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Handbook of WMA Policies
World Medical Association
Handbook of WMA Policies
World Medical Association
PREFACE
Before World War II came to an end, a number of medical associations gathered in London to
reinvent the approach to international collaboration among the world’s physicians. The old
model, represented by the pre-war “Association Professionnelle Internationale des Médecins”
(APIM), would no longer meet the needs of the post-war medical profession. It was time to
create something new.
After only two years of preparation, 27 national medical associations met in Paris on September
18th, 1947 for the inauguration of a new global physicians’ association, the World Medical
Association (WMA). The lead-up to this first Assembly was paralleled by the Nuremberg trial
against Nazi doctors, which was a key driver of the mission focus of the new WMA. This
terrible episode in the history of medicine dictated that the organization must seek to become
the authoritative voice on global standards for medical ethics and professional conduct, rather
than focus solely on protecting the interests of the profession.
Effectively coordinating an international organization was anything but easy in the late 1940s.
There was no internet, e-mail, mobile phones, personal computers, fax, or even photocopiers.
For many physicians, attending the Assembly required a cross-continental, multi-day journey
across a deeply scarred planet, by train and ship and only in exceptional circumstances by plane.
Yet the commitment of these founding WMA members to their vision was even greater than
the challenges they faced in achieving it. That vision, and the accompanying goals, ideals, and
unity of purpose, are as relevant today as they were during those early days. They are now ours
to carry on.
The WMA Handbook of Policies is evidence that the engagement of the world medical
profession does, in fact, persist. The WMA now is bigger, stronger and more active then ever
before, and our Handbook is the product of physicians coming together for more than half a
century to provide ethical guidance, moral support and practical advice to help their colleagues
serve their patients to the best of their ability. From the Declaration of Geneva, often referred
to as the “Modern Hippocratic Oath” to the Declaration of Helsinki advising physicians doing
medical research on human subjects, to the Declaration of Tokyo prohibiting physicians from
participating in torture and degrading treatment − to mention just a few of WMA’s landmark
policies − the guidance provided by the WMA is as necessary now as it has ever been.
There are many other policies in this world dealing with physician conduct, many of which try
to be “modern”, “easily readable” and “politically correct”. The WMA has never capitulated
against the “Zeitgeist”, but has stood firm with its values, the most important of which are
caring, ethics and science.
Sir William Osler said: “The most important thing is caring, so do it first, for the caring
physicians best inspires hope and trust.” Hope and trust are the basis for any treatment. A
physician who cannot generate trust will face more challenges than the one who receives the
trust of the patients. A patient with hope is far better off than one without.
World Medical Association
But caring must go hand-in-hand with medical ethics and proper conduct. Physicians are often
confronted with questions of life and death, resource allocations, and dual loyalties when
serving a single patient and at the same time respecting the needs of a community or population.
The questions are often too difficult and the problems too burdensome for one person alone.
We are far away from having answers for all such questions, but for many, the WMA can
provide the ethical guidance that protects patients, supports physicians, and duly considers the
interests of the communities and populations they both belong to.
Finally, science is what distinguishes medicine from well-intended kindness. In medicine,
quality care and ethical conduct cannot be separated from sound science. Still, despite our
sincere and continual quest for increased scientific knowledge, understanding and solutions,
we will never be protected from all mistakes. Therefore, practicing the science of medicine
with faithful adherence to clear ethical guidance is the best we can do.
This new handbook*
provides a good part of this guidance. It is proof of our continued
engagement with our colleagues in the different parts of this world and our commitment to our
patients, wherever and whoever they may be. It is a living document and the WMA will
continue to improve and expand it, in service to the profession and the health of those we serve
as physicians.
J. Edward Hill Otmar Kloiber
Chairman of Council Secretary General
Wonchat Subchaturas
President 2010-2011
*
The World Medical Association is most grateful to the Korean Medical Association for
seconding Ms. Seongmi LEE to the WMA Office at Ferney-Voltaire, providing valuable help
in putting this collection of policies together.
Handbook of WMA Policies
Chronological Order
TABLE OF CONTENTS
– Chronological Order –
DECLARATIONS
Declaration of Geneva ………………………………………………………………………………….. D-1948-01-2017
International Code of Medical Ethics ………………………………………………………………. D-1949-01-2022
Declaration of Helsinki
– Ethical Principles for Medical Research involving Human Subjects ………………. D-1964-01-2013
Declaration of Sydney
on the Determination of Death and the Recovery of Organs ………………………… D-1968-01-2016
Declaration of Oslo on Therapeutic Abortion …………………………………………………… D-1970-01-2006
Declaration of Tokyo with guidelines for Medical Doctors concerning
Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment in relation to Detention and Imprisonment ………………………………. D-1975-01-2016
Declaration of Lisbon on the Rights of the Patient ……………………………………………. D-1981-01-2015
Declaration on Principles of Health Care for Sports Medicine ……………………………. D-1981-02-2021
Declaration of Venice on Terminal Illness ……………………………………………………….. D-1983-01-2022
Declaration of Hong Kong on the Abuse of the Elderly ……………………………………… D-1989-01-2015
Declaration of Malta on Hunger Strikers …………………………………………………………. D-1991-01-2017
Declaration on Guidelines for
Continuous Quality Improvement in Health Care ………………………………………… D-1997-01-2019
Declaration of Hamburg concerning Support for Medical Doctors Refusing to
Participate in, or to Condone, the Use of Torture or Other Forms of Cruel,
Inhuman, or Degrading Treatment …………………………………………………………….. D-1997-02-2017
Declaration of Ottawa on Child Health ……………………………………………………………. D-1998-01-2020
Declaration of Edinburgh on Prison Conditions and the Spread of Tuberculosis
and Other Communicable Diseases ……………………………………………………………. D-2000-01-2022
Declaration of Washington on Biological Weapons ………………………………………….. D-2002-01-2012
Declaration on Ethical Considerations regarding Health Databases …………………….. D-2002-02-2016
Declaration on Patient Safety …………………………………………………………………………. D-2002-03-2022
Declaration on Medical Ethics and Advanced Technology …………………………………. D-2002-04-2012
Declaration on the Relation of Law and Ethics ………………………………………………….. D-2003-01-2019
Declaration of Reykjavik – Ethical considerations regarding
the use of genetics in health care ………………………………………………………………. D-2005-01-2019
Table of Contents
Declaration of Seoul on Professional Autonomy and
Clinical Independence ………………………………………………………………………………. D-2008-01-2018
Declaration of Delhi on Health and Climate Change …………………………………………. D-2009-01-2017
Declaration of Madrid on Professionally-led Regulation ……………………………………. D-2009-02-2019
Declaration of Montevideo on Disaster Preparedness and
Medical Response ……………………………………………………………………………………. D-2011-01-2011
Declaration on Leprosy Control around the World and
Elimination of Discrimination against persons affected by Leprosy ……………….. D-2011-03-2021
Declaration of Oslo on Social Determinants of Health ……………………………………….. D-2011-04-2011
Declaration on the Protection and Integrity of Medical Personnel
in Armed Conflicts and Other Situations of Violence ……………………………………. D-2011-05-2022
Declaration on Alcohol …………………………………………………………………………………… D-2015-01-2017
Declaration of Chicago on Quality Assurance in Medical Education …………………….. D-2017-01-2017
Declaration on Fair Trade in Medical Products and Devices ……………………………….. D-2017-02-2017
Declaration on Euthanasia and Physician-Assisted Suicide …………………………………. D-2019-01-2019
Declaration of Cordoba on Patient-Physician Relationship …………………………………. D-2020-01-2020
Declaration on Pseudoscience and Pseudotherapies in the field of health …………… D-2020-02-2020
Declaration of Berlin on Racism in Medicine …………………………………………………….. D-2022-01-2022
Declaration on Discrimination against Elderly Individuals
within Healthcare Settings …………………………………………………………………………. D-2022-02-2022
STATEMENTS
Regulations in Time of Armed Conflict and Other Situations of Violence …………….. S-1956-01-2012
Statement on Medically-Indicated Termination of Pregnancy ……………………………. S-1970-01-2018
Statement on Boxing …………………………………………………………………………………….. S-1983-01-2017
Statement on Child Abuse and Neglect …………………………………………………………… S-1984-01-2017
Statement on Freedom to Attend Medical Meetings ……………………………………….. S-1984-02-2020
Statement on Non-Discrimination in Professional Membership and
Activities of Physicians ……………………………………………………………………………… S-1985-01-2015
Statement on Access to Health Care ………………………………………………………………. S-1988-01-2017
Statement on the Role of Physicians in Environmental Issues ……………………………. S-1988-04-2016
Statement on Health Hazards of Tobacco Products and
Tobacco-Derived Products ………………………………………………………………………… S-1988-05-2022
Statement on Animal Use in Biomedical Research ……………………………………………. S-1989-01-2016
Statement on Injury Control ………………………………………………………………………….. S-1990-01-2016
Statement on Traffic Injury ……………………………………………………………………………. S-1990-04-2016
Statement on Adolescent Suicide …………………………………………………………………… S-1991-01-2016
Handbook of WMA Policies
Chronological Order
Statement on Alcohol and Road Safety …………………………………………………………… S-1992-01-2016
Statement on Noise Pollution ………………………………………………………………………… S-1992-05-2017
Statement on Body Searches of Prisoners ……………………………………………………….. S-1993-01-2016
Statement on Female Genital Mutilation ………………………………………………………… S-1993-02-2016
Statement on Patient Advocacy and Confidentiality …………………………………………. S-1993-03-2016
Statement on Medical Ethics in the Event of Disasters ……………………………………… S-1994-01-2017
Statement on Ethical Issues concerning Patients with Mental Illness …………………. S-1995-02-2015
Statement on Physicians and Public Health …………………………………………………….. S-1955-04-2016
Statement on Antimicrobial Resistance ………………………………………………………….. S-1996-01-2019
Statement on Family Violence ……………………………………………………………………….. S-1996-02-2021
Statement on Family Planning and the Right of a Woman to Contraception ……….. S-1996-04-2017
Statement on Weapons of Warfare and Their Relation to Life and Health ………….. S-1996-05-2016
Proposal for a United Nations Rapporteur on the Independence and
Integrity of Health Professionals ……………………………………………………………….. S-1997-01-2007
Statement on Physicians convicted of Genocide, War Crimes or Crimes Against
Humanity ……………………………………………………………………………………………….. S-1997-02-2018
Statement on Access of Women and Children to Health Care …………………………….. S-1997-03-2021
Statement on Nuclear Weapons …………………………………………………………………….. S-1998-01-2018
Statement on Medical Care for Migrants …………………………………………………………. S-1998-02-2021
Statement on Patenting Medical Procedures …………………………………………………… S-1999-01-2019
Statement on the Relationship between Physicians and Pharmacists
in Medical Therapy ………………………………………………………………………………….. S-1999-02-2020
Statement on Safe Injections in Health Care ……………………………………………………. S-2002-01-2022
Statement on Self-Medication ……………………………………………………………………….. S-2002-02-2022
Statement on Sex Selection Abortion and Female Foeticide ………………………………. S-2002-03-2019
Statement on the Women’s Right to Health Care and
How that Relates to the Prevention of Mother-to-Child HIV Infection …………… S-2002-04-2021
Statement on Forensic Investigations of the Missing ……………………………………….. S-2003-01-2013
Statement on Advance Directives (“Living Wills”) …………………………………………….. S-2003-02-2013
Statement on the Ethical Guidelines for the International Migration of
Health Workers ……………………………………………………………………………………….. S-2003-03-2014
Statement on Violence and Health …………………………………………………………………. S-2003-04-2019
Statement concerning the Relationship
between Physicians and Commercial Enterprises ………………………………………… S-2004-02-2020
Statement on Water and Health …………………………………………………………………….. S-2004-03-2017
Statement on Drug Substitution …………………………………………………………………….. S-2005-02-2015
Table of Contents
Statement on Medical Liability ………………………………………………………………………. S-2005-04-2021
Statement on Assisted Reproductive Technologies ………………………………………….. S-2006-01-2022
Statement on Avian and Pandemic Influenza …………………………………………………… S-2006-02-2018
Statement on HIV/AIDS and the Medical Profession ………………………………………… S-2006-03-2017
Statement on Medical Education …………………………………………………………………… S-2006-04-2017
Statement on The Physician’s Role in Obesity ………………………………………………….. S-2006-05-2016
Statement on the Responsibilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug Abuse …………………………………………….. S-2006-06-2016
Statement on Medical Assistance in Air Travel ………………………………………………… S-2006-07-2022
Statement on Reducing Dietary Sodium Intake ………………………………………………… S-2008-01-2019
Statement on Reducing the Global Burden of Mercury …………………………………….. S-2008-02-2018
Statement on Conflict of Interest …………………………………………………………………… S-2009-01-2009
Statement on Stem Cell Research …………………………………………………………………… S-2009-02-2020
Statement on Digital Health ………………………………………………………………………….. S-2009-04-2022
Statement on Environmental Degradation and
Sound Management of Chemicals ……………………………………………………………… S-2010-01-2018
Statement on Violence against Women …………………………………………………………… S-2010-02-2020
Statement on the Global Burden of Chronic Non-Communicable Disease…………….. S-2011-01-2022
Recommendation on the Development of a Monitoring and
Reporting Mechanism to permit Audit of
Adherence of States to the Declaration of Tokyo ………………………………………… S-2011-02-2021
Statement on the Professional and Ethical Usage of Social Media …………………….. S-2011-05-2022
Statement on Electronic Cigarettes and
Other Electronic Nicotine Delivery Systems ……………………………………………….. S-2012-01-2012
Statement on the Ethical Implications of Collective Action by Physicians …………… S-2012-02-2022
Statement on Forced and Coerced Sterilisation ………………………………………………. S-2012-03-2012
Statement on Organ and Tissue Donation ………………………………………………………. S-2012-04-2017
Statement on the Prioritisation of Immunisation …………………………………………….. S-2012-05-2019
Statement on Workplace Violence in the Health Sector ……………………………………. S-2012-06-2022
Statement on Fungal Disease Diagnosis and Management ………………………………. S-2013-01-2013
Statement on Human Papillomavirus Vaccination …………………………………………… S-2013-02-2013
Statement on Natural Variations of Human Sexuality ………………………………………. S-2013-03-2013
Statement on the Right to Rehabilitation of Victims of Torture ………………………… S-2013-04-2013
Statement on the United Nations Resolution for a Moratorium on the
Use of the Death Penalty …………………………………………………………………………. S-2013-05-2013
Statement on Aesthetic Treatment …………………………………………………………. S-2014-01-2014
Handbook of WMA Policies
Chronological Order
Statement on the Prevention of Air Pollution and Vehicle Emissions …………………. S-2014-02-2014
Statement on Solitary Confinement ………………………………………………………………. S-2014-03-2019
Statement on Physicians Well-Being ………………………………………………………………. S-2015-02-2015
Statement on Providing Health Support to Street Children ……………………………….. S-2015-03-2015
Statement on Riot Control Agents ………………………………………………………………….. S-2015-04-2015
Statement on Transgender People …………………………………………………………………. S-2015-05-2015
Statement on Vitamin D Insufficiency …………………………………………………………….. S-2015-06-2015
Guidelines on Promotional Mass Media Appearances by Physicians ………………….. S-2015-07-2015
Statement on Trade Agreements and Public Health ………………………………………….. S-2015-08-2021
Statement on Ageing ……………………………………………………………………………………. S-2016-01-2016
Statement on Cyber-Attacks on Health and Other Critical Infrastructure ……………. S-2016-02-2016
Statement on Divestment from Fossil Fuels …………………………………………………….. S-2016-03-2016
Statement on Ethical Considerations in Global Medical Electives ………………………. S-2016-04-2016
Statement on Obesity in Children …………………………………………………………………… S-2016-05-2016
Statement on Occupational and Environmental Health and Safety …………………….. S-2016-06-2016
Statement on Bullying and Harassment within the Profession …………………………… S-2017-01-2017
Statement on Armed Conflicts ……………………………………………………………………….. S-2017-02-2017
Statement on Medical Cannabis …………………………………………………………………….. S-2017-03-2017
Statement on the Cooperation of National Medical Associations
during or in the Aftermath of Conflicts ………………………………………………………. S-2017-04-2017
Statement on Epidemics and Pandemics …………………………………………………………. S-2017-05-2017
Statement on the Role of Physicians in Preventing Exploitation
in Adoption Practices ……………………………………………………………………………….. S-2017-06-2017
Statement on Biosimilar Medicinal Products …………………………………………………… S-2018-01-2018
Statement on the Development and Promotion of a Maternal
and Child Health Handbook ………………………………………………………………………. S-2018-02-2018
Statement on Gender Equality in Medicine …………………………………………………….. S-2018-03-2018
Statement on Medical Tourism ……………………………………………………………………… S-2018-04-2018
Statement on Sustainable Development …………………………………………………………. S-2018-05-2018
Statement on Augmented Intelligence in Medical Care …………………………………….. S-2019-01-2019
Statement on Free Sugar Consumption and Sugar-sweetened Beverages ……………. S-2019-02-2019
Statement on Healthcare Information for All ……………………………………………………. S-2019-03-2019
Statement on Medical Age Assessment of Unaccompanied
Minor Asylum Seekers ………………………………………………………………………………. S-2019-04-2019
Statement on Human Genome Editing …………………………………………………………….. S-2020-01-2020
Statement on Hypertension and Cardiovascular Disease …………………………………… S-2020-02-2020
Table of Contents
Statement on Measures for the Prevention and Fight against
Transplant-Related Crimes ………………………………………………………………………… S-2020-03-2020
Statement in support of ensuring the Availability, the Quality
and the Safety of Medicines Worldwide ……………………………………………………… S-2021-01-2021
Statement on Access of Women and Children to Health Care …………………………….. S-2021-02-2021
Statement on Solar Radiation and Photoprotection ………………………………………….. S-2021-03-2021
Statement on Physicians Treating Relatives ……………………………………………………… S-2022-01-2022
RESOLUTIONS
Resolution on Academic Sanctions or Boycotts ……………………………………………….. R-1988-01-2021
Resolution on Economic Embargoes and Health ………………………………………………. R-1997-01-2022
Resolution on the Medical Workforce …………………………………………………………….. R-1998-04-2009
Resolution supporting the Ottawa Convention ………………………………………………… R-1998-01-2018
Resolution on the Inclusion of Medical Ethics and
Human Rights in the Curriculum of Medical Schools World-wide ………………….. R-1999-01-2015
Resolution on Political Abuse of Psychiatry ……………………………………………………… R-2002-05-2021
Resolution on the Designation of an Annual Medical Ethics Day ………………………… R-2003-01-2021
Resolution on the Responsibility of Physicians in the Denunciation of
Acts of Torture or Cruel, Inhuman or Degrading Treatment ………………………….. R-2003-02-2020
Resolution on the Non-Commercialization of
Human Reproductive Material ………………………………………………………………….. R-2003-03-2021
Resolution on WFME Global Standards for
Quality Improvement of Medical Education ……………………………………………….. R-2004-01-2021
WMA Resolution in support of Taiwan’s participation in all WHO Health Programs
and inclusion in the International Health Regulations (IHR) Mechanism …………. R-2005-04-2021
Resolution on Implementation of the WHO Framework Convention
on Tobacco Control ………………………………………………………………………………….. R-2005-05-2021
Resolution on Child Safety in Airline Travel ……………………………………………………… R-2006-02-2021
Resolution on North Korean Nuclear Testing …………………………………………………… R-2006-04-2021
Resolution on Tuberculosis ……………………………………………………………………………. R-2006-05-2022
Resolution in Support of the Medical Associations
in Latin America and the Caribbean …………………………………………………………… R-2007-02-2017
Resolution on Collaboration Between Human and Veterinary Medicine …………….. R-2008-01-2018
Emergency Resolution on Legislation against Abortion in Nicaragua ………………….. R-2009-01-2019
Resolution supporting the Rights of
Handbook of WMA Policies
Chronological Order
Patients and Physicians in the Islamic Republic of Iran …………………………………. R-2009-02-2021
Resolution on Task Shifting from the Medical Profession ………………………………….. R-2009-03-2019
Resolution on Drug Prescription …………………………………………………………………….. R-2010-01-2020
Resolution on the Access to Adequate Pain Treatment …………………………………….. R-2011-01-2020
Resolution on Bahrain …………………………………………………………………………………… R-2011-02-2011
Resolution reaffirming the WMA Resolution on
Economic Embargoes and Health ………………………………………………………………. R-2011-03-2011
Resolution on Independence of Medical Associations ………………………………………. R-2011-04-2021
Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking
Product …………………………………………………………………………………………………… R-2012-02-2021
Resolution to reaffirm the WMA’s Prohibition of Physician Participation in
Capital Punishment ………………………………………………………………………………….. R-2012-03-2012
Resolution in Support of Professor Cyril Karabus ………………………………………………. R-2012-04-2012
Resolution on Criminalisation of Medical Practice …………………………………………….. R-2013-01-2021
Resolution on the Healthcare Situation in Syria ………………………………………………… R-2013-02-2020
Resolution on the Prohibition of Chemical Weapons ………………………………………… R-2013-03-2020
Resolution on Patient Safety and Standardisation in Medical Practice ………………… R-2013-04-2021
Resolution in Support of the Brazilian Medical Association ………………………………… R-2013-05-2013
Resolution on Ebola Viral Disease …………………………………………………………………… R-2014-01-2014
Resolution on Migrant Workers’ Health and Safety in Qatar ………………………………. R-2014-02-2021
Resolution on Unproven Therapy and the Ebola Virus ………………………………………. R-2014-03-2014
Resolution to Stop Attacks Against Healthcare Workers
and Facilities In Turkey ……………………………………………………………………………. R-2015-01-2015
Resolution about the Bombing on the Hospital of MSF in Kunduz ……………………… R-2015-02-2015
Resolution on the Protection of Health Care Facilities
and Personnel in Syria ……………………………………………………………………………… R-2016-01-2021
Resolution on Zika Virus Infection ………………………………………………………………….. R-2016-04-2016
Resolution on Prohibition of Forced Anal Examinations
to Substantiate Same-Sex Sexual Activity …………………………………………………… R-2017-02-2022
Resolution in support of Dr Serdar Küni …………………………………………………………… R-2017-03-2020
Resolution on Prohibition of Physician Participation in Capital Punishment ………… R-2018-02-2018
Resolution on Climate Emergency …………………………………………………………………… R-2019-01-2019
Resolution on the Revocation of WHO Guidelines on Opioid Use ……………………….. R-2019-02-2019
Resolution in Support of an International Day of the Medical Profession,
October 30 ………………………………………………………………………………………………. R-2020-01-2020
Resolution in support to the Turkish Medical Association ………………………………….. R-2020-02-2020
Resolution on Equitable Global Distribution of COVID-19 Vaccine ………………………. R-2020-03-2020
Resolution on Human Rights Violations against Uighur people in China ………………. R-2020-04-2020
Table of Contents
* Code explanation (sorting criteria):
D-1948-01-2006
Year of last action
Serial number
Year of adoption
Document type
D: Declarations / S: Statements / R: Resolutions
——–
Resolution on Protecting the Future Generation’s Right to Live in a Healthy
Environment ……………………………………………………………………………………………. R-2020-05-2020
Resolution regarding the Medical Profession and COVID-19 ………………………………. R-2020-06-2020
Resolution in support of the countries worst affected by the Covid-19 crisis ……….. R-2021-01-2021
Resolution in support of Medical Personnel and Citizens of Myanmar ………………… R-2021-02-2021
Resolution on Covid-19 Vaccines and International Travel Requirements ……………. R-2021-03-2021
Resolution on the Repression of Nicaraguan Doctors ………………………………………… R-2021-04-2021
Resolution in support of Medical Personnel and Citizens of Ukraine
in the face of the Russian invasion………………………………………………………………. R-2022-01-2022
Resolution for Providing Covid-19 Vaccines for All ……………………………………………. R-2022-02-2022
Resolution on Humanitarian and Medical Aid to Ukraine …………………………………… R-2022-03-2022
Handbook of WMA Policies
Order by Short Title
TABLE OF CONTENTS
– Order by Short Title –
[A]
Abuse of Psychiatry ……………………………………………………………………………………… R-2002-05-2021
Academic Sanctions or Boycotts ……………………………………………………………………. R-1998-01-2015
Access to Health Care ………………………………………………………………………………….. S-1988-01-2017
Access to Surgery and Anesthesia Care…………………………………………………………….. S-2021-03-2021
Adequate Pain Treatment …………………………………………………………………………….. R-2011-01-2020
Adolescent Suicide ………………………………………………………………………………………. S-1991-01-2016
Advanced Technology ……………………………………………………………………………………. D-2002-04-2012
Aesthetic Treatment …………………………………………………………………………………….. S-2014-01-2014
Ageing ………………………………………………………………………………………………………… S-2016-01-2016
Air Pollution ………………………………………………………………………………………………… S-2014-02-2014
Air Travel …………………………………………………………………………………………………….. S-2006-07-2022
Alcohol ……………………………………………………………………………………………………….. D-2015-01-2017
Alcohol and Road Safety ………………………………………………………………………………. S-1992-01-2016
Alcohol on Health and Society ………………………………………………………………………. S-2005-01-2014
Animal Use in Biomedical Research ……………………………………………………………….. S-1989-01-2016
Annual Medical Ethics Day ……………………………………………………………………………. R-2003-01-2013
Antimicrobial Resistance ………………………………………………………………………………. S-1996-01-2019
Armed Conflict ……………………………………………………………………………………………. S-1956-01-2012
Armed Conflicts ……………………………………………………………………………………………. S-2017-02-2017
Assisted Reproductive Technologies ……………………………………………………………… S-2006-01-2022
Augmented Intelligence in Medical Care ………………………………………………………….. S-2019-01-2019
Availability, Quality and Safety of Medicines ……………………………………………………. S-2021-01-2021
Avian and Pandemic Influenza ……………………………………………………………………….. S-2006-02-2018
[B]
Bahrain ………………………………………………………………………………………………………… R-2011-02-2011
Biological Weapons (Washington) ………………………………………………………………….. D-2002-01-2012
Biosimilar Medicinal Products ……………………………………………………………………….. S-2018-01-2018
Body Searches of Prisoners …………………………………………………………………………… S-1993-01-2016
Bombing on the Hospital of MSF in Kunduz …………………………………………………….. R-2015-02-2015
Boxing ………………………………………………………………………………………………………… S-1983-01-2017
Bullying and Harassment within the Profession ……………………………………………….. S-2017-01-2017
Order by Short Title
Handbook of WMA Policies
[C]
Capital Punishment ……………………………………………………………………………………… R-2018-02-2018
Chicago (Quality Assurance in Basic Medical Education) ……………………………………. D-2017-01-2017
Child Abuse and Neglect ………………………………………………………………………………. S-1984-01-2017
Child Health (Ottawa) …………………………………………………………………………………… D-1998-01-2020
Child Safety in Airline Travel …………………………………………………………………………. R-2006-02-2021
Chronic Disease …………………………………………………………………………………………… S-2011-01-2022
Climate Change (Delhi) ………………………………………………………………………………… D-2009-01-2017
Climate Emergency ……………………………………………………………………………………….. R-2019-01-2019
Collective Action by Physicians ……………………………………………………………………… S-2012-02-2022
Conflict of Interest ………………………………………………………………………………………. S-2009-01-2015
Cooperation of NMAs during or in the Aftermath of Conflicts …………………………… S-2017-04-2017
COVID-19 Crisis …………………………………………………………………………………………….. R-2021-01-2021
COVID-19 Vaccine …………………………………………………………………………………………. R-2020-03-2020
COVID-19 Vaccines and International Travel …………………………………………………….. R-2021-03-2021
Covid-19 Vaccines for All ……………………………………………………………………………….. R-2022-02-2022
Criminal Offences and Licensing ……………………………………………………………………. S-1997-02-2007
Criminalisation of Medical Practice ……………………………………………………………….. R-2013-01-2021
Curriculum of Medical Schools World-wide ……………………………………………………. R-1999-01-2021
Cyber-Attacks on Health ……………………………………………………………………………….. S-2016-02-2016
[D]
Death Penalty ………………………………………………………………………………………………. S-2013-05-2013
Delhi (Climate Change) ………………………………………………………………………………… D-2009-01-2017
Denunciation of Acts of Torture ……………………………………………………………………. R-2003-02-2020
Designation of an Annual Medical Ethics Day …………………………………………………… R-2003-01-2020
Detention and Imprisonment (Tokyo) …………………………………………………………….. D-1975-01-2016
Determination of Death (Sydney) …………………………………………………………………… D-1968-01-2016
Dietary Sodium Intake ………………………………………………………………………………….. S-2008-01-2019
Disaster Preparedness (Montevideo) ……………………………………………………………… D-2011-01-2011
Disasters …………………………………………………………………………………………………….. S-1994-01-2017
Discrimination against Elderly Individuals ………………………………………………………… D-2022-02-2022
Digital Health ……………………………………………………………………………………………….. S-2009-04-2022
Divestment from Fossil Fuels …………………………………………………………………………. S-2016-03-2016
Dr Serdar Küni ………………………………………………………………………………………………. R-2017-03-2020
Drug Prescription ………………………………………………………………………………………… R-2010-01-2020
Drug Substitution ………………………………………………………………………………………… S-2005-02-2015
Handbook of WMA Policies
Order by Short Title
[E]
Ebola Viral Disease ………………………………………………………………………………………. R-2014-01-2014
Ebola Virus ………………………………………………………………………………………………….. R-2014-03-2014
Economic Embargoes and Health …………………………………………………………………… R-1997-01-2022
Economic Embargoes and Health [Revised] …………………………………………………….. R-2011-03-2011
Edinburgh (Prison Conditions on TB) ………………………………………………………………. D-2000-01-2011
Elderly Abuse (Hong Kong) …………………………………………………………………………….. D-1989-01-2015
Electronic Cigarettes …………………………………………………………………………………….. S-2012-01-2012
Environmental Degradation ………………………………………………………………………….. S-2010-01-2018
Environmental Issues …………………………………………………………………………………… S-1988-04-2016
Epidemics and Pandemics ……………………………………………………………………………… S-2017-05-2017
Euthanasia and Physician-Assisted Suicide ……………………………………………………… D-2019-01-2019
[F]
Fair Medical Trade ……………………………………………………………………………………….. D-2017-02-2017
Family Violence …………………………………………………………………………………………… S-1996-02-2021
Female Genital Mutilation ……………………………………………………………………………. S-1993-02-2016
Forced Anal Examinations ……………………………………………………………………………… R-2017-02-2022
Forced and Coerced Sterilisation …………………………………………………………………… S-2012-03-2012
Forensic Investigations of the Missing ……………………………………………………………. S-2003-01-2013
Freedom to Attend Medical Meetings ……………………………………………………………. S-1984-02-2020
Fungal Disease …………………………………………………………………………………………….. S-2013-01-2013
[G]
Genetics and Medicine ………………………………………………………………………………… S-2005-03-2009
Geneva ………………………………………………………………………………………………………. D-1048-01-2017
Gender Equality in Medicine ………………………………………………………………………….. S-2018-03-2018
Global Medical Electives ……………………………………………………………………………….. S-2016-04-2016
[H]
Hamburg (Refusing Torture) ………………………………………………………………………….. D-1997-02-2017
Health Care Facilities and Personnel in Syria ……………………………………………………. R-2016-01-2021
Healthcare Information for All ………………………………………………………………………… S-2019-03-2019
Healthcare In Turkey …………………………………………………………………………………….. R-2015-01-2015
Healthcare Situation in Syria ………………………………………………………………………….. R-2013-02-2020
Health Databases ………………………………………………………………………………………… D-2002-02-2016
Healthy Environment …………………………………………………………………………………….. R-2020-05-2020
Helsinki (Medical Research involving Human Subjects) …………………………………….. D-1964-01-2013
HIV/AIDS and the Medical Profession …………………………………………………………….. S-2006-03-2017
Order by Short Title
Handbook of WMA Policies
Hong Kong (Elderly Abuse) …………………………………………………………………………….. D-1989-01-2015
Human Genome Editing …………………………………………………………………………………. S-2020-01-2020
Human Papillomavirus Vaccination ……………………………………………………………….. S-2013-02-2013
Humanitarian and Medical Aid to Ukraine ……………………………………………………….. R-2022-03-2022
Hunger Strikers (Malta) …………………………………………………………………………………. D-1991-01-2017
Hypertension and Cardiovascular Disease ……………………………………………………….. S-2020-02-2020
[ I ]
Independence of Medical Associations ………………………………………………………….. R-2011-04-2021
Injury Control ……………………………………………………………………………………………… S-1990-01-2016
International Day of the Medical Profession …………………………………………………….. R-2020-01-2020
International Migration of Health Workers ……………………………………………………… S-2003-03-2014
[ L ]
Latin American and the Caribbean Medical Associations ………………………………….. R-2007-02-2017
Law and Ethics ………………………………………………………………………………………………. D-2003-01-2019
Legislation against Abortion in Nicaragua ………………………………………………………. R-2009-01-2019
Leprosy Control ……………………………………………………………………………………………. D-2011-03-2021
Lisbon (Patient’s Rights) ………………………………………………………………………………… D-1981-01-2015
Living Wills ………………………………………………………………………………………………….. S-2003-02-2013
[M]
Madrid (Professionally-led Regulation) …………………………………………………………… D-2009-02-2009
Malta (Hunger Strikers) …………………………………………………………………………………. D-1991-01-2017
Maternal and Child Health Handbook …………………………………………………………….. S-2018-02-2018
Medical Cannabis …………………………………………………………………………………………. S-2017-03-2017
Medical Education ……………………………………………………………………………………….. S-2006-04-2017
Medical Ethics …………………………………………………………………………………………….. D-1949-01-2022
Medical Liability ………………………………………………………………………………………….. S-2005-04-2021
Medical Personnel and Citizens of Myanmar ……………………………………………………. R-2021-02-2021
Medical Profession and COVID-19 …………………………………………………………………… R-2020-06-2020
Medical Research involving Human Subjects (Helsinki) …………………………………….. D-1964-01-2013
Medical Tourism ………………………………………………………………………………………….. S-2018-04-2009
Medical Workforce ………………………………………………………………………………………. R-1998-04-2009
Mercury ……………………………………………………………………………………………………… S-2008-02-2018
Migrant Workers’ Health and Safety in Qatar …………………………………………………. R-2014-02-2021
Monitoring Tokyo Declaration ………………………………………………………………………. S-2011-02-2021
Montevideo (Disaster Preparedness) ……………………………………………………………… D-2011-01-2011
Handbook of WMA Policies
Order by Short Title
[N]
Natural Variations of Human Sexuality …………………………………………………………… S-2013-03-2013
Nicaraguan Doctors ………………………………………………………………………………………. R-2021-04-2021
Noise Pollution ……………………………………………………………………………………………. S-1992-05-2017
Non-Commercialization of Human Reproductive Material ……………………………….. R-2003-03-2021
Non-Discrimination in Professional Membership …………………………………………….. S-1985-01-2015
Nuclear Testing in North Korea ……………………………………………………………………… R-2006-04-2021
Nuclear Weapons ………………………………………………………………………………………… S-1998-01-2018
[O]
Obesity ………………………………………………………………………………………………………. S-2006-05-2016
Obesity in Children ……………………………………………………………………………………….. S-2016-05-2016
Occupational and Environmental Health and Safety …………………………………………. S-2016-06-2022
Opiate and Psychotropic Drug Abuse …………………………………………………………….. S-2006-06-2016
Organ and Tissue Donation …………………………………………………………………………… S-2012-04-2017
Oslo (Social Determinants of Health) ………………………………………………………………. D-2011-04-2020
Ottawa (Child Health) …………………………………………………………………………………… D-1998-01-2009
Ottawa Convention ……………………………………………………………………………………… R-1998-01-2018
[P]
Patenting Medical Procedures ………………………………………………………………………. S-1999-01-2019
Patient Advocacy and Confidentiality ……………………………………………………………… S-1993-03-2016
Patient-Physician Relationship ……………………………………………………………………….. D-2020-01-2020
Patient Safety ……………………………………………………………………………………………… D-2002-03-2022
Patient’s Rights (Lisbon) ………………………………………………………………………………… D-1981-01-2015
Patients with Mental Illness ………………………………………………………………………….. S-1995-02-2015
Physicians and Commercial Enterprises …………………………………………………………. S-2004-02-2020
Physicians and Pharmacists in Medical Therapy ……………………………………………… S-1999-02-2020
Physicians convicted of Genocide or Crimes ……………………………………………………. S-1997-02-2018
Physicians Treating Relatives ………………………………………………………………………….. S-2022-01-2022
Physicians Well-Being …………………………………………………………………………………… S-2015-02-2015
Plain Packaging of Cigarettes ………………………………………………………………………… R-2012-02-2021
Preventing Exploitation in Adoption Practices…………………………………………………… S-2017-06-2017
Prioritisation of Immunisation ……………………………………………………………………….. S-2012-05-2019
Prison Conditions on TB (Edinburgh) ………………………………………………………………. D-2000-01-2022
Professional Autonomy and Clinical Independence (Seoul) ……………………………….. D-2008-01-2018
Professionally-led Regulation (Madrid) …………………………………………………………… D-2009-02-2019
Professor Cyril Karabus …………………………………………………………………………………. R-2012-04-2012
Prohibition of Chemical Weapons ………………………………………………………………….. R-2013-03-2020
Promotional Mass Media Appearances by Physicians ………………………………………. S-2015-07-2015
Order by Short Title
Handbook of WMA Policies
Protection and integrity of Medical Personnel …………………………………………………. D-2011-05-2022
Pseudoscience and Pseudotherapies ………………………………………………………………. D-2020-02-2020
Public Health ………………………………………………………………………………………………. S-1995-04-2016
[Q]
Quality Improvement in Health Care ……………………………………………………………… D-1997-01-2019
Quality Assurance in Basic Medical Education …………………………………………………. D-2017-01-2017
[R]
Racism in Medicine ……………………………………………………………………………………….. D-2022-01-2022
Refugees’ Medical Care ………………………………………………………………………………… S-1998-02-2021
Refusing Torture (Hamburg) ………………………………………………………………………….. D-1997-02-2017
Right of Woman on Family Planning ………………………………………………………………. S-1996-04-2017
Rights of Patients and Physicians in Iran ………………………………………………………… R-2009-02-2021
Riot Control Agents ……………………………………………………………………………………… S-2015-04-2015
Russian Invasion of Ukraine ……………………………………………………………………………. R-2022-01-2022
[S]
Safe Injections in Health Care ……………………………………………………………………….. S-2002-01-2022
Self-Medication ……………………………………………………………………………………………. S-2002-02-2022
Seoul (Professional Autonomy and Clinical Independence) ……………………………….. D-2008-01-2018
Sex Selection Abortion and Female Foeticide …………………………………………………… S-2002-03-2019
Social Determinants of Health ………………………………………………………………………. D-2011-04-2020
Social Media ………………………………………………………………………………………………… S-2011-05-2022
Solar Radiation and Photoprotection ………………………………………………………………. S-2021-03-2021
Solitary Confinement ……………………………………………………………………………………. S-2014-03-2019
Sports Medicine ………………………………………………………………………………………….. D-1981-02-2021
Standardisation in Medical Practice and Patient Safety ……………………………………. R-2013-04-2021
Stem Cell Research ………………………………………………………………………………………… S-2009-02-2020
Street Children …………………………………………………………………………………………….. S-2015-03-2015
Sugar Consumption ……………………………………………………………………………………….. S-2019-02-2019
Support of the AMB ……………………………………………………………………………………… R-2013-05-2013
Sustainable Development ……………………………………………………………………………… S-2018-05-2018
Sydney (Determination of Death) …………………………………………………………………… D-1968-01-2016
[T]
Taiwan’s Observer Status to the WHO …………………………………………………………….. R-2005-04-2021
Task Shifting ……………………………………………………………………………………………….. R-2009-03-2019
Terminal Illness (Venice) ……………………………………………………………………………….. D-1983-01-2022
Therapeutic Abortion …………………………………………………………………………………….. D-1970-01-2006
Handbook of WMA Policies
Order by Short Title
Tobacco Products Health Hazards …………………………………………………………………. S-1988-05-2022
Tobacco-WHO FCTC …………………………………………………………………………………….. R-2005-05-2021
Tokyo (Detention and Imprisonment) …………………………………………………………….. D-1975-01-2016
Trade Agreements and Public Health ………………………………………………………………. S-2015-08-2021
Traffic Injury ……………………………………………………………………………………………….. S-1990-04-2016
Transgender People ……………………………………………………………………………………… S-2015-05-2015
Transplant-Related Crimes …………………………………………………………………………….. S-2020-03-2020
Tuberculosis ……………………………………………………………………………………………….. R-2006-05-2022
Turkish Medical Association …………………………………………………………………………… R-2020-02-2020
[U]
Unaccompanied Minor Asylum Seekers …………………………………………………………… S-2019-04-2019
Uighur people in China ………………………………………………………………………………….. R-2020-04-2020
[V]
Venice (Terminal Illness) ……………………………………………………………………………….. D-1983-01-2006
Veterinary Medicine ……………………………………………………………………………………. R-2008-03-2018
Victims of Torture ……………………………………………………………………………………….. S-2013-04-2013
Violence against Women ……………………………………………………………………………… S-2010-02-2020
Violence and Health …………………………………………………………………………………….. S-2003-04-2019
Violence in the Health Sector ……………………………………………………………………….. S-2012-06-2022
Vitamin D Insufficiency …………………………………………………………………………………. S-2015-06-2015
[W]
Washington (Biological Weapons) ………………………………………………………………….. D-2002-01-2012
Water and Health ………………………………………………………………………………………… S-2004-03-2017
Weapons of Warfare ……………………………………………………………………………………. S-1996-05-2016
WFME ………………………………………………………………………………………………………… R-2004-01-2021
WHO Guidelines on Opioid Use ………………………………………………………………………. R-2019-02-2019
Women and Children to Health Care ……………………………………………………………… S-1997-03-2021
Women’s Right to Health Care ………………………………………………………………………. S-2002-04-2021
[Z]
Zika Virus Infection ………………………………………………………………………………………. R-2016-02-2016
Handbook of WMA Policies
D-1948-01-2017 ⏐ World Medical Association
WMA DECLARATION OF GENEVA
Adopted by the 2nd
General Assembly of the World Medical Association,
Geneva, Switzerland, September 1948
and amended by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
and the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 46th
WMA General Assembly, Stockholm, Sweden, September 1994
and editorially revised by the 170th
WMA Council Session,
Divonne-les-Bains, France, May 2005
and the 173rd
WMA Council Session, Divonne-les-Bains, France, May 2006
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
The Physician’s Pledge
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, social standing or any other factor to
intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good
medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of
healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the
highest standard;
Geneva
Chicago⏐ D-1948-01-2017
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under
threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Handbook of WMA Policies
World Medical Association D-1949-01-2022
WMA INTERNATIONAL CODE OF MEDICAL ETHICS
Adopted by the 3rd
General Assembly of the World Medical Association, London, England,
October 1949
revised by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
the 35th
World Medical Assembly, Venice, Italy, October 1983
the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The World Medical Association (WMA) has developed the International Code of Medical
Ethics as a canon of ethical principles for the members of the medical profession worldwide.
In concordance with the WMA Declaration of Geneva: The Physician’s Pledge and the WMA’s
entire body of policies, it defines and elucidates the professional duties of physicians towards
their patients, other physicians and health professionals, themselves, and society as a whole.
The physician must be aware of applicable national ethical, legal, and regulatory norms and
standards, as well as relevant international norms and standards.
Such norms and standards must not reduce the physician’s commitment to the ethical principles
set forth in this Code.
The International Code of Medical Ethics should be read as a whole and each of its constituent
paragraphs should be applied with consideration of all other relevant paragraphs. Consistent
with the mandate of the WMA, the Code is addressed to physicians. The WMA encourages
others who are involved in healthcare to adopt these ethical principles.
GENERAL PRINCIPLES
1. The primary duty of the physician is to promote the health and well-being of individual
patients by providing competent, timely, and compassionate care in accordance with good
medical practice and professionalism.
The physician also has a responsibility to contribute to the health and well-being of the
populations the physician serves and society as a whole, including future generations.
The physician must provide care with the utmost respect for human life and dignity, and
for the autonomy and rights of the patient.
International Code of Medical Ethics
Berlin D-1949-01-2022
2. The physician must practise medicine fairly and justly and provide care based on the
patient’s health needs without bias or engaging in discriminatory conduct on the basis of
age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race,
culture, sexual orientation, social standing, or any other factor.
3. The physician must strive to use health care resources in a way that optimally benefits the
patient, in keeping with fair, just, and prudent stewardship of the shared resources with
which the physician is entrusted.
4. The physician must practise with conscience, honesty, integrity, and accountability, while
always exercising independent professional judgement and maintaining the highest
standards of professional conduct.
5. Physicians must not allow their individual professional judgement to be influenced by the
possibility of benefit to themselves or their institution. The physician must recognise and
avoid real or potential conflicts of interest. Where such conflicts are unavoidable, they must
be declared in advance and properly managed.
6. Physicians must take responsibility for their individual medical decisions and must not alter
their sound professional medical judgements on the basis of instructions contrary to
medical considerations.
7. When medically appropriate, the physician must collaborate with other physicians and
health professionals who are involved in the care of the patient or who are qualified to
assess or recommend care options. This communication must respect patient confidentiality
and be confined to necessary information.
8. When providing professional certification, the physician must only certify what the
physician has personally verified.
9. The physician should provide help in medical emergencies, while considering the
physician’s own safety and competence, and the availability of other viable options for
care.
10. The physician must never participate in or facilitate acts of torture, or other cruel, inhuman,
or degrading practices and punishments.
11. The physician must engage in continuous learning throughout professional life in order to
maintain and develop professional knowledge and skills.
12. The physician should strive to practise medicine in ways that are environmentally
sustainable with a view to minimising environmental health risks to current and future
generations.
Handbook of WMA Policies
World Medical Association D-1949-01-2022
Duties to the patient
13. In providing medical care, the physician must respect the dignity, autonomy, and rights of
the patient. The physician must respect the patient’s right to freely accept or refuse care in
keeping with the patient’s values and preferences.
14. The physician must commit to the primacy of patient health and well-being and must offer
care in the patient’s best interests. In doing so, the physician must strive to prevent or
minimise harm for the patient and seek a positive balance between the intended benefit to
the patient and any potential harm.
15. The physician must respect the patient’s right to be informed in every phase of the care
process. The physician must obtain the patient’s voluntary informed consent prior to any
medical care provided, ensuring that the patient receives and understands the information
needed to make an independent, informed decision about the proposed care. The physician
must respect the patient’s decision to withhold or withdraw consent at any time and for any
reason.
16. When a patient has substantially limited, underdeveloped, impaired, or fluctuating
decision-making capacity, the physician must involve the patient as much as possible in
medical decisions. In addition, the physician must work with the patient’s trusted
representative, if available, to make decisions in keeping with the patient’s preferences,
when those are known or can reasonably be inferred. When the patient’s preferences cannot
be determined, the physician must make decisions in the patient’s best interests. All
decisions must be made in keeping with the principles set forth in this Code.
17. In emergencies, where the patient is not able to participate in decision making and no
representative is readily available, the physician may initiate an intervention without prior
informed consent in the best interests of the patient and with respect for the patient’s
preferences, where known.
18. If the patient regains decision-making capacity, the physician must obtain informed consent
for further intervention.
19. The physician should be considerate of and communicate with others, where available, who
are close to the patient, in keeping with the patient’s preferences and best interests and with
due regard for patient confidentiality.
20. If any aspect of caring for the patient is beyond the capacity of a physician, the physician
must consult with or refer the patient to another appropriately qualified physician or health
professional who has the necessary capacity.
21. The physician must ensure accurate and timely medical documentation.
International Code of Medical Ethics
Berlin D-1949-01-2022
22. The physician must respect the patient’s privacy and confidentiality, even after the patient
has died. A physician may disclose confidential information if the patient provides
voluntary informed consent or, in exceptional cases, when disclosure is necessary to
safeguard a significant and overriding ethical obligation to which all other possible
solutions have been exhausted, even when the patient does not or cannot consent to it. This
disclosure must be limited to the minimal necessary information, recipients, and duration.
23. If a physician is acting on behalf of or reporting to any third parties with respect to the care
of a patient, the physician must inform the patient accordingly at the outset and, where
appropriate, during the course of any interactions. The physician must disclose to the
patient the nature and extent of those commitments and must obtain consent for the
interaction.
24. The physician must refrain from intrusive or otherwise inappropriate advertising and
marketing and ensure that all information used by the physician in advertising and
marketing is factual and not misleading.
25. The physician must not allow commercial, financial, or other conflicting interests to affect
the physician’s professional judgement.
26. When providing medical care remotely, the physician must ensure that this form of
communication is medically justifiable and that the necessary medical care is provided. The
physician must also inform the patient about the benefits and limitations of receiving
medical care remotely, obtain the patient’s consent, and ensure that patient confidentiality
is upheld. Wherever medically appropriate, the physician must aim to provide care to the
patient through direct, personal contact.
27. The physician must maintain appropriate professional boundaries. The physician must
never engage in abusive, exploitative, or other inappropriate relationships or behaviour with
a patient and must not engage in a sexual relationship with a current patient.
28. In order to provide care of the highest standards, physicians must attend to their own health,
well-being, and abilities. This includes seeking appropriate care to ensure that they are able
to practise safely.
29. This Code represents the physician’s ethical duties. However, on some issues there are
profound moral dilemmas concerning which physicians and patients may hold deeply
considered but conflicting conscientious beliefs.
The physician has an ethical obligation to minimise disruption to patient care. Physician
conscientious objection to provision of any lawful medical interventions may only be
exercised if the individual patient is not harmed or discriminated against and if the patient’s
health is not endangered.
Handbook of WMA Policies
World Medical Association D-1949-01-2022
The physician must immediately and respectfully inform the patient of this objection and
of the patient’s right to consult another qualified physician and provide sufficient
information to enable the patient to initiate such a consultation in a timely manner.
Duties to other physicians, health professionals, students, and other personnel
30. The physician must engage with other physicians, health professionals and other personnel
in a respectful and collaborative manner without bias, harassment, or discriminatory
conduct. The physician must also ensure that ethical principles are upheld when working
in teams.
31. The physician should respect colleagues’ patient-physician relationships and not intervene
unless requested by either party or needed to protect the patient from harm. This should not
prevent the physician from recommending alternative courses of action considered to be in
the patient’s best interests.
32. The physician should report to the appropriate authorities conditions or circumstances
which impede the physician or other health professionals from providing care of the highest
standards or from upholding the principles of this Code. This includes any form of abuse
or violence against physicians and other health personnel, inappropriate working
conditions, or other circumstances that produce excessive and sustained levels of stress.
33. The physician must accord due respect to teachers and students.
Duties to society
34. The physician must support fair and equitable provision of health care. This includes
addressing inequities in health and care, the determinants of those inequities, as well as
violations of the rights of both patients and health professionals.
35. Physicians play an important role in matters relating to health, health education, and health
literacy. In fulfilling this responsibility, physicians must be prudent in discussing new
discoveries, technologies, or treatments in non-professional, public settings, including
social media, and should ensure that their own statements are scientifically accurate and
understandable.
Physicians must indicate if their own opinions are contrary to evidence-based scientific
information.
36. The physician must support sound medical scientific research in keeping with the WMA
Declaration of Helsinki and the WMA Declaration of Taipei.
37. The physician should avoid acting in such a way as to weaken public trust in the medical
profession. To maintain that trust, individual physicians must hold themselves and fellow
physicians to the highest standards of professional conduct and be prepared to report
behaviour that conflicts with the principles of this Code to the appropriate authorities.
International Code of Medical Ethics
Berlin D-1949-01-2022
38. The physician should share medical knowledge and expertise for the benefit of patients and
the advancement of health care, as well as public and global health.
Duties as a member of the medical profession
39. The physician should follow, protect, and promote the ethical principles of this Code. The
physician should help prevent national or international ethical, legal, organisational, or
regulatory requirements that undermine any of the duties set forth in this Code.
40. The physician should support fellow physicians in upholding the responsibilities set out in
this Code and take measures to protect them from undue influence, abuse, exploitation,
violence, or oppression.
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
WMA DECLARATION OF HELSINKI
– ETHICAL PRINCIPLES FOR MEDICAL RESEARCH INVOLVING HUMAN SUBJECTS –
Adopted by the 18th
WMA General Assembly, Helsinki, Finland, June 1964
and amended by the:
29th
WMA General Assembly, Tokyo, Japan, October 1975
35th
WMA General Assembly, Venice, Italy, October 1983
41st
WMA General Assembly, Hong Kong, September 1989
48th
WMA General Assembly, Somerset West, Republic of South Africa, October 1996
52nd
WMA General Assembly, Edinburgh, Scotland, October 2000
53rd
WMA General Assembly, Washington DC, USA, October 2002
(Note of Clarification added)
55th
WMA General Assembly, Tokyo, Japan, October 2004
(Note of Clarification added)
59th
WMA General Assembly, Seoul, Republic of Korea, October 2008
64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
1. The World Medical Association (WMA) has developed the Declaration of Helsinki as
a statement of ethical principles for medical research involving human subjects,
including research on identifiable human material and data.
The Declaration is intended to be read as a whole and each of its constituent para-
graphs should be applied with consideration of all other relevant paragraphs.
2. Consistent with the mandate of the WMA, the Declaration is addressed primarily to
physicians. The WMA encourages others who are involved in medical research in-
volving human subjects to adopt these principles.
GENERAL PRINCIPLES
3. The Declaration of Geneva of the WMA binds the physician with the words, “The
health of my patient will be my first consideration,” and the International Code of
Medical Ethics declares that, “A physician shall act in the patient’s best interest when
providing medical care.”
4. It is the duty of the physician to promote and safeguard the health, well-being and
rights of patients, including those who are involved in medical research. The physi-
cian’s knowledge and conscience are dedicated to the fulfilment of this duty.
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5. Medical progress is based on research that ultimately must include studies involving
human subjects.
6. The primary purpose of medical research involving human subjects is to understand
the causes, development and effects of diseases and improve preventive, diagnostic
and therapeutic interventions (methods, procedures and treatments). Even the best
proven interventions must be evaluated continually through research for their safety,
effectiveness, efficiency, accessibility and quality.
7. Medical research is subject to ethical standards that promote and ensure respect for all
human subjects and protect their health and rights.
8. While the primary purpose of medical research is to generate new knowledge, this
goal can never take precedence over the rights and interests of individual research
subjects.
9. It is the duty of physicians who are involved in medical research to protect the life,
health, dignity, integrity, right to self-determination, privacy, and confidentiality of
personal information of research subjects. The responsibility for the protection of
research subjects must always rest with the physician or other health care pro-
fessionals and never with the research subjects, even though they have given consent.
10. Physicians must consider the ethical, legal and regulatory norms and standards for
research involving human subjects in their own countries as well as applicable
international norms and standards. No national or international ethical, legal or
regulatory requirement should reduce or eliminate any of the protections for research
subjects set forth in this Declaration.
11. Medical research should be conducted in a manner that minimises possible harm to
the environment.
12. Medical research involving human subjects must be conducted only by individuals
with the appropriate ethics and scientific education, training and qualifications. Re-
search on patients or healthy volunteers requires the supervision of a competent and
appropriately qualified physician or other health care professional.
13. Groups that are underrepresented in medical research should be provided appropriate
access to participation in research.
14. Physicians who combine medical research with medical care should involve their
patients in research only to the extent that this is justified by its potential preventive,
diagnostic or therapeutic value and if the physician has good reason to believe that
participation in the research study will not adversely affect the health of the patients
who serve as research subjects.
15. Appropriate compensation and treatment for subjects who are harmed as a result of
participating in research must be ensured.
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Medical Rsearch involving Human Subjects (Helsinki)
RISKS, BURDENS AND BENEFITS
16. In medical practice and in medical research, most interventions involve risks and
burdens.
Medical research involving human subjects may only be conducted if the importance
of the objective outweighs the risks and burdens to the research subjects.
17. All medical research involving human subjects must be preceded by careful assess-
ment of predictable risks and burdens to the individuals and groups involved in the
research in comparison with foreseeable benefits to them and to other individuals or
groups affected by the condition under investigation.
Measures to minimise the risks must be implemented. The risks must be continuously
monitored, assessed and documented by the researcher.
18. Physicians may not be involved in a research study involving human subjects unless
they are confident that the risks have been adequately assessed and can be satis-
factorily managed.
When the risks are found to outweigh the potential benefits or when there is con-
clusive proof of definitive outcomes, physicians must assess whether to continue,
modify or immediately stop the study.
VULNERABLE GROUPS AND INDIVIDUALS
19. Some groups and individuals are particularly vulnerable and may have an increased
likelihood of being wronged or of incurring additional harm.
All vulnerable groups and individuals should receive specifically considered protec-
tion.
20. Medical research with a vulnerable group is only justified if the research is responsive
to the health needs or priorities of this group and the research cannot be carried out in
a non-vulnerable group. In addition, this group should stand to benefit from the
knowledge, practices or interventions that result from the research.
SCIENTIFIC REQUIREMENTS AND RESEARCH PROTOCOLS
21. Medical research involving human subjects must conform to generally accepted
scientific principles, be based on a thorough knowledge of the scientific literature,
other relevant sources of information, and adequate laboratory and, as appropriate,
animal experimentation. The welfare of animals used for research must be respected.
22. The design and performance of each research study involving human subjects must be
clearly described and justified in a research protocol.
Handbook of WMA Policies
World Medical Association ⏐ D-1964-01-2013
The protocol should contain a statement of the ethical considerations involved and
should indicate how the principles in this Declaration have been addressed. The pro-
tocol should include information regarding funding, sponsors, institutional affilia-
tions, potential conflicts of interest, incentives for subjects and information regarding
provisions for treating and/or compensating subjects who are harmed as a conse-
quence of participation in the research study.
In clinical trials, the protocol must also describe appropriate arrangements for post-
trial provisions.
RESEARCH ETHICS COMMITTEES
23. The research protocol must be submitted for consideration, comment, guidance and
approval to the concerned research ethics committee before the study begins. This
committee must be transparent in its functioning, must be independent of the
researcher, the sponsor and any other undue influence and must be duly qualified. It
must take into consideration the laws and regulations of the country or countries in
which the research is to be performed as well as applicable international norms and
standards but these must not be allowed to reduce or eliminate any of the protections
for research subjects set forth in this Declaration.
The committee must have the right to monitor ongoing studies. The researcher must
provide monitoring information to the committee, especially information about any
serious adverse events. No amendment to the protocol may be made without con-
sideration and approval by the committee. After the end of the study, the researchers
must submit a final report to the committee containing a summary of the study’s find-
ings and conclusions.
PRIVACY AND CONFIDENTIALITY
24. Every precaution must be taken to protect the privacy of research subjects and the
confidentiality of their personal information.
INFORMED CONSENT
25. Participation by individuals capable of giving informed consent as subjects in medical
research must be voluntary. Although it may be appropriate to consult family mem-
bers or community leaders, no individual capable of giving informed consent may be
enrolled in a research study unless he or she freely agrees.
26. In medical research involving human subjects capable of giving informed consent,
each potential subject must be adequately informed of the aims, methods, sources of
funding, any possible conflicts of interest, institutional affiliations of the researcher,
the anticipated benefits and potential risks of the study and the discomfort it may
entail, post-study provisions and any other relevant aspects of the study. The potential
subject must be informed of the right to refuse to participate in the study or to with-
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Medical Rsearch involving Human Subjects (Helsinki)
draw consent to participate at any time without reprisal. Special attention should be
given to the specific information needs of individual potential subjects as well as to
the methods used to deliver the information.
After ensuring that the potential subject has understood the information, the physician
or another appropriately qualified individual must then seek the potential subject’s
freely-given informed consent, preferably in writing. If the consent cannot be expressed
in writing, the non-written consent must be formally documented and witnessed.
All medical research subjects should be given the option of being informed about the
general outcome and results of the study.
27. When seeking informed consent for participation in a research study the physician
must be particularly cautious if the potential subject is in a dependent relationship
with the physician or may consent under duress. In such situations the informed
consent must be sought by an appropriately qualified individual who is completely
independent of this relationship.
28. For a potential research subject who is incapable of giving informed consent, the
physician must seek informed consent from the legally authorised representative.
These individuals must not be included in a research study that has no likelihood of
benefit for them unless it is intended to promote the health of the group represented
by the potential subject, the research cannot instead be performed with persons
capable of providing informed consent, and the research entails only minimal risk and
minimal burden.
29. When a potential research subject who is deemed incapable of giving informed con-
sent is able to give assent to decisions about participation in research, the physician
must seek that assent in addition to the consent of the legally authorised representa-
tive. The potential subject’s dissent should be respected.
30. Research involving subjects who are physically or mentally incapable of giving con-
sent, for example, unconscious patients, may be done only if the physical or mental
condition that prevents giving informed consent is a necessary characteristic of the
research group. In such circumstances the physician must seek informed consent
from the legally authorised representative. If no such representative is available and if
the research cannot be delayed, the study may proceed without informed consent
provided that the specific reasons for involving subjects with a condition that renders
them unable to give informed consent have been stated in the research protocol and
the study has been approved by a research ethics committee. Consent to remain in the
research must be obtained as soon as possible from the subject or a legally authorised
representative.
31. The physician must fully inform the patient which aspects of their care are related to
the research. The refusal of a patient to participate in a study or the patient’s decision
to withdraw from the study must never adversely affect the patient-physician
relationship.
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World Medical Association ⏐ D-1964-01-2013
32. For medical research using identifiable human material or data, such as research on
material or data contained in biobanks or similar repositories, physicians must seek
informed consent for its collection, storage and/or reuse. There may be exceptional
situations where consent would be impossible or impracticable to obtain for such
research. In such situations the research may be done only after consideration and
approval of a research ethics committee.
USE OF PLACEBO
33. The benefits, risks, burdens and effectiveness of a new intervention must be tested
against those of the best proven intervention(s), except in the following circums-
tances:
Where no proven intervention exists, the use of placebo, or no intervention, is accept-
able; or
Where for compelling and scientifically sound methodological reasons the use of any
intervention less effective than the best proven one, the use of placebo, or no inter-
vention is necessary to determine the efficacy or safety of an intervention
and the patients who receive any intervention less effective than the best proven one,
placebo, or no intervention will not be subject to additional risks of serious or
irreversible harm as a result of not receiving the best proven intervention.
Extreme care must be taken to avoid abuse of this option.
POST-TRIAL PROVISIONS
34. In advance of a clinical trial, sponsors, researchers and host country governments
should make provisions for post-trial access for all participants who still need an
intervention identified as beneficial in the trial. This information must also be dis-
closed to participants during the informed consent process.
RESEARCH REGISTRATION AND PUBLICATION AND DISSEMINATION OF RESULTS
35. Every research study involving human subjects must be registered in a publicly
accessible database before recruitment of the first subject.
36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with
regard to the publication and dissemination of the results of research. Researchers
have a duty to make publicly available the results of their research on human subjects
and are accountable for the completeness and accuracy of their reports. All parties
should adhere to accepted guidelines for ethical reporting. Negative and inconclusive
as well as positive results must be published or otherwise made publicly available.
Sources of funding, institutional affiliations and conflicts of interest must be declared
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Medical Rsearch involving Human Subjects (Helsinki)
in the publication. Reports of research not in accordance with the principles of this
Declaration should not be accepted for publication.
UNPROVEN INTERVENTIONS IN CLINICAL PRACTICE
37. In the treatment of an individual patient, where proven interventions do not exist or
other known interventions have been ineffective, the physician, after seeking expert
advice, with informed consent from the patient or a legally authorised representative,
may use an unproven intervention if in the physician’s judgement it offers hope of
saving life, re-establishing health or alleviating suffering. This intervention should
subsequently be made the object of research, designed to evaluate its safety and effi-
cacy. In all cases, new information must be recorded and, where appropriate, made
publicly available.
Handbook of WMA Policies
D-1968-01-2016 ⏐ World Medical Association
WMA DECLARATION OF SYDNEY
ON
THE DETERMINATION OF DEATH AND THE RECOVERY OF ORGANS
Adopted by the 22nd
World Medical Assembly, Sydney, Australia, August 1968
and amended by the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
Determination of death can be made on the basis of the irreversible cessation of all functions
of the entire brain, including the brain stem, or the irreversible cessation of circulatory and
respiratory functions. This determination will be based on clinical judgment according to
accepted criteria, supplemented, if necessary, by standard diagnostic procedures, and it will
be made by a physician.
Even without intervention, cell, organ and tissue activity in the body may continue
temporarily after a determination of death. Cessation of all life at the cellular level is not a
necessary criterion for determination of death.
The use of deceased donor organs for transplantation has made it important for physicians to
be able to determine when mechanically-supported patients have died.
After death has occurred, it may be possible to maintain circulation to the organs and tissues
of the body mechanically. This may be done to preserve organs and tissues for
transplantation.
Prior to post-mortem transplantation, the determination that death has occurred shall be
made by a physician who is in no way immediately involved in the transplantation
procedure.
Following the determination of death, all treatment and resuscitation attempts may be ceased
and donor organs may be recovered, provided that prevailing requirements of consent and
other relevant ethical and legal requirements have been fulfilled. Physicians should follow
the protocol on organ donation for deceased donors as outlined in the WMA Statement on
Organ and Tissue Donation.
Handbook of WMA Policies
D-1975-01-2016 ⏐ World Medical Association
WMA DECLARATION OF TOKYO
– GUIDELINES FOR PHYSICIANS CONCERNING TORTURE AND OTHER CRUEL,
INHUMAN OR DEGRADING TREATMENT OR
PUNISHMENT IN RELATION TO DETENTION AND IMPRISONMENT –
Adopted by the 29th
World Medical Assembly, Tokyo, Japan, October 1975
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and the 173rd
WMA Council Session, Divonne-les-Bains, France, May 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
It is the privilege of the physician to practise medicine in the service of humanity, to
preserve and restore bodily and mental health without distinction as to persons, to comfort
and to ease the suffering of his or her patients. The utmost respect for human life is to be
maintained even under threat, and no use made of any medical knowledge contrary to the
laws of humanity.
For the purpose of this Declaration, torture is defined as the deliberate, systematic or
wanton infliction of physical or mental suffering by one or more persons acting alone or
on the orders of any authority, to force another person to yield information, to make a
confession, or for any other reason.
DECLARATION
1. The physician shall not countenance, condone or participate in the practice of torture
or other forms of cruel, inhuman or degrading procedures, whatever the offense of
which the victim of such procedures is suspected, accused or guilty, and whatever the
victim’s beliefs or motives, and in all situations, including armed conflict and civil
strife.
2. The physician shall not provide any premises, instruments, substances or knowledge to
facilitate the practice of torture or other forms of cruel, inhuman or degrading
treatment or to diminish the ability of the victim to resist such treatment.
3. When providing medical assistance to detainees or prisoners who are, or who could
later be, under interrogation, physicians should be particularly careful to ensure the
Taipei ⏐ D-1975-01-2016
Detention and Imprisonment (Tokyo)
confidentiality of all personal medical information. A breach of the Geneva
Conventions shall in any case be reported by the physician to relevant authorities.
4. As stated in WMA Resolution on the Responsibility of Physicians in the
Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or
Degrading Treatment and as an exception to professional confidentiality, physicians
have the ethical obligation to report abuses, where possible with the subject’s consent,
but in certain circumstances where the victim is unable to express him/herself freely,
without explicit consent.
5. The physician shall not use nor allow to be used, as far as he or she can, medical
knowledge or skills, or health information specific to individuals, to facilitate or
otherwise aid any interrogation, legal or illegal, of those individuals.
6. The physician shall not be present during any procedure during which torture or any
other forms of cruel, inhuman or degrading treatment is used or threatened.
7. A physician must have complete clinical independence in deciding upon the care of a
person for whom he or she is medically responsible. The physician’s fundamental role
is to alleviate the distress of his or her fellow human beings, and no motive, whether
personal, collective or political, shall prevail against this higher purpose.
8. Where a prisoner refuses nourishment and is considered by the physician as capable of
forming an unimpaired and rational judgment concerning the consequences of such a
voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in
WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the
prisoner to form such a judgment should be confirmed by at least one other
independent physician. The consequences of the refusal of nourishment shall be
explained by the physician to the prisoner.
9. Recalling the Declaration of Hamburg concerning Support for Medical Doctors
Refusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel,
Inhuman or Degrading Treatment, the World Medical Association supports, and
encourages the international community, the National Medical Associations and
fellow physicians to support, the physician and his or her family in the face of threats
or reprisals resulting from a refusal to condone the use of torture or other forms of
cruel, inhuman or degrading treatment.
10. The World Medical Association calls on National Medical Associations to encourage
physicians to continue their professional development training and education in human
rights.
Handbook of WMA Policies
D-1981-01-2015 ⏐ World Medical Association
WMA DECLARATION OF LISBON
ON
THE RIGHTS OF THE PATIENT
Adopted by the 34th
World Medical Assembly, Lisbon, Portugal,
September/October 1981
and amended by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and editorially revised by the 171st
WMA Council Session, Santiago, Chile, October 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
PREAMBLE
The relationship between physicians, their patients and broader society has undergone
significant changes in recent times. While a physician should always act according to his/
her conscience, and always in the best interests of the patient, equal effort must be made
to guarantee patient autonomy and justice. The following Declaration represents some of
the principal rights of the patient that the medical profession endorses and promotes.
Physicians and other persons or bodies involved in the provision of health care have a joint
responsibility to recognize and uphold these rights. Whenever legislation, government
action or any other administration or institution denies patients these rights, physicians
should pursue appropriate means to assure or to restore them.
PRINCIPLES
1. Right to medical care of good quality
a. Every person is entitled without discrimination to appropriate medical care.
b. Every patient has the right to be cared for by a physician whom he/she knows to
be free to make clinical and ethical judgements without any outside interference.
c. The patient shall always be treated in accordance with his/her best interests. The
treatment applied shall be in accordance with generally approved medical princi-
ples.
d. Quality assurance should always be a part of health care. Physicians, in parti-
cular, should accept responsibility for being guardians of the quality of medical
services.
e. In circumstances where a choice must be made between potential patients for a
particular treatment that is in limited supply, all such patients are entitled to a fair
selection procedure for that treatment. That choice must be based on medical cri-
teria and made without discrimination.
Patient’s Right (Lisbon)
Oslo ⏐ D-1981-01-2015
f. The patient has the right to continuity of health care. The physician has an obli-
gation to cooperate in the coordination of medically indicated care with other
health care providers treating the patient. The physician may not discontinue treat-
ment of a patient as long as further treatment is medically indicated, without
giving the patient reasonable assistance and sufficient opportunity to make alter-
native arrangements for care.
2. Right to freedom of choice
a. The patient has the right to choose freely and change his/her physician and hospi-
tal or health service institution, regardless of whether they are based in the private
or public sector.
b. The patient has the right to ask for the opinion of another physician at any stage.
3. Right to self-determination
a. The patient has the right to self-determination, to make free decisions regarding
himself/herself. The physician will inform the patient of the consequences of his/
her decisions.
b. A mentally competent adult patient has the right to give or withhold consent to
any diagnostic procedure or therapy. The patient has the right to the information
necessary to make his/her decisions. The patient should understand clearly what
is the purpose of any test or treatment, what the results would imply, and what
would be the implications of withholding consent.
c. The patient has the right to refuse to participate in research or the teaching of
medicine.
4. The unconscious patient
a. If the patient is unconscious or otherwise unable to express his/her will, informed
consent must be obtained whenever possible, from a legally entitled represen-
tative.
b. 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 con-
viction that he/she would refuse consent to the intervention in that situation.
c. However, physicians should always try to save the life of a patient unconscious
due to a suicide attempt.
5. The legally incompetent patient
a. If a patient is a minor or otherwise legally incompetent, the consent of a legally
entitled representative is required in some jurisdictions. Nevertheless the patient
must be involved in the decision-making to the fullest extent allowed by his/her
capacity.
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D-1981-01-2015 ⏐ World Medical Association
b. If the legally incompetent patient can make rational decisions, his/her decisions
must be respected, and he/she has the right to forbid the disclosure of information
to his/her legally entitled representative.
c. If the patient’s legally entitled representative, or a person authorized by the pa-
tient, forbids treatment which is, in the opinion of the physician, in the patient’s
best interest, the physician should challenge this decision in the relevant legal or
other institution. In case of emergency, the physician will act in the patient’s best
interest.
6. Procedures against the patient’s will
Diagnostic procedures or treatment against the patient’s will can be carried out only in
exceptional cases, if specifically permitted by law and conforming to the principles of
medical ethics.
7. Right to information
a. The patient has the right to receive information about himself/herself recorded
in any of his/her medical records, and to be fully informed about his/her health
status including the medical facts about his/her condition. However,
confidential information in the patient’s records about a third party should not be
given to the patient without the consent of that third party.
b. Exceptionally, information may be withheld from the patient when there is good
reason to believe that this information would create a serious hazard to his/her
life or health.
c. Information should be given in a way appropriate to the patient’s culture and in
such a way that the patient can understand.
d. The patient has the right not to be informed on his/her explicit request, unless
required for the protection of another person’s life.
e. The patient has the right to choose who, if anyone, should be informed on his/
her behalf.
8. Right to confidentiality
a. All identifiable information about a patient’s health status, medical condition,
diagnosis, prognosis and treatment and all other information of a personal kind
must be kept confidential, even after death. Exceptionally, descendants may have
a right of access to information that would inform them of their health risks.
b. Confidential information can only be disclosed if the patient gives explicit con-
sent or if expressly provided for in the law. Information can be disclosed to other
health care providers only on a strictly “need to know” basis unless the patient
has given explicit consent.
Patient’s Right (Lisbon)
Oslo ⏐ D-1981-01-2015
c. All identifiable patient data must be protected. The protection of the data must be
appropriate to the manner of its storage. Human substances from which identifi-
able data can be derived must be likewise protected.
9. Right to health education
Every person has the right to health education that will assist him/her in making
informed choices about personal health and about the available health services. The
education should include information about healthy lifestyles and about methods of
prevention and early detection of illnesses. The personal responsibility of everybody
for his/her own health should be stressed. Physicians have an obligation to participate
actively in educational efforts.
10. Right to dignity
a. The patient’s dignity and right to privacy shall be respected at all times in medical
care and teaching, as shall his/her culture and values.
b. The patient is entitled to relief of his/her suffering according to the current state
of knowledge.
c. The patient is entitled to humane terminal care and to be provided with all avail-
able assistance in making dying as dignified and comfortable as possible.
11. Right to religious assistance
The patient has the right to receive or to decline spiritual and moral comfort including the
help of a minister of his/her chosen religion
Handbook of WMA Policies
World Medical Association D-1981-02-2021
WMA DECLARATION
ON
PRINCIPLES OF HEALTH CARE IN SPORTS MEDICINE
Adopted by the 34th
WMA General Assembly, Lisbon, Portugal, September/October 1981
amended by the 39th
WMA General Assembly, Madrid, Spain, October 1987
by the 45th
WMA General Assembly, Budapest, Hungary, October 1993
by the 51st
WMA General Assembly, Tel Aviv, Israel, October 1999
reaffirmed by the 185th
WMA Council Session, Evian-les-Bains, France, May 2010
and amended by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
Sports medicine physicians are physicians concerned with the prevention and treatment of
injuries and disorders that are related to participation in sports. In some countries, sports
medicine physicians are recognized as medical specialists. They are trained to address issues
associated with nutrition, sports psychology and substance misuse, and may also counsel
athletes on injury prevention.
Considering the involvement of physicians in sports medicine, the World Medical Association
(WMA) recommends ethical guidelines for sports medicine physicians, recognizing the special
circumstances in which their medical care and health guidance is given.
Anabolic Agents and Performance Enhancing Drugs and Methods
The use of anabolic agents, performance enhancing drugs, pain killers and performance
enhancing methods by athletes is contrary to the rules and ethical principles of athletic
competition as set forth by most sports governing bodies. Performance enhancing drugs and
methods have been associated with adverse health effects.
The sports medicine physician should be aware that methods, drugs or interventions which
artificially modify blood constituents, biochemistry, genome sequence, gene expression or
hormone levels and do not benefit patients, violate the basic principles of the WMA’s
Declaration of Geneva, which states: “the health and wellbeing of my patient will be my first
consideration.”
The WMA believes that the use of anabolic agents and performance enhancing drugs and
methods is a threat to the health of athletes and is in conflict with the principles of medical
ethics. The physician must oppose and refuse to administer or condone any means or method
Sport Medicine
London D-1981-02-2021
which is not in accordance with medical ethics, or which might be harmful to the athlete using
it. The physician must also inform athletes of potential health risks.
Examples of these drugs and methods include, but are not limited to:
• The use of drugs or other substances whatever their nature and route of administration,
including central-nervous-system stimulants or depressants and procedures which
artificially modify reflexes, alter a sense of well-being and/or general mental outlook.
• Procedures or therapeutics to mask pain or other protective symptoms if used to enable
the athlete to take part in events or training activities when clinical signs make his or
her participation inadvisable. This includes allowing participation in athletic activity
when doing so would be dangerous to the athlete.
• Procedures or therapeutics used to mask the presence of other performance enhancing
drugs or to induce rapid water or weight loss.
• Measures aimed at an unnatural improvement in or maintenance of endurance or
oxygen carrying capacity during competition. This includes the manipulation of blood
and/or blood components defined as the administration or reintroduction of blood or
red blood cell products of any origin into the circulatory system, artificially enhancing
the uptake, transport, or delivery of oxygen using chemicals such as erythropoietin, or
other forms of intravascular manipulation to artificially increase red blood cell mass,
unless medically indicated for the treatment of a documented disease or medical
condition. Blood doping also exposes the athlete to unwarranted and potentially serious
health risks.
• Use of anabolic agents including “designer steroids”, which are substances that are
undetectable through the use of standard testing methods.
• Use of anabolic steroid precursors, including dietary supplements, that claim to provide
“safe” steroid equivalents, but that metabolize in the body into anabolic steroids.
• Use of non-approved substances which have no current approval by any governmental
regulatory health authority for human therapeutic use, for example, drugs under pre-
clinical or clinical development, discontinued drugs, designer drugs or substances
approved only for veterinary use.
• Use of peptide hormones, growth factors and related substances to increase red blood
cell count, blood oxygenation or oxygen-carrying capacity.
• Use of hormone and metabolic modulators, which are substances to modify hormone
activity by blocking the action or increasing the activity of a hormone.
Of special concern is the use of anabolic agents and steroid precursors in adolescents. Young
users are considered particularly susceptible to potentially serious health problems during this
physically and emotionally vulnerable period when their own hormonal cycles are changing.
Handbook of WMA Policies
World Medical Association D-1981-02-2021
In females, anabolic agents have been associated with a number of adverse effects, some of
which appear to be permanent even when drug use is stopped. Physicians should strongly
discourage using these products.
World Athletics Gender Rules for Classifying Female Athletes
World Athletics 2018 Eligibility Regulations for Female Classification1
imposes an upper
hormonal limit for athletes wishing to compete in the female category in certain disciplines of
international athletics competitions.
The WMA opposes World Athletics’ rules2
requiring female athletes with differences in sex
development to take drugs to reduce and maintain their natural level of blood testosterone in
order to compete. The mere existence of a condition caused by a difference in sex development,
in a person who has not expressed a desire to change that condition, does not constitute a
medical indication for treatment. Medical treatment solely to alter athletic performance is
unethical.
RECOMMENDATIONS
Sports medicine physicians have an obligation and duty to respect and comply with the ethical
standards of the medical profession.
The sports medicine physician who cares for athletes has an ethical responsibility to recognize
the special physical and mental demands placed upon athletes by their participation in athletic
activities. The physician’s duty is to preserve the athlete’s mental and physical health and not
solely to increase athletic performance.
When the sports participant is a professional athlete and derives livelihood from that activity,
the physician should understand the occupational health aspects involved.
The sports physician should give his or her objective opinion about the athlete’s state of fitness
clearly and precisely, leaving no doubt as to his or her conclusions.
In all sporting events, it is the physician’s duty to decide whether the athlete is medically fit to
compete in an event. This decision cannot be delegated to other non-physician professionals.
In order to carry out his or her ethical obligations, the sports medicine physician’s authority
must be fully recognized and upheld, particularly when it concerns the health and safety of the
athlete. Concern for the athlete’s health and safety must override the interests of any third party.
The sports medicine physician is obligated to uphold the ethical principles of the medical
profession. This includes the right to privacy and respect for the confidential nature of the
patient-physician relationship. These principles and obligations should be supported by an
agreement between the sports medicine physician and the athletic organization involved.
1 Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”
2 Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”
Sport Medicine
London D-1981-02-2021
The sports medicine physician must oppose and refuse to administer any substance or condone
any means or treatment method which is not in accordance with medical ethics and/or which
might be harmful to the athlete using it. The physician must also inform athletes of potential
health risks.
The sports medicine physician should be invited to participate in the design and modification
of a sport’s rules and regulations in order to protect the health and safety of athletes.
The sports medicine physician, with patient consent, should work cooperatively with the
patient’s personal physician, and keep him or her fully informed of the patient’s current
condition.
All physicians should recognize that the desire to enhance performance, appearance, and/or
well-being is not limited to elite athletes. Amateur and recreational athletes, as well as
adolescents, are also at risk of and subject to sociocultural pressures to misuse anabolic agents
and performance enhancing drugs and methods. A harm-reduction approach with discussions
focused on risks, harm minimization, prevention strategies, and health promotion is
recommended.
Handbook of WMA Policies
World Medical Association D-1983-01-2022
WMA DECLARATION OF VENICE
ON
END OF LIFE MEDICAL CARE
Adopted by the 35th
World Medical Assembly, Venice, Italy, October 1983
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
When a patient is seriously ill and the restoration of health may not be possible, the physician
and the patient are often faced with a complex set of decisions regarding medical treatment.
The end of life must be recognized and respected as an important part of a person’s life.
Advances in medical science have improved the ability of physicians to address many issues
associated with end-of-life care. While the priority of research to cure disease should not be
compromised, more attention must be paid to developing palliative treatments and improving
assessment and response to the physical, psychological, social and spiritual or existential
components of terminal illnesses and other conditions at the end of life.
WMA remains firmly opposed to euthanasia and physician-assisted suicide, as set forth in the
WMA Declaration on Euthanasia and Physician-Assisted Suicide.
Ethically-appropriate care at the end of life should routinely promote patient autonomy and
shared decision-making, and be respectful of the values of the patient, his or her family or
intimate associates, and surrogate(s). The WMA recognizes that attitudes and beliefs toward
death and dying vary widely from culture to culture and among different religions, and
palliative care resources are unevenly distributed. The approach to medical care at the end of
life will be influenced significantly by these factors, and thus attempting to develop detailed
universal guidelines on terminal care is neither practical nor wise. Therefore, the WMA
articulates the following:
RECOMMENDATIONS
Pain and Symptom Management
1. Palliative care at the end of life is part of good medical care. The objective of palliative
care is to maintain patient dignity and freedom from distressing symptoms. Care plans
should emphasize keeping a patient as comfortable as possible and the patient’s pain
End of Life Medical Care
Berlin D-1983-01-2022
controlled while recognizing the importance of attention to the social, psychological and
spiritual needs of the patient, and his or her family and intimate associates.
2. The clinical management of pain in patients at the end of life is of paramount importance
in terms of alleviating suffering. The WMA Resolution on Access to Adequate Pain
Treatment (2020) makes recommendations for physicians and governments that optimize
treatment of pain and other distressing symptoms. Physicians and National Medical
Associations should promote the dissemination and sharing of information regarding pain
management to ensure that all physicians involved in end-of-life care have access to best
practice guidelines and the most current treatments and methods available. National
Medical Associations should oppose laws or regulations that unduly inhibit physicians
from providing intensive, clinically appropriate symptoms management for patients at the
end of life in keeping with recognized best practices.
3. When a patient at the end of life experiences severe pain or other distressing clinical
symptoms that do not respond to intensive, symptom-specific palliation, it can be
appropriate to offer sedation to unconsciousness as an intervention of last resort. Sedation
to unconsciousness must never be used to intentionally cause a patient’s death and should
be restricted to patients in the final stages of life. Thorough efforts should be made to obtain
consent of the patient or the patient’s surrogate(s).
4. Palliative care is often provided by multidisciplinary healthcare teams. When possible, the
physician should be the leader of the team, being responsible, amongst other obligations,
for diagnosis and medical treatment plans. A carefully kept medical record is of the utmost
importance. The rationale for all symptom management interventions, including
medications for symptom relief, should be documented in the medical record, including the
degree and length of sedation and specific expectations for continuing, withdrawing, or
withholding future life-sustaining treatments.
5. The health care team should promote collaborative care of the patient and offer
bereavement support after the patient’s death. The needs of children and families or
intimate associates may require special attention and competence, both when children are
patients and when they are dependents of patients.
Education and Research
6. Education of healthcare professionals should include the teaching of end-of-life medical
care. Where it does not exist, the establishment of palliative medicine as a medical specialty
should be considered. In countries where palliative medicine is not a recognized specialty,
post-graduate training in palliative medicine can nevertheless improve the quality of
palliative care provided.
7. Physician education should help to develop the skills necessary to increase the prevalence
and quality of meaningful patient advance care planning for patients with life-threatening
illness and the right of patients to use written advance directives that describe their wishes
Handbook of WMA Policies
World Medical Association D-1983-01-2022
and goals regarding care in the event that they are unable to communicate. Physicians
should receive education to encourage their patients to formally document their goals,
values and treatment preferences and to appoint a substitute health care decision maker
with whom the patient can discuss in advance his or her values regarding health care and
treatment.
8. Governments and research institutions are encouraged to invest additional resources in
developing treatments to improve end-of-life care. This includes, but is not limited to,
supporting research on general medical care, specific treatments, psychological
implications and organization to improve end-of-life care.
9. When employing treatments, the physician must carefully consider the balance between the
intended benefits to the patient and the potential harm. National Medical Associations
should support the formulation of palliative treatment guidelines.
10. The physician must also communicate to the patient a willingness to discuss at any time
the natural course of the disease and what to expect during the dying process, while also
providing guidance about treatments and alternatives that could ease the patient’s suffering,
including palliative care or psychotherapy. If a patient indicates a desire to die or expresses
suicidal thoughts, the physician has a duty to engage in open and confidential discussions
with the patient to understand the motives and reasoning behind these thoughts.
11. Physicians should assist the dying patient in maintaining an optimal quality of life by
controlling symptoms and addressing psychosocial and spiritual needs, to enable the patient
to die with dignity and in comfort. Physicians should inform patients of the availability,
benefits and other aspects of palliative care. Discussions about patient preferences should
be initiated early, routinely offered to all patients and should be revisited regularly to
explore any changes patients may have in their wishes, especially as their clinical condition
changes. Information and communication among the patient, his or her family or intimate
associates, surrogates and members of the health care team are one of the fundamental
pillars of quality care at the end of life.
12. Physicians should endeavor to identify, understand and address the psychosocial and
spiritual needs of their patients, especially as they relate to patients’ physical symptoms.
Physicians should try to ensure that psychological, social and spiritual resources are
available to patients, their families and intimate associates, to help them deal with the
anxiety, fear and grief associated with the end of life.
13. Physicians should encourage patients to designate a substitute decision-maker/surrogate to
make decisions that are not expressed in an advance directive. In particular, physicians
should discuss the patient’s wishes regarding the approach to life-sustaining interventions
as well as palliative measures that might have the additional effect of accelerating death.
Because documented advance directives are sometimes not available in emergency
situations, physicians should emphasize to patients the importance of discussing treatment
preferences with individuals who are likely to act as substitute health care decision-
End of Life Medical Care
Berlin D-1983-01-2022
makers/surrogates. Whenever possible and consented to by the patient, the patient’s
substitue decision-makers/surrogates should be included in these conversations.
14. If a patient has decision-making capacity, his or her autonomous right to refuse any medical
treatments or interventions must be respected even if the patient’s life may be shortened.
Physicians should make sure that the patient is adequately treated for pain and discomfort
before consent for end-of-life care is obtained in order to ensure that unnecessary physical
and mental suffering do not interfere with decision making. Laws regarding the decision-
making capacity of minor patients vary greatly, but discussions with the family, and child,
if possible, are encouraged.
15. Upon a patient’s death, physicians may apply such means as are necessary to keep organs
viable for transplantation, provided that they act in accordance with the ethical guidelines
established in the WMA Declaration of Sydney on the Determination of Death and the
Recovery of Organs. In addition, any transplantation must be in accordance with the
principles in the WMA Statement on Organ and Tissue Donation.
Handbook of WMA Policies
World Medical Association ⏐ D-1989-01-2015
WMA DECLARATION OF HONG KONG
ON
THE ABUSE OF THE ELDERLY
Adopted by the 41st
World Medical Assembly, Hong Kong, September 1989
and editorially revised by the 126th
WMA Council Session, Jerusalem, Israel, May 1990
and the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
Elderly people may suffer pathological problems such as motor disturbances and psychic
and orientation disorders. As a result of such problems, elderly patients may require assis-
tance with their daily activities that can lead to a state of dependence. This may cause their
families and the community to consider them to be a burden and to subsequently limit or
deny care and services.
Abuse or neglect of the elderly can be manifested in a variety of ways: physical, psycho-
logical, financial and/or material, and medical. Variations in the definition of elder abuse
present difficulties in comparing findings on the nature and causes of the problem. A num-
ber of preliminary hypotheses have been proposed on the etiology of elder abuse includ-
ing: dependency on others to provide services; lack of close family ties; family vio-
lence; lack of financial resources; psychopathology of the abuser; lack of community sup-
port, and institutional factors such as low pay and poor working conditions that contribute
to pessimistic attitudes of caretakers.
The phenomenon of elder abuse is becoming increasingly recognized by both medical
facilities and social agencies. The first step in preventing elder abuse and neglect is to in-
crease levels of awareness and knowledge among physicians and other health profes-
sionals. Once high-risk individuals and families have been identified, physicians can parti-
cipate in the primary prevention of maltreatment by making referrals to appropriate com-
munity and social service centres. Physicians may also participate by providing support
and information on high-risk situations directly to patients and their families. At the same
time, physicians should employ care and sensitivity to preserve patient trust and confiden-
tiality, particularly in the case of competent patients.
The World Medical Association therefore adopts the following general principles relating
to abuse of the elderly.
GENERAL PRINCIPLES
1. The elderly have the same rights to care, welfare and respect as other human beings.
2. Physicians have a responsibility to help prevent the physical and psychological abuse
of elderly patients.
Elderly Abuse
Oslo ⏐ D-1989-01-2015
3. Whether consulted by an aged person directly, a nursing home or the family, phy-
sicians should see that the patient receives the best possible care.
4. If physicians verify or suspect ill treatment, as defined in this statement, they should
discuss the situation with those in charge, be it the nursing home or the family. If ill
treatment is confirmed, or if death is considered to be suspicious, they should report
the findings to the appropriate authorities.
5. To guarantee protection of the elderly in any environment there should be no restric-
tions on their right of free choice of a physician. National Medical Associations should
strive to make certain that such free choice is preserved within the socio-medical sys-
tem.
The World Medical Association also makes the following recommendations to physicians
involved in treating the elderly, and urges all National Medical Associations to publicize
this Declaration to their members and the public.
RECOMMENDATIONS
Physicians involved in treating the elderly should:
• make increased attempts to establish an atmosphere of trust with elderly patients in
order to encourage them to seek medical care when necessary and to feel comfort-
able confiding in the physician;
• provide medical evaluation and treatment for injuries resulting from abuse and/or
neglect;
• attempt to establish or maintain a therapeutic alliance with the family (often the
physician is the only professional who maintains long-term contact with the patient
and the family), while preserving to the greatest extent possible the confidentiality
of the patient;
• report all suspected cases of elder abuse and/or neglect in accordance with local
legislation;
• utilize a multidisciplinary team of caretakers from the medical, social service,
mental health, and legal professions, whenever possible; and
• encourage the development and utilization of supportive community resources that
provide in-home services, respite care, and stress reduction with high-risk families.
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
WMA DECLARATION OF MALTA
ON
HUNGER STRIKERS
Adopted by the 43rd
World Medical Assembly, St. Julians, Malta, November 1991
and editorially revised by the 44th
World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in
settings where people are detained (prisons, jails and immigration detention
centres). They are usually a form of protest by people who lack other ways of
making their demands known. In refusing nutrition for a significant period,
prisoners and detainees may hope to obtain certain goals by inflicting negative
publicity on the authorities. Short-term food refusals rarely raise ethical problems.
Prolonged fasting risks death or permanent damage for hunger strikers and can
create a conflict of values for physicians. Hunger strikers rarely wish to die but
some may be prepared to do so to achieve their aims.
2. Physicians need to ascertain the individual’s true intention, especially in collective
strikes or situations where peer pressure may be a factor. An emotional challenge
arises when hunger strikers who have apparently issued clear instructions not to be
resuscitated reach a stage of cognitive impairment. The principle of beneficence
urges physicians to resuscitate them but respect for individual autonomy restrains
physicians from intervening when a valid and informed refusal has been made.
This has been well worked through in many other clinical situations including
refusal of life saving treatment. An added difficulty arises in custodial settings
because it is not always clear whether the hunger striker’s advance instructions
were made voluntarily and with appropriate information about the consequences.
PRINCIPLES
3. Duty to act ethically. All physicians are bound by medical ethics in their
professional contact with vulnerable people, even when not providing therapy.
Whatever their role, physicians must try to prevent coercion or maltreatment of
detainees and must protest if it occurs.
4. Respect for autonomy. Physicians should respect individuals’ autonomy. This can
involve difficult assessments as hunger strikers’ true wishes may not be as clear as
they appear. Any decisions lack moral force if made by use of threats, peer
pressure or coercion. Hunger strikers should not forcibly be given treatment they
refuse. Applying, instructing or assisting forced feeding contrary to an informed
and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker’s
explicit or necessarily implied consent is ethically acceptable.
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
5. ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to
benefit those they treat. This is the concept of ‘beneficence’, which is
complemented by that of ‘non-maleficence’ or primum non nocere. These two
concepts need to be in balance. ‘Benefit’ includes respecting individuals’ wishes as
well as promoting their welfare. Avoiding ‘harm’ means not only minimising
damage to health but also not forcing treatment upon competent people nor
coercing them to stop fasting. Beneficence does not necessarily involve prolonging
life at all costs, irrespective of other determinants.
Physicians must respect the autonomy of competent individuals, even where this
will predictably lead to harm. The loss of competence does not mean that a
previous competent refusal of treatment, including artificial feeding should be
ignored.
6. Balancing dual loyalties. Physicians attending hunger strikers can experience a
conflict between their loyalty to the employing authority (such as prison
management) and their loyalty to patients. In this situation, physicians with dual
loyalties are bound by the same ethical principles as other physicians, that is to say
that their primary obligation is to the individual patient. They remain independent
from their employer in regard to medical decisions.
7. Clinical independence. Physicians must remain objective in their assessments and
not allow third parties to influence their medical judgement. They must not allow
themselves to be pressured to breach ethical principles, such as intervening
medically for non medical reasons.
8. Confidentiality. The duty of confidentiality is important in building trust but it is
not absolute. It can be overridden if non-disclosure seriously and imminently
harms others. As with other patients, hunger strikers’ confidentiality and privacy
should be respected unless they agree to disclosure or unless information sharing is
necessary to prevent serious harm. If individuals agree, their relatives and legal
advisers should be kept informed of the situation.
9. Establishing trust. Fostering trust between physicians and hunger strikers is often
the key to achieving a resolution that both respects the rights of the hunger strikers
and minimises harm to them. Gaining trust can create opportunities to resolve
difficult situations. Trust is dependent upon physicians providing accurate advice
and being frank with hunger strikers about the limitations of what they can and
cannot do, including situations in which the physician may not be able to maintain
confidentiality.
10. Physicians must assess the mental capacity of individuals seeking to engage in a
hunger strike. This involves verifying that an individual intending to fast is free of
any mental conditions that would undermine the person’s ability to make informed
health care decisions. Individuals with seriously impaired mental capacity may not
be able to appreciate the consequences of their actions should they engage in a
hunger strike. Those with treatable mental health problems should be directed
towards appropriate care for their mental conditions and receive appropriate
treatment. Those with untreatable conditions, including severe learning disability
D-1991-01-2017 ⏐ Chicago
Hunger Strikers (Malta)
or advanced dementia should receive treatment and support to enable them to make
such decisions as lie within their competence.
11. As early as possible, physicians should acquire a detailed and accurate medical
history of the person who is intending to fast. The medical implications of any
existing conditions should be explained to the individual. Physicians should verify
that hunger strikers understand the potential health consequences of fasting and
forewarn them in plain language of the disadvantages. Physicians should also
explain how damage to health can be minimised or delayed by, for example,
increasing fluid and thiamine intake. Since the person’s decisions regarding a
hunger strike can be momentous, ensuring full patient understanding of the
medical consequences of fasting is critical. Consistent with best practices for
informed consent in health care, the physician should ensure that the patient
understands the information conveyed by asking the patient what he or she
understands.
12. A thorough examination of the hunger striker should be made at the start of the fast
including measuring body weight. Management of future symptoms, including
those unconnected to the fast, should be discussed with hunger strikers. Also, the
person’s values and wishes regarding medical treatment in the event of a prolonged
fast should be noted. If the hunger striker consents, medical examinations should
be carried out regularly in order to determine necessary treatments. The physical
environment should be evaluated in order to develop recommendations for
preventing negative effects.
13. Continuing communication between the physician and hunger strikers is essential.
Physicians should ascertain on a daily basis whether individuals wish to continue a
hunger strike and what they want to be done when they are no longer able to
communicate meaningfully. The clinician should identify whether the individual is
willing, in the absence of their demands being met, to continue the fast even until
death. These findings must be appropriately recorded.
14. Sometimes hunger strikers accept an intravenous solution transfusion or other
forms of medical treatment. A refusal to accept certain interventions must not
prejudice any other aspect of the medical care, such as treatment of infections or of
pain.
15. Physicians should talk to hunger strikers in privacy and out of earshot of all other
people, including other detainees. Clear communication is essential and, where
necessary, interpreters unconnected to the detaining authorities should be available
and they too must respect confidentiality.
16. Physicians need to satisfy themselves that food or treatment refusal is the
individual’s voluntary choice. Hunger strikers should be protected from coercion.
Physicians can often help to achieve this and should be aware that coercion may
come from the authorities, the peer group, or others, such as family members.
Physicians or other health care personnel may not apply undue pressure of any sort
on the hunger striker to suspend the strike. Treatment or care of the hunger striker
must not be conditional upon suspension of the hunger strike. Any restraint or
pressure including but not limited to hand-cuffing, isolation, tying the hunger
Handbook of WMA Policies
World Medical Association ⏐ D-1991-01-2017
striker to a bed or any kind of physical restraint due to the hunger strike is not
acceptable.
17. If a physician is unable for reasons of conscience to abide by a hunger striker’s
refusal of treatment or artificial feeding, the physician should make this clear at the
outset, and must be sure to refer the hunger striker to another physician who is
willing to abide by the hunger striker’s refusal.
18. When a physician takes over the case, the hunger striker may have already lost
mental capacity so that there is no opportunity to discuss the individual’s wishes
regarding medical intervention to preserve life. Consideration and respect must be
given to any advance instructions made by the hunger striker. Advance refusals of
treatment must be followed if they reflect the voluntary wish of the individual
when competent. In custodial settings, the possibility of advance instructions
having been made under pressure needs to be considered. Where physicians have
serious doubts about the individual’s intention, any instructions must be treated
with great caution. If well informed and voluntarily made, however, advance
instructions can only generally be overridden if they become invalid because the
situation in which the decision was made has changed radically since the
individual lost competence.
19. If no discussion with the individual is possible and no advance instructions or any
other evidence or note in the clinical records of a discussion exist, physicians have
to act in what they judge to be in the person’s best interests. This means
considering the hunger strikers’ previously expressed wishes, their personal and
cultural values as well as their physical health. In the absence of any evidence of
hunger strikers’ former wishes, physicians should decide whether or not to provide
feeding, without interference from third parties.
20. Physicians may rarely and exceptionally consider it justifiable to go against
advance instructions refusing treatment because, for example, the refusal is thought
to have been made under duress. If, after resuscitation and having regained their
mental faculties, hunger strikers continue to reiterate their intention to fast, that
decision should be respected. It is ethical to allow a determined hunger striker to
die with dignity rather than submit that person to repeated interventions against his
or her will. Physicians acting against an advanced refusal of treatment must be
prepared to justify that action to relevant authorities including professional
regulators.
21. Artificial feeding, when used in the patient’s clinical interest, can be ethically
appropriate if competent hunger strikers agree to it. However, in accordance with
the WMA Declaration of Tokyo, where a prisoner refuses nourishment and is
considered by the physician as capable of forming an unimpaired and rational
judgment concerning the consequences of such a decision, he or she shall not be
fed artificially. Artificial feeding can also be acceptable if incompetent individuals
have left no unpressured advance instructions refusing it, in order to preserve the
life of the hunger striker or to prevent severe irreversible disability. Rectal
hydration is not and must never be used as a form of therapy for rehydration or
nutritional support in fasting patients.
D-1991-01-2017 ⏐ Chicago
Hunger Strikers (Malta)
22. When a patient is physically able to begin oral feeding, every caution must be
taken to ensure implementation of the most up to date guidelines of refeeding.
23. All kinds of interventions for enteral or parenteral feeding against the will of the
mentally competent hunger striker are “to be considered as “forced feeding”.
Forced feeding is never ethically acceptable. Even if intended to benefit, feeding
accompanied by threats, coercion, force or use of physical restraints is a form of
inhuman and degrading treatment. Equally unacceptable is the forced feeding of
some detainees in order to intimidate or coerce other hunger strikers to stop
fasting.
THE ROLE OF NATIONAL MEDICAL ASSOCIATIONS (NMAS) AND THE WMA
24. NMAs should organize and provide educational programmes highlighting the
ethical dimensions of hunger strikes, appropriate medical approaches, treatments,
and interventions. They shall make efforts to update physicians’ professional
knowledge and skills.
NMAs should work to provide mechanisms for supporting physicians working in
prisons/jails/immigration detention centers, who may often find themselves in
conflict situations and, as stated in the WMA Declaration of Hamburg, shall
support any physicians experiencing pressure to compromise their ethical
principles.
NMAs have a responsibility to make efforts to prevent unethical practices, to take
a position and speak out against ethical violations, and to investigate them
properly.
25. The World Medical Association will support physicians and NMAs confronted
with political pressures as a result of defending an ethically justifiable position, as
stated in the WMA Declaration of Hamburg.
Handbook of WMA Policies
World Medical Association ⏐ D-1997-01-2019
WMA DECLARATION
ON
GUIDELINES FOR CONTINUOUS QUALITY IMPROVEMENT IN
HEALTH CARE
Adopted by the 49th
World Medical Assembly, Hamburg, Germany, November 1997
amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and reaffirmed with minor revision by the 213th
WMA Council Session, Tbilisi, Georgia,
October 2019
PREAMBLE
The purpose of health care is to prevent, diagnose and treat illness and to maintain and to
promote the health of the population. The goal of quality review in health care is
continuous improvement of the quality of services provided for patients and the
population, and of the ways and means of producing these services. The ultimate goal is to
improve both individual patient outcomes and population health.
The obligation to continuously improve one’s professional ability and to rigorously
evaluate the methods one uses has long been a fundamental tenet of the ethical codes of
physicians. According to these codes, a physician must always strive to maintain and
increase his/her knowledge and skills. The physician shall recommend only examinations
and treatments that are believed to be effective and appropriate according to the best
available evidence-based medicine.
Physicians and health care institutions have an ethical and professional obligation to strive
for continuous quality improvement of services and patient safety, as stated in particular in
WMA International Code of Medical Ethics, the Lisbon Declaration on the Rights of the
Patient and the Resolution on Standardisation in Medical Practice and Patient Safety.
These guidelines are intended to articulate the ethical grounds for these obligations and to
strengthen quality review practices.
Ethical guidelines for health care quality improvement matter to all physicians, as well as
to institutions providing health care services for patients, those providing continuous
quality improvement services to assist physicians and organizations, health care payers
and regulators, patients, and every other stakeholder in the health care system.
THE OBLIGATION TO ESTABLISH STANDARDS FOR GOOD QUALITY WORK
Professionals, by definition, are responsible for specifying the standards that constitute
good quality in their work and the processes needed for the evaluation of that quality.
D-1997-01-2019 ⏐ Tbilisi
Quality Improvement in Health Care
Health professionals, therefore, must define high quality health care and determine the
best methods of measuring the quality of care delivered.
THE OBLIGATION TO COLLECT DATA
In order to assess quality of care, it is necessary to obtain reliable data on the patients and
populations served as well as on care processes and outcomes. Patient records, whether
recorded on paper, digitally or in any other way, must be created written and preserved
with care and, with attention to confidentiality requirements in accordance with the WMA
Declaration of Taipei. Procedures, decisions and other matters connected with patients
should be recorded in a format that will allow information for measuring specific
standards to be available on a timely basis when needed.
THE ROLE OF PROFESSIONAL EDUCATION
Health care professionals should have adequate opportunities to maintain and develop
their knowledge and skills by participating in continuing medical education and/or
continuing professional development. Clinical guidelines based on professional standards
for high quality care should be created and made easily available to those requiring them.
Health care training should include specific instruction in quality improvement techniques,
including opportunities for hands-on practice in measuring and improving quality. Health
care institutions should create quality improvement systems for their own use and to
ensure that instructions concerning such systems are followed.
Good quality work requires resources. Every effort should be made to make sure that
adequate time and economic means are available for quality work.
ATTENTION TO INAPPROPRIATE USE OF SERVICES
Inappropriate use of health care services includes overuse, underuse and misuse. Quality
measurement in health care should include a balanced set of measures in all three areas.
Overuse of services occurs when health care services are provided under circumstances in
which the potential for harm exceeds the possible benefit. Physicians can improve quality
by reducing overuse, thus sparing patients the unnecessary risk that results from
inappropriate health services.
Underuse of services is the failure to provide health care services that would be likely to
produce a favourable outcome for the patient. Physicians should strive to expand the use
of beneficial health care services that are underused.
Misuse of services occurs when an incorrect diagnosis is made or when an appropriate
service has been selected for a correct diagnosis but the patient does not receive the full
potential benefit of the service because of a preventable adverse event. Misuse of services
can be greatly reduced by using risk management and error prevention strategies.
MONITORING QUALITY: CLINICAL AUDITS
Active participation in critical self-evaluation, usually through clinical audit programs, is a
Handbook of WMA Policies
World Medical Association ⏐ D-1997-01-2019
useful mechanism for healthcare professionals, including healthcare administrators and
physicians, and the institutions in which they work, to improve the quality of their work.
External independent examination and accreditation of the institution can also be of use,
when carried out appropriately and with due attention to potential unintended effects.
Healthcare professionals and institutions should systematically record and reflect on
adverse incidents and medical error for the purposes of learning and quality improvement.
This should occur in an environment of trust (and confidentiality when appropriate) and to
actively avoid a blame culture.
INTERNAL AND EXTERNAL QUALITY ASSESSMENT
At the individual level, a physician should continuously update their knowledge and skills
and subject their level of ability to critical self-appraisal.
In organizations, the quality of health care can be assessed by both internal and external
methods.
Health care institutions should create internal quality improvement systems for their own
use and ensure that instructions concerning such systems are followed. These systems
should include continuous conducting of internal clinical peer review and learning from
adverse incidents, review examination and treatment methods and their attendant results,
tracking of the organization’s ability to react to quality data, and monitoring of patient
feedback.
External quality review initiatives, such as external peer review and audit, should be
carried out regularly and with a frequency corresponding to the evolution of the field or
when there is special reason for external assessment. Any review should take into account
risk adjustment of the patient population under consideration.
Whether internal or external, if the results of any quality assessment carry significant
opportunities for benefit or threats of harms for the organization or individual being
assessed, special attention must be paid to potential unintended and dangerous
consequences of such quality assessments. It is especially important to monitor the results
of quality improvement measurement and intervention strategies over time, with attention
to their effects on especially vulnerable patient populations.
Protocols to be used for quality review should be replicable and transparent. Appeals
mechanisms should be built into the protocols.
CONFIDENTIALITY OF PATIENT RECORDS
Patient records are an invaluable source of data for quality improvement. As with other uses
of individually identifiable patient-based information, consent is usually required from the
patient prior to use. If consent cannot reasonably be obtained, then all attempts should be
made to ensure that medical records are anonymised or pseudonimised for use in quality
improvement efforts. In every case, patient records used for quality improvement must only
be accessible to those who need to see them for the purposes of quality improvement.
D-1997-01-2019 ⏐ Tbilisi
Quality Improvement in Health Care
CONFIDENTIALITY OF PEER REVIEW
For peer review to be most effective, all parties involved must participate and recognize its
importance. It is recommended that informed voluntary consent be obtained from those to
be reviewed. Within a healthcare team, the work of each physician must be able to be
evaluated. Information regarding an individual physician’s evaluation should not be
published without the consent of the physician concerned. It is recommended that consent
be obtained prior to publishing information regarding an individual physician’s evaluation.
A provider of services may inform his/her patients about the results of quality review.
If reviews are made available to the public, careful monitoring must be undertaken to track
the effects, intended and unintended, of such public reporting of performance data.
ETHICAL REVIEW OF QUALITY IMPROVEMENT ACTIVITIES
National codes of medical ethics and ethical principles and guidelines that relate to
continuous quality improvement, audit and clinical review must be followed.
Quality improvement should be an ongoing and integral part of the operations of every
health care organization. As such, the majority of quality improvement projects will not
require specific review by an ethics committee. If there are doubts about specific issues or
if a project poses more than minimal risk compared to the existing processes for care, then
the project should be referred to an appropriate ethics committee or institutional review
board. When such formal ethical review is needed, it should be undertaken by a committee
with members who are knowledgeable about quality improvement techniques.
COMPETENCE AND IMPARTIALITY OF THE REVIEWER
Those who conduct performance reviews must be competent in quality improvement
techniques and in clinical audit as well as experienced in the clinical field relating to the
review. Where medical care is being reviewed, the reviewer should be a physician whose
knowledge and experience is accepted by those being reviewed.
The reviewer should be impartial and independent. Whilst he/she must be aware of the
activities under review, he/she must be objective in the report and base conclusions on
critical evaluation of observation and facts. Commercial or competitive matters should not
be allowed to influence the content of the reviewer’s report.
SEPARATION OF QUALITY REVIEWS AND SUPERVISION BY AUTHORITIES
Quality improvement of services and of health care systems is a requirement for every
physician and health care institution. It is not supervision of professional activities by
authorities and it must be kept independent of this. The results of performance reviews or
audits of physician activities should be used by supervising authorities only subject to a
Handbook of WMA Policies
World Medical Association ⏐ D-1997-01-2019
separate agreement between them and the physicians concerned unless national legislation
mandates an alternative approach. These activities must be fully cognizant of the local
legal framework and must not expose participating physicians to litigation.
Handbook of WMA Policies
World Medical Association ⏐ D-1997-02-2017
WMA DECLARATION OF HAMBURG
CONCERNING SUPPORT FOR MEDICAL DOCTORS
REFUSING TO PARTICIPATE IN, OR TO CONDONE,
THE USE OF TORTURE OR OTHER FORMS OF CRUEL,
INHUMAN OR DEGRADING TREATMENT
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
PREAMBLE
1. On the basis of a number of international ethical declarations and guidelines subs-
cribed to by the medical profession, medical doctors throughout the world are
pro-hibited from countenancing, condoning or participating in the practice of
torture or other forms of cruel, inhuman or degrading procedures for any reason.
2. Primary among these declarations are the World Medical Association’s
International Code of Medical Ethics, Declaration of Geneva, Declaration of
Tokyo, and Resolu-tion on Physician Participation in Capital Punishment; the
Standing Committee of European Doctors’ Statement of Madrid; the Nordic
Resolution Concerning Physician Involvement in Capital Punishment; and, the
World Psychiatric Association’s Decla-ration of Hawaii.
3. However, none of these declarations or statements addresses explicitly the issue of
what protection should be extended to medical doctors if they are pressured, called
upon, or ordered to take part in torture or other forms of cruel, inhuman or
degrading treatment or punishment. Nor do these declarations or statements
express explicit sup-port for, or the obligation to protect, doctors who encounter or
become aware of such procedures.
