Policy Type: Statement

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

 

PREAMBLE

The World Medical Association joins with other international agencies in condemning the practice of genital mutilation or cutting of women and girls, regardless of the level of mutilation, and opposes the participation of physicians in these practices.

Stopping female genital mutilations (FGM) requires action on strict enforcement of laws prohibiting the practice, medical and psychological care for women who are victims and prevention of FGM by education, risk assessment, early detection and engagement with community leaders.

FGM is a common practice in more than 30 countries of the world, including some in Africa, Asia and the Middle East. The phrase FGM is used to convey a number of different forms of surgery, mutilation or cutting of the female external genitalia. The term female circumcision is no longer used as it suggests equivalence with male circumcision, which is both inaccurate and counterproductive.  Most girls undergo FGM/C between the ages of 7 and 10.  There is no medical necessity for any such cutting, which is often performed by an unqualified individual in un-hygienic surroundings.

FGM of any type is a violation of the human rights of girls and women, as it is a harmful procedure performed on a child who cannot give valid consent.  As a result of migration a growing number of girls living outside countries where the practice is common are being affected.

Respecting the social norms of immigrants is increasingly posing problems for physicians and the wider community.

Because of its impact on the physical and mental health of women and children, and because it is a violation of human rights, FGM is a matter of concern to physicians.  Physicians worldwide are confronted with the effects of this traditional practice.  They may be asked to perform this mutilating procedure or to restore the result of mutilating “surgery” on women after childbirth has reopened the introitus.

There are various forms of FGM, classified by WHO.[1] It can be a primary procedure for young girls, usually between 5 and 12 years of age, or a secondary one, e.g., after childbirth. The extent of a primary procedure may vary: from an incision in the foreskin of the clitoris, up to the maximally mutilating so-called pharaonic infibulation which involves partly removing the clitoris and labia minora and stitching up of the labia majora so that only a small opening remains to allow the passage of urine and menstrual blood. The majority of procedures performed are somewhere in between these two extremes.

While the term female circumcision is no longer used it remains useful, familiar and readily accessible in the context of physician/patient consultations in some cases.

FGM has no health benefits and harms girls and women in many ways, regardless of which procedure is performed.  Research shows grave permanent damage to health, including: haemorrhage, infections, urinary retention, injury to adjacent organs, shock and very severe pain. Long-term complications include severe scarring, chronic bladder and urinary tract infections, urologic and obstetric complications, and psychological and social problems. FGM has serious consequences for sexuality and how it is experienced, including the loss of capacity for orgasm. There are also many complications during childbirth including expulsion disturbances, formation of fistulae, and traumatic tears of vulvar tissue.

There are a number of reasons given for the continuation of the practice of FGM: custom, community tradition (preserving the virginity of young girls and limiting the sexual expression of women) and as part of a girl’s initiation into womanhood. These reasons do not justify the considerable damages to physical and mental health.

None of the major religions supports this practice, which is otherwise often wrongly linked to religious beliefs.  FGM is a form of violence usually perpetuated on young women and girls and represents a lack of respect for their individuality, freedom and autonomy.

Physicians may be faced with parents seeking a physician to perform FGM, or they may become aware of parents who seek to take girls to places where the practice is commonly available.  They must be prepared to intervene to protect the girl.

Medical associations should prepare guidance on how to manage these requests which may include invoking local laws that protect children from harm and may include involving police and other agencies.

When patients who have undergone FGM give birth, physicians may receive requests to restore the results of the FGM. They should be confident in handling such requests and supported with appropriate educational material that will enable them to discuss with the patient the medically approved option of repairing the damage done by FGM and by childbirth. Physicians also have a responsibility to have a discussion with the spouse of the patient, with the consent of the patient, who might otherwise seek “restoration” of the FGM, if not given a full explanation of the harm that is done by FGM.

There is a growing tendency for physicians and other health care professionals in some countries to perform FGM because of a wish to reduce the risks involved. Some practitioners may believe that medicalization of the procedure is a step towards its eradication.  Performing FGM is a breach of medical ethics and human rights, and involvement by physicians may give it credibility.  In most countries performing this procedure is a violation of the law.

Governments in several countries have developed legislation, such as prohibiting FGM in their criminal codes.

RECOMMENDATIONS

  1. Taking into account the psychological needs and ‘cultural identity’ of the people involved, physicians should explain the dangers and consequences of FGM and discourage performing or promoting FGM. Physicians should integrate women’s health promotion and counselling against FGM into their work.
  2. Physicians should assist in educating health professionals and work with local community, cultural and social leaders to educate them about the adverse consequences of FGM. They should support persons who want to end FGM and the establishment of community programmes designed to outlaw the practice, offering medical information about its damaging effects as necessary.
  3. There are active campaigns against FGM that are led by women leaders and heads of state in Africa and elsewhere.  These campaigns have issued strong statements against the practice.
  4. Physicians should work with groups such as these and others who manage pregnant women including midwives, nurses and traditional birth attendants, to ensure all practitioners have standardized and sensitive information about FGM.
  5. Physicians should cooperate with any preventive legal strategy when a child is at risk of undergoing FGM.
  6. National Medical Associations should stimulate public and professional awareness of the damaging effects of FGM.
  7. National Medical Associations should ensure that FGM education and awareness are part of its advocacy to prevent violence against women and girls.
  8. National Medical Associations should work with opinion leaders, encouraging them to become active advocates against FGM.
  9. National Medical Associations should stimulate government action in preventing the practice of FGM. This should include sustained advocacy programmes and the development of legislation prohibiting FGM.
  10. NMAs must prohibit involvement by physicians in the practice of FGM, including re-infibulation after childbirth. Physicians should be encouraged to perform reconstructive surgery on women who have undergone FGM. Physicians should seek to ensure the provision of adequate (and non-judgemental) medical and psychological care for women who have undergone FGM.
  11. Physicians should be aware that the risk of FGM might be a justification for overriding patient confidentiality, and allow disclosure to social or other relevant services to protect a child from serious harm.

[1] FGM can be classified into four types: clitoridectomy, excision, infibulation and other harmful procedures such as pricking, piercing, incising, scraping and cauterizing the genital area.

Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992,
editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005,
reaffirmed by the 200th WMA Council Session, Oslo, Norway, April 2015 and
rescinded and archived by the 70th WMA General Assembly, Tbilisi, October 2019
* This document has been replaced by the completely rewritten  “WMA Declaration on Euthanasia and Physician-Assisted Suicide” (2019)

 

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.

Approved by the 55th WMA General Assembly, Tokyo, Japan, October 2004
and rescinded by the 65th WMA General Assembly, Durban, South Africa, October 2014

A.  INTRODUCTION

  1. In late 2002, an outbreak of a new severe acute respiratory syndrome (SARS) began in southern China. The disease, which was caused by the SARS coronavirus, spread internationally in late February 2003. The most severely affected countries were China, Canada, Singapore and Vietnam, all of which experienced outbreaks before the issue of global alerts by the World Health Organization (WHO). According to WHO data, altogether 8422 cases occurred in 29 countries; in the four afore-mentioned countries, 908 cases were fatal.
  2. SARS was an especially difficult new disease to diagnose and treat – it passed readily from person to person, required no vector, had no particular geographic affinity, mimicked the symptoms of many other diseases, took its heaviest toll on hospital staff, and spread internationally with alarming ease. The spread of SARS along the routes of international air travel emphasizes the fact that pathogens know no boundaries and reinforces the critical need for global public health strategies.
  3. The main outbreaks of SARS occurred in areas with well-developed health systems. If SARS had become established in areas with weak health infrastructure, it is unlikely that containment would have been achieved so quickly. But even in well-developed health care systems, certain very significant flaws were demonstrated during this epidemic:
    • Lack of effective real-time, two-way communication channels to front-line physicians;
    • Lack of adequate resources, stockpiles of medication and supplies to deal with this type of catastrophe;
    • Lack of surge capacity within acute care and public health systems.
  4. A gap between public health authorities (national and international) and clinical medicine was demonstrated during this episode. At its September 2003 General Assembly, the WMA adopted a Resolution on SARS that: “strongly encouraged the World Health Organization to enhance its emergency response protocol to provide for the early, ongoing and meaningful engagement and involvement of the medical community globally.…”

