Policy Type: Statement

Adopted by the 50th World Medical Assembly, Ottawa, Canada, October 1998
and revised by the 59th WMA General Assembly, Seoul, Korea, October 2008
and by the 66th WMA General Assembly, Moscow, Russia, October 2015
and by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018 

 

Preamble

The WMA Declarations of Geneva, of Helsinki and of Tokyo make clear the duties and responsibilities of the medical profession to preserve and safeguard the health of the patient and to dedicate itself to the service of humanity. Therefore, and in light of the catastrophic humanitarian consequences that any use of nuclear weapons would have, and the impossibility of a meaningful health and humanitarian response, the WMA considers that it has a duty to work for the elimination of nuclear weapons. To achieve a world free of nuclear weapons is a necessity.

 

Recommendations

Therefore, the WMA:

  1. Condemns the development, testing, production, stockpiling, transfer, deployment, threat and use of nuclear weapons;
  2. Requests all governments to refrain from the development, testing, production, stockpiling, transfer, deployment, threat and use of nuclear weapons and to work in good faith towards the elimination of nuclear weapons;
  3. Advises all governments that even a limited nuclear war would bring about immense human suffering and substantial death toll together with catastrophic effects on the earth’s ecosystem, which could subsequently decrease the worlds food supply and would put a significant portion of the world’s population at risk of famine;
  4. Is deeply concerned by plans to retain indefinitely and modernize nuclear arsenals; the absence of progress in nuclear disarmament by nuclear-armed states; and the growing dangers of nuclear war, whether by intent, including cyberattack, inadvertence or accident;
  5. Welcomes the Treaty on the Prohibition of Nuclear Weapons, and joins with others in the international community, including the Red Cross and Red Crescent movement, International Physicians for the Prevention of Nuclear War, the International Campaign to Abolish Nuclear Weapons, and a large majority of UN member states, in calling, as a mission of physicians, on all states to promptly sign, ratify or accede to, and faithfully implement the Treaty on the Prohibition of Nuclear Weapons; and
  6. Requests that all National Medical Associations join the WMA in supporting this Declaration, use available educational resources to educate the general public and to urge their respective governments to work urgently to prohibit and eliminate nuclear weapons, including by joining and implementing the UN Treaty on the Prohibition of Nuclear Weapons.

Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992,
Amended by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007
And reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017

 

PREAMBLE

Given growing environmental awareness and knowledge of the impact of noise on health, the psyche, performance and well-being, environmental noise is becoming a serious public health threat. The World Health Organization (WHO) describes noise as the principal environmental nuisance in industrial nations.

Noise affects people in various ways. Its effects relate to hearing, the vegetative nervous system, the psyche, spoken communication, sleep and performance. Since noise acts as a stressor, an increased burden on the body leads to higher energy consumption and greater wear. It is thus suspected that noise can primarily favour diseases in which stress plays a contributory role, such as cardiovascular diseases, which can then be manifested in the form of hypertension, myocardial infarction, angina pectoris, or even apoplexy.

The effects in the psychosocial field are likewise dramatic. The stress caused by environmental noise is a central concern, not only in the industrial nations, but increasingly also in the developing countries. Owing to the continuous and massive growth of traffic volumes, both on the roads and in the air, the stress caused by environmental noise has increased steadily in terms of both its duration and the area affected.

Similarly, occupational noise generates increasingly work-related hearing impairment.

Damage to hearing caused by leisure-time noise is also of growing concern. The most common source of noise in this context is music, to which the ear is exposed by different audio media at different places (portable music players, stereo systems, discotheques, concerts). The risk of suffering hearing damage is underestimated by most people, or even consciously denied. The greatest issue (or aspect) lies in creating awareness of the problem in the high-risk group – which generally means young people. In this respect, the legislature is called upon to intervene and reduce the potential for damage by introducing sound level limiters in audio playback units and maximum permissible sound levels at music events, or by banning children’s toys that are excessively loud or produce excessive noise levels.

In keeping with its socio-medical commitment, the World Medical Association is issuing a statement on the problem of noise pollution with the aim of making a contribution to the fight against environmental noise through more extensive information and more acute awareness.

RECOMMENDATIONS

The World Medical Association calls upon the National Medical Associations to:

  1. Inform the public, especially persons affected by environmental noise, as well as policy and decision makers, of the dangers of noise pollution.
  2. Call upon ministers of transport and urban planners to develop alternative concepts that are capable of countering the growing level of environmental noise pollution.
  3. Advocate appropriate statutory regulations for combating environmental noise pollution.
  4. Support enforcement of noise pollution legislation and monitor the effectiveness of control measures.
  5. Inform young people of the risks associated with listening to excessively loud music, such as that which emanates, for example, from portable music players, use of stereo systems with earphones, audio systems in cars, and attendance at rock concerts and discotheques.
  6. Prompt the educational authorities to inform pupils at an early stage regarding the effects of noise on people, how stress due to environmental noise can be counteracted, the role of the individual in contributing to noise pollution, and the risks associated with listening to excessively loud music.
  7. Provide information about risks of damage to hearing that arise in the private sector as a result of working with power tools or operating excessively loud motor vehicles.
  8. Emphasize to those individuals who are exposed to excessive levels of noise in the workplace the importance of protecting themselves against irreducible noise.
  9. Call upon the persons responsible for occupational safety and health in businesses to take further action to reduce noise emission, and mandate access to physical hearing protection in high risk occupations, in order to ensure protection of the health of employees at the workplace.

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

 

PREAMBLE

Opiate and psychotropic drugs are valuable therapeutic tools when used as medically indicated for a variety of symptoms and conditions. Indeed, the WMA has called for the greater provision of pain management treatment in its Resolution on the Access to Adequate Pain Treatment (Montevideo, Uruguay, October 2011). Unfortunately, non-clinical misuse of these addictive substances is an enormous problem worldwide. Drug addiction is a complex social, economic and legal issue as well as a threat to public health and safety globally. It affects people from all demographic and social groups and economic spheres. In addition to exposing themselves to the direct health risks related to the inappropriate use of these substances, persons addicted to drugs may engage in high risk behaviour, such as needle-sharing and unprotected sex, and many resort to criminal activity to finance their expensive addiction. These factors increase transmission of viral infections, such as Hepatitis B and C and HIV/AIDS, among both users and non-users alike. Other results of addiction include failure to maintain employment or to function in social and family life.

The legal ramifications of non-medical drug use, which is illegal in most countries, generally do little to assist users in breaking free from their addiction. Despite the presence of drug programs in many correctional facilities, illegal substances are very often available to inmates and, in fact, some users begin their addiction in these institutions. Addressing addiction therefore falls largely to society and the health profession.

The World Medical Association, concerned by the widespread misuse of psychotropic and opiate drugs, urges physicians to prioritize this problem in the practice of medicine and to adhere to the following guidelines. 

PRINCIPLES

Responsible prescribing practices

Physicians should be aware of the addictive properties of certain psychotropic and opiate drugs. Such drugs should be prescribed with the greatest restraint, observing the strictest possible generally accepted medical indications. Physicians must take all necessary measures to ensure that they are fully informed of the effects of these drugs. This includes reviewing up-to-date research regarding dosage, potential effectiveness for the specific condition, potential side effects and pharmacological interactions and prevalence of misuse.

When such drugs are medically indicated, their use must be carefully monitored to ensure that the patient is following strict dosage instructions, timing and any other factors associated with the safe use of the particular drug. All appropriate measures must be taken to prevent the stockpiling, resale or other illicit usage of the drug.

Patients must be fully informed of all potential therapeutic and non-therapeutic effects of psychotropic and opiate drugs, including potential for addiction, and be fully involved in the decision to take them. No competent patient should be forced to take any psychotropic drug against his or her will.

Physicians should be aware of non-medical factors that may predispose patients to addiction. These may include, among others, family history, past addiction, emotional trauma, depression or other mental health conditions and peer pressure, especially among young persons.

Physicians should learn to recognize ‘drug seekers’, addicted patients who attempt to obtain psychotropic and opiate drugs under false medical pretenses. Drug seekers often consult more than one physician in an effort to obtain multiple prescriptions. In extreme cases, drug seekers may harm themselves to create symptoms to obtain a prescription. All patient conditions and symptoms should be clinically verified, to the extent possible, and meticulous records maintained regarding the patient’s drug history. If databases containing patient drug records and prescribing histories are available, they should be consulted.

When prescribing any psychotropic or opiate substance to minors, physicians must ensure that the parents or guardians of the patient are fully informed of the potential misuse of the drug and encouraged to monitor the child carefully to ensure adherence to the physician’s instructions. Parents or guardians should be informed that, in some countries, it is increasingly common for children to sell prescription drugs to their peers.

Non-drug therapy for addicts to opiate and psychotropic drugs

Physicians should be aware of all non-drug treatment options for addicts to opiate and psychotropic drugs, including inpatient and outpatient programs and therapeutic communities, in which recovering addicts live in a supportive, drug-free environment. Most treatment programs are focused on breaking the cycle of drug dependence through detoxification, counselling – including ongoing peer support – and permanent abstinence from the use of any addictive opiate or psychotropic substance, including alcohol. Some offer educational and/or vocational programs to facilitate successful reintegration into community life.

Physicians should encourage their patients to participate in drug treatment programs at the earliest possible stage of addiction.

All efforts should be made to respect the dignity and autonomy of addicted patients. Involuntary inpatient treatment of addicted persons should be a last resort, according to established guidelines and, where applicable, legal requirements.

Drug therapy for addicts to opiate drugs

In some cases, persons addicted to opiate drugs may be treated using medications that relieve withdrawal symptoms and cravings for the addictive substance without producing the ‘high’ associated with opiates. These medications also provide cross tolerance to other opioids. The objective of drug treatment is the immediate cessation of the use of opiate drugs.

Drug therapy can assist the opiate-dependent patient to function in his or her normal environment and activities while working to overcome the opiate addiction. However, it should always be part of a multi-disciplinary approach that includes proven non-drug treatment elements, such as counselling and peer support.

Drug therapy should be administered according to established evidence-based guidelines and supervised by specially trained physicians with an appropriate support team.

Awareness raising and policy development

National Medical Associations (NMAs) should engage in cross-sectoral national efforts to raise awareness of the risks associated with the abuse of opiate and psychotropic drugs and to ensure the availability of appropriate treatment options for addicted persons. NMAs should encourage their members to participate in similar programs at the community level.

NMAs should promote appropriate drug prevention programming at all levels of the educational system, recognizing that experimentation with drugs is increasingly prevalent among younger age groups.

NMAs and physicians should participate in the development of evidence-based guidelines that support a multi-disciplinary approach to the treatment of drug addiction, including harm reduction strategies such as needle exchange programmes.

NMAs should participate in the development of legal procedures relating to illegal drug use to ensure that addicted persons are recognized as entitled to receive appropriate medical and rehabilitative care, including in correctional institutions.

CONCLUSION

Physicians have an important role to play in the treatment of drug addiction, both as clinicians and as advocates for the treatment, rights and dignity of persons addicted to these harmful substances. Treatment of addiction, like treatment for any disease or condition, should be undertaken in the best interests of the patient and according to established principles of medical ethics.

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

Obesity is one of the single most important health issues facing the world in the twenty-first century, affecting all countries and socio-economic groups and representing a serious drain on health care resources.

Obesity in children is of increasing concern and is emerging as a growing epidemic in itself.

Obesity has complex origins linked to economic and social changes in society including the obeso-genic environment within which much of the population lives.

Therefore the WMA urges physicians to use their roles as leaders to advocate for recognition by national health authorities that reduction in obesity should be a priority, with culturally and age appropriate policies involving physicians and other key stakeholders.

THE WMA RECOMMENDS THAT PHYSICIANS:

  • Lead the development of societal changes that emphasize environments which support healthy food choices and regular exercise or physical activity for all people, with a specific focus on children;
  • Individually and through medical associations, express concern that excessive television viewing and video game playing are impediments to physical activity among children and adolescents in many countries;
  • Encourage individuals to make healthy choices and guide parents in helping their children to do so;
  • Recognise the role of personal decision making and the adverse influences exerted by current environments;
  • Recognise that collection and evaluation of data can contribute to evidence based management, and should be part of routine medical screening and evaluation throughout life;
  • Encourage the development of life skills that contribute to a healthy lifestyle in all persons and to better public knowledge of healthy diets, exercise and the dangers of smoking and excess alcohol consumption;
  • Advocate for appropriately trained professionals to be placed in educational facilities, highlighting the importance of education on healthy lifestyles from an early age;
  • Contribute to the development of better assessment tools and databases to enable better targeted and evaluated interventions;
  • Ensure that obesity, its causes and management remain part of continuing professional development programmes for health care workers, including physicians;
  • Use pharmacotherapy and bariatric surgery consistent with evidence-based guidelines and an assessment of the risks and benefits associated with such therapies.

Adopted by the 52nd WMA General Assembly, Edinburgh, Scotland, October 2000,
revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006,
and rescinded at the 65th WMA General Assembly, Durban, South Africa, October 2014

A.  INTRODUCTION

  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 organs. In the light of these developments, there is a need for renewed reflection on ethical issues concerning organ donation and transplantation and on principles relevant to the resolution of these issues. Therefore, the World Medical Association has undertaken a review of issues and principles concerning transplantation and has developed this policy to provide guidance to medical associations, physicians and other health care providers as well as to those who develop policy and protocols bearing on these issues.
  2. This policy is based on principles of general and medical ethics. In matters of ethics, conflicts of values and principles are unavoidable; for example, there is a tension between a desire to procure organs for the purpose of providing important medical treatments on the one hand and the preservation of choice and personal liberty on the other. Applicable principles are referenced throughout this policy where they may help to clarify and make explicit the reasoning behind a given statement.

B.  PROFESSIONAL OBLIGATIONS OF PHYSICIANS

  1. The primary obligation of physicians is to their individual patients, whether they are potential donors or recipients of transplanted organs. In conjunction with this obligation physicians may also have responsibilities to the family members and close friends of their patients, for example, to seek and consider their views on organ retrieval from their deceased relative or friend. The obligation to the patient has primacy over any obligations that may exist in relationship to family members. Nevertheless, this obligation is not absolute; for example, the physician’s responsibility for the well-being of a patient who needs a transplant does not justify unethical or illegal procurement of organs.
  2. Physicians have responsibilities to society, which include promoting the fair use of resources, preventing harm and promoting health benefit for all; this may include promoting donation of organs.
  3. Transplant surgeons should attempt to ensure that the organs they transplant have been obtained in accordance with the provisions of this policy and shall refrain from transplanting organs that they know or suspect have not been procured in a legal and ethical manner.

C.  ORGAN PROCUREMENT: SOCIAL ASPECTS

  1. The WMA encourages its members to support the development of comprehensive, coordinated national strategies concerning organ procurement in consultation and cooperation with all relevant stakeholders. In developing strategy, due consideration should be given to human rights, ethical principles and medical ethics. Ethical, cultural and societal issues arising in connection with such a strategy, and with the subject of donation and transplantation in general, should be resolved, wherever possible, in an open process involving public dialogue and debate informed by sound evidence.
  2. Some types of organ transplantation have become established and important health care services. To the extent that the lack of organs is a barrier to the provision of needed treatment, the medical profession has an obligation to promote policies and protocols to procure organs for needed treatment consistent with societal values.
  3. It is important that individuals become aware of the option of donation and have the opportunity to choose whether or not to donate (e.g. facilitated choice). 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. Physicians should provide their patients with the opportunity to make a choice with respect to organ donation, ideally in the context of an ongoing relationship with the patient and in advance of any crisis giving urgency to the choice.
  4. The WMA supports informed donor choice. National Medical Associations in countries that have adopted or are considering a policy of “presumed consent”, whereby there is a presumption that consent has been given unless there is evidence to the contrary, or “mandated choice”, whereby all persons would be required to declare whether they wish to donate, should make every effort to ensure that these policies do not diminish informed donor choice, including the patient’s right to refuse to donate.
  5. Consideration should be given to the establishment of national donor registries to collect and maintain a list of country citizens who have chosen either to donate or not to donate their organs. 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 purposes other than registration. Provisions must be in place to ensure that the decision is adequately informed and that registrants can withdraw from the registry without penalty.

D.  ORGAN PROCUREMENT AT THE INSTITUTIONAL AND INDIVIDUAL LEVELS

  1. Organ donation can be enhanced by local policies and protocols. The WMA recommends that organ procurement programmes, hospitals and other institutions in which procurement occurs should:
    1. Develop policies and protocols encouraging the procurement of organs consistent with the statements in this policy. Such policies should be consistent with physicians’ professional obligations and societal values, including free and informed decision making, privacy, and equitable access to needed medical care.
    2. Make these policies and protocols known to transplant coordinators, physicians and other health care providers in the institution.
    3. Ensure that adequate resources are available to support proper implementation of the policies and protocols.

E.  DONATION AFTER DEATH

  1. Physicians have an obligation to ensure that interactions at the bedside, including those discussions related to organ donation, are sensitive and consistent with ethical principles and with their fiduciary obligations to their patients. This is particularly so given that conditions at the bedside of dying patients are not ideal for the process of free and informed decision making. Protocols should specify that whoever approaches the patient, family members or other designated decision maker about the donation of organs 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. It is mandatory that the person who approaches the patient or family about the donation decision not be a member of the transplant team.

F.  FREE AND INFORMED DECISION MAKING ABOUT ORGAN DONATION

  1. The WMA considers that the potential donor’s wishes are paramount. In the event that the potential donor’s wishes about donation are unknown and the potential donor has died without expressing a clear wish about donation, the family or a specified other person may serve as a substitute decision-maker and may be entitled to give or refuse permission for donation unless there are previously expressed wishes to the contrary.
  2. Evidence of the free and informed decision of the potential donor, or, where legally relevant, of the appropriate substitute decision-maker, must be ascertained before organ procurement can begin. In countries where presumed consent is the legal norm, the organ procurement process should include reasonable steps to discover whether the potential donor has opted out of donation.
  3. Success in procuring organs for transplant should not be construed as a criterion for measuring the quality of the process of free and informed decision-making. The quality of this process depends on whether the choice was adequately informed and free of coercion and not on whether the outcome is a decision to donate.
  4. 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 organs must not be used for transplantation except for members of their immediate family.
  5. In order for the choice to donate organs to be duly informed, prospective donors or their substitute decision makers should, if they desire, be provided with meaningful and relevant information. Normally, this will include information about:
    1. in the case of living donors, the benefits and risks of transplantation,
    2. in the case of deceased donors, procedures and definitions involved in the determination of death,
    3. testing of organs to determine their suitability for transplantation, which may reveal unsuspected health risks in the prospective donors and their families,
    4. in the case of deceased donors measures that may be required to preserve organ function until death is determined and transplantation can occur,
    5. in the case of deceased donors what will happen to the body once death has been declared,
    6. what organs they are agreeing to donate,
    7. the protocol that will be followed concerning the family in the event that the family objects to donation, and
    8. in the case of living donors, the implications of living without the donated organ.
  6. Prospective donors should be informed that families sometimes object to donation; donors should be encouraged to discuss their choice with their family to prevent conflict.
  7. Prospective donors or their substitute decision makers should be given the opportunity to ask questions about donation and should have their questions answered sensitively and intelligibly.
  8. Where the wishes of the patient are known and there is no reason to believe that the choice to donate has been coerced, has not been adequately informed, or has changed, these wishes should be carried out. This should be clarified in law, policy and protocols. Under these circumstances, families should be encouraged to respect the patient’s clearly expressed wishes.
  9. Where the wishes of the patient are unknown or there is uncertainty about the patient’s wishes, national law should prevail.
  10. Protocols for free and informed decision making should also be followed in the case of recipients of organs. Normally, this should include information about:
    1. the risks of the procedure,
    2. the likely short, medium and long-term survival, morbidity, and quality-of-life prospects,
    3. alternatives to transplantation, and
    4. how organs are obtained.
  11. In the case of living donors, special efforts should be made to ensure that the choice about donation is free of coercion. Financial incentives for providing or obtaining organs for transplantation can be coercive and should be prohibited. Individuals who are incapable of making informed decisions, for example minors or mentally incompetent persons, should not be considered as potential living donors except in extraordinary circumstances and in accordance with ethics committee review or established protocols. In order to avoid a conflict of interest, the physician who obtains informed consent from the living donor should not be part of the transplant team for the recipient.