RESOLUTION
4. The World Medical Association (WMA) hereby reiterates and reaffirms the
responsibility of the organised medical profession:
4.1 To encourage physicians to honour their commitment as physicians to serve
humanity and to resist any pressure to act contrary to the ethical principles
governing their dedication to this task;
4.2 To support physicians experiencing difficulties as a result of their resistance to
any such pressure or as a result of their attempts to speak out or to act against
such inhuman procedures;
Refusing Torture
Berlin ⏐ D-1997-02-2007
4.3 To extend its support and to encourage other international organisations, as
well as the constituent members of the World Medical Association (WMA), to
support physicians encountering difficulties as a result of their attempts to act
in accordance with the highest ethical principles of the profession; and
4.4 To encourage physicians to report and document any acts of torture and other
cruel, inhuman or degrading treatment or punishment they are aware of.
5. Furthermore, in view of the continued employment of such inhumane procedures
in many countries throughout the world, and the documented incidents of pressure
upon physicians to act in contravention to the ethical principles subscribed to by
the profession, the WMA finds it necessary:
5.1 To protest internationally against any involvement of, or any pressure to
involve, physicians in acts of torture and or other forms of cruel, inhuman or
degrading treatment or punishment;
5.2 To support and protect, and to call upon its constituent members NMAs to
support and protect, physicians who are resisting involvement in such
inhuman procedures or who are documenting and reporting these procedures,
or who are working to treat and rehabilitate victims thereof, as well as to
secure the right to uphold the highest ethical principles including medical
confidentiality;
5.3 To publicize information about and to support physicians reporting evidence
of torture and to make known proven cases of attempts to involve physicians
in such procedures;
5.4 To encourage its constituent members to take action so that physicians are
held accountable before the law in case of complicity in acts of torture and
other cruel, inhuman or degrading treatment or punishment; and
5.5 To encourage its constituent members to ask corresponding academic
authorities to teach and investigate in all schools of medicine and hospitals the
consequences of torture and its treatment, the rehabilitation of the survivors,
the documentation of torture, and the professional protection described in this
Declaration.
Handbook of WMA Policies
World Medical Association ⏐ D-1998-01-2020
WMA DECLARATION OF OTTAWA
ON
CHILD HEALTH
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Science has now proven that to reach their potential, children need to grow up in an
environment where they can thrive – spiritually, emotionally, mentally, physically and
intellectually. That place must be characterized by four fundamental elements:
• A healthy, safe and sustainable physical and emotional environment.
• the opportunity for optimal growth and development;
• adequate health services for healthy child development; and
• monitoring and research for evidence-based continual improvement into the future
Physicians know that the future of our world depends on our children. Early childhood
experiences strongly influence future development, including basic learning, school
success, economic participation, social citizenry, and health. In most situations, parents
and caregivers are only able to provide nurturing environments with help from local,
regional, national and international organizations.
The principles of this Declaration apply to all children in the world from birth to 18 years
of age, regardless of race, age, ethnicity, nationality, political affiliation, creed, language,
gender, sex, disease or disability, physical ability, mental ability, sexual orientation,
cultural history, life experience or the socioeconomic status of the child or her/his parents
or legal guardian. In all countries of the world, regardless of resources, meeting these
principles should be a priority for parents, communities and governments. The United
Nations Convention on the Rights of Children (1989) and National Children’s rights
Charters, set out the broader rights of all children and young people, but those rights
cannot exist without health. Furthermore, the United Nations Sustainable and
Development Goals, especially SDG3, SDG4, SDG5, and SDG6, apply directly to the
health of children and the social determinants of health. Responsibility for giving effect to
the principles herein lies with the government of the region where the child is primarily
domiciled.
All children should be treated with dignity, tolerance and respect and be taught the same.
All children have the right to the highest attainable standard of physical and mental health
Child Health (Ottawa)
Cordoba ⏐ D-1998-01-2020
and wellbeing.
Addressing the social determinants of health is essential to achieving equity in health
and healthcare in children.
While children are generally regarded as the vulnerable groups, the most vulnerable
groups of children include children with special needs, orphans, the homeless, refugees
and asylum seekers, disabled, children from low-income homes and conflict zones. These
groups require special consideration in all areas.
1. A healthy, safe and sustainable physical and emotional environment comprises
the following elements:
• A safe and sustainable physical environment with minimum climate change,
optimum ecosystem free from water, air and soil pollution and degradation;
• Urgent implementation of climate change adaptation and mitigation
strategies, and age-appropriate education on climate change to achieve a better and
more sustainable environment for all children;
• A safe home, a family setting, available parental care and a community that cares;
• Healthy, safe and stable families, homes, schools and communities;
• Protection from bullying and an environment that promotes positive mental
health;
• Protection from discrimination based on age, disease or disability, creed, ethnic
origin, gender, nationality, political affiliation, race, sexual orientation, social
standing or any other factor;
• Access to a safe infrastructure, including safe sanitation, transportation, and places
to play;
• Protection from natural and man-made disasters;
• Protection from physical, sexual, emotional and verbal abuse and neglect;
• Prevention of exploitation in the form of child labour;
• Protection from harmful traditional practices;
• Freedom from witnessing and participating in violence and armed conflict
including forced recruitment as child soldiers or into gangs;
• Protection from the harms associated with alcohol, tobacco and
substance abuse, including the right to age-appropriate information.
All infants should be officially registered within one month of birth or as soon as possible
to enable them to have an official identity, access to health care, social security and any
other resources where identification is mandatory.
Asylum seeking children, whether accompanied or unaccompanied, should not be
detained, separated from the parents and families sent back to a place where they are at
risk of human rights violations.
D-1998-01-2020 ⏐ Cordoba
Child Health (Ottawa)
2. The opportunity for optimal growth and development entails:
• Access to adequate healthy and nutritious food to promote long-term health
development. This includes the promotion of exclusive breastfeeding, where
possible, for the first six months of life as long as the mother and baby are
comfortable, access to adequate safe food that satisfies dietary diversity, and
protection from obesogenic environments through regulation of unhealthy and
processed food and beverages;
• Promotion and encouragement of nutritional literacy, physical activity and physical
education from an early age;
• Access to education from early childhood through secondary education with
provisions for those without access;
• Access to age-appropriate information as it pertains to health, including the
provision of evidence-based comprehensive sexuality education;
• Access to social assistance.
3. Access to the full range or appropriate and high-quality healthcare services for all
stages of childhood development entails:
The best interests of the child shall be the primary consideration in the provision of health
care. The following principles of child health care must be ensured:
• Appropriate preventive, curative, rehabilitative and emergency care for mother and
child;
• Prenatal and maternal care for the best possible health at birth and good postnatal
care to ensure the best possible outcomes for mother and child;
• Respect for the privacy of children;
• Medical care for all children of asylum seekers and refugees;
• Specialized training necessary to enable caregivers to respond appropriately to
the specific medical, physical, emotional and developmental needs of children &
their families;
• Basic health care including developmental assessment, health promotion,
recommended immunization, early detection of disease, access to medicines, oral
and eye-health;
• Multidisciplinary (i.e. consisting of physicians, social workers, psychologists,
therapists, occupational therapists, education specialists and others) and
community-based mental health prevention, care and prompt referral for
intervention when problems are identified;
• Priority access to emergency medical care for life-threatening conditions;
• Hospitalization when appropriate. Hospitals should provide access to parental
facilities and policies for continuous parental care;
• Specialist diagnosis, care and treatment when needed;
Child Health (Ottawa)
Cordoba ⏐ D-1998-01-2020
• Rehabilitation services and supports within the community;
• Pain management and care and prevention (or minimization) of suffering;
• End of life care / Palliative care;
• Informed consent is necessary before initiating any diagnostic, therapeutic,
rehabilitative, or research procedure on a child. In the majority of cases, the
consent shall be obtained from the parent(s) or legal guardian, or, in some cases, by
extended family, although the wishes of a competent child should be taken into
account before consent is given. Where a child lacks competence and is able to
express a view, his/her wishes should still be taken into account before consent is
given. Where appropriate (e.g. reproductive health services), competent children
should be allowed to consent to treatment without parental consent. In case of a
life-threatening, and when competent children cannot give consent and
parents/caregivers are not accessible, for treatment, consent should be presumed
for life-saving treatment;
• The full range of sexual and reproductive health services for adolescents including
access to abortion according to national legislation;
• Respect for the sexual and gender identity of the child. Harmful practices like genital
mutilation or so-called conversion therapies must be forbidden;
• Social assistance and mechanisms to provide for universal access to health care are
ensured for all particularly vulnerable children;
• The homeless, orphaned, asylum seeker, refugees and children from conflict zones
should be provided with essential and emergency medical care without
discrimination.
4. Monitoring & and research for evidence-based continual improvement into the
future includes:
• The principles of the Declaration of Helsinki must be observed in any research study
involving children as research subjects.
Handbook of WMA Policies
World Medical Association D-2000-01-2022
WMA DECLARATION OF EDINBURGH
ON
PRISON CONDITIONS AND THE SPREAD OF COMMUNICABLE
DISEASES
Adopted by the 52nd
WMA General Assembly, Edinburgh, Scotland, October 2000
and revised by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The WMA Declaration of Lisbon on the Rights of the Patient states ‘Every person is entitled
without discrimination to appropriate medical care’.
The Constitution of the World Health Organization states that “The enjoyment of the highest
attainable standard of health is one of the fundamental rights of every human being without
distinction of race, religion, political belief, economic or social condition”.
Persons deprived of liberty (“prisoners”) should receive the same standard of health care as
people outside prisons. They have the same rights as all other people. This includes the right
to humane treatment and appropriate medical care. The standards for the treatment of prisoners
have been set down in a number of United Nations Declarations and Guidelines, in particular
the Standard Minimum Rules for the Treatment of Prisoners – known as the Nelson Mandela
Rules in its 2015 revised version, they are supplemented by the UN Bangkok Rules on
women.
The term “persons deprived of liberty” refers to all regardless of the reason for their detention
as well as of their legal status, from pre-trial detainees to sentenced persons.
It is the responsibility of the states to guarantee the right to life and health of persons
deprived of liberty. This implies caring for them with the aim that prison does not become a
determining factor of communicable disease.
The relationship between physician and persons deprived of liberty is governed by the
same ethical principles as that between the physician and any other patient. However, the
particular prison setting can lead to tensions within the patient/physician relationship as a
result of the physician potentially being subject to pressure from authorities and
seeming to be hierarchically subordinate to his/her employer, the prison service, and of
the general attitude of society towards persons deprived of liberty.
Prison Conditions on TB
Berlin D-2000-01-2022
Beyond the States responsibilities to treat all persons deprived of liberty with respect for their
inherent dignity and value as human beings, there are strong public health reasons for ensuring
the adequate implementation of the Nelson Mandela Rules. The high incidence of tuberculosis
and other communicable diseases amongst prisoners in a number of countries reinforces the
urgent need to consider public health as a critical element when designing new prison regimens,
and for reforming existing penal and prison systems.
Individuals facing imprisonment are often from the most vulnerable sections of society. They
may have had limited access to health care before imprisonment, may suffer worse health
conditions that many other citizens and as a result may have a high risk of entering prison with
undiagnosed, undetected and untreated health problems.
Overcrowding, lengthy confinement within tightly enclosed, poorly lit, badly heated and
consequently poorly ventilated and often humid spaces are all conditions frequently associated
with imprisonment and all of which contribute to the spread of communicable disease and ill-
health. Where these factors are combined with poor hygiene, inadequate nutrition and limited
access to adequate health care, prisons can represent a major public health challenge.
Keeping persons deprived of liberty in conditions that expose them to substantial medical risk,
poses a serious humanitarian challenge. The most effective and efficient way to reduce disease
transmission is to improve the prison environment.
It is the responsibility of states to dedicate sufficient resources to ensure adequate prison
conditions, that prison health care is appropriate in relation to the size and needs of the prison
population, and to define and implement sustainable health strategies to prevent communicable
diseases transmission. The organization of health care in prison requires a suitable team of
health personnel capable of detecting and treating communicable diseases as part of its essential
mission to provide care and treatment to their patients in detention.
The increase in active tuberculosis in prison populations and the development of resistant,
especially “multi-drug” and “extensively-drug” resistant forms of TB, as recognised by the
World Medical Association in its Resolution on Tuberculosis, is reaching very high
prevalence and incidence rates in prisons in some parts of the world. Likewise, the
Covid-19 pandemic has severely impacted prisons with outbreaks reported around the world.
Other conditions, such as hepatitis C and HIV disease, pose transmission risks from blood-
borne spread, exchange of body fluids. Overcrowded prison conditions also promote the
spread of sexually transmitted diseases, while intravenous drug use contributes to the spread
of HIV as well as hepatitis B and C.
RECOMMENDATIONS
Recalling its Declaration of Lisbon on the Rights of the Patient, the World Medical
Association calls on all relevant actors to take the necessary measures to guarantee the
highest attainable standard of health for persons deprived of liberty, in particular:
Handbook of WMA Policies
World Medical Association D-2000-01-2022
Governments, prison and health authorities
1. To protect the rights of persons deprived of liberty according to the various United Nations
instruments relating to conditions of imprisonment, in particular the Nelson Mandela Rules
for the Treatment of Prisoners.
2. To allocate the necessary resources to health care in prisons, proportionate to the number
and needs of the persons deprived of liberty and including adequate funding for health
personnel and appropriate level of staffing of such personnel.
3. To define and implement robust health strategies that ensure a safe and healthy prison
environment, through vaccination, hygiene, surveillance and other measures to prevent
transmission of communicable diseases.
4. To guarantee that persons deprived of liberty with an infectious illness are treated with
dignity and that their rights to health care are respected, in particular that they are not
isolated, or placed in solitary confinement, as a response to their infected status, without
adequate access to health care and the appropriate medical treatment.
5. To ensure that the conditions of detention, at any stage from arrest to sentencing or once
sentenced, do not contribute to the development, worsening or transmission of diseases.
6. To ensure that diagnosis and treatment of non-communicable chronic disease and acute
non-communicable illness and/or injury is reasonably and adequately treated so as to not
cause undue burden on health personnel or increase risk of communicable disease spread
due to prisoners with decompensated illness or injury.
7. To ensure the appropriate planning for and provision of continuing care as essential
elements of prison health care, coordination of health services within and outside prisons
facilitates, including continuity of care and epidemiological monitoring of prisoner patients
when they are released.
8. To ensure that, upon admission to or transfer to a different prison, individuals’ health status
is reviewed within 24 hours of arrival to ensure continuity of care.
9. To avoid disruption of care within the institution, particularly when the prisoner is receiving
opiate substitution treatment by continuing the prescribed treatment.
10. Imprisonment is unacceptable in cases where infection or the risk of transmission is the
cause of deprivation of liberty. Imprisonment is not an effective way to prevent the
transmission of infectious diseases, and further, it is a cause of concealment of the diagnosis
due to fear, leading to greater aggregate dissemination.
11. To respect autonomy and responsibilities of physicians working in prisons who must
observe principles of medical ethics to protect health of persons deprived of liberty.
Prison Conditions on TB
Berlin D-2000-01-2022
12. To conduct independent and transparent investigations to prevent denial of health care to
inmates in prison.
WMA constituent members and the medical profession
13. To work with national and local governments, and health and prison authorities to prioritize
health and health care, including that for mental health issues, in prisons and to adopt
strategies that ensure a safe and healthy prison environment.
14. In accordance with the ethical principles of the medical profession, to encourage physicians
to report and document any deficiency in health care provision, leading to ill-treatments of
persons deprived of liberty.
15. To support and protect physicians encountering difficulties as a result of their attempts to
denounce deficiencies in prison health care provision.
16. To support improving prison conditions and prison systems from a viewpoint of health of
persons deprived of liberty.
Physicians working in prisons
17. To report duly to the health authorities and professional organisations of their country any
deficiency in health care, including that for mental health issues, provided to the persons
deprived of liberty and any situation involving high epidemiological risk.
18. To follow national public health guidelines, where these are ethically appropriate,
particularly concerning the mandatory reporting of infectious and communicable diseases.
Handbook of WMA Policies
World Medical Association ⏐ D-2002-01-2012
WMA DECLARATION OF WASHINGTON
ON
BIOLOGICAL WEAPONS
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and editorialiy revised by the 164th
WMA Council Session, Divonne-les-Bains, France,
May 2003
and reaffirmed by the 191st
WMA Council Session, Prague, Czech Republic, April 2012
A. INTRODUCTION
1. The World Medical Association recognizes the growing threat that biological wea-
pons might be used to cause devastating epidemics that could spread internationally.
All countries are potentially at risk. The release of organisms causing smallpox,
plague, anthrax or other diseases could prove catastrophic in terms of the resulting
illnesses and deaths compounded by the panic such outbreaks would generate. At
the same time, there is a growing potential for production of new microbial agents,
as expertise in biotechnology grows and methods for genetic manipulation of
organisms become simpler. These developments are of special concern to medical
and public health professionals because it is they who best know the potential
human suffering caused by epidemic disease and it is they who will bear primary
responsibility for dealing with the victims of biological weapons. Thus, the World
Medical Association believes that medical associations and all who are concerned
with health care bear a special responsibility to lead in educating the public and
policy makers about the implications of biological weapons and to mobilize uni-
versal support for condemning research, development, or use of such weapons as
morally and ethically unacceptable.
2. Unlike the use of nuclear, chemical, and conventional weapons, the consequences
of a biological attack are likely to be insidious. Their impact might continue with
secondary and tertiary transmission of the agent, weeks or months after the initial
epidemic. The consequences of a successful biological attack, especially if the
infection were readily communicable, could far exceed those of a chemical or even
a nuclear event. Given the ease of travel and increasing globalization, an outbreak
anywhere in the world could be a threat to all nations.
3. A great many severe, acute illnesses occurring over a short span of time would
almost certainly overwhelm the capacities of most health systems in both the
developing and industrialized world. Health services throughout the world are
struggling to meet the demands created by HIV/AIDS and antimicrobial-resistant
organisms, the problems created by civil strife, refugees and crowded, unsanitary
urban environments as well as the increased health needs of aging populations.
Coping over a short period of time with large numbers of desperately ill persons
could overwhelm entire health systems.
Handbook of WMA Policies
World Medical Association ⏐ D-2002-01-2012
4. Actions can be taken to diminish the risk of biological weapons as well as the
potentially harmful consequences of serious epidemics whatever their origin. Inter-
national collaboration is needed to build a universal consensus that condemns the
development, production, or use of biological weapons. Programs of surveillance
are needed in all countries for the early detection, identification, and response to
serious epidemic disease; health education and training is needed for professionals,
civic leaders, and the public alike; and collaborative programs of research are
needed to improve disease diagnosis, prevention, and treatment.
5. The proliferation of technology and scientific progress in biochemistry, biotech-
nology, and the life sciences provides the opportunity to create novel pathogens
and diseases and simplified production methods for bioweapons. The technology is
relatively inexpensive and, because production is similar to that used in biological
facilities such as vaccine manufacturing, it is easy to obtain. Capacity to produce
and effectively disperse biological weapons exists globally, allowing extremists
(acting collectively or individually) to threaten governments and endanger peoples
around the world. Nonproliferation and arms control measures can diminish but
cannot completely eliminate the threat of biological weapons. Thus, there is a need
for the creation of and adherence to a globally accepted ethos that rejects the
development and use of biological weapons.
B. STRENGTHENING PUBLIC HEALTH AND DISEASE SURVEILLANCE SYSTEMS
2.
1. A critical component in dealing with epidemic disease is a strong public health
infrastructure. Investment in public health systems will enhance capacity to detect
and to contain expeditiously, rare or unusual disease outbreaks, whether deli-
berately induced or naturally occurring. Core public health functions (disease sur-
veillance and supporting laboratory services) are needed as a foundation for detec-
tion, investigation, and response to all epidemic threats. A more effective global
surveillance program will improve response to naturally occurring infectious dis-
eases and will permit earlier detection and characterization of new or emerging
diseases.
2. It is especially important that physicians be alert to the occurrence of cases or
clusters of unusual infectious diseases, to seek help from infectious disease
specialists in diagnosis, and to report cases promptly to public health authorities.
Because any physician may see only one or a few cases and may not recognize that
an outbreak is occurring, cooperation between primary care physicians and public
health authorities is especially important.
3. Public health officials, dealing with an epidemic, will require the cooperation of
emergency management agencies, law enforcement officials, healthcare facilities,
and a variety of community service organizations. For these different groups to work
together effectively, advance planning will be important. In addition to developing
surveillance activities for early detection and reporting, public health efforts should
be directed toward educating primary caregivers and public health staff about
potential agents that might be used, building laboratory capacity for rapid identifi-
cation of biological agents, providing medical and hospital services as well as
vaccines and drugs to control the epidemic.
D-2002-01-2012 ⏐ Prague
Biological Weapons (Washington)
4. C. ENHANCEMENT OF MEDICAL PREPAREDNESS AND RESPONSE CAPACITY
a.
1. The first indication that a biological weapon may have been disseminated is likely
to be the appearance of patients in the offices of practicing physicians, especially
those in acute care settings. Physicians thus play a critical role in early detection of
an outbreak and must be prepared to recognize and deal with diseases resulting
from the use of biological weapons as well as other infectious disease agents and to
promptly report suspicious illnesses and diseases to public health officials.
2. In the course of an epidemic, physicians will be directly involved with mass patient
care, with mass immunization and antibiotic prophylaxis, with providing informa-
tion to the public, and in a variety of hospital and community efforts to control the
epidemic. Thus, physicians should participate with local and national health
authorities to develop and implement disaster preparedness and response plans for
intentional and natural infectious disease outbreaks.
5. D. BIOWEAPONS RESEARCH AND MEDICAL ETHICS
a.
1. Rapid advances in microbiology, molecular biology, and genetic engineering have
created extraordinary opportunities for biomedical research and hold great promise
for improving human health and the quality of life. Better and more rapid diag-
nostic tools, novel vaccines, and therapeutic drugs can be foreseen. At the same
time, there is concern about the possible misuse of research for the development of
more potent biological weapons and the spread of new infectious diseases. It may
be difficult to distinguish legitimate biomedical research from research by un-
scrupulous scientists with the malign purpose of producing more effective biologi-
cal weapons.
2. All who participate in biomedical research have a moral and ethical obligation to
consider the implications of possible malicious use of their findings. Through
deliberate or inadvertent means, genetic modification of microorganisms could
create organisms that are more virulent, are antibiotic-resistant, or have greater
stability in the environment. Genetic modification of microorganisms could alter
their immunogenicity, allowing them to evade natural- and vaccine-induced im-
munity. Advances in genetic engineering and gene therapy may allow modification
of the immune response system of the target population to increase or decrease
susceptibility to a pathogen or disrupt the functioning of normal host genes.
3. Research specifically for the purposes of creating biological weapons is to be
condemned. As scientists and humanitarians, physicians have a societal respon-
sibility to decry scientific research for the development and use of biological wea-
pons and to express abhorrence for the use of biotechnology and information
technologies for potentially harmful purposes.
4. Physicians and medical organizations have important societal roles in demanding a
global prohibition on biological weapons and stigmatizing their use, guarding
against unethical and illicit research, and mitigating civilian harm from use of
biological weapons.
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6. E. RECOMMENDATIONS
a.
1. That the World Medical Association and National Medical Associations world-
wide take an active role in promoting an international ethos condemning the
development, production, or use of toxins and biological agents that have no justi-
fication for prophylactic, protective, or other peaceful purposes.
2. That the World Medical Association, National Medical Associations and health-
care workers worldwide promote, with the World Health Organization, the United
Nations, and other appropriate entities, the establishment of an international con-
sortium of medical and public health leaders to monitor the threat of biological
weapons, to identify actions likely to prevent bioweapons proliferation, and to
develop a coordinated plan for monitoring the worldwide emergence of infectious
diseases. This plan should address: (a) international monitoring and reporting sys-
tems so as to enhance the surveillance and control of infectious disease outbreaks
throughout the world; (b) the development of an effective verification protocol
under the UN Biological and Toxin Weapons Convention; (c) education of physi-
cians and public health workers about emerging infectious diseases and potential
biological weapons; (d) laboratory capacity to identify biological pathogens; (e)
availability of appropriate vaccines and pharmaceuticals; and (f) financial, tech-
nical, and research needs to reduce the risk of use of biological weapons and other
major infectious disease threats.
3. That the World Medical Association urge physicians to be alert to the occurrence
of unexplained illnesses and deaths in the community and knowledgeable of
disease surveillance and control capabilities for responding to unusual clusters of
diseases, symptoms, or presentations.
4. That the World Medical Association encourage physicians, National Medical
Associations and other medical societies to participate with local, national, and
international health authorities in developing and implementing disaster prepared-
ness and response protocols for acts of bioterrorism and natural infectious disease
outbreaks. These protocols should be used as the basis for physician and public
education.
5. That the World Medical Association urge all who participate in biomedical
research to consider the implications and possible applications of their work and to
weigh carefully in the balance the pursuit of scientific knowledge with their ethical
responsibilities to society.
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WMA DECLARATION
ON
ETHICAL CONSIDERATIONS REGARDING HEALTH DATABASES AND
BIOBANKS
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
1. The Declaration of Helsinki lays down ethical principles for medical research involving
human subjects, including the importance of protecting the dignity, autonomy, privacy
and confidentiality of research subjects, and obtaining informed consent for using
identifiable human biological material and data.
2. In health care provision, health information is gathered by physicians or other members
of the medical team to record health care events and to aid physicians in the on-going
care of their patient.
3. This Declaration is intended to cover the collection, storage and use of identifiable data
and biological material beyond the individual care of patients. In concordance with the
Declaration of Helsinki, it provides additional ethical principles for their use in Health
Databases and Biobanks.
This Declaration should be read as a whole and each of its constituent paragraphs should
be applied with consideration of all other relevant paragraphs.
4. A Health Database is a system for collecting, organising and storing health information.
A Biobank is a collection of biological material and associated data. Biological material
refers to a sample obtained from an individual human being, living or deceased, which
can provide biological information, including genetic information, about that individual.
Health Databases and Biobanks are both collections on individuals and population, and
both give rise to the similar concerns about dignity, autonomy, privacy, confidentiality
and discrimination.
5. Research using Health Databases and Biobanks can often significantly accelerate the
improvement in the understanding of health, diseases, and the effectiveness, efficiency,
safety and quality of preventive, diagnostic and therapeutic interventions. Health
research represents a common good that is in the interest of individual patients, as well
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as the population and the society.
6. Physicians must consider the ethical, legal and regulatory norms and standards for
Health Database and Biobanks in their own countries as well as applicable international
norms and standards. No national or international ethical, legal or regulatory
requirement should reduce or eliminate any of the protections for individuals and
population set forth in this Declaration.
When authorized by a national law adopted through a democratic process in respect of
human rights, other procedures could be adopted to protect the dignity, autonomy and
privacy of the individuals. Such procedures are only acceptable when strict rules on data
protection are implemented.
7. Consistent with the mandate of WMA, the Declaration is addressed primarily to
physicians. The WMA encourages others who are involved in using data or biological
material in Health Databases and Biobanks to adopt these principles.
ETHICAL PRINCIPLES
8. Research and other Health Databases and Biobanks related activities should contribute
to the benefit of society, in particular public health objectives.
9. Respecting the dignity, autonomy, privacy and confidentiality of individuals, physicians
have specific obligations, both ethical and legal, as stewards protecting information
provided by their patients. The rights to autonomy, privacy and confidentiality also
entitle individuals to exercise control over the use of their personal data and biological
material.
10. Confidentiality is essential for maintaining trust and integrity in Health Databases and
Biobanks. Knowing that their privacy will be respected gives patients and donors the
confidence to share sensitive personal data. Their privacy is protected by the duty of
confidentiality of all who are involved in handling data and biological material.
11. The collection, storage and use of data and biological material from individuals capable
of giving consent must be voluntary. If the data and biological material are collected for
a given research project, the specific, free and informed consent of the participants must
be obtained in accordance with the Declaration of Helsinki.
12. If the data or biological material are collected and stored in a Health Database or a
Biobank for multiple and indefinite uses, consent is only valid if the concerned
individuals have been adequately informed about:
• The purpose of the Health Database or Biobank;
• The risks and burdens associated with collection, storage and use of data and
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Health Databases and Biobanks
material;
• The nature of the data or material to be collected;
• The procedures for return of results including incidental findings;
• The rules of access to the Health Database or Biobank;
• How privacy is protected;
• The governance arrangements as stipulated in paragraph 21;
• That in case the data and material are made non-identifiable the individual may
not be able to know what is done with their data/material and that they will not
have the option of withdrawing their consent;
• Their fundamental rights and safeguards established in this Declaration; and
• When applicable, commercial use and benefit sharing, intellectual property
issues and the transfer of data or material to other institutions or third countries.
13. In addition to the requirements set forth in the Declaration of Helsinki, when persons
who were not able to consent, whose data and biological materials have been stored for
future research, attain or regain the capacity to consent, reasonable efforts should be
made to seek the consent of those persons for continued storage and research use of their
data and biological materials.
14. Individuals have the right to request for and be provided with information about their
data and its use as well as to request corrections of mistakes or omissions. Health
Databases and Biobanks should adopt adequate measures to inform the concerned
individuals about their activities.
15. Individuals have the right, at any time and without reprisal, to alter their consent or to
ask for their identifiable data to be withdrawn from the Health Database and their
biological material to be withdrawn from a Biobank. This applies to future use of the
data and biological materials.
16. In the event of a clearly identified, serious and immediate threat where anonymous data
will not suffice, the requirements for consent may be waived to protect the health of the
population. An independent ethics committee should confirm that each exceptional case
is justifiable.
17. The interests and rights of the communities concerned, in particular when vulnerable,
must be protected, especially in terms of benefit sharing.
18. Special considerations should be given to the possible exploitation of intellectual
property. Protections for ownership of materials, rights and privileges must be
considered and contractually defined before collecting and sharing the material.
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Intellectual property issues should be addressed in a policy, which covers the rights of all
stakeholders and communicated in a transparent manner.
19. An independent ethics committee must approve the establishment of Health Databases
and Biobanks used for research and other purposes. In addition the ethics committee
must approve use of data and biological material and check whether the consent given at
the time of collection is sufficient for the planned use or if other measures have to be
taken to protect the donor. The committee must have the right to monitor on-going
activities. Other ethical review mechanisms that are in accordance to par 6 can be
established.
GOVERNANCE
20. In order to foster trustworthiness, Health Databases and Biobanks must be governed by
internal and external mechanisms based on the following principles:
• Protection of individuals: Governance should be designed so the rights of
individuals prevail over the interests of other stakeholders and science;
• Transparency: any relevant information on Health Databases and Biobanks must
be made available to the public;
• Participation and inclusion: Custodians of Health Databases and Biobanks must
consult and engage with individuals and their communities.
• Accountability: Custodians of Health Databases and Biobanks must be accessible
and responsive to all stakeholders.
21. Governance arrangements must include the following elements:
• The purpose of the Health Database or Biobank;
• The nature of health data and biological material that will be contained in the
Health Database or Biobank;
• Arrangements for the length of time for which the data or material will be stored;
• Arrangements for regulations of the disposal and destruction of data or material;
• Arrangement for how the data and material will be documented and traceable in
accordance with the consent of the concerned persons;
• Arrangement for how the data and material will be dealt with in the event of
change of ownership or closure;
• Arrangement for obtaining appropriate consent or other legal basis for data or
material collection;
• Arrangements for protecting dignity, autonomy, privacy and preventing
discrimination;
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Health Databases and Biobanks
• Criteria and procedures concerning the access to and the sharing of the health
data or biological material including the systematic use of Material Transfer
Agreement (MTA) when necessary;
• The person or persons who are responsible for the governance;
• The security measures to prevent unauthorized access or inappropriate sharing;
• The procedures for re-contacting participants where relevant;
• The procedures for receiving and addressing enquiries and complaints.
22. Those professionals contributing to or working with Health Databases and Biobanks
must comply with the appropriate governance arrangements.
23. Health Databases and Biobanks must be operated under the responsibility of an
appropriately qualified professional assuring compliance with this Declaration.
24. The WMA urges relevant authorities to formulate policies and law that protect health
data and biological material on the basis of the principles set forth in this document.
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WMA DECLARATION
ON
PATIENT SAFETY
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 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Physicians strive to provide safe, high-quality health and medical care to patients.
Progress in medical and allied science and technology has transformed how modern medicine
is delivered in advanced and complex health systems.
Inherent risks always exist in clinical medicine. Developments in modern medicine often
reduce risk but may also introduce new or increased risks – some avoidable, others inherent.
Physicians and healthcare organisations should attempt to foresee these risks and manage them
to the best of their ability.
Many health services continue to struggle with demand exceeding capacity, often with an
inadequate infrastructure due to underinvestment by governments or other providers of
healthcare. Patient safety is at risk where physicians work in systems under pressure.
Patient safety is affected by the working culture that physicians operate within. In many
healthcare systems there is often a culture of blame, where individuals are targeted rather than
examining wider organisational causes of error (such as resource constraints, workforce
shortages, or systemic failures).
Many physicians fear being unfairly blamed for medical errors which may have been caused
or exacerbated by systemic factors, and often feel unable to be open or raise concerns.
A workplace culture of learning assures and improves patient safety. Embedding a just and
learning culture approach can be an antidote to cultures of blame and fear.
In a just and learning culture, the initial focus is on what went wrong when patient safety
incidents took place, rather than seeking to determine who may individually be responsible.
Patient Safety
Berlin D-2002-03-2022
Medical regulation and a fear of litigation can compromise physicians’ ability to be open about
medical error. A system where physicians feel unable to speak up, due to fear of personal
recrimination, will compromise the identification of systemic causes of error or poor care and
imped measures to improve patient safety.
Working in a system under pressure that has a culture of fear and blame can erode physician
wellbeing. Physicians’ performance in stressful working environments may be impaired,
potentially leading to error or poor patient outcomes.
Improving physician wellbeing significantly improves productivity, care quality, patient safety
and the sustainability of health services.
Positive cultures within workplaces are vital to minimize medical error, improve physician
wellbeing and assure patient safety.
Principles
1. Physicians must ensure that patient safety is always considered during their medical
decision-making.
2. Individuals and processes are rarely solely responsible for errors. Rather, separate elements
combine and together produce a high-risk situation. Therefore, there should be a non-
punitive culture for confidential reporting healthcare errors that focuses on preventing and
correcting systems failures and not on individual or organization culpability.
3. A realistic understanding of the risks inherent in modern medicine requires physicians to
cooperate with all relevant parties, including patients, to adopt a proactive systems
approach to patient safety.
4. To create such an approach, physicians must continuously absorb a wide range of advanced
scientific knowledge and continuously strive to improve medical practice.
5. All information that concerns a patient’s safety must be shared with the patient and all
relevant parties. However, patient confidentiality must be strictly protected.
6. When medical error or a patient safety incident occurs, investigations should always begin
by fully reviewing the wider environment that the physician operates within to identify
systemic factors and pressures that may have contributed to the error.
7. Where medical error is found to have been caused fully or partly by systemic factors, any
judgement by the regulator(s) should also hold the healthcare providing organisation to
account.
8. Regulators of healthcare providing organisations must promote and ensure positive, just,
and learning workplace cultures, where physicians and patients feel supported and
empowered to learn when adverse events occur.
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9. Regulators have a responsibility to identify systemic and contextual constraints that impact
on patient safety, including a lack of resources and infrastructure.
RECOMMENDATIONS
Recognizing the importance of system pressures, workplace culture, physician wellbeing, and
healthcare regulation on patient safety, the WMA recommends that its Constituent members:
1. promote policies on patient safety to all physicians in their countries;
2. encourage individual physicians, other health care professionals, patients and other relevant
individuals and organizations to work together to establish systems that secure patient
safety;
3. encourage the development of effective models to promote patient safety through
continuing medical education/continuing professional development;
4. cooperate with one another and exchange information about adverse events, including
errors, their solutions, and “lessons learned” to improve patient safety;
5. demand that the investigation of medical error and patient safety incidents always consider
wider contextual and systemic factors or pressures;
6. demand that healthcare providing organisations foster a culture of learning, support and
improvement that facilitates patient safety;
7. work to ensure that the regulation of the medical profession encourages and supports patient
safety;
8. support regulation that works to prevent medical error, promoting good practice and
learning among individuals and organisations providing healthcare;
9. work to ensure healthcare environments have the necessary resources, infrastructure, and
workforce to support patient safety.
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WMA DECLARATION
ON
MEDICAL ETHICS AND ADVANCED MEDICAL TECHNOLOGY
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
It is essential to balance the benefits and risks for persons inherent in the development and
application of advanced medical technology. Maintaining this balance is entrusted to the
judgment of the physician.
Therefore:
Medical technology should be used to promote health. Patient safety should be fully
considered by the physician in the development and application of medical technology.
In order to foster physicians’ ability to provide appropriate medical care and having
sufficient knowledge of medical technology efforts must be made to ensure the provision
of comprehensive medical education focusing on the safe and effective use and develop-
ment of medical technology.
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WMA DECLARATION
ON
THE RELATION OF LAW AND ETHICS
Adopted by the 164th
WMA Council Session, Divonne-les-Bains, France, May 2003
and adopted as a Declaration by the 70th
WMA General Assembly, Tbilisi, Georgia,
October 2019
Ethical Values and legal principles are usually closely related, but ethical obligations
typically exceed legal duties. In some cases, the law mandates unethical conduct. The fact
that a physician has complied with the law does not necessarily mean that the physician
acted ethically.
When law is in conflict with medical ethics, physicians should work to change the law. In
circumstances of such conflict, ethical responsibilities supersede legal obligations.
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WMA DECLARATION OF REYKJAVIK
– ETHICAL CONSIDERATIONS REGARDING
THE USE OF GENETICS IN HEALTH CARE
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
Genetics contributes to the growing understanding of the causes, developments,
classifications and treatments of diseases. The use of genetics is increasing, moving from
the identification of monogenic diseases and use in cancer treatment towards predicting
risks of multifactorial diseases and manipulation of individual genes. In these ways, the
use of genetics does and increasingly will create great value at an individual as well as at a
societal level. However, the use of genetic information about individuals also raises issues
concerning confidentiality, privacy and the risk of psychological distress, stigmatization,
and discrimination.
This declaration provides recommendations for the use of medical genetics that respects
the ethical challenges that such use entails. It is primarily aimed at the use of genetics in
the provision of health care. The collection, storage and use of genetic data beyond the
individual care of patients should adhere to the principles put forward in the WMA
Declaration of Taipei on Ethical Considerations regarding Health Databases and
Biobanks. The use of genetics in medical research involving human subjects, including
research on identifiable human material and data, should adhere to the principles put
forward in the WMA Declaration of Helsinki Ethical Principles for Medical Research
Involving Human Subjects.
This Declaration should be read as a whole and each of its constituent paragraphs should
be applied with consideration of all other relevant paragraphs. The declaration should be
updated in accordance with developments in the field of genetics.
Genetic information has characteristics that are ethically significant. Individually, these
characteristics can also be found in other types of health care information. However, the
combination of these characteristics makes genetic information particularly sensitive. This
sensitivity – combined with the intense interest in genetic information from many different
stakeholders – underscores the importance of respecting the fundamental principles of
medical ethics, particularly the patient’s right to autonomy, confidentiality, privacy and
benefit in relation to generating, storing, using or sharing genetic information.
Central among the ethically significant characteristics are:
• Genetic information is identifying for an individual.
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• Genetic analysis can generate extensive and detailed information about an
individual.
• Genetic analysis may generate additional findings.
• The full significance of the information generated by genetic analysis is not yet
known.
• Genetic information about an individual cannot be fully anonymized, and de-
identified genetic information may be re-identified.
• Genetic data contains information not only about the individual who has
undergone testing, but also about individuals who are genetically related to the
tested individual.
• Genetic testing of one individual may entail that the physician asks for access to
health care information about – or genetic testing of – genetically related persons
(family members).
ETHICAL PRINCIPLES
1. Benefit
Genetic testing in the context of healthcare provision should primarily be done for the
benefit of the patient being tested.
2. Relevance
Genetics test should not be wider in scope than what is relevant for the purpose of the test.
3. Informed consent
a. Genetic testing should only be done with the informed consent of the individual or
his/her legal guardian. Genetic testing for predisposition to disease should be
performed on children only if there are clear clinical indications and being aware of
the test results would be in the best interests of the child.
b. The consent process must include providing the patient with understandable, accurate
and adequate information about the following:
• The purpose, nature and benefits of the test.
• The risks, burdens and limitations of the test.
• The nature and significance of the information to be generated by the test.
• The procedures for return of results including additional findings and future
discoveries.
• The options for responding to the results, including possible treatments.
• How, where, and for how long the test results, data and biological samples will be
stored, and who can gain access to current and future results.
• The possible secondary uses of the information generated by the test
• The measures protecting confidentiality, privacy and autonomy, including data
security measures
• The procedures for managing results that have implications for genetically related
persons
• When applicable, commercial use and benefit sharing, intellectual property issues
and the transfer of data or material to third parties.
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Ethical considerations regarding the use of genetics in health care
4. Additional findings (secondary and incidental findings)
a. A genetic test may generate additional findings that are not related to the primary
purpose of the test, also referred to as secondary or incidental findings. Procedures for
handling such findings should be determined before the test, and information about
these procedures should be communicated to the patient as part of the consent process.
b. The principles for managing additional findings must include consideration for:
• The patient’s preferences regarding the management of additional findings.
• The significance of the additional findings for the patient’s health and other
interests.
• The significance of the findings for the health and other interests of persons who
are genetically related to the patient.
• The scientific validity of the additional findings.
• The strengths of the evidence for the correlation between the additional findings
and health related risks for the patient.
• The degree to which the additional findings are actionable, medically or otherwise.
5. Genetic counselling
a. Appropriate genetic counselling should always be offered when genetic tests or
genetics-based treatments are offered or performed and for the interpretation of results.
Counselling should enable the patient to make informed decisions according to their
own values and interests. Counselling must not be biased by the personal values of the
counsellor. The individual’s right not to be tested should be protected, and if the
individual has been tested, there should be no obligation for the individual to act on
the results of the test.
b. Medical students and physicians should receive education and training in genetic
counselling, particularly counselling related to pre-symptomatic diagnosis of disease.
6. Confidentiality
Like all medical records, information from genetic testing or genetic therapy must be kept
strictly confidential and must not be revealed to third parties in identifiable form without
the consent of the individual tested. Third parties, to whom results may in certain
circumstances be released, are identified in paragraph 15.
7. Informing third parties
In the case of a test result that may have implications for third parties such as close
relatives, the individual tested should be encouraged to discuss the results of the test with
such third parties. In cases where not disclosing the results involves an expected harm that
is serious and unavoidable except by disclosure, and clearly greater than the harm likely to
result from disclosure, the physician may reveal necessary information to such third
parties without the consent of the patient but should usually discuss this with the patient
first. If the physician has access to an ethics committee, it is preferable to consult such a
committee prior to revealing information to third parties.
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8. Data protection
The collection, storage and use of genetic data requires the highest level of data protection.
9. Discrimination
No individual or group must be discriminated against in any way based on genetic
makeup, including the fields of human rights, employment and insurance. This protection
should apply to those individuals who have undergone genetic testing or genetic therapy
as well as those individuals about whom genetic information can be inferred. Particular
care should be taken to protect vulnerable individuals and groups.
10. Cost of testing
The decision to include genetic analysis as part of medical care can introduce significant
cost for the patient and the health care system. Therefore, such a decision should always
be based on the expectation that the costs of the analysis are justified by the benefits for
the patient.
11. Reliability and limitations
a. The identification of disease-related genes has led to an increase in the number of
available genetic tests, analyses and treatments. As the number, types and complexity
of these increase, great care must be taken to ensure their reliability, accuracy and
quality and to inform patients about their limitations.
b. The benefit of a genetic test for an individual may depend on the availability of
information about the relevant background population. Medical professionals should
be aware of the scope and the limitations of genetic background data and health
information stored in databases used in providing clinical genetic testing services.
12. Direct-to-consumer tests
If genetic tests are offered directly to consumers for medical purposes, they must meet the
same technical, professional, legal and ethical standards as tests offered by certified
laboratories and must be in accordance with the recommendations put forward in this
statement. In particular, providers of direct-to-consumer tests must provide
understandable, accurate and adequate information about the reliability and limitations of
their services.
13. Clinical use of data from research
For research projects that involve genetic testing, and where the participant can be
identified, the research participant must be informed about the possibility of findings that
indicate a serious threat to the health of the participant. If there are such findings, the
participant should be offered a referral to genetic counseling and appropriate medical
intervention.
14. Gene therapy and editing
Gene therapy and editing represents a combination of techniques used to manipulate
disease related genes. The use of these techniques should adhere to the following
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Ethical considerations regarding the use of genetics in health care
guidelines:
The use of gene therapy and somatic genome editing should conform to standards of
medical ethics and professional responsibility.
Patient autonomy should be respected, and informed consent should always be obtained.
This informed consent process should include disclosure of the risks of gene therapy and
editing, including the fact that the patient may have to undergo multiple rounds of gene
therapy, the risk of an immune response, the potential problems arising from the use of
viral vectors and off-target genome effects.
Gene therapy and editing should only be undertaken after a careful analysis of the risks
and benefits involved and an evaluation of the perceived effectiveness of the therapy, as
compared to the risks, side effects, availability and effectiveness of other treatments.
Gene editing of germline cells has scientifically unresolved risks and should not be
clinically applied. This does not preclude testing gene editing or other similar research.
15. Cloning
Cloning includes both therapeutic cloning, namely the cloning of individual stem cells to
produce a healthy copy of a diseased tissue or organ for transplant, and reproductive
cloning, namely the cloning of an existing human to produce a genetic duplicate of that
human. The WMA opposes reproductive cloning of humans.
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D-2008-01-2018 ⏐ World Medical Association
WMA DECLARATION
OF SEOUL ON
PROFESSIONAL AUTONOMY
AND CLINICAL INDEPENDENCE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
And amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
The WMA reaffirms the Declaration of Madrid on professionally-led regulation.
The World Medical Association recognises the essential nature of professional autonomy
and physician clinical independence, and states that:
1. Professional autonomy and clinical independence are essential elements in
providing quality health care to all patients and populations. Professional
autonomy and independence are essential for the delivery of high-quality health
care and therefore benefit patients and society.
2. Professional autonomy and clinical independence describe the processes under
which individual physicians have the freedom to exercise their professional
judgment in the care and treatment of their patients without undue or inappropriate
influence by outside parties or individuals.
3. Medicine is highly complex. Through lengthy training and experience, physicians
become medical experts weighing evidence to formulate advice to patients.
Whereas patients have the right to self-determination, deciding within certain
constraints which medical interventions they will undergo, they expect their
physicians to be free to make clinically appropriate recommendations.
4. Physicians recognize that they must take into account the structure of the health
system and available resources when making treatment decisions. Unreasonable
restraints on clinical independence imposed by governments and administrators are
not in the best interests of patients because they may not be evidence based and
risk undermining trust which is an essential component of the patient-physician
relationship.
5. Professional autonomy is limited by adherence to professional rules, standards and
the evidence base.
6. Priority setting and limitations on health care coverage are essential due to limited
resources. Governments, health care funders (third party payers), administrators
and Managed Care organisations may interfere with clinical autonomy by seeking
to impose rules and limitations. These may not reflect evidence-based medicine
principles, cost-effectiveness and the best interest of patients. Economic evaluation
studies may be undertaken from a funder’s not a users’ perspective and emphasise
cost-savings rather than health outcomes.
7. Priority setting, funding decision making and resource allocation/limitations
Professional Autonomy and Clinical Independence
World Medical Association ⏐ D-2008-01-2018
processes are frequently not transparent. A lack of transparency further perpetuates
health inequities.
8. Some hospital administrators and third-party payers consider physician
professional autonomy to be incompatible with prudent management of health care
costs. Professional autonomy allows physicians to help patients make informed
choices, and supports physicians if they refuse demands by patients and family
members for access to inappropriate treatments and services.
9. Care is given by teams of health care professionals, usually led by physicians. No
member of the care team should interfere with the professional autonomy and
clinical independence of the physician who assumes the ultimate responsibility for
the care of the patient. In situations where another team member has clinical
concerns about the proposed course of treatment, a mechanism to voice those
concerns without fear of reprisal should exist.
10. The delivery of health care by physicians is governed by ethical rules, professional
norms and by applicable law. Physicians contribute to the development of
normative standards, recognizing that this both regulates their work as
professionals and provides assurance to the public.
11. Ethics committees, credentials committees and other forms of peer review have
long been established, recognised and accepted by organised medicine as ways of
scrutinizing physicians’ professional conduct and, where appropriate, may impose
reasonable restrictions on the absolute professional freedom of physicians.
12. The World Medical Association reaffirms that professional autonomy and clinical
independence are essential components of high-quality medical care and the
patient-physician relationship that must be preserved. The WMA also affirms that
professional autonomy and clinical independence are core elements of medical
professionalism.
Handbook of WMA Policies
World Medical Association ⏐ D-2009-01-2017
WMA DECLARATION OF DELHI
ON
HEALTH AND CLIMATE CHANGE
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Human influence on the climate system is clear, and recent emissions of green-
house gases are the highest in history. Recent climate changes have had
widespread impacts on human and natural systems.
2. Compelling evidence substantiates the numerous health risks posed by climate
change, which threaten all countries. These include more frequent and potentially
more severe heatwaves, droughts, floods and other extreme weather events
including storms and bushfires. Climate change, especially warming, is already
leading to changes in the environment in which disease vectors flourish. There is
reduced availability and quality of potable water, and worsening food insecurity
leading to malnutrition and population displacement. Climate Change is universal
but its effects are uneven and many of the areas most affected are least able to
manage the challenges it poses.
3. Tackling climate change offers opportunities to improve health and wellbeing both
because of the health co-benefits of low carbon solutions and because mitigation
and adaptation may allow action on all the social determinants of health.
Transition to renewable energy, the use of active transport, and dietary change
including a reduction in consumption of beef and other animal products, may all
contribute to improving health and wellbeing.
4. The social determinants of health are those factors that correlate to health through
exposure before and after people are born and as they grow live, and work. They
vary between and within countries. Those with generally the poorest health and
lowest life and health expectancy will be least able to adapt to the adverse effects
of climate change thereby exacerbating adverse social determinants of health.
5. Climate change research and surveillance are important. The WMA supports
studies that describe the patterns of disease attributed to climate change, including
the impacts of climate change on communities and households; the burden of
known and emergent disease caused by climate change, and those diseases
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World Medical Association ⏐ D-2009-01-2017
projected to occur with new development activities (Health Impacts Assessment).
Such studies should also define the most vulnerable populations.
6. The Paris Agreement highlights a transition to a new model of global collaboration
to address climate change and is an opportunity for the health sector to contribute
to climate action. It includes a series of actions to be undertaken by each party to
achieve a long-term goal of keeping the increase in global average temperature to
less than 1.5 C above pre-industrial levels. Whether or not individual states are
parties to the Paris agreement, NMAs have an obligation to consider the effects of
climate change on the planet and on human, animal, and environmental
sustainability and to take action as follows.
RECOMMENDATIONS
7. The World Medical Association and its Constituent Members:
• Urge national governments and non-state actors to recognize the serious health
consequences of climate change and to adopt strategies to adapt to and mitigate
its effects;
• Urge national governments to ensure the fulfilment of national commitments to
international agreements, including both mitigation and adaptation measures as
well as action on losses and damage;
• Urge national governments to provide climate financing that includes
designated funds to support the strengthening of health systems, and health and
climate co-benefit policies and, provide sufficient global, regional and local
financing for climate mitigation, adaptation measures, disaster risk reduction,
and the attainment of the Sustainable Development Goals (SDGs);
• Urge national governments to facilitate the active participation of health sector
representatives in the creation and implementation of climate change
preparedness plans and emergency planning and response on local, national
and international levels;
• Urge national governments to provide for the health and wellbeing of people
displaced by environmental causes including those becoming refugees due to
the consequences of climate change;
• Asks national governments to invest in public health and climate change
research to ensure of better understanding of adaptation needs and health co-
benefits at the national level;
• Urge national governments to facilitate collaboration between the Ministry of
Health and other ministries to ensure that health is considered in their national
commitments and sustainable strategies.
D-2009-01-2017 ⏐ Chicago
Climate Change
8. National Medical Associations and their physician members should:
• Advocate for sustainable, environmentally responsible low-carbon practices
across the health sector to reduce the environmental impact of health care
facilities and practices;
• Prepare for the infrastructure disruptions that accompany health emergencies,
in particular by planning in advance for the delivery of services and increased
patient care demands during these crisis situations;
• Encourage and support advocacy for environmental protection and greenhouse
gas emissions reductions including through emissions trading systems and/or
carbon taxes;
• Become educated as to the health effects of climate change and be prepared to
treat and manage them in individual patients;
• Promote medical research into improved use of antibiotherapy to be able to
respond, in the future, to the new infectious diseases linked to climate change.
9. The WMA and its Constituent Members should:
• Encourage sustainable low-carbon living respectful of planetary limits
including active lifestyle and sustainable production and consumption patterns;
• Seek to build professional and public awareness of the importance of the
environment and climate change to personal, community and societal health;
• Work towards the integration of key climate change concepts and
competencies in undergraduate, graduate and continuing medical education
curricula;
• Collaborate with the WHO and other stakeholders as appropriate, to produce
educational and advocacy materials on climate change for national medical
associations, physicians, other health professionals, as well as the general
public;
• Advocate for their respective governments to finance, promote research into
the effects of climate change on health and collaborate with NGOs and other
health professionals;
• Work collaboratively with government, NGOs, businesses, civil societies and
others to create alert systems to ensure that health care systems and physicians
are aware of climate-related events as they unfold, and receive timely accurate
information regarding the management of emerging health events;
• Have climate change as a priority issue on their agendas and actively
participate in the creation of policies and initiatives that mitigate the effects of
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World Medical Association ⏐ D-2009-01-2017
climate change on health.
10. The WMA urges National Medical Associations to:
• Work with health-care institutions, and individual physicians to adopt climate
policies and act as role models by reducing their carbon emissions;
• Recognize environmental factors as a key social determinants of health (SDH),
and encourage governments to foster collaboration between the health and non-
health sectors in addressing these determinants.
Handbook of WMA Policies
D-2009-02-2019 ⏐ World Medical Association
WMA DECLARATION OF MADRID
ON
PROFESSIONALLY-LED REGULATION
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and revised by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
The WMA reaffirms the Declaration of Seoul on professional autonomy and clinical
independence of physicians.
The medical profession must play a central role in regulating the conduct and professional
activities of its members, ensuring that their professional practice is in the best interests of
citizens.
The regulation of the medical profession plays an essential role in ensuring and
maintaining public confidence in the standards of care and of behaviour that they can
expect from medical professionals. That regulation requires very strong independent
professional involvement.
Physicians aspire to the development or maintenance of systems of regulation that will
best protect the highest possible standards of care for all patients. Professionally led
models can provide an environment that enhances and assures the individual physician’s
right to treat patients without interference, based on his or her best clinical judgment.
Therefore, the WMA urges its constituent members and all physicians to work with
regulatory bodies and take appropriate actions to ensure effective systems are in place.
These actions should be informed by the following principles:
1. Physicians are accorded a high degree of professional autonomy and clinical
independence, whereby they are able to make recommendations based on their
knowledge and experience, clinical evidence and their holistic understanding of the
patient including his/her best interests without undue or inappropriate outside
influence. This is expounded in more detail in the Declaration of Seoul.
2. The regulation of the profession must be proportionate and facilitative and not be
burdensome, and be based on a model that applies to every physician equally and that
protects and benefits patients and is based upon an ethical code. The planning and
delivery of all types of health care is based upon an ethical model and current
evidence-based medical knowledge by which all physicians are governed. This is a
core element of professionalism and protects patients. Physicians are best qualified to
judge the actions of their peers against such normative standards, bearing in mind
relevant local circumstances.
3. The medical profession has a continuing responsibility to be strongly involved in
regulation or self-regulating. Ultimate control and decision-making authority must
Tbilisi ⏐ D-2009-02-2019
Professionally-led Regulation (Madrid)
include physicians, based on their specific medical training, knowledge, experience
and expertise. In countries where Professionally led regulation is in place physicians
must ensure that this retains the confidence of the public. In countries that have a
mixed regulation system physicians must seek to ensure that it maintains professional
and public confidence.
4. Physicians in each country are urged to consider establishing, maintaining and actively
participating in a proportionate, fair, rigorous and transparent system of professionally-
led regulation. Such systems are intended to balance physicians’ rights to exercise
medical judgment freely with the obligation to do so wisely and temperately.
5. National Medical Associations must do their utmost to promote and support the
concept of well-informed and effective regulation amongst their membership and the
public. To ensure that any potential conflicts of interest between their representative
and regulatory roles are avoided they must ensure separation of the two processes and
pay rigorous attention to a transparent and fair system of regulation that will assure the
public of its independence and fairness.
6. Any system of professionally-led regulation must enhance and ensure:
• the delivery of high quality safe and competent healthcare to patients
• the competence of the physician providing that care the professional, including
ethical, conduct of all physicians
• the protection of society and the rights of patients
• the promotion of trust and confidence of patients, their families and the public
• the quality assurance of the regulation system
• the maintenance of trust by patients and society
• the development of solutions to potential conflicts of interest
• a commitment to wide professional responsibilities
7. To ensure that the patient is offered quality continuing care, physicians should
participate actively in the process of Continuing Professional Development, including
reflective practice, in order to update and maintain their clinical knowledge, skills and
competence. Employers and management have a responsibility to enable physicians to
meet this requirement.
8. The professional conduct of physicians must always be within the bounds of the Code
of Ethics governing physicians in each country. National Medical Associations must
promote professional and ethical conduct among physicians for the benefit of patients,
and ethical violations must be promptly recognized, reported to the relevant regulatory
authority and acted upon. Physicians are obligated to intervene in a timely manner to
ensure that impaired colleagues do not put patients or colleagues at risk and receive
appropriate assistance from a physician health program or appropriate training
enabling a return to active practice.
9. The regulatory body should, when the judicial or quasi-judicial processes are
complete, and assuming that a case is found against the physician, publish their
findings and include details of the remedial action taken. Lessons learned from every
case should, to the extent possible, be extracted and used in professional education
processes.The regulation process should ensure that the incorporation of such lessons
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D-2009-02-2019 ⏐ World Medical Association
is, as far as possible, seamless.
10. National Medical Associations are urged to assist each other in coping with new and
developing challenges including potential threats to professionally-led regulation. The
ongoing exchange of information and experiences between National Medical
Associations is essential for the benefit of patients.
11. Whatever judicial or regulatory process a country has established, any judgment on a
physician’s professional conduct or performance must incorporate evaluation by the
physician’s professional peers who, by their training, knowledge and experience,
understand the complexity of the medical issues involved.
12. An effective and responsible system of professionally-led regulation must not be self-
serving or internally protective of the profession. National Medical Associations
should assist their members in understanding that professionally-led regulation, in
countries where that system exists, must maintain the safety, support and confidence of
the general public, including their health-related rights, as well as the honour of the
profession itself.
Handbook of WMA Policies
D-2011-01-2011 ⏐ World Medical Association
WMA DECLARATION OF MONTEVIDEO
ON
DISASTER PREPAREDNESS AND MEDICAL RESPONSE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
In the last decade, the attention of the world has been drawn to a number of severe events
which seriously tested and overwhelmed the capacity of local healthcare and emergency
medical response systems. Armed conflicts, terrorist attacks and natural disasters such as
earthquakes, floods and tsunamis in various parts of the world have not only affected the
health of people living in these areas but have also drawn the support and response of the
international community. Many National Medical Associations have sent groups to assist
in such disaster situations.
According to the World Health Organization (WHO) Center for Research on the Epide-
miology of Disasters (CRED), the frequency, magnitude, and toll of natural disasters and
terrorism have increased throughout the world. In the previous century, about 3.5 million
people were killed worldwide as a result of natural disasters; about 200 million were killed
as a result of human-caused disasters (e.g., wars, terrorism, genocides). Each year, dis-
asters cause hundreds of deaths and cost billions of dollars due to disruption of commerce
and destruction of homes and critical infrastructure.
Population vulnerability (e.g. due to increased population density, urbanization, aging)
has increased the risk of disasters and public health emergencies. Globalization, which
connects countries through economic interdependencies, has led to increased international
travel and commerce. Such activity has also led to increased population density in cities
around the world and increased movement of people to coastal areas and other disaster-
prone regions. Increases in international travel may speed the rate at which an emerging
infectious disease or bioterrorism agent spreads across the globe. Climate change and ter-
rorism have emerged as important global factors that can influence disaster trends and thus
require continued monitoring and attention.
The emergence of infectious diseases, such as H1N1 influenza A and severe acute respi-
ratory syndrome (SARS), and the recent arrival of West Nile virus and monkey pox in the
Western hemisphere, reinforces the need for constant vigilance and planning to prepare for
and respond to new and unexpected public health emergencies.
The growing likelihood of terrorist-related disasters affecting large civilian populations
affects all nations. Concern continues about the security of the worldwide arsenal of nu-
clear, chemical, and biological agents as well as the recruitment of people capable of manu-
facturing or deploying them. The potentially catastrophic nature of a “successful” terrorist
attack configures an event that may demand a disproportionate amount of resources and
healthcare professionals preparedness. Natural disasters such as tornadoes, hurricanes,
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D-2009-02-2019 ⏐ World Medical Association
floods, and earthquakes, as well as industrial and transportation-related catastrophes, are
far more common and can also severely stress existing medical, public health, and emer-
gency response systems.
In light of recent world events, it is increasingly clear that all physicians need to become
more proficient in the recognition, diagnosis, and treatment of mass casualties under an
all-hazards approach to disaster management and response. They must be able to recog-
nize the general features of disasters and public health emergencies, and be knowledgeable
about how to report them and where to get more information should the need arise. Physi-
cians are on the front lines when dealing with injury and disease-whether caused by mi-
crobes, environmental hazards, natural disasters, highway collisions, terrorism, or other
calamities. Early detection and reporting are critical to minimize casualties through astute
teamwork by public- and private-sector health and emergency response personnel.
The WMA, representing the doctors of the world, calls upon its members to advocate for
the following:
• To promote a standard competency set to ensure consistency among disaster
training programs for physicians across all specialties. Many NMAs have dis-
aster courses and previous experiences in disaster response. These NMAs can
share this knowledge and advocate for the integration of some standardized
level of training for all physicians, regardless of specialty or nationality.
• To work with national and local governments to establish or update regional
databases and geographic mapping of information on health system assets, ca-
pacities, capabilities, and logistics to assist medical response efforts, domesti-
cally and worldwide, when needed. This could include information on local
response organizations, the condition of local hospitals and health system infra-
structures, endemic and emerging diseases, and other important public health
and clinical information to assist medical response in the event of a disaster. In
addition, systems for communicating directly with physicians and other front
line health care providers should be identified and strengthened.
• To work with national and local governments to ensure the developing and
testing of disaster management plans for clinical care and public health includ-
ing the ethical basis for delivering such plans.
• To encourage governments at national and local levels to work across normal
departmental and other boundaries in developing the necessary planning.
The WMA could serve as a channel of communication for NMAs during such times of
crisis, enabling them to coordinate activities and work together.
Handbook of WMA Policies
World Medical Association D-2011-03-2021
WMA DECLARATION
ON
LEPROSY CONTROL AROUND THE WORLD AND
ELIMINATION OF DISCRIMINATION
AGAINST PERSONS AFFECTED BY LEPROSY
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
Leprosy is a widespread public health problem, with approximately 200.000 new cases
diagnosed annually worldwide. It is a curable disease and after starting treatment, the chain of
transmission is interrupted. Leprosy is a disease that have been inadequately addressed from
the point of view of investments in research and medical treatment.
The World Medical Association recommends to all National Medical Associations to defend
the right of the people affected with leprosy and members of their families, that they should be
treated with dignity and free from any kind of prejudice or discrimination. Physicians, health
professionals and civil society should be engaged in combating all forms of prejudice and
discrimination. Research centers should acknowledge leprosy as a major public health problem
and continue to research this disease since there are still gaps in understanding its patho-
physiological mechanisms. These gaps in knowledge may be overcome through the allocation
of resources to new research, which will contribute to more efficient control worldwide.
Medical schools, especially in countries with high prevalence of leprosy, should enhance its
importance in the curriculum. The public, private, and civil sectors should unify their best
efforts in order to disseminate information that would counteract prejudice towards leprosy and
that acknowledges its curability.
Handbook of WMA Policies
D-2011-04-2020 ⏐ World Medical Association
WMA DECLARATION OF OSLO
ON
SOCIAL DETERMINANTS OF HEALTH
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and the title (Statement to Declaration) changed by the 66th
WMA General Assembly,
Moscow, Russia, October 2015
amended by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
The social determinants of health are the conditions in which people are born, grow, are
educated, live, work and age; and the societal influences on these conditions. The social
determinants of health are major influences on both quality of life, including good health,
and length of disability-free life expectancy. Social determinants of health also include the
impact of racism and discrimination, not just from an individualized or interpersonal
perspective, but from structural and institutional perspectives.
While health care aims to cure and restore health, it is these social, cultural,
environmental, economic and other factors that are the major causes of rates of illness and,
in particular, the magnitude of health inequities.
Achieving health equity for all requires strong commitment from governments, the health
care sector, health professionals and the international community among others. The UN
Sustainable Development Goals (SDG)1
specifically aims to ensure healthy lives and
promote well-being for all at all ages (goal 3), to ensure inclusive and equitable education
and promote lifelong learning opportunities for all (goal 4) and to reduce inequality within
and among countries (goal 10). In the WMA Statement on Access to Health Care, the
WMA stresses the importance of health care access for all and suggests ways to act on
inadequate access and health inequalities. The WMA further supports and promotes the
introduction of adequate Universal Health Coverage in all countries. Universal Health
Coverage will improve access to appropriate health care for all and thus promote
awareness of and action on the social determinants of health.
Historically, the primary role of physicians and other health care professionals has been to
treat the sick – a vital and much cherished role in all societies. To a lesser extent, health
care professionals have dealt with individual exposures to the causes of disease –
smoking, obesity, and alcohol in chronic disease, for example. These familiar aspects of
lifestyle can be thought of as ‘proximate’ causes of disease.
The work on social determinants goes far beyond this focus on proximate causes and
considers the “causes of the causes”. For example, smoking, obesity, alcohol, sedentary
lifestyle are all causes of illness. A social determinants approach addresses the causes of
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Social Determinants of Health
these causes; and in particular how they contribute to social inequities in health. This
approach focuses not only on individual behaviors but seeks to address the social and
economic circumstances that give rise to premature poor health, throughout the life
course. The voice of the medical profession has been and continues to be important in
tackling these causes of the causes.
In many societies, unhealthy behaviors follow the social gradient: the lower in the
socioeconomic hierarchy, the higher the rate of smoking, the worse the diet, and the less
the physical activity. Central to the issue of addressing social determinants of health is the close
interrelation between poverty and illness. A major, but not the only, cause of the social
distribution of these causes is level of education. Structural inequity can also make access
to healthy food difficult.
Specific examples of addressing the causes of the causes are: regulating the price and
availability of alcohol, which are key drivers of alcohol consumption; and promoting
tobacco taxation, package labeling, bans on advertising and smoking in public places, all
of which have had demonstrable effects on tobacco consumption.
There is a growing movement globally that seeks to address gross inequities in health and
length of life through action on the social determinants of health. This movement has
involved the World Health Organization, several national governments, civil society
organizations, and academics. Solutions are being sought and knowledge
shared. Physicians need to be well informed about the implications of perpetuating
inequalities and be willing to participate in this debate. They can be advocates for action
on social conditions that have important effects on health and for strengthening of primary
care and public health institutions. The medical profession can contribute significantly to
public health, including through working with other sectors to find innovative solutions.
RECOMMENDATIONS
1. The WMA and National Medical Associations should take an active role in combating
social and health inequities and barriers to obtaining health care, striving to enable
physicians to provide equal, high quality health care to all. Adequate Universal Health
Coverage in all countries should be a core objective as it will help reduce health
inequity.
2. The WMA can add significant value to the global efforts to address the social
determinants of health by helping physicians, other health professionals and National
Medical Associations to understand what the emerging evidence shows and what
works in different circumstances. WMA can call on physicians to lobby more
effectively within their countries and across international borders and ensure that
medical knowledge and skills are shared.
3. The WMA should help to gather data on successful initiatives and help to engage
physicians and other health professionals in sharing experiences and implementing
new and innovative solutions.
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Social Determinants of Health
4. The WMA should work with National Medical Associations to promote education to
medical students and physicians on health inequity and the social determinants of
health, and to put pressure on national governments and international bodies to take
the appropriate steps to minimise health inequity and these root causes of premature
poor health.
5. The WMA and National Medical Associations should encourage governments and
international bodies to take action on and implement specific policies and tools
addressing health inequity and the social determinants of health. Some governments
have taken initial steps to reduce health inequity by taking action on the social
determinants of health; local areas have drawn up plans of action; there are good
examples of general practice that work across sectors improving the quality of
people’s lives and hence reduce health inequity. The WMA should gather examples of
good practice from its members and promote further work in this area.
Handbook of WMA Policies
World Medical Association D-2011-05-2022
WMA DECLARATION
ON
THE PROTECTION AND INTEGRITY OF MEDICAL PERSONNEL IN
ARMED CONFLICTS AND OTHER SITUATIONS OF VIOLENCE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The right to health and medical assistance is a basic human right that should be guaranteed at
all times; ethical principles of healthcare remain the same in times of emergencies and in times
of peace. Healthcare personnel must be duly protected.
Various international agreements, including the Geneva Conventions (1949), Additional
Protocols to the Geneva Conventions (1977, 2005) and the Basic Principles on the Use of Force
and Firearms by Law Enforcement Officials of the United Nations, must guarantee safe access
to medical assistance as well as the protection of healthcare personnel.
The United Nations Security Council Resolution 2286 (2016) condemns attacks and threats
against health care personnel, demands an end to impunity for those responsible, and that all
parties to armed conflict comply fully with their obligations under international law.
Despite recognized international standards and the mobilization of humanitarian and human
rights stakeholders over the last years denouncing the surge of violence against healthcare
worldwide, the WMA notes with great concerns persistent attacks and misuses of hospitals and
other medical facilities, as well as threats, killings and other violence against patients and
healthcare personnel in emergency contexts.
The WMA condemns in the strongest terms this scourge of violence against healthcare
personnel and facilities, which has disastrous humanitarian implications with critical impacts
on the capacity of the health system to provide the care needed, resulting in unjustifiable
suffering and death. Violence against healthcare personnel constitutes an international
emergency, requiring urgent actions.
Recalling its Statement on Armed Conflicts, the WMA reaffirms that armed conflicts should
always be a last resort and that States and other authorities who enter into armed conflict must
accept responsibility for the consequences of their actions.
The safety and personal security of physicians and other healthcare personnel are essential in
enabling them to provide care and save lives in situations of conflicts. They must always be
Protection and Integrity of Medical Personnel
Berlin D-2011-05-2022
respected as neutral and should never be prevented from fulfilling their duties. Healthcare
personnel and facilities should never be instrumentalised as means of war.
Recalling its Regulations in Times of Armed Conflict and Other Situations of Violence, the
WMA reaffirms that the primary obligation of physicians and other healthcare personnel is
always to their patients; they have the same ethical responsibilities in situation of violence or
armed conflicts as in peacetime, the same duty of preserving health and saving lives; they shall
at all times act in accordance with the ethical principles of the profession, relevant international
and national law, and their conscience.
RECOMMENDATIONS
The WMA calls upon all parties involved in situations of violence to:
1. Fully comply with their obligations under international law, including human rights law
and international humanitarian law, in particular with their obligations under the Geneva
Conventions of 1949 and the obligations applicable to them under the Additional Protocols
of 1977 and 2005;
2. Ensure the safety, independence and personal security of healthcare personnel at all times,
including during armed conflicts and other situations of violence, in accordance with the
Geneva Conventions and their additional protocols;
3. Respect and promote the principles of international humanitarian and human rights law
which safeguard medical neutrality in situations of conflict;
4. Protect medical facilities, medical transport and the people being treated in them, provide
the safest possible working environment for healthcare personnel, and protect them from
threats, interference and attack;
5. Never misuse hospitals and other health facilities for military purposes and dedicate them
exclusively to health care;
6. Enable healthcare personnel to treat injured and sick patients, regardless of their role in a
conflict, and to carry out their medical duties freely, independently and in accordance with
the principles of their profession without fear of punishment or intimidation;
7. Ensure that safe access to adequate medical facilities for the injured and others in need of
medical aid is not unduly impeded;
8. Ensure that the equipment, including personal protection equipment, necessary for the
safety of healthcare workers, is available to them as needed, and that the staffing is
adequate;
9. Support and strictly respect the ethical rules of the medical profession as defined, among
other documents, in the Ethical Principles of Health Care in Times of Armed Conflict and
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World Medical Association D-2011-05-2022
Other Emergencies and in the WMA Regulations in Times of Armed Conflict and Other
Situations of Violence, and to never require from physicians or force them to breach or
renounce these rules, in particular:
• privileges and facilities afforded to physicians and other health care professionals in
times of armed conflict and other situations of violence must never be used for purposes
other than health care;
• physicians must at all times show appropriate respect for medical confidentiality;
• physicians must never accept acts of torture or any other form of cruel, inhuman or
degrading treatment under any circumstances; they must never be present at nor take
part in such acts;
• physicians have a duty to recognize and support vulnerable populations, including
women, children, refugees, the disabled and displaced persons;
• physicians and WMA constituent members should alert governments and non-state
actors of the human consequences of warfare;
• where conflict appears to be imminent and inevitable, physicians should ensure that
authorities are planning for the protection of the public health infrastructure and for any
necessary repair in the immediate post-conflict period.
The WMA calls upon governments to:
10. Establish efficient, secure and unbiased reporting mechanisms with sufficient resources to
collect and disseminate data regarding assaults on physicians, other healthcare personnel
and medical facilities;
11. Provide to the WHO the necessary support to fulfil its leadership role in documenting
attacks on healthcare personnel and facilitiesi
;
12. Foster the mechanisms of investigating and bringing to justice those responsible for
reported violations of the international agreements pertaining to the protection of healthcare
personnel in armed conflicts and other situations of violence, and of enforcing the sanctions
when such have been decided;
13. Develop and implement more efficient legal protection for medical and other healthcare
personnel, so that whoever attacks a nurse, physician or another healthcare personnel
knows that such actions will be severely penalised.
The WMA calls upon governments, its member organisations and the appropriate international
bodies to:
14. Raise awareness of international norms on the protection of healthcare personnel and
cooperate with different actors to identify strategies to tackle threats to healthcare and
strengthen the mechanism of investigating the reported violations;
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Berlin D-2011-05-2022
15. Raise awareness at both national and local level of the fundamental importance of
protecting the healthcare personnel and of upholding their neutrality in times of conflict;
16. Support the development of pregraduate, postgraduate and continuous education for the
healthcare personnel to ensure their competencies and their security and to minimize the
psychological toll when confronted with armed conflicts and other situations of violence.
i The WMA recognizes that in some circumstances, documenting and denouncing acts of torture or other violence
may put the physician, and those close to him or her, at great risk. Doing so may have excessive personal
consequences. Physicians must avoid putting individuals in danger while assessing, documenting or reporting
signs of torture and cruel, inhuman and degrading treatment and punishments.
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WMA DECLARATION
ON
ALCOHOL
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. The burden of disease and injury associated with alcohol consumption is a critical
challenge to global public health and development around the world. The World
Medical Association offers this declaration on alcohol as its commitment to
reducing excessive alcohol consumption and as a means to support its members in
promulgating harm-reduction policies and other measures.
2. There are significant health, social and economic problems associated with
excessive alcohol use. Overall, there are causal relationships between alcohol
consumption and more than 200 types of disease and injury including traffic
fatalities. The harmful use of alcohol kills approximately 3.3 million people every
year (5.9 % of all deaths worldwide), and is the third leading risk factor for poor
health globally, accounting for 5.1 % of disability-adjusted life years lost. Beyond
the numerous chronic and acute health effects, alcohol use is associated with
widespread social, mental and emotional consequences. The problem has a special
magnitude among young people and adolescents who are beginning to consume
alcohol at earlier ages, and the risk to their physical, mental and social health is of
concern.
3. Although alcohol consumption is deeply rooted in many societies, alcohol cannot
be considered an ordinary beverage or consumer commodity. It is a substance that
causes extensive medical, psychological and social harm by means of physical
toxicity, intoxication and dependence.
There is increasing evidence that genetic vulnerability to alcohol dependence is a
risk factor for some individuals. Foetal alcohol syndrome and foetal alcohol
effects, preventable causes of intellectual disability, result from alcohol
consumption during pregnancy.
Adolescence is a stage of significant vulnerability because the neurological
development is not complete and alcohol has a negative impact on it. Growing
scientific evidence has demonstrated the harmful effects of consumption prior to
adulthood on the brains, mental, cognitive and social functioning of youth and
increased likelihood of adult alcohol dependence and alcohol related problems
among those who drink before full physiological maturity. Regular alcohol
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Alcohol
consumption and binge drinking in adolescents can negatively affect school
performance, increase participation in crime and adversely affect sexual
performance and behaviour.
4. Effective alcohol harm-reduction policies and measures will include legal and
regulatory measures that target overall alcohol consumption in the population, as
well as health and social policy interventions that specifically target high-risk
drinkers, vulnerable groups and harms to people affected by those who consume
alcohol, e.g. domestic violence.
When developing policies it should be taken into account that the majority of
alcohol-related problems in a population are associated with harmful or hazardous
drinking by non-dependent ‘social’ drinkers, particularly when intoxicated. This is
particularly a problem of young people in many regions of the world who drink
with the intent of becoming intoxicated.
5. There are many evidence-based alcohol policies and prevention programmes that
are effective in reducing the health, safety and socioeconomic problems
attributable to harmful use of alcohol. International public health advocacy and
partnerships are needed to strengthen and support the ability of governments and
civil society worldwide to commit to, and deliver on, reducing the harmful use of
alcohol through effective interventions, including action on social determinants of
health.
Health professionals in general and physicians in particular have an important role
to play in preventing, treating and mitigating alcohol-related harm, and in using
effective preventive and therapeutic interventions.
The World Medical Association encourages and supports the development and
implementation of evidence-based national alcohol policies by promoting and
facilitating partnerships, information exchange and health policy capacity building.
POLICY OBJECTIVES
In developing alcohol policies, the WMA recommends the following broad objectives:
6. Strengthen health systems to identify and improve a country’s capacity to develop
policy and lead actions that target excessive alcohol consumption.
7. Promote the development and evaluation in all countries of national alcohol
strategies which are comprehensive, evidence-based and include measures to
address the supply, distribution, sale, advertising, sponsorship and promotion of
alcohol. The WHO ‘best buys’ cost-effective policies should be particularly
promoted, such as (i) increasing alcoholic beverage taxes, (ii) regulating the
availability of alcoholic beverages, (iii) restricting marketing of alcoholic
beverages and (iv) drink-driving countermeasures. Strategies should be routinely
reviewed and updated.
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8. Through government health departments, accurately measure the health burden
associated with alcohol consumption through the collection of sales data,
epidemiological data, and per capita consumption figures.
9. Support and promote the role of health and medical professionals in early
identification, screening and treatment of harmful alcohol use.
10. Dispel myths and dispute alcohol control strategies that are not evidence-based.
11. Reduce the impact of harmful alcohol consumption in at risk populations.
12. Foster multi-disciplinary collaboration and coordinated inter-sectoral action.
13. Raise awareness of alcohol-related harm through public education and information
campaigns.
14. Promote social determinants of health approach in fighting harmful alcohol
consumption.
REOMMENDATIONS
he following priorities are suggested for WMA members, National Medical Associations
and governments when developing integrated and comprehensive policy and legislative
responses.
15. Regulate affordability, accessibility and availability
15.1 Pricing policies
Evidence from epidemiological and other research demonstrates a clear link between the
price of alcohol and levels of consumption, especially amongst young drinkers and those
who are heavy alcohol users.
Therefore, action is needed to increase alcohol prices, through volumetric taxation of
products based on their alcohol strength, and other proven pricing mechanisms, to reduce
alcohol consumption, particularly in heavy drinkers and high-risk groups.
Setting a minimum unit price at a level that will reduce alcohol consumption is a strong
public health measure, which will both reduce average alcohol consumption throughout
the population and be especially effective in heavy drinkers and young drinkers.
15.2 Accessibility and availability
Regulate access to, and availability of, alcohol by limiting the hours and days of sale, the
number and location of alcohol outlets and licensed premises, and the imposition of a
minimum legal drinking age. Governments should tax and control the production and
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Alcohol
consumption of alcohol, with licensing that emphasises public health and safety and
empowers licensing authorities to control the total availability of alcohol in their
jurisdictions. Governments should also control importation and sale of illegal alcohol
across borders.
Public authorities must strengthen the prohibition of selling to and by minors and must
systematically request proof of age before alcohol can be purchased in shops or bars.
16. Regulation of non-commercial alcohol
The production and consumption of non-commercial forms of alcohol, such as home
brewing, illicit distillation, and illegal diversion alcohol to avoid taxes, should be curtailed
using appropriate taxing and pricing mechanisms.
17. Regulation of alcohol marketing
Alcohol marketing should be restricted to prevent the early adoption of drinking by young
people and to minimise their alcohol consumption. Regulatory measures range from
wholesale bans and restrictions on measures that promote excessive consumption, to
restrictions on the placement and content of alcohol advertising and sponsorship that are
attractive to young people. There is evidence that industry self-regulation and voluntary
codes are ineffective at protecting vulnerable populations from exposure to alcohol
marketing and promotion.
Increase public awareness of harmful alcohol consumption through mandatory product
labelling that clearly states alcoholic content in units, advice on recommended drinking
levels and a health warning, supported by public awareness campaigns.
In conjunction with other measures, social marketing campaigns should be implemented
together with the media to educate the public about harmful alcohol use, to adopt driving
while intoxicated policies, and to target the behaviour of specific populations at high risks
of harm.
18. The role of health and medical services in prevention
Health, medical and social services professionals should be provided with the training,
resources and support necessary to prevent harmful use of alcohol and treat people with
alcohol dependence, including routinely providing brief interventions to motivate high-
risk drinkers to moderate their consumption. Health professionals also play a key role in
education, advocacy and research.
Specialised treatment and rehabilitation services should be available in due time and
affordable for alcohol dependent individuals and their families.
Together with national and local medical societies, specialty medical organizations,
concerned social, religious and economic groups (including governmental, scientific,
professional, nongovernmental and voluntary bodies, the private sector, and civil society)
physicians and other health and social professionals can work to:
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18.1 Reduce harmful use of alcohol, especially among young people and pregnant
women, in the workplace, and when driving;
18.2 Increase the likelihood that everyone will be free of pressures to consume alcohol
and free from the harmful and unhealthy effects of drinking by others;
18.3 Promote evidence-based prevention strategies in schools and communities;
18.4 Assist in informing the public of alcohol related harm and demystifying the myth of
health enhancing properties of alcohol.
Physicians have an important role in facilitating epidemiologic and health service data
collection on the impact of alcohol with the aim of prevention and promotion of public
health. Data collection must respect the confidentiality of health data of individual
patients.
19. Driving while intoxicated measures
Key deterrents should be implemented for driving while intoxicated, which include a
strictly enforced legal maximum blood alcohol concentration for drivers of no more than
50mg/100ml, supported by social marketing campaigns and the power of authorities to
impose immediate sanctions.
These measures should also include active enforcement of traffic safety measures, random
breath testing, and legal and medical interventions for repeat intoxicated drivers.
20. Limit the role of the alcohol industry in alcohol policy development
The commercial priorities of the alcohol industry are in direct conflict with the public
health objective of reducing overall alcohol consumption. Internationally, the alcohol
industry is frequently included in alcohol policy development by national authorities, but
the industry is often active in opposing and weakening effective alcohol policies.
Ineffective and non-evidence-based alcohol control strategies promoted by the alcohol
industry and the social organisations that the industry sponsors should be countered. The
role of the alcohol industry in the reduction of alcohol-related harm should be confined to
their roles as producers, distributors and marketers of alcohol, and not include alcohol
policy development or health promotion.
21. Convention on Alcohol Control
Promote consideration of a Framework Convention on Alcohol Control similar to that of
the WHO Framework Convention on Tobacco Control.
22. Exclude alcohol from trade agreements
Furthermore, in order to protect current and future alcohol control measures, advocate for
alcohol to be classified as an extra-ordinary commodity and that measures affecting the
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supply, distribution, sale, advertising, sponsorship, promotion of or investment in
alcoholic beverages be excluded from international trade agreements.
23. Action against positive media messaging
It is important to act on the impact of media messages on beliefs, intentions, attitudes and
social norms. Well-designed media campaigns can have direct effects on behavior. The
media also influence the social conception of a problem, and indirectly influence political
decision-making on measures for intervention on alcohol.
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WMA DECLARATION
OF CHICAGO ON
QUALITY ASSURANCE IN MEDICAL EDUCATION
Adopted by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
he goals of medical education are to prepare practitioners to apply the latest scientific
knowledge to promote health, to prevent and cure human diseases, and to impart the
ethical standards governing the thought and behavior of physicians. All physicians have a
responsibility to themselves, the profession, and their patients to maintain high standards
for basic medical education.
Well-planned and well-executed quality assurance programs are essential to ensuring that
medical schools meet these goals and expectations. There are many threats to the quality
of basic medical education. The ability to deliver a high standard of education can be
affected by the availability of infrastructure, clinical resources, faculty, and finances. Also,
the growth of basic medical education globally, with a rapid increase in the number of
medical schools in some countries, raises concerns about the quality of graduates. A well-
developed quality assurance program allows schools to identify and address conditions
that threaten the quality of their basic medical education. Such programs need to be
implemented as far as possible at medical schools around the world.
BACKGROUND
Standards developed by and for a medical school are designed to reflect what the school
believes to be important quality measures. Institutional reviews using such internally-
developed standards can ensure that the school’s missions are being met and that students
are being prepared to achieve the desired outcomes. The presence of an institutional
quality assurance program that uses its own defined criteria and is supported by
knowledgeable personnel can be important to ensure educational program quality over
time.
However, a better outcome will more likely be achieved by also including a second
dimension of review that includes an external perspective. A national quality assurance
system includes the use of standards of quality that are developed and approved at the
national or regional level. Evaluating a medical school based on what a country or region
expects of its basic medical educational programs leads to a higher and more consistent
level of student preparation.
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Quality Assurance in Basic Medical Education
Unless compliance with standards set by a national evaluation system is required of
medical schools, there is no guarantee that schools will undertake an internal evaluation or
correct problems that interfere with educational quality. The World Medical Association
(WMA) recognises the need for and importance of sound global standards for assuring the
quality of basic medical education programs.
An accreditation/recognition system is a quality assurance mechanism that is increasingly
common around the world. Accreditation/recognition systems are based on standards of
educational quality that are developed to meet national needs and that use valid, reliable,
and widely-accepted processes to assess the attainment of these standards by schools.
After evaluating compliance with standards, cooperation and coordination among various
stakeholder groups within and external to a medical school is needed to implement
solutions to the problems identified.
PRINCIPLES FOR ACCREDITATION SYSTEMS
An accreditation system reviews educational programs or institutions using a pre-
determined (typically national) set of process and outcome standards. The accreditation
systems that exist around the world differ in several ways. In some countries,
accreditation of medical schools has been occurring for decades; in other countries,
accreditation is relatively new. Participation in accreditation is either mandatory or
voluntary for medical schools and reviews take place over different intervals.
Accreditation is defined as the evaluation of educational programs or institutions based on
a clear and specific set of standards. Accreditation guidelines should be articulated as
standards that have been created with national needs in mind and with the input of relevant
stakeholder groups within the country.
Certain general principles should form the basis for an accreditation system to ensure that
the process is valid and decisions related to educational program quality are trustworthy.
These principles include transparency, absence of conflict of interest, and
reliability/consistency. Transparency means that the accreditation standards and processes
are known to and understood by schools, evaluators, and decision-makers. To reduce the
potential for conflict of interest, evaluators and decision-makers should have no ties to the
institution being evaluated or to other institutions that may affect their ability to make a
judgment free from positive or negative bias. Reliability and consistency require a
common understanding of what constitutes compliance with standards and that, as far as
possible, this understanding is applied consistently in reviews and decisions across
schools.
Accreditation standards are measurable, but need not be quantitative. Standards are
normally developed for both the process and the outcomes of a medical education
program. Specific information should be identified to evaluate compliance. For example,
the standards related to process could address the objectives for and structure of the
curriculum; the qualifications of entering students and teaching faculty; and the
availability of resources for program support, including adequate finances, sufficient
faculty, and an appropriate educational infrastructure for the scientific and clinical phases
of training. The outcomes of the medical education program are then evaluated to
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determine if graduates have been adequately prepared based on the school’s objectives.
In order to be most effective, standards used in accreditation need to be widely
disseminated and thoroughly explicated so that medical schools, evaluators, and decision-
makers share a common understanding of their meaning and the expectations for
compliance. For the sake of process effectiveness and transparency, the medical school
faculty, the evaluators who review the medical schools’ compliance with accreditation
standards, and the decision-makers who determine accreditation status will require
training.
Institutions will have achieved their objectives if they have continually complied with
accreditation standards and when internal monitoring becomes a formal responsibility for
one or more individuals within the medical school who have access to relevant quality-
linked information (e.g., the results of student satisfaction surveys and student
performance data). Ongoing review of some or all accreditation standards allows schools
to correct problem areas before they are identified as part of the formal accreditation
review and ensures that educational program quality remains high.
If an accreditation review identifies areas where improvement is needed, a medical school
should promptly correct the deficiencies. The accreditation/recognition body normally sets
a timeline for follow-up by the end of which the educational program should be able to
demonstrate the actions that have been taken and the outcomes that have been achieved.
This may require the medical school/university to provide financial resources and to
provide faculty time, effort, and adequate infrastructure, to make the needed corrections.
To assist schools in addressing identified deficiencies, support and consultation could be
provided by the staff of the accrediting body or other trained individuals. To avoid
conflict of interest, those who provide consultation should not take part in accreditation
reviews or in decisions about accreditation status.
RESPONSIBILITIES OF STAKEHOLDERS GROUPS WITHIN AND EXTERNAL TO MEDICAL
SCHOOLS
The creation of an accreditation system that meets the principles for validity and
trustworthiness requires actions by a variety of stakeholder groups, such as:
• Entities that sponsor accrediting bodies (e.g., governments, medical associations)
need to ensure that the accrediting body is appropriately funded and staffed for its
activities. Funding may come from the sponsors and/or from the accrediting
body’s ability to generate its own funding from accreditation review fees.
Accrediting bodies in certain countries may require additional funding and staffing
to address the increase in the number of medical schools.
• It is advisable for school leadership to encourage an environment that values
educational quality assurance activities. Faculty should be given time and
recognition for their participation in program evaluation and accreditation
activities, and medical students should be prepared and encouraged to provide
feedback on all relevant aspects of the medical education program.
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Quality Assurance in Basic Medical Education
RECOMMENDATIONS
The WMA calls upon National Medical Associations (NMAs)to encourage medical
schools to develop quality assurance programs regarding ongoing review of educational
program quality.
The WMA urges NMAs to support and promote the ongoing development of national and
regional accreditation/recognition systems for medical schools. These systems should be
designed and led by physicians in collaboration with experienced medical educators and
with input from other relevant experts.
The WMA calls upon NMAs to urge national governmental and private-sector policy-
makers to ensure that the national accreditation system has adequate and appropriate
resources for its activities. This includes sufficient and consistent funding to support the
infrastructure and staffing of the accrediting body.
The WMA recommends that accreditation systems use nationally-relevant standards
applied consistently by trained evaluators and decision-makers when reviewing medical
schools.
The WMA encourages NMAs to advocate to policy-makers that participation in the
national accreditation system should be required for all medical schools within a country.
The WMA calls upon NMA’s to urge national accreditation systems to participate in
external reviews of their policies, practices, and standards. This may include seeking
recognition by the World Federation for Medical Education (WFME). Recognised
accrediting bodies and similar organisations are urged to establish a forum for discussion
and collaboration among national accrediting bodies to share best practices and
mechanisms to overcome challenges.
Physicians should be encouraged to lead and actively participate in national accreditation
activities as evaluators and decision-makers and in quality assurance activities at their own
medical schools.
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WMA DECLARATION
ON
FAIR TRADE IN MEDICAL PRODUCTS AND DEVICES
Adopted by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Every year trillions of dollars are spent on medical supplies globally. Little
consideration is given to the conditions in which they are made, nor to the impact on
the people who make them.
2. Abuses of labour standards, evidence of modern slavery, and unethical working
conditions have been uncovered in the manufacture of many medical products bound
for health systems around the world. Evidence shows that many supplies used in the
healthcare sector are produced in unhealthy, unsafe and unfair working conditions.
Widescale abuses have been reported in numerous manufacturing sites – from
uniforms, to latex gloves, to disposable surgical instruments – international labour core
conventions are persistently disregarded, and the use of child labour is widespread.
3. The global healthcare community should not condone unethical trade practices that are
detrimental to global health and encourage modern slavery. Healthcare organisations
and professionals around the world must insist that the goods they use are not
produced at the expense of the health of workers in the global community.
4. It is important to maintain trading with developing countries to ensure jobs and
livelihoods, and commitment to the UN sustainable development goals. These goals
provide an overarching opportunity for sustained action to be taken by health
professionals in protecting human health globally.
5. As enshrined in the UN Guiding Principles on Business and Human rights (June 2011)
– applicable to all States- businesses have a responsibility to minimise human rights
violations in their supply and procurement chains, irrespective of whether the business
contributed directly to the violation, and a duty to adequately address any abuses that
do occur.
6. Introduction of fair and ethical trade in health service purchasing should be used to
secure improvement in the health system supply chains. Modern approaches to
addressing labour rights abuses focus on models of ‘ethical procurement’.
7. Ethical procurement refers to the steps that purchasing organisations, such as hospitals,
take to improve the pay and conditions of people involved in the supply of goods and
services. It asks purchasers to systematically assess the risk of labour rights abuses in
the goods they procure, and to push for improvement where necessary. This includes
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Fair Medical Trade
working with companies throughout the supply chain to help workers exercise
fundamental rights such as the right to safe and decent working conditions. This model
aims to make international trade work better for poor and otherwise disadvantaged
people.
RECOMMANDATIONS
8. Recognizing this, the World Medical Association and its national medical association
members on behalf of their physician members, support and commit to the following
actions:
• Call upon purchasing bodies, to develop a fair and ethical purchasing policy for
medical goods to promote good working conditions and eradicate modern
slavery throughout the supply chains of the products purchased within the
health sector.
• Promote multiple health product production sources throughout the world.
National medical associations
9. National medical associations should advocate for labour/ human rights to be protected
throughout the global supply chains of products used in their healthcare systems.
10. National medical associations should work with their members to promote fair and
ethical trade in the health sector.
11. National medical associations should support community action and initiatives with to
promote ethical working conditions across the health sector as a whole.
12. National medical associations should harness government support to formulate
national guidance and/or policy on fair and ethical trade in healthcare purchasing.
Physicians
13. Physicians should play a leadership role in integrating considerations of labour
standards into purchasing decisions within healthcare organisations.
14. Physicians should raise awareness of the issues, and promote the development of fair
and ethically produced medical goods, amongst colleagues and those working with
health systems.
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WMA DECLARATION
ON
EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
The WMA reiterates its strong commitment to the principles of medical ethics and that
utmost respect has to be maintained for human life. Therefore, the WMA is firmly
opposed to euthanasia and physician-assisted suicide.
For the purpose of this declaration, euthanasia is defined as a physician deliberately
administering a lethal substance or carrying out an intervention to cause the death of a
patient with decision-making capacity at the patient’s own voluntary request. Physician-
assisted suicide refers to cases in which, at the voluntary request of a patient with
decision-making capacity, a physician deliberately enables a patient to end his or her own
life by prescribing or providing medical substances with the intent to bring about death.
No physician should be forced to participate in euthanasia or assisted suicide, nor should
any physician be obliged to make referral decisions to this end.
Separately, the physician who respects the basic right of the patient to decline medical
treatment does not act unethically in forgoing or withholding unwanted care, even if
respecting such a wish results in the death of the patient.
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WMA DECLARATION OF CORDOBA
ON
PATIENT-PHYSICIAN RELATIONSHIP
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
The patient-physician relationship is part of a human relationship model that dates back to
the origins of medicine. It represents a privileged bond between a patient and a physician
based on trust. It is a space of creativity where information, feelings, visions, help and
support are exchanged.
The patient-physician relationship is a moral activity that arises from the obligation of the
physician to alleviate suffering and respect the patient’s beliefs and autonomy. It is usually
initiated by mutual consent – expressed or implied – to provide quality medical care.
The patient-physician relationship is the fundamental core of medical practice. It has a
universal scope and aims at improving a person’s health and wellbeing. This is made
possible by knowledge sharing, common decision making, patient and physician
autonomy, help, comfort and companionship in an atmosphere of trust. Trust is an
inherent component of the relationship that can be therapeutic in and of itself.
The patient-physician relationship is essential to patient-centred care. It requires both the
physician and the patient to be active participants in the healing process. While the
relationship encourages and supports collaboration in medical care, competent patients
make decisions that direct their care. The relationship may be terminated by either party.
The physician must then assist the patient in securing transfer of care and refer the patient
to another physician with the necessary ability to continue the care.
The patient-physician relationship is a complex issue subject to myriad cultural,
technological, political, social, economic or professional influences. It has evolved
throughout history, according to culture and civilisation, in the pursuit of what is most
appropriate based on scientific evidence for patients by improving their mental and
physical health and well-being and alleviating pain. The relationship underwent deep
changes as a result of momentous milestones such as the Universal Declaration of Human
Rights (1948), the WMA declarations of Geneva (1948), Helsinki (1964), and the Lisbon
(1981).The relationship has slowly progressed towards the empowerment of the patient.
Today, the patient-physician relationship is frequently under threat from influences both
within and outside health care systems. In some countries and health care systems, these
influences risk alienating physicians from their patients and potentially harming patients.
Amongst those challenges likely to undermine the therapeutic efficacy of the relationship,
we note a growing trend to:
A technologization of medicine, sometimes leading to a mechanistic view of health care,
neglecting human considerations;
The dilution of trustworthy relationships between people in our societies, which
negatively influences healthcare relationships;
A primary focus on economic aspects of medical care to the detriment of other factors,
posing sometimes difficulties to establish genuine relationships of trust between the
physician and the patient.
It is of the utmost importance that the patient-physician relationship addresses these
factors of influence in such a way that the relationship is enriched, and that its specificity
is warranted. The relationship should never be subject to undue administrative, economic,
or political interferences.
RECOMMENDATIONS
Reiterating its Declaration of Geneva, the International Code of Medical Ethics and its
Lisbon Declaration on Patient Rights and given the vital importance of the relationship
between physician and patient in history and in the current and future context of medicine,
the WMA and its Constituent Members:
1. Reaffirm that professional autonomy and clinical independence are essential
components of high-quality medical care and medical professionalism, protecting
the right of the patients to receive the health care they need.
2. Urge all actors involved in the regulation of the patient-physician relationship
(governments and health authorities, medical associations, physicians, and
patients) to defend, protect and strengthen the patient-physician relationship, based
of high-quality care, as a scientific, health, cultural and social heritage.
3. Call on Constituent Members and individual physicians to preserve this
relationship as the fundamental core of any medical action centred on a person, to
defend the medical profession and its ethical values, including compassion,
competence, mutual respect, and professional autonomy, and to support patient-
centred care.
4. Reaffirm its opposition to interference from governments, other agents and
institutional administrations in the practice of medicine and in the Patient-
physician
5. Reaffirm its dedication to providing competent medical service in full professional
and moral independence, with compassion and respect for human dignity.
6. Commit to address emerging factors which could pose a threat to the patient-
physician relationship and to take action to mitigate against those factors.
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WMA DECLARATION
ON
PSEUDOSCIENCE AND PSEUDOTHERAPIES IN THE FIELD OF
HEALTH
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
DEFINITIONS
• “Pseudoscience” (false science) refers to the set of statements, assumptions,
methods, beliefs or practices that, without following a valid and recognised
scientific method, are falsely presented as scientific or evidence-based.
• “Pseudotherapies” (false therapies) are those practices intended for curing diseases,
alleviating symptoms or improving health with procedures, techniques, products or
substances based on criteria without the support of available up-to-date scientific
evidence; and which may have significant potential risks and harms.
PREAMBLE
Medical practice must be based on the best available up-to-date scientifically proven
evidence. The differences between conventional medicine and other practices that are not
supported by scientific evidence make up the complex universe of pseudosciences and
pseudotherapies.
Pseudosciences and pseudotherapies represent a complex system of theories, assumptions,
assertions and methods erroneously regarded as scientific, they may cause some patients
to perceive a cause-and-effect relationship between pseudotherapies and the perception of
improvement, hence they may be very dangerous and are unethical.
There are therapies and techniques accepted by the scientific community that, used in a
complementary manner (such as nutritional, comfort or wellness, environmental and
relaxation therapies, psychotherapeutic support or reinforcement, affectivity and the use of
placebos), provide benefits to the validated main and effective medical therapy.
Many countries lack the regulatory framework to address these pseudotherapies, which
has allowed their proliferation. In the past, the medical profession considered them to be
harmless due to their perceived lack of side effects, but nowadays there is enough
evidence to suggest that they can pose a risk to patient safety.
Pseudoscience and Pseudotherapies may have significant potential risks and harms for
various reasons:
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There is a risk that patients abandon effective proved-to-be effective medical treatments or
prevention measures in favour of practices that have not demonstrated therapeutic value,
sometimes leading to treatment failure for critical conditions that may even lead to death.
There are frequent likelihood of dangerous delays and loss of opportunity in the
application of medicines, procedures and techniques recognised and endorsed by the
scientific medical community as evidence-based effective interventions.
They may cause patients to suffer financial damages psychological-physical traumas, and
go against the dignity of people, threatening their moral integrity.
Unproven therapies may contribute to the rising costs of healthcare procedures.
All new diagnostic, preventive and therapeutic methods should be tested in accordance
with scientific methods and ethical principles in order to assess their safety, efficiency,
efficacy and scope of application.
A physician’s duty is to provide quality medical care to all patients based on best available
scientific evidence, as referred in the WMA Declaration of Geneva and the International
Code of Medical Ethics commending the highest ethical norms and quality care for the
safety of the patient. The interest of the patient must be placed before any other interest,
including the physician’s own.
The WMA reaffirms its Lisbon Declaration on Patient Rights and recalls that Patient
Safety requires addressing all opportunities for the patient to receive appropriate,
evidence-based care.
RECOMMENDATIONS
Thus, the WMA makes the following recommendations:
National Health Authorities
1. Appropriate and rigorous regulation commensurate with best practices is necessary
to address the risks and reduce the potential harms arising from pseudotherapies
and pseudoscience.
2. National authorities and healthcare systems should decline approval of and
reimbursement of costs providing pseudotherapies.
3. In collaboration with professional medical organizations, scientific societies and
patients’ associations, national authorities should develop public campaign raising
awareness on the risk of pseudotherapies and pseudosciences.
WMA Constituent members and the medical profession
4. WMA constituent members and the medical profession must recognize and be
aware of the risks of pseudotherapies and pseudosciences.
5. Pseudotherapies and pseudosciences should not be regarded as medical specialties
recognized by the scientific community and legally endorsed as a specialist or sub-
D-2020-02-2020 ⏐ Cordoba
Pseudoscience and Pseudotherapies
specialist pseudoscience.
6. All acts of professional intrusion , pseudoscience and pseudotherapy activities that
put public health at risk must be reported to the competent authorities, including
misleading advertising and unaccredited healthcare websites that offer services
and/or products and that put the health of patients at risk, yet patient confidentiality
has to be respected. The role of the general and specialized media for transparency
and truthfulness in increasing critical public scientific awareness is essential.
7. Constituent members should work with governments to establish the highest level
of protection for patients treated with pseudotherapies/pseudosciences. When such
a practice is found to be harmful or unethical to apply, there should be a system in
place to either immediately stop or substantially restrict any given treatment
classified as complementary and/or alternative in order to protect public health.
Physicians
8. With the support of the relevant organizations and authorities involved in the
governance and regulation of the medical profession, physicians must continue to
practice medicine as a service based on the application of critical scientific current
knowledge, specialist skills and ethical behaviour and to maintain their skills up to
date on developments in their professional field.
9. For the patient’s safety and quality of care, the physician must have the freedom to
prescribe, while respecting scientific evidence and the standard of care.
10. The patient must be kept duly informed about the available therapy options, their
effectiveness and risks, and be able to participate in the best therapeutic decision-
making. Good communication, mutual trust and person-centered healthcare are
cornerstones of the physician-patient relationship. Patients and physicians should
and must be able to discuss the risks of pseudoscience and pseudotherapies. Health
education is fundamental.
11. Physicians should be educated to identify pseudoscience/pseudotherapies, logical
fallacies, and cognitive biases and counsel their patients accordingly. They should
be aware that some patient groups, such as patients with cancer, psychiatric
illnesses or serious chronic diseases, as well as children, are particularly vulnerable
to the risks associated with using pseudotherapies.
12. When obtaining the patient’s history (anamnesis), the physician should inquire
about all therapeutic measures (proven or otherwise) the patient has been exposed
or is still exposed to. If necessary, the physician should inform the patient on
potential harms associated with the previous use of Pseudotherapies and
pseudosciences.
13. The physician must inform the patient that complementary treatment is not a
therapeutic alternative or substitute for a validated main medical treatment.
Handbook of WMA Policies
World Medical Association ⏐ D-2020-02-2020
Note: The aim of this declaration is not the traditional ancestral medicines nor the so-
called indigenous medicines, firmly rooted in peoples and nations, forming an intrinsic
part of their culture, rites, traditions and history.
Handbook of WMA Policies
World Medical Association D-2022-01-2022
WMA DECLARATION OF BERLIN
ON RACISM IN MEDICINE
Adopted by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Racism is rooted in the false idea that human beings can be ranked as superior or inferior based
on inherited physical traits. This harmful social construct has no basis in biological reality;
however, racist policies and ideas have been used throughout history and are still used to
perpetuate, justify, and sustain unequal treatment.
Despite the fact that races do not exist in the genetic sense, in some cultures racial categories
are used as a form of cultural expression or identity, or a means of reflecting shared historical
experiences. This is one aspect of the concepts of “ethnicity” or “ancestry”.
Acknowledging that the words “race” and “racial” have different connotations in different
linguistic and cultural contexts, these terms are used throughout this document to denote
socially constructed categories and not a biological reality.
While the false conflation of racial categories with inherent biological or genetic traits has no
scientific basis, the detrimental impact racial discrimination has on historically marginalized
and minoritized communities is well documented. The experience of racism in all its forms –
for example, interpersonal, institutional, and systemic – is recognized as a social determinant
of health and a driving force behind persistent health inequities, as noted in the WMA
Declaration of Oslo on Social Determinants of Health. These inequities can be compounded by
other factors like national origin, age, gender, sexual orientation, religion, socioeconomic
status, disabilities, and more. Individuals subjected to racism are often also affected negatively
by other social determinants of health.
Racially motivated violence and overt bias, housing and employment discrimination, education
and health care inequity, environmental injustice, daily microaggressions, pay gaps, and the
legacy of intergenerational trauma experienced by those who are subjected to racism are just
some of the many factors that may impact health and illustrate why racism poses a serious
threat to public health. These and other structural barriers faced by historically marginalized
communities can lead to disproportionate rates of infant and maternal mortality and certain
illnesses, mental health struggles, poorer health outcomes, as well as shorter life expectancies.
Racism in Medicine
Berlin D-2022-01-2022
Racism in medicine
With the WMA Declaration of Geneva, the Physician’s Pledge, the physician vows to respect
the dignity of all patients, to respect teachers, colleagues, and students, and to “not permit
considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political
affiliation, race, sexual orientation, social standing or any other factor to intervene between
[the physician’s] duty and [the] patient.”
Nonetheless, racism in all its forms also exists in medicine throughout the world and has a
direct impact on patients and their health. Systemic racial disparities in access to care and health
resources at a global and local scale can translate to disparities in health outcomes.
At the interpersonal level, prejudice and stereotypes held and acted upon by medical
professionals can lead them to be reluctant to see patients or dismissive of symptoms from
patients from marginalized communities, which can result in suboptimal communication, as
well as inappropriate or delayed treatment. Racism can hinder or undermine the foundation of
trust that is essential to a successful patient-physician relationship.
Physicians from marginalized communities also face racism from patients, other physicians,
and health professionals. This can take the form of bullying, harassment, and professional
undermining in the workplace. These distressing experiences may not only impact the
physician’s health and well-being, but consequently the physician’s performance. They may
also leave marginalized physicians less confident to raise concerns about patient safety for fear
of being blamed or suffering adverse consequences. Large and growing racial disparities in
adequate professional treatment and advancement opportunities can have an impact on
physicians’ career trajectories.
Furthermore, systemic racism can create barriers to entry to the medical profession for certain
historically excluded groups, leading to a lack of representation, which may contribute to
adverse health outcomes for patients. These barriers are caused by a variety of factors,
including implicit and explicit bias in admissions and hiring practices, a dearth in inclusive
professional environments, and lifelong racial disparities in educational funding.
A medical profession that is representative of the population is crucial to addressing health
disparities among patients.
Racism in medical education
In medical education, implicit and explicit bias not only impact the admissions process, but
also the curriculum, faculty development, and how marginalized students are treated and
assessed. Non-inclusive and harmful learning environments can leave minoritized students
with an increased risk of anxiety and depression. In addition, learning materials and curricula
often do not reflect a diversity of experiences, imagery, and disease presentations and fail to
address the issue of racism in medicine head-on.
Handbook of WMA Policies
World Medical Association D-2022-01-2022
Racism in medical research / medical journals
Structural racism also influences participation and therefore inclusivity in medical research.
Historical examples of unethical experimentation or research in the absence of informed
consent on marginalized communities have led to a high level of mistrust of the medical
establishment. On the other hand, exclusion of marginalized groups from clinical trials results
in a lack of data about how certain drugs, treatments, or health conditions might impact
individuals in those groups. A lack of racial data transparency can lead to a lack of
understanding about how racial disparities lead to health inequities. It can also jeopardize the
potential of artificial intelligence to reveal and override biases in medicine. Algorithms are only
as inclusive as the health and technology professionals who create them.
Furthermore, medical journals – the gatekeepers of evidence-based research – have generally
been remiss in addressing the issue of racism and its impact on health inequities, as well as in
addressing underrepresentation among journal decision makers and authors.
DECLARATION
Therefore, the World Medical Association
• condemns unequivocally racism in all its forms and wherever and whenever it occurs;
• declares racism to be a public health threat;
• acknowledges that racism is structural and deeply engrained in health care;
• asserts that racism is based on a social construct with no basis in biological reality and
that any effort to claim superiority by exploiting racist assumptions is unethical, unjust,
and harmful;
• recognizes that the experience of racism is a social determinant of health and
responsible for persistent health inequities;
• commits to actively promote equity and diversity in medicine and to strive for an
inclusive and equitable health environment.