B.  BASIC PRINCIPLES

  1. The international community must be constantly alert to the threat of emerging disease outbreaks and ready to respond with a global strategy. The Global Outbreak Alert and Response Network (GOARN) of WHO has a significant role to play in global health security by:
    • combating the international spread of outbreaks;
    • ensuring that appropriate technical assistance reaches affected states rapidly; and
    • contributing to long-term epidemic preparedness and capacity-building.
    • The WMA has been actively involved in GOARN, where appropriate. The role of GOARN must, however, be acknowledged and actively promoted within the medical profession.
  2. Sovereign states have a responsibility to address the health needs within their borders. Today, however, many urgent health security risks are not confined by national boundaries. Early detection, through effective national surveillance systems, of unusual disease events that threaten public health, and international cooperation between WHO, its member states, and non-governmental partners like the WMA, are required to effectively respond to public health emergencies of international concern. A strengthening of the International Health Regulations to broaden their scope to include new and future health emergencies and enable WHO to actively assist States in responding to international health security threats will provide additional tools for global epidemic control.
  3. Effective communication between WHO and the WMA, the WMA and its member National Medical Associations (NMAs), and NMAs and physicians can strengthen the information exchange between WHO and its Member States during public health emergencies.
  4. Physicians are often the first point of contact with the emergence of new diseases; therefore they are in a position to aid in all elements of diagnosis, treatment and reporting of affected patients and prevention of disease. Physicians with key expertise must be incorporated into the health emergency decision-making process so that the impact of national and international directives on clinical settings and patient care is understood.
  5. WHO and its Member States must work with the WMA and NMAs to proactively address the safety of patients and of health professionals involved in caring for the sick during outbreaks of new diseases. Delays in identifying and distributing supplies of protective equipment to health professionals and their patients exacerbate anxiety and risk of spread of infectious disease. National and international systems that stockpile relevant and adequate supplies and rapidly move them to affected areas should be created or enhanced. All the principles employed in the safeguarding of patient safety should be respected and followed in emergencies such as SARS.

C.  RECOMMENDATIONS

  1. That the WMA and member NMAs should work closely with WHO, national governments, and other professional groups to jointly promote the elements of this Statement.
  2. That the WMA urge physicians to a) be alert to the occurrence of unexplained illnesses and deaths in the community, b) be knowledgeable of disease surveillance and control capabilities for responding to unusual clusters of diseases, symptoms and presentations, and assiduous in the timely reporting of suspicious cases of illness to appropriate authorities; c) utilize appropriate procedures to prevent exposure of infectious pathogens to themselves and others; d) understand the principles of risk communication so that they can communicate clearly and non-threateningly with patients, their families, and the media about issues such as exposure risks and potential preventive measures (e.g., vaccinations); and e) understand the roles of the public health, emergency medical services, emergency management, and incident management systems in response to a health crisis and the individual health professional’s role in these systems.
  3. That the WMA encourage physicians, NMAs, and other medical societies to participate with local, national, and international health authorities in developing and implementing disaster preparedness and response protocols for natural infectious disease outbreaks. These protocols should be used as the basis for physician and public education.
  4. That the WMA call on NMAs to promote and support WHO’s GOARN as a control coordinating entity in combating global health security threats.
  5. That the WMA call for the establishment of a strategic partnership agreement with WHO, so that in case of epidemics, health communication can be stepped up considerably and two-way flow of information ensured.
  6. That WHO should coordinate the development of an inventory based on existing stockpiles of supplies, so that such supplies can be rapidly deployed and accessed by physicians involved in the care of victims.
  7. That WHO should strengthen the International Health Regulations to broaden their scope to include reporting of new and future health emergencies, and to enable WHO to actively assist States in responding to international health security threats.
  8. That international agreements should be proactively explored to facilitate the movement of health professionals who are involved in the management of epidemics.
  9. That research in the field of emergency preparedness should be enhanced by national governments and NMAs where appropriate, to better understand current flaws in the system and how to improve preparedness in the future.
  10. That education and training of physicians should be modified to take into account the realities and specific needs required in the event of emergencies, and to ensure that due diligence is paid to patient and health care worker safety when managing patients with acute infectious diseases.
  11. That physicians everywhere in the world, including those in Taiwan, have unlimited access to WHO programs and information concerning health emergencies.

Approved by the 55thWMA General Assembly, Tokyo, Japan, October 2004
and revised by the 65th WMA General Assembly, Durban, South Africa 2014
and by the 68th WMA General Assembly, Chicago, United States, October 2017

 

PREAMBLE

1.          An adequate supply of fresh (i.e. clean potable and uncontaminated) water is essential for individual and public health, as well as being a social determinant of health. It is central to living a life in dignity and health and upholding human rights. Many individuals, families and communities do not have access to such a supply, and even in those places where there is an abundance of fresh water, it is threatened by pollution,  activities such as industry and waste, inadequate or ineffective sanitation and other negative forces.

2.          A recent review of the evidence demonstrates that inadequate access to clean water, sanitation and soap for hand washing is the norm in many healthcare facilities worldwide, even in normal operating conditions.  Natural and manmade major events, including war, reduce access to clean water still further.

3.          In keeping with its mission to serve humanity by endeavouring to achieve the highest international standards in health care for all people in the world, the World Medical Association has developed this statement to encourage all those responsible for health to consider the importance and work towards achieving universal access to of water, sanitation and hygiene for individual and public health

4.          Hygiene, sanitation and water (HSW) are important determinants of health.  And key intervention strategies for reducing preventable morbidity, mortality and health care costs.  The health sector, and physicians in particular, play a key role in ensuring such determinants are properly managed.

 

CONSIDERATIONS

5.          Water-borne diseases account for a large proportion of mortality and morbidity, especially in developing countries. These problems are accentuated in times of disasters such as conflicts nuclear and man-made accidents with oil and/or chemicals, earthquakes, epidemics, droughts and floods.

6.          Anthropogenic changes to ecosystems, lowered retention by the earth’s surface, and the limitation of the inherent capacity of nature to filter dirt from the water are causing increasing damage to the natural environment, especially the water environment. Fracking for fossil fuels may have a significant effect on ground water as does the accumulation of micropollutant substances including pharmaceuticals and pesticides.

7.          The commodification of water, whereby it is provided for profit rather than as a public service, has potentially significant negative implications for access to an adequate supply of drinking water.

8.          The development of sustainable infrastructure for the provision of safe water and adequate sanitation contributes greatly to sound public health and national well-being. Curtailing infectious diseases and other ailments that are caused by unsafe water lowers the burden of health care costs and improves productivity. This creates a positive ripple effect on national economies

9.          Water as a vital and necessary resource for life has become scarce in many parts of the world and therefore must be used reasonably and with care.

10.       Water and effective sanitation are assets that are shared by humanity and the earth. Thus, water-related issues should be addressed collaboratively by the global community.

11.       Water, sanitation and hygiene are essential to the safe and effective provision of health care services, and are fundamental to public health.

 

RECOMMENDATIONS

13.    The WMA encourages National Medical Associations, health authorities and physicians to support all measures related to improving access to adequate, safe water and health including:

13.1.      International and national programmes to provide ready access to safe drinking water at low cost, or free, to every human on the planet and to prevent the pollution of water supplies.

13.2.      International, national, local and regional programmes to provide access to sanitation and to prevent the degradation of water resources.

13.3.      Research on the relationship between water pollution, water supply systems, including wastewater treatment, and health.

13.4.      The development of plans for providing potable water and proper wastewater disposal during emergencies. These will vary according to the nature of the emergency, but may include on-site water disinfection, identifying sources of water, and back-up power to run pumps.

13.5.      Preventive measures to secure safe water, sanitation and good hygiene for all health care institutions, including after the occurrence of natural disasters, especially earthquakes. Such measures should include the development of infrastructure and training programs to help health care institutions cope with such crises. The implementation of continued emergency water supply programs should be done in conjunction with regional authorities and with community involvement.

13.6.      More efficient use of water resources by each nation. The WMA especially urges hospitals and health institutions to examine their impact on sustainable water resources and to adhere to the highest safety standards for drug and medical waste disposal from healthcare settings.

13.7.      Preventive measures and emergency preparedness to save water from pollution.

13.8.      The promotion of the universal access to clean and affordable water and sanitation as a human right[1] and as a common good of humanity.

13.9.      Instruction on the link between hygiene supported by hand washing, and ill health prevention are health promotion and health education measures and requires work by government and health agencies, especially where access to water has previously been too limited for persons to exploit it for hygiene purposes.

13.10.   The establishment of a real-time alert system accessible to both the local population and to tourists providing information about the risks of contamination of water in a particular area.

 

[1] In 2010, the United Nations General Assembly and the Human Rights Council explicitly recognized the human right to water and sanitation, derived from the right to an adequate standard of living as stipulated in article 11 of the International Covenant on Economic, Social and Cultural Rights and other international human rights treaties. Hence, it is part of international human rights law.

