pulmonary aspergillosis (CPA), weight loss and nutritional deficiency with oesophageal candidiasis and CPA, and inability to engage in healthy sexual activity with vulvovaginal candidiasis.

Serious fungal diseases are often opportunistic, occurring as a consequence of other conditions that suppress the immune system, such as asthma, AIDS, cancer, post–transplant immunosuppressive drugs and corticosteroid therapies.

Even though many fungal diseases can be treated relatively simply, in many cases, these diseases go untreated. Fungal infections alone are often not distinctive enough to allow a clinical diagnosis, and as cultures are frequently falsely negative, missed diagnoses are common. In addition, a relatively narrow diagnostic window to cure the patient is frequently missed, resulting in prolonged expensive hospital stays, often with a fatal outcome. Lastly, effective medicine to treat fungal infections are often not available when and where they are needed.

Despite the increasing concern, WHO emphasizes the inadequate attention and resources allocated to fungal infections, resulting in a lack of reliable data regarding the distribution of fungal diseases and patterns of antifungal resistance. Consequently, “the exact burden of fungal diseases and antifungal resistance, are unknown, and the response is therefore undermined” [1].

RECOMMENDATIONS

  1. In line with WHO Fungal Priority Pathogens List (WHO FPPL), the WMA recommends strategies aimed at generating evidence and improving response to fungal pathogens including preventing the development of antifungal drug resistance, and in particular urges governments as well as other health stakeholders concerned to:
    • ensure that both diagnostic tests and antifungal therapies are available for their populations;
    • depending on the prevalence of fungal diseases and their underlying conditions, guarantee the provision of specific antigen testing or microscopy and culture;
    • ensure the availability of these tests, and of health personnel educated to administer and interpret the tests, in all countries where systemic fungal infections occur;
    • consider developing diagnostic centre of excellence with a sufficient health personnel with adequate education on fungal infections diagnosis;
    • provide monitoring for antifungal toxicities;
    • support medical associations in developing adequate medical courses to ensure an effective diagnostic approach of fungal infections.
  1. The WMA encourages its constituent members to undertake and support epidemiologic studies on the burden of fungal disease in their country and to inform the national government of the results.

 

[1] WHO releases first-ever list of health-threatening fungi.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed by the 212th WMA Council Session, Santiago, Chile, April 2019

 

PREAMBLE

Vaccination use to prevent against disease was first done successfully by Jenner in 1796 when he used cowpox material for vaccination against smallpox.  Since then, vaccination and immunisation have been acknowledged as an effective preventive strategy for several communicable diseases and are now being developed for the control of some non-communicable diseases.

Vaccine development and administration are some of the most significant interventions to influence global health in modern times.  It is estimated that immunisation currently prevents approximately 2.5 million deaths every year, saving lives from diseases such as diphtheria, tetanus, whooping cough (pertussis) and measles. Approximately 109 million children under the age of one are fully vaccinated with the diphtheria-tetanus-pertussis (DTP3) vaccine alone.

Mostly the ultimate goal of immunisation is the total eradication of a communicable disease.  This was achieved for smallpox in 1980 and there is a realistic goal for the eradication of polio within the next few years.

The Global Immunisation Vision Strategy (GIVS) 2006-2015 was developed by the WHO and UNICEF in the hope of reaching target populations who currently do not have immunisation services or who do not have an adequate level of coverage.

The four strategies promoted in this vision are:

  • Protecting more people in a changing world
  • Introducing new vaccines and technologies
  • Integrating immunisation, other linked health interventions and
  • Surveillance in the health systems context
  • Immunizing in the context of global interdependence [1]

Vaccine research is constantly revealing new possibilities to protect populations from serious health threats.  Additionally, new strains of diseases emerge requiring the adaptation of vaccines in order to offer protection.

The process of immunisation requires an environment that is resourced with appropriate materials and health workers to ensure the safe and effective administration of vaccines.  Administration of vaccines often requires injections, and safety procedures for injections must always be followed.

Immunisation schedules can vary according to the type of vaccine, with some requiring multiple administrations to be effective.  It is vitally important that the full schedule is followed otherwise the effectiveness of the vaccine may be compromised.

The benefits of immunisation have had a profound effect on populations, not only in terms of preventing ill health but also in permitting resources previously required to treat the diseases to be redirected to other health priorities.  Healthier populations are economically beneficial and can contribute more to society.

Reducing child mortality is the fourth of the United Nation’s Millennium Development Goals, with immunisation of children having a significant impact on mortality rates on children aged under five. According to the WHO, there are still more than 19 million children who have not received the DTP3 vaccine. In addition, basic health care services for maternal health with qualified health care personnel must be established.

Immunisation of adults for diseases such as influenza and pneumococcal infections has been shown to be effective, not only in decreasing the number of cases amongst those that have received immunisation but also in decreasing the disease burden in society.

The medical profession denounce any claims that are unfounded and inaccurate with respect to the possible dangers of vaccine administration.  Claims such as these have resulted in diminished immunisation rates in some countries.  The result is that the incidences of the diseases to be prevented have increased with serious consequences for a number of persons.

Countries differ in immunisation priorities, with the prevalence and risk of diseases varying among populations. Not all countries have the same coverage rates, nor do they have the resources to acquire, coordinate, distribute or effectively administer vaccines to their populations, often relying on non-governmental organizations to support immunisation programmes.  These organizations in turn often rely on external funding that may not be secure.  In times of global financial crisis, funding for such programmes is under considerable pressure.

The risk of health complications from vaccine-preventable diseases is greatest in those who experience barriers in accessing immunisation services. These barriers could be cost, location, lack of awareness of immunisation services and their health benefits or other limiting factors.

Those with chronic diseases, underlying health issues or other risk factors such as age are at particular risk of major complications due to vaccine-preventable diseases and therefore should be targeted to ensure adequate immunisation.

Supply chains can be difficult to secure, particularly in countries that lack coordination or support of their immunisation programmes.  Securing the appropriate resources, such as qualified health professionals, equipment and administrative support can present significant challenges.

Data collection on vaccine administration rates, side effects of vaccines and disease surveillance can often be difficult to achieve, particularly in isolated and under-resourced areas. Nevertheless, reporting incidents and monitoring disease spread are vital tools in combating global health threats.

 

RECOMMENDATIONS

The WMA supports the recommendations of the Global Immunisation Vision Strategy (GIVS) 2006-2015, and calls on the international community to:

  • Encourage governments to commit resources to immunisation programmes targeted to meet country specific needs.
  • Recognise the importance of vaccination/immunisation through the continued support and adoption of measures to achieve global vaccination targets and to meet the Millennium Development Goals, especially four (reduce child mortality), five (improve maternal health) and six (combat HIV/AIDS, malaria and other diseases).
  • Recognise the global responsibility of immunisation against preventable diseases and support work in countries that have difficulties in meeting the 2012 targets in the Global Polio Eradication Initiative [2].
  • Support national governments with vulnerable populations at risk of vaccine-preventable diseases, and the local agencies that work to deliver immunisation services and to work with them to alleviate retrictions in accessing services.
  • Support vaccine research and development and ensure commitment through the adequate funding of vital vaccine research.
  • Promote vaccination and the benefits of immunisation, particularly targeting those at-risk and those who are difficult to reach. Comply with monitoring activities undertaken by WHO and other health authorities.Promote high standards in the research, development and administration of vaccines to ensure patient safety. Vaccines need to be thoroughly tested before implemented on a large scale and subsequently monitored in order to identify possible complications and untoward side effects. In order to be successful, immunisation programmes need public trust which depends on safety.

In delivering vaccination programmes, the WMA recommends that:

  • The full immunisation schedule is delivered to provide optimum coverage.  Where possible, the schedule should be managed and monitored by suitably trained individuals to ensure consistent delivery and prompt appropriate management of adverse reactions to vaccines.
  • Strategies are employed to reach populations that may be isolated because of location, race, religion, economic status, social marginalization, gender and/or age.
  • Ensure that qualified health professionals receive comprehensive training to safely deliver vaccinations and immunisations, and that vaccination/immunisations are targeted to those whose need is greatest.
  • Educate people on the benefits of immunisation and how to access immunisation services.
  • Maintain accurate medical records to ensure that valid data on vaccine administration and coverage rates are available, enabling immunisation policies to be based upon sound and reliable evidence.
  • Healthcare professionals should be seen as a priority population for the receipt of immunisation services due to their exposure to patients and to diseases.

The WMA calls upon its members to advocate the following:

  • To increase awareness of national immunisation schedules and of their own (and their dependents) personal immunisation history.
  • To work with national and local governments to ensure that immunisation programmes are resourced and implemented.
  • To ensure that health personnel delivering vaccines and immunisation services receive proper education and training.
  • To promote the evidence base and increase awareness about the benefits of immunisation amongst physicians and the public.

 

References

[1] World Health Organization and United Nations Children’s Fund. Global Immunisation Vision and Strategy, 2006-2015. Geneva, Switzerland: World Health Organization and United Nations Children’s Fund; 2005.  Available at: http://www.who.int/immunisation/givs/related_docs/en/index.html

[2] World Health Organization. Global Polio Eradication Initiative: Strategic Plan 2010-2012. Geneva, Switzerland: World Health Organization; 2010. Available at: http://polioeradication.org/who-we-are/strategy/

Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Occupational and environmental health and safety (OEHS) is an integral part of public health, and the primary health care (PHC) system in particular, since it is often the first level of contact of individuals, the family and the community with a health system, bringing health care as close as possible to where people live and work.

Workers represent at least half of the world’s population and are the backbone of many economies, but many may have inadequate access to occupational and environmental health services and do not operate in a safe working environment.

The International Labour Organization (ILO) defines decent work as opportunities for work that are productive and deliver fair income with dignity, equality, and within safe working conditions. Despite the fact that the right to decent work is recognized in the Universal Declaration of Human Rights, every 15 seconds, a worker dies from a work-related accident or disease , resulting in an annual 4% loss in global GDP.

Despite this, the proportion of work accidents and occupational diseases that are recorded and reported worldwide is incredibly small. It is estimated that less than 1% of occupational diseases are recorded.

Additionally, as many workers face greater pressures to meet the demands of working life, many of them are at risk to develop work-related stress which may occur when the demands of the job do not match or exceed the capabilities, resources or needs of the worker or when the knowledge or abilities of an individual worker or group to cope are not matched with the expectations of the organizational culture of an enterprise. High-level of stress can result in health impairments such as burnout, depression, anxiety, cardiovascular disease or even suicide.

Recently and even more due to the COVID-19 pandemic, the world has witnessed an increased number of employees working outside the employer’s premises using digital information and communication technologies either full-time or part-time. Despite some positive aspects, there are risks associated with this work arrangement as it isolates employees, particularly individuals living alone and can result in increased levels of stress and anxiety. Extended working hours and employee availability in addition to diminished boundaries between personal and professional life may impact work-life balance. A healthy digital working environment needs to be in place to ensure employee health and safety.

The United Nations Development Programme’s Sustainable Development Goals 3, 5, 8 and 13 call for action in health promotion for all people of all ages, gender equality, decent work and management of the impact of climate change; OEHS is well positioned to maintain physical, mental and social well-being for all workers, that will result in poverty reduction, sustainable development and saving millions of lives every year.

Physicians have a critical role in preventing, diagnosing, monitoring, treating and reporting work accidents and occupational diseases. In addition, physicians should promote equal, decent and inclusive work environments for all regardless of age, gender, ethnic origin, nationality, religion, political affiliation, race, sexual orientation, or the presence of a disability.

Despite many governments and employers’ and workers’ organizations placing greater emphasis on the prevention of occupational diseases. prevention is not receiving the priority warranted by the scale and severity of the occupational disease epidemic.

Physicians and medical associations can contribute to the identification of problems, development of national reporting systems, and formulation of relevant policies in the field of OEHS.

Unsatisfactory and unsafe working conditions play a significant role in the development of occupational diseases and injuries, which are subsequently causes of mortality in the working population.

 

RECOMMENDATIONS

  1. Physicians should play a pivotal role in the development of a workforce that is educated in and raise workplace awareness about the social determinants of health.
  2. The field of occupational and environmental health and safety (OEHS) should be accorded the necessary importance in both graduate and post-graduate medical studies
  3. Physicians must cooperate with the healthcare and occupational authorities to promote health and safety in the workplace.
  4. All workers should have access to risk based OEHS services from the first day of work and extending beyond the last day at work in order to account for occupational diseases with a long latency period.  Service content should be standardized and the role of physicians in the planning and implementation of OEHS systems that are essentially preventive/protective must be recognized.
  5. WMA Constituent members should act proactively and encourage the expansion of the scope of OEHS services, in order to prevent and reduce occupational diseases, and injuries, reproductive health issues and protect the environment. They should also promote workplace gender equality and encourage improvement of recording and reporting systems for OEHS-related metrics. They should also focus on workforce capacity building, teaching and training, and collaborative research.
  6. WMA Constituent members, together with governments, should take an active role, where appropriate, in the formulation and development of national systems that facilitate OEHS prevention, and the recording and reporting of occupational diseases and incidents in their respective countries.
  7. Physicians who are evaluating workers’ compensation patients should be experienced in occupational and environmental medicine. When a relationship between the diagnosis and occupational and environmental exposures is established, the physician should report it through the appropriate reporting system.
  8. Occupational diseases and injuries are often addressed in the context of insurance and compensation. Where these mechanisms are not in place, WMA Constituent members should advocate for the protection of workers by means of insurance or social security.
  9. When rendering services for an employer, physicians should advocate that employers fulfil the minimum requirements set in the International Labour Organization’s (ILO) occupational standards, especially when such requirements are not set by national legislation.
  10. Employers should provide a safe working environment, recognising and addressing the impact of adverse working conditions on individuals and society.
  11. Employers should consider promoting and offering essential vaccines to employees.
  12. WMA Constituent members should consider forming an internal body for addressing the problems of physicians working in OEHS and encourage them to contribute to research and related scientific studies.
  13. Governments should collaborate in setting up an international system to assess occupational hazards and develop strategies to protect the health of workers.
  14. Governments should establish legislative frameworks that protect the rights and health of workers, including reproductive health and health effects of work at home.
  15. Governments and NMAs must promote the development of training, information and research programs in occupational health to their members.

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Electronic cigarettes (e-cigarettes) and other electronic nicotine delivery systems (ENDS) are products designed to deliver nicotine to a user in the form of an aerosol. These products are usually composed of a mouthpiece, a rechargeable battery-operated heating element, a replaceable cartridge that contains liquid nicotine and/or other chemicals, and an atomizer that, when heated, turns the contents of the cartridge into an aerosol. This aerosol is then inhaled by the user and exhaled. These products are often made to look like other tobacco-derived products like cigarettes, cigars, pipes, toys and electronics that appeal to young people. They can also be made to look like everyday items such as pens and USB memory sticks. ENDS and their risks are outlined in more detail in the WMA Statement on Health Hazards of Tobacco Products and Tobacco- Derived Products.

Nicotine exposure, no matter how it is delivered, can affect brain development and lead to addiction. No standard definition of e-cigarettes exists, and manufacturers use different designs and different ingredients. Quality control processes used to manufacture e-cigarettes are substandard or non-existent, and few studies have been done to analyze the level of nicotine delivered to the user and the composition of the aerosol or vapor produced. Unknown amounts of nicotine are delivered to the user, and the level of absorption is unclear, leading to potentially toxic levels of nicotine in the system, especially in children, adolescents and young adults. E-cigarettes and ENDS may also contain other ingredients toxic or carcinogenic to humans including delivery solvents, propylene glycol, glycerin, pulegone, formaldehyde, acetaldehyde, acrolein, and heavy metals, such as chromium, copper, zinc, tin and lead.

Manufacturers and marketers of e-cigarettes and ENDS often claim that use of their products is a safe or safer alternative to smoking cigarettes, particularly since e-cigarettes and ENDS do not produce carcinogenic smoke. However, no studies have conclusively determined that the aerosol is not toxic or carcinogenic. There is some evidence of a risk of carcinogenicity of the respiratory tract due to long-term, cumulative exposure to nitrosamines and to acetaldehyde and formaldehyde. As with tobacco products, the safest option is to abstain from using e-cigarettes and ENDS.

Evidence already exists that e-cigarettes and ENDS are harmful and not safe.  Risks include:

  • appeal to children, adolescents and young adults, through packaging and marketing designed to appeal to these age groups, and especially when flavors like strawberry or chocolate are added to the cartridges. These factors can increase nicotine addiction among young people, and may be a gateway to experimenting with other tobacco products. Packaging and marketing targeted to young people has contributed to the dramatic increase in e-cigarette and ENDS use which in some regions is more popular than tobacco smoking.
  • the belief promoted by manufacturers that these devices are acceptable alternatives to scientifically proven cessation techniques, when neither their value as therapeutic aids for smoking cessation nor their safety as cigarette replacements is established. Evidence reveals that these products are harmful to health and not safe. In addition, evidence on the use of ENDS as a way to decrease tobacco use in adults is inconclusive;
  • inconsistent and unknown dosage, manufacturing processes, and ingredients, including the potential for abusing or manipulating the product, e.g., by adding cannabis, and simultaneous use with other tobacco products (dual or poly use);
  • high potential of toxic exposure to nicotine by children, either by ingestion or dermal absorption from contents of a nicotine cartridge, because the cartridges and refill liquids are readily available over the Internet and are not always sold in child resistant packaging;
  • worse clinical outcomes in patients with the SARS-COV2 virus who also use e-cigarettes.

 

RECOMMENDATIONS

  1. That e-cigarettes and ENDS be subject to the WHO Framework Convention on Tobacco Control, and to jurisdictional smoke-free laws and regulations.
  2. That the manufacture and sale of e-cigarettes and ENDS be subject to national regulatory bodies as either a new form of tobacco product or as a drug delivery device. At a minimum, regulations should address maximum strength of nicotine fluids, tank size on vaping devices, product labeling, and child-resistant packaging. This recommendation also applies to devices using synthetic nicotine.
  3. That clinical testing, large population studies and full analyses of e-cigarette ingredients and manufacturing processes be conducted to determine their level of risk, viability, and efficacy as tools for tobacco cessation.
  4. That e-cigarettes and other ENDS should never be marketed as a valid or efficacious method for smoking cessation without validated clinical research that is assessed by appropriate regulatory bodies. In all other instances, plain package marketing should be required, in accordance with the WMA Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Product.
  5. That the sale, marketing, distribution, and accessibility of e-cigarettes and other tobacco products to children and adolescents be prohibited.
  6. That the production, distribution and sale of flavored e-cigarette cartridges and candy products that depict or resemble tobacco products be prohibited.
  7. That the sale of e-cigarettes and ENDS via the internet be prohibited in order to prevent access to these products by minors.
  8. That physicians, pediatric practitioners and dentists inform their patients of the potential risks of using e-cigarettes and ENDS, e.g., addiction, cardiovascular disease, lung disease, impact on brain development due to nicotine, physical injuries, etc., even if regulatory authorities have not taken a position on the efficacy and safety of these products.
  9. That the WMA and its members support further research on the harmful effects of e-cigarettes and ENDS, especially in children, adolescents and young adults.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

PREAMBLE

1.     Advances in medical sciences, especially surgical techniques, tissue typing and immuno-suppressive drugs, have made possible a significant increase in the rates of successful transplantation of human organs and tissue. Yet, in all countries, a shortage of organ donors results in potentially avoidable loss of life. National medical associations should support attempts to maximise the number of donor organs available in their countries and to ensure that the highest ethical standards are maintained.  The World Medical Association has developed this policy to assist medical associations, physicians, other health care providers and policy makers to achieve this.