G.  DETERMINATION OF DEATH

  1. The WMA considers that the determination of death is a clinical matter that should be made according to widely accepted guidelines established by expert medical groups, and as outlined in The World Medical Association’s Declaration of Sydney on the Determination of Death and the Recovery of Organs.
  2. Protocols and procedures should be developed to educate patients and families about procedures for diagnosing death and the opportunities for donation after death.
  3. In order to avoid a conflict of interest, the physician who determines and/or certifies the death of a potential organ donor should not be involved in the organ removal or in subsequent transplantation procedures or responsible for the care of potential recipients of these organs.

H.  JUSTICE IN ACCESS TO ORGANS

  1. The WMA considers there should be explicit policies open to public scrutiny governing all aspects of organ donation and transplantation, including the management of waiting lists for organs to ensure fair and appropriate access.
  2. Policies governing the management of waiting lists should ensure efficiency and fairness. Criteria that should be considered in allocating organs include severity of medical need, length of time on the waiting list, and medical probability of success measured by such factors as type of disease, other complications, and histocompatibility. There should be no discrimination based on social status, lifestyle or behaviour.
  3. Special appeals for organs for a specific recipient require further study and ethical examination to evaluate the potential impact on the fairness of allocation.
  4. Payment for organs for donation and transplantation must be prohibited. A financial incentive compromises the voluntariness of the choice and the altruistic basis for organ donation. Furthermore, access to needed medical treatment based on ability to pay is inconsistent with the principles of justice. Organs suspected to have been obtained through commercial transaction must not be accepted for transplantation. In addition, the advertisement of organs in exchange for money should be prohibited. However, reasonable reimbursement of expenses such as those incurred in procurement, transport, processing, preservation, and implantation is permissible.
  5. Physicians who are asked to transplant an organ that has been obtained through a commercial transaction should refuse to do so and should explain to the patient why such a medical act would be unethical: because the person who provided the organ risked his or her future health for financial rather than altruistic motives, and because such transactions are contrary to the principle of justice in the allocation of organs for transplantation.

I.  EXPERIMENTAL AND NEWLY DEVELOPING TRANSPLANTATION PROCEDURES

  1. The WMA considers that, although many transplantation procedures have become standard medical care for a range of medical conditions, others are experimental and/or morally controversial and require further research, safeguards, guidelines, and public debate.
  2. Experimental procedures require protocols, including ethics review, that are different and more rigorous than those for standard medical procedures.
  3. Xenotransplantation raises special issues, particularly in light of the risk of unwitting cross-species transmission of viruses and other pathogens. There is an urgent need for extensive public debate about xenotransplantation to ensure that developments in this field are consistent with societal values. International guidelines to govern these practices should be developed.
  4. Transplantation of organs developed using cell nuclear replacement technologies requires scientific review, public debate and appropriate guidelines before becoming accepted.

Adopted by the 46th WMA General Assembly, Stockholm, Sweden, September 1994
revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th WMA General Assembly, Chicago, United States, October 2017
and rescinded and archived by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

PREAMBLE

1.      According to International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.

This definition excludes situations arising from conflicts and wars, whether international or internal, which give rise to other problems in addition to those considered in this paper.

2.      Disasters often result in substantial material damage, considerable displacement of people, many victims and significant social disruptions. Adequate preparation would make major consequences less likely and less severe and protect people especially the most vulnerable.

This document will focus particularly on the medical aspects of disasters. From a medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between resources and the capacity of medical professionals, and the needs of survivors who are injured whose health is threatened, over a given period of time.

3.      Disasters, irrespective of cause, share several common features:

3.1.     Their sudden and unexpected but often predictable occurrence, demanding prompt action;

3.2.     Material or natural damage making access to the survivors difficult and/or dangerous;

3.3.     Displacement or movement of often large numbers of people;

3.4.     Adverse effects on health due to various reasons such as physical injuries and high energy trauma, direct and indirect consequences of pollution, the risks of epidemics and emotional and psychological factors as well as factors such as reduced access to food, potable water, shelter, health care and other health determinants;

3.5.     A context of insecurity sometimes requiring police or military measures to maintain order; and

3.6.     Media coverage, and the use of social media.

4.      Disasters require multifaceted responses involving many different types of relief ranging from transportation and food supplies to medical services. Physicians are likely to be part of coordinated operations involving other responders such as law enforcement personnel. These operations require an effective and centralized authority to coordinate public and private efforts.

Rescue workers and physicians are confronted with exceptional circumstances, which require the continued need of a professional and ethical standard of care. This is to ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not influenced by other motivations. Inadequate and/or disrupted medical resources on site and a large number of people injured in a short time present specific ethical challenges.

RECOMMENDATIONS

5.      Medical profession is at the service of the patients and society at all times and in all circumstances. Therefore, the physicians should be firmly committed to addressing the health consequences of disasters, without excuse or delay.

6.      The World Medical Association (WMA) reaffirms its Declaration of Montevideo on Disaster Preparedness and Medical Response (2011) recommending the development of adequate training of physicians, accurate mapping of information on health system assets and advocacy towards governments to ensure planning for clinical care.

7.      The WMA recalls the primary necessity to ensure the personal safety of physicians and other responders during the event of disasters (Declaration on the Protection of Health Care Workers in situation of Violence, 2014).

Physicians and other responders must have access to appropriate and functional equipment, both medical and protective.

8.      Furthermore, the WMA recommends the following ethical principles and procedures with regard to the physician’s role in disaster situations:

8.1    A system of triage may be necessary to determine treatment priorities. Despite triage often leading to some of the most seriously injured receiving only symptom control such as analgesia, such systems are ethical provided they adhere to normative standards.  Demonstrating care and compassion despite the need to allocate limited resources is an essential aspect of triage.

Ideally, triage should be entrusted to authorized, experienced physicians or to physician teams, assisted by a competent staff. Since cases may evolve and thus change category, it is essential that the official in charge of the triage regularly assesses the situation.

8.2     The following statements apply to treatment beyond emergency care:

8.2.1      It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed else-where. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

8.2.2      The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum.

8.3    Relation with the patients

8.3.1      In selecting the patients who may be saved, the physician should consider only their medical status and predicted response to the treatment, and should exclude any other consideration based on non-medical criteria.

8.3.2      Survivors of a disaster are entitled to the same respect as other patients, and the most appropriate treatment available should be administered with the patient’s consent.

8.4    Aftermath of disaster

8.4.1      In the post-disaster period the needs of survivors must be considered. Many may have lost family members and may be suffering psychological distress. The dignity of survivors and their families must be respected.

8.4.2      The physician must make every effort to respect the customs, rites and religions of the patients and act in impartiality.

8.4.3      As far as possible, detailed records should be kept, including details of any difficulties encountered.  Identification of patients, including the deceased should be recorded.

8.5    Media and other third parties

Physicians should take into consideration that in any disaster media is present. The work of the media should be respected and facilitated as appropriate in the circumstances. If needed, physicians should be empowered to restrict the entrance of reporters and other media representatives to the medical premises. Appropriately trained personnel should handle media relations.

The physician has a duty to each patient to exercise discretion and to seek to ensure confidentiality when dealing with third parties. The physician must also exercise caution and objectivity and respect the often emotional and politicized atmosphere surrounding disaster situations. Any and all media especially filming must only occur with the explicit consent of each patient who is filmed. With regard to social media use, physicians must adhere to these same standards of discretion and respect for patient privacy.

8.6    Duties of paramedical personnel

The ethical principles that apply to physicians in disaster situations should also apply to other health care workers.

8.7    Training

The World Medical Association recommends that disaster medicine training be included in the curricula of university and post-graduate courses in medicine.

8.8    Responsibility

8.8.1      The World Medical Association calls upon governments and insurance companies to cover both civil liability and any personal damages to which physicians might be subject when working in disaster or emergency situations. This should also include life and disability coverage for physicians who die or are harmed in the line of duty.

8.8.2      The WMA requests that governments:

  • Ensure the preparedness of healthcare system to serve in disaster settings.
  • Share all information related to public health timely and accurately.
  • Accept the participation of demonstrably qualified foreign physicians, where needed, without discrimination on the basis of factors such as affiliation (e.g. Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or religion.
  • Give priority to the rendering of medical services over anything else that might delay necessary treatment of patients.

 

 

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

 

PREAMBLE

1.      Medical education consists of basic medical education, postgraduate medical education, and continuing professional development. Medical education is a dynamic process that commences at the start of basic medical education (medical school) and continues until a physician retires from active practice. Its goal is to prepare physicians to apply the latest scientific knowledge to promote health, prevent and cure human disease and mitigate symptoms. All physicians have a responsibility to themselves, the profession and their patients to maintain a high standard for medical education.

BASIC PRINCIPLES OF MEDICAL EDUCATION

2.      Medical education consists of training aimed at ensuring physicians acquire the competencies, skills and aptitudes that that allow them to practice professionally and ethically at the highest level.  All physicians, the profession as a whole, medical faculties, educational institutions, and governments share the responsibility for guaranteeing that medical education meets a high quality standard throughout the medical education continuum.

I.       BASIC MEDICAL EDUCATION

3.      The goal of basic medical education is to ensure that medical students have acquired the knowledge, skills, and professional behaviors that prepare them for a spectrum of career choices, including, but not limited to, patient care, public health, clinical or basic research, leadership and management, or medical education. Each of these career choices will require additional education beyond the first professional degree.

4.      At a medical school, the knowledge, skills and professional behavior that students should acquire should be based on the professional judgment of the faculty and accreditation councils, and be responsive to the healthcare needs of the region and/or the country. These decisions will inform the selection of students, the curriculum design and content, the student assessment system, and the evaluation of whether the school has achieved its goals. Such decisions should also be subject to relevant standards, the needs of fairness and accessibility, and diversity and inclusion in the medical workforce.

II.          SELECTION OF STUDENTS

5.          Prior to their entry to medical school, medical students should have acquired a broad education, ideally including background in the arts, humanities, and social sciences, as well as biological and physical sciences. Students should be chosen for the study of medicine based on their intellectual ability, motivation for medicine, previous relevant experiences, and character and integrity. The selection process for students must  not be discriminatory and should reflect the importance of increasing diversity in the medical workforce. A medical school should also consider its mission when developing admission requirements.

6.          Within a given country or region, there should be enough medical students to meet local and regional needs. National medical associations (NMAs) and national governments should collaborate to mitigate the economic barriers that prevent qualified individuals from entering and completing medical school.

7.          Curriculum and Assessment

7.1    A medical school’s educational program should be based on educational program objectives developed in response to the healthcare needs of the region and/or country. These educational program objectives must be used in the selection of curriculum content, the development of the system for student assessment, and the evaluations of whether the school has achieved its educational goals, subject to relevant regulatory and educational standards.

7.2    The medical curriculum should equip the student with a broad base of general medical knowledge.  This includes the biological and behavioral sciences, as well as the socio-economics of health care, the social determinants of health, and population and public health.  These disciplines, together with basic medical science,  are central to an understanding and practice of clinical medicine.  The WMA recommends that content related to medical ethics and human rights should be a core requirement in the medical curriculum.1 The student should also be introduced to the principles and methodology of medical research and how the results of research are used in clinical practice.  Students should have opportunities, if desired or required by the medical school, to participate in research.  The cognitive skills of self-directed learning, critical thinking, and medical problem solving should be introduced early in the medical curriculum to prepare students for clinical training.

7.3    Before beginning independent practice, every physician should complete a formal program of supervised clinical education.  Within basic medical education, clinical experiences should range from primary to tertiary care in a variety of inpatient and outpatient settings, such as university hospitals, community hospitals, clinics, physician practices, and other health care facilities.  The clinical component of basic medical education should use an apprenticeship  model of teaching using defined objectives and must involve direct experiences in the diagnosis and treatment of disease, with a gradual increase in the student’s responsibility based on his/her demonstration of the relevant knowledge and skills.  Experiences and training in interprofessional teams providing collaborative care to patients is important in preparing medical students for practice.

7.4    The medical school faculty have the responsibility to ensure that students who have graduated and received the first professional degree have acquired a basic understanding of clinical medicine, have the basic skills needed to evaluate clinical problems and take appropriate action, and exhibit the attitudes and character to be an ethical physician.  The assessment system within a medical school should include appropriate and valid methods to ensure that all graduates have met each of these expectations.  It would be useful for medical schools to have access to individuals with expertise in student assessment, either from within the medical school or from external sources.

8.      Student Support

8.1    Medical students should receive academic and social support, such as counselling for personal problems and programs to support well-being, to assist them in meeting the demands of medical school.  Academic support includes tutoring  and advice for study and time management skills.  Social support includes access to activities to promote their physical and mental well-being, as well as access to general and mental health services.  Mentors and advisors to assist students in specialty choice and career planning also should be available.

9.      Faculty and Institutional Resources

9.1    Basic medical education must be taught by appropriate staff including faculty who possess the appropriate qualifications that can only be achieved through formal training and experience. There should be a sufficient number of faculty to meet the educational, research, and other missions of the medical school. The selection process for faculty must be not be discriminatory. The faculty should have a formal commitment to the medical school, such as a faculty appointment, and be part of and subject to the medical school’s governance and departmental structures.

9.2    The faculty of a medical school are accountable for developing the medical curriculum and the student assessment system. As such, the educational program objectives, curriculum content and format, and evaluation of the curriculum are the responsibility of the faculty.  The faculty should review the curriculum frequently, ideally utilizing statistics on student achievement and input from students, graduates, and the practicing community. Furthermore, the faculty must regularly evaluate the quality of each component of the educational program and the program as a whole through the utilization of student and peer feedback. Medical schools should provide opportunities for faculty development to support the acquisition and maintenance of teaching and assessment, and curriculum development skills so that they can meet their responsibilities for the medical education program and curriculum design skills.

9.3    Medical schools must provide an academic environment which encourages learning and inquiry by faculty including an active institutional research program to advance the body of medical knowledge and the quality of care. Medical schools should provide support for faculty to acquire research skills and to engage in independent or collaborative research.

9.4    In addition to sufficient numbers of well-prepared faculty, medical schools must ensure that there are adequate library and information technology resources, classrooms, research laboratories, clinical facilities, and study areas for students in sufficient quantity to meet the needs of all learners. There must be an administrative support structure for things such as academic records maintenance and registrar functions.

10.    Financing Medical Education

10.1  National governments and medical schools should collaborate to develop financing mechanisms to support basic medical education. Support is needed for individual students and for the medical schools themselves. There should be sufficient financial resources for medical schools to educate the number of medical students required to meet national or regional health care system needs.

III.   POSTGRADUATE MEDICAL EDUCATION

11.    A graduate from a basic medical education institution must participate in a clinically-based advanced training program prior to being legally authorized to enter independent medical practice and, if required, obtaining a license to practice. Postgraduate medical education, the second phase of medical education continuum, prepares physicians for practice in a medical discipline or specialty and focuses on specific competencies needed for practice in that specialty area.

12.    Postgraduate medical education programs, also termed residency programs, include educational experiences that support the resident’s acquisition of the knowledge and skills characteristic of the specialty area. Depending on the specialty, postgraduate programs will use a variety of inpatient and ambulatory clinical settings, including community-based clinics, hospitals or other health care institutions. The education of residents should combine a structured didactic curriculum with clinical activity that includes the diagnosis and management of patients under appropriate and supportive levels of supervision. A residency program must ensure that each resident has opportunities to care for an adequate number of patients in order to gain experience in the range of conditions that characterize the specialty. These clinical experiences should occur in settings where high quality care is delivered, since educational quality and patient care quality are interdependent and must be pursued in a manner so that they enhance one another.

13.    A proper balance must be maintained so that residents are not required to meet clinical service needs at the expense of their education. The residency program should further the resident’s teaching and leadership skills and ability to contribute to continuous improvement. The program should also provide opportunities for scholarly activity aimed at enhancing scientific and critical thinking, clinical problem-solving, and life-long learning skills. These opportunities will have been introduced during basic medical education and should be reinforced during residency to prepare and motivate the resident to exercise these skills during practice. Additionally, a proper balance must be maintained among clinical work, education, and personal life.

14.    During the residency program, a resident takes on progressively greater responsibility for patient care based on his or her individual growth in clinical experience, knowledge, and skill. Allowing the resident to assume increased responsibility requires a system of assessment to monitor the resident’s increase in knowledge and skills over time. There also needs to be a process in place to conclusively determine that the resident is prepared to undertake independent medical practice.

15.    Postgraduate medical education should take place in institutions that are accredited or have been reviewed for quality.

IV.    CONTINUING PROFESSIONAL DEVELOPMENT

16.    Continuing professional development* (CPD) is defined as the activities that maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses on a daily basis to provide services for patients, the public, or the profession. CPD can include activities such as involvement in national or regional medical associations; committee work in hospitals or group practices; and teaching, mentoring and participating in education within his or her chosen specialty or more broadly within medicine.

17.    One of the components of CPD is continuing medical education (CME), in which the physician participates in medically-related educational activities. Physicians should further their medical education throughout their careers, including acquiring new knowledge and skills in response to scientific discoveries and the introduction of new treatments. Such educational experiences are essential to for the physician to keep abreast of developments in clinical medicine and the health care delivery environment, and to continue to maintain the knowledge and skills necessary to provide high quality care. In many jurisdictions, CME is specialty-defined and may be required for maintaining a medical license.

18.    The goal of continuing professional development is to broadly sustain and enhance the competent physician. Medical schools, hospitals and professional societies all share a responsibility for developing and making available to all physicians effective opportunities for continuing professional development, including continuing medical education.

 

RECOMMENDATIONS

19.    The demand for physicians to provide medical care, prevent disease, and give advice in health matters to patients, the public, and policy-makers calls for the highest standards of basic, postgraduate, and continuing professional development. Recommendations are as follows:

19.1  That the WMA encourage NMAs, governments, and other relevant stakeholder groups to engage in planning for a high quality continuum of medical education within countries that is informed by and supports the health care needs of the population.

19.2  That the WMA encourage NMAs to work with medical schools to plan and deliver faculty development that enhances the skills of medical school faculty as teachers and researchers.

19.3  That the WMA encourage NMAs and governments to engage in dialogue related to medical school and postgraduate program funding so that adequate numbers of well-trained physicians are available to meet national health care needs.

19.4  That NMAs and national governments collaborate to mitigate the economic barriers that prevent qualified individuals from entering and completing medical school.