RECOMMENDATIONS
The WMA urges its members and all physicians to:
1. enact the above-mentioned declaration in their own organizations;
2. acknowledge the harmful impact of racism on the health and well-being of marginalized
communities and act upon it;
3. promote equitable access to health and other societal resources locally, nationally and on a
global scale;
Racism in Medicine
Berlin D-2022-01-2022
4. commit to actively work to dismantle racist policies and practices in health care and
advocate for antiracist policies and practices that support equity in health care and social
justice;
5. implement organizational and institutional changes to foster diversity in the medical
profession and the organizations that support it;
6. support and, where possible, implement admissions and curriculum changes in medical
education that promote inclusivity and raise awareness about the harmful impact of racism
on health;
7. promote just and safe learning environments in medical education;
8. promote equitable access to quality medical and public health education;
9. center the experiences of physicians from underrepresented communities to ensure the
visibility of role models and foster a feeling of inclusivity and empowerment among
prospective students from historically marginalized communities;
10. ensure safe, supportive, and respectful work environments for all physicians, including
those from historically marginalized communities;
11. establish channels for physicians and students of medicine to safely report cases of racially
motivated harassment or bias;
12. enact disciplinary measures against perpetrators of racial harassment or bias in the medical
profession and implement measures to prevent such harassment and discrimination, to
protect those who suffer from it and to eliminate it from the medical field;
13. take measures to identify research gaps and promote evidence-based research on the health
impact of racism;
14. encourage medical journals to amplify the voices of medical researchers and health experts
from underrepresented and historically excluded communities;
15. make all efforts to promote representation in ethically conducted clinical trials in
accordance with the WMA Declaration of Helsinki as a means of advancing health equity;
16. promote further research on the impact of racism in the health system.
Handbook of WMA Policies
World Medical Association D-2022-02-2022
WMA DECLARATION OF BERLIN
ON
DISCRIMINATION AGAINST ELDERLY INDIVIDUALS WITHIN
HEALTHCARE SETTINGS
Adopted by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The ageing of the population due to increased life expectancy is one of the main challenges of
many health systems given the increasing amount of resources needed to provide healthcare
for the elderly population. This puts a strain on these systems, since ageing often causes a
higher demand for care, with a high dependence on medical, pharmaceutical and hospital
services. On the other hand, older people are perceived as recipients of help, care and financial
support, which is inaccurate, as they make significant contributions to the well-being of their
environment, which has a high social value.
The increase in longevity must be accompanied by appropriate quality-of-care standards,
promoting health, reducing risk factors, and providing accessible and sustainable quality health
and social services that are accessible, affordable, sustainable and which are of quality.
Biological age should never be used as a basis for discrimination, although it can be a relevant
factor in medical decision-making. Reference to age can therefore be professionally sound.
Health discrimination in elderly patients
Elderly individuals experience all kinds of discrimination with one of the main types of
discrimination being related to health. The elderly may be perceived as a burden on the
healthcare systems and their financial sustainability. Elderly individuals are not uniquely
responsible for the increase in healthcare costs in developed countries. There are other factors
that play a key role in healthcare costs, such as the improvement in standards of living,
accessibility to health services, quality of care and the use of new technologies.
Rationing of certain costly and time-consuming diagnostic or therapeutic procedures or
particular settings that have a certain more expensive intensity of care is more common in the
elderly population. Clinical trials often exclude patients of a certain age, even if they meet the
criteria for enrolment.
Discrimination against Elderly Individuals
Berlin D-2022-02-2022
Age has become a barrier when putting patients forward for certain interventions. The reasons
tend to be physical; however, these may be underpinned by economic motivations, such as the
recovery time being higher which increases the length of hospital stay, or by arguing that there
are scarce resources and that elderly people have a shorter life expectancy.
There is consensus that from a physiological and psychological point of view, the determining
factors for health in ageing patients are intrinsically linked to gender; therefore, the solutions
need to address the differences between genders in order to reduce inequalities.
Health discrimination experienced by elderly individuals may have a negative impact on their
physical, mental and social well-being and contributes to deterioration in their quality of life,
loss of autonomy, confidence, safety and an active lifestyle, in turn, decreasing their levels of
health. Is therefore a complex topic that requires the involvement of professionals, institutions,
healthcare systems and authorities. Dealing with such discrimination requires awareness and
coordination aided by moral and legal principles.
The need for a holistic approach
Healthcare systems do not always adapt to the changing population needs, as may occur with
some hospitals, designed to care for adult patients with acute illnesses yet not elderly patients
with chronic illnesses.
An increase in longevity must be accompanied by the highest quality-of-care standards, and
should promote health, reduce risk factors, and provide accessible, sustainable and quality
health and social services. Emphasis should be on patient-focused medicine that heals, cares
for, alleviates and comforts.
The ethical duty of physicians
In line with the WMA Declaration of Geneva, physicians must strive to improve the health,
well-being and quality of life for all patients without any forms of discrimination towards the
elderly.
RECOMMENDATIONS
Recalling its Declarations of Geneva and of Lisbon on the Rights of the Patient, and its
Statement on Ageing, the WMA makes the following recommendations:
To governments, medical associations and physicians
1. As priority actions, to defend the human rights and health of all individuals, including the
elderly, as well as to ensure that their dignity is respected;
To governments
2. Develop appropriate and non-discriminatory healthcare policies for the elderly based on
the efficient use of available healthcare resources;
Handbook of WMA Policies
World Medical Association D-2022-02-2022
3. To establish measures to eradicate discrimination against elderly individuals in healthcare;
4. Provide sufficient resources which ensure adequate healthcare for elderly individuals;
To the WMA, its members and the medical profession in general
5. To commit to eliminating all forms of discrimination due to health and age;
6. Promote training for primary care physicians on how to approach health problems in elderly
individuals;
7. Promote development of the geriatric specialty or supplementary post-graduate training and
increase of the number of physicians in this field, an increase of the number of physicians
in this speciality and an adequate number of geriatric departments in hospitals and
consultants, in order to ensure the availability of comprehensive care for elderly
individuals;
8. Raise awareness and take action against discrimination of elderly individuals;
9. Promote ethical, responsible, effective and efficient practices for treating the elderly;
10. To set ethical standards that aim to prevent discrimination against any individual due to
age;
11. To actively try to include elderly patients in medical scientific research;
To physicians
12. Not limit or impede patients’ autonomy on the basis of their age;
13. Provide healthcare of scientific and human quality according to good medical practice to
all patients, without any discrimination;
14. Not apply limitations solely based on age in protocols for diagnosis and treatment;
15. To report any discrimination against the elderly that is observed in healthcare.
Handbook of WMA Policies
World Medical Association ⏐ S-1956-01-2012
WMA REGULATIONS
IN
TIMES OF ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
Adopted by the 10th
World Medical Assembly, Havana, Cuba, October 1956
and edited by the 11th
World Medical Assembly, Istanbul, Turkey, October 1957
and revised by the 35th
World Medical Assembly, Venice, Italy, October 1983
and the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and editorially revised by the 173rd
WMA Council Session, Divonne-les-Bains, France,
May 2006
and revised by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
GENERAL GUIDELINES
Medical ethics in times of armed conflict is identical to medical ethics in times of peace,
as stated in the International Code of Medical Ethics of the WMA. If, in performing their
professional duty, physicians have conflicting loyalties, their primary obligation is to their
patients; in all their professional activities, physicians should adhere to international con-
ventions on human rights, international humanitarian law and WMA declarations on medi-
cal ethics.
The primary task of the medical profession is to preserve health and save life. Hence it is
deemed unethical for physicians to:
• Give advice or perform prophylactic, diagnostic or therapeutic procedures that are
not justifiable for the patient’s health care;
• Weaken the physical or mental strength of a human being without therapeutic
justification;
• Employ scientific knowledge to imperil health or destroy life;
• Employ personal health information to facilitate interrogation;
• Condone, facilitate or participate in the practice of torture or any form of cruel, in-
human or degrading treatment.
During times of armed conflict and other situations of violence, standard ethical norms
apply, not only in regard to treatment but also to all other interventions, such as research.
Research involving experimentation on human subjects is strictly forbidden on all persons
deprived of their liberty, especially civilian and military prisoners and the population of
occupied countries.
The medical duty to treat people with humanity and respect applies to all patients. The
physician must always give the necessary care impartially and without discrimination on
the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political af-
filiation, race, sexual orientation, or social standing or any other similar criterion.
S-1956-01-2012 ⏐ Bangkok
Armed Conflict
Governments, armed forces and others in positions of power should comply with the
Geneva Conventions to ensure that physicians and other health care professionals can
provide care to everyone in need in situations of armed conflict and other situations of
violence. This obligation includes a requirement to protect health care personnel and
facilities.
Whatever the context, medical confidentiality must be preserved by the physician. However,
in armed conflict or other situations of violence, and in peacetime, there may be cir-
cumstances in which a patient poses a significant risk to other people and physicians will
need to weigh their obligation to the patient against their obligation to other individuals
threatened.
Privileges and facilities afforded to physicians and other health care professionals in times
of armed conflict and other situations of violence must never be used other than for health
care purposes.
Physicians have a clear duty to care for the sick and injured. Physicians should recognise
the special vulnerability of some groups, including women and children. Provision of such
care should not be impeded or regarded as any kind of offence. Physicians must never be
prosecuted or punished for complying with any of their ethical obligations.
Physicians have a duty to press governments and other authorities for the provision of the
infrastructure that is a prerequisite to health, including potable water, adequate food and
shelter.
Where conflict appears to be imminent and inevitable, physicians should, as far as they are
able, ensure that authorities are planning for the protection of the public health infra-
structure and for any necessary repair in the immediate post-conflict period.
In emergencies, physicians are required to render immediate attention to the best of their
ability. Whether civilian or combatant, the sick and wounded must receive promptly the
care they need. No distinction shall be made between patients except those based upon
clinical need.
Physicians must be granted access to patients, medical facilities and equipment and the
protection needed to carry out their professional activities freely. Such access must include
patients in detention centres and prisons. Necessary assistance, including unimpeded
passage and complete professional independence, must be granted.
In fulfilling their duties and where they have the legal right, physicians and other health
care professionals shall be identified and protected by internationally recognized symbols
such as the Red Cross, Red Crescent or Red Crystal.
Hospitals and health care facilities situated in areas where there is either armed conflict or
other situations of violence must be respected by all combatants and media personnel.
Health care given to the sick and wounded, civilians or combatants, cannot be used for
publicity or propaganda. The privacy of the sick, wounded and dead must always be res-
Handbook of WMA Policies
World Medical Association ⏐ S-1956-01-2012
pected. This includes visits from important political figures for media purposes and also
when important political figures are among the wounded and the sick.
Physicians must be aware that, during armed conflict or other situations of violence, health
care becomes increasingly susceptible to unscrupulous practice and the distribution of
poor quality / counterfeit materials and medicines, and attempt to take action on such
practices.
The WMA supports the collection and dissemination of data related to assaults on phy-
sicians, other health care personnel and medical facilities, by an international body. Such
data are important to understand the nature of such attacks and to set up mechanisms to
prevent them. Assaults against medical personnel must be investigated and those res-
ponsible must be brought to justice.
CODE OF CONDUCT: DUTIES OF PHYSICIANS WORKING IN ARMED CONFLICT AND
OTHER SITUATIONS OF VIOLENCE
Physicians must in all circumstances:
• Neither commit nor assist violations of international law (international humanitarian
law or human rights law);
• Not abandon the wounded and sick;
• Not take part in any act of hostility;
• Remind authorities of their obligation to search for the wounded and sick and to
ensure access to health care without unfair discrimination;
• Advocate and provide effective and impartial care to the wounded and sick
(without reference to any ground of unfair discrimination, including whether they
are the “enemy”);
• Recognise that security of individuals, patients and institutions are a major
constraint to ethical behaviour and not take undue risk in the discharge of their
duties;
• Respect the individual wounded or sick person, his / her will, confidence and his /
her dignity;
• Not take advantage of the situation and the vulnerability of the wounded and sick
for personal financial gain;
• Not undertake any kind of experimentation on the wounded and sick without their
real and valid consent and never where they are deprived of liberty;
• Give special consideration to the greater vulnerability of women and children in
armed conflict and other situations of violence and to their specific health-care
needs;
• Respect the right of a family to know the fate and whereabouts of a missing family
member whether or not that person is dead or receiving health care;
• Provide health care for anyone taken prisoner;
• Advocate for regular visits to prisons and prisoners by physicians, if such a me-
chanism is not already in place;
• Denounce and act, where possible, to put an end to any unscrupulous practices or
distribution of poor quality/counterfeit materials and medicines;
S-1956-01-2012 ⏐ Bangkok
Armed Conflict
• Encourage authorities to recognise their obligations under international humani-
tarian law and other pertinent bodies of international law with respect to protection
of health care personnel and infrastructure in armed conflict and other situations of
violence;
• Be aware of the legal obligations to report to authorities the outbreak of any noti-
fiable disease or trauma;
• Do anything within their power to prevent reprisals against the wounded and sick
or health care;
• Recognise that there are other situations where health care might be compromised
but in which there are dilemmas.
Physicians should to the degree possible:
• Refuse to obey an illegal or unethical order;
• Give careful consideration to any dual loyalties that the physician may be bound
by and discuss these dual loyalties with colleagues and anyone in authority;
• As an exception to professional confidentiality, and in line with WMA Resolution
on the Responsibility of Physicians in the Documentation and Denunciation of
Acts of Torture or Cruel or Inhuman or Degrading Treatment and the Istanbul Pro-
tocol1
, denounce acts of torture or cruel, inhuman or degrading treatment of which
physicians are aware, where possible with the subject’s consent, but in certain
circumstances where the victim is unable to express him/herself freely, without
explicit consent;
• Listen to and respect the opinions of colleagues;
• Reflect on and try to improve the standards of care appropriate to the situation;
• Report unethical behaviour of a colleague to the appropriate superior;
• Keep adequate health care records;
• Support sustainability of civilian health care disrupted by the context;
• Report to a commander or to other appropriate authorities if health care needs are
not met;
• Give consideration to how health care personnel might shorten or mitigate the
effects of the violence in question, for example by reacting to violations of interna-
tional humanitarian law or human rights law.
1
Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment, OHCHR, 1999
Handbook of WMA Policies
World Medical Association ⏐ S-1970-01-2018
WMA STATEMENT
ON
MEDICALLY-INDICATED TERMINATION OF PREGNANCY
Adopted by the 24th
World Medical Assembly, Oslo, Norway, August 1970
and amended by the 35th
World Medical Assembly, Venice, Italy, October 1983
the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. Medically-indicated termination of pregnancy refers only to interruption of pregnancy
due to health reasons, in accordance with principles of evidence-based medicine and
good clinical practice. This Declaration does not include or imply any views on
termination of pregnancy carried out for any reason other than medical indication.
2. Termination of pregnancy is a medical matter between the patient and the physician.
Attitudes toward termination of pregnancy are a matter of individual conviction and
conscience that should be respected.
3. A circumstance where the patient may be harmed by carrying the pregnancy to term
presents a conflict between the life of the foetus and the health of the pregnant woman.
Diverse responses to resolve this dilemma reflect the diverse cultural, legal, traditional,
and regional standards of medical care throughout the world.
RECOMMENDATIONS
1. Physicians should be aware of local termination of pregnancy laws, regulations and
reporting requirements. National laws, norms, standards, and clinical practice related
to termination of pregnancy should promote and protect women’s health, dignity and
their human rights, voluntary informed consent, and autonomy in decision-making,
confidentiality and privacy. National medical associations should advocate that
national health policy upholds these principles.
2. Where the law allows medically-indicated termination of pregnancy to be performed,
the procedure should be performed by a competent physician and only in extreme
cases by another qualified health care worker, in accordance with evidence-based
medicine principles and good medical practice in an approved facility that meets
required medical standards.
3. The convictions of both the physician and the patient should be respected.
4. Patients must be supported appropriately and provided with necessary medical and
psychological treatment along with appropriate counselling if desired.
S-1970-01-2018 ⏐ Reykjavik
Medically-Indicated Termination of Pregnancy
5. Physicians have a right to conscientious objection to performing an abortion;
therefore, they may withdraw while ensuring the continuity of medical care by a
qualified colleague. In all cases, physician must perform those procedures necessary to
save the woman’s life and to prevent serious injury to her health.
6. Physicians must work with relevant institutions and authorities to ensure that no
woman is harmed because medically-indicated termination of pregnancy services are
unavailable.
Handbook of WMA Policies
World Medical Association ⏐ S-1983-01-2017
WMA STATEMENT
ON
BOXING
Adopted by the 35th
World Medical Assembly, Venice, Italy, October 1983
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
1. Boxing is a dangerous sport. Unlike other sports, its basic intent is to produce
bodily harm by specifically targeting the head. The main medical argument against
boxing is the risk of chronic traumatic encephalopathy (CTE), also known as
chronic traumatic brain injury (CTBI), and dementia pugilistica or “punch-drunk”
syndrome. Other injuries caused by boxing can lead to loss of sight, loss of
hearing, and fractures. Studies show that boxing is associated with devastating
short-term injuries and chronic neurological damage on the participants in the long
term.
2. The past few decades have witnessed vigorous campaigns by national medical
bodies to have all forms of boxing abolished. In the absence of such a ban, a series
of boxing tragedies worldwide has pressured various sports regulatory bodies to
adopt a variety of rules and standards to enhance the safety of boxers.
3. Despite regulation of boxing in various countries, injuries and death still occur as a
result of boxing related head trauma, indicating that regulation does not provide
adequate protection to participants.
4. In addition to regulated boxing, unchecked and unsupervised boxing competitions
(bareknuckle battles or “street fights”) still take place in many parts of the world.
This underground boxing puts at risk the lives and health of a significant number
of persons who participate in these fights.
5. Health and safety concerns in boxing extend to other professional sports where
boxing is a component, such as mixed martial arts (MMA), kickboxing etc. For
this reason, the recommendations in this statement should be applied to these
sports as well.
6. The WMA believes that boxing is qualitatively different from other sports because
of the injuries it causes and that it should be banned.
7. Until a full ban is achieved the WMA urges that the following measures be
implemented:
S-1983-01-2017 ⏐ Chicago
Boxing
7.1 Boxing must be regulated and all boxers licensed. Boxers should be provided
with written information on the risks of participating in boxing.
7.2 No children (as per country-specific definition) should be permitted to
participate in boxing.
7.3 A national registry of all amateur and professional boxers, including sparring
partners, should be established in each country where boxing is allowed. The
registry should record the results of all matches, including technical
knockouts, knockouts, and other boxing injuries, and compile injury records
for individual boxers. All boxers should be followed up for a period of at least
twenty years to document long-term outcomes.
7.4 All boxers should undergo a baseline medical examination, which should
include neurological assessment, including brain imaging, at the beginning of
their careers. Medical and neurological assessments should also be performed
before and after each event. Boxers who do not pass the examination must be
reported to the national registry and must not be allowed to participate in
future matches.
7.5 Personal protective equipment recommendations (such as size and weight of
gloves, head gear and gum shields) should take into consideration medical
recommendations.
7.6 A physician serving at a boxing match has a professional responsibility to
protect the health and safety of the contestants. To that end, the physician
should receive specialized training in athlete evaluation, especially traumatic
brain injury assessment. The physician’s judgment should be governed only by
medical considerations, and the physician must be allowed to stop any match
in progress to examine a contestant and to terminate a match that, in the
physician´s opinion, could result in serious injury.
7.7 Funding and sponsorship of boxing should be discouraged, and TV coverage of
boxing events should be age restricted and include a warning statement on the
risks of boxing.
Handbook of WMA Policies
World Medical Association ⏐ S-1984-01-2017
WMA STATEMENT
ON
CHILD ABUSE AND NEGLECT
Adopted by the 36th
World Medical Assembly, Singapore, October 1984
and amended by the 41st
World Medical Assembly, Hong Kong, September 1989
42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
44th
World Medical Assembly, Marbella, Spain, September 1992
47th
WMA General Assembly, Bali, Indonesia, September 1995
and the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and 67th
WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
OVER-ARCHING PRINCIPLE
1. The welfare of children[1] is of paramount importance. Health professionals should
put the welfare of children at the centre of all decision-making related to the child and
act in the best interests of children in all of their interactions with children, young
people, families, policy-makers and other professionals.
INTRODUCTION
2. One of the most destructive manifestations of family violence and upheaval is child
abuse[2] in all its forms. Prevention, protection, early identification, suitable
interventions and comprehensive treatment of child abuse victims remain challenging
for the world medical community. The World Medical Association (WMA) has called
for increased health support of children living on the streets in its Statement on
Supporting Health Support to Street Children, but it is also important to address the
root causes of child abuse in all its forms.[3]
3. Definitions of child abuse vary from culture to culture. Unfortunately, cultural
rationalizations for harmful behaviour toward children may be accepted all too readily
as proof that the treatment of children is neither abusive nor harmful. For instance, the
work contribution of children in the everyday lives of families and in society should be
recognized and encouraged only as long as it also contributes to the child’s own
development. In contrast, exploitation of children in the labour market deprives them
of their childhood and of educational opportunities and endangers their present and
future health. The WMA considers such exploitation of children a serious form of
child abuse in all its forms.
4. For the purposes of this Statement, the various forms of child abuse include emotional
abuse, physical abuse, sexual abuse, child trafficking, child exploitation and child
neglect. Child neglect represents a failure of a parent, or other person legally
responsible for a child’s welfare, to provide for the child’s basic needs and an adequate
level of care.
S-1984-01-2017 ⏐ Chicago
Child Abuse and Neglect
RECOMMENDATIONS
The WMA recognizes that child abuse in all its forms is a world health problem and
recommends that National Medical Associations adopt the following guidelines for
physicians:
5. Physicians have both a unique and special role in identifying and helping abused
children and their families.
6. All physicians should be educated about the paramount importance of the welfare of
children.
7. Physicians must be aware of and observe local laws regarding consent to undertake
examinations of children. Physicians must act in the best interests of children in all of
their interactions with children, young people, families, policy-makers and other
professionals.
8. Collaboration with an experienced multidisciplinary team is strongly recommended for
the physician. Such a team is likely to include physicians, social workers, child and
adult psychiatrists, developmental specialists, psychologists and attorneys. When
participation in a team is not possible or such a team is not available, the physician
must consult with other medical, social, law enforcement and mental health personnel
as appropriate.
9. Primary care physicians, family practitioners, internists, paediatricians, emergency
medicine specialists, surgeons, psychiatrists and other specialists who treat children
must acquire knowledge and skills in the physical, psychological and emotional
assessment of child abuse in all its forms, the assessment of child development and
parenting skills, the utilization of community resources, and the physician’s legal
responsibilities.
10. All physicians who treat children, and those adults with caring responsibilities for
children, should be aware of the principles of the UN Convention on the Rights of the
Child as well as relevant national protective legal provisions applying to children and
young people.
11. The medical evaluation of children who are suspected of having been abused should
be performed by physicians skilled in both paediatrics and abuse evaluation. The
medical evaluation needs to be tailored to the child’s age, injuries, and condition and
may include blood testing, a trauma radiographic survey, and developmental and
behavioural screenings. Follow up radiographs are strongly urged in some children
who present with serious, apparently abusive injuries.
12. The medical assessment and management of sexually abused children includes a
complete history and physical examination, as physical and sexual abuses often occur
together; examination of the genitalia and anus; the collection and processing of
evidence, including photographs; and the treatment and/or prevention of pregnancy
and venereal disease. Specific attention should be paid to the child’s right to privacy.
13. It is essential for the physician to understand and be sensitive to the following: the
quality of relationships between care-givers; disciplinary actions or styles used within
the child’s home; economic stresses on the family; emotional stresses or issued
Handbook of WMA Policies
World Medical Association ⏐ S-1984-01-2017
experienced by members of the family; mental health problems exhibited by any
members of the family; violence between the care-givers or other members of the
family; substance use and abuse, including alcohol and legal and illegal drugs; and any
other forms of stress that could relate to child abuse in all its forms.
14. All physicians need to be aware that all forms of abuse of children by other children
can occur. Recognition that this may be a result of prior or current abuse of the
alleged abuser must be at the forefront of the physician’s mind when such situations
are suspected or encountered.
15. The signs of abuse are often subtle, and the diagnosis may require comprehensive,
careful interviews with the child, parent(s), care-givers, and siblings. Inconsistencies
among explanation(s) and characteristics of the injury(s), such as the severity, type and
age, should be documented and further investigated.
16. In any child presenting to a medical facility, the emergent medical and mental health
needs should be addressed first. If abuse is suspected, safety needs must be addressed
prior to discharge from the facility. These measures should include:
• Reporting all suspected cases to child protective services;
• Hospitalizing any abused child needing protection during the initial evaluation
period;
• Informing the parents of the suspicion of abuse or diagnosis of abuse if it is
safe to do so; and
• Reporting the child’s injuries to child protective services or other relevant
authorities.
17. If hospitalization is required, a prompt evaluation of the child’s physical, emotional
and developmental problems is necessary. This comprehensive assessment should be
conducted by physicians with expertise or through a multidisciplinary team of experts
with specialized training in child abuse.
18. If child abuse is suspected, the physician should discuss with the parent(s) the fact that
child abuse is in the differential diagnosis of their child’s problem. Advice may be
required from child protective services.
19. During discussions with the parent(s), guardians, or care-givers it is essential that the
physician maintain objectivity and avoid accusatory or judgmental statements in
interactions with the parent(s) or individual(s) responsible for the child’s care.
20. It is essential that the physician record the history and examination findings in the
medical chart contemporaneously during the evaluation process. Injuries should be
documented using photographs, illustrations, and detailed descriptions. The medical
record often provides critical evidence in court proceedings.
21. Physicians should participate at all levels of prevention by providing prenatal and
postnatal family counselling, identifying problems in child rearing and parenting, and
advising about family planning and birth control.
22. Public health measures such as home visits by nurses and other health professionals,
anticipatory guidance by parents, and well-infant and well-child examinations should
be encouraged by physicians. Programs that improve the child’s general health also
tend to prevent child abuse in all its forms and should be supported by physicians and
S-1984-01-2017 ⏐ Chicago
Child Abuse and Neglect
their representative bodies.
23. Physicians should recognize that child abuse and neglect is a complex problem and
more than one type of treatment or service may be needed to help abused children and
their families. The development of appropriate treatment requires contributions from
many professions, including medicine, law, nursing, education, psychology and social
work.
24. Physicians should promote the development of innovative programs that will advance
medical knowledge and competence in the field of child abuse and neglect. Inclusion
of on-going reviews of knowledge, skills and competency in relation to protecting the
rights of children and young people, promoting their health and well-being and the
recognition of and response to suspected cases of child abuse and neglect is crucial in
professional educational programs. Physicians should obtain education on child
neglect and abuse in all its forms during training as medical students.
25. In the interests of the child, patient confidentiality may be waived in cases of child
abuse. The first duty of a doctor is to protect his or her patient if victimization is
suspected. No matter what the type of abuse (including physical abuse, emotional
abuse, sexual abuse, trafficking, exploitation or neglect), an official report must be
made to the appropriate authorities.
26. Inclusion of on-going reviews of knowledge, skills and competency in relation to
protecting the rights of children and young people, promoting their health and well-
being and the recognition of and response to suspected cases of child abuse in all its
forms and neglect is crucial in professional educational programmes.
27. The undergraduate medical curriculum must include a mandatory course on child
abuse, in all its forms, within the paediatrics program, that can be developed within
postgraduate and continuing medical education for those intending to work within this
field.
[1] The United Nations Convention on the Rights of the Child defines a child as anyone who
has not reached their 18th birthday.
[2] Child abuse and Child maltreatment are used synonymously in this Statement.
[3] Neglect is the persistent failure to meet a child’s basic needs, likely to result in the serious
impairment of a child’s health, well-being or development.
Handbook of WMA Policies
S-1984-02-2020 ⏐ World Medical Association
WMA STATEMENT
ON
FREEDOM TO ATTEND MEDICAL MEETINGS
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, whether philosophical, religious, racial, political, geographic, physical or of any
other nature to prevent physicians from participating in professional activities that will
enable them to acquire the information, knowledge, skills and techniques required to pro-
vide 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.
Handbook of WMA Policies
World Medical Association ⏐ S-1985-01-2015
WMA STATEMENT
ON
NON-DISCRIMINATION IN PROFESSIONAL MEMBERSHIP
AND ACTIVITIES OF PHYSICIANS
Adopted by the 37th
World Medical Assembly, Brussels, Belgium, October 1985
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and revised by the 66th
WMA General Assembly, Moscow, Russia, October 2015
The World Medical Association is in favour of equality of opportunity in medical associa-
tion activities, medical education and training, employment, and all other medical profess-
sional endeavours regardless of any factors of discrimination.
The World Medical Association is unalterably opposed to the denial of membership pri-
vileges and responsibilities in National Medical Associations to any duly registered physi-
cian because of any factors of discrimination.
The World Medical Association calls upon the medical profession and all individual
members of National Medical Associations to exert every effort to prevent any instance in
which such equal rights, privileges or responsibilities are denied.
Handbook of WMA Policies
S-1988-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
ACCESS TO HEALTH CARE
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Health is not simply the absence of illness, but is also more than a state of physical,
psychological and social flourishing, and includes an individual’s ability to adapt to
physical, social and mental adversity. It is affected by many factors, including
access to health care and especially the Social Determinants of Health (SDH), and
its restoration is similarly multidimensional. Society has an obligation to make
access to an adequate level of care available to all its members, regardless of ability
to pay.
2. Health care professionals regularly confront the effects of lack of access to adequate
care and health inequality and have a corresponding responsibility to contribute their
expertise to work with governments at local, regional and national levels to ensure
they understand the Social Determinants of Health and integrate reduction of factors
leading to inequality into all policies. Health care policies should suggest ways to
eliminate health inequality.
3. Access to health care is an important factor in reducing the short, medium and long
term consequences of poor health, caused by adverse social and other conditions.
Access is itself multidimensional, and is constrained by factors including health
human resources, training, finance, transportation, geographical availability,
freedom of choice, public education, quality assurance and technology.
GUIDELINES
Health Human Resources
4. The delivery of health care is highly dependent upon the availability of trained
health care workers. The training should not only include socio-medical
competencies, but particularly emphasize an understanding of how the social
determinants of health affect people’s health outcomes.
The distribution of health care workers varies widely as do the demographics in
most countries, where an ageing population forms a huge challenge for the years to
come. There is global mal-distribution. While all countries train health care workers,
global movement, especially from less to better developed countries, is leading to
continuing shortages. The development of ethical recruitment codes may help to
reduce inappropriate recruitment activities by states. Ethical recruitment codes
should also be applied to commercial recruitment agencies.
S-1988-01-2017 ⏐ Chicago
Access to Health Care
5. Research is needed to determine the best mix of different health care workers for
different clinical settings to meet the needs of populations. Mal-distribution within
countries should be addressed by seeking methods of attracting health care workers
to rural and remote areas, or other underserved regions, at least for a part of their
careers. Innovative concepts should be explored to make working in underserved
areas interesting; punitive and coercive recruiting methods must not be used.
Recruiting students who express a wish to return to their home area may help to
alleviate this problem.
Training
6. Primary training of health care workers has to be appropriate, accessible and of good
quality, which makes the training costly, with the country of origin meeting this
cost. Workers move to continue with secondary training, including higher
professional training and specialisation for physicians, and also to earn more money
that may be remitted home to support the family and community.
7. The ambition for self-improvement is understandable; efforts to increase retention of
health care workers should include consideration of encouraging a return to the
home country, with use of the new skills and knowledge to improve health care
access.
8. Countries should not actively recruit from other states. Even when they do so
passively, this recruitment should take place in accordance with ethical standards
and the WMA Statement on Ethical Guidelines for the International Migration of
Health Care workers.
Finance
9. Access to care is essential for the whole population. Methods of financing care are
for each country to decide, according to their own resources, health and social
priorities, and health needs. Countries should develop revenue systems that reduce
reliance on out-of-pocket payments and private health insurance as these increase
inequalities between population groups.
10. No single system of finance is ideal for every country; the exact balance needs to be
locally decided. In making decision about financing systems governments must
understand the essential nature of health care, the absolute requirement that it be
available to all, based upon clinical need and not on the ability to pay, and that
access can be constrained by financial fears. Eligibility for care does not ensure
access, especially if co-payment schemes exclude those with the fewest financial
resources.
11. Innovative means should be used to provide comprehensive health care, including
partnerships with private providers and commercial entities, who may be able to
provide elements of specialised care. In doing so states must ensure that this does
not limit specialised care to the wealthiest proportion of their population nor should
this be seen as a preference for a private health care model.
12. Decisions to limit access to elements of health care should be done on the basis of
objective information, based on the best available scientific data about the efficacy
Chicago⏐ S-1988-01-2017
Access to Health Care
and safety of health care services. It must include public debate about, and
acceptance of, the concepts involved. Nothing should be introduced which
discriminates against the elderly or vulnerable populations.
13. The public should have access to clear information on the health care resources
available to them and how they may be accessed. Specific processes should be
established to ensure that poverty or illiteracy will never be a barrier to access care.
Vulnerable and hard to reach people
14. There are groups of people in every country who are hard to reach with health care
messages, and who often seek health care late in the progress of disease.
15. A variety of methods should be used to ensure hard to reach people are aware of the
availability of health care, without direct cost, including methods to reduce fear and
other barriers to access.
16. Where specific vulnerabilities such as learning disabilities or sensory impairments
exist, solutions should include identifying and dealing with those vulnerabilities.
17. Health care workers have a duty to provide care that is free from any form of unfair
discrimination.
Transportation
18. Health care facilities should be situated in locations that are easy to access. This may
mean working with local transportation providers to ensure formal and informal
public transport routes pass the facilities. Consideration should be made to making
health care facilities more accessible by active transport methods. Especially in rural
and remote locations, patients may travel considerable distances to attend the
facilities.
19. Patients who need referral to secondary and specialized care should be provided
with access to transportation. Those needing help with accessing primary care
should also receive support. Transportation should also be offered to isolated rural
patients who require a level of care that can be found only in metropolitan medical
centres. Telemedicine can sometimes be an acceptable substitute for transportation
of patients.
Geographical availability
20. Working with other health providers, including traditional birth attendants, may
provide assistance. They should be integrated into the health care system, offered
training, and be assisted to offer care that is safe and effective and that includes
referral where necessary. This does not extend to the state health care system
providing or funding care which is not evidence based, including so-called
complementary therapies.
Freedom of choice
21. The freedom to choose care providers, and the options of care they offer is an
essential element of care in every system. It requires the ability to understand that
S-1988-01-2017 ⏐ Chicago
Access to Health Care
choice, and the freedom to choose a provider from among alternatives.
22. Barriers to freedom of choice may lie in access to financial resources, understanding
of the options, and in cultural geographic, or other factors. Access to information
about the available options is crucial in making an appropriately informed choice.
23. The health authorities should ensure that all populations understand how to access
care, and should seek to ensure that populations have access to objective information
about the availability of different health care suppliers.
24. Once individuals access care through a particular provider or physician they should
be given opportunities to consider the clinical options open to them; access to
systematically available information resources is an essential element supporting
choice.
Public education
25. General education is a determinant of health; the better educated a person is,
generally the better their health likelihood. When ill-health presents, prior education
may be a determinant of the speed at which the person accesses health care.
Education also aids individuals to make appropriate choices about the care options
they access.
26. Specific education about health matters can be an important adjunct to lifestyle
planning. While education alone does not, for example, stop people from smoking,
using drugs or alcohol, it can aid in decision making about risk behaviour.
27. A general level of health literacy assists patients to make choices among different
options for treatment, and to comply or co-operate with the requirements of that
treatment. It will also improve self-care and the appropriateness of self-referral.
28. Educational programs that assist people in making informed choices about their
personal health and about the appropriate uses of both self-care and professional
care should be established. These programs should include information about the
costs and benefits associated with alternative courses of treatment within the context
of modern medicine; the use of professional services that permit early detection and
treatment or prevention of illnesses; personal responsibilities in preventing illnesses;
and the effective use of the health care system. Physicians should actively
participate, wherever appropriate, in such educational efforts and must be provided
with adequate resources to enable them to undertake such education.
29. Public education also assists governments by increasing understanding of public
health measures, including taxation of tobacco, banning of human consumption of
some products, and restrictions on individual freedoms because of health concerns.
When legislative or other regulatory mechanisms are to be imposed by governments,
a campaign of public education and explanation must be undertaken to gain public
understanding and voluntary compliance.
Quality assurance
30. Quality assurance mechanisms should be part of every system of health care
Chicago⏐ S-1988-01-2017
Access to Health Care
delivery. Physicians share responsibility for assuring the quality of health care and
must not allow other considerations to jeopardize the quality of care provided.
Technology
31. Technology is playing an increasing role in the provision of health care services.
Capital purchase prices are high because of the need for specific logistical services,
including skilled technicians and adequate facilities. Advanced technologies are not
available in all locales; access to their benefits must be well planned to ensure they
benefit all patients in need, not simply those local to advanced technology centres.
Extraordinary circumstances
32. In extraordinary circumstances, including armed conflicts and major natural events
such as earthquakes, physicians have a specific duty to ensure that policy makers
protect access to care, especially for those most vulnerable and least able to move to
more secure areas.
RECOMMENDATIONS
33. Social Determinants of Health greatly affect access to health care as well as directly
impacting on health. Physicians should work with governments to ensure they are
able to take effective action on SDH.
34. Access to health care requires systematic consideration to ensure appropriate
conditions are met. These include:
34.1 Having an appropriate, universal, solidaristic and equitable health system,
adequately resourced facilities, being available throughout a country, providing
health centers and their professional staff with sufficient and sustainable
financing, with individuals being treated on the basis of need and not on the
ability to pay.
34.2 Patient choice should include which facility to access.
34.3 Access to adequate information for all is essential for making choices and for co-
operating with health care providers.
34.4 Education is both a social determinant and a key factor in co-operation with
health care provision, fostering responsible self-care with accessible support.
34.5 Health care professionals should be free to move around the world, especially to
access educational and professional opportunities. This mobility must not
damage resource availability, especially in resource poor countries.
34.6 Physicians must be provided with transparent and efficient ethical criteria for
working in overcrowded or underserved areas.
34.7 Provision of health care requires action by government at all levels, working
with populations to ensure that people understand the benefit of this care and are
able to access it.
S-1988-01-2017 ⏐ Chicago
Access to Health Care
34.8 Physicians have an important role in ensuring that health care planning makes
clinical sense, is communicated well to the population being served, and that
patients are not endangered by inadequate resources, poor planning or other
system flaws.
34.9 Physicians are aware of the health system and this forces them to play a socially
conscious role regarding the social determinants of health and access to health
care by themselves or through their representative medical associations.
34.10 Medical associations should work with their members to promote access to
health care systems that equitably support the needs of populations.
Handbook of WMA Policies
World Medical Association ⏐ S-1988-04-2016
WMA STATEMENT
ON
THE ROLE OF PHYSICIANS IN ENVIRONMENTAL ISSUES
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
INTRODUCTION
1. The effective practice of medicine increasingly requires that physicians and their pro-
fessional associations turn their attention to environmental issues that have a bearing
on the health of individuals and populations.
2. More than ever, due to diminishing natural resources, these problems relate to the
quality and protection of resources necessary to maintain health and indeed sustain
life itself. In concrete terms, the key environmental issues are as follow:
a. The degradation of the environment, which must be halted as a matter of urgency
so that resources essential to life and health – water and pure air – remain accessi-
ble to all.
b. The ongoing contamination of our reserves of fresh water with hydrocarbons and
heavy metals, along with the contamination of ambient and indoor health by
toxic agents, which have serious medical consequences, especially in the poorest
segments of the globe. Moreover, the greenhouse effect with its concomitant pro-
ven rise in temperature should drive our discussions forward and prepare us for
increasingly serious environmental and public health consequences.
c. The need to control the use of non-renewable resources such as topsoil, which
should constantly be at the forefront of our minds, as should the importance of
safeguarding this vital heritage so that it can be passed on to future generations.
d. The need to mobilise resources beyond national frontiers and to co-ordinate
global solutions for the planet as a whole, so as to formulate a unified strategy to
confront these worldwide medical and economic problems.
e. The foremost objective is to increase awareness of the vital balance between
environmental resources on the one hand, and on the other, biological essentials
for the health of everyone everywhere.
3. Our growing awareness of these issues today has, however, failed to prevent an in-
S-1988-04-2016 ⏐ Buenos Aires
Environmental Issues
crease in our societies’ negative impact on the environment, e.g., melting of glaciers
and increasing desertification, nor has it halted the over-exploitation of natural re-
sources, e.g. pollution of rivers and seas, air pollution, deforestation and diminishing
arable land. In this context, the migration of people from disadvantaged or developing
countries, together with the emergence of new diseases, exacerbates the lack of socio-
economic policies in many parts of the world. From a medical point of view, growth
of the population and irresponsible destruction of the environment are unacceptable,
and medical organizations throughout the world should redouble their efforts, not only
to speak out about these problems, but also to suggest solutions.
PRINCIPLES
1. In their role as representatives of physicians, medical associations are duty bound to
grapple with these environmental issues. They have a duty to produce analytical stu-
dies that include the identification of problems and current international regulations
on environmental issues, as well as their impact on the field of health.
2. As physicians operate within the framework of ethics and medical deontology, the
environmental regulations advocated should not seek to limit individual autonomy,
but rather to enrich the quality of life for all and to perpetuate life-forms on the planet.
3. The WMA should therefore act as an international platform for research, education,
and advocacy to help further sustain the environment and its potential to promote
health.
4. Thus, when new environmental diseases or syndromes are identified, the WMA
should help coordinate the scientific/medical discussions on the available data and
their implications for human health. It should foster the development of consensus
thinking within medicine, and help to stimulate preventive measures, accurate diagno-
sis and treatment of these emerging disorders.
5. The WMA should therefore provide a framework for the international co-ordination
of medical associations, NGOs, research clinicians, international health organizations,
decision-makers and funding providers, in their examination of the human health ef-
fects of environmental problems, their prevention, remediation and treatment for indi-
viduals and communities.
Handbook of WMA Policies
World Medical Association S-1988-05-2022
WMA STATEMENT
ON
HEALTH HAZARDS OF TOBACCO PRODUCTS
AND TOBACCO-DERIVED PRODUCTS
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
Tobacco Products Health Hazards
Berlin S-1988-05-2022
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
Handbook of WMA Policies
World Medical Association S-1988-05-2022
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.
Tobacco Products Health Hazards
Berlin S-1988-05-2022
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:
9. Refuse funding or educational materials from the tobacco industry, and urge medical
schools, research institutions, and individual researchers to do the same.
Handbook of WMA Policies
World Medical Association S-1988-05-2022
10. 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.
11. 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.
12. 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.
13. Introduce or strengthen educational programs for medical students and physicians to
prepare them to identify and treat tobacco dependence in their patients.
14. 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.
15. 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:
16. 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.
17. 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.
18. 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.
Handbook of WMA Policies
World Medical Association ⏐ S-1989-01-2016
WMA STATEMENT
ON
ANIMAL USE IN BIOMEDICAL RESEARCH
Adopted by the 41st
World Medical Assembly, Hong Kong, September 1989
revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
PREAMBLE
1. Biomedical research is essential to the health and well-being of our society. Advances
in biomedical research have dramatically improved the quality and prolonged the
duration of life throughout the world. However, the ability of the scientific commu-
nity to continue its efforts to improve personal and public health is being threatened
by a movement to eliminate the use of animals in biomedical research. This move-
ment is spearheaded by groups of radical animal rights activists whose views are
considered to be far outside mainstream public attitudes and whose tactics range from
sophisticated lobbying, fund-raising, propaganda and misinformation campaigns to
violent attacks on biomedical research facilities and individual scientists. These violent
attacks are carried out by a relatively small number of activists compared with those
who use peaceful means of protest, but they have profound and wide-ranging effects.
2. The magnitude of violent animal rights activities is staggering, and these activities
take place in many different parts of the world. Various animal rights groups have
claimed responsibility for the bombing of cars, institutions, stores, and the private
homes of researchers.
3. Animal rights violence has had a chilling effect on the scientific community inter-
nationally. Scientists, research organizations, and universities have been intimidated
into altering or even terminating important research efforts that depend on the use of
animals. Laboratories have been forced to divert thousands of research dollars for the
purchase of sophisticated security equipment. Young people who might otherwise
pursue a career in biomedical research are turning their sights to alternative profes-
sions.
4. Despite the efforts of many groups striving to protect biomedical research from
radical animal activism, the response to the animal rights movement has been frag-
mented, underfunded, and primarily defensive. Many groups within the biomedical
community are hesitant to take a public stand about animal activism because of fear of
reprisal. As a result, the research establishment has been backed into a defensive pos-
ture. Its motivations are questioned, and the need for using animals in research is re-
S-1989-01-2016 ⏐ Buenos Aires
Animal Use in Biomedical Research
peatedly challenged.
5. While properly designed and executed research involving animals is necessary to
enhance the medical care of all persons, we recognize also that humane treatment of
research animals must be ensured. Appropriate training for all research personnel
should be prescribed and adequate veterinary care should be available. Experiments
must comply with any rules or regulations promulgated to govern humane handling,
housing, care, treatment and transportation of animals.
6. International medical and scientific organizations must develop a stronger and more
cohesive campaign to counter the growing threat to public health posed by animal
activists. Leadership and coordination must be provided. In addition, there must be a
clear understanding of the rights of animals who are part of medical research, and the
obligations of those who undertake it.
The World Medical Association therefore affirms the following principles:
1. Animal use in biomedical research is essential for continued medical progress.
2. The WMA Declaration of Helsinki requires that biomedical research involving human
subjects should be based, where appropriate, on animal experimentation, but also re-
quires that the welfare of animals used for research be respected.
3. Humane treatment of animals used in biomedical research is essential and research
facilities should be required to comply with all guiding principles for humane treat-
ment. Education about these principles should be provided to all researchers in train-
ing.
4. Animals should only be used in biomedical research when it is clear that their use is
required to achieve an important outcome, and where no other feasible method is
available.
5. Duplication of animal experiments should not occur unless scientifically justified.
6. The use of animals for the futile testing of cosmetic products and their ingredients,
alcohol and tobacco should not be supported.
7. Although rights to free speech should not be compromised, the anarchistic element
among animal right activists should be condemned.
8. The use of threats, intimidation, violence, and personal harassment of scientists and
their families should be condemned internationally.
9. A maximum coordinated effort from international law enforcement agencies should
be sought to protect researchers and research facilities from activities of a terrorist
nature.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-01-2016
WMA STATEMENT
ON
INJURY CONTROL
Adopted by the 42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
njuries are the leading cause of death and disability in children and young adults,
destroying the health, livelihoods and lives of millions of people each year. Causes of
injury include, among others, acts of violence against oneself or others, traffic crashes,
falls, poisonings, drowning, and burns. Yet many injuries are preventable. Injury control
should be recognized as a public health priority requiring coordination among health,
transportation and social service agencies in each country. Physician participation and
leadership through medicine, education and advocacy is necessary to ensure the success of
such injury control programmes.
As the World Health Organization states in Injuries and Violence: The Facts, the rate of
injury is far from uniform around the world. Indeed, about 90% of injury-related deaths
occur in low- and middle-income countries. Within countries, injury rates vary by social
class as well. The impoverished face more dangerous living and working conditions than
the more affluent. For example, buildings in poorer communities are more likely to be
older and in need of repair. Poor communities are also plagued by much higher rates of
homicide. What’s more, people living in poverty also have less access to quality
emergency care and rehabilitation services. Greater attention must be given to these root
causes of injuries.
The World Medical Association urges National Medical Associations to work with
appropriate public and private agencies to develop and implement programmes to prevent
and treat injuries. Included in the programmes must be efforts to improve medical
treatment and rehabilitation of injured patients. Research and education on injury control
must be increased, and international cooperation is a vital and necessary component of
successful programmes.
National Medical Associations should recommend that the following basic elements be
incorporated in their countries’ programmes:
EPIDEMIOLOGY
The initial activity of such programmes must be the acquisition of more adequate data on
which to base priorities, interventions and research. An effective injury surveillance
system should be implemented in each country to gather and integrate information. A
consistent and accurate system for coding injuries must be implemented by hospitals and
health agencies. There should also be international uniformity in the coding of injury
severity.
S-1990-01-2006 ⏐ Pilanesberg
Injury Control
PREVENTION
Injury prevention requires education and training to teach and persuade people to alter
their behaviour in order to reduce their risk of injury. Laws and regulations based on
scientifically sound methods of preventing injuries may be appropriate for effecting
changes in behaviour (for example, the use of seatbelts and protective helmets). These
laws must in turn be strictly enforced. An effective injury surveillance system as
mentioned above will help determine how to target further preventive efforts. Urban and
traffic planning should support safe environments for the residents.
BIOMECHANICS
A better understanding of the biomechanics of injury and disability could inform the
development of improved safety standards and regulations of products and their designs.
TREATMENT
Injury management at the scene of the occurrence must be enhanced by an effective
system of communication between first responders and health professionals at hospitals to
facilitate decision-making. Rapid and safe transportation to the hospital should be
provided. An experienced team of trauma practitioners should be available at the hospital.
There should also be adequate equipment and supplies available for the care of the injured
patient, including immediate access to a blood bank. Education and training of medical
practitioners in trauma care must be encouraged to assure optimal technique by an
adequate number of physicians at all times.
REHABILITATION
Trauma victims need continuity of care emphasizing not only survival but also the
identification and preservation of residual functions. Rehabilitation to restore biological,
psychological and social functions must be undertaken in an effort to allow the injured
person to achieve maximal personal autonomy and an independent lifestyle. Where
feasible, community integration is a desirable goal for people chronically disabled by
injury. Rehabilitation may also require changes in the patient’s physical and social
environment.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-04-2016
WMA STATEMENT
ON
TRAFFIC INJURY
Adopted by the 42nd
World Medical Assembly, Rancho Mirage, CA., USA, October 1990
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Serious injuries and mortality in road collisions are a public health problem with
consequences similar to those of major diseases such as cancer and cardiovascular disease.
Worldwide, about 1.2 million persons are killed each year on the roads, and an additional
20-50 million are injured. By 2020, road traffic injuries are expected to be the third largest
contributor to the global burden of disease and injury.
In addition to the immeasurable personal and social price paid by road crash victims and
their relatives, traffic injury has a significant economic impact. The economic costs of
traffic injury and disability, including emergency and rehabilitative health care, costs of
disability and disability adjusted life years (DALYs), amount to 1% of the GDP of poorer
countries and 1.5-2% of wealthier countries. Much of this burden is borne by the health
sector.
Road injuries continue to increase in many countries, particularly in low- and middle-
income nations which currently account for 85% of all road traffic deaths, and are the
second leading cause of death among youth worldwide.
Most traffic injuries could be prevented by better countermeasures. Combating traffic
injury is the shared responsibility of groups and individuals at the international, national,
and community levels, including governments, NGOs, industry, public health
professionals, engineers and law enforcement personnel.
Speed is widely recognized as the most important determinant of road safety, affecting
both the likelihood that a crash will occur and the severity of a crash. On average, an
increase in speed of 1 km/h is associated with a 3% higher risk of a crash involving injury
and a 5% higher risk of serious or fatal injury.
However, efforts to decrease road crashes and injury also require a “systems approach”
that recognizes and addresses the many factors that contribute to the risk of traffic crashes
and resulting injury, including human, vehicle and road design variables.
Preventing traffic injury requires addressing the social determinants of health—the social,
economic, environmental, and political factors in society that influence a population’s
S-1990-04-2016 ⏐ Taipei
Traffic Injury
health. Low- and middle-income countries, where there is less safe infrastructure, fewer
minimum standards on vehicle safety, and poorer quality emergency care, experience the
greatest number of traffic injuries. In this way, human, vehicular and environmental
factors interact before, during and after a collision. Intervention at each of these stages will
help reduce crashes and injury. Effective intervention requires public education as well as
professional involvement in the fields of engineering, law enforcement and medical care.
Pre-collision intervention is aimed at preventing crashes and reducing risk factors.
Examples include preventing drivers from driving when fatigued (especially drivers of
heavy vehicles), distracted or under the influence of drugs or alcohol. Necessary policies
may include prohibiting the use of hand-held cellular phones and night curfews or
graduated licensing for young drivers. Pre-collision intervention also includes setting
vehicle design standards that ensure that vehicles are roadworthy and cannot be driven at
excessive speeds. Other interventions include setting and enforcing appropriate speed
limits, installing speed cameras, and optimizing road design and layout to prevent crashes.
A second level of intervention is aimed at preventing or reducing injury during the crash.
Such interventions include: enforcing the use of seat belts and child restraints; requiring
helmets for cyclists; manufacturing vehicles equipped with safety devices and crash-
protective design; lowering and enforcing speed limits; and removing heavy, rigid objects
such as concrete or metal dividers, light posts and abutments from the sides of roads.
Post-crash intervention is aimed at maximizing life-saving and injury-reducing treatment
and includes improved pre-hospital and emergency trauma care and rehabilitation.
RECOMMENDATIONS
1. The WMA supports the findings and key recommendations of the WHO’s 2015
Report on road traffic injury prevention and calls for their implementation by its
member National Medical Associations and their governments and relevant bodies.
2. Physicians must view traffic injury as a public health problem and recognize their
responsibility in fighting this global problem.
3. National Medical Associations and their member physicians should work to
persuade governments and policy makers of the importance of this issue and
should assist in adapting empirical and scientific information into workable
policies.
4. National Medical Associations and physicians should be key players in public
education and should include road safety in health promotion activities.
5. Physicians should be involved in the collection and analysis of data regarding road
crashes and concomitant injuries, including injury surveillance systems.
6. Physicians should work toward changing the public attitude of road travel,
including pressing for improved public transportation, bicycle paths and proper
sidewalks to encourage less car use and the adoption of healthier options such as
walking and cycling.
Handbook of WMA Policies
World Medical Association ⏐ S-1990-04-2016
7. Physicians should address the human factor and medical reasons for road crashes,
including, but not limited to, the use of prescription drugs or medical conditions
that may impair driving ability, and explore ways to prevent and reduce the
severity of injuries.
8. Physicians should lobby for the implementation and enforcement of the measures
listed above, which have been shown to decrease the risk and severity of vehicle
crashes, and the evaluation of their impact.
9. National Medical Associations and their member physicians should encourage the
research and development of improved training systems and medical care at all
stages, including effective communication and transport systems to locate and
evacuate the victims, emergency medical care systems to provide life-saving first
aid services, and expert trauma and rehabilitative care, and should lobby for
increased resources to help provide these services.
Handbook of WMA Policies
S-1991-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ADOLESCENT SUICIDE
Adopted by the 43rd
World Medical Assembly, Malta, November 1991
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
The past several decades have witnessed a dramatic change in causes of adolescent
mortality. Previously, adolescents mostly died of natural causes, whereas they now more
likely die from preventable causes. Part of this change has been a worldwide rise in
adolescent suicide rates in both developed and developing countries. In the adolescent
population, suicide is currently one of the leading causes of death. Suicides are probably
under-reported due to cultural and religious stigma attached to self-destruction and to an
unwillingness to recognize certain traumas, such as some automobile accidents, as self-
inflicted.
Adolescent suicide is a tragedy that affects not only the individual but also the family,
peers and larger community in which the adolescent lived. Suicide is often experienced as
a personal failure by parents, friends and physicians who blame themselves for not
detecting warning signs. It is also viewed as a failure by the community, serving as a vivid
reminder that modern society often does not provide a nurturing, supportive and healthy
environment in which children can grow and develop.
Factors contributing to adolescent suicide are varied and include: affective disorders,
trauma, emotional isolation, low self-esteem, excessive emotional stress, eating disorders,
harassment (school bullying, cyber bullying and sexual harassment), romantic fantasies,
thrill-seeking, drug and alcohol abuse, the availability of firearms and other agents of self-
destruction, and media reports of other adolescent suicides, which may inspire copycat
acts. In addition, the prolonged exposure to electronic media, which predominantly affects
adolescents through their use of computer games and social media, can contribute to social
isolation, school failure and malaise amongst young people.
Youth within correctional facilities are at a higher risk for suicide than the general
population, yet they have fewer resources available to them. The lack of resources makes
it difficult to identify those at risk for suicide.
The incidence of adolescent suicide is observed to be greater in the “first peoples” of some
nations. The reasons for this are complex.
The health care of adolescents is best achieved when physicians provide comprehensive
Taipei⏐ S-1991-01-2016
Adolescent Suicide
services, including both medical and psychosocial evaluation and treatment. Continuous,
comprehensive care provides the physician the opportunity to obtain the information
necessary to detect adolescents at risk for suicide or other self-destructive behaviour. This
service model also helps to build a socially supportive patient-physician relationship that
may moderate adverse influences adolescents experience in their environment.
In working to prevent adolescent suicide, the World Medical Association recognizes the
complex nature of adolescent bio-psycho-social development; the changing social world
faced by adolescents; and the introduction of new, more lethal, agents of self-destruction.
In response to these concerns, the World Medical Association recommends that National
Medical Associations adopt the following guidelines for physicians. In doing so, we
recognise that many other players – parents, governmental agencies, schools,
communities, social services – also have important roles in this area.
RECOMMENDATIONS
1. All physicians should receive, during medical school and postgraduate training,
education in child psychiatry and adolescent bio-psycho-social development,
including education in the risk factors for suicide.
2. Physicians should be trained to identify early signs and symptoms of physical,
emotional, and social distress of adolescent patients. They should also be trained to
identify the signs and symptoms of psychiatric disorders, like depression, bipolar
disorder and substance use disorders, that may contribute to suicide as well as
other self-destructive behaviours.
3. Physicians should be taught how and when to assess suicidal risk in their
adolescent patients.
4. Physicians should be taught and keep up-to-date on the treatment and referral
options appropriate for all levels of self-destructive behaviours of their adolescent
patients. The physicians with the most significant training in adolescent suicide are
child and adolescent psychiatrists, so the patient should be referred to one if
available.
5. Physicians should also collaborate with other relevant stakeholders, such as social
workers, school officials, and psychologists who bear expertise in child and
adolescent behavior.
6. When caring for adolescents with any type of trauma, physicians should consider
the possibility that the injuries might have been self-inflicted.
7. When caring for adolescents who demonstrate deterioration in thinking, feeling or
behaviour, the possibility of substance abuse and addiction should be considered,
and the threshold should be low for urine toxicology assessment.
8. Health care systems should facilitate the establishment of mental health
consultation services aimed at preventing suicide and should pay for the socio-
medical care given to patients who have attempted suicide. Services should be
tailored to the specific needs of adolescent patients.
Adolescent Suicide
S-1991-01-2016 ⏐ Taipei
9. Epidemiological studies on suicide, its risk factors and methods of prevention
should be conducted, and physicians should keep up-to-date with such studies.
10. When caring for adolescents with psychiatric disorders or risk factors for suicide,
physicians should educate parents or guardians to watch for the signs of suicide
and educate them about the options for evaluation.
11. Physicians should advocate for the identification of at risk groups of adolescents
with the mobilization of specifically targeted resources directed at prevention and
risk reduction.
Handbook of WMA Policies
S-1992-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ALCOHOL AND ROAD SAFETY
Adopted by the 44th
World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
INTRODUCTION
Deaths and injuries resulting from road crashes and collisions are a major public health
problem. The World Health Organization’s 2015 Global status report on road safety
indicates that the total number of road traffic deaths per year has reached 1.25 million
worldwide, with the highest road traffic fatality rates in low-income countries.
Driving while under the influence of alcohol has caused a large number of the deaths and
injuries resulting from road crashes. The prevalence of drinking and driving is increasing
worldwide each year.
A change in the behaviour of road users with regard to alcohol consumption would appear
to be the most promising approach to preventing traffic deaths and injuries. Measures
forbidding driving while under the influence of alcohol will lead to a considerable
improvement in road safety and an appreciable reduction in the number of dead and
injured.
CONSEQUENCES OF DRINKING AND DRIVING
Driving a vehicle implies the acceptance of a certain number of risks. The careful driver
will always be aware of the risks but also ensure that the level of risk never rises to an
unacceptable level. Alcohol not only impairs one’s ability to drive, but it also alters a
driver’s subjective assessment of risk so that he or she drives more recklessly.
Irrespective of the amount of alcohol consumed, the maximum concentration of alcohol in
the body is reached:after half an hour when taken
• on an empty stomach;
• after an hour when taken with a meal.
On the other hand, it takes the body a long time to eliminate alcohol. An individual in
good health eliminates alcohol at a rate that reduces blood alcohol concentration by 0.1 to
0.15 gram/litre/hour. Thus, one’s driving ability remains impaired long after he or she has
stopped drinking.
Alcohol abuse has both short- and long-term neurological and psychiatric consequences
that can endanger road safety.
Handbook of WMA Policies
S-1992-01-2016 ⏐ World Medical Association
Certain drugs interact negatively with alcohol, and in particular some combinations are
known to reduce alertness. When drugs, whether legal or illegal, are taken with alcohol,
the effect of the latter is intensified. This mixture can trigger mental dysfunctions that are
extremely dangerous for road users. Physicians should be educated and informed about
these pharmacological facts.
RECOMMENDATIONS
1. The WMA reaffirms its commitments to work for reducing excessive alcohol
consumption and for fostering harm-reduction policies and other measures (WMA
Declaration on Alcohol, October 2015.)
2. Physicians and National Medical Associations should play an active role in promoting
and advocating for the development of evidence-based government policies to reduce
alcohol use and driving:
Policy interventions
3. At the present time, permitted blood alcohol levels while driving vary from country to
country. Even small amounts of alcohol have a direct effect on the brain, with
disturbances noted at levels as low as 0.3 grams per litre. Therefore, it would be
desirable to lower the maximum permissible level of blood alcohol to a minimum, but
not above 0.5 grams per litre, which is low enough to allow the average driver to retain
the ability to assess risk.
4. The especially high prevalence in certain countries of driving while under the
influence of alcohol may justify more coercive policies, which physicians and
National Medical Associations should play an active role in supporting. For example,
the driver may be declared unfit to drive for a period of time sufficient to ensure he or
she will no longer be a threat to road safety in the future.
5. Government officials should consider implementing restrictions on the sale or
affordability of alcohol, perhaps through taxation, licensing systems, and/or limits on
the days and hours of sale. Restrictions on the promotion of alcoholic beverages,
including advertising and event sponsorship, should also be considered.
6. A minimum legal age for alcohol purchase and consumption should be adopted in each
country. Government officials should consider implementing a separate, lower or zero
blood alcohol content law for young drivers.
7. There should be strict consequences to selling alcoholic beverages to individuals under
the age to purchase and consume alcohol. These laws should be properly enforced.
8. Any driver who has been in a road traffic crash must undergo a blood alcohol
concentration test or a breath test.
9. The practice of random driver testing for breath alcohol levels should become more
widespread, and there should be further research into other ways to test urine, breath
Taipei ⏐ S-1992-01-2016
Alcohol and Road Safety
and saliva to identify impaired drivers and prevent subsequent operation of motor
vehicles.
10. Devices that prevent individuals with an unauthorised level of blood alcohol from
starting the engine of or operating the vehicle should be developed and experimented
with.
Educational interventions
11. Educational interventions should promote moderation and responsibility in the
consumption of alcohol and seek to reduce the likelihood that someone will consume
alcohol and drive afterwards.
12. The information dispensed by physicians and other health professionals should be
aimed at making everyone aware of the dangers of driving under the influence of
alcohol. When physicians and other health professionals issue fitness-to-drive
certificates, they can use this opportunity to educate road users and pass on a message
of prevention and personal responsibility.
13. In most countries, road crashes linked to alcohol consumption affect adolescents and
young adults to a disproportionately high degree, and every available resource should
be mobilised to reduce their consumption of alcohol. The problem of alcohol
consumption in adolescents and young adults and its relation to road safety should be
addressed in the school curricula so that a responsible attitude becomes the norm.
Clinical and rehabilitative interventions
14. Physicians should also be involved in reducing the likelihood of impaired driving by
participating in the detoxification and rehabilitation of drunk drivers. These initiatives
should be based on a detailed analysis of the problem as it manifests itself within each
country or culture. Generally speaking, however, alcoholism is a medical condition
with concomitant psychological or social and interpersonal difficulties that affect the
family, work or social environment.
15. Alcoholic subjects should be given access to rehabilitation services. When drivers are
found to have excess alcohol in their blood (or their breath), other factors linked to
their excessive drinking should be examined and included in a rehabilitation
programme. These rehabilitation programmes should be publicly funded.
16. Road crashes linked to the consumption of alcohol can be considered as possible
predictors of other addictive and violent behaviours. This should be taken into
consideration in the medical treatment of the patient.
Community interventions
17. Strategies should be developed by relevant stakeholders to ensure safe transportation
home in situations where alcohol consumption occurs.
18. Eliminating alcohol from the workplace and in situations where consumers must drive
should be a goal of organizational policies. The promotion of non-alcoholic drinks is
an important tool to facilitate these policies.
Handbook of WMA Policies
S-1992-05-2017 ⏐ World Medical Association
WMA STATEMENT
ON
NOISE POLLUTION
Adopted by the 44th
World Medical Assembly, Marbella, Spain, September 1992
amended by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
PREAMBLE
Given growing environmental awareness and knowledge of the impact of noise on health,
the psyche, performance and well-being, environmental noise is becoming a serious public
health threat. The World Health Organization (WHO) describes noise as the principal
environmental nuisance in industrial nations.
Noise affects people in various ways. Its effects relate to hearing, the vegetative nervous
system, the psyche, spoken communication, sleep and performance. Since noise acts as a
stressor, an increased burden on the body leads to higher energy consumption and greater
wear. It is thus suspected that noise can primarily favour diseases in which stress plays a
contributory role, such as cardiovascular diseases, which can then be manifested in the
form of hypertension, myocardial infarction, angina pectoris, or even apoplexy.
The effects in the psychosocial field are likewise dramatic. The stress caused by
environmental noise is a central concern, not only in the industrial nations, but
increasingly also in the developing countries. Owing to the continuous and massive
growth of traffic volumes, both on the roads and in the air, the stress caused by
environmental noise has increased steadily in terms of both its duration and the area
affected.
Similarly, occupational noise generates increasingly work-related hearing impairment.
Damage to hearing caused by leisure-time noise is also of growing concern. The most
common source of noise in this context is music, to which the ear is exposed by different
audio media at different places (portable music players, stereo systems, discotheques,
concerts). The risk of suffering hearing damage is underestimated by most people, or even
consciously denied. The greatest issue (or aspect) lies in creating awareness of the
problem in the high-risk group – which generally means young people. In this respect, the
legislature is called upon to intervene and reduce the potential for damage by introducing
sound level limiters in audio playback units and maximum permissible sound levels at
music events, or by banning children’s toys that are excessively loud or produce excessive
noise levels.
In keeping with its socio-medical commitment, the World Medical Association is issuing a
statement on the problem of noise pollution with the aim of making a contribution to the
fight against environmental noise through more extensive information and more acute
awareness.
Chicago ⏐ S-1992-05-2017
Noise Pollution
RECOMMENDATIONS
The World Medical Association calls upon the National Medical Associations to:
1. Inform the public, especially persons affected by environmental noise, as well as poli-
cy and decision makers, of the dangers of noise pollution.
2. Call upon ministers of transport and urban planners to develop alternative concepts
that are capable of countering the growing level of environmental noise pollution.
3. Advocate appropriate statutory regulations for combating environmental noise pollu-
tion.
4. Support enforcement of noise pollution legislation and monitor the effectiveness of
control measures.
5. Inform young people of the risks associated with listening to excessively loud music,
such as that which emanates, for example, from portable music players, use of stereo
systems with earphones, audio systems in cars, and attendance at rock concerts and
discotheques.
6. Prompt the educational authorities to inform pupils at an early stage regarding the
effects of noise on people, how stress due to environmental noise can be counteracted,
the role of the individual in contributing to noise pollution, and the risks associated
with listening to excessively loud music.
7. Provide information about risks of damage to hearing that arise in the private sector as
a result of working with power tools or operating excessively loud motor vehicles.
8. Emphasize to those individuals who are exposed to excessive levels of noise in the
workplace the importance of protecting themselves against irreducible noise.
9. Call upon the persons responsible for occupational safety and health in businesses to
take further action to reduce noise emission, in order to ensure protection of the health
of employees at the workplace.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-01-2016
WMA STATEMENT
ON
BODY SEARCHES OF PRISONERS
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
1. The World Medical Association adopts this statement for the purpose of providing
guidance for National Medical Associations as they develop guidelines for their
members.
2. Physician participation in body cavity searches for purposes of law enforcement or
public safety involves complex issues of patient rights, informed consent,
physicians’ fiduciary obligations (dual loyalty matters) and their responsibilities to
contribute to public health. A request to conduct a body cavity search puts the
physician in the untenable position of potentially violating the ethical standards of
his/her profession. Physician participation should be in exceptional cases only.
3. There are several types of searches of prisoners carried out within the detention
system. These will include searches for contraband and searches for items
immediately dangerous to the prisoner and those around him/her. Searches range
from the least invasive “pat-down” searches to the most invasive strip searches
(including examination of the mouth) and body cavity searches.
4. The prison systems in many countries mandate body cavity searches of prisoners.
Such searches, which include rectal and pelvic (vaginal) examination, may be
performed when an individual initially enters the prison population and thereafter
whenever the individual is permitted to have direct personal contact with someone
outside the prison population. They may also be undertaken when there is a reason
to believe a breach of security or of prison regulations has occurred. For example,
when a prisoner is taken to Court for a hearing, or to the hospital for treatment, or
to work outside the prison, the prisoner, upon returning to the institution, may be
subjected to a body cavity search that will include all body orifices. Where
prisoners have direct contact with visitors – family members or otherwise – prison
rules may also require body cavity searches. The purpose of the search is primarily
security-related, to prevent contraband, such as weapons or drugs, from entering
the prison.
5. These searches are performed for security reasons and not for medical or health-
Body Searches of Prisoners
Taipei ⏐ S-1993-01-2016
related reasons. They should only be done by someone with appropriate training.
In most cases this will mean someone working within the detention system who
has been trained to perform safely such searches. This person should not be a
physician except under unusual and specific circumstances.
6. A physician’s obligation to provide medical care to the prisoner can be
compromised by an obligation to participate in the prison’s security system. A
physician should seek to be as far removed from performing body searches as
possible. Any directive to search should be separated from the physician’s broad
general medical care duties in order to protect the patient/physician relationship.
7. In exceptional cases the detaining authority, may indicate that a search be
performed by a physician. The physician, will decide whether medical
participation is necessary, and act accordingly and ethically.
8. If the search could, if carried out by someone with lesser skills, cause harm, for
example if the prisoner is a pregnant, or has severe haemorrhoids, then this non-
medical procedure may be performed by a physician to protect the prisoner from
harm. In such a case the physician should explain this to the prisoner. The
physician should also explain to the prisoner that s/he is performing this search not
as a physician caring for the patient, but for patient safety and as required by the
detention authorities for which the normal patient/doctor relationship does not
exist. The physician should inform the prisoner that the usual conditions of
medical confidentiality do not apply during this procedure and the results of the
search will be revealed to the authorities. If a physician is properly mandated by an
authority and agrees to perform a body cavity search on a prisoner for reasons of
patient safety, the authority should be informed that it is necessary for this
procedure to be done in a humane manner.
9. If the search is conducted by a physician, it should not be done by any physician
who will subsequently provide medical care to the prisoner.
10. Forced examinations are not ethically acceptable, and physicians must not perform
them. If the prisoner acquiesces to a search, the doctor, or other individual carrying
out the body cavity search, should ensure that the prisoner is fully aware of what
will be done, including the facilities in which the search will be performed.
11. Searches should be performed humanely, and, where possible, in a private,
confidential setting respecting the prisoner. The person performing the search
should be of the same gender as the prisoner being searched. When applicable,
transgender persons should be asked first with which gender they identify.
12. The World Medical Association urges all governments and public officials with
responsibility for public safety to recognize that invasive searches are serious
assaults on a person’s privacy and dignity, and they also carry some risk of
physical and psychological injury. The World Medical Association urges that, to
S-1993-01-2016 ⏐ Taipei
Body Searches of Prisoners
the extent feasible without compromising public security, the following
recommendations be followed:
• Alternate methods be used for routine screening of prisoners, including
ultrasound and other scans, and body cavity searches be used only as a last
resort;
• Squatting over mirrors to examine the anus while making the prisoner bear
down, a degrading procedure with questionable reliability, must be banned;
• If a body cavity search must be conducted, the responsible public official must
ensure that the search is conducted humanely by personnel who are of the same
gender as the prisoner and who possess sufficient medical and skills to safely
perform the search;
• The same responsible authority must ensure that the individual’s privacy and
dignity be guaranteed.
• Physician participation in body cavity searches should be in exceptional cases
only. In these cases, the duty to search should be separated from the
physician’s delivery of medical care.
13. Finally, the World Medical Association urges all governments and responsible
public officials to provide body searches that are performed by a qualified
physician whenever warranted by the individual’s physical condition. A specific
request by a prisoner for a physician shall be respected, so far as possible.
14. In specific cases, it may be the detaining authority, which requires a search be
performed by a physician, for the well-being of this prisoner. The physician, in
such a case, will decide whether medical participation is indeed necessary, and act
accordingly and ethically.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-02-2016
WMA STATEMENT
ON
FEMALE GENITAL MUTILATION
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.
S-1993-02-2016 ⏐ Taipei
Female Genital Mutilation
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
Female Genital Mutilation
Taipei ⏐ S-1993-02-2016
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.
S-1993-02-2016 ⏐ Taipei
Female Genital Mutilation
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.
Handbook of WMA Policies
World Medical Association ⏐ S-1993-03-2016
WMA STATEMENT
ON
PATIENT ADVOCACY AND CONFIDENTIALITY
Adopted by the 45th
World Medical Assembly, Budapest, Hungary, October 1993
revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
PREAMBLE
Medical practitioners have an ethical duty and a professional responsibility to act in the
best interests of their patients without regard to age, gender, sexual orientation, physical
ability or disability, race, religion, culture, beliefs, political affiliation, financial means or
nationality.
This duty includes advocating for patients, both as a group (such as advocating on public
health issues) and as individuals.
Occasionally, this duty may conflict with a physician’s other legal, ethical and/or pro-
fessional duties, creating social, professional and ethical dilemmas for the physician.
Potential conflicts with the physician’s obligation of advocacy on behalf of his or her pa-
tient may arise in a number of contexts:
1. Conflict between the obligation of advocacy and confidentiality – A physician is
ethically and often legally obligated to preserve in confidence a patient’s personal
health information and any information conveyed to the physician by the patient
in the course of his or her professional duties. This may conflict with the
physician’s obligation to advocate for and protect patients where the patients may
be incapable of doing so themselves.
2. Conflict between the best interest of the patient and employer or insurer dictates –
Often there exists potential for conflict between a physician’s duty to act in the best
interest of his or her patients, and the dictates of the physician’s employer or the in-
surance body, whose decision may be shaped by economic or administrative factors
unrelated to the patient’s health. Examples of such might be an insurer’s instructions
to prescribe a specific drug only, where the physician believes a different drug
would better suit a particular patient, or an insurer’s denial of coverage for
treatment that a physician believes is necessary.
3. Conflict between the best interests of the individual patient and society – Although
the physician’s primary obligation is to his or her patient, the physician may, in
certain circumstances, have responsibilities to a patient’s family and/or to society
S-1993-03-2016 ⏐ Buenos Aires
Patient Advocacy and Confidentiality
as well. This may arise in cases of conflict between the patient and his or her
family, in the case of minor or incapacitated patients, or in the context of limited
resources.
4. Conflict between the patient’s wishes and the physician’s professional judgment or
moral values – Patients are presumed to be the best arbiters of their best interests
and, in general, a physician should advocate for and accede to the wishes of his or
her pa-tient. However, in certain instances such wishes may be contrary to the
physician’s professional judgment or personal values.
RECOMMENDATION
1. The duty of confidentiality must be paramount except in cases where the physician
is legally or ethically obligated to disclose such information in order to protect the
wel-fare of the individual patient, third parties or society. In such cases, the
physician must make a reasonable effort to notify the patient of the obligation to
breach confi-dentiality, and explain the reasons for doing so, unless this is clearly
inadvisable (such as where telling the patient would exacerbate a threat). In certain
cases, such as gene-tic or HIV testing, physicians should discuss with their
patients, prior to performing the test, instances in which confidentiality might need
to be breached.
A physician should breach confidentiality in order to protect the individual patient
only in cases of minor or incompetent patients (such as certain cases of child or
elder abuse) and only where alternative measures are not available. In all other
cases, confidentiality may be breached only with the specific consent of the patient
or his/ her legal representative or where necessary for the treatment of the patient,
such as in consultations between medical practitioners.
Whenever confidentiality must be breached, it should be done so only to the extent
necessary and only to the relevant party or authority.
2. In all cases where a physician’s obligation to his or her patient conflicts with the
administrative dictates of the employer or the insurer, a physician must strive to
change the decision of the employing/insuring body. His or her ultimate obligation
must be to the patient.
Mechanisms should be in place to protect physicians who wish to challenge
decisions of employers/insurers without jeopardizing their jobs, and to resolve
disagreements between medical professionals and administrators with regard to
allocation of re-sources.
Such mechanisms should be embodied in medical practitioners’ employment con-
tracts. These employment contracts should acknowledge that medical practitioners’
ethical obligations override purely contractual obligations related to employment.
3. A physician should be aware of and take into account economic and other factors
before making a decision regarding treatment. Nonetheless, a physician has an
obliga-tion to advocate on behalf of his or her patient for access to the best
Handbook of WMA Policies
World Medical Association ⏐ S-1993-03-2016
available treat-ment.
In all cases of conflict between a physician’s obligation to the individual patient
and the obligation to the patient’s family or to society, the obligation to the
individual pa-tient should typically take precedence.
4. Competent patients have the right to determine, on the basis of their needs, values
and preferences, what constitutes for them the best course of treatment in any given
situa-tion. Unless it is an emergency situation, physicians should not be required to
participate in any procedures that conflict with their personal values or professional
judgment. In such non-emergency cases, the physician should explain to the patient
his or her in-ability to carry out the patient’s wishes, and the patient should be
referred to another physician, if required.
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
MEDICAL ETHICS IN THE EVENT OF DISASTERS
Adopted by the 46th
WMA Gener al Assembly, Stockholm, Sweden, September 1994
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. According to International Federation of Red Cross and Red Crescent Societies (IFRC)
a disaster is a sudden, calamitous event that seriously disrupts the functioning of a
community or society and causes human, material, and economic or environmental
losses that exceed the community’s or society’s ability to cope using its own resources.
Though often caused by nature, disasters can have human origins.
This definition excludes situations arising from conflicts and wars, whether international
or internal, which give rise to other problems in addition to those considered in this
paper.
2. Disasters often result in substantial material damage, considerable displacement of
people, many victims and significant social disruptions. Adequate preparation would
make major consequences less likely and less severe and protect people especially the
most vulnerable.
This document will focus particularly on the medical aspects of disasters. From a
medical standpoint, disaster situations are characterized by an acute and unforeseen
imbalance between resources and the capacity of medical professionals, and the needs of
survivors who are injured whose health is threatened, over a given period of time.
3. Disasters, irrespective of cause, share several common features:
3.1. Their sudden and unexpected but often predictable occurrence, demanding prompt
action;
3.2. Material or natural damage making access to the survivors difficult and/or
dangerous;
3.3. Displacement or movement of often large numbers of people;
3.4. Adverse effects on health due to various reasons such as physical injuries and high
Chicago ⏐ S-1994-01-2017
Disasters
energy trauma, direct and indirect consequences of pollution, the risks of epidemics and
emotional and psychological factors as well as factors such as reduced access to food,
potable water, shelter, health care and other health determinants;
3.5. A context of insecurity sometimes requiring police or military measures to maintain
order; and
3.6. Media coverage, and the use of social media.
4. Disasters require multifaceted responses involving many different types of relief ranging
from transportation and food supplies to medical services. Physicians are likely to be
part of coordinated operations involving other responders such as law enforcement
personnel. These operations require an effective and centralized authority to coordinate
public and private efforts.
Rescue workers and physicians are confronted with exceptional circumstances, which
require the continued need of a professional and ethical standard of care. This is to
ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not
influenced by other motivations. Inadequate and/or disrupted medical resources on site
and a large number of people injured in a short time present specific ethical challenges.
RECOMMENDATIONS
5. Medical profession is at the service of the patients and society at all times and in all
circumstances. Therefore, the physicians should be firmly committed to addressing the
health consequences of disasters, without excuse or delay.
6. The World Medical Association (WMA) reaffirms its Declaration of Montevideo on
Disaster Preparedness and Medical Response (2011) recommending the development of
adequate training of physicians, accurate mapping of information on health system
assets and advocacy towards governments to ensure planning for clinical care.
7. The WMA recalls the primary necessity to ensure the personal safety of physicians and
other responders during the event of disasters (Declaration on the Protection of Health
Care Workers in situation of Violence, 2014).
Physicians and other responders must have access to appropriate and functional
equipment, both medical and protective.
8. Furthermore, the WMA recommends the following ethical principles and procedures
with regard to the physician’s role in disaster situations:
8.1 A system of triage may be necessary to determine treatment priorities. Despite triage
often leading to some of the most seriously injured receiving only symptom control
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
such as analgesia, such systems are ethical provided they adhere to normative
standards. Demonstrating care and compassion despite the need to allocate limited
resources is an essential aspect of triage.
Ideally, triage should be entrusted to authorized, experienced physicians or to
physician teams, assisted by a competent staff. Since cases may evolve and thus
change category, it is essential that the official in charge of the triage regularly
assesses the situation.
8.2 The following statements apply to treatment beyond emergency care:
8.2.1 It is ethical for a physician not to persist, at all costs, in treating individuals
“beyond emergency care”, thereby wasting scarce resources needed else-
where. The decision not to treat an injured person on account of priorities
dictated by the disaster situation cannot be considered an ethical or medical
failure to come to the assistance of a person in mortal danger. It is justified
when it is intended to save the maximum number of individuals. However, the
physician must show such patients compassion and respect for their dignity,
for example by separating them from others and administering appropriate
pain relief and sedatives, and if possible ask somebody to stay with the patient
and not to leave him/her alone.
8.2.2 The physician must act according to the needs of patients and the resources
available. He/she should attempt to set an order of priorities for treatment that
will save the greatest number of lives and restrict morbidity to a minimum.
8.3 Relation with the patients
8.3.1 In selecting the patients who may be saved, the physician should consider only
their medical status and predicted response to the treatment, and should
exclude any other consideration based on non-medical criteria.
8.3.2 Survivors of a disaster are entitled to the same respect as other patients, and the
most appropriate treatment available should be administered with the patient’s
consent.
8.4 Aftermath of disaster
8.4.1 In the post-disaster period the needs of survivors must be considered. Many
may have lost family members and may be suffering psychological distress.
The dignity of survivors and their families must be respected.
8.4.2 The physician must make every effort to respect the customs, rites and
religions of the patients and act in impartiality.
Chicago ⏐ S-1994-01-2017
Disasters
8.4.3 As far as possible, detailed records should be kept, including details of any
difficulties encountered. Identification of patients, including the deceased
should be recorded.
8.5 Media and other third parties
Physicians should take into consideration that in any disaster media is present. The work
of the media should be respected and facilitated as appropriate in the circumstances. If
needed, physicians should be empowered to restrict the entrance of reporters and other
media representatives to the medical premises. Appropriately trained personnel should
handle media relations.
The physician has a duty to each patient to exercise discretion and to seek to ensure
confidentiality when dealing with third parties. The physician must also exercise caution
and objectivity and respect the often emotional and politicized atmosphere surrounding
disaster situations. Any and all media especially filming must only occur with the
explicit consent of each patient who is filmed. With regard to social media use,
physicians must adhere to these same standards of discretion and respect for patient
privacy.
8.6 Duties of paramedical personnel
The ethical principles that apply to physicians in disaster situations should also apply to
other health care workers.
8.7 Training
The World Medical Association recommends that disaster medicine training be included
in the curricula of university and post-graduate courses in medicine.
8.8 Responsibility
8.8.1 The World Medical Association calls upon governments and insurance
companies to cover both civil liability and any personal damages to which
physicians might be subject when working in disaster or emergency situations.
This should also include life and disability coverage for physicians who die or
are harmed in the line of duty.
8.8.2 The WMA requests that governments:
• Ensure the preparedness of healthcare system to serve in disaster settings.
• Share all information related to public health timely and accurately.
• Accept the participation of demonstrably qualified foreign physicians, where
Handbook of WMA Policies
S-1994-01-2017 ⏐ World Medical Association
needed, without discrimination on the basis of factors such as affiliation (e.g.
Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or
religion.
• Give priority to the rendering of medical services over anything else that
might delay necessary treatment of patients.
Handbook of WMA Policies
S-1995-02-2015 ⏐ World Medical Association
WMA STATEMENT
ON
ETHICAL ISSUES CONCERNING PATIENTS WITH MENTAL ILLNESS
Adopted by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Historically, many societies have regarded patients with mental illness as a threat to those
around them rather than as people in need of support and care. In the absence of effective
treatment, to prevent self-destructive behaviour or harm to others, many persons with
mental illness were confined to asylums for all or part of their lives.
Today, progress in psychiatric treatment allows for better care of patients with mental ill-
ness. Efficacious drugs and psychosocial interventions offer outcomes ranging from
complete recovery to remission for varying lengths of time.
The adoption in 2006 of the United Nations Convention on the Rights of Persons with
Disabilities constituted a major step towards viewing them as full members of society with
the same rights as everyone else. It is the first comprehensive human rights treaty of the
21st
century. It aims to promote, protect and reinforce the human rights and dignity of all
persons with disabilities, including those with mental impairments.
Persons with major mental illnesses and those with learning disability have the same right
to preventive services and interventions to promote health as others members of the com-
munity, for which they often have greater need because they are more likely to live
unhealthy lifestyles.
Patients with psychiatric morbidity may also experience non- psychiatric illness. Persons
with mental illness have the same right to health care as any other patient. Psychiatrists
and health care professionals who provide mental health services should refer patients to
other appropriate professionals when patients need medical care. Health care professionals
should never decline to provide needed medical care solely because the patient has a
mental illness.
Physicians have the same obligations to all patients, including patients with mental illness.
Psychiatrists or other physicians who treat patients with mental illness must adhere to the
same ethical standards as any physician.
The physician’s primary obligation is to the patient and not to serve as agents of society,
Patients with Mental Illness
S-1995-02-2015 ⏐ Moscow
except in circumstances when a patient presents clear danger to himself/ herself or others
due to mental illness.
PHYSICIANS’ ETHICAL PRINCIPLES
The stigma and discrimination associated with psychiatry and the mentally ill should be
eliminated. Stigma and discrimination may discourage people in need from seeking
medical care, thereby aggravating their situation and placing them at risk of emotional or
physical harm.
Physicians have a responsibility to respect the autonomy of all patients. When patients
who are being treated for mental illness have decision-making capacity, they have the
same right to make decisions about their care as any other patient. Because decision-
making capacity is specific to the decision to be made and can vary over time, including as
a result of treatment, physicians must continually evaluate the patient’s capacity. When a
patient lacks decision-making capacity, physicians should seek consent from an
appropriate surrogate in accordance with applicable law.
The therapeutic relationship between physician and patient is founded on mutual trust, and
physicians have a responsibility to seek patients’ informed consent to treatment, including
patients who are being treated for mental illness. Physicians should inform all patients of
the nature of the psychiatric or other medical condition, and the expected benefits,
outcomes and risks of treatment alternatives.
Physicians should always base treatment recommendations on their best professional
judgment and treat all patients with solicitude and respect, regardless of the setting of care.
Physicians who practice in mental health facilities, the military, or correctional institutions
may have concurrent responsibilities to society that create conflicts with the physician’s
primary obligation to the patient. In such situations, physicians should disclose the conflict
of interest to minimize possible feelings of betrayal on the patient’s part.
Involuntary treatment or hospitalization of persons with mental illness is ethically
controversial. While laws regarding involuntary hospitalization and treatment vary
worldwide, it is generally acknowledged that this treatment decision without the patient’s
informed consent or against the patient’s will is ethically justifiable only when: (a) a
severe mental disorder prevents the individual from making autonomous treatment
decisions; and/or (b) There is significant likelihood that the patient may harm him/her self
or others. Involuntary treatment or hospitalization should be exceptional and physicians
should utilize it only when there is good evidence that it is medically appropriate and
necessary and should ensure that the individual is hospitalized for the shortest duration
feasible under the circumstances. Wherever possible and in accordance with local laws,
physicians should include an advocate for the rights of that patient in the decision process.
Physicians must protect the confidentiality and privacy of all patients. When legally
required to disclose patient information, the physician should disclose only the minimum
relevant information necessary and only to an entity legally authorized to request or
require the information. When databanks allow access to or transfer of information from
Moscow ⏐ S-1995-02-2015
Patients with Mental Illness
one authority to another confidentiality must be respected and such access or transfer must
comply fully with applicable law.
The participation of individuals with psychiatric illness in research needs to be in full
accordance with the Declaration of Helsinki’s recommendations.
Physicians must never use their professional position to violate the dignity or human rights
of any individual or group, and should never allow their personal desires, needs, feelings,
prejudices or beliefs to interfere with a patient’s treatment. Physicians must never abuse
their authority or take advantage of a patient’s vulnerability.
RECOMMENDATION
The World Medical Association and National Medical Associations are encouraged to:
• Publicize this Statement and affirm the ethical foundations for treatment of patients
with mental illness;
• While doing so, call for full respect – at all times – of the dignity and human rights
of patients with mental illness;
• Raise awareness of physicians’ responsibilities to support the well-being and rights
of patients with mental illness;
• Promote recognition of the privileged relationship between patient and physician
based on trust, professionalism and confidentiality;
• Advocate for appropriate resources to meet the needs of persons with mental
illness.
Handbook of WMA Policies
S-1995-04-2016 ⏐ World Medical Association
WMA STATEMENT
ON
PHYSICIANS AND PUBLIC HEALTH
Adopted by the 47th
WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
The health of a community or population is determined by several factors that go beyond
traditionally understood causes of disease. Social determinants of health include factors
that affect behavioural lifestyle choices; the physical, psychosocial and economic
environments in which individuals live; and the health services available to people. Public
health involves monitoring, assessing and planning a variety of programs and activities
targeted to the identified needs of the population, and the public health sector should have
the capacity to carry out those functions effectively to optimise community health. A key
tenet of public health policy should be inclusivity and health equity; public health agencies
must pay specific attention to populations and communities whose social, economic, and
political conditions put them at greater risk of poor health than the general population.
Physicians and their professional associations have an ethical and professional
responsibility to act in the best interests of patients at all times. This involves collaboration
with public health agencies to integrate medical care of individual patients with a broader
promotion of the health of the public.
The key functions of public health agencies are:
1. Health promotion:
• Working with health care providers to inform and enable the general public to take
an active role in preventing and controlling disease, adopting healthful lifestyles,
and using medical services appropriately;
• Assuring that conditions contributing to good health, including high-quality
medical services, safe water supplies, good nutrition, an unpolluted atmosphere,
and opportunities for exercise and recreation are accessible for the entire
population;
• Working with the responsible public authorities to create healthy public policy and
supportive environments in which healthy behavioural choices are the easy
choices, and to develop human and social capital.
• Prevention: assuring access to screening and other preventive services and curative
care to the entire population.
2. Protection: monitoring and protecting the health of communities against
communicable diseases and exposure to toxic environmental pollutants, occupational
Taipei ⏐ S-1995-04-2016
Public Health
hazards, harmful products, and poor quality health services. This function includes the
need to set priorities, establish essential programs, obtain requisite resources and
assure the availability of necessary public health laboratory services.
3. Surveillance: identifying outbreaks of infectious disease and patterns of chronic
disease and injury and establishing appropriate control or prevention programmes;
4. Population Health Assessment: assessing community health needs and marshalling the
resources for responding to them, and developing health policy in response to specific
community and national health needs.
The specific programs and activities carried out in each jurisdiction (local or national)
will depend on the problems and needs identified, the organization of the health care
delivery system, the types and scope of the partnerships developed and the resources
available to address the identified needs.
Public health agencies benefit greatly from the support and close cooperation of
physicians and their professional associations. The health of a community or a nation
is measured by the health of all its residents, and the preventable health problems that
affect an individual person affect the health and resources of the community. The
effectiveness of many public health programs, therefore, depends on the active
collaboration of physicians and their professional associations with public health
agencies and other governmental and nongovernmental agencies.
The medical sector and the public health sector should effectively co-operate on the
dissemination of public health information and education programs that promote
healthful lifestyles and reduce preventable risks to health, including those from the use
of tobacco, alcohol and other drugs; sexual activities that increase the risk of HIV
transmission and sexually transmitted diseases; poor diet and physical inactivity; and
inadequate childhood immunization levels. For example, health education can
substantially reduce infant morbidity and mortality (e.g. through the promotion of
breast-feeding and providing nutrition education to parents together with providing
supportive conditions, both at work and in the community).
The formal responsibility of public health agencies is primarily disease surveillance,
investigation and control. These activities cannot be conducted effectively, however,
without the active cooperation and support of physicians at the community level who
are aware of individual and community illness patterns and can notify health
authorities promptly of problems that might require further investigation and action.
For example, physicians can help identify populations at high risk for particular
diseases, such as tuberculosis, and report cases of communicable diseases such as
measles, whooping cough, or infectious causes of diarrhoea, as well as cases of
exposure to lead or other toxic chemicals and substances in the community or work
place. Close collaboration between public health agencies and physicians as well as
other health professionals is critical for an efficient disease monitoring system.
Regardless of the effectiveness of existing public health programs in a jurisdiction,
professional medical associations should be aware of unmet health needs in their
S-1995-04-2016 ⏐ Taipei
Public Health
communities and nations and advocate for activities, programs and resources to meet
those needs. These efforts might be in areas of public education for health promotion
and disease prevention; monitoring and controlling environmental hazards; identifying
and publicising adverse health effects resulting from social problems, such as
interpersonal violence or social practices that affect health; or identifying and
advocating for services such as improvements in emergency treatment preparedness.
In jurisdictions in which basic public health services are not being provided
adequately, medical associations must work with other health agencies and groups to
establish priorities for advocacy and action. For example, in a country or area with
limited resources in which potable water and sewage facilities are not available to
most residents, these needs should be given priority over medical technologies that
would provide service to only a small portion of the population.
Some health-related issues are extremely complex and involve multiple levels of
response. For example, those diagnosed with high blood lead levels need not only
appropriate medical treatment, but the source of contamination must also be
determined, and measures need to be taken to eliminate the danger. At times policies
that promote public health create concern because of their potential economic impact.
For example, strong opposition to the potential economic impact of tobacco control
policies could come from regions or groups that derive significant revenue from
growing or processing tobacco. However, economic concerns should not deter a strong
public health advocacy program against the use of tobacco products. The promotion of
tobacco products should be rigorously opposed, and every effort should be made to
reduce tobacco consumption in both developed and developing countries.
Physicians and their associations should collaborate with political authorities and other
organizations to encourage the media to send positive messages for health education
regarding diet, drug use, sexually transmitted diseases, cardiovascular risk, etc.
Medical associations should ask their members to educate their patients on the
availability of public health services.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-01-2019
WMA STATEMENT
ON
RESISTANCE TO ANTIMICROBIAL DRUGS
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
AMR is a growing threat to global public health that transcends national boundaries and
socioeconomic divisions. AMR affects human, animal and environmental health. It is a
multi-faceted problem of crisis proportions with significant economic, health, and human
implications.
Addressing the threat of antimicrobial resistance is a fundamental global health priority,
and the responsibility of all countries.
Antimicrobial drugs form an essential component of modern medicine, ensuring that
complex procedures, such as surgery and chemotherapy, can be performed with lower
risk.
AMR threatens the effective prevention and treatment of an increasing range of infections
caused by bacteria, parasites, viruses and fungi.
AMR occurs when microorganisms develop the ability to resist the actions of
antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and
anthelmintics).
Infections caused by bacteria that are resistant to multiple classes of antibiotic are
increasingly being documented.
While AMR is a natural evolutionary phenomenon, it is exacerbated by the overuse and
misuse of antimicrobials in medicine, as well as in veterinary practice and agriculture, and
can be exacerbated when antimicrobials are given as growth promoters in animals or used
to prevent diseases in healthy animals.
The emergence and spread of AMR is further enhanced by lack of access to effective
drugs, access to antibiotics “over the counter” in some countries, the availability of
substandard and falsified products, misuse of antibiotics in food production, increased
global travel, medical tourism and trade, and the poor application of infection control
measures.
Another major cause of AMR is the release of antibiotics into the environment. This can
occur as either as a result of poor manufacturing practices, the improper disposal of
unused medication, human and animal excretion, and the inadequate disposal of human
S-1996-01-2019 ⏐ Tbilisi
Antimicrobial Resistance
and animal corpses.
In many countries, particularly in low-and middle-income countries, access to effective
antimicrobials as well as complementary technologies including vaccines and diagnostics
continues to remain a significant challenge, furthering AMR.
The ramifications of resistance manifest themselves not just in the impact on human
health, but also in potentially heavy economic costs. The World Health Organization
(WHO) has warned that resistance has reached alarming levels in many parts of the world,
and that a continued increase in resistance could lead to 10 million people dying per year
and a reduction of 2-3.5% in global gross domestic product by 2050.
At the rate at which resistance is growing globally, it poses a significant threat to
successfully achieving the UN Sustainable Development Goals and undermines efforts to
reduce health inequalities. Without harmonized and coordinated cross-sector action on a
global, scale, the world is heading towards a post-antibiotic era in which common
infections and minor injuries can once again kill.
AMR has reached great prominence at the highest political levels including the UN
General Assembly, and the agenda of the G7 and G20.
There is a need for an effective ‘one health’ approach to minimize unnecessary or
inappropriate use of antimicrobials and to prevent and control the transmission of existing
resistance. A ‘one health’ approach recognizes that action is required across human
medicine, veterinary practice and agriculture.
RECOMMENDATIONS
Global
1. The primary prevention of community and healthcare associated infections is
necessary to reduce the demand for antibiotics. Addressing the social determinants
of infectious disease, such as poor living conditions and sanitation, will have co-
benefits of reducing health inequalities and tackling AMR.
2. Nations have varying resources available to combat antimicrobial resistance, and
must cooperate with the WHO, Food and Agriculture Organization and World
Organization for Animal Health that support the WHO Global Action Plan on
AMR which provides the framework for national action plans.
3. The World Medical Association and its constituent members should advocate for:
• investment in the surveillance of drug resistant infections across human health,
veterinary medicine, agriculture, fishing industry, and food production, and
international cooperation for data-sharing procedures to improve global
responses;
• the WHO and other UN agencies should examine the role of international
travel and trade agreements on the development of antimicrobial resistance,
and promote measures in those agreements to act as safeguards against the
globalisation of drug resistant pathogens in our food supply;
• the WHO should continue to encourage the use of Trade Related Aspects of
Handbook of WMA Policies
World Medical Association ⏐ S-1996-01-2019
Intellectual Property Rights (TRIPS) flexibilities to help ensure affordable
access to quality medicines and oppose the proliferation of ‘TRIPS-plus’
provisions within trade agreements, which restrict the use of TRIPS
flexibilities and limit their effectiveness;
• the widespread application of verifiable technology such as track-and-trace
systems to ensure the authenticity of pharmaceutical products;
• equitable access to, and appropriate use of, existing and new quality-assured
antimicrobial medicines. This requires effectively applying the Access, Watch
and Reserve lists of the WHO Essential Medicines program. For the WHO
global action plan and national action plans to be effective, access to health
facilities, health care professionals, veterinarians, knowledge, education and
information are vital;
• greater use of vaccinations which will reduce the burden of infectious disease,
reducing the need for antibiotics and therefore limiting the emergence of
resistance;
• for global health organisations and governments to scale up their action and
coordination in promoting appropriate antibiotic use and work together to
reduce AMR using a One Health approach, which recognises that human,
animal and environmental health is inextricably linked. to reduce the spread of
resistance.
4. The World Medical Association and its constituent members should encourage
their governments to:
• fund more basic and applied research directed toward the development of
innovative antimicrobial agents, diagnostic tools and vaccines (innovative
antimicrobial vaccines), and on the appropriate and safe use of such therapeutic
tools;
• ensure parity between financial and technical resources towards the
development of innovative antimicrobial medicines, vaccines, and diagnostics
as well as innovative infection control and prevention methods across human
health, veterinary, and agricultural sectors;
• support Research and Development efforts for novel antimicrobial agents,
vaccines, and rapid diagnostic methods that are needs-driven and guided by the
principles outlined in the UN Declaration on AMR, adopted in September
2016, including affordability, effectiveness, efficiency, and equity [1];
• initiate regulatory measures to control the environmental pollution that allows
the spread of antibiotic- resistant genes across soil, water and air;
• educate a sufficient number of clinical infectious disease specialists in every
country, which is a fundamental requirement for tackling antimicrobial
resistance and hospital-acquired infections.
National
1. National medical associations should urge their governments to:
• require that antimicrobial agents be available only through a prescription
provided by healthcare professionals and/or veterinary professionals and
S-1996-01-2019 ⏐ Tbilisi
Antimicrobial Resistance
dispensed or sold by professionals;
• to initiate national campaigns to raise awareness among the public of the
harmful consequences of overuse and misuse of antibiotics. This should be
supported through the introduction of national targets to raise public
awareness;
• to support professional societies, civil society, and healthcare delivery systems
to pilot and adopt proven behaviour change strategies to ensure appropriate use
of antibiotics;
• to ensure access to appropriate and fit-for-purpose point-of-care diagnostics in
hospitals and clinics to support decision making and prevent inappropriate
prescribing of antibiotic;
• to mandate the collection of data on antibiotic use, prescriptions, prices,
resistance patterns, and trade in both the healthcare and agricultural sectors.
This data should be made publicly accessible;
• promote effective programs of antimicrobial stewardship and training on the
appropriate use of antimicrobials agents, and infection control;
• actively pursue the development of a national surveillance system for the
provision of antimicrobials and for antimicrobial resistance. Data from this
system should be linked with or contributed to the WHO’s global surveillance
network;
• monitoring of antimicrobial use in food producing animals must be sufficiently
granular to ensure accountability.
2. National medical associations should:
• encourage medical schools and continuing medical education programs to
renew their efforts to educate physicians, who can in turn inform their patients,
about the appropriate use of antimicrobial agents and appropriate infection
control practices, including antibiotic use in the outpatient setting;
• support the education of their members in areas of AMR, including
antimicrobial stewardship, rational use of antimicrobials, and infection control
measures including hand hygiene;
• advocate for the publishing and communication of local information relating to
resistance patterns, clinical guidelines and recommended treatment options for
physicians;
• in collaboration with veterinary authorities, encourage their governments to
introduce regulations to reduce the use of antimicrobials in agriculture, in
particular food producing animals, including restrictions on the routine use of
antimicrobials for both prophylaxis and growth promotion, and on the use of
classes of antimicrobial that are critically important in human medicine;
• support regulation that prevents conflicts of interest among veterinarians, such
as roles where veterinarians both prescribe and sell antibiotics;
• consider the use of social media to educate and promote the proper use and
disposal of antibiotic medications;
• encourage parents to comply with the national recommended immunization
schedules for children. Adults should also have easy access to vaccines against
influenza and pneumococcal infections among others.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-01-2019
Local
1. Health professionals and health systems have a vital role in preserving
antimicrobial medicines.
2. Physicians should:
• have access to high-quality and reliable, evidence-based information free of
conflict of interest and actively participate in and lead antimicrobial
stewardship programs in their hospitals, clinics and communities to optimise
antibiotic use;
• raise awareness amongst their patients about antimicrobial therapy, its risks and
benefits, the importance of adherence with the prescribed regimen, infection
prevention practices, and the problem of AMR;
• promote and ensure adherence hygiene measures (especially hand hygiene) and
other infection prevention practices.
Handbook of WMA Policies
World Medical Association S-1996-02-2021
WMA STATEMENT
ON
FAMILY VIOLENCE
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
editorially revised by the 174th
WMA Council Session, Pilanesberg, South Africa,
October 2006
amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and by the 72nd
WMA General Assembly (online), London, United Kingdom, October 2021
PREAMBLE
Family violence is a grave universal public health and human rights problem that affects
individuals, regardless of age, gender, sexual orientation, racial/ethnic background, culture,
religion, socio-economic status or any other factor.
Though definitions vary, the term family violence is generally applied to the physical, sexual,
verbal, economic, spiritual, psychological or emotional abuse, or neglect of a person by
someone with whom the victim is physically, financially, emotionally or socially related and/or
dependent.
Although the causes of family violence are complex, a number of contributing factors are
known, such as lack of basic education, lack of economic independence/poverty, underlying
and/or undiagnosed mental health issues, substance abuse (particularly alcohol), stress, rigid
gender roles, poor parenting skills, interpersonal conflicts within the family, the perpetrator’s
experience of maltreatment and family violence as a child, or familial social isolation.
Family violence has adverse physical, mental, emotional and psycho-social consequences on
the individual and negatively impacts the health and wellbeing of the affected individual. There
may also be socio-economic impacts as well as impacts on a witness of family violence, the
family and community. These adverse effects could be short-term/immediate or long-
term/chronic. They include physical harm/injuries, death, impact on reproductive
health/miscarriage, dysfunctional families, educational disruptions and poor academic
performance, sexually transmitted diseases, juvenile delinquency, professional disruptions and
loss of employment, social exclusions and homelessness, insomnia, anxiety, depression, resort
to substance abuse and crime, post-traumatic stress disorder, and suicide. Victims can become
perpetrators of family violence and violent acts against non-intimates (intergenerational
transmission of violence).
London S-1996-02-2021
Family Violence
The World Medical Association (WMA) firmly condemns all forms of violence and reaffirms
its policies on Violence against Women and Girls, Child Abuse and Neglect, the Abuse of the
Elderly, and Violence and Health.
RECOMMENDATIONS
Governments and National Health Authorities
WMA urges governments to:
1. Strengthen the sense of social responsibility, develop and enforce policies, legal
frameworks, and national plans with allocated budget for the prevention and elimination of
family violence, as well as for protection of victims and witnesses of family violence.
2. Address the root causes of violence in relation to social determinants of health and to
promote health equity. This should include addressing gender inequality and other harmful
societal practices.
3. Recognize that times of intense individual and/or national stress increase the risk of family
violence and ensure that appropriate resources are publicized and made available during
such times.
4. Provide tools to recognize, act upon and if necessary report cases of family violence.
5. Develop data collection systems on family violence, that holistically include vital aspects
of family violence such as mortality, morbidity, injuries, family or community
environment, risk factors, costs of interventions, loss in productivity, legal costs among
others.
6. Provide secure private reporting mechanisms and safe havens to protect the individual from
feelings of guilt and shame to avoid stigma and retaliation.
7. Require a guideline that indicates how to act on suspicion of family violence and what
interventions are available. Reporting should only be done when, in the opinion of the
physician, doing so will not endanger the individual experiencing the violence. If possible,
this should be done in consultation with the individual experiencing the violence.
8. Institute and promote high-quality research programs to provide a strong evidence base on
the multiple facets of family violence such as the magnitude, risk profiles, underlying
factors, and the complex interplay of factors, as well as cross comparisons among settings,
countries and regions.
9. Develop and offer family violence services to those experiencing family violence,
including policy and legal accompaniments, case management, advocacy, counselling, safe
housing and safety planning.
Handbook of WMA Policies
World Medical Association S-1996-02-2021
10. Encourage multi-stakeholder constructive collaboration between sectors, disciplines, as
well as governmental and nongovernmental bodies, including traditional and religious
institutions, to eliminate and prevent family violence.
WMA constituent members and the medical profession
WMA constituent members should:
1. Encourage coordination of action against family violence between and among components
of the health care system, criminal justice systems and law enforcement authorities,
including family and juvenile courts, and victims’ services organizations.
2. Encourage and facilitate research to understand the prevalence, risk factors, outcomes and
optimal care for victims of family violence.
3. Promote advocacy, public and professional awareness creation, and community education
programs on family violence.
4. Encourage managers of public and private health facilities to provide educational materials
in reception/patient waiting rooms and emergency departments, to offer patients and clients
general information about family violence, as well as to inform them about available
integrated and professionally good local services that can be accessed.
5. Advocate for inclusion of courses on violence, including family violence, in the academic
curricula for undergraduate and postgraduate medical education.
6. Promote capacity building and Continuous Medical Education programs for physicians, on
prevention of family violence.
7. Advocate for rehabilitation, counseling, and therapy to those who either cause, experience
or are exposed to the violent acts, especially traumatized children.
8. Encourage adequate undergraduate family medicine education and training in family
dynamics, including the medical, sociological, psychological and preventive aspects of all
types of family violence.
Physicians
In the light of their obligation to promote the well-being of patients, physicians have an ethical
obligation to take appropriate action to recognize and offer assistance to patients harmed by
family violence and abuse.
Physicians should:
London S-1996-02-2021
Family Violence
1. Routinely consider and be sensitive to signs indicating the need for further evaluations
about current or past abuse as part of their general health screening or in response to
suggestive clinical findings, as physicians are often the first to suspect family violence.
2. Be acquainted on ways to take an appropriate and culturally sensitive history of current and
past abuse and be acutely aware of the need to maintain confidentiality and a trusting
patient-physician relationship in cases of family violence.
3. Be aware of social, community and other services useful for victims, and in some cases,
perpetrators of violence and refer to and use these routinely to support victims, witnesses
and/or perpetrators of family violence.
4. Report suspected violence against children and other family members to appropriate
protection and security services in keeping with applicable requirements, and take
necessary measures to ensure that victims and witnesses of violence are not at risk.
5. Be encouraged to participate in coordinated community activities that seek to reduce the
burden and impact of family violence.
6. Be encouraged to embrace patient-centred, community specific care, and to develop
impartial attitudes toward those involved in family violence.
Handbook of WMA Policies
World Medical Association ⏐ S-1996-04-2017
WMA STATEMENT
ON
FAMILY PLANNING AND THE RIGHT OF A WOMAN
TO CONTRACEPTION
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
amended by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
and reaffirmed with minor revision by the 207th
WMA Council session, Chicago, United
States, October 2017
PREAMBLE
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.
Handbook of WMA Policies
S-1996-05-2016 ⏐ World Medical Association
WMA STATEMENT
ON
WEAPONS OF WARFARE AND
THEIR RELATION TO LIFE AND HEALTH
Adopted by the 48th
WMA General Assembly, Somerset West, South Africa, October 1996
and editorially revised by the 174th
WMA Council Session, Pilanesberg, South Africa,
October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Recalling its Declaration of Washington on Biological Weapons, its Resolution on the
Prohibition of chemical weapons and its Statement on Nuclear Weapons, the World
Medical Association condemns the use of any forms of weapons – conventional,
biological, chemicals and nuclear weapons – which has the potential to bring immense
human suffering and substantial death together with catastrophic effects on the earth’s
ecosystem, a reduction of the world food supply and increased poverty. The use of such
weapons against human beings is in opposition with physicians’ duties and responsibilities
to preserve life.
When nations enter into warfare or into weapons development, they do not usually
consider the effects of the use of weapons on the health of individual non-combatants and
on public health in general, either in the short or in the longer term.
Nevertheless the medical profession is required to deal with both the immediate and long
term health effects of warfare, and in particular with the effects of different forms of
weaponry including the threat of nuclear, chemical and biological warfare.
The potential for scientific and medical knowledge to contribute to the development of
new weapons systems, targeted against specific individuals, specific populations or
against body systems, is considerable. This includes the development of weapons designed
to target anatomical or physiological systems, including vision, or which use knowledge
of human genetic similarities and differences to target weapons.
There are no current and commonly used criteria to measure weapons effects on health.
International Humanitarian Law states that weapons that cause injuries, which would
constitute “unnecessary suffering or superfluous injury”, are illegal. These terms are not
defined and require interpretation against objective criteria for the law to be effective.
Physicians can aid in developing criteria for weapons that cause injury or suffering so
extreme as to invoke the terms of International Humanitarian Law.
Such criteria could aid lawyers in the use of International Humanitarian Law, allow
assessment of the legality of new weapons currently in development against an agreed,
Taipei ⏐ S-1996-05-2016
Weapons of Warfare
objective system of assessment of their medical effects, and identify breaches of the Law
once it is developed.
Physician involvement in the delineation of such objective criteria is essential if it is to
become part of the legal process. However, it must be recognised that physicians are
firmly opposed to any use of weapons against human beings.
RECOMMENDATIONS
The WMA believes that the development, manufacture and sale of weapons for use
against human beings are abhorrent. To support the prevention and reduction of weapons
injuries, the WMA:
• Supports international efforts to define objective criteria to measure the effects of
current and future weapons, which could be used to stop the development,
manufacture, sale and use of those weapons;
• Calls on National Medical Associations to urge national governments to cooperate
with the collection of such data as are necessary for establishing objective criteria;
• Calls on National Medical Associations to support and encourage research into the
global public health effects of weapons use, and to publicise the results of that
research, both nationally and internationally. This will ensure that both governments
and the public are aware of the long-term health consequences of weapons use on
non-combatant individuals and populations.