This policy is based on a number of core ethical principles: altruism, autonomy, beneficence, equity and justice. These principles should guide those developing national policies and those operating within it, both in relation to organ procurement and to the distribution and transplantation of donor organs. All systems and processes should be transparent and open to scrutiny.

This statement applies to organ and tissue donation from both deceased and living donors. It does not apply to blood donation.

RAISING PUBLIC AWARENESS

2.     It is important that individuals are aware of the option of donation and have the opportunity to choose whether or not to donate organs and/or tissue before and after their death. Awareness and choice should be facilitated in a coordinated multi-faceted approach by a variety of stakeholders and means, including media awareness and public campaigns. In designing such campaigns account needs to be taken of any religious or cultural sensitivities of the target audience.

3. Through awareness raising campaigns, individuals should be informed of the benefits of transplantation, the impact on the lives of those who are waiting for a transplant and the shortage of donors available.  They should be encouraged to think about their own wishes about donation, to discuss their wishes with their family and friends and to use established mechanisms to formally record them by opting into, or out of, donation.

4. The WMA advocates informed donor choice. National medical associations in countries that have adopted or are considering a policy of “presumed consent” (or opt-out), in which there is an assumption that the individual wishes to donate unless there is evidence to the contrary, or “mandated choice”, in which all persons would be required to declare whether they wish to donate, should make every effort to ensure that these policies have been adequately publicised and do not diminish informed donor choice, including the patient’s right not to donate.

5. Consideration should be given to the establishment of national donor registries to collect and maintain a list of citizens who have chosen either to donate or not to donate their organs and/or tissue. Any such registry must protect individual privacy and the individual’s ability to control the collection, use, disclosure of, and access to, his or her health information for other purposes. Provisions must be in place to ensure that the decision to sign up to a register is adequately informed and that registrants can withdraw from the registry easily and quickly and without prejudice.

6. Living organ donation is becoming an increasingly important component of transplantation programmes in many countries. Most living donation is between related or emotionally close individuals and small but increasing numbers are donating to people they do not know. Given that there are health risks associated with living organ donation, proper controls and safeguards are essential. Information aimed at informing people about the possibility of donating organs as a living donor should be carefully designed so as not to put pressure on them to donate and to minimise the risk of financial or other coercion. Potential donors should know where to obtain detailed information about what is involved, should be informed of the inherent risks and should know that there are safeguards in place to protect those offering to donate.

PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM DECEASED DONORS

7.     The WMA encourages its members to support the development of comprehensive, coordinated national protocols for deceased (also referred to as cadaveric) organ and tissue procurement in consultation and cooperation with all relevant stakeholders. Ethical, cultural and societal issues arising in connection with donation and transplantation should be resolved, wherever possible, in an open process involving public debate informed by sound evidence.

8.     National and local protocols should provide detailed information about the identification, referral and management of potential donors as well as communication with those close to people who have died.  They should encourage the procurement of organs and tissues consistent with this statement. Protocols should uphold the following key principles:

  • Decisions to withhold or withdraw life-prolonging treatment should be based on an assessment of whether the treatment is able to benefit the patient.  Such decisions must be, and must be seen to be, completely separate from any decisions about donation.
  • The diagnosis of death should be made according to national guidelines and as outlined in the WMA’s Declaration of Sydney on the Determination of Death and Recovery of Organs.
  • There should be a clear separation between the treating team and the transplant team. In particular, the physician who declares or certifies the death of a potential donor should not be involved in the transplantation procedure. Nor should he/she be responsible for the care of the organ recipient.
  • Countries that carry out donation following circulatory/cardiac death should have specific and detailed protocols for this practice.
  • Where an individual has expressed a clear and voluntary wish to donate organs and/or tissue after death, steps should be taken to facilitate that wish wherever possible.  This is part of the treating team’s responsibility to the dying patient.
  • The WMA considers that the potential donor’s wishes are paramount. Relatives and those close to the patient should be strongly encouraged to support a deceased person’s previously expressed wish to donate organs and/or tissues. Whenever possible, these conversations should occur prior to the death of the patient.
  • Those charged with approaching the patient, family members or other designated decision maker about organ and tissue donation should possess the appropriate combination of knowledge, skill and sensitivity for engaging in such discussions. Medical students and practising physicians should seek the necessary training for this task, and the appropriate authorities should provide the resources necessary to secure that training.
  • Donation must be unconditional. In exceptional cases, requests by potential donors, or their substitute decision makers, for the organ or tissue to be given to a particular recipient may be considered if permitted by national law.  Donors seeking to apply conditions that could be seen as discriminatory against certain groups, however, should be declined.

9.     Hospitals and other institutions where donation occurs should ensure that donation protocols are publicised amongst those likely to use them and that adequate resources are available for their implementation.  They should also foster a pro-donation culture within the institution in which consideration of donation is the norm, rather than the exception, when a patient dies.

10.  The role of transplant coordination is critical to organ donation. Those performing coordination act as the key point of contact between the bereaved family and the donation team and usually also undertake the complex logistical arrangements to make donation happen. Their role must be recognised and supported.

11.  Deceased organ donation must be based on the notion of a gift, freely and voluntarily given. It should involve the voluntary and unpressured consent of the individual provided before death (by opting in or opting out of donation depending upon the jurisdiction) or the voluntary authorisation of those close to the deceased patient if that person’s wishes are unknown. The WMA is strongly opposed to the commercialisation of donation and transplantation.

12.  Prospective donors or their substitute health care decision makers should have access to accurate and relevant information, including through their general practitioners. Normally, this will include information about:

  • The procedures and definitions involved in the determination of death,
  • The testing that is undertaken to determine the suitability of the organs and/or tissue for transplantation and that this may reveal previously unsuspected health risks in prospective donors and their families,
  • Measures that may be required to preserve organ function until death is determined and transplantation can occur,
  • What will happen to the body once death has been declared,
  • What organs and tissues can be donated,
  • The protocol that will be followed in the event that the family objects to donation, and
  • The possibility and the process of withdrawing consent.

13.  Prospective donors or their substitute health care decision makers should be given the opportunity to ask questions about donation and should have their questions answered sensitively and intelligibly.

14.  Where both organs and tissues are to be donated, information should be provided, and consent obtained, for both together in order to minimise distress and disruption to those close to the deceased.

15.  In some parts of the world a contribution towards funeral costs is given to the family of those who donate. This can be viewed either as appropriate recognition of their altruistic act or as a payment that compromises the voluntariness of the choice and the altruistic basis for donation. The interpretation may depend, in part, on the way it is set up and managed.  When considering the introduction of such a system, care needs to be taken to ensure that the core principles of altruism, autonomy, beneficence, equity and justice are met.

16.  Free and informed decision making requires not only the provision of information but also the absence of coercion. Any concerns about pressure or coercion must be resolved before the decision to donate organs or tissue is made.

17.  Prisoners and other people who are effectively detained in institutions should be eligible to donate after death where checks have been made to ensure that donation is in line with the individual’s prior, un-coerced wishes and, where the individual is incapable of giving consent, authorisation has been provided by a family member or other authorized decision-maker. Such authorisation may not override advance withholding or refusal of consent.

18.  Their death is from natural causes and this is verifiable.

19.  In jurisdictions where the death penalty is practised, executed prisoners must not be considered as organ and/or tissue donors. While there may be individual cases where prisoners are acting voluntarily and free from pressure, it is impossible to put in place adequate safeguards to protect against coercion in all cases.

ALLOCATION OF ORGANS FROM DECEASED DONORS

20.  The WMA considers there should be explicit policies, open to public scrutiny, governing all aspects of organ and tissue donation and transplantation, including the management of waiting lists for organs to ensure fair and appropriate access.

21.  Policies governing the management of waiting lists should ensure efficiency and fairness. Criteria that should be considered in allocating organs or tissue include:

  • Severity and urgency of medical need,
  • Length of time on the waiting list,
  • Medical probability of success measured by such factors as age, type of disease, likely improvements in quality of life, other complications, and histocompatibility.

22.  There must be no discrimination based on social status, lifestyle or behaviour. Non-medical criteria must not be considered.

PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM LIVING DONORS

23.  Living donation is becoming increasingly common as a way to overcome the shortage of organs from deceased donors. In most cases donors provide organs to relatives or people to whom they are emotionally close. A small number of individuals choose to donate an organ altruistically to a stranger. Another scenario is where one or more donor and recipient pairs are incompatible with each other but donate in the form of a cross-over or pooled donation system (for example, donor A donates to recipient B, donor B donates to recipient C and donor C donates to recipient A).

24.  All potential donors should be given accurate and up to date information about the procedure and the risks of donation and have the opportunity to discuss the issue privately with a member of the healthcare team or a counsellor.  Normally this information will include:

  • The risks of becoming a living donor,
  • The tests that are undertaken to assess suitability for donation and that this may reveal previously unsuspected health problems,
  • What will happen before, during and after donation takes place, and
  • In the case of solid organs, the long-term implications of living without the donated organ.

25.  Prospective donors should be given the opportunity to ask questions about donation and should have their questions answered sensitively and intelligibly.

26.  Procedures should be in place to ensure that living donors are acting voluntarily and free from pressure or coercion. In order to avoid donors being paid and then posing as a known donor, independent checks should also be undertaken to verify the claimed relationship and, where this cannot be proven, the donation should not proceed. Such checks should be independent of the transplant team and those who are caring for the potential recipient.

27.  Additional safeguards should be in place for vulnerable donors, including but not limited to, people who are dependent in some way (such as competent minors donating to a parent or sibling).

28.  Prisoners should be eligible to be living donors only in exceptional circumstances, to first or second degree family members; evidence should be provided of any claimed relationship before the donation may proceed. Where prisoners are to be considered as living donors, extra safeguards are required to ensure they are acting voluntarily and are not subject to coercion.

29.  Those who lack the capacity to consent should not be considered as living organ donors because of their inability to understand and decide voluntarily. Exceptions may be made in very limited circumstances, following legal and ethical review.

30.  Donors should not lose out financially as a result of their donation and so should be reimbursed for general and medical expenses and any loss of earnings incurred.

31.  In some parts of the world individuals are paid for donating a kidney, although in virtually all countries the sale of organs is unlawful. The WMA is strongly opposed to a market in organs.

PROTOCOLS FOR RECIPIENTS

32.  Protocols for free and informed decision making should be followed in the case of recipients of organs or tissue. Normally, this will include providing information about:

  • The risks of the procedure,
  • The likely short, medium and long-term survival, morbidity, and quality-of-life prospects,
  • Alternatives to transplantation, and
  • How organs and tissues are obtained.

33.  In the case of a delayed diagnosis for infection, disease or malignancy in the donor, there should be a strong presumption that the recipient will be informed of any risk to which they may have been exposed. Individual decisions about disclosure need to take account of the particular circumstances, including the level and severity of risk. In most cases disclosure will be appropriate and should be managed carefully and sensitively.

COSTS AND ORIGIN OF ORGANS AND TISSUES

34.  Organs or tissue suspected to have been obtained through unlawful means must not be accepted for transplantation.

35.  Organs and tissues must not be sold for profit.  In calculating the cost of transplantation, charges related to the organ or tissue itself should be restricted to those costs directly associated with its retrieval, storage, allocation and transplantation.

36.  Transplant surgeons should seek to ensure that the organs and tissues they transplant have been obtained in accordance with the provisions of this policy and should refrain from transplanting organs and tissues that they know, or suspect, have not been procured in a legal and ethical manner.

TRANSPARENCY AND ACCOUNTABILITY

37.  National Medical Associations should work with governments and relevant institutions to ensure that appropriate, effective structures and processes are in place to:

  • support relevant traceability and follow-up of all transplant recipients and living donors including those who require ongoing medical management receive care and support;
  • record information on donation and transplantation rates and outcomes;
  • assess the short and long-term outcomes, quality, safety and efficacy of organ donation and transplantation activities;
  • assess the adherence to ethical and clinical protocols of organ donation and transplantation activities;

38.  The data arising from these activities should be publicly accessible and open to scrutiny (notwithstanding appropriate protection of donor and recipient confidentiality).

FUTURE OPTIONS

39.  Public health measures to reduce the demand for donated organs should be seen as a priority, alongside initiatives to increase the effectiveness and success of organ donation systems.

40.  New developments and possibilities, such as xenotransplantation and the use of stem cell technology to repair damaged organs, should be monitored. Before their introduction into clinical practice such technologies should be subject to scientific review and robust safety checks as well as ethical review. Where, as with xenotransplantation, there are potential risks that go beyond individual recipients, this process must also involve public debate.

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Violence in the health sector has increased substantially in the new millennium, especially in time of COVID-19 pandemic. All persons have the right to work in a safe environment without the threat of violence. Workplace violence includes both physical and non-physical, such as (psychological) violence, intimidation and cyber harassment, among others.

Cyber and social media harassment particularly includes online threats and intimidation towards physicians who take part in a public debate in order to give adequate information and fight disinformation. These physicians are increasingly confronted with, amongst others, malicious messages on social media, death threats and intimidating home visits.

For the purposes of this document, the broad WHO definition of workplace violence will be used: “The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation”.

In addition to the numerous consequences on victims’ health, violence against health personnel has potentially destructive social effects. It affects the entire healthcare system and undermines the quality of the working environment, ultimately impacting the quality of patient care. Furthermore, violence can affect the availability of health care, particularly in impoverished areas.

While workplace violence is indisputably a global issue, various cultural differences among countries must be taken into consideration in order to accurately understand the concept of violence on a universal level.  Significant differences exist in terms of what defines various levels of violence and what specific forms of workplace violence are most likely to occur. This may create tolerance for some levels of violence in those places. However, threats and other forms of psychological violence are widely recognized to be more prevalent than physical violence.

Causes of violence in the healthcare setting are extremely complex. Several studies have identified common triggers for acts of violence by patients and relatives to be delays in receiving treatment, dissatisfaction with the treatment provided, aggressive patient behavior caused by the patient’s medical condition, the medication they take or the use of alcohol and other drugs. Additionally, individuals may threaten or perpetrate violence against health personnel because they oppose a specific area of medical practice, based on their social, political or religious beliefs. Cases of violence from the bystanders are reported as well. Co-worker violence, such as bullying, including initiation ceremonies and practical jokes, or harassment, constitutes another important pattern of workplace violence in the health sector.

Collaboration among various stakeholders (including governments, medical associations, hospitals, general health services, management, insurance companies, trainers, preceptors, researchers, media, police and legal authorities) together with a multi-faceted approach encompassing the areas of legislation, security, data collection, training/education, environmental factors, public awareness and financial incentives is required in order to successfully address this issue. As the representatives of physicians, medical associations should take a proactive role in combating violence in the health sector and also encourage other key stakeholders to act, thus further protecting the quality of the working environment for health personnel and the quality of patient care.

 

RECOMMENDATIONS

The WMA condemns in the strongest terms any forms of violence against healthcare personnel and facilities, which may include coworker violence, aggressive behavior exhibited by patients or family members, as well as acts of malicious intent from individuals in the general public, and calls on its constituent members, the health authorities and other relevant stakeholders to act through a collaborative, coordinated and effective strategy approach:

Policy-making

  1. The state has obligations to ensure the safety and security of patients, physicians, and other health personnel. This includes providing an appropriate physical environment.
  2. Governments should provide the necessary framework so that the prevention and elimination of workplace violence in the health sector be an essential part of national/regional/local policies on occupational health and safety, human rights protection, healthcare-facility management standards and gender equality.

Financial

  1. Governments should allocate appropriate and sustainable funds in order to effectively tackle violence in the health sector.

Protocols for situation of violence in healthcare facilities

  1. Healthcare facilities should adopt a zero-tolerance policy towards workplace violence eliminating its “normalization” through the development and implementation of adequate protocols including the following:
  • A predetermined plan for maintaining security in the workplace; including recognition of non-physical abuse as a risk factor for physical abuse.
  • A designated plan of action for health personnel when violence takes place.
  • A strengthened internal communication strategy, involving the staff in decisions concerning their security.
  • A system for reporting and recording acts of violence, which may include reporting to legal and/or police authorities.
  • A means to ensure that employees who report violence do not face reprisals.
  1. In order for these protocols to be effective, the management and administration of healthcare facilities should communicate and take the necessary steps to ensure that all staff are aware of the protocols. Managers should be urged to verbalize a no-tolerance policy towards violence in healthcare settings.
  2. Patients with acute, chronic or illness-induced mental health disturbances or other underlying medical conditions may act violently toward health personnel; those taking care of these patients must be adequately protected. Except in emergency cases, physicians might have the right to refuse to treat and, in such situations, they must ensure that adequate alternative arrangements are made by the relevant authorities in order to safeguard the patient’s health and treatment.

Training/Education

  1. A well-trained and vigilant staff supported by management can be a key deterrent of violent acts. Constituent members should work with undergraduate and postgraduate education providers to ensure that health personnel are trained in the following areas: communication skills, empathy as well as recognising and handling potentially violent persons and high-risk situations in order to prevent incidents of violence.
  2. Continuous education should include ethical principles of healthcare and the cultivation of the patient-physician relationships based on respect and mutual trust. This not only improves the quality of patient care but also fosters feelings of security resulting in a reduced risk of violence.

Communication and Social Awareness

  1. Medical associations, health authorities and other stakeholders should work together to increase awareness of violence in the health sector, creating networks of information and expertise in this area. When appropriate, health personnel and the public should be informed of acts of violence.
  2. Broadcasting agencies, newspapers, and other news outlets are encouraged to thoroughly verify their sources in order to keep the information shared to the highest standard of professional reporting. Social media companies and associated stakeholders should also take active steps to create a cyber-violence-free environment for its users. This includes strengthening policies to protect user data, making reporting and flagging such violence easy and accessible, and engaging law enforcement for proper legal action when warranted.