19.5  That the WMA encourage NMAs to individually or collaboratively provide opportunities for continuing physician professional development and continuing medical education.

 

* Note on terminology: There are different uses of the term ‘Continuing Professional Development’ (CPD). One way to describe it is all those activities that contribute to the professional development of a physician including involvement in organized medicine, committee work in hospitals or group practices, teaching, mentoring and reading, to name just a few. One of the components of CPD can be Continuing Medical Education, which in many jurisdictions is specially defined and possibly required for licensure.

 

 

Adopted by the 36th World Medical Assembly, Singapore, October 1984
and revised by the 41st World Medical Assembly, Hong Kong, September 1989
42nd World Medical Assembly, Rancho Mirage, CA., USA, October 1990
44th World Medical Assembly, Marbella, Spain, September 1992
47th WMA General Assembly, Bali, Indonesia, September 1995
57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and 67th WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

 

OVER-ARCHING PRINCIPLE

1.     The welfare of children[1] is of paramount importance. Health professionals should put the welfare of children at the centre of all decision-making related to the child and act in the best interests of children in all of their interactions with children, young people, families, policy-makers and other professionals.

INTRODUCTION

2.     One of the most destructive manifestations of family violence and upheaval is child abuse[2] in all its forms. Prevention, protection, early identification, suitable interventions and comprehensive treatment of child abuse victims remain challenging for the world medical community. The World Medical Association (WMA) has called for increased health support of children living on the streets in its Statement on Supporting Health Support to Street Children, but it is also important to address the root causes of child abuse in all its forms.[3]

3.     Definitions of child abuse vary from culture to culture. Unfortunately, cultural rationalizations for harmful behaviour toward children may be accepted all too readily as proof that the treatment of children is neither abusive nor harmful. For instance, the work contribution of children in the everyday lives of families and in society should be recognized and encouraged only as long as it also contributes to the child’s own development. In contrast, exploitation of children in the labour market deprives them of their childhood and of educational opportunities and endangers their present and future health. The WMA considers such exploitation of children a serious form of child abuse in all its forms.

4.     For the purposes of this Statement, the various forms of child abuse include emotional abuse, physical abuse, sexual abuse, child trafficking, child exploitation and child neglect. Child neglect represents a failure of a parent, or other person legally responsible for a child’s welfare, to provide for the child’s basic needs and an adequate level of care.

RECOMMENDATIONS

The WMA recognizes that child abuse in all its forms is a world health problem and recommends that National Medical Associations adopt the following guidelines for physicians:

5.     Physicians have both a unique and special role in identifying and helping abused children and their families.

6.     All physicians should be educated about the paramount importance of the welfare of children.

7.     Physicians must be aware of and observe local laws regarding consent to undertake examinations of children. Physicians must act in the best interests of children in all of their interactions with children, young people, families, policy-makers and other professionals.

8.     Collaboration with an experienced multidisciplinary team is strongly recommended for the physician. Such a team is likely to include physicians, social workers, child and adult psychiatrists, developmental specialists, psychologists and attorneys. When participation in a team is not possible or such a team is not available, the physician must consult with other medical, social, law enforcement and mental health personnel as appropriate.

9.     Primary care physicians, family practitioners, internists, paediatricians, emergency medicine specialists, surgeons, psychiatrists and other specialists who treat children must acquire knowledge and skills in the physical, psychological and emotional assessment of child abuse in all its forms, the assessment of child development and parenting skills, the utilization of community resources, and the physician’s legal responsibilities.

10.  All physicians who treat children, and those adults with caring responsibilities for children, should be aware of the principles of the UN Convention on the Rights of the Child as well as relevant national protective legal provisions applying to children and young people.

11.  The medical evaluation of children who are suspected of having been abused should be performed by physicians skilled in both paediatrics and abuse evaluation. The medical evaluation needs to be tailored to the child’s age, injuries, and condition and may include blood testing, a trauma radiographic survey, and developmental and behavioural screenings. Follow up radiographs are strongly urged in some children who present with serious, apparently abusive injuries.

12.  The medical assessment and management of sexually abused children includes a complete history and physical examination, as physical and sexual abuses often occur together; examination of the genitalia and anus; the collection and processing of evidence, including photographs; and the treatment and/or prevention of pregnancy and venereal disease. Specific attention should be paid to the child’s right to privacy.

13.  It is essential for the physician to understand and be sensitive to the following: the quality of relationships between care-givers; disciplinary actions or styles used within the child’s home; economic stresses on the family; emotional stresses or issued experienced by members of the family; mental health problems exhibited by any members of the family; violence between the care-givers or other members of the family; substance use and abuse, including alcohol and legal and illegal drugs; and any other forms of stress that could relate to child abuse in all its forms.

14.  All physicians need to be aware that all forms of abuse of children by other children can occur.  Recognition that this may be a result of prior or current abuse of the alleged abuser must be at the forefront of the physician’s mind when such situations are suspected or encountered.

15.  The signs of abuse are often subtle, and the diagnosis may require comprehensive, careful interviews with the child, parent(s), care-givers, and siblings. Inconsistencies among explanation(s) and characteristics of the injury(s), such as the severity, type and age, should be documented and further investigated.

16.  In any child presenting to a medical facility, the emergent medical and mental health needs should be addressed first. If abuse is suspected, safety needs must be addressed prior to discharge from the facility. These measures should include:

  • Reporting all suspected cases to child protective services;
  • Hospitalizing any abused child needing protection during the initial evaluation period;
  • Informing the parents of the suspicion of abuse or diagnosis of abuse if it is safe to do so; and
  • Reporting the child’s injuries to child protective services or other relevant authorities.

17.  If hospitalization is required, a prompt evaluation of the child’s physical, emotional and developmental problems is necessary. This comprehensive assessment should be conducted by physicians with expertise or through a multidisciplinary team of experts with specialized training in child abuse.

18.  If child abuse is suspected, the physician should discuss with the parent(s) the fact that child abuse is in the differential diagnosis of their child’s problem. Advice may be required from child protective services.

19.  During discussions with the parent(s), guardians, or care-givers it is essential that the physician maintain objectivity and avoid accusatory or judgmental statements in interactions with the parent(s) or individual(s) responsible for the child’s care.

20.  It is essential that the physician record the history and examination findings in the medical chart contemporaneously during the evaluation process. Injuries should be documented using photographs, illustrations, and detailed descriptions. The medical record often provides critical evidence in court proceedings.

21.  Physicians should participate at all levels of prevention by providing prenatal and postnatal family counselling, identifying problems in child rearing and parenting, and advising about family planning and birth control.

22.  Public health measures such as home visits by nurses and other health professionals, anticipatory guidance by parents, and well-infant and well-child examinations should be encouraged by physicians. Programs that improve the child’s general health also tend to prevent child abuse in all its forms and should be supported by physicians and their representative bodies.

23.  Physicians should recognize that child abuse and neglect is a complex problem and more than one type of treatment or service may be needed to help abused children and their families. The development of appropriate treatment requires contributions from many professions, including medicine, law, nursing, education, psychology and social work.

24.  Physicians should promote the development of innovative programs that will advance medical knowledge and competence in the field of child abuse and neglect. Inclusion of on-going reviews of knowledge, skills and competency in relation to protecting the rights of children and young people, promoting their health and well-being and the recognition of and response to suspected cases of child abuse and neglect is crucial in professional educational programs. Physicians should obtain education on child neglect and abuse in all its forms during training as medical students.

25.  In the interests of the child, patient confidentiality may be waived in cases of child abuse. The first duty of a doctor is to protect his or her patient if victimization is suspected. No matter what the type of abuse (including physical abuse, emotional abuse, sexual abuse, trafficking, exploitation or neglect), an official report must be made to the appropriate authorities.

26.  Inclusion of on-going reviews of knowledge, skills and competency in relation to protecting the rights of children and young people, promoting their health and well-being and the recognition of and response to suspected cases of child abuse in all its forms and neglect is crucial in professional educational programmes.

27.  The undergraduate medical curriculum must include a mandatory course on child abuse, in all its forms, within the paediatrics program, that can be developed within postgraduate and continuing medical education for those intending to work within this field.

 

[1] The United Nations Convention on the Rights of the Child defines a child as anyone who has not reached their 18th birthday.
[2] Child abuse and Child maltreatment are used synonymously in this Statement.
[3] Neglect is the persistent failure to meet a child’s basic needs, likely to result in the serious impairment of a child’s health, well-being or development.

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

PREAMBLE

The world is undergoing a longevity extension at an unprecedentedly rapid pace. Over the last century, some 30 years have been added to global average Life Expectancy at Birth (LEB) – with more gains expected in the future. By 2050, LEB is projected to reach 74 years with an ever-increasing number of countries reaching 80 years and beyond. In 1950 the total number of people aged 80+ was 14 million – by 2050 the estimated number is 384 million, a 26-fold increase. The proportion of elderly will more than double from 10% in 2015 to 22% of the total population in 2050. These improvements are very variable; many of the poorest communities in all countries and a larger percentage of the population in the poorest countries have gained little in terms of life expectancy over this period of time.

The increase in longevity has been paired with a decreasing number of children, adolescents and younger adults as more and more countries experience Total Fertility Rates below replacement level, raising the average age in these countries.

The challenges of aging in developing countries are complicated by the fact that basic infrastructure is not always in place. In some cases, populations in developing countries are aging more quickly than infrastructure is being developed.

Longevity is arguably the greatest societal achievement of the 20th century but it could turn into a major problem during the 21st century. The World Health Organization (WHO) defines Active Ageing as “the process of optimizing opportunities for Health, Lifelong learning, Participation and Security in order of enhancing quality of life as individuals age”. This definition presupposes a life course perspective as the determinants that influence active ageing operates throughout the life course of an individual. These are social determinants of health and include behavioral determinants (life-styles), personal determinants (not only hereditary factors which are, overall, responsible for no more than 25% of the chances of ageing well but also psychological characteristics), the physical environment where one lives as well as broad social and economic determinants. All of these act individually on the prospects of active ageing but also interact among themselves: the more they interact and overlap, the higher the chance of an individual ageing actively. Gender and culture are crosscutting determinants, influencing all the others.

GENERAL PRINCIPLES

Medical Expenses

There is strong evidence that chronic diseases increase the use (and costs) of health services rather than age per se.

However, chronic conditions and disabilities become more prevalent with advancing age – therefore health care use and spending rise in tandem with age.

In many countries health care spending for older persons has increased over the years as more interventions and new technologies have become available for problems common in older age.

Effect of Ageing on Health Systems

Health care systems face two major challenges in the longevity revolution: preventing chronic disease and disability and delivering high quality and cost-effective care that is appropriate for individuals regardless of age.

In less developed regions the disease burden in old age is higher than in more developed regions.

Special Health Care Considerations

The leading diseases contributing to disability in all regions are cardiovascular diseases, cancers, chronic respiratory diseases, musculoskeletal disorders, and neurological and mental diseases, including the dementias. Some common conditions in older age are especially disabling and require early detection and management.

Chronic diseases common among older people include diseases preventable through healthy behaviors and/or lifestyle interventions and effective preventive health services – typically cardiovascular disease, diabetes, chronic obstructive pulmonary disease and many types of cancer. Other diseases are more closely linked to ageing processes and are not understood well enough to prevent them – such as dementia, depression and some musculoskeletal and neurological disorders.

While research may eventually lead to effective disability prevention or treatment, early management is key to controlling disability and/or maintaining quality of life.

Older persons may be more vulnerable to the effects of accidents within and outside the home. This will include risks when operating machinery such as road vehicles, but also risks from handling other potentially dangerous equipment. As older people continue to work these risks must be assessed and managed. Those who suffer injuries may have their recovery complicated by other medical vulnerabilities and comorbidities.

Considerations for Health Care Professionals

Health care for elderly people usually requires a variety of professionals working as an articulated team.

Education and training of health professionals to treat and manage the conditions common in the elderly are generally not sufficiently emphasized in undergraduate curricula.

Reducing Impact on Health Care

A comprehensive continuum of health services needs to be adopted urgently as population age. It should include health promotion, disease prevention, curative treatments, rehabilitation, management and prevention of decline, and palliative care.

Different types of health care providers offer these services, from self and family/informal care – sometimes in a voluntary capacity – to community-based providers and institutions.

Establishing Optimal Health Care Systems

Universal Health Care coverage ideally should be provided to all, including elderly people.

The vast majority of health problems can and should be dealt with at the community level. In order to provide optimal community care and ensure care coordination over time it is critical to strengthen Primary Health Care (PHC) services.

In order to strengthen PHC to promote active ageing, WHO advanced evidence-based principles for age-friendly PHC in three areas which should be considered: information/education/communication/ training, health management systems and the physical environment.

The health sector should encourage health systems to support all such dimensions of care provided to individuals as they age given the importance of health to ensure quality of life.

Specificities of Health Care

Many formal systems of health care have been developed with an emphasis on “acute or catastrophic care” of a much younger population, often focused on communicable diseases and/or injuries. Health systems should emphasize other needs, especially chronic diseases management and cognitive decline, when treating the elderly.

While acute care services are essential for people of all ages, but they are not focused on keeping people healthy or providing the ongoing support and care required to manage chronic conditions. A paradigm shift is needed to avoid treating chronic diseases as if they were acute conditions.

Medical conditions in older age often occur simultaneously with social problems and both need to be considered by health professionals when providing health care. Doctors, particularly specialists, should bear in mind that elderly patients may have other concurrent chronic diseases or comorbidities that interact with each other and that their treatment should not lead to inadvertent and preventable induction of complications.

When initiating a pharmacologic treatment for chronic disease in an elderly patient, prescribers should generally start low (doses) and go slow (increasing the doses) to accommodate the specific needs of the patient.

If the patient cannot decide for him/herself, due to the high prevalence of memory and cognitive problems in old age, physicians treating elderly patients should actively communicate with the family, and frequently with the formal caretaker, to better educate them about the patient’s health condition and about medication administration, in order to avoid complications.

When considering different therapeutic options, physicians should always seek to find out the wishes of the patient and recognize that for some patients quality of life will be more important than the potential results of more aggressive treatment options.

Education and Training for Physicians

All physicians should be appropriately trained to diagnose and treat the health problems of older people, which means mainstreaming ageing in the medical curriculum.

Secondary health care for the elderly should be provided as necessary. It should be holistic, including taking into consideration psychosocial as well as environmental aspects. Physicians should also be aware of the risks of elder abuse and measures to be taken when abuse is identified or suspected. (See the WMA Declaration of Hong Kong on the Abuse of the Elderly.)

Every doctor, particularly general practitioners, should have access to information and undergo training to identify and prevent polypharmacy and adverse drugs interactions that may be more common in elderly patients.

Continuing medical education on topics relevant to the ageing patient should be emphasized in order to help physicians adequately diagnose, treat, and manage the complexities of caring for an ageing population.

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

 

INTRODUCTION

1.      HIV/AIDS, a chronic manageable disease, is a global pandemic that has created unprecedented challenges for physicians and health infrastructures.

In addition to representing a staggering public health crisis, HIV/AIDS is also fundamentally a human rights issue.

Many factors drive the spread of the disease, such as poverty, homelessness, illiteracy, prostitution, human trafficking, drug (substance) abuse, stigma, discrimination and gender-based inequality.

These social, economic, legal and human rights factors affect not only the public health dimension of HIV/AIDS but also individual physicians/health workers and patients, their decisions and relationships.

Efforts to tackle the disease are also constrained by the lack of human and financial resources available in health care systems.

2.      Discrimination against HIV / AIDS patients by physicians is unacceptable and must be eliminated completely from the practice of medicine.

2.1    All persons with HIV/AIDS are entitled to adequate and timely support, treatment and care with compassion and respect for human dignity.

2.2    It is unethical for a physician to refuse to treat a patient whose condition is within his or her current realm of competence, solely because the patient is seropositive.

2.3    National Medical Associations should work with respective governments, patient groups and relevant national and international organizations to ensure that national health policies clearly and explicitly prohibit discrimination against people infected with or affected by HIV/AIDS, including vulnerable groups such as males having sex with males and transgender persons.

2.4    Woman and man having sex with same sex partners are at a higher risk of discrimination at all levels. National Medical organizations shall work with Government, Non-Governmental Organizations, and Community based organizations to remove the discrimination for these under-privileged disadvantaged groups.

 

APPROPRIATE / COMPETENT MEDICAL CARE

3.      Patients with HIV/AIDS must be provided with competent and appropriate medical care at all stages of the disease.

4.      A physician who is not able to provide the care and services required by patients with HIV/AIDS must make an appropriate timely referral to those physicians or facilities that are equipped to provide such services. Unless or until the referral can be accomplished, the physician must take care for the patient.

5.      All physicians should be able to timely suspect and identify common opportunistic infections such as tuberculosis, fungal infections in HIV-AIDs patients and also suspect HIV-AIDS in presence of these infections especially in high risk individuals like IV drug users.

They must timely counsel these patient about the nexus of these infections with HIV infection.

6.      Physicians and other appropriate professional bodies must ensure that patients have accurate information regarding transmission of HIV/AIDS and strategies to protect themselves against infection.

Proactive measures should be taken to ensure that all members of the population, particularly at-risk groups, are educated to this effect.

Public information and related strategies should recognise that everyone is at risk, and attempt to spell out methods of risk reduction.

7.      Physicians must effectively counsel all seropositive patients regarding responsible behaviour to prevent the spread of the infection to their partners and prevention of opportunistic infections.

8.      Physicians must recognize that many people still believe HIV/AIDS to be an automatic and immediate death sentence and therefore will not seek testing.

Physicians must ensure that patients have accurate information regarding the treatment options available to them.

Patients should understand the potential and need of starting early antiretroviral treatment (ART) to improve not only their medical condition but also the quality of their lives. The new strategy is test and treat strategy.

Effective ART can greatly extend the period that patients are able to lead healthy productive lives, functioning socially and in the workplace and maintaining their independence.

HIV/AIDS is now manageable chronic condition.

For ART country – specific WHO evidence based practice guidelines should be followed and promoted by all NMAs.

9.      Physicians should be aware that misinformation regarding the negative aspects of ART has created resistance toward treatment by patients in some areas. Where misinformation is being spread about ART, physicians and medical associations must make it an immediate priority to publicly challenge the source of the misinformation and to work with the HIV/AIDS community to counteract the negative effects of the misinformation.

10.    Physicians should encourage the involvement of support networks to assist patients in adhering to ART regimens. With the patient’s consent, counselling and training should be available to family members to assist them in providing care.

11.    Physicians must be aware of the discriminatory attitudes toward HIV/AIDS that are prevalent in society and local culture. Because physicians are the first, and sometimes the only, people who are informed of their patients’ HIV status, physicians should be able to counsel them about their basic social and legal rights and responsibilities or should refer them to counsellors who specialize in the rights of persons living with HIV/AIDS.

12.    Physicians should be aware of the current availability and prescribing guidelines for pre-exposure and post-exposure prophylaxis for any patient and health care providers who may have been exposed to HIV.

 

TESTING

13.    Mandatory testing for HIV must be required of donated blood and blood fractions collected for donation or to be used in the manufacture of blood products; organs and other tissues intended for transplantation; and semen or ova collected for assisted reproduction procedures.

Newer technologies which are more sensitive, specific, and reduce the window period of HIV detection, such as nuclear acid testing (NAT), should be encouraged for such screening.