Handbook of WMA Policies
S-1997-01-2007 ⏐ World Medical Association
WMA PROPOSAL
FOR
A UNITED NATIONS RAPPORTEUR ON THE INDEPENDENCE
AND INTEGRITY OF HEALTH PROFESSIONALS
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
The British Medical Association (BMA) requests that the World Medical Association
(WMA) supports a proposal, put forward by a network of medical organizations*
con-
cerned 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 con-
siderable 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 govern-
ment circles to have detailed knowledge of human rights violations, including viola-tions
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:
Berlin ⏐ S-1997-01-2007
UN Rapporteur on the Independence and Integrity of Health Professionals
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 be-
cause 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 rap-
porteur’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 rap-
porteur 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 en-
couraged to disseminate such information to health professionals during their train-
ing. 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 interna-
tional and national professional associations, human rights bodies and humani-
tarian 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 trans-
gressing guidelines about impartiality and non-discrimination.
Handbook of WMA Policies
S-1997-01-2007 ⏐ World Medical Association
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 trans-
gressing of impartiality by health professionals. The rapporteur’s role will be to en-
sure 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 rap-
porteur to monitor would be the introduction of national or local legislation, civil
or military regulations or other rules prohibiting or limiting the provision of medi-
cal or nursing care to certain categories of patient.
• It will be within the remit of the rapporteur to bring the evidence or reports of viola-
tions of medical impartiality, including those in health professionals cooperating
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 col-
lectively 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 ma-
terialize 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 profes-
sionals 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 avail-
able medical treatment will be investigated.
Berlin ⏐ S-1997-01-2007
UN Rapporteur on the Independence and Integrity of Health Professionals
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 res-
ponsibilities 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 medi-
cal impartiality would be within the rapporteur’s remit. In the long term this func-
tion should ideally be dealt with by delegation through medical schools, profes-
sional bodies and voluntary national networks;
• while government measures to regulate aspects of care, (such as the equitable dis-
tribution of medical resources of the prioritizing of treatment on basis of need)
would not generally be a matter for monitoring for the rapporteur, extreme meas-
ures 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 rappor-
teur;
• 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 Asso-
ciation; 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.
Handbook of WMA Policies
S-1997-02-2018 ⏐ World Medical Association
WMA STATEMENT
ON
PHYSICIANS CONVICTED OF GENOCIDE, WAR CRIMES OR CRIMES
AGAINST HUMANITY
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
reaffirmed by the 176th
WMA Council Session, Berlin, Germany, May 2007
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
SCOPE AND DEFINITIONS
The scope of this Statement includes the following specified crimes: genocide, war
crimes, and crimes against humanity, as defined by the Rome Statute of the International
Criminal Court.
PREAMBLE
• Physicians are bound by medical ethics to dedicate themselves to the good of their
patients. Physicians who have been convicted of genocide, war crimes or crimes
against humanity1
, have violated medical ethics, human rights and international
law and are therefore unworthy of practising medicine.
• In accordance with the principle of the presumption of innocence, only physicians
who have been convicted of the specified crimes should be declared unworthy of
practising medicine.
DISCUSSION
1. Physicians seeking to work in any country are subject to the regulations of that
country’s relevant authorities or jurisdiction. The duty to demonstrate suitability to
practice medicine rests with the person seeking licensure.
2. Physicians who have been convicted of genocide, war crimes or crimes against
humanity must not be allowed to practise in another country or jurisdiction.
3. The relevant licensing authorities must ensure both that physicians have the
required qualifications and that they have not been convicted of genocide, war
crimes or crimes against humanity.
4. Physicians who have been convicted of the specified crimes have sometimes been
able to leave the country in which these crimes were committed and obtain a
licence to practise medicine from the relevant licensing authority in another
Reykjavik ⏐ S-1997-02-2018
Physicians convicted of Genocide or Crimes
country.
5. This practice is contrary to the public interest, damaging to the reputation of the
medical profession, and may be detrimental to patient safety.
RECOMMENDATIONS
1. The WMA recommends that physicians who have been convicted of the specified
crimes be denied a license to practice medicine and membership to national
medical associations by the relevant regulatory and licensing authority of that
jurisdiction.
2. The WMA recommends that relevant regulatory and licensing authorities use their
own authority to inform themselves, in so far as is possible, if verifiable allegations
of participation in genocide, war crimes or crimes against humanity have been
made against physicians, while at the same time respecting the presumption of
innocence.
3. National Medical Associations must be sure that a thorough investigation into
those allegations is performed by an appropriate authority.
4. The WMA recommends that national medical associations ensure that there is
efficient communication amongst themselves and that where possible and
appropriate they inform relevant national regulatory and licensing authorities of
physicians’ convictions of genocide, war crimes, or crimes against humanity.
1
As defined by the Rome Statute of the International Criminal Court.
Handbook of WMA Policies
World Medical Association S-1997-03-2021
WMA STATEMENT
ON
ACCESS OF WOMEN AND CHILDREN TO HEALTH CARE
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019 and
by the 72nd
WMA General Assembly (online), London, United Kingdom, October 2021
PREAMBLE
For centuries, women and girls worldwide have suffered from gender inequality and an uneven
balance of power between men and women. Historically based gender bias has led to women
and girls being restricted in their access to, inter alia, employment, education and health care.
Gender inequality creates dangers in medical treatment. When both genders are not offered
equal quality treatment and care for the same medical complaints or when different
manifestations of disease are not considered based on sex, patient outcomes will suffer.
In addition, in some countries, female healthcare providers have been prevented from, or face
barriers to practicing their profession or being promoted to leadership positions due to religious
and/or cultural convictions, or discrimination based on the intersecting grounds of sex and
religion/ethnicity. A lack of gender representation and diversity within the medical profession
may lead to female patients and their children not having equitable access to health care.
Discrimination against girls and women damages their health expectation. It serves as a barrier
to accessing health services, affects the quality of health services provided, and reinforces
exclusion from society for women and girls. For example, the education of girls positively
affects their health and well-being as adults. Education also improves the chances of their
children surviving infancy and contributes to the overall well-being of their families.
Conversely, secondary discrimination due to social, religious and cultural practices – which
diminishes women’s freedom to make decisions for themselves and to access employment and
healthcare opportunities – has a negative impact on health expectation.
National laws, policies and practices can also foster and perpetuate discrimination in health
care settings, prohibiting or discouraging women and girls from seeking the broad range of
health care services they may need. Evidence demonstrates the harmful health and human
rights impacts of such laws. For example, in some countries and due to national laws,
Women and Children to Health Care
London S-1997-03-2021
legislations or social norms, women and girls lack decision-making power about their own
medical treatment, surgery, childbearing or contraception.
Addressing discrimination in health care settings will contribute to the achievement of many
of the United Nations Sustainable Development Goads (SDGs), ensuring that no woman or girl
is left behind. It is fundamental to securing progress towards SDG 3, Good health and
wellbeing, including achieving universal health coverage and ending the AIDS and
tuberculosis epidemics; SDG 4, Quality education; SDG 5, Gender equality and women’s
empowerment; SDG 8, Decent work and inclusive economic growth; SDG 10, Reduced
inequalities; and SDG 16, Peace, justice and strong institutions.
Gender is a social determinant of health and health problems may manifest themselves
differently in men and women. There is a need to address the differences in health and unequal
health care between men and women, including both the biological and socio-cultural
dimensions.
Access to healthcare, including both therapeutic and preventative 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 in all
aspects of healthcare.
Machine learning, predictive algorithms and artificial intelligence (AI) in healthcare are
expected to drastically change the way healthcare is practiced and managed. For example, AI
could change the way in which diseases such as cancer are diagnosed and treated. However,
even with the introduction of AI in healthcare, resource limitations may prevent most women
globally from accessing such healthcare. In order not to amplify any gender inequalities,
information being programmed into artificial intelligence algorithms being created to inform
medical diagnoses and management must take into account the specific health considerations
of women, for example women may present with different symptoms to men.
The WMA Declaration of Geneva establishes the physician’s respect for human dignity and
that it should not allow considerations of gender to come between “my duties and my patients.”
RECOMMENDATIONS
Therefore, the World Medical Association urges its constituent members to:
1. Promote the equal human right of health for women and children;
2. Categorically condemn violations of the basic human rights of women and children,
including violations stemming from social, political, religious, economic and cultural
practices;
Handbook of WMA Policies
World Medical Association S-1997-03-2021
3. Insist on the rights of all women and children to full and adequate medical care,
especially where religious, social, and cultural restrictions or discrimination may hinder
access to such medical care, and promote women’s and children’s health and access to
health as human rights;
4. Advocate for parity of health insurance premiums and coverage to ensure that women’s
access to care is not impeded by prohibitively high expenses;
5. Governments have an obligation to ensure that the information being programmed into
artificial intelligence algorithms being created to inform medical diagnoses and
management must include a representative sample of data from women to ensure the
gender inequality gap is not amplified further.
6. Ensure universal access to sexual and reproductive healthcare;
7. Promote the provision of pre-conception, prenatal and maternal care, and post-natal
care including immunization, nutrition for proper growth and healthcare development
for children.
8. Advocate for educational, employment and economic opportunities for women and for
their access to information about healthcare and health services.
9. Work towards the achievement of the human right to gender equality of opportunity
and gender equality of treatment.
Handbook of WMA Policies
S-1998-01-2018 ⏐ World Medical Association
WMA STATEMENT
ON
NUCLEAR WEAPONS
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and revised by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
The WMA Declarations of Geneva, of Helsinki and of Tokyo make clear the duties and
responsibilities of the medical profession to preserve and safeguard the health of the
patient and to dedicate itself to the service of humanity. Therefore, and in light of the
catastrophic humanitarian consequences that any use of nuclear weapons would have, and
the impossibility of a meaningful health and humanitarian response, the WMA considers
that it has a duty to work for the elimination of nuclear weapons. To achieve a world free
of nuclear weapons is a necessity.
RECOMMENDATIONS
Therefore, the WMA:
1. Condemns the development, testing, production, stockpiling, transfer, deployment,
threat and use of nuclear weapons;
2. Requests all governments to refrain from the development, testing, production,
stockpiling, transfer, deployment, threat and use of nuclear weapons and to work in
good faith towards the elimination of nuclear weapons;
3. Advises all governments that even a limited nuclear war would bring about immense
human suffering and substantial death toll together with catastrophic effects on the
earth’s ecosystem, which could subsequently decrease the worlds food supply and
would put a significant portion of the world’s population at risk of famine;
4. Is deeply concerned by plans to retain indefinitely and modernize nuclear arsenals; the
absence of progress in nuclear disarmament by nuclear-armed states; and the growing
dangers of nuclear war, whether by intent, including cyberattack, inadvertence or
accident;
5. Welcomes the Treaty on the Prohibition of Nuclear Weapons, and joins with others in
Reykjavik ⏐ S-1998-01-2018
Nuclear Weapons
the international community, including the Red Cross and Red Crescent movement,
International Physicians for the Prevention of Nuclear War, the International
Campaign to Abolish Nuclear Weapons, and a large majority of UN member states, in
calling, as a mission of physicians, on all states to promptly sign, ratify or accede to,
and faithfully implement the Treaty on the Prohibition of Nuclear Weapons; and
6. Requests that all National Medical Associations join the WMA in supporting this
Declaration, use available educational resources to educate the general public and to
urge their respective governments to work urgently to prohibit and eliminate nuclear
weapons, including by joining and implementing the UN Treaty on the Prohibition of
Nuclear Weapons.
Handbook of WMA Policies
World Medical Association S-1998-02-2021
WMA STATEMENT
ON
MEDICAL CARE FOR MIGRANTS
Adopted by the 50th
WMA General Assembly, Ottawa, Canada, October 1998
reaffirmed by the 59th
WMA General Assembly, Seoul, Korea, October 2008
amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and by the 72nd
WMA General Assembly (online), London, United Kingdom, October 2021
PREAMBLE
For the purpose of this Statement, in line with the International Organisation for Migration
index, “migrant” is an umbrella term reflecting the common lay understanding of a person who
moves away from his or her place of usual residence, whether within a country or across an
international border, temporarily or permanently, and for a variety of reasons.
The WMA considers health to be a basic need, a human right, and one of the essential drivers
of economic and social development.
According to the World Health Organisation, universal access to health implies that all people
and communities have access to comprehensive health services, without barriers or
discrimination, according to their needs, within the framework of equitable and supportive
health systems.
Recalling the WMA Declaration of Geneva, the WMA underlines every physician’s duty to
not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality,
political affiliation, race, sexual orientation, social standing or any other factor to interfere with
the physician’s duty to his or her patient.
The WMA underlines that physicians should offer help in medical emergencies in accordance
with the WMA International Code of Medical Ethics.
Taking into account the WMA Declaration of Ottawa on Child Health and the WMA Statement
on Medical Age Assessment of Unaccompanied Minor Asylum Seekers, the WMA reiterates
that children should enjoy special protection, including the right to adequate health care without
discrimination.
Medical Care for Migrants
London S-1998-02-2021
These fundamental WMA principles also echo the principles laid down in the Universal
Declaration of Human Rights, the United Nations Convention on the Rights of the Child and
the International Covenant on Economic, Social and Cultural Rights.
The WMA Declaration of Lisbon on the Rights of the Patient declares that every person is
entitled without discrimination to appropriate medical care. However, national legislation
varies and is often not in accordance with this fundamental principle.
At any time, large numbers of migrants are seeking protection, fleeing from natural disasters,
desperate poverty, violence and other injustices and abuses with potentially very harmful
effects to mental and physical health.
Recalling the WMA statement on Armed Conflicts and the WMA declaration on Health and
Climate Change, the WMA recognizes that climate change, natural disasters, warfare, armed
conflicts and other emergencies, including continuous civil strife, unrest and violence, will
inevitably lead to the displacement of people from their homes.
The WMA is concerned by the precarious situation of certain categories of migrants, such as
refugees, asylum seekers, refused asylum seekers, undocumented migrants and displaced
persons, whose access to health care is often undermined, and where physicians are required
in some countries to intervene outside the scope of their medical duty, in contradiction with
medical ethics.
Bearing in mind the above-mentioned principles, international conventions and WMA policies,
the WMA advocates a strong and continued engagement of physicians in the defence of human
rights and dignity of all people including migrants worldwide, while making the following
recommendations for its constituent members and individual physicians:
RECOMMENDATIONS
WMA constituent members should:
• Prioritize the medical care of human beings above any other personal, material,
economic, or political interest.
• Actively support and promote the right of all people to receive medical care on the basis
of clinical need alone and speak out against legislation and practices that contradict this
fundamental right.
• Call for governments to reach political agreements that facilitate the availability of
sufficient resources for the delivery of adequate and coordinated health services to
migrant populations, including in refugee camps where the conditions of living make
them more susceptible to the spread of disease and viruses.
Handbook of WMA Policies
World Medical Association S-1998-02-2021
• Urge governments to ensure access to safe and adequate living conditions and essential
services to all migrants, even with support from the donor agencies and/or
philanthropists if needed.
• Promote equality, solidarity and social justice, guaranteeing access of migrants and
refugees to health and social services.
• Implement policies, actions and commitments that promote the health of all, without
discrimination, addressing the social determinants of health related to migrants and
refugees.
Physicians:
• Have a duty to provide appropriate medical care, based solely on clinical need,
regardless of the civil or political status of the patient.
• Should speak out against legislation and practices that prevent the fulfilment of this
duty.
• Cannot be compelled to participate in any punitive or judicial action against migrants,
including refugees, asylum seekers, refused asylum seekers, undocumented migrants
and or displaced persons, or to withhold medically necessary treatment, or to administer
any non-medically justified diagnostic measure or treatment, such as sedatives to
facilitate easy deportation from the country or relocation.
• Must be allowed adequate time and be provided with sufficient resources, including
interpretation services, to assess the physical and psychological condition of migrants,
including refugees, asylum seekers, refused asylum seekers, undocumented migrants
and displaced persons.
Handbook of WMA Policies
S-1999-01-2019 ⏐ World Medical Association
WMA STATEMENT
ON
PATENTING MEDICAL PROCEDURES
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212th
WMA Council Session, Santiago, Chile, April 2019
PREAMBLE
1. Under the law of some jurisdictions medical procedures are patentable. Patents on
medical procedures are often called medical procedure patents. A medical procedure
patent or patent claim is one that only confers rights over procedural steps and does
not confer rights over any new devices.
2. Over 80 countries prohibit medical procedure patents. The practice of excluding
medical procedures from patentability is consistent with the Uruguay Round of
Amendments to the General Agreements on Tariffs and Trade Agreement on Trade
Related Aspects of International Property Rights (GATT-TRIPs), which states:
“Members may also exclude from patentability: (a) diagnostic, therapeutic and surgical
methods for the treatment of humans or animals” (Article 27).
3. The purpose of patents is to encourage private investment in research and
development. However, physicians, particularly those who work in research
institutions, already have incentives to innovate and improve their skills. These
incentives include professional reputation, professional advancement, and ethical and
legal obligations to provide competent medical care (International Code of Medical
Ethics, 17.A). Physicians are already paid for these activities, and public funding is
sometimes available for medical research. The argument that patents are necessary to
spur invention of medical procedures, and that without procedure there would be fewer
beneficial medical procedures for patients, is not particularly persuasive when these
other incentives and financing mechanisms are available.
4. Another argument is that patents are necessary, not so much for invention but for
product development. This argument also is not persuasive in the case of medical
procedure patents. Unlike device development, which requires investment in
engineers, production processes, and factories, development of medical procedures
consists of physicians attain-ing and perfecting manual and intellectual skills. As
discussed above, physicians already have both obligations to engage in these
professional activities as well as rewards for doing so.
5. Whether or not it is ethical to patent medical devices does not bear directly on whether
it is ethical for physicians to patent medical procedures. Devices are manufactured and
disseminated by companies, whereas medical procedures are “produced and
disseminated” by physicians. Physicians have ethical or legal obligations to patients
and professional obligations towards each other, which companies do not have.
Having particular ethical obliga-tions is part of what defines medicine as a profession.
S-1999-01-2019 ⏐ Santiago
Patenting Medical Procedures
6. There is no a priori reason to believe that those holding medical procedure patents
would make patented medical procedures widely available. Patentees might attempt to
maximize their profits by making the procedure widely available through
nonexclusive licensing with low fees. Alternatively, they might attempt to maximize
profits by limiting avail-ability of the procedure and charging higher prices to those
for whom the procedure is extremely important and who have the means to pay.
7. Competition between organizations providing health care could provide incentives
for some organizations to negotiate exclusive licenses, or licenses which sharply limit
who else could practice the procedure. Such a license might provide the organization
with an advantage in attracting patients, if the organization could advertise that it was
the only organization in a region which could provide a particularly desirable service.
Thus, at least some of the time patentees will probably limit access to patented medical
procedures.
8. Medical procedure patents may negatively affect patient care. If medical procedure
patents are obtained, then patients’ access to necessary medical treatments might
diminish and thereby undermine the quality of medical care. Access could diminish for
the following reasons:
• the cost of medical practice would likely increase because of licensing and royalty
fees, and because the cost of physicians’ insurance would likely increase to cover
patent litigation expenses.
• some physicians capable of performing the patented procedure might not obtain
licenses to perform it. The number of licensed physicians might be restricted be-
cause certain physicians cannot or will not pay the licensing fees or royalties, or
because the patentee refuses to make the license widely available. Limiting the
number of licenses would, in some circumstances, limit patients’ choice of physi-
cians.
• The presence of patents may prevent physicians from undertaking even those pro-
cedures which do not infringe. It may also deter a physician from introducing new
or modified procedures into his or her practice. Devices can be labelled if they are
patented, but procedures cannot, and therefore it is not immediately obvious
whether what one is doing infringes somebody else’s medical procedure patent.
However, lack of knowledge is no defence against patent infringement, so if a
physician is uncertain he or she may simply refrain from performing the procedure.
9. Enforcement of medical procedure patents can also result in invasion of patients’
privacy or in the undermining of physicians’ ethical obligation to maintain the
confidentiality of patients’ medical information. Where physicians practice in small
groups or as sole practi-tioners, the most expedient methods for a patentee to identify
instances of infringement might be to look through patients’ medical records or to
interview patients. Removing obvious identifiers for the record review would not
guarantee confidentiality, because identity can often be “reconstructed” with very few
pieces of information. This would be parti-cularly true in small towns or small
practices.
10. Physicians have ethical obligations both to teach skills and techniques to their
Santiago ⏐ S-1999-01-2019
Patenting Medical Procedures
colleagues, and to continuously learn and update their own skills. Medical procedure
patents can undermine these obligations. Once a patent has issued on a procedure,
the procedure would be fully disclosed (this is one requirement for obtaining a patent);
however, those without licenses would not be able to practice it. Limiting who can
practice the procedure undermines the spirit of the ethical mandate to teach and
disseminate knowledge. It also undermines the obligation to update one’s skills,
because it does not do much good to acquire skills which cannot be used legally.
11. The obligation to teach and impart skills may also be impaired if the possibility of
patents causes physicians to delay publishing new results or presenting them at
conferences. Physicians may be inclined to keep new techniques secret while waiting
to complete a patent application. This is because public use of a procedure, or
publication of a description of the procedure, prior to applying for a patent may
invalidate the application.
12. Physicians also have an ethical obligation not to permit profit motives to influence
their free and independent medical judgment (International Code of Medical Ethics,
17.A). For physicians to pursue, obtain, or enforce medical procedure patents could
violate this requirement. Physicians holding patents or licenses for procedures might
advocate for the use of those procedures even when they are not indicated, or not the
best procedure under the circumstances. Physicians who are not licensed to perform a
particular procedure might advocate against that procedure, even when it is the best
procedure under the circumstances.
13. Finally, physicians’ professional obligations to practice their profession with
conscience and dignity (Declaration of Geneva) might be violated by the enforcement
of medical procedure patents. The spectacle of physicians suing each other on a
regular basis is unlikely to enhance the standing of the profession.
POSITION
14. The World Medical Association
• states that physicians have an ethical responsibility to make relevant scientific in-
formation available to colleagues and the public, when possible.
• states that the patenting of medical procedures poses serious risks to the effective
practice of medicine by potentially limiting the availability of new procedures to
patients.
• considers that the patenting of medical procedures is unethical and contrary to the
values of the medical profession that should guide physicians’ service to their pa-
tients and relations with their colleagues.
• encourages national medical associations to make every effort to protect physi-
cians’ incentives to advance medical knowledge and develop new medical proce-
dures.
Handbook of WMA Policies
World Medical Association ⏐ S-1999-02-2020
WMA STATEMENT
ON
THE RELATIONSHIP BETWEEN PHYSICIANS AND PHARMACISTS
IN MEDICINAL THERAPY
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and amended by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and reaffirmed with minor revisions by the 215th
Council session (online), Cordoba, Spain,
October 2020
PREAMBLE
The goal of pharmacological treatment is to improve patients´ health and quality of life.
Optimal pharmacological treatment should be safe, effective and efficient. There should
be equity of access to this kind of treatment and an accurate and up-to-date information
base that meets the needs of patients and practitioners.
Pharmacological treatment has become increasingly complex, often requiring the input of
a multi-disciplinary team to administer and monitor the chosen therapy. In the hospital
setting the inclusion of a clinical pharmacist in such a team is increasingly common and
helpful. The right to prescribe medicine should be competency based and ideally the
responsibility of the physician.
Physicians and pharmacists have complementary and supportive responsibilities in
achieving the goal of providing optimal pharmacological treatment. This requires
communication, respect, trust and mutual recognition of each other’s professional
competence. Access by both physicians and pharmacists to the same accurate and up-to-
date information base is important to avoid providing patients with conflicting
information.
Physicians and pharmacists must provide quality service to their patients and ensure safe
use of drugs. Therefore, collaboration between these professions is imperative, including
with respect to the development of training and in terms of information sharing with one
another and with patients. It is necessary to keep an open and continued dialogue between
physicians’ and pharmacists’ representative organizations in order to define each
profession’s respective functions and promote the optimal use of drugs within a
framework of transparency and cooperation, all in the best interests of patients.
The Joint Statement on Counterfeiting Medical Products of the World Health Professions
Alliance (WHPA) states that physicians and pharmacists share the same priority of
identifying, investigating and eliminating counterfeit medicines, in which both physicians
and pharmacists play a crucial role.
Patients are best served when pharmacists and physicians collaborate, recognizing and
respecting each other’s roles, to ensure that medicines are used safely and appropriately to
achieve the best outcome for the patient’s health.
Handbook of WMA Policies
World Medical Association ⏐ S-1999-02-2020
THE PHYSICIAN’S RESPONSIBILITIES
1. Diagnosing diseases on the basis of the physician’s education and specialized skills
and competence.
2. Assessing the need for pharmacological treatment and prescribing the corresponding
medi-cines in consultation with patients, pharmacists and other health care
professionals, when appropriate.
3. Providing information to patients about diagnosis, indications and treatment goals, as
well as action, benefits, risks and potential side effects of pharmacological treatment.
In the case of off-label prescriptions the patient must be informed about the character
of the pre-scription.
4. Monitoring and assessing response to pharmacological treatment, progress toward
thera-peutic goals, and, as necessary, revising the therapeutic plan in collaboration
with pharma-cists, other health professionals and, when appropriate, caregivers.
5. Providing and sharing information in relation to pharmacological treatment with other
health care practitioners.
6. Leading the multi-disciplinary team of health professionals responsible for managing
com-plex pharmacological treatment.
7. Maintaining adequate records for each patient, according to the need for therapy and in
compliance with legislation respecting confidentiality and protecting the patient’s data.
8. Where practically possible, actively participating in establishing electronic drug
delivery systems within their workplace and supporting those systems with their
professional knowledge.
9. Maintaining a high level of knowledge of pharmacological treatment through
continuing professional development.
10. Ensuring safe procurement and storage of medicines that the physician is required to
supply or permitted to dispense.
11. Reviewing prescription orders to identify interactions, allergic reactions, contra-indica-
tions and therapeutic duplications.
12. Reporting adverse reactions to medicines to health authorities, in accordance with
national legislation.
13. Monitoring and limiting, where appropriate, prescriptions of medications that may
have addictive properties.
14. Documenting adverse reactions to medicines in the patient’s medical record.
S-1999-02-2020 ⏐ Cordoba
Physicians and Pharmacists in Medical Therapy
THE PHARMACIST’S RESPONSIBILITIES
15. Ensuring safe procurement, adequate storage and dispensing of medicines in
compliance with the relevant regulations.
16. Providing information to patients, which may include the information leaflet, name of
the medicine, its purpose, potential interactions and side effects, as well as correct
usage and storage.
17. Reviewing prescription orders to identify interactions, allergic reactions, contra-indica-
tions and therapeutic duplications. Concerns should be discussed with the prescribing
phy-sician but the pharmacist should not change the prescription without
consulting the prescriber.
18. Discussing medicine-related problems or concerns with regard to the prescribed
medicines when appropriate and when requested by the patient.
19. Advising patients, when appropriate, on the selection and the use of non-prescription
medicines and the patient’s management of minor symptoms or ailments. Where self-
medication is not appropriate, advising patients to consult their physician for diagnosis
and treatment.
20. Participating in multi-disciplinary teams concerning complex pharmacological
treatment in collaboration with physicians and other health care providers, typically in
a hospital setting.
21. Reporting adverse reactions to medicines to the prescribing physician and to health au-
thorities in accordance with national legislation.
22. Providing and sharing general as well as specific medicine-related information and
advice with the public and health care practitioners.
23. Maintaining a high level of knowledge of pharmacological treatment through
continuing professional development.
Handbook of WMA Policies
World Medical Association S-2002-01-2022
WMA STATEMENT
ON
SAFE INJECTIONS IN HEALTH CARE
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.
Safe Injections in Health Care
Berlin S-2002-01-2022
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
3. Educate patients on equivalent action and efficacy of non-injectable medications;
4. Prescribe non-injectable medication whenever possible and promote the use of non-
injectable medication that are viable alternatives;
5. 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;
6. 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
7. 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.
Handbook of WMA Policies
World Medical Association S-2002-02-2022
WMA STATEMENT
ON
SELF-MEDICATION
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:
Self-Medication
Berlin S-2002-02-2022
For individuals
3. 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.
4. 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.
5. 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
6. 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.
7. 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.
8. 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.
9. 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.
10. Health professionals should seek to identify potentially relevant self-medication during
medical consultations, drug dispensing at the pharmacy and during home-based nursing
interventions.
Handbook of WMA Policies
World Medical Association S-2002-02-2022
For other stakeholders
11. 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.
12. 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.
13. 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.
14. 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
15. 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.
16. 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.
Handbook of WMA Policies
World Medical Association ⏐ S-2002-03-2019
WMA STATEMENT
ON
SEX SELECTION ABORTION AND FEMALE FOETICIDE
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.
Handbook of WMA Policies
World Medical Association S-2002-04-2021
WMA STATEMENT
ON
WOMEN’S RIGHTS TO HEALTH CARE AND HOW THAT RELATES TO
THE PREVENTION OF MOTHER-TO-CHILD HIV INFECTION
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
amended 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:
Women’s Right to Health Care
London S-2002-04-2021
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.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-01-2013
WMA STATEMENT
ON
FORENSIC INVESTIGATIONS OF THE MISSING
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and amended by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
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 catas-
trophes, 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 by the ICRC’s forensic services and they provide a frame-
work for humanitarian forensic action in situations of armed conflicts, other situations of
violence and catastrophes.1
The principles also ensure the proper and dignified manage-
ment and identification of the dead, and help provide answers to the bereaved.
National Medical Associations have a role in promoting these principles and 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.
In many countries NMAs will not have a role in certifying the qualifications and experi-
ence of forensic medical practitioners. NMAs should 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.
RECOMMENDATIONS
The WMA calls upon all NMAs to help ensure that, when its 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
Fortaleza ⏐ S-2003-01-2013
Forensic Investigations of the Missing
standards, and conform with the principles and practice of humanitarian forensic action
developed by the ICRC.
The WMA calls upon NMAs to develop expertise in the principles collated by the dif-
ferent authorities on forensic investigations for humanitarian and human rights purposes,
including those developed by the ICRC to prevent new cases and resolve those of existing
missing persons, and to assist their members in applying these principles to forensic
investigations worldwide.
The WMA calls upon NMAs to disseminate the principles that should apply to such
investigations, including those developed by the ICRC, and to attempt to ensure that phy-
sicians refuse to take part in investigations that are ethically or otherwise unacceptable.
The WMA calls upon NMAs to help ensure compliance by forensic medical practitioners
with the principles enshrined in international humanitarian law for the dignified and
proper management, documentation and identification of the dead, and, where possible,
providing answers to the bereaved.
The WMA invites NMAs to be mindful of academic qualifications and ethical under-
standing, ensuring that forensic doctors practice with competence and independence.
1
The ICRC defines catastrophes as disasters beyond expectations. See: M. Tidball-Binz, Man-
aging the dead in catastrophes: guiding principles and practical recommendations for first
responders. International review of the Red Cross, Vol 89 Number 866 June 2007; 421- 442
Handbook of WMA Policies
World Medical Association ⏐ S-2003-02-2013
WMA STATEMENT
ON
ADVANCE DIRECTIVES (“LIVING WILLS”)
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and reaffirmed by the 194th
WMA Council Session, Bali, Indonesia, April 2013
A. PREAMBLE
1. 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.
2. 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
and religious and other factors.
3. 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.
4. 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.”
B. 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 physi-
cian’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
Bali ⏐ S-2003-02-2013
Living Wills
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 should be 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 pa-
tient’s best interests.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-03-2014
WMA STATEMENT
ON
ETHICAL GUIDELINES FOR
THE INTERNATIONAL MIGRATION OF HEALTH WORKERS
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and revised by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
The WMA acknowledges that temporary stays of physicians in other countries help both
the receiving and the sending countries to exchange medical knowledge, skills and atti-
tudes. The exchange of medical professionals is therefore beneficial for the development
of medicine and healthcare systems and in general deserves the support of national medi-
cal associations as well as governments.
The WMA Statement on Medical Manpower – 1 (1983, 1986) called upon all National
Medical Associations to work with their governments towards solutions to the emerging
problems related to the medical workforce.
The WMA Resolution on the Medical Workforce (1998) identified the major components
of the medical workforce situation that need to be taken into account when developing a
national workforce policy.
For several decades many governments, employers and medical associations have mis-
interpreted demographical data regarding the number of physicians that are required.
Young people seeing employment as physicians have often been seriously affected by
poor medical workforce planning.
In many countries, including the wealthiest ones, there is a shortage of physicians. A
major reason for the shortage is a failure to educate enough physicians to meet the needs
of the country. Other reasons for the net loss of physicians are the recruitment of physi-
cians to other professions, early retirement and emigration, and the problems of combining
professional and family responsibilities, all of which are often due to poor working con-
ditions for physicians.
Some countries have traditionally solved their need for physicians by recruiting medical
graduates from other countries. This practice continues today.
The flow of international migration of physicians is generally from poorer to wealthier
countries. The poorer countries bear the expense of educating the migrating physicians
and receive no recompense when they enter other countries. The receiving countries gain a
valuable resource without paying for it, and in the process they save the cost of educating
their own physicians.
Physicians do have valid reasons for migrating, for example, to seek better career oppor-
tunities and to escape poor working and living conditions, which may include the pursuit
of more political and personal freedoms and other benefits.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-03-2014
RECOMMENDATIONS
1.
1. National medical associations, governments and employers should exercise utmost
care in utilizing demographic data to make projections about future requirements
for physicians and in communicating these projections to young people contem-
plating a medical career.
2. Every country should do its utmost to educate an adequate number of physicians,
taking into account its needs and resources. A country should not rely on immi-
gration from other countries to meet its need for physicians.
3. Every country should do its utmost to retain its physicians in the profession as well
as in the country by providing them with the support they need to meet their
personal and professional goals, taking into account the country’s needs and re-
sources.
4. Countries that wish to recruit physicians from another country should only do so in
terms of and in accordance with the provisions of a Memorandum of Under-
standing entered into between the countries.
5. Physicians should not be prevented from leaving their home or adopted country to
pursue career opportunities in another country.
6. Countries that recruit physicians from other countries should ensure that recruiters
provide full and accurate information to potential recruits on the nature and re-
quirements of the position to be filled, on immigration, administrative and con-
tractual requirements, and on the legal and regulatory conditions for the practice of
medicine in the recruiting country, including language skills.
7. Physicians who are working, either permanently or temporarily, in a country other
than their home country should be treated fairly in relation to other physicians in
that country (for example, equal opportunity career options and equal payment for
the same work).
8. Nothing should prevent countries from entering into bilateral agreements and
agreements of understanding, as provided for in international law and with due
cognizance of international human rights law, so as to effect meaningful co-
operation on health care delivery, including the exchange of physicians.
9. The WHO Global Code of Practice on the International Recruitment of Health
Personnel (May 2010) was established to promote voluntary principles and prac-
tices for the ethical international recruitment of health professionals and to facilitate
the strengthening of health systems. The Code takes into account the rights, obliga-
tions and expectations of source countries and migrant health professionals. The
WMA was involved in the drafting of the Code and supports its implementation.
10. The WHO Code states that international recruitment should be “conducted in ac-
cordance with the principles of transparency, fairness and promotion of sustain-
ability of health systems in developing countries.”
11. The monitoring and information-sharing system established by the WHO should be
robustly supported with the goal of international cooperation. Stakeholders should
regularly collate and share data, which should be monitored and anlaysed by the
WHO. The WHO should provide substantive critical feedback to governments.
Information should be shared about how to overcome challenges encountered.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-04-2019
WMA STATEMENT
ON
VIOLENCE AND HEALTH
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.
Handbook of WMA Policies
World Medical Association ⏐ S-2003-04-2019
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,
S-2003-04-2019 ⏐ Tbilisi
Violence and Health
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
Handbook of WMA Policies
World Medical Association ⏐ S-2003-04-2019
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.
Handbook of WMA Policies
S-2004-02-2020 ⏐ World Medical Association
WMA STATEMENT
CONCERNING THE RELATIONSHIP
BETWEEN PHYSICIANS AND COMMERCIAL ENTERPRISES
Adopted by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
and by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
In the treatment of their patients, physicians use medicines, instruments, diagnostic
tools, equipment and materials developed and produced by commercial enterprises.
Industry possesses resources to finance expensive research and development
programmes, for which the knowledge and experience of physicians are essential.
Moreover, industry support enables the progress of medical research, scientific
conferences and continuing medical education that can be of benefit to patients and the
entire health care system. The combination of financial resources and product
knowledge contributed by industry and the medical knowledge possessed by physicians
enables the development of new diagnostic procedures, drugs, therapies, and treatments
and can lead to great advances in medicine.
However, conflicts of interest between commercial enterprises and physicians occur and
can affect the care of patients as well as the reputation of the medical profession. The
duty of the physician is to objectively evaluate what is best for the patient and to
promote the patient-physician relationship, while commercial enterprises are expected to
bring profit to owners by selling their own products and competing for customers.
Commercial considerations can affect the physician’s objectivity, especially if the
physician is in any way dependent on the enterprise.
Rather than forbidding any relationships between physicians and industry, it is
preferable to establish guidelines for such relationships. These guidelines must
incorporate the key principles of disclosure, transparency, avoidance of conflicts of
interest and promoting the physician’s ability to act in the best interests of patients.
The guidelines regulating the Physician-Commercial Enterprise relationship should be
understood in the light of WMA core ethical values, as stated in particular in the
Declaration of Geneva, the International Code of Medical Ethics. the Statement on
Conflict of Interest, and the Declaration of Seoul on Professional Autonomy and Clinical
Independence.
The autonomy and clinical independence of physicians should be foremost in all
physician decisions for patients, regardless of practice setting, whether government-
sponsored, private, for profit or not for profit, investor funded, insurance company
Cordoba ⏐ S-2004-02-2020
Physicians and Commercial Enterprises
employers or otherwise.
Curricula of medical schools and residency programs should include educational courses
on the relation between enterprises and the medical profession in the light of ethical
principles and values of the profession.
RECOMMENDATIONS
Medical conferences
1. These guidelines related to medical conferences apply, where pertinent, to corporation
events, such as educational events, and promotional activities including for items of
medical utility, sponsored by a commercial enterprise.
2. Physicians may attend medical conferences, sponsored in whole or in part by a
commercial entity if these conform to the following principles:
• The main purpose of the conference is the exchange of professional or scientific
information for the benefit of patient care.
• Hospitality during the conference is secondary to the professional exchange of
information and does not exceed what is locally customary and generally
acceptable.
• Physicians do not receive payment directly from a commercial entity to cover
travelling expenses, room and board at the conference for themselves or an
accompanying person or compensation for their time unless provided for by law
and/or the policy of their National Medical Association, or unless it is a reasonable
honorarium for speaking at the conference.
• The name of a commercial entity providing financial support is publicly disclosed
in order to allow the medical community and the public to fairly evaluate the
information presented. In addition, conference organizers and lecturers are
transparent and disclose any financial affiliations that could potentially influence
educational activities or any other substantial outcome that may result from the
conference.
• In accordance with the WMA Guidelines on Promotional Mass Media
Appearances by Physicians, presentation of material by a physician should be
scientifically accurate, give a balanced review of possible treatment options, and
not be influenced by the sponsoring organization.
3. In addition, a conference can be recognized for purposes of continuing medical
education/ continuing professional development (CME/CPD) only if it conforms to the
following principles:
• The commercial entities acting as sponsors, such as pharmaceutical companies or
enterprises in the medical devices sector, have no influence on the content,
presentation, choice of lecturers, or publication of results.
• Funding for the conference is accepted only as a contribution to the general costs
of the meeting.
• The independence of the contents of the conference is guaranteed.
S-2004-02-2020 ⏐ Cordoba
Physicians and Commercial Enterprises
Gifts
4. To preserve the trust between patients and physicians, physicians should decline:
• cash, cash equivalents and other gifts for personal benefit from a commercial entity
• gifts designed to influence clinical practice, including direct prescription
incentives.
5. Physicians may accept:
• Promotional aids provided that the gift is of minimal value and is not connected to
any stipulation that the physician uses certain instruments, medications or
materials or refers patients to a certain facility.
• Cultural courtesy gifts on an infrequent basis according to local standards if the
gift is of minimal value and not related to the practice of medicine.
Research
6. A physician may carry out research funded by a commercial entity, whether
individually or in an institutional setting, if it conforms to the following principles:
• The physician is subject only to the law, the ethical principles and guidelines of the
Declaration of Helsinki, and clinical judgment when undertaking research and
should guard against external pressure regarding the research results or its
publications.
• If possible, a physician or institution wishing to undertake research approaches
more than one commercial source for research funds.
• Identifiable personal information about research patients or voluntary participants
is not passed to the sponsoring company without the consent of the individuals
concerned.
• A physician’s compensation for research is based on his or her time and effort and
such compensation must not be connected to the results of the research.
• The results of research are made public with the name of the sponsoring entity
disclosed, along with a statement disclosing who requested the research. This
applies whether the sponsorship is direct or indirect, full or partial.
• Commercial entities allow unrestricted publication of research results.
• Where possible, research financed by commercial enterprises should be managed
by interposed, non-profit entities, such as institutes or foundations.
Affiliations with Commercial Entities
7. A physician may not enter into an affiliation with a commercial entity, such as
consulting or membership on an advisory board unless the affiliation conforms to the
following principles:
• The affiliation does not compromise the physician’s integrity.
• The affiliation does not conflict with the physician’s obligations to his or her
Cordoba ⏐ S-2004-02-2020
Physicians and Commercial Enterprises
patients.
• The affiliation or other relationship with a commercial entity is fully disclosed in
all relevant situations, such as lectures, personal appearances, articles, reports and
influential contributions to the mission of medical associations or other non-profit
health entities.
Handbook of WMA Policies
World Medical Association ⏐ S-2004-03-2017
WMA STATEMENT
ON
WATER AND HEALTH
Approved by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and revised by the 65th
WMA General Assembly, Durban, South Africa, October 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
Chicago ⏐ S-2004-03-2017
Water and Health
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
12. 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:
12.1. 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.
12.2. International, national, local and regional programmes to provide access to
sanitation and to prevent the degradation of water resources.
12.3. Research on the relationship between water pollution, water supply systems,
including wastewater treatment, and health.
12.4. 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.
12.5. 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
S-2004-03-2017 ⏐ Chicago
Water and Health
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.
12.6. 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.
12.7. Preventive measures and emergency preparedness to save water from
pollution.
12.8. 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.
12.9. 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.
12.10. 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 recog-
nized 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.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-02-2015
WMA STATEMENT
ON
DRUG SUBSTITUTION
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
INTRODUCTION
1. The prescription of a drug represents the culmination of a careful deliberative process
between physician and patient aimed at the prevention, amelioration or cure of a
disease or problem. This deliberative process requires that the physician evaluate a
variety of scientific and other data including costs and make an individualized choice
of therapy for the patient. Sometimes, however, a pharmacist is required to substitute
a different drug for the one prescribed by the physician. The World Medical Associa-
tion has serious concerns about this practice.
2. Drug substitution can take two forms: generic substitution and therapeutic substitu-
tion.
3. In generic substitution, a generic drug is substituted for a brand name drug. However,
both drugs have the same active chemical ingredient, same dosage strength, and same
dosage form.
4. Therapeutic substitution occurs when a pharmacist substitutes a chemically different
drug for the drug that the physician prescribed. The drug substituted by the pharmacist
belongs to the same pharmacologic class and/or to the same therapeutic class. How-
ever since the two drugs have different chemical structures, adverse outcomes for the
patient can occur.
5. The respective roles of physicians and pharmacists in serving the patient’s need for
optimal drug therapy are outlined in the WMA Statement on the Working Relation-
ship between Physicians and Pharmacists in Medicinal Therapy.
6. The physician should be assured by national regulatory authorities of the bioequi-
valence and the chemical and therapeutic equivalence of prescription drug products
from both multiple and single sources. Quality assurance procedures should be in
place to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equi-
valence.
7. Many considerations should be addressed before prescribing the drug of choice for a
particular indication in any given patient. Drug therapy should be individualized
based on a complete clinical patient history, current physical findings, all relevant
laboratory data, and psychosocial factors. Once these primary considerations are met,
the physician should then consider comparative costs of similar drug products avail-
able to best serve the patient’s needs. The physician should select the type and quan-
tity of drug product that he or she considers to be in the best medical and financial
interest of the patient.
S-2005-02-2015 ⏐ Oslo
Drug Substitution
8. Once the patient gives his or her consent to the drug selected, that drug should not be
changed without the consent of the patient and his or her physician. Failure to follow
this principle can result in harm to patients. On behalf of patients and physicians alike,
National Medical Associations should do everything possible to ensure the imple-
mentation of the following recommendations:
RECOMMENDATIONS
1. Physicians should become familiar with specific laws and/or regulations governing
drug substitution where they practise.
2. Pharmacists should be required to dispense the exact chemical, dose, and dosage form
prescribed by the physician. Once medication has been prescribed and begun, no drug
substitution should be made without the prescribing physician’s permission.
3. If substitution of a drug product occurs, the physician should carefully monitor and
adjust the dose to ensure therapeutic equivalence of the drug products.
4. If drug substitution leads to serious adverse drug reaction or therapeutic failure, the
physician should document this finding and report it to appropriate drug regulatory
authorities.
5. National Medical Associations should regularly monitor drug substitution issues and
keep their members advised on developments that have special relevance for patient
care. Collection and evaluation of information reports on significant developments in
this area is encouraged.
6. Appropriate drug regulatory bodies should evaluate and ensure the bioequivalence
and the chemical and therapeutic equivalence of all similar drug products, whether
generic or brand-name, in order to ensure safe and effective treatment.
7. National Medical Associations should oppose any action to restrict the freedom and
the responsibility of the physician to prescribe in the best medical and financial
interest of the patient.
8. National Medical Associations should urge national regulatory authorities to declare
therapeutic substitution illegal, unless such substitution has the immediate prior con-
sent of the prescribing physician.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-03-2009
WMA STATEMENT
ON
GENETICS AND MEDICINE
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
1. In recent years, the field of genetics has undergone rapid change and development.
The areas of gene therapy and genetic engineering and the development of new tech-
nology have presented possibilities inconceivable only decades ago.
2. The Human Genome Project opened new spheres of research. Its applications also
proved useful to clinical care, by allowing physicians to utilize knowledge of the
human genome in order to diagnose future disease as well as to individualize drug
therapy (pharmacogenomics).
3. Because of this, genetics has become an integral part of primary care medicine.
Whereas at one time, medical genetics was devoted to the study of relatively rare
genetic disorders, the Human Genome Project has established a genetic contribution to
a variety of common diseases. It is therefore incumbent upon all physicians to have a
working knowledge of the field.
4. Genetics is an area of medicine with enormous medical, social, ethical and legal
implications. The WMA has developed this statement in order to address some of
these concerns and provide guidance to physicians. These guidelines should be up-
dated in accordance with developments in the field of genetics.
MAJOR ISSUES:
Genetic testing
5. The identification of disease-related genes has led to an increase in the number of
available genetic tests that detect disease or an individual’s risk of disease. As the
number and types of such tests and the diseases they detect increases, there is concern
about the reliability and limitations of such tests, as well as the implications of testing
and disclosure. The ability of physicians to interpret test results and counsel their pa-
tients has also been challenged by the proliferation of knowledge.
6. Genetic testing may be undergone prior to marriage or childbearing to detect the pre-
sence of carrier genes that might affect the health of future offspring. Physicians
should actively inform those from populations with high incidence of certain genetic
S-2005-03-2009 ⏐ New Delhi
Genetics and Medicine
diseases about the possibility of pre-marital and pre-pregnancy testing, and genetic
counselling should be made available to those individuals or couples who are consi-
dering such testing.
7. Genetic counselling and testing during pregnancy should be offered as an option. In
cases where no medical intervention is possible following diagnosis, this should be
explained to the couple prior to their decision to test.
8. In recent years, with the advent of IVF, genetic testing has been extended to pre-
implantation genetic diagnosis of embryos (PGD). This can be a useful tool in cases
where a couple has a high chance of conceiving a child with genetic disease.
9. Since the purpose of medicine is to treat, in cases where no sickness or disability is
involved, genetic screening should not be employed as a means of producing children
with pre-determined characteristics. For example, genetic screening should not be
used to enable sex selection unless there is a gender-based illness involved. Similarly,
physicians should not countenance the use of such screening to promote non-health
related personal attributes.
10. Genetic testing should be done only with informed consent of the individual or his/her
legal guardian. Genetic testing for predisposition to disease should be performed only
on consenting adults, unless there is treatment available for the condition and the test
results would facilitate earlier instigation of this treatment.
11. Valid consent to genetic testing should include the following factors:
• The limitations of genetic testing, including the fact that the presence of a specific
gene may denote predisposition to disease rather than the disease itself and does
not definitively predict the likelihood of developing a certain disease, particularly
in multi-factorial disorders.
• The fact that a disease may manifest itself in one of several forms and in varying
degrees. Information about the nature and predictability of information received
from the tests.
• The benefits of testing including the relief of uncertainty and the ability to make
informed choices, including the possible need to increase or reduce regular screen-
ings and checkups and to implement risk reduction measures.
• The implications of a positive result and the prevention, screening and/or
treatment possibilities.
• The possible implications for the family members of the patient involved.
12. In the case of a positive test result that may have implications for third parties such as
close relatives, the individual tested should be encouraged to discuss the results of the
test with such third parties. In cases where not disclosing the results involves a direct
and imminent threat to the life or health of an individual, the physician may reveal the
results to such third parties, but should usually discuss this with the patient first. If the
physician has access to an ethics committee, it is preferable to consult such a com-
mittee prior to revealing results to third parties.
Handbook of WMA Policies
World Medical Association ⏐ S-2005-03-2009
Genetic counselling
13. Genetic counselling is generally offered prior to marriage or conception, in order to
predict the likelihood of conceiving an affected child, during pregnancy, in order to
determine the condition of the fetus, or to an adult, in order to determine susceptibility
to a certain disease.
14. Individuals at higher risk for conceiving a child with a specific disease should be
offered genetic counselling prior to conception or during pregnancy. In addition,
adults at higher risk for various diseases such as cancer, mental illness or neuro-
degenerative diseases in which the risk can be tested for, should be made aware of the
availability of genetic counselling.
15. Because of the scientific complexity involved in genetic testing as well as the prac-
tical and emotional implications of the results, the WMA sees great importance in
educating and training medical students and physicians in genetic counselling, parti-
cularly counselling related to pre-symptomatic diagnosis of disease. Independent ge-
netic counsellors also have an important role to play. The WMA acknowledges that
there can be very complex situations requiring the involvement of medical genetics
specialists.
16. In all cases where genetic counselling is offered, it should be non-directive and
protect the individual’s right not to be tested.
17. In cases of counselling prior to or during pregnancy, the prospective parents should be
given information to provide the basis for an informed decision regarding child-
bearing, but should not be influenced by the physicians’ personal views in this matter
and physicians should be careful not to substitute their own moral judgment for that
of the prospective parents. In cases where a physician is morally opposed to
contracep-tion or abortion, he/she may choose not to provide these services but should
alert pro-spective parents that a potential genetic problem exists and make note of the
option of contraception or abortion as well as treatment alternatives, relevant genetic
tests, and the availability of genetic counselling.
Confidentiality of results
18. Like all medical records, the results of genetic testing should be kept strictly
confidential, and should not be revealed to outside parties without the consent of the
individual tested. Third parties to whom results may in certain circumstances be
released are identified in paragraph 12.
19. Physicians should support the passage of laws guaranteeing that no individual shall be
discriminated against on the basis of genetic makeup in the fields of human rights,
employment and insurance.
Gene therapy and genetic research
20. Gene therapy represents a combination of techniques used to correct defective genes
that cause disease, especially in the fields of oncology, hematology and immune dis-
orders. Gene therapy is not yet an active current therapy but is still in a stage of clini-
S-2005-03-2009 ⏐ New Delhi
Genetics and Medicine
cal investigation. However, with the continued development of this field, it should
proceed according to the following guidelines:
• Gene therapy performed in a research context should conform to the requirements
of the Declaration of Helsinki while therapy performed in a treatment context
should conform to standards of medical practice and professional responsibility.
• Informed consent should always be obtained from the patient undergoing the
therapy. This informed consent should include disclosure of the risks of gene
therapy, including the fact that the patient may have to undergo multiple rounds of
gene therapy, the risk of an immune response, and the potential problems arising
from the use of viral vectors.
• Gene therapy should only be undertaken after a careful analysis of the risks and
benefits involved and an evaluation of the perceived effectiveness of the therapy,
as compared to the risks, side effects, availability and effectiveness of other treat-
ments.
21. It is currently possible to undertake screening of an embryo in order to provide stem
cell or other therapies for an existing sibling with a genetic disorder. This may be
considered acceptable medical practice where no evidence exists that the embryo is
being created exclusively for this purpose.
22. Genetic discoveries should be shared as much as possible between countries so as to
benefit humankind and reduce duplication of research and the risk inherent in research
in this area.
23. The mapping of human genomes must be anonymous but the information acquired
will apply to every human being. The genetic information should be general property.
Therefore, no patents should be given for the human genome or parts of it.
24. In the case of genetic research performed on large, defined population groups, efforts
should be made to avoid potential stigmatization.
Cloning
25. Recent developments in science have led to the cloning of a mammal and raise the
possibility of such cloning techniques being used in humans.
26. Cloning includes both therapeutic cloning, namely the cloning of individual stem cells
in order to produce a healthy copy of a diseased tissue or organ for transplant, and re-
productive cloning, namely the cloning of an existing mammal to produce a duplicate
of such mammal. The WMA currently opposes reproductive cloning, and in many
countries it is considered to pose more of an ethical problem than therapeutic cloning.
27. Physicians should act in accordance with the codes of medical ethics in their countries
regarding the use of cloning and be mindful of the law governing this activity
Handbook of WMA Policies
World Medical Association S-2005-04-2021
WMA STATEMENT
ON
MEDICAL LIABILITY
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October 2005
reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
and amended by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
In this statement the World Medical Association (WMA) addresses issues related to medical
liability claims and the implications of defensive medicine. The laws and legal systems in each
country, as well as the social traditions, social welfare and economic conditions of the country,
will affect the relevance of some portions of this statement for some countries, but do not
detract from its fundamental importance.
A culture of medical liability litigation is growing in some countries, increasing health care
costs, restraining access to health care services, and hindering efforts to improve patient safety
and health care quality. In other countries, medical liability claims are less prevalent, but
National Medical Associations (NMAs) in those countries should be aware of the issues and
circumstances that could result in an increase in the frequency and severity of medical liability
claims brought against physicians.
Many medical liability systems divert scarce health care resources away from direct patient
care, research, and physician training. The lawsuit culture has also blurred the distinction
between negligence and unavoidable adverse outcomes. This has led to undue reliance on
litigation and other dispute resolution systems to distinguish between the two, and a culture
that enables the pursuit of cases without genuine merit in the interest of financial gain. Such a
culture breeds cynicism and distrust in both the medical and legal systems with damaging
consequences to the patient-physician relationship.
An increase in the frequency and severity of medical liability claims may result, in part, from
one or more of the following circumstances:
• Advances in medical knowledge and medical technology that have enabled physicians
to achieve treatment results that were not possible in the past, but that may involve
considerable risks.
• Pressures on physicians by private managed care, other healthcare organizations or
government-managed health care systems to limit the costs of medical care.
Medical Liability
London S-2005-04-2021
• Confusing the right of access to health care, which is attainable, with the right to achieve
and maintain health, which cannot be guaranteed.
• The role of the media, advocacy groups and even regulatory bodies in fostering mistrust
of physicians by questioning their ability, knowledge, behaviour, and management of
patients, and by encouraging patients to submit complaints against physicians.
A growing culture of litigation and an increase in medical liability claims may result, among
other things, in a rise in defensive medicine, defined as “the practice of ordering medical tests,
procedures, or consultations of doubtful clinical value in order to protect the prescribing
physician from malpractice suits.”1
Depending on the situation, defensive medicine may entail
active behaviour, such as performing tests and procedures that are not clinically indicated or
prescribing unnecessary hospitalization, or passive behaviour, such as avoiding high-risk
patients or avoiding potentially beneficial but risky procedures.
A distinction must be made between harm caused by medical negligence, defined as failure to
conform to the standard of care in treating the patient, and harm caused by adverse outcomes
occurring in the course of medical care provided in accordance with appropriate standards of
care.
Compensation for patients suffering a medical injury should be determined differently for
injuries caused by negligence than for adverse outcomes that may occur during medical care,
unless there is an alternative system in place such as a no-fault system.
The laws of each jurisdiction should provide the procedures for establishing liability and for
determining the amount of compensation to be awarded to the patient in those cases where
negligence is proven.
Criminalizing medical judgment interferes with appropriate medical decision making and is a
disservice to patients.
The mounting evidence of preventable deaths as a result of medical error has led for experts to
call for improved safety measurements in hospitals. With this in mind, investigations should
take into account the wider context, identifying systemic failings, with recommendations for
change, in order to improve patient safety.
RECOMMENDATIONS
The WMA:
1 “Defensive medicine.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-
webster.com/dictionary/defensive%20medicine. Accessed 12 Mar. 2020
Handbook of WMA Policies
World Medical Association S-2005-04-2021
1. Makes an urgent call to all national governments to ensure the existence of a reliable system
of medical justice in their respective countries. Legal systems should ensure that patients
are protected against harmful practices, and physicians are protected against unmeritorious
lawsuits.
2. Demands that investigations consider the complete context, in order to identify systemic
failings.
3. Encourages health care providers to develop systems which improve the quality of patient-
safety practices.
NMAs should consider the following activities to encourage fair and equitable treatment for
both physicians and patients:
4. Educate and instruct physicians to have clear and detailed documentation of patient records.
5. Develop appropriate remedial training for physicians found to be deficient in knowledge or
skills.
6. Encourage NMAs and Specialist Interest Groups to produce updated protocols and
guidelines to guide medical professionals and staff.
7. Inform the public, physicians, and government of the dangers that various manifestations
of defensive medicine may pose. These include:
• an increase in health care costs;
• an undermining of the doctor-patient relationship;
• the commission of unnecessary test or treatments;
• the avoidance of high-risk treatments;
• the over-prescription of medications;
• the disaffection of young physicians for certain higher risk specialties and
• the reluctance by or avoidance of physicians or hospitals to treat higher-risk patients.
8. Educate the public as to the possible occurrence of adverse medical outcomes, and
increased fees, and establish simple procedures to allow patients to receive explanations in
such cases and to be informed of the steps that must be taken to seek resolution, if
appropriate.
9. Encourage medical workplaces to break the culture of blame in the wake of medical errors
or adverse outcomes and advocate for confidentiality of quality assurance processes in
order to enable physicians to practice medicine to the best of their ability free from the
threat of medical liability litigation and discipline.
Medical Liability
London S-2005-04-2021
10. Advocate for legal protection for physicians when patients are injured by adverse results
not caused by any negligence.
11. Develop emotional and practical support for physicians involved in adverse events.
12. Participate in the development of the laws and procedures applicable to medical liability
claims, with special emphasis on highlighting the difference between errors and adverse
outcomes.
13. Actively oppose meritless or frivolous claims.
14. Explore innovative alternative dispute resolution procedures for efficiently resolving
medical liability claims, such as mediation and arbitration.
15. Require physicians to have adequate medical liability insurance coverage or other resources
against medical liability claims, paid by the practitioners themselves or by their employer.
16. Encourage the development of voluntary, confidential, and legally protected internal
systems for reporting adverse outcomes or medical errors for the purpose of analysis and
for making recommendations on reducing errors and improving patient safety and health
care quality.
17. Advocate against the increasing criminalization or penal liability of medical judgment in
consideration of adverse events. Aside from truly negligent behaviour or intentional
misconduct, most adverse events are the result of unintentional human error, system
failures, or uncontrollable circumstances and should not brand the physician with criminal
motive or behaviour.
18. Support the principles set forth in the WMA’s Declaration of Madrid on Professional
Autonomy and Self-Regulation.
Handbook of WMA Policies
World Medical Association S-2006-01-2022
WMA STATEMENT
ON
ASSISTED REPRODUCTIVE TECHNOLOGIES
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Assisted Reproductive Technology [ART] encompasses a wide range of techniques designed
primarily to aid individuals unable to conceive without medical assistance.
ART is defined as any fertility treatments in which either gametes or embryos are handled.
Assisted reproductive technologies may raise profound ethical and legal issues. Views and
beliefs on assisted reproductive technologies vary both within and among countries and are
subject to different regulations in different countries.
Central to much of the debate in this area are issues around the moral status of the embryo, the
way in which ART is viewed morally, societally and religiously, the child/ren born from ART,
and the rights of all participants involved, i.e. donors, surrogates, the child/ren and the intended
parents are just some of the issues central to the debate in ART. Whilst consensus can be
reached on some issues, there remain fundamental differences of opinion that are more difficult
to resolve.
Assisted conception differs from the treatment of illness in that the inability to become a parent
without medical intervention is not always regarded as an illness. Notwithstanding, the inability
to conceive may also be as a result of prior illness.
In many jurisdictions, the process of obtaining consent must follow a process of information
giving and the offer of counselling and might also include a formal assessment of the patient
in terms of the welfare of the potential child.
Faced with the progress of new technologies of assisted reproduction, physicians should keep
in mind that not everything that is technically feasible is ethically acceptable. Genetic
manipulation that does not have a therapeutic purpose is not ethical, nor is the manipulation on
the embryo or foetus without a clear and beneficial diagnostic or therapeutic purpose.
Assisted Reproductive Technologies
Berlin S-2006-01-2022
RECOMMENDATIONS
1. Physicians involved in providing assisted reproductive technologies should always
consider their ethical responsibilities towards all parties involved in a reproductive plan,
which may include the future child/ren, donor, surrogate or parents. If there is compelling
evidence that a future child, donor, surrogate or parent would be exposed to serious harm,
treatment should not be provided.
2. As with all other medical procedures, physicians have an ethical obligation to limit their
practice to areas in which they have relevant expertise, skill, and experience and to respect
the autonomy and rights of patients.
3. In practice this means that informed consent is required as with other medical procedures;
the validity of such consent is dependent upon the adequacy of the information offered to
the patient and their freedom to make a decision, including freedom from coercion or other
pressures or influences to decide in a particular way.
4. The consent process should include providing the participant/s with understandable,
accurate and adequate information about the following:
• The purpose, nature, procedure, and benefits of the assisted reproductive technology
that will be used.
• The risks, burdens and limitations of the assisted reproductive technology that will be
used.
• The success rates of the treatment and possible alternatives, such as adoption.
• The availability of psychological support for the duration of the treatment and, in
particular, if a treatment is unsuccessful.
• The measures protecting confidentiality, privacy and autonomy, including data security
measures.
5. The following should be discussed during the informed consent process:
• Detailed medical risks;
• whether or not all biological samples involved in ART, including but not limited to
donor eggs, sperm, gametes and genetic information, may be used for research
purposes;
• The risks of multiple donations and donating at multiple clinics;
• Confidentiality and privacy issues;
• Compensation issues.
Handbook of WMA Policies
World Medical Association S-2006-01-2022
6. Donors, surrogates and any resulting child/ren seeking assisted reproductive technologies
are entitled to the same level of confidentiality and privacy as for any other medical
treatment.
7. Assisted reproductive technology involves handling and manipulation of human gametes
and embryos. There are different levels of concern with the handling of such material, yet
there is general agreement that such material should be subject to specific safeguards to
protect from inappropriate, unethical, or illegal use.
8. Physicians should uphold the principles in the WMA Statement on Stem Cell Research,
WMA Statement on Human Genome Editing, the WMA Declaration of Helsinki, and the
WMA Declaration of Reykjavik – Ethical Considerations Regarding the Use of Genetics
in Health Care.
9. Physicians should, where appropriate, provide ART in a non-discriminatory manner.
Physicians should not withhold services based on nonclinical considerations such as marital
status.
Multiple pregnancies
10. Replacement of more than one embryo will raise the likelihood of more than one embryo
implanting. This is offset by the increased risk of premature labour and other complications
in multiple pregnancies, which can endanger the health of both the mother and child/ren.
Practitioners should follow professional guidance on the maximum number of embryos to
be transferred per treatment cycle.
11. If multiple pregnancies occur, selective termination or fetus reduction will only be
considered on medical grounds and with the consent of all participants involved to increase
the chances of the pregnancy proceeding to term, provided this is compatible with
applicable laws and codes of ethics.
Donation
12. Donation should follow counselling and be carefully controlled to avoid abuses, including
coercion or undue influence of potential donors. Explicit instructions should be provided
about what will be done with any donated samples if the donor is known to have died prior
to implantation.
13. The WMA holds the view that gamete donation should at best not be commodified, thus
serving a humanitarian benefit.
14. To ensure appropriate controls and limits on methods used to encourage donations, this
must be done in a manner that complies with national law and ethical guidance. Physicians
should advocate for and contribute to such ethical guidance if it does not exist.
15. Due to the widespread use of genetic technology and registries, it has become possible to
identify donors, despite clinics and donors’ attempts to maintain strict confidentiality. A
Assisted Reproductive Technologies
Berlin S-2006-01-2022
child/ren born as a result of donation may in future contact donors. Potential donors must
be made aware of this possibility as part of the consent process.
16. Where a child is born following donation, families should be encouraged and supported to
be open with the child about this, irrespective of whether or not domestic law entitles the
child to information about the donor. This may require the development of supportive
materials, which should be produced to a national normative standard.
Surrogacy
17. Where a woman is unable, for medical reasons, to carry a child to term, surrogate pregnancy
may be used to overcome childlessness unless prohibited by national law or the ethical rules
of the National Medical Association or other relevant organizations. Where surrogacy is
legally practiced, great care must be taken to protect the interests of all parties involved.
18. Prospective parents and surrogates should receive independent and appropriate legal
counsel.
19. Medical tourism for surrogacy purposes should be discouraged.
20. Commercial surrogacy should be condemned. However, this must not preclude
compensating the surrogate mother for necessary expenses.
21. The rights of surrogate mothers must be upheld, and great care must be taken to ensure that
they are not exploited. The rights of surrogate mothers include, but are not limited to:
• Having her autonomy respected;
• Where appropriate, having health insurance;
• Being informed about any medical procedure and the potential side effects;
• Where possible, choosing her medical team if side effects develop;
• Having psychological help at any point during the pregnancy;
• Having medical expenses such as doctor visits, the actual birthing process, fertilization
and any examinations related to the surrogacy covered by the intended parent/s;
• Loss if income covered if unable to work during the pregnancy;
• Receiving the compensation and/or reimbursements agreed to in any legal agreement
Pre-implantation Genetic Diagnosis (PGD)
22. Pre-implantation genetic diagnosis (PGD) and pre-implantation genetic screening (PGS)
may be performed on early embryos to search for the presence of genetic or chromosomal
abnormalities, especially those associated with severe illness and very premature death, and
for other ethically acceptable reasons, including identifying those embryos most likely to
implant successfully in women who have had multiple spontaneous abortions.
Handbook of WMA Policies
World Medical Association S-2006-01-2022
23. It is recommended to encourage screening for infectious diseases in sperm donors and to
determine whether to inform donors of positive tests.
24. Physicians must never be involved with sex selection unless it is used to avoid a serious
sex-chromosome related condition, such as Duchenne’s Muscular Dystrophy.
Research
25. Physicians have an ethical duty to comply with such regulation and to help inform public
debate and understanding of these issues.
26. Research on human gametes and embryos should be carefully controlled and monitored
and in accordance with all applicable national laws and ethical guidelines.
27. Views and legislation differ on whether embryos may be created specifically for, or in the
course of, research. Physicians should act in accordance with the declarations of Taipei and
Helsinki, as well as all applicable local laws and ethical and professional standards advice.
28. The principles of the Convention on Human Rights and Biomedicine should be followed.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2018
WMA STATEMENT
ON
AVIAN AND PANDEMIC INFLUENZA
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
Pandemic influenza occurs approximately three or four times every century. It usually
occurs when a novel influenza A virus emerges that can easily be transmitted from person-
to-person, to which humans have little or no immunity. Infection control and social
distancing practices can help slow down the spread of the virus. Vaccine development can
be challenging as the pandemic strain may not be accurately predicted. Adequate supplies
of antivirals are key for treatment of specific at-risk population and controlling further
spread of the outbreak.
Avian influenza is a zoonotic infection of birds and poultry, and can cause sporadic human
infections. Birds act as reservoir and shed the virus in their feces, mucous and saliva. In
addition, a new pandemic virus could develop if a human became simultaneously infected
with avian and human influenza viruses, resulting in gene swapping and a new virus strain
for which there may be no immunity. Humans are infected if they are exposed through the
mouth, eyes, or from the inhalation of virus particles. Limited evidence of human to
human transmission has been reported as well.
This statement alongside with WMA Statement on Epidemics and Pandemics provides
guidance to National Medical Associations and physicians on how they should be
involved in their respective country’s pandemic influenza planning and how to respond to
Avian Influenza or pandemic influenza.
RECOMMENDATIONS
Avian Influenza
• In the event of an avian influenza outbreak, the following measures should be
taken:
• Sources of exposure should be avoided when possible as this is the most effective
prevention measure.
• Personal protective equipment should be used and hand hygiene practices
emphasized for personnel handling poultry as well as members of the healthcare
S-2006-02-2018 ⏐ Reykjavik
Avian and Pandemic Influenza
team.
• All infected/exposed birds should be destroyed with proper disposal of carcasses,
and rigorous disinfection or quarantine of farms.
• Stockpiles of vaccines and antivirals should be maintained for use during an
outbreak.
• Antiviral medications such as neuraminidase inhibitors may be used for treatment.
Pandemic Influenza Preparedness
WHO and National Public Health Officials:
• The coordination of the international response to an influenza pandemic is the
responsibility of the World Health Organization (WHO). The WHO currently uses
an all-hazards risk based approach, to allow for a coordinated response based on
varying degrees of severity of the pandemic.
The WHO should:
• Offer technical and laboratory assistance to affected countries if needed and
continuously monitor activity levels of potential pandemic influenza strains
continuously, ensuring that the designation of “Public Health Emergency of
International Concern” is done in a timely manner if needed.
• Monitor and coordinate processes by which governments share biological
materials including virus strains, to facilitate the production of and ensure access to
vaccines globally.
• Communicate available information on influenza activity of concern as early as
possible to allow for a timely response.
National governments are urged to develop National Action plans to address the following
points:
• Ensure that there is adequate local capacity for diagnosis and surveillance to allow
continuous monitoring of influenza activity around the country.
• Consider the surge capacity of hospitals, laboratories, and public health
infrastructure and improve them if necessary.
• Identify legal and ethical frameworks as well as governance structures in relation
to the pandemic planning.
• Identify the mechanisms and the relevant authorities to initiate and escalate
interventions to slow the spread of the virus in the community such as school
closures, quarantine, border closures etc.
• Prepare risk and crisis communication strategies and messages in anticipation of
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2018
public and media fear and anxiety.
• Governments are also urged to share biological materials namely virus strains and
others, to facilitate the production and ensure access to vaccines globally.
• Ensure that diagnostics and surveillance efforts are continued and that adequate
vaccine and antiviral stockpiles are established.
• Establish protocols to manage patients in the community, carry out triage in
healthcare facilities, provide ventilation management, and handle infectious waste.
• Allocation of vaccine doses, antivirals and hospital beds should be coordinated
with experts.
• Priority for vaccination should be given to the highest risk groups including those
required to maintain essential services, including health care services.
• Guidance and timely information to regional health departments, health care
organizations, and physicians.
• Preparation for an increase in demand for healthcare services and absences of
health care providers especially if clinical severity of the illness is high. In such
cases prioritization and coordination of available resources is essential. This may
include tapping into private sector capacity where state resources are insufficient.
• Ensure adequate funding is allocated for pandemic preparedness and response as
well as its health and social consequences.
• Make sure that mechanisms are in place to ensure the safety of healthcare facilities,
personnel and the supply chains for vaccines and antivirals
• Promote and fund research to develop vaccines and effective treatments with
lasting effects against influenza.
• Encourage collaboration between human and veterinary medicine in the
prevention, research and control of avian influenza.
National Medical Associations are urged to:
• Delineate their involvement in the national pandemic influenza preparedness plan,
which may include increasing capacity building amongst physicians, participating
in guideline development and communication with healthcare professionals.
• Help educate the public about avian and pandemic influenza.
• When feasible, coordinate with other healthcare professionals’ organizations as
well as other NMAs to identify common issues and congruent policies related to
pandemic influenza preparedness and response.
• Consider implementing support strategies for members involved in the response
including mental health services, facilitation of health emergency response teams,
and locum relief.
S-2006-02-2018 ⏐ Reykjavik
Avian and Pandemic Influenza
• Advocate before and during a pandemic, for allocation of adequate resources to
meet foreseeable and emerging needs of healthcare, patients and the general
public.
• Encourage health personnel to protect themselves by vaccination.
• Develop their own organization-specific business contingency plans to ensure
continued support of their members.
Physicians:
• Must be sufficiently knowledgeable about pandemic influenza and transmission
risks, including local, national and international epidemiology.
• Should implement infection control practices and vaccination, to protect
themselves as well as other staff members during seasonal and pandemic influenza
outbreaks.
• Must participate in local/regional pandemic influenza preparedness planning and
training.
• Should develop contingency plans to deal with possible disruptions in essential
services and personnel shortages.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-03-2017
WMA STATEMENT
ON
HIV/AIDS AND THE MEDICAL PROFESSION
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and amended by the 68th
WMA General Assembly, Chicago, United States, October 2017
INTRODUCTION
1. HIV/AIDS, a chronic manageable disease, is a global pandemic that has created
unprecedented challenges for physicians and health infrastructures.
In addition to representing a staggering public health crisis, HIV/AIDS is also
fundamentally a human rights issue.
Many factors drive the spread of the disease, such as poverty, homelessness, illiteracy,
prostitution, human trafficking, drug (substance) abuse, stigma, discrimination and
gender-based inequality.
These social, economic, legal and human rights factors affect not only the public
health dimension of HIV/AIDS but also individual physicians/health workers and
patients, their decisions and relationships.
Efforts to tackle the disease are also constrained by the lack of human and financial
resources available in health care systems.
2. Discrimination against HIV / AIDS patients by physicians is unacceptable and must be
eliminated completely from the practice of medicine.
2.1 All persons with HIV/AIDS are entitled to adequate and timely support,
treatment and care with compassion and respect for human dignity.
2.2 It is unethical for a physician to refuse to treat a patient whose condition is
within his or her current realm of competence, solely because the patient is
seropositive.
2.3 National Medical Associations should work with respective governments,
patient groups and relevant national and international organizations to ensure
that national health policies clearly and explicitly prohibit discrimination
against people infected with or affected by HIV/AIDS, including vulnerable
groups such as males having sex with males and transgender persons.
2.4 Woman and man having sex with same sex partners are at a higher risk of
discrimination at all levels. National Medical organizations shall work with
Government, Non-Governmental Organizations, and Community based
organizations to remove the discrimination for these under-privileged
disadvantaged groups.
S-2006-03-2017 ⏐ Chicago
HIV/AIDS and the Medical Profession
APPROPRIATE / COMPETENT MEDICAL CARE
3. Patients with HIV/AIDS must be provided with competent and appropriate medical
care at all stages of the disease.
4. A physician who is not able to provide the care and services required by patients with
HIV/AIDS must make an appropriate timely referral to those physicians or facilities
that are equipped to provide such services. Unless or until the referral can be
accomplished, the physician must take care for the patient.
5. All physicians should be able to timely suspect and identify common opportunistic
infections such as tuberculosis, fungal infections in HIV-AIDs patients and also
suspect HIV-AIDS in presence of these infections especially in high risk individuals
like IV drug users.
They must timely counsel these patient about the nexus of these infections with HIV
infection.
6. Physicians and other appropriate professional bodies must ensure that patients have
accurate information regarding transmission of HIV/AIDS and strategies to protect
themselves against infection.
Proactive measures should be taken to ensure that all members of the population,
particularly at-risk groups, are educated to this effect.
Public information and related strategies should recognise that everyone is at risk, and
attempt to spell out methods of risk reduction.
7. Physicians must effectively counsel all seropositive patients regarding responsible
behaviour to prevent the spread of the infection to their partners and prevention of
opportunistic infections.
8. Physicians must recognize that many people still believe HIV/AIDS to be an
automatic and immediate death sentence and therefore will not seek testing.
Physicians must ensure that patients have accurate information regarding the treatment
options available to them.
Patients should understand the potential and need of starting early antiretroviral
treatment (ART) to improve not only their medical condition but also the quality of
their lives. The new strategy is test and treat strategy.
Effective ART can greatly extend the period that patients are able to lead healthy
productive lives, functioning socially and in the workplace and maintaining their
independence.
HIV/AIDS is now manageable chronic condition.
For ART country – specific WHO evidence based practice guidelines should be
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followed and promoted by all NMAs.
9. Physicians should be aware that misinformation regarding the negative aspects of ART
has created resistance toward treatment by patients in some areas. Where
misinformation is being spread about ART, physicians and medical associations must
make it an immediate priority to publicly challenge the source of the misinformation
and to work with the HIV/AIDS community to counteract the negative effects of the
misinformation.
10. Physicians should encourage the involvement of support networks to assist patients in
adhering to ART regimens. With the patient’s consent, counselling and training should
be available to family members to assist them in providing care.
11. Physicians must be aware of the discriminatory attitudes toward HIV/AIDS that are
prevalent in society and local culture. Because physicians are the first, and sometimes
the only, people who are informed of their patients’ HIV status, physicians should be
able to counsel them about their basic social and legal rights and responsibilities or
should refer them to counsellors who specialize in the rights of persons living with
HIV/AIDS.
12. Physicians should be aware of the current availability and prescribing guidelines for
pre-exposure and post-exposure prophylaxis for any patient and health care providers
who may have been exposed to HIV.
TESTING
13. Mandatory testing for HIV must be required of donated blood and blood fractions
collected for donation or to be used in the manufacture of blood products; organs and
other tissues intended for transplantation; and semen or ova collected for assisted
reproduction procedures.
Newer technologies which are more sensitive, specific, and reduce the window period
of HIV detection, such as nuclear acid testing (NAT), should be encouraged for such
screening.
14. Mandatory HIV testing of an individual against his or her will is a violation of medical
ethics and human rights.
15. Physicians must clearly explain the purpose of an HIV test, the reasons it is
recommended and the implications of a positive test result.
Before a test is administered, the physician should have an action plan in place in case
of a positive test result. Informed consent must be obtained from the patient prior to
testing.
16. While certain groups are labeled “high risk”, anyone who has had unprotected sex
should be considered at risk.
Physicians must become increasingly proactive about recommending testing to
patients, based on a mutual understanding of the level of risk and the potential to
benefit from testing. Pregnant women and her partner should routinely be offered
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testing for HIV, and those pregnant women found to be HIV positive should be offered
immediate counseling and offered timely ART (at diagnosis) in order to prevent
transmission of the virus to the fetus and treatment of the fetus if seropositive.
17. Counselling and voluntary anonymous testing for HIV should be available to all
persons who request it, along with adequate post-testing support mechanisms.
PROTECTION FROM HIV IN THE HEALTH CARE ENVIRONMENT
18. Physicians and all health care workers have the right to a safe work environment.
Especially in developing countries, the problem of occupational exposure to HIV has
contributed to high attrition rates of the health labour force. In some cases, employees
become infected with HIV, and in other cases fear of infection causes health care
workers to leave their jobs voluntarily. Fear of infection among health workers can
also lead to refusal to treat HIV/AIDS patients. Likewise, patients have the right to be
protected to the greatest degree possible from transmission of HIV from health
professionals and in health care institutions.
18.1 Proper infection control procedures and universal precautions consistent with
the most current national or international standards, as appropriate, should be
implemented in all health care facilities. This includes procedures for the use
of preventive and timely ART for health professionals who have been exposed
to HIV.
18.2 If the appropriate safeguards for protecting physicians or patients against
infection are not in place, physicians and National Medical Associations
should take action to correct the situation.
18.3 Physicians who are infected with HIV should not engage in any activity that
creates a risk of transmission of the disease to others.
In the context of possible exposure to HIV, the activity in which the physician
wishes to engage will be the determining factor.
There may be nationally agreed standards but if not a determination should be
made by a suitable expert panel or committee of health workers.
18.4 In the provision of medical care, if a risk of transmission of an infectious
disease from a physician to a patient exists, disclosure of that risk to patients is
not enough; patients are entitled to expect that their physicians will not
increase their exposure to the risk of contracting an infectious disease.
18.5 If no risk exists, disclosure of the physician’s medical condition to his or her
patients will serve no rational purpose.
18.6 Physicians should be aware of current professional guidelines for post-
exposure prophylaxis of health care workers in case of any accidental
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exposure to HIV.
PROTECTING PATIENT PRIVACY AND ISSUES RELATED TO NOTIFICATION
19. Fear of stigma and discrimination is a driving force behind the spread of HIV/AIDS.
The social and economic repercussions of being identified as infected can be
devastating and can include violence, rejection by family and community members,
loss of housing and loss of employment.
Normalizing the presence of HIV/AIDS in society through public education is the only
way to reduce discriminatory attitudes and practices. Until that can be universally
achieved, or a cure is developed, potentially infected individuals may refuse testing to
avoid these consequences.
The result of individuals not knowing their HIV status is not only disastrous on a
personal level in terms of not receiving treatment, but may also lead to high rates of
avoidable transmission of the disease. Fear of unauthorized disclosure of information
also provides a disincentive to participate in HIV/AIDS research and generally thwarts
the efficacy of prevention programs. Lack of confidence in protection of personal
medical information regarding HIV status is a threat to public health globally and a
core factor in the continued spread of HIV/AIDS. At the same time, in certain
circumstances, the right to privacy must be balanced with the right of partners (sexual
and injection drug) of persons with HIV/AIDS to be informed of their potential
infection. Failure to inform partners not only violates their rights but also leads to the
health problems of avoidable transmission and delay in treatment.
20. All standard ethical principles and duties related to confidentiality and protection of
patients’ health information, as articulated in the WMA Declaration of Lisbon on the
Rights of the Patient, apply equally in the context of HIV/AIDS. In addition, National
Medical Associations and physicians should take note of the special circumstances and
obligations (outlined below) associated with the treatment of HIV/AIDS patients.
20.1 National Medical Associations and physicians must, as a matter of priority,
ensure that HIV/AIDS public education, prevention and counselling programs
contain explicit information related to protection of patient information as a
matter not only of medical ethics but of their human right to privacy.
20.2 Special safeguards are required when HIV/AIDS care involves a physically
dispersed care team that includes home-based service providers, family
members, counsellors, case workers or others who require medical information
to provide comprehensive care and assist in adherence to treatment regimens. In
addition to implementing protection mechanisms regarding transfer of
information, ethics training regarding patient privacy should be given to all
team members.
Many countries have specific legislation to protect the privacy of those who are
HIV positive. Others may consider the same.
20.3 Physicians must make all efforts to convince HIV/AIDS patients to take action
to notify all partners (sexual and/or injection drug) about their exposure and
potential infection. Physicians must be competent to counsel patients about the
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options for notifying partners. These options should include:
20.3.1 Notification of the partner(s) by the patient. In this case, the patient should
receive counselling regarding the information that must be provided to the
partner and strategies for delivering it with sensitivity and in a manner that
is easily understood. A timetable for notification should be established and
the physician should follow-up with the patient to ensure that notification
has occurred.
20.3.2 Notification of the partner(s) by a third party. In this case, the third party
must make every effort to protect the identity of the patient.
20.4 When all strategies to convince the patient to take such action have been
exhausted, and if the physician knows the identity of the patient’s partner(s), the
physician is compelled, either by law or by moral obligation, to take action to
notify the partner(s) of their potential infection. Depending on the system in
place, the physician will either notify directly the person at risk or report the
information to a designated authority responsible for notification. Physicians
must be aware of the laws and regulations in the jurisdiction in which they are
practicing. In cases where a physician must disclose the information regarding
exposure, the physician must:
20.4.1 inform the patient of his or her intentions,
20.4.2 to the extent possible, ensure that the identity of the patient is protected,
20.4.3 take the appropriate measures to protect the safety of the patient, especially
in the case of a female patient vulnerable to domestic violence.
20.5 Regardless of whether it is the patient, the physician or a third party who
undertakes notification, the person learning of his or her potential infection
should be offered support and assistance in order to access testing and
treatment.
20.6 National Medical Associations should develop guidelines to assist physicians in
decision-making related to notification. These guidelines should help physicians
understand the legal requirements and consequences of notification decisions as
well as the medical, psychological, social and ethical considerations.
20.7 As per local and national laws and guidelines requiring the reporting of new
HIV infections, sexually transmitted diseases, and opportunistic infections,
physicians must protect the privacy and confidentiality of all patients and
maintain the highest ethical standards.
20.8 National Medical Associations should work with governments to ensure that
physicians who carry out their ethical obligation to notify individuals at risk,
and who take precautions to protect the identity of their patient, are afforded
adequate legal protection.
MEDICAL EDUCATION
21. National Medical Associations should assist in ensuring that there is training and
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education of physicians in the most current prevention strategies and medical
treatments available for all stages of HIV/AIDS and associated infections, including
prevention and support.
22. National Medical Associations should, when appropriate, collaborate with NGOs and
community based organizations, insist upon, and when possible assist with, the
education of physicians in the relevant psychological, legal, cultural and social
dimensions of HIV/AIDS.
23. National Medical Associations should fully support the efforts of physicians wishing
to concentrate their expertise in HIV/AIDS care, even where HIV/AIDS is not
recognized as an official specialty or sub-specialty within the medical education
system.
24. The WMA encourages its national medical associations to promote the inclusion of
designated, comprehensive courses on HIV/AIDS in undergraduate and postgraduate
medical education programs, as well as continuing medical education.
INTEGRATION of HIV/AIDS SERVICES with other STDs MANAGEMENT ACTIVITES
25. The National Medical Associations should support governments to integrate
HIV/AIDS preventive and curative services with other STD management activities in
a comprehensive manner.
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WMA STATEMENT
ON
MEDICAL EDUCATION
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
1. Medical education consists of basic medical education, postgraduate medical
education, and continuing professional development. Medical education is a dynamic
process that commences at the start of basic medical education (medical school) and
continues until a physician retires from active practice. Its goal is to prepare physicians
to apply the latest scientific knowledge to promote health, prevent and cure human
disease and mitigate symptoms. All physicians have a responsibility to themselves, the
profession and their patients to maintain a high standard for medical education.
BASIC PRINCIPLES OF MEDICAL EDUCATION
2. Medical education consists of training aimed at ensuring physicians acquire the
competencies, skills and aptitudes that that allow them to practice professionally and
ethically at the highest level. All physicians, the profession as a whole, medical
faculties, educational institutions, and governments share the responsibility for
guaranteeing that medical education meets a high-quality standard throughout the
medical education continuum.
I. BASIC MEDICAL EDUCATION
3. The goal of basic medical education is to ensure that medical students have acquired
the knowledge, skills, and professional behaviors that prepare them for a spectrum of
career choices, including, but not limited to, patient care, public health, clinical or
basic research, leadership and management, or medical education. Each of these career
choices will require additional education beyond the first professional degree.
4. At a medical school, the knowledge, skills and professional behavior that students
should acquire should be based on the professional judgment of the faculty and
accreditation councils, and be responsive to the healthcare needs of the region and/or
the country. These decisions will inform the selection of students, the curriculum
design and content, the student assessment system, and the evaluation of whether the
school has achieved its goals. Such decisions should also be subject to relevant
standards, the needs of fairness and accessibility, and diversity and inclusion in the
medical workforce.
II. SELECTION OF STUDENTS
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5. Prior to their entry to medical school, medical students should have acquired a broad
education, ideally including background in the arts, humanities, and social sciences, as
well as biological and physical sciences. Students should be chosen for the study of
medicine based on their intellectual ability, motivation for medicine, previous relevant
experiences, and character and integrity. The selection process for students must not
be discriminatory and should reflect the importance of increasing diversity in the
medical workforce. A medical school should also consider its mission when
developing admission requirements.
6. Within a given country or region, there should be enough medical students to meet
local and regional needs. National medical associations (NMAs) and national
governments should collaborate to mitigate the economic barriers that prevent
qualified individuals from entering and completing medical school.
7. Curriculum and Assessment
7.1 A medical school’s educational program should be based on educational program
objectives developed in response to the healthcare needs of the region and/or
country. These educational program objectives must be used in the selection of
curriculum content, the development of the system for student assessment, and the
evaluations of whether the school has achieved its educational goals, subject to
relevant regulatory and educational standards.
7.2 The medical curriculum should equip the student with a broad base of general
medical knowledge. This includes the biological and behavioral sciences, as well
as the socio-economics of health care, the social determinants of health, and
population and public health. These disciplines, together with basic medical
science, are central to an understanding and practice of clinical medicine. The
WMA recommends that content related to medical ethics and human rights should
be a core requirement in the medical curriculum.1 The student should also be
introduced to the principles and methodology of medical research and how the
results of research are used in clinical practice. Students should have opportunities,
if desired or required by the medical school, to participate in research. The
cognitive skills of self-directed learning, critical thinking, and medical problem
solving should be introduced early in the medical curriculum to prepare students for
clinical training.
7.3 Before beginning independent practice, every physician should complete a formal
program of supervised clinical education. Within basic medical education, clinical
experiences should range from primary to tertiary care in a variety of inpatient and
outpatient settings, such as university hospitals, community hospitals, clinics,
physician practices, and other health care facilities. The clinical component of
basic medical education should use an apprenticeship model of teaching using
defined objectives and must involve direct experiences in the diagnosis and
treatment of disease, with a gradual increase in the student’s responsibility based on
his/her demonstration of the relevant knowledge and skills. Experiences and
training in interprofessional teams providing collaborative care to patients is
important in preparing medical students for practice.
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Medical Education
7.4 The medical school faculty have the responsibility to ensure that students who have
graduated and received the first professional degree have acquired a basic
understanding of clinical medicine, have the basic skills needed to evaluate clinical
problems and take appropriate action, and exhibit the attitudes and character to be
an ethical physician. The assessment system within a medical school should
include appropriate and valid methods to ensure that all graduates have met each of
these expectations. It would be useful for medical schools to have access to
individuals with expertise in student assessment, either from within the medical
school or from external sources.
8. Student Support
8.1 Medical students should receive academic and social support, such as counselling
for personal problems and programs to support well-being, to assist them in meeting
the demands of medical school. Academic support includes tutoring and advice for
study and time management skills. Social support includes access to activities to
promote their physical and mental well-being, as well as access to general and
mental health services. Mentors and advisors to assist students in specialty choice
and career planning also should be available.
9. Faculty and Institutional Resources
9.1 Basic medical education must be taught by appropriate staff including faculty who
possess the appropriate qualifications that can only be achieved through formal
training and experience. There should be a sufficient number of faculty to meet the
educational, research, and other missions of the medical school. The selection
process for faculty must be not be discriminatory. The faculty should have a formal
commitment to the medical school, such as a faculty appointment, and be part of
and subject to the medical school’s governance and departmental structures.
9.2 The faculty of a medical school are accountable for developing the medical
curriculum and the student assessment system. As such, the educational program
objectives, curriculum content and format, and evaluation of the curriculum are the
responsibility of the faculty. The faculty should review the curriculum frequently,
ideally utilizing statistics on student achievement and input from students,
graduates, and the practicing community. Furthermore, the faculty must regularly
evaluate the quality of each component of the educational program and the program
as a whole through the utilization of student and peer feedback. Medical schools
should provide opportunities for faculty development to support the acquisition and
maintenance of teaching and assessment, and curriculum development skills so that
they can meet their responsibilities for the medical education program and
curriculum design skills.
9.3 Medical schools must provide an academic environment which encourages learning
and inquiry by faculty including an active institutional research program to advance
the body of medical knowledge and the quality of care. Medical schools should
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provide support for faculty to acquire research skills and to engage in independent
or collaborative research.
9.4 In addition to sufficient numbers of well-prepared faculty, medical schools must
ensure that there are adequate library and information technology resources,
classrooms, research laboratories, clinical facilities, and study areas for students in
sufficient quantity to meet the needs of all learners. There must be an administrative
support structure for things such as academic records maintenance and registrar
functions.
10. Financing Medical Education
10.1 National governments and medical schools should collaborate to develop financing
mechanisms to support basic medical education. Support is needed for individual
students and for the medical schools themselves. There should be sufficient financial
resources for medical schools to educate the number of medical students required to
meet national or regional health care system needs.
III. POSTGRADUATE MEDICAL EDUCATION
11. A graduate from a basic medical education institution must participate in a clinically-
based advanced training program prior to being legally authorized to enter independent
medical practice and, if required, obtaining a license to practice. Postgraduate medical
education, the second phase of medical education continuum, prepares physicians for
practice in a medical discipline or specialty and focuses on specific competencies
needed for practice in that specialty area.
12. Postgraduate medical education programs, also termed residency programs, include
educational experiences that support the resident’s acquisition of the knowledge and
skills characteristic of the specialty area. Depending on the specialty, postgraduate
programs will use a variety of inpatient and ambulatory clinical settings, including
community-based clinics, hospitals or other health care institutions. The education of
residents should combine a structured didactic curriculum with clinical activity that
includes the diagnosis and management of patients under appropriate and supportive
levels of supervision. A residency program must ensure that each resident has
opportunities to care for an adequate number of patients in order to gain experience in
the range of conditions that characterize the specialty. These clinical experiences
should occur in settings where high quality care is delivered, since educational quality
and patient care quality are interdependent and must be pursued in a manner so that
they enhance one another.
13. A proper balance must be maintained so that residents are not required to meet clinical
service needs at the expense of their education. The residency program should further
the resident’s teaching and leadership skills and ability to contribute to continuous
improvement. The program should also provide opportunities for scholarly activity
aimed at enhancing scientific and critical thinking, clinical problem-solving, and life-
long learning skills. These opportunities will have been introduced during basic
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medical education and should be reinforced during residency to prepare and motivate
the resident to exercise these skills during practice. Additionally, a proper balance
must be maintained among clinical work, education, and personal life.
14. During the residency program, a resident takes on progressively greater responsibility
for patient care based on his or her individual growth in clinical experience,
knowledge, and skill. Allowing the resident to assume increased responsibility
requires a system of assessment to monitor the resident’s increase in knowledge and
skills over time. There also needs to be a process in place to conclusively determine
that the resident is prepared to undertake independent medical practice.
15. Postgraduate medical education should take place in institutions that are accredited or
have been reviewed for quality.
IV. CONTINUING PROFESSIONAL DEVELOPMENT
16. Continuing professional development* (CPD) is defined as the activities that maintain,
develop, or increase the knowledge, skills, and professional performance and
relationships a physician uses on a daily basis to provide services for patients, the
public, or the profession. CPD can include activities such as involvement in national or
regional medical associations; committee work in hospitals or group practices; and
teaching, mentoring and participating in education within his or her chosen specialty
or more broadly within medicine.
17. One of the components of CPD is continuing medical education (CME), in which the
physician participates in medically-related educational activities. Physicians should
further their medical education throughout their careers, including acquiring new
knowledge and skills in response to scientific discoveries and the introduction of new
treatments. Such educational experiences are essential to for the physician to keep
abreast of developments in clinical medicine and the health care delivery environment,
and to continue to maintain the knowledge and skills necessary to provide high quality
care. In many jurisdictions, CME is specialty-defined and may be required for
maintaining a medical license.
18. The goal of continuing professional development is to broadly sustain and enhance the
competent physician. Medical schools, hospitals and professional societies all share a
responsibility for developing and making available to all physicians effective
opportunities for continuing professional development, including continuing medical
education.
RECOMMENDATIONS
19. The demand for physicians to provide medical care, prevent disease, and give advice
in health matters to patients, the public, and policy-makers calls for the highest
standards of basic, postgraduate, and continuing professional development.
Recommendations are as follows:
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19.1 That the WMA encourage NMAs, governments, and other relevant stakeholder
groups to engage in planning for a high quality continuum of medical education
within countries that is informed by and supports the health care needs of the
population.
19.2 That the WMA encourage NMAs to work with medical schools to plan and deliver
faculty development that enhances the skills of medical school faculty as teachers
and researchers.
19.3 That the WMA encourage NMAs and governments to engage in dialogue related to
medical school and postgraduate program funding so that adequate numbers of
well-trained physicians are available to meet national health care needs.
19.4 That NMAs and national governments collaborate to mitigate the economic barriers
that prevent qualified individuals from entering and completing medical school.
19.5 That the WMA encourage NMAs to individually or collaboratively provide
opportunities for continuing physician professional development and continuing
medical education.
* Note on terminology
There are different uses of the term ‘Continuing Professional Development’ (CPD). One way to
describe it is all those activities that contribute to the professional development of a physician
including involvement in organized medicine, committee work in hospitals or group practices,
teaching, mentoring and reading, to name just a few. One of the components of CPD should be
Continuing Medical Education, which in many jurisdictions is specially defined and possibly
required for licensure.
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WMA STATEMENT
ON
THE PHYSICIAN’S ROLE IN OBESITY
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Obesity is one of the single most important health issues facing the world in the twenty-
first century, affecting all countries and socio-economic groups and representing a serious
drain on health care resources.
Obesity in children is of increasing concern and is emerging as a growing epidemic in
itself.
Obesity has complex origins linked to economic and social changes in society including
the obeso-genic environment within which much of the population lives.
Therefore the WMA urges physicians to use their roles as leaders to advocate for
recognition by national health authorities that reduction in obesity should be a priority,
with culturally and age appropriate policies involving physicians and other key
stakeholders.
THE WMA RECOMMENDS THAT PHYSICIANS:
• Lead the development of societal changes that emphasize environments which
support healthy food choices and regular exercise or physical activity for all
people, with a specific focus on children;
• Individually and through medical associations, express concern that excessive
television viewing and video game playing are impediments to physical activity
among children and adolescents in many countries;
• Encourage individuals to make healthy choices and guide parents in helping their
children to do so;
• Recognise the role of personal decision making and the adverse influences exerted
by current environments;
• Recognise that collection and evaluation of data can contribute to evidence based
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Obesity
management, and should be part of routine medical screening and evaluation
throughout life;
• Encourage the development of life skills that contribute to a healthy lifestyle in all
persons and to better public knowledge of healthy diets, exercise and the dangers
of smoking and excess alcohol consumption;
• Advocate for appropriately trained professionals to be placed in educational
facilities, highlighting the importance of education on healthy lifestyles from an
early age;
• Contribute to the development of better assessment tools and databases to enable
better targeted and evaluated interventions;
• Ensure that obesity, its causes and management remain part of continuing
professional development programmes for health care workers, including
physicians;
• Use pharmacotherapy and bariatric surgery consistent with evidence-based
guidelines and an assessment of the risks and benefits associated with such
therapies.
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WMA STATEMENT
ON
THE RESPONSIBILITIES OF PHYSICIANS IN PREVENTING
AND TREATING OPIATE AND PSYCHOTROPIC DRUG ABUSE
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Opiate and psychotropic drugs are valuable therapeutic tools when used as medically
indicated for a variety of symptoms and conditions. Indeed, the WMA has called for the
greater provision of pain management treatment in its Resolution on the Access to
Adequate Pain Treatment (Montevideo, Uruguay, October 2011). Unfortunately, non-
clinical misuse of these addictive substances is an enormous problem worldwide. Drug
addiction is a complex social, economic and legal issue as well as a threat to public health
and safety globally. It affects people from all demographic and social groups and
economic spheres. In addition to exposing themselves to the direct health risks related to
the inappropriate use of these substances, persons addicted to drugs may engage in high
risk behaviour, such as needle-sharing and unprotected sex, and many resort to criminal
activity to finance their expensive addiction. These factors increase transmission of viral
infections, such as Hepatitis B and C and HIV/AIDS, among both users and non-users
alike. Other results of addiction include failure to maintain employment or to function in
social and family life.
The legal ramifications of non-medical drug use, which is illegal in most countries,
generally do little to assist users in breaking free from their addiction. Despite the
presence of drug programs in many correctional facilities, illegal substances are very often
available to inmates and, in fact, some users begin their addiction in these institutions.
Addressing addiction therefore falls largely to society and the health profession.
The World Medical Association, concerned by the widespread misuse of psychotropic and
opiate drugs, urges physicians to prioritize this problem in the practice of medicine and to
adhere to the following guidelines.
PRINCIPLES
Responsible prescribing practices
Physicians should be aware of the addictive properties of certain psychotropic and opiate
drugs. Such drugs should be prescribed with the greatest restraint, observing the strictest
possible generally accepted medical indications. Physicians must take all necessary
measures to ensure that they are fully informed of the effects of these drugs. This includes
reviewing up-to-date research regarding dosage, potential effectiveness for the specific
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condition, potential side effects and pharmacological interactions and prevalence of
misuse.
When such drugs are medically indicated, their use must be carefully monitored to ensure
that the patient is following strict dosage instructions, timing and any other factors
associated with the safe use of the particular drug. All appropriate measures must be taken
to prevent the stockpiling, resale or other illicit usage of the drug.
Patients must be fully informed of all potential therapeutic and non-therapeutic effects of
psychotropic and opiate drugs, including potential for addiction, and be fully involved in
the decision to take them. No competent patient should be forced to take any psychotropic
drug against his or her will.
Physicians should be aware of non-medical factors that may predispose patients to
addiction. These may include, among others, family history, past addiction, emotional
trauma, depression or other mental health conditions and peer pressure, especially among
young persons.
Physicians should learn to recognize ‘drug seekers’, addicted patients who attempt to
obtain psychotropic and opiate drugs under false medical pretenses. Drug seekers often
consult more than one physician in an effort to obtain multiple prescriptions. In extreme
cases, drug seekers may harm themselves to create symptoms to obtain a prescription. All
patient conditions and symptoms should be clinically verified, to the extent possible, and
meticulous records maintained regarding the patient’s drug history. If databases containing
patient drug records and prescribing histories are available, they should be consulted.
When prescribing any psychotropic or opiate substance to minors, physicians must ensure
that the parents or guardians of the patient are fully informed of the potential misuse of the
drug and encouraged to monitor the child carefully to ensure adherence to the physician’s
instructions. Parents or guardians should be informed that, in some countries, it is
increasingly common for children to sell prescription drugs to their peers.
Non-drug therapy for addicts to opiate and psychotropic drugs
Physicians should be aware of all non-drug treatment options for addicts to opiate and
psychotropic drugs, including inpatient and outpatient programs and therapeutic
communities, in which recovering addicts live in a supportive, drug-free environment.
Most treatment programs are focused on breaking the cycle of drug dependence through
detoxification, counselling – including ongoing peer support – and permanent abstinence
from the use of any addictive opiate or psychotropic substance, including alcohol. Some
offer educational and/or vocational programs to facilitate successful reintegration into
community life.
Physicians should encourage their patients to participate in drug treatment programs at the
earliest possible stage of addiction.
All efforts should be made to respect the dignity and autonomy of addicted patients.
Involuntary inpatient treatment of addicted persons should be a last resort, according to
established guidelines and, where applicable, legal requirements.
S-2006-06-2016 ⏐ Taipei
Opiate and Psychotropic Drug Abuse
Drug therapy for addicts to opiate drugs
In some cases, persons addicted to opiate drugs may be treated using medications that
relieve withdrawal symptoms and cravings for the addictive substance without producing
the ‘high’ associated with opiates. These medications also provide cross tolerance to other
opioids. The objective of drug treatment is the immediate cessation of the use of opiate
drugs.
Drug therapy can assist the opiate-dependent patient to function in his or her normal
environment and activities while working to overcome the opiate addiction. However, it
should always be part of a multi-disciplinary approach that includes proven non-drug
treatment elements, such as counselling and peer support.
Drug therapy should be administered according to established evidence-based guidelines
and supervised by specially trained physicians with an appropriate support team.
Awareness raising and policy development
National Medical Associations (NMAs) should engage in cross-sectoral national efforts to
raise awareness of the risks associated with the abuse of opiate and psychotropic drugs and
to ensure the availability of appropriate treatment options for addicted persons. NMAs
should encourage their members to participate in similar programs at the community level.
NMAs should promote appropriate drug prevention programming at all levels of the
educational system, recognizing that experimentation with drugs is increasingly prevalent
among younger age groups.
NMAs and physicians should participate in the development of evidence-based guidelines
that support a multi-disciplinary approach to the treatment of drug addiction, including
harm reduction strategies such as needle exchange programmes.
NMAs should participate in the development of legal procedures relating to illegal drug
use to ensure that addicted persons are recognized as entitled to receive appropriate
medical and rehabilitative care, including in correctional institutions.
CONCLUSION
Physicians have an important role to play in the treatment of drug addiction, both as
clinicians and as advocates for the treatment, rights and dignity of persons addicted to
these harmful substances. Treatment of addiction, like treatment for any disease or
condition, should be undertaken in the best interests of the patient and according to
established principles of medical ethics.
Handbook of WMA Policies
World Medical Association S-2006-07-2022
WMA STATEMENT
ON
MEDICAL ASSISTANCE IN AIR TRAVEL
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
and reaffirmed with minor revisions by the 221st
WMA Council Session, Berlin, Germany,
October 2022
PREAMBLE
Air travel is the preferred mode of long-distance transportation for people across the world.
The growing convenience and affordability of air travel has led to an increase in the number of
air passengers. In addition, long-duration flights are becoming increasingly common,
increasing the risk of in-flight medical emergencies.
The environment in normal passenger planes is not conducive to delivering quality medical
care, especially in medical emergencies. Noise and movement of the plane, the very confined
space, the presence of other passengers who may be experiencing stress or fear as a result of
the situation, the insufficiency or complete lack of diagnostic and therapeutic materials as well
as other factors often create extremely difficult conditions for diagnosis and treatment. Even
the most experienced medical professional is likely to be challenged by these circumstances.
Air travel can significantly affect people who suffer from mental health challenges and
resources for in-flight mental health emergencies are often lacking.
Most airlines require flight personnel to be trained in basic first aid. In addition, many provide
some degree of training beyond this minimum level and may also carry certain emergency
medicines and equipment on board. Some carriers even have the capacity to provide remote
ECG reading and medical counselling services. The ICAO (International Civil Aviation
Organization) standard requires medical supplies to be carried on airplanes, but the detailed
quantity and contents are in non-mandatory recommended practices. Requirements for
individual airlines are determined by the national aviation regulatory authorities. Detailed
requirements of the cabin crew training program are also determined by the respective national
aviation regulatory authority as ICAO standards states that “An operator (airline) shall establish
and maintain a training program approved by the State of the operator.”
Even well-trained flight personnel are often limited in their knowledge and experience and
cannot offer the same assistance as a physician or other certified health professional. Currently,
continuing medical education courses are available to physicians in some locales to train them
specifically for in-flight emergencies.
Air Travel
Berlin S-2006-07-2022
Physicians are often concerned about providing assistance due to uncertainty regarding legal
liability. While many airlines provide some liability insurance for medical professionals and
lay persons who will provide voluntary assistance during a flight, this is not always the case
and even where it does exist, the terms of the insurance cannot always be adequately explained
and understood in an acute medical crisis. The financial and professional consequences of
litigation against physicians who offer assistance can be very costly, though actual examples
of this appear to be quite limited.
Some important steps have been taken to protect the life and health of airline passengers, yet
this is far from ideal and still needs improvement. Many of the major problems could be
mitigated by simple actions taken by both airlines and national legislatures, ideally in
cooperation with one another and with the International Air Transport Association (IATA) to
arrive at coordinated and consensus-based international policies and programs.
Constituent Members have an important leadership role to play in promoting measures to
improve the availability and efficacy of in-flight medical care.
RECOMMENDATIONS
The World Medical Association calls on its Constituent Members to advocate for the delivering
of quality medical care in air travel, in particular:
Airline companies
1. To encourage their national airlines companies, especially those providing medium and
long-range passenger flights, to take the following specific actions:
• Equip their airplanes with a sufficient and standardised set of medical emergency
materials and drugs that are easily identifiable packaging with instruction in English as
well as consideration of other languages, and include Automated External Defibrillators
(AED), considered essential equipment in non-professional settings, while ensuring that
at least one crew member is competent in the use of that particular AED.
• Provide stand-by medical assistance, including a mental health component, that can be
contacted by radio or telephone to help either the flight attendants or to support a
volunteering health professional, if one is on board and willing to assist.
• Develop medical emergency plans to guide airline personnel in responding to the
medical needs of passengers.
• Provide sufficient medical and organisational instruction to flight personnel, beyond
basic first aid training, to enable them to better attend to passenger needs and to assist
medical professionals who volunteer their services during emergencies.
• Provide sufficiently comprehensive insurance for medical professionals and assisting
lay personnel to protect them from damages and liabilities (material and non-material)
resulting from in-flight diagnosis and treatment.
Handbook of WMA Policies
World Medical Association S-2006-07-2022
• Accept all legal and financial consequences of any assistance provided by a physician,
in the absence of legal immunity for physicians.
National authorities
2. To encourage their national aviation authorities to provide yearly summarised reports of in-
flight medical incidents based on mandatory standardised incident reports for every medical
incident requiring the administration of first aid or other medical assistance and/or causing
a change in flight plans.
3. To urge their legislators to enact Good Samaritan legislation to guarantee immunity from
legal action to physicians who provide appropriate emergency assistance during in-flight
medical incidents.
4. To advocate for the inclusion of potential challenges of in-flight medical emergencies in
the ordinary emergency education courses for physicians.
Physicians
5. To inform physicians of training opportunities or promote the development of training
programs where they do not exist;
6. To encourage physicians to consider whether they wish to identify themselves prior to
departure as being willing to help in the event of a medical emergency;
7. To incite physicians to discuss potential problems with their own patients who are at high
risk for requiring in-flight medical attention prior to their flight;
8. To encourage physicians to determine if their liability insurance includes cover for
Samaritan deeds;
9. To inform and motivate physicians to attend appropriate training programs so they can
make informed decisions when declaring their patients fit to travel by air.
International Civil Aviation Organization
The World Medical Association also calls on the ICAO to:
10. Further develop precise standards in the following areas and, where appropriate, work with
governments to implement these standards as legal requirements:
• Medical equipment and drugs on board medium and long-range flights;
• Packaging and information materials standards, including multilingual descriptions and
instructions in appropriate languages;
• Medical, inclusive of mental health emergency procedures and training programs for
medical personnel.
Air Travel
Berlin S-2006-07-2022
11. Define global guidelines guaranteeing physicians immunity from legal action when
providing appropriate emergency assistance during in-flight medical incidents and ensure
its implementation by its Member States.
Handbook of WMA Policies
S-2008-01-2019 ⏐ World Medical Association
WMA STATEMENT
ON
REDUCING DIETARY SODIUM INTAKE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
Dietary table salt is an ionic compound comprising of sodium chloride, which is 40%
sodium (Na+) and 60% chloride (Cl-). There is overwhelming evidence that excessive
sodium intake is a risk factor for the development, or worsening of hypertension, which is
one of the main cardiovascular risk factors. Hypertension may also be an independent risk
factor for cardiovascular diseases as well as all-cause mortality. The effect of dietary
sodium on blood pressure is influenced by various demographic factors such as age and
ethnicity.
Salt intake is also a risk factor for gastric cancer [1].
The World Health Organization (WHO) recommends that average daily sodium
consumption in adults (≥16 years of age) should be less than 2000 mg (5 g salt). For
children (2–15 years of age), the adult intake limit of 2 g/day sodium should be adjusted
downward based on the energy requirements of children relative to those of adults [2].
The majority of the world’s population consumes too much sodium – 3.95 (3.89–4.01)
g/day, equivalent to table salt level of 10.06 (9.88–10.21) g/day. These consumption levels
are far above the recommended limit [3].
The main source of sodium is dietary consumption, 90% of it in the form of salt [4], as
added salt during cooking or eating, or in processed foods such as canned soups,
condiments, commercial meals, baking soda, processed meats (such as ham, bacon,
bologna), cheese, snacks, and instant noodles, among others. In higher-income countries
sodium added during food processing can be as high as 75%-80% of total salt intake [5].