Security

  1. Appropriate security measures should be in place in all healthcare facilities and acts of violence should be given a high priority by law-enforcement authorities. A routine violence risk audit, including a risk assessment, should be implemented in order to identify which jobs and locations are at highest risk for violence, especially in places where violence has already occurred, and to determine weaknesses in facilities’ security. Examples of high-risk areas include general practice premises, mental health treatment facilities and high traffic areas of hospitals including the emergency department.
  2. The risk of violence may be ameliorated by a variety of means which include placing security personnel in high-risk areas and at the entrance of buildings, the installation of security cameras and alarm devices for use by health personnel, the use distinguishable items to identify the staff and by maintaining sufficient lighting in work areas, contributing to an environment conducive to vigilance and safety. The implementation of a system to screen patients and visitors for weapons upon entering certain areas, especially the high-risk ones, should be considered.

Support to victims

  1. Adequate medical, psychological and legal support should be provided to victims of violence. Such support should be free of access for all the health personnel.

Investigation

  1. In all cases of violence there should be investigation to better understand the causes and to aid in prevention of future violence. The investigation may lead to prosecution of perpetrators under civil or criminal codes. The procedure should be led by relevant officials in law enforcement and should not expose the victim to further physical or psychological harm.

Data Collection

  1. Appropriate reporting systems should be established to enable health personnel to report anonymously and without reprisal, any threats or incidents of violence. Such a system should assess in terms of number, type and severity, incidents of violence within an institution and resulting injuries. The system should be used to analyse the effectiveness of preventative strategies. Aggregated data and analyses should be made available to health professional organizations and other relevant stakeholders.

Adopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,
edited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957,
revised by the 35th World Medical Assembly, Venice, Italy, October 1983 and the 55th WMA General Assembly, Tokyo, Japan, October 2004,
editorially revised by the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006, and
revised by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012 and the 74th WMA General Assembly, Kigali, Rwanda, October 2023*

*The WMA Regulations of the WMA in times of armed conflict and other situations of violence adopted in 1956 were reclassified as a ‘Statement’ by the 63rd General Assembly, Kigali, Rwanda, October 2023.

 

 

PREAMBLE

The primary task of the medical profession is to promote health and save life; the primary obligation of the physicians is to their patients; in all their professional activities, physicians should adhere to international conventions on human rights, to international humanitarian law and to the WMA’s Declaration of Geneva, International Code of Medical Ethics and other relevant WMA declarations on medical ethics[1], as well as to the Ethical Principles of Health Care in Times of Conflict and Other Emergencies, elaborated by civilian and military healthcare organisations, including the WMA, under the initiative of the International Committee of the Red Cross.

In situations of armed conflict and other situations of violence, governments, belligerent armed forces and others in positions of power must comply with their obligations in accordance with international law, including, as applicable, Geneva Conventions (1949) and the Additional Protocols to the Geneva Conventions (1977, 2005).

This obligation includes a requirement to protect healthcare personnel and facilities (see e.g. the WMA Declaration on the protection and integrity of healthcare personnel in armed conflicts and other situations of violence, 2022), including any means of transportation devoted to the wounded and sick, to health personnel or medical equipment.

This obligation also includes condemning the targeting of health care facilities and personnel and using denial of medical services, including as a tactic or strategy in war, by any party, wherever and whenever it occurs.

The WMA supports efficient, secure and unbiased reporting mechanisms with sufficient resources to collect and disseminate data regarding assaults on physicians, other healthcare personnel and healthcare facilities, and to provide to the WHO and other relevant agencies the necessary support to fulfill their role in documenting attacks on healthcare personnel and facilities.

Assaults against healthcare personnel must be investigated and those responsible must be brought to justice; to this end, adequate enforcement mechanisms must be used, or where relevant, developed, and necessary resources must be guaranteed.

Physicians must be granted access to all persons in need of care, including those deprived of liberty.

Physicians have a responsibility to press governments and other authorities for the provision of the infrastructure and equipment that is a prerequisite to health and healthcare, including potable water, adequate food and shelter, proper infrastructure, clinical equipment and available healthcare personnel, and the necessary personal protection equipment (PPE).

Where conflict appears to be imminent and inevitable, relevant authorities are responsible for guaranteeing the protection of the health infrastructure and for planning any necessary repair in the immediate post-conflict period.

Respect of professional ethical rules

During times of armed conflict and other situations of violence, the ethical standards of the medical profession apply as in times of peace. The professional duty to treat people with humanity and respect applies to all patients. The physician must always act in accordance with medical neutrality and give the necessary care impartially and without discrimination.

Physicians must never be persecuted for complying with any of their ethical obligations, and may not be compelled by governments, armed forces or others in positions of power, to undertake any action that contravenes the medical profession’s ethical rules.

The privacy of the sick, wounded and dead must always be respected and confidentiality duly respected.

Health care given to the sick and wounded, civilians or combatants, cannot be used for publicity or propaganda.

Physicians must not spread disinformation, or manipulate facts for the public, for the media, or for the social media outlets.

Ethics training on the issue of medical treatment of prisoners of war and detainees should be provided in medical schools and during postgraduate training.

 

RECOMMENDATIONS

In situations of armed conflict and other situations of violence, the physician must:

General principles

  1. Not take part in any act of hostility and refuse any illegal or unethical order;
  2. Neither commit nor assist in violations of international law;
  3. Not abandon the wounded and sick, while considering the physician’s own safety and competence and the availability of other viable options for care;
  4. Promote medical neutrality by advocating for and providing effective and impartial patient care without discrimination; no distinction must be made between patients except based upon clinical facts;
  5. Give special consideration to the most vulnerable or marginalized parts of the population in need of care (e.g. women, children, older persons, people with specific healthcare needs, and displaced persons) and to their specific healthcare needs while adhering to triage principles;
  6. Respect the individual wounded or sick person´s autonomy, trust and dignity;
  7. Respect confidentiality, in line with the Declaration of Geneva and the International Code of Medical Ethics;
  8. Give careful consideration to any dual loyalties that the physician may be bound by or conflicts of interest that may be present.

Detention

  1. Provide healthcare to anyone taken as a prisoner;
  2. Advocate for regular visits to prisons and prisoners by physicians;
  3. Never condone, facilitate or participate in the practice of torture or any form of cruel, inhuman or degrading treatment, nor in any form of abuse, including forced feeding, human trafficking or human organ trafficking;
  4. In line with the WMA International Code of Medical Ethics, the WMA Declaration of Tokyo, the WMA Statement on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment, the Istanbul Protocol and the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), denounce acts of torture or cruel, inhuman or degrading treatment and punishments.

Forbidden activities

  1. Never use the situation and the vulnerability of the wounded and sick for personal advantage;
  2. Never make use of healthcare privileges and facilities contrary to their intended purposes;

Public Health

  1. Report to the appropriate authorities if healthcare needs are not met;
  2. Respect the legal obligations to report to the appropriate authorities in matters of epidemiology;
  3. Respect the WMA Declarations of Helsinki and the WMA Declaration of Taipei on research and data management;
  4. Denounce and intervene against any unscrupulous practices, including distribution of poor quality or counterfeit medicines and materials;
  5. Be aware of war-related mental health trauma when caring for patients, internally displaced persons and refugees.

 

 

[1] WMA Declaration on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations of Violence / WMA Statement on Armed Conflicts

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

Preamble

In recent years, in countries where physicians’ satisfaction with their working conditions has decreased, collective action by physicians to advocate for better conditions has become increasingly common.

Physicians may carry out protests and sanctions, including collective resignations, in order to improve direct and indirect working conditions and to ensure safe and resilient health care systems. Physicians must consider not only their duty to individual patients, but also their responsibility to improve the system, such that it meets the requirements of accessibility and quality.

In addition to their professional obligations, physicians are often also employees. There may be tension between physicians’ duty not to cause harm, and their rights as employees. Therefore, physicians’ strikes or other forms of collective action often give rise to public debate on ethical and moral issues. This statement attempts to address these issues.

 

RECOMMENDATIONS

The World Medical Association recommends that Constituent Members adopt the following guidelines for physicians with regard to collective action:

  1. Physicians who take part in collective action are not exempt from their ethical or professional obligations to patients.
  2. Even when the action taken is not organized by or associated with the Constituent Member, the Constituent Member should ensure that the individual physician is aware of and abides by their ethical obligations.
  3. Whenever possible, physicians should press for reforms through non-violent public demonstrations, lobbying and publicity or informational campaigns, and/or through negotiation or mediation.
  4. If involved in collective action, Constituent Members should act to minimize the harm to the public and ensure that essential and emergency health services, and the continuity of care, are provided throughout a strike. Further, Constituents Members should advocate for measures to review exceptional cases. If involved in collective action, Constituent Members should provide continuous and up-to-date information to their patients and the general public with regard to the demands of the conflict and the actions being undertaken. The general public must be kept informed in a timely manner about any strike actions and the restrictions they may have on health care.

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012, and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

The United Nations states forced or coerced sterilisation is a violation of fundamental human rights, including the right to health, to information and privacy, and to be free from torture and other cruel, inhuman or degrading treatment or punishment. The United Nations also states specific populations are disproportionately affected by forced or coerced sterilisation, including women, women living with HIV, indigenous and ethnic minority girls and women, persons with disabilities, and transgender persons and intersex persons.

The WMA recognises that no person, regardless of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor, should be subjected to forced or coerced sterilisation.

A full range of contraceptive services, including sterilisation, should be accessible and affordable to every individual. The state has a role to play in ensuring that such services are available, along with private, charitable and third sector organisations.

As with all other medical treatments, sterilisation should only be performed on a competent patient after an informed choice has been made and the free and valid consent of the individual has been obtained. Where a patient is incompetent, a valid decision about treatment must be made in accordance with the patient’s best interest as well as with relevant legal requirements and the ethical standards of the medical profession before the procedure is carried out.

The WMA condemns practices where a state or any other actor attempts to bypass ethical requirements necessary for obtaining free and valid consent for sterilization, which must be:

  • Free from material or social coercion;
  • Not a condition of other medical care (including safe abortion), social, insurance, institutional or other benefits and
  • Obtained when the person is not facing any stressor limiting their capacity of discernment, such as detention or a medical emergency (unless sterilization is the subject of the emergency).

 

RECOMMENDATIONS

Recalling the core ethical values of the medical profession enshrined in its International Code of Medical Ethics and the Declaration of Geneva: The Physician’s Pledge, and its long-standing commitment against torture and other cruel, inhuman or degrading treatment, the WMA condemns forced or coerced sterilisation and calls on:

Its Constituent Members

1. To advocate against such practices contrary to human dignity;

2. To support the provision of safe and ethical sterilization services or interventions, with due respect for the physical and mental integrity of the persons, including by guaranteeing their autonomous reproductive choices;

Physicians

3. To be alert to situations and settings where there is a risk of forced or coerced sterilisation, particularly for vulnerable and disproportionately affected persons, to ensure consent is valid and freely given and to oppose any form of involvement in forced or coerced sterilisation.

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

DEFINITION

 Social media is a collective term for the different interactive platforms, websites and applications intended for digital networking, that allow individuals and organizations to create and share user-generated content digitally.

The objectives of this policy are to:

  • Examine the professional and ethical challenges related to the increasing usage of social media by physicians, medical students, and patients.
  • Establish a framework that protects their respective interests.
  • Ensure trust and reputation by maintaining high professional and ethical standards.
  • Promote the availability of quality information across social media.
  • Stand against misinformation and disinformation on social media.

The use of social media has become a fact of life for billions of people worldwide including physicians, medical students, and patients.

Interactive, collaborative tools such as wikis, social networking platforms, chat applications and blogs have transformed passive Internet users into active participants. These tools are means for gathering, sharing and disseminating information, including healthcare and science information, socializing and connecting with friends, relatives, professionals etc. They can be used to seek medical advice, and patients share their health and healthcare experiences. They can also be used in research, public health, and education.

The positive aspects of social media should be recognized such as in promoting a healthy lifestyle, the dissemination of medical knowledge to society and in reducing patients’ isolation.

Areas, which may require special attention include:

  • Sensitive content, photographs, videos, other personal materials posted on online social forums often exist in the public domain and have the capacity to remain on the internet permanently. Individuals may not have control over the ultimate distribution of material they post on-line.
  • Patient portal, blogs and tweets are not a substitute for one on one consultation with physicians but may widen engagement with health services amongst certain groups. Online “friendships” with patients may also alter the patient-physician relationship, and may result in unnecessary, possibly problematic physician and patient self-disclosure.
  • Each party’s privacy may be compromised in the absence of adequate and conservative privacy settings or by their inappropriate use. Privacy settings are not absolute; social media sites may change default privacy settings unilaterally, without the user’s knowledge. Social media sites may also make communications available to third parties.
  • Misinformation and disinformation often spread more rapidly through social media than fact-based accurate information. It may cause harm to the health of individuals as well as to public health and foster doubt and distrust towards professionals seeking to promote truth and science-based evidence.
  • Appropriate disclaimers to include in biographical information (e.g., “my opinions are my own”, “posts are not personalized medical advice”, etc).

The dissemination of medical knowledge, best practices and treatment options on social media can increase and expedite access to new and valid information among medical professionals. However, individuals or companies can take advantage of these channels in misleading ways, including to market or promote their medical products or treatments.

 

RECOMMENDATIONS

The WMA urges National Medical Associations (NMA) to establish social media guidelines for their members addressing the following objectives:

  1. To maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just as they would in any other context.
  2. To ensure that no identifiable patient information is posted in any social media by their physician, by increasing the understanding of privacy provisions of social networking sites and their limitations while considering intended audience and the technical feasibility to restrict access to the content to predefined individuals or groups.
  3. To exercise care when using applications that might compromise the security of the data, including when consulting with colleagues.
  4. To promote and apply the principles in the WMA Guidelines on Promotional Mass Media Appearances by Physicians to all social media activities by physicians.
  5. To encourage physicians to routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others is accurate and appropriate.
  6. To prevent the use of technological devices from diverting our attention during direct consultation with the patient.
  7. To provide factual, concise, understandable information, declare any conflicts of interest and adopt a sober tone when discussing professional matters.
  8. To avoid inappropriate use of the networks, frivolous, insensitive attitudes or light-hearted opinions on medical matters.
  9. To draw the attention of physicians to the fact that social media content posted by health professionals may contribute to the public perception of the profession and should be done in accordance with the principles in the WMA Declaration of Geneva and the International Code of Medical Ethics.
  10. To include education on the use of social media in medical curricula and continuing medical education.
  11. To behave in the media and on social networks with the same scientific rigor and the same approach as in a consultation and show the same respect to patients and colleagues.
  12. To create mechanisms for accountability in professional settings when inappropriate behavior on social media is observed and reported.
  13. To promote health literacy and knowledge among populations and with individual patients by using objective and evidence based messages in accordance with the principles in the WMA Declaration of Geneva, the WMA International Code of Medical Ethics, and the WMA Statement on Healthcare Information for All.
  14. To combat misinformation, disinformation, and the promotion of pseudoscience and pseudotherapy on social media, all of which can result in negative health outcomes for patients and communities.
  15. To counsel fellow physicians who engage in misinformation, disinformation, or violation of patient trust on social media and/or report to relevant authorities for ongoing deliberate acts of the same.
  16. To raise awareness among physicians and medical students about the possibility that information shared on social media could be used in misleading ways by individuals or companies.

 

 

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011,
and reaffirmed with minor revisions by the 218th Council session (online), London, United Kingdom, October 2021 

 

The WMA reaffirms its Declaration of Tokyo establishing guidelines for physicians concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment, and recommends that a monitoring and reporting mechanism be established to permit audit of adherence of States to the terms of the said declaration, in particular: 

  1. Where physicians are working in situations of dual loyalties, support must be offered to ensure they are not put in positions that might lead to violations of fundamental professional ethics, whether by active breaches of medical ethics or omission of ethical conduct, and/or of human rights, as laid out in the Declaration of Tokyo. 
  2. Its constituent members should offer support for physicians in difficult situations, including, as feasible and without endangering either patients or doctors, helping individuals to report violations of patients’ health rights and physicians’ professional ethics in custodial settings. The support given must adhere to the principles put forward in the WMA Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment. 
  3. The WMA should review the evidence available of the violation of human rights codes by states and/or the forcing of physicians to violate the Declaration of Tokyo and refer as appropriate such cases to the relevant national and international authorities. 
  4. The WMA should encourage its member associations to investigate accusations of physician involvement in torture and similar abuses of human rights reported to it from reputable sources, and to report back in particular on whether physicians are at risk and in need of support.  
  5. The WMA should provide support to its constituent members and their individual physicians members to resist such violations, and as far as realistically possible, stand firm in their ethical convictions. The medical profession and governments should also protect physicians endangered because they adhere to their professional and ethical obligations. 
  6. The WMA shall encourage and support its member associations in their calls for investigations by the relevant United Nations special rapporteur or any other standard and reliable accountability mechanism in place when valid concerns are raised. 

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Chronic non-communicable diseases (NCDs), are the leading cause of mortality and disability in both the developed and developing world. The four main NCDs are cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes (referred to as NCD4 hereafter) and they account for seven of every ten deaths worldwide. Eighty per cent of deaths due to NCDs occur in low- and middle-income countries (WHO).

NCD4 are not replacing existing causes of disease and disability, such as infectious disease and trauma, but are adding to the disease burden. While all countries face the triple burden of infectious diseases, traumas and chronic diseases, it is a much more difficult challenge for developing countries. This increased burden is straining the capacity of many countries to provide adequate healthcare services as well as increase life expectancy.

Chronic diseases are not equally distributed, which has a significant effect on health inequalities. For example, NCDs occur more frequently among socioeconomically underprivileged individuals with inferior chronic disease outcomes. Conversely, life expectancy and other health outcomes are markedly higher in more developed countries than in less developed countries, and in the higher socio-economic segments of society.

In addition, this burden is also undermining nations’ efforts to spur economic growth. NCDs are a barrier to development. In low- and middle-income countries (LMICs), poverty exposes people to lifestyle-mediated risk factors for NCDs and in turn, resulting NCDs become an important driver for poverty. Chronic diseases and poverty are linked in a vicious circle, hindering economic development and worsening poverty.