14.    Mandatory HIV testing of an individual against his or her will is a violation of medical ethics and human rights.

15.    Physicians must clearly explain the purpose of an HIV test, the reasons it is recommended and the implications of a positive test result.

Before a test is administered, the physician should have an action plan in place in case of a positive test result. Informed consent must be obtained from the patient prior to testing.

16.    While certain groups are labeled “high risk”, anyone who has had unprotected sex should be considered at risk.

Physicians must become increasingly proactive about recommending testing to patients, based on a mutual understanding of the level of risk and the potential to benefit from testing. Pregnant women and her partner should routinely be offered testing for HIV, and those pregnant women found to be HIV positive should be offered immediate counseling and offered timely ART (at diagnosis) in order to prevent transmission of the virus to the fetus and treatment of the fetus if seropositive.

17.    Counselling and voluntary anonymous testing for HIV should be available to all persons who request it, along with adequate post-testing support mechanisms.

 

PROTECTION FROM HIV IN THE HEALTH CARE ENVIRONMENT

18.    Physicians and all health care workers have the right to a safe work environment. Especially in developing countries, the problem of occupational exposure to HIV has contributed to high attrition rates of the health labour force. In some cases, employees become infected with HIV, and in other cases fear of infection causes health care workers to leave their jobs voluntarily. Fear of infection among health workers can also lead to refusal to treat HIV/AIDS patients. Likewise, patients have the right to be protected to the greatest degree possible from transmission of HIV from health professionals and in health care institutions.

18.1  Proper infection control procedures and universal precautions consistent with the most current national or international standards, as appropriate, should be implemented in all health care facilities. This includes procedures for the use of preventive and timely bART for health professionals who have been exposed to HIV.

18.2  If the appropriate safeguards for protecting physicians or patients against infection are not in place, physicians and National Medical Associations should take action to correct the situation.

18.3  Physicians who are infected with HIV should not engage in any activity that creates a risk of transmission of the disease to others.

In the context of possible exposure to HIV, the activity in which the physician wishes to engage will be the determining factor.

There may be nationally agreed standards but if not a determination should be made by a suitable expert panel or committee of health workers.

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

18.5  If no risk exists, disclosure of the physician’s medical condition to his or her patients will serve no rational purpose.

18.6  Physicians should be aware of current professional guidelines for post-exposure prophylaxis of health care workers in case of any accidental exposure to HIV.

 

PROTECTING PATIENT PRIVACY AND ISSUES RELATED TO NOTIFICATION

19.    Fear of stigma and discrimination is a driving force behind the spread of HIV/AIDS. The social and economic repercussions of being identified as infected can be devastating and can include violence, rejection by family and community members, loss of housing and loss of employment.

Normalizing the presence of HIV/AIDS in society through public education is the only way to reduce discriminatory attitudes and practices. Until that can be universally achieved, or a cure is developed, potentially infected individuals may refuse testing to avoid these consequences.

The result of individuals not knowing their HIV status is not only disastrous on a personal level in terms of not receiving treatment, but may also lead to high rates of avoidable transmission of the disease. Fear of unauthorized disclosure of information also provides a disincentive to participate in HIV/AIDS research and generally thwarts the efficacy of prevention programs. Lack of confidence in protection of personal medical information regarding HIV status is a threat to public health globally and a core factor in the continued spread of HIV/AIDS. At the same time, in certain circumstances, the right to privacy must be balanced with the right of partners (sexual and injection drug) of persons with HIV/AIDS to be informed of their potential infection. Failure to inform partners not only violates their rights but also leads to the health problems of avoidable transmission and delay in treatment.

20.    All standard ethical principles and duties related to confidentiality and protection of patients’ health information, as articulated in the WMA Declaration of Lisbon on the Rights of the Patient, apply equally in the context of HIV/AIDS. In addition, National Medical Associations and physicians should take note of the special circumstances and obligations (outlined below) associated with the treatment of HIV/AIDS patients.

20.1  National Medical Associations and physicians must, as a matter of priority, ensure that HIV/AIDS public education, prevention and counselling programs contain explicit information related to protection of patient information as a matter not only of medical ethics but of their human right to privacy.

20.2  Special safeguards are required when HIV/AIDS care involves a physically dispersed care team that includes home-based service providers, family members, counsellors, case workers or others who require medical information to provide comprehensive care and assist in adherence to treatment regimens. In addition to implementing protection mechanisms regarding transfer of information, ethics training regarding patient privacy should be given to all team members.

Many countries have specific legislation to protect the privacy of those who are HIV positive. Others may consider the same.

20.3  Physicians must make all efforts to convince HIV/AIDS patients to take action to notify all partners (sexual and/or injection drug) about their exposure and potential infection. Physicians must be competent to counsel patients about the options for notifying partners. 
These options should include:

20.3.1    Notification of the partner(s) by the patient. In this case, the patient should receive counselling regarding the information that must be provided to the partner and strategies for delivering it with sensitivity and in a manner that is easily understood. A timetable for notification should be established and the physician should follow-up with the patient to ensure that notification has occurred.

20.3.2    Notification of the partner(s) by a third party. In this case, the third party must make every effort to protect the identity of the patient.

20.4  When all strategies to convince the patient to take such action have been exhausted, and if the physician knows the identity of the patient’s partner(s), the physician is compelled, either by law or by moral obligation, to take action to notify the partner(s) of their potential infection. Depending on the system in place, the physician will either notify directly the person at risk or report the information to a designated authority responsible for notification.

Physicians must be aware of the laws and regulations in the jurisdiction in which they are practicing. In cases where a physician must disclose the information regarding exposure, the physician must:

20.4.1    inform the patient of his or her intentions,

20.4.2    to the extent possible, ensure that the identity of the patient is protected,

20.4.3    take the appropriate measures to protect the safety of the patient, especially in the case of a female patient vulnerable to domestic violence.

20.5  Regardless of whether it is the patient, the physician or a third party who undertakes notification, the person learning of his or her potential infection should be offered support and assistance in order to access testing and treatment.

20.6  National Medical Associations should develop guidelines to assist physicians in decision-making related to notification. These guidelines should help physicians understand the legal requirements and consequences of notification decisions as well as the medical, psychological, social and ethical considerations.

20.7  As per local and national laws and guidelines requiring the reporting of new HIV infections, sexually transmitted diseases, and opportunistic infections, physicians must protect the privacy and confidentiality of all patients and maintain the highest ethical standards.

20.8  National Medical Associations should work with governments to ensure that physicians who carry out their ethical obligation to notify individuals at risk, and who take precautions to protect the identity of their patient, are afforded adequate legal protection.

 

MEDICAL EDUCATION

21.    National Medical Associations should assist in ensuring that there is training and education of physicians in the most current prevention strategies and medical treatments available for all stages of HIV/AIDS and associated infections, including prevention and support.

22.    National Medical Associations should, when appropriate, collaborate with NGOs and community based organizations, insist upon, and when possible assist with, the education of physicians in the relevant psychological, legal, cultural and social dimensions of HIV/AIDS.

23.    National Medical Associations should fully support the efforts of physicians wishing to concentrate their expertise in HIV/AIDS care, even where HIV/AIDS is not recognized as an official specialty or sub-specialty within the medical education system.

24.    The WMA encourages its national medical associations to promote the inclusion of designated, comprehensive courses on HIV/AIDS in undergraduate and postgraduate medical education programs, as well as continuing medical education.

INTEGRATION of HIV/AIDS SERVICES with other STDs MANAGEMENT ACTIVITES

25.    The National Medical Associations should support governments to integrate HIV/AIDS preventive and curative services with other STD management activities in a comprehensive manner.

 

Adopted by the 45th World Medical Assembly, Budapest, Hungary, October 1993,
revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd WMA Council Session, Buenos Aires, Argentina, April 2016 

 

PREAMBLE

Medical practitioners have an ethical duty and a professional responsibility to act in the best interests of their patients without regard to age, gender, sexual orientation, physical ability or disability, race, religion, culture, beliefs, political affiliation, financial means or nationality.

This duty includes advocating for patients, both as a group (such as advocating on public health issues) and as individuals.

Occasionally, this duty may conflict with a physician’s other legal, ethical and/or professional duties, creating social, professional and ethical dilemmas for the physician.

Potential conflicts with the physician’s obligation of advocacy on behalf of his or her patient may arise in a number of contexts:

  1. Conflict between the obligation of advocacy and confidentiality – A physician is ethically and often legally obligated to preserve in confidence a patient’s personal health information and any information conveyed to the physician by the patient in the course of his or her professional duties. This may conflict with the physician’s obligation to advocate for and protect patients where the patients may be incapable of doing so themselves.
  2. Conflict between the best interest of the patient and employer or insurer dictates – Often there exists potential for conflict between a physician’s duty to act in the best interest of his or her patients, and the dictates of the physician’s employer or the insurance body, whose decision may be shaped by economic or administrative factors unrelated to the patient’s health. Examples of such might be an insurer’s instructions to prescribe a specific drug only, where the physician believes a different drug would better suit a particular patient, or an insurer’s denial of coverage for treatment that a physician believes is necessary.
  3. Conflict between the best interests of the individual patient and society – Although the physician’s primary obligation is to his or her patient, the physician may, in certain circumstances, have responsibilities to a patient’s family and/or to society as well. This may arise in cases of conflict between the patient and his or her family, in the case of minor or incapacitated patients, or in the context of limited resources.
  4. Conflict between the patient’s wishes and the physician’s professional judgment or moral values – Patients are presumed to be the best arbiters of their best interests and, in general, a physician should advocate for and accede to the wishes of his or her patient. However, in certain instances such wishes may be contrary to the physician’s professional judgment or personal values.

RECOMMENDATION

  1. The duty of confidentiality must be paramount except in cases where the physician is legally or ethically obligated to disclose such information in order to protect the welfare of the individual patient, third parties or society. In such cases, the physician must make a reasonable effort to notify the patient of the obligation to breach confidentiality, and explain the reasons for doing so, unless this is clearly inadvisable (such as where telling the patient would exacerbate a threat). In certain cases, such as genetic or HIV testing, physicians should discuss with their patients, prior to performing the test, instances in which confidentiality might need to be breached.A physician should breach confidentiality in order to protect the individual patient only in cases of minor or incompetent patients (such as certain cases of child or elder abuse) and only where alternative measures are not available. In all other cases, confidentiality may be breached only with the specific consent of the patient or his/her legal representative or where necessary for the treatment of the patient, such as in consultations between medical practitioners.Whenever confidentiality must be breached, it should be done so only to the extent necessary and only to the relevant party or authority.
  2. In all cases where a physician’s obligation to his or her patient conflicts with the administrative dictates of the employer or the insurer, a physician must strive to change the decision of the employing/insuring body. His or her ultimate obligation must be to the patient.Mechanisms should be in place to protect physicians who wish to challenge decisions of employers/insurers without jeopardizing their jobs, and to resolve disagreements between medical professionals and administrators with regard to allocation of resources.Such mechanisms should be embodied in medical practitioners’ employment contracts. These employment contracts should acknowledge that medical practitioners’ ethical obligations override purely contractual obligations related to employment.
  3. A physician should be aware of and take into account economic and other factors before making a decision regarding treatment. Nonetheless, a physician has an obligation to advocate on behalf of his or her patient for access to the best available treatment.In all cases of conflict between a physician’s obligation to the individual patient and the obligation to the patient’s family or to society, the obligation to the individual patient should typically take precedence.
  4. Competent patients have the right to determine, on the basis of their needs, values and preferences, what constitutes for them the best course of treatment in any given situation.Unless it is an emergency situation, physicians should not be required to participate in any procedures that conflict with their personal values or professional judgment. In such non-emergency cases, the physician should explain to the patient his or her inability to carry out the patient’s wishes, and the patient should be referred to another physician, if required.

Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992
Revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th WMA General Assembly, Taipei, Taiwan, October 2016

 

INTRODUCTION

Deaths and injuries resulting from road crashes and collisions are a major public health problem. The World Health Organization’s 2015 Global status report on road safety indicates that the total number of road traffic deaths per year has reached 1.25 million worldwide, with the highest road traffic fatality rates in low-income countries.

Driving while under the influence of alcohol has caused a large number of the deaths and injuries resulting from road crashes. The prevalence of drinking and driving is increasing worldwide each year.

A change in the behaviour of road users with regard to alcohol consumption would appear to be the most promising approach to preventing traffic deaths and injuries. Measures forbidding driving while under the influence of alcohol will lead to a considerable improvement in road safety and an appreciable reduction in the number of dead and injured.

CONSEQUENCES OF DRINKING AND DRIVING

Driving a vehicle implies the acceptance of a certain number of risks. The careful driver will always be aware of the risks but also ensure that the level of risk never rises to an unacceptable level. Alcohol not only impairs one’s ability to drive, but it also alters a driver’s subjective assessment of risk so that he or she drives more recklessly.

Irrespective of the amount of alcohol consumed, the maximum concentration of alcohol in the body is reached:After half an hour when taken

  • on an empty stomach;
  • After an hour when taken with a meal.

On the other hand, it takes the body a long time to eliminate alcohol. An individual in good health eliminates alcohol at a rate that reduces blood alcohol concentration by 0.1 to 0.15 gram/litre/hour. Thus, one’s driving ability remains impaired long after he or she has stopped drinking.

Alcohol abuse has both short- and long-term neurological and psychiatric consequences that can endanger road safety.

Certain drugs interact negatively with alcohol, and in particular some combinations are known to reduce alertness. When drugs, whether legal or illegal, are taken with alcohol, the effect of the latter is intensified. This mixture can trigger mental dysfunctions that are extremely dangerous for road users. Physicians should be educated and informed about these pharmacological facts.

RECOMMENDATIONS 

1. The WMA reaffirms its commitments to work for reducing excessive alcohol consumption and for fostering harm-reduction policies and other measures (WMA Declaration on Alcohol, October 2015.)

2. Physicians and National Medical Associations should play an active role in promoting and advocating for the development of evidence-based government policies to reduce alcohol use and driving:

Policy interventions

3. At the present time, permitted blood alcohol levels while driving vary from country to country. Even small amounts of alcohol have a direct effect on the brain, with disturbances noted at levels as low as 0.3 grams per litre. Therefore, it would be desirable to lower the maximum permissible level of blood alcohol to a minimum, but not above 0.5 grams per litre, which is low enough to allow the average driver to retain the ability to assess risk.

4. The especially high prevalence in certain countries of driving while under the influence of alcohol may justify more coercive policies, which physicians and National Medical Associations should play an active role in supporting. For example, the driver may be declared unfit to drive for a period of time sufficient to ensure he or she will no longer be a threat to road safety in the future.

5. Government officials should consider implementing restrictions on the sale or affordability of alcohol, perhaps through taxation, licensing systems, and/or limits on the days and hours of sale. Restrictions on the promotion of alcoholic beverages, including advertising and event sponsorship, should also be considered.

6. A minimum legal age for alcohol purchase and consumption should be adopted in each country. Government officials should consider implementing a separate, lower or zero blood alcohol content law for young drivers.

7. There should be strict consequences to selling alcoholic beverages to individuals under the age to purchase and consume alcohol. These laws should be properly enforced.

8. Any driver who has been in a road traffic crash must undergo a blood alcohol concentration test or a breath test.

9. The practice of random driver testing for breath alcohol levels should become more widespread, and there should be further research into other ways to test urine, breath and saliva to identify impaired drivers and prevent subsequent operation of motor vehicles.

10. Devices that prevent individuals with an unauthorised level of blood alcohol from starting the engine of or operating the vehicle should be developed and experimented with.

Educational interventions

12. Educational interventions should promote moderation and responsibility in the consumption of alcohol and seek to reduce the likelihood that someone will consume alcohol and drive afterwards.

13. The information dispensed by physicians and other health professionals should be aimed at making everyone aware of the dangers of driving under the influence of alcohol. When physicians and other health professionals issue fitness-to-drive certificates, they can use this opportunity to educate road users and pass on a message of prevention and personal responsibility.

14. In most countries, road crashes linked to alcohol consumption affect adolescents and young adults to a disproportionately high degree, and every available resource should be mobilised to reduce their consumption of alcohol. The problem of alcohol consumption in adolescents and young adults and its relation to road safety should be addressed in the school curricula so that a responsible attitude becomes the norm.

Clinical and rehabilitative interventions

15. Physicians should also be involved in reducing the likelihood of impaired driving by participating in the detoxification and rehabilitation of drunk drivers. These initiatives should be based on a detailed analysis of the problem as it manifests itself within each country or culture. Generally speaking, however, alcoholism is a medical condition with concomitant psychological or social and interpersonal difficulties that affect the family, work or social environment.

16. Alcoholic subjects should be given access to rehabilitation services. When drivers are found to have excess alcohol in their blood (or their breath), other factors linked to their excessive drinking should be examined and included in a rehabilitation programme. These rehabilitation programmes should be publicly funded.

17. Road crashes linked to the consumption of alcohol can be considered as possible predictors of other addictive and violent behaviours. This should be taken into consideration in the medical treatment of the patient.

Community interventions

18. Strategies should be developed by relevant stakeholders to ensure safe transportation home in situations where alcohol consumption occurs.

19. Eliminating alcohol from the workplace and in situations where consumers must drive should be a goal of organizational policies. The promotion of non-alcoholic drinks is an important tool to facilitate these policies.

Adoptée par le 43e Assemblée médicale mondiale, Malte, Novembre 1991
et révisée par la 57e Assemblée générale de l’AMM, Pilanesberg, Afrique du Sud,
et par la 67e Assemblée générale de l’AMM, Taipei, Taiwan, Octobre 2016

PRÉAMBULE

Au cours des dernières décennies, il s’est produit un changement important concernant les causes de mortalité chez les adolescents. Alors que la plupart de ces derniers mouraient précédemment d’une mort naturelle, aujourd’hui ils risquent davantage de mourir de causes prévisibles. Ainsi assiste-t-on au niveau mondial à une augmentation du suicide chez les jeunes dans les pays développés comme dans les pays en voie développement. Parmi les adolescents, le suicide est actuellement l’une des causes majeures de décès. On sous-estime probablement les suicides à cause de la stigmatisation culturelle et religieuse liée à l’autodestruction et à un refus de voir dans certains traumatismes, tout comme dans quelques accidents de la route, une cause volontaire.

Le suicide d’un adolescent est une tragédie affectant non seulement l’individu mais aussi la famille, ses semblables et son entourage. Souvent, le suicide est vécu par les parents, les amis et médecins comme un échec personnel, ces derniers se reprochant de ne pas avoir décelé les signes d’avertissement. C’est également considéré comme un échec par la communauté ce qui prouve bien que la société moderne souvent n’assure pas un environnement nourricier, fraternel et sain permettant aux enfants de grandir et d’évoluer.

Il existe différents facteurs de suicide dont notamment : les troubles affectifs, les traumatismes, la solitude émotionnelle, le manque d’estime de soi, les graves tensions émotionnelles, les troubles alimentaires, le harcèlement ( à l’école, sur internet  et le harcèlement sexuel), les fantasmes romantiques, la recherche de sensations fortes, l’abus de drogues et d’alcool, l’existence d’armes à feu et d’autres agents d’autodestruction ainsi que les media rapportant des cas de suicides d’adolescents susceptibles d’inspirer des actes similaires. De plus l’exposition prolongée au média électronique, qui concerne principalement les adolescents au travers des jeux électroniques et des réseaux sociaux, peut contribuer à un isolement social, à des échecs scolaires et à un mal être parmi les jeunes.