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003,
revised by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007,
editorially revised by the 179th WMA Council Session, Divonne-les-Bains, France, May 2008
and by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

The dignity and value of every human being are acknowledged globally and expressed in numerous distinguished ethical codes and codifications of human rights, including the Universal Declaration of Human Rights. Any act of torture or cruel, inhuman or degrading treatment constitutes a violation of these codes and is irreconcilable with the ethical principles that lie at their core. These codes are listed at the end of this Statement (1).

However, in the medical professional codes and legal texts, there is no consistent and explicit reference to an obligation upon physicians to document cases and denounce acts of torture or cruel, inhuman or degrading treatment of which they become aware or witness.

The careful and consistent documentation and denunciation of torture or cruel, inhuman or degrading treatment by physicians contributes to the human rights of the victims and to the protection of their physical and mental integrity. The absence of documentation and denunciation of these acts may be considered as a form of tolerance thereof.

Because of the psychological sequelae from which they suffer, or the pressures brought upon them, victims are often unable or unwilling to formulate by themselves complaints against those responsible for the torture or cruel, inhuman and degrading treatment and punishments they have undergone.

By ascertaining the sequelae and treating the victims of torture, either early or late after the event, physicians witness the effects of these violations of human rights.

The WMA recognizes that in some circumstances, documenting and denouncing acts of torture may put the physician, and those close to him or her, at great risk. Consequently, doing so may have excessive personal consequences.

This statement relates to torture and other cruel, inhuman and degrading treatment and punishments as referred by the United Nations Convention against torture, excluding purposely the role of physicians in detention appraisal addressed in particular by the UN Standard Minimum Rules for the Treatment of Prisoners (Mandela rules).

 

RECOMMENDATIONS

The WMA recommends that its constituent members:

  1. Promote awareness among physicians of The Istanbul Protocol, including its Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment. This should be done at the national level.
  2. Promote training of physicians on the identification of different methods of torture and cruel, inhuman and degrading treatment and punishments, to enable them to provide high quality medical documentation that can be used as evidence in legal or administrative proceedings.
  3. Encourage professional training to ensure that physicians include assessment and documentation of signs and symptoms of torture or cruel, inhuman and degrading treatment and punishments in the medical records, including the correlation between the allegations given and the clinical findings.
  4. Work to ensure that physicians carefully balance potential conflicts between their ethical obligation to document and denounce acts of torture or cruel, inhuman and degrading treatment and punishments and a patient’s right to informed consent before documenting torture cases.
  5. Work to ensure that physicians avoid putting individuals in danger while assessing, documenting or reporting signs of torture and cruel, inhuman and degrading treatment and punishments.
  6. Promote access to immediate and independent health care for victims of torture or cruel, inhuman and degrading treatment and punishments.
  7. Support the adoption of ethical rules and legislative provisions:
  • Aimed at affirming the ethical obligation on physicians to report and denounce acts of torture or cruel, inhuman and degrading treatment and punishments of which they become aware; depending on the circumstances, the report or denunciation should be addressed to the competent national or international authorities for further investigation.
  • Addressing that a physician’s obligation to document and denounce instances of torture and cruel, inhuman and degrading treatment and punishments may conflict with their obligations to respect patient confidentiality and autonomy.
  • Physicians should use their discretion in this matter, bearing in mind paragraph 69 of the Istanbul Protocol (2).
  • cautioning physicians to avoid putting in danger victims who are deprived of freedom, subjected to constraint or threat or in a compromised psychological situation when disclosing information that can identify them.
  • Work to ensure protection of physicians, who risk reprisals or sanctions of any kind due to the compliance with these guidelines.
  • Provide physicians with all relevant information on procedures and requirements for reporting torture or cruel, inhuman and degrading treatment and punishments, particularly to national authorities, non-governmental organizations and the International Criminal Court.
  1. The WMA recommends that the constituent members’ codes of ethics include the physician’s obligations concerning documentation and denunciation of acts of torture and cruel, inhuman and degrading treatment and punishments as they are stated in this document.

 

(1) Codes and codifications:

  1. The Preamble to the United Nations Charter of 26 June 1945 solemnly proclaiming the faith of the people of the United Nations in the fundamental human rights, the dignity and value of the human person.
  2. The Preamble to the Universal Declaration of Human Rights of 10 December 1948 which states that disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind.
  3. Article 5 of the Universal Declaration of Human Rights which proclaims that no one shall be subjected to torture or cruel, inhuman or degrading treatment.
  4. The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), Adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders, held at Geneva in 1955, and approved by the Economic and Social Council by its resolutions 663 C (XXIV) of 31 July 1957 and 2076 (LXII) of 13 May 1977, revised and adopted by the General Assembly on 17 December 2015.
  5. The American Convention on Human Rights, which was adopted by the Organization of American States on 22 November 1969 and entered into force on 18 July 1978, and the Inter-American Convention to Prevent and Punish Torture, which entered into force on 28 February 1987.
  6. The Declaration of Tokyo, Adopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975 Editorially revised by the 170thWMA Council Session, Divonne-les-Bains, France, May 2005 and the 173rdWMA Council Session, Divonne-les-Bains, France, May 2006.
    Revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2017.
  7. The Declaration of Hawaii, adopted by the World Psychiatric Association in 1977.
  8. The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by the United Nations General Assembly on 18 December 1982, and particularly Principle 2, which states: “It is a gross contravention of medical ethics… for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment…”.
  9. The Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which was adopted by the United Nations General Assembly on December 1984 and entered into force on 26 June,1987.
  10. The European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, which was adopted by the Council of Europe on 26 June 1987 and entered into force on 1 February 1989.
  11. The WMA Declaration of Hamburg, adopted by the World Medical Association in November 1997 during the 49th General Assembly, and reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017 calling on physicians to protest individually against ill-treatment and on national and international medical organizations to support physicians in such actions.
  12. The Istanbul Protocol (Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment), adopted by the United Nations General Assembly on 4 December 2000.
  13. The Convention on the Rights of the Child, which was adopted by the United Nations on 20 November 1989 and entered into force on 2 September 1990.
  14. The World Medical Association Declaration of Malta on Hunger Strikers, adopted by the 43rd World Medical Assembly Malta, November 1991and amended by the WMA General Assembly, Pilanesberg, South Africa, October 2006, and revised by the 68th WMA General Assembly, Chicago, United States, October 2017.

(2) Istanbul Protocol, paragraph 69: “In some cases, two ethical obligations are in conflict. International codes and ethical principles require the reporting of information concerning torture or maltreatment to a responsible body. In some jurisdictions, this is also a legal requirement. In some cases, however, patients may refuse to give consent to being examined for such purposes or to having the information gained from examination disclosed to others. They may be fearful of the risks of reprisals for themselves or their families. In such situations, health professionals have dual responsibilities: to the patient and to society at large, which has an interest in ensuring that justice is done and perpetrators of abuse are brought to justice. The fundamental principle of avoiding harm must feature prominently in consideration of such dilemmas. Health professionals should seek solutions that promote justice without breaking the individual’s right to confidentiality. Advice should be sought from reliable agencies; in some cases, this may be the national medical association or non-governmental agencies. Alternatively, with supportive encouragement, some reluctant patients may agree to disclosure within agreed parameters.”

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003
reaffirmed by the 194th WMA Council Session, Bali, Indonesia, April 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE 

An advance directive is a written and signed document or a witnessed verbal statement whereby persons record their wishes regarding the medical care they wish to receive, or not receive, if they become unconscious or otherwise unable to express their will.

This type of document may have different names in different countries (e.g., “living will” or “biological wills”). The acceptability and legal status of such directives may differ from one country to another, depending on social, cultural, religious and other factors.

The majority of persons who draw up such directives are particularly concerned about excessive, ineffective or prolonged therapeutic interventions in the terminal phases of life, in situations where there is clear and irreversible physical or mental degeneration.

The WMA Declaration of Lisbon on the Rights of the Patient states that if the patient is unconscious and “if a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed unless it is obvious and beyond any doubt on the basis of the patient’s previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.”