Ongoing and anticipated global trends that will lead to more chronic disease problems in the future include an aging population, urbanization and inadequate community planning, increasingly sedentary lifestyles, increasing psychosocial stress, climate change and the rapidly increasing cost of medical technology to treat NCDs. Chronic disease prevalence is closely linked to global social and economic development, globalization and mass marketing of unhealthy foods and other products.

The prevalence and cost of addressing the chronic disease burden is expected to rise in coming years. In addition to the individual and public expenses, chronic diseases lead to a marked economic burden because of the mutual effects of healthcare costs and lost productivity from disability and death. The WHO considers the global burden of chronic diseases as one of the most important challenges facing the field of health for this century.

 The rapid increase in chronic diseases represents a major health challenge for global development, for which immediate global action is needed.

Eighty percent of the global burden of chronic diseases affects LMICs, where most of the world’s population lives. The impact of this devastating burden is constantly growing. Chronic diseases and poverty are linked in a vicious circle, hindering economic development and worsening poverty.

Solutions

The NCD4 merit global attention. The primary solution for these diseases is prevention. Tobacco use, poor diet, physical inactivity and alcohol abuse are the four most common modifiable risk factors for NCDs. Poor mental health has recently been included as an additional risk factor for NCD. National policies that help people achieve healthy lifestyles and behaviours are the foundation for all possible solutions.

Increased access to primary care combined with well-designed and affordable disease-control, disease prevention and health promotion programs can greatly improve healthcare. Partnerships of national ministries of health with institutions in developed countries may overcome many barriers in the poorest settings. In addition, having health insurance improves health outcomes. Conversely, in some countries the lack of health insurance hinders the practice of preventive and primary care and is linked with adverse health outcomes. Uninsured individuals may postpone pursuing assistance when ill or injured, and they are more likely to be hospitalized for chronic illnesses such as diabetes or hypertension. Furthermore, children without health insurance are less likely to receive immunizations, and regular primary care.

Medical education systems should become more socially accountable. The World Health Organization (WHO) defines social accountability of medical schools as the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. There is an urgent need to adopt accreditation standards and norms that support social accountability and community engagement. Educating physicians and other health care professionals to deliver health care that is concordant with the needs of the population and the resources of the country must be a primary consideration. Led by primary care physicians, teams of physicians, nurses and community health workers will provide care that is driven by the principles of quality, equity, relevance and effectiveness.

Distributions of funds for health should be based on all individual nation needs. No nation can accomplish positive NCD4 outcomes by tackling a single cause of death.

Strengthening the healthcare infrastructure, including training the primary healthcare team, chronic disease surveillance, public health promotion campaigns, quality assurance and establishment of national and local standards of care, is important in caring for the increasing numbers of patients with NCD4. Most premature deaths due to NCDs are preventable; however, in most developing countries health systems are inadequate, or unprepared to appropriately act on NCDs.

One of the most important components of healthcare infrastructure is human resources; well-trained and motivated health care professionals led by primary care physicians are crucial to success. International aid and development programs need to move from “vertical focus” on single diseases or objectives to a more sustainable and effective primary care health infrastructure development.

 

RECOMMENDATIONS

Recalling its Statement on Hypertension and Cardiovascular Disease and its Declaration of Oslo on Social Determinants of Health, the WMA calls on:

National Governments to:

  1. Recognize the importance of socio-economic development for health and reduce socioeconomic status disparities in income, education, and occupation;
  2. Support global immunization strategies;
  3. Support global tobacco and alcohol control strategies, as well as control strategies addressing other forms of addiction, particularly drug use;
  4. Promote healthy living and implement comprehensive, collaborative policies and strategies at all relevant levels and divisions of government that support prevention and healthy lifestyle behaviours;
  5. Set aside a fixed percentage of the national budget for healthcare infrastructure development and promotion of healthy lifestyles and invest in better management of NCDs4 including detection, care and treatment;
  6. Advocate for trade / commercial agreements that protect rather than undermine public health;
  7. Develop and execute global and national action strategies for mitigating the health effects of climate change;
  8. Promote research for prevention and treatment of NCDs, including research on occupational health hazards leading to chronic diseases;
  9. Promote access to good quality effective medicines to treat NCDs;
  10. Develop monitoring and surveillance systems for NCDs and,
  11. Reinforce primary health care, human resources and infrastructure.

Its Constituent Members to:

  1. Increase physician, public and NGO awareness of optimal disease prevention behaviours;
  2. Enhance skills and capacity to promote a team-based multidisciplinary approach to chronic disease management;
  3. Advocate for integration of NCD prevention and control strategies in government-wide policies;
  4. Promote high quality training and professional associations for more primary care physicians and advocate for their equitable distribution;
  5. Advocate for high quality readily accessible resources for continuing medical education that is responsive to societal needs;
  6. Support establishing evidence-based standards of care for NCDs;
  7. Promote an environment of support for continuity of care for NCDs, including collaborative efforts to encourage patient education and self-management;
  8. Support strong public health infrastructure and,
  9. Recognize and support the concept that addressing and acting on social determinants are part of prevention and health care.

Medical Schools to:

  1. Develop curriculum objectives that meet current societal needs;
  2. Create primary care departments;
  3. Provide community-oriented and community-based primary care training opportunities in primary care specialties that allow students to become acquainted with the basic elements of chronic care infrastructure and continuity of care;
  4. Promote the use of interdisciplinary, interprofessional, intersectoral and other collaborative training methodologies within primary and continuing education programs and,
  5. Include instruction in chronic disease prevention, including nutrition and lifestyle promotion counselling, in the general curriculum.

Individual Physicians to:

  1. Work to create communities that promote healthy lifestyles and prevention behaviours;
  2. Offer patients smoking cessation, weight control strategies, substance abuse counselling, early screening, self-management education and support, nutritional counselling, and ongoing coaching;
  3. Inform patients about the dangers of illusory or insufficiently proven remedies or procedures, and charlatanism practices;
  4. Promote a team-based multidisciplinary and value-based approach to chronic disease management;
  5. Ensure continuity of care for patients with chronic disease;
  6. Model healthy lifestyles by maintaining personal health;
  7. Become community advocates for improved social determinants of health, equity in health care and for best prevention methods and,
  8. Work with parents and the community at large to ensure that parents have the best advice on maintaining the health of their children.

Adopted by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

Preamble

  1. This Statement focuses on one important aspect of environmental degradation, which is environmental contamination by domestic and industrial substances. It emphasizes the harmful chemical contribution to environmental degradation and physicians’ role in promoting sound management of chemicals as part of sustainable development, especially in the healthcare environment.
  2. Unsafe management of chemicals has potential adverse impacts on human health and human rights, with vulnerable populations being most at risk.
  3. Most chemicals to which humans are exposed come from industrial sources and include, toxic gases, food additives, household consumer and cosmetic products, agrochemicals, and substances used for therapeutic purposes, such as drugs and dietary supplements. Recently, attention has been concentrated on the effects of human engineered (or synthetic) chemicals on the environment, including specific industrial or agrochemicals and on new patterns of distribution of natural substances due to human activity. As the number of such compounds has multiplied, governments and international organizations have begun to develop a more comprehensive approach to their safe regulation. The increasing amount of plastic waste in our environment is another serious concern, that needs to be addressed.
  4. While governments have the primary responsibility for establishing a framework to protect the public’s health from chemical hazards, the World Medical Association, on behalf of its members, emphasizes the need to highlight the human health risks and make recommendations for further action.

BACKGROUND

Chemicals of Concern

  1. During the last half-century, the use of chemical pesticides and fertilizers dominated agricultural practice and manufacturing industries rapidly expanded their use of synthetic chemicals in the production of consumer and industrial goods.
  2. The greatest concern relates to chemicals, which persist in the environment, have low rates of degradation, bio-accumulate in human and animal tissue (concentrating as they move up the food chain), and which have significant harmful impacts on human health and the environment (particularly at low concentrations). Some naturally occurring metals including lead, mercury, and cadmium have industrial sources and are also of concern. Advances in environmental health research including environmental and human sampling and measuring techniques, and better information about the potential of low dose human health effects have helped to underscore emerging concerns.
  3. Health effects from chemical emissions can be direct (occurring as an immediate effect of the emission) or indirect. Indirect health effects are caused by the emissions’ effects on water, air and food quality as well as the alterations in regional and global systems, such as red tide in many oceans, and the ozone layer and the climate, to which the emissions may contribute.

National and International Actions

  1. The model of regulation of chemicals varies widely both within and between countries, from voluntary controls to statutory legislation. It is important that all countries move to a coherent, standardized national legislated approach to regulatory control.  Furthermore, international regulations must be coherent such that developing countries will not be forced by economic circumstances to accept elevated toxic exposure levels.
  2. Synthetic chemicals include all substances that are produced by, or result from, human activities including industrial and household chemicals, fertilizers, pesticides, chemicals contained in products and in wastes, prescription and over-the-counter drug products and dietary supplements, and unintentionally produced byproducts of industrial processes or incineration, like dioxins. Furthermore, nanomaterials may need explicit regulation beyond existing frameworks.

Strategic approach to international chemicals management

  1. Worldwide hazardous environmental contamination persists despite several international agreements on chemicals, making a more comprehensive approach to chemicals essential. Reasons for ongoing contamination include persistence of companies, absolute lack of controls in some countries, lack of awareness of the potential hazards, inability to apply the precautionary principle, non-adherence to the various conventions and treaties and lack of political will. The Strategic Approach to International Chemicals Management (SAICM) was adopted in Dubai, on February 6, 2006 by delegates from over 100 governments and representatives of civil society. This is a voluntary global plan of action designed to assure the sound management of chemicals throughout their life cycle so that, by 2020, chemicals are used and produced in ways that minimize significant adverse effects on human health and the environment. The SAICM addresses both agricultural and industrial chemicals, covers all stages of the chemical life cycle of manufacture, use and disposal, and includes chemicals in products and in wastes.

Plastic waste

  1. Plastic has been part of life for more than 100 years and is regularly used in some form by nearly everyone. While some biodegradable varieties are being developed, most plastics break down very slowly with the decomposition process taking hundreds of years. This means that most plastics that have ever been manufactured are still on Earth, unless they have been burnt, thus polluting the atmosphere with poisonous smoke.
  2. Concerns about the use of plastic include accumulation of waste in landfills and in natural habitats, terrestrial and marine, physical problems for wildlife resulting from ingestion or entanglement in plastic, the leaching of chemicals from plastic products and the potential for plastics to transfer chemicals to wildlife and humans. Many plastics in use today are halogenated plastics or contain other additives used in production, that have potentially harmful effects on health (e.g. carcinogenic or promoting endocrine disruption).
  3. Our current usage of plastic is not sustainable, accumulating waste and therefore contributing to environmental degradation and potentially harmful effects on health. Specific regulation is therefore needed to counter the harmful distribution of slowly degradable plastic waste into the environment and the incineration of such waste which often creates toxic byproducts.

WORLD MEDICAL ASSOCIATION (WMA) RECOMMENDATIONS

  1. Despite national and international initiatives, chemical contamination of the environment due to inadequately controlled production and usage continues to exert harmful effects on global public health. Evidence linking some chemicals to some health issues is strong, but far from all chemicals have been tested for their health or environmental impacts. This is especially true for newer chemicals or nano materials, particularly at low doses over long periods of time. Plastic contamination of our natural environment, including in the sea where plastic decomposes to minute particles, is an additional area of serious concern. Physicians and the healthcare sector are frequently required to make decisions concerning individual patients and the public as a whole based on existing data. Physicians therefore recognize that they, too, have a significant role to play in closing the gap between policy formation and chemicals management and in reducing risks to human health.
  2. The World Medical Association reaffirms its commitment to advocate for the environment in order to protect health and life, and recommends that:

ADVOCACY

  1. National Medical Associations (NMAs) advocate for legislation that reduces chemical pollution, enhances the responsibities of chemical manufacturers, reduces human exposure to chemicals, detects and monitors harmful chemicals in both humans and the environment, and mitigates the health effects of toxic exposures with special attention to fertility for women and men and vulnerability during pregnancy and early childhood.
  2. NMAs urge their governments to support international efforts to restrict chemical pollution through safe management, or phase out and safer substitution when unmanageable (e.g. asbestos), with particular attention to developed countries aiding developing countries to achieve a safe environment and good health for all.
  3. NMAs facilitate better inter-sectoral collaboration between government ministries/departments responsible for the environment and public health.
  4. NMAs promote public awareness about hazards associated with chemicals (including plastics) and what can be done about it.
  5. Modern medical diagnosis and treatment relies heavily on the single use of packaged clean or sterile materials with various plastic components, whether the device itself or its packaging. NMAs should encourage research and the dissemination of practices that can reduce or eliminate this component of environmental degradation.
  6. Physicians and their medical associations advocate for environmental protection, disclosure of product constituents, sustainable development, green chemistry and green hospitals within their communities, countries and regions.
  7. Physicians and their medical associations should support the phase out of mercury and persistent bioaccumulative and toxic chemicals in health care devices and products and avoid incineration of wastes from these products which may create further toxic pollution.
  8. Physicians and their medical associations should support the Globally Harmonized System of Classification and Labelling of Chemicals (GHS) and legislation to require an environmental and health impact assessment prior to the introduction of a new chemical or a new industrial facility.
  9. Physicians should encourage the publication of evidence of the effects of different chemicals and plastics, and dosages on human health and the environment.  These publications should be accessible internationally and readily available to media, non-governmental organizations (NGOs) and concerned citizens locally.
  10. Physicians and their medical associations should advocate for the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed. They should also advocate for the introduction worldwide of efficient systems to collect and dispose of plastic waste.
  11. Physicians and their medical associations should encourage efforts to curb the manufacture and use of plastic packaging and plastic bags, to halt the introduction of plastic waste into the environment, and to phase out and replace plastics with more biocompatible materials. These efforts may include measures to enhance recycling and specific regulations limiting the use of plastic packaging and plastic bags.
  12. Physicians and their medical associations should support efforts to rehabilitate or clean areas of environmental degradation based on a “polluter pays” and precautionary principles and ensure that moving forward, such principles are built into legislation.
  13. The WMA, NMAs and physicians should urge governments to collaborate within and between departments to ensure coherent regulations are developed.

LEADERSHIP

The WMA:

  1. Supports the goals of the Strategic Approach to International Chemicals Management (SAICM), which promotes best practices in the handling of chemicals by utilizing safer substitution, waste reduction, sustainable non-toxic building, recycling, as well as safe and sustainable waste handling in the health care sector.
  2. Cautions that these chemical practices must be coordinated with efforts to reduce greenhouse gas emissions from health care and other sources to mitigate its contribution to global warming.
  3. Urges physicians, medical associations and countries to work collaboratively to develop systems for event alerts to ensure that health care systems and physicians are aware of high-risk industrial accidents as they occur, and receive timely and accurate information regarding the management of these emergencies.
  4. Urges local, national and international organizations to focus on sustainable production, safer substitution, green safe jobs, and consultation with the health care community to ensure that damaging health impacts of development are anticipated and minimized.
  5. Emphasizes the importance of the safe disposal of pharmaceuticals as one aspect of health care’s responsibility and the need for collaborative work in developing best practice models to reduce this part of the chemical waste problem.
  6. Encourages environmental classification of pharmaceuticals in order to stimulate prescription of environmentally less harmful pharmaceuticals.
  7. Encourages local, national and international efforts to reduce the use of plastic packaging and plastic bags.
  8. Encourages ongoing outcomes research on the impact of regulations and monitoring of chemicals on human health and the environment.

The WMA recommends that Physicians:

  1. Work to reduce toxic medical waste and exposures within their professional settings as part of the World Health Professional Alliance’s campaign for Positive Practice Environments.
  2. Work to provide information on the health impacts associated with exposure to toxic chemicals, how to reduce patient exposure to specific agents and encourage behaviors that improve overall health.
  3. Inform patients about the importance of safe disposal of pharmaceuticals that are not consumed.
  4. Work with others to help address the gaps in research regarding the environment and health (i.e., patterns and burden of disease attributed to environmental degradation; community and household impacts of industrial chemicals; the effects, including on health, of distribution of plastic and of plastic waste into our natural environment; the most vulnerable populations and protections for such populations).

PROFESSIONAL EDUCATION & CAPACITY BUILDING

The WMA recommends that:

  1. Physicians and their professional associations assist in building professional and public awareness of the importance of the environment and global chemical pollutants on personal health.
  2. NMAs develop tools for physicians to help assess their patients’ risk from chemical exposures.
  3. Physicians and their medical associations develop locally appropriate continuing medical education on the clinical signs, diagnosis, treatment and prevention of diseases that are introduced into communities as a result of chemical pollution and exacerbated by climate change.
  4. Environmental health and occupational medicine should become a core theme in medical education.  Medical schools should encourage the training of sufficient specialists in environmental health and occupational medicine.

Adopted by the 48th WMA General Assembly, Somerset West, South Africa, October 1996,
editorially revised by the 174th WMA Council Session, Pilanesberg, South Africa, October 2006,
amended by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

Family violence is a grave universal public health and human rights problem that affects individuals, regardless of age, gender, sexual orientation, racial/ethnic background, culture, religion, socio-economic status or any other factor. 

Though definitions vary, the term family violence is generally applied to the physical, sexual, verbal, economic, spiritual, psychological or emotional abuse, or neglect of a person by someone with whom the victim is physically, financially, emotionally or socially related and/or dependent. 

Although the causes of family violence are complex, a number of contributing factors are known, such as lack of basic education, lack of economic independence/poverty, underlying and/or undiagnosed mental health issues, substance abuse (particularly alcohol), stress, rigid gender roles, poor parenting skills, interpersonal conflicts within the family, the perpetrator’s experience of maltreatment and family violence as a child, or familial social isolation. 

Family violence has adverse physical, mental, emotional and psycho-social consequences on the individual and negatively impacts the health and wellbeing of the affected individual. There may also be socio-economic impacts as well as impacts on a witness of family violence, the family and community. These adverse effects could be short-term/immediate or long-term/chronic. They include physical harm/injuries, death, impact on reproductive health/miscarriage, dysfunctional families, educational disruptions and poor academic performance, sexually transmitted diseases, juvenile delinquency, professional disruptions and loss of employment, social exclusions and homelessness, insomnia, anxiety, depression, resort to substance abuse and crime, post-traumatic stress disorder, and suicide. Victims can become perpetrators of family violence and violent acts against non-intimates (intergenerational transmission of violence). 

 The World Medical Association (WMA) firmly condemns all forms of violence and reaffirms its policies on Violence against Women and Girls, Child Abuse and Neglect, the Abuse of the Elderly, and Violence and Health. 