Les jeunes dans les maisons de correction courent davantage de risques de suicide que la population en général tout en ayant moins de moyens disponibles. Le manque de ressources rend difficile l’identification de ceux  présentant des risques suicidaires.

On constate une proportion de suicides d’adolescent plus élevée au sein des populations “Autochtones” de certains pays. Les raisons pour cela sont complexes.

Les adolescents sont mieux soignés lorsque les médecins délivrent des prestations complètes, une évaluation et un traitement à caractère médical et psychosocial. Des soins complets et permanents permettent au médecin de recueillir les renseignements nécessaires pour identifier les adolescents présentant des risques suicidaires ou ayant un comportement autodestructeur. Ce type de prestations aide également à établir une relation patient-médecin socialement protectrice et susceptible de contrecarrer les mauvaises influences que subissent les adolescents dans leur entourage.

Dans son travail de prévention du suicide des adolescents, L’Association Médicale Mondiale reconnaît la nature complexe du développement bio-psycho-social de l’adolescent, les mutations sociales dans le monde auxquelles sont confrontés les adolescents et l’introduction de nouveaux agents plus létaux d’autodestruction. En réponse à ces préoccupations, elle recommande aux Associations Médicales Nationales d’adopter les directives suivantes pour les médecins. En agissant ainsi, nous reconnaissons que de nombreux autres acteurs – parents, gouvernements, agences, écoles, communautés, services sociaux – ont aussi un rôle important dans ce domaine.

RECOMMENDATIONS

  1. Tout médecin doit, au cours de ses études et pendant sa formation postuniversitaire, recevoir une formation en psychiatrie pédiatrique, y compris sur les facteurs de risque de suicide.
  2. La formation des médecins devrait permettre l’identification des premiers signes ou des premiers symptômes de détresse physique, émotionnelle et sociale chez l’adolescent. Ils devraient aussi être aussi formés à l’identification des signes et troubles psychiatriques tels que la dépression, les troubles bipolaires et l’addiction à des substances susceptibles de contribuer au suicide ainsi qu’aux autres comportements autodestructeurs.
  3. Les médecins devraient apprendre comment et quand évaluer un risque de suicide parmi ses patients adolescents.
  4. Les médecins doivent connaître et se tenir à jour des traitements, savoir où diriger ses patients adolescents quel que soit le degré de leur comportement autodestructeur. Les médecins ayant la plus grande formation en matière de suicide des adolescents sont les psychiatres pédiatres et c’est à l’un d’entre eux lorsqu’il existe que devraient être adressés les patients.
  5. Les médecins devraient aussi collaborer avec d’autres personnes compétentes telles que les travailleurs sociaux, les cadres scolaires et les psychologues spécialisés dans le comportement des enfants et des adolescents.
  6. Lorsqu’ils soignent des adolescents ayant un quelconque type de traumatisme, les médecins doivent envisager la possibilité que ces blessures résultent d’un acte volontaire.
  7. Lorsqu’ils soignent des adolescents présentant une détérioration au niveau cognitif, sentimental ou comportemental, il faudrait penser à l’abus de substances et l’addiction et fixer un faible seuil au-delà duquel un test toxicologique par les urines s’impose.
  8. Les systèmes de santé doivent permettre l’organisation de consultations de santé mentale afin de prévenir les suicides et prendre financièrement en charge les soins médico-sociaux des patients ayant fait une tentative de suicide. Les services doivent être adaptés aux besoins spécifiques des patients adolescents.
  9. Il faudrait de mener des études épidémiologiques sur le suicide, ses facteurs de risques ainsi que ses méthodes de prévention. Les médecins devraient être toujours informés de telles études.
  10. Lorsqu’ils soignent des adolescents présentant des troubles psychiatriques ou des risques suicidaires, les médecins devraient éduquer les parents ou les tuteurs à être attentifs aux signes de suicide et leur apprendre les modes d’évaluation.
  11. Les médecins devraient soutenir l’identification des groupes d’adolescents à risque avec la mobilisation de ressources identifiées spécifiquement à la prévention et la réduction des risques.

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

 

PREAMBLE

Serious injuries and mortality in road collisions are a public health problem with consequences similar to those of major diseases such as cancer and cardiovascular disease. Worldwide, about 1.2 million persons are killed each year on the roads, and an additional 20-50 million are injured. By 2020, road traffic injuries are expected to be the third largest contributor to the global burden of disease and injury.

In addition to the immeasurable personal and social price paid by road crash victims and their relatives, traffic injury has a significant economic impact. The economic costs of traffic injury and disability, including emergency and rehabilitative health care, costs of disability and disability adjusted life years (DALYs), amount to 1% of the GDP of poorer countries and 1.5-2% of wealthier countries. Much of this burden is borne by the health sector.

Road injuries continue to increase in many countries, particularly in low- and middle-income nations which currently account for 85% of all road traffic deaths, and are the second leading cause of death among youth worldwide.

Most traffic injuries could be prevented by better countermeasures. Combating traffic injury is the shared responsibility of groups and individuals at the international, national, and community levels, including governments, NGOs, industry, public health professionals, engineers and law enforcement personnel.

Speed is widely recognized as the most important determinant of road safety, affecting both the likelihood that a crash will occur and the severity of a crash. On average, an increase in speed of 1 km/h is associated with a 3% higher risk of a crash involving injury and a 5% higher risk of serious or fatal injury.

However, efforts to decrease road crashes and injury also require a “systems approach” that recognizes and addresses the many factors that contribute to the risk of traffic crashes and resulting injury, including human, vehicle and road design variables.

Preventing traffic injury requires addressing the social determinants of health—the social, economic, environmental, and political factors in society that influence a population’s health. Low- and middle-income countries, where there is less safe infrastructure, fewer minimum standards on vehicle safety, and poorer quality emergency care, experience the greatest number of traffic injuries. In this way, human, vehicular and environmental factors interact before, during and after a collision. Intervention at each of these stages will help reduce crashes and injury. Effective intervention requires public education as well as professional involvement in the fields of engineering, law enforcement and medical care.

Pre-collision intervention is aimed at preventing crashes and reducing risk factors. Examples include preventing drivers from driving when fatigued (especially drivers of heavy vehicles), distracted or under the influence of drugs or alcohol. Necessary policies may include prohibiting the use of hand-held cellular phones and night curfews or graduated licensing for young drivers. Pre-collision intervention also includes setting vehicle design standards that ensure that vehicles are roadworthy and cannot be driven at excessive speeds. Other interventions include setting and enforcing appropriate speed limits, installing speed cameras, and optimizing road design and layout to prevent crashes.

A second level of intervention is aimed at preventing or reducing injury during the crash. Such interventions include: enforcing the use of seat belts and child restraints; requiring helmets for cyclists; manufacturing vehicles equipped with safety devices and crash-protective design; lowering and enforcing speed limits; and removing heavy, rigid objects such as concrete or metal dividers, light posts and abutments from the sides of roads.

Post-crash intervention is aimed at maximizing life-saving and injury-reducing treatment and includes improved pre-hospital and emergency trauma care and rehabilitation.

RECOMMENDATIONS

  1. The WMA supports the findings and key recommendations of the WHO’s 2015 Report on road traffic injury prevention and calls for their implementation by its member National Medical Associations and their governments and relevant bodies.
  2. Physicians must view traffic injury as a public health problem and recognize their responsibility in fighting this global problem.
  3. National Medical Associations and their member physicians should work to persuade governments and policy makers of the importance of this issue and should assist in adapting empirical and scientific information into workable policies.
  4. National Medical Associations and physicians should be key players in public education and should include road safety in health promotion activities.
  5. Physicians should be involved in the collection and analysis of data regarding road crashes and concomitant injuries, including injury surveillance systems.
  6. Physicians should work toward changing the public attitude of road travel, including pressing for improved public transportation, bicycle paths and proper sidewalks to encourage less car use and the adoption of healthier options such as walking and cycling.
  7. Physicians should address the human factor and medical reasons for road crashes, including, but not limited to, the use of prescription drugs or medical conditions that may impair driving ability, and explore ways to prevent and reduce the severity of injuries.
  8. Physicians should lobby for the implementation and enforcement of the measures listed above, which have been shown to decrease the risk and severity of vehicle crashes, and the evaluation of their impact.
  9. National Medical Associations and their member physicians should encourage the research and development of improved training systems and medical care at all stages, including effective communication and transport systems to locate and evacuate the victims, emergency medical care systems to provide life-saving first aid services, and expert trauma and rehabilitative care, and should lobby for increased resources to help provide these services.

Adopted by the 41st World Medical Assembly, Hong Kong, September 1989
revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd WMA Council Session, Buenos Aires, Argentina, April 2016 

 

PREAMBLE

  1. Biomedical research is essential to the health and well-being of our society. Advances in biomedical research have dramatically improved the quality and prolonged the duration of life throughout the world. However, the ability of the scientific community to continue its efforts to improve personal and public health is being threatened by a movement to eliminate the use of animals in biomedical research. This movement is spearheaded by groups of radical animal rights activists whose views are considered to be far outside mainstream public attitudes and whose tactics range from sophisticated lobbying, fund-raising, propaganda and misinformation campaigns to violent attacks on biomedical research facilities and individual scientists. These violent attacks are carried out by a relatively small number of activists compared with those who use peaceful means of protest, but they have profound and wide-ranging effects.
  2. The magnitude of violent animal rights activities is staggering, and these activities take place in many different parts of the world. Various animal rights groups have claimed responsibility for the bombing of cars, institutions, stores, and the private homes of researchers.
  3. Animal rights violence has had a chilling effect on the scientific community internationally. Scientists, research organizations, and universities have been intimidated into altering or even terminating important research efforts that depend on the use of animals. Laboratories have been forced to divert thousands of research dollars for the purchase of sophisticated security equipment. Young people who might otherwise pursue a career in biomedical research are turning their sights to alternative professions.
  4. Despite the efforts of many groups striving to protect biomedical research from radical animal activism, the response to the animal rights movement has been fragmented, under-funded, and primarily defensive. Many groups within the biomedical community are hesitant to take a public stand about animal activism because of fear of reprisal. As a result, the research establishment has been backed into a defensive posture. Its motivations are questioned, and the need for using animals in research is repeatedly challenged.
  5. While properly designed and executed research involving animals is necessary to enhance the medical care of all persons, we recognize also that humane treatment of research animals must be ensured. Appropriate training for all research personnel should be prescribed and adequate veterinary care should be available. Experiments must comply with any rules or regulations promulgated to govern humane handling, housing, care, treatment and transportation of animals.
  6. International medical and scientific organizations must develop a stronger and more cohesive campaign to counter the growing threat to public health posed by animal activists. Leadership and coordination must be provided. In addition, there must be a clear understanding of the rights of animals who are part of medical research, and the obligations of those who undertake it.

The World Medical Association therefore affirms the following principles:

  1. Animal use in biomedical research is essential for continued medical progress.
  2. The WMA Declaration of Helsinki requires that biomedical research involving human subjects should be based, where appropriate, on animal experimentation, but also requires that the welfare of animals used for research be respected.
  3. Humane treatment of animals used in biomedical research is essential and research facilities should be required to comply with all guiding principles for humane treatment. Education about these principles should be provided to all researchers in training.
  4. Animals should only be used in biomedical research when it is clear that their use is required to achieve an important outcome, and where no other feasible method is available.
  5. Duplication of animal experiments should not occur unless scientifically justified.
  6. The use of animals for the futile testing of cosmetic products and their ingredients, alcohol and tobacco should not be supported.
  7. Although rights to free speech should not be compromised, the anarchistic element among animal right activists should be condemned.
  8. The use of threats, intimidation, violence, and personal harassment of scientists and their families should be condemned internationally.
  9. A maximum coordinated effort from international law enforcement agencies should be sought to protect researchers and research facilities from activities of a terrorist nature.

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
Revised by the 68th WMA General Assembly, Chicago, United States, October 2017,
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

 

PREAMBLE

Air travel is the preferred mode of long-distance transportation for people across the world. The growing convenience and affordability of air travel has led to an increase in the number of air passengers. In addition, long-duration flights are becoming increasingly common, increasing the risk of in-flight medical emergencies.

The environment in normal passenger planes is not conducive to delivering quality medical care, especially in medical emergencies. Noise and movement of the plane, the very confined space, the presence of other passengers who may be experiencing stress or fear as a result of the situation, the insufficiency or complete lack of diagnostic and therapeutic materials as well as  other factors often create extremely difficult conditions for diagnosis and treatment. Even the most experienced medical professional is likely to be challenged by these circumstances.

Air travel can significantly affect people who suffer from mental health challenges and resources for in-flight mental health emergencies are often lacking.

Most airlines require flight personnel to be trained in basic first aid. In addition, many provide some degree of training beyond this minimum level and may also carry certain emergency medicines and equipment on board. Some carriers even have the capacity to provide remote ECG reading and medical counselling services. The ICAO (International Civil Aviation Organization) standard requires medical supplies to be carried on airplanes, but the detailed quantity and contents are in non-mandatory recommended practices. Requirements for individual airlines are determined by the national aviation regulatory authorities. Detailed requirements of the cabin crew training program are also determined by the respective national aviation regulatory authority as ICAO standards states that “An operator (airline) shall establish and maintain a training program approved by the State of the operator.”

Even well-trained flight personnel are often limited in their knowledge and experience and cannot offer the same assistance as a physician or other certified health professional. Currently, continuing medical education courses are available to physicians in some locales to train them specifically for in-flight emergencies.

Physicians are often concerned about providing assistance due to uncertainty regarding legal liability. While many airlines provide some liability insurance for medical professionals and lay persons who will provide voluntary assistance during a flight, this is not always the case and even where it does exist, the terms of the insurance cannot always be adequately explained and understood in an acute medical crisis. The financial and professional consequences of litigation against physicians who offer assistance can be very costly, though actual examples of this appear to be quite limited.

Some important steps have been taken to protect the life and health of airline passengers, yet this is far from ideal and still needs improvement. Many of the major problems could be mitigated by simple actions taken by both airlines and national legislatures, ideally in cooperation with one another and with the International Air Transport Association (IATA) to arrive at coordinated and consensus-based international policies and programs.

Constituent Members have an important leadership role to play in promoting measures to improve the availability and efficacy of in-flight medical care.

 

RECOMMENDATIONS

The World Medical Association calls on its Constituent Members to advocate for the delivering of quality medical care in air travel, in particular:

Airline companies

  1. To encourage their national airlines companies, especially those providing medium and long-range passenger flights, to take the following specific actions:
  • Equip their airplanes with a sufficient and standardised set of medical emergency materials and drugs that are easily identifiable packaging with instruction in English as well as consideration of other languages, and include Automated External Defibrillators (AED), considered essential equipment in non-professional settings, while ensuring that at least one crew member is competent in the use of that particular AED.
  • Provide stand-by medical assistance, including a mental health component, that can be contacted by radio or telephone to help either the flight attendants or to support a volunteering health professional, if one is on board and willing to assist.
  • Develop medical emergency plans to guide airline personnel in responding to the medical needs of passengers.
  • Provide sufficient medical and organisational instruction to flight personnel, beyond basic first aid training, to enable them to better attend to passenger needs and to assist medical professionals who volunteer their services during emergencies.
  • Provide sufficiently comprehensive insurance for medical professionals and assisting lay personnel to protect them from damages and liabilities (material and non-material) resulting from in-flight diagnosis and treatment.
  • Accept all legal and financial consequences of any assistance provided by a physician, in the absence of legal immunity for physicians.

National authorities

  1. To encourage their national aviation authorities to provide yearly summarised reports of in-flight medical incidents based on mandatory standardised incident reports for every medical incident requiring the administration of first aid or other medical assistance and/or causing a change in flight plans.
  2. To urge their legislators to enact Good Samaritan legislation to guarantee immunity from legal action to physicians who provide appropriate emergency assistance during in-flight medical incidents.
  3. To advocate for the inclusion of potential challenges of in-flight medical emergencies in the ordinary emergency education courses for physicians.

Physicians

  1. To inform physicians of training opportunities or promote the development of training programs where they do not exist;
  2. To encourage physicians to consider whether they wish to identify themselves prior to departure as being willing to help in the event of a medical emergency;
  3. To incite physicians to discuss potential problems with their own patients who are at high risk for requiring in-flight medical attention prior to their flight;
  4. To encourage physicians to determine if their liability insurance includes cover for Samaritan deeds;
  5. To inform and motivate physicians to attend appropriate training programs so they can make informed decisions when declaring their patients fit to travel by air.

International Civil Aviation Organization

The World Medical Association also calls on the ICAO to:

  1. Further develop precise standards in the following areas and, where appropriate, work with governments to implement these standards as legal requirements:
  • Medical equipment and drugs on board medium and long-range flights;
  • Packaging and information materials standards, including multilingual descriptions and instructions in appropriate languages;
  • Medical, inclusive of mental health emergency procedures and training programs for medical personnel.
  1. Define global guidelines guaranteeing physicians immunity from legal action when providing appropriate emergency assistance during in-flight medical incidents and ensure its implementation by its Member States.

 

Adopted by the 47th WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th WMA General Assembly, Taipei, Taiwan, October 2016

 

The health of a community or population is determined by several factors that go beyond traditionally understood causes of disease. Social determinants of health include factors that affect behavioural lifestyle choices; the physical, psychosocial and economic environments in which individuals live; and the health services available to people. Public health involves monitoring, assessing and planning a variety of programs and activities targeted to the identified needs of the population, and the public health sector should have the capacity to carry out those functions effectively to optimise community health. A key tenet of public health policy should be inclusivity and health equity; public health agencies must pay specific attention to populations and communities whose social, economic, and political conditions put them at greater risk of poor health than the general population.

Physicians and their professional associations have an ethical and professional responsibility to act in the best interests of patients at all times. This involves collaboration with public health agencies to integrate medical care of individual patients with a broader promotion of the health of the public.

The key functions of public health agencies are:

1. Health promotion:

  • Working with health care providers to inform and enable the general public to take an active role in preventing and controlling disease, adopting healthful lifestyles, and using medical services appropriately;
  • Assuring that conditions contributing to good health, including high-quality medical services, safe water supplies, good nutrition, an unpolluted atmosphere, and opportunities for exercise and recreation are accessible for the entire population;
  • Working with the responsible public authorities to create healthy public policy and supportive environments in which healthy behavioural choices are the easy choices, and to develop human and social capital.
  • Prevention: assuring access to screening and other preventive services and curative care to the entire population.

2. Protection: monitoring and protecting the health of communities against communicable diseases and exposure to toxic environmental pollutants, occupational hazards, harmful products, and poor quality health services. This function includes the need to set priorities, establish essential programs, obtain requisite resources and assure the availability of necessary public health laboratory services.

3. Surveillance: identifying outbreaks of infectious disease and patterns of chronic disease and injury and establishing appropriate control or prevention programs;

4. Population Health Assessment: assessing community health needs and marshalling the resources for responding to them, and developing health policy in response to specific community and national health needs.

The specific programs and activities carried out in each jurisdiction (local or national) will depend on the problems and needs identified, the organization of the health care delivery system, the types and scope of the partnerships developed and the resources available to address the identified needs.