The Global Action Plan for the Prevention and Control of Non-Communicable Disease
(NCDs) 2013-2020 is made up of 9 global targets, including a 30 % relative reduction in
mean population intake of sodium. The WHO has created the S.H.A.K.E technical
package to assist Member States with the development, implementation and monitoring of
salt reduction strategies.
The WHO recognises that while salt reduction is recommended globally, there is concern
that iodine deficiency disorders (IDD) may re-emerge as iodized salt is the main vehicle
for dietary iodine intake through fortification. Therefore the WHO, in recognition of the
importance of both sodium reduction and iodine fortification, urges that efforts of the two
programs be coordinated [6].
S-2008-01-2019 ⏐ Tbilisi
Dietary Sodium Intake
Substantial overall benefits can result from even small reductions in the population’s
blood pressure. Population-wide efforts to reduce dietary sodium intake are a cost-
effective way to reduce overall hypertension levels and subsequent cardiovascular disease.
Evidence shows that keeping sodium consumption within the reference level could
prevent an estimated premature 2.5 million deaths each year globally [7].
RECOMMENDATIONS
1. WMA and its Constituent Members should:
a. Urge governments to recognise that salt consumption is a serious public health
problem and prioritise prevention as an equitable, cost effective and lifesaving
population-wide approach to address high sodium intake and the associated high
burden of cardiovascular diseases.
b. Work in cooperation with national and international health organisations to educate
consumers from childhood about the effects of excessive sodium intake on
hypertension and cardiovascular disease, the benefits of long-term reductions in
sodium intake, and about the dietary sources of salt/sodium and how these can be
reduced.
c. Urge the governments and other stakeholders work together to achieve the targets
set in the Global Action Plan for the Prevention and Control of NCDs 2013-2020.
d. Recognise the critical role of the food processing and food services industry in
reducing dietary sodium, and support regulatory efforts involving mandatory
targets in food processing, sodium content of foodstuffs, and clear labelling. Food
reformulation efforts must target food products that are most commonly consumed
in the population.
2. Constituent members of WMA should:
1. Encourage their governments strictly to enforce laws regulating the sodium content
in processed foods.
2. Embrace a multi stakeholder approach in working towards reducing the
consumption of excessive sodium by the population, including active promotion of
physician awareness regarding the effects of excessive dietary sodium.
3. Recognise that sodium reduction and salt iodization programmes need to be
compatible and support sodium reduction strategies that do not compromise
dietary iodine content, or increase or worsen iodine deficiency disorders, especially
in low income settings.
4. Contribute to making the public aware of the potential consequences of low iodine
levels as a result of restricted iodized salt intake.
5. Encourage their members to contribute to scientific research on sodium reduction
strategies.
6. Encourage the initiation of food labeling, media campaigns and population-wide
policies such as mandatory reformulation to achieve larger reductions in
population-wide salt consumption than individually focused interventions.
Tbilisi⏐ S-2008-01-2019
Dietary Sodium Intake
3. Individual physicians should:
Counsel patients about the major sources of sodium in their diets and how to reduce
sodium intake, including reducing the amount of salt used in cooking at home, use of salt
substitutes, and addressing any relevant local practices and beliefs that contribute to high
sodium intake.
References:
[1] World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition,
Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR,
2007.
[2] Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO),
2012.
[3] Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata, Khatibzadeh,
Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz, Ezzati, Majid and Powles, John
(2014) Global sodium consumption and death from cardiovascular causes. New England Journal
of Medicine, 371 7: 624-634. doi:10.1056/NEJMoa1304127.
[4] J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent hypertension and
cardiovascular disease. Rev. Panam. Salud Publica, 32 (4) (2012), pp. 293-300.
[5] World Health Organization Regional Office for Europe Mapping salt reduction initiatives in
the WHO European Region (Web. 10 May 2014.)
http://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping-salt-reduction-initiatives-
in-the-WHO-European-Region.pdf (2013).
[6] Salt reduction and iodine fortification strategies in public health. 2014.
http://www.who.int/nutrition/publications/publichealth_saltreduc_iodine_fortification/en/.
[7] McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V, Webster J, Campbell
NRC.Population-level interventions in government jurisdictions for dietary sodium reduction.
Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010166. doi:
10.1002/14651858.CD010166.pub2.
Handbook of WMA Policies
S-2008-02-2018 ⏐ World Medical Association
WMA STATEMENT
ON
REDUCING THE GLOBAL BURDEN OF MERCURY
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed with minor revision by the 210th
WMA Council Session, Reykjavik, Iceland,
October 2018
PREAMBLE
Mercury is a naturally occurring heavy metal that is a potent neurotoxin. The most likely
routes of human exposure on a population basis are ingestion of methylmercury from
contaminated fish. Less commonly, individuals are exposed via inhalation of inorganic
mercury vapor after a spill or during a manufacturing process.
Mercury has been the ideal choice for use in medical devices that measure temperature
and pressure. Therefore, a typical large hospital may have more than a hundred pounds of
mercury onsite incorporated into various devices in separate locations.
Hospitals and clinics can avoid the occupational or environmental risk of mercury by
using products that don’t rely on mercury-based technology. Major healthcare institutions
around the world have demonstrated that safe, effective alternative products exist, and can
be safely used for most situations, such as electronic thermometers, recently calibrated
aneroid devices and mercury-free batteries.
Although the rationale for instituting voluntary mercury replacement initiatives is
compelling from both occupational and environmental perspectives, financial
considerations may ultimately motivate hospitals to undertake a mercury replacement
program. Hazardous waste clean-up costs, reporting requirements for spills, disruptions in
services, and staff training are costly. The cost of cleaning up one significant
contamination can be substantially higher than the cost of converting to mercury-free
alternatives.
By implementing a “best practices” management method for mercury use, the need for
increased government regulations in the future, may be avoided. Such regulations may
create costly burdens that some facilities may not be able to meet.
The World Medical Association (WMA) recalls its statement on Environmental
Degradation and Sound Management of Chemicals that provides recommendations for
advocacy measures and capacity building in order to tackle this issue.
Reykjavik ⏐ S-2008-02-2018
Mercury
RECOMMENDATIONS
The following recommendations are based on the urgent need to reduce both the supply
and demand of mercury in the health care sector:
Global
The World Medical Association and its member national medical associations should:
• Advocate for the United Nations and individual governments to voluntarily
cooperate to implement key features of the United Nations Environment
Programme (UNEP) Mercury Programme, which provides a framework for
reducing the use, release, trade and risk related to mercury.
• Enhance the activity of existing partnerships.
Regional/National
National medical associations should advocate that their governments work to reduce risks
related to mercury in the environment by:
• Reducing reliance on mercury mining in favor of environmentally-friendly sources
of mercury, such as recycled mercury.
• Developing options and scientifically sound plans for the long term safe storage of
excess mercury supplies.
• Urging Member States to ratify and implement the United Nations Minamata
Convention on Mercury adopted in 2013 and designed to protect human health and
the environment from anthropogenic emissions and releases of mercury and
mercury compounds.
• Encouraging a phase-out of mercury use in the health care sector
• Designing and implementing regulations and/or requirements designed to
significantly reduce mercury emissions from coal combustion and cement
production by using specific mercury emission controls.
Local
Physicians should:
1. Explore eliminating mercury-containing products in their offices and clinical
practices, including thermometers, sphygmomanometers, gastrointestinal tubes,
batteries, lamps, electrical supplies, thermostats, pressure gauges, and other
laboratory reagents and devices.
2. Ensure that local hospitals and medical facilities have a plan to identify sources of
mercury in their workplace, a commitment to mercury reduction, and a mercury
management policy regarding recycling, disposal and education.
3. Encourage local hospitals and medical facilities to phase out mercury-containing
products and switch to non-mercury equivalents.
4. Counsel patients about local and national advisories related to fish consumption
designed to limit exposure to mercury in children and women of childbearing age.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
WMA STATEMENT
ON
CONFLICT OF INTEREST
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
This policy is intended to identify areas where a conflict of interest might occur during the
day-to-day practice of medicine, and to assist physicians in resolving such conflicts in the
best interests of their patients. A conflict of interest is understood to exist when profes-
sional judgement concerning direct patient care might be unduly influenced by a second-
ary interest.
In some cases, it may be enough to acknowledge that a potential or perceived conflict
exists. In others, specific steps to resolve the conflict may be required. Some conflicts of
interest are inevitable and there is nothing inherently unethical in the occurrence of con-
flicts of interest in medicine but it is the manner in which they are addressed that is cru-
cial.
In addition to the clinical practice of medicine and direct patient care, physicians have
traditionally served in several different roles and pursued various other interests, such as
participation in research, the education of future physicians and physicians in training and
the occupation of administrative or managerial positions. As private interests within medi-
cine have expanded in many locales, physicians have occasionally provided their expertise
to these endeavours as well, acting as consultants (and sometimes employees) for private
enterprise.
Although the participation of physicians in many of these activities will ultimately serve
the greater public good, the primary obligation of the individual physician continues to be
the health and well-being of his or her patients. Other interests must not be allowed to
influence clinical decision-making (or even have the potential to do so).
Each doctor has a moral duty to scrutinise his or her own behaviour for potential conflicts
of interest, even if the conflicts fall outside the kinds of examples or situations addressed
in this document. If unacknowledged, conflicts of interest can seriously undermine patient
trust in the medical profession as well as in the individual practitioner.
Physicians may also wish to avail themselves of additional resources such as specialty
societies, national medical associations or regulatory authorities, and should be aware of
applicable national regulations and laws.
New Delhi ⏐ S-2009-01-2009
Conflict of Interest
RECOMMENDATION
Research
The interests of the clinician and the researcher may not be the same. If the same indivi-
dual is assuming both roles, as is often the case, the potential conflict should be addressed
by ensuring that appropriate steps are put in place to protect the patient, including dis-
closure of the potential conflict to the patient.
As stated in the Declaration of Helsinki:
• The Declaration of Geneva of the World Medical Association states that, “The
health of my patient will be my first consideration,” and the International Code of
Medical Ethics declares that, “A physician shall act only in the patient’s interest
when providing medical care which might have the effect of weakening the phy-
sical and mental condition of the patient.”
• The Declaration of Helsinki states that “In medical research involving human
subjects, the well-being of the individual research subject must take precedence
over all other interests.”
Research should be conducted primarily for the advancement of medical science. A
physician should never place his or her financial interests above the welfare of his or her
patient. Patient interests and scientific integrity must be paramount.
All relevant and material physician-researcher relationships and interests must be dis-
closed to potential research participants, research ethics boards, appropriate regulatory
oversight bodies, medical journals, conference participants and the medical centre where
the research is conducted.
All hypothesis-testing research trials should be registered with a publicly-accessible re-
search registry.
A clear contract should be signed by all parties, including sponsors, investigators and
program participants, clarifying terms relating to, at a minimum:
• financial compensation for the physician-researcher (which should approximate
lost clinical earnings)
• ownership of research results (which should rest with the investigator)
• the right of the investigator to publish negative results
• the right of the investigator to release relevant information to trial participants at
any point during the study.
Physician-researchers should retain control of and should have full access to all trial data,
and should decline non-disclosure clauses.
Physician-researchers should ensure that, regardless of the trial results, the presentation or
publication of the results of hypothesis-testing trials will not be unduly delayed or other-
wise obstructed.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
Referral fees should not be accepted for providing the names of potential trial participants,
and patient information should not be released without the consent of the patient, except
where required by legislation or regulatory authorities.
Any compensation received from trial sponsors should approximately replace lost clinical
income and should be commensurate with the efforts and responsibilities of the physician
performing the research. When enrolment is particularly challenging and time-consuming,
reasonable additional payments may be made to compensate the clinical investigator or
institution specifically for time and effort spent on extra recruiting efforts to enrol appro-
priate research participants. Escalating bonuses designed to increase trial enrolment should
not be accepted.
Physician-researchers should decline requests to review grant applications or research
paper submissions from colleagues or competitors where their relationship would have the
potential to influence their judgment on the matter.
Payments or compensation of any sort should not be tied to the outcome of clinical trials.
Physician-researchers should not have a financial interest in a company sponsoring a trial
or a product being studied in a clinical trial if this financial interest could be affected
positively or negatively by the results of the trial; they should have no direct financial
stake in the results of the trial. They should not purchase, buy or sell stock (shares) in the
company while the trial is ongoing and until the results have been made public. This
might not apply for those physicians who have developed a medication but are not part of
the enrolment process.
Physician-researchers should only participate in clinical trials when they relate to their
area of medical expertise and they should have adequate training in the conduct of re-
search and the principles of research ethics.
Authorship should be determined prior to the start of the trial and should be based on
substantive scientific contribution.
Education
The educational needs of students and the quality of their training experience must be
balanced with the best interests of patients. Where these are in conflict, the interests of
patients will take precedence.
While recognizing that medical trainees require experience with real patients, physician-
educators must ensure that these trainees receive supervision commensurate with their
level of training.
Patients should be made aware that their medical care may be performed in part by stu-
dents and physicians in training, including the performance of procedures and surgery, and
where possible should give appropriate informed consent to this effect.
Patients should be made aware of the identity and qualifications of the individuals in-
volved in their care.
Refusal by a patient to involve trainees in their care should not affect the amount or
quality of care they subsequently receive.
New Delhi ⏐ S-2009-01-2009
Conflict of Interest
Self-referrals and fee-splitting
All referrals and prescriptions (whether for specific goods or services) should be based on
an objective assessment of the quality of the service or of the physician to whom the pa-
tient has been referred.
Referral by physicians to health care facilities (such as laboratories) where they do not
engage in professional activities but in which they have a financial interest is called self-
referral. This practice has the potential to significantly influence clinical decision-making
and is not generally considered acceptable unless there is a need in that particular com-
munity for the facility and other ownership is not a possibility (for example, in small rural
communities). The physician in this situation should receive no more financial interest
than would an ordinary investor.
Kickbacks (or fee-splitting) occur when a physician receives financial consideration for
referring a patient to a specific practitioner or for a specific service for which a fee is
charged. This practice is not acceptable.
Physician offices
For reasons of patient convenience, many physician offices are located in close geographic
proximity to other medical services such as laboratories, pharmacies and opticians. The
physician should not receive any financial compensation or other consideration either for
referring a patient to these services, or for being located in close geographical proximity to
them. Physician-owned buildings should not charge above-market or below-market rates
to tenants.
Non-medical products (those having nothing to do with patient health or the practice of
medicine) and scientifically non-validated medical products should not be sold out of the
physician’s office. If scientifically validated medical products are sold out of the physi-
cian’s office charges should be limited to the costs incurred in making them available and
the products should be offered in such a way that the patient does not feel pressured to
purchase them.
Organizational/institutional conflicts
Health care institutions in particular are increasingly subject to a number of pressures that
threaten several of their roles, and many academic medical centres have begun to identify
alternate sources of revenue. Policies should be in place to ensure that these new sources
are not in conflict with the values and mission of the institution (for example, tobacco
funding in medical schools).
Individual medical organizations and institutions (including, but not limited to, medical
schools, hospitals, national medical associations, official/state regulators and research in-
stitutions) should develop and, where possible, enforce conflict of interest guidelines for
their employees and members.
Handbook of WMA Policies
S-2009-01-2009 ⏐ World Medical Association
Physician-researchers and others will benefit from the development of institutional con-
flict of interest guidelines to assist them in making appropriate disclosure and clearly
identifying situations where a conflict would preclude them from participating in a re-
search study or other activity.
Academic health care institutions should have a clear demarcation between investment
decision-making committees, technology transfer and the research arm of the institution.
Written policies should provide guidelines for disclosure requirements, or for disconti-
nuing participation in the decision-making process, for those individuals who are con-
flicted due to sponsored research, consulting agreements, private holdings or licensing
agreements.
Handbook of WMA Policies
World Medical Association ⏐ S-2009-02-2020
WMA STATEMENT
ON
STEM CELL RESEARCH
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and revised by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
The fields of stem cell research and therapy are among the fastest growing areas of
biotechnology.
Stem cells can be harvested from established tissue (adult stem cells) or from the blood of
the placenta via the umbilical cord. These sources may create no specific ethical
dilemmas.
Stem cells can also be obtained from an embryo (embryonic stem cells). Obtaining and
using these stem cells raises specific ethical questions and may be problematic for some
people. Another source of stem cells valuable for research is induced pluripotent stem
cells, which can be generated from adult tissues, and may in some cases be functionally
equivalent to embryonic stem cells, although they are not derived from embryos.
Some jurisdictions have prohibited using embryonic stem cells. Others have allowed using
so-called “spare or excess embryos” from assisted reproduction procedures for research
purposes, but the production of embryos solely for research purposes may be prohibited.
Other jurisdictions have no specific laws or regulations with respect to embryonic stem
cells.
Human embryos are considered by some people to have a specific and special ethical
status. This has generated debate amongst ethicists, philosophers, theologians, clinicians,
scientists, health workers, the public and legislators.
In vitro fertilisation involves the production of embryos outside of the human body. In
many cases, some of the embryos are not used to achieve pregnancies. Those not used
may be donated for the treatment of others, or for research, or stored for some time and
then destroyed.
Stem cells can be used to conduct research into basic developmental biology, human
physiology and disease pathogenesis. There are many current research programs
investigating the use of stem cells to treat human disease. Adult stem cell therapies,
including using bone marrow, cord blood or blood-derived stem cells for transplantation,
include several important and well-validated clinical advances. In contrast, clinical studies
have not yet validated the use of embryonic stem cells in therapy.
S-2009-02-2020 ⏐ Cordoba
Stem Cell Research
Embryonic stem cells may at times be superior to induced pluripotent stem cells for
certain applications, and research with embryonic stem cells may continue to be needed.
Some experts anticipate future use of a variety of therapies based on stem cells, including
transplants of genetically matched tissue. It is too early to assess the likelihood of success
of any specific therapy based on stem cells.
Public views of stem cell research are as varied as those of doctors and scientists. Much
public debate centers on concerns of abuse of the technology and the potential for harm in
recipients, and specific concerns continue to be raised about the use of embryos.
Investigational stem cell products also may pose unique risks, including unknown long-
term health effects such as mutations.
Adoption of laws in accordance with established ethical principles is likely to alleviate
concerns for many members of the public, especially if such laws are carefully and
credibly monitored and enforced.
RECOMMENDATION
1. Whenever possible, research should be carried out using stem cells that are not of
embryonic origin. Research with stem cells from unused embryos after in vitro
fertilization techniques should only be carried out if obtaining the potential results
could not also be addressed with the use of other types of stem cells, including induced
pluripotent stem cells. Research and other uses should be in accordance with the
WMA Resolution on the Non-Commercialisation of Human Reproductive Material.
2. All research on stem cells, regardless of stem cell type, must be carried out according
to established ethical principles and with appropriate informed consent. Both
established and proposed laws must conform to these principles to avoid confusion or
conflicts between law and ethics.
3. The ethical principles should, where possible, follow international agreements.
Recognising that different groups have widely varying views on the use of specific
stem cell types, these principles should be drafted with enough flexibility to allow
different jurisdictions to appropriately regulate levels of research.
Handbook of WMA Policies
World Medical Association S-2009-04-2022
WMA STATEMENT
ON
DIGITAL HEALTH
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
1. Digital health is a broad term that refers to “the use of information and communication
technologies in medicine and other health professions to manage illnesses and health risks
and to promote wellness.” Digital health encompasses electronic health (eHealth) and
developing areas such as the use of advanced computer sciences (including ‘big data’,
bioinformatics and artificial intelligence). The term also includes telehealth, telemedicine,
and mobile health (mHealth).
2. The term “digital health” may be used interchangeably with “eHealth.” These terms also
include within them: Telehealth” or “Telemedicine,” which both utilize information and
communications technology to deliver healthcare services and information at a distance
(large or small). They are used for remote clinical services, including real-time patient
monitoring such as in critical care settings. Also, they serve for patient-physician
consultation where access is limited due to physicians’/patients’ schedules or preferences,
or patient limitations such as physical disability. Alternatively, they can be used for
consultation between two or more physicians. The difference between the two terms is that
“Telehealth” refers also to remote clinical and non-clinical services: preventive health
support, research, training, and continuing medical education for health professionals.
3. Technological developments and the increasing availability and affordability of mobile
devices have led to an exponential increase in the number and variety of digital health
services in use in both developed and developing countries. Simultaneously, this relatively
new and rapidly evolving sector remains largely unregulated, which could have potential
patient safety and ethical
4. The driving force behind digital health should be improving quality of care, patient safety
and equity of access to services otherwise unavailable.
5. Digital health differs from conventional health care in the medium used, its accessibility,
and its effect on the patient-physician relationship, as well as on the traditional principles
of patient care.
Digital Health
Berlin S-2009-04-2022
6. The development and application of digital health has expanded access to health care and
health education in both regular and emergency situations. At the same time, its effect on
the patient-physician relationship, accountability, patient safety, multistakeholder
interactions, privacy and data confidentiality, fair access, and other social and ethical
principles should be taken into consideration. However, the scope and application of digital
health, telemedicine or telehealth are context-dependent. Factors such as human resources
for health, size of service area and level of healthcare facilities should also be taken into
consideration.
7. Physicians should be involved in the development and implementation of digital health
solutions to be used in health care, in order to ensure they meet the needs of patients and
health professionals.
8. Consistent with the mandate of the WMA, this statement is addressed primarily to
physicians and their role in the health care setting. The WMA encourages others who are
involved in healthcare to develop and adhere to similar principles, as appropriate to their
role in the healthcare system.
Physician autonomy
9. Acceptable boundaries in the patient-physician relationship necessary for the provision of
optimal care, should exist in digital as well as physical practice. The nearly continuous
availability of digital health care has the potential to unduly interfere with a physician’s
work-life balance due to theoretical 24/7 availability. The physician should inform patients
about his or her availability and recommend services when he or she is not available.
10. Physicians should exercise their professional autonomy in deciding whether digital health
consultation is appropriate. This autonomy should consider the type of visit scheduled, the
physician’s comfort with the medium, and the physician’s assessment, together with the
patient, of the patient’s comfort level with this type of care.
Patient-physician relationship
11. Face to face consultation should be the gold standard where a physical examination is
required to establish a diagnosis, or where there is a wish on the part of the physician or
patient to communicate in person as part of establishing a trusted physician-patient
relationship. Face to face consultations may be preferable in some circumstances to take
stock of non-verbal cues, and for consultations where there may be communication barriers
or discussion of sensitive matters. Ideally, the patient-physician relationship in the context
of digital health, should be based on a previously established relationship and sufficient
knowledge of the patient’s medical history.
12. However, in emergency and critical situations, or in settings where access to doctors is not
available other than via telemedicine, delivery of care via telemedicine should be prioritized
even when a prior patient-physician relationship was not established. Telemedicine can be
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World Medical Association S-2009-04-2022
employed when a physician cannot be physically present within a safe and acceptable
period. It can also be used to manage patients remotely including self-management and for
chronic conditions or follow-up after initial treatment, where it has been proven to be safe
and effective.
13. The physician providing telemedicine services should be familiar with the technology
and/or should receive sufficient resources, training and orientation in effective digital
communication. Additionally, the physician should strive to ensure that quality of
communication during a digital health encounter is maximized. It is also important that the
patient is comfortable using the technology employed. Any significant technical
deficiencies should be noted in the documentation of the consultation and reported, if
applicable.
14. The patient-physician relationship is based on mutual trust and respect. Therefore, the
physician and the patient must identify each other reliably when telemedicine is employed.
However, it must be recognized that sometimes third parties or ‘surrogates’ such as a family
member should become involved in the case of minors, the frail, the elderly, or in an
emergency situation.
15. The physician should give clear and explicit direction to the patient during the telemedicine
encounter regarding who has ongoing responsibility for any required follow-up and
ongoing health care.
16. In a digital consultation between two or more professionals, the primary physician remains
responsible for the patient’s care and coordination. The primary physician remains
responsible for protocols, conferencing, and medical record review in all settings and
circumstances. Physicians providing consultation should be able to contact other health
professionals and technicians, as well as patients, in a timely manner.
Informed consent
17. Proper informed consent requires that the patient be informed of, have capacity for, and
provide consent specific to the type of digital health being used. All necessary information
regarding the distinctive features of digital health, in general, and telemedicine, in
particular, must be explained fully to patients including, but not limited to: how
telemedicine works, how to schedule appointments, privacy concerns, the possibility of
technological failure, including confidentiality breaches; possible secondary use of data;
protocols for contact during virtual visits, prescribing policies and coordinating care with
other health professionals. This information should be provided clearly and understandably
without coercion or undue influence of the patient’s voluntary choices, while taking into
account the patient’s perceived level of health literacy and other resource limitations
specific to the type of digital health being used.
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Berlin S-2009-04-2022
Quality of care
18. The physician must ensure the standard of care delivered via digital health is at least
equivalent to any other type of care given to the patient, considering the specific context,
location and timing, and relative availability of face to face care. If the standard of care
cannot be satisfied via digital technology, the physician should inform the patient and
suggest an alternative form of healthcare delivery.
19. The physician should have clear and transparent protocols for delivering digital health care
such as clinical practice guidelines, whenever possible, to guide the delivery of care in the
digital setting, recognizing that certain modifications may need to be made to accommodate
specific circumstances. Changes to clinical practice guidelines for the digital setting should
be approved by the appropriate governing and/or regulatory body or association. If the
digital health solution is equipped with automated clinical practice support, this support
must be strictly professionally based and not influenced by economic interests in any way.
20. The physician providing digital services should follow all regulatory requirements and
relevant protocols and procedures related to informed consent (verbal, written, and
recorded); privacy and confidentiality; documentation; ownership of patient records; and
appropriate video/telephone behaviors.
21. The physician providing care by means of telehealth should keep a clear and detailed record
of the advice delivered, the information on which the advice was based and the patient’s
informed consent.
22. The physician should be aware of and respect the particular challenges and uncertainties
that may arise when in contact with the patient through telecommunication. The physician
must be prepared to recommend direct patient-physician contact whenever possible if
he/she believes it is in the patient’s best interests or will improve compliance.
23. The possibilities and weaknesses of digital health in emergencies must be duly identified.
If it is necessary to use telemedicine in an emergency, the advice and treatment suggestions
will be influenced by the severity of the patient’s medical condition and the patient’s
technological and health literacy. To ensure patient safety, entities that deliver telemedicine
services should establish protocols for referrals in emergency situations.
Clinical Outcomes
24. Entities providing digital health programs should monitor and continuously strive to
improve the quality of services to achieve the best possible outcomes.
25. Entities providing digital health programs should have a systematic protocol for collecting,
evaluating, monitoring and reporting meaningful health care outcomes, safety data and
clinical effectiveness. Quality indicators should be identified and utilized. Like all health
care interventions, digital technology must be tested for its effectiveness, efficiency, safety,
Handbook of WMA Policies
World Medical Association S-2009-04-2022
feasibility, and cost-effectiveness. Quality assurance and improvement data should be
shared to improve its equitable use.
26. Entities implementing digital health are urged to report unintended consequences to help
improve patient safety and further the overall development of the field. Countries are
encouraged to implement these guiding principles in their own legislation and regulation.
Equity of care
27. Although digital health can provide greater access to distant and underserved populations,
it may also exacerbate existing inequalities due to, among other things, age, race,
socioeconomic status, cultural factors, or literacy issues. Physicians must be aware that
certain digital technologies might be unavailable or unaffordable to patients, impeding
access and further widening the health outcomes gaps.
28. Digital technologies should be implemented and monitored carefully to avoid inequity of
access to these technologies. Where appropriate, social or healthcare services should
facilitate access to technologies as part of basic benefit packages while taking all necessary
precautions to guarantee data security and privacy. Access to vital technologies should not
be denied to anyone based on financial status or a lack of technical expertise.
Confidentiality and data security
29. In order to ensure data confidentiality, officially recognized data protection measures must
be used. Data obtained during a digital consultation must be secured to avoid unauthorized
access and breaches of identifiable patient information through appropriate and up-to-date
security and privacy measures. If data breaches do occur, the patient must be notified
immediately in accordance with the law.
30. Digital health technologies generally involve the measurement or manual input of medical,
physiological, lifestyle, activity, and environmental data to fulfill their primary purpose.
The large amount of data generated also may be used for research or other purposes to
improve healthcare and disease prevention. However, secondary uses of personal mHealth
data can result in misuse and abuse.
31. Robust policies and safeguards to regulate and secure the collection, storage, protection,
and processing of digital health users’ data, especially personal health data, must be
implemented to assure valid informed consent and guarantee patients’ rights.
32. If patients believe that their privacy rights have been violated, they may file a complaint
with the covered entity’s Privacy Officer or data protection authorities, in accordance with
local regulations.
Digital Health
Berlin S-2009-04-2022
Legal principles
33. A clear legal framework must be drawn up to address potential liability arising from the
use of digital technologies. Physicians should only practice telemedicine in
countries/jurisdictions where they are licensed to practice and should adhere to the legal
framework and regulations as defined by the country/jurisdiction where the physician
originates care and the countries in which they practice. Physicians should ensure that their
medical indemnity includes telemedicine and digital health coverage.
34. Reimbursement models must be set up in consultation with national medical associations
and healthcare providers to ensure that physicians receive appropriate reimbursement for
providing digital health services.
Specific principles of mHealth technology
35. Mobile health (mHealth) is a form of electronic health (eHealth) for which there is no fixed
definition. It has been described as medical and public health practice supported by mobile
devices, such as mobile phones, patient monitoring devices, personal digital assistants
(PDAs), and other devices intended to be used in connection with mobile devices. It
includes voice and short messaging services (SMS), applications (apps), and the use of the
global positioning system (GPS).
36. A clear distinction must be made between mHealth technologies used for lifestyle purposes
and those that require physicians’ medical expertise and meet the definition of medical
devices. The latter must be appropriately regulated, and users must be able to verify the
source of medical information provided, as these applications could potentially recommend
non-scientific or non-evidence-based treatments. The information provided must be
comprehensive, clear, reliable, non-technical, and easily understood by laypeople.
37. Concerted work must improve the interoperability, reliability, functionality, and safety of
mHealth technologies, e.g., through the development of standards and certification
schemes.
38. Comprehensive and independent evaluations must be carried out regularly by competent
authorities with appropriate medical expertise to assess the functionality, limitations, data
integrity, security, and privacy of mHealth technologies. This information must be made
publicly available.
39. mHealth can only positively contribute to improvements in care if services are based on
sound medical rationale. As evidence of clinical usefulness is developed, findings should
be published in peer-reviewed journals and be reproducible.
Handbook of WMA Policies
World Medical Association S-2009-04-2022
RECOMMENDATIONS
1. The WMA recognizes the value of digital health to supplement traditional ways of
managing health and delivering healthcare. The driving force behind digital health should
be improving quality of care and equity of access to services otherwise unavailable.
2. The WMA emphasizes that the principles of medical ethics, as outlined in The Declaration
of Geneva: The Physician’s Pledge and the International Code of Medical Ethics, must be
respected in the practice of all forms of digital health.
3. The WMA recommends that the training of digital health literacy and skills be included in
medical education and continuing professional development.
4. The WMA urges patients and physicians to be discerning in their use of digital health and
to be mindful of potential risks and implications.
5. The WMA recommends further research in digital health to assess safety, efficacy, cost-
effectiveness, feasibility of implementation, and patient outcomes.
6. The WMA recommends monitoring the risks of excessive or inappropriate use of digital
health technologies and the potential psychological impact on patients and ensuring that
the benefits of such technologies outweigh the risks.
7. The WMA recommends special attention be given to patients’ disabilities (audio-visual or
physical) and patients who are minors, when using digital healthcare.
8. Where appropriate, National Medical Associations should encourage the development and
update of ethical norms, practice guidelines, national legislation, and international
agreements on digital health.
9. The WMA recommends that other regulatory bodies, professional societies, organizations,
institutions, and private industry, monitor the proper use of digital health technologies and
share these findings widely.
Handbook of WMA Policies
S-2010-01-2018 ⏐ World Medical Association
WMA STATEMENT
ON
ENVIRONMENTAL DEGRADATION
AND SOUND MANAGEMENT OF CHEMICALS
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and amended by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. This Statement focuses on one important aspect of environmental degradation, which
is environmental contamination by domestic and industrial substances. It emphasizes
the harmful chemical contribution to environmental degradation and physicians’ role
in promoting sound management of chemicals as part of sustainable development,
especially in the healthcare environment.
2. Unsafe management of chemicals has potential adverse impacts on human health and
human rights, with vulnerable populations being most at risk.
3. Most chemicals to which humans are exposed come from industrial sources and
include, toxic gases, food additives, household consumer and cosmetic products,
agrochemicals, and substances used for therapeutic purposes, such as drugs and dietary
supplements. Recently, attention has been concentrated on the effects of human
engineered (or synthetic) chemicals on the environment, including specific industrial
or agrochemicals and on new patterns of distribution of natural substances due to
human activity. As the number of such compounds has multiplied, governments and
international organizations have begun to develop a more comprehensive approach to
their safe regulation. The increasing amount of plastic waste in our environment is
another serious concern, that needs to be addressed.
4. While governments have the primary responsibility for establishing a framework to
protect the public’s health from chemical hazards, the World Medical Association, on
behalf of its members, emphasizes the need to highlight the human health risks and
make recommendations for further action.
BACKGROUND
Chemicals of Concern
5. During the last half-century, the use of chemical pesticides and fertilizers dominated
agricultural practice and manufacturing industries rapidly expanded their use of
synthetic chemicals in the production of consumer and industrial goods.
6. The greatest concern relates to chemicals, which persist in the environment, have low
rates of degradation, bio-accumulate in human and animal tissue (concentrating as they
move up the food chain), and which have significant harmful impacts on human health
and the environment (particularly at low concentrations). Some naturally occurring
Reykjavik ⏐ S-2010-01-2018
Environmental Degradation
metals including lead, mercury, and cadmium have industrial sources and are also of
concern. Advances in environmental health research including environmental and
human sampling and measuring techniques, and better information about the potential
of low dose human health effects have helped to underscore emerging concerns.
7. Health effects from chemical emissions can be direct (occurring as an immediate effect
of the emission) or indirect. Indirect health effects are caused by the emissions’ effects
on water, air and food quality as well as the alterations in regional and global systems,
such as red tide in many oceans, and the ozone layer and the climate, to which the
emissions may contribute.
National and International Actions
8. The model of regulation of chemicals varies widely both within and between
countries, from voluntary controls to statutory legislation. It is important that all
countries move to a coherent, standardized national legislated approach to regulatory
control. Furthermore, international regulations must be coherent such that developing
countries will not be forced by economic circumstances to accept elevated toxic
exposure levels.
9. Synthetic chemicals include all substances that are produced by, or result from, human
activities including industrial and household chemicals, fertilizers, pesticides,
chemicals contained in products and in wastes, prescription and over-the-counter drug
products and dietary supplements, and unintentionally produced byproducts of
industrial processes or incineration, like dioxins. Furthermore, nanomaterials may need
explicit regulation beyond existing frameworks.
Strategic approach to international chemicals management
10. Worldwide hazardous environmental contamination persists despite several
international agreements on chemicals, making a more comprehensive approach to
chemicals essential. Reasons for ongoing contamination include persistence of
companies, absolute lack of controls in some countries, lack of awareness of the
potential hazards, inability to apply the precautionary principle, non-adherence to the
various conventions and treaties and lack of political will. The Strategic Approach to
International Chemicals Management (SAICM) was adopted in Dubai, on February 6,
2006 by delegates from over 100 governments and representatives of civil society.
This is a voluntary global plan of action designed to assure the sound management of
chemicals throughout their life cycle so that, by 2020, chemicals are used and
produced in ways that minimize significant adverse effects on human health and the
environment. The SAICM addresses both agricultural and industrial chemicals, covers
all stages of the chemical life cycle of manufacture, use and disposal, and includes
chemicals in products and in wastes.
Plastic waste
11. Plastic has been part of life for more than 100 years and is regularly used in some form
by nearly everyone. While some biodegradable varieties are being developed, most
plastics break down very slowly with the decomposition process taking hundreds of
years. This means that most plastics that have ever been manufactured are still on
Earth, unless they have been burnt, thus polluting the atmosphere with poisonous
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S-2010-01-2018 ⏐ World Medical Association
smoke.
12. Concerns about the use of plastic include accumulation of waste in landfills and in
natural habitats, terrestrial and marine, physical problems for wildlife resulting from
ingestion or entanglement in plastic, the leaching of chemicals from plastic products
and the potential for plastics to transfer chemicals to wildlife and humans. Many
plastics in use today are halogenated plastics or contain other additives used in
production, that have potentially harmful effects on health (e.g. carcinogenic or
promoting endocrine disruption).
13. Our current usage of plastic is not sustainable, accumulating waste and therefore
contributing to environmental degradation and potentially harmful effects on health.
Specific regulation is therefore needed to counter the harmful distribution of slowly
degradable plastic waste into the environment and the incineration of such waste
which often creates toxic byproducts.
WORLD MEDICAL ASSOCIATION (WMA) RECOMMENDATIONS
14. Despite national and international initiatives, chemical contamination of the
environment due to inadequately controlled production and usage continues to exert
harmful effects on global public health. Evidence linking some chemicals to some
health issues is strong, but far from all chemicals have been tested for their health or
environmental impacts. This is especially true for newer chemicals or nano materials,
particularly at low doses over long periods of time. Plastic contamination of our
natural environment, including in the sea where plastic decomposes to minute
particles, is an additional area of serious concern. Physicians and the healthcare sector
are frequently required to make decisions concerning individual patients and the public
as a whole based on existing data. Physicians therefore recognize that they, too, have a
significant role to play in closing the gap between policy formation and chemicals
management and in reducing risks to human health.
15. The World Medical Association reaffirms its commitment to advocate for the
environment in order to protect health and life, and recommends that:
ADVOCACY
16. National Medical Associations (NMAs) advocate for legislation that reduces chemical
pollution, enhances the responsibilities of chemical manufacturers, reduces human
exposure to chemicals, detects and monitors harmful chemicals in both humans and
the environment, and mitigates the health effects of toxic exposures with special
attention to fertility for women and men and vulnerability during pregnancy and early
childhood.
17. NMAs urge their governments to support international efforts to restrict chemical
pollution through safe management, or phase out and safer substitution when
unmanageable (e.g. asbestos), with particular attention to developed countries aiding
developing countries to achieve a safe environment and good health for all.
18. NMAs facilitate better inter-sectoral collaboration between government
ministries/departments responsible for the environment and public health.
19. NMAs promote public awareness about hazards associated with chemicals (including
plastics) and what can be done about it.
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Environmental Degradation
20. Modern medical diagnosis and treatment relies heavily on the single use of packaged
clean or sterile materials with various plastic components, whether the device itself or
its packaging. NMAs should encourage research and the dissemination of practices
that can reduce or eliminate this component of environmental degradation.
21. Physicians and their medical associations advocate for environmental protection,
disclosure of product constituents, sustainable development, green chemistry and
green hospitals within their communities, countries and regions.
22. Physicians and their medical associations should support the phase out of mercury and
persistent bioaccumulative and toxic chemicals in health care devices and products and
avoid incineration of wastes from these products which may create further toxic
pollution.
23. Physicians and their medical associations should support the Globally Harmonized
System of Classification and Labelling of Chemicals (GHS) and legislation to require
an environmental and health impact assessment prior to the introduction of a new
chemical or a new industrial facility.
24. Physicians should encourage the publication of evidence of the effects of different
chemicals and plastics, and dosages on human health and the environment. These
publications should be accessible internationally and readily available to media, non-
governmental organizations (NGOs) and concerned citizens locally.
25. Physicians and their medical associations should advocate for the development of
effective and safe systems to collect and dispose of pharmaceuticals that are not
consumed. They should also advocate for the introduction worldwide of efficient
systems to collect and dispose of plastic waste.
26. Physicians and their medical associations should encourage efforts to curb the
manufacture and use of plastic packaging and plastic bags, to halt the introduction of
plastic waste into the environment, and to phase out and replace plastics with more
biocompatible materials. These efforts may include measures to enhance recycling and
specific regulations limiting the use of plastic packaging and plastic bags.
27. Physicians and their medical associations should support efforts to rehabilitate or clean
areas of environmental degradation based on a “polluter pays” and precautionary
principles and ensure that moving forward, such principles are built into legislation.
28. The WMA, NMAs and physicians should urge governments to collaborate within and
between departments to ensure coherent regulations are developed.
LEADERSHIP
The WMA:
29. Supports the goals of the Strategic Approach to International Chemicals Management
(SAICM), which promotes best practices in the handling of chemicals by utilizing
safer substitution, waste reduction, sustainable non-toxic building, recycling, as well as
safe and sustainable waste handling in the health care sector.
30. Cautions that these chemical practices must be coordinated with efforts to reduce
greenhouse gas emissions from health care and other sources to mitigate its
contribution to global warming.
31. Urges physicians, medical associations and countries to work collaboratively to
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S-2010-01-2018 ⏐ World Medical Association
develop systems for event alerts to ensure that health care systems and physicians are
aware of high-risk industrial accidents as they occur, and receive timely and accurate
information regarding the management of these emergencies.
32. Urges local, national and international organizations to focus on sustainable
production, safer substitution, green safe jobs, and consultation with the health care
community to ensure that damaging health impacts of development are anticipated and
minimized.
33. Emphasizes the importance of the safe disposal of pharmaceuticals as one aspect of
health care’s responsibility and the need for collaborative work in developing best
practice models to reduce this part of the chemical waste problem.
34. Encourages environmental classification of pharmaceuticals in order to stimulate
prescription of environmentally less harmful pharmaceuticals.
35. Encourages local, national and international efforts to reduce the use of plastic
packaging and plastic bags.
36. Encourages ongoing outcomes research on the impact of regulations and monitoring of
chemicals on human health and the environment.
The WMA recommends that Physicians:
37. Work to reduce toxic medical waste and exposures within their professional settings as
part of the World Health Professional Alliance’s campaign for Positive Practice
Environments.
38. Work to provide information on the health impacts associated with exposure to toxic
chemicals, how to reduce patient exposure to specific agents and encourage behaviors
that improve overall health.
39. Inform patients about the importance of safe disposal of pharmaceuticals that are not
consumed.
40. Work with others to help address the gaps in research regarding the environment and
health (i.e., patterns and burden of disease attributed to environmental degradation;
community and household impacts of industrial chemicals; the effects, including on
health, of distribution of plastic and of plastic waste into our natural environment; the
most vulnerable populations and protections for such populations).
PROFESSIONAL EDUCATION & CAPACITY BUILDING
The WMA recommends that:
41. Physicians and their professional associations assist in building professional and public
awareness of the importance of the environment and global chemical pollutants on
personal health.
42. NMAs develop tools for physicians to help assess their patients’ risk from chemical
exposures.
43. Physicians and their medical associations develop locally appropriate continuing
medical education on the clinical signs, diagnosis, treatment and prevention of
diseases that are introduced into communities as a result of chemical pollution and
exacerbated by climate change.
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Environmental Degradation
44. Environmental health and occupational medicine should become a core theme in
medical education. Medical schools should encourage the training of sufficient
specialists in environmental health and occupational medicine.
Handbook of WMA Policies
S-2010-02-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
VIOLENCE AGAINST WOMEN
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and amended by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Violence against women is a worldwide phenomenon and includes violence within the
family, within the community and violence perpetrated by or condoned by the state. Many
excuses are given for violence generally and specifically; in cultural and societal terms,
these include tradition, beliefs, customs, values and religion. Intimate partner violence,
rape, sexual abuse and harassment, intimidation at work or in education, modern slavery,
trafficking and forced prostitution, are all forms of violence condoned by some societies.
One extreme form of such violence is sexual violence used as a weapon of war (United
Nations Security Council Resolution 1820). Specific cultural practices that harm women,
including female genital mutilation, forced marriages, dowry attacks and so-called
“honour” killings are all practices that may occur within the family setting.
All human beings enjoy fundamental human rights. The examples listed above involve
denial of many of those rights, and each abuse can be examined against the Universal
Declaration of Human Rights, as well as the Convention on the Elimination of All Forms
of Discrimination against Women and the Protocol to Prevent, Suppress and Punish
Trafficking in Persons Especially Women and Children, supplementing the United
Nations Convention against Transnational Organized Crime (2000).
The denial of rights and the violence itself have health consequences to women. In
addition to the specific and direct physical and health consequences, the general way in
which women are treated can lead to an excess of mental health problems and increase of
suicidal behavior. The short and long-term mental health consequences of violence may
severely influence later wellbeing, enjoyment of life, function in society and the ability to
provide appropriate care for dependents. Lack of good nutritional opportunities can lead to
generations of women with poorer health, poorer growth and development. Denial of
educational opportunities leads to poorer health for all the family members since good
education of women is a major factor in the wellbeing of the family.
In addition to being unacceptable in and of itself, violence against women is also socially
and economically damaging to the family and to society. There are direct and indirect
economic consequences to violence against women that are far greater than the direct
health sector costs. Lack of economic independence, and of basic education, also mean
that women who survive abuse are more likely to be or to become dependent upon the
state or society and less able to support themselves and contribute to that society.
Cordoba ⏐ S-2010-02-2020
Violence against Women
Physicians have a unique insight into the combined effects of violence against women.
The holistic view from physicians can be used to influence society and politicians.
Gaining societal support for improving the rights, freedom and status of women is
essential.
This Statement alongside with other WMA key related policies, including the statements
on Female Genital Mutilation, Sex Selection and Female Foeticide, Medically-indicated
Termination of Pregnancy, Family Violence, Violence and Health, Child Abuse and
Neglect and on the Right of Rehabilitation of Victims of Torture, provide guidance to
WMA Constituent Members and physicians on ways to support women who are victims of
violence, and strive for eradicating violence against women.
RECOMMENDATIONS
The WMA:
1. Calls for zero tolerance for all forms of violence against women.
2. Asserts that violence against women is not only about physical, psychological and
sexual violence but includes neglect and abuses such as harmful cultural and
traditional practices and is a major public health issue as well as a social
determinant of health.
3. Recognizes the linkage between better education, other women’s rights and
societal health and wellbeing, and emphasizes that equality in civil liberties and
human rights are health-related issue.
4. Calls on WHO, other United Nations agencies and relevant actors at national and
international levels to accelerate actions towards ending discrimination and
violence against women.
5. Urges the governments to implement WHO’s Global Plan of Action to Strengthen
the Role of the Health System within a National Multisectoral Response to
Address Interpersonal Violence, in particular Against Women and Girls, and
Against Children.
6. Encourages the development of free educational materials online to provide
guidance to front line health care personnel on abuse and its effects, and on
prevention strategies.
National Medical Associations are urged to:
7. Use and promote the available educational materials on preventing and treating the
consequences of violence against women and act as advocates within their own
country.
8. Seek to ensure that physicians and other health care personnel are alerted on the
phenomenon of violence, its consequences, and the evidence on preventative
strategies that work, and place appropriate emphasis on this in undergraduate,
Handbook of WMA Policies
S-2010-02-2020 ⏐ World Medical Association
graduate and continuing education.
9. Recognise the importance of more complete reporting of violence and encourage
the development of education emphasising violence awareness and prevention.
10. Advocate for legislation against specific harmful practices including female
feticide, female genital mutilation, forced marriage, and corporal punishment.
11. Advocate for the criminalization of intimate partner violence as well as rape in all
circumstances including within marriage.
12. Advocate for the development of research data on the impact of violence and
neglect upon primary and secondary victims and upon society, and for increased
funding for such research.
13. Encourage medical journals to publish more of the research on the complex
interactions in this area, thus keeping it in the professions’ awareness and
contributing to the development of a solid research base and ongoing
documentation of types and incidence of violence.
14. Advocate for the national implementation of the Convention on the Elimination of
All Forms of Discrimination against Women (CEDAW).
Physicians are encouraged to:
15. Use the material developed for their education to better inform themselves about
the effects of violence and the successful strategies for prevention.
16. Treat and reverse, where possible, the complications and adverse effects of female
genital mutilation and refer the patient to social support services.
17. Oppose the publication or broadcast of victims’ names or addresses without the
explicit permission of the victim.
18. Assess risk of family violence in the context of taking a routine social history of a
patient.
19. Be alert to the association between alcohol or drug dependence among women and
a history of abuse.
20. Where appropriate, report suspected violence or ill-treatment against women to
relevant protection services and take the necessary measures to ensure that victims
of violence are not at risk.
21. Support global and local action to better understand the health consequences both
of violence and of the denial of rights, and advocate for increased services for
victims.
Handbook of WMA Policies
World Medical Association S-2011-01-2022
WMA STATEMENT
ON
THE GLOBAL BURDEN OF CHRONIC NON-COMMUNICABLE DISEASE
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Chronic non-communicable diseases (NCDs), are the leading cause of mortality and disability
in both the developed and developing world. The four main NCDs are cancers, cardiovascular
diseases, chronic respiratory diseases, and diabetes (referred to as NCD4 hereafter) and they
account for seven of every ten deaths worldwide. Eighty per cent of deaths due to NCDs occur
in low- and middle-income countries (WHO).
NCD4 are not replacing existing causes of disease and disability, such as infectious disease and
trauma, but are adding to the disease burden. While all countries face the triple burden of
infectious diseases, traumas and chronic diseases, it is a much more difficult challenge for
developing countries. This increased burden is straining the capacity of many countries to
provide adequate healthcare services as well as increase life expectancy.
Chronic diseases are not equally distributed, which has a significant effect on health
inequalities. For example, NCDs occur more frequently among socioeconomically
underprivileged individuals with inferior chronic disease outcomes. Conversely, life
expectancy and other health outcomes are markedly higher in more developed countries than
in less developed countries, and in the higher socio-economic segments of society.
In addition, this burden is also undermining nations’ efforts to spur economic growth. NCDs
are a barrier to development. In low- and middle-income countries (LMICs), poverty exposes
people to lifestyle-mediated risk factors for NCDs and in turn, resulting NCDs become an
important driver for poverty. Chronic diseases and poverty are linked in a vicious circle,
hindering economic development and worsening poverty.
Ongoing and anticipated global trends that will lead to more chronic disease problems in the
future include an aging population, urbanization and inadequate community planning,
increasingly sedentary lifestyles, increasing psychosocial stress, climate change and the rapidly
increasing cost of medical technology to treat NCDs. Chronic disease prevalence is closely
linked to global social and economic development, globalization and mass marketing of
unhealthy foods and other products.
Chronic Disease
Berlin S-2011-01-2022
The prevalence and cost of addressing the chronic disease burden is expected to rise in coming
years. In addition to the individual and public expenses, chronic diseases lead to a marked
economic burden because of the mutual effects of healthcare costs and lost productivity from
disability and death. The WHO considers the global burden of chronic diseases as one of the
most important challenges facing the field of health for this century.
The rapid increase in chronic diseases represents a major health challenge for global
development, for which immediate global action is needed.
Eighty percent of the global burden of chronic diseases affects LMICs, where most of the
world’s population lives. The impact of this devastating burden is constantly growing. Chronic
diseases and poverty are linked in a vicious circle, hindering economic development and
worsening poverty.
Solutions
The NCD4 merit global attention. The primary solution for these diseases is prevention.
Tobacco use, poor diet, physical inactivity and alcohol abuse are the four most common
modifiable risk factors for NCDs. Poor mental health has recently been included as an
additional risk factor for NCD. National policies that help people achieve healthy lifestyles and
behaviours are the foundation for all possible solutions.
Increased access to primary care combined with well-designed and affordable disease-control,
disease prevention and health promotion programs can greatly improve healthcare.
Partnerships of national ministries of health with institutions in developed countries may
overcome many barriers in the poorest settings. In addition, having health insurance improves
health outcomes. Conversely, in some countries the lack of health insurance hinders the
practice of preventive and primary care and is linked with adverse health outcomes. Uninsured
individuals may postpone pursuing assistance when ill or injured, and they are more likely to
be hospitalized for chronic illnesses such as diabetes or hypertension. Furthermore, children
without health insurance are less likely to receive immunizations, and regular primary care.
Medical education systems should become more socially accountable. The World Health
Organization (WHO) defines social accountability of medical schools as the obligation to direct
their education, research and service activities towards addressing the priority health concerns
of the community, region, or nation they have a mandate to serve. The priority health concerns
are to be identified jointly by governments, health care organizations, health professionals and
the public. There is an urgent need to adopt accreditation standards and norms that support
social accountability and community engagement. Educating physicians and other health care
professionals to deliver health care that is concordant with the needs of the population and the
resources of the country must be a primary consideration. Led by primary care physicians,
teams of physicians, nurses and community health workers will provide care that is driven by
the principles of quality, equity, relevance and effectiveness.
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World Medical Association S-2011-01-2022
Distributions of funds for health should be based on all individual nation needs. No nation can
accomplish positive NCD4 outcomes by tackling a single cause of death.
Strengthening the healthcare infrastructure, including training the primary healthcare team,
chronic disease surveillance, public health promotion campaigns, quality assurance and
establishment of national and local standards of care, is important in caring for the increasing
numbers of patients with NCD4. Most premature deaths due to NCDs are preventable;
however, in most developing countries health systems are inadequate, or unprepared to
appropriately act on NCDs.
One of the most important components of healthcare infrastructure is human resources; well-
trained and motivated health care professionals led by primary care physicians are crucial to
success. International aid and development programs need to move from “vertical focus” on
single diseases or objectives to a more sustainable and effective primary care health
infrastructure development.
RECOMMENDATIONS
Recalling its Statement on Hypertension and Cardiovascular Disease and its Declaration of
Oslo on Social Determinants of Health, the WMA calls on:
National Governments to:
1. Recognize the importance of socio-economic development for health and reduce
socioeconomic status disparities in income, education, and occupation;
2. Support global immunization strategies;
3. Support global tobacco and alcohol control strategies, as well as control strategies
addressing other forms of addiction, particularly drug use;
4. Promote healthy living and implement comprehensive, collaborative policies and strategies
at all relevant levels and divisions of government that support prevention and healthy
lifestyle behaviours;
5. Set aside a fixed percentage of the national budget for healthcare infrastructure
development and promotion of healthy lifestyles and invest in better management of
NCDs4 including detection, care and treatment;
6. Advocate for trade / commercial agreements that protect rather than undermine public
health;
7. Develop and execute global and national action strategies for mitigating the health effects
of climate change;
Chronic Disease
Berlin S-2011-01-2022
8. Promote research for prevention and treatment of NCDs, including research on
occupational health hazards leading to chronic diseases;
9. Promote access to good quality effective medicines to treat NCDs;
10. Develop monitoring and surveillance systems for NCDs and,
11. Reinforce primary health care, human resources and infrastructure.
Its Constituent Members to:
12. Increase physician, public and NGO awareness of optimal disease prevention behaviours;
13. Enhance skills and capacity to promote a team-based multidisciplinary approach to chronic
disease management;
14. Advocate for integration of NCD prevention and control strategies in government-wide
policies;
15. Promote high quality training and professional associations for more primary care
physicians and advocate for their equitable distribution;
16. Advocate for high quality readily accessible resources for continuing medical education
that is responsive to societal needs;
17. Support establishing evidence-based standards of care for NCDs;
18. Promote an environment of support for continuity of care for NCDs, including collaborative
efforts to encourage patient education and self-management;
19. Support strong public health infrastructure and,
20. Recognize and support the concept that addressing and acting on social determinants are
part of prevention and health care.
Medical Schools to:
21. Develop curriculum objectives that meet current societal needs;
22. Create primary care departments;
23. Provide community-oriented and community-based primary care training opportunities in
primary care specialties that allow students to become acquainted with the basic elements
of chronic care infrastructure and continuity of care;
24. Promote the use of interdisciplinary, interprofessional, intersectoral and other collaborative
training methodologies within primary and continuing education programs and,
Handbook of WMA Policies
World Medical Association S-2011-01-2022
25. Include instruction in chronic disease prevention, including nutrition and lifestyle
promotion counselling, in the general curriculum.
Individual Physicians to:
26. Work to create communities that promote healthy lifestyles and prevention behaviours;
27. Offer patients smoking cessation, weight control strategies, substance abuse counselling,
early screening, self-management education and support, nutritional counselling, and
ongoing coaching;
28. Inform patients about the dangers of illusory or insufficiently proven remedies or
procedures, and charlatanism practices;
29. Promote a team-based multidisciplinary and value-based approach to chronic disease
management;
30. Ensure continuity of care for patients with chronic disease;
31. Model healthy lifestyles by maintaining personal health;
32. Become community advocates for improved social determinants of health, equity in health
care and for best prevention methods and,
33. Work with parents and the community at large to ensure that parents have the best advice
on maintaining the health of their children.
Handbook of WMA Policies
World Medical Association S-2011-02-2021
WMA STATEMENT
ON
THE DEVELOPMENT OF A MONITORING AND REPORTING
MECHANISM TO PERMIT AUDIT OF ADHERENCE OF STATES TO THE
DECLARATION OF TOKYO
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
The WMA reaffirms its Declaration of Tokyo establishing guidelines for physicians concerning
torture and other cruel, inhuman or degrading treatment or punishment in relation to detention
and imprisonment, and recommends that a monitoring and reporting mechanism be established
to permit audit of adherence of States to the terms of the said declaration, in particular:
1. Where physicians are working in situations of dual loyalties, support must be offered to
ensure they are not put in positions that might lead to violations of fundamental
professional ethics, whether by active breaches of medical ethics or omission of ethical
conduct, and/or of human rights, as laid out in the Declaration of Tokyo.
2. Its constituent members should offer support for physicians in difficult situations,
including, as feasible and without endangering either patients or doctors, helping
individuals to report violations of patients’ health rights and physicians’ professional ethics
in custodial settings. The support given must adhere to the principles put forward in the
WMA Resolution on the Responsibility of Physicians in the Documentation and
Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment.
3. The WMA should review the evidence available of the violation of human rights codes by
states and/or the forcing of physicians to violate the Declaration of Tokyo and refer as
appropriate such cases to the relevant national and international authorities.
4. The WMA should encourage its member associations to investigate accusations of
physician involvement in torture and similar abuses of human rights reported to it from
reputable sources, and to report back in particular on whether physicians are at risk and in
need of support.
5. The WMA should provide support to its constituent members and their individual
physicians members to resist such violations, and as far as realistically possible, stand firm
in their ethical convictions. The medical profession and governments should also protect
physicians endangered because they adhere to their professional and ethical obligations.
Monitoring Tokyo Declaration
London S-2011-02-2021
6. The WMA shall encourage and support its member associations in their calls for
investigations by the relevant United Nations special rapporteur or any other standard and
reliable accountability mechanism in place when valid concerns are raised.
Handbook of WMA Policies
World Medical Association S-2011-05-2022
WMA STATEMENT
ON
THE PROFESSIONAL AND ETHICAL USE OF SOCIAL MEDIA
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
DEFINITION
Social media is a collective term for the different interactive platforms, websites and
applications intended for digital networking, that allow individuals and organizations to create
and share user-generated content digitally.
The objectives of this policy are to:
• Examine the professional and ethical challenges related to the increasing usage of social
media by physicians, medical students, and patients.
• Establish a framework that protects their respective interests.
• Ensure trust and reputation by maintaining high professional and ethical standards.
• Promote the availability of quality information across social media.
• Stand against misinformation and disinformation on social media.
The use of social media has become a fact of life for billions of people worldwide including
physicians, medical students, and patients.
Interactive, collaborative tools such as wikis, social networking platforms, chat applications
and blogs have transformed passive Internet users into active participants. These tools are
means for gathering, sharing and disseminating information, including healthcare and science
information, socializing and connecting with friends, relatives, professionals etc. They can be
used to seek medical advice, and patients share their health and healthcare experiences. They
can also be used in research, public health, and education.
The positive aspects of social media should be recognized such as in promoting a healthy
lifestyle, the dissemination of medical knowledge to society and in reducing patients’ isolation.
Areas, which may require special attention include:
• Sensitive content, photographs, videos, other personal materials posted on online social
forums often exist in the public domain and have the capacity to remain on the internet
permanently. Individuals may not have control over the ultimate distribution of material
they post on-line.
Social Media
Berlin S-2011-05-2022
• Patient portal, blogs and tweets are not a substitute for one on one consultation with
physicians but may widen engagement with health services amongst certain groups.
Online “friendships” with patients may also alter the patient-physician relationship, and
may result in unnecessary, possibly problematic physician and patient self-disclosure.
• Each party’s privacy may be compromised in the absence of adequate and conservative
privacy settings or by their inappropriate use. Privacy settings are not absolute; social
media sites may change default privacy settings unilaterally, without the user’s
knowledge. Social media sites may also make communications available to third
parties.
• Misinformation and disinformation often spread more rapidly through social media
than fact-based accurate information. It may cause harm to the health of individuals as
well as to public health and foster doubt and distrust towards professionals seeking to
promote truth and science-based evidence.
• Appropriate disclaimers to include in biographical information (e.g., “my opinions are
my own”, “posts are not personalized medical advice”, etc).
The dissemination of medical knowledge, best practices and treatment options on social media
can increase and expedite access to new and valid information among medical professionals.
However, individuals or companies can take advantage of these channels in misleading ways,
including to market or promote their medical products or treatments.
RECOMMENDATIONS
The WMA urges National Medical Associations (NMA) to establish social media guidelines
for their members addressing the following objectives:
1. To maintain appropriate boundaries of the patient-physician relationship in accordance
with professional ethical guidelines just as they would in any other context.
2. To ensure that no identifiable patient information is posted in any social media by their
physician, by increasing the understanding of privacy provisions of social networking sites
and their limitations while considering intended audience and the technical feasibility to
restrict access to the content to predefined individuals or groups.
3. To exercise care when using applications that might compromise the security of the data,
including when consulting with colleagues.
4. To promote and apply the principles in the WMA Guidelines on Promotional Mass Media
Appearances by Physicians to all social media activities by physicians.
5. To encourage physicians to routinely monitor their own Internet presence to ensure that the
personal and professional information on their own sites and, to the extent possible, content
posted about them by others is accurate and appropriate.
Handbook of WMA Policies
World Medical Association S-2011-05-2022
6. To prevent the use of technological devices from diverting our attention during direct
consultation with the patient.
7. To provide factual, concise, understandable information, declare any conflicts of interest
and adopt a sober tone when discussing professional matters.
8. To avoid inappropriate use of the networks, frivolous, insensitive attitudes or light-hearted
opinions on medical matters.
9. To draw the attention of physicians to the fact that social media content posted by health
professionals may contribute to the public perception of the profession and should be done
in accordance with the principles in the WMA Declaration of Geneva and the International
Code of Medical Ethics.
10. To include education on the use of social media in medical curricula and continuing medical
education.
11. To behave in the media and on social networks with the same scientific rigor and the same
approach as in a consultation and show the same respect to patients and colleagues.
12. To create mechanisms for accountability in professional settings when inappropriate
behavior on social media is observed and reported.
13. To promote health literacy and knowledge among populations and with individual patients
by using objective and evidence based messages in accordance with the principles in the
WMA Declaration of Geneva, the WMA International Code of Medical Ethics, and the
WMA Statement on Healthcare Information for All.
14. To combat misinformation, disinformation, and the promotion of pseudoscience and
pseudotherapy on social media, all of which can result in negative health outcomes for
patients and communities.
15. To counsel fellow physicians who engage in misinformation, disinformation, or violation
of patient trust on social media and/or report to relevant authorities for ongoing deliberate
acts of the same.
16. To raise awareness among physicians and medical students about the possibility that
information shared on social media could be used in misleading ways by individuals or
companies.
Handbook of WMA Policies
World Medical Association ⏐ S-2012-01-2012
WMA STATEMENT
ON
ELECTRONIC CIGARETTES AND
OTHER ELECTRONIC NICOTINE DELIVERY SYSTEMS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
INTRODUCTION
Electronic cigarettes (e-cigarettes) are products designed to deliver nicotine to a user in the
form of a vapor. They are usually composed of a rechargeable battery-operated heating
element, a replaceable cartridge that contains nicotine and/or other chemicals, and an
atomizer that, when heated, turns the contents of the cartridge into a vapor (not smoke).
This vapor is then inhaled by the user. These products are often made to look like other
tobacco-derived products like cigarettes, cigars, and pipes. They can also be made to look
like everyday items such as pens and USB memory sticks.
No standard definition of e-cigarettes exists and different manufacturers use different
designs and different ingredients. Quality control processes used to manufacture these
products are substandard or non-existent. Few studies have been done to analyze the level
of nicotine delivered to the user and the composition of the vapor produced.
Manufacturers and marketers of e-cigarettes often claim that use of their products is a safe
alternative to smoking, particularly since they do not produce carcinogenic smoke.
However, no studies have been conducted to determine that the vapor is not carcinogenic,
and there are other potential risks associated with these devices: Appeal to children,
especially when flavors like strawberry or chocolate are added to the cartridges. E-
cigarettes can increase nicotine addiction among young people and their use may lead to
experimenting with other tobacco products.
Manufacturers and distributors mislead people into believing these devices are acceptable
alternatives to scientifically proven cessation techniques, thus delaying actual smoking
cessation. E-cigarettes are not comparable to scientifically-proven methods of smoking
cessation. Their dosage, manufacture, and ingredients are not consistent or clearly la-
belled. Brand stretching by using known cigarette logos is to be deplored.
Unknown amounts of nicotine are delivered to the user, and the level of absorption is
unclear, leading to potentially toxic levels of nicotine in the system. These products may
also contain other ingredients toxic to humans.
High potential of toxic exposure to nicotine by children, either by ingestion or dermal
absorption, because the nicotine cartridges and refill liquid are readily available over the
Internet and are not sold in child resistant packaging.
S-2012-01-2012 ⏐ Bangkok
Electronic Cigarettes
Due to the lack of rigorous chemical and animal studies, as well as clinical trials on com-
mercially available e-cigarettes, neither their value as therapeutic aids for smoking ces-
sation nor their safety as cigarette replacements is established. Lack of product testing
does not permit the conclusion that e-cigarettes do not produce any harmful products even
if they produce fewer dangerous substances than conventional cigarettes.
Clinical testing, large population studies and full analyses of e-cigarette ingredients and
manufacturing processes need to be conducted before their safety, viability and impacts
can be determined as either clinical tools or as widely available effective alternatives to
tobacco use.
RECOMMENDATIONS
That the manufacture and sale of e-cigarettes and other electronic nicotine delivery sys-
tems be subject to national regulatory bodies prior approval based on testing and research
as either a new form of tobacco product or as a drug delivery device.
That the marketing of e-cigarettes and other electronic nicotine delivery systems as a valid
method for smoking cessation must be based on evidence and must be approved by ap-
propriate regulatory bodies based on safety and efficacy data.
That e-cigarettes and other electronic nicotine delivery systems be included in smoke free
laws.
Physicians should inform their patients of the risks of using e-cigarettes even if regulatory
authorities have not taken a position on the efficacy and safety of these products.
Handbook of WMA Policies
World Medical Association S-2012-02-2022
WMA STATEMENT
ON
THE ETHICAL IMPLICATIONS OF COLLECTIVE ACTION BY PHYSICIANS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed with minor revisions by the 221st
WMA Council Session, Berlin, Germany,
October 2022
PREAMBLE
In recent years, in countries where physicians’ satisfaction with their working conditions has
decreased, collective action by physicians to advocate for better conditions has become
increasingly common.
Physicians may carry out protests and sanctions, including collective resignations, in order to
improve direct and indirect working conditions and to ensure safe and resilient health care
systems. Physicians must consider not only their duty to individual patients, but also their
responsibility to improve the system, such that it meets the requirements of accessibility and
quality.
In addition to their professional obligations, physicians are often also employees. There may
be tension between physicians’ duty not to cause harm, and their rights as employees.
Therefore, physicians’ strikes or other forms of collective action often give rise to public debate
on ethical and moral issues. This statement attempts to address these issues.
RECOMMENDATIONS
The World Medical Association recommends that Constituent Members adopt the following
guidelines for physicians with regard to collective action:
1. Physicians who take part in collective action are not exempt from their ethical or
professional obligations to patients.
2. Even when the action taken is not organized by or associated with the Constituent Member,
the Constituent Member should ensure that the individual physician is aware of and abides
by their ethical obligations.
3. Whenever possible, physicians should press for reforms through non-violent public
demonstrations, lobbying and publicity or informational campaigns, and/or through
negotiation or mediation.
Collective Action by Physicians
Berlin S-2012-02-2022
4. If involved in collective action, Constituent Members should act to minimize the harm to
the public and ensure that essential and emergency health services, and the continuity of
care, are provided throughout a strike. Further, Constituents Members should advocate for
measures to review exceptional cases. If involved in collective action, Constituent
Members should provide continuous and up-to-date information to their patients and the
general public with regard to the demands of the conflict and the actions being undertaken.
The general public must be kept informed in a timely manner about any strike actions and
the restrictions they may have on health care.
Handbook of WMA Policies
S-2012-03-2012 ⏐ World Medical Association
WMA STATEMENT
ON
FORCED AND COERCED STERILISATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
The WMA recognises that no person, regardless of gender, ethnicity, socio-economic
status, medical condition or disability, should be subjected to forced or coerced permanent
sterilisation.
A full range of contraceptive services, including sterilisation, should be accessible and
affordable to every individual. The state may have a role to play in ensuring that such ser-
vices are available, along with private, charitable and third sector organisations. The
decision to undergo contraception, including sterilisation, must be the sole decision of the
individual concerned.
As with all other medical treatments, sterilisation should only be performed on a com-
petent patient after an informed choice has been made and the free and valid consent of the
individual has been obtained. Where a patient is incompetent, a valid decision about treat-
ment must be made in accordance with relevant legal requirements and the ethical
standards of the WMA before the procedure is carried out. Sterilization of those unable to
give consent would be extremely rare and done only with the consent of the surrogate
decision maker.
Such consent should be obtained when the patient is not facing a medical emergency, or
other major stressor.
The WMA condemns practices where a state or any other actor attempts to bypass ethical
requirements necessary for obtaining free and valid consent.
Consent to sterilisation should be free from material or social incentives which might
distort freedom of choice and should not be a condition of other medical care (including
safe abortion), social, insurance, institutional or other benefits.
The WMA calls on national medical associations to advocate against forced and coerced
sterilisation in their own countries and globally.
Handbook of WMA Policies
World Medical Association ⏐ S-2012-04-2017
WMA STATEMENT
ON
ORGAN AND TISSUE DONATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
• Advances in medical sciences, especially surgical techniques, tissue typing and
immuno-suppressive drugs, have made possible a significant increase in the rates of
successful transplantation of human organs and tissue. Yet, in all countries, a shortage
of organ donors results in potentially avoidable loss of life. National medical
associations should support attempts to maximise the number of donor organs
available in their countries and to ensure that the highest ethical standards are
maintained. The World Medical Association has developed this policy to assist
medical associations, physicians, other health care providers and policy makers to
achieve this.
This policy is based on a number of core ethical principles: altruism, autonomy,
beneficence, equity and justice. These principles should guide those developing
national policies and those operating within it, both in relation to organ procurement
and to the distribution and transplantation of donor organs. All systems and processes
should be transparent and open to scrutiny.
This statement applies to organ and tissue donation from both deceased and living
donors. It does not apply to blood donation.
RAISING PUBLIC AWARENESS
• It is important that individuals are aware of the option of donation and have the
opportunity to choose whether or not to donate organs and/or tissue before and after
their death. Awareness and choice should be facilitated in a coordinated multi-faceted
approach by a variety of stakeholders and means, including media awareness and
public campaigns. In designing such campaigns account needs to be taken of any
religious or cultural sensitivities of the target audience.
• Through awareness raising campaigns, individuals should be informed of the benefits
of transplantation, the impact on the lives of those who are waiting for a transplant and
the shortage of donors available. They should be encouraged to think about their own
wishes about donation, to discuss their wishes with their family and friends and to use
established mechanisms to formally record them by opting into, or out of, donation.
• The WMA advocates informed donor choice. National medical associations in
S-2012-04-2017 ⏐ Chicago
Organ and Tissue Donation
countries that have adopted or are considering a policy of “presumed consent” (or opt-
out), in which there is an assumption that the individual wishes to donate unless there
is evidence to the contrary, or “mandated choice”, in which all persons would be
required to declare whether they wish to donate, should make every effort to ensure
that these policies have been adequately publicised and do not diminish informed
donor choice, including the patient’s right not to donate.
• Consideration should be given to the establishment of national donor registries to
collect and maintain a list of citizens who have chosen either to donate or not to donate
their organs and/or tissue. Any such registry must protect individual privacy and the
individual’s ability to control the collection, use, disclosure of, and access to, his or
her health information for other purposes. Provisions must be in place to ensure that
the decision to sign up to a register is adequately informed and that registrants can
withdraw from the registry easily and quickly and without prejudice.
• Living organ donation is becoming an increasingly important component of
transplantation programmes in many countries. Most living donation is between
related or emotionally close individuals and small but increasing numbers are donating
to people they do not know. Given that there are health risks associated with living
organ donation, proper controls and safeguards are essential. Information aimed at
informing people about the possibility of donating organs as a living donor should be
carefully designed so as not to put pressure on them to donate and to minimise the risk
of financial or other coercion. Potential donors should know where to obtain detailed
information about what is involved, should be informed of the inherent risks and
should know that there are safeguards in place to protect those offering to donate.
PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM DECEASED DONORS
• The WMA encourages its members to support the development of comprehensive,
coordinated national protocols for deceased (also referred to as cadaveric) organ and
tissue procurement in consultation and cooperation with all relevant stakeholders.
Ethical, cultural and societal issues arising in connection with donation and
transplantation should be resolved, wherever possible, in an open process involving
public debate informed by sound evidence.
• National and local protocols should provide detailed information about the
identification, referral and management of potential donors as well as communication
with those close to people who have died. They should encourage the procurement of
organs and tissues consistent with this statement. Protocols should uphold the
following key principles:
• Decisions to withhold or withdraw life-prolonging treatment should be based on an
assessment of whether the treatment is able to benefit the patient. Such decisions
must be, and must be seen to be, completely separate from any decisions about
donation.
• The diagnosis of death should be made according to national guidelines and as
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outlined in the WMA’s Declaration of Sydney on the Determination of Death and
Recovery of Organs.
• There should be a clear separation between the treating team and the transplant
team. In particular, the physician who declares or certifies the death of a potential
donor should not be involved in the transplantation procedure. Nor should he/she
be responsible for the care of the organ recipient.
• Countries that carry out donation following circulatory/cardiac death should have
specific and detailed protocols for this practice.
• Where an individual has expressed a clear and voluntary wish to donate organs
and/or tissue after death, steps should be taken to facilitate that wish wherever
possible. This is part of the treating team’s responsibility to the dying patient.
• The WMA considers that the potential donor’s wishes are paramount. Relatives
and those close to the patient should be strongly encouraged to support a deceased
person’s previously expressed wish to donate organs and/or tissues. Whenever
possible, these conversations should occur prior to the death of the patient.
• Those charged with approaching the patient, family members or other designated
decision maker about organ and tissue donation should possess the appropriate
combination of knowledge, skill and sensitivity for engaging in such discussions.
Medical students and practising physicians should seek the necessary training for
this task, and the appropriate authorities should provide the resources necessary to
secure that training.
• Donation must be unconditional. In exceptional cases, requests by potential
donors, or their substitute decision makers, for the organ or tissue to be given to a
particular recipient may be considered if permitted by national law. Donors
seeking to apply conditions that could be seen as discriminatory against certain
groups, however, should be declined.
• Hospitals and other institutions where donation occurs should ensure that donation
protocols are publicised amongst those likely to use them and that adequate resources
are available for their implementation. They should also foster a pro-donation culture
within the institution in which consideration of donation is the norm, rather than the
exception, when a patient dies.
• The role of transplant coordination is critical to organ donation. Those performing
coordination act as the key point of contact between the bereaved family and the
donation team and usually also undertake the complex logistical arrangements to make
donation happen. Their role must be recognised and supported.
• Deceased organ donation must be based on the notion of a gift, freely and voluntarily
given. It should involve the voluntary and unpressured consent of the individual
provided before death (by opting in or opting out of donation depending upon the
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Organ and Tissue Donation
jurisdiction) or the voluntary authorisation of those close to the deceased patient if that
person’s wishes are unknown. The WMA is strongly opposed to the commercialisation
of donation and transplantation.
• Prospective donors or their substitute health care decision makers should have access
to accurate and relevant information, including through their general practitioners.
Normally, this will include information about:
• the procedures and definitions involved in the determination of death,
• the testing that is undertaken to determine the suitability of the organs and/or tissue
for transplantation and that this may reveal previously unsuspected health risks in
prospective donors and their families,
• measures that may be required to preserve organ function until death is determined
and transplantation can occur,
• what will happen to the body once death has been declared,
• what organs and tissues can be donated,
• The protocol that will be followed in the event that the family objects to donation,
and
• the possibility of withdrawing consent.
• Prospective donors or their substitute health care decision makers should be given the
opportunity to ask questions about donation and should have their questions answered
sensitively and intelligibly.
• Where both organs and tissues are to be donated, information should be provided, and
consent obtained, for both together in order to minimise distress and disruption to
those close to the deceased.
• In some parts of the world a contribution towards funeral costs is given to the family
of those who donate. This can be viewed either as appropriate recognition of their
altruistic act or as a payment that compromises the voluntariness of the choice and the
altruistic basis for donation. The interpretation may depend, in part, on the way it is set
up and managed. When considering the introduction of such a system, care needs to
be taken to ensure that the core principles of altruism, autonomy, beneficence, equity
and justice are met.
• Free and informed decision making requires not only the provision of information but
also the absence of coercion. Any concerns about pressure or coercion must be
resolved before the decision to donate organs or tissue is made.
• Prisoners and other people who are effectively detained in institutions should be
eligible to donate after death where checks have been made to ensure that donation is
in line with the individual’s prior, un-coerced wishes and, where the individual is
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incapable of giving consent, authorisation has been provided by a family member or
other authorized decision-maker. Such authorisation may not override advance
withholding or refusal of consent.
• Their death is from natural causes and this is verifiable.
• In jurisdictions where the death penalty is practised, executed prisoners must not be
considered as organ and/or tissue donors. While there may be individual cases where
prisoners are acting voluntarily and free from pressure, it is impossible to put in place
adequate safeguards to protect against coercion in all cases.
ALLOCATION OF ORGANS FROM DECEASED DONORS
• The WMA considers there should be explicit policies, open to public scrutiny,
governing all aspects of organ and tissue donation and transplantation, including the
management of waiting lists for organs to ensure fair and appropriate access.
• Policies governing the management of waiting lists should ensure efficiency and
fairness. Criteria that should be considered in allocating organs or tissue include:
• Severity and urgency of medical need,
• Length of time on the waiting list,
• Medical probability of success measured by such factors as age, type of disease,
likely improvements in quality of life, other complications, and histocompatibility.
• There must be no discrimination based on social status, lifestyle or behaviour. Non-
medical criteria must not be considered.
PROTOCOLS FOR ORGAN AND TISSUE DONATION FROM LIVING DONORS
• Living donation is becoming increasingly common as a way to overcome the shortage
of organs from deceased donors. In most cases donors provide organs to relatives or
people to whom they are emotionally close. A small number of individuals choose to
donate an organ altruistically to a stranger. Another scenario is where one or more
donor and recipient pairs are incompatible with each other but donate in the form of a
cross-over or pooled donation system (for example, donor A donates to recipient B,
donor B donates to recipient C and donor C donates to recipient A).
• All potential donors should be given accurate and up to date information about the
procedure and the risks of donation and have the opportunity to discuss the issue
privately with a member of the healthcare team or a counsellor. Normally this
information will include:
• The risks of becoming a living donor,
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Organ and Tissue Donation
• The tests that are undertaken to assess suitability for donation and that this may
reveal previously unsuspected health problems,
• What will happen before, during and after donation takes place, and
• In the case of solid organs, the long-term implications of living without the
donated organ.
• Prospective donors should be given the opportunity to ask questions about donation
and should have their questions answered sensitively and intelligibly.
• Procedures should be in place to ensure that living donors are acting voluntarily and
free from pressure or coercion. In order to avoid donors being paid and then posing as
a known donor, independent checks should also be undertaken to verify the claimed
relationship and, where this cannot be proven, the donation should not proceed. Such
checks should be independent of the transplant team and those who are caring for the
potential recipient.
• Additional safeguards should be in place for vulnerable donors, including but not
limited to, people who are dependent in some way (such as competent minors donating
to a parent or sibling).
• Prisoners should be eligible to be living donors only in exceptional circumstances, to
first or second degree family members; evidence should be provided of any claimed
relationship before the donation may proceed. Where prisoners are to be considered as
living donors, extra safeguards are required to ensure they are acting voluntarily and
are not subject to coercion.
• Those who lack the capacity to consent should not be considered as living organ
donors because of their inability to understand and decide voluntarily. Exceptions may
be made in very limited circumstances, following legal and ethical review.
• Donors should not lose out financially as a result of their donation and so should be
reimbursed for general and medical expenses and any loss of earnings incurred.
• In some parts of the world individuals are paid for donating a kidney, although in
virtually all countries the sale of organs is unlawful. The WMA is strongly opposed to
a market in organs.
PROTOCOLS FOR RECIPIENTS
• Protocols for free and informed decision making should be followed in the case of
recipients of organs or tissue. Normally, this will include providing information about:
The risks of the procedure,
The likely short, medium and long-term survival, morbidity, and quality-of-life
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prospects,
Alternatives to transplantation, and
How organs and tissues are obtained.
• In the case of a delayed diagnosis for infection, disease or malignancy in the donor,
there should be a strong presumption that the recipient will be informed of any risk to
which they may have been exposed. Individual decisions about disclosure need to take
account of the particular circumstances, including the level and severity of risk. In
most cases disclosure will be appropriate and should be managed carefully and
sensitively.
COSTS AND ORIGIN OF ORGANS AND TISSUES
• Organs or tissue suspected to have been obtained through unlawful means must not be
accepted for transplantation.
• Organs and tissues must not be sold for profit. In calculating the cost of
transplantation, charges related to the organ or tissue itself should be restricted to those
costs directly associated with its retrieval, storage, allocation and transplantation.
• Transplant surgeons should seek to ensure that the organs and tissues they transplant
have been obtained in accordance with the provisions of this policy and should refrain
from transplanting organs and tissues that they know, or suspect, have not been
procured in a legal and ethical manner.
TRANSPARENCY AND ACCOUNTABILITY
• National Medical Associations should work with governments and relevant institutions
to ensure that appropriate, effective structures and processes are in place to:
1. support relevant traceability and follow-up of all transplant recipients and living
donors including those who require ongoing medical management receive care and
support;
2. record information on donation and transplantation rates and outcomes;
3. assess the short and long-term outcomes, quality, safety and efficacy of organ
donation and transplantation activities;
4. assess the adherence to ethical and clinical protocols of organ donation and
transplantation activities;
• The data arising from these activities should be publicly accessible and open to
scrutiny (notwithstanding appropriate protection of donor and recipient
confidentiality).
FUTURE OPTIONS
• Public health measures to reduce the demand for donated organs should be seen as a
priority, alongside initiatives to increase the effectiveness and success of organ
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Organ and Tissue Donation
donation systems.
• New developments and possibilities, such as xenotransplantation and the use of stem
cell technology to repair damaged organs, should be monitored. Before their
introduction into clinical practice such technologies should be subject to scientific
review and robust safety checks as well as ethical review. Where, as with
xenotransplantation, there are potential risks that go beyond individual recipients, this
process must also involve public debate.
Handbook of WMA Policies
S-2012-05-2019 ⏐ World Medical Association
WMA STATEMENT
ON
THE PRIORITISATION OF IMMUNISATION
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed by the 212th
WMA Council Session, Santiago, Chile, April 2019
PREAMBLE
Vaccination use to prevent against disease was first done successfully by Jenner in 1796
when he used cowpox material for vaccination against smallpox. Since then, vaccination
and immunisation have been acknowledged as an effective preventive strategy for several
communicable diseases and are now being developed for the control of some non-
communicable diseases.
Vaccine development and administration are some of the most significant interventions to
influence global health in modern times. It is estimated that immunisation currently
prevents approximately 2.5 million deaths every year, saving lives from diseases such as
diphtheria, tetanus, whooping cough (pertussis) and measles. Approximately 109 million
children under the age of one are fully vaccinated with the diphtheria-tetanus-pertussis
(DTP3) vaccine alone.
Mostly the ultimate goal of immunisation is the total eradication of a communicable
disease. This was achieved for smallpox in 1980 and there is a realistic goal for the
eradication of polio within the next few years.
The Global Immunisation Vision Strategy (GIVS) 2006-2015 was developed by the WHO
and UNICEF in the hope of reaching target populations who currently do not have
immunisation services or who do not have an adequate level of coverage.
The four strategies promoted in this vision are:
• Protecting more people in a changing world
• Introducing new vaccines and technologies
• Integrating immunisation, other linked health interventions and
• Surveillance in the health systems context
• Immunizing in the context of global interdependence [1]
Vaccine research is constantly revealing new possibilities to protect populations from
serious health threats. Additionally, new strains of diseases emerge requiring the
adaptation of vaccines in order to offer protection.
The process of immunisation requires an environment that is resourced with appropriate
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materials and health workers to ensure the safe and effective administration of vaccines.
Administration of vaccines often requires injections, and safety procedures for injections
must always be followed.
Immunisation schedules can vary according to the type of vaccine, with some requiring
multiple administrations to be effective. It is vitally important that the full schedule is
followed otherwise the effectiveness of the vaccine may be compromised.
The benefits of immunisation have had a profound effect on populations, not only in terms
of preventing ill health but also in permitting resources previously required to treat the
diseases to be redirected to other health priorities. Healthier populations are economically
beneficial and can contribute more to society.
Reducing child mortality is the fourth of the United Nation’s Millennium Development
Goals, with immunisation of children having a significant impact on mortality rates on
children aged under five. According to the WHO, there are still more than 19 million
children who have not received the DTP3 vaccine. In addition, basic health care services
for maternal health with qualified health care personnel must be established.
Immunisation of adults for diseases such as influenza and pneumococcal infections has
been shown to be effective, not only in decreasing the number of cases amongst those that
have received immunisation but also in decreasing the disease burden in society.
The medical profession denounce any claims that are unfounded and inaccurate with
respect to the possible dangers of vaccine administration. Claims such as these have
resulted in diminished immunisation rates in some countries. The result is that the
incidences of the diseases to be prevented have increased with serious consequences for a
number of persons.
Countries differ in immunisation priorities, with the prevalence and risk of diseases
varying among populations. Not all countries have the same coverage rates, nor do they
have the resources to acquire, coordinate, distribute or effectively administer vaccines to
their populations, often relying on non-governmental organizations to support
immunisation programmes. These organizations in turn often rely on external funding that
may not be secure. In times of global financial crisis, funding for such programmes is
under considerable pressure.
The risk of health complications from vaccine-preventable diseases is greatest in those
who experience barriers in accessing immunisation services. These barriers could be cost,
location, lack of awareness of immunisation services and their health benefits or other
limiting factors.
Those with chronic diseases, underlying health issues or other risk factors such as age are
at particular risk of major complications due to vaccine-preventable diseases and therefore
should be targeted to ensure adequate immunisation.
Supply chains can be difficult to secure, particularly in countries that lack coordination or
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Prioritisation of Immunisation
support of their immunisation programmes. Securing the appropriate resources, such as
qualified health professionals, equipment and administrative support can present
significant challenges.
Data collection on vaccine administration rates, side effects of vaccines and disease
surveillance can often be difficult to achieve, particularly in isolated and under-resourced
areas. Nevertheless, reporting incidents and monitoring disease spread are vital tools in
combating global health threats.
RECOMMENDATIONS
The WMA supports the recommendations of the Global Immunisation Vision Strategy
(GIVS) 2006-2015, and calls on the international community to:
• Encourage governments to commit resources to immunisation programmes targeted
to meet country specific needs.
• Recognise the importance of vaccination/immunisation through the continued
support and adoption of measures to achieve global vaccination targets and to meet
the Millennium Development Goals, especially four (reduce child mortality), five
(improve maternal health) and six (combat HIV/AIDS, malaria and other diseases).
• Recognise the global responsibility of immunisation against preventable diseases
and support work in countries that have difficulties in meeting the 2012 targets in
the Global Polio Eradication Initiative [2].
• Support national governments with vulnerable populations at risk of vaccine-
preventable diseases, and the local agencies that work to deliver immunisation
services and to work with them to alleviate retrictions in accessing services.
• Support vaccine research and development and ensure commitment through the
adequate funding of vital vaccine research.
• Promote vaccination and the benefits of immunisation, particularly targeting those
at-risk and those who are difficult to reach. Comply with monitoring activities
undertaken by WHO and other health authorities.Promote high standards in the
research, development and administration of vaccines to ensure patient safety.
Vaccines need to be thoroughly tested before implemented on a large scale and
subsequently monitored in order to identify possible complications and untoward
side effects. In order to be successful, immunisation programmes need public trust
which depends on safety.
In delivering vaccination programmes, the WMA recommends that:
• The full immunisation schedule is delivered to provide optimum coverage. Where
possible, the schedule should be managed and monitored by suitably trained
individuals to ensure consistent delivery and prompt appropriate management of
adverse reactions to vaccines.
• Strategies are employed to reach populations that may be isolated because of
location, race, religion, economic status, social marginalization, gender and/or age.
• Ensure that qualified health professionals receive comprehensive training to safely
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deliver vaccinations and immunisations, and that vaccination/immunisations are
targeted to those whose need is greatest.
• Educate people on the benefits of immunisation and how to access immunisation
services.
• Maintain accurate medical records to ensure that valid data on vaccine
administration and coverage rates are available, enabling immunisation policies to
be based upon sound and reliable evidence.
• Healthcare professionals should be seen as a priority population for the receipt of
immunisation services due to their exposure to patients and to diseases.
The WMA calls upon its members to advocate the following:
• To increase awareness of national immunisation schedules and of their own (and
their dependents) personal immunisation history.
• To work with national and local governments to ensure that immunisation
programmes are resourced and implemented.
• To ensure that health personnel delivering vaccines and immunisation services
receive proper education and training.
• To promote the evidence base and increase awareness about the benefits of
immunisation amongst physicians and the public.
References
[1] World Health Organization and United Nations Children’s Fund. Global Immunisation Vision
and Strategy, 2006-2015. Geneva, Switzerland: World Health Organization and United Nations
Children’s Fund; 2005. Available at:
http://www.who.int/immunisation/givs/related_docs/en/index.html
[2] World Health Organization. Global Polio Eradication Initiative: Strategic Plan 2010-2012.
Geneva, Switzerland: World Health Organization; 2010. Available at:
http://polioeradication.org/who-we-are/strategy/
Handbook of WMA Policies
S-2012-06-2012 ⏐ World Medical Association
WMA STATEMENT
ON
VIOLENCE IN THE HEALTH SECTOR BY PATIENTS AND
THOSE CLOSE TO THEM
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
PREAMBLE
All persons have the right to work in a safe environment without the threat of violence.
Workplace violence includes both physical and non-physical (psychological) violence.
Given that non-physical abuse, such as harassment and threats, can have severe psy-
chological consequences, a broad definition of workplace violence should be used. For
the purposes of this statement we will use the widely accepted definition of workplace
violence, as used by the WHO: “The intentional use of power, threatened or actual, against
another person or against a group, in work-related circumstances, that either results in or
has a high degree of likelihood of resulting in injury, death, psychological harm, mal-
development, or deprivation”.
Violence, apart from the numerous health effects it can have on its victims, also has
potentially destructive social effects. Violence against health workers, including physi-
cians, not only affects the individuals directly involved, but also impacts the entire health-
care system and its delivery. Such acts of violence affect the quality of the working
environment, which has the potential to detrimentally impact the quality of patient care.
Further, violence can affect the availability of care, particularly in impoverished areas.
While workplace violence is indisputably a global issue, various cultural differences
among countries must be taken into consideration in order to accurately understand the
concept of violence on a universal level. Significant differences exist in terms of what
constitutes violence and what specific forms of workplace violence are most likely to
occur. Threats and other forms of psychological violence are widely recognized to be
more prevalent than physical violence. Reasons and causes of violence in the healthcare
setting are extremely complex.
Several studies have identified common triggers for acts of violence in the health sector to
be delays in receiving treatment and dissatisfaction with the treatment provided1
.
Moreover, patients may act aggressively as a result of their medical condition, the medi-
cation they take or the use of alcohol and other drugs. Another important example is that
individuals may threaten or perpetrate physical violence against healthcare workers
because they oppose, on the basis of their social, political or religious beliefs, a specific
area of medical practice.
A multi-faceted approach encompassing the areas of legislation, security, data collection,
training, environmental factors, public awareness and financial incentives is required in
order to successfully address the issue of violence in the health sector.
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S-2012-06-2012 ⏐ World Medical Association
In addition, collaboration among various stakeholders (including governments, National
Medical Associations (NMAs), hospitals, general health services, management, insurance
companies, trainers, preceptors, researchers, police and legal authorities) is more effective
than the individual efforts of any one party. As the representatives of physicians, NMAs
should take an active role in combating violence in the health sector and also encourage
other key stakeholders to act, thus further protecting the quality of the working environ-
ment for healthcare employees and the quality of patient care.
This collaborative approach to addressing violence in the health sector must be promoted
throughout the world.
RECOMMENDATIONS
The WMA encourages National Medical Associations (NMAs) to act in the following areas:
Strategy – NMAs should encourage healthcare institutions to develop and implement a
protocol to deal with acts of violence. The protocol should include the following:
1. A zero-tolerance policy towards workplace violence.
2. A universal definition of workplace violence.
3. A predetermined plan for maintaining security in the workplace.
4. A designated plan of action for healthcare professionals to take when violence
takes place.
5. A system for reporting and recording acts of violence, which may include
reporting to legal and/or police authorities.
6. A means to ensure that employees who report violence do not face reprisals.
In order for this protocol to be effective, it is necessary for the management and admin-
istration of healthcare institutions to communicate and take the necessary steps to ensure
that all staff are aware of the strategy.
Policymaking – In order to help increase patient satisfaction, national priorities and limita-
tions on medical care should be clearly addressed by government institutions.
The state has obligations to ensure the safety and security of patients, physicians, and
other healthcare workers. This includes providing an appropriate physical environment.
Hence, healthcare systems should be designed to promote the safety of healthcare staff and
patients. An institution which has experienced an act of violence by a patient may require
the provision of extra security, as all healthcare workers have the right to be protected in
their work place.
In some jurisdictions, physicians might have the right to refuse to treat a violent patient.
In such cases, they must ensure that adequate alternative arrangements are made by the
relevant authorities in order to safeguard the patient’s health and treatment.
Patients with acute, chronic or illness-induced mental health disturbances may act
violently toward caregivers; those offering care to these patients must be adequately pro-
tected.
Training – A well-trained and vigilant staff supported by management can be a key
deterrent of violent acts. NMAs should work with undergraduate and postgraduate edu-
cation providers to ensure that healthcare professionals are trained in the following: com-
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Violence in the Health Sector
munication skills and recognising and handling potentially violent persons and high risk
situations in order to prevent incidents of violence. The cultivation of physician-patient
relationships based on respect and mutual trust will not only improve the quality of patient
care, but will also foster feelings of security resulting in a reduced risk of violence.
Communication – NMAs should work with other key stakeholders to increase awareness
of violence in the health sector. When appropriate, they should inform healthcare workers
and the public when acts of violence occur and encourage physicians to report acts of
violence through the appropriate channels.
Further, once an act of violence has taken place, the victim should be informed about the
procedures undertaken thereafter.
Support to victims – Medical, psychological and legal counselling and support should be
provided to staff members who have been the victims of threats and/or acts of violence
while at work.
Data Collection – NMAs should lobby their governments and/or hospital boards to
establish appropriate reporting systems enabling all healthcare workers to report anony-
mously and without reprisal, any threats or incidents of violence. Such a system should
assess in terms of number, type and severity, incidents of violence within an institution
and resulting injuries. The system should be used to analyse the effectiveness of pre-
ventative strategies. Aggregated data and analyses should be made available to NMAs.
Investigation – In all cases of violence there should be some form of investigation to
better understand the causes and to aid in prevention of future violence. In some cases, the
investigation may lead to prosecution under civil or criminal codes. The procedure should
be, as much as possible, authoritative-led and uncomplicated for the victim.
Security – NMAs should work to ensure that appropriate security measures are in place in
all healthcare institutions and that acts of violence in the healthcare sector are given a high
priority by law-enforcement institutions. A routine violence risk audit should be imple-
mented in order to identify which jobs and locations are at highest risk for violence.
Examples of high risk areas include general practice premises, mental health treatment
facilities and high traffic areas of hospitals including the emergency department.
The risk of violence may be ameliorated by a variety of means which could include
placing security guards in these high risk areas and at the entrance of buildings, by the
installation of security cameras and alarm devices for use by health professionals, and by
maintaining sufficient lighting in work areas, contributing to an environment conducive to
vigilance and safety.
Financial – NMAs should encourage their governments to allocate appropriate funds in
order to effectively tackle violence in the health sector.
1
Carmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence towards hospital-
and community- based physicians in the Negev: an observational study BMC Health Service
Research 2005; 5: 54
Derazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department
(Article in Hebrew) Harefuah. 1999 Aug; 137(3-4): 95-101, 175
Landua SF. Violence against medical and non-medical personnel in hospital emergency wards
in Israel Research Report, Submitted to the Israel National Institute for Health Policyand Health
Services Research, December 2004
Handbook of WMA Policies
World Medical Association S-2012-06-2022
WMA STATEMENT
ON
WORKPLACE VIOLENCE IN THE HEALTH SECTOR
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Violence in the health sector has increased substantially in the new millennium, especially in
time of COVID-19 pandemic. All persons have the right to work in a safe environment without
the threat of violence. Workplace violence includes both physical and non-physical, such as
(psychological) violence, intimidation and cyber harassment, among others.
Cyber and social media harassment particularly includes online threats and intimidation
towards physicians who take part in a public debate in order to give adequate information and
fight disinformation. These physicians are increasingly confronted with, amongst others,
malicious messages on social media, death threats and intimidating home visits.
For the purposes of this document, the broad WHO definition of workplace violence will be
used: “The intentional use of power, threatened or actual, against another person or against a
group, in work-related circumstances, that either results in or has a high degree of likelihood
of resulting in injury, death, psychological harm, mal-development, or deprivation”.
In addition to the numerous consequences on victims’ health, violence against health personnel
has potentially destructive social effects. It affects the entire healthcare system and undermines
the quality of the working environment, ultimately impacting the quality of patient care.
Furthermore, violence can affect the availability of health care, particularly in impoverished
areas.
While workplace violence is indisputably a global issue, various cultural differences among
countries must be taken into consideration in order to accurately understand the concept of
violence on a universal level. Significant differences exist in terms of what defines various
levels of violence and what specific forms of workplace violence are most likely to occur. This
may create tolerance for some levels of violence in those places. However, threats and other
forms of psychological violence are widely recognized to be more prevalent than physical
violence.
Causes of violence in the healthcare setting are extremely complex. Several studies have
identified common triggers for acts of violence by patients and relatives to be delays in
receiving treatment, dissatisfaction with the treatment provided, aggressive patient behavior
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caused by the patient’s medical condition, the medication they take or the use of alcohol and
other drugs. Additionally, individuals may threaten or perpetrate violence against health
personnel because they oppose a specific area of medical practice, based on their social,
political or religious beliefs. Cases of violence from the bystanders are reported as well. Co-
worker violence, such as bullying, including initiation ceremonies and practical jokes, or
harassment, constitutes another important pattern of workplace violence in the health sector.
Collaboration among various stakeholders (including governments, medical associations,
hospitals, general health services, management, insurance companies, trainers, preceptors,
researchers, media, police and legal authorities) together with a multi-faceted approach
encompassing the areas of legislation, security, data collection, training/education,
environmental factors, public awareness and financial incentives is required in order to
successfully address this issue. As the representatives of physicians, medical associations
should take a proactive role in combating violence in the health sector and also encourage other
key stakeholders to act, thus further protecting the quality of the working environment for
health personnel and the quality of patient care.
RECOMMENDATIONS
The WMA condemns in the strongest terms any forms of violence against healthcare personnel
and facilities, which may include coworker violence, aggressive behavior exhibited by patients
or family members, as well as acts of malicious intent from individuals in the general public,
and calls on its constituent members, the health authorities and other relevant stakeholders to
act through a collaborative, coordinated and effective strategy approach:
Policy-making
1. The state has obligations to ensure the safety and security of patients, physicians, and other
health personnel. This includes providing an appropriate physical environment.
2. Governments should provide the necessary framework so that the prevention and
elimination of workplace violence in the health sector be an essential part of
national/regional/local policies on occupational health and safety, human rights protection,
healthcare-facility management standards and gender equality.
Financial
3. Governments should allocate appropriate and sustainable funds in order to effectively
tackle violence in the health sector.
Protocols for situation of violence in healthcare facilities
4. Healthcare facilities should adopt a zero-tolerance policy towards workplace violence
eliminating its “normalization” through the development and implementation of adequate
protocols including the following:
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• A predetermined plan for maintaining security in the workplace; including recognition
of non-physical abuse as a risk factor for physical abuse.
• A designated plan of action for health personnel when violence takes place.
• A strengthened internal communication strategy, involving the staff in decisions
concerning their security.
• A system for reporting and recording acts of violence, which may include reporting to
legal and/or police authorities.
• A means to ensure that employees who report violence do not face reprisals.
5. In order for these protocols to be effective, the management and administration of
healthcare facilities should communicate and take the necessary steps to ensure that all staff
are aware of the protocols. Managers should be urged to verbalize a no-tolerance policy
towards violence in healthcare settings.
6. Patients with acute, chronic or illness-induced mental health disturbances or other
underlying medical conditions may act violently toward health personnel; those taking care
of these patients must be adequately protected. Except in emergency cases, physicians
might have the right to refuse to treat and, in such situations, they must ensure that adequate
alternative arrangements are made by the relevant authorities in order to safeguard the
patient’s health and treatment.
Training/Education
7. A well-trained and vigilant staff supported by management can be a key deterrent of violent
acts. Constituent members should work with undergraduate and postgraduate education
providers to ensure that health personnel are trained in the following areas: communication
skills, empathy as well as recognising and handling potentially violent persons and high-
risk situations in order to prevent incidents of violence.
8. Continuous education should include ethical principles of healthcare and the cultivation of
the patient-physician relationships based on respect and mutual trust. This not only
improves the quality of patient care but also fosters feelings of security resulting in a
reduced risk of violence.
Communication and Social Awareness
9. Medical associations, health authorities and other stakeholders should work together to
increase awareness of violence in the health sector, creating networks of information and
expertise in this area. When appropriate, health personnel and the public should be
informed of acts of violence.
10. Broadcasting agencies, newspapers, and other news outlets are encouraged to thoroughly
verify their sources in order to keep the information shared to the highest standard of
professional reporting. Social media companies and associated stakeholders should also
take active steps to create a cyber-violence-free environment for its users. This includes
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strengthening policies to protect user data, making reporting and flagging such violence
easy and accessible, and engaging law enforcement for proper legal action when warranted.
Security
11. Appropriate security measures should be in place in all healthcare facilities and acts of
violence should be given a high priority by law-enforcement authorities. A routine violence
risk audit, including a risk assessment, should be implemented in order to identify which
jobs and locations are at highest risk for violence, especially in places where violence has
already occurred, and to determine weaknesses in facilities’ security. Examples of high-
risk areas include general practice premises, mental health treatment facilities and high
traffic areas of hospitals including the emergency department.
12. The risk of violence may be ameliorated by a variety of means which include placing
security personnel in high-risk areas and at the entrance of buildings, the installation of
security cameras and alarm devices for use by health personnel, the use distinguishable
items to identify the staff and by maintaining sufficient lighting in work areas, contributing
to an environment conducive to vigilance and safety. The implementation of a system to
screen patients and visitors for weapons upon entering certain areas, especially the high-
risk ones, should be considered.
Support to victims
13. Adequate medical, psychological and legal support should be provided to victims of
violence. Such support should be free of access for all the health personnel.
Investigation
14. In all cases of violence there should be investigation to better understand the causes and to
aid in prevention of future violence. The investigation may lead to prosecution of
perpetrators under civil or criminal codes. The procedure should be led by relevant officials
in law enforcement and should not expose the victim to further physical or psychological
harm.
Data Collection
15. Appropriate reporting systems should be established to enable health personnel to report
anonymously and without reprisal, any threats or incidents of violence. Such a system
should assess in terms of number, type and severity, incidents of violence within an
institution and resulting injuries. The system should be used to analyse the effectiveness of
preventative strategies. Aggregated data and analyses should be made available to health
professional organizations and other relevant stakeholders.
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WMA STATEMENT
ON
FUNGAL DISEASE DIAGNOSIS AND MANAGEMENT
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
Annual WHO Global Burden of Disease estimates recognize that fungal diseases account
for a significant proportion of health problems worldwide. These include cutaneous fungal
infections which affect up to a billion persons and vulvovaginal candidiasis which affects
tens of millions of women, often multiple times annually.
Even more serious are invasive and chronic fungal diseases that lead to estimated annual
morbidity rates that are similar to those caused by commonly recognized global health
concerns such as malaria and tuberculosis. In addition to death, these fungal diseases
commonly lead to chronic ill health, including blindness with keratitis, respiratory distress
with allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensiti-
sation (SAFS) and chronic pulmonary aspergillosis (CPA), weight loss and nutritional
deficiency with oesophageal candidiasis and CPA, and inability to engage in healthy
sexual activity with vulvovaginal candidiasis.
Serious fungal diseases are often opportunistic, occurring as a consequence of other condi-
tions that suppress the immune system, such as asthma, AIDS, cancer, post-transplant im-
munosuppressive drugs and corticosteroid therapies. Some occur in critically ill patients.
Despite the fact that many fungal diseases can be treated relatively simply, in many cases,
these diseases go untreated. Fungal infections alone are often not distinctive enough to
allow a clinical diagnosis, and as cultures are frequently falsely negative, missed diagnosis
is common. In addition, a relatively narrow diagnostic window to cure the patient is fre-
quently missed, resulting in prolonged expensive hospital stays, often with a fatal out-
come. Despite the existence of effective medicine to treat fungal infections, these are often
not available when and where they are needed.
STATEMENT
The WMA stresses the need to support the diagnosis and management of fungal diseases
and urges national governments to ensure that both diagnostic tests and antifungal ther-
apies are available for their populations. Depending on the prevalence of fungal diseases
and their underlying conditions, specific antigen testing or microscopy and culture are
essential. These tests, and personnel trained to administer and interpret the tests, should be
available in all countries where systemic fungal infections occur. This will likely include
developing at least one diagnostic centre of excellence with a sufficient staff of trained
diagnostic personnel. Monitoring for antifungal toxicities should be available.
Fortaleza ⏐ S-2013-01-2013
Fungal Disease
Physicians will be the first point of contact for most patients with a fungal infection and
should be sufficiently educated about the topic in order to ensure an effective diagnostic
approach.
The WMA encourages its members to undertake and support epidemiologic studies on the
burden of fungal disease in their country and to inform the national government of the
results.
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WMA STATEMENT
ON
HUMAN PAPILLOMAVIRUS VACCINATION
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Human papillomavirus (HPV) vaccination presents a unique and valuable opportunity for
physicians to substantially prevent morbidity and mortality from certain cancers in all
populations, and to improve maternal health. The HPV vaccine therefore merits considera-
tion by the World Medical Association (WMA) separately from other vaccines.
HPV is a sexually transmitted virus and is so common that most sexually active adults
become infected at some point in their lives. Most infections are asymptomatic and
resolve without medical intervention. However, some of the 40 types of HPV can cause
cervical cancer. HPV is the cause of nearly 100% of cervical cancer cases and may also
cause cancer of the vagina, vulva, anus, penis and the head and neck. Cervical cancer
accounts for more than 10% of all female cancers, and the majority of cervical cancer
deaths are in developing countries.
Vaccines can protect against infection by the most common HPV types and afford pro-
tection against cancer. The U.S. Advisory Committee on Immunization Practices recom-
mends HPV vaccination for both females and males starting at age 11 years up to age 26
years. Benefits of vaccinating young men include protection against genital warts and
cancer in addition to preventing transmission of HPV to sexual partners. The additional
protection afforded by the quadrivalent vaccine against genital warts as well as cervical
and other cancers should be taken into consideration when developing HPV vaccination
programmes. The HPV vaccines are effective; post-marketing studies have shown decreases
in HPV prevalence and HPV related disorders such as genital warts and abnormal cervical
cytology. Studies concerning the safety of HPV vaccines have been reassuring.
These vaccines should be made widely available and should be promoted by physicians as
a matter of individual patient wellbeing and public health.
RECOMMANDATIONS
The WMA urges physicians to educate themselves and their patients about HPV and
associated diseases, HPV vaccination and routine cervical cancer screening; and encourages
the development and funding of programs to make HPV vaccine available and to provide
cervical cancer screening in countries without organized cervical cancer screening pro-
grams.
Fortaleza ⏐ S-2013-02-2013
Human Papillomavirus Vaccination
National medical associations (NMAs) are encouraged to carry out intensive education of
and advocacy efforts toward their members to:
• Improve awareness and understanding of HPV and associated diseases;
• Understand the availability and efficacy of HPV vaccines;
• Understand the desirability of including HPV vaccines in national immunization
programs;
• Understand the need for routine cervical cancer screening; and
• Integrate HPV cancer prevention methods, early detection and screening, diagnosis,
treatment and palliative care into existing continuing professional development pro-
grams and pre-service training. Such training will leverage existing support for HPV
programs and help in capacity building and quality assurance efforts.
NMAs are also encouraged to:
• Integrate HPV vaccination for all adolescents and routine cervical cancer screening
for young women into all appropriate health care settings and visits;
• Support the availability of the HPV vaccine and routine cervical cancer screening
for appropriate populations that benefit most from preventive measures, including
but not limited to at-risk patients such as low-income, disadvantaged and popula-
tions that are not yet sexually active;
• Recommend HPV vaccination for all appropriate populations;
• Promote member advocacy for HPV prevention, care and treatment; and
• Create a network of physicians and practitioners who are willing and able to mentor
and support one another and establish linkages to existing HPV vaccine and cancer
prevention networks.
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WMA STATEMENT
ON
NATURAL VARIATIONS OF HUMAN SEXUALITY
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
Healthcare professionals encounter many aspects of human diversity when providing care,
including different variations of human sexuality.
A large body of scientific research indicates that homosexuality is a natural variation of
human sexuality without any intrinsically harmful health effects.
As a consequence homosexuality was removed from the American Psychiatric Associa-
tion’s official diagnostic manual in 1973. The World Health Organization (WHO) removed
it from the ICD in 1990 following a similar process of scientific review. The Pan
American Health Organization (WHO) states: “In none of its individual manifestations
does homosexuality constitute a disorder or an illness, and therefore it requires no cure.”
Direct and indirect discrimination, stigmatisation, peer rejection, and bullying continue to
have a serious impact upon the psychological and physical health of people with a homo-
sexual or bisexual orientation. These negative experiences lead to higher prevalence rates
of depression, anxiety disorders, substance misuse, and suicidal ideations and attempts.
The suicide rate among adolescents and young adults with a homosexual or bisexual
orientation is, consequently, three times higher than that of their peers.
This can be exacerbated by so-called “conversion” or “reparative” procedures, which
claim to be able to convert homosexuality into asexual or heterosexual behaviour and give
the impression that homosexuality is a disease. These methods have been rejected by
many professional organisations due to a lack of evidence of their effectiveness. They
have no medical indication and represent a serious threat to the health and human rights of
those so treated.
RECOMMENDATIONS
The WMA strongly asserts that homosexuality does not represent a disease, but rather a
natural variation within the range of human sexuality.
The WMA condemns all forms of stigmatisation, criminalisation and discrimination of
people based on their sexual orientation.
Fortaleza ⏐ S-2013-03-2013
Natural Variations of Human Sexuality
The WMA calls upon all physicians to classify physical and psychological diseases on the
basis of clinically relevant symptoms according to ICD-10 criteria regardless of sexual
orientation, and to provide therapy in accordance with internationally recognised treat-
ments and protocols.
The WMA asserts that psychiatric or psychotherapeutic approaches to treatment must not
focus upon homosexuality itself, but rather upon conflicts, which arise between homo-
sexuality, and religious, social and internalised norms and prejudices.