 

RECOMMENDATIONS 

 Governments and National Health Authorities  

WMA urges governments to: 

  1. Strengthen the sense of social responsibility, develop and enforce policies, legal frameworks, and national plans with allocated budget for the prevention and elimination of family violence, as well as for protection of victims and witnesses of family violence.
  2. Address the root causes of violence in relation to social determinants of health and to promote health equity. This should include addressing gender inequality and other harmful societal practices.
  3. Recognise that times of intense individual and/or national stress increase the risk of family violence and ensure that appropriate resources are publicized and made available during such times.
  4. Provide tools to recognize, act upon and if necessary report cases of family violence.
  5. Develop data collection systems on family violence, that holistically include vital aspects of family violence such as mortality, morbidity, injuries, family or community environment, risk factors, costs of interventions, loss in productivity, legal costs among others.
  6. Provide secure private reporting mechanisms and safe havens to protect the individual from feelings of guilt and shame to avoid stigma and retaliation.
  7. Require a guideline that indicates how to act on suspicion of family violence and what interventions are available. Reporting should only be done when, in the opinion of the physician, doing so will not endanger the individual experiencing the violence. If possible, this should be done in consultation with the individual experiencing the violence.
  8. Institute and promote high-quality research programs to provide a strong evidence base on the multiple facets of family violence such as the magnitude, risk profiles, underlying factors, and the complex interplay of factors, as well as cross comparisons among settings, countries and regions.
  9. Develop and offer family violence services to those experiencing family violence, including policy and legal accompaniments, case management, advocacy, counselling, safe housing and safety planning.
  10. Encourage multi-stakeholder constructive collaboration between sectors, disciplines, as well as governmental and nongovernmental bodies, including traditional and religious institutions, to eliminate and prevent family violence.

WMA constituent members and the medical profession

WMA constituent members should :

  1. Encourage coordination of action against family violence between and among components of the health care system, criminal justice systems and law enforcement authorities, including family and juvenile courts, and victims’ services organizations.
  2. Encourage and facilitate research to understand the prevalence, risk factors, outcomes and optimal care for victims of family violence.
  3. Promote advocacy, public and professional awareness creation, and community education programs on family violence.
  4. Encourage managers of public and private health facilities to provide educational materials in reception/patient waiting rooms and emergency departments, to offer patients and clients general information about family violence, as well as to inform them about available integrated and professionally good local services that can be accessed.
  5. Advocate for inclusion of courses on violence, including family violence, in the academic curricula for undergraduate and postgraduate medical education.
  6. Promote capacity building and Continuous Medical Education programs for physicians, on prevention of family violence.
  7. Advocate for rehabilitation, counseling, and therapy to those who either cause, experience or are exposed to the violent acts, especially traumatized children.
  8. Encourage adequate undergraduate family medicine education and training in family dynamics, including the medical, sociological, psychological and preventive aspects of all types of family violence. 

Physicians 

In the light of their obligation to promote the well-being of patients, physicians have an ethical obligation to take appropriate action to recognize and offer assistance to patients harmed by family violence and abuse.

Physicians should:

  1. Routinely consider and be sensitive to signs indicating the need for further evaluations about current or past abuse as part of their general health screening or in response to suggestive clinical findings, as physicians are often the first to suspect family violence.
  2. Be acquainted on ways to take an appropriate and culturally sensitive history of current and past abuse and be acutely aware of the need to maintain confidentiality and a trusting patient-physician relationship in cases of family violence.
  3. Be aware of social, community and other services useful for victims, and in some cases, perpetrators of violence and refer to and use these routinely to support victims, witnesses and/or perpetrators of family violence.
  4. Report suspected violence against children and other family members to appropriate protection and security services in keeping with applicable requirements, and take necessary measures to ensure that victims and witnesses of violence are not at risk.
  5. Be encouraged to participate in coordinated community activities that seek to reduce the burden and impact of family violence.
  6. Be encouraged to embrace patient-centred, community specific care, and to develop impartial attitudes toward those involved in family violence. 

 

Adopted by the 51st World Medical Assembly, Tel Aviv, Israel, October 1999
revised by the 61st WMA General Assembly, Vancouver, Canada, October 2010
and reaffirmed with minor revisions by the 215th Council session (online), Cordoba, Spain, October 2020

 

PREAMBLE

The goal of pharmacological treatment is to improve patients´ health and quality of life. Optimal pharmacological treatment should be safe, effective and efficient. There should be equity of access to this kind of treatment and an accurate and up-to-date information base that meets the needs of patients and practitioners.

Pharmacological treatment has become increasingly complex, often requiring the input of a multi-disciplinary team to administer and monitor the chosen therapy. In the hospital setting the inclusion of a clinical pharmacist in such a team is increasingly common and helpful. The right to prescribe medicine should be competency based and ideally the responsibility of the physician.

Physicians and pharmacists have complementary and supportive responsibilities in achieving the goal of providing optimal pharmacological treatment. This requires communication, respect, trust and mutual recognition of each other’s professional competence. Access by both physicians and pharmacists to the same accurate and up-to-date information base is important to avoid providing patients with conflicting information.

Physicians and pharmacists must provide quality service to their patients and ensure safe use of drugs. Therefore, collaboration between these professions is imperative, including with respect to the development of training and in terms of information sharing with one another and with patients. It is necessary to keep an open and continued dialogue between physicians’ and pharmacists’ representative organizations in order to define each profession’s respective functions and promote the optimal use of drugs within a framework of transparency and cooperation, all in the best interests of patients.

The Joint Statement on Counterfeiting Medical Products of the World Health Professions Alliance (WHPA) states that physicians and pharmacists share the same priority of identifying, investigating and eliminating counterfeit medicines, in which both physicians and pharmacists play a crucial role.

Patients are best served when pharmacists and physicians collaborate, recognizing and respecting each other’s roles, to ensure that medicines are used safely and appropriately to achieve the best outcome for the patient’s health.

 

THE PHYSICIAN’S RESPONSIBILITIES

  1. Diagnosing diseases on the basis of the physician’s education and specialized skills and competence.
  2. Assessing the need for pharmacological treatment and prescribing the corresponding medicines in consultation with patients, pharmacists and other health care professionals, when appropriate.
  3. Providing information to patients about diagnosis, indications and treatment goals, as well as action, benefits, risks and potential side effects of pharmacological treatment. In the case of off-label prescriptions the patient must be informed about the character of the prescription.
  4. Monitoring and assessing response to pharmacological treatment, progress toward therapeutic goals, and, as necessary, revising the therapeutic plan in collaboration with pharmacists, other health professionals and, when appropriate, caregivers.
  5. Providing and sharing information in relation to pharmacological treatment with other health care practitioners.
  6. Leading the multi-disciplinary team of health professionals responsible for managing complex pharmacological treatment.
  7. Maintaining adequate records for each patient, according to the need for therapy and in compliance with legislation respecting confidentiality and protecting the patient’s data.
  8. Where practically possible, actively participating in establishing electronic drug delivery systems within their workplace and supporting those systems with their professional knowledge.
  9. Maintaining a high level of knowledge of pharmacological treatment through continuing professional development.
  10. Ensuring safe procurement and storage of medicines that the physician is required to supply or permitted to dispense.
  11. Reviewing prescription orders to identify interactions, allergic reactions, contra-indications and therapeutic duplications.
  12. Reporting adverse reactions to medicines to health authorities, in accordance with national legislation.
  13. Monitoring and limiting, where appropriate, prescriptions of medications that may have addictive properties.
  14. Documenting adverse reactions to medicines in the patient’s medical record.

THE PHARMACIST’S RESPONSIBILITIES

  1. Ensuring safe procurement, adequate storage and dispensing of medicines in compliance with the relevant regulations.
  2. Providing information to patients, which may include the information leaflet, name of the medicine, its purpose, potential interactions and side effects, as well as correct usage and storage.
  3. Reviewing prescription orders to identify interactions, allergic reactions, contra-indications and therapeutic duplications. Concerns should be discussed with the prescribing physician but the pharmacist should not change the prescription without consulting the prescriber.
  4. Discussing medicine-related problems or concerns with regard to the prescribed medicines when appropriate and when requested by the patient.
  5. Advising patients, when appropriate, on the selection and the use of non-prescription medicines and the patient’s management of minor symptoms or ailments. Where self-medication is not appropriate, advising patients to consult their physician for diagnosis and treatment.
  6. Participating in multi-disciplinary teams concerning complex pharmacological treatment in collaboration with physicians and other health care providers, typically in a hospital setting.
  7. Reporting adverse reactions to medicines to the prescribing physician and to health authorities in accordance with national legislation.
  8. Providing and sharing general as well as specific medicine-related information and advice with the public and health care practitioners.
  9. Maintaining a high level of knowledge of pharmacological treatment through continuing professional development.

Adopted by the 50th World Medical Assembly, Ottawa, Canada, October 1998,
reaffirmed by the 59th WMA General Assembly, Seoul, Korea, October 2008,
amended by the 61st WMA General Assembly, Vancouver, Canada, October 2010,
and by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

For the purpose of this Statement, in line with the International Organisation for Migration index, “migrant” is an umbrella term reflecting the common lay understanding of a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons.   

The WMA considers health to be a basic need, a human right, and one of the essential drivers of economic and social development.  

According to the World Health Organisation, universal access to health implies that all people and communities have access to comprehensive health services, without barriers or discrimination, according to their needs, within the framework of equitable and supportive health systems.   

Recalling the WMA Declaration of Geneva, the WMA underlines every physician’s duty to not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to interfere with the physician’s duty to his or her patient.   

The WMA underlines that physicians should offer help in medical emergencies in accordance with the WMA International Code of Medical Ethics. 

Taking into account the WMA Declaration of Ottawa on Child Health and the WMA Statement on Medical Age Assessment of Unaccompanied Minor Asylum Seekers, the WMA reiterates that children should enjoy special protection, including the right to adequate health care without discrimination. 

These fundamental WMA principles also echo the principles laid down in the Universal Declaration of Human Rights, the United Nations Convention on the Rights of the Child and the International Covenant on Economic, Social and Cultural Rights.  

The WMA Declaration of Lisbon on the Rights of the Patient declares that every person is entitled without discrimination to appropriate medical care. However, national legislation varies and is often not in accordance with this fundamental principle. 

At any time, large numbers of migrants are seeking protection, fleeing from natural disasters, desperate poverty, violence and other injustices and abuses with potentially very harmful effects to mental and physical health. 

Recalling the WMA statement on Armed Conflicts and the WMA declaration on Health and Climate Change, the WMA recognizes that climate change, natural disasters, warfare, armed conflicts and other emergencies, including continuous civil strife, unrest and violence, will inevitably lead to the displacement of people from their homes.   

The WMA is concerned by the precarious situation of certain categories of migrants, such as refugees, asylum seekers, refused asylum seekers, undocumented migrants and displaced persons, whose access to health care is often undermined, and where physicians are required in some countries to intervene outside the scope of their medical duty, in contradiction with medical ethics.  

Bearing in mind the above-mentioned principles, international conventions and WMA policies, the WMA advocates a strong and continued engagement of physicians in the defence of human rights and dignity of all people including migrants worldwide, while making the following recommendations for its constituent members and individual physicians: 

 

RECOMMENDATIONS  

WMA constituent members should: 

  • Prioritize the medical care of human beings above any other personal, material, economic, or political interest. 
  • Actively support and promote the right of all people to receive medical care on the basis of clinical need alone and speak out against legislation and practices that contradict this fundamental right. 
  • Call for governments to reach political agreements that facilitate the availability of sufficient resources for the delivery of adequate and coordinated health services to migrant populations, including in refugee camps where the conditions of living make them more susceptible to the spread of disease and viruses. 
  • Urge governments to ensure access to safe and adequate living conditions and essential services to all migrants, even with support from the donor agencies and/or philanthropists if needed. 
  • Promote equality, solidarity and social justice, guaranteeing access of migrants and refugees to health and social services. 
  • Implement policies, actions and commitments that promote the health of all, without discrimination, addressing the social determinants of health related to migrants and refugees. 

Physicians: 

  • Have a duty to provide appropriate medical care, based solely on clinical need, regardless of the civil or political status of the patient. 
  • Should speak out against legislation and practices that prevent the fulfilment of this duty. 
  • Cannot be compelled to participate in any punitive or judicial action against migrants, including refugees, asylum seekers, refused asylum seekers, undocumented migrants and or displaced persons, or to withhold medically necessary treatment, or to administer any non-medically justified diagnostic measure or treatment, such as sedatives to facilitate easy deportation from the country or relocation. 
  • Must be allowed adequate time and be provided with sufficient resources, including interpretation services, to assess the physical and psychological condition of migrants, including refugees, asylum seekers, refused asylum seekers, undocumented migrants and displaced persons. 

Adopted by the 61st WMA General Assembly, Vancouver, Canada, October 2010
And amended by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

Violence against women is a worldwide phenomenon and includes violence within the family, within the community and violence perpetrated by or condoned by the state. Many excuses are given for violence generally and specifically; in cultural and societal terms, these include tradition, beliefs, customs, values and religion. Intimate partner violence, rape, sexual abuse and harassment, intimidation at work or in education, modern slavery, trafficking and forced prostitution, are all forms of violence condoned by some societies. One extreme form of such violence is sexual violence used as a weapon of war (United Nations Security Council Resolution 1820). Specific cultural practices that harm women, including female genital mutilation, forced marriages, dowry attacks and so-called “honour” killings are all practices that may occur within the family setting.

All human beings enjoy fundamental human rights. The examples listed above involve denial of many of those rights, and each abuse can be examined against the Universal Declaration of Human Rights, as well as the Convention on the Elimination of All Forms of Discrimination against Women and the Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000).

The denial of rights and the violence itself have health consequences to women. In addition to the specific and direct physical and health consequences, the general way in which women are treated can lead to an excess of mental health problems and increase of suicidal behavior. The short and long-term mental health consequences of violence may severely influence later wellbeing, enjoyment of life, function in society and the ability to provide appropriate care for dependents. Lack of good nutritional opportunities can lead to generations of women with poorer health, poorer growth and development. Denial of educational opportunities leads to poorer health for all the family members since good education of women is a major factor in the wellbeing of the family.

In addition to being unacceptable in and of itself, violence against women is also socially and economically damaging to the family and to society. There are direct and indirect economic consequences to violence against women that are far greater than the direct health sector costs. Lack of economic independence, and of basic education, also mean that women who survive abuse are more likely to be or to become dependent upon the state or society and less able to support themselves and contribute to that society.

Physicians have a unique insight into the combined effects of violence against women. The holistic view from physicians can be used to influence society and politicians. Gaining societal support for improving the rights, freedom and status of women is essential.

This Statement alongside with other WMA key related policies, including the statements on Female Genital Mutilation, Sex Selection and Female Foeticide, Medically-indicated Termination of Pregnancy, Family Violence, Violence and Health, Child Abuse and Neglect and on the Right of Rehabilitation of Victims of Torture, provide guidance to WMA Constituent Members and physicians on ways to support women who are victims of violence, and strive for eradicating violence against women.

 

RECOMMENDATIONS

The WMA:

  1. Calls for zero tolerance for all forms of violence against women.
  2. Asserts that violence against women is not only about physical, psychological and sexual violence but includes neglect and abuses such as harmful cultural and traditional practices and is a major public health issue as well as a social determinant of health.
  3. Recognizes the linkage between better education, other women’s rights and societal health and wellbeing, and emphasizes that equality in civil liberties and human rights are health-related issue.
  4. Calls on WHO, other United Nations agencies and relevant actors at national and international levels to accelerate actions towards ending discrimination and violence against women.
  5. Urges the governments to implement WHO’s Global Plan of Action to Strengthen the Role of the Health System within a National Multisectoral Response to Address Interpersonal Violence, in particular Against Women and Girls, and Against Children.
  6. Encourages the development of free educational materials online to provide guidance to front line health care personnel on abuse and its effects, and on prevention strategies.

National Medical Associations are urged to:

  1. Use and promote the available educational materials on preventing and treating the consequences of violence against women and act as advocates within their own country.
  2. Seek to ensure that physicians and other health care personnel are alerted on the phenomenon of violence, its consequences, and the evidence on preventative strategies that work, and place appropriate emphasis on this in undergraduate, graduate and continuing education.
  3. Recognise the importance of more complete reporting of violence and encourage the development of education emphasising violence awareness and prevention.
  4. Advocate for legislation against specific harmful practices including female feticide, female genital mutilation, forced marriage, and corporal punishment.
  5. Advocate for the criminalization of intimate partner violence as well as rape in all circumstances including within marriage.
  6. Advocate for the development of research data on the impact of violence and neglect upon primary and secondary victims and upon society, and for increased funding for such research.
  7. Encourage medical journals to publish more of the research on the complex interactions in this area, thus keeping it in the professions’ awareness and contributing to the development of a solid research base and ongoing documentation of types and incidence of violence.
  8. Advocate for the national implementation of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).

Physicians are encouraged to:

  1. Use the material developed for their education to better inform themselves about the effects of violence and the successful strategies for prevention.
  2. Treat and reverse, where possible, the complications and adverse effects of female genital mutilation and refer the patient to social support services.
  3. Oppose the publication or broadcast of victims’ names or addresses without the explicit permission of the victim.
  4. Assess risk of family violence in the context of taking a routine social history of a patient.
  5. Be alert to the association between alcohol or drug dependence among women and a history of abuse.
  6. Where appropriate, report suspected violence or ill-treatment against women to relevant protection services and take the necessary measures to ensure that victims of violence are not at risk.
  7. Support global and local action to better understand the health consequences both of violence and of the denial of rights, and advocate for increased services for victims.

Adopted by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007
and rescinded at the 65th WMA General Assembly, Durban, South Africa, October 2014

INTRODUCTION

The use of human cells and tissue for therapeutic purposes in medicine covers a broad spectrum. A differentiated examination is necessary in order to do justice to the different requirements of the various sectors of tissue medicine.

The use of so-called “tissue transplants”, such as corneas, bone, blood vessels and cardiac valves, is an established treatment method in medicine. Tissues are removed, conserved, stored and then implanted in patients after varying periods of time. In principle, they should therefore be treated in the same way as organs that are used for transplantation (cf. WMA Statement on Human Organ and Tissue Donation and Transplantation, Edinburgh 2000).

In contrast, so-called “advanced therapies”, such as tissue engineering and other techniques of regenerative medicine, involve the use of human tissue as starting material for manufacturing a processed end product. Even though established therapeutic options already exist, it can be expected that the therapeutic importance of these methods may continue to increase, and that there may be many developments in this field in the future. In view of the further processing of the tissue involved, the frequently industrial nature of the manufacturing organizations and the possibility of tissue being pooled, different regulations are necessary for this sector of tissue medicine than for tissue transplantation.