Public health agencies benefit greatly from the support and close cooperation of physicians and their professional associations. The health of a community or a nation is measured by the health of all its residents, and the preventable health problems that affect an individual person affect the health and resources of the community. The effectiveness of many public health programs, therefore, depends on the active collaboration of physicians and their professional associations with public health agencies and other governmental and nongovernmental agencies.

The medical sector and the public health sector should effectively co-operate on the dissemination of public health information and education programs that promote healthful lifestyles and reduce preventable risks to health, including those from the use of tobacco, alcohol and other drugs; sexual activities that increase the risk of HIV transmission and sexually transmitted diseases; poor diet and physical inactivity; and inadequate childhood immunization levels. For example, health education can substantially reduce infant morbidity and mortality (e.g. through the promotion of breast-feeding and providing nutrition education to parents together with providing supportive conditions, both at work and in the community).

The formal responsibility of public health agencies is primarily disease surveillance, investigation and control. These activities cannot be conducted effectively, however, without the active cooperation and support of physicians at the community level who are aware of individual and community illness patterns and can notify health authorities promptly of problems that might require further investigation and action. For example, physicians can help identify populations at high risk for particular diseases, such as tuberculosis, and report cases of communicable diseases such as measles, whooping cough, or infectious causes of diarrhoea, as well as cases of exposure to lead or other toxic chemicals and substances in the community or work place. Close collaboration between public health agencies and physicians as well as other health professionals is critical for an efficient disease monitoring system.

Regardless of the effectiveness of existing public health programs in a jurisdiction, professional medical associations should be aware of unmet health needs in their communities and nations and advocate for activities, programs and resources to meet those needs. These efforts might be in areas of public education for health promotion and disease prevention; monitoring and controlling environmental hazards; identifying and publicising adverse health effects resulting from social problems, such as interpersonal violence or social practices that affect health; or identifying and advocating for services such as improvements in emergency treatment preparedness.

In jurisdictions in which basic public health services are not being provided adequately, medical associations must work with other health agencies and groups to establish priorities for advocacy and action. For example, in a country or area with limited resources in which potable water and sewage facilities are not available to most residents, these needs should be given priority over medical technologies that would provide service to only a small portion of the population.

Some health-related issues are extremely complex and involve multiple levels of response. For example, those diagnosed with high blood lead levels need not only appropriate medical treatment, but the source of contamination must also be determined, and measures need to be taken to eliminate the danger. At times policies that promote public health create concern because of their potential economic impact. For example, strong opposition to the potential economic impact of tobacco control policies could come from regions or groups that derive significant revenue from growing or processing tobacco. However, economic concerns should not deter a strong public health advocacy program against the use of tobacco products. The promotion of tobacco products should be rigorously opposed, and every effort should be made to reduce tobacco consumption in both developed and developing countries.

Physicians and their associations should collaborate with political authorities and other organizations to encourage the media to send positive messages for health education regarding diet, drug use, sexually transmitted diseases, cardiovascular risk, etc.

Medical associations should ask their members to educate their patients on the availability of public health services.

Adopted by the 47th WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 66th WMA General Assembly, Moscow, Russia, October 2015 

 

PREAMBLE

Historically, many societies have regarded patients with mental illness as a threat to those around them rather than as people in need of support and care. In the absence of effective treatment, to prevent self-destructive behaviour or harm to others, many persons with mental illness were confined to asylums for all or part of their lives.

Today, progress in psychiatric treatment allows for better care of patients with mental illness. Efficacious drugs and psychosocial interventions offer outcomes ranging from complete recovery to remission for varying lengths of time.

The adoption in 2006 of the United Nations Convention on the Rights of Persons with Disabilities constituted a major step towards viewing them as full members of society with the same rights as everyone else. It is the first comprehensive human rights treaty of the 21st century. It aims to promote, protect and reinforce the human rights and dignity of all persons with disabilities, including those with mental impairments.

Persons with major mental illnesses and those with learning disability have the same right to preventive services and interventions to promote health as others members of the community, for which they often have greater need because they are more likely to live unhealthy lifestyles.

Patients with psychiatric morbidity may also experience non- psychiatric illness. Persons with mental illness have the same right to health care as any other patient. Psychiatrists and health care professionals who provide mental health services should refer patients to other appropriate professionals when patients need medical care. Health care professionals should never decline to provide needed medical care solely because the patient has a mental illness.

Physicians have the same obligations to all patients, including patients with mental illness. Psychiatrists or other physicians who treat patients with mental illness must adhere to the same ethical standards as any physician.

The physician’s primary obligation is to the patient and not to serve as agents of society, except in circumstances when a patient presents clear danger to himself/ herself or others due to mental illness.

PHYSICIANS’ ETHICAL RESPONSIBILITIES

The stigma and discrimination associated with psychiatry and the mentally ill should be eliminated. Stigma and discrimination may discourage people in need from seeking medical care, thereby aggravating their situation and placing them at risk of emotional or physical harm.

Physicians have a responsibility to respect the autonomy of all patients. When patients who are being treated for mental illness have decision-making capacity, they have the same right to make decisions about their care as any other patient. Because decision-making capacity is specific to the decision to be made and can vary over time, including as a result of treatment, physicians must continually evaluate the patient’s capacity. When a patient lacks decision-making capacity, physicians should seek consent from an appropriate surrogate in accordance with applicable law.

The therapeutic relationship between physician and patient is founded on mutual trust, and physicians have a responsibility to seek patients’ informed consent to treatment, including patients who are being treated for mental illness. Physicians should inform all patients of the nature of the psychiatric or other medical condition, and the expected benefits, outcomes and risks of treatment alternatives.

Physicians should always base treatment recommendations on their best professional judgment and treat all patients with solicitude and respect, regardless of the setting of care. Physicians who practice in mental health facilities, the military, or correctional institutions may have concurrent responsibilities to society that create conflicts with the physician’s primary obligation to the patient. In such situations, physicians should disclose the conflict of interest to minimize possible feelings of betrayal on the patient’s part.

Involuntary treatment or hospitalization of persons with mental illness is ethically controversial. While laws regarding involuntary hospitalization and treatment vary worldwide, it is generally acknowledged that this treatment decision without the patient’s informed consent or against the patient’s will is ethically justifiable only when: (a) a severe mental disorder prevents the individual from making autonomous treatment decisions; and/or (b) There is significant likelihood that the patient may harm him/her self or others. Involuntary treatment or hospitalization should be exceptional and physicians should utilize it only when there is good evidence that it is medically appropriate and necessary and should ensure that the individual is hospitalized for the shortest duration feasible under the circumstances. Wherever possible and in accordance with local laws, physicians should include an advocate for the rights of that patient in the decision process.

Physicians must protect the confidentiality and privacy of all patients.. When legally required to disclose patient information, the physician should disclose only the minimum relevant information necessary and only to an entity legally authorized to request or require the information. When databanks allow access to or transfer of information from one authority to another confidentiality must be respected and such access or transfer must comply fully with applicable law.

The participation of individuals with psychiatric illness in research needs to be in full accordance with the Declaration of Helsinki’s recommendations.

Physicians must never use their professional position to violate the dignity or human rights of any individual or group, and should never allow their personal desires, needs, feelings, prejudices or beliefs to interfere with a patient’s treatment. Physicians must never abuse their authority or take advantage of a patient’s vulnerability.

RECOMMENDATIONS

The World Medical Association and National Medical Associations are encouraged to:

  • Publicize this Statement and affirm the ethical foundations for treatment of patients with mental illness;
  • While doing so, call for full respect – at all times – of the dignity and human rights of patients with mental illness;
  • Raise awareness of physicians’ responsibilities to support the well-being and rights of patients with mental illness;
  • Promote recognition of the privileged relationship between patient and physician based on trust, professionalism and confidentiality;
  • Advocate for appropriate resources to meet the needs of persons with mental illness.

Adopted by the 40th World Medical Assembly, Vienna, Austria, September 1988
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th WMA General Assembly, Chicago, United States, October 2017

 

PREAMBLE

1.      Health is not simply the absence of illness, but is also more than a state of physical, psychological and social flourishing, and includes an individual’s ability to adapt to physical, social and mental adversity. It is affected by many factors, including access to health care and especially the Social Determinants of Health (SDH), and its restoration is similarly multidimensional. Society has an obligation to make access to an adequate level of care available to all its members, regardless of ability to pay.

2.      Health care professionals regularly confront the effects of lack of access to adequate care and health inequality and have a corresponding responsibility to contribute their expertise to work with governments at local, regional and national levels to ensure they understand the Social Determinants of Health and integrate reduction of factors leading to inequality into all policies. Health care policies should suggest ways to eliminate health inequality.

3.      Access to health care is an important factor in reducing the short, medium and long term consequences of poor health, caused by adverse social and other conditions.  Access is itself multidimensional, and is constrained by factors including health human resources, training, finance, transportation, geographical availability, freedom of choice, public education, quality assurance and technology.

GUIDELINES

Health care workers

4.         The delivery of health care is highly dependent upon the availability of trained health care workers. The training should not only include socio-medical competencies, but particularly emphasize an understanding of how the social determinants of health affect people’s health outcomes.

The distribution of health care workers varies widely as do the demographics in most countries, where an ageing population forms a huge challenge for the years to come. There is global mal-distribution. While all countries train health care workers, global movement, especially from less to better developed countries, is leading to continuing shortages. The development of ethical recruitment codes may help to reduce inappropriate recruitment activities by states. Ethical recruitment codes should also be applied to commercial recruitment agencies.

5.      Research is needed to determine the best mix of different health care workers for different clinical settings to meet the needs of populations. Mal-distribution within countries should be addressed by seeking methods of attracting health care workers to rural and remote areas, or other underserved regions, at least for a part of their careers. Innovative concepts should be explored to make working in underserved areas interesting; punitive and coercive recruiting methods must not be used. Recruiting students who express a wish to return to their home area may help to alleviate this problem.

Training

6.      Primary training of health care workers has to be appropriate, accessible and of good quality, which makes the training costly, with the country of origin meeting this cost. Workers move to continue with secondary training, including higher professional training and specialisation for physicians, and also to earn more money that may be remitted home to support the family and community.

7.      The ambition for self-improvement is understandable; efforts to increase retention of health care workers should include consideration of encouraging a return to the home country, with use of the new skills and knowledge to improve health care access.

8.      Countries should not actively recruit from other states. Even when they do so passively, this recruitment should take place in accordance with ethical standards and the WMA Statement on Ethical Guidelines for the International Migration of Health Care workers.

Finance

9.      Access to care is essential for the whole population. Methods of financing care are for each country to decide, according to their own resources, health and social priorities, and health needs. Countries should develop revenue systems that reduce reliance on out-of-pocket payments and private health insurance as these increase inequalities between population groups.

10.    No single system of finance is ideal for every country; the exact balance needs to be locally decided. In making decision about financing systems governments must understand the essential nature of health care, the absolute requirement that it be available to all, based upon clinical need and not on the ability to pay, and that access can be constrained by financial fears. Eligibility for care does not ensure access, especially if co-payment schemes exclude those with the fewest financial resources.

11.    Innovative means should be used to provide comprehensive health care, including partnerships with private providers and commercial entities, who may be able to provide elements of specialised care. In doing so states must ensure that this does not limit specialised care to the wealthiest proportion of their population nor should this be seen as a preference for a private health care model.

12.    Decisions to limit access to elements of health care should be done on the basis of objective information, based on the best available scientific data about the efficacy and safety of health care services. It must include public debate about, and acceptance of, the concepts involved. Nothing should be introduced which discriminates against the elderly or vulnerable populations.

13.    The public should have access to clear information on the health care resources available to them and how they may be accessed. Specific processes should be established to ensure that poverty or illiteracy will never be a barrier to access care.

Vulnerable and hard to reach people

14.    There are groups of people in every country who are hard to reach with health care messages, and who often seek health care late in the progress of disease.

15.    A variety of methods should be used to ensure hard to reach people are aware of the availability of health care, without direct cost, including methods to reduce fear and other barriers to access.

16.    Where specific vulnerabilities such as learning disabilities or sensory impairments exist, solutions should include identifying and dealing with those vulnerabilities.

17.    Health care workers have a duty to provide care that is free from any form of unfair discrimination.

Transportation

18.    Health care facilities should be situated in locations that are easy to access. This may mean working with local transportation providers to ensure formal and informal public transport routes pass the facilities. Consideration should be made to making health care facilities more accessible by active transport methods. Especially in rural and remote locations, patients may travel considerable distances to attend the facilities.

19.    Patients who need referral to secondary and specialized care should be provided with access to transportation. Those needing help with accessing primary care should also receive support. Transportation should also be offered to isolated rural patients who require a level of care that can be found only in metropolitan medical centres. Telemedicine can sometimes be an acceptable substitute for transportation of patients.

Geographical availability

20.    Working with other health providers, including traditional birth attendants, may provide assistance. They should be integrated into the health care system, offered training, and be assisted to offer care that is safe and effective and that includes referral where necessary. This does not extend to the state health care system providing or funding care which is not evidence based, including so-called complementary therapies.

Freedom of choice

21.    The freedom to choose care providers, and the options of care they offer is an essential element of care in every system. It requires the ability to understand that choice, and the freedom to choose a provider from among alternatives.

22.    Barriers to freedom of choice may lie in access to financial resources, understanding of the options, and in cultural geographic, or other factors. Access to information about the available options is crucial in making an appropriately informed choice.

23.    The health authorities should ensure that all populations understand how to access care, and should seek to ensure that populations have access to objective information about the availability of different health care suppliers.

24.    Once individuals access care through a particular provider or physician they should be given opportunities to consider the clinical options open to them; access to systematically available information resources is an essential element supporting choice.

Public education

25.    General education is a determinant of health; the better educated a person is, generally the better their health likelihood.  When ill-health presents, prior education may be a determinant of the speed at which the person accesses health care. Education also aids individuals to make appropriate choices about the care options they access.

26.    Specific education about health matters can be an important adjunct to lifestyle planning. While education alone does not, for example, stop people from smoking, using drugs or alcohol, it can aid in decision making about risk behaviour.

27.    A general level of health literacy assists patients to make choices among different options for treatment, and to comply or co-operate with the requirements of that treatment. It will also improve self-care and the appropriateness of self-referral.

28.    Educational programs that assist people in making informed choices about their personal health and about the appropriate uses of both self-care and professional care should be established. These programs should include information about the costs and benefits associated with alternative courses of treatment within the context of modern medicine; the use of professional services that permit early detection and treatment or prevention of illnesses; personal responsibilities in preventing illnesses; and the effective use of the health care system. Physicians should actively participate, wherever appropriate, in such educational efforts and must be provided with adequate resources to enable them to undertake such education.

29.    Public education also assists governments by increasing understanding of public health measures, including taxation of tobacco, banning of human consumption of some products, and restrictions on individual freedoms because of health concerns. When legislative or other regulatory mechanisms are to be imposed by governments, a campaign of public education and explanation must be undertaken to gain public understanding and voluntary compliance.

Quality assurance

30.       Quality assurance mechanisms should be part of every system of health care delivery. Physicians share responsibility for assuring the quality of health care and must not allow other considerations to jeopardize the quality of care provided.

Technology

31.    Technology is playing an increasing role in the provision of health care services. Capital purchase prices are high because of the need for specific logistical services, including skilled technicians and adequate facilities.  Advanced technologies are not available in all locales; access to their benefits must be well planned to ensure they benefit all patients in need, not simply those local to advanced technology centres.

Extraordinary circumstances

32.    In extraordinary circumstances, including armed conflicts and major natural events such as earthquakes, physicians have a specific duty to ensure that policy makers protect access to care, especially for those most vulnerable and least able to move to more secure areas.

RECOMMENDATIONS

33.    Social Determinants of Health greatly affect access to health care as well as directly impacting on health. Physicians should work with governments to ensure they are able to take effective action on SDH.

34.    Access to health care requires systematic consideration to ensure appropriate conditions are met. These include:

34.1  Having an appropriate, universal, solidaristic and equitable health system, adequately resourced facilities, being available throughout a country, providing health centers and their professional staff with sufficient and sustainable financing, with individuals being treated on the basis of need and not on the ability to pay.

34.2  Patient choice should include which facility to access.

34.3  Access to adequate information for all is essential for making choices and for co-operating with health care providers.

34.4  Education is both a social determinant and a key factor in co-operation with health care provision, fostering responsible self-care with accessible support.

34.5  Health care professionals should be free to move around the world, especially to access educational and professional opportunities. This mobility must not damage resource availability, especially in resource poor countries.

34.6  Physicians must be provided with transparent and efficient ethical criteria for working in overcrowded or underserved areas.

34.7  Provision of health care requires action by government at all levels, working with populations to ensure that people understand the benefit of this care and are able to access it.

34.8  Physicians have an important role in ensuring that health care planning makes clinical sense, is communicated well to the population being served, and that patients are not endangered by inadequate resources, poor planning or other system flaws.

34.9  Physicians are aware of the health system and this forces them to play a socially conscious role regarding the social determinants of health and access to health care by themselves or through their representative medical associations.

34.10   Medical associations should work with their members to promote access to health care systems that equitably support the needs of populations.

 

Adopted by the 41st World Medical Assembly Hong Kong, September 1989
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

PREAMBLE

The prospect of therapeutically effective fetal tissue transplants for disorders such as diabetes and Parkinson’s disease has raised new questions in the ethical discussion on fetal research. These questions are distinct from those addressed in the 1970s that focused on invasive procedures performed by some researchers on living, viable fetuses. They are also separate from the questions that were raised by the development of new techniques for prenatal diagnosis such as fetoscopy and chorionic villus sampling. Although the use of transplanted tissue from a fetus after spontaneous or induced abortion would appear to be analogous to the use of cadaver tissue and organs, the moral issue for many is the possibility that the decision to have an abortion will become coupled with the decision to donate fetal tissue for the transplantation procedure itself.

The utilization of human fetal tissue for transplantations is, for the most part, based upon a large body of research data derived from experimental animal models. At this time, the number of such transplants performed has been relatively small but the various applications are promising avenues of clinical investigation for certain disorders. The demand for fetal tissue transplantation for neural or pancreatic cell engrafments may be expected to increase if further clinical studies conclusively show that this procedure provides long-term reversal of neural or endrocrine deficits.

Prominent among the currently identified ethical concerns is the potential for fetal transplants to influence a woman’s decision to have an abortion. These concerns are based, at least in part, on the possibility that some women may wish to become pregnant for the sole purpose of aborting the fetus and either donating the tissue to a relative or selling the tissue for financial gain. Others suggest that a woman who is ambivalent about a decision to have an abortion might be swayed by arguments about the good that could be achieved if she opts to terminate the pregnancy. These concerns demand the prohibition of:

  1. the donation of fetal tissue to designated recipients;
  2. the sale of such tissue; and
  3. the request for consent to use the tissue for transplantation before a final decision regarding abortion has been made.

The abortion process may also be influenced inappropriately by the physician. Consequently, measures must be taken to assure that decisions to donate fetal tissue for transplantation do not affect either the techniques used to induce the abortion or the timing of the procedure itself with respect to the gestational age of the fetus. Also to avoid conflict of interest, physicians and other health care personnel involved in performing abortions should not receive any direct or indirect benefit from the research or transplantation use of tissues derived from the aborted fetus. The retrieval and preservation of usable tissue cannot become the primary focus of abortion. Therefore, members of the transplant team should not influence or participate in the abortion process.