 

RECOMMENDATIONS

  1. A patient’s duly executed advance directive should be honoured unless there are reasonable grounds to suppose that it is not valid because it no longer represents the wishes of the patient or that the patient’s understanding was incomplete at the time the directive was prepared. If the advance directive is contrary to the physician’s convictions, provisions should be made to transfer the care of the patient to another consenting physician.
  2. If the physician is uncertain about the validity of an advance directive to terminate life-prolonging treatment, he/she should consult family members or legal guardians of the patient concerned and should seek advice from at least one other physician or the relevant ethics committee. The family members or legal guardians should be designated in the advance directive, be trustworthy and willing to testify as to the intention(s) expressed in the advance directive by the signatory. The physician should consider any relevant legislation concerning substitute decision making for incompetent patients.
  3. Patients and their family members should be educated on the possibility of having living wills and advised to review their advance directives periodically.
  4. In the absence of an advance directive or a legally designated substitute decision maker, physicians should render such treatment as they believe to be in the patient’s best interests.
  5. Constituent Members of countries that do not have adequately developed legal frameworks and hospital protocols for advance directives, are encouraged to work with relevant authorities to develop such frameworks, integrate these changes both in the medical curricula and public education, as well as promote awareness among practicing physicians through continuing professional development programs.

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003
revised by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

PREAMBLE

Over the last three decades, forensic investigations into the whereabouts and fate of people killed and missing as a result of armed conflict, other situations of violence and catastrophes, have made an important contribution to humanitarian action on behalf of victims, including [the deceased and] bereaved families. Forensic investigations have also helped in achieving justice and reparations for victims.

In 2003 the International Conference on The Missing and Their Families, organized by the International Committee of the Red Cross (ICRC), adopted a set of recommendations to help prevent people going missing, and resolve the cases of those already missing, as a result of armed conflicts and other situations of violence. The recommendations include ethical, scientific and legal principles that must apply to forensic investigations in the search, recovery, management and identification of human remains. These principles have since been further developed and provide a framework for humanitarian forensic action in situations of armed conflicts, other situations of violence and catastrophes [1]. The principles also ensure the dignified and professional management of the dead [2], adherence to cultural and religious practices and help provide answers to the bereaved.

The WMA and its Constituent Members have a role in promoting these principles, encouraging compliance with them, and for ensuring the highest possible ethical, scientific and legal standards in forensic investigations aimed at addressing the humanitarian consequences of armed conflicts, other situations of violence and catastrophes.

RECOMMENDATIONS

  1. The WMA calls upon its Constituent Members to:
    • draw the attention of practitioners to the best practice guidelines produced by the ICRC, the United Nations and Interpol, and recommend or, where possible, require compliance with those standards;
    • help ensure that, when its individual physicians members take part in forensic investigations for humanitarian and human rights purposes, such investigations are established with a clear mandate based upon the highest ethical, scientific and legal standards, and conform with the principles and practice of humanitarian forensic action developed by the ICRC [3] and the United Nations [4];
    • acquire expertise in the principles collated by the different authorities on forensic investigations for humanitarian and human rights purposes, including those developed by the ICRC and the United Nations to prevent new cases and resolve those of existing missing persons, and to assist their members in applying these principles to forensic investigations worldwide;
    • disseminate those principles and support physicians refusing to take part in investigations that are ethically or otherwise unacceptable;
    • help ensure compliance by forensic medical practitioners with the principles enshrined in international humanitarian law for the dignified and professional management of the dead, including taking all measures to ensure their identification, while ensuring respect for their families.
  1. The WMA invites its Constituent Members to be mindful of academic qualifications and ethical understanding, ensuring that forensic physicians practice with competence and independence.

 

[1] The ICRC defines catastrophes as disasters beyond expectations. See: M. Tidball-Binz, Managing the dead in catastrophes: guiding principles and practical recommendations for first responders. International review of the Red Cross, Vol 89 Number 866 June 2007 p.p. 421-442.

[2] Management of the deceased (MotD) refers to a process encompassing different stages that begin with the information or report of death and finalizes with the return of the body to the bereaved, issuance of death certificates and final disposition.

[3] ICRC Guiding Principles for Dignified Management of the Dead in Humanitarian Emergencies and to Prevent them Becoming Missing Persons; Forensic Identification of Human Remains; Management of dead bodies after disasters: A manual for 1st responders; Guidelines for the use of Forensic Genetics in Investigations into Human Rights and International Humanitarian Law Violations

[4] UN Minnesota protocol applicable for the MotD in context of violations of human rights and criminal investigations.

 

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003
reaffirmed by the 59th WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.’’

Violence is multi-dimensional, has multiple driving factors, and can be physical, sexual, psychological or exerted through acts of deprivation or neglect.

The World Medical Association (WMA) has developed policies condemning different forms of violence. These include statements on Violence Against Women and Girls, Family Violence, Child Abuse and Neglect, Abuse of the Elderly, Adolescent Suicide, Violence in the Health Sector by Patients and those close to them, Protection of Health Care Workers in Situation of Violence, WMA Declaration on Alcohol and the WMA Statement on Armed-Conflicts.

Violence is a manifestation of the health, socio-economic, policy, legal, and political conditions of a country. It occurs in all social classes and is strongly associated with leadership failure and poor governance, and social determinants such as unemployment, poverty, health and gender inequality, and poor access to educational opportunities.

Despite regional and country-wide disparities in the scale and burden of violence, along with the under reporting of data, it is evident that violence results in fatal and non-fatal consequences. These include the devastation of individual, family, and community life, as well as disruption of the social, economic, and political development of nations.

Violence impacts the economy because of increased health and administrative expenditures by the criminal justice, law enforcement, and social welfare systems. It also has negative impact on a nation’s productivity because of a loss in human capital and the productivity of the workforce.

Impact on health

The effects of violence on health vary and can be life-long. Health consequences include physical disability, depression, post-traumatic stress disorder and other mental health challenges, unwanted pregnancies, miscarriages, and sexually transmitted infections.

Behavioral risk factors such as substance use, which can give rise to violent behaviour, are also risk factors for cancer, cardiovascular and cerebrovascular diseases.

Direct victims of violence are prone to traumatizing experiences such as physical, sexual and psychological abuse, and may be unwilling or unable to disclose or report their experiences to appropriate authorities due to shame, cultural taboo, fear of societal stigma or reprisal, and the justice system’s undue delay in dispensing justice.

In institutions such as healthcare facilities, violence is often interpersonal in nature, and may be perpetrated against patients by healthcare workers, or against health care workers by patients and their caregivers, or among healthcare personnel in the form of bullying, intimidation, and harassment.

Additionally, healthcare professionals and healthcare facilities are increasingly subjected to violent attacks. Such violence and targeted attacks on healthcare facilities, healthcare personnel, and the sick and wounded are in direct breach of medical ethics, international humanitarian and human rights laws.

Though many countries are increasingly accepting the need to institute violence prevention programs in their respective jurisdictions, the field of violence prevention and management still faces many challenges. Challenges include inadequate or non-existent reporting of data, inadequate investment in violence prevention programs and support services for victims of violence, and failure to enforce existing laws against violence, including measures to restrict access to alcohol.

Recognizing that violence remains a significant public health challenge which is multi-dimensional and preventable in nature, and affirming the pre-eminent role of physicians as role models, and in the care and support of victims of violence, the WMA commits itself to act against this global scourge.

 

RECOMMENDATIONS

WMA encourages its constituent members to:

  1. Educate and advise political and public office holders at all levels of government with appropriate and adequate knowledge and scientific evidence on the benefits of investing more resources in violence prevention.
  2. Advocate for and support good governance based on the rule of law, transparency, and accountability.
  3. Conduct and support effective media campaigns to inform and raise the public’s awareness on the burden and consequences of violence and the need to prevent it.
  4. Raise public awareness of international laws, norms, and ethical codes that mandate the protection of healthcare workers and facilities in times of peace and conflict.
  5. Advocate for and promote the inclusion of courses on violence and its prevention in academic curricula, including those for undergraduate and postgraduate medical training and Continuing Medical Education (CME).
  6. Consider organizing capacity building and CME programs for physicians on violence prevention, caring for victims of violence, emergency preparedness and response, and early recognition of signs of interpersonal and sexual violence.