The WMA limits this Statement to tissue in the sense of tissue transplants, and gives the following Recommendations for this sector of tissue medicine:

  1. Physicians are fundamentally obliged to treat patients according to the best of their knowledge and expertise. However, this obligation must not be taken to the point where, for example, the human tissue necessary for therapy is procured in an unethical or illegal manner. Tissue must always be procured with due consideration for human rights and the principles of medical ethics.
  2. To secure the provision of tissue for transplantation, physicians should inform potential donors and/or their family members about the possibility of tissue donation. In the event of combined organ and tissue donation, information should be provided, and consent obtained, in one step.
  3. The voluntariness of tissue donation must be ensured. The informed and non-coerced consent of the donor or his/her family members is required for any use of human tissue for transplantation. Free and informed decision-making is a process requiring the exchange and understanding of information and the absence of coercion. Because prisoners and other individuals in custody are not in a position to give consent freely and can be subject to coercion, their tissues must not be used for transplantation except for members of their immediate family.
  4. Financial incentives such as direct payments for donating tissue for transplantation are to be rejected – in the same what that they are in connection with organ transplants. All other steps, such as the procurement, testing, processing, conservation, storage and allocation of tissue transplants, should likewise not be commercialised.
  5. If both organs and tissue can be removed from a potential donor for transplantation, organ donation must be given priority over tissue donation.
  6. Posthumous donation of tissue to a specific recipient (directed donation beyond the immediate family) is to be avoided. Living directed donation requires both:a) proof of direct personal ties between donor and recipient (e.g. blood relations, spouses), andb) exclusion of potentially coercive  material interests.
  7. For posthumous tissue donation, the WMA calls for the determination of death to be conducted in accordance with its Declaration of Sydney on the Determination of Death.
  8. The risk of diseases (e.g. infections, malignant tumors) being transmitted by transplanted tissue must be minimized through appropriate testing that does not merely comply with sufficient standards, but additionally reflects the respective, nationally implemented state of medical science and technology.
  9. In the case of a delayed diagnosis for infectious disease or malignancy of the donor, an alert should immediately be reported to all tissue recipients in order to institute the appropriate precautionary steps
  10. Contamination must be avoided when removing, storing, processing and transplanting tissue.
  11. Unethical allocation formulas for tissue transplants are to be rejected. Allocation should be based on the medical indication, urgency and prospects of success.
  12. Experimental and clinical studies, as well as open discussions on ethical and moral principles in society, are important for establishing new therapeutic methods. All experimental and clinical studies are to be conducted in accordance with the WMA Declaration of Helsinki. Scientists and physicians should continuously inform the public about developments in tissue medicine and its therapeutic options.
  13. International exchange of tissue for transplantation should be properly regulated according to agreed upon standards.
  14. Information on tissue donors should be stored and maintained by national transplant organizations and should be provided only if the living donor or family of the deceased donor provides free and informed consent.

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and amended by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

The fields of stem cell research and therapy are among the fastest growing areas of biotechnology.

Stem cells can be harvested from established tissue (adult stem cells) or from the blood of the placenta via the umbilical cord. These sources may create no specific ethical dilemmas.

Stem cells can also be obtained from an embryo (embryonic stem cells). Obtaining and using these stem cells raises specific ethical questions and may be problematic for some people. Another source of stem cells valuable for research is induced pluripotent stem cells, which can be generated from adult tissues, and may in some cases be functionally equivalent to embryonic stem cells, although they are not derived from embryos.

Some jurisdictions have prohibited using embryonic stem cells. Others have allowed using so-called “spare or excess embryos” from assisted reproduction procedures for research purposes, but the production of embryos solely for research purposes may be prohibited. Other jurisdictions have no specific laws or regulations with respect to embryonic stem cells.

Human embryos are considered by some people to have a specific and special ethical status. This has generated debate amongst ethicists, philosophers, theologians, clinicians, scientists, health workers, the public and legislators.

In vitro fertilisation involves the production of embryos outside of the human body. In many cases, some of the embryos are not used to achieve pregnancies. Those not used may be donated for the treatment of others, or for research, or stored for some time and then destroyed.

Stem cells can be used to conduct research into basic developmental biology, human physiology and disease pathogenesis. There are many current research programs investigating the use of stem cells to treat human disease. Adult stem cell therapies, including using bone marrow, cord blood or blood-derived stem cells for transplantation, include several important and well-validated clinical advances. In contrast, clinical studies have not yet validated the use of embryonic stem cells in therapy.

Embryonic stem cells may at times be superior to induced pluripotent stem cells for certain applications, and research with embryonic stem cells may continue to be needed. Some experts anticipate future use of a variety of therapies based on stem cells, including transplants of genetically matched tissue. It is too early to assess the likelihood of success of any specific therapy based on stem cells.

Public views of stem cell research are as varied as those of doctors and scientists.  Much public debate centers on concerns of abuse of the technology and the potential for harm in recipients, and specific concerns continue to be raised about the use of embryos. Investigational stem cell products also may pose unique risks, including unknown long-term health effects such as mutations.

Adoption of laws in accordance with established ethical principles is likely to alleviate concerns for many members of the public, especially if such laws are carefully and credibly monitored and enforced.

 

RECOMMENDATIONS

  1.  Whenever possible, research should be carried out using stem cells that are not of embryonic origin. Research with stem cells from unused embryos after in vitro fertilization techniques should only be carried out if obtaining the potential results could not also be addressed with the use of other types of stem cells, including induced pluripotent stem cells. Research and other uses should be in accordance with the WMA Resolution on the Non-Commercialisation of Human Reproductive Material.
  2. All research on stem cells, regardless of stem cell type, must be carried out according to established ethical principles and with appropriate informed consent. Both established and proposed laws must conform to these principles to avoid confusion or conflicts between law and ethics.
  3. The ethical principles should, where possible, follow international agreements. Recognising that different groups have widely varying views on the use of specific stem cell types, these principles should be drafted with enough flexibility to allow different jurisdictions to appropriately regulate levels of research.

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and revised by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

  1. Digital health is a broad term that refers to “the use of information and communication technologies in medicine and other health professions to manage illnesses and health risks and to promote wellness.” Digital health encompasses electronic health (eHealth) and developing areas such as the use of advanced computer sciences (including ‘big data’, bioinformatics and artificial intelligence). The term also includes telehealth, telemedicine, and mobile health (mHealth).
  2. The term “digital health” may be used interchangeably with “eHealth.” These terms also include within them: Telehealth” or “Telemedicine,” which both utilize information and communications technology to deliver healthcare services and information at a distance (large or small). They are used for remote clinical services, including real-time patient monitoring such as in critical care settings. Also, they serve for patient-physician consultation where access is limited due to physicians’/patients’ schedules or preferences, or patient limitations such as physical disability. Alternatively, they can be used for consultation between two or more physicians. The difference between the two terms is that “Telehealth” refers also to remote clinical and non-clinical services: preventive health support, research, training, and continuing medical education for health professionals.
  3. Technological developments and the increasing availability and affordability of mobile devices have led to an exponential increase in the number and variety of digital health services in use in both developed and developing countries. Simultaneously, this relatively new and rapidly evolving sector remains largely unregulated, which could have potential patient safety and ethical implications.
  4. The driving force behind digital health should be improving quality of care, patient safety and equity of access to services otherwise unavailable.
  5. Digital health differs from conventional health care in the medium used, its accessibility, and its effect on the patient-physician relationship, as well as on the traditional principles of patient care.
  6. The development and application of digital health has expanded access to health care and health education in both regular and emergency situations. At the same time, its effect on the patient-physician relationship, accountability, patient safety, multistakeholder interactions, privacy and data confidentiality, fair access, and other social and ethical principles should be taken into consideration. However, the scope and application of digital health, telemedicine or telehealth are context-dependent. Factors such as human resources for health, size of service area and level of healthcare facilities should also be taken into consideration.
  7. Physicians should be involved in the development and implementation of digital health solutions to be used in health care, in order to ensure they meet the needs of patients and health professionals.
  8. Consistent with the mandate of the WMA, this statement is addressed primarily to physicians and their role in the health care setting. The WMA encourages others who are involved in healthcare to develop and adhere to similar principles, as appropriate to their role in the healthcare system.

Physician autonomy

  1. Acceptable boundaries in the patient-physician relationship necessary for the provision of optimal care, should exist in digital as well as physical practice. The nearly continuous availability of digital health care has the potential to unduly interfere with a physician’s work-life balance due to theoretical 24/7 availability. The physician should inform patients about his or her availability and recommend services when he or she is not available.
  2. Physicians should exercise their professional autonomy in deciding whether digital health consultation is appropriate. This autonomy should consider the type of visit scheduled, the physician’s comfort with the medium, and the physician’s assessment, together with the patient, of the patient’s comfort level with this type of care.

Patient-physician relationship

  1. Face to face consultation should be the gold standard where a physical examination is required to establish a diagnosis, or where there is a wish on the part of the physician or patient to communicate in person as part of establishing a trusted physician-patient relationship. Face to face consultations may be preferable in some circumstances to take stock of non-verbal cues, and for consultations where there may be communication barriers or discussion of sensitive matters. Ideally, the patient-physician relationship in the context of digital health, should be based on a previously established relationship and sufficient knowledge of the patient’s medical history.
  2. However, in emergency and critical situations, or in settings where access to doctors is not available other than via telemedicine, delivery of care via telemedicine should be prioritized even when a prior patient-physician relationship was not established. Telemedicine can be employed when a physician cannot be physically present within a safe and acceptable period. It can also be used to manage patients remotely including self-management and for chronic conditions or follow-up after initial treatment, where it has been proven to be safe and effective.
  3. The physician providing telemedicine services should be familiar with the technology and/or should receive sufficient resources, training and orientation in effective digital communication. Additionally, the physician should strive to ensure that quality of communication during a digital health encounter is maximized. It is also important that the patient is comfortable using the technology employed. Any significant technical deficiencies should be noted in the documentation of the consultation and reported, if applicable.
  4. The patient-physician relationship is based on mutual trust and respect. Therefore, the physician and the patient must identify each other reliably when telemedicine is employed. However, it must be recognized that sometimes third parties or ‘surrogates’ such as a family member should become involved in the case of minors, the frail, the elderly, or in an emergency situation.
  5. The physician should give clear and explicit direction to the patient during the telemedicine encounter regarding who has ongoing responsibility for any required follow-up and ongoing health care.
  6. In a digital consultation between two or more professionals, the primary physician remains responsible for the patient’s care and coordination.  The primary physician remains responsible for protocols, conferencing, and medical record review in all settings and circumstances. Physicians providing consultation should be able to contact other health professionals and technicians, as well as patients, in a timely manner.

Informed consent

  1. Proper informed consent requires that the patient be informed of, have capacity for, and provide consent specific to the type of digital health being used. All necessary information regarding the distinctive features of digital health, in general, and telemedicine, in particular, must be explained fully to patients including, but not limited to: how telemedicine works, how to schedule appointments, privacy concerns, the possibility of technological failure, including confidentiality breaches; possible secondary use of data; protocols for contact during virtual visits, prescribing policies and coordinating care with other health professionals.  This information should be provided clearly and understandably without coercion or undue influence of the patient’s voluntary choices, while taking into account the patient’s perceived level of health literacy and other resource limitations specific to the type of digital health being used.

Quality of care

  1. The physician must ensure the standard of care delivered via digital health is at least equivalent to any other type of care given to the patient, considering the specific context, location and timing, and relative availability of face to face care. If the standard of care cannot be satisfied via digital technology, the physician should inform the patient and suggest an alternative form of healthcare delivery.
  2. The physician should have clear and transparent protocols for delivering digital health care such as clinical practice guidelines, whenever possible, to guide the delivery of care in the digital setting, recognizing that certain modifications may need to be made to accommodate specific circumstances. Changes to clinical practice guidelines for the digital setting should be approved by the appropriate governing and/or regulatory body or association. If the digital health solution is equipped with automated clinical practice support, this support must be strictly professionally based and not influenced by economic interests in any way.
  3. The physician providing digital services should follow all regulatory requirements and relevant protocols and procedures related to informed consent (verbal, written, and recorded); privacy and confidentiality; documentation; ownership of patient records; and appropriate video/telephone behaviors.
  4. The physician providing care by means of telehealth should keep a clear and detailed record of the advice delivered, the information on which the advice was based and the patient’s informed consent.
  5. The physician should be aware of and respect the particular challenges and uncertainties that may arise when in contact with the patient through telecommunication. The physician must be prepared to recommend direct patient-physician contact whenever possible if he/she believes it is in the patient’s best interests or will improve compliance.
  6. The possibilities and weaknesses of digital health in emergencies must be duly identified. If it is necessary to use telemedicine in an emergency, the advice and treatment suggestions will be influenced by the severity of the patient’s medical condition and the patient’s technological and health literacy. To ensure patient safety, entities that deliver telemedicine services should establish protocols for referrals in emergency situations.

Clinical Outcomes

  1. Entities providing digital health programs should monitor and continuously strive to improve the quality of services to achieve the best possible outcomes.
  2. Entities providing digital health programs should have a systematic protocol for collecting, evaluating, monitoring and reporting meaningful health care outcomes, safety data and clinical effectiveness. Quality indicators should be identified and utilized. Like all health care interventions, digital technology must be tested for its effectiveness, efficiency, safety, feasibility, and cost-effectiveness. Quality assurance and improvement data should be shared to improve its equitable use.
  3. Entities implementing digital health are urged to report unintended consequences to help improve patient safety and further the overall development of the field. Countries are encouraged to implement these guiding principles in their own legislation and regulation.

Equity of care

  1. Although digital health can provide greater access to distant and underserved populations, it may also exacerbate existing inequalities due to, among other things, age, race, socioeconomic status, cultural factors, or literacy issues. Physicians must be aware that certain digital technologies might be unavailable or unaffordable to patients, impeding access and further widening the health outcomes gaps.
  2. Digital technologies should be implemented and monitored carefully to avoid inequity of access to these technologies. Where appropriate, social or healthcare services should facilitate access to technologies as part of basic benefit packages while taking all necessary precautions to guarantee data security and privacy. Access to vital technologies should not be denied to anyone based on financial status or a lack of technical expertise.

Confidentiality and data security

  1. In order to ensure data confidentiality, officially recognized data protection measures must be used. Data obtained during a digital consultation must be secured to avoid unauthorized access and breaches of identifiable patient information through appropriate and up-to-date security and privacy measures. If data breaches do occur, the patient must be notified immediately in accordance with the law.
  2. Digital health technologies generally involve the measurement or manual input of medical, physiological, lifestyle, activity, and environmental data to fulfill their primary purpose. The large amount of data generated also may be used for research or other purposes to improve healthcare and disease prevention. However, secondary uses of personal mHealth data can result in misuse and abuse.
  3. Robust policies and safeguards to regulate and secure the collection, storage, protection, and processing of digital health users’ data, especially personal health data, must be implemented to assure valid informed consent and guarantee patients’ rights.
  4. If patients believe that their privacy rights have been violated, they may file a complaint with the covered entity’s Privacy Officer or data protection authorities, in accordance with local regulations.

Legal principles

  1. A clear legal framework must be drawn up to address potential liability arising from the use of digital technologies. Physicians should only practice telemedicine in countries/jurisdictions where they are licensed to practice and should adhere to the legal framework and regulations as defined by the country/jurisdiction where the physician originates care and the countries in which they practice. Physicians should ensure that their medical indemnity includes telemedicine and digital health coverage.
  2. Reimbursement models must be set up in consultation with national medical associations and healthcare providers to ensure that physicians receive appropriate reimbursement for providing digital health services.

Specific principles of mHealth technology

  1. 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).
  2. A clear distinction must be made between mHealth technologies used for lifestyle purposes and those that require physicians’ medical expertise and meet the definition of medical devices. The latter must be appropriately regulated, and users must be able to verify the source of medical information provided, as these applications could potentially recommend non-scientific or non-evidence-based treatments. The information provided must be comprehensive, clear, reliable, non-technical, and easily understood by laypeople.
  3. Concerted work must improve the interoperability, reliability, functionality, and safety of mHealth technologies, e.g., through the development of standards and certification schemes.
  4. Comprehensive and independent evaluations must be carried out regularly by competent authorities with appropriate medical expertise to assess the functionality, limitations, data integrity, security, and privacy of mHealth technologies. This information must be made publicly available.
  5. mHealth can only positively contribute to 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.

 

RECOMMENDATIONS

  1. The WMA recognizes the value of digital health to supplement traditional ways of managing health and delivering healthcare. The driving force behind digital health should be improving quality of care and equity of access to services otherwise unavailable.
  2. The WMA emphasizes that the principles of medical ethics, as outlined in The Declaration of Geneva: The Physician’s Pledge and the International Code of Medical Ethics, must be respected in the practice of all forms of digital health.
  3. The WMA recommends that the training of digital health literacy and skills be included in medical education and continuing professional development.
  4. The WMA urges patients and physicians to be discerning in their use of digital health and to be mindful of potential risks and implications.
  5. The WMA recommends further research in digital health to assess safety, efficacy, cost-effectiveness, feasibility of implementation, and patient outcomes.
  6. The WMA recommends monitoring the risks of excessive or inappropriate use of digital health technologies and the potential psychological impact on patients and ensuring that the benefits of such technologies outweigh the risks.
  7. The WMA recommends special attention be given to patients’ disabilities (audio-visual or physical) and patients who are minors, when using digital healthcare.
  8. Where appropriate, National Medical Associations should encourage the development and update of ethical norms, practice guidelines, national legislation, and international agreements on digital health.
  9. The WMA recommends that other regulatory bodies, professional societies, organizations, institutions, and private industry, monitor the proper use of digital health technologies and share these findings widely.

 

 

 

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and editorially revised by the 201st WMA Council Session, Moscow, Russia, October 2015 

PREAMBLE

This policy is intended to identify areas where a conflict of interest might occur during the day-to-day practice of medicine, and to assist physicians in resolving such conflicts in the best interests of their patients. A conflict of interest is understood to exist when professional judgement concerning direct patient care might be unduly influenced by a secondary interest.

In some cases, it may be enough to acknowledge that a potential or perceived conflict exists. In others, specific steps to resolve the conflict may be required. Some conflicts of interest are inevitable and there is nothing inherently unethical in the occurrence of conflicts of interest in medicine but it is the manner in which they are addressed that is crucial.