There is a potential commercial gain for those involved in the retrieval, storage, testing, preparation, and delivery of fetal tissues. Providing fetal tissue by nonprofit mechanisms designated to cover costs only would reduce the possibility of direct or indirect influence on a woman to acquire her consent for donation of the aborted fetal remains.

RECOMMENDATIONS

The World Medical Association affirms that the use of fetal tissue for transplantation purposes is still in an experimental stage and should only be ethically permissible when:

  1. The World Medical Association Declaration of Helsinki and the Declaration on Human Organ Transplantation are followed, as they pertain to the donor and the recipient of the fetal tissue transplant.
  2. Fetal tissue is provided in a manner consistent with the World Medical Association Statement on Live Organ Trade and that such tissue not be provided in exchange for financial remuneration above that which is necessary to cover reasonable expenses.
  3. The recipient of the tissue is not designated by the donor.
  4. A final decision regarding abortion is made before initiating discussion of the transplantation use of fetal tissue. Absolute independence is established and guaranteed between the medical team performing the abortion and the team using the fetus for therapeutic purposes.
  5. Decision concerning the timing of the abortion is based on the state of health of the mother, and of the fetus. Decisions regarding the technique used to induce abortion, as well as the timing of the abortion in relation to the gestational age of the fetus, are based on concern for the safety of the pregnant woman.
  6. Health care personnel involved in the termination of a particular pregnancy do not participate in or receive any benefit from the transplantation of tissue from the abortus of the same pregnancy.
  7. Informed consent on behalf of both the donor and the recipient is obtained in accordance with applicable law.

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

PREAMBLE

Childhood obesity is a serious medical condition and a major public health concern affecting many children.  Childhood obesity is emerging as a growing epidemic and is a challenge in both developed and developing countries.  Due to its increasing prevalence and its immediate and long-term impact on health, including predisposition to diabetes and cardiovascular abnormalities, childhood obesity should be viewed as a serious concern for public health. The increase in childhood obesity may be attributed to many factors:

  • Recent studies show that marketing targeted at children has a wide influence on the shopping trends and food preferences of households all over the world. Special offers, short-term price reductions and other price promotions and advertising on social as well as traditional media all play a role in increasing product demand.
  • Many advertisements are in conflict with nutritional recommendations of medical and scientific bodies. TV advertisements for food and drink products with little or no nutritional value are often scheduled for broadcast hours with a large concentration of child viewers and are intended to promote the desire to consume these products regardless of hunger. Advertisements increase children’s emotional response to food and exploit their trust. These methods and techniques are also used in non-traditional media, such as social networks, video games and websites aimed at children.
  • Unhealthy dietary patterns, together with a sedentary lifestyle and lack of exercise, contribute to childhood obesity.  The sedentary lifestyle is the most predominant one in the developed world today. Many children typically spend more time than ever in front of screens, rarely engaging in physical activities.
  • International corporations and conglomerates that manufacture foods and beverages are not always subject to regional regulations that govern food labeling. Concern for profits may come at the expense of corporate responsibility for environmental and public health issues.
  • Products containing large amounts of added sugar, fat, and salt can be addictive, especially when combined with flavor enhancers. In some countries, not all ingredients are required to be listed on food labels and manufacturers often refuse to release data on methods employed to maximize consumption of their products.  Governments should require that all ingredients in food and beverages be clearly labeled, including those proprietary ingredients intended to increase consumption of the product.
  • Socioeconomic disparities also correlate with increasing rates of childhood obesity. The link between living in poverty and early childhood obesity continues to negatively affect health in adult life.[1] Exposure to environmental contaminants, sporadic medical checkups, insufficient access to nutritious foods and limited physical activity lead to obesity and other chronic illnesses that are all more prevalent among children living in poverty.

RECOMMENDATIONS

  1. A comprehensive program is needed to prevent and address obesity in all segments of the population, with a specific focus on children.  The approach must include initiatives on price and availability of nutritious foods, access to education, advertising and marketing, information, labeling and other areas specific to regions and countries.  An approach similar to that on tobacco in the WHO Framework Convention on Tobacco Control is advocated.
  2. International studies stress the importance of adopting an integrated approach to education and health promotion.  Investment in education is key to minimizing poverty, improving health and providing economic benefits.
  3. Quality education offered in formal settings to children aged 2 to 3 years, combined with enrichment activities for parents, and sufficient supply of nutritious food and beverages may help to reduce the rate of adolescent obesity and reduce its health implications throughout the life course. Developing early healthy eating practices and experiencing flavors of healthy food when very young appear to be positive factors in prevention of childhood obesity.
  4. Governments should invest in education related to menu design, food shopping including budget setting, storage and preparation so that people are better equipped to plan their food intake.
  5. Governments should seek to regulate the availability of food and beverages of poor nutritional value, by a range of methods including price.  Attention should be paid to the availability close to schools of establishments selling products of poor nutritional quality.  Governments should seek to persuade manufacturers to reformulate products to reduce their obesogenic effects.  Where possible government and local authorities should seek to manage the density of such establishments in the area.
  6. Governments should consider imposing a tax on non-nutritious foods and sugary drinks and use the additional revenue to fund research and epidemiological studies aimed at preventing childhood obesity and reducing the resulting disease risk.
  7. Ministries of health and education should regulate food and beverages that are sold and served at educational and healthcare facilities.
  8. Given the scientifically proven link between the extent of media consumption and adverse effects on body weight in children, the WMA recommends that the advertising of non-nutritious products be restricted during television programming and other forms of media that appeal to children.  Regulators should be aware that children access television programs designed for adults and ensure that legislation and regulation also limits marketing associated with such programs.
  9. Governments should work with independent health experts to produce sound guidance on food and nutrition, with no involvement of the food and drink industry.
  10. Governments and local authorities should subsidize and encourage activities that promote good health among their residents, including providing safe spaces for walking, bike riding and other forms of physical activity. 
  11. Parents have a crucial role in fostering physical activity in their children. Schools should incorporate daily physical activity into their daily routine.  Participation in sport activities should be possible for everyone regardless of their economic situation.
  12. National Medical Associations should support or develop guidelines and recommendations to ensure that they reflect current knowledge of prevention and treatment of childhood obesity.
  13. National Medical Associations should work to raise public awareness on the issue of childhood obesity and highlight the need to tackle the rising prevalence of obesity and its health and economic burden.
  14. Clinics and Health Maintenance Organizations should employ appropriately trained professionals to offer classes and consultation in selecting appropriate amounts of nutritious foods and beverages and attaining optimal levels of physical activity for children.  They should also ensure that their premises are exemplars in the provision of healthy food options.
  15. Educational facilities should employ appropriately trained professionals who educate for healthy lifestyles from an early age and allow all children, whatever their social environment, to practice regular physical activities.
  16. Physicians should guide parents and children in how to live healthy lives and emphasize the importance of doing so, and must identify as soon as possible obesity in their patients, particularly children. They should direct patients suffering from obesity to the appropriate services at the earliest possible stage, and conduct regular follow-ups.
  17. Physicians and health professionals should be educated in nutrition assessment, obesity prevention and treatment. This could be accomplished by strengthening CME activities focused on nutritional medicine.

[1] WHO Commission on Social Determinants of Health (Closing the Gap in a Generation) 2008.

Adopted by the 48th WMA General Assembly, Somerset West, South African, October 1996
and editorially revised by the 174th WMA Council Session, Pilanesberg, South Africa, October 2006
and rescinded at the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

Recognising that:

  1. The physician has an obligation to provide his or her patients with competent medical service and to report to the appropriate authorities those physicians who practice unethically and incompetently or who engage in fraud or deception (International Code of Medical Ethics); and
  2. The physician should be free to make clinical and ethical judgements without inappropriate outside interference; and
  3. Ethics committees, credentials committees and other forms of peer review have been long established, recognised and accepted by organised medicine to scrutinise physicians’ professional conduct and, where appropriate, impose reasonable restrictions on the absolute professional freedom of physicians; and

Reaffirming that:

  1. Professional autonomy and the duty to engage in vigilant self-regulation are essential requirements for high quality care and therefore are patient benefits that must be preserved;
  2. And, as a corollary, the medical profession has a continuing responsibility to support, participate in, and accept appropriate peer review activity that is conducted in good faith;

POSITION

  1. A physician’s professional service should be considered distinct from commercial goods and services, not least because a physician is bound by specific ethical duties, which include the dedication to provide competent medical practice (International Code of Medical Ethics).
  2. Whatever judicial or regulatory process a country has established, any judgement on a physician’s professional conduct or performance must incorporate evaluation by the physician’s professional peers who, by their training and experience, understand the complexity of the medical issues involved.
  3. Any procedure for considering complaints from patients which fails to be based upon good faith evaluation of the physician’s actions or omissions by the physician’s peers is unacceptable. Such a procedure would undermine the overall quality of medical care provided to all patients.

Adopted by the 48th WMA General Assembly, Somerset West, South Africa, October 1996
and editorially revised by the 174th WMA Council Session, Pilanesberg, South Africa, October 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

 

PREAMBLE

Recalling its Declaration of Washington on Biological Weapons, its Resolution on the Prohibition of chemical weapons and its Statement on Nuclear Weapons, the World Medical Association condemns the use of any forms of weapons – conventional, biological, chemicals and nuclear weapons – which has the potential to bring immense human suffering and substantial death together with catastrophic effects on the earth’s ecosystem, a reduction of the world food supply and increased poverty. The use of such weapons against human beings is in opposition with physicians’ duties and responsibilities to preserve life.

When nations enter into warfare or into weapons development, they do not usually consider the effects of the use of weapons on the health of individual non-combatants and on public health in general, either in the short or in the longer term.

Nevertheless the medical profession is required to deal with both the immediate and long term health effects of warfare, and in particular with the effects of different forms of weaponry including the threat of nuclear, chemical and biological warfare.

The potential for scientific and medical knowledge to contribute to the development of new weapons systems, targeted against specific individuals, specific populations or against body systems, is considerable. This includes the development of weapons designed to target anatomical or physiological systems, including vision, or which use knowledge of human genetic similarities and differences to target weapons.

There are no current and commonly used criteria to measure weapons effects on health. International Humanitarian Law states that weapons that cause injuries, which would constitute “unnecessary suffering or superfluous injury”, are illegal. These terms are not defined and require interpretation against objective criteria for the law to be effective.

Physicians can aid in developing criteria for weapons that cause injury or suffering so extreme as to invoke the terms of International Humanitarian Law.

Such criteria could aid lawyers in the use of International Humanitarian Law, allow assessment of the legality of new weapons currently in development against an agreed, objective system of assessment of their medical effects, and identify breaches of the Law once it is developed.

Physician involvement in the delineation of such objective criteria is essential if it is to become part of the legal process. However, it must be recognised that physicians are firmly opposed to any use of weapons against human beings.

RECOMMENDATIONS

The WMA believes that the development, manufacture and sale of weapons for use against human beings are abhorrent. To support the prevention and reduction of weapons injuries, the WMA:

  • Supports international efforts to define objective criteria to measure the effects of current and future weapons, which could be used to stop the development, manufacture, sale and use of those weapons;
  • Calls on National Medical Associations to urge national governments to cooperate with the collection of such data as are necessary for establishing objective criteria;
  • Calls on National Medical Associations to support and encourage research into the global public health effects of weapons use, and to publicise the results of that research, both nationally and internationally. This will ensure that both governments and the public are aware of the long-term health consequences of weapons use on non-combatant individuals and populations.

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

PREAMBLE

  • Medical trainees are increasingly participating in global educational and service experiences, commonly referred to as ‘international medical electives’ (IMEs). These experiences are normally short term, i.e., less than 12 months, and are often undertaken in resource-limited settings in low-and middle-income countries.
  • Although IMEs can provide valuable learning experience, this must be weighed against the potential risks to the host community, the sponsor organization and the visiting trainee. Successful placements help to ensure that there are mutual benefits for all parties and are built upon an agreed understanding of concepts including non-maleficence and justice.
  • Published ethical guidelines, such as the Ethics and Best Practice Guidelines for Training Experiences in Global Health by the Working Group on Ethics Guidelines for Global Health Training (WEIGHT), call on sponsor institutions (i.e., universities and organizations facilitating electives) to commit to sustainable partnerships with host institutions and local communities. All parties are also called upon to work collaboratively in creating professional guidelines and standards for medical electives.
  • In turn, trainees undertaking IMEs must adhere to relevant ethical principles outlined in WMA ethical documents, including the WMA’s Declaration of Geneva, the WMA International Code of Medical Ethics and the WMA Statement on the Professional and Ethical Use of Social Media.

RECOMMENDATIONS

Therefore the WMA recommends that:

  1. Sponsor institutions work closely with host institutions and local communities to create professional and ethical guidelines on best practices for international medical electives. Both institutions should be actively engaged in guideline development. The sponsor organization should evaluate the proposed elective using such standards prior to approval.
  2. Guidelines should be appropriate to local context and endorse the development of sustainable, mutually-beneficial and just partnerships between institutions and the patients and the local community, with their health as the first consideration. These must take account of best practice guidelines, already available in many countries.
  3. Guidelines must hold patient and community safety as paramount, and outline processes to ensure informed consent, patient confidentiality, privacy, and continuity of care as outlined in the WMA International Code of Medical Ethics.
  4. Guidelines should also outline processes to protect the safety and health of the trainee, and highlight the obligations of the sponsor and host institutions to ensure adequate supervision of the trainee at all times.  Institutions should consider means of addressing possible natural disasters, political instability, and exposure to disease.  Emergency care should be available.
  5. Sponsor and host institutions have a responsibility to ensure that IMEs are well planned, including, at a minimum, appropriate pre-departure briefings, which should include training in culture and language competency and explicit avoidance of any activity which could be exploitative, provision of language services as required, and sufficient introduction and guidance at the host institution. Post-departure debriefing should be planned on return of the trainee, including reviewing ethical situations encountered and providing appropriate emotional and medical support needed.
  6. It is expected that the trainee will receive feedback and assessment for the experience so that he/she can receive academic credit. The trainee should have the opportunity to evaluate the quality and utility of the experience.
  7. Trainees must be fully informed of their responsibility to follow instructions given by local supervisors, and to treat local host staff and patients with respect.
  8. These guidelines and processes should be reviewed and updated on a regular basis as sponsor and host institutions develop more experience with one another.
  9. National Medical Associations should develop best practices for international medical electives, and encourage their adoption as standards by national or regional accrediting bodies, as feasible, and their implementation by sponsor and host institutions.

Adopted by the 37th World Medical Assembly, Brussels, Belgium, October 1985,
editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005,
revised by the 66th WMA General Assembly, Moscow, Russia, October 2015
and reaffirmed with minor revisions by the 227th WMA Council, Helsinki, Finland, October 2024

 

The World Medical Association is in favour of equality of opportunity in medical association activities, medical education and training, employment, and all other medical professional endeavours without discrimination of any kind.

The World Medical Association is unalterably opposed to the denial of membership privileges and responsibilities in medical associations to any duly registered physician because of any factors of discrimination.

The World Medical Association calls upon the medical profession and all individual members of medical associations to exert every effort to prevent any instance in which such equal rights, privileges or responsibilities are denied.

 

Adopted by the 56th WMA General Assembly, Santiago, Chile, October 2005,
reaffirmed by the 200th WMA Council Session, Oslo, Norway, April 2015
and amended by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021

 

PREAMBLE

In this statement the World Medical Association (WMA) addresses issues related to medical liability claims and the implications of defensive medicine. The laws and legal systems in each country, as well as the social traditions, social welfare and economic conditions of the country, will affect the relevance of some portions of this statement for some countries, but do not detract from its fundamental importance.

A culture of medical liability litigation is growing in some countries, increasing health care costs, restraining access to health care services, and hindering efforts to improve patient safety and health care quality. In other countries, medical liability claims are less prevalent, but National Medical Associations (NMAs) in those countries should be aware of the issues and circumstances that could result in an increase in the frequency and severity of medical liability claims brought against physicians.

Many medical liability systems divert scarce health care resources away from direct patient care, research, and physician training. The lawsuit culture has also blurred the distinction between negligence and unavoidable adverse outcomes. This has led to undue reliance on litigation and other dispute resolution systems to distinguish between the two, and a culture that enables the pursuit of cases without genuine merit in the interest of financial gain.  Such a culture breeds cynicism and distrust in both the medical and legal systems with damaging consequences to the patient-physician relationship.

An increase in the frequency and severity of medical liability claims may result, in part, from one or more of the following circumstances:

  • Advances in medical knowledge and medical technology that have enabled physicians to achieve treatment results that were not possible in the past, but that may involve considerable risks.
  • Pressures on physicians by private managed care, other healthcare organizations or government-managed health care systems to limit the costs of medical care.
  • Confusing the right of access to health care, which is attainable, with the right to achieve and maintain health, which cannot be guaranteed.
  • The role of the media, advocacy groups and even regulatory bodies in fostering mistrust of physicians by questioning their ability, knowledge, behaviour, and management of patients, and by encouraging patients to submit complaints against physicians.

A growing culture of litigation and an increase in medical liability claims may result, among other things, in a rise in defensive medicine, defined as “the practice of ordering medical tests, procedures, or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits.”[1] Depending on the situation, defensive medicine may entail active behaviour, such as performing tests and procedures that are not clinically indicated or prescribing unnecessary hospitalization, or passive behaviour, such as avoiding high-risk patients or avoiding potentially beneficial but risky procedures.

A distinction must be made between harm caused by medical negligence, defined as failure to conform to the standard of care in treating the patient, and harm caused by adverse outcomes occurring in the course of medical care provided in accordance with appropriate standards of care.

Compensation for patients suffering a medical injury should be determined differently for injuries caused by negligence than for adverse outcomes that may occur during medical care, unless there is an alternative system in place such as a no-fault system.

The laws of each jurisdiction should provide the procedures for establishing liability and for determining the amount of compensation to be awarded to the patient in those cases where negligence is proven.

Criminalizing medical judgment interferes with appropriate medical decision making and is a disservice to patients.

The mounting evidence of preventable deaths as a result of medical error has led for experts to call for improved safety measurements in hospitals. With this in mind, investigations should take into account the wider context, identifying systemic failings, with recommendations for change, in order to improve patient safety.

 

RECOMMENDATIONS

The WMA:

1.     Makes an urgent call to all national governments to ensure the existence of a reliable system of medical justice in their respective countries.  Legal systems should ensure that patients are protected against harmful practices, and physicians are protected against unmeritorious lawsuits.

2.     Demands that investigations consider the complete context, in order to identify systemic failings.

3.     Encourages health care providers to develop systems which improve the quality of patient-safety practices.

 

NMAs should consider the following activities to encourage fair and equitable treatment for both physicians and patients:

4.     Educate and instruct physicians to have clear and detailed documentation of patient records.

5.     Develop appropriate remedial training for physicians found to be deficient in knowledge or skills.

6.     Encourage NMAs and Specialist Interest Groups to produce updated protocols and guidelines to guide medical professionals and staff.

7.     Inform the public, physicians, and government of the dangers that various manifestations of defensive medicine may pose. These include:

  • an increase in health care costs;
  • an undermining of the doctor-patient relationship;
  • the commission of unnecessary test or treatments;
  • the avoidance of high-risk treatments;
  • the over-prescription of medications;
  • the disaffection of young physicians for certain higher risk specialties and
  • the reluctance by or avoidance of physicians or hospitals to treat higher-risk patients.