The WMA condemns so-called “conversion” or “reparative” methods. These constitute
violations of human rights and are unjustifiable practices that should be denounced and
subject to sanctions and penalties. It is unethical for physicians to participate during any
step of such procedures.
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WMA STATEMENT
ON
THE RIGHT OF REHABILITATION OF VICTIMS OF TORTURE
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
The World Medical Association notes with grave concern the continued use of torture in
many countries throughout the world.
The WMA reaffirms its total condemnation of all form of torture, and other cruel, in-
human or degrading treatment or punishment, as defined by the UN Convention Against
Torture (CAT, 1984). Torture is one of the gravest violations of international human rights
law and has devastating consequences for victims, their families and society as a whole.
Torture causes severe physical and mental injuries and is a crime absolutely prohibited
under international law.
The WMA reaffirms its policies adopted previously, namely:
• The Declaration of Tokyo laying down Guidelines for Physicians Concerning Tor-
ture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to
Detention and Imprisonment (1975)
• The Declaration of Hamburg concerning Support for Medical Doctors Refusing to
Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman
or Degrading Treatment (1997)
• The Resolution on the Responsibility of Physicians in the Documentation and De-
nunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment (2003).
The medical evaluation is an essential factor in pursuing the documentation of torture and
the reparation of victims of torture. Physicians have a critical role to play in gathering
information about torture, documenting evidence of torture for legal purposes, as well as
supporting and rehabilitating victims.
The WMA recognizes the adoption, in December 2012, by the UN Committee Against
Torture of the General Comment on the Implementation of article 14 of Convention
against Torture relating to the right to reparation of victims of torture.
The General Comment outlines the right of rehabilitation as an obligation on States and
specifies the scope of these services. The WMA welcomes in particular:
• The obligation of State parties to adopt a “long-term and integrated approach and
Fortaleza ⏐ S-2013-04-2013
Victims of Torture
ensure that specialized services for the victim of torture or ill treatment are available,
appropriate and promptly accessible” (paragraph 13), without making access to these
services dependent on the victim pursuing judicial remedies.
• The recognition of the right of victims to choose a rehabilitation service provider, be
it a State institution, or a non-State service provider, which is funded by the State.
• The recognition that State parties should provide torture victims with access to
rehabilitation programs as soon as possible following an assessment by qualified
independent healthcare professionals.
• The references in paragraph 18 to measures aimed at protecting health and legal
professionals who assist torture victims, developing specific training on the Istanbul
Protocol for health professionals, and promoting the observance of international
standards and codes of conduct by public servants, including medical, psychological
and social service personnel.
RECOMMENDATIONS
The WMA emphasizes the vital function of reparation for victims of torture and their
families in rebuilding their lives and achieve redress and the important role of physicians
in rehabilitation.
The WMA encourages its member associations to work with relevant agencies – govern-
mental and non-governmental – acting for the reparation of victims of torture, in particular
in the areas of documentation and rehabilitation, as well as prevention.
The WMA encourages its members to support agencies that are under threat of – or
subjected to – reprisals from state parties due to their involvement in the documentation of
torture, rehabilitation and reparation of torture victims.
The WMA calls on its members to use their medical experience to support torture victims
in accordance with article 14 of the UN Convention against Torture.
The WMA calls on its member associations to support and facilitate data collection at the
national level in order to monitor the implementation of the State’s obligation to provide
rehabilitation services.
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WMA STATEMENT
ON
THE UNITED NATIONS RESOLUTION FOR A MORATORIUM ON
THE USE OF THE DEATH PENALTY
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
The WMA Resolution on Physician Participation in Capital Punishment states that it is
unethical for physicians to take part in capital punishment, and the WMA Declaration of
Geneva obliges physicians to maintain the utmost respect for human life.
The WMA acknowledges that the views prevalent in the countries of some of its members
prevent all members unconditionally opposing the death penalty.
The WMA therefore supports the suspension of the use of the death penalty through a
global moratorium.
The WMA has long recognized that it cannot hold its national medical association mem-
bers responsible for the actions and policies of their respective governments.
RECOMMANDATIONS
The World Medical Association supports United Nations General Assembly Resolution
65/206 calling for a moratorium on the use of the death penalty.
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WMA STATEMENT
ON
AESTHETIC TREATMENT
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
Aesthetic treatments have become increasingly common in recent years as society appears
to have become more preoccupied with physical appearance. These treatments are per-
formed by practitioners with widely differing clinical and educational backgrounds.
For the purpose of this statement, aesthetic treatment is defined as an intervention that is
performed not to treat an injury, a disease or a deformity, but for non-therapeutic reasons,
with the sole purpose of enhancing or changing the physical appearance of the individual
concerned. In this statement, the individual undergoing treatment is referred to as the
patient. The treatments available include a great variety of interventions, ranging from
surgical procedures to injections and different kinds of skin treatments. This statement
focuses on interventions that are methodologically similar to those performed in con-
ventional health care. Tattooing, scarring and similar interventions are therefore not con-
sidered in this statement.
Body image affects a person’s self-esteem and mental health and is an integral part of a
person’s overall health and well-being. However, media images of “perfect bodies” have
become the norm, causing some people, to develop unrealistic and unhealthy body images.
Many aesthetic treatments involve risks and may potentially harm the health of the patient.
Minors1
are particularly vulnerable, as their bodies are often not fully developed. In order
to protect persons considering or undergoing aesthetic treatment the WMA has developed
the following basic principles regarding aesthetic treatments.
Reaffirming the medical ethics principles laid out in the WMA Declaration of Geneva, the
WMA Declaration of Lisbon on the Rights of the Patient and the WMA International
Code of Medical Ethics, and consistent with the mandate of the WMA, this statement is
addressed primarily to physicians. However, the WMA encourages other practitioners per-
forming aesthetic treatments to adopt these principles.
PRINCIPLES
1. The patient´s dignity, integrity and confidentiality must always be respected.
2. Physicians have a role in helping to identify unhealthy body images and to address
and treat disorders when these exist.
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3. Aesthetic treatments must only be performed by practitioners with sufficient knowl-
edge, skills and experience of the interventions performed.
4. All practitioners providing aesthetic treatments must be registered with and/or li-
censed by the appropriate regulatory authority. Ideally, the practitioner should also
be authorized by this authority to provide these specific aesthetic treatments.
5. All aesthetic treatments must be preceded by a thorough examination of the patient.
The practitioner should consider all circumstances, physical and psychological,
that may cause an increased risk of harm for the individual patient and should
refuse to perform the treatment if the risk is unacceptable. This is especially true in
the case of minors. Practitioners should always choose the most appropriate treat-
ment option, rather than the most lucrative one.
6. Minors may need or benefit from plastic medical treatments but pure aesthetic
procedures should not be performed on minors. If, in exceptional cases, aesthetic
treatment is performed on a minors, it should only be done with special care and
consideration and only if the aim of the treatment is to avoid negative attention
rather than gain positive attention. All relevant medical factors, such as whether
the minor is still growing or whether the treatment will need to be repeated at a
later date, must be considered.
7. The patient must consent explicitly to any aesthetic treatment, preferably in writing.
Before seeking consent the practitioner should inform the patient of all relevant
aspects of the treatment, including how the procedure is performed, possible risks
and the fact that many of these treatments may be irreversible. The patient should
be given sufficient time to consider the information before the treatment starts.
Where the patient requesting the treatment is a minor, the informed consent of his
or her parents or legally authorized representative should be obtained.
8. All aesthetic treatments performed should be carefully documented by the practi-
tioner. The documentation should include a detailed description of the treatment
performed, information on medications used, if any, and all other relevant aspects
of the treatment.
9. Aesthetic treatments must only be performed under strictly hygienic and medically
safe conditions on premises that are adequately staffed and equipped. This must
include equipment for treating life-threatening allergic reactions and other poten-
tial complications.
10. Advertising and marketing of aesthetic treatments should be responsible and should
not foster unrealistic expectations of treatment results. Unrealistic or altered pho-
tographs showing patients before and after treatments must not be used in adver-
tising.
11. Advertising and marketing of aesthetic treatments should never be targeted to
minors.
12. Practitioners should never offer or promote financial loans as a means of paying
for aesthetic treatment.
1
For the purpose of this statement minor is defined as a person who, according to applicable
national legislation, is not an adult.
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WMA STATEMENT
ON
THE PREVENTION OF AIR POLLUTION DUE TO VEHICLE EMISSIONS
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
PREAMBLE
There are a number of ways in which the volume of harmful emissions can be reduced.
These include encouraging fewer road traffic journeys, active transport for individuals
undertaking relatively short journeys, the use of mass public transit in preference to
individual vehicles, and alternative energy sources for vehicles, including electric and
hybrid technologies. Where vehicle use is essential, means of reducing harmful emissions
should be used.
Physicians around the world are aware of air pollution. It impacts the quality of life for
hundreds of millions of people worldwide, causing both, a large burden of disease as well
as economic losses and increased health care costs. According to WHO estimates, in 2012,
urban outdoor air pollution was responsible for 3.7 million annual deaths, representing
6.7% of the total deaths (WHO, 2014).
Especially, diesel soot is acknowledged as a proven carcinogen (IARC, 07/2012). Further-
more, it has many other toxic effects, most prominently in the cardiovascular (Brook et al.,
2010) and respiratory systems (ERS, 2010). Moreover, in the context of global warming,
soot, along with methane, is identified as the second most important greenhouse driving
force substance after CO2 (Kerr, 2013).
Despite the fact that new vehicles will have to comply with stricter emission standards
which take into account most harmful ultra fine particles too, a high-polluting in-use fleet,
including off-road vehicles such as construction engines and ships, will continue polluting
for many more years.
BACKGROUND
In many densely populated cities around the world, fine dust concentrations measurable as
aerosols exceed up to 50 times the maximum WHO recommendation. High volumes of
transport, power generated from coal, and pollution caused by construction machinery are
among the contributing factors. People living and working near major (high density
volume traffic) streets are most affected by pollutants. For fighting the health risks men-
tioned above, there exist a variety of highly efficient and reliable filter systems on the
market (Best Available Technology (BAT) filters1
). They are applicable to all internal
combustion engines and they reduce even most harmful ultra-fine particles by a factor of
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S-2014-02-2014 ⏐ World Medical Association
over one hundred. As soon as 90% of heavy duty vehicles, both, new and upgraded ones,
satisfy this standard, health problems attributable to emissions of heavy duty traffic will be
greatly reduced, and no further tightening of emission standards will be possible or even
needed at all because of an almost total elimination of the pollutant as such.
In a variety of countries on different continents and under varying conditions retrofit or
upgrading programs have been successfully performed. The UN’s Working Party on Pol-
lution Prevention and Energy in Geneva has just proposed a technical standard for
regulation in their member states, which will be applicable worldwide.
The WMA supports these efforts and calls on policy makers in all countries, especially in
urban regions, to introduce regulatory restrictions of access for vehicles without filter,
and/or to provide financial assistance to support the retrofitting of in-use vehicles.
RECOMMENDATIONS
The WMA therefore recommends that all NMAs should encourage their respective govern-
ments to:
1. Introduce BAT standards for all new diesel vehicles (on road and off-road)
2. Incentivise retrofitting with BAT filters for all in-use engines
3. Monitor and limit the concentration of nanosize soot particles in the urban breathing
air
4. Conduct epidemiological studies detecting and differentiating the health effects of
ultrafine particles
5. Build professional and public awareness of the importance of diesel soot and the
existing methods of eliminating the particles
6. Contribute to developing strategies to protect people from soot particles in aircraft
passenger cabins, trains, homes and in the general environment. These strategies
should include plans to develop and increase use of public transportation systems.
ABBREVIATIONS:
EPA: Environmental Protection Agency (US)
ERS: European Respiratory Society
IARC: International Agency for Research of Cancer
BAT Standards: Emission standards for passenger cars, heavy-duty vehicles and off-road
machinery, based on count of ultrafine particles rather than mass and aimed at the
protection of human health from the most hazardous soot particles, the lung and even cell
membrane penetrating ultra-fines.
Durban ⏐ S-2014-02-2014
Air Pollution
REFERENCES:
• Brook, Robert D. et al. (2010): AHA Scientific Statement: Particulate Matter Air
Pollution and Cardiovascular Disease. An Update to the Scientific Statement from
the American Heart Association. Circulation 121: 2331-2378.
• ERS (2010): The ERS report on air pollution and public health. European
Respiratory Society, Lausanne, Switzerland. ISBN: 978-1-84984-008-8
• IARC (2012): “IARC: Diesel Engine Exhaust Carcinogenic”. Press Release No.
213.http://www.iarc.fr/en/media-centre/pr/2012/pdfs/pr213_E.pdf. (access: 14/02/14)
• Kerr, Richard R. (2013): “Soot is Warming the World Even More Than Thought”.
In: Science 339(6118), p. 382.
• WHO (2014): “Burden of disease from Ambient Air Pollution for 2012.” http://
www.who.int/phe/health_topics/outdoorair/databases/AAP_BoD_results_March20
14.pdf?ua=1 (access: 26/08/14)
1
Euro 6/VI, US/EPA/CARB, Chinese and equivalent standards.
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World Medical Association ⏐ S-2014-03-2019
WMA STATEMENT
ON
SOLITARY CONFINEMENT
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
and revised by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
In many countries, a substantial number of prisoners are held in solitary confinement.
Solitary confinement is a form of confinement used in detention settings where individuals
are separated from the general detained population and held alone in a separate cell or
room for upwards of 22 hours a day. Jurisdictions may use a range of different terms to
refer to the process (such as segregation, separation, isolation or removal from association)
and the conditions and environment can vary from place to place. However, it may be
defined or implemented, solitary confinement is characterised by complete social
isolation; a lack of meaningful contact; and reduced activity and environmental stimuli.
Some countries have strict provisions on how long and how often prisoners can be kept in
solitary confinement, but many countries lack clear rules on this.
Solitary confinement can be distinguished from other brief interventions when individuals
must be separated as an immediate response to violent or disruptive behaviour or where a
person must be isolated to protect themselves or others. These interventions should take
place in a non-solitary confinement environment.
The reasons for the use of solitary confinement vary in different jurisdictions and it can be
used at various stages of the criminal justice process. It may be used as a disciplinary
measure for the maintenance of order or security; as an administrative measure, for the
purposes of investigation or questioning; as a preventive measure against future harm
(either to the individual or to others); or it may be the consequence of a restrictive regime
that limits contact with others. It can be imposed for hours to days or even years.
Medical impacts of solitary confinement
People react to isolation in different ways. For a significant number of prisoners, solitary
confinement has been documented to cause serious psychological, psychiatric, and
sometimes physiological effects. These include insomnia, confusion, hallucinations,
psychosis, and aggravation of pre-existing health problems. Solitary confinement is also
associated with a high rate of suicidal behaviour. Negative health effects can occur after
only a few days and may in some cases persist when isolation ends.
Certain populations are particularly vulnerable to the negative health effects of solitary
confinement. Persons with psychotic disorders, major depression, or post-traumatic stress
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disorder or people with severe personality disorders may find isolation unbearable and
suffer considerable health harms. Solitary confinement may complicate treating such
individuals and their associated health problems successfully later in the prison
environment or when they are released back into the community. Prisoners with physical
disabilities or other medical conditions often have their conditions aggravated, not only as
a result of the physical conditions of isolation, but also as the particular health
requirements linked to their disability or condition are often not accommodated.
For children and young people, who are in the crucial stages of developing socially,
psychologically, and neurologically, there are serious risks of solitary confinement
causing long-term mental and physical harm. A growing international consensus about the
harms of solitary confinement on children and young people has resulted in some
jurisdictions abolishing the practice completely.
International norms on solitary confinement
The increasing documentation on the harmful impact of solitary confinement on the health
of prisoners led to the development of a range of international norms and
recommendations seeking to mitigate the use and the harmful effect of solitary
confinement.
The United Nations Standard Minimum Rules for the Treatment of Prisoners (SMR) were
first adopted in 1957, and revised in 2015 as the Nelson Mandela Rules unanimously
adopted by the United Nations Assembly. The SMR constitute the key international
framework for the treatment of prisoners.
Other international standards and recommendations, such as the United Nations Rules for
the Treatment of Women Prisoners and Non-Custodial Sanctions for Women Offenders
(the Bangkok Rules), the United Nations Rules for the Protection of Juveniles Deprived of
their Liberty and the observations of the Special Rapporteur on Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment, support and complete the Nelson
Mandela Rules.
The misuse of solitary confinement can include indefinite or prolonged solitary
confinement (defined as a period of solitary confinement in excess of 15 days), but can
also include corporal or collective punishment, the reduction of a prisoner’s diet or
drinking water, or the placement of a prisoner in a dark or constantly lit cell. Misuse of
solitary confinement in these ways can constitute a form of torture or ill-treatment and as
such must be prohibited in line with international human rights law and medical ethics.
The WMA and its members reiterate their firm and long-standing position condemning
any forms of torture and other cruel, inhuman or degrading treatment or punishment and
reaffirm the basic principle that doctors should never participate in or condone torture or
other cruel, inhuman or degrading treatment.
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RECOMMENDATIONS
1. Given the harmful impact of solitary confinement, which can on occasion result in a
form of torture or ill-treatment, the WMA and its members call for the implementation
of the Nelson Mandela Rules and other associated international standards and
recommendations, with a view to protect the human rights and the dignity of the
prisoners.
2. The WMA and its members emphasize in particular the respect of the following
principles:
• In light of the serious consequences solitary confinement can have on physical and
mental health (including an increased risk of suicide or self-harm), it should be
imposed only in exceptional cases as a last resort and subject to independent
review, and for the shortest period of time possible. The authority imposing the
solitary confinement must be acting in line with clear rules and regulations as to its
use.
• All decisions on solitary confinement must be transparent and regulated by law.
The use of solitary confinement should be time-limited by law. The detainee
should be informed of the duration of the isolation, and the period of duration
should be determined before the measure takes place. Prisoners subject to solitary
confinement should have a right of appeal.
• Solitary confinement should not exceed a time period of 15 consecutive days.
Releasing the prisoner from solitary confinement for a very limited period of time,
with the intention that the individual will be placed in solitary confinement
immediately again to get around the rules on length of stay must also be
prohibited.
Prohibitions of the use of solitary confinement
The indefinite or prolonged solitary confinement should be prohibited as amounting to
torture or other cruel, inhuman or degrading treatment or punishment [1].
Solitary confinement should be prohibited for children and young people (as defined by
domestic law), pregnant women, women up to six months post-partum, women with
infants and breastfeeding mothers as well as for prisoners with mental health problems
given that isolation often results in severe exacerbation of pre-existing mental health
conditions.
The use of solitary confinement should be prohibited in the case of prisoners with physical
disabilities or other medical conditions where their conditions would be exacerbated by
such measures.
Where children and young people must be separated, in order to ensure their safety or the
safety of others, this should be carried out in a non-solitary confinement setting with
adequate resources to meet their needs, including ensuring regular human contact and
purposeful activity.
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Conditions of solitary confinement
The human dignity of prisoners confined in isolation must always be respected.
Prisoners in isolation should be allowed a reasonable amount of meaningful regular human
contact, activity, and environmental stimuli, including daily outside exercise. As with all
prisoners, they must not be subjected to extreme physically and/or mentally taxing
conditions.
Prisoners who have been in solitary confinement should have an adjustment period,
including a medical examination, before they are released from prison. This must never
extend their period of incarceration.
Role of physician
The physician’s role is to protect, advocate for, and improve prisoners’ physical and
mental health, not to inflict punishment. Therefore, physicians should never participate in
any part of the decision-making process resulting in solitary confinement, which includes
declaring an individual as “fit” to withstand solitary confinement or participating in any
way in its administration. This does not prevent physicians from carrying out regular visits
to those in solitary confinement to assess health and provide care and treatment where
necessary, or from raising concerns where they identify a deterioration in an individual’s
health.
The provision of medical care should take place upon medical need or the request of the
prisoner. Physicians should be guaranteed daily access to prisoners in solitary
confinement, upon their own initiative. More frequent access should be granted if
physicians deem this to be necessary.
Physicians working in prisons must be able to practice with complete clinical
independence from the prison administration. In order to maintain that independence,
physicians working in prisons should be employed and managed by a body separate from
the prison or criminal justice system.
Physicians should only provide drugs or treatment that are medically necessary and should
never prescribe drugs or treatment with the intention of enabling a longer period of solitary
confinement.
Healthcare should always be provided in a setting that respects the privacy and dignity of
prisoners. Physicians working in the prison setting are bound by the sample codes and
principles of medical ethics as they would be in any other setting.
Physicians should report any concerns about the impact solitary confinement is having on
the health and wellbeing of an individual prisoner to those responsible for reviewing
solitary confinement decisions. If necessary, they should make a clear recommendation
that the person be removed from solitary confinement, and this recommendation should be
respected and acted upon by the prison authorities.
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Solitary Confinement
Physicians have a duty to consider the conditions in solitary confinement and to raise
concerns with the authorities if they believe that they are unacceptable or might amount to
inhumane or degrading treatment. There should be clear mechanisms in place in each
system to allow physicians to report such concerns.
Reference
[1] Rule 43 SMR
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WMA STATEMENT
ON
PHYSICIANS WELL-BEING
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Physician well-being refers to the optimization of all factors affecting biological,
psychological and social health and preventing or treating acute or chronic diseases
experienced by physicians including mental illness, disabilities and injuries resulting from
work hazards, occupational stress and burnout.
Physician’s well-being could have positive impact on patient care, but more research is
needed. The profession should therefore encourage and support on-going research on
physician’s health. Evidence that already exists should be implemented in policy and
practice. While physicians tend to have healthy habits, it is essential to enhance their
health as a way to improve health for the whole population.
Physicians and medical students at all career stages are exposed to both positive
experiences as well as a variety of stressors and work injuries The medical profession
should seek to identify and revise policies and practices that contribute to these stressors
and collaborate with NMA’s in order to develop policies and practices that have protective
effects. Like all human beings, physicians experience illness, and they also have family
obligations and other commitments outside their professional lives that should be taken
into account.
One reason physicians delay seeking help is their concern about confidentiality and feeling
ill at ease in the patient role. They experience feelings of responsibility towards their
patients and are sensitive to external expectations on their health. Therefore, physicians
must be assured of the same right of confidentiality as any other patient when seeking and
undergoing treatment. The health care system may need to provide special arrangements
for the care of physician-patients in order to uphold its duty to provide privacy and
confidentiality. Prevention, early assistance and intervention should be available
separately from any disciplinary process.
THREATS, BARRIERS AND OPPORTUNITIES FOR PHYSICIAN WELL-BEING
Professional Roles and Expectations
The medical profession often attracts highly driven individuals with a strong sense of
duty. Successfully completing the long and intense educational requirements often confers
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upon physicians a high degree of respect and responsibility in their communities.
With these high levels of respect and responsibility, physicians are subject to high
expectations from patients and the public. These expectations can contribute to
prioritizing the care of others over care of self and feelings of guilt and selfishness for
managing their own well-being.
There is a direct relationship between physicians’ and patients’ preventive health
practices. This relationship should encourage healthcare systems to better support and
evaluate the effects on patients of improving physician and medical student health.
Work Environment
Working conditions, including workload and working hours, affect physicians’
motivation, job satisfaction, personal life and psychological health during their careers.
Physicians are often perceived as being immune to injury and diseases as they care for
their patients, and workplace health and safety programs may be overlooked. Physician
who are employed by small organizations or who are self-employed may be at even a
higher risk for occupational diseases and may not have access to health and safety
programs provided by large health care establishments.
As a consequence of their professional duties, physicians and physicians in postgraduate
education often confront emotionally challenging and traumatic situations including
patients’ suffering, injury and death. Physicians may also be exposed to physical hazards
like radiation, noise, poor ergonomics, and biological hazards like HIV, TB and hepatitis.
Some healthcare systems may exacerbate stress because of the hierarchies and competition
inherent in them. Physicians in postgraduate education and medical students can be
victims of harassment and discrimination during their medical education. Due to their
position within the medical hierarchy, they may feel powerless to confront these
behaviours.
Physician autonomy is one of the strongest predictors of physician satisfaction. Increasing
external regulatory pressures such as undue emphasis on cost efficiencies and concerns
about consequences of reporting medical errors may unduly influence medical decision-
making and diminish a physician’s autonomy.
Illness
Even though medical professionals recognize that it is preferable to identify and treat
illness early, physicians are often adept at hiding their own illnesses and may continue to
function without seeking help until they become incapable of carrying out their duties.
There are many potential obstacles to an ill physician seeking care including: denial,
confidentiality issues, aversion to the patient role, practice coverage, fear of disciplinary
action, potential loss of practice privileges, loss of performance based payment and the
efficiencies of self-care. Because of these obstacles doctors are often reluctant to refer
themselves or their colleagues for treatment.
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Physicians Well-Being
Illnesses can include mental and behavioural health problems, burnout, communication
and interpersonal issues, physical and cognitive problems and substance use disorders.
These illnesses and problems can overlap and can occur throughout the professional life
cycle from basic medical education to retirement. It is important to acknowledge the
continuum of physician well-being, ranging from optimal health, to minor illness, to
debilitating illness.
Substance abuse may disrupt a physician’s personal life and may also significantly affect
his or her ability to care for patients. Easy access to medications may contribute to
physicians’ risk for abuse of recreational drugs and prescription medications. Assistance
prior to impairment in the workplace is protective for physicians, their professional
credentials and their patients.
Improved wellness promotion, prevention strategies and earlier intervention can help
mitigate the severity of mental and physical illnesses and help reduce incidence of suicide
in physicians, physicians in postgraduate education and medical students.
RECOMMENDATIONS
The World Medical Association recommends that National Medical Associations (NMAs)
recognize and, where possible, actively address the following:
1. In partnership with medical schools and workplaces, NMAs recognize their obligation
to provide education at all levels about physician well-being. NMAs should
collaboratively promote research to establish best practices that promote physician
health and to determine the impact of physician well-being on patient care.
2. Physician well-being should be supported and provided within and outside the
workplace. Support may include but is not limited to referral to medical treatment,
counselling, support networks, recognized physician health programs, occupational
rehabilitation and primary prevention programs including resiliency training, healthy
lifestyles and case management.
3. NMA’s should recognize the strong and consistent link between physicians’ and
patients’ personal health practices, providing yet another critically important reason
for health systems to promote physician health.
4. Physician health programs can help all physicians to proactively help themselves via
prevention strategies and can assist physicians who are ill via assessment, referral to
treatment and follow-up. Programs and resources to help promote positive
psychological health should be available to all physicians. Early identification,
intervention and special arrangements for the care of physician-patients should be
available to protect the health of physicians. Fostering a supportive and accepting
culture is critical to successful early referral and intervention.
5. Physicians at risk for abuse of alcohol or drugs should have access to appropriate
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confidential medical treatment and comprehensive professional support. NMAs
should promote programs that help physicians re-enter medical practice with
appropriate ongoing supervision at the completion of their treatment programs. More
research should be conducted to determine best practices in preventing substance
abuse among physicians and physicians in postgraduate education.
6. Physicians have the right to working conditions that help limit the risk of burnout and
empower them to care for their personal health by balancing their professional
medical commitments and their private lives and responsibilities. Optimal working
conditions include a safe and reasonable maximum number of consecutive and total
working hours, adequate rest between shifts and appropriate number of non-working
days. Relevant organizations should constructively address professional autonomy
and work-life balance problems and involve physicians in making decisions about
their work lives. Working conditions must not put the safety of patients or physicians
at risk, and ultimately physicians should be engaged in establishing optimal
workplace conditions.
7. Workplaces should promote conditions conducive to healthy lifestyles, including
access to healthy food choices, exercise, nutrition counselling and support for
smoking cessation.
8. Physicians, physicians in postgraduate education and medical students have the right
to work in a harassment and violence-free workplace. This includes freedom from
verbal, sexual and physical abuse.
9. Physicians, physicians in postgraduate education and medical students have the right
to a collaborative safe workplace. Workplaces should promote interdisciplinary
teamwork, and communication between physicians and all other professionals in the
workplace should be offered in a spirit of cooperation and respect. Education on
communications skills, self-awareness and team-work should be considered.
10. Medical staff should undergo training in recognizing, handling and communicating
with potentially violent persons. Health care facilities should safeguard against
violence including routine violence risk audits, especially in mental health treatment
facilities and emergency departments. Staff members who are victims of violence or
who report violence should be supported by management and offered medical,
psychological and legal counselling.
11. Medical schools and teaching hospitals should develop and maintain confidential
services for physicians in postgraduate education and medical students and to raise
awareness of and access to such programs. Workplaces should consider offering
medical consultations to physicians in postgraduate education in order to identify any
health issues at the outset of medical education.
12. Workplace support for all physicians should be easily accessible and confidential.
Physicians evaluating and treating their medical colleagues should not be required to
report any aspects of their physician-patients’ care in any manner not required for
their non-physician patients.
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WMA STATEMENT
ON
SUPPORTING HEALTH SUPPORT TO STREET CHILDREN
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
The WMA recognises that having children in living on the streets is unacceptable in a
society even though this phenomenon is difficult to avoid in many communities around
the world.
The WMA intends to raise awareness within civil and medical society about the
fundamental role played by medical contact in improving the situation of street children.
In this regard, it is important that the initial contact with street children be based on trust.
Therefore, together with other healthcare professionals and social workers, medical
contact should be viewed as the first step towards resocialising street children by building
trust between the physician and the street child. Once achieved, a more global
multidisciplinary and multidimensional approach can follow to improve the well-being of
street children.
Childhood and adolescence are the beginnings of a long physical, mental, cultural and
social growth process;
The health of young people shapes the health of tomorrow’s population;
Young people play a part in social cohesion and they are an asset to any country;
Addressing the social determinants of health is essential to achieving equity in healthcare.
The social determinants leading to the appearance and growth of the phenomenon of
“street children” are varied and complex;
The negative health impact of living on the streets for children, both in terms of the
additional health risks to which these children are exposed and their lack of access to
healthcare and prevention; street children are, in particular, more vulnerable to acute
illnesses and traumatic injuries. In addition, preventive care and continuity of care are
non-existent for street children due to frequent relocation;
The health of street children remains critical and has been exacerbated by the global
financial and economic crisis, which has contributed to family break-ups, social upheaval
and disruptions in healthcare and education;
Children may be victims of discrimination arising from their gender, ethnic origin,
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language, religion, political opinion, handicap, social status or population migration;
Street children are especially vulnerable to abuse, violence, exploitation and manipulation,
including trafficking;
Child homelessness often goes unrecognised at a national and international level since it is
difficult to quantify and assess.
RECOMMENDATIONS
• The WMA strongly condemns any violations of the rights of children living on the
streets and any infringements of these rights, in particular discrimination and
stigmatisation and their exposure to abuse, violence, exploitation and manipulation,
including trafficking.
• The WMA calls upon governments to address the factors, which lead to children living
on the streets and to take action to implement all applicable legislation and systems of
protection to reduce the health implications for street children. National authorities
have an obligation to provide care for all children and, where necessary, to support
their return to a living environment appropriate for a child.
• Reducing health implications includes not only direct treatment of health issues but
also protection of Street Children from health risks such as exposure to drugs, HIV
infection, smoking and drinking.
• The WMA calls upon governments, national medical associations and healthcare
professionals to acknowledge the scale of this phenomenon and to instigate prevention
and awareness campaigns. These children must be able to access the full range of
necessary health and social protection.
• The WMA urges all national medical associations to work with legal counterparts,
governments, health care professionals and public authorities to ensure the
fundamental rights of children, who are a particularly vulnerable population in need of
protection, particularly access to healthcare and education. The right to food and
housing should be guaranteed, and any form of discrimination or exploitation should
be forbidden.
• The WMA condemns any improper age-assessment practices that make use of
insufficiently reliable clinical or paraclinical investigations. Until they reach
adulthood, adolescents must be able to enjoy their status as minors, as recognised by
the UN International Convention on the Rights of the Child.
• The WMA urges physicians to remain vigilant in terms of delivering all the support
required to provide suitable and comprehensive care for ‘street children’. Physicians
should be aware that homelessness is a pervasive problem. They should be
knowledgeable about the existence of homelessness in their own communities and are
encouraged to establish a relationship of trust between the physician and the street
child to become involved in local relief and advocacy programs.
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Health Support to Street Children
• The WMA maintains that every effort should be made to provide all children, and
particularly those that are homeless, with access to a suitable and balanced psycho-
social environment, in which their rights, including the right to health, are respected.
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WMA STATEMENT
ON
RIOT CONTROL AGENTS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
There has been a long-standing concern regarding the use of chemical weapons. Despite
this concern, poison gas was used fairly extensively during World War I, leading to a call
from the International Committee of the Red Cross (ICRC) in February 1918 for cessation
of its use.
This led to the Geneva Protocol of 1925, the Biological and Toxin Weapons Convention
of 1972 (BTWC) and the Chemical Weapons Convention of 1993 (CWC).
All but six countries in the world have signed and ratified the CWC; two more have
signed but not yet ratified, making it a nearly universally accepted Convention.
The conventions prohibit the development, production and stockpiling of chemical
weapons in addition to their usage in warfare and call for measures to decommission or
destroy existing stores. However, the CWC allows the use of specific chemicals in
domestic law enforcement including riot control situations, which means that governments
might hold stockpiles of certain agents. Even so, riot control agents cannot be used in
warfare; the exclusion has reached the status of customary law, which allows their use
only in domestic or national jurisdictions.
Although there is academic and military interest in what is often called non-lethal
weapons, the incidence of morbidity and mortality caused by weapons are not criteria used
in prohibition. A tiered approach based upon degrees of lethality of specific weapons is
contrary to the ethos of both conventions.
In situations of widespread public unrest and political or other uprisings governments
unfortunately may choose to deploy riot control agents in a domestic setting. Although
this is not in conflict with the principles of the CWC their use may still give rise to
specific medical, legal and ethical challenges.
While riot control agents are designed to make remaining within the riot unpleasant and
impractical, they are not expected to directly cause any injuries or deaths. As with all other
agents, how they are used determines the concentration to which individuals are exposed.
The ability to take evasive actions, such as leaving the area, to reduce exposure may also
have an impact. It is recognised that individual determinants including general health and
age will affect an individual’s response to chemical agent.
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Release of chemical agents such as tear gas in a small enclosed space exposes individuals
to concentrations far higher than those expected in normal deployment in riot situations,
causing higher levels of serious morbidity and potentially death.
Misuse of riot control agents, leading to serious harms or deaths of demonstrators,
exposing individuals excessively or using them for oppressing non-violent peaceful
demonstrations, may lead to a breach of the human rights of the individuals concerned, in
particular the right to life (article 3), the right to freedom of expression (article 19) and of
peaceful assembly (article 20) of the Universal Declaration of Human Rights.
Governments, who authorize the stockpiling and use of such agents by their police and
security forces, are urged to consider that there might be fatal results of their usage.
Governments are required to ensure that they are used in a manner, which minimise their
likelihood of causing serious morbidity and mortality.
RECOMMENDATION
The WMA recognises that the inappropriate use of riot control agents risks the lives of
those targeted and exposes people around, amounting to a potential breach of human rights
standards, in particular the right to life, the right to freedom of expression and of peaceful
assembly as stated in the Universal Declaration of Human Rights.
In case of use of riot control agents, the WMA urges States to do so in a manner designed
to minimise the risk of serious harm to individuals, and to prohibit its use in the presence
of vulnerable populations, such as children, older people or pregnant women;
The WMA insists that riot control agents should never be used in enclosed spaces where
chemical concentrations may reach dangerous levels, and where people cannot move away
from areas with high concentrations of the agent;
The WMA insists that governments train police and other security forces in the safe and
legal use of riot control agents, in order to minimise the risk of harm when they are
deployed. This must include the rapid evacuation of any individual who is apparently
suffering from a high level of exposure, not aiming people, and not using the agent
excessively;
The WMA insists that States penalise individuals who misuse riot control agents and who
deliberately endanger human life and safety by using the agents. Such misuse leading to
serious physical harms or death of individuals should be investigated by independent
experts.
The WMA calls for unimpeded and protected access of healthcare personnel to allow them
to fulfil their duty of attending to the injured as set forth in the “WMA Declaration on the
protection of healthcare workers in situations of violence”.
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Riot Control Agents
The WMA recommends that, because of the significant difficulties and risks to health and
life associated with the use of such riot control agents, States should refrain from using
them in any circumstances.
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WMA STATEMENT
ON
TRANSGENDER PEOPLE
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
In most cultures, an individual’s sex is assigned at birth according to primary physical sex
characteristics. Individuals are expected to identify with their assigned sex (gender
identity) and behave according to specific cultural norms strongly associated with this
(gender expression). Gender identity and gender expression make up the concept of
“gender” itself.
There are individuals who experience different manifestations of gender that do not
conform to those typically associated with their sex assigned at birth. The term
“transgender” refers to people who experience gender incongruence, which is defined as a
marked mismatch between one’s gender and the sex assigned at birth.
While conceding that this is a complex ethical issue, the WMA would like to acknowledge
the crucial role played by physicians in advising and consulting with transgender people
and their families about desired treatments. The WMA intends this statement to serve as a
guideline for patient-physician relations and to foster better training to enable physicians
to increase their knowledge and sensitivity toward transgender people and the unique
health issues they face.
Along the transgender spectrum, there are people who, despite having a distinct
anatomically identifiable sex, seek to change their primary and secondary sex
characteristics and gender role completely in order to live as a member of the opposite sex
(transsexual). Others choose to identify their gender as falling outside the sex/gender
binary of either male or female (genderqueer). The generic term “transgender” represents
an attempt to describe these groups without stigmatisation or pathological characterisation.
It is also used as a term of positive self-identification. This statement does not explicitly
address individuals who solely dress in a style or manner traditionally associated with the
opposite sex (e.g. transvestites) or individuals who are born with physical aspects of both
sexes, with many variations (intersex). However, there are transvestites and intersex
individuals who identify as transgender. Being transvestite or intersex does not exclude an
individual from being transgender. Finally, it is important to point out that transgender
relates to gender identity, and must be considered independently from an individual’s
sexual orientation.
Although being transgender does not in itself imply any mental impairment,
transgender people may require counseling to help them understand their gender
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and to address the complex social and relational issues that are affected by it. The
Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association (DSM-5) uses the term “gender dysphoria” to classify people who experience
clinically significant distress resulting from gender incongruence.
Evidence suggests that treatment with sex hormones or surgical interventions can be
beneficial to people with pronounced and long-lasting gender dysphoria who seek gender
transition. However, transgender people are often denied access to appropriate and
affordable transgender healthcare (e.g. sex hormones, surgeries, mental healthcare) due to,
among other things, the policies of health insurers and national social security benefit
schemes, or to a lack of relevant clinical and cultural competence among healthcare
providers. Transgender persons may be more likely to forego healthcare due to fear of
discrimination.
Transgender people are often professionally and socially disadvantaged, and experience
direct and indirect discrimination, as well as physical violence. In addition to being denied
equal civil rights, anti-discrimination legislation, which protects other minority groups,
may not extend to transgender people. Experiencing disadvantage and discrimination may
have a negative impact upon physical and mental health.
RECOMMENDATION
• The WMA emphasises that everyone has the right to determine one’s own gender
and recognises the diversity of possibilities in this respect. The WMA calls for
physicians to uphold each individual’s right to self-identification with regards to
gender.
• The WMA asserts that gender incongruence is not in itself a mental disorder;
however it can lead to discomfort or distress, which is referred to as gender
dysphoria (DSM-5).
• The WMA affirms that, in general, any health-related procedure or treatment
related to an individual’s transgender status, e.g. surgical interventions, hormone
therapy or psychotherapy, requires the freely given informed and explicit consent
of the patient.
• The WMA urges that every effort be made to make individualised, multi-
professional, interdisciplinary and affordable transgender healthcare (including
speech therapy, hormonal treatment, surgical interventions and mental healthcare)
available to all people who experience gender incongruence in order to reduce or to
prevent pronounced gender dysphoria.
• The WMA explicitly rejects any form of coercive treatment or forced behaviour
modification. Transgender healthcare aims to enable transgender people to have
the best possible quality of life. National Medical Associations should take action
to identify and combat barriers to care.
• The WMA calls for the provision of appropriate expert training for physicians at
S-2015-05-2015 ⏐ Moscow
Transgender People
all stages of their career to enable them to recognise and avoid discriminatory
practises, and to provide appropriate and sensitive transgender healthcare.
• The WMA condemns all forms of discrimination, stigmatisation and violence
against transgender people and calls for appropriate legal measures to protect their
equal civil rights. As role models, individual physicians should use their medical
knowledge to combat prejudice in this respect.
• The WMA reaffirms its position that no person, regardless of gender, ethnicity,
socio-economic status, medical condition or disability, should be subjected to
forced or coerced permanent sterilisation (WMA Statement on Forced and Coerced
Sterilisation). This also includes sterilisation as a condition for rectifying the
recorded sex on official documents following gender reassignment.
• The WMA recommends that national governments maintain continued interest in
the healthcare rights of transgender people by conducting health services research
at the national level and using these results in the development of health and
medical policies. The objective should be a responsive healthcare system that
works with each transgender person to identify the best treatment options for that
individual.
Handbook of WMA Policies
World Medical Association ⏐ S-2015-06-2015
WMA STATEMENT
ON
VITAMIN D INSUFFICIENCY
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Vitamin D has major role in calcium and bone metabolism. Normal values are 75-100
nmol/L (30-40 ng/ml). Vitamin D deficiency is defined if serum hydroxyvitamin D levels
are less than 50nmol/L (20 ng/ml), insufficiency as 50-75 nmol/L (20-30 ng/ml).
Studies demonstrate that vitamin D is essential also for overall health and well-being. In
the body vitamin D is produced during exposure to sunlight and in lesser degree by food
intake.
Vitamin D exists in two forms: vitamin D3 (cholecalciferol in humans and other
mammals) and vitamin D2(ergocalciferol in plants), but both are similarly metabolized.
Vitamin D3 is more active than vitamin D2.
The serum concentration of the hepatic metabolite of vitamin D3, the 25-hydroxyvitamin
D, is consideredas the best biomarker of vitamin D status.
Vitamin D deficiency is an important health issue globally. About one third of the
population is estimated to have lower serum concentration of vitamin D.
Many studies have shown that vitamin D deficiency is linked to impaired growth and
development. Because vitamin D receptors are broadly distributed in tissues, vitamin D
deficiency is associated with musculoskeletal disorders (osteoporosis), falls, fractures,
autoimmune disorders, chronic inflammatory diseases, type 2 diabetes mellitus, and
cardiovascular, neurologic and psychiatric disorders. High risk groups are young children,
the elderly and pregnant women. Primary factors, contributing to vitamin D deficiency,
include reduced sunshine exposure, poor quality diet, availability of fortified foods and
supplement use.
RECOMMANDATIONS
Because of widespread occurrence of vitamin D deficiency/insufficiency it is desirable to
focus attention on adequate preventive actions in populations at risk. Determining vitamin
D levels requires only a blood test, and oral supplementation is a simple treatment method.
Sun exposure is not generally recommended because it can increase the risk of skin
cancer.
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Vitamin D Insufficiency
The World Medical Association recommends that national medical associations:
• Support continued research in vitamin D and its metabolites
• Educate physicians about the evolving science of vitamin D and its impact on
health (documents, brochures, posters)
• Encourage physicians to consider measuring the serum concentrations of 25-
hydroxyvitamin D in the patients at risk of vitamin D deficiency
• Monitor development of dietary recommendations for vitamin D.
Handbook of WMA Policies
S-2015-07-2015 ⏐ World Medical Association
WMA GUIDELINES
ON PROMOTIONAL MASS MEDIA
APPEARANCES BY PHYSICIANS
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Mass media can effectively play diverse roles in medical communication. Physicians, as
professionals and experts can contribute to improved public health by providing the public
with accurate health related information. Mass media provides a channel through which
physicians may contribute to society by leveraging mass media appearances in positive
ways.
However, the increase in instances of physicians’ frequent appearances on mass media to
recommend unproven treatments or products and to use such appearances for marketing
purposes is posing a serious concern. The public may readily accept groundless
recommendations by physicians and may develop unrealistic expectations. The subsequent
confusion and disappointment can damage the patient-physician-relationship.
This issue is more serious in some countries where there are different systems of
medicine, including alternative medicine.
RECOMMANDATIONS
The WMA recommends the following guidelines regarding mass media appearances by
physicians to prevent them from being involved in commercial activities that may
compromise professional ethics and to contribute to patient safety by ensuring physicians
providing accurate, timely, and objective information.
Accurate and Objective Delivery of Scientifically Proven Medical Information
When appearing in media, physicians shall provide objective and evidence-based
information and shall not recommend medical procedures or products that are not
medically proven or justified.
A physician shall not use expressions that may promote unrealistic patient expectations or
mislead viewers about the function and effect of medical procedures, drugs or other
products.
Physicians shall include important information including possible adverse effects and risks
when explaining medical procedures, drugs, or other products.
S-2015-07-2015 ⏐ Moscow
Promotional Mass Media Appearances by Physicians
Not Abusing Mass Media as a Means of Advertisement
Physicians should not recommend specific products by either specifically introducing or
intentionally highlighting the name or trademark of a product.
Physicians shall practice prudence regarding personal appearances on home shopping
programs.. The physician should have no financial stake in the products being sold.
Physicians shall not be a part of mass media advertisement on any product, which is
harmful to human, and/or environment.
Maintaining Professional Integrity
Physicians shall not require or receive economic benefits for mass media appearances
other than a customary appearance fee.
Physicians shall not provide economic benefits to broadcasting personnel in order to
secure mass media appearances.
Physicians shall not engage in the promotion, sale or advertising of commercial products
and shall not introduce false or exaggerated statements regarding their qualifications such
as academic background, professional experience, medical specialty and licensure as a
specialist, for the benefit of the economic interests of any commercial entity.
Handbook of WMA Policies
World Medical Association S-2015-08-2021
WMA STATEMENT
ON
TRADE AGREEMENTS AND PUBLIC HEALTH
Adopted by the 200th
WMA Council Session, Oslo, April 2015
and amended by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
Trade agreements are treaties between two or more countries which include provisions
addressing trade in goods and/or services. Trade agreements are tools of globalization and
typically seek to promote global wealth through trade liberalization. They can have significant
implications for the social, commercial, political and ecological determinants of health as well
as the delivery of health care.
International trade contributes significantly to increases in national wealth which is a key factor
in building strong health care systems.
While trade agreements are designed to produce economic benefits and global wealth, it is
fundamental to identify public health implications that may arise from these agreements.
Negotiations should take into account broad impact to ensure that the right to health and to a
healthy natural and social environment are well-prioritized. Trade agreements should be
directed at contributing to global health and equity.
Trade agreements may have the ability to promote the health and wellbeing of all people when
they are well-designed to protect health and preserve the ability of governments to legislate,
regulate and plan for health promotion, health care delivery and health equity.
Recent trade agreement negotiations have sought to establish a new global governance
framework for trade and have been unprecedented in their size, scope and secrecy. A lack of
transparency and the selective sharing of information with a limited set of stakeholders are anti-
democratic.
There must be recognition of the importance of innovation sharing in public health. This is
particularly important during health emergencies. Access to medicines and medical supplies is
essential to address the major public health problems such as pandemics and trade agreements
must not act as a barrier to that access.
Trade Agreements and Public Health
London S-2015-08-2021
Investor-state dispute settlement (ISDS) provides a mechanism for investors to bring claims
against governments and seek compensation, operating outside existing systems of
accountability and transparency. ISDS in existing trade agreements has been used to challenge
evidence-based public health measures including tobacco plain packaging. Inclusion of a broad
ISDS mechanism could threaten public health actions designed to support evidence-based
tobacco control, alcohol control, healthy and safe food consumption including regulation of
obesogenic foods and beverages, access to medicines, health care services, environmental
protection/climate change and occupational / environmental health protections. Efforts by
industry to challenge domestic public health laws and regulation have targeted nations with
limited access to legal resources and some of the world’s most vulnerable populations.
Access to affordable medicines is critical to controlling the global burdens of communicable
and non-communicable diseases. The World Trade Organization’s Agreement on Trade-
Related Aspects of Intellectual Property Rights (TRIPS) established a set of common
international rules governing the protection of intellectual property including the patenting of
pharmaceuticals. TRIPS safeguards and flexibilities including compulsory licensing seek to
ensure that patent protection does not supersede public health.
The WMA Statement on Patenting Medical Procedures states that patenting of diagnostic,
therapeutic and surgical techniques is unethical and “poses serious risks to the effective practice
of medicine by potentially limiting the availability of new procedures to patients.”
Trade agreements should not pose a new difficulty in accessing medicines, especially for
developing countries and for the most vulnerable populations.
There must be a fair balance established between the prices of medicines and the protection of
intellectual property through patents.
The WMA considers that patenting on medicines/vaccines must be regulated in accordance
with the ethical principles and values of the medical profession in order to ensure effective and
global action for public health and therefore recognizes that it may be necessary to temporarily
waive patents in times of public health emergencies. Moreover, to produce fast and
comprehensive results, sustainable solutions for patent issues must be supplemented by the
transfer of technology, knowledge, and manufacturing expertise, global investment in
manufacturing sites, training of personnel, and quality control.
The WMA Resolution on Medical Workforce states that the WMA has recognized the need for
investment in medical education and has called on governments to “…allocate sufficient
financial resources for the education, training, development, recruitment and retention of
physicians to meet the medical needs of the entire population…”
Handbook of WMA Policies
World Medical Association S-2015-08-2021
The WMA Declaration of Delhi on Health and Climate Change states that global climate
change has had and will continue to have serious consequences for health and demands
comprehensive action.
The WMA Declaration on Fair Trade in Medical Products and Devices states that purchasing
policies for medical goods should be fair and ethical, working conditions should be safe and
modern slavery should be eradicated throughout supply chains. Health product manufacturers
should establish a plan for continuity of supply of vital and life-sustaining products to avoid
production shortages whenever possible. This plan should include establishing the necessary
resiliency and redundancy in manufacturing capability to minimize disruptions of supplies.
RECOMMENDATIONS
Therefore, the WMA calls on national governments and constituent member associations to:
1. Call for transparency and openness in all trade agreement negotiations including public
access to negotiating texts and meaningful opportunities for stakeholder engagement.
2. Call for a proactive assessment of anticipated effects on health, human rights, and the
environment for all trade agreements.
3. Advocate for trade agreements that protect, promote and prioritize public health over
commercial or political interests, and secure services in the public interest, especially those
affecting individual and public health. This should include new modalities of health care
provision including eHealth.
4. Ensure that trade agreements do not have negative impacts on health systems, human
resources for health and universal health coverage (UHC). Ensure trade agreements do not
interfere with governments’ ability to protect and regulate health and health care, or to
guarantee a right to health for all. Government action to protect and promote health should
not be subject to challenge through an investor-state dispute settlement (ISDS) or similar
mechanism.
5. Work to ensure that patents on medicines and vaccines are regulated in accordance with
the principles of medical ethics, in order to protect public health in global emergency
situations.
6. Therefore, urge NMAs to promote the possibility of temporarily waiving patents on
medicines and vaccines to protect public health in global emergency situations while
ensuring fair compensation for the intellectual property of the patent holders, global
investment in manufacturing sites, and knowledge transfer. Promote public health, equity,
solidarity and social justice and protect countries and people who are weaker economically
and health-wise, and therefore most vulnerable.
Trade Agreements and Public Health
London S-2015-08-2021
7. Oppose any trade agreement provisions which would compromise access to health care
services or medicines including but not limited to:
• Patenting (or patent enforcement) of diagnostic, therapeutic and surgical techniques;
• “Evergreening”, or patent protection for minor modifications of existing drugs;
• Patent linkage or other patent term adjustments that serve as a barrier to generic entry
into the market;
• Data exclusivity for biologics;
• Any effort to undermine TRIPS safeguards or restrict TRIPS flexibilities including
compulsory licensing;
• Limits on clinical trial data transparency.
8. Oppose any trade agreement provision which would reduce public support for or facilitate
commercialization of medical education.
9. Oppose any trade agreement which would facilitate the inappropriate privatization of public
services in areas such as conservation of natural environment, education, healthcare, and
daily necessities such as energy and water.
10. Ensure that trade agreements promote environmental protection and support efforts to
reduce activities that cause climate change.
11. Ensure that trade agreements promote equity and human rights and include mechanisms for
accountability following implementation.
Handbook of WMA Policies
S-2016-01-2016 ⏐ World Medical Association
WMA STATEMENT
ON AGEING
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
The world is undergoing a longevity extension at an unprecedentedly rapid pace. Over the
last century, some 30 years have been added to global average Life Expectancy at Birth
(LEB) – with more gains expected in the future. By 2050, LEB is projected to reach 74
years with an ever-increasing number of countries reaching 80 years and beyond. In 1950
the total number of people aged 80+ was 14 million – by 2050 the estimated number is
384 million, a 26-fold increase. The proportion of elderly will more than double from 10%
in 2015 to 22% of the total population in 2050. These improvements are very variable;
many of the poorest communities in all countries and a larger percentage of the population
in the poorest countries have gained little in terms of life expectancy over this period of
time.
The increase in longevity has been paired with a decreasing number of children,
adolescents and younger adults as more and more countries experience Total Fertility
Rates below replacement level, raising the average age in these countries.
The challenges of aging in developing countries are complicated by the fact that basic
infrastructure is not always in place. In some cases, populations in developing countries
are aging more quickly than infrastructure is being developed.
Longevity is arguably the greatest societal achievement of the 20th century but it could
turn into a major problem during the 21st century. The World Health Organization (WHO)
defines Active Ageing as “the process of optimizing opportunities for Health, Lifelong
learning, Participation and Security in order of enhancing quality of life as individuals
age”. This definition presupposes a life course perspective as the determinants that
influence active ageing operates throughout the life course of an individual. These are
social determinants of health and include behavioral determinants (life-styles), personal
determinants (not only hereditary factors which are, overall, responsible for no more than
25% of the chances of ageing well but also psychological characteristics), the physical
environment where one lives as well as broad social and economic determinants. All of
these act individually on the prospects of active ageing but also interact among
themselves: the more they interact and overlap, the higher the chance of an individual
ageing actively. Gender and culture are crosscutting determinants, influencing all the
others.
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GENERAL PRINCIPLES
Medical Expenses
There is strong evidence that chronic diseases increase the use (and costs) of health
services rather than age per se.
However, chronic conditions and disabilities become more prevalent with advancing age –
therefore health care use and spending rise in tandem with age.
In many countries health care spending for older persons has increased over the years as
more interventions and new technologies have become available for problems common in
older age.
Effect of Ageing on Health Systems
Health care systems face two major challenges in the longevity revolution: preventing
chronic disease and disability and delivering high quality and cost-effective care that is
appropriate for individuals regardless of age.
In less developed regions the disease burden in old age is higher than in more developed
regions.
Special Health Care Considerations
The leading diseases contributing to disability in all regions are cardiovascular diseases,
cancers, chronic respiratory diseases, musculoskeletal disorders, and neurological and
mental diseases, including the dementias. Some common conditions in older age are
especially disabling and require early detection and management.
Chronic diseases common among older people include diseases preventable through
healthy behaviors and/or lifestyle interventions and effective preventive health services –
typically cardiovascular disease, diabetes, chronic obstructive pulmonary disease and
many types of cancer. Other diseases are more closely linked to ageing processes and are
not understood well enough to prevent them – such as dementia, depression and some
musculoskeletal and neurological disorders.
While research may eventually lead to effective disability prevention or treatment, early
management is key to controlling disability and/or maintaining quality of life.
Older persons may be more vulnerable to the effects of accidents within and outside the
home. This will include risks when operating machinery such as road vehicles, but also
risks from handling other potentially dangerous equipment. As older people continue to
work these risks must be assessed and managed. Those who suffer injuries may have their
recovery complicated by other medical vulnerabilities and comorbidities.
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Ageing
Considerations for Health Care Professionals
Health care for elderly people usually requires a variety of professionals working as an
articulated team.
Education and training of health professionals to treat and manage the conditions common
in the elderly are generally not sufficiently emphasized in undergraduate curricula.
Reducing Impact on Health Care
A comprehensive continuum of health services needs to be adopted urgently as population
age. It should include health promotion, disease prevention, curative treatments,
rehabilitation, management and prevention of decline, and palliative care.
Different types of health care providers offer these services, from self and family/informal
care – sometimes in a voluntary capacity – to community-based providers and institutions.
Establishing Optimal Health Care Systems
Universal Health Care coverage ideally should be provided to all, including elderly
people.
The vast majority of health problems can and should be dealt with at the community level.
In order to provide optimal community care and ensure care coordination over time it is
critical to strengthen Primary Health Care (PHC) services.
In order to strengthen PHC to promote active ageing, WHO advanced evidence-based
principles for age-friendly PHC in three areas which should be considered:
information/education/communication/ training, health management systems and the
physical environment.
The health sector should encourage health systems to support all such dimensions of care
provided to individuals as they age given the importance of health to ensure quality of life.
Specificities of Health Care
Many formal systems of health care have been developed with an emphasis on “acute or
catastrophic care” of a much younger population, often focused on communicable diseases
and/or injuries. Health systems should emphasize other needs, especially chronic diseases
management and cognitive decline, when treating the elderly.
While acute care services are essential for people of all ages, but they are not focused on
keeping people healthy or providing the ongoing support and care required to manage
chronic conditions. A paradigm shift is needed to avoid treating chronic diseases as if they
were acute conditions.
Medical conditions in older age often occur simultaneously with social problems and both
Handbook of WMA Policies
S-2016-01-2016 ⏐ World Medical Association
need to be considered by health professionals when providing health care. Doctors,
particularly specialists, should bear in mind that elderly patients may have other
concurrent chronic diseases or comorbidities that interact with each other and that their
treatment should not lead to inadvertent and preventable induction of complications.
When initiating a pharmacologic treatment for chronic disease in an elderly patient,
prescribers should generally start low (doses) and go slow (increasing the doses) to
accommodate the specific needs of the patient.
If the patient cannot decide for him/herself, due to the high prevalence of memory and
cognitive problems in old age, physicians treating elderly patients should actively
communicate with the family, and frequently with the formal caretaker, to better educate
them about the patient’s health condition and about medication administration, in order to
avoid complications.
When considering different therapeutic options, physicians should always seek to find out
the wishes of the patient and recognize that for some patients quality of life will be more
important than the potential results of more aggressive treatment options.
Education and Training for Physicians
All physicians should be appropriately trained to diagnose and treat the health problems of
older people, which means mainstreaming ageing in the medical curriculum.
Secondary health care for the elderly should be provided as necessary. It should be
holistic, including taking into consideration psychosocial as well as environmental
aspects. Physicians should also be aware of the risks of elder abuse and measures to be
taken when abuse is identified or suspected. (See the WMA Declaration of Hong Kong on
the Abuse of the Elderly.)
Every doctor, particularly general practitioners, should have access to information and
undergo training to identify and prevent polypharmacy and adverse drugs interactions that
may be more common in elderly patients.
Continuing medical education on topics relevant to the ageing patient should be
emphasized in order to help physicians adequately diagnose, treat, and manage the
complexities of caring for an ageing population.
Handbook of WMA Policies
S-2016-02-2016 ⏐ World Medical Association
WMA STATEMENT
ON
CYBER-ATTACKS ON HEALTH AND OTHER CRITICAL
INFRASTRUCTURE
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
1. Advancements in modern information technology (IT) pave the way for
improvements in healthcare delivery and help streamline physician workflow,
from medical record keeping to patient care. At the same time, implementing new
and more sophisticated IT infrastructure is not without its challenges and risks,
including cyber-attacks and data breaches.
2. Cyber security threats are an unfortunate reality in an age of digital information
and communication. Attacks on critical infrastructure and vital assets of public
interest, including those used in the fields of energy, food and water supply,
telecommunications, transportation and healthcare, are on the rise and pose a
serious threat to the health and well-being of the general public.
3. With the proliferation of electronic medical records and billing systems, the
healthcare sector is especially susceptible to cyber intrusions and has become a
prime soft target for cyber criminals. Healthcare institutions and business partners,
from the smallest of private practices to the largest of hospitals, are vulnerable not
only to the theft, alteration and manipulation of patients’ electronic medical and
financial records, but also to increasingly sophisticated system breaches that could
jeopardise their ability to provide care for patients and respond to health
emergencies. Especially disconcerting is the threat posed to a patient’s
fundamental right to data privacy and safety. In addition, repairing the damage
caused by successful cyber-attacks can entail significant costs.
4. Patient data also demands protection because it often contains sensitive personal
information that can be used by criminals to access bank accounts, steal identities,
or obtain prescriptions illegally. For this reason, it is worth far more on the black
market than credit card information alone. Alterations to or abuse of patient data in
the case of a breach can be detrimental to the health, safety and material situation
of patients. In some cases, breaches can even have life-threatening consequences.
5. Current security procedures and strategies in the healthcare sector have generally
not kept pace with the volume and magnitude of cyber-attacks. If not adequately
protected, hospital information systems, practice management systems or control
systems for medical devices can become gateways for cybercriminals. Radiology
imaging software, video conferencing systems, surveillance cameras, mobile
Handbook of WMA Policies
S-2016-02-2016 ⏐ World Medical Association
devices, printers, routers and digital video systems used for online health
monitoring and remote procedures are just some of the many IT structures at risk
of being compromised.
6. Despite this danger, many healthcare organisations and institutions lack the
financial resources (or the will to provide them) and the administrative or technical
skills and personnel required to detect and prevent cyber-attacks. They may also
fail to adequately communicate the seriousness of cyber threats both internally and
to patients and external business partners.
RECOMMENDATIONS
• The WMA recognises that cyber-attacks on healthcare systems and other critical
infrastructure represent a cross-border issue and a threat to public health. It
therefore calls upon governments, policy makers and operators of health and other
vital infrastructure throughout the world to work with the competent authorities for
cyber security in their respective countries and to collaborate internationally in
order to anticipate and defend against such attacks.
• The WMA urges national medical associations to raise awareness among their
members, health care institutions and other industry stakeholders about the threat
of cyber-attacks and to support an effective, consistent healthcare IT strategy to
protect sensitive medical data and to assure patient privacy and safety.
• The WMA underscores the heightened risk of cyber intrusions and other data
breaches faced by the healthcare sector and urges medical institutions to
implement and maintain comprehensive systems for preventing security breaches,
including but not limited to providing training to ensure employee compliance with
optimal data handling practices and to maintain security of computing devices.
• In the event of a data security breach, healthcare institutions should have proven
response systems in place, including but not limited to notifying and offering
protection services to victims and implementing processes to correct errors in
medical records that result from malicious use of stolen data. Data breach
insurance policies could be considered as a precautionary measure for defraying
the costs associated with a potential cyber intrusion.
• The WMA calls upon physicians, as guardians of patient safety and data
confidentiality, to remain aware of the unique challenge cyber-attacks could pose
to their ability to practice their profession and to take all necessary measures that
have been shown to safeguard patient data, patient safety and other vital
information.
• The WMA recommends that undergraduate and postgraduate medical education
curricula include comprehensive information on how physicians can use modern
IT and electronic communications systems to full advantage, while still ensuring
data protection and maintaining the highest standards of professional conduct.
• The WMA acknowledges that physicians and healthcare providers may not always
S-2016-02-2016 ⏐ Taipei
Cyber-Attacks on Health
have access to the resources (including financial), infrastructure and expertise
required to establish fail-safe defence systems and stresses the need for the
appropriate public as well as private bodies to support them in overcoming these
limitations.
Handbook of WMA Policies
S-2016-03-2016 ⏐ World Medical Association
WMA STATEMENT
ON
DIVESTMENT FROM FOSSIL FUELS
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
• As noted by the 65th World Medical Assembly in Durban in 2014, physicians
around the world are aware that fossil fuel air pollution reduces quality of life
for millions of people worldwide, causing a substantial burden of disease,
economic loss, and costs to health care systems.
• According to World Health Organization data, in 2012, approximately “7
million people died, one in eight of total global deaths, as a result of air
pollution” (WHO, 2014).
• The United Nations’ Intergovernmental Panel on Climate Change (IPCC) notes
that global economic and population growth, relying on an increased use of
coal, continues to be the most important driver of increases in Carbon Dioxide
emissions. These emissions are the major component of an accelerating the
amount of human fossil fuel Greenhouse Gas (GHG) emissions despite the
adoption of climate change mitigation policies (IPCC, 2014).
• The burden of disease arising from Climate Change will be differentially
distributed across the globe and, while it will affect everyone, the most
marginal populations will be the most vulnerable to the impacts of climate
change and have the least capacity for adaptation.
BACKGROUND
• In many densely settled populated cities around the world, the fine dust measurable
in the air is up to 50 times higher than the WHO recommendations. A high volume
of transport, power generated from coal, and pollution caused by construction
equipment are among the contributing factors (WMA, SMAC 197, Air Pollution
WMA Statement on the Prevention of Air pollution due to Vehicle Emissions
2014).
• Evidence from around the world shows that the effects of climate change and its
extreme weather are having significant and sometimes devastating impacts on
human health. Fourteen of the 15 warmest years on record have occurred in the
first 15 years of this century (World Meteorological Organization 2014). The
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Divestment from Fossil Fuels
vulnerable among us including children, older adults, people with heart or lung
disease, and people living in poverty are most at risk from these changes.
• The WMA notes the Lancet Commission’s description of Climate Change as “the
greatest threat to human health of the 21st century”, and that the Paris agreement at
COP21 on Climate calls upon governments “when taking action on climate
change” to “respect, promote and consider their respective obligations on human
rights (and) the right to health”.
• As the WMA states in its Delhi Declaration on Health and Climate Change,
“Although governments and international organizations have the main
responsibility for creating regulations and legislation to mitigate the effects of
climate change and to help their populations adapt to it, the World Medical
Association, on behalf of (…) its physician members, feels an obligation to
highlight the health consequences of climate change and to suggest solutions. (…)
The WMA and NMAs should develop concrete actionable plans/practical steps” to
both mitigate and adapt to climate change (WMA 2009).
RECOMMENDATIONS
The WMA recommends that its national medical associations and all health organizations:
1. Continue to educate health scientists, businesses, civil society, and governments
concerning the benefits to health of reducing greenhouse gas emissions and
advocate for the incorporation of health impact assessments into economic policy.
2. Encourage governments to adopt strategies that emphasize strict environmental
regulations and standards that encourage energy companies to move toward
renewable fuel sources.
3. Begin a process of transferring their investments, when feasible without damage,
from energy companies whose primary business relies upon extraction of, or
energy generation from, fossil fuels to those generating energy from renewable
energy sources.
4. Strive to invest in companies upholding the environmental principles consistent
with the United Nations Global Compact (www.unglobalcompact.org), and refrain
from investing in companies that do not adhere to applicable legislation and
conventions regarding environmental responsibility.
Handbook of WMA Policies
S-2016-04-2016 ⏐ World Medical Association
WMA STATEMENT
ON
ETHICAL CONSIDERATIONS IN GLOBAL MEDICAL ELECTIVES
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
1. Medical trainees are increasingly participating in global educational and service
experiences, commonly referred to as ‘international medical electives’ (IMEs).
These experiences are normally short term, i.e., less than 12 months, and are often
undertaken in resource-limited settings in low-and middle-income countries.
2. Although IMEs can provide valuable learning experience, this must be weighed
against the potential risks to the host community, the sponsor organization and the
visiting trainee. Successful placements help to ensure that there are mutual benefits
for all parties and are built upon an agreed understanding of concepts including
non-maleficence and justice.
3. Published ethical guidelines, such as the Ethics and Best Practice Guidelines for
Training Experiences in Global Health by the Working Group on Ethics
Guidelines for Global Health Training (WEIGHT), call on sponsor institutions
(i.e., universities and organizations facilitating electives) to commit to sustainable
partnerships with host institutions and local communities. All parties are also
called upon to work collaboratively in creating professional guidelines and
standards for medical electives.
4. In turn, trainees undertaking IMEs must adhere to relevant ethical principles
outlined in WMA ethical documents, including the WMA’s Declaration of
Geneva, the WMA International Code of Medical Ethics and the WMA Statement
on the Professional and Ethical Use of Social Media.
RECOMMENDATIONS
Therefore the WMA recommends that:
• Sponsor institutions work closely with host institutions and local communities to
create professional and ethical guidelines on best practices for international
medical electives. Both institutions should be actively engaged in guideline
development. The sponsor organization should evaluate the proposed elective
using such standards prior to approval.
• Guidelines should be appropriate to local context and endorse the development of
S-2016-04-2016 ⏐ Taipei
Global Medical Electives
sustainable, mutually-beneficial and just partnerships between institutions and the
patients and the local community, with their health as the first consideration. These
must take account of best practice guidelines, already available in many countries.
• Guidelines must hold patient and community safety as paramount, and outline
processes to ensure informed consent, patient confidentiality, privacy, and
continuity of care as outlined in the WMA International Code of Medical Ethics.
• Guidelines should also outline processes to protect the safety and health of the
trainee, and highlight the obligations of the sponsor and host institutions to ensure
adequate supervision of the trainee at all times. Institutions should consider means
of addressing possible natural disasters, political instability, and exposure to
disease. Emergency care should be available.
• Sponsor and host institutions have a responsibility to ensure that IMEs are well
planned, including, at a minimum, appropriate pre-departure briefings, which
should include training in culture and language competency and explicit avoidance
of any activity which could be exploitative, provision of language services as
required, and sufficient introduction and guidance at the host institution. Post-
departure debriefing should be planned on return of the trainee, including
reviewing ethical situations encountered and providing appropriate emotional and
medical support needed.
• It is expected that the trainee will receive feedback and assessment for the
experience so that he/she can receive academic credit. The trainee should have the
opportunity to evaluate the quality and utility of the experience.
• Trainees must be fully informed of their responsibility to follow instructions given
by local supervisors, and to treat local host staff and patients with respect.
• These guidelines and processes should be reviewed and updated on a regular basis
as sponsor and host institutions develop more experience with one another.
• National Medical Associations should develop best practices for international
medical electives, and encourage their adoption as standards by national or
regional accrediting bodies, as feasible, and their implementation by sponsor and
host institutions.
Handbook of WMA Policies
S-2016-05-2016 ⏐ World Medical Association
WMA STATEMENT
ON
OBESITY IN CHILDREN
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Childhood obesity is a serious medical condition and a major public health concern
affecting many children. Childhood obesity is emerging as a growing epidemic and is a
challenge in both developed and developing countries. Due to its increasing prevalence
and its immediate and long-term impact on health, including predisposition to diabetes and
cardiovascular abnormalities, childhood obesity should be viewed as a serious concern for
public health. The increase in childhood obesity may be attributed to many factors:
1. Recent studies show that marketing targeted at children has a wide influence on the
shopping trends and food preferences of households all over the world. Special
offers, short-term price reductions and other price promotions and advertising on
social as well as traditional media all play a role in increasing product demand.
2. Many advertisements are in conflict with nutritional recommendations of medical
and scientific bodies. TV advertisements for food and drink products with little or
no nutritional value are often scheduled for broadcast hours with a large
concentration of child viewers and are intended to promote the desire to consume
these products regardless of hunger. Advertisements increase children’s emotional
response to food and exploit their trust. These methods and techniques are also
used in non-traditional media, such as social networks, video games and websites
aimed at children.
3. Unhealthy dietary patterns, together with a sedentary lifestyle and lack of exercise,
contribute to childhood obesity. The sedentary lifestyle is the most predominant
one in the developed world today. Many children typically spend more time than
ever in front of screens, rarely engaging in physical activities.
4. International corporations and conglomerates that manufacture foods and
beverages are not always subject to regional regulations that govern food labeling.
Concern for profits may come at the expense of corporate responsibility for
environmental and public health issues.
5. Products containing large amounts of added sugar, fat, and salt can be addictive,
especially when combined with flavor enhancers. In some countries, not all
ingredients are required to be listed on food labels and manufacturers often refuse
to release data on methods employed to maximize consumption of their products.
Handbook of WMA Policies
S-2016-05-2016 ⏐ World Medical Association
Governments should require that all ingredients in food and beverages be clearly
labeled, including those proprietary ingredients intended to increase consumption
of the product.
6. Socioeconomic disparities also correlate with increasing rates of childhood
obesity. The link between living in poverty and early childhood obesity continues
to negatively affect health in adult life.[1] Exposure to environmental
contaminants, sporadic medical checkups, insufficient access to nutritious foods
and limited physical activity lead to obesity and other chronic illnesses that are all
more prevalent among children living in poverty.
RECOMMENDATIONS
1. A comprehensive program is needed to prevent and address obesity in all segments
of the population, with a specific focus on children. The approach must include
initiatives on price and availability of nutritious foods, access to education,
advertising and marketing, information, labeling and other areas specific to regions
and countries. An approach similar to that on tobacco in the WHO Framework
Convention on Tobacco Control is advocated.
2. International studies stress the importance of adopting an integrated approach to
education and health promotion. Investment in education is key to minimizing
poverty, improving health and providing economic benefits.
3. Quality education offered in formal settings to children aged 2 to 3 years,
combined with enrichment activities for parents, and sufficient supply of nutritious
food and beverages may help to reduce the rate of adolescent obesity and reduce its
health implications throughout the life course. Developing early healthy eating
practices and experiencing flavors of healthy food when very young appear to be
positive factors in prevention of childhood obesity.
4. Governments should invest in education related to menu design, food shopping
including budget setting, storage and preparation so that people are better equipped
to plan their food intake.
5. Governments should seek to regulate the availability of food and beverages of poor
nutritional value, by a range of methods including price. Attention should be paid
to the availability close to schools of establishments selling products of poor
nutritional quality. Governments should seek to persuade manufacturers to
reformulate products to reduce their obesogenic effects. Where possible
government and local authorities should seek to manage the density of such
establishments in the area.
6. Governments should consider imposing a tax on non-nutritious foods and sugary
drinks and use the additional revenue to fund research and epidemiological studies
aimed at preventing childhood obesity and reducing the resulting disease risk.
7. Ministries of health and education should regulate food and beverages that are sold
and served at educational and healthcare facilities.
S-2016-05-2016 ⏐ Taipei
Obesity in Children
8. Given the scientifically proven link between the extent of media consumption and
adverse effects on body weight in children, the WMA recommends that the
advertising of non-nutritious products be restricted during television programming
and other forms of media that appeal to children. Regulators should be aware that
children access television programs designed for adults and ensure that legislation
and regulation also limits marketing associated with such programs.
9. Governments should work with independent health experts to produce sound
guidance on food and nutrition, with no involvement of the food and drink
industry.
10. Governments and local authorities should subsidize and encourage activities that
promote good health among their residents, including providing safe spaces for
walking, bike riding and other forms of physical activity.
11. Parents have a crucial role in fostering physical activity in their children. Schools
should incorporate daily physical activity into their daily routine. Participation in
sport activities should be possible for everyone regardless of their economic
situation.
12. National Medical Associations should support or develop guidelines and
recommendations to ensure that they reflect current knowledge of prevention and
treatment of childhood obesity.
13. National Medical Associations should work to raise public awareness on the issue
of childhood obesity and highlight the need to tackle the rising prevalence of
obesity and its health and economic burden.
14. Clinics and Health Maintenance Organizations should employ appropriately
trained professionals to offer classes and consultation in selecting appropriate
amounts of nutritious foods and beverages and attaining optimal levels of physical
activity for children. They should also ensure that their premises are exemplars in
the provision of healthy food options.
15. Educational facilities should employ appropriately trained professionals who
educate for healthy lifestyles from an early age and allow all children, whatever
their social environment, to practice regular physical activities.
16. Physicians should guide parents and children in how to live healthy lives and
emphasize the importance of doing so, and must identify as soon as possible
obesity in their patients, particularly children. They should direct patients suffering
from obesity to the appropriate services at the earliest possible stage, and conduct
regular follow-ups.
17. Physicians and health professionals should be educated in nutrition assessment,
obesity prevention and treatment. This could be accomplished by strengthening
CME activities focused on nutritional medicine.
Handbook of WMA Policies
S-2016-05-2016 ⏐ World Medical Association
[1] WHO Commission on Social Determinants of Health (Closing the Gap in a
Generation) 2008.
Handbook of WMA Policies
World Medical Association S-2016-06-2022
WMA STATEMENT
ON
OCCUPATIONAL AND ENVIRONMENTAL HEALTH AND SAFETY
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Occupational and environmental health and safety (OEHS) is an integral part of public health,
and the primary health care (PHC) system in particular, since it is often the first level of contact
of individuals, the family and the community with a health system, bringing health care as close
as possible to where people live and work.
Workers represent at least half of the world’s population and are the backbone of many
economies, but many may have inadequate access to occupational and environmental health
services and do not operate in a safe working environment.
The International Labour Organization (ILO) defines decent work as opportunities for work
that are productive and deliver fair income with dignity, equality, and within safe working
conditions. Despite the fact that the right to decent work is recognized in the Universal
Declaration of Human Rights, every 15 seconds, a worker dies from a work-related accident or
disease , resulting in an annual 4% loss in global GDP.
Despite this, the proportion of work accidents and occupational diseases that are recorded and
reported worldwide is incredibly small. It is estimated that less than 1% of occupational
diseases are recorded.
Additionally, as many workers face greater pressures to meet the demands of working life,
many of them are at risk to develop work-related stress which may occur when the demands of
the job do not match or exceed the capabilities, resources or needs of the worker or when the
knowledge or abilities of an individual worker or group to cope are not matched with the
expectations of the organizational culture of an enterprise. High-level of stress can result in
health impairments such as burnout, depression, anxiety, cardiovascular disease or even
suicide.
Recently and even more due to the COVID-19 pandemic, the world has witnessed an increased
number of employees working outside the employer’s premises using digital information and
communication technologies either full-time or part-time. Despite some positive aspects, there
are risks associated with this work arrangement as it isolates employees, particularly
individuals living alone and can result in increased levels of stress and anxiety. Extended
Occupational and Environmental Health and Safety
Berlin S-2016-06-2022
working hours and employee availability in addition to diminished boundaries between
personal and professional life may impact work-life balance. A healthy digital working
environment needs to be in place to ensure employee health and safety.
The United Nations Development Programme’s Sustainable Development Goals 3, 5, 8 and 13
call for action in health promotion for all people of all ages, gender equality, decent work and
management of the impact of climate change; OEHS is well positioned to maintain physical,
mental and social well-being for all workers, that will result in poverty reduction, sustainable
development and saving millions of lives every year.
Physicians have a critical role in preventing, diagnosing, monitoring, treating and reporting
work accidents and occupational diseases. In addition, physicians should promote equal, decent
and inclusive work environments for all regardless of age, gender, ethnic origin, nationality,
religion, political affiliation, race, sexual orientation, or the presence of a disability.
Despite many governments and employers’ and workers’ organizations placing greater
emphasis on the prevention of occupational diseases. prevention is not receiving the priority
warranted by the scale and severity of the occupational disease epidemic.
Physicians and medical associations can contribute to the identification of problems,
development of national reporting systems, and formulation of relevant policies in the field of
OEHS.
Unsatisfactory and unsafe working conditions play a significant role in the development of
occupational diseases and injuries, which are subsequently causes of mortality in the working
population.
RECOMMENDATIONS
1. Physicians should play a pivotal role in the development of a workforce that is educated in
and raise workplace awareness about the social determinants of health.
2. The field of occupational and environmental health and safety (OEHS) should be accorded
the necessary importance in both graduate and post-graduate medical studies
3. Physicians must cooperate with the healthcare and occupational authorities to promote
health and safety in the workplace.
4. All workers should have access to risk based OEHS services from the first day of work and
extending beyond the last day at work in order to account for occupational diseases with a
long latency period. Service content should be standardized and the role of physicians in
the planning and implementation of OEHS systems that are essentially
preventive/protective must be recognized.
5. WMA Constituent members should act proactively and encourage the expansion of the
scope of OEHS services, in order to prevent and reduce occupational diseases, and injuries,
Handbook of WMA Policies
World Medical Association S-2016-06-2022
reproductive health issues and protect the environment. They should also promote
workplace gender equality and encourage improvement of recording and reporting systems
for OEHS-related metrics. They should also focus on workforce capacity building, teaching
and training, and collaborative research.
6. WMA Constituent members, together with governments, should take an active role, where
appropriate, in the formulation and development of national systems that facilitate OEHS
prevention, and the recording and reporting of occupational diseases and incidents in their
respective countries.
7. Physicians who are evaluating workers’ compensation patients should be experienced in
occupational and environmental medicine. When a relationship between the diagnosis and
occupational and environmental exposures is established, the physician should report it
through the appropriate reporting system.
8. Occupational diseases and injuries are often addressed in the context of insurance and
compensation. Where these mechanisms are not in place, WMA Constituent members
should advocate for the protection of workers by means of insurance or social security.
9. When rendering services for an employer, physicians should advocate that employers fulfil
the minimum requirements set in the International Labour Organization’s (ILO)
occupational standards, especially when such requirements are not set by national
legislation.
10. Employers should provide a safe working environment, recognising and addressing the
impact of adverse working conditions on individuals and society.
11. Employers should consider promoting and offering essential vaccines to employees.
12. WMA Constituent members should consider forming an internal body for addressing the
problems of physicians working in OEHS and encourage them to contribute to research and
related scientific studies.
13. Governments should collaborate in setting up an international system to assess occupational
hazards and develop strategies to protect the health of workers.
14. Governments should establish legislative frameworks that protect the rights and health of
workers, including reproductive health and health effects of work at home.
15. Governments and NMAs must promote the development of training, information and
research programs in occupational health to their members.
Handbook of WMA Policies
S-2017-01-2017 ⏐ World Medical Association
WMA STATEMENT
ON
BULLYING AND HARASSMENT WITHIN THE PROFESSION
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Workplace bullying has been recognised as a major occupational stressor since the
early 1980s.
2. Workplace bullying is unreasonable and inappropriate behaviour directed towards a
worker or a group of workers that creates a risk to health and safety. By definition,
bullying is behaviour that is repeated over time or occurs as part of a pattern of
behaviour, rather than a single episode. Unreasonable behaviour is what a reasonable
person in the same circumstances would see as unreasonable. It includes behaviour
that intimidates, offends, victimises, threatens, degrades, insults or humiliates.
Bullying can take psychological, social and physical forms. It is not the perpetrator’s
intention, but the victim’s perception, that is key to determining whether bullying has
occurred.
3. Harassment is unwanted, unwelcome or uninvited behaviour that makes a person feel
humiliated, intimidated or offended. Harassment can be related to a person’s ethnicity,
gender, sexual orientation, disability or other factors such as whether a person has
made a complaint.
4. Employers generally have a legal duty to ensure the health, safety and welfare of their
employees. This includes identifying bullying and harassment and taking steps to
eliminate and prevent it. Employees are generally required to take reasonable care for
their own health and safety as well as for the health and safety of others who may be
affected by their acts in the workplace.
5. In recent years, bullying and harassment have become more recognised in the medical
profession; there is good evidence that disruptive behaviour, inappropriate behaviour
and harassment occurs in the medical workplace. International research has shown that
bullying in the healthcare profession is not associated with specialty or sex. It appears
that bullying is widespread and occurs across all specialties and at all levels of
seniority, although it is fair to say that where bullying occurs it is more common to be
inflicted by a more senior employee upon a more junior one. The hierarchical nature of
medicine and the inherent power imbalance associated with this can however create a
culture of bullying and harassment which, in some cases, becomes pervasive and
institutionalized.
6. Workplace bullying can have detrimental effects such as decreased job satisfaction,
depression, anxiety, and absenteeism, all of which impact adversely on staff retention
and quality of patient care.
S-2017-01-2017 ⏐ Chicago
Bullying and Harassment within the Profession
RECOMMENDATIONS
7. The WMA condemns bullying or harassment under any circumstances. It further
believes that raising awareness of inappropriate behaviour, disruptive behaviour and
harassment in the medical profession is an important step in the process of eliminating
the problem. The WMA is of the view that this is an issue of professionalism and it
encourages National Medical Associations (NMAs), medical schools, employers, and
medical colleges to establish and implement anti-bullying and harassment policies.
8. The WMA recommends that NMAs recognise and, where possible, actively address
the following:
8.1 Bullying in the health workplace is an entirely unprofessional and destructive
behaviour and should not be tolerated.
8.2 Steps should be taken to prevent, confront, report and eliminate bullying at any
level.
8.3 Bystanders also have a responsibility to take action.
8.4 There can be significant barriers for junior doctors to speak out about bullying by
senior colleagues, for example fear of career retribution.
8.5 Professionalism is not just how we treat our patients, but how we treat each other
as professional colleagues. Acting professionally means also being vigilant and
stepping in to intervene, for the good of all.
8.6 Bullying is unprofessional, contradicts the fundamentals of the profession and
raises fitness to medical practise concerns.
8.7 Healthcare needs good teams. Eliminating bullying ensures a safer team
environment and a safer healthcare environment for patients.
8.8 It is the responsibility of the management to maintain a good working
environment and address all signs of harassment and bullying. There should be
zero tolerance of bullying and harassment
Handbook of WMA Policies
S-2017-02-2017 ⏐ World Medical Association
WMA STATEMENT
ON
ARMED CONFLICTS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. The duties of physicians in times of armed conflict are set out in the WMA Statement
on Ethical Principles of Health Care in Times of Armed Conflict and Other
Emergencies and WMA Regulations in Times of Armed Conflict and Other Situations
of Violence.
2. Physicians should encourage politicians, governments, and others in positions of
power to be more aware of the consequences, including the impact on health, of their
decisions on the commencement or continuation of armed conflict.
3. Armed conflict damages the health of individuals and of populations as well as critical
infrastructure including health care facilities, housing, potable-water supplies and
sewerage. It also leads to environmental degradation. Such destruction of critical
infrastructure may lead to adverse health consequences including malnutrition, and
infectious or waterborne diseases, such as cholera and typhoid. Warfare also destroys
work-related infrastructure, including factories and manufacturing centres as well as
agriculture. Repair to damaged infrastructure cannot proceed until cessation of the
conflict.
4. Wars start for many different reasons. Efforts to avoid conflicts are often insufficient
and inadequate and country leaders may not seek all alternatives. Avoiding war and
seeking constructive alternatives is always desirable.
5. It is essential that those claiming that a war us a “just war” understand that this is a
rare and extreme circumstance, which must not be overcited. The concept of a “just”
war must not be used to legitimize violence.
6. Warfare and other forms of armed conflict are likely to worsen the suffering of the
poorest and to contribute to the development of large numbers of Internally Displaced
Persons and refugees.
7. Physicians should seek, during conflicts, to influence parties in order to alleviate the
suffering of populations.
RECOMMENDATIONS
8. The WMA believes that armed conflict should always be a last resort. Physicians and
NMAs should alert governments and non-state actors of the human consequence of
S-2017-02-2017 ⏐ Chicago
Armed Conflicts
warfare.
9. Physicians should encourage politicians, governments, and others in positions of
power to be more aware of the consequence of their decisions related to armed
conflict.
10. The WMA recognizes that armed conflict always produces enormous human suffering.
States and other authorities, including non-state actors, who enter into armed conflict
must accept responsibility for the consequences of their actions, and be prepared to
answer for their consequences including to international courts and tribunals and
recommends that authorities recognize and cooperate to ensure this occurs.
11. The WMA recognizes that the impact of armed conflict will be most significant upon
women and vulnerable populations, including children, the young, the elderly and the
poorest members of society. Physicians should seek to ensure that allocation of
medical care resources does not have a discriminatory impact.
12. Physicians must continually remind those in power of the need to provide essential
services to those within areas damaged and disrupted by conflict.
13. After a conflict ends, priority must be given to rebuilding the essential infrastructure
necessary for a healthy life, including shelter, sewerage, fresh water supplies, and food
provision, followed by the restoration of educational and occupational opportunities.
14. The WMA demands that parties to a conflict respect relevant Humanitarian Law and
do not use health facilities as military quarters, nor target health institutions, workers
and vehicles, and respect established International Humanitarian Law (IHL) and do not
use health facilities as military quarters, nor initiate attacks against health institutions,
workers and vehicles, or restrict the access of wounded persons and patients to
healthcare, as set out in the WMA Declaration on the Protection of Health Workers in
Situations of Violence.
15. Physicians should work with aid and other agencies to seek to ensure that parties
protect family integrity and, wherever possible, remove people from direct and
immediate danger.
16. Physicians should be aware of the likely prevalence of Post-Traumatic Stress Disorder
(PTSD) and other post-conflict psychosocial and psychosomatic problems and provide
appropriate care and treatment to combatants and civilians.
17. Physicians, including forensic medicine specialists, should help families ensure that
efforts to identify the missing and the dead are not subverted by security forces.
Handbook of WMA Policies
S-2017-03-2017 ⏐ World Medical Association
WMA STATEMENT
ON
MEDICAL CANNABIS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Cannabis is the generic term used to denote psychoactive preparations of the plant
Cannabis sativa, which grows wild in many parts of the world and is known by
numerous other names, such as: “marijuana”, “dagga”, “weed”, “pot”, “hashish”, or
“hemp”.
2. Cannabis for medical use refers to the use of cannabis and its constituents, natural or
synthetic, to treat disease or alleviate symptoms under professional supervision;
however, there is no single agreed upon definition.
3. Recreational cannabis refers to the use of cannabis to alter one’s mental state in a way
that modifies emotions, perceptions, and feelings regardless of medical need.
4. This WMA statement is intended to provide a position on legalisation of cannabis for
medical use and highlight the adverse effects associated with recreational use.
5. Recreational cannabis use is an important health and social issue across the world.
Cannabis is the most commonly used illicit drug in the world. The World Health
Organisation estimates that about 147 million people, 2.5% of the world population,
use cannabis compared with 0.2% using cocaine and 0.2% using opiates.
6. The WMA opposes recreational cannabis use due to serious adverse health effects
such as increased risk of psychosis, fatal motor vehicle accidents, dependency, as well
as deficits in verbal learning, memory and attention. Use of cannabis before the age
of 18 doubles the risk of psychotic disorder. The ominously growing availability of
cannabis or its forms in foodstuffs such as sweets and “concentrates”, which have
enormous appeal to children and adolescent, requires intensive vigilance and policing.
7. National Medical Associations should support strategies to prevent and reduce
recreational cannabis use.
8. Evidence for use of cannabis for medical use
8.1 Cannabinoids are chemical constituents of Cannabis sativa that contain similar
structural features; some of the chemical constituents act on human cannabinoid
receptor cells. Conceptually, cannabinoids that activate these receptors (1) occur
naturally in the human body like other endogenous neurotransmitters
(endocannabinoids); (2) occur naturally in the cannabis plant
S-2017-03-2017 ⏐ Chicago
Medical Cannabis
(phytocannabinoids); or (3) are pharmaceutical preparations containing either
synthetic cannabinoids, (e.g. delta9-tetrahydrocannabinol [dronabinol,
Marinol™], or a related compound, nabilone [Cesamet™], or extracts of
phytocannabinoids (nabiximols [Sativex™]).
8.2 Amongst phytocannabinoids is naturally occurring Cannabis sativa, delta-9-
tetrahydrocannabinol (THC), the main bioactive cannabinoid and the principal
psychoactive constituent, while cannabidiol (CBD) is the second most
abundant. CBD lacks significant psychoactive properties but may possess
analgesic and antiseizure properties.
8.3 The human endocannabinoid system is believed to mediate the psychoactive
effects of cannabis and is involved in a variety of physiologic processes
including appetite, pain-sensation, mood, and memory. The significant medical
and pharmacological therapeutic potential of influencing the endocannabinoid
system has been widely recognized.
8.4 The medical benefits of cannabis reported in scientific literature are widely
debated globally. Cannabis has been used for the treatment of severe spasticity
in multiple sclerosis, chronic pain, nausea and vomiting due to cytotoxics, and
loss of appetite and cachexia associated with AIDS. Evidence suggest that
certain cannabinoids are effective in the treatment of chronic pain, particularly
as an alternative or adjunct to the use of opiates when the development of opiate
tolerance and withdrawal can be avoided. Evidence supporting use of cannabis
for medicinal purposes is of low to moderate quality, and inconsistent. The
inconsistency can be partially attributable to the prohibition of cannabis. Its
classification as an illegal substance in some countries has constrained safe and
high-quality clinical research.
8.5 The short-term adverse effects of cannabis use are well documented. However,
the long-term adverse effects are less well understood, particularly the risk of
dependence and cardiovascular disease. There are also significant public health
concerns for vulnerable populations such as adolescents, and pregnant or
breastfeeding women.
8.6 Despite weak evidence of its medical benefits, cannabis for medical use has
been legalised in some countries. In other countries medical cannabis is
forbidden or under debate.
9. Medical professionals may find themselves in a medico-legal dilemma as they try to
balance their ethical responsibility to patients for whom cannabis may be an effective
therapy and compliance with applicable legislation. This dilemma can manifest itself
both with patients who may medically benefit from the use of cannabis, and those
who are not likely to do so, but pressure the medical professionals to prescribe it.
RECOMMENDATIONS
10. Cannabis Research
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S-2017-03-2017 ⏐ World Medical Association
10.1 In the light of the low-quality scientific evidence on the health effects and
therapeutic effectiveness of cannabis, more rigorous research involving larger
samples is necessary before governments decide whether or not to legalise
medical cannabis for medical purposes. Comparators must include the existing
standards of treatment. Expansion of such research should be supported. Research
should also examine the public health, social and economic consequences of
cannabis use.
10.2 Governments may consider reviewing laws governing access to and
possession of research-grade cannabis for the purpose of allowing well-designed
scientific research studies to broaden the evidence base on the health effects and
therapeutic benefits of cannabis.
11. In countries where cannabis is legalised for medicinal purposes, the following
requirements should apply:
11.1 Requirements for producers and products:
11.1.1 Provision of cannabis plant products for treatment must be in accordance
with the UN Single Convention on Narcotic Drugs from 30 March 1961,
including the Convention’s rules on production, trade, and distribution.
Thus, it is essential that the cannabis included in the products delivered for
medical treatment must be provided and handled in accordance with the
requirements of the Convention.
11.1.2 Requirements must include that the cannabis plants meet appropriate
quality demands for growing and standardization. The produced cannabis
plant products must have a specific indication (interval) of ingredients,
including the content of delta-9-tetrahydrocannabinol (THC) and
cannabidiol (CBD) and strength indication of these.
11.2 Requirements for prescription and dispensing of cannabis for medical
purposes:
11.2.1 Cannabis must be prescribed by an authorised physician/prescriber in
accordance with the best level of evidence and the country’s regulatory
frameworks.
11.2.2 It is recommended that treatment with approved conventional drugs is
undertaken before cannabis products are used for treatment.
11.2.3 Each individual physician must take responsibility for and make a decision
regarding treatment with cannabis products, in accordance with the best
available evidence and country specific registered indications.
11.2.4 Cannabis for medical purposes must only be dispensed at pharmacies or by
authorised dispensers in accordance with the country´s regulatory
frameworks.
11.2.5 Effective control measures must be put in place to impede illicit use of
medical cannabis.
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Medical Cannabis
11.2.6 Public health surveillance systems to monitor prevalence of cannabis use
and trends in utilisation patterns are necessary.
12. In considering policy and legislation on cannabis, governments, NMAs,
policymakers, and other health stakeholders, should emphasize and examine the
health effects and therapeutic benefits based on the available evidence, while also
recognizing various contextual factors such as regulatory capacity, cost-effectiveness,
societal values, social circumstances of the country, and the public health and safety
impact on the wider population.
Handbook of WMA Policies
S-2017-04-2017 ⏐ World Medical Association
WMA STATEMENT
ON
THE COOPERATION OF NATIONAL MEDICAL ASSOCIATIONS
DURING OR IN THE AFTERMATH OF CONFLICTS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. Throughout history, there have been cases of political conflict in which physicians and
the professional bodies that represent them have adopted and reinforced the policies of
their respective governments in violation of medical ethical standards. There have also
been cases of physicians themselves deliberately engaging in criminal activities and
embracing unethical ideologies. Even today, on-going moral and political conflicts can
lead physicians and their representative organisations to overstep ethical boundaries.
2. To prevent such breaches of ethical conduct from occurring, physicians and their
representative organisations have a responsibility to rise above national conflicts, to
foster mutual professional support and to base their actions on the highest medical
ethical standards, including the physician’s primary obligation to the health of
individual patients.
3. All national medical associations and their members have an obligation to uphold the
ethos of medicine, to demonstrate absolute forthrightness and honesty in confronting
historical and ongoing national conflicts, as well as to preserve the lessons gleaned
from all forms of unethical behaviour. This includes maintaining a clear commitment
to human rights, explicitly rejecting racial, religious, gender, sexual orientation and
any other forms of discrimination and actively confronting moral failures of the
medical profession.
4. Physicians have professional and ethical obligations that go beyond ethnic and
national interests. Medical associations have a role to play in bridging the gap between
different groups based on their common medical ethical codes, regardless of political,
religious, ethnic and social background. Medical expertise as represented in the
medical associations could be a powerful agent for re-establishing respect for human
rights in general at times of war and other conflicts.
RECOMMENDATIONS
5. The World Medical Association urges National Medical Associations to:
5.1 Meet regularly in the spirit of enduring friendship and cooperation;
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Cooperation of NMAs during or in the Aftermath of Conflicts
5.2 Take initiative to invite colleagues from medical associations from nations in
conflict to meetings with the intention of re-establishing the contact and
cooperation between the associations;
5.3 Engage in a meaningful exchange of experience and knowledge with the regional
and global medical community in order to maintain the highest levels of ethical
standards and care;
5.4 Ensure that all generations of physicians, including those who have not been
involved in any wrongdoing, are made aware of the vital importance of medical
ethics and the dire consequences of any departure therefrom. This can be
accomplished by including these principles as part of basic medical training (see
WMA Resolution on the Inclusion of Medical Ethics and Human Rights in the
Curriculum of Medical Schools Worldwide) and continuing throughout
physicians’ careers;
5.5 Recognise their obligation to work with each other and with other competent
authorities to keep the memory of any deviations from medical ethics or
violations of human rights alive, in order to prevent them from happening again;
5.6 Promote the preservation and growth of constructive relations in the medical
profession, even in the aftermath of regretful pasts or on-going conflicts. To
achieve this, it is particularly important to engage in continuous communication
in an atmosphere of professional collegiality.
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WMA STATEMENT
ON
EPIDEMICS AND PANDEMICS
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
1. History demonstrates that new diseases may emerge and old diseases re-emerge,
unpredictably. The rapid global movement of people and goods now means that
infections spread globally at unprecedented rates, challenging health systems to
respond in a timely manner. Therefore, quickly recognizing and reacting appropriately
to such epidemics or pandemics must be an international concern, with effective
communication and collaboration between nations.
2. Epidemics may be caused by a variety of infectious agents with different methods of
transmission. These diseases may be self-limiting, may lead to few obvious symptoms
or may cause short or long term, sometimes serious, effects. Relatively minor illnesses
may become life threatening in some vulnerable individuals. This may include the
elderly and the very young as well as those with some degree of compromised
immunity.
3. Investment in public health systems will enhance capacity to effectively detect and to
contain rare or unusual disease outbreaks. Core public health functions are needed as a
foundation for detection, investigation and response to all epidemics. A more effective
global surveillance program will improve response to infectious diseases and will
allow earlier detection and identification of new or emerging diseases. Epidemics and
pandemics have the potential to spread more rapidly in countries with systematically
underfunded and underdeveloped public health systems.
RECOMMENDATIONS
WHO and National Governments
4. The World Health Organization (WHO) has the responsibility for coordinating the
international response to epidemics and pandemics. It has defined phases that allow an
escalating approach to preparedness planning and response as an epidemic evolves.
The WMA recommends:
4.1 WHO should ensure that all relevant data on the development of infectious
diseases and their spread is collected, including working with voluntary bodies or
non-state actors as well as national and local governments who observe
developments in areas where documentation may be limited. A global system of
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Epidemics and Pandemics
data capture and surveillance is essential for tracking infectious diseases and their
consequences.
4.2 WHO should work closely with the Centers for Disease Control in Atlanta and
Europe (CDC and ECDC), National Centres for Disease Control and other
applicable regional public health agencies to examine reports of disease pattern
changes and to declare epidemics and pandemics as soon as they are identified.
Emergence and identification may be on different time scales.
4.3 WHO and others should work with national governments and international
government groups to coordinate responses to emerging and reemerging infectious
diseases.
4.4 WHO should collaborate with national medical associations and other health
authorities to ensure that accurate and timely clinical care guidelines are made
available to physicians and health care providers.
4.5 As infections emerge or reemerge WHO and other UN agencies must ensure that
easy-to-understand information is made available to all people in the affected zone
in local languages, working with governments and other partners. This should
include information on disease prevention, including appropriate information on
optimal hygiene and infection control practices.
4.6 Where diseases lead to the development of birth defects, governments must
provide support to families that are affected.
4.7 A cadre of public health specialists who can offer support during a developing
health emergency should be developed and supported by all national governments.
They and other physicians should be prepared to make themselves available to assist in
epidemic control, according to their relevant skill set.
National Medical Associations (NMAs)
5.1 NMAs should clearly identify their responsibilities during an epidemic including
the extent of their participation in the national epidemic planning process. These
responsibilities should include communicating vital information to the public and
especially to health care professionals.
5.2 Where applicable, NMAs should offer training, information and clinical support
tools to physicians and regional medical associations, working with public health
and educational institutions.
5.3 NMAs should be prepared to advocate for adequate government funding for
supporting the health care workforce and preparing for an epidemic.
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Physicians
6.1 Physicians should be sufficiently educated about transmission risks, infection
control, and concurrent chronic illness management during an epidemic.
6.2 Since physicians will be the first responders, they must remain involved in planning
for epidemics and all stages of epidemic response at the local level.
6.3 Physicians should take all measures necessary to protect their own health and the
health of their staff and co-workers.
6.4 Physicians should assist in primary data collection to monitor epidemics with due
regard to confidentiality and protecting the vulnerable.
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WMA STATEMENT
ON
THE ROLE OF PHYSICIANS IN PREVENTING EXPLOITATION IN
ADOPTION PRACTICES
Adopted by the 68th
General Assembly, Chicago, October 2017
PREAMBLE
• UNICEF’s Convention on the Rights of the Child calls in article 21 for a transparent
and proper adoption process in which the best interests of the child are the principal
concern.
• The Hague Convention on the Protection of Children and Co-operation in Respect of
Inter-Country Adoption (Hague Adoption Convention) establishes safeguards to
ensure that intercountry adoptions take place in the best interests of the child. Its
principles should form the basis for global intercountry adoption practices.
• Physicians may be in touch with children who are going to be adopted, with parents
and/or legal guardians of those children, and with parents who are going to adopt a
child. Because physicians may confront the consequences of exploitation in adoptive
practices, their role is crucial in seeking to ensure adherence to children’s’ rights, and
in particular to article 21 of UNICEF´s Convention on the Rights of the Child.
Professional awareness of the legal adoption process is necessary to protect the rights
and health of the child.
RECOMMENDATIONS
• The WMA condemns all forms of exploitation in child adoption practices.
Unacceptable practices may include criminal acts, including trafficking and sexual
crimes.
• WMA calls on National Medical Associations and physicians to actively participate in
preventing exploitation in adoption practices.
• Physicians should be educated about the nature and importance of their role during the
adoption process. Physicians should become knowledgeable about exploitative
adoption practices and should be aware of resources to help them identify and address
the needs of victims.
• Physicians having contact with families who are adopting minors, should strongly
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Epidemics and Pandemics
encourage them to verify that the adoption practices meet all legal and regulatory
requirements in their jurisdiction.
• The WMA supports providing information to families who are considering adoption
about the existence of networks that may engage in exploitation in adoption practices,
especially when adoption will take place across legal jurisdictions.
• Physicians who have justifiable reason to suspect that a child or adult patient may be
involved in exploitative adoption practices should, according to national regulations,
notify appropriate authorities.
• Physicians should be educated about the existence of tools that may help identify
family members of adopted children, including DNA identification testing.
• The WMA encourages scientific and professional activities that could support local
authorities’ efforts to deter exploitation in adoption practices.
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WMA STATEMENT
ON
BIOSIMILAR MEDICINAL PRODUCTS
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. he expiry of patents for original biotherapeutics has led to the development and
approval of copies, called ‘similar biological medicinal products’ or ‘biosimilars’
that are highly similar to a previously approved biological product, known as the
originator or reference product.
2. In light of the fact that biosimilars are made in living organisms, there may be
some minor differences from the reference medicine, as minor variability is a
characteristic attribute of all biological medicines. The manufacture of biosimilars
is generally more complex than the manufacture of chemically derived molecules.
Therefore, the active substance in the final biosimilar can have an inherent degree
of minor variability. Innovator biologics also have inherent batch-to-batch
variability, and for that reason biosimilars are not always interchangeable with the
reference products, even after regulatory approval.
3. Biosimilars are not the same as generics. A generic drug is an identical copy of a
currently licenced pharmaceutical product that has an expired patent protection and
must contain the ‘same active ingredients as the original formulation’. A biosimilar
is a different product with a similar, but not identical, structure that elicits a similar
clinical response. As a result, biosimilar medicines have the potential to cause an
unwanted immune response. Whereas generics are interchangeable, biosimilars are
not always interchangeable.
4. Biosimilars have been available in Europe for almost a decade following their
approval by the European Medicines Agency (EMA) in 2005. The first biosimilar
was approved by the Food and Drug Administration (FDA) for use in the United
States in 2015.
5. Biosimilar medicines have transformed the outlook for patients with chronic and
debilitating conditions, as it is possible to obtain similar efficacy as that of the
reference product at a lower cost.
6. Biosimilars will also increase availability for patients without access to the bio-
originator. Greater global access to effective biopharmaceuticals can reduce
disability, morbidity, and mortality associated with various chronic diseases.
7. Nonetheless, the potentially lower cost of biosimilars raises the risk that insurers
and health care providers may favor them over the originator product, even when
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Biosimilar Medicinal Products
they may not be appropriate for an individual patient or in situations when they
have not demonstrated adequate clinical equivalence to an original biological
product. The decision to prescribe biosimilars or to switch patients from reference
medicine to a biosimilar must be made by the attending physicians, not by health
insurance companies.
RECOMMENDATIONS
1. National medical associations should work with their governments to develop
national guidance on safety of biosimilars.
2. National medical associations should advocate for delivering biosimilar therapies
that are as safe and effective as their reference products.
3. National medical associations should strive to ensure that physician autonomy is
preserved in directing which biologic product is dispensed.
4. Where appropriate, national medical associations should lobby against allowing
insurers and health funds to require biosimilar and originator product’s
interchangeability, and for safe regulations of interchanging biosimilar medicines
where this is allowed.
5. Physicians must ensure that patient medical records accurately reflect the
biosimilar medicine that is being prescribed and taken.
6. Physicians shouldn’t prescribe a biosimilar to patients already showing success
with the originator product, unless clinical equivalence has been clearly
demonstrated and established and patients are adequately informed and have given
consent. There should be no substitution between biosimilars and other drugs
without the attending physcian’s permission.
7. Physicians should seek to improve their understanding of the distinctions between
biosimilar products that are highly similar to or are interchangeable with an
originator product; raise awareness of the issues surrounding biosimilars and
interchangeability; and promote clearly delineated labelling of biosimilar products.
8. Physicians should remain vigilant and report to the manufacturer, as well as
through the designated regulatory pathways, any adverse events suffered by
patients using originator biological products or biosimilars.
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WMA STATEMENT
ON
THE DEVELOPMENT AND PROMOTION OF A MATERNAL AND
CHILD HEALTH HANDBOOK
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
The WMA believes that both a continuum of care and family empowerment is necessary
to improve the health and wellbeing of the mother and child. The reduction of maternal
mortality ratio and infant deaths was an important objective of the Millennium
Development Goals (MDGs). The reductions of the maternal mortality ratio, neonatal
mortality rate and the under-five mortality rate are important targets to be achieved under
the Sustainable Development Goals (SDGs).
The maternal and child health (MCH) handbook is a comprehensive home-based booklet
designed to provide relevant health information and include integrated mother and child
health records. The MCH handbook covers health records and information on pregnancy,
delivery, neonatal and childhood periods, and child growth and immunizations. The MCH
handbook supports the integration of maternal, neonatal and child health services. The
MCH handbook is not only about health education, but about creating ownership with
women and families.
In 1948, Japan became the first country in the world to create and distribute a maternal
and child health (MCH) handbook, in order to protect and improve the health and
wellbeing of the mother and child.
There are now approximately 40-country versions of the MCH handbook, all adapted to
the local culture and socio-economic context. There are a variety of handbooks and
educational materials concerned to MCH in many countries. The use of MCH handbooks
has helped improve the knowledge of mothers on maternal and child health issues, and has
contributed to changing behaviors during pregnancy, delivery and post-delivery period.
The MCH handbook can promote the health of pregnant women, neonates and children by
using it as a tool for strengthening a continuum of care. Physicians can make better care
decisions, by referring to the patient’s medical history and health-check data recorded in
the MCH handbook. The MCH handbook alone has not been shown to improve health
indicators. The benefits are maximized when women and children have access to relevant
healthcare services based on information recorded in the handbook. Such benefits of the
handbook could be shared globally.
In Japan, a digital handbook is spreading progressively. The digital handbook is expected
to be utilized in a way that protects confidentiality of the patient’s health information.
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Maternal and Child Health Handbook
Some private kindergarten and primary schools request access to the MCH as part of their
admission process, placing pressure on parents and physicians to modify the answers to
questions in the handbook.
RECOMMENDATIONS
1. The WMA recommends that the constituent member associations encourage their
health authorities and health institutions to provide accessible and easy to
understand information regarding maternal and child health. The MCH handbook,
or equivalents, can be an important tool to improve continuity of care and benefit
health promotion for mothers, neonates and children.
2. The WMA recommends that the constituent member associations and medical
professionals promote the adaptation to local setting and the utilization of MCH
handbooks, or equivalents, in order to leave no one behind with respect to SDGs,
especially for non-literate people, migrant families, refugees, minorities, people in
underserved and remote areas.
3. When using a MCH handbook or similar documentation, in either digital or print
form, the confidentiality of the individual health information and the privacy of
mothers and children should be strictly protected. It should be used exclusively to
improve health and wellbeing of mothers, neonates, and children. It should not be
used in the admission procedures of schools.
4. The constituent member associations should promote local research to evaluate the
utilization of the MCH handbooks, or equivalents, and make recommendations to
improve the quality of care in the local setting.
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WMA STATEMENT
ON
GENDER EQUALITY IN MEDICINE
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
• The WMA notes the increasing trend around the world for women to enter medical
schools and the medical profession, and believes that the study and the practice of
medicine must be transformed to a greater or lesser extent in order to support all
people who study to become or practice as physicians, of whatever gender. This is an
essential process of modernization by which inclusiveness is promoted by gender
equality. This statement proposes mechanisms to identify and address barriers causing
discrimination between genders.
• In many countries around the world, the number of women studying and practicing
medicine has steadily risen over the past decades, surpassing 50% in many places.
• This development offers opportunities for action, including in the following areas:
• Greater emphasis on a proper balance of work and family life, while supporting
the professional development of individual physicians.
• Encouragement and actualization of women in academia, leadership and
managerial roles.
• Equalization of pay and employment opportunities for men and women, the
elimination of gender pay gaps in medicine, and the removal of barriers
negatively affecting the advancement of female physicians.
• The issue of women in medicine was previously recognized in the WMA Resolution
on Access of Women and Children to Health Care and the Role of Women in the
Medical Profession which, among other things, called for increased representation and
participation in the medical profession, especially in light of the growing enrolment of
women in medical schools. It also called for a higher growth rate of membership of
women in National Medical Associations (NMAs) through empowerment, career
development, training and other strategic initiatives.
RECOMMENDATIONS
Increased presence of women in academia, leadership and management roles.
• National Medical Associations/Medical Schools/Employers are urged to facilitate the
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establishment of mentoring programs, sponsorship, and active recruitment to provide
medical students and physicians with the necessary guidance and encouragement
necessary to undertake leadership and management roles.
• NMAs should explore opportunities and incentives to encourage both men and women
to pursue diverse careers in medicine and apply for fellowships, academic, senior
leadership and management positions.
• NMAs should lobby for gender equal medical education and work policies.
• NMAs should encourage the engagement of both men and women in health policy
organizations and professional medical organizations.