In addition to the clinical practice of medicine and direct patient care, physicians have traditionally served in several different roles and pursued various other interests, such as participation in research, the education of future physicians and physicians in training and the occupation of administrative or managerial positions. As private interests within medicine have expanded in many locales, physicians have occasionally provided their expertise to these endeavours as well, acting as consultants (and sometimes employees) for private enterprise.

Although the participation of physicians in many of these activities will ultimately serve the greater public good, the primary obligation of the individual physician continues to be the health and well-being of his or her patients. Other interests must not be allowed to influence clinical decision-making (or even have the potential to do so).

Each doctor has a moral duty to scrutinise his or her own behaviour for potential conflicts of interest, even if the conflicts fall outside the kinds of examples or situations addressed in this document. If unacknowledged, conflicts of interest can seriously undermine patient trust in the medical profession as well as in the individual practitioner.

Physicians may also wish to avail themselves of additional resources such as specialty societies, national medical associations or regulatory authorities, and should be aware of applicable national regulations and laws.

RECOMMENDATION

Research

The interests of the clinician and the researcher may not be the same. If the same individual is assuming both roles, as is often the case, the potential conflict should be addressed by ensuring that appropriate steps are put in place to protect the patient, including disclosure of the potential conflict to the patient.

As stated in the Declaration of Helsinki:

  • The Declaration of Geneva of the World Medical Association states that, “The health of my patient will be my first consideration,” and the International Code of Medical Ethics declares that, “A physician shall act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient.”
  • The Declaration of Helsinki states that  “While the primary purpose of medical research is to generate new knowledge, this goal can never take precedence over the rights and interests of individual research subjects.”

Research should be conducted primarily for the advancement of medical science. A physician should never place his or her financial interests above the welfare of his or her patient. Patient interests and scientific integrity must be paramount.

All relevant and material physician-researcher relationships and interests must be disclosed to potential research participants, research ethics boards, appropriate regulatory oversight bodies, medical journals, conference participants and the medical centre where the research is conducted.

All hypothesis-testing research trials should be registered with a publicly-accessible research registry.

A clear contract should be signed by all parties, including sponsors, investigators and program participants, clarifying terms relating to, at a minimum:

  • financial compensation for the physician-researcher (which should approximate lost clinical earnings)
  • ownership of research results (which should rest with the investigator)
  • the right of the investigator to publish negative results
  • the right of the investigator to release relevant information to trial participants at any point during the study.

Physician-researchers should retain control of and should have full access to all trial data, and should decline non-disclosure clauses.

Physician-researchers should ensure that, regardless of the trial results, the presentation or publication of the results of hypothesis-testing trials will not be unduly delayed or otherwise obstructed.

Referral fees should not be accepted for providing the names of potential trial participants, and patient information should not be released without the consent of the patient, except where required by legislation or regulatory authorities.

Any compensation received from trial sponsors should approximately replace lost clinical income and should be commensurate with the efforts and responsibilities of the physician performing the research. When enrolment is particularly challenging and time-consuming, reasonable additional payments may be made to compensate the clinical investigator or institution specifically for time and effort spent on extra recruiting efforts to enrol appropriate research participants. Escalating bonuses designed to increase trial enrolment should not be accepted.

Physician-researchers should decline requests to review grant applications or research paper submissions from colleagues or competitors where their relationship would have the potential to influence their judgment on the matter.

Payments or compensation of any sort should not be tied to the outcome of clinical trials.  Physician-researchers should not have a financial interest in a company sponsoring a trial or a product being studied in a clinical trial if this financial interest could be affected positively or negatively by the results of the trial; they should have no direct financial stake in the results of the trial. They should not purchase, buy or sell stock (shares) in the company while the trial is ongoing and until the results have been made public. This might not apply for those physicians who have developed a medication but are not part of the enrolment process.

Physician-researchers should only participate in clinical trials when they relate to their area of medical expertise and they should have adequate training in the conduct of research and the principles of research ethics.

Authorship should be determined prior to the start of the trial and should be based on substantive scientific contribution.

Education

The educational needs of students and the quality of their training experience must be balanced with the best interests of patients. Where these are in conflict, the interests of patients will take precedence.

While recognizing that medical trainees require experience with real patients, physician-educators must ensure that these trainees receive supervision commensurate with their level of training.

Patients should be made aware that their medical care may be performed in part by students and physicians in training, including the performance of procedures and surgery, and where possible should give appropriate informed consent to this effect.

Patients should be made aware of the identity and qualifications of the individuals involved in their care.

Refusal by a patient to involve trainees in their care should not affect the amount or quality of care they subsequently receive.

Self-referrals and fee-splitting

All referrals and prescriptions (whether for specific goods or services) should be based on an objective assessment of the quality of the service or of the physician to whom the patient has been referred.

Referral by physicians to health care facilities (such as laboratories) where they do not engage in professional activities but in which they have a financial interest is called self-referral. This practice has the potential to significantly influence clinical decision-making and is not generally considered acceptable unless there is a need in that particular community for the facility and other ownership is not a possibility (for example, in small rural communities). The physician in this situation should receive no more financial interest than would an ordinary investor.

Kickbacks (or fee-splitting) occur when a physician receives financial consideration for referring a patient to a specific practitioner or for a specific service for which a fee is charged. This practice is not acceptable.

Physician offices

For reasons of patient convenience, many physician offices are located in close geographic proximity to other medical services such as laboratories, pharmacies and opticians. The physician should not receive any financial compensation or other consideration either for referring a patient to these services, or for being located in close geographical proximity to them. Physician-owned buildings should not charge above-market or below-market rates to tenants.

Non-medical products (those having nothing to do with patient health or the practice of medicine) and scientifically non-validated medical products should not be sold out of the physician’s office. If scientifically validated medical products are sold out of the physician’s office charges should be limited to the costs incurred in making them available and the products should be offered in such a way that the patient does not feel pressured to purchase them.

Organizational/institutional conflicts

Health care institutions in particular are increasingly subject to a number of pressures that threaten several of their roles, and many academic medical centres have begun to identify alternate sources of revenue. Policies should be in place to ensure that these new sources are not in conflict with the values and mission of the institution (for example, tobacco funding in medical schools).

Individual medical organizations and institutions (including, but not limited to, medical schools, hospitals, national medical associations, official/state regulators and research institutions) should develop and, where possible, enforce conflict of interest guidelines for their employees and members.

Physician-researchers and others will benefit from the development of institutional conflict of interest guidelines to assist them in making appropriate disclosure and clearly identifying situations where a conflict would preclude them from participating in a research study or other activity.

Academic health care institutions should have a clear demarcation between investment decision-making committees, technology transfer and the research arm of the institution.

Written policies should provide guidelines for disclosure requirements, or for discontinuing participation in the decision-making process, for those individuals who are conflicted due to sponsored research, consulting agreements, private holdings or licensing agreements.

Adopted by the 55th WMA General Assembly, Tokyo, Japan, October 2004,
amended by the 60th WMA General Assembly, New Delhi, India, October 2009
and by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

In the treatment of their patients, physicians use medicines, instruments, diagnostic tools, equipment and materials developed and produced by commercial enterprises. Industry possesses resources to finance expensive research and development programmes, for which the knowledge and experience of physicians are essential. Moreover, industry support enables the progress of medical research, scientific conferences and continuing medical education that can be of benefit to patients and the entire health care system. The combination of financial resources and product knowledge contributed by industry and the medical knowledge possessed by physicians enables the development of new diagnostic procedures, drugs, therapies, and treatments and can lead to great advances in medicine.

However, conflicts of interest between commercial enterprises and physicians occur and can affect the care of patients as well as the reputation of the medical profession. The duty of the physician is to objectively evaluate what is best for the patient and to promote the patient-physician relationship, while commercial enterprises are expected to bring profit to owners by selling their own products and competing for customers. Commercial considerations can affect the physician’s objectivity, especially if the physician is in any way dependent on the enterprise.

Rather than forbidding any relationships between physicians and industry, it is preferable to establish guidelines for such relationships. These guidelines must incorporate the key principles of disclosure, transparency, avoidance of conflicts of interest and promoting the physician’s ability to act in the best interests of patients.

The guidelines regulating the Physician-Commercial Enterprise relationship should be understood in the light of WMA core ethical values, as stated in particular in the Declaration of Geneva, the International Code of Medical Ethics. the Statement on Conflict of Interest, and the Declaration of Seoul on Professional Autonomy and Clinical Independence.

The autonomy and clinical independence of physicians should be foremost in all physician decisions for patients, regardless of practice setting, whether government-sponsored, private, for profit or not for profit, investor funded, insurance company employers or otherwise.

Curricula of medical schools and residency programs should include educational courses on the relation between enterprises and the medical profession in the light of ethical principles and values of the profession.

RECOMMENDATIONS

Medical conferences

  1. These guidelines related to medical conferences apply, where pertinent, to corporation events, such as educational events, and promotional activities including for items of medical utility, sponsored by a commercial enterprise.
  2. Physicians may attend medical conferences, sponsored in whole or in part by a commercial entity if these conform to the following principles:
    • The main purpose of the conference is the exchange of professional or scientific information for the benefit of patient care.
    • Hospitality during the conference is secondary to the professional exchange of information and does not exceed what is locally customary and generally acceptable.
    • Physicians do not receive payment directly from a commercial entity to cover travelling expenses, room and board at the conference for themselves or an accompanying person or compensation for their time unless provided for by law and/or the policy of their National Medical Association, or unless it is a reasonable honorarium for speaking at the conference.
    • The name of a commercial entity providing financial support is publicly disclosed in order to allow the medical community and the public to fairly evaluate the information presented. In addition, conference organizers and lecturers are transparent and disclose any financial affiliations that could potentially influence educational activities or any other substantial outcome that may result from the conference.
    • In accordance with the WMA Guidelines on Promotional Mass Media Appearances by Physicians, presentation of material by a physician should be scientifically accurate, give a balanced review of possible treatment options, and not be influenced by the sponsoring organization.
  1. In addition, a conference can be recognized for purposes of continuing medical education/ continuing professional development (CME/CPD) only if it conforms to the following principles:
    • The commercial entities acting as sponsors, such as pharmaceutical companies or enterprises in the medical devices sector, have no influence on the content, presentation, choice of lecturers, or publication of results.
    • Funding for the conference is accepted only as a contribution to the general costs of the meeting.
    • The independence of the contents of the conference is guaranteed.

Gifts

  1. To preserve the trust between patients and physicians, physicians should decline:
    • cash, cash equivalents and other gifts for personal benefit from a commercial entity
    • gifts designed to influence clinical practice, including direct prescription incentives.
  1. Physicians may accept:
    • Promotional aids provided that the gift is of minimal value and is not connected to any stipulation that the physician uses certain instruments, medications or materials or refers patients to a certain facility.
    • Cultural courtesy gifts on an infrequent basis according to local standards if the gift is of minimal value and not related to the practice of medicine.

Research

  1. A physician may carry out research funded by a commercial entity, whether individually or in an institutional setting, if it conforms to the following principles:
    • The physician is subject only to the law, the ethical principles and guidelines of the Declaration of Helsinki, and clinical judgment when undertaking research and should guard against external pressure regarding the research results or its publications.
    • If possible, a physician or institution wishing to undertake research approaches more than one commercial source for research funds.
    • Identifiable personal information about research patients or voluntary participants is not passed to the sponsoring company without the consent of the individuals concerned.
    • A physician’s compensation for research is based on his or her time and effort and such compensation must not be connected to the results of the research.
    • The results of research are made public with the name of the sponsoring entity disclosed, along with a statement disclosing who requested the research. This applies whether the sponsorship is direct or indirect, full or partial.
    • Commercial entities allow unrestricted publication of research results.
    • Where possible, research financed by commercial enterprises should be managed by interposed, non-profit entities, such as institutes or foundations.

Affiliations with Commercial Entities

  1. A physician may not enter into an affiliation with a commercial entity, such as consulting or membership on an advisory board unless the affiliation conforms to the following principles:
    • The affiliation does not compromise the physician’s integrity.
    • The affiliation does not conflict with the physician’s obligations to his or her patients.
    • The affiliation or other relationship with a commercial entity is fully disclosed in all relevant situations, such as lectures, personal appearances, articles, reports and influential contributions to the mission of medical associations or other non-profit health entities.

Adopted by the 51st World Medical Assembly, Tel Aviv, Israel, October 1999,
revised by the 60th WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212th WMA Council Session, Santiago, Chile, April 2019

 

PREAMBLE

1. Under the law of some jurisdictions medical procedures are patentable. Patents on medical procedures are often called medical procedure patents. A medical procedure patent or patent claim is one that only confers rights over procedural steps and does not confer rights over any new devices.

2. Over 80 countries prohibit medical procedure patents. The practice of excluding medical procedures from patentability is consistent with the Uruguay Round of Amendments to the General Agreements on Tariffs and Trade Agreement on Trade Related Aspects of International Property Rights (GATT-TRIPs), which states: “Members may also exclude from patentability: (a) diagnostic, therapeutic and surgical methods for the treatment of humans or animals” (Article 27).

3. The purpose of patents is to encourage private investment in research and development. However, physicians, particularly those who work in research institutions, already have incentives to innovate and improve their skills. These incentives include professional reputation, professional advancement, and ethical and legal obligations to provide competent medical care (International Code of Medical Ethics, 17.A). Physicians are already paid for these activities, and public funding is sometimes available for medical research. The argument that patents are necessary to spur invention of medical procedures, and that without procedure there would be fewer beneficial medical procedures for patients, is not particularly persuasive when these other incentives and financing mechanisms are available.

4. Another argument is that patents are necessary, not so much for invention but for product development. This argument also is not persuasive in the case of medical procedure patents. Unlike device development, which requires investment in engineers, production processes, and factories, development of medical procedures consists of physicians attaining and perfecting manual and intellectual skills. As discussed above, physicians already have both obligations to engage in these professional activities as well as rewards for doing so.

5. Whether or not it is ethical to patent medical devices does not bear directly on whether it is ethical for physicians to patent medical procedures. Devices are manufactured and disseminated by companies, whereas medical procedures are “produced and disseminated” by physicians. Physicians have ethical or legal obligations to patients and professional obligations towards each other, which companies do not have. Having particular ethical obligations is part of what defines medicine as a profession.

7. There is no a priori reason to believe that those holding medical procedure patents would make patented medical procedures widely available. Patentees might attempt to maximize their profits by making the procedure widely available through nonexclusive licensing with low fees. Alternatively, they might attempt to maximize profits by limiting availability of the procedure and charging higher prices to those for whom the procedure is extremely important and who have the means to pay.

8. Competition between organizations providing health care could provide incentives for some organizations to negotiate exclusive licenses, or licenses which sharply limit who else could practice the procedure. Such a license might provide the organization with an advantage in attracting patients, if the organization could advertise that it was the only organization in a region which could provide a particularly desirable service. Thus, at least some of the time patentees will probably limit access to patented medical procedures.

9. Medical procedure patents may negatively affect patient care. If medical procedure patents are obtained, then patients’ access to necessary medical treatments might diminish and thereby undermine the quality of medical care. Access could diminish for the following reasons:

  • the cost of medical practice would likely increase because of licensing and royalty fees, and because the cost of physicians’ insurance would likely increase to cover patent litigation expenses.
  • some physicians capable of performing the patented procedure might not obtain licenses to perform it. The number of licensed physicians might be restricted because certain physicians cannot or will not pay the licensing fees or royalties, or because the patentee refuses to make the license widely available. Limiting the number of licenses would, in some circumstances, limit patients’ choice of physicians.
  • The presence of patents may prevent physicians from undertaking even those procedures which do not infringe. It may also deter a physician from introducing new or modified procedures into his or her practice. Devices can be labelled if they are patented, but procedures cannot, and therefore it is not immediately obvious whether what one is doing infringes somebody else’s medical procedure patent. However, lack of knowledge is no defence against patent infringement, so if a physician is uncertain he or she may simply refrain from performing the procedure.

10. Enforcement of medical procedure patents can also result in invasion of patients’ privacy or in the undermining of physicians’ ethical obligation to maintain the confidentiality of patients’ medical information. Where physicians practice in small groups or as sole practitioners, the most expedient methods for a patentee to identify instances of infringement might be to look through patients’ medical records or to interview patients. Removing obvious identifiers for the record review would not guarantee confidentiality, because identity can often be “reconstructed” with very few pieces of information. This would be particularly true in small towns or small practices.

11. Physicians have ethical obligations both to teach skills and techniques to their colleagues, and to continuously learn and update their own skills. Medical procedure patents can undermine these obligations. Once a patent has issued on a procedure, the procedure would be fully disclosed (this is one requirement for obtaining a patent); however, those without licenses would not be able to practice it. Limiting who can practice the procedure undermines the spirit of the ethical mandate to teach and disseminate knowledge. It also undermines the obligation to update one’s skills, because it does not do much good to acquire skills which cannot be used legally.

12. The obligation to teach and impart skills may also be impaired if the possibility of patents causes physicians to delay publishing new results or presenting them at conferences. Physicians may be inclined to keep new techniques secret while waiting to complete a patent application. This is because public use of a procedure, or publication of a description of the procedure, prior to applying for a patent may invalidate the application.

13. Physicians also have an ethical obligation not to permit profit motives to influence their free and independent medical judgment (International Code of Medical Ethics, 17.A). For physicians to pursue, obtain, or enforce medical procedure patents could violate this requirement. Physicians holding patents or licenses for procedures might advocate for the use of those procedures even when they are not indicated, or not the best procedure under the circumstances. Physicians who are not licensed to perform a particular procedure might advocate against that procedure, even when it is the best procedure under the circumstances.

14. Finally, physicians’ professional obligations to practice their profession with conscience and dignity (Declaration of Geneva) might be violated by the enforcement of medical procedure patents. The spectacle of physicians suing each other on a regular basis is unlikely to enhance the standing of the profession.

POSITION

15. The World Medical Association

  • states that physicians have an ethical responsibility to make relevant scientific information available to colleagues and the public, when possible.
  • states that the patenting of medical procedures poses serious risks to the effective practice of medicine by potentially limiting the availability of new procedures to patients.
  • considers that the patenting of medical procedures is unethical and contrary to the values of the medical profession that should guide physicians’ service to their patients and relations with their colleagues.
  • encourages national medical associations to make every effort to protect physicians’ incentives to advance medical knowledge and develop new medical procedures.