The WMA urges governments to:

  1. Work towards achieving a zero-tolerance for violence, through prevention programs, establishment of violence prevention and victim support clinics, establishment of safe domestic violence shelters, increased public and private investment in public safety, security, and strengthening of health and educational institutions.
  2. Encourage collaborative action on violence prevention, with integrated violence prevention and victim support in health care institutions.
  3. Promote social justice and equity by eliminating inequities and inequalities that may create the conditions for violence.
  4. Focus on addressing social determinants of health through the creation and improvement of socio-economic, educational and health infrastructure and opportunities, and elimination of adverse and oppressive cultural attitudes and practices and all forms of inequality or discrimination on the basis of gender, creed, ethnic origin, nationality, political affiliation, race, sexual orientation, social standing, disease or disability.
  5. Secure the enactment and enforcement of policies and laws on violence prevention, protection and support of victims of violence, and punishment of offenders.
  6. Strengthen institutions concerned with public safety and security.
  7. Develop policies and enforce legislations that regulate access to alcohol.
  8. Develop and implement effective legal frameworks that protect individuals and entities that deliver healthcare. Such frameworks should guarantee the protection of physicians and other healthcare professionals, as well as the free and safe access of healthcare personnel and patients to health care facilities.
  9. Support comprehensive research studies on the nature and character of the various forms of violence, including the effectiveness of response strategies, to assist them in the preparation and implementation of policies, laws and strategies on violence prevention, protection and support of victims, and punishment of perpetrators.
  10. Initiate and foster multi-stakeholder involvement and collaboration among relevant bodies and organizations at global, national, state and local levels, in the development, implementation and promotion of violence prevention and management strategies, including engagement of traditional, religious, and political leaders.
  11. Develop robust multi-sectoral partnerships at local, state and national levels with violence prevention made a priority concern in all government ministries, including health, education, labour, and defense ministries.
  12. Institute a Safe Care Initiative that guarantees the safety and security of physicians and other healthcare workers, patients, healthcare facilities, and the uninterrupted delivery of healthcare services in times of peace and conflict.
  13. The initiative should include the following components:
    • Routine violence risk audit.
    • Efficient and effective violence surveillance and reporting mechanisms.
    • Transparent and timely investigation of all reported cases of violence.
    • A system for protecting patients and healthcare personnel who report cases of violence.
    • Legal support for physicians and other healthcare workers subjected to violence in the workplace.
    • Establishment of security posts in healthcare facilities as deemed necessary.
    • Financial coverage for injured medical personnel and other healthcare workers.
    • Compensated time off for injured medical personnel and other healthcare workers.

Adopted by the 53rd WMA General Assembly, Washington, DC, USA, October 2002,
revised by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013
and by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021

 

PREAMBLE

 Since the start of the global HIV epidemic, women and girls in many regions have been disproportionately affected by HIV. Young women (aged 15-24), and adolescent girls (aged 10-19) in particular, account for a disproportionate number of new HIV infections.

Gender inequality contributes to the spread of HIV. It can increase infection rates and reduce the ability of women and girls to cope with the illness. Often, they have less information about HIV and fewer resources to take preventive measures. Sexual violence, a widespread violation of women’s rights, exacerbates the risk of HIV transmission.

Many women and girls living with HIV struggle with stigma and exclusion, aggravated by their lack of rights. Women widowed by AIDS or living with HIV may face property disputes with in-laws, complicated by limited access to justice to uphold their rights. Regardless of whether they themselves are living with HIV, women generally assume a disproportionate burden of care for others who are sick from or dying of AIDS, along with the orphans left behind. This, in turn, can reduce prospects for education and employment. It can also significantly reduce prevention of mother-to-child transmission (PMTCT) efforts and strategies.

Access to healthcare, including both preventative and therapeutic strategies, is a fundamental human right. This imposes an obligation on government to ensure that these human rights are fully respected and protected.  Gender inequalities must be addressed and eradicated.  This should impact every aspect of healthcare.

The promotion and protection of the reproductive rights of women are critical to the ultimate success of confronting and resolving the HIV/AIDS pandemic.

 

RECOMMENDATIONS

The WMA requests all national member associations to encourage their governments to undertake and promote the following actions:

  1. Develop empowerment programs for women of all ages to ensure that women are better supported and free from discrimination. Such programs should include universal and free access to reproductive health education and life skills training,
  2. Develop programme to provide HIV testing and post-exposure prophylaxis in the form of antiretrovirals to all survivors of assault.
  3. Governments must provide universal access to antiviral therapy and treatment to all HIV infected women, protecting their health, and in the case of pregnant women, preventing mother to child transmission.
  4. Provide universal HIV testing of all pregnant women, with patient notification of the right of refusal, as a routine component of perinatal care, and such testing should be accompanied by privacy protection, basic counseling and awareness of appropriate treatment, if necessary.
  5. Patient notification should be consistent with the principles of informed consent. Universal and free access to antiretroviral therapy must also be provided to all HIV-positive pregnant women in order to prevent mother to child transmission of HIV.

 

 

Adopted by the 53rd WMA General Assembly, Washington, DC, USA, October 2002,
reaffirmed by the 191st WMA Council Session, Prague, Czech Republic, April 2012
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

The WMA is gravely concerned that female foeticide and sex selection abortion is commonly practiced in certain countries.

The WMA denounces female foeticide and sex selection abortion as a totally unacceptable example form of gender discrimination.

The WMA holds that sex selection abortion for reasons of gender preference is discriminatory, where it is solely due to parental preference and where there are no health implications for the foetus or the woman.

The World Medical Association calls on National Medical Associations:

  • To denounce the practice of female foeticide and the use of sex selection abortion for gender preference and;
  • To advise their governments accordingly.

 

Adopted by the 53rd WMA General Assembly, Washington, DC, USA, October 2002
revised with minor revisions by the 192nd WMA Council, Bangkok, Thailand, October 2012
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

 

PREAMBLE

According to the World Health Organization, billions of injections are administered worldwide each year in health care and many of them are unsafe.

The most common diseases acquired from unsafe injections are hepatitis B, hepatitis C and HIV.

Physicians are involved in the prescription and/or administration of injections. Therefore, they are in a prime position to bring about changes in behaviour, which could lead to the appropriate and safe use of injections.

The WMA recognizes that unsafe injections result from inadequate education, the overuse of therapeutic injections and unsafe injection practices, including the use of unsterilized or inadequately sterilized needles, the re-use of syringes, the misuse equipment and supplies or inappropriate disposal of sharps waste.

Unsafe injections are a waste of precious healthcare resources and can easily be prevented through integrated interventions, developing effective local, national and regional promotion strategies.

Physician attitudes and inappropriate practice standards may be important determinants in the overuse of “therapeutic” injections incorrectly assuming that patients’ satisfaction depends on injection prescription or accepting incentives for unnecessary use of them.

Behavior change among patients and health professionals needs to be developed to decrease injection overuse and achieve injection safety.

Safe injection practices prevent harm to the recipient, the provider and the community, while avoiding the widespread of different pathogens that can result from unsafe injections such as hepatitis B and C and HIV. In this sense, it is a necessary component of prevention for these infections.

 

RECOMMENDATIONS

Taking into consideration that reducing unsafe injections in healthcare involves different parties, the WMA calls:

Constituent Members to

  1. Cooperate with their national governments or other appropriate authorities to develop effective policies on the safe and suitable use of injections, including appropriate financing, the assessment of current injection practices and the development of an integrated plan;
  2. Develop a plan that supports the provision of adequate supplies of injection equipment, measures to enforce proper standards of sterilization where needed, the management of sharps waste, and education programs to deter the overuse of injections as well as promote safe injection practices;

Physicians worldwide to

  1. Educate patients on equivalent action and efficacy of non-injectable medications;
  2. Prescribe non-injectable medication whenever possible and promote the use of non-injectable medication that are viable alternatives;
  3. Use injectable medications only if safe and appropriate and administer injections in a way that does not harm the recipient, the provider and the community;
  4. Ensure that only waste disposal containers for sharp objects be used to safely dispose of used surgical material (e.g. needles, blades, etc.), that the covers of sharp instruments not be re-utilised, and, if possible, use auto-disable syringes
  5. Raise awareness regarding the risks involved with unsafe injections and help bring about behaviour changes in patients and health professionals to promote safe and appropriate injections. Education in this area should emphasise that needles should not be re-sheathed.

 

Adopted by the 53rd WMA General Assembly, Washington, DC, USA, October 2002
Reaffirmed by the 191st WMA Council Session, Prague, Czech Republic, April 2012
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

 

PREAMBLE

This statement aims to provide guidance on responsible self-medication.

Medicinal products can generally be divided into two separate categories: prescription and non-prescription medicines. This classification may differ from country to country. The national authorities must assure that medicines, categorized as non-prescription medicines, are sufficiently safe not to be harmful to health.

Prescription medicines are those which are only available to individuals on prescription from a physician or other authorized health professionals following a consultation. Prescription medicines are not safe for use except under the supervision of the health professional because of toxicity, other potential or harmful effects (e.g. addictiveness), the method of use, or the collateral measures necessary for use.