Work-Life Balance
• Physicians should recognize that an appropriate work-life balance is beneficial to all
physicians, but that women may face unique challenges to work-life balance imposed
by societal expectations concerning gender roles that must be addressed to solve the
issue. Healthcare employers can show leadership and help tackle this imbalance by:
1. Ensuring women who go on maternity leave are able to access all their rights and
entitlements;
2. Introducing programmes which encourage men as well as women to take parental
leave, so that women are able to pursue their careers and men are able to spend
important time with their families.
• Hospitals and other places of employment should strive to provide and promote access
to high quality, affordable, flexible childcare for working parents, including the
provision of onsite housing and childcare where appropriate. These services should be
available to both male and female physicians, recognizing the need for a better work-
life balance. Employers should provide information on available services which
support the compatibility of work and family.
• Hospitals and other places of employment should be receptive to the possibility of
flexible and family-friendly working hours, including part-time residencies, posts, and
professional appointments.
• There is a need for increased research on alternative work schedules and
telecommunication opportunities that will allow flexibility in balancing work-life
demands.
• NMAs should advocate for the enforcement and, where necessary, the introduction of
policy mandating appropriate paid parental leave and rights in their respective
countries.
• Medical workplaces and professional organisations should have fair, impartial and
transparent policies and practices to give all physicians and medical students equal
access to employment, education and training opportunities in medicine.
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Gender Equality in Medicine
Pregnancy and Parenthood
• It should be illegal for employers to ask applicants about pregnancy and/or family
planning in relation to work.
• Employers should assess the risks to pregnant physicians and their unborn children,
when a physician has recently given birth and when she is breastfeeding. Where it is
found, or a medical practitioner considers, that an employee or her child would be at
risk were she to continue with her normal duties, the employer should provide suitable
alternative work for which the physician should receive her normal rate of pay.
Physician should have the right to not work night shifts or on-call shifts during the
later part of pregnancy, without negative consequences on salary, employment or
progression in residency.
• Pregnant physicians should have equal training opportunities in post-graduate training.
• Parents should have the right to take adequate parental leave without negative
consequences on their employment, training or career opportunities.
• Parents should have the right to return to the same position after parental leave,
without the fear of termination.
• Employers and training bodies should provide necessary support to any physician
returning after a prolonged period of absence including parental, maternity and elder-
care leave.
• Mothers should be able to breastfeed (or be given protected time for breast pumping)
during work hours, within the current guidelines from the WHO.
• Workplaces should provide adequate accommodation for women who are
breastfeeding including designated areas for breastfeeding, breast pumping, and milk
storage, which are quiet, hygienic, and private.
Changes in organisational culture
• The medical profession and employers should work to eliminate discrimination and
harassment on the basis of gender and create a supportive environment that allows
equal opportunities for training, employment and advancement.
• Family friendliness should be part of the organizational culture of hospitals and other
places of employment.
Workforce planning and research
• NMAs should encourage governments to take the increasing number of women
entering medicine into consideration in the context of long-term workforce planning.
A diverse workforce is beneficial to the health care system and to patients.
Organizations delivering healthcare should focus on ensuring systems are
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appropriately resourced to ensure that all those working within them are able to deliver
safe care to patients and are appropriately and equitably rewarded. Governments
should also work to counteract negative attitudes and behaviour, bias, and/or outdated
norms and values from organizations and individuals.
• NMAs should encourage governments to invest in research to identify those factors
that drive women and men to choose certain fields of specialization early on in their
medical education and training and strive to address any identified barriers in order to
achieve equal representation of men and women in all fields of medicine.
• NMAs should encourage governments and employers to ensure that men and women
receive equal compensation for commensurate work and strive to eliminate the gender
pay gap in medicine.
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WMA STATEMENT
ON
MEDICAL TOURISM
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
1. Medical tourism is an expanding phenomenon, although to date it has no agreed upon
definition and, as a result, practices and protocols in different countries can vary
substantially. For purposes of this statement, medical tourism is defined as a situation
where patients travel voluntarily across international borders to receive medical
treatment, most often at their own cost. Treatments span a range of medical services,
and commonly include: dental care, cosmetic surgery, elective surgery, and fertility
treatment (OECD, 2011).
2. This statement does not cover cases where a national health care system or treating
hospital sends a patient abroad to receive treatment at its own cost or where, as in the
European Union, patients are allowed to seek care in another EU Member State
according to legally defined criteria, and their home health system bears the costs.
Also not covered is a situation in which people are in a foreign country when they
become ill and need medical care.
3. If not regulated appropriately, medical tourism may have medico-legal and ethical
ramifications and negative implications, including but not limited to: internal brain
drain, establishment of a two-tiered health system, and the spread of antimicrobial
resistance. Therefore, it is imperative that there are clear rules and regulation to govern
this growing phenomenon.
4. Medical tourism is an emerging global industry, with health service providers in many
countries competing for foreign patients, whose treatment represents a significant
potential source of income. The awareness of health as a potential economic benefit
and the willingness to invest in it rise with the economic welfare of countries, and
billions of dollars are invested each year in medical tourism all over the world. The
key stakeholders within this industry include patients, brokers, governments, health
care providers, insurance providers, and travel agencies. The proliferation of medical
tourism websites and related content raise concerns about unregulated and inaccurate
on-line health information.
5. A medical tourist is in a more fragile and vulnerable situation than that of a patient in
his or her home country. Therefore, extra sensitivity on the part of caretakers is needed
at every stage of treatment and throughout the patient’s care, including linguistic and
cultural accommodation wherever possible. When medical treatment is sought abroad,
the normal continuum of care may be interrupted and additional precautions should
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therefore be taken.
6. Medical tourism bears many ethical implications that should be considered by all
stakeholders. Medical tourists receive care in both state-funded and private medical
institutions and regulations must be in place in both scenarios. These
recommendations are addressed primarily to physicians. The WMA encourages others
who are involved in medical tourism to adopt these principles.
RECOMMENDATIONS
General
7. The WMA emphasises the importance of developing health care systems in each
country in order to prevent excessive medical tourism resulting from limited treatment
options in a patient´s home country. Financial incentives to travel outside a patient’s
home country for medical care should not inappropriately limit diagnostic and
therapeutic alternatives in the patient’s home country, or restrict treatment or referral
options.
8. The WMA calls on governments to carefully consider all the implications of medical
tourism to the healthcare system of a country by developing comprehensive,
coordinated national protocols and legislation for medical tourism in consultation and
cooperation with all relevant stakeholders. These protocols should assess the
possibilities of each country to receive medical tourists, to agree on necessary
procedures, and to prevent negative impacts to the country´s health care system.
9. The WMA calls on governments and service providers to ensure that medical tourism
does not negatively affect the proper use of limited health care resources or the
availability of appropriate care for local residents in hosting countries. Special
attention should be paid to treatments with long waiting times or involving scarce
medical resources. Medical tourism must not promote unethical or illegal practices,
such as organ trafficking. Authorities, including government, should be able to stop
elective medical tourism where it is endangering the ability to treat the local
population.
10. The acceptance of medical tourists should never be allowed to distort the normal
assessment of clinical need and, where appropriate, the development of waiting lists,
or priority lists for treatment. Once accepted to treatment by a health care provider,
medical tourists should be treated in accordance with the urgency of their medical
condition. Whenever possible patients should be referred to institutions that have been
approved by national authorities or accredited by appropriately recognised
accreditation bodies.
Prior to travel
11. Patients should be made aware that treatment practices and health care laws may be
different than in their home country and that treatment is provided according to the
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Medical Tourism
laws and practices of the host country. Patients should be informed by the
physician/service provider of their rights and legal recourse prior to travelling outside
their home country for medical care, including information regarding legal recourse in
case of patient injury and possible compensation mechanisms.
12. The physician in the host country should establish a treatment plan, including a cost
estimate and payment plan, prior to the medical tourist’s travel to the host country. In
addition, the physician and the medical tourism company (if any) should collaborate in
order to ensure that all arrangements are made in accordance with the patient´s
medical needs. Patients should be provided with information about the potential risks
of combining surgical procedures with long flights and vacation activities.
13. Medical tourists should be informed that privacy laws are not the same in all countries
and, in the context of the supplementary services they receive, it is possible that their
medical information will be exposed to individuals who are not medical professionals
(such as interpreters). If a medical tourist nonetheless decides to avail him or herself of
these services, he or she should be provided with documentation specifying the
services provided by non-medical practitioners (including interpreters) and an
explanation as to who will have access to his or her medical information, and the
medical tourist should be asked to consent to the necessary disclosure.
14. All stakeholders (clinical and administrative) involved in the care of medical tourists
must be made aware of their ethical obligations to protect confidentiality. Interpreters,
and other administrative staff with access to health information of the medical tourist
should sign confidentiality agreements.
15. The medical tourist should be informed that a change in his or her clinical condition
might result in a change in the cost estimate and in associated travel plans and visa
requirements.
16. If the treatment plan is altered because of a medical need that becomes clear after the
initial plan has been established, the medical tourist should be notified of the change
and why it was necessary. Consent should be obtained from the patient for any
changes to the treatment plan.
17. When a patient is suffering from an incurable condition, the physician in the host
country shall provide the patient with accurate information about his or her medical
treatment options, including the limitations of the treatment, the ability of the
treatment to alter the course of the disease in an appreciable manner, to increase life
expectancy and to improve the quality of life. If, after examining all the data, the
physician concludes that it is not possible to improve the patient’s medical condition,
the physician should advise the patient of this and discourage the patient from
travelling.
Treatment
18. Physicians are obligated to treat every individual accepted for treatment, both local
and foreigner, without discrimination. All the obligations detailed in law and
international medical ethical codes apply equally to the physician in his or her
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encounter with medical tourists.
19. Medical decisions concerning the medical tourist should be made by physicians, in
cooperation with the patient, and not by non-medical personnel.
20. At the discretion of the treating physicians, and where information is available and of
good quality, the patient should not be required to undergo tests previously performed,
unless there is a clinical need to repeat tests.
21. The patient should receive information about his or her treatment in a language he or
she understands. This includes the right to receive a summary of the treatment
progress and termination by the treating physician and a translation of the documents,
as needed.
22. Agreement should be reached before treatment begins, on the transfer of test results
and diagnostic images, back to the home country of the patient.
23. Where possible, communication between the physicians in the host and home country
should be established in order to ensure appropriate aftercare and clinical follow-up of
the medical problems for which the patient was treated.
24. The physician who prepares the treatment plan for the patient should confirm the
diagnosis, the prognosis and the treatments that the medical tourist has received.
25. The patient should receive a copy of his or her medical documents for the purpose of
continuity of care and follow-up in his or her home country. Where necessary, the
patient should be given a detailed list of medical instructions and recommendations for
the period following his or her departure. This information should include a
description of the expected recovery time and the time required before travelling back
to his or her home is possible.
Advertising
26. Advertising for medical tourism services, whether via the internet or in any other
manner, should comply with accepted principles of medical ethics and include detailed
information regarding the services provided. Information should address the service
provider’s areas of specialty, the physicians to whom it refers the benefits of its
services, and the risks that may accompany medical tourism. Access to
licensing/accreditation status of physicians and facilities and the facility’s outcomes
data should be made readily available. Advertising material should note that all
medical treatment carries risks and specific additional risks may apply in the context
of medical tourism.
27. National Medical Associations should do everything in their power to prevent
improper advertising or advertising that is in violation of medical ethical principles,
including advertising that contains incorrect or partial information and/or any
information that is liable to mislead patients, such as overstatement of potential
benefits.
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Medical Tourism
28. Advertising that notes the positive attributes of a specific medical treatment should
also present the risks inherent in such treatment and should not guarantee treatment
results or foster unrealistic expectations of benefits or treatment results.
Transparency and the prevention of conflicts of interest
29. Possible conflicts of interest may be inevitable for physicians treating medical tourists,
including at the behest of their employing institution. It is essential that all clinical
circumstances and relationships are managed in an open and transparent manner.
30. A physician shall exercise transparency and shall disclose to the medical tourist any
personal, financial, professional or other conflict of interest, whether real or perceived,
that may be connected to his or her treatment.
31. A physician should not accept any benefit, other than remuneration for the treatment,
in the context of the medical treatment, and should not offer the medical tourist nor
accept from him or her any business or personal offer, as long as the physician-patient
relationship exists. Where the physician is treating the medical tourist as another fee
paying patient, the same rules should apply as with his/her other fee paying patients.
32. A physician should ensure that any contract with a medical tourism company or
medical tourist does not constitute a conflict of interest with his or her current
employment, or with his or her ethical and professional obligations towards other
patients.
Transparency in payment and in the physician’s fees
33. A treatment plan and estimate should include a detailed report of all costs, including a
breakdown of physician’s fees, such as: consultancy and surgery and additional fees
the patient might incur, such as: hospital costs, surgical assistance, prosthesis (if
separate), and costs for post-operative care.
34. The cost estimate may be changed after the treatment plan has been given only in the
event that the clinical condition of the patient has changed, or where circumstances
have changed in a way that it was impossible to anticipate or prevent. If the pricing
was thus changed, the patient must be informed as to the reason for the change in costs
in as timely a fashion as possible.
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WMA STATEMENT
ON
SUSTAINABLE DEVELOPMENT
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
PREAMBLE
• The WMA believes that health and well-being are dependent upon social determinants
of health (SDHs), the conditions in which people are born, grow, live, work and age.
These social determinants will directly influence the achievement of the United
Nations Sustainable Development Goals (SDGs). Many of the SDG goals, targets and
indicators that have been developed to measure progress towards them, will also be
useful measures of the impact of action is having on improving the SDH and, in
particular, on reducing health inequities.
• This statement builds upon WMA policy on Social Determinants of Health as set out
in the Declaration of Oslo, and upon the basic principles of medical ethics set out in
the Declaration of Geneva.
• The WMA recognizes the important efforts undertaken by the United Nations with the
adoption on 25 September 2015 of the resolution “Transforming our world: the 2030
Agenda for Sustainable Development”. The Sustainable Development Agenda is based
upon five key themes: people, planet, prosperity, peace and partnership and the
principle of leaving no one behind. The WMA affirms the importance of global efforts
on sustainable development and the impact that they can bring to humanity.
• SDGs are built on the lessons learned from successes and failures in achieving the
Millennium Development Goals (MDGs), including inequity in many areas of life.
While there is no overarching concept unifying the SDGs, the WMA believes that
inequity in health and wellbeing encapsulates much of the 2030 Agenda. The WMA
notes that while only SDG 3 is overtly about health, many of the goals have major
health components.
• The WMA recognizes all governments must commit and invest to fully implement the
goals by 2030, in alignment with the Addis Ababa Action Agenda. The WMA also
recognizes the risk that the SDGs might be considered unaffordable due to their
estimated potential cost of between US$ 3.3 and US$ 4.5 trillion a year.
• The WMA emphasises the need for cross and inter-sectoral work to achieve the goals
and believes that health must be addressed in all SDGs and not only under health
specific SDG 3.
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Policy priorities:
• Recognition of Health in All Policies and the Social Determinants of Health / Whole
of Society approach.
• Policy areas that are essential to achieving the SDG 3:
• Patient Empowerment and Patient Safety
• Continuous Quality Improvement in Health Care
• Overcoming the Impact of Aging on Health Care
• Addressing Antimicrobial Resistance
• The safety and welfare of Health care staff
• Ensuring policy alignment among all the UN Agencies and the work of regional
governmental organizations such as EU, African Union, Arab League, ASEAN, and
Organization of American States.
• The WMA commits to support implementation of the other three global agreements
regarding the sustainable development process:
1. The Addis Ababa Action Agenda as the mechanism that will provide the financial
support for the 2030 Agenda.
2. The Paris Agreement is the binding mechanism of the sustainable development
process that sets out a global action plan to put the world on track to avoid
dangerous climate change by limiting global warming to well below 2°C above
pre-industrial levels.
3. The Sendai Framework for Disaster Risk Reduction as the agreement which
recognizes that the State has the primary role to reduce disaster risk but that
responsibility should be shared with local government, the private sector and other
stakeholders.
Recommendations and Commitments
• The WMA commits to work with other intergovernmental organizations, including the
UN, the WHO, healthcare professionals’ organizations and other stakeholders, for the
implementation and follow-up of this Agenda and related international agreements,
and for policy and advocacy alignment.
• The WMA commits to collaborate with its constituent member Associations to support
their work at regional and national levels, and with their governments on the 2030
Agenda implementation.
• The WMA recommends that NMAs create strategies regarding data collection,
implementation, capacity building and advocacy, to enhance policy coherence and to
maximise the 2030 Agenda implementation at national and global levels.
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• The WMA also recommends that NMAs collaborate with development banks, NGOs,
intergovernmental organisations and other stakeholders who are also working to
implement of the 2030 Agenda, especially in their own countries.
• The WMA encourages the UN and the WHO to develop guidelines on how financing
for health will be implemented to reach the targets established by the 2030 Agenda and
the economic implications of NCDs, aging and antimicrobial resistance.
Handbook of WMA Policies
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WMA STATEMENT
ON
AUGMENTED INTELLIGENCE IN MEDICAL CARE
Adopted by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
Artificial Intelligence (AI) is the ability of a machine to simulate intelligent behavior, a
quality that enables an entity to function appropriately and with foresight in its
environment. The term AI covers a range of methods, techniques and systems. Common
examples of AI systems include, but are not limited to, natural language processing
(NLP), computer vision and machine learning. In health care, as in other sectors, AI
solutions may include a combination of these systems and methods.
(Note: A glossary of terms appears as an appendix to this statement.)
In health care, a more appropriate term is “augmented intelligence”, an alternative
conceptualization that more accurately reflects the purpose of such systems because they
are intended to coexist with human decision-making [1]. Therefore, in the remainder of
this statement, AI refers to augmented intelligence.
An AI system utilizing machine learning employs an algorithm programmed to learn
(“learner algorithm”) from data referred to as “training data.” The learner algorithm will
then automatically adjust the machine learning model based on the training data. A
“continuous learning system” updates the model without human oversight as new data is
presented, whereas “locked learners” will not automatically update the model with new
data. In health care, it is important to know whether the learner algorithm is eventually
locked or whether the learner algorithm continues to learn once deployed into clinical
practice in order to assess the systems for quality, safety, and bias. Being able to trace the
source of training data is critical to understanding the risk associated with applying a
health care AI system to individuals whose personal characteristics are significantly
different than those in the training data set.
Health care AI generally describes methods, tools and solutions whose applications are
focused on health care settings and patient care. In addition to clinical applications, there
are many other applications of AI systems in health care including business operations,
research, health care administration, and population health.
The concepts of AI and machine learning have quickly become attractive to health care
organizations, but there is often no clear definition of terminology used. Many see AI as a
technological panacea; however, realizing the promise of AI may have its challenges,
since it might be hampered by evolving regulatory oversight to ensure safety and clinical
efficacy, lack of widely accepted standards, liability issues, need for clear laws and
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regulations governing data uses, and a lack of shared understanding of terminology and
definitions.
Some of the most promising uses for health care AI systems include predictive analytics,
precision medicine, diagnostic imaging of diseases, and clinical decision support.
Development in these areas is underway, and investments in AI have grown over the past
several years [2]. Currently, health care AI systems have started to provide value in the
realm of pattern recognition, NLP, and deep learning. Machine learning systems are
designed to identify data errors without perpetuating them. However, health care AI
systems do not replace the need for the patient-physician relationship. Such systems
augment physician-provided medical care and do not replace it.
Health care AI systems must be, transparent, reproducible, and be trusted by both health
care providers and patients. Systems must focus on users’ needs. Usability should be
tested by participants who reflect similar needs and practice patterns of the end user, and
systems must work effectively with people. Physicians will be more likely to accept AI
systems that can be integrated into or improve their existing practice patterns, and also
improve patient care.
Opportunities
Health care AI can offer a transformative set of tools to physicians and patients and has
the potential to make health care safer and more efficient. By automating hospital and
office processes, physician productivity would improve. The use of data mining to
produce accurate useful data at the right time may improve electronic health records. and
access to relevant patient information. Results of data mining may also provide evidence
for trends that may serve to inform resource allocation and utilization decisions. New
insights into diagnosis and best practices for treatment may be produced because of
analyzing all known data about a patient. The potential also exists to improve the patient
experience, patient safety, and treatment adherence.
Applications of health care AI to medical education include continuing medical education,
training simulations, learning assistance, coaching for medical students and residents, and
may provide objective assessment tools to evaluate competencies. These applications
would help customize the medical education experience and facilitate independent
individual or group learning.
There are a number of stakeholders and policy makers involved in shaping the evolution
of AI in health care besides physicians. These include medical associations, businesses,
governments, and those in the technology industry. Physicians have an unprecedented
opportunity to positively inform and influence the discussions and debates currently taking
place around AI. Physicians should proactively engage in these conversations in order to
ensure that their perspectives are heard and incorporated into this rapidly developing
technology.
Challenges
Developers and regulators of health care AI systems must ensure proper disclosure and
note the benefits, limitations, and scope of appropriate use of such systems. In turn,
physicians will need to understand AI methods and systems in order to rely upon clinical
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recommendations. Instruction in the opportunities and limitations of health care AI
systems must take place both with medical students and practicing physicians, as
physician involvement is critical to successful evolution of the field. AI systems must
always adhere to professional values and ethics of the medical profession.
Protecting confidentiality, control and ownership of patient data is a central tenet of the
patient-physician relationship. Anonymization of data does not provide enough protection
to a patient’s information when machine-learning algorithms can identify an individual
from among large complex data sets when provided with as few as three data points,
which could put patient data privacy at risk. Current expectations patients have for
confidentiality of their personal information must be addressed, and new models that
include consent and data stewardship developed. Viable technical solutions to mitigate
these risks are being explored and will be critical to widespread adoption of health care AI
systems.
Data structure, and integrity are major challenges that need to be addressed when
designing health care AI systems. The data sets on which machine learning systems are
trained are created by humans and may reflect bias and contain errors. Because of this,
these data sets will normalize errors and the biases inherent in their data sets. Minorities
may be disadvantaged because there is less data available about minority populations.
Another design consideration is how a model will be evaluated for accuracy and involves
very careful analysis of the training data set and its relationship to the data set used to
evaluate the algorithms.
Liability concerns present significant challenges to adoption. As existing and new
oversight models develop health care AI systems, the developers of such systems will
typically have the most knowledge of risks and be best positioned to mitigate the risk. As
a result, developers of health care AI systems and those who mandate use of such systems
must be accountable and liable for adverse events resulting from malfunction(s) or
inaccuracy in output. Physicians are often frustrated with the usability of electronic health
records. Systems designed to support team-based care and other workflow patterns but
often fall short. In addition to human factors in the design and development of health care
AI systems, significant consideration must be given to appropriate system deployment.
Not every system can be deployed to every setting due to data source variations.
Work is already underway to advance governance and oversight of health care AI,
including standards for medical care, intellectual property rights, certification procedures
or government regulation, and ethical and legal considerations.
RECOMMENDATIONS
That the WMA:
• Recognize the potential for improving patient outcomes and physicians’
professional satisfaction through the use of health care AI, provided they conform
to the principles of medical ethics, confidentiality of patient data, and non-
discrimination.
• Support the process of setting priorities for health care AI.
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• Encourage the review of medical curricula and educational opportunities for
patients, physicians, medical students, health administrators and other health care
professionals to promote greater understanding of the many aspects, both positive
and negative, of health care AI.
The WMA urges its member organizations to:
• Find opportunities to bring the practicing physician’s perspective to the
development, design, validation and implementation of health care AI.
• Advocate for direct physician involvement in the development and management of
health care AI and appropriate government and professional oversight for safe,
effective, equitable, ethical, and accessible AI products and services.
• Advocate that all healthcare AI systems be transparent, reproducible, and be
trusted by both health care providers and patients.
• Advocate for the primacy of the patient-physician relationship when developing
and implementing health care AI systems.
APPENDIX: GLOSSARY OF TERMS USED IN HEALTH CARE AUGMENTED
INTELLIGENCE
Algorithm is a set of detailed, ordered instructions that are followed by a computer to
solve a mathematical problem or to complete a computer process.
Artificial intelligence consists of a host of computational methods used to produce
systems that perform tasks which exhibit intelligent behavior that is indistinguishable from
human behavior.
Augmented intelligence (AI) is a conceptualization of artificial intelligence that focuses
on artificial intelligence’s assistive role, emphasizing that its design enhances human
intelligence rather than replaces it.
Computer vision is an interdisciplinary scientific field that deals with how computers can
be made to gain high-level understanding from digital images or videos and seeks to
automate tasks that the human visual system can do.
Data mining is an interdisciplinary subfield of computer science and statistics whose
overall goal is to extract information (with intelligent methods) from a data set and
transform the information into a comprehensible structure for further use.
Machine learning (ML) is the scientific study of algorithms and statistical models that
computer systems use to effectively perform specific tasks with minimal human
interaction and without using explicit instructions, by learning from data and identification
of patterns.
Natural language processing (NLP) is a subfield of computer science, information
engineering, and artificial intelligence concerned with the interactions between computers
and human (natural) languages, in particular how to program computers to process and
analyze large amounts of natural language data.
Training data is used to train an algorithm; it generally consists of a certain percentage of
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Augmented Intelligence in Medical Care
an overall dataset along with a testing set. As a rule, the better the training data, the better
the algorithm performs. Once an algorithm is trained on a training set, it’s usually
evaluated on a test set. The training set should be labelled or enriched to increase an
algorithm’s confidence and accuracy.
Reference
[1] For purposes of this statement, the term “health care AI” will be used to refer to systems that
augment, not replace, the work of clinicians.
[2] CB Insights. The Race for AI: Google, Baidu, Intel, Apple in a Rush to Grab Artificial
Intelligence Startups. https://www.cbinsights.com/research/top-acquirers-ai-startups-ma-timeline/.
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WMA STATEMENT
ON
FREE SUGAR CONSUMPTION AND SUGAR-SWEETENED
BEVERAGES
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
Non-communicable diseases (NCDs) are the leading causes of death worldwide. Every
year 40 million people die from NCDs [1]. The most common causes of these diseases are
poorly balanced diet and physical inactivity. A high level of free sugar consumption has
been associated with NCDs because of its association with obesity and poor dietary
quality.
According to the World Health Organization (WHO), free sugar is sugar that is added to
foods and beverages by the manufacturer, cook or consumer that results in excess energy
intake which in turn may lead to parallel changes in body weight.
WHO defines free sugar as ‘all sugars that are added during food manufacturing and
preparation as well as sugars that are naturally present in honey, syrups, fruit juices, and
fruit concentrates.’
Sugar has become widely available and its global consumption has grown from about 130
to 178 million tonnes over the last decade4.
Excess free sugar intake, particularly in the form of sugar-sweetened beverages, threatens
the nutrient quality of the diet by contributing to the overall energy density but without
adding specific nutrients. This can lead to unhealthy weight gain and increases the risk of
dental disease, obesity and NCDs. Sugar-sweetened beverages are defined as all types of
beverages containing free sugars (include monosaccharides and disaccharide) including
soft drinks, fruit/vegetables juices and drinks, liquid and powder concentrates, flavored
water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee and flavored
milk drinks.
The World Health Organization recommends reducing sugar intake to a level that
comprises 5% of total energy intake (that is around 6 teaspoons per day) and not to exceed
10% of total energy intake [2].
The price elasticity of sugar-sweetened beverages according to a meta-analysis published
in USA, is -1.21. This means that for each 10% increase in the price of sugar-sweetened
beverages, there is a -12.1% decrease in consumption. Successful examples of price
elasticity were seen in Mexico as the consumption of sugar-sweetened beverages
decreased after imposing the sugar tax.
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Free Sugar Consumption and Sugar-sweetened Beverages
Data and experience from across the world demonstrate that a tax on sugar works best as
part of a comprehensive set of interventions to address obesity and related chronic
diseases. Such interventions include food advertising regulations, food labelling,
educational campaigns, and subsidy on healthy foods.
RECOMMENDATIONS
The World Medical Association (WMA) and its constituent members should:
• call upon the national governments to reduce the affordability of free sugar and
sugar-sweetened beverages through sugar taxation. The tax revenue collected
should be used for health promotion and public health preventive programs aimed
at reducing obesity and NCDs in their countries;
• encourage food manufacturers to clearly label sugar, if present, in their products
and urge governments to mandate such labeling;
• urge governments to strictly regulate the advertising of sugar containing food and
beverages targeted especially at children;
• urge national governments to restrict availability of sugar-sweetened beverages
and products that are highly concentrated with free sugar from educational and
healthcare institutions and replace with healthier alternatives.
Constituent members of the WMA and their physician members should work with
national stakeholders to:
• advocate for healthy sustainable food with limited free sugar intake that is less than
5% of total energy intake;
• encourage nutrition education and skills programs toward preparing healthy meals
from foods without added sugar;
• initiate and/or support campaigns focused on healthy diets to reduce sugars intake;
• advocate for an inter-sectoral, multidisciplinary and comprehensive approach
to reducing free sugar intake.
References
[1] http://www.who.int/fr/news-room/fact-sheets/detail/noncommunicable-diseases
[2] WHO Guideline: Sugars Intake for Adults and Children 2015
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WMA STATEMENT
ON
HEALTHCARE INFORMATION FOR ALL
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
The WHO constitution states that “the extension to all people of the benefits of medical,
psychological and related knowledge is essential to the fullest attainment of health”.
Access to relevant, reliable, unbiased, up-to-date and evidence-based healthcare
information is crucial for the public, patients and health personnel for every aspect of
health, including (but not limited to) health education, informed choice, professional
development, safety and efficacy of health services, and public health policy.
Lack of access to healthcare information is a major contributor to morbidity and mortality,
especially in low- and middle-income countries, and among vulnerable groups in all
countries.
Healthcare information is only useful if it is relevant, appropriate, timely, updated,
understandable and accurate. It covers a broad spectrum of issues and refers to diseases,
treatments, services, as well as the promotion and preservation of health.
Health literacy is a key factor in understanding how health services work and how to use
them. Health professionals need access to adequate training and support to communicate
with patients with low health literacy or with those who have difficulty understanding
healthcare information, for example because of a disability.
Globally, thousands of children and adults die needlessly because they do not receive
basic life-saving interventions. Some interventions may be available locally but are simply
not provided due to indecision, delays, misdiagnosis and incorrect treatment. Failure to
provide basic life-saving interventions more commonly affects those who are
socioeconomically disadvantaged.
In the case of children with acute diarrhea, for example, the widespread misconception
among parents that they should withhold fluids, and among health workers that they
should give antibiotics rather than oral rehydration, contributes to thousands of
unnecessary deaths every day worldwide.
Governments have a moral obligation to ensure that the public, patients and health
workers have access to the healthcare information they need to protect their own health
and the health of those for whom they are responsible. This obligation includes providing
adequate education, in form and content, to identify and use such information effectively.
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The public, patients and healthcare workers need easy, reliable access to evidence-based,
relevant healthcare information as part of a learning process throughout the life-course to
enhance understanding, and to make informed and conscious decisions about their health,
healthcare options and the health care they receive. These groups need information in the
right language, and in a format and technical level that is understandable to them, with
relevant services signposted as appropriate. This should take into account the
characteristics, customs and beliefs of the population to which it is directed, and a
feedback process should be established. The public, patients and families need information
that is appropriate to their specific context and situation, which may change over time.
They need guidance on when and how to make important health decisions, which are
usually best made when there is time to consider, understand and discuss the issue at hand.
Meeting the information needs of the public, patients and healthcare providers is a
prerequisite for the realisation of quality universal health coverage and the UN Sustainable
Development Goals (SDGs).” UN SDG Target 3.8 on universal health coverage
specifically aims to deliver ‘quality essential health-care services and access to safe,
effective, quality and affordable essential medicines and vaccines for all’. Achieving this
requires empowerment of the public and patients, as well as health workers, with the
healthcare information they need to recognize and assume their rights and responsibilities
to access, use and provide appropriate services and to prevent, diagnose and manage
disease.
The development and availability of evidence-based, relevant healthcare information
depends on the integrity of the global healthcare information system. This system
comprises researchers, publishers, systematic reviewers, producers of end-user content
(including academic publishers, health education, journalists and others), information
professionals, policymakers, frontline health professionals and patient representatives,
among others.
RECOMMENDATIONS
Recognizing this, the World Medical Association and its constituent members on behalf of
their physician members, will support and commit to the following actions:
1. Promote initiatives to improve access to timely, current, evidence-based healthcare
information for health professionals, patients and the public to support appropriate
decision-making, lifestyle changes, care-seeking behaviour and improved quality
of care – thereby upholding the right to health.
2. Promote standards of good practice and ethics to be met by information providers,
guaranteeing reliable and quality information that is produced with the
participation of physicians, other health professionals, and patient representatives.
3. Support research to identify enablers and barriers to the availability of healthcare
information, including how to improve the production and dissemination of
evidence-based information for the public, patients and health professionals, and
measures to increase health literacy and the ability to find and interpret such
information.
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4. Ensure that health professionals have access to evidence-based information on
diagnosis and treatment of diseases, including unbiased information on medicines.
Particular attention should be paid to those working in primary care in low- and
middle-income countries.
5. Combat myths and misinformation around healthcare through validated scientific
and clinical evidence, and by urging the media to report responsibly on health
issues. This includes the study of health-related beliefs stemming from cultural or
sociological differences. This will improve the effectiveness of health promotion
activities and allow the dissemination of healthcare information to be adequately
targeted to different segments of the population.
• Urge governments to recognize their moral obligation to take measures to
improve the availability and use of evidence-based healthcare information.
This includes:
• resources to select, compile, integrate and channel scientifically validated
information and knowledge. This should be adapted to target various different
recipients;
• measures to increase availability of healthcare information for healthcare
workers and patients at health centres;
• leveraging modern communication technology and social media;
• policies that support efforts to increase the availability and use of reliable
healthcare information.
6. Urge governments to provide the political and financial support needed for
‘WHO’s function to ensure access to authoritative and strategic information on
matters that affect peoples’ health’, based on the WHO General Programme of
Work 2019-23.
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Unaccompanied Minor Asylum Seekers
WMA STATEMENT
ON
MEDICAL AGE ASSESSMENT OF UNACCOMPANIED MINOR
ASYLUM SEEKERS
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
PREAMBLE
Population displacement resulting from war, violence or persecution has wide-ranging
implications for the entire global community. Refugees – that is, individuals who have
been forced to flee their respective countries of origin for these reasons – generally must
undergo rigorous procedures for determining their legal status according to the national
legislation of the country in which they are seeking asylum.
An increasing number of refugees fall under the category of unaccompanied minors,
which are defined as people under the age of 18 who have been separated from or who
have fled their countries of origin without their families. In light of their unique
vulnerability, unaccompanied minor refugees are eligible for special protections, as
outlined in the United Nations’ Convention on the Rights of the Child, which states that
the best interests of the child must be the primary consideration in all stages of the
displacement cycle.
Given the differences in how adults and unaccompanied minors are processed and
protected when seeking asylum, recipient countries have an interest in verifying the age of
applicants outside the context of criminal proceedings. However, some asylum seekers
either do not have access to documentation confirming their age or originate from
countries in which there is no central birth registry. In cases where there is doubt as to
whether an asylum seeker is a child or an adult, e.g. if the authenticity of available
documentation is called into question or if there is reason to believe the applicant’s
physical appearance suggests a discrepancy between the reported age and the actual age,
the competent authorities may resort to medical and/or non-medical methods for assessing
the applicant’s age.
Medical age assessments carried out by medical professionals may take the form of X-ray
scans of the jaw, hand or wrist; CT scans of the collarbone; MRI scans of the knee; or the
examination of secondary sex characteristics to determine the applicant’s stage of puberty.
However, ethical concerns have been raised about these and other forms of examination,
as they can potentially endanger the health of those being examined and violate the
privacy and dignity of young people who may already be severely traumatized [1].
Furthermore, there is conflicting evidence about the accuracy and reliability of the
available methods of medical age assessment, which may generate significant margins of
error [2]. For example, some available studies do not appear to take into account potential
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delays in skeletal maturation caused by malnutrition, which is just one factor that could
translate into a risk of age misclassification among asylum seekers [3]. Comparative
assessments are further impeded by a lack of standard images from certain world regions
and limited representation in age assessment reference data, much of which was compiled
on the basis of European and North American populations [4]. An imprecise assessment of
an individual’s age can have far-reaching administrative, ethical, psychological and other
significant consequences, including potential breaches of children’s rights.
The following recommendations apply explicitly and exclusively to cases outside the
context of the criminal justice system.
RECOMMENDATIONS
1. The WMA recognizes that there is sometimes a need to assess the age of asylum
seekers to ensure that all unaccompanied minors receive the protections afforded
them under international and national law.
2. The WMA recommends that medical age assessments only be carried out in
exceptional cases and only after all non-medical methods have been exhausted.
The WMA recognizes that non-medical methods, e.g. questioning children about
traumatic events, may also have a negative impact and must therefore be carried
out with great care. Each case must be evaluated carefully based on the totality of
circumstances and the preponderance of available evidence.
3. The WMA asserts that, in cases where medical age assessment is unavoidable, the
health and safety and dignity of the young asylum seeker must be the highest
priority. Physical examinations must be carried out by a qualified physician with
appropriate pediatric examination experience in accordance with the highest
medical and ethical standards, in observance of the principles of proportionality, in
adherence to the standards of prior informed consent and with consideration of
cultural and religious sensitivities and potential language barriers. The asylum
seeker must always be made aware that the examination is carried out as part of the
age assessment procedure and not to provide healthcare.
4. The WMA underscores that any medical methods that could involve a health risk
for the applicant, e.g. radiological examinations without medical indication, or that
infringe upon the dignity or privacy of an already potentially traumatized asylum
seeker, e.g. genital examinations, must be avoided.
5. The WMA stresses that medical certificates indicating the results of medical age
assessment examinations should include information concerning the accuracy and
reliability of the methods used and the relevant margins of error.
6. The WMA urges constituent members to develop or promote the development of
internationally accepted interdisciplinary guidelines which outline the scientific
basis, as well as ethical and legal or regulatory principles of medical age
assessment of asylum seekers, including the potential health risks and
psychological impact of specific procedures.
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Unaccompanied Minor Asylum Seekers
7. The WMA emphasizes that, in cases where doubts regarding the age of an asylum
seeker cannot be resolved or confirmed with absolute certainty, any remaining
uncertainty should be interpreted in favor of the asylum seeker.
References:
[1] Zentrale Ethikkommission der Bundesärztekammer (2016): Stellungnahme
“Medizinische Altersschätzung bei unbegleiteten jungen Flüchtlingen. Deutsches
Ärzteblatt 2016; A1-A6. / German Medical Association’s Central Ethics Committee:
Statement on Medical Age Assessment of Unaccompanied Minor Refugees.
[2] Separated Children in Europe Programme (2012): Position Paper on Age Assessment
in the Context of Separated Children in Europe. Online http://www.separated-children-
europe-programme.org/separated_children/good_practice/index.html. Last accessed
03.07.2018.
[3] Sauer PJJ, Nicholson A, Neubauer D, On behalf of the Advocacy and Ethics Group of
the European Academy of Paediatrics (2016): Age determination in asylum seekers:
physicians should not be implicated. European Journal of Pediatrics 175, (3): 299-303.
[4] Aynsley-Green et al. (2012): Medical, statistical, ethical and human rights
considerations in the assessment of age in children and young people subject to
immigration control. British Medical Bulletin 2012; 102: 39.
S-2020-01-2020 ⏐ Cordoba
Human Genome Editing
WMA STATEMENT
ON
HUMAN GENOME EDITING
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Genome editing, enabled by recent scientific advances, can generate targeted insertions
and deletions in DNA and may even offer enough precision to modify a single base pair
within the genome of an organism. Basic science research with genome editing is now
underway in laboratories globally.
Human genome editing is also advancing rapidly, with clinical trials now in progress for
prevention and treatment of various human diseases. These trials, which are currently in
early stages, involve somatic (non-reproductive) cells, and thus are not anticipated to
introduce genetic changes that will be passed on to offspring or the germline
(reproductive) cells.
While genome editing holds great potential to help improve human lives, the technology
raises profound safety, ethical, legal, and social concerns. These concerns are compounded
by the fact that regulatory and ethical guidance often lag rapid technological
developments.
Safety concerns for genome editing include the risk of unintended or unforeseen
pleiotropic effects off-target effects (edits in the wrong place) unwanted on-target
modifications (imprecise edits), and mosaicism (when only some cells carry the edit), and
abnormal immunological responses.
Ethical issues regarding genome editing include concerns that editing may be used for
non-therapeutic and enhancement purposes rather than for therapeutic purposes, i.e.
improving health or curing disease. There are also concerns that germline modifications
could create classes of individuals defined by the quality of their engineered genome,
possibly enabling eugenics, which could exacerbate social inequalities or be used
coercively.
The effect of epigenomic changes are unpredictable, and there is disquiet as to how this
will affect the existing healthy biological systems, including interactions with other
genetic variants, and societal norms. Once introduced into the human population, genetic
alterations would be difficult to remove and would not remain within any single
community or country. The effects could remain uncertain for many subsequent
generations, during which time deleterious modifications could be dispersed throughout
the population.
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Legal issues include providing clarity for risk management and assignment of duties and
liabilities, particularly when modifications can be passed to subsequent generations. There
are also risks, both legal and ethical, involved in the proliferation of unvalidated direct-to-
consumer CRISPR (clustered regularly interspaced short palindromic repeats) kits that
allow individuals to undertake gene editing independently in a home setting.
At a social level, debates revolve around the concerns that access to beneficial genome
editing will be inequitable (e.g., only the wealthy will have access) and will increase
existing disparities in health and medical care.
The WMA reaffirms principles in the Declaration of Reykjavik on the ethical
considerations regarding the use of genetics in health care, the Declaration of Taipei on
Ethical Considerations regarding Health Databases and Biobanks and the Declaration of
Helsinki and makes the following recommendations:
RECOMMENDATIONS
1. Human genome-editing, like any other medical intervention, should be implemented
according to appropriate evidence that is collected via well-conducted and ethically
approved research studies.
2. When contemplating use of germline cells for research purposes, germline editing
should be permitted only within a separate ethical and legal framework, distinct from
an ethical and legal framework applied to somatic genome editing.
3. Governments should:
• Develop robust and enforceable regulatory frameworks for genome editing in their
own countries.
• Urge continued development of an international consensus, grounded in science
and ethics, to determine permissible therapeutic applications of germline genome
editing.
4. WMA constituent members should:
• Be cognisant of the advances in research in genomic medicine and inform their
members on scientific advances in genome
• Advocate for research to understand (i) the benefits and risks of human genome
editing, (ii) the socio-political, ethical, and legal aspects of editing the human
germline and (iii) the necessity of physician involvement in therapeutic genome
editing.
• Develop and promote ethical guidelines for genome editing for their members,
taking into consideration societal perspectives, professional consensus, national
laws and regulations, and international standards.
• Advocate for the development of appropriate laws and regulations for genome
editing in accordance with both international and national norms and standards.
• Where human genome editing is safe and effective, advocate for equal patient
access to the technology.
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Human Genome Editing
5. Physicians should:
• Educate themselves on the technical, ethical, social, and legal aspects of genome
editing.
• Familiarise themselves with the international and local ethical frameworks
regulating genome
• Follow all ethical standards for approved research in these areas, including
appropriate informed consent.
S-2020-02-2020 ⏐ Cordoba
Hypertension and Cardiovascular Disease
WMA STATEMENT
ON
HYPERTENSION AND CARDIOVASCULAR DISEASE
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Hypertension is the single most important risk factor for cardiovascular death globally. It
accounts for more deaths from cardiovascular disease than any other modifiable risk
factor. More than half of people who die from coronary heart disease and stroke had
hypertension. “As populations age, adopt more sedentary lifestyles, and increase their
body weight, the prevalence of hypertension worldwide will continue to rise.
Uncontrolled hypertension is a major cause of stroke and other co-morbid, chronic
conditions, such as heart failure, kidney disease, vision loss, or mild cognitive impairment.
Because hypertension can be asymptomatic, it may often go undiagnosed.
In 2010, hypertension emerged as the leading risk factor for disease burden in every
region of the world. Moreover, elevated systolic blood pressure (SBP) is a leading global
health risk. The WHO Global Plan of Action for the prevention of non-communicable
diseases calls for a 25% reduction in the prevalence of elevated blood pressure by 2025.
Prevalence
Worldwide prevalence of hypertension has grown significantly over the past four decades,
and most with hypertension are not achieving optimal control.
Of concern is an increasing disparity in hypertension prevalence between high-income and
low/middle–income countries. Almost three times as many people with hypertension live
in low/middle–income countries than in high-income countries. Low-income countries in
south Asia, sub-Saharan Africa, and central and eastern Europe, are particularly impacted.
Moreover, the prevalence of elevated blood pressure was highest in certain regions of
Africa in both sexes.
Risk Factors
Hypertension risk factors are attributes that increase the likelihood of developing the
disease. Risk factors include the following:
• Lifestyle/Diet: Unavailability of healthy food choices, lack of access to safe
neighborhoods for exercising, and unhealthy lifestyle habits can raise the risk of
hypertension. Unhealthy lifestyle habits include unhealthy eating patterns such as
eating too much sodium and highly processed food, drinking too much alcohol,
smoking, and being physically inactive.
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• Age: Blood pressure (BP) tends to increase with age. However, the risk of
hypertension is increasing for children and teens, possibly due to the rise in the
number of children and teens who are overweight or obese.
• Socioeconomic Status: In high-income countries, the greatest absolute burden of
hypertension disease is in age groups 60 years and older, whereas in low/middle-
income countries, the greatest absolute burden is in the middle-aged groups, such
as 40 to 59 years. The age-standardized prevalence of hypertension is higher in
low/middle-income countries than in high-income countries.
• Sex: Before age 55, men are more likely than women to develop hypertension.
After age 55, women are more likely than men to develop it.
• Genetics/Family History: Research has identified many gene variations associated
with small increases in the risk of developing hypertension. Some people are
genetically predisposed to dietary sodium sensitivity.
Accurate blood pressure measurement
The accurate measurement of BP—both within the clinical setting and at home—is
essential for the diagnosis and management of hypertension. In many countries, national
clinical guidelines recommend how to achieve an accurate BP measurement and offer best
practice recommendations.
Policy implications
Policies and actions at the global, national, and local levels are necessary to recognize and
combat hypertension. Much effort is needed worldwide to improve awareness, treatment,
and control for all populations. Current guidelines to diagnose and treat hypertension, and
evidence-based guidance on the importance of proper BP measurement, offer anchors for
national policies on BP measurement and control. Implementation can make significant
progress towards lowering global hypertension prevalence and improving patient
outcomes. To address the risk factors for hypertension, policies should also focus on
addressing socioeconomic, lifestyle and dietary factors which contribute to the
development of the disease.
RECOMMENDATIONS
1. The World Medical Association recommends that national governments:
• Recognize hypertension as the single most important risk factor for cardiovascular
disease and death.
• Declare hypertension control a national health priority.
• Support campaigns to raise public awareness of hypertension, including
recognition of its widespread and asymptomatic nature, and its risk of contributing
to development of other serious diseases.
• Deploy adequate resources to improve hypertension awareness, diagnosis,
measurement, and management.
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Hypertension and Cardiovascular Disease
• Develop country-specific strategies which address the risk factors for hypertension
and advocate for improvements in awareness, diagnosis, measurement and
management.
• Promote the recommendations adopted by the WMA as stated in the Statement on
Reducing Dietary Sodium Intake.
2. The World Medical Association recommends that its constituent members:
• Advocate at the international, national, and local levels to promote hypertension
awareness, healthy lifestyles, and patient access to hypertension diagnosis and
treatment including medications. This includes supporting the concept that social
determinants of health are part of hypertension disease prevention.
• Recognize and support national guidelines and strategies for measuring BP
accurately.
• Support the exchange of hypertension research, information, tools, and other
resources amongst healthcare teams and patients.
• Support the development of medical curricula that respond to societal hypertension
needs with a focus on community-based primary care training and BP
measurement and management skills.
• Promote research on the causes, mechanisms and effective treatments of
hypertension.
• Advocate for sustained availability antihypertensive medications.
3. The World Medical Association recommends that physicians:
• Emphasize the risk factors for hypertension and ways to mitigate them, paying
special attention to prevention and treatment in high-risk populations.
• Emphasize team-based care to help prevent and, where it has been diagnosed by a
physician, to treat hypertension.
• Implement BP measurement best practices and techniques, including training and
retraining of all healthcare team members.
• Promote patient hypertension treatment adherence by facilitating ongoing patient
BP self-management and involvement in the patient’s own care.
S-2020-03-2020 ⏐ Cordoba
Transplant-Related Crimes
WMA STATEMENT
ON
MEASURES FOR THE PREVENTION AND FIGHT AGAINST
TRANSPLANT-RELATED CRIMES
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
In 2017, almost 140,000 solid organ transplants were performed worldwide. Although
impressive, this activity provided for only 10% of the global need for transplanted organs.
The disparity between supply and demand of organs has led to the emergence of
transplant-related crimes, including trafficking in persons for the purpose of the removal
of organs and trafficking in human organs.
These crimes violate fundamental human rights and pose serious risks to both individual
and public health. The true extent of transplant-related crimes remains unknown, but it is
estimated that 5% to 10% of transplants globally take place in the context of the
international organ trade, often involving transplant tourism to destinations where laws
against the sale and purchase of human organs are nonexistent or poorly enforced.
Trafficking in persons for the purpose of the removal of organs and trafficking in human
organs can also take place within the boundaries of a given jurisdiction, not involving
travel for transplantation. In all cases, the most vulnerable parts of the population often
become victims of exploitation and coercion.
Concerned by the increasing demand for organs and by emerging unethical practices in the
field, the World Health Organization has called on governments and health professionals
to pursue self-sufficiency in transplantation, through strategies targeted at decreasing the
burden of diseases treatable with transplantation and increasing the availability of organs,
maximising donation from the deceased and ensuring the overall protection of the living
donor. Progress towards self-sufficiency in transplantation is consistent with the
establishment of official cooperation agreements between countries to share organs or to
facilitate patients’ access to transplant programs that have not been developed in their
countries of origin. Agreements between countries should be based on the principles of
justice, solidarity and reciprocity.
Progress towards self-sufficiency in transplantation is the best long-term strategy to
prevent transplant-related crimes.
The distinctive feature of transplant-related crimes is the necessary involvement of health
professionals. It is precisely this feature that provides a unique opportunity to prevent and
combat these crimes. Health professionals are key in evaluating prospective living donor
and recipient pairs. They also care for desperate patients who are vulnerable and at risk of
engaging in illicit transplant activities. In addition, since patients who receive a transplant
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require long-term specialised care, physicians must deal with the many challenges of
providing care to patients who have received an organ through illicit means, while
unveiling trafficking rings.
International organisations, including the Council of Europe, the European Union and the
United Nations, as well as international professional platforms, have developed treaties,
resolutions and recommendations for a concerted fight against transplant-related crimes.
The WMA emphasises the responsibility of physicians in preventing and combatting
trafficking in persons for the purpose of the removal of organs and trafficking in human
organs, as well as the important role of physicians and other health-care professionals in
assisting international organisations, medical associations and policy makers in the fight
against these criminal activities.
In the fight against transplant-related crimes it is of utmost importance that the principles
of transparency of practice, traceability of organs and continuity of care are guaranteed for
every transplant procedure performed nationally or abroad.
The WMA reaffirms its Statement on organ and tissue donation and its Declaration of
Sydney on the determination of death and the recovery of organs. Condemning all forms
of trafficking in persons for the purpose of the removal of organs and trafficking in human
organs, the WMA calls for the implementation of the following recommendations.
RECOMMENDATIONS
Policy makers and health actors:
1. Governments should develop, implement and vigorously enforce legislative
frameworks that prohibit and criminalise trafficking in persons for the purpose of the
removal of organs and trafficking in human organs, these should include provisions to
prevent these crimes and protect their victims.
2. Governments should consider ratifying or acceding to the United Nations Convention
against Transnational Organised Crime and the Protocol to Prevent, Suppress and
Punish Trafficking in Persons, Especially Women and Children, supplementing the
United Nations Convention against Transnational Organised Crime, as well as the
Council of Europe Convention against Trafficking in Human Organs. They should
also consider cooperating with existing international organisations for a more effective
fight against transplant-related crimes. The WMA should play a leading role in
influencing ethical practices in donation and transplantation.
3. Health authorities should develop and maintain registries to record information
regarding each organ recovery and transplantation procedure, as well as information
on the outcomes of living donors and organ recipients, to ensure the traceability of
organs, with due regard to professional confidentiality and personal data protection.
Registries should be designed to record information on procedures that take place
within a country and on transplant and living donation procedures on residents of that
country carried out in other destinations.
S-2020-03-2020 ⏐ Cordoba
Transplant-Related Crimes
4. Countries are encouraged to periodically contribute this information to the Global
Observatory on Donation and Transplantation developed in collaboration with the
World Health Organization.
5. Health authorities and medical associations should ensure that all health professionals
are trained in the nature, extent and consequences of transplant-related crimes, as well
as in their responsibilities and duties in preventing and fighting these criminal
activities and in the means to do so.
6. As self-sufficiency is the best long-term strategy to prevent transplant-related crimes,
health authorities and policy makers should develop preventive strategies to decrease
the burden of diseases treatable with transplantation and increase the availability of
organs.
7. Increasing organ availability should be based on the development and optimisation of
ethically sound deceased donation programs following the determination of death by
neurological and by circulatory criteria. Of note is that donation after the
determination of death by circulatory criteria is accepted in a limited number of
countries. Governments should explore whether donation after the circulatory
determination of death is a practice acceptable within their community and, should this
be the case, consider introducing it within their jurisdiction.
8. In addition, governments should develop and optimise living donation programs based
on recognised ethical and professional standards and ensure due protection and follow-
up of living donors.
9. Health authorities and/or insurance providers should not reimburse the costs of
transplant procedures that have occurred in the context of transplant-related crimes.
However, the costs of medications and post-transplant care should be covered, as for
any other transplant patient.
10. Authorities should also ensure that medical and psychosocial care is provided to
victims of trafficking in persons for the purpose of organ removal and of trafficking in
human organs. Consideration should be given to effective compensation of these
persons for the damage suffered.
11. National Medical Associations should advocate for and cooperate with authorities in
developing frameworks for health professionals to report any confirmed or suspected
case of trafficking of persons for the purpose of the removal of organs and of
trafficking in human organs to the relevant authorities. National Medical Associations
should advocate for the ability of health professionals to report suspected trafficking of
individual persons, on an anonymous basis if necessary, to protect the safety of the
reporter. Where applicable, the reporting of trafficking cases should be a permitted
exception to the physician’s obligation to maintain patient confidentiality
Physicians and other health professionals:
12. Physicians should never perform a transplant using an organ that has been illicitly
obtained. If there are reasonable concerns about the origin of an organ, the organ must
not be used. If a physician or a surgeon is asked to perform a transplant with an organ
that has been obtained through a financial transaction, without the valid consent of the
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donor or without the authorisation required in a given jurisdiction, they must refrain
from performing the transplant and should explain the reasons to the potential
recipient.
13. Physicians who participate in the preoperative evaluation of potential living donors
should not only assess the medical suitability of the individual, but also attempt to
ensure that the person has not been subject to coercion of any kind or is participating
in the procedure for financial gain or any other comparable advantage. The legitimacy
of the donor-recipient relationship and the altruistic motivations for donation should be
scrutinised. Physicians should be particularly vigilant of “red flags” suggestive of a
transplant-related crime. Non-resident living donors may be particularly vulnerable
and should be given special consideration. For linguistic, cultural and other reasons,
assessing the validity of their consent to donation can be especially challenging, as can
ensuring that appropriate follow-up is offered to them. A referring physician should be
identified in the country of origin of the living donor – and in that of their intended
recipient, where appropriate.
14. Physicians should never promote or facilitate the engagement of patients in transplant-
related crimes. Moreover, they should inform patients of the risks these activities pose
for their own health, that of their loved ones and, more generally, for public health.
Patients should also understand that these activities entail an exploitation of vulnerable
individuals who may themselves suffer from severe medical and psychosocial
complications. By counselling patients, professionals may dissuade them from
engaging in illicit transplant activities.
15. Physicians have a duty to care for transplant patients, even if their organ was illicitly
Should a physician have ethical or moral objections about caring for a patient who has
received an illicit organ, they should make the necessary arrangements to transfer the
care of the patient to another physician.
16. Physicians should contribute to guaranteeing transparency of practices and traceability
of organs. When patients who have undergone a donation or a transplantation
procedure abroad seek follow-up care in their country of residence, all relevant
information should be recorded in national transplant-registries and reported to health
authorities, as should happen for all donation and transplantation procedures
performed within the national transplant system.
17. Physicians have a responsibility to increase the deceased donor pool in order to satisfy
the transplantation needs of patients. Physicians also have a duty towards possible
organ donors in considering and facilitating organ donation if this is consistent with
patients’ values and principles. Donation should be routinely offered as an option at
the end of life, always in a respectful manner, taking into account the culture and
religion of the potential donor and their surrogates. Conversations about donation
opportunities should be led by experienced and trained professionals.
18. Physicians should promote research in the field of donation and transplantation, in
particular research targeted at increasing the availability of organs for transplantation,
improving the outcomes of transplanted organs, and identifying alternative organ
replacement strategies, as in the case of bioartificial organs.
Handbook of WMA Policies
World Medical Association S-2021-01-2021
WMA STATEMENT
IN SUPPORT OF
ENSURING THE AVAILABILITY, THE QUALITY AND THE SAFETY OF
MEDICINES WORLDWIDE
Adopted by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
INTRODUCTION
Over the past decade, pressure on supply has led to shortages of certain medical products,
including vaccines. In many situations, these shortages result from putting economic
objectives before public health. These shortages are detrimental to patient care, to maintaining
public health and to the organization of healthcare systems.
The world is going through rapid change; technological progress, radical progress in matters
of communication and access to information as well as the increasing power of multi-nationals
are transforming the global landscape, including the pharmaceutical industry. Unfortunately,
some of these developments have encouraged the production and sale of medical products
which do not meet the required safety standards, whether due to the manufacturing process or
inappropriate storage, or due to the criminal manufacture and fraudulent distribution of sub-
standard or falsified medicines.
According to the WHO’s Global Surveillance and Monitoring System (GSMS) for sub-
standard and falsified medical products, around one out of ten medicines is either of a sub-
standard quality or falsified in countries with low or medium income. This observation is not
limited to the most expensive medicines or the most well-known brands, but also concerns
patented and generic products. The medicines most often flagged are the antimicrobials and
antimalarials.
The WMA reiterates its position on biosimilar medicines, its resolution on prescribing
medicines, its position on the substitution of medicines and resistance to antimicrobials.
The rational use of medicines implies ensuring that research, regulation, production,
distribution, prescription, financing, delivery and proper administration of these medicines
comply with coherent and rational scientific, professional, economic and social criteria.
From a healthcare point of view, a shortage of medicines is unacceptable, as it has a negative
impact on confidence for patients, doctors, pharmacists and the healthcare system, it leads to
insecurity and uncertainty and compromises treatment continuity; with all the risks that this
implies.
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With the objective of combatting the intolerable missed opportunities that such shortages
represent for patients, undermining public trust in the healthcare system, the WMA is calling
for the implementation of the following recommendations:
RECOMMENDATIONS
Availability of medicines
1. As a public health issue and out of concerns for safety, the WMA urges national
governments to improve the availability of medicines.
2. National governments and regulatory authorities should:
• Create a national entity responsible for gathering and communicating information
relative to demand and offer for medicines under their jurisdiction. Establish standards
and mechanisms guaranteeing the continuity and the supply of medicines and thus avoid
shortages.
• Improve the monitoring of medical product supply chains, as the weakness of
regulatory structures make the application of good medical product distribution
particularly difficult.
• Design contingency strategies to counter the dependence of States on foreign medicine
production due to the delocalization and centralization of the majority of structures
which produce the main pharmaceutical components used in the composition of major
medicines.
• Encourage national healthcare authorities to maintain stocks of essential medicines in
order to minimize the risk of shortages. Indeed, the Covid-19 health crisis has
demonstrated the limits of stocks held by States and has constrained them to reorganize
and restrict access to certain medicines.
• In the case of global epidemic, to pool scientific research and clinical trials with the
objective of accelerating the development of vaccines and/or treatments to eradicate the
pandemic.
• Support legislative and regulatory initiatives which guarantee an appropriate national
capacity to produce pharmaceutical products, in the interests of the well-being of the
populace and national security.
• Identify and create sustainable mechanisms which will guarantee sufficient stocks and
sufficient access to necessary medicines.
• Promote co-operation between governments in the prevention and the management of
medicine and vaccine shortages.
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• Encourage governments to be more directive in their dealings with the pharmaceutical
industry, notably in terms of adjusting quotas, of accelerating approvals and of
importing substitute medicines when pharmaceutical companies are not able to ensure
a continuous and adequate supply of medicines.
• Consider demanding that medicine producers establish a continuity plan for the supply
of vital and necessary medicines and vaccines in order to avoid production shortages
wherever possible.
• Ensure the transparency, sharing and availability of quality information coming from
reliable sources in order to establish a trustworthy flow of communications between all
stake-holders and healthcare professionals and to the patients. In the case of shortages,
governments should divulge and detail the causes to all stake-holders.
• Enable WMA member states to acquire, via common supply contracts, healthcare and
vaccine products in sufficient quantities during a pandemic and thus to have greater
influence in negotiations with laboratories.
• Avoid the ‘first come, first served’ approach, notably during a pandemic, leading to
counter productive competition acting against the safeguarding of public health.
• Allow an industrial level of security of supply in line with the deployment of Interpol’s
programme combatting pharmaceutical criminality.
Safety of medicines
3. The objective is to set up active supply processes to ensure the continuity of quality medical
supplies while guaranteeing their safety.
4. Elements of a high-quality, active supply process comprise:
• Improvements in quantification, including forecasting.
• Direct communication between supply agents and the manufacturers on the question of
sustainable capacity.
• Deliberate and well-considered approaches to a specific situation for each product (long
term, short term, split contracts, etc.)
• Responsible pricing with the emphasis on quality
• Rational and necessary contracts.
• Establish frameworks which limit the excessive accumulation of medicines and the
useless scrapping of unused medicines with the objective of preserving the quality of
their pharmaceutical properties.
• Encourage governments to promote the sharing of public information on the real price
of medicines. The authorities must regulate and limit the possibility of reaching
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agreements on price and discounting confidentiality in the medicine evaluation process.
The system must be made more transparent in all areas, including the evaluation of new
medicines.
5. The WMA is clear on the fact that the quality of medicines is a public health priority and
is recommending national medical associations and doctor members to:
• Increase awareness among the public and medical practitioners of sub-standard and
fake products.
• Create a list of ‘essential’ medicines meeting a country’s healthcare needs.
• Create an early alert system, based around vital medicines and those intended to treat a
debilitating pathology, in particular those for which no alternative therapeutic options
are available. The activation of such a system would trigger a sequence of measures for
all the stake-holders (licensed manufacturers, wholesalers, hospital pharmacists)
alongside reporting obligations and a close monitoring of corrective actions.
• Create a scenario and emergency programmes, including a stress test for manufacture
and inspection systems at regular intervals, with appropriate communication strategies
adapted to the different stake-holders.
• Persue efforts to harmonise regulatory standards between the countries and beyond
regions.
• Set up proactive and productive collaboration between all the essential stake-holders in
order to prevent medicine shortages and mitigate the harmful effects these have on
patient care.
• Work with healthcare user associations to fight against the growing culture of ill-
advised self-diagnosis, self-prescription and self-medication, which could make the
supply chain vulnerable to the introduction of non-approved or counterfeit products.
• Restrict the prevalence of low quality medicines by implementing and applying current
good practices in manufactuting, storage and distribution which respect the
environment (cGMP) and by preventing the deterioration of medicines.
• Encourage the pharmaceutical sector to undertake to guarantee the continuity of supply
of medicines, in order to avoid any interruptions in treatment.
6. The WMA is insisting that national governments, in tandem with healthcare user
associations and other stake-holders, do everything possible to ensure awareness of
medicine safety for all patients.
• At an international level and working together, Health Ministers and Medical
Regulators should recommend that national medical associations actively oppose the
illegal misappropriation of medicines, the illegal sales of medicines on the internet, the
illegal importing of medicines and the counterfeiting of medicines.
Handbook of WMA Policies
World Medical Association S-2021-01-2021
• Improve regulation and monitoring of the online pharmaceutical market through
national regulation of e-commerce activities.
• Regulations and mechanisms should be adopted to immediately close all websites
illegally offering medical products not controlled by state authorities.
• Improve the identification and the revelation of counterfeit medical products all over
the world.
• Launch international campaigns warning of the health risks linked to the use of
counterfeit medical products, informing people about the dangers of buying medicines,
or products offered as such, on the internet (counterfeit or fake medicines, etc.).
• Improvement in detecting falsified and sub-standard medicines, including vaccines and
other medical products, and their reporting worldwide. Falsified and sub-standard
medicines, including vaccines and other other medical products, should be reported to
the appropriate authorities whenever they are discovered. Pharmacies, hospital
pharmacies and patients must be prevented by whatever means from being supplied
with falsified or sub-standard medicines. All adverse side-effects of a falsified or sub-
standard medicine must be immediately highlighted via an efficient and adapted
reporting system.
• Strengthen and align international rules against conterfeit medical products, allowing
an efficient fight against the growing challenges of the systems of governance caused
by the globalisation of manufacturing processes and supply chains.
Covid-19 health crisis
7. The Covid-19 health crisis has highlighted the fundamental problems of availability,
quality and safety of medicines.
8. The already significant problems of availability, quality and safety of medicines have been
starkly brought to light by the Covid-19 health crisis. The importance of these questions is
even bigger, on a global scale, and the Covid-19 pandemic has created unprecedented
challenges for the authorities of every State. A pandemic leads to a sharp increase in
demand for certain medicines and major expectations of specific medicines and vaccines,
creating the conditions for multiple tensions.
9. The problem of medicine availability is particularly apparent for anesthetics and curares in
life support, which are subject to closely monitored delivery in order to avoid any break in
supply. The prescription and delivery of certain other medicines have been closely
supervised in order to maintain supply for chronic illnesses.
10. As a response to the unequal access to vaccinations, the implementation of the COVAX
mechanism must be developed in the future so as to promote access to and distribution of
vaccines, with the objective of protecting the people of all countries.
Availability, Quality and Safety of Medicines
London S-2021-01-2021
11. The WHO warns and cautions consumers, healthcare professionals and health authorities
about medicine safety: the growing offer of falsified medical products in the context of the
Covid-19 pandemic is aided by the possibility of shortages.
12. Concerning the quality of medicine, the health crisis has highlighted the risks of self-
medication and the need for the States to set up information systems aimed at the general
population. False hopes of possible cures for or prevention of Covid-19 by scientifically
unproven methods have been known to have serious consequences for the health of the
individual.
13. Economic and/or political interests must not be in competition with the health of the public.
Pooling of public health interests must be developed in order that economic and/or political
interests are not the cause of failure to manage the situation, of stock shortages or of anti-
competitive behaviour.
14. The evolution of the current health crisis and notably the arrival of new variants show that
States must be able to respond scientifically to this evolution without being hampered by
overly-restrictive international regulations.
Handbook of WMA Policies
World Medical Association S-2021-02-2021
WMA STATEMENT
ON
ESSENTIAL SURGICAL CARE AS A PART OF ACCESS TO HEALTHCARE
Adopted by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
Surgery and anesthesia care encompass all clinical fields and all health care providers dealing
with surgical disease and pathologies. This includes, but is not limited to anesthesia, obstetrics
and gynaecology and surgery including all of its subspecialties. They have historically been a
neglected part of global health with very little investments made in developing surgical health
systems, while an estimated quarter of the burden of disease worldwide can be attributed to
surgical diseases. Moreover, the majority of the world’s population lacks access to safe, timely
and affordable surgical care.
A workforce of 20 surgical, anesthesia and obstetric physician providers for every 100.000
members of the population is necessary to provide 80% of the world population essential and
emergency surgical care within 2 hours. This includes emergency surgical and obstetric care
such as caesarian sections and surgical care to prevent death and disability due to illnesses
likely to benefit from surgical treatment such as injuries, cataracts and cancer. The majority of
low- and middle-income countries (LMICs) fall far below this target, with the need being
especially great in the poorest regions of the world.
Surgeon shortages may be exacerbated by a lack of gender equity in the surgical workforce
which remains a challenge. Despite the fact that in a number of countries, there are more female
than male medical students, men still outnumber women by far in the surgical workforce.
Surgery and anesthesia care have been proven to be cost-effective, especially in LMICs.
Surgical interventions are as cost-effective as common public health interventions like malaria
bed nets, HIV drugs or childhood vaccinations.
Sixty percent of cancer patients and eighty percent of trauma patients will need some form of
surgical intervention throughout their treatment. Considering both non-communicable diseases
(NCDs) and injuries are on the rise globally, the demand for surgical care is expected to
continue to increase.
In 2015 the World Health Assembly recognized surgery and anesthesia care as a vital
component of Universal Health Coverage (UHC) through their Resolution 68.15
“Strengthening emergency and essential surgical care and anesthesia as a component of
universal health coverage”.
Access to Surgery and Anesthesia Care
London S-2021-02-2021
RECOMMENDATIONS
WMA recommends that the relevant national authorities:
1. Integrate quality surgical and anesthesia care in all levels of health care, including
comprehensive primary health care in order to realize UHC and Sustainable
Development Goals by 2030.
2. Develop specific surgery and anesthesia guidelines and policies for their respective
countries or jurisdictions adapted to local needs and capacities.
3. Implement policies regulating the process of task shifting in surgery and anesthesia care
in line with the “WMA Resolution on Task Shifting from the Medical Profession”.
4. Invest in health system strengthening and advocate for increased financing and
budgetary allocation for surgery and anesthesia care without depriving other areas of
necessary funds.
5. Provide the necessary infrastructure and procurement lines for hospitals to deliver safe,
high-quality surgical care.
6. Ensure policies, including narcotic and regulated drugs policies, do not hamper access
to necessary surgical medications including analgesia and anesthetic agents.
7. Create clinical protocols or guidelines at the national or regional level to assure
antibiotics use in the peri-operative period are prescribed in a sustainable manner and
in line with applicable antimicrobial resistance guidelines.
8. Include surgical care and diseases in relevant courses to fight the dogma that surgical
care is too expensive and complex to provide in low-resource settings.
9. Offer equitable residency training opportunities to locally trained medical students of
both genders in the field of surgery and anesthesia based on scientifically projected
needs of the country or region in line with the “WMA Statement on Gender Equality”
and contributing to the Global strategy on human resources for health: Workforce 2030.
10. Allow adaptive training and work schedules to accommodate the potential need for
maternity or paternity leave, and a healthy work-life balance, in order to make training
programs more accessible irrespective of the trainee’s family responsibilities.
11. Seek regional, national and international collaboration in clinical and academic
domains where local capacity and resources may be lacking and where exposure could
be beneficial to those from areas without high capacity or resources, such as through
bilateral exchange programs.
12. Support national initiatives on surgical data collection, capacity building, advocacy,
policy planning and systems strengthening through collaboration with NGOs,
Handbook of WMA Policies
World Medical Association S-2021-02-2021
universities, research initiatives, local communities, development banks, governmental
organizations, and other stakeholders;
WMA commits to:
13. Advocate at local, regional and national, and international fora in favor of person-
centered care creating a more holistic health care system, offering medical, surgical,
mental health and preventive health services in a national UHC approach, supporting
WHA Resolution 68.15 “Strengthening emergency and essential surgical care and
anesthesia as a component of universal health coverage”.
Handbook of WMA Policies
World Medical Association S-2021-03-2021
WMA STATEMENT
ON
SOLAR RADIATION AND PHOTOPROTECTION
Adopted by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
The sun is a great source of health benefits, but it is important to know its harmful consequences
as well. The prevention of the harmful effects of the sun on our skin is advisable at all ages,
especially in children and adolescents. Solar radiation generates a series of biological and
physiological effects in the body that depend on the proportion and intensity of the radiation
and that have beneficial effects, such as stimulating the synthesis of vitamin D, favoring the
formation of hemoglobin and improving the mood, while other effects are harmful and
aggressive to the skin, such as erythema, photoaging of the skin and precancerous or cancerous
lesions. Dermatoses produced or aggravated by sun exposure are a health problem that
healthcare professionals face most frequently.
Solar light is composed of a continuous spectrum of electromagnetic radiation divided into
three major groups: ultraviolet (UV), visible and infrared. UV radiation is classified as UV-A,
UV-B and UV-C.
The intensity of UV radiation can be measured by international standardized instruments such
as the UV index which measures the strength of sunburn-producing solar UV radiation at a
particular place and time.
Solar UV radiation, especially through UV-B, is an extremely important, yet neglected
causative factor for skin cancers, both melanoma and non-melanoma, for ocular pathologies
(e.g., cataracts, and age-related macular degeneration), and harmful effects on the immune
system [3]. Recurrent and severe sunburns are a risk factor for non-melanoma skin cancer.
Solar radiation can also induce the onset and exacerbation of chronic actinic dermatitis (CAD)
and melasma. Blue light plays an important role as well in the pathogenesis of melasma,
therefore broad-spectrum photoprotection should be advocated and the intake of photosensitive
foods and drugs should be reduced.
Risk of skin cancer differs according to skin type as well as the duration and intensity of solar
light exposure. Chronic, long-term, cumulative UV exposure is associated with actinic
keratosis and squamous cell carcinomas, while high-intensity, intermittent UV exposure,
especially at a young age, is associated with basal cell carcinomas and melanomas. Therefore,
photoprotection is important in young ages.
Solar Radiation and Photoprotection
London S-2021-03-2021
The World Health Organization (WHO), through the International Agency for Research on
Cancer has raised the issue of solar UV radiation being a carcinogen since 1992 and since 2012
has classified solar UV radiation as a group 1 carcinogen (carcinogen to humans). Other well-
known group 1 carcinogens are plutonium, asbestos and ionizing radiation.
Furthermore, current climate changes and the depletion of the ozone layer by approximately
4% per decade since the 1970s has led to a diminished filtration of UV-A and UV-B radiation
and to increased UV radiation that reaches sea-level.
As a consequence, the incidence of melanoma and non-melanoma skin cancer is increasing
worldwide.
WHO evidence indicates that four out of five cases of skin cancer can be prevented and simple
preventive measures, such as limiting UV exposure in the midday sun, wearing UV protective
clothing and hats or using mineral-based sunscreens, are recommended.
Photoprotection also includes make-up products, sunglasses, and windshields.
The WHO recognizes that while protection against UV exposure is recommended globally,
there is concern that lack of UV exposure may reduce beneficial effects of vitamin D, including
its potential to reduce the risk of some types of cancer.
RECOMMENDATIONS
1. Photoprotection is a key preventative health strategy as most skin cancers are a result of
UV solar exposure.
National Governments should:
2. Inform health professionals and the public about the characteristics that sunscreen should
meet (one that provides balanced, safe and easy-to-use protection) in order to avoid
variability between the products supplied by laboratories, as well as improve safety and the
labelling of the sunscreen.
3. Recognize solar UV exposure as an important risk factor for developing skin cancer. UV
exposure also is a prime cause of some ocular diseases and immune system dysfunctions.
4. Work together to develop a Global Action Plan for the Prevention of Skin Cancer based on
Photoprotective measures. This should include action against climate change to help reduce
damage from ultra-violet radiation.
5. Support skin cancer screening campaigns.
6. Recognize prevention of skin cancer as a national health priority.
Handbook of WMA Policies
World Medical Association S-2021-03-2021
7. Improve skin cancer’s screening, diagnosis and management.
8. Include all forms of skin cancer in all Nationals Cancer Registries and improve the
reporting of UV induced skin cancers and legislative frameworks to protect outdoor
workers (recognition as occupational disease).
9. Work with relevant stakeholders to liaise, engage and organize online and offline skin
cancer prevention campaigns and educational programs on sun protection, with a primary
focus on ages 0 – 18, in order to raise awareness of this health hazard and to encourage sun
safety (use of protective clothing and hats, adequate sunscreen use, avoidance of excessive
exposure) and healthy lifestyle choices among the young.
10. Promote policies to fight climate change and air pollution.
11. Consider the environmental impact of sunscreen.
WMA and its members should:
12. Interact with healthcare providers and medical practitioners who have a significant role in
empowering and educating their patients in the promotion of skin cancer awareness, sun-
protective measures and encouraging patient access to screening, diagnosis and treatment.
13. Educate primary care physicians and occupational physicians to recognise and refer
patients with suspect lesions to dermatologists.
14. Support the development of national guidelines on photoprotective measures and continued
scientific research in this field to derive the risk-benefit balance of UV exposure.
15. Support continued research and development of adequate protective clothing.
16. Promote campaigns to encourage the measurement of UV exposure within each nation.
17. Support media campaigns and educational programs that explain the harmful effects of UV
exposure and optimal photoprotective measures targeting the most vulnerable, such as
children and teenagers, fair skinned people, outdoor workers (e.g. agriculture, fishery,
construction, forestry, athletes, swimming pool attendants).
18. Promote health education and information on sunscreens and the most recommended and
healthy habits for the skin, establishing correct sun protection habits that make it possible
to enjoy the beneficial effects of the sun and avoid sun damage.
Individual physicians should:
19. Counsel patients about the major health risks associated with excessive solar UV radiation
exposure, inform patients about appropriate sun protective measures (e.g. skin coverage,
sunscreen, and sunglasses) and encourage patients to undergo regular medical check-ups
and to participate in skin cancer screening campaigns, where available.
Solar Radiation and Photoprotection
London S-2021-03-2021
20. Counsel patients to self-examine their skin.
21. Counsel those patients at risk (for example, patients on certain anti-cancer drugs) to
understand the extra importance of protective measures.
22. Counsel employers on UV light as a work-related health risk.
Handbook of WMA Policies
World Medical Association S-2022-01-2022
WMA STATEMENT
ON
PHYSICIANS TREATING RELATIVES
Adopted by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The interaction between the physicians and their relatives seeking medical care can be
complex. Moreover, this possibility is highly conditioned by cultural aspects. Interaction can
start with asking for simple advice, consultation for minor ailments, and general questions
about healthcare and health promotion. This can escalate to seeking medical care and even
surgery. Physicians are often their relatives’ first point of call for medical and emotional
support. Physicians may be able to offer immediate care in cases of emergency and contribute
to well-informed, evidence-based self-care. Other than in emergencies, offering general health
information or for minor health problems, physicians should avoid treating those close to them.
The ethical principles governing the work of physicians are equally important and valid when
treating relatives. Respect for autonomy may be compromised by lack of privacy, unintentional
breaches of confidentiality, and failure to seek informed consent. The relationship with the
physician might compromise the patient’s ability to make independent decisions.
Treating relatives may pose challenges in the following circumstances:
• When objectivity is compromised and decisively affected by emotional factors, there
could be a risk of either under- or over-treating relatives or of encountering problems
that are beyond the physician’s expertise or abilities, which could cause serious harms.
• When there are potential barriers to considering sensitive medical history and/or
conducting an appropriate physical examination, which may result in incorrect medical
diagnosis and treatment.
• When the physician fails to fulfil requirements concerning patient clinical records,
which may result in difficulties if the related patient needs follow-up treatment or when
liability issues arise.
• When a negative medical outcome could compromise the relationship between the
physician and the related patient.
• When the treatment is not in the best interest or against the will of the related patient.
• When the physician risks providing relatives, perhaps unintentionally and
unconsciously, with undue advantages.
Physicians Treating Relatives
Berlin S-2022-01-2022
RECOMMENDATIONS
1. Physicians should avoid routinely acting as a relative’s primary care physician or serving
as the attending physician when treating a potentially life-threatening condition. Physicians
may provide care to a relative in emergencies, for minor health problems or when there is
no other qualified physician available.
2. Related patients may ask for a second opinion about another physician’s care. If a second
opinion is shared, it should be consistent with these recommendations and fulfil the duties
of physicians to colleagues. Care should be taken to only discuss the treatment, which is
most appropriate and recommended, rather than any judgements about the other treating
physician’s care and advice.
3. If a physician treats a relative, the physician should be mindful of the following:
• Strict respect for medical ethics, the patient’s autonomy and consent, with special
consideration for minors.
• The physician has the duty to respect a patient’s right to confidentiality and should not
share information with anyone else without a lawful basis, including other family
members, with the exception of necessary clinical documentation when referring to
other health care personnel.
• If a relative indicates an intention to seek a second opinion about another physician’s
care, that intention must be respected.
• Consent for treatment must be given by the patient, including competent minors, and
for that consent to be valid, it must be fully informed.
• Depending on the nature of the relationship, taking a sensitive history and performing
a physical examination may be emotionally difficult or uncomfortable for the patient or
the physician. In such situations the physician and the patient should consider
consulting another physician.
• Clear and concise patient records must be maintained at all times.
4. If the physician cannot accommodate the recommendations above, the physician should
avoid treating relatives.
5. While physicians are encouraged not to treat relatives except in certain circumstances, it is
acknowledged that physicians are often approached by their relatives for medical advice or
treatment, and their help is frequently beneficial and appreciated.
6. In all circumstances, physicians shall maintain the highest professional and ethical
standards, in accordance with the Declaration of Geneva, the WMA International Code of
Medical Ethics, and the WMA Declaration of Lisbon on the Rights of the Patient.
Handbook of WMA Policies
World Medical Association ⏐ R-1988-01-2015
WMA RESOLUTION
ON
ACADEMIC SANCTIONS OR BOYCOTTS
Adopted by the 40th
World Medical Assembly, Vienna, Austria, September 1988
and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France,
May 2005
and reaffirmed by the 200th
WMA Council Session, Oslo, Norway, April 2015
WHEREAS
academic sanctions or boycotts are discriminatory restrictions on academic, professional
and scientific freedoms that deny or exclude physicians and others from educational, cul-
tural and scientific meetings and other opportunities for the exchange of information and
knowledge, the purpose of such restrictions being to protest the social and political poli-
cies of governments, and
WHEREAS
such restrictions are in direct conflict with the major objectives of the WMA, viz., to
achieve the highest international standards in medical education, medical science, medical
art and medical ethics, and
WHEREAS
such restrictions adversely affect health care, particularly of the disadvantaged, and there-
fore thwart the WMA’s objective of obtaining the best possible health care for all people
of the world, and
WHEREAS
such restrictions discriminate against physicians and patients on grounds of political per-
suasion or of political decisions taken by governments and are therefore in conflict with
the WMA’s Declaration of Geneva, Statement on Non-Discrimination in Professional Mem-
bership and Activities of Physicians and Statement on Freedom to Attend Medical Meet-
ings, and
WHEREAS
a basic rule of medical practice is “primum non nocere”, i.e. first, do no harm,
THEREFORE BE IT RESOLVED,
that the WMA regards the application of such restrictions as arbitrary political decisions
designed to deny international scholarly exchange and to blacklist particular physicians or
R-1988-01-2015 ⏐Oslo
Academic Sanctions Boycotts
bodies of physicians because of their nationality or because of the political policies of
their governments. The WMA is unalterably opposed to such restrictions and calls on all
Na-tional Medical Associations to resist the imposition of such restrictions by every
means at their disposal and to heed the WMA’s Statement on Non-Discrimination in
Professional Membership and Activities of Physicians and the WMA Statement on
Freedom to Attend Medical Meetings.
Handbook of WMA Policies
World Medical Association R-1997-01-2022
WMA RESOLUTION
ON
ECONOMIC EMBARGOES AND HEALTH
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, November 1997
reaffirmed by the 58th
WMA General Assembly, Copenhagen, Denmark, October 2007
reaffirmed with minor revision by the 207th
WMA Council Session, Chicago, United States,
October 2017
and reaffirmed by the 220th
WMA Council Session, Paris, France, April 2022
RECOGNISING THAT:
all people have the right to the preservation of health; and,
the Geneva Convention (Article 23, Number IV, 1949) requires the free passage of medical
supplies intended for civilians;
Recalling the standards of international human rights law, specifically the Universal
Declaration of Human Rights and the International Covenant on Economic, Social and Cultural
Rights guarantees in its article 12 “the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health”;
The WMA urges national medical associations to ensure that Governments employing
economic sanctions against other States respect the agreed exemptions for medicines, medical
supplies and basic food items. Exemptions should not be exploited for inappropriate purposes.
Handbook of WMA Policies
R-1998-01-2018 ⏐ World Medical Association
WMA RESOLUTION
SUPPORTING THE OTTAWA CONVENTION
(Convention on the prohibition of the use, stockpiling, production
and transfer of anti-personnel mines and on their destruction)
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed by the 209th
WMA Council Session, Riga, April 2018
The World Medical Association:
• expresses its support for the Ottawa Convention (also known as the landmine ban
convention); and
• urges its member National Medical Associations to press their governments to sign
and ratify the Convention.
• urges its member National Medical Associations to press their governments to
cease manufacture, sale, deployment and use of landmines.
Handbook of WMA Policies
R-1998-04-2009 ⏐ World Medical Association
WMA RESOLUTION
ON
MEDICAL WORKFORCE
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, October 1998
and amended by the 60th
WMA General Assembly, New Delhi, India, October 2009
PREAMBLE
The health of our countries depends upon keeping the population healthy. Health care is a
key right of individuals. This care is dependent upon access to highly-trained medical and
other healthcare professionals. Well-functioning health care systems depend upon these
sufficient human resources. Comprehensive and extensive planning on a national level is
required in order to ensure that a country has a medical workforce in all fields of medicine
that meets the present and future health needs of the entire population of that country.
There are currently significant shortages in the area of health human resources. These
shortages are present in all countries but are especially pronounced in developing coun-
tries where health human resources are more limited.
The problem is made more severe by the fact that many countries have not invested ade-
quately in the education, training, recruitment and retention of their medical workforce.
The ageing population in developed countries has also been reflected by an ageing medi-
cal workforce. Many developed countries address their medical workforce shortages by
employing health care professionals from developing countries to bolster their own health
care systems.
The migration of health care professionals from developing countries to developed coun-
tries has, over the past ten years, impaired the performance of health systems in develop-
ing countries. Economic realities of insufficient investments in health care and inadequate
facilities and support for health care professionals have continued to be responsible for
this migration.
The World Health Organization has recognized that the crisis of health workforce short-
ages is impeding the provision of essential, life-saving interventions. It has therefore esta-
blished structures such as the Global Health Workforce Alliance, a partnership dedicated
to identifying and implementing solutions to the health workforce problems. The WHO is
promoting the development of a cadre of medical/clinical assistants who propose to join
the medical workforce to partially address these shortages.
RECOMMENDATIONS
Recognizing that health care systems require adequate numbers of qualified and com-
petent health care professionals, the World Medical Association asks all National Medical
Associations to participate and be active in addressing these requirements and to:
R-1999-01-2021 ⏐ Seoul
Curriculum of Medical Schools World-wide
1. Call on their respective governments to allocate sufficient financial resources for the
education, training, development, recruitment and retention of physicians to meet the
medical needs of the entire population in their countries.
2. Call on their respective governments to ensure that the education, training and develop-
ment of healthcare professionals meets the highest possible standards including:
• The training and development of medical/clinical assistants where this is applica-
ble and appropriate and
• Ensuring clear definitions of scope of practice and conditions for adequate support
and supervision;
3. Call on governments to ensure that appropriate ratios are maintained between popula-
tion and the medical workforce at all levels, including mechanisms to address reduced
access to care in rural and remote areas, based on accepted international norms and
standards where these are available;
4. Take measures to attract and support individuals within their countries to enter the
medical profession and also call on their respective governments to take such action;
5. Actively advocate for programs that will ensure the retention of physicians within
their respective countries and ensure governments’ recognition of this need;
6. Call on governments to improve the health care working environment (including ac-
cess to appropriate facilities, equipment, treatment modalities and professional sup-
port), physician remuneration, physician living environment and career development
of the medical workforce at all levels;
7. Advocate for the development of transparent memoranda of understanding between
countries where migration of trained health care professionals is an issue of concern
and enlist where possible the NMA of origin and receiving NMA’s to support these
physicians.
Handbook of WMA Policies
World Medical Association ⏐ R-1999-01-2021
WMA RESOLUTION
ON
THE INCLUSION OF MEDICAL ETHICS AND HUMAN RIGHTS
IN THE CURRICULUM OF MEDICAL SCHOOLS WORLD-WIDE
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel, October 1999
and revised by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and reaffirmed by the 217th
WMA Council Session, Seoul (online), April 2021
PREAMBLE
Medical School curricula are designed to prepare medical students to enter the profession
of medicine. Increasingly, in addition to core biomedical and clinical knowledge, they
teach skills including critical appraisal and reflective practice. These additional skills help
to enable future doctors to understand and assess the importance of published research
evidence, and how to evaluate their own practice against norms and standards set nation-
ally and internationally.
In much the way same that anatomy, physiology and biochemistry are a solid base for
understanding the human body, how it works, how it can fail or otherwise go wrong, and
how different mechanisms can be used to repair damaged structure and functions, there is
a clear need for physicians in training to understand the social, cultural and environmental
contexts within which they will practice. This includes a solid understanding of the social
determinants of health.
Medical ethics includes the social contract made between the health care professions and
the societies they serve, based upon established principles, on the limits that apply to
medical practice It also establishes a system or set of principles through which new
treatments or other clinical interventions will be sieved before decisions are made on
whether elements are acceptable within medical practice. There is a complex intermingl-
ing of medical ethics and the duties of physicians to patients, and the rights patients enjoy
as citizens.
At the same time physicians face challenges and opportunities in relation to the human
rights of their patients and of populations, for example occasions for imposing treatments
without consent, and will also often be the first to observe and to itemize the infringement
of these rights by others, including the state. This places very specific responsibilities
upon the observing physician.
Physicians have a duty to use their knowledge to improve the wellbeing and health of
patients and the population. This will mean considering social and societal change,
including legislation and regulation, and can only be done well if doctors can take a
holistic view within clinical and ethical parameters.
R-1999-01-2021 ⏐ Seoul
Curriculum of Medical Schools World-wide
Physicians should press government to ensure legislation supports principled medical
practice.
Given the core nature of health care ethics in establishing medical practice in a manner
that is acceptable to society and that does not violate civil, political and other human
rights, it is essential that all physicians are trained to perform an ethics evaluation of every
clinical scenario they may encounter, while simultaneously understanding their role in
protecting the rights of individuals.
Physicians’ ability to act and communicate in a way that respects the values of the
individual patient is a prerequisite for successful treatment. Physicians must also be able to
work effectively in teams with other health care professionals including other physicians.
Failures of individual physicians to recognize the ethical obligations they owe patients and
communities can damage the reputation of doctors both locally and globally. Therefore it
is essential that all doctors are taught to understand and respect medical ethics and human
rights from the beginning of their medical school careers.
In many countries ethics and human rights are an integral part of the medical curriculum,
but this is not universal. Too often teaching is undertaken by volunteers, and can fail if
those volunteers are unable or unavailable to teach, or if that teaching is unduly idiosync-
ratic or inadequately based upon clinical scenarios.
The teaching of medical ethics should become an obligatory and examined part of the
medical curriculum within every medical school.
RECOMMENDATIONS
1. The WMA urges that medical ethics and human rights be taught at every medical
school as obligatory and examined parts of the curriculum, and should continue at all
stages of post graduate medical education and continuing professional development.
2. The WMA believes that medical schools should seek to ensure that they have
sufficient faculty skilled at teaching ethical enquiry and human rights to make these
courses sustainable.
3. The WMA commends the inclusion of medical ethics and human rights within post
graduate and continuing medical education.
Handbook of WMA Policies
R-2002-05-2021 ⏐ World Medical Association
WMA RESOLUTION
ON
THE ABUSE OF PSYCHIATRY
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and revised by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed by the 217th
WMA Council Session, Seoul (online), April 2021
The World Medical Association (WMA) notes with concern evidence from a number of
countries that political dissidents, practitioners of various religions and social activists
have been detained in psychiatric institutions and subjected to unnecessary psychiatric
treatment as a punishment and not to treat a substantiated psychiatric illness.
The WMA:
• Declares that such detention and unwarranted treatment is abusive, unethical and
unacceptable;
• Calls on physicians and psychiatrists to resist involvement in these abusive prac-
tices;
• Calls on member NMAs to support their physician members who resist involve-
ment in these abuses, and
• Calls on governments to stop abusing medicine and psychiatry in this manner, and
on non-governmental organizations and the World Health Organization to work to
end these abuses; and
• Calls on governments to uphold the United Nations International Covenant on
Civil and Political Rights, which states that “all persons are equal before the law
and are entitled without any discrimination to the equal protection of the law.”
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WMA RESOLUTION
ON
WOMEN’S RIGHTS TO HEALTH CARE
AND HOW THAT RELATES TO THE PREVENTION
OF MOTHER-TO-CHILD HIV INFECTION
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA, October 2002
and amended by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
PREAMBLE
In many parts of the world the prevalence of HIV infection continues to increase. One of
the Millennium Development Goals (MDG 6), specifically targets combating HIV/AIDS,
malaria and other diseases, with 2015 being its target year to halt HIV/AIDS infection and
to begin reversing the spread of HIV/AIDS. In addition, it was hoped that by 2010
universal access to treatment for HIV/AIDS for all those requiring it would be achieved. A
December 2012 UN resolution declared that countries must develop programmes for
Universal Health Access after 2015 when the MDGs end.
HIV/AIDS is a disease that disproportionately affects people in their reproductive years
although today, due to better management of the condition, there are also many older
people who are infected. In addition, many who were infected as infants are now reaching
reproductive maturity.
In developed countries men who have sex with men and injection drug users constitute
significant risk groups for contracting HIV. In many developing countries, women are at
risk due to heterosexual contact with HIV infected partners. In 2011 approximately 58
percent of people living with HIV in sub-Saharan Africa were women, equating to about
13.6 million women living with HIV and AIDS, compared to about 9.9 million men
(UNAIDS ‘Global Fact Sheet 2012: World AIDS Day 2012).
In the absence of HIV, maternal mortality worldwide would be significantly (20% ) lower
(Murray et al. Maternal mortality for 181 countries, 1980~2008: a systematic analysis of
progress towards Millennium Development Goal 5).
HIV infection increases the risk of invasive cervical cancer 2 to 22 fold. Some evidence
exists that the use of antiretroviral therapy may decrease this risk. Hence, the appropriate
management of patients infected with HIV may have a long-term impact on other aspects
of women’s health.
The WMA believes that access to healthcare, including both therapeutic and preventative
strategies, is a fundamental human right. This imposes an obligation on government to
Fortaleza ⏐ R-2002-06-2013
Women’s Right to Health Care
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.
Many of the MDGs address empowering women and promoting their role in society and
specifically in healthcare. MDG 5B, in particular, promotes universal access to repro-
ductive health including contraceptive access, reduction in adolescent birth rate, antenatal
care coverage and addressing unmet needs for family planning. In addition, MDG 3
which promotes gender equality and empowers women, and MDGs 1 and 2 will influence
women’s status in society and therefore their access to healthcare and health promotion.
RECOMMENDATIONS
The WMA requests all national member associations to encourage their governments to
undertake and promote the following actions:
• Develop empowerment programs for women of all ages to ensure that women are
free from discrimination and enjoy universal and free access to reproductive health
education and life skills training. It is recommended that campaigns be initiated and
activated in the media, including social media and popular programmes on radio and
television in order to eradicate myths, stigma and stereotypes that might degrade or
dehumanise women. This must include campaigns against genital mutilation and
forced adolescent marriages and unwanted pregnancies. In addition, promoting the
availability and choice of contraception for women, without necessarily having to
get input from their partners, and promoting the availability of HIV testing and treat-
ment are essential for reproductive health. It is also important to provide for the eco-
nomic means for the infected populations in terms of prevention, treatment and
medical follow-up.
• Women must have the same access as men, without discrimination to education,
employment, economic independence, information about healthcare and health ser-
vices.
• Laws, policies and practices that facilitate the full recognition and respect of human
rights and the fundamental freedom of women should be initiated or reviewed and
revised where appropriate. It is essential that women are empowered to make deci-
sions regarding their children, their financial status and their future.
• All governments should develop programmes to provide prophylactic treatment in
the form of antiretrovirals to women who have been raped or sexually assaulted.
Universal and free access to antiretroviral therapy must also be provided to all HIV
infected women.
• HIV infected women who are pregnant should receive counselling and access to
anti-retroviral prophylaxis or treatment in order to prevent mother to child trans-
mission of HIV.
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World Medical Association ⏐ R-2003-01-2020
WMA RESOLUTION
ON
THE DESIGNATION OF AN ANNUAL MEDICAL ETHICS DAY
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and reaffirmed by the 194th
WMA Council Session, Bali, Indonesia, April 2013
and by the 215th
WMA Council Session (online), Cordoba, Spain, October 2020
Whereas the World Medical Association has a specific focus and function in the field of
medical ethics, and came into being on 18 September 1947 during the first General
Assembly, it is resolved that NMAs are encouraged to annually observe the 18th
September as “Medical Ethics Day”.
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R-2003-02-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
THE RESPONSIBILITY OF PHYSICIANS IN THE DOCUMENTATION
AND DENUNCIATION OF ACTS OF TORTURE OR CRUEL
OR INHUMAN OR DEGRADING TREATMENT
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and amended 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.
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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.
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Denunciation of Acts of Torture
• 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.
8. 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.
7. Revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2017.
8. The Declaration of Hawaii, adopted by the World Psychiatric Association in 1977.
9. 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…”.
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10. 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.
11. 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.
12. 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.
13. 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.
14. 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.
15. 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.”
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R-2003-03-2021 ⏐ World Medical Association
WMA RESOLUTION
ON
THE NON-COMMERCIALISATION OF
HUMAN REPRODUCTIVE MATERIAL
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, September 2003
and revised by 65th
WMA General Assembly, Durban, South Africa, October 2014
and reaffirmed by the 217th
WMA Council Session, Seoul (online), April 2021
PREAMBLE
The rapid advances in biomedical technologies have led to growth of the reproductive
assistance industry, which tends to be poorly regulated. Despite the fact that many govern-
ments have laws prohibiting commercial transactions of reproductive material, most have
not been successful in universally preventing the sale of human ova, sperm and embryos
on the internet and elsewhere. The market value of human material, including cells, tis-
sues, and cellular tissue can be lucrative, creating a potential conflict for physicians and
others between economic interests and professional ethical obligations.
For the purposes of this resolution human reproductive material is defined as human
gametes and embryos.
According to the WHO, transplant commercialism “is a policy or practice in which cells,
tissues or organs are treated as a commodity, including by being bought or sold or used for
material gain.”1
The principle that the “human body and its parts shall not, as such, give rise to financial
gain”2
is laid down in numerous international declarations and recommendations.3
The
2006 WMA Statement on Human Organ Donation and Transplantation and the 2012
WMA Statement on Organ and Tissue Donation call for the prohibition of the sale of or-
gans and tissues for transplantation. The WMA Statement on Assisted Reproductive
Technologies (2006) also states that it is inappropriate to offer financial benefits to en-
courage donation of human reproductive material.
The same principles should be in place for the use of human reproductive material in the
area of medical research. The International Bioethics Committee of the United Nations
Educational, Scientific and Cultural Organization (UNESCO IBC) in its report on the
ethical aspects of human embryonic stem cell research states that the transfer of human
embryos must not be a commercial transaction and that measures should be taken to
discourage any financial incentive.
It is important to distinguish between the sale of clinical assisted reproductive services,
which is legal, and the sale of the human reproductive materials, which is usually illegal.
Due to the special nature of human embryos, the commercialization of gametes is unlike
that of other cells and tissues as sperm and eggs may develop into a child if fertilization is
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successful.
Before human reproductive material is donated, the donor must give informed consent that
is free of duress. This requires that the individual donor is deemed fully competent and has
been given all the available information regarding the procedure and its outcome. If re-
search is to be conducted on the material, it is subject to a separate consent process that
must be consistent with the provisions in the WMA’s Declaration of Helsinki. There must
not be any inducement or other undue pressure to donate or offers of compensation.
Monetary compensation given to individuals for economic losses, expenses or incon-
veniences associated with the retrieval of donated reproductive materials should be dis-
tinguished from payment for the purchase of reproductive materials.
RECOMMENDATIONS
1.
1. National Medical Associations (NMAs) should urge their governments to prohibit
commercial transactions in human ova, sperm and embryos and any human material
for reproductive purpose.
2. Physicians involved in the procurement and use of human ova, sperm, and em-
bryos should implement protocol to ensure that materials have been acquired ap-
propriately with the consent and authorization of the source individuals. In doing
so, they can uphold the ethical principle of non-commercialization of human repro-
ductive material.
3. Physicians should consult with potential donors prior to donation in order to ensure
free and informed consent.
4. Physicians should adhere to the WMA Statement on Conflict of Interest when
treating patients who seek reproductive services.
1
Global Glossary of Terms and Definitions on Donation and Transplantation, WHO, November
2009
2
European convention of human rights and biomedicine – Article 21 – Prohibition of financial
gain
3
Declaration of Istanbul guiding principle 5
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WMA RESOLUTION
ON
WFME GLOBAL STANDARDS FOR QUALITY IMPROVEMENT OF
MEDICAL EDUCATION
Approved by the 55th
WMA General Assembly, Tokyo, Japan, October 2004
and reaffirmed by the 197th
WMA Council Session, Tokyo, Japan, April 2014
and by the 217th
WMA Council Session, Seoul (online), April 2021
Whereas the WMA:
1. Recognizes the need and importance for sound global standards for quality improve-
ment of medical education;
2. Acknowledges the WMA’s special relationship with the World Federation for Medical
Education (WFME) as one of the founders of the Federation;
3. Recognizes that it is represented in the WFME Executive Council and in this capacity
is co-responsible for the WFME Project on International Standards in Medical Educa-
tion, conducted since 1997 1
;
4. Acknowledges the recent development of the WFME Trilogy of Documents of Global
Standards in Medical Education for Quality Improvement, covering Basic Medical
Education2
, Postgraduate Medical Education3
and the Continuing Professional De-
velopment (CPD) of Medical Doctors4
;
5. Recognizes the endorsement5
of the WFME Global Standards at the World Confer-
ence in Medical Education: Global Standards in Medical Education for Better Health
Care, in Copenhagen, Denmark, March 20036
;
It hereby:
1. Expresses its encouragement and support of the ongoing work of implementing the
Trilogy of WFME Documents on Global Standards in Medical Education.
1
The Executive Council, The World Federation for Medical Education: International standards in
medical education: assessment and accreditation of medical schools´ educational programmes. A
WFME position paper. Med Ed 1998; 32: 549-558.
2
World Federation for Medical Education: Basic Medical Education. WFME Global Standards for
Quality Improvement. WFME, Copenhagen 2003. http://www.wfme.org
3
World Federation for Medical Education. Postgraduate Medical Education. WFME Global
Standards for Quality Improvement. WFME, Copenhagen 2003. http://www.wfme.org
4
World Federation for Medical Education: Continuing Professional Development (CPD) of Me-
dical Doctors. WFME Global Standards for Quality Improvement. WFME Copenhagen 2003.
5
J.P. de V. van Niekerk. WFME Global Standards receive ringing endorsement. Med Ed, 2003;
37: 586-587.
6
WFME website: http://www.wfme.org
Handbook of WMA Policies
World Medical Association R-2005-04-2021
WMA RESOLUTION
IN SUPPORT OF
TAIWAN’S PARTICIPATION IN ALL WHO HEALTH PROGRAMS AND
INCLUSION IN THE INTERNATIONAL HEALTH REGULATIONS (IHR)
MECHANISM
Adopted by the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
and amended by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
PREAMBLE
In line with the Charter of the United Nations, Member States of the WHO recognize the
“enjoyment of the highest attainable standard of health” as a fundamental right of every human
being “without distinction of race, religion, political belief, economic or social condition”,
uphold that “the health of all peoples is fundamental to the attainment of peace and security
and is dependent upon the fullest co-operation of individuals and States” (Preamble of WHO’s
Constitution).
Taiwan, located at a key position in the Asia-Pacific region, has long enjoyed close relationship
with countries and areas of the region, with over 20 million regional and international travelers
per year. Thus, the devastating outbreak of the 2019 Novel Coronavirus further highlights the
urgency and importance of inclusiveness and leaving no one behind in the global health
network. By continuing to refuse to grant Taiwan observer status to the WHA and full access
to its meetings, mechanisms and activities, the WHO fails to fulfill the principles of universality
and equality established in WHO’s constitution as well as the ethical standards of the
organization.
From 2009 to 2016, Taiwan was invited to participate in the World Health Assembly (WHA)
as an Observer, with very limited access to WHO technical briefings, mechanisms and
activities. Since 2017, the WHO has not granted the Observer status to Taiwan anymore.
Although Taiwan has been officially included in the implementation framework of the
International Health Regulations (IHR) since 2009, its contact point information is not included
on the IHR Portal established by WHO, impeding timely exchange of information and
communication to the detriment of Taiwan. Delayed and/or incomplete medical information
can impact adversely on the Taiwanese population, causing a gap in Taiwan’s domestic disease
control network, with unavoidable implications for global health.
Taiwan’s Observer Status to the WHO
London R-2005-04-2021
Allowing the participation of Taiwan to the World Health Assembly and fostering its inclusion
in all WHO’s health programmes and in the International Health Regulations would benefit the
people in Taiwan, but also the WHO and its member states as well as all related parties.
RECOMMENDATIONS
1. Considering the Sustainable Development Goal 3 aiming to ensure healthy lives and
promoting well-being for all at all ages and WHO’s primary objective to “attain by all
peoples the highest possible level of health” (article 1 of WHO’s Constitution), both aims
requiring a true inclusive strategy comprising all populations worldwide,
2. Reminding the ethical core value of the medical profession to serve humanity regardless of
any other considerations than people’s health and well-being, and firmly committed to the
safeguard and promotion of health-related human rights, the WMA and its constituent
members call on:
• WHO to grant Taiwan observer status to the World Health Assembly and to ensure
Taiwan’s participation in all its health programs based on a substantive, timely and
professional basis,
• WHO and its Member States to include Taiwan as a full participating party to the
International Health Regulations, allowing its critical contribution to the global health
protection network.
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World Medical Association S-2005-05-2021
WMA STATEMENT
ON
IMPLEMENTATION OF THE WHO FRAMEWORK CONVENTION ON
TOBACCO CONTROL
Adopted by the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005
and amended by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
The World Medical Association:
1. Acknowledges the essential role of health professionals in tobacco control and urges its
constituent members and other representatives of the medical community to use World
No Tobacco Day each year to advocate for tobacco control measures;
2. Recognises the importance of the WHO Framework Convention on Tobacco Control
(FCTC) as a mechanism to protect people from exposure and addiction to tobacco;
3. Encourages Member States to the Convention to recognize (ratify, accept, approve,
confirm or accede) the Protocol to Eliminate Trade in Tobacco Products;
4. Encourages its constituent members to work assiduously and energetically to get their
governments to implement the measures set out in the FCTC as a minimum;
5. In line with its Statement on Electronic Cigarettes, calls on Member States to include
e-cigarettes and other electronic nicotine delivery systems in the scope of application
of the WHO Framework Convention and to ensure that that these products be subjected
to local regulatory approval and be entrenched in smoke free laws.
6. Urges governments to introduce regulations and other control measures as described in
the FCTC including regulation of smokeless tobacco products. Governments should
ban smoking and vaping in public places and workplaces as an urgent public health
intervention and also consider additional measures, especially those tobacco control
measures that have been proven to be successful in other countries;
7. Urges governments to introduce initiatives that break brand recognition, including plain
packaging of cigarettes and other smoking products, as stated in its Resolution on Plain
Packaging of Cigarettes, e-Cigarettes and Other Smoking Product
8. Strongly encourages governments to set a distinct method to ensure adequate funding
for tobacco control and research;
Tobacco-WHO FCTC
London R-2005-05-2021
9. Urges governments to promote ready access to smoking cessation advice and services
to all smokers, including children;
10. Recognises the vital role of health professionals in public health education and in
promoting smoking cessation;
11. Combats the tobacco industry’s predatory marketing tactics by adopting comprehensive
bans on advertising, promotion and sponsorship, as set forth in the WHO FCTC, in
order to protect the health of individuals and communities;
12. Contributes to the improvements and updating of international tobacco control
regulations as needed.
Handbook of WMA Policies
World Medical Association R-2006-02-2021
WMA STATEMENT
ON
CHILD SAFETY IN AIR TRAVEL
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
PREAMBLE
Air travel is a common mode of transportation and is used by people of all ages every day. The
WMA notes that high standards of safety for adult passengers in air travel have been achieved,
with strict safety procedures increasing greatly the chance of survival during emergency
situations in aircraft.
Restraint and safety systems for infants and children have been successfully tested to reduce
the risk of suffering injuries in case of emergency. Those systems have been approved for usage
in standard passenger aircrafts and successfully introduced by several airlines. However, the
practice of holding an infant or child in a lap or using a “loop belt” continues and is not a
sufficient safety measure.
RECOMMENDATIONS
Therefore, the World Medical Association and its constituent members
1. Express grave concern regarding the fact that adequate safety systems for infants and
children have not been generally implemented;
2. Call on all airline companies to take immediate steps to introduce safe, thoroughly tested
and standardized child restraint systems;
3. Call on all airline companies to train their staff in the appropriate handling and usage of
child restraint systems;
4. Call for the establishment of a universal standard or specification for the testing and
manufacturing of child restraint systems, and
5. Call on national legislators and air transportation safety authorities to:
• require for infants and children, as a matter of law, safe individual child restraint
systems that are approved for use in standard passenger aircraft;
Child Safety in Airline Travel
London R-2006-02-2021
• ensure that airlines provide child restraint systems or welcome passengers using their
own systems, if the equipment is qualified and approved for the specific aircraft;
• ban the usage of inappropriate “loop belts” frequently used to secure infants and
children in passenger aircraft;
• provide appropriate information about infant and child safety on board of aircraft to all
airline passengers.
Handbook of WMA Policies
World Medical Association R-2006-04-2021
WMA RESOLUTION
ON
NORTH KOREAN NUCLEAR TESTING
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203rd
WMA Council Session, Buenos Aires, Argentina, April 2016
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
Recalling its Statement on Nuclear Weapons, the WMA:
• Denounces North Korean nuclear testing conducted at a time of heightened global
vigilance on nuclear testing and arsenals;
• Calls for the immediate abandonment of the testing of nuclear weapons by any nation;
• Requests its constituent members and other representatives of the medical profession
across the world to urge their governments to understand the adverse health and
environmental consequences of the testing and use of nuclear weapons; and
• Requests its constituent members and other representatives of the medical profession
across the world to advocate for the entry into force of the Comprehensive Nuclear-
Test-Ban Treaty (CTBT) and for the prompt ratification and implementation of the UN
Treaty on the Prohibition of Nuclear Weapons.
Handbook of WMA Policies
World Medical Association R-2006-05-2022
WMA RESOLUTION
ON
TUBERCULOSIS
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
revised by the 68th
WMA General Assembly, Chicago, United States, October 2017
and reaffirmed with minor revisions by the 221st
WMA Council Session, Berlin, Germany,
October 2022
PREAMBLE
According to the World Health Organization, tuberculosis is a significant global public health
problem. South East Asian and African countries are most affected.
In developing countries, the incidence of tuberculosis (TB) has risen dramatically because of
high prevalence of HIV/AIDS, increasing migration of populations, urbanisation and over-
crowding. The incidence and severity of the disease are closely associated with the social and
economic living conditions within a population as well as the availability of resources within
a health system.
Tuberculosis is also a significant threat to patients with cancers, organ transplants, and those
receiving immunologic therapies for various diseases.
The emergence of strains of tuberculosis bacteria resistant to first line drugs have become a
major public and global health threat in the forms of multidrug-resistant tuberculosis (MDR-
TB) and extensively drug-resistant tuberculosis (XDR-TB). MDR-TB and XDR-TB are
indicators of the growing antimicrobial resistance whose drivers are multifactorial and complex
and require a multisectoral approach.
Community awareness and public health education and promotion are essential elements of
tuberculosis prevention.
Screening of high-risk groups including PLHIV (people living with HIV), health personnel
from endemic countries as well as vulnerable populations including migrants, prisoners, and
the homeless should be considered within each national epidemiological context as a
component of tuberculosis prevention. Systematic screening of contacts of infected persons is
also recommended.