8.     Educate the public as to the possible occurrence of adverse medical outcomes, and increased fees, and establish simple procedures to allow patients to receive explanations in such cases and to be informed of the steps that must be taken to seek resolution, if appropriate.

9.     Encourage medical workplaces to break the culture of blame in the wake of medical errors or adverse outcomes and advocate for confidentiality of quality assurance processes in order to enable physicians to practice medicine to the best of their ability free from the threat of medical liability litigation and discipline.

10.  Advocate for legal protection for physicians when patients are injured by adverse results not caused by any negligence.

11.  Develop emotional and practical support for physicians involved in adverse events.

12.  Participate in the development of the laws and procedures applicable to medical liability claims, with special emphasis on highlighting the difference between errors and adverse outcomes.

13.  Actively oppose meritless or frivolous claims.

14.  Explore innovative alternative dispute resolution procedures for efficiently resolving medical liability claims, such as mediation and arbitration.

15.  Require physicians to have adequate medical liability insurance coverage or other resources against medical liability claims, paid by the practitioners themselves or by their employer.

16.  Encourage the development of voluntary, confidential, and legally protected internal systems for reporting adverse outcomes or medical errors for the purpose of analysis and for making recommendations on reducing errors and improving patient safety and health care quality.

17.  Advocate against the increasing criminalization or penal liability of medical judgment in consideration of adverse events. Aside from truly negligent behaviour or intentional misconduct, most adverse events are the result of unintentional human error, system failures, or uncontrollable circumstances and should not brand the physician with criminal motive or behaviour.

18.  Support the principles set forth in the WMA’s Declaration of Madrid on Professional Autonomy and Self-Regulation.

 

[1] “Defensive medicine.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/defensive%20medicine. Accessed 12 Mar. 2020

Adopted by the 56th WMA General Assembly, Santiago, Chile, October 2005
and reaffirmed by the 200th WMA Council Session, Oslo, Norway, April 2015

 

INTRODUCTION

  1. The prescription of a drug represents the culmination of a careful deliberative process between physician and patient aimed at the prevention, amelioration or cure of a disease or problem. This deliberative process requires that the physician evaluate a variety of scientific and other data including costs and make an individualized choice of therapy for the patient. Sometimes, however, a pharmacist is required to substitute a different drug for the one prescribed by the physician. The World Medical Association has serious concerns about this practice.
  2. Drug substitution can take two forms: generic substitution and therapeutic substitution.
  3. In generic substitution, a generic drug is substituted for a brand name drug. However, both drugs have the same active chemical ingredient, same dosage strength, and same dosage form.
  4. Therapeutic substitution occurs when a pharmacist substitutes a chemically different drug for the drug that the physician prescribed. The drug substituted by the pharmacist belongs to the same pharmacologic class and/or to the same therapeutic class. However since the two drugs have different chemical structures, adverse outcomes for the patient can occur.
  5. The respective roles of physicians and pharmacists in serving the patient’s need for optimal drug therapy are outlined in the WMA Statement on the Working Relationship between Physicians and Pharmacists in Medicinal Therapy.
  6. The physician should be assured by national regulatory authorities of the bioequivalence and the chemical and therapeutic equivalence of prescription drug products from both multiple and single sources. Quality assurance procedures should be in place to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equivalence.
  7. Many considerations should be addressed before prescribing the drug of choice for a particular indication in any given patient. Drug therapy should be individualized based on a complete clinical patient history, current physical findings, all relevant laboratory data, and psychosocial factors. Once these primary considerations are met, the physician should then consider comparative costs of similar drug products available to best serve the patient’s needs. The physician should select the type and quantity of drug product that he or she considers to be in the best medical and financial interest of the patient.
  8. Once the patient gives his or her consent to the drug selected, that drug should not be changed without the consent of the patient and his or her physician. Failure to follow this principle can result in harm to patients. On behalf of patients and physicians alike, National Medical Associations should do everything possible to ensure the implementation of the following recommendations:

RECOMMENDATIONS

  1. Physicians should become familiar with specific laws and/or regulations governing drug substitution where they practise.
  2. Pharmacists should be required to dispense the exact chemical, dose, and dosage form prescribed by the physician. Once medication has been prescribed and begun, no drug substitution should be made without the prescribing physician’s permission.
  3. If substitution of a drug product occurs, the physician should carefully monitor and adjust the dose to ensure therapeutic equivalence of the drug products.
  4. If drug substitution leads to serious adverse drug reaction or therapeutic failure, the physician should document this finding and report it to appropriate drug regulatory authorities.
  5. National Medical Associations should regularly monitor drug substitution issues and keep their members advised on developments that have special relevance for patient care. Collection and evaluation of information reports on significant developments in this area is encouraged.
  6. Appropriate drug regulatory bodies should evaluate and ensure the bioequivalence and the chemical and therapeutic equivalence of all similar drug products, whether generic or brand-name, in order to ensure safe and effective treatment.
  7. National Medical Associations should oppose any action to restrict the freedom and the responsibility of the physician to prescribe in the best medical and financial interest of the patient.
  8. National Medical Associations should urge national regulatory authorities to declare therapeutic substitution illegal, unless such substitution has the immediate prior consent of the prescribing physician.

Adopted by the 56th WMA General Assembly, Santiago, Chile, October 2005
And rescinded at the 68th WMA General Assembly, Chicago, USA, October 2017

PREAMBLE

  1. Alcohol use is deeply embedded in many societies. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco or hypertension. Overall, there are causal relationships between alcohol consumption and more than 60 types of disease and injury including traffic fatalities. Alcohol consumption is the leading risk factor for disease burden in low mortality developing countries and the third largest risk factor in developed countries. Beyond the numerous chronic and acute health effects, alcohol use is associated with widespread social, mental and emotional consequences. The global burden related to alcohol consumption, both in terms of morbidity and mortality, is considerable.
  2. Alcohol-related problems are the result of a complex interplay between individual use of alcoholic beverages and the surrounding cultural, economic, physical environment, political and social contexts.
  3. Alcohol cannot be considered an ordinary beverage or consumer commodity since it is a drug that causes substantial medical, psychological and social harm by means of physical toxicity, intoxication and dependence. There is increasing evidence that genetic vulnerability to alcohol dependence is a risk factor for some individuals. Fetal alcohol syndrome and fetal alcohol effects, preventable causes of mental retardation, may result from alcohol consumption during pregnancy. Growing scientific evidence has demonstrated the harmful effects of consumption prior to adulthood on the brains, mental, cognitive and social functioning of youth and increased likelihood of adult alcohol dependence and alcohol related problems among those who drink before full physiological maturity. Regular alcohol consumption and binge drinking in adolescents can negatively affect school performance, increase participation in crime and adversely affect sexual performance and behaviour.
  4. Alcohol advertising and promotion is rapidly expanding throughout the world and is increasingly sophisticated and carefully targeted, including to youth. It is aimed to attract, influence, and recruit new generations of potential drinkers despite industry codes of self-regulation that are widely ignored and often not enforced.
  5. Effective alcohol social policy can put into place measures that control the supply of alcohol and/or affect population-wide demand for alcohol beverages. Comprehensive policies address legal measures to: control supply and demand, control access to alcohol (by age, location and time), provide public education and treatment for those who need assistance, levy taxation to affect prices and to pay for problems generated by consumption, and harm-reduction strategies to limit alcohol-related problems such as impaired driving and domestic violence.
  6. Alcohol problems are highly correlated with per capita consumption so that reductions of use can lead to decreases in alcohol problems. Because alcohol is an economic commodity, alcohol beverage sales are sensitive to prices, i.e., as prices increase, demand declines, and visa versa. Price can be influenced through taxation and effective penalties for inappropriate sales and promotion activities. Such policy measures affect even heavy drinkers, and they are particularly effective among young people.
  7. Heavy drinkers and those with alcohol-related problems or alcohol dependence cause a significant share of the problems resulting from consumption. However, in most countries, the majority of alcohol-related problems in a population are associated with harmful or hazardous drinking by non-dependent ‘social’ drinkers, particularly when intoxicated. This is particularly a problem of young people in many regions of the world who drink with the intent of becoming intoxicated.
  8. Although research has found some limited positive health effects of low levels of alcohol consumption in some populations, this must be weighed against potential harms from consumption in those same populations as well as in population as a whole.
  9. Thus, population-based approaches that affect the social drinking environment and the availability of alcoholic beverages are more effective than individual approaches (such as education) for preventing alcohol related problems and illness. Alcohol policies that affect drinking patterns by limiting access and by discouraging drinking by young people through setting a minimum legal purchasing age are especially likely to reduce harms. Laws to reduce permitted blood alcohol levels for drivers and to control the number of sales outlets have been effective in lowering alcohol problems.
  10. In recent years some constraints on the production, mass marketing and patterns of consumption of alcohol have been weakened and have resulted in increased availability and accessibility of alcoholic beverages and changes in drinking patterns across the world. This has created a global health problem that urgently requires governmental, citizen, medical and health care intervention.

RECOMMENDATIONS

The WMA urges National Medical Associations and all physicians to take the following actions to help reduce the impact of alcohol on health and society:

  1. Advocate for comprehensive national policies that
    1. incorporate measures to educate the public about the dangers of hazardous and unhealthy use of alcohol (from risky amounts through dependence), including, but not limited to, education programs targeted specifically at youth;
    2. create legal interventions that focus primarily on treating or provide evidence-based legal sanctions that deter those who place themselves or others at risk, and
    3. put in place regulatory and other environmental supports that promote the health of the population as a whole.
  2. Promote national and sub-national policies that follow ‘best practices’ from the developed countries that with appropriate modification may also be effective in developing nations. These may include setting of a minimum legal purchase age, restricted sales policies, restricting hours or days of sale and the number of sales outlets, increasing alcohol taxes, and implementing effective countermeasures for alcohol impaired driving (such as lowered blood alcohol concentration limits for driving, active enforcement of traffic safety measures, random breath testing, and legal and medical interventions for repeat intoxicated drivers).
  3. Be aware of and counter non-evidence-based alcohol control strategies promoted by the alcohol industry or their social aspect organizations.
  4. Restrict the promotion, advertising and provision of alcohol to youth so that youth can grow up with fewer social pressures to consume alcohol. Support the creation of an independent monitoring capability that assures that alcohol advertising conforms to the content and exposure guidelines described in alcohol industry self-regulation codes.
  5. Work collaboratively with national and local medical societies, specialty medical organizations, concerned social, religious and economic groups (including governmental, scientific, professional, nongovernmental and voluntary bodies, the private sector, and civil society) to:
    1. reduce harmful use of alcohol, especially among young people and pregnant women, in the workplace, and when driving;
    2. increase the likelihood that everyone will be free of pressures to consume alcohol and free from the harmful and unhealthy effects of drinking by others; and
    3. promote evidence-based prevention strategies in schools.
  6. Undertake to
    1. screen patients for alcohol use disorders and at-risk drinking, or arrange to have screening conducted systematically by qualified personnel using evidence-based screening tools that can be used in clinical practice;
    2. promote self-screening/mass screening with questionnaires that could then select those needing to be seen by a provider for assessment;
    3. provide brief interventions to motivate high-risk drinkers to moderate their consumption; and
    4. provide specialized treatment, including use of evidence-based pharmaceuticals, and rehabilitation for alcohol-dependent individuals and assistance to their families.
  7. Encourage physicians to facilitate epidemiologic and health service data collection on the impact of alcohol.
  8. Promote consideration of a Framework Convention on Alcohol Control similar to that of the WHO Framework Convention on Tobacco Control that took effect on February 27, 2005.
  9. Furthermore, in order to protect current and future alcohol control measures, advocate for consideration of alcohol as an extra-ordinary commodity and that measures affecting the supply, distribution, sale, advertising, promotion or investment in alcoholic beverages be excluded from international trade agreements.

Adopted by the 45th World Medical Assembly, Budapest, Hungary, October 1993
editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
and revised by the 67th WMA General Assembky, Taipei, Taiwan, October 2016 

 

1. The World Medical Association adopts this statement for the purpose of providing guidance for National Medical Associations as they develop guidelines for their members.

2. Physician participation in body cavity searches for purposes of law enforcement or public safety involves complex issues of patient rights, informed consent, physicians’ fiduciary obligations (dual loyalty matters) and their responsibilities to contribute to public health. A request to conduct a body cavity search puts the physician in the untenable position of potentially violating the ethical standards of his/her profession. Physician participation should be in exceptional cases only.

3. There are several types of searches of prisoners carried out within the detention system.  These will include searches for contraband and searches for items immediately dangerous to the prisoner and those around him/her.  Searches range from the least invasive  “pat-down” searches to the most invasive strip searches (including examination of the mouth) and body cavity searches.

4. The prison systems in many countries mandate body cavity searches of prisoners. Such searches, which include rectal and pelvic (vaginal) examination, may be performed when an individual initially enters the prison population and thereafter whenever the individual is permitted to have direct personal contact with someone outside the prison population. They may also be undertaken when there is a reason to believe a breach of security or of prison regulations has occurred. For example, when a prisoner is taken to Court for a hearing, or to the hospital for treatment, or to work outside the prison, the prisoner, upon returning to the institution, may be subjected to a body cavity search that will include all body orifices. Where prisoners have direct contact with visitors – family members or otherwise – prison rules may also require body cavity searches. The purpose of the search is primarily security-related, to prevent contraband, such as weapons or drugs, from entering the prison.

5. These searches are performed for security reasons and not for medical or health-related reasons. They should only be done by someone with appropriate training. In most cases this will mean someone working within the detention system who has been trained to perform safely such searches.  This person should not be a physician except under unusual and specific circumstances.

6. A physician’s obligation to provide medical care to the prisoner can be compromised by an obligation to participate in the prison’s security system. A physician should seek to be as far removed from performing body searches as possible. Any directive to search should be separated from the physician’s broad general medical care duties in order to protect the patient/physician relationship.

7. In exceptional cases the detaining authority, may indicate that a search be performed by a physician. The physician, will decide whether medical participation is necessary, and act accordingly and ethically.

8. If the search could, if carried out by someone with lesser skills, cause harm, for example if the prisoner is a pregnant, or has severe haemorrhoids, then this non-medical procedure may be performed by a physician to protect the prisoner from harm. In such a case the physician should explain this to the prisoner. The physician should also explain to the prisoner that s/he is performing this search not as a physician caring for the patient, but for patient safety and as required by the detention authorities for which the normal patient/doctor relationship does not exist. The physician should inform the prisoner that the usual conditions of medical confidentiality do not apply during this procedure and the results of the search will be revealed to the authorities. If a physician is properly mandated by an authority and agrees to perform a body cavity search on a prisoner for reasons of patient safety, the authority should be informed that it is necessary for this procedure to be done in a humane manner.

9. If the search is conducted by a physician, it should not be done by any physician who will subsequently provide medical care to the prisoner.

10. Forced examinations are not ethically acceptable, and physicians must not perform them. If the prisoner acquiesces to a search, the doctor, or other individual carrying out the body cavity search, should ensure that the prisoner is fully aware of what will be done, including the facilities in which the search will be performed.

11. Searches should be performed humanely, and, where possible, in a private, confidential setting respecting the prisoner. The person performing the search should be of the same gender as the prisoner being searched. When applicable, transgender persons should be asked first with which gender they identify.

12. The World Medical Association urges all governments and public officials with responsibility for public safety to recognize that invasive searches are serious assaults on a person’s privacy and dignity, and they also carry some risk of physical and psychological injury. The World Medical Association urges that, to the extent feasible without compromising public security, the following recommendations be followed:

  • Alternate methods be used for routine screening of prisoners, including ultrasound and other scans, and body cavity searches be used only as a last resort;
  • Squatting over mirrors to examine the anus while making the prisoner bear down, a degrading procedure with questionable reliability, must be banned;
  • If a body cavity search must be conducted, the responsible public official must ensure that the search is conducted humanely by personnel who are of the same gender as the prisoner and who possess sufficient medical and skills to safely perform the search;
  • The same responsible authority must ensure that the individual’s privacy and dignity be guaranteed.
  • Physician participation in body cavity searches should be in exceptional cases only. In these cases, the duty to search should be separated from the physician’s delivery of medical care.

13. Finally, the World Medical Association urges all governments and responsible public officials to provide body searches that are performed by a qualified physician whenever warranted by the individual’s physical condition. A specific request by a prisoner for a physician shall be respected, so far as possible.

14. In specific cases, it may be the detaining authority, which requires a search be performed by a physician, for the well-being of this prisoner. The physician, in such a case, will decide whether medical participation is indeed necessary, and act accordingly and ethically.

Adopted by the 35th World Medical Assembly, Venice, Italy, October 1983
and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

 

1. Boxing is a dangerous sport. Unlike other sports, its basic intent is to produce bodily harm by specifically targeting the head. The main medical argument against boxing is the risk of chronic traumatic encephalopathy (CTE), also known as chronic traumatic brain injury (CTBI), and dementia pugilistica or “punch-drunk” syndrome. Other injuries caused by boxing can lead to loss of sight, loss of hearing, and fractures. Studies show that boxing is associated with devastating short-term injuries and chronic neurological damage on the participants in the long term.

2. The past few decades have witnessed vigorous campaigns by national medical bodies to have all forms of boxing abolished. In the absence of such a ban, a series of boxing tragedies worldwide has pressured various sports regulatory bodies to adopt a variety of rules and standards to enhance the safety of boxers.

3. Despite regulation of boxing in various countries, injuries and death still occur as a result of boxing related head trauma, indicating that regulation does not provide adequate protection to participants.

4. In addition to regulated boxing, unchecked and unsupervised boxing competitions (bareknuckle battles or “street fights”) still take place in many parts of the world. This underground boxing puts at risk the lives and health of a significant number of persons who participate in these fights.

5. Health and safety concerns in boxing extend to other professional sports where boxing is a component, such as mixed martial arts (MMA), kickboxing etc. For this reason, the recommendations in this statement should be applied to these sports as well.

6. The WMA believes that boxing is qualitatively different from other sports because of the injuries it causes and that it should be banned.

7. Until a full ban is achieved the WMA urges that the following measures be implemented:

7.1 Boxing must be regulated and all boxers licensed. Boxers should be provided with written information on the risks of participating in boxing.

7.2 No children (as per country-specific definition) should be permitted to participate in boxing.

7.3 A national registry of all amateur and professional boxers, including sparring partners, should be established in each country where boxing is allowed. The registry should record the results of all matches, including technical knockouts, knockouts, and other boxing injuries, and compile injury records for individual boxers. All boxers should be followed up for a period of at least twenty years to document long-term outcomes.

7.4  All boxers should undergo a baseline medical examination, which should include neurological assessment, including brain imaging, at the beginning of their careers. Medical and neurological assessments should also be performed before and after each event. Boxers who do not pass the examination must be reported to the national registry and must not be allowed to participate in future matches.

7.5  Personal protective equipment recommendations (such as size and weight of gloves, head gear and gum shields) should take into consideration medical recommendations.

7.6 A physician serving at a boxing match has a professional responsibility to protect the health and safety of the contestants. To that end, the physician should receive specialized training in athlete evaluation, especially traumatic brain injury assessment. The physician’s judgment should be governed only by medical considerations, and the physician must be allowed to stop any match in progress to examine a contestant and to terminate a match that, in the physician´s opinion, could result in serious injury.

7.7 Funding and sponsorship of boxing should be discouraged, and TV coverage of boxing events should be age restricted and include a warning statement on the risks of boxing.