Responsible self-medication, as referred in this document, is the use of a registered or monographed medicine legally available without a physician’s prescription, either on an individual’s own initiative or following advice of a healthcare professional. The use of prescription medicines without a prior medical prescription is not part of responsible self-medication.

 

RECOMMENDATIONS

  1. The safety, efficacy and quality of non-prescription medicines must be proved according to the same principles as prescription medicines.
  2. Given the risk of using unprescribed medicine and/or irresponsible self-medication, the WMA recommends the following:

For individuals

  1. Patients should inform their physicians or other healthcare professionals concerned whenever they self-medicate in conjunction with other prescribed medication. A course of treatment may combine self-medication and prescription medication, either concurrently or sequentially. The patient must be informed about possible interactions between prescription medicines and non-prescription medicines. For this reason, the patient should be encouraged to inform the health professional about his / her self-medication.
  2. In self-medication, the individual bears primary responsibility for the use of self-medication products. Special caution must be exercised when vulnerable groups such as children, elderly people or pregnant women use self-medication.
  3. If individuals choose to use self-medication, they should be able:
  • to recognize the symptoms they are treating;
  • to determine that their condition is suitable for self-medication;
  • to choose an appropriate self-medication product;
  • to follow the directions for use of the product as provided in the product labelling.

For health professionals

  1. Physicians and other health professionals concerned must educate patients about the potential risks involved in self-medication and its appropriate use, and instructions them to seek further medical advice if they are unsure. This is particularly important where self-medication is inappropriate for certain conditions the patient may suffer from.
  2. Information to the patients should include a warning against pseudoscience and pseudo therapies, which have no scientific basis, as stated in the WMA Declaration on Pseudoscience and Pseudotherapies in the field of health.
  3. Health professionals should encourage patients to carefully read a product’s label and leaflet (if provided), to seek further advice if necessary, and to recognize circumstances in which self-medication is not, or is no longer, appropriate.
  4. Pharmacists have a professional responsibility to recommend that patients seek medical attention, especially when in case of symptoms that warrant them to do so or if patients ask for medication that can be only be given to them after prescription.
  5. Health professionals should seek to identify potentially relevant self-medication during medical consultations, drug dispensing at the pharmacy and during home-based nursing interventions.

For other stakeholders

  1. Governments should recognize and enforce the distinction between prescription and non-prescription medicines and ensure that the users of self-medication are well informed and protected from possible harm or negative long-term effects.
  2. Manufacturers are obliged to follow the various codes or regulations already in place to ensure that information provided to consumers is appropriate in style and content. This refers in particular to the labelling, advertising and all notices concerning non-prescription medicines.
  3. Advertising and marketing of non-prescription medicines should be responsible, provide clear and accurate information and exhibit a fair balance between benefit and risk information. Promotion and marketing should not encourage irresponsible self-medication, purchase of medicines that are inappropriate, or purchases of larger quantities of medicines than are necessary.
  4. Pharmacovigilance for self-medication should be organized and reinforced by both governments and the industry to control the risks associated with self-medication.

For all

  1. All parties involved in self-medication should treat medicines (prescription and non-prescription) as special products. Standard precautions should be followed in terms of safe storage and usage, in accordance with professional advice.
  2. All parties involved in self-medication should be aware of the benefits and risks of any self-medication product. The benefit-risk balance should be communicated in a fair, rational manner without overemphasizing either the risks or the benefits.

 

Adopted by the 40th World Medical Assembly, Vienna, Austria, September 1988
Revised by the 49th WMA General Assembly, Hamburg, Germany, November 1997,
the 58th WMA General Assembly, Copenhagen, Denmark, October 2007,
the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Over 80 percent of the world’s 1.3 billion smokers live in low- and middle-income countries. Smoking and other forms of tobacco use adversely affect every organ system in the body, and are major causes of cancer, heart disease, stroke, chronic obstructive pulmonary disease, fetal damage, and many other conditions. Smokers have up to a 50% higher risk of developing severe disease and death from COVID-19. Eight million deaths occur worldwide each year due to tobacco and tobacco- derived products. Tobacco will kill one billion people in the 21st century unless effective interventions are implemented.

Exposure to secondhand smoke occurs anywhere the burning of tobacco products occurs in enclosed spaces. There is no safe exposure level to secondhand smoke, which causes millions of deaths each year. It is especially damaging to children and pregnant patients. On May 29, 2007, the WHO called for a global ban on smoking at work and in enclosed public places to eliminate secondhand smoke and encourage people to quit.

The phenomenon known as “thirdhand smoke” occurs when nicotine and other chemical residues occur on indoor surfaces from smoking, which can persist long after the smoke itself has cleared. It is increasingly recognized as a potential danger, especially to children, who not only inhale fumes released by these residues but also ingest residues that get on their hands after crawling on floors or touching walls and furniture.

World Health Organization Action

With the hope of mitigating the effects of tobacco use, the World Health Organization (WHO) Member States unanimously adopted the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003. In force since 2005, it currently has 182 parties covering more than 90 percent of the world’s population. Further strengthening implementation of the milestone treaty is specifically included in the 2030 Agenda for Sustainable Development Goals (SDG) as Target 3.a. The WMA has long supported the WHO FCTC (see WMA Resolution on Implementation of the WHO Framework Convention on Tobacco Control). The Protocol to Eliminate Illicit Trade in Tobacco Products, the first protocol to the WHO FCTC, was adopted in 2012 in response to the growing international illicit trade in tobacco products. The objective of the Protocol is the elimination of all forms of illicit trade in tobacco products, in accordance with the terms of Article 15 of the WHO FCTC.

 New and Emerging Nicotine Products

 The WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems outlines the still-unknown risks associated with these products.  The use of e-cigarettes by young people has risen dramatically, and in some regions is more popular than tobacco smoking.  Nicotine exposure, no matter how it is delivered, can affect brain development and lead to addiction.

New and rediscovered forms of tobacco and nicotine ingestion are also emerging, including:

  • dissolvable tobacco, from sweet, candy-like lozenges that contain tobacco and nicotine that are held in the mouth, chewed, or sucked until they dissolve;
  • snus, a finely ground form of moist snuff that that contains carcinogens and is usually packaged in small pouches;
  • hookahs, a water pipe that burns tobacco mixed with flavors such as honey, molasses or fruit, where the smoke is inhaled through a long hose. The WHO reports that one hookah smoking session is the same as smoking 100 cigarettes, largely due to the length of time a user smokes;
  • bidis, flavored cigarettes that are unfiltered and deliver up to five times more nicotine than regular cigarettes, and clove cigarettes (also called Kreteks) also deliver more nicotine, carbon monoxide, and tar than regular cigarettes;
  • other heated tobacco products that typically use an electronic heating element to heat specially designed sticks, plugs, or capsules containing tobacco. The heat releases nicotine (and other chemicals) that can then be inhaled into the lungs, but the tobacco does not get hot enough to burn. These devices are not the same as e-cigarettes, and
  • Nicotine pouches, tobacco free pouches of nicotine with different flavors which are placed in the mouth.

Pregnant Patients and Children

Smoking or using nicotine during pregnancy is linked with a range of poor birth outcomes including low birth weight and preterm birth, restricted head growth, placental problems, increased risk of still birth and increased risk of miscarriage. Breathing secondhand smoke during pregnancy also increases the risk of having a low-birth-weight baby, and babies who are exposed to secondhand smoke have an increased risk of Sudden Infant Death Syndrome.

Health and developmental consequences among children have also been linked to prenatal smoke exposure, including poorer lung function, (including coughs, colds, bronchitis and pneumonia), persistent wheezing, asthma and visual difficulties such as strabismus, refractive errors and retinopathy. Children who breathe more secondhand smoke have more ear infections, coughs, colds, bronchitis and pneumonia. Children who grow up with parents who smoke are themselves more likely to smoke and to have long term health effects similar to adults who smoke.

Health Equity

Health equity in tobacco prevention and control focuses on the opportunity for all people to live a healthy life, regardless of their race, level of education, gender identity, sexual orientation, occupation, geographic location, or disability status. Tobacco control programs, including evidence-based cessation services, can work toward health equity by focusing efforts on decreasing the prevalence of tobacco use, and second-hand and thirdhand smoke exposure, and by improving access to tobacco control resources, among populations experiencing greater tobacco-related health and economic burdens.