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and rescinded and archived by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

For over 150 years, the existence of health inequality has been acknowledged worldwide. The recently published Final Report of the WHO Commission on Social Determinants of Health  has highlighted the critical importance of health equity to the health, economy and social cohesiveness of all countries. It is clear that while there are major differences between countries, especially between the developing and developed countries, there are also substantial disparities within countries with respect to various measures of socio-economic and cultural diversity. Disparities in health can be defined as either disparities in access to healthcare, disparities in quality of care received, or both. The differences manifest themselves in a wide variety of health measures, such as life expectancy, infant mortality, and childhood mortality. Particularly disturbing is evidence of the gradual and ongoing widening of specific disparities.

At the core of this issue is the healthcare provided by physicians. National medical associations should take an active role in combating social and health inequalities in order to allow their physician members the ability to provide equal, quality service to all.

The Role of the Health Care System:

While the major causes of health disparities lie in the socio-economic and cultural diversity of population groups, there is a very significant role for the health care system in their prevention and reduction. This role can be summarized as follows:

  • To prevent the health effects of socio-economic and cultural inequality and inequity – especially by health promotion and disease prevention activities (Primary Prevention)
  • To Identify, treat and reduce existing health inequality, e.g. early diagnosis of disease, quality management of chronic disease, rehabilitation (Secondary and Tertiary Prevention).

RECOMMENDATIONS

The members of the medical profession, faced with treating the results of this inequity, have a major responsibility and call on their national medical associations to:

  • Recognize the importance of health inequality and the need to influence national policy and action for its prevention and reduction
  • Identify the social and cultural risk factors to which patients and families are exposed and to plan clinical activities (diagnostic and treatment) to counter their consequences.
  • Advocate for the abolishment of financial barriers to obtaining needed medical care.
  • Advocate for equal access for all to health care services irrespective of geographic, social, age, gender, religious, ethnic and economic differences or sexual orientation.
  • Require the inclusion of health inequality studies (including the scope, severity, causes, health, economic and social implications) as well as the provision of cultural competence tools, at all levels of academic medical training, including further training for those already in clinical practice.

Adopted by the 48th WMA General Assembly, Somerset West, South Africa, October 1996,
revised by the 59th WMA General Assembly, Seoul, Korea, October 2008 and
by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

AMR is a growing threat to global public health that transcends national boundaries and socioeconomic divisions. AMR affects human, animal and environmental health. It is a multi-faceted problem of crisis proportions with significant economic, health, and human implications.

Addressing the threat of antimicrobial resistance is a fundamental global health priority, and the responsibility of all countries.

Antimicrobial drugs form an essential component of modern medicine, ensuring that complex procedures, such as surgery and chemotherapy, can be performed with lower risk.

AMR threatens the effective prevention and treatment of an increasing range of infections caused by bacteria, parasites, viruses and fungi.

AMR occurs when microorganisms develop the ability to resist the actions of antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics).

Infections caused by bacteria that are resistant to multiple classes of antibiotic are increasingly being documented.

While AMR is a natural evolutionary phenomenon, it is exacerbated by the overuse and misuse of antimicrobials in medicine, as well as in veterinary practice and agriculture, and can be exacerbated when antimicrobials are given as growth promoters in animals or used to prevent diseases in healthy animals.

The emergence and spread of AMR is further enhanced by lack of access to effective drugs, access to antibiotics “over the counter” in some countries, the availability of substandard and falsified products, misuse of antibiotics in food production, increased global travel, medical tourism and trade, and the poor application of infection control measures.

Another major cause of AMR is the release of antibiotics into the environment. This can occur as either as a result of poor manufacturing practices, the improper disposal of unused medication, human and animal excretion, and the inadequate disposal of human and animal corpses.

In many countries, particularly in low-and middle-income countries, access to effective antimicrobials as well as complementary technologies including vaccines and diagnostics continues to remain a significant challenge, furthering AMR.

The ramifications of resistance manifest themselves not just in the impact on human health, but also in potentially heavy economic costs. The World Health Organization (WHO) has warned that resistance has reached alarming levels in many parts of the world, and that a continued increase in resistance could lead to 10 million people dying per year and a reduction of 2-3.5% in global gross domestic product by 2050.

At the rate at which resistance is growing globally, it poses a significant threat to successfully achieving the UN Sustainable Development Goals and undermines efforts to reduce health inequalities. Without harmonized and coordinated cross-sector action on a global, scale, the world is heading towards a post-antibiotic era in which common infections and minor injuries can once again kill.

AMR has reached great prominence at the highest political levels including the UN General Assembly, and the agenda of the G7 and G20.

There is a need for an effective ‘one health’ approach to minimize unnecessary or inappropriate use of antimicrobials and to prevent and control the transmission of existing resistance. A ‘one health’ approach recognizes that action is required across human medicine, veterinary practice and agriculture.

 

RECOMMENDATIONS

Global

  1. The primary prevention of community and healthcare associated infections is necessary to reduce the demand for antibiotics. Addressing the social determinants of infectious disease, such as poor living conditions and sanitation, will have co-benefits of reducing health inequalities and tackling AMR.
  2. Nations have varying resources available to combat antimicrobial resistance, and must cooperate with the WHO, Food and Agriculture Organization and World Organization for Animal Health that support the WHO Global Action Plan on AMR which provides the framework for national action plans.
  3. The World Medical Association and its constituent members should advocate for:
    • investment in the surveillance of drug resistant infections across human health, veterinary medicine, agriculture, fishing industry, and food production, and international cooperation for data-sharing procedures to improve global responses;
    • the WHO and other UN agencies should examine the role of international travel and trade agreements on the development of antimicrobial resistance, and promote measures in those agreements to act as safeguards against the globalisation of drug resistant pathogens in our food supply;
    • the WHO should continue to encourage the use of Trade Related Aspects of Intellectual Property Rights (TRIPS) flexibilities to help ensure affordable access to quality medicines and oppose the proliferation of ‘TRIPS-plus’ provisions within trade agreements, which restrict the use of TRIPS flexibilities and limit their effectiveness;
    • the widespread application of verifiable technology such as track-and-trace systems to ensure the authenticity of pharmaceutical products;
    • equitable access to, and appropriate use of, existing and new quality-assured antimicrobial medicines. This requires effectively applying the Access, Watch and Reserve lists of the WHO Essential Medicines program. For the WHO global action plan and national action plans to be effective, access to health facilities, health care professionals, veterinarians, knowledge, education and information are vital;
    • greater use of vaccinations which will reduce the burden of infectious disease, reducing the need for antibiotics and therefore limiting the emergence of resistance;
    • for global health organisations and governments to scale up their action and coordination in promoting appropriate antibiotic use and work together to reduce AMR using a One Health approach, which recognises that human, animal and environmental health is inextricably linked. to reduce the spread of resistance.
  4. The World Medical Association and its constituent members should encourage their governments to:
    • fund more basic and applied research directed toward the development of innovative antimicrobial agents, diagnostic tools and vaccines (innovative antimicrobial vaccines), and on the appropriate and safe use of such therapeutic tools;
    • ensure parity between financial and technical resources towards the development of innovative antimicrobial medicines, vaccines, and diagnostics as well as innovative infection control and prevention methods across human health, veterinary, and agricultural sectors;
    • support Research and Development efforts for novel antimicrobial agents, vaccines, and rapid diagnostic methods that are needs-driven and guided by the principles outlined in the UN Declaration on AMR, adopted in September 2016, including affordability, effectiveness, efficiency, and equity;
    • initiate regulatory measures to control the environmental pollution that allows the spread of antibiotic-resistant genes across soil, water and air;
    • educate a sufficient number of clinical infectious disease specialists in every country, which is a fundamental requirement for tackling antimicrobial resistance and hospital-acquired infections.

National

  1. National medical associations should urge their governments to:
    • require that antimicrobial agents be available only through a prescription provided by healthcare professionals and/or veterinary professionals and dispensed or sold by professionals;
    • initiate national campaigns to raise awareness among the public of the harmful consequences of overuse and misuse of antibiotics. This should be supported through the introduction of national targets to raise public awareness;
    • support professional societies, civil society, and healthcare delivery systems to pilot and adopt proven behaviour change strategies to ensure appropriate use of antibiotics;
    • ensure access to appropriate and fit-for-purpose point-of-care diagnostics in hospitals and clinics to support decision making and prevent inappropriate prescribing of antibiotic;
    • mandate the collection of data on antibiotic use, prescriptions, prices, resistance patterns, and trade in both the healthcare and agricultural sectors. This data should be made publicly accessible;
    • promote effective programs of antimicrobial stewardship and training on the appropriate use of antimicrobials agents, and infection control;
    • actively pursue the development of a national surveillance system for the provision of antimicrobials and for antimicrobial resistance. Data from this system should be linked with or contributed to the WHO’s global surveillance network;
    • monitoring of antimicrobial use in food producing animals must be sufficiently granular to ensure accountability.
  2. National medical associations should:
    • encourage medical schools and continuing medical education programs to renew their efforts to educate physicians, who can in turn inform their patients, about the appropriate use of antimicrobial agents and appropriate infection control practices, including antibiotic use in the outpatient setting;
    • support the education of their members in areas of AMR, including antimicrobial stewardship, rational use of antimicrobials, and infection control measures including hand hygiene;
    • advocate for the publishing and communication of local information relating to resistance patterns, clinical guidelines and recommended treatment options for physicians;
    • in collaboration with veterinary authorities, encourage their governments to introduce regulations to reduce the use of antimicrobials in agriculture, in particular food producing animals, including restrictions on the routine use of antimicrobials for both prophylaxis and growth promotion, and on the use of classes of antimicrobial that are critically important in human medicine;
    • support regulation that prevents conflicts of interest among veterinarians, such as roles where veterinarians both prescribe and sell antibiotics;
    • consider the use of social media to educate and promote the proper use and disposal of antibiotic medications;
    • encourage parents to comply with the national recommended immunization schedules for children. Adults should also have easy access to vaccines against influenza and pneumococcal infections among others.

Local

  1. Health professionals and health systems have a vital role in preserving antimicrobial medicines.
  2. Physicians should:
    • have access to high-quality and reliable, evidence-based information free of conflict of interest and actively participate in and lead antimicrobial stewardship programs in their hospitals, clinics and communities to optimise antibiotic use;
    • raise awareness amongst their patients about antimicrobial therapy, its risks and benefits, the importance of adherence with the prescribed regimen, infection prevention practices, and the problem of AMR;
    • promote and ensure adherence hygiene measures (especially hand hygiene) and other infection prevention practices.

Adopted by the 59th WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed with minor revision by the 210th WMA Council Session, Reykjavik, Iceland, October 2018

PREAMBLE

Mercury is a naturally occurring heavy metal that is a potent neurotoxin. The most likely routes of human exposure on a population basis are ingestion of methylmercury from contaminated fish. Less commonly, individuals are exposed via inhalation of inorganic mercury vapor after a spill or during a manufacturing process.

Mercury has been the ideal choice for use in medical devices that measure temperature and pressure. Therefore, a typical large hospital may have more than a hundred pounds of mercury onsite incorporated into various devices in separate locations.

Hospitals and clinics can avoid the occupational or environmental risk of mercury by using products that don’t rely on mercury-based technology. Major healthcare institutions around the world have demonstrated that safe, effective alternative products exist, and can be safely used for most situations, such as electronic thermometers, recently calibrated aneroid devices and mercury-free batteries.

Although the rationale for instituting voluntary mercury replacement initiatives is compelling from both occupational and environmental perspectives, financial considerations may ultimately motivate hospitals to undertake a mercury replacement program. Hazardous waste clean-up costs, reporting requirements for spills, disruptions in services, and staff training are costly. The cost of cleaning up one significant contamination can be substantially higher than the cost of converting to mercury-free alternatives.

By implementing a “best practices” management method for mercury use, the need for increased government regulations in the future, may be avoided. Such regulations may create costly burdens that some facilities may not be able to meet.

The World Medical Association (WMA) recalls its statement on Environmental Degradation and Sound Management of Chemicals that provides recommendations for advocacy measures and capacity building in order to tackle this issue.

RECOMMENDATIONS

The following recommendations are based on the urgent need to reduce both the supply and demand of mercury in the health care sector:

Global

The World Medical Association and its member national medical associations should:

  • Advocate for the United Nations and individual governments to voluntarily cooperate to implement key features of the United Nations Environment Programme (UNEP) Mercury Programme, which provides a framework for reducing the use, release, trade and risk related to mercury.
  • Enhance the activity of existing partnerships.

Regional/National

National medical associations should advocate that their governments work to reduce risks related to mercury in the environment by:

  • Reducing reliance on mercury mining in favor of environmentally-friendly sources of mercury, such as recycled mercury.
  • Developing options and scientifically sound plans for the long term safe storage of excess mercury supplies.
  • Urging Member States to ratify and implement the United Nations Minamata Convention on Mercury adopted in 2013 and designed to protect human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds.
  • Encouraging a phase-out of mercury use in the health care sector
  • Designing and implementing regulations and/or requirements designed to significantly reduce mercury emissions from coal combustion and cement production by using specific mercury emission controls.

Local

Physicians should:

  • Explore eliminating mercury-containing products in their offices and clinical practices, including thermometers, sphygmomanometers, gastrointestinal tubes, batteries, lamps, electrical supplies, thermostats, pressure gauges, and other laboratory reagents and devices.
  • Ensure that local hospitals and medical facilities have a plan to identify sources of mercury in their workplace, a commitment to mercury reduction, and a mercury management policy regarding recycling, disposal and education.
  • Encourage local hospitals and medical facilities to phase out mercury-containing products and switch to non-mercury equivalents.
  • Counsel patients about local and national advisories related to fish consumption designed to limit exposure to mercury in children and women of childbearing age.

Adopted by the 59th WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

Dietary table salt is an ionic compound comprising of sodium chloride, which is 40% sodium (Na+) and 60% chloride (Cl-). There is overwhelming evidence that excessive sodium intake is a risk factor for the development, or worsening of hypertension, which is one of the main cardiovascular risk factors. Hypertension may also be an independent risk factor for cardiovascular diseases as well as all-cause mortality. The effect of dietary sodium on blood pressure is influenced by various demographic factors such as age and ethnicity.

Salt intake is also a risk factor for gastric cancer [1].

The World Health Organization (WHO) recommends that average daily sodium consumption in adults (≥16 years of age) should be less than 2000 mg (5 g salt). For children (2–15 years of age), the adult intake limit of 2 g/day sodium should be adjusted downward based on the energy requirements of children relative to those of adults [2].

The majority of the world’s population consumes too much sodium – 3.95 (3.89–4.01) g/day, equivalent to table salt level of 10.06 (9.88–10.21) g/day. These consumption levels are far above the recommended limit [3].

The main source of sodium is dietary consumption, 90% of it in the form of salt [4], as added salt during cooking or eating, or in processed foods such as canned soups, condiments, commercial meals, baking soda, processed meats (such as ham, bacon, bologna), cheese, snacks, and instant noodles, among others. In higher-income countries sodium added during food processing can be as high as 75%-80% of total salt intake [5].

The Global Action Plan for the Prevention and Control of Non-Communicable Disease (NCDs) 2013-2020 is made up of 9 global targets, including a 30 % relative reduction in mean population intake of sodium. The WHO has created the S.H.A.K.E technical package to assist Member States with the development, implementation and monitoring of salt reduction strategies.

The WHO recognises that while salt reduction is recommended globally, there is concern that iodine deficiency disorders (IDD) may re-emerge as iodized salt is the main vehicle for dietary iodine intake through fortification. Therefore the WHO, in recognition of the importance of both sodium reduction and iodine fortification, urges that efforts of the two programs be coordinated [6].

Substantial overall benefits can result from even small reductions in the population’s blood pressure. Population-wide efforts to reduce dietary sodium intake are a cost-effective way to reduce overall hypertension levels and subsequent cardiovascular disease. Evidence shows that keeping sodium consumption within the reference level could prevent an estimated premature 2.5 million deaths each year globally [7].

 

RECOMMENDATIONS

1. WMA and its Constituent Members should:

a. Urge governments to recognise that salt consumption is a serious public health problem and prioritise prevention as an equitable, cost effective and lifesaving population-wide approach to address high sodium intake and the associated high burden of cardiovascular diseases.

b. Work in cooperation with national and international health organisations to educate consumers from childhood about the effects of excessive sodium intake on hypertension and cardiovascular disease, the benefits of long-term reductions in sodium intake, and about the dietary sources of salt/sodium and how these can be reduced.

c. Urge the governments and other stakeholders work together to achieve the targets set in the Global Action Plan for the Prevention and Control of NCDs 2013-2020.

d. Recognise the critical role of the food processing and food services industry in reducing dietary sodium, and support regulatory efforts involving mandatory targets in food processing, sodium content of foodstuffs, and clear labelling. Food reformulation efforts must target food products that are most commonly consumed in the population.

2. Constituent members of WMA should:

a. Encourage their governments strictly to enforce laws regulating the sodium content in processed foods.

b. Embrace a multi stakeholder approach in working towards reducing the consumption of excessive sodium by the population, including active promotion of physician awareness regarding the effects of excessive dietary sodium.

c. Recognise that sodium reduction and salt iodization programmes need to be compatible and support sodium reduction strategies that do not compromise dietary iodine content, or increase or worsen iodine deficiency disorders, especially in low income settings.

d. Contribute to making the public aware of the potential consequences of low iodine levels as a result of restricted iodized salt intake.

e. Encourage their members to contribute to scientific research on sodium reduction strategies.

f. Encourage the initiation of food labeling, media campaigns and population-wide policies such as mandatory reformulation to achieve larger reductions in population-wide salt consumption than individually focused interventions.

3. Individual physicians should:

Counsel patients about the major sources of sodium in their diets and how to reduce sodium intake, including reducing the amount of salt used in cooking at home, use of salt substitutes, and addressing any relevant local practices and beliefs that contribute to high sodium intake.

 

References:

[1] World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007.

[2] Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012.

[3] Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata, Khatibzadeh, Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz, Ezzati, Majid and Powles, John (2014) Global sodium consumption and death from cardiovascular causes. New England Journal of Medicine, 371 7: 624-634. doi:10.1056/NEJMoa1304127.

[4] J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev. Panam. Salud Publica, 32 (4) (2012), pp. 293-300.

[5] World Health Organization Regional Office for Europe Mapping salt reduction initiatives in the WHO European Region (Web. 10 May 2014.) http://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping-salt-reduction-initiatives-in-the-WHO-European-Region.pdf (2013).

[6] Salt reduction and iodine fortification strategies in public health. 2014. http://www.who.int/nutrition/publications/publichealth_saltreduc_iodine_fortification/en/.

[7] McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V, Webster J, Campbell NRC.Population-level interventions in government jurisdictions for dietary sodium reduction. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010166. doi: 10.1002/14651858.CD010166.pub2.