Tobacco Industry Marketing

 The tobacco industry spends billions of dollars annually around the globe on advertising, promotion and sponsorship. The tobacco industry’s manipulative and predatory marketing tactics increase consumption of its products and replace smokers who quit or die. By investing huge sums of money in low- and middle-income countries, the industry hopes to increase the social acceptability of tobacco and tobacco companies. The tobacco industry has also long employed strategies targeting children, from developing special packaging or candy-flavored cigarettes and e-cigarette cartridges, and has used the internet, text messaging and youth-oriented social networking sites to advertise sponsored events or promotions.

The best strategy to combat the tobacco industry’s marketing tactics is to adopt and enforce comprehensive bans on tobacco advertising, promotion and sponsorship, as set forth in the WHO FCTC.

The tobacco industry claims that it is committed to determining the scientific truth about the health effects of tobacco, both by conducting internal research and by funding external research through jointly funded industry programs. However, the industry has consistently denied, withheld, and suppressed information concerning the deleterious effects of tobacco smoking.

Tobacco companies also manipulate the public’s attitude about their reputation and have often engaged in so-called ‘corporate social responsibility’, which are activities to promote their products while portraying themselves as good corporate citizens.

 

RECOMMENDATIONS

The WMA recommends that national governments:

  1. Increase taxation of tobacco and tobacco-derived products, which is the single most effective tobacco control measure to reduce tobacco use according to the World Health Organization (WHO). Taxation is also a highly cost-effective and inexpensive tool. Increased revenues should be used for prevention programs, evidence-based cessation programs and services, and other health care measures.
  2. Urge the WHO to add tobacco cessation medications with established efficacy to the WHO’s Model List of Essential Medicines.
  3. Ratify and fully implement the WHO Framework Convention on Tobacco Control.
  4. Implement comprehensive regulation of the manufacture, sale, distribution, and promotion of tobacco and tobacco-derived products, including total bans on tobacco advertising, promotion and partnership, including abroad. Require plain packaging of tobacco products (as set forth in the WMA Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Products), and packaging that includes prominent written and pictorial warnings about health hazards of tobacco.
  5. Prohibit smoking in all enclosed public places, including public transportation, prisons, airports and on airplanes. Require all medical schools, biomedical research institutions, hospitals, and other health care facilities to prohibit smoking, and the use of smokeless tobacco and other tobacco-derived products on their premises.
  6. Prohibit the sale, distribution, and accessibility of cigarettes and other tobacco products to children and adolescents. Ban the production, distribution and sale of candy products that depict or resemble tobacco products.
  7. Prohibit all government subsidies for tobacco and tobacco-derived products and assist tobacco farmers in switching to alternative crops. Exclude tobacco products from international trade agreements, and work to curtail or eliminate illegal trade in tobacco and tobacco-derived products and the sale of smuggled tobacco products.
  8. Provide for research into the prevalence of tobacco use and the effects of tobacco and tobacco-derived products on the health status of the population.

The WMA recommends that national medical associations:

  1. Refuse funding or educational materials from the tobacco industry, and urge medical schools, research institutions, and individual researchers to do the same.
  2. Adopt policies opposing smoking and the use of tobacco and tobacco-derived products and publicize the policy. Endorse or promote clinical practice guidelines on the treatment of tobacco use and dependence.
  3. Prohibit smoking, including use of smokeless tobacco and vaping, in national medical association premises and at all business, social, scientific, and ceremonial meetings of national medical associations, in line with the decision of the World Medical Association to impose a similar ban.
  4. Develop, support, and participate in programs to educate the profession and the public about the health hazards of tobacco use (including addiction) and exposure to secondhand smoke.
  5. Introduce or strengthen educational programs for medical students and physicians to prepare them to identify and treat tobacco dependence in their patients.
  6. Speak out against the shift in focus of tobacco marketing from developed to less developed nations, from adults to youth, and urge national governments to do the same.
  7. End investment in companies or firms producing or promoting the use or sale of tobacco or tobacco-derived products. Divest current assets that support tobacco production or promotion.

The WMA recommends that physicians:

  1. Be positive role models by not using tobacco or tobacco-derived products, and by acting as spokespersons to educate and raise the awareness of the public about the deleterious health effects of tobacco use and the benefits of tobacco-use cessation.
  2. Support widespread access to evidence-based treatment for tobacco dependence through individual patient encounters, counseling, pharmacotherapy, cessation classes, telephone quit-lines, web-based cessation services, and other appropriate means.
  3. Recognize that tobacco and second-hand smoke exposure to adult tobacco use cause harm to children. Special efforts should be made by physicians to:
  • promote tobacco-free environments for children
  • target parents and pregnant patients who smoke for tobacco cessation interventions
  • promote programs that contribute to the prevention and decreased use of tobacco and tobacco-derived products by youth
  • support policies that control access to and marketing of tobacco and tobacco-derived products and make pediatric tobacco-control research a higher priority.

Adopted by the 49th WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176th WMA Council Session, Berlin, Germany, May 2007
and rescinded at the 68th WMA General Assembly, Chicago, USA, October 2017

The British Medical Association (BMA) requests that the World Medical Association (WMA) supports a proposal, put forward by a network of medical organizations* concerned with human rights issues, for the establishment of a new UN post of rapporteur on the independence and integrity of health professionals.

It is envisaged that the role of the rapporteur will supplement the work already done by a series of existing UN rapporteurs on issues such as torture, arbitrary execution, violence against women, etc. The new rapporteur would be charged with the task of monitoring that doctors are allowed to move freely and that patients have access to medical treatment, without discrimination as to nationality or ethnic origin, in war zones or in situations of political tension. The role of the proposed rapporteur is detailed on pages two, three and four of this submission.

The original proposal was drawn up by a lawyer, Cees Flinterman, who is a professor of constitutional and international law at the University of Limburg, Maastricht, in The Netherlands. It has the support of a range of doctors’ organizations listed below*, whose interests are in protection of human rights and protection of doctors who act impartially in conflict situations. This group will be consulting widely and acting with the help of the International Commission of Jurists to interest the United Nations in this proposal.

The Council of the BMA supported this proposal after debate in 1996. It would lend considerable weight to the campaign if the WMA would also support this concept whose fundamental aim is to protect doctors and their patients in war situations and other cases where medical independence may come under threat from political or military factions.

PROPOSAL FOR A RAPPORTEUR ON THE INDEPENDENCE AND INTEGRITY OF HEALTH PROFESSIONALS

Goals

accepting that in many situations of political conflict (such as civil or international war) or political tension (such as during suspension of civil rights in a government-declared state of emergency), health professionals are often the first people outside military of government circles to have detailed knowledge of human rights violations, including violations of the right of populations to access medical treatment, a network of physicians is anxious that a range of national and international reporting mechanisms be established to achieve the following goals:

  1. To monitor the role of health professionals working in situations where either their rights to give, or the rights of their patients to receive, treatment are threatened;
  2. To make appeals for the protection of health professionals when they are in danger solely because of their professional or human rights activities;
  3. To defend patients who are in danger of suffering human rights violations solely because of seeking medical treatment;
  4. To encourage reporting of human rights violations by health professionals;
  5. To analyse information about health professionals voluntarily adopting discriminatory practices. The group consider that existing UN reporting mechanisms need expansion. Key among proposals for new mechanisms is the development of a new UN rapporteur’s post which would link together relevant information emerging from other existing UN mechanisms and also suggest where other useful local and national reporting networks could be developed in the long-term. Therefore, on the basis of materials prepared by the Law Department at the University of Limburg, Maastricht and circulated by the Dutch medical group, the Johannes Wier Foundation, the group is campaigning for a new post of UN Rapporteur of the Independence and Integrity of Health Professionals.

Defining the Role

The potential role of a UN Rapporteur need not be exhaustively defined in advance since the experience of the individual and the practical applicability of the goals must have an influence.

It should include the following:

  • Receive, evaluate, investigate and report allegations of repression directed at health professionals or intended to prevent individuals receiving medical care. The rapporteur should be a clearing house for reports from individuals, groups of doctors, NGOs etc. and as well as simply receiving information, should pro-actively seek our information, including on-site visits.
  • To build upon existing principles as found in humanitarian lay and the codes of medical ethics applicable in armed conflicts to develop specific guidelines on the subject of medical impartiality in relation to the treatment of patients in situations of political or armed conflict.The World Medical Association and national medical association should be encouraged to disseminate such information to health professionals during their training. Arising also form such guidance should be the institution of mechanisms to help health professionals protect themselves in situations where human rights are at risk.
  • The rapporteur should also have a consultative role, seeking the views of international and national professional associations, human rights bodies and humanitarian organizations with regards to the protection of health professionals and the defence of the right to treat patients impartially.
  • The rapporteur should investigate reports of health professionals voluntarily transgressing guidelines about impartiality and non-discrimination.

Issues within the Remit

  • The fundamental concern is to protect the nature of the doctor-patient relationship from unjustified external interference although it will also include voluntary transgressing of impartiality by health professionals. The rapporteur’s role will be to ensure the independence, integrity and impartiality of health professionals.Ensuring these aims requires analysis of whether:
    • the treatment decisions of health professionals can be carried out without coming into conflict with improper pressure from authorities;
    • the physical integrity and ability of health professionals to act in accordance with their professional principles are both protected;
    • health professionals are able to provide treatment on the basis of patient need;
    • people in need of medical treatment are able to access it safely;
    • health professionals are ensured their freedom of movement, in the capacity as medical care providers, and be able to have access to people in need of medical services.

    Monitoring the degree to which external pressures influence negatively the provision of medical treatment will be within the remit of the rapporteur.

  • The remit will be global.
  • For lack of a reporting mechanism, health professionals are often disempowered form taking action on violations of patient rights. One of the issues of the rapporteur to monitor would be the introduction of national or local legislation, civil or military regulations or other rules prohibiting or limiting the provision of medical or nursing care to certain categories of patient.
  • It will be within the remit of the rapporteur to bring the evidence or reports of violations of medical impartiality, including those in health professionals co-operating voluntarily, to responsible bodies in the medical field and to the governments concerned.
  • Blanket restrictions on the medical or nursing services to be provided to members of vulnerable groups, such as refugees, asylum seekers, prisoners, minority ethnic groups, should be among the issues monitored by the rapporteur. The rapporteur should contribute to the empowerment of the health professionals to resist collectively the erosion of such patients’ rights.
  • Threats, intimidation or pressures on health professionals to discriminate against patients on the basis solely of non-medical related considerations such as ethics, religious or racial affiliation should be investigated even if the threats do not materialize into action.
  • Reports of health professionals being harassed or detained simply because of their profession or because of the exercise of professional skills will be investigated by the rapporteur. Similarly repressive measures designed to prevent health professionals reporting infringements of medical integrity will be investigated. Measures to encourage health professionals actively to document and report such violations should be put forward by the rapporteur in consultation with other bodies.
  • Reports of patients being impeded or discouraged from gaining access to the available medical treatment will be investigated.

Issues Outside the Remit

Just as important as defining what is within the rapporteur’s remit is the matter of clarifying those issues which fall outside it. We anticipate that this too will become clearer as practice and experience develop. In the meantime, however, we suggest that:

  • health professionals in every country should be educated about the ethical responsibilities they owe to patients and potential patients. Whereas such education is not within the remit of the rapproteur, acting as a resource for advice about medical impartiality would be within the rapporteur’s remit. In the long term this function should ideally be dealt with by delegation through medical schools, professional bodies and voluntary national networks;
  • while government measures to regulate aspects of care, (such as the equitable distribution of medical resources of the prioritizing of treatment on basis of need) would not generally be a matter for monitoring for the rapporteur, extreme measures likely to result in the disenfranchising of groups of patients from medical or nursing services would be monitored and investigated;
  • governments’ indiscriminate failure to provide health promotion or treatment to many or all sectors of the community does not fall within the remit of the rapporteur;
  • since a principal concern is to ensure access to medical treatment by patients who need and want it, the voluntary decision of some individuals or patient groups to exclude themselves (for example on religious or cultural grounds) from orthodox medicine does not fall within the remit of the rapporteur.

* organizations participating in the network include: Amnesty International; British Medical Association; Centre for Enquiry into Health & Allied Themes (Bombay); Graza Community Mental Health; International Committee of the Red Cross; Physicians for Human Rights (in Denmark, Israel, South Africa, the UK, & the USA); Turkish Medical Association; and, the Johannes Weir Foundation.

Adopted by the 48th WMA General Assembly, Somerset West, South Africa, October 1996,
revised 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

The WMA recognizes that unwanted pregnancies and pregnancies that are too closely spaced can have a serious adverse effect on the health of a woman and of her children. These adverse effects can include the premature deaths of women. Existing children in the family can also suffer starvation, neglect or abandonment resulting in their death or impaired health, when families are unable to provide for all their children. Social functioning and the ability to reach their full potential can also be impaired.

The WMA recalls its Declaration of Ottawa on Child Health, and supports the universal health rights of all children worldwide.

The WMA recognizes the benefits for women who are able to control their fertility. They should be helped to make such choices themselves, as well as in discussion with their partners. The ability to do so by choice and not chance is a principal component of women’s physical and mental health and social well-being.

Access to adequate fertility control methods is not universal; many of the poorest women in the world have the least access. Knowledge about how their bodies work, information on how to control their fertility and the materials necessary to make those choices are universal and basic human rights for all women.

The Sustainable Development Goals 5, target 6 calls for the “universal access to sexual and reproductive health and reproductive rights…”.

RECOMMENDATIONS

The WMA recommends that National Medical Associations:

  • Promote family planning education by working with governments, NGOs and others to provide secure and high-quality services and assistance;
  • Demand from governments to ensure that such information, materials, products and services are available without regard to nationality, creed, race, religion or socioeconomic status.

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

The World Medical Association has adopted the following statement to assist physicians with the ethical and professional issues that arise from scientific advances in the field of genetics.

GENETIC COUNSELING

There are two primary areas of genetic diagnosis:

  1. screening or evaluating prospective parents before conception for genetic disease to predict the likelihood of conceiving an affected child; and
  2. in utero testing after conception, such as ultrasonography, amniocentesis, and fetoscopy, to determine the condition of the fetus.
    Physicians engaged in genetic counseling are ethically obligated to provide prospective parents with the basis for an informed decision for childbearing. In providing information to couples who choose to reproduce, physicians should adhere to the ethical requirements and the professional standards for medical practice in the community, as established by WMA National Medical Association and other appropriate medical organizations.

Technological developments have improved the accuracy of predicting and detecting genetic disorders. Where a genetic defect is found in the fetus, the prospective parents may, or may not, request an abortion. Physicians, for personal moral reasons may, or may not, oppose the provision of contraception, sterilization or abortion as part of the genetic counseling services. Whether they advocate or oppose providing such services, physicians should avoid the imposition of their personal moral values and the substitution of their own moral judgment for that of the prospective parents.

Physicians who consider contraception, sterilization and abortion to be in conflict with their moral values and conscience may choose not to provide genetic services. However, in appropriate circumstances, the physician is nevertheless obligated to alert prospective parents that a potential genetic problem does exist, and that the patient should seek medical genetic counseling from a qualified specialist.

GENETIC ENGINEERING

As genetic engineering research develops, appropriate guidance must be provided by the scientific community, medicine, industry, government and the public to regulate such research.

If and when gene replacement with Normal DNA becomes a practical reality for the treatment of human disorders, the World Medical Association urges that the following factors be considered:

  1. If procedures are performed in research setting, reference should be made to the World Medical Association Declaration of Helsinki on biomedical research involving human subjects.
  2. If procedures are performed in research setting, reference should be made to the World Medical Association Declaration of Helsinki on biomedical research involving human subjects.
  3. Full discussion of the proposed procedure with the patient must be required. The consent of the patient or his legal representative must be informed, voluntary, and written.
  4. There must be no hazardous or other unwanted virus on the viral DNA containing the replacement or corrective gene.
  5. The inserted DNA must function under normal control within the recipient cell to prevent metabolic damage that could damage healthy tissue and the patient.
  6. The effectiveness of the gene therapy should be evaluated as best as possible. This will include determination of the natural history of the disease and follow-up examination of subsequent generations.
  7. Such procedures should be undertaken in the future only after careful evaluation of the availability and effectiveness of other possible therapy. If simpler and safer treatment is available, it should be pursued.
  8. These considerations should be reviewed, as appropriate, as procedures and scientific information are developed in the future.

Adopted by the 36th World Medical Assembly, Singapore, October 1984
and reaffirmed with minor revision by the 215th WMA Council Session (online), Cordoba, Spain, October 2020

Professional independence and professional freedom are indispensable to physicians to enable them to give appropriate health care to their patients. Therefore, there should be no barriers based on disease or disability, creed, ethic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to prevent physicians from participating in professional activities that will enable them to acquire the information, knowledge, skills and techniques required to provide appropriate health care to their patients.

In as much as the purpose of the WMA is to serve humanity by endeavoring to achieve the highest international standards in medical education, medical science, medical art and medical ethics, and health care for all people of the world, there should accordingly be no barriers which will prevent physicians from attending meetings of the WMA, or other medical meetings, wherever such meetings are convened.