Rapid diagnosis with molecular tests and starting supervised daily treatment early should help
arrest the spread of disease.
Tuberculosis
Berlin R-2006-05-2022
BCG (Bacille Calmette-Guérin) vaccination as early as possible after birth should continue, in
line with International Union against Tuberculosis and Lung Disease (IUATLD) criteria, until
a new more effective vaccine is available.
Intensified research and innovation are also considered imperative if attempts to address the
epidemic and emerging resistance are to be successful.
RECOMMANDATIONS
In line with its “Declaration of Oslo on Social Determinants of Health” and its “Declaration of
Edinburgh on Prison Conditions and the Spread of Tuberculosis and Other Communicable
Diseases”, the World Medical Association emphasizes that tuberculosis is a disease associated
with socioeconomic factors such as poverty, poor housing, malnutrition and stigma, and
recommends that these factors are fully considered and integrated in policies to end TB.
The WMA supports WHO “End TB Strategy” and calls upon all governments, communities,
civil societies and the private sectors to act together to end tuberculosis world-wide.
The WMA, in consultation with WHO and national and international health authorities and
organizations, will therefore continue advocating to generate community awareness about
symptoms of TB and increase capacity building of health personnel in early identification and
diagnosis of TB cases and to ensure complete treatment utilizing patient-centered treatment
support, including Directly Observed Treatment Short course or other appropriate therapy.
The WMA further calls:
Member States
1. To ensure equitable access to existing tuberculosis interventions;
2. To allocate adequate financial, material and human resources for tuberculosis and
HIV/AIDS research and prevention, including adequately educated health care providers
and adequate public health infrastructure;
3. To ensure to health care professionals full access to all required medical and protective
equipment to guard against the risk of infection and spread of the disease;
4. To foster efforts to build up the capacity of health care professionals in the use of rapid
diagnostics methods, the availability of these methods in the public and private sector and
in the management of all forms of TB, including MDR and XDR.
5. To address the burden of MDR and XDR TB in prison populations by ensuring drug
susceptibility tests on isolates from patients with active TB are performed as soon as
possible, and when patient compliance is a problem, implementing programs of directly
observed therapy.
Handbook of WMA Policies
World Medical Association R-2006-05-2022
Constituent Members
6. To support their National TB Programmes by generating awareness among healthcare
professionals about TB management and early reporting of cases in the community.
7. To promote methods of TB prevention including respiratory hygiene, cough etiquettes, and
safe sputum disposal.
8. To encourage their members to notify to relevant authorities, about all patients diagnosed
with TB or put on TB treatment in a timely manner for initiation of contact screening and
adequate follow up till the completion of treatment.
9. To encourage the development of strong pharmacovigilance and active TB drug-safety
monitoring and management, to detect, manage and report suspected or confirmed drug
toxicities, and encourage all their members to contribute actively to these systems.
10. To co-ordinate with their TB National Programme and promote the adopted guidelines to
all members.
Handbook of WMA Policies
R-2007-02-2017 ⏐ World Medical Association
RESOLUTION
IN
SUPPORT OF THE MEDICAL ASSOCIATIONS
IN LATIN AMERICA AND THE CARIBBEAN
Adopted 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
There are credible reports that arrangements between the Cuban government and certain
Latin American and Caribbean governments to supply Cuban health workers as physicians
to these countries are bypassing systems, established to protect patients, that have been set
up to verify physicians’ credentials and competence.
The World Medical Association (WMA) is significantly concerned that patients are put at
risk by unregulated medical practices and recalls its Statement on Ethical Guidelines for
the International Migration of Health workers, whereby “Physicians who are working,
either permanently or temporarily, in a country other than their home country should be
treated fairly in relation to other physicians in that country” (Parag.7) and that bilateral
agreements require “due cognizance of international human rights law, so as to effect
meaningful co-operation on health care delivery” (parag. 8).
There exist already duly constituted and legally authorized medical associations within
this region that are charged with the registration of physicians and which should be
consulted by their respective Ministries of Health.
Therefore, the WMA:
1. Condemns any actions by governments in policies and practices that subvert or bypass
the accepted standards of medical credentialing and medical care;
2. Calls upon the governments in Latin America and the Caribbean to work with the
medical associations on all matters related to physician certification and the practice of
medicine and to respect the role and rights of these medical associations and the
autonomy of the medical profession.
3. Urges, as a matter of utmost concern, that the governments in Latin America and the
Caribbean respect the WMA International Code of Medical Ethics, the Declarations of
Madrid on Professionally-led Regulation, and of Seoul on Professional Autonomy and
Clinical Independence as well as the Statement on Ethical Guidelines for the
International Migration of Health workers that guide the medical practice of
physicians all over the world..
Handbook of WMA Policies
World Medical Association ⏐ R-2008-01-2018
WMA RESOLUTION
ON
COLLABORATION BETWEEN HUMAN AND VETERINARY MEDICINE
Adopted by the 59th
WMA General Assembly, Seoul, Korea, October 2008
and reaffirmed with minor revision by the 210th
WMA Council Session, Reykjavik, Iceland,
October 2018
PREAMBLE
The majority of the existing human infectious diseases, including the bioterrorist agents,
are zoonoses. Zoonoses can, by definition, infect both animals and humans. By their
very nature, the fields of human medicine and veterinary medicine are complementary
and synergistic in confronting, controlling and preventing zoonotic diseases from
infecting across species.
Collaboration and communication between human medicine and veterinary medicine
have been limited in recent decades, yet the challenges of the 21st Century demand that
these two professions work together in times when there is an increased risk of zoonotic
diseases due to globalization and climate change, in addition to changes in human
behavior.
An initiative, often called the “One Health” initiative, is being developed to improve the
lives of all species through the integration of human and veterinary medicine. “One
Health” aims to promote and implement close meaningful collaboration and
communication between human medicine, veterinary medicine and all allied health
scientists with the goal of hastening human public health efficacy as well as advanced
health care options for humans (and animals) via comparative biomedical research.
The World Medical Association (WMA) recognizes the ways in which animals and
animal care may affect human health and disease through its own current policies,
particularly its statements on Animal Use in Biomedical Research, Resistance to
Antimicrobial Drugs and Avian and Pandemic Influenza. The WMA also recognized the
impact that climate change has on health, through the WMA Declaration on Health and
Climate Change. The WMA already works with other health professions including
dentists, nurses and pharmacists though the World Health Professions Alliance.
RECOMMENDATIONS
That the World Medical Association:
• Support collaboration between human and veterinary medicine.
Reykjavik⏐ R-2008-01-2018
Veterinary Medicine
• Support the concept of joint educational efforts between human medical and
veterinary medical schools.
• Encourage joint efforts in clinical care through the assessment, treatment, and
prevention of cross-species disease transmission.
• Support cross-species disease surveillance and control efforts in public health,
particularly the identification of early disease and outbreak trends.
• Support the need for joint efforts in the development, integration and evaluation
of screening tools, diagnostic methods, medicines, vaccines, surveillance systems
and policies for the prevention, management and control of zoonotic diseases.
• Engage in a dialogue with the World Veterinary Association to discuss strategies
for enhancing collaboration between human and veterinary medical professions
in medical education, clinical care, public health, and biomedical research.
• Encourage National Medical Associations to engage in a dialogue with their
veterinary counterparts to discuss strategies for enhancing collaboration between
human and veterinary medical professions within their own countries.
Handbook of WMA Policies
World Medical Association ⏐ R-2009-01-2019
WMA EMERGENCY RESOLUTION
ON
LEGISLATION AGAINST ABORTION IN NICARAGUA
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and revised by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
WHEREAS,
In 2006, Nicaragua adopted a penal code that criminalises abortion in all circumstances,
including any medical treatment of a pregnant woman which results in the death of or
injury to an embryo or fetus.
According to the UN Population Fund (UNFPA), despite improvement of national sexual
and reproductive health indicators, Nicaragua continues to have one of the highest teenage
pregnancy and maternal mortality rates in the Americas region, in particular in lower
income rural population groups.
This legislation:
• Has a negative impact on the health of women in Nicaragua resulting in
preventable deaths of women and the embryo or fetus they are carrying.
• Places physicians at risk of imprisonment if they carry out abortions, even to save
a pregnant woman’s life, unless they follow the Nicaraguan Ministry of Health’s
(MINSA) 2006 Obstetric Protocols designed for high emergency care alone.
• Requires physicians to report to police, women and girls for suspected abortions,
in breach of their duty of confidentiality towards patients and placing them in a
conflict between the law and medical ethics.
The WMA Statement on Medically-Indicated Termination of Pregnancy (October 2018)
provides that: “National laws, norms, standards, and clinical practice related to termination
of pregnancy should promote and protect women’s health, dignity and their human rights,
voluntary informed consent, and autonomy in decision-making, confidentiality and
privacy. National medical associations should advocate that national health policy upholds
these principles.”
The WMA reiterates its Resolution on Criminalisation of Medical Practice (October 2013)
recommending that its members “oppose government intrusions into the practice of
medicine and in healthcare decision making, including the government’s ability to define
appropriate medical practice through imposition of criminal penalties.”
THEREFORE, the World Medical Association and its constituent members urge the
Nicaraguan government to repeal its penal code criminalizing abortion and develop in its
place a legislation that promotes and protects women’s human rights, dignity and health,
Tbilisi⏐ R-2009-01-2019
Sex Selection Abortion and Female Foeticide
including adequate access to reproductive healthcare, and that allows physicians to
perform their duties in line with medical ethics and particularly medical confidentiality.
Handbook of WMA Policies
World Medical Association R-2009-02-2021
WMA RESOULUTION
SUPPORTING
THE RIGHTS OF PATIENTS AND PHYSICIANS IN THE ISLAMIC
REPUBLIC OF IRAN
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and amended by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
WHEREAS,
Physicians in the Islamic Republic of Iran have reported:
• Deliberate denial of medical care in detention, withholding of essential and readily
available medications by physicians and other health professionals;
• Widespread use of torture and ill-treatments in detention;
• Concern about the veracity of documentation related to the death of patients and
physicians being forced to produce clinically incorrect documentation;
• Lack of essential functioning medical equipment and supplies
• Denial of the rights of hunger strikers; and
• Physicians’ complicity in facilitating the death penalty for juveniles in violation of
children’s rights.
THEREFORE, the World Medical Association
1. Reaffirms its Declaration of Lisbon on the Rights of the Patient, which states that whenever
legislation, government action or any other administration or institution denies patients the
right to medical care, physicians should pursue appropriate means to assure or to restore it.
2. Reaffirms its Declaration of Hamburg Concerning Support for Medical Doctors Refusing
to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman or
Degrading Treatment, which encourages doctors to honor their commitment as physicians
to serve humanity and to resist any pressure to act contrary to the ethical principles
governing their dedication to this task.
3. Reaffirms its Declaration of Tokyo – Guidelines for Physicians Concerning Torture and
other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and
Imprisonment, which:
Rights of Patients and Physicians in Iran
London R-2009-02-2021
• Prohibits physicians from participating in, or even being present during the practice
of torture or other forms of cruel or inhuman or degrading procedures;
• requires that physicians maintain utmost respect for human life even under threat
and prohibits them from using any medical knowledge contrary to the laws of
humanity.
4. Reaffirms its Resolution on the Responsibility of Physicians in the Documentation and
Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment, which states
that physicians should attempt to:
• ensure that detainees or victims of torture or cruelty or mistreatment have access to
immediate and independent health care;
• ensure that physicians include assessment and documentation of symptoms of
torture or ill-treatment in the medical records using the necessary procedural
safeguards to prevent endangering detainees.
5. Refers to the WMA International Code of Medical Ethics, which states that physicians shall
be dedicated to providing competent medical service in full professional and moral
independence, with compassion and respect for human dignity.
6. Reaffirms its Declaration of Malta on hunger strikers which prohibits force-feeding of
hunger strikers as “degrading and inhuman,” even when this is the only way to save their
lives.
7. Refers to the United Nations Nelson Mandela Rules, which emphasizes that the provision
of health care for prisoners is a State responsibility, and that the relationship between
health-care professionals and prisoners is governed by the same ethical and
professional standards as those applicable to patients in the community.
8. Refers to the WMA Statement on Access of Women and Children to Health Care, which
categorically condemns violations of the basic human right of women and children,
including violations stemming from social, political, religious, economic and cultural
practices.
9. Refers to the WMA Statement on Natural Variations of Human Sexuality, which condemns
all forms of stigmatization, criminalization and discrimination of people based on their
sexual orientation.
10. Urges the government of the Islamic Republic of Iran to respect the International Code of
Medical Ethics and the standards included in the aforementioned declarations to which
physicians are committed.
11. Stresses that physicians who adhere to the professional and ethical obligations outlined in
the entire WMA policy apparatus, including the aforementioned declarations, must be
protected
Handbook of WMA Policies
R-2009-03-2019 ⏐ World Medical Association
WMA RESOLUTION
ON
TASK SHIFTING FROM THE MEDICAL PROFESSION
Adopted by the 60th
WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212th
WMA Council Session, Santiago, Chile, April 2019
1. In health care, the term “Task Shifting” is used to describe a situation where a task
normally performed by a physician is transferred to a health professional with a
different or lower level of education and training, or to a person specifically trained to
perform a limited task only, without having a formal health education. Task shifting
occurs both in countries facing shortages of physicians and those not facing shortages.
2. A major factor leading to task shifting is the shortage of qualified workers resulting
from migration or other factors. In countries facing a critical shortage of physicians,
task shifting may be used to train alternate health care workers or laypersons to
perform tasks generally considered to be within the purview of the medical profession.
The rationale behind the transferring of these tasks is that the alternative would be no
service to those in need. In such countries, task shifting is aimed at improving the
health of extremely vulnerable populations, mostly to address current shortages of
healthcare professionals or tackle specific health issues such as HIV. In countries with
the most extreme shortage of physicians, new cadres of health care workers have been
established. However, those persons taking over physicians’ tasks lack the broad
education and training of physicians and must perform their tasks according to
protocols, but without the knowledge, experience and professional judgement required
to make proper decisions when complications arise or other deviations occur. This
may be appropriate in countries where the alternative to task shifting is no care at all
but should not be extended to countries with different circumstances.
3. In countries not facing a critical shortage of physicians, task shifting may occur for
various reasons: social, economic, and professional, sometimes under the guise of
efficiency, savings or other unproven claims. It may be spurred, or, conversely,
impeded, by professions seeking to expand or protect their traditional domain. It may
be initiated by health authorities, by alternate health care workers and sometimes by
physicians themselves. It may be facilitated by the advancement of medical
technology, which standardizes the performance and interpretation of certain tasks,
therefore allowing them to be performed by non-physicians or technical assistants
instead of physicians. This has typically been done in close collaboration with the
medical profession. However, it must be recognized that medicine can never be
viewed solely as a technical discipline.
4. Task shifting may occur within an already existing medical team, resulting in a
reshuffling of the roles and functions performed by the members of such a team. It
may also create new types of personnel whose function is to assist other health
professionals, specifically physicians, as well as personnel trained to independently
perform specific tasks.
Santiago ⏐ R-2009-03-2019
Task Shifting
5. Although task shifting may be useful in certain situations, and may sometimes
improve the level of patient care, it carries with it significant risks. First and foremost
among these is the risk of decreased quality of patient care, particularly if medical
judgment and decision making is transferred. In addition to the fact that the patient
may be cared for by a lesser trained health care worker, there are specific quality
issues involved, including reduced patient-physician contact, fragmented and
inefficient service, lack of proper follow up, incorrect diagnosis and treatment and
inability to deal with complications.
6. In addition, task shifting which deploys assistive personnel may actually increase the
demand on physicians. Physicians will have increasing responsibilities as trainers and
supervisors, diverting scarce time from their many other tasks such as direct patient
care. They may also have increased professional and/or legal responsibility for the care
given by health care workers under their supervision.
7. The World Medical Association expresses particular apprehension over the fact that
task shifting is often initiated by health authorities, without consultation with
physicians and their professional representative associations.
RECOMMENDATIONS
8. Therefore, the World Medical Association recommends the following guidelines:
8.1 Quality and continuity of care and patient safety must never be compromised and
should be the basis for all reforms and legislation dealing with task shifting.
8.2 When tasks are shifted away from physicians, physicians and their professional
representative associations should be consulted and closely involved from the
beginning in all aspects concerning the implementation of task shifting,
especially in the reform of legislations and regulations. Physicians might
themselves consider initiating and training a new cadre of assistants under their
supervision and in accordance with principles of safety and proper patient care.
8.3 Quality assurance standards and treatment protocols must be defined, developed
and supervised by physicians. Credentialing systems should be devised and
implemented alongside the implementation of task shifting in order to ensure
quality of care. Tasks that should be performed only by physicians must be
clearly defined. Specifically, the role of diagnosis and prescribing should be
carefully studied.
8.4 In countries with a critical shortage of physicians, task shifting should be viewed
as an interim strategy with a clearly formulated exit strategy. However, where
conditions in a specific country make it likely that it will be implemented for the
longer term, a strategy of sustainability must be implemented.
8.5 Task shifting should not replace the development of sustainable, fully functioning
health care systems. Assistive workers should not be employed at the expense of
unemployed and underemployed health care professionals. Task shifting also
R-2009-03-2019 ⏐ Santiago
Task Shifting
should not replace the education and training of physicians and other health care
professionals. The aspiration should be to train and employ more skilled workers
rather than shifting tasks to less skilled workers.
8.6 Task shifting should not be undertaken or viewed solely as a cost saving measure
as the economic benefits of task shifting remain unsubstantiated and because cost
driven measures are unlikely to produce quality results in the best interest of
patients. Credible analysis of the economic benefits of task shifting should be
conducted in order to measure health outcomes, cost effectiveness and
productivity.
8.7 Task shifting should be complemented with incentives for the retention of health
professionals such as an increase of health professionals’ salaries and
improvement of working conditions.
8.8 The reasons underlying the need for task shifting differ from country to country
and therefore solutions appropriate for one country cannot be automatically
adopted by others.
8.9 The effect of task shifting on the overall functioning of health systems remains
unclear. Assessments should be made of the impact of task shifting on patient and
health outcomes as well as on efficiency and effectiveness of health care delivery.
In particular, when task shifting occurs in response to specific health issues, such
as HIV, regular assessment and monitoring should be conducted of the entire
health system. Such work is essential in order to ensure that these programs are
improving the health of patients.
8.10 Task shifting must be studied and assessed independently and not under the
auspices of those designated to perform or finance task shifting measures.
8.11 Task shifting is only one response to the health workforce shortage. Other
methods, such as collaborative practice or a team/partner approach, should be
developed in parallel and viewed as the gold standard. Task shifting should not
replace the development of mutually supportive, interactive health care teams,
coordinated by a physician, where each member can make his or her unique
contribution to the care being provided.
8.12 In order for collaborative practice to succeed, training in leadership and
teamwork must be improved. There must also be a clear understanding of what
each person is trained for and capable of doing, clear understanding of
responsibilities and a defined, uniformly accepted use of terminology.
8.13 Task shifting should be preceded by a systematic review, analysis and discussion
of the potential needs, costs and benefits. It should not be instituted solely as a
reaction to other developments in the health care system.
8.14 Research must be conducted in order to identify successful training models.
Work will need to be aligned to various models currently in existence. Research
should also focus on the collection and sharing of information, evidence and
Santiago ⏐ R-2009-03-2019
Task Shifting
outcomes. Research and analysis must be comprehensive and physicians must be
part of the process.
8.15 When appropriate, National Medical Associations should collaborate with
associations of other health care professionals in setting the framework for task
shifting. The WMA shall consider establishing a framework for the sharing of
information on this topic where members can discuss developments in their
countries and their effects on patient care and outcomes.
Handbook of WMA Policies
World Medical Association ⏐ R-2010-01-2020
WMA RESOLUTION
ON
DRUG PRECSRIPTION
Adopted by the 61st
WMA General Assembly, Vancouver, Canada, October 2010
and reaffirmed with minor revisions by the 215th
Council session (on line), Cordoba, Spain,
October 2020
PREAMBLE
From the beginning of their studies and throughout their professional careers, doctors ac-
quire the knowledge, training and competence required to treat their patients with the ut-
most skill and care.
Physicians determine the most accurate diagnosis and the most effective treatment to cure
illness, or alleviate its effects, taking into consideration the overall condition of the
patient.
Pharmaceutical products are often an essential part of the treatment approach. In order to
make the right decisions in accordance with the ethical and professional principles of me-
dical practice, the doctor must have a thorough knowledge and understanding of the prin-
ciples of pharmacology and possible interactions among different drugs and their effects
on the health of the patient.
The prescribing of medication is a significant clinical intervention, which should be pre-
ceded by multiple, integrated processes to assess the patient and determine the correct cli-
nical diagnosis. These processes include:
• Taking a history of the current condition and past medical history;
• The ability to make differential diagnosis;
• Understanding any multiple chronic and complex illnesses involved;
• Taking a history of the medications currently being administered successfully or
previously withdrawn and also being aware of possible interactions.
Inappropriate drug prescription without proper knowledge and accurate diagnosis may
cause serious adverse effects on the patient’s health. In view of the possible serious conse-
quences that may result from an inappropriate therapeutic decision, the WMA affirms the
following principles on high quality treatment and ensuring patient safety.
The WMA reiterates its support to its statements on the Relationship between Physicians
and Pharmacists in Medicinal Therapy and on Biosimilar Medicinal Products.
Cordoba ⏐ R-2010-01-2020
Drug Prescription
PRINCIPLES
1. Prescription of drugs should be based on a correct diagnosis of the patient’s condition
and should be performed by those who have successfully completed a curriculum on
disease mechanisms, diagnostic methods and medical treatment of the condition in
question.
2. Prescriptions issued by physicians are vital for ensuring patient safety, which in turn is
critical for maintaining the relationship of trust between patients and their physicians.
3. Although nurses and other healthcare workers cooperate in the overall treatment of
patients, the physician is the best qualified individuals to prescribe independently. In
some countries, laws may allow for other professionals to prescribe drugs under
specific circum-stances, generally with extra training and education and most often
under medical super-vision. In all cases, the responsibility for the patient’s treatment
must remain with the phy-sician. Each country’s medical system should ensure the
protection of public interest and safety in the diagnosis and treatment of patients. If a
system fails to comply with this basic framework due to social, economical or other
compelling reasons, it should make every effort to improve the situation and to protect
the safety of the patients.
Handbook of WMA Policies
R-2011-01-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
THE ACCESS TO ADEQUATE PAIN TREATMENT
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and amended by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Around the world, tens of millions of people with cancer and other diseases and conditions
experience moderate to severe pain without access to adequate treatment. These people
face severe suffering, often for months on end, and many eventually die in pain. Those
who may not be able to adequately express their pain – such as children, people with
intellectual disabilities and those with altered consciousness– and individuals and
populations that have historically been undertreated for pain and pain management due to
bias, are especially at risk of receiving inadequate pain treatment.
Inadequate pain treatment contributes to individual suffering physically and emotionally,
but also causes huge care burdens and negative economic impact on a national level.
However, most of the suffering is unnecessary and is almost always preventable and
treatable.
In most cases, pain can be stopped or relieved with inexpensive and relatively simple
treatment interventions, which can dramatically improve the quality of life for patients.
Sometimes, especially in severe chronic pain, psycho-emotional factors are even more
significant than physiologic factors.
Pain treatment in these cases may require a multi-faceted approach to care by
multidisciplinary teams.
Over the years, the use of opioids has seen significant growth in some countries. In many
other areas around the world, however, access to essential pain treatment remains limited
for patients in pain. Even in countries with a high volume of use, it can be difficult for
specific populations to receive adequate treatment for their pain. Incomplete pain
assessment or improper use of pain medication can bring about adverse drug reactions. All
of these are very important and urgent issues need to be addressed.
Governments should adopt effective measures, wherever possible, for adequate pain
treatment. For this goal, governments shall ensure that healthcare professionals across
fields are entitled to educational training on pain evaluation and management; that the
right of all patients in pain to pain treatment is not compromised due to unnecessary
regulations; and that policies on the management of controlled drugs help with effective
monitoring of and prevention against risks associated with controlled drugs.
Cordoba ⏐ R-2011-01-2020
Adequate Pain Treatment
RECOMMENDATIONS
1. Access to adequate pain treatment is a human right. Physicians, medical professionals
and health care workers must offer pain assessment and pain treatment to patients with
pain. Governments must provide sufficient resources and proper pain treatment
regulations.
2. Pain is a complex perception consisting of physical, psychological, social, cultural and
spiritual sufferings. Physicians, medical professionals and health care workers must
offer holistic pain assessment and appropriate pain treatment, such as pharmacological
and/or non-pharmacological interventions to patients with pain. All healthcare
professionals should seek to fulfill the goal of effectively evaluating the pain of all
patients, including pain suffered by children, cognitively impaired patients and those
unable to properly express themselves. Healthcare professionals should also seek to
effectively evaluate and treat pain in patients and populations who have historically
been undertreated for pain due to implicit and explicit biases.
Pain treatment and control education shall be provided to healthcare professionals
including physicians, other medical professionals, and other health care workers.
3. Education should include pain assessment, evidence-based pain control, and the
efficacy and risks of painkillers. Education should include pain medicine, including
the action of opioids, preventing adverse reactions, and the adjustment and conversion
of the dosage of opioids. Patient-centered care should be taught to fulfill the goal of
adequately stopping pain and reducing the incidence of adverse reactions. The
curriculum shall be highly competence-based in design enhancing the knowledge, the
attitude, and the skills of healthcare professionals while treating pain.
Education should support the development of pain and palliative specialists, in order
for them to effectively support first-line physicians and other medical professionals.
Pain treatment education for medical professionals shall include the non-medicinal
treatment options. Education should equip medical professionals with proper
interpersonal communication skills, cultural sensitivity, and the ability to evaluate the
overall pain suffered by patients at the physiological, psychological, and spiritual
levels and to empower them in inter-professional practice so that professionals can
work together to alleviate the pain felt by patients with and without medication.
4. Governments, regulators and healthcare administrators must acknowledge the
consequences of pain in terms of health, productivity, and economic burden.
Governments should provide ample resources and have suitable regulations governing
controlled drugs.
For policies on the control of drugs, governments shall periodically review and
adequately revise them to ensure the availability and accessibility of controlled drugs
such as opioids. In addition, abuse and illicit use must be prevented.
• Patients in pain shall be given access to effective pain medication, including
R-2011-01-2020 ⏐Cordoba
Adequate Pain Treatment
opioids. Depriving them of such right is a violation of their right to health and is
medically unethical.
• Governments must ensure that controlled drugs, including opioids, are made
available and accessible to help relieve the suffering. Relief of suffering and
prevention against abuse shall be balanced in the management of controlled drugs.
• Government shall provide abundant resources and create a national pain
management research institute to explore issues in pain treatment and to come up
with solutions, in particular:
• Explore issues that become barriers to pain treatment, such as financial condition,
socioeconomic status, patient race and ethnicity, urban and rural differences,
logistics, insufficient training, and culture (the misunderstanding that people have
about opioids, for example)
• Promote the use of validated pain assessment tools.
• Conduct studies of emerging therapies or non-medicinal therapies.
• Establish a system and a standard procedure to record and collect pain-related data
for correct statistics and monitoring. Pain-related data includes the incidence and
prevalence of pain, cause of pain, burden of pain, pain treatment status, reason for
pain not properly treated, and number of people with drug abuse, etc.
5. Governments shall prepare a national pain treatment plan to be followed in pain
prevention, pain treatment, pain education, and policies on the management of
controlled drugs.
• The national pain treatment plan shall be evidence-based.
• Governments must take into consideration opinions of policymakers, medical
professionals, and the general public in order to prepare a national pain treatment
plan that is extensive, practical, and forward-looking, contributing to enhanced
nationwide pain treatment efficacy.
Handbook of WMA Policies
R-2011-02-2011 ⏐ World Medical Association
WMA RESOLUTION
ON
BAHRAIN
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
The WMA General Assembly notes that
A number of doctors, nurses and other health care professionals in the Kingdom of
Bahrain were arrested in March 2011 after the civil unrest in that country and tried under
emergency powers before a special court, led by a military judge. Twenty of this group
were found guilty of a number of charges, on 29 September 2011 and sentenced to fifteen,
ten or five years imprisonment.
These trials failed to meet international standards for fair trials, including the accused not
being allowed to make statements in their own defence, and their lawyers not being
allowed to question all the witnesses. Allegations from the accused and their lawyers of
mistreatment, abuse and other human right violations during arrest and while in detention
have not been investigated.
While various criminal charges were brought it appears that the major offence was treating
all the patients who presented for care, including leaders and members of the rebellion.
Other charges appear to be closely related to providing such treatment and were, in any
case, not proven to the standard expected in court proceedings. In treating patients without
considering the circumstances of their injury these health care professionals were honour-
ing their ethical duty as set out in the Declaration of Geneva.
The WMA welcomes the announcement by the government of Bahrain of 6 October 2011
that all twenty will be re-tried before a full civil court.
Therefore, the WMA requires that no doctor or other health care professional be arrested,
accused or tried for treating patients, regardless of the origins of the patient’s injury or
illness.
The WMA demands that all states understand, respect and honour the concept of medical
neutrality. This includes providing working conditions which are as safe as possible, even
under difficult circumstances, including armed conflict or civil unrest.
The WMA expects that if any individual, including health care professionals, are subject
to trial that there is due process of law including during arrest, questioning and trial in
accordance with the highest standards of international law.
The WMA demands that states investigate any allegations of torture or cruel and inhu-
mane treatment by prisoners against its agents, and act quickly to stop such abuses.
R-2011-02-2011 ⏐ Montevideo
Bahrain
The WMA recommends that independent international assessors are allowed to observe
the trials and meet privately with the accused, so that the state of Bahrain can prove to the
watching world that the future legal proceedings follow fair process.
The WMA recognises that health care workers and health care facilities are increasingly
under attack during wars, conflicts and civil unrest. We demand that states throughout the
world recognise, respect and honour principles of medical neutrality and their duty to pro-
tect health care institutions and facilities for humanitarian reasons.
Handbook of WMA Policies
R-2011-03-2011 ⏐ World Medical Association
WMA RESOLUTION REAFFIRMING THE WMA RESOLUTION
ON
ECONOMIC EMBARGOES AND HEALTH
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
The World Medical Association is deeply concerned about reports of potential serious
health impacts resulting from economic sanctions imposed by the European Union against
Ivory Coast leader, Laurent Gbagbo, and numerous individuals and entities associated
with his regime, including two major ports linked to Gbagbo’s government. The sanctions
aim to severely restrict EU-registered vessels from transacting business with these ports,
which could inhibit the delivery of necessary and life-saving medicines.
The WMA General Assembly reiterates the following position from the WMA Resolution
on Economic Embargoes and Health:
• All people have the right to the preservation of health; and,
• the Geneva Convention (Article 23, Number IV, 1949) requires the free passage
of medical supplies intended for civilians;
1.
The WMA therefore urges the European Union to take steps immediately to ensure the
delivery of medical supplies to the Ivory Coast, in order to protect the life and health of
the population.
Handbook of WMA Policies
World Medical Association ⏐ R-2011-04-2021
WMA RESOLUTION
ON
THE INDEPENDENCE OF NATIONAL MEDICAL ASSOCIATIONS
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay, October 2011
and reaffirmed by the 217th
WMA Council Session, Seoul (online), April 2021
National medical associations are established to act as representatives of their physicians,
and to negotiate on their behalf, sometimes as a trade union or regulatory body but also as
a professional association, representing the expertise of medical doctors in relation to mat-
ters of public health and wellbeing.
They represent the views of the medical profession, including attempting to ensure the
practice of ethical medicine, the provision of good quality medical care, and the adherence
to high standards by all practitioners.
These associations may also campaign or advocate on behalf of their members, often in
the field of public health. Such advocacy is not always welcomed by governments who
may consider the advocacy to have oppositional politics attached, when in reality it is
based upon an understanding of the medical evidence and the needs of patients and popu-
lations.
The WMA is aware that because of those advocacy efforts some governments attempt to
silence the medical association by placing it’s own nominated representatives into posi-
tions of authority, to subvert the message into one they are better able to tolerate.
The WMA denounces such action and demands that no government interferes with the
independent functioning of national medical associations. It encourages governments to
understand better the reasons behind the work of their national medical association, to
consider the medical evidence and to work with physicians to improve the health and well
being of their populations.
Handbook of WMA Policies
World Medical Association ⏐ R-2012-02-2021
WMA RESOLUTION
ON
PLAIN PACKAGING OF CIGARETTES, E-CIGARETTES AND OTHER
SMOKING PRODUCT
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
and reaffirmed with minor revision by the 217th
WMA Council Session (online), Seoul,
South Korea, April 2021
The WMA reaffirms its Resolution on Implementation of the WHO Framework
Convention on Tobacco Control and emphasizes the importance of this global mechanism
to protect people from exposure and addiction to tobacco and tobacco products such as
nicotine.
The WMA also reaffirms its statement on e-cigarettes and the recommendation that these
products be subjected to local regulatory approval and be entrenched in smoke free laws.
The WMA recognises that :
• Cigarettes offer a serious threat to the life and health of individuals that use them,
and a considerable cost to the health care services of every country;
• Those who smoke predominantly start to do so while adolescents;
• There is mounting evidence that e-cigarette use predicts initiation of the use of
traditional tobacco products among young people and/or non-smokers, and of
additional health risks from the use of e-cigarette products.
• There is a proven link between brand recognition and likelihood of starting to
smoke;
• Brand recognition is strongly linked to cigarette packaging;
• Plain packaging reduces the impact of branding, promotion and marketing of
cigarettes and e-cigarette products.
The WMA strongly encourages national governments to support the introduction of
initiatives that break brand recognition, including plain packaging of cigarettes, other
tobacco products, and e-cigarettes and deplores strategies from the tobacco industry to
oppose the adoption and implementation of such policy.
Handbook of WMA Policies
R-2012-03-2012 ⏐ World Medical Association
WMA RESOLUTION
TO REAFFIRM
THE WMA’S PROHIBITION OF PHYSICIAN PARTICIPATION
IN CAPITAL PUNISHMENT
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
There is universal agreement that physicians must not participate in executions because
such participation is incompatible with the physician’s role as healer. The use of a
physician’s knowledge and clinical skill for purposes other than promoting health,
wellbeing and welfare undermines a basic ethical foundation of medicine—first, do no
harm.
The WMA Declaration of Geneva states: “I will maintain the utmost respect for human
life”; and, “I will not use my medical knowledge to violate human rights and civil
liberties, even under threat.”
As citizens, physicians have the right to form views about capital punishment based on
their individual moral beliefs. As members of the medical profession, they must uphold
the prohibition against participation in capital punishment.
Therefore, be it RESOLVED that:
• Physicians will not facilitate the importation or prescription of drugs for execution.
• The WMA reaffirms: “that it is unethical for physicians to participate in capital
punishment, in any way, or during any step of the execution process, including its
planning and the instruction and/or training of persons to perform executions”, and
• The WMA reaffirms: that physicians “will maintain the utmost respect for human
life and will not use [my] medical knowledge to violate human rights and civil
liberties, even under threat.”
Handbook of WMA Policies
World Medical Association ⏐ R-2012-04-2012
WMA RESOLUTION
IN
SUPPORT OF PROFESSOR CYRIL KARABUS
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand, October 2012
The WMA welcomes the bail granted on the 11th
of October to the retired South African
paediatric haematologist, 78-year-old Professor Cyril Karabus, as a positive step given his
state of health; he has cardiac disease. Dr Karabus had been detained in an Abu Dhabi,
UAE prison since August 18th
2012. He was arrested in Dubai, whilst in transit to South
Africa, owing to alleged charges emanating from a brief period that he worked in the UAE
in 2002.
Professor Karabus was neither informed of the charges leveled against him nor the subse-
quent trial that was held in absentia relating to the unfortunate death of a child with acute
leukemia under his care during his tenure in the UAE in 2002. His defense lawyer has also
been unable to access any documents or files relating to the case that may assist in
providing a fair defense.
Therefore,
The WMA General Assembly urgently calls on the authorities of the United Arab
Emirates to ensure that Professor Karabus:
• Is guaranteed a fair trial according to international standards;
• Has access to the relevant documents or information he may require to prepare his
defense.
Handbook of WMA Policies
R-2013-01-2021 ⏐ World Medical Association
WMA RESOLUTION
ON
CRIMINALISATION OF MEDICAL PRACTICE
Adopted as a Council Resolution by the 194th
WMA Council Session, Bali, Indonesia,
April 2013
and adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
and reaffirmed by the 217th
WMA Council Session, Seoul (online), April 2021
PREAMBLE
Doctors who commit criminal acts which are not part of patient care must remain as liable
to sanctions as all other members of society. Serious abuses of medical practice must be
subject to sanctions, usually through professional regulatory processes.
Numerous attempts are made by governments to control physicians’ practice of medicine
at local, regional and national levels worldwide. Physicians have seen attempts to:
• Prevent medically indicated procedures;
• Mandate medical procedures that are not indicated; and
• Mandate certain drug prescribing practices.
Criminal penalties have been imposed on physicians for various aspects of medical prac-
tice, including medical errors, despite the availability of adequate non-criminal redress.
Criminalizing medical decision making is a disservice to patients.
In times of war and civil strife, there have also been attempts to criminalize compassionate
medical care to those injured as a result of these conflicts.
RECOMMENDATIONS
Therefore, the WMA recommends that its members:
1. Oppose government intrusions into the practice of medicine and in healthcare
decision making, including the government’s ability to define appropriate medical
practice through imposition of criminal penalties.
2. Oppose criminalizing medical judgment.
3. Oppose criminalizing healthcare decisions, including physician variance from
guidelines and standards.
4. Oppose criminalizing medical care provided to patients injured in civil conflicts.
Fortaleza ⏐ R-2013-01-2021
Criminalisation of Medical Practice
5. Implement action plans to alert opinion leaders, elected officials and the media
about the detrimental effects on healthcare that result from criminalizing healthcare
decision making.
6. Support the principles set forth in the WMA’s Declaration of Madrid on Profes-
sional Autonomy and Self-Regulation.
7. Support the guidance set forth in the WMA’s Regulations in Times of Armed
Conflict and Other Situations of Violence.
Handbook of WMA Policies
R-2013-02-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
THE HEALTHCARE SITUATION IN SYRIA
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
and reaffirmed with minor revisions by the 215th
Council session (online), Cordoba, Spain,
October 2020
PREAMBLE
During wars and armed conflicts, hospitals and other medical facilities have often been
attacked and misused and patients and medical personnel have been killed or wounded.
Such attacks are a violation of the Geneva Conventions (1949), Additional Protocols to
the Geneva Conventions (1977) and WMA policies, in particular, the WMA Statement on
the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations
of Violence (Montevideo 2011) as well as WMA Regulations in Times of Armed
Conflicts and Other Situations of Violence (Bangkok 2012).
The World Medical Association (WMA) has been active in condemning documented
attacks on medical personnel and facilities in armed conflicts, including civil wars. The
Geneva Conventions and their Additional Protocols are designed to protect medical
personnel, medical facilities and their patients in international and non-international armed
conflicts. The parties on both sides of the conflict have legal and moral duties not to inter-
fere with medical care for wounded or sick combatants and civilians, and to not attack,
threaten or impede medical functions. Physicians and other health care personnel must act
as and be considered neutral and must not be prevented from fulfilling their duties.
RECOMMENDATIONS
•
1. The WMA recalls the United Nations Security Council Resolution 2286 adopted in
2016 condemning attacks and threats against medical personnel and facilities in
conflict situations and demanding an end to impunity for those responsible.
2. The WMA calls upon all parties in the Syrian conflict to ensure the safety of
healthcare personnel and their patients, as well as medical facilities and medical
transport, and to respect the ethical obligation of health personnel to treat all
patients, irrespective of who they are in line with the Ethical Principles of Health
Care in Times of Armed Conflict and other Emergencies endorsed by civilian and
military health-care organizations in 2015.
3. The WMA calls upon its members to approach local governments in order to
facilitate international cooperation in the United Nations, the European Union or
other international body with the aim of ensuring the safe provision of health care
to the Syrian people.
Handbook of WMA Policies
World Medical Association ⏐ R-2013-03-2013
WMA RESOLUTION
ON
THE PROHIBITION OF CHEMICAL WEAPONS
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
and reaffirmed with minor revisions by the 215th
Council session (online), Cordoba, Spain,
October 2020
PREAMBLE
It has been recognised for centuries that certain chemical agents can affect consciousness,
or other factors influencing the ability of an individual to take part in fighting, predomi-
nantly during warfare. More recently some agents have been used to temporarily disable
participants in civil unrest, protests or riots. In warfare such agents have, historically, had
a significant morbidity and mortality and included nerve gases and related agents.
Despite widespread condemnation such weapons were extensively used in the early 20th
century. A global movement to outlaw the use of such weapons led to the development of
the Chemical Weapons Convention (CWC), which entered into force in 1997 having been
opened to signature in 1993. Currently only six countries have not ratified or acceded to
the CWC.
The production, stockpiling and use of CW is prohibited. Despite this, such weapons have
been used by state forces and by non-state actors in a number of countries. By their nature
such weapons are indiscriminate. This use has led to deaths, injuries and human suffering
in those countries.
Chemical agents used in policing actions, including by the military acting in a policing
role, are allowed under the CWC. There is a significant international dialogue underway
on the definition of such agents and the situations in which they can be used. It should be
noted that the CWC appears to assume such agents will not be lethal, but the use of any
agent might have fatal consequences. Those using them, or authorising their use, must
seek to ensure that they are not used in a manner which risks death or serious injury to
targeted persons.
RECOMMENDATIONS
1. The WMA notes that the development, production, stockpiling and use of
Chemical Weapons is banned under the CWC, and that use of such weapons is
regarded by some to be a crime against humanity, regardless of whether the target
populations are civilian or military.
2. The WMA urges all relevant parties to make active efforts to abide by the CWC
R-2013-03-2013 ⏐ Fortaleza
Prohibition of Chemical Weapons
ban on the development, production, stockpiling and use of Chemical Weapons.
3. The WMA urges support from all states party to the CWC for the safe destruction
of all stockpiles of Chemical weapons.
4. The WMA calls for efficient independent accountabiliy measures bringing to
justice those responsible for the use of Chemical Weapons.
5. The WMA urges states using chemical agents in riot control and related situations
to carefully consider and minimise the risks and to, wherever possible, refrain from
such use. Any use must follow the establishment of the necessary procedures to
reduce the risk of death or serious injury. They should not be used in a manner,
which deliberately increases the risk of injury, harm or death to their targets.
6. Reaffirming its Statement on the Protection and Integrity of Medical Personnel in
Situations of Violence and its Declaration on the Protection of Health Care
Workers in Situation of Violence, the WMA emphasizes the serious risk of
exposing health professionals to chemical agents while performing their medical
duties to provide first-aid to injured people in unrest contexts.
Handbook of WMA Policies
World Medical Association ⏐ R-2013-04-2021
WMA RESOLUTION
ON
STANDARDISATION IN MEDICAL PRACTICE
AND PATIENT SAFETY
Adopted as a Council Resolution by the 194th
WMA Council Session, Bali, Indonesia,
April 2013
and adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
and reaffirmed by the 217th
WMA Council Session, Seoul (online), South Korea,
April 2021
Ensuring patient safety and quality of care is at the core of medical practice. For patients, a
high level of performance can be a matter of life or death. Therefore, guidance and stand-
ardisation in healthcare must be based on solid medical evidence and has to take ethical
considerations into account.
Currently, trends in the European Union can be observed to introduce standards in clinical,
medical care developed by non-medical standardisation bodies, which neither have the
necessary professional ethical and technical competencies nor a public mandate.
The WMA has major concerns about such tendencies which are likely to reduce the
quality of care offered, and calls upon governments and other institutions not to leave
standardisation of medical care up to non-medical self selected bodies.
Handbook of WMA Policies
R-2013-05-2013 ⏐ World Medical Association
WMA RESOLUTION
IN
SUPPORT OF THE BRAZILIAN MEDICAL ASSOCIATION
Adopted by the 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
There are credible reports that the Brazilian Government program “Mais Médicos” to
create more medical schools, extend the duration of the medical course, compulsorily
place last years medical students to work in public services and attract foreign physicians
to work in remote areas of the country and in the poorest outskirts of big cities, was
proposed without the appropriate consultation to the medical community and medical
schools, and departs from a wrong diagnosis about the causes of the insufficient health
care provided to the Brazilian population. The program as proposed bypass systems
established to verify physicians’ credentials, medical competence and language skills in
order to protect patients.
The World Medical Association is concerned that patients are put at risk by unregulated
medical license, inadequate medical competence and potential misunderstanding of patient
communication and of drugs and medical supplies labels.
Therefore, the WMA:
• Condemns any policy and practice that disrupt the accepted standards of medical
credentialing and medical care;
• Calls upon the Brazilian government to work with the medical community and
medical schools on all matters related to medical education, physician certification
and the practice of medicine, and to respect the role of the Brazilian Medical
Association on behalf of the Brazilian physicians and population;
• Urges, as a matter of utmost concern, that the Brazilian government respect the
WMA International Code of Medical Ethics that guides the medical practice of
physicians all over the world.
Handbook of WMA Policies
World Medical Association ⏐ R-2014-01-2014
WMA RESOLUTION
ON
EBOLA VIRAL DISEASE
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
BACKGROUND
A number of viral diseases have caused occasional health emergencies in parts of Africa,
with local or wider spread epidemics. These include Lassa, Marburg and Ebola Viral
Diseases (EVD). The 2013-14 outbreak of EVD in West Africa has proven far more dif-
ficult to control than previous epidemics and is now present in Sierra Leone, Liberia and
Guinea with more than 2000 deaths. This epidemic appears to have a case related mor-
tality of approximately 55% against a range for EVD of 50~95%.
Following infection, patients remain asymptomatic for a period of 2~21 days, and during
this time tests for the virus will be negative, and patients are not infectious, posing no
public health risk. Once the patient becomes symptomatic, EVD is spread through contact
with body fluids including blood. Symptoms include diarrhoea, vomiting and bleeding,
and all these body fluids are potential sources of infection.
Management is primarily through infection control, the use of personal protective equip-
ment (PPE) by health care workers and those disposing of body fluids and of bodies, and
supportive care for sick patients including using IV fluids and inotropes. Contact tracing is
also important but may be difficult in many of the communities currently affected. Vac-
cines are in development as are some antivirals, but they will arrive late in this epidemic if
they are proven successful.
Evidence from those treating patients in affected communities is that a shortage of re-
sources, including health care workers and PPE, as well as poor infection control training
of health care workers, caregivers and others at risk are making epidemic control difficult.
Some governments have indicated that they will build new treatment centres in affected
areas as a matter of urgency, while others are directly providing personal protective equip-
ment and other supplies.
RECOMMENDATIONS
1. The WMA honours those working in these exceptional circumstances, and strongly
recommends that national governments and international agencies work with health
care providers on the ground and offer stakeholders training and support to reduce
the risks that they face in treating patients and in seeking to control the epidemic.
R-2014-01-2014 ⏐ Durban
Ebola Viral Disease
2. The WMA commends those countries that have committed resources for the urgent
establishment of new treatment and isolation centres in the most heavily burdened
countries and regions. The WMA calls upon all nations to commit enhanced sup-
port for combatting the EVD epidemic.
3. The WMA calls on the international community, acting through the United
Nations and its agencies as well as aid agencies, to immediately provide the
necessary sup-plies of PPE to protect health care workers and ancillary staff and
reduce the risk of cross infection. This must include adequate supplies of gloves,
masks and gowns, and distribution must include treatment centres at all levels.
4. The WMA calls on all those managing the epidemic, including local and national
governments and agencies such as WHO, to commit to adequate training in infec-
tion control measures, including PPE for all staff and caregivers who might come
into contact with infective materials.
5. The WMA calls on national and local governments to increase public communica-
tion about basic infection control practices.
6. The WMA calls upon WHO to facilitate research into the timeliness and effective-
ness of international interventions, so that planning and interventions in future health
emergencies can be better informed.
7. The WMA strongly urges all countries, especially those not yet affected, to educate
health care providers about the current case definition in addition to strengthening
infection control methodologies and contact tracing in order to prevent transmis-
sion within their countries.
8. The WMA calls for NMAs to contact their national governments to act as des-
cribed in this document.
Handbook of WMA Policies
World Medical Association ⏐ R-2014-02-2021
WMA RESOLUTION
ON
MIGRANT WORKERS’ HEALTH AND SAFETY IN QATAR
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
and reaffirmed by the 217th
WMA Council Session, Seoul (online), South Korea,
April 2021
PREAMBLE
Reliable reports indicate that migrant workers in Qatar suffer from exploitation and viola-
tion of their rights. Workers basic needs, e.g. access to sufficient water and food, are not
met. Less than half of the workers are entitled to health care. Hundreds of workers have
already died in the construction sites since 2010 as the country prepares to host the 2022
FIFA1 World Cup. Workers are not free to leave when they see their situation hopeless or
health endangered since their passports are confiscated.
Despite the pleas of international labour and human rights organizations, such as ITUC
(International Trade Union Confederation) and Amnesty International, the response of the
Qatar government to solve the situation has not been adequate. FIFA has been inefficient
and has not taken the full responsibility to facilitate the improvements to the worker´s
living and working conditions.
The World Medical Association reminds that health is a human right that should be safe-
guarded in all situations.
The World Medical Association is concerned that migrant workers are continuously put at
risk in construction sites in Qatar, and their right to freedom of movement and right to
health care and safe working conditions are not respected.
RECOMMENDATIONS
1. The WMA calls upon the Qatar government and construction companies to ensure
the health and safety of migrant workers;
2. The WMA demands the FIFA as the responsible organization of the World Cup to
take immediate action by changing the venue as soon as possible;
3. The WMA calls upon its members to approach local governments in order to fa-
cilitate international cooperation with the aim of ensuring the health and safety of
migrant workers in Qatar.
1
Fédération Internationale de Football Association
Handbook of WMA Policies
R-2014-03-2014 ⏐ World Medical Association
WMA RESOLUTION
ON
UNPROVEN THERAPY AND THE EBOLA VIRUS
Adopted by the 65th
WMA General Assembly, Durban, South Africa, October 2014
In the case of Ebola virus, the WMA strongly supports the intention of Paragraph 37 of the
2013 revision of the Declaration of Helsinki, which reads:
In the treatment of an individual patient, where proven interventions do not exist or other
known interventions have been ineffective, the physician, after seeking expert advice, with
informed consent from the patient or a legally authorized representative, may use an un-
proven intervention if in the physician’s judgement it offers hope of saving life, re-
establishing health or alleviating suffering. This intervention should subsequently be made
the object of research, designed to evaluate its safety and efficacy. In all cases, new in-
formation must be recorded and, where appropriate, made publicly available.
Handbook of WMA Policies
R-2015-01-2015 ⏐ World Medical Association
WMA RESOLUTION
TO STOP ATTACKS AGAINST
HEALTHCARE WORKERS AND FACILITIES IN TURKEY
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
PREAMBLE
Several media report that over the last two months of conflict in Turkey, healthcare
workers have been killed, wounded or threatened with guns. Some physicians have been
taken out of ambulances and beaten. Access to wounded people is prevented by security
forces, and ambulances as well as health facilities are regularly targeted. A rather
comprehensive study conducted by the Turkish Medical Association confirms these facts.
There are indications that attacks on healthcare workers and the obstructions of service
delivery are used as a deliberate political instrument to intimidate people, depriving them
of their democratic rights.
Parties in armed conflict have the obligation to protect health care provision to wounded
and sick and to prevent attack on or threat to medical activities, healthcare workers and
facilities. Physicians and other healthcare workers should not be impeded to perform their
duties. Such attacks constitute blatant violation of international human rights law, in
particular the inherent right to life that shall be protected by law, and the right to enjoy the
highest attainable standard of health[1].
These attacks undermine gravely as well fundamental medical ethics principles, in
particular WMA international Code of Medical Ethics and the Ethical Principles of Health
Care in Times of Armed Conflict and Other Emergencies endorsed by civilian and
military health-care organisations[2], stating that: “Health-care personnel, as well as
health-care facilities and medical transports, whether military or civilian, must be
respected by all. They are protected while performing their duties and the safest possible
working environment shall be provided to them » (article 10).
RECOMMENDATIONS
The WMA urges all parties to:
Stop attacks on healthcare workers and patients, health care facilities, and ambulances and
ensure their safety,
Respect the professional autonomy and impartiality of healthcare workers,
Comply fully with international human rights law as well as other relevant international
regulations that Turkey is a State Party to, and
Document and record all violations and duly prosecute their perpetrators.
R-2015-01-2015 ⏐ Moscow
Healthcare in Turkey
[1] International Covenant on Economic, Social and Cultural Rights, article 12 – December 1966
[2] Adopted by the ICRC, the WMA, the International Committee of Military Medicine (ICMM),
the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) –
June 2015
Handbook of WMA Policies
R-2015-02-2015 ⏐ World Medical Association
WMA RESOLUTION
ABOUT THE BOMBING ON THE HOSPITAL
OF MSF IN KUNDUZ
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
After the events of October 3 in Kunduz (Afghanistan), the WMA:
• Extends its deepest condolences to families, colleagues and friends of doctors,
healthcare workers and patients killed in the bombing
• Deeply regrets and condemns the bombing of the Hospital of MSF , considering it
a violation of human rights.
• Reaffirms its positional statements on “Healthcare in Danger” and calls on all
countries to respect healthcare personnel in conflict situations
• Demands an immediate enquiry into the attack by an independent body and the
assumption of responsibilities.
Handbook of WMA Policies
World Medical Association R-2016-01-2021
WMA STATEMENT
ON
THE PROTECTION OF HEALTH CARE FACILITIES AND PERSONNEL IN
SYRIA
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
and reaffirmed with minor revisions by the 218th
Council session (online), London, United
Kingdom, October 2021
The World Medical Association notes with great concern the repeated attacks on health care
facilities, health personnel and patients since the beginning of the war in Syria in 2011. These
attacks have killed and injured civilian people, and the most vulnerable among them, children
and patients. The WMA recalls that health care facilities and personnel must, according to the
international law, be protected by all parties of the conflict.
Therefore, the WMA
• Deeply regrets and condemns the recurring attacks on health care facilities, health
personnel and patients, considering these as a violation of human rights;
• Reaffirms its Declaration on the protection of healthcare in situation of violence and
demands all countries to ensure the safety of healthcare personnel and patients in
conflict situations;
• Reasserts the Ethical Principles of Health Care in Times of Armed Conflict and Other
Emergencies adopted by civilian and military health-care organizations in 2015, and
demands urgent action to guarantee the full respect of medical neutrality;
• Calls on all countries to fully implement the UN Resolution 2286 (2016) which
demands all parties to armed conflicts to fully comply with their obligations under
international law, to ensure the respect and protection of all health and humanitarian
personnel exclusively engaged in medical duties, of their means of transport and
equipment, as well as hospitals and other medical facilities;
• Demands an immediate and impartial enquiry into the attacks against health care
facilities and personnel, and actions taken against those responsible in accordance with
domestic and international law.
Handbook of WMA Policies
R-2016-04-2016 ⏐ World Medical Association
WMA RESOLUTION
ON
ZIKA VIRUS INFECTION
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October 2015
and adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October 2016
Recognizing that the WHO has designated the Zika virus infection a global health
emergency, the WMA provides the following recommendations:
• WHO should work with ECDC, CDC and other disease control organisations to
better understand the natural history and current epidemiology of Zika virus
infection.
• Information should be disseminated widely to advise and protect all women and
men who live in or must travel to Zika-affected areas and who are considering
becoming parents. Advice should also include recommendations for women who
are already pregnant who may have been directly exposed to the Zika virus or
whose partners live in or have travelled to Zika-affected areas.
• Relevant agencies, including WHO, should gather data on the efficacy of different
mosquito control methodologies, including the potentially harmful or teratogenic
effects of the use of various insecticides.
• Work on diagnostic tests, antivirals, and vaccines should continue with an
emphasis on producing a product that is safe for use in pregnant women and public
funding should be assured for this research. When such products are developed
states should ensure that they are available to, and affordable by, those most at
risk.
• States which have witnessed the delivery of a number of babies with microcephaly
and other fetal brain abnormalities must ensure that these infants are properly
followed up by health and other services, and provide support to families seeking
to cope with a child with developmental abnormalities. Wherever possible
research on the consequences of microcephaly should be published, to better
inform future parents, and to allow the development of optimal service provision.
Handbook of WMA Policies
World Medical Association R-2017-02-2022
WMA RESOLUTION
ON
PROHIBITION OF FORCED ANAL EXAMINATIONS TO SUBSTANTIATE
SAME-SEX SEXUAL ACTIVITY
Adopted by the 68th
General Assembly, Chicago, United States, October 2017
and reaffirmed with minor revisions by the 221st
WMA Council Session, Berlin, Germany,
October 2022
PREAMBLE
The WMA Declaration of Tokyo strictly forbids physicians to countenance, condone or
participate in the practice of torture or other forms of cruel, inhuman or degrading treatment
and requires them to respect the confidentiality of medical information.
The United Nations 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 prohibits health personnel from
“participation in, complicity in, incitement to or attempts to commit torture or other cruel,
inhuman or degrading treatment or punishment”.
Since 2011, in at least eleven countries, physicians have participated in forced anal
examinations of men and transgender women who are charged with consensual same-sex
conduct.
The UN Special Rapporteur on Torture has described forced anal examinations as a form of
torture or cruel, inhuman and degrading treatment that is “medically worthless” due to the lack
of scientific validity of the tests.
Furthermore, in its Statement on Anal Examinations in Cases of Alleged Homosexuality, the
Independent Forensic Expert Group, composed of forensic medicine specialists from around
the world, has determined that “the examination has no value in detecting abnormalities in anal
sphincter tone that can be reliably attributed to consensual anal intercourse”.
The WMA is deeply disturbed by the complicity of physicians in these non-voluntary and
unscientific examinations, including the preparation of medical reports that are used in trials to
convict men and transgender women of consensual same-sex conduct.
In accordance with its Statement on Body Searches of Prisoners, the WMA reminds that forced
examinations are not ethically acceptable and physicians must not perform them.
Forced Anal Examinations
Berlin R-2017-02-2022
The ability of persons in custody to provide free and informed consent is limited. Even when
consent is given, physicians should refrain from undertaking procedures that are scientifically
unfounded, discriminatory and potentially incriminating.
RECOMMENDATIONS
Recognizing that persons who have undergone forced anal exams have described them as
painful, humiliating, and amounting to sexual assault and recalling that physicians should never
engage in acts of torture or other forms of cruel, inhuman or degrading treatment, the WMA:
1. Calls on its Constituent Members, physicians and other health professionals, to stand firmly
against participation in forced anal examinations because they are medically invalid;
2. Urges its Constituent Members to issue written communications prohibiting their members
from participating in such examinations;
3. Urges its Constituent Members to educate physicians and other health professionals about
the unscientific and futile nature of forced anal exams and the fact that they are a form of
torture or cruel, inhuman and degrading treatment;
4. Calls on the World Health Organization to make an official statement opposing forced anal
examinations to prove same-sex sexual activity as unscientific and unethical in violation of
medical ethics.
Handbook of WMA Policies
R-2017-03-2020 ⏐ World Medical Association
WMA RESOLUTION
IN SUPPORT OF DR SERDAR KÜNI
Adopted by the 206th WMA Council Session, Livingstone, April 2017
and reaffirmed as a Resolution by the 71st
WMA General Assembly (online), Cordoba,
Spain, October 2020
The World Medical Association notes with serious concerns that Dr Serdar Küni, the
Human Rights Foundation of Turkey’s representative in Cizre and former president of the
Şırnak medical chamber, is still imprisoned after 6 months of detention, on charges that he
provided medical treatment to alleged members of Kurdish armed groups.
The case of Dr. Küni is one example amongst many of ongoing arrests, detentions, and
dismissals of physicians and other health professionals in Turkey since July 2015, when
unrest broke out in the southeast.
The WMA condemns such practices that threaten gravely the safety of physicians and the
provision of health-care services. The protection of health professionals is fundamental, so
that they can fulfil their duties to provide care for those in need, without regard to any
element of identity, affiliation, or political opinion.
The WMA recalls the standards of international human rights law, specifically the
Universal Declaration of Human Rights (1948) and the International Covenants on Civil
and Political Rights and on Economic, Social and Cultural Rights (1966) ratified by
Turkey. The Covenant on Economic, Social and Cultural Rights guarantees in its article
12 “the right of everyone to the enjoyment of the highest attainable standard of physical
and mental health”. This implies ensuring access to high quality healthcare, supported by a
functioning healthcare system and safe conditions for the health workforce.
The WMA recalls as well the standards of international humanitarian law as well as the
UN Security Council Resolution S/RES/2286 on Health Care in Armed Conflict that
mandates that states should not punish medical personnel for carrying out medical
activities compatible with medical ethics, or compel them to undertake actions that
contravene these standards.
Furthermore, the WMA reaffirms the principles of medical ethics, including the WMA
Regulations in Times of Armed Conflict and Other Situations of Violence as well as the
Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies
endorsed by the ICRC, civilian and military health-care organisations.
The WMA considers that punishing a physician for providing care to a patient constitutes
a flagrant breach of international humanitarian and human rights standards as well as
medical ethics. Ultimately it contravenes to the principle of humanity that includes the
imperative to preserve human dignity.
Thus, in view of the next hearing on 24 April regarding Dr. Küni case at the Şırnak 2nd
Cordoba ⏐ R-2017-03-2020
Dr Serdar Küni
Heavy Penal Court, the WMA urges national medical associations and the international
health community to mobilise in support of the immediate release of Dr. Serdar Küni and
the charges based on his medical practice be dropped immediately and unconditionally.
The WMA calls as well national medical associations and the international health
community to advocate for:
• The full respect of Turkey’s humanitarian and human rights obligations, including
the right to health, freedom of association and expression as well as the access to a
fair trial;
• The provision of effective remedy and reparation to victims of arbitrary arrests and
detentions.
Handbook of WMA Policies
R-2018-02-2018 ⏐ World Medical Association
WMA RESOLUTION
ON
PROHIBITION OF PHYSICIAN PARTICIPATION IN CAPITAL
PUNISHMENT
Adopted by the 69th
WMA General Assembly, Reykjavik, Iceland, October 2018
There is universal agreement that physicians must not participate in executions because
such participation is incompatible with the physician’s role as healer. The use of a
physician’s knowledge and clinical skill for purposes other than promoting health,
wellbeing and welfare undermines a basic ethical foundation of medicine. The WMA
Declaration of Geneva states: “I will maintain the utmost respect for human life”, and “I
will not use my medical knowledge to violate human rights and civil liberties, even under
threat”.
As citizens, physicians have the right to form views about capital punishment based on
their individual moral beliefs. As members of the medical profession, they must uphold
the prohibition against participation in capital punishment.
Therefore, the World Medical Association
AFFIRMS that it is unethical for physicians to participate in capital punishment, in any
way, or during any step of the execution process, including its planning and the instruction
and/or training of persons to perform executions.
REQUESTS firmly its constituent members to advise all physicians that any participation
in capital punishment as stated above is unethical.
URGES its constituent members to lobby actively national governments and legislators
against any participation of physicians in capital punishment.
*The WMA Resolution on Prohibition of Physician Participation in Capital Punishment is
a minor revision that merges two existing WMA policies, the Resolution on Physician
Participation in Capital Punishment (2008) and the WMA Resolution to Reaffirm WMA’s
Prohibition of Physician Participation in Capital Punishment (2012). As a result of the
new merged document, these two policies have been rescinded and archived.
Handbook of WMA Policies
R-2019-01-2019 ⏐ World Medical Association
WMA RESOLUTION
ON
CLIMATE EMERGENCY
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
Health professionals have an important role in advocating to protect the health of citizens
around the world, and therefore have a responsibility to demand greater action on climate
change.
The UN summit on climate action that took place in September 2019 further demonstrated
the growing recognition that climate change action must be accelerated, with many
countries making commitments to achieving net zero emissions by 2050 and others
committing to boost national action plans by 2020.
There is emerging consensus within the medical profession globally that action on climate
change must be accelerated.
The WMA and its constituent members and the international health community:
• declare a climate emergency and call the international health community to join
their mobilisation;
• commit to advocate to protect the health of citizens across the globe in relation to
climate change;
• urge national government to rapidly work to deliver carbon neutrality by 2030, so
as to minimise the life-threatening impacts of climate change on health;
• must acknowledge the environmental footprint of the global healthcare sector, and
act to reduce waste and prevent pollution to ensure healthcare sustainability.
Handbook of WMA Policies
R-2019-02-2019 ⏐ World Medical Association
WMA RESOLUTION
ON
THE REVOCATION OF WHO GUIDELINES ON OPIOID USE
Adopted by the 70th
WMA General Assembly, Tbilisi, Georgia, October 2019
The World Medical Association expresses concern about the abrupt discontinuation of
WHO 2011 guidance “Ensuring balance in national policies on controlled substances:
Guidance for availability and accessibility of controlled medicines”, as well as its 2012
“WHO guidelines on the pharmacological treatment of persisting pain in children with
medical illnesses”.
This revocation, which took place last Summer without consulting the medical
community, will deprive many physicians of support and regulation in countries without
related national legislation, thus endangering their medically justified use of such
substances. Ultimately, suffering patients will not have access to proper medication.
The WMA notes that the withdrawal was decided unilaterally, without providing any
supporting evidence and without including any replacement or substitution. Moreover, the
discontinued guidelines were fully removed from WHO online publications portal, thus
impeding the ability of physicians to justify and validate retrospectively the use of
controlled substances, exposing them potentially to criminal prosecution.
Without further information, the WMA considers it necessary to reinstate the mentioned
guidelines until they are replaced by new or amended ones.
The WMA demands the adherence to the principle of evidence-based development of
treatment guidelines. This should apply to the definition, amendment and discontinuation
of such guidance in addition to the application of a precautionary principle. Evidence
supporting the revocation of the opioid-guidelines must be published and made available
for scientific scrutiny.
The WMA welcomes the efforts to assemble a new team of experts and strongly
recommends an open and transparent process, including a reliable mechanism to ensure
the disqualification of experts with conflicts of interest.
Handbook of WMA Policies
R-2020-01-2020 ⏐ World Medical Association
WMA RESOLUTION
IN SUPPORT OF
AN INTERNATIONAL DAY OF THE MEDICAL PROFESSION,
OCTOBER 30
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
On the eve of the WMA General Assembly, Córdoba 2020, we are facing an escalation of
the COVID-19 pandemic around the world and an alarming exponential pressure on
healthcare professionals.
The WMA and its members request that October 30 be recognised as the International Day
of the Medical Profession as a tribute to the commitment of physicians to the service of
humankind, to the health and well-being of their patients, in the respect the ethical values
of the profession.
Handbook of WMA Policies
R-2020-02-2020 ⏐ World Medical Association
WMA RESOLUTION
IN SUPPORT OF
THE TURKISH MEDICAL ASSOCIATION
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
The WMA and its members are deeply concerned by the recent Turkish governmental
announcement to dismantle the Turkish Medical Association as a national professional
organization, allegedly to “protect patients and the profession from terrorists”.
The Turkish Medical Association is a dedicated member of the WMA, recognised for its
commitment to serve public health interests, to protect patients and physicians with
respect of the ethical values of the profession.
The WMA considers that qualifying the thousand physicians’ members of the Turkish
Medical Association as terrorists constitutes a grave defamation and an insult to the entire
profession.
Recalling its Resolution on the Independence of National Medical Associations, the WMA
opposes such governmental interference with the independent functioning of a national
medical association and urges the government of Turkey and the members of the
parliament to:
1. Protect the establishment of the Turkish Medical Association as a national
independent association and main representative of all physicians in the country,
and prevent any legal regulation that will harm its professional autonomy;
2. Respect the universal professional values of medicine, which were built upon
thousands of years of experience and aim to prioritise patient and public health;
3. Comply fully with international human rights instruments that Turkey is a State
Party to.
Handbook of WMA Policies
R-2020-03-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
EQUITABLE GLOBAL DISTRIBUTION OF COVID-19 VACCINE
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
The SARS-CoV-2 pandemic has a tight grip on the world. Over a million people have
died worldwide and millions more are still suffering the effects of this virus and the
disease it causes.
A vaccine is widely seen as the best way to stop the spread of the virus, gain control of the
pandemic and save human lives.
WMA policy clearly states that “vaccination and immunisation have been acknowledged
as an effective and safe preventive strategy for several communicable diseases. And
vaccine development and administration have been the most significant intervention to
eradicate infectious diseases and influence global health in modern times”.
While there are currently no approved vaccines for COVID-19, an unprecedented global
effort is underway, both in terms of scale and speed, to develop a safe and effective
vaccine and to optimise procurement and distribution to ensure that all regions of the
world stand to benefit as quickly as possible. Some current predictions anticipate an initial
COVID-19 vaccine rollout in the first half of 2021. Due to intensive efforts to produce
effective vaccines and fast track them for market authorisation, many clinical trials have
been placed on extremely accelerated schedules. Processes usually requiring years are
being condensed into months, which could potentially pose a threat to the ethical
principles outlined in the WMA Declaration of Helsinki.
Questions arose quite early in the pandemic about how to distribute a potential new
vaccine quickly and equitably. Many higher-income countries have already signed
bilateral agreements with pharmaceutical companies to supply or distribute COVID-19
vaccine candidates, which, given the limitations on production capacity, could leave
developing countries at a disadvantage as they strive to protect their populations.
It is a fact that a pandemic cannot be contained by one country alone; it requires a
collaborative, global effort, as the WMA has outlined in its Statement on Epidemics and
Pandemics and the Statement on Avian and Pandemic Influenza.
In the same spirit, GAVI, the Vaccine Alliance, the Coalition for Epidemic Preparedness
Innovations (CEPI) and the World Health Organization (WHO) have initiated the
COVAX platform in order to guarantee that all participating countries, regardless of their
income, have equal access to new COVID-19 vaccines once they are developed.
Cordoba ⏐ R-2020-03-2020
COVID-19 Vaccine
RECOMMENDATIONS
The World Medical Association
1. welcomes multilateral solutions in the global battle against COVID-19, in
particular the COVAX platform, for ensuring equitable, global distribution of a
safe and effective COVID-19 vaccine;
2. emphasises that no country should be left behind in the race to vaccinate its
population against this global threat;
3. stresses the need to balance between the desire of each country to protect its
citizens and the need for the vaccine to be distributed worldwide;
4. reiterates that all clinical trials must follow the ethical principles for medical
research involving human subjects as set forth in the WMA Declaration of
Helsinki;
5. states that longer-term, formal safety monitoring is necessary in cases where
clinical trials have been accelerated to fast track vaccines for market authorisation;
6. calls attention to the heightened risk faced by health workers and vulnerable
populations in a pandemic situation and therefore urges that these individuals be
among the first to receive a safe and effective vaccine;
7. renews its call to all constituent members to increase awareness of immunisation
schedules and calls upon individual physicians to pay special attention to
addressing the concerns of vaccine-hesitant patients;
8. reaffirms its warning on vaccine hesitancy (April 2019) and reiterates the
importance of maintaining other important routine vaccinations, e.g. against polio,
measles and influenza;
9. calls for coordinated efforts to increase public trust in vaccination in the face of
disinformation campaigns and anti-vaccine movements which undermine the
health of both children and adults.
Handbook of WMA Policies
R-2020-04-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
HUMAN RIGHTS VIOLATIONS AGAINST UIGHUR PEOPLE IN CHINA
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
It is incumbent upon health professionals to consider the health and human rights of
people globally and denounce instances where these rights are being abused. The
treatment of the Uighur people in the Xinjiang region of China is one such case.
Documented reports of physical and sexual abuse of Uighur people in China reveal
unequivocal human rights violations. Reports note numerous violations of the Universal
Declaration of Human Rights. The transgressions include, but are not limited to:
• Article 5: No one shall be subjected to torture or to cruel, inhuman or degrading
treatment or punishment.
• Article 9: No one shall be subjected to arbitrary arrest, detention or exile.
• Article 25 (i): Everyone has the right to a standard of living adequate for the health
and well-being of himself and of his family, including food, clothing, housing and
medical care and necessary social services, and the right to security in the event of
unemployment, sickness, disability, widowhood, old age or other lack of
livelihood in circumstances beyond his control.[1]
Human rights organizations and sovereign states are increasingly drawing attention to the
situation in Xinjiang, with over 20 United Nations ambassadors taking the rare step of
issuing a joint letter to the UN Human Rights Council in 2019 expressing concerns about
the treatment of the Uighurs in China and demanding that international independent
observers be allowed into the region.
RECOMMENDATIONS
In the light of information and reports of systematic and repeated human rights violations
against Uighur people in China, and its impact on the health of the Uighur people and
health care supplies throughout the world, the WMA calls on its constituent members,
physicians and the international health community to:
1. formally condemn the treatment of the Uighurs in China’s Xinjiang region and call
upon physicians to uphold the guidelines set out in the WMA Declaration of
Tokyo and the WMA Resolution on the Responsibility of Physicians in the
Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or
Degrading Treatment;
Cordoba ⏐ R-2020-04-2020
Uighur people in China
2. support the requests made in the July 2019 letter to the UN Human Rights Council
High Commissioner calling for international independent observers to be allowed
into the Xinjiang region of China.
3. Reaffirm its Statement on Forced and Coerced Sterilisation, asserting that no
person, regardless of gender, ethnicity, socio-economic status, medical condition
or disability, should be subjected to forced or coerced permanent sterilisation, and
call on its members medical associations to advocate against forced and coerced
sterilisation in their own countries and globally; and
4. Reiterate support of its Declaration on Fair Trade in Medical Products and Devices
and urge its medical association members to promote fair and ethical trade in the
health sector, and insist that the goods they use are not produced at the expense of
the health of workers in the global community. To do this, physicians should;
• raise awareness of the issue of ethical trade and promote the development of
fair and ethically produced medical goods amongst colleagues and those
working within health systems.
• play a leadership role in integrating considerations of labour standards into
purchasing decisions within healthcare organizations.[1]
https://www.un.org/en/universal-declaration-human-rights/
Handbook of WMA Policies
R-2020-05-2020 ⏐ World Medical Association
WMA RESOLUTION
ON
PROTECTING THE FUTURE GENERATION’S RIGHT TO LIVE IN A
HEALTHY ENVIRONMENT
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
Exponential increase in the number of climate change related fires, hurricanes, ice
meltdowns, heat waves and deforestation, especially of the rainforests, show that there is
no time to waste. There is an urgent need to accelerate the efforts that will trigger the
changes to be implemented by international and national policy and decision makers in
order to stop as well as to adapt to the climate crisis.
Climate change and air pollution are closely connected, both have huge impacts on human
health and result from anthropogenic emissions due to the combustion of fossil fuels. As it
is mentioned by international bodies such as Clean Air Initiative founded by the UN, the
World Health Organization (WHO), the UN Environment Programme (UNEP) and the
Climate and Clean Air Coalition (CCAC); all governments, researchers and non-
governmental organisations should urgently start to tackle the air pollution and climate
crisis together.
Considering the urgency and complexity of climate change, it is needed to create a global
change to stop the causes of this crisis. Therefore, WMA calls on international, national,
regional or provincial decision makers such as politicians, policy makers and judges to
recognize the urgency, complexity, and interconnectedness of the essence of the climate
crisis action and to take immediate action in order to protect the rights of future
generations for the sake of climate justice.
Climate crisis causes a serious loss, damage or destruction of ecosystems and cultural
damage, which has severe impacts on all inhabitants of the world. In order to ensure the
right to live for the future generations, there is an imminent need for binding legal
measures to be adopted and implemented at the national and international arena against
the polluters causing emissions that cause especially climate crisis as well as air, water and
soil pollution.
Health professionals have a duty to care, respect and protect the human life, as well as the
right to live for future generations and all forms of the natural living world. WMA
believes that all people, including future generations, have the right to the environmental,
economic and social resources needed for healthy and productive lives; such as clean air,
soil, water and food security. Therefore; WMA has a historical responsibility of acting
proactively in order to initiate the necessary changes and solutions to struggle with the
climate crisis.
Cordoba ⏐ R-2020-05-2020
Healthy Environment
RECOMMENDATIONS
WMA proposes the following recommendations to its members and other related
organizations:
1. Urge to ask its members to collaborate with relevant bodies in their countries in
order to raise awareness about the necessity for legally binding sanctions and
policies at the national and international level for the polluters that threaten the
right to live for the future generations by emitting gases which are proven to cause
climate crisis and air, soil and water pollution.
2. Urge all national governments, policy makers, researchers and health professionals
to mobilize in order to develop and implement comprehensive policies to struggle
with the problems due to the use of fossil fuels by industry as well as the
individuals that lead to problems such as climate crisis air, water and soil pollution.
3. Urge all medical professionals, media, governmental and non – governmental
institutions to refer climate change as ‘climate crisis’ and calls the leaders of
national, state or provincial, regional, city, and local governments to declare a
climate emergency in order to initiate a society-wide action. Moreover, encourage
the media to promote the concept and meaning of the right to live for future
generations.
4. Update the curriculum at medical schools and add compulsory sections on
environmental health in order to educate health professionals that are able to think
critically about the health impacts of the environmental problems, are aware of the
reasons, impacts/dimensions of the climate crisis and able to offer solutions
designed to protect the rights and health of future generations.
5. Advocate and organize interdisiplinary campaigns in order to stop the new
permissions from being given to the industrial facilities using fossil fuels that
cause climate crisis and pollution.
6. Urge national governments and international bodies such as WHO to adopt stricter
regulations on environmental protection and evaluation, permission, monitoring
and control procedures of new industrial facilities to limit the health impact
resulting from their emissions.
7. Advocate actively for policies that will maximize health benefits by reducing air
pollutants (such as ground ozone and particulate matter etc.) and carbon emissions,
increase walking, cycling, and use of public transport, and consumption of
nutritious, plant-rich diets to ensure climate justice. Urge international, national,
state or provincial, regional, city, and local governments to adopt and implement
air quality and climate change policies that will achieve the WHO Ambient Air
Quality Guideline values.
8. Urge national, state or provincial, regional, city, and local governments through
public campaigns and advocacy to cut subsidies given to fossil fuel industries and
to direct these subsidies to support just transition, energy efficiency measures,
green energy resources and public welfare.
Handbook of WMA Policies
R-2020-05-2020 ⏐ World Medical Association
9. Urge governments and private sector to invest in policies that support a just
transition for workers and communities adversely impacted by the move to a low-
carbon economy and to build social protection through investment in and transition
to green jobs.
10. Urge national, state or provincial, regional, city, and local governments to act on
other causes of climate crisis such as industrial agriculture, animal husbandry and
deforestation, to promote legal trade and financing policies that prioritize and
enable sustainable agro-ecological practices, end deforestation for the expansion of
industrial agriculture and to reduce reliance on industrial animal-based agriculture
and environmentally damaging agricultural and fisheries practices.
11. Urge national, state or provincial, regional, city, and local governments to invest in
human capacity and knowledge infrastructure to spread regenerative agriculture
solutions that can produce the change needed while providing myriad co-benefits
to farmers and consumers, providing a global support network – on the ground –
for farmers and capturing carbon in the soil. Emphasize building resilient and
regenerative local food systems that can reduce carbon emissions, support the
livelihoods of agricultural communities and provide food security for future
generations.
12. Urge national governments, together with the involvement of health sector, to
develop national adaptation plans and to conduct national assessments of climate
crisis impacts, vulnerability, and adaptation for health.
Handbook of WMA Policies
R-2020-06-2020 ⏐ World Medical Association
WMA RESOLUTION
REGARDING
THE MEDICAL PROFESSION AND COVID-19
Adopted by the 71st
WMA General Assembly (online), Cordoba, Spain, October 2020
PREAMBLE
The current COVID-19 pandemic is causing one of the greatest challenges that healthcare
professionals have ever faced in recent decades. According to the World Health
Organization (WHO), COVID-19 has exposed healthcare professionals and their social
and family environment to unprecedented levels of risk. Although not representative, data
from many countries across all regions indicate that the number of SARS CoV-2 virus
infections among healthcare professionals has reached alarming numbers for any
healthcare system.
The constant risk of infection and, in many cases, the lack of adequate material and human
resources, the high number of infected, the physicians’ morbidity and mortality and the
lack of human resources policies is causing a physical and emotional exhaustion among
health professionals. Moreover, thousands of physicians are losing their lives practicing
their profession and fulfilling their ethical duties, a number that is increasing as the
pandemic advances in most countries.
As a result of this global situation, the WMA offered its support to the World Health
Professions Alliance open letter which calls on immediate G20 action to secure personal
protective equipment for health personnel dated April 9, 2020, and denounced it through
its Urgent Call for governments to support healthcare staff in the battle against Covid-19
on April 2, 2020.
The derived consequences that the pandemic will cause in the political, economic and
social spheres in all countries should be added to this situation. All of this will worsen the
global population’s health and will require an effort and commitment from the medical
profession, its National Medical Associations and the WMA.
RECOMMENDATIONS
The WMA wants to recognise the fight of the medical profession against the pandemic
through this Urgent Resolution and advocates to:
1. Sufficient provision of equipment and personal protection material (PPE) for
health professionals, which allows healthcare and guarantees the availability of this
material in a situation of possible outbreaks.
2. Urge governments to adopt a multilateral and coordinated approach on a global
Cordoba ⏐ R-2020-06-2020
Medical Profession and COVID-19
scale of the crisis to promote equality in interventions, access to health services,
treatments and future vaccines.
3. Provide enough financing to healthcare systems so that they can face the costs of
the pandemic and guarantee accessible and quality healthcare.
4. The National Medical Associations and the WMA encourage an active
participation in the planning and management of all stages of the response to the
epidemic.
5. Recognise that SARS CoV-2 infection be recognised as an occupational disease
and that the medical profession be declared a “profession at risk”. Likewise, we
request that taking care of healthcare professionals be a priority, especially in the
field of mental health.
6. Fight against violence towards doctors and against any sign of their stigmatisation
by promoting zero tolerance of violence in healthcare settings.
7. Support the medical profession that continues to honour its commitment to science
and patients. Because current medical professionalism is one of the few and last
defence that the seriously ill, excluded and helpless patients have to maintain a
minimum of health, quality of life and human dignity.
8. Urge governments to include health system strengthening and resilience as part of
national COVID recovery plans.
Handbook of WMA Policies
World Medical Association R-2021-01-2021
WMA RESOLUTION
IN SUPPORT OF
THE COUNTRIES WORST AFFECTED BY THE COVID-19 CRISIS
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
and adopted as a resolution by the 72nd
WMA General Assembly (online), London,
United Kingdom, October 2021
The World Medical Association is deeply concerned to see the alarming and worsening Covid
crisis in many countries worldwide. We recognize the huge challenges doctors and other
healthcare professionals are facing in maintaining healthcare systems in such harrowing
conditions. The WMA calls on the international community and governments to urgently
priorities support and aid to these the worst affected nations, including oxygen, drugs, vaccines,
Personnal Protective Equipment (PPE) and other equipment as needed, and to strengthen
healthcare system resilience in the face of future pandemics. The pandemic will not end until
we tackle Covid in every nation and this is a time for global cooperation, solidarity and support
for one another.
Handbook of WMA Policies
World Medical Association R-2021-02-2021
WMA RESOLUTION
IN SUPPORT OF
MEDICAL PERSONNEL AND CITIZENS OF MYANMAR
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
and adopted as a resolution by the 72nd
WMA General Assembly (online), London,
United Kingdom, October 2021
The World Medical Association notes with increasing alarm, the continuing actions of the
current police and Myanmar security forces including arbitrary arrests and detention of health
personnel and other citizens, attacks against physicians and other health personnel and
facilities, and continuing harassment and intimidation of protesters, human rights defenders
and journalists. The WMA and its members are seriously disturbed by their terrorizing,
arresting, kidnapping and murdering health care workers for treating protesters.
With a collapsed health system, the Covid pandemic is devastating Myanmar with lack of
medical equipment and personnel and increasing deaths. Recent reports of forcing hundreds of
physicians to secretly treat Covid patients and ambushing and arresting physicians after luring
them to a non-existent Covid patient’s home, are cause for further dismay.
These activities are in total opposition to the international recommendations in the WMA
Declaration on the Protection of Health Care Workers in situation of Violence, the WMA
Statement on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other
Situations of Violence as well as the United Nations Declaration on Human Rights Defenders.
Thus, the WMA and its members demand that the Myanmar security forces take immediate
action to:
• Guarantee, in all circumstances, the physical and psychological integrity of protesters,
including health personnel who are arrested;
• Release protesters and personnel immediately and unconditionally, and drop all charges
against them since their detention is arbitrary as it only aims at preventing freedom of
expression and their human rights activities;
• Put an urgent end to attacks against health personnel and facilities and ensure their
protection to provide adequate health care provisions to all.
• Stop all acts of harassment, intimidation, and killing, against protesters, human rights
defenders and journalists and comply with all the provisions of the United Nations
Declaration on Human Rights Defenders;
Medical Personnel and Citizens of Myanmar
London R-2021-02-2021
• Ensure in all circumstances respect for human rights and fundamental freedoms in
accordance with international human rights standards and international instruments,
including the International Covenant on Economic, Social and Cultural Rights.
• Cooperate with international fact-finding commissions.
Handbook of WMA Policies
World Medical Association R-2021-03-2021
WMA RESOLUTION
ON
COVID-19 VACCINES AND INTERNATIONAL TRAVEL REQUIREMENTS
Adopted by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
While international travel has begun to normalize for many of those who have been vaccinated
against SARS-CoV 2, fully vaccinated citizens of some countries are still subject to significant
travel restrictions, as the vaccines they have received are not accepted as proof of full protection
in all countries. Many countries only consider those who have received certain vaccines from
specific countries to be fully vaccinated, while other vaccines are not recognized or available.
These practices effectively lead to discriminatory border restrictions against travelers who have
been fully vaccinated using vaccine regimens approved in their home countries. This may
restrict international cooperation and business, mainly disadvantaging poorer countries and
regions. In some cases, it has even led fully vaccinated individuals to request third and fourth
vaccine doses in order to provide proof of the required level of protection.
The WMA understands the reluctance of pharmaceutical authorities to allow the market
introduction of vaccines for which an authorization has not been applied in their jurisdiction,
or which are still in the process of authorization, or which may have been rejected because their
ethical or technical standards of testing or production do not meet the required standards.
However, the WMA considers it necessary to evaluate Covid-19 vaccines based solely on their
effectiveness against infection and severe illness when determining the reliability of their
protection for travel purposes. Presently, there are enough data available to assess the
protection offered by vaccines, independent of their marketing authorization status. Should
vaccines be deemed to be ineffective, and therefore not acceptable as proof of protection, the
reasons for such decisions should be made public.
We call on national governments and the European Union to immediately adopt fair,
harmonized, and non-discriminatory rules to enable safe and fair travel opportunities, and to
inform the public about any serious concerns that may hinder the acceptance of specific
vaccines.
Handbook of WMA Policies
World Medical Association R-2021-04-2021
WMA RESOLUTION
ON
THE REPRESSION OF NICARAGUAN DOCTORS
Adopted by the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
Nicaragua is currently in a phase of accelerated expansion and community transmission of
Covid-19. It is urgent for health authorities to promote necessary and proportionate measures
to contain the progress of the pandemic.
The exponential increase in Covid-19 cases has caused a collapse of Nicaragua’s public and
private healthcare system. The lack of basic medical devices has contributed to dozens of
doctors and healthcare professionals becoming infected and a large number who have died.
The Nicaraguan medical profession, through more than 30 medical societies and the Covid-19
citizen observatory, has been denouncing this situation for a long time. Nonetheless, the Special
Cybercrime Act approved by the Government of Nicaragua, in force since 30 December 2020,
establishes sentences of 1 to 10 years in prison for all those who spread news that produces
fear or anxiety in the population.
This situation of persecution is compounded by the approach to the Covid-19 pandemic, as
doctors in the public sector who demanded protective measures like masks, gloves or vaccines,
were dismissed under the accusation that they disrupted the public peace. Private-sector
physicians who cared for patients or guided the population on self-protection measures against
the pandemic were called to stop those statements, under penalty of withdrawing their licence
to practice medicine or the imposition of criminal penalties, among other terrorism-related
charges.
The General Assembly of the World Medical Association (WMA) hereby ratifies the letter
from its president, Dr Barbe, sent on 31 August to the president of the Republic of Nicaragua,
Mr Daniel Ortega, which outlines the dramatic situation suffered by Nicaraguan medical
professionals and offers its support to the Declarations of 25 June 2018 and 23 August 2021
from CONFEMEL (Latin American and Caribbean Medical Confederation).
The World Medical Association (WMA) opposes and observes with extreme concern any
governmental interference that threatens the freedom of professional practice and freedom of
expression of any doctor. It also urges the government of Nicaragua and the members of its
National Assembly:
• to protect all health professionals;
• to avoid or modify any legal regulation that may harm the professional autonomy of
physicians.
Nicaraguan Doctors
London R-2021-04-2021
The World Medical Association (WMA) also wishes to highlight the extraordinary role of
Nicaraguan doctors, which is inherent to our ancient profession. It actively supports and
promotes the right of everyone to receive information and medical care based solely on their
clinical needs.
Handbook of WMA Policies
World Medical Association R-2022-01-2022
WMA RESOLUTION
IN SUPPORT OF
MEDICAL PERSONNEL AND CITIZENS OF UKRAINE IN THE FACE OF
THE RUSSIAN INVASION
Adopted as Council Resolution by the 220th
WMA Council Session, Paris (hybrid), France,
April 2022
and as Resolution by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
Reminding that the World Medical Association was founded on the backdrop of the atrocities
of war and how the medical profession was abused for violation of human rights and dignity;
Reaffirming the WMA Declaration of Geneva as a beacon of fundamental principles to which
the world’s physicians are committed;
Deeply shocked by the Russian army’s bombing of Ukrainian civilians and hospitals, including
maternity wards, thus infringing on medical neutrality in conflict zones. The WMA and its
members express their solidarity with the Ukrainian people and provide their support for
Ukrainian and international healthcare workers mobilized under extremely difficult conditions;
Recalling the WMA’s Statements on the Cooperation of National Medical Associations during
or in the Aftermath of Conflicts, on Armed Conflicts, the Regulations in Times of Armed
Conflict and Other Situations of Violence, the Statement on the Protection and Integrity of
Medical Personnel in Armed Conflicts and Other Situations of Violence, the Declaration on
the protection of healthcare workers in emergency situations and the Statement on Medical
Care for Migrants;
Emphasizing the need to respect the Geneva Conventions and their protocols as the core of
international humanitarian law, as well as the United Nations Security Council Resolution
2286;
Considering the suffering and human tragedy caused by the Russian invasion of Ukraine,
including a refugee crisis on a massive scale;
RECOMMENDATIONS
1. The Constituent Members of the WMA stand in solidarity with the Ukrainian Medical
Association and all healthcare professionals.
Russian Invasion of Ukraine
Berlin R-2022-01-2022
2. The WMA condemns Russia’s invasion of Ukraine and calls for an end to hostilities.
3. The WMA considers that Russia’s political leadership and armed forces bear responsibility
for the human suffering caused by the conflict.
4. The WMA calls on Russian and Ukrainian doctors to hold high the principles in the WMA
Declaration of Geneva and other documents that serve as guidance for medical personnel
during times of conflict.
5. The WMA demands that the parties to the conflict respect relevant Humanitarian Law and
do not use health facilities as military quarters, nor target health institutions, workers and
vehicles, or restrict the access of wounded persons and patients to healthcare, as set out in
the WMA Declaration on the Protection of Health Workers in Situations of Violence.
6. The WMA stresses that the parties to the conflict must strive to protect the most vulnerable
populations.
7. The WMA underlines that it is essential that access to medical care be guaranteed to all
victims, civil or military, of this conflict, without distinction.
8. Physicians and all other medical personnel, both Ukrainian and international, involved in
NGOs, must not under any circumstances be hindered in the exercise of their unwavering
duty, in accordance with the international recommendations provided in the WMA
declaration on the protection of healthcare workers in emergency situations, the WMA’s
position on the protection and integrity of medical personnel in armed conflicts and other
violent situations and in the declaration of the United Nations General Assembly on the
rights and responsibility of individuals, groups and organs of society to promote and protect
human rights and universally recognized fundamental freedoms.
9. The WMA calls on the parties to ensure that essential services are provided to those within
areas damaged and disrupted by conflict.
10. The WMA calls on the international community and governments to come to the aid of all
persons displaced by this conflict who may choose their country as a destination following
their departure from Ukraine.
11. The WMA urges all nations receiving persons fleeing the conflict to ensure access to safe
and adequate living conditions and essential services to all migrants, including appropriate
medical care, as needed.
12. The WMA calls on the parties to the conflict as well as the international community to
ensure that when the conflict ends, priority must be given to rebuilding the essential
infrastructure necessary for a healthy life, including shelter, sewerage, fresh water supplies,
and food provision, followed by the restoration of educational and occupational
opportunities.
Handbook of WMA Policies
World Medical Association R-2022-02-2022
WMA RESOLUTION
FOR
PROVIDING COVID-19 VACCINES FOR ALL
Adopted by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
SARS-COV-2 Pandemic caused more than 400 million cases and nearly 6 million deaths. It is
quite comforting that vaccines that ensure protection from the disease have been produced, and
data relating to the course of the pandemic in countries with high vaccination coverage is
promising. 62.3% of the world population has received at least one dose of a COVID-19
vaccine. Only 11.4% of people in low-income countries have received at least one dose. Deep
inequalities in access to vaccines are still observed globally and failure to achieve collective
immunity leads to the -further spread of new, more contagious and immunity-evading variants
of the disease through mutation. Worldwide application of vaccines is of critical importance in
terminating the Covid-19 pandemic. Every minute of delay in vaccinations means further
spread of the disease at global scale and more lives lost. It is not sufficient to immunize all
citizens in any given country; immunization has to reach a sufficient level in the world as a
whole to effectively combat and control the pandemic.
RECOMMENDATIONS
The WMA urges all parties to:
1. Remove barriers to promote equity of access to COVID-19 vaccines that are globally
proven to be safe and effective;
2. Work with governmental and appropriate regulatory bodies to encourage prioritization of
equity when providing COVID-19 pandemic-related resources such as diagnostics, free
medications, therapeutics, vaccines, raw materials for vaccine production, personal
protective equipment, and/or financial support, and guarantee universal accessibility and
free distribution;
3. Establish vaccination strategies that consider the specific peculiarities, challenges and
vulnerabilities of each region, prioritising the most vulnerable people, including health
professionals;
4. Insist on the importance of vaccination and take action to achieve maximum coverage and
protect the population in need;
Covid-19 Vaccines for All
Berlin R-2022-02-2022
In this context,
5. Confront vaccine hesitancy by providing evidence-based guidance on the safety and
necessity of vaccines;
6. Share of knowledge required for vaccine production to the COVID-19 Technology Access
Pool created by WHO to ensure that vaccines are produced at as many centres as possible
and sharing of this knowledge;
7. Allocate public funds to improve the capacity of vaccine production centres and increase
the channels of safe distribution so as to ensure fair access, to provide equitable and
efficient vaccine supply and distribution;
8. Design national vaccine programmes that take into account a global analysis rather than
only national considerations;
9. Promote sustainable solutions to patent issues. This may include the temporary lifting of
patents on COVID-19 vaccines under the Trade-Related Aspects of Intellectual Property
Rights (TRIPS) and similar agreements to promote equity of access in global emergency
situations, while ensuring fair compensation for the intellectual property of the patent
holders if asked, global investment in manufacturing sites, training of personnel, quality
control, and the transfer of knowledge, technology and manufacturing expertise;
10. Support WHO efforts and initiatives to increase production and distribution of therapeutics
and vaccines necessary to combat COVID-19 and future pandemics in order to provide
vaccine doses to low and middle-income countries with limited access, including:
• technological transfers relevant for vaccine production;
• other support, financial and otherwise, necessary to scale up global vaccine
manufacturing; and
• measures that ensure the safety and efficacy of products manufactured by such means.
11. Call on governments and the United Nations to take all necessary measures to facilitate
equitable access to vaccines throughout the world by supporting and promoting the sharing
of all vaccine-related processes for combating pandemics (R&D, patenting, production,
licensing, procurement and application).
Handbook of WMA Policies
World Medical Association R-2022-03-2022
WMA RESOLUTION
ON
HUMANITARIAN AND MEDICAL AID TO UKRAINE
Adopted by the 73rd
WMA General Assembly, Berlin, Germany, October 2022
PREAMBLE
The ongoing war in Ukraine has led to millions of refugees who have experienced trauma and
an unprecedented mental health crisis situation. Aid workers and some physicians who are
assisting the refugees may not be well prepared to treat this war-related trauma.
Through the Ukraine Medical Help Fund, the WMA is leading a successful effort to provide
material aid to Ukrainian refugees. The longevity and brutality of the war now require even
more dedication to this effort and the expansion of aid to include mental health personnel
trained in war-related trauma.
RECOMMENDATIONS
1. That the WMA, through the Ukraine Medical Help Fund and other appropriate means, its
constituent members and the medical community, continue to send medical supplies to
Ukraine and offer support to organizations providing humanitarian missions and medical
care to Ukrainian refugees, resource permitting.
2. That the WMA, its constituent members and the medical community, advocate for early
implementation of mental health measures, including suicide prevention efforts, and for
addressing war-related trauma and post-traumatic stress disorder when assisting Ukrainian
refugees. Special attention should be paid to disadvantaged groups.
3. That the WMA, its constituent members and the medical community, advocate for
educational measures to enhance the understanding of war-related trauma in war survivors
and promote broad protective factors for war-affected people such as employment, housing,
and food stability, especially in disadvantaged groups.
Version History
© World Medical Association
Version 2010, Vancouver; Printed in March 2011
Version 2011, Montevideo; Printed in December 2011
• Replacements
Code Short Title
D-2000-01-2010 by
D-2000-01-2011
Prison Conditions on TB (amended in 2011)
S-1988-01-2005 by
R-1988-01-2005
Correction of misclassified document type
S-1988-05-2007 by
S-1988-05-2011
Tobacco Products Health Hazards (amended in 2011)
S-1996-05-2006 Replacement due to typo in the footer
S-1997-01-2007 Correction (in 2007 it was reaffirmed, not amended)
S-1997-02-2007 Correction of typo in the header
• Additions of the policies newly adopted by the 62nd WMA General Assembly,
Montevideo, Uruguay, October 2011
D-2011-01-2011 Disaster Preparedness
D-2011-02-2011 End-of-Life Medical Care
D-2011-03-2011 Leprosy Control
S-2011-01-2011 Chronic Disease
S-2011-02-2011 Monitoring Tokyo Declaration
S-2011-03-2011 Protection and Integrity of Medical Personnel
S-2011-04-2011 Social Determinants of Health
S-2011-05-2011 Social Media
R-2011-01-2011 Adequate Pain Treatment
R-2011-02-2011 Bahrain
R-2011-03-2011 Economic Embargoes and Health
R-2011-04-2011 Independence of Medical Associations
Version 2012, Bangkok; Printed in October 2012
• Replacements
D-2002-04-2002 by
D-2002-04-2012
Advanced Technology (amended in 2012)
S-1956-01-2006 by
S-1956-01-2012
Armed Conflict (amended in 2012)
R-2002-05-2002 by
R-2002-05-2012
Abuse of Psychiatry (amended in 2012)
• Removals of the policies rescinded and archived by the 63rd WMA General Assembly,
Bangkok, Thailand, October 2012
R-2002-03-2002 Health Care Services in Afghanistan
R-2002-04-2002 Pan American Health Organization
• Additions of the policies newly adopted by the 63rd WMA General Assembly,
Bangkok, Thailand, October 2012
S-2012-01-2012 Electronic Cigarettes
S-2012-02-2012 Collective Action by Physicians
S-2012-03-2012 Forced and Coerced Sterilisation
S-2012-04-2012 Organ and Tissue Donation
S-2012-05-2012 Prioritisation of Immunisation
S-2012-06-2012 Violence in the Health Sector
R-2012-01-2012 Minimum Price for Alcohol
R-2012-02-2012 Plain Packaging of Cigarettes
R-2012-03-2012 Capital Punishment
R-2012-04-2012 Professor Cyril Karabus
Version 2013-1, Bali; Printed in April 2013
• Replacements
Code Short Title
D-1981-02-1999 by
D-1981-02-2010
Correction (in 2010 it was reaffirmed, not amended)
S-2003-02-2003 by
S-2003-02-2013
Living Wills (reaffirmed in 2013)
R-2002-01-2002 by
R-2002-01-2013
Euthanasia (reaffirmed in 2013)
R-2003-01-2003 by
R-2003-01-2013
Annual Medical Ethics Day (reaffirmed in 2013)
Version 2013-2, Fortaleza; Printed in February 2014
• Replacements
Code Short Title
S-2003-01-2003 by
S-2003-01-2013
Forensic Investigations of the Missing
(amended in 2013)
R-2002-06-2002 by
R-2002-06-2013
Women’s Right to Health Care
(amended in 2013)
• Removals of the policies rescinded and archived by the 64th WMA General Assembly,
Fortaleza, Brazil, October 2013
R-2003-04-2003 SARS
• Additions of the policies newly adopted by the 64th WMA General Assembly,
Fortaleza, Brazil, October 2013
S-2013-01-2013 Fungal Disease
S-2013-02-2013 Human Papillomavirus Vaccination
S-2013-03-2013 Natural Variations of Human Sexuality
S-2013-04-2013 Victims of Torture
S-2013-05-2013 Death Penalty
R-2013-01-2013 Criminalisation of Medical Practice
R-2013-02-2013 Healthcare Situation in Syria
R-2013-03-2013 Prohibition of Chemical Weapons
R-2013-04-2013 Standardisation in Medical Practice and Patient Safety
R-2013-05-2013 Support of the AMB
Version 2014-1, Tokyo; Printed in June 2014
• Replacements
Code Short Title
R-2004-01-2004 by
R-2004-01-2014
WFME (reaffirmed in 2014)
Version 2014-2, Durban; Printed in January 2015
• Replacements
Code Short Title
D-2002-01-2003 by
D-2002-01-2012
Biological Weapons (reaffirmed in 2012)
D-2002-03-2002 by
D-2002-03-2012
Patient Safety (reaffirmed in 2012)
S-2002-01-2002 by
S-2002-01-2012
Safe Injections in Health Care (amended in 2012)
S-2002-02-2002 by
S-2002-02-2012
Self-Medication (reaffirmed in 2012)
S-2003-03-2003 by
S-2003-03-2014
International Migration of Health Workers
(amended in 2014)
S-2004-03-2004 by
S-2004-03-2014
Water and Health (amended in 2014)
R-2002-02-2002 by
R-2002-02-2012
Female Foeticide (reaffirmed in 2012)
R-2003-03-2003 by
R-2003-03-2014
Non-Commercialization of Human Reproductive
Material (amended in 2014)
• Removals of the policies rescinded and archived by the 65th WMA General Assembly,
Durban, South Africa, October 2014
S-2004-01-2004 Health Emergencies Communication & Coordination
• Additions of the policies newly adopted by the 65th WMA General Assembly,
Durban, South Africa, October 2014
D-2014-01-2014 Protection of Healthcare Workers
S-2014-01-2014 Aesthetic Treatment
S-2014-02-2014 Air Pollution
S-2014-03-2014 Solitary Confinement
R-2014-01-2014 Ebola Viral Disease
R-2014-02-2014 Migrant Workers’ Health and Safety in Qatar
Version 2015-1, Oslo; Printed in June 2015
• Replacements
Code Short Title
D-1981-01-2005 by
D-1981-01-2015
Lisbon (Patient’s Rights) (reaffirmed in 2015)
D-1987-01-2005 by
D-1987-01-2015
Euthanasia (reaffirmed in 2015)
D-1989-01-2005 by
D-1989-01-2015
Hong Kong (Elderly Abuse) (reaffirmed in 2015)
S-2005-02-2005 by
S-2005-02-2015
Drug Substitution (reaffirmed in 2015)
S-2005-04-2005 by
S-2005-04-2015
Medical Liability Reform (reaffirmed in 2015)
R-1988-01-2005 by
R-1988-01-2015
Academic Sanctions or Boycotts (reaffirmed in 2015)
Version 2015-2, Moscow; Printed in June 2016
• Replacements
Code Short Title
S-2011-04-2011 by
D-2011-04-2015
Social Determinants of Health (adopted in 2011 and
the title (S to D) changed in 2015)
S-1995-02-2006 by
S-1995-02-2015
Patients with Mental Illness (amended in 2015)
S-1985-01-2005 by
S-1985-01-2015
Non-Discrimination in Professional Membership and
Activities of Physicians (amended in 2015)
S-1998-01-2008 by
S-1998-01-2015
Nuclear Weapons (amended in 2015)
R-1999-01-1999 by
R-1999-01-2015
Curriculum of Medical Schools World-wide (amended
in 2015)
• Additions of the policies newly adopted by the 66th WMA General Assembly,
Moscow, Russia, October 2015
Code Short Title
D-2015-01-2015 Alcohol
S-2015-01-2015 Mobile Health
S-2015-02-2015 Physicians Well-Being
S-2015-03-2015 Health Support to Street Children
S-2015-04-2015 Riot Control Agents
S-2015-04-2015 Riot Control Agents
S-2015-05-2015 Transgender People
S-2015-06-2015 Vitamin D Insufficiency
S-2015-07-2015 Promotional Mass Media Appearances by Physicians
R-2015-01-2015 Healthcare In Turkey
R-2015-02-2015 Bombing on the Hospital of MSF in Kunduz
R-2015-03-2015 Global Refugee Crisis
Version 2016-1, Buenos Aires; Printed in January 2019
• Replacements
Code Short Title
S-1988-04-2006 by
S-1988-04-2016
Environmental Issues (reaffirmed in 2016)
S-1993-03-2006 by
S-1993-03-2016
Patient Advocacy and Confidentiality (reaffirmed in
2016)
S-1989-01-2006 by
S-1989-01-2016
Animal Use in Biomedical Research (reaffirmed in
2016)
R-2006-02-2006 by
R-2006-02-2016
Child Safety in Airline Travel (reaffirmed in 2016)
R-2006-04-2006 by
R-2006-04-2016
North Korean Nuclear Testing (reaffirmed in 2016)
Version 2016-2, Taipei; Printed in January 2019
• Replacements
Code Short Title
D-1968-01-2006 by
D-1968-01-2016
Determination of Death and the Recovery of Organs
(amended in 2016)
D-1975-01-2006 by
D-1975-01-2016
Medical Doctors concerning Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment in
relation to Detention and Imprisonment (amended in
2016
D-2002-02-2002 by
D-2002-02-2016
Ethical Considerations regarding Health Databases and
Biobanks (amended in 2016)
S-1984-01-2006 by
S-1984-01-2016
Child Abuse and Neglect (amended in 2016)
S-1990-01-2006 by
S-1990-01-2016
Injury Control (amended in 2016)
S-1990-04-2006 by
S-1990-04-2016
Traffic Injury (amended in 2016)
S-1991-01-2006 by
S-1991-01-2016
Adolescent Suicide (amended in 2016)
S-1992-01-2006 by
S-1992-01-2016
Alcohol and Road Safety (amended in 2016)
S-1993-01-2005 by
S-1993-01-2016
Body Searches of Prisoners (amended in 2016)
S-1993-02-2005 by
S-1993-02-2016
Female Genital Mutilation (amended in 2016)
S-1995-04-2006 by
S-1995-04-2016
Physicians and Public Health (amended in 2016)
S-1996-05-2006 by
S-1996-05-2016
Weapons of Warfare and Their Relation to Life and
Health (amended in 2016)
S-2006-05-2006 by
S-2006-05-2016
Physician’s Role in Obesity (amended in 2016)
S-2006-06-2006 by
S-2006-06-2016
Responsibilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug Abuse
(amended in 2016)
CR-2005-05-2005 by
R-2005-05-2016
Implementation of the WHO Framework Convention
on Tobacco Control (amended in 2016)
CR-2016-01-2016 by
R-2016-03-2016
Refugees and Migrants (adopted as a Council
Resolution in April 2016 and adopted as a Resolution in
October 2016)
CR-2016-02-2016 by
R-2016-04-2016
Zika Virus Infection (adopted as a Council Resolution in
April 2016 and adopted as a Resolution in October
2016)
• Removals of the policies and archived by the 67th WMA General assembly,
Taipei, Taiwan, October 2016
Code Short Title
R-2006-03-2006 Combating HIV/AIDS
• Addition of the resolution newly adopted by the 67th WMA General Assembly,
Taipei, Taiwan, October 2016
S-2016-01-2016 Ageing
S-2016-02-2016 Cyber-Attacks on Health and Other Critical
Infrastructure
S-2016-03-2016 Divestment from Fossil Fuels
S-2016-04-2016 Ethical Considerations in Global Medical Electives
S-2016-05-2016 Obesity in Children
R-2016-01-2016 Protection of Health Care Facilities and Personnel in
Syria
R-2016-02-2016 Occupational and Environmental Health and Safety
Version 2017-1, Livingstone; Printed in January 2019
• Replacements
Code Short Title
R-2007-01-2007 by
R-2007-01-2017
Health and Human Rights Abuses in Zimbabwe
(reaffirmed in 2017)
Version 2017-2, Chicago, United States; Printed in January 2019
• Replacements
Code Short Title
D-1948-01-2006 by
D-1948-01-2017
Declaration of Geneva (amended in 2017)
D-1991-01-2006 by
D-1991-01-2017
Hunger Strikers (amended in 2017)
D-1997-02-2007 by
D-1997-02-2017
Support for Medical Doctors Refusing to Participate in,
or to Condone, the Use of Torture or Other Forms of
Cruel, Inhuman, or Degrading Treatment (reaffirmed in
2017)
D-2009-01-2009 by
D-2009-01-2017
Health and Climate Change (amended in 2017)
D-2015-01-2015 by
D-2015-01-2017
Alcohol (amended in 2017)
S-1983-01-2005 by
S-1983-01-2017
Boxing (amended in 2017)
S-1984-01-2016 by
S-1984-01-2017
Child Abuse and Neglect (amended in 2017)
S-1988-02-2006 by
S-1988-01-2017
Access to Health Care (amended in 2017)
S-1992-05-2007 by
S-1992-05-2017
Noise Pollution (reaffirmed in 2017)
S-1994-01-2006 by
S-1994-01-2017
Medical Ethics in the Event of Disasters (amended in
2017)
S-1996-04-2007 by
S-1996-04-2017
Family Planning and the Right of a Woman to
Contraception (reaffirmed in 2017)
S-2004-03-2014 by
S-2004-03-2017
Water and Health (amended in 2017)
S-2006-03-2006 by
S-2006-03-2017
HIV/AIDS and the Medical Profession (amended in
2017)
S-2006-04-2006 by
S-2006-04-2017
Medical Education (amended in 2017)
S-2012-04-2012 by
S-2012-04-2017
Organ and Tissue Donation (amended in 2017)
R-1997-02-2007 by
R-1997-01-2017
Economic Embargoes and Health (reaffirmed in 2017)
R-2006-01-2006 by
R-2006-01-2017
Medical Assistance in Air Travel (amended in 2017
R-2006-05-2006 by
R-2006-05-2017
Tuberculosis (amended in 2017)
R-2007-02-2007 by
R-2007-02-2017
Support of the Medical Associations in Latin America
and the Caribbean (reaffirmed in 2017)
• Removals of the policies rescinded and archived by the 68th WMA General Assembly,
Chicago, United States, October 2017
S-1997-01-2007 Unites Nations Rapporteur on the Independence and
Integrity of Health Professionals
S-2005-01-2005 Reducing the Global Impact of Alcohol on Health and
Society
R-2012-01-2012 Minimum Price for Alcohol
• Additions of the policies newly adopted by the 68th WMA General Assembly, Chicago, United
States, October 2017
D-2017-01-2017 Quality Assurance in Basic Medical Education
D-2017-02-2017 Fair Medical Trade
S-2017-01-2017 Bullying and Harassment within the Profession
S-2017-02-2017 Armed Conflicts
S-2017-03-2017 Medical Cannabis
S-2017-04-2017 Cooperation of National Medical Associations during or
in the Aftermath of Conflicts
S-2017-05-2017 Epidemics and Pandemics
S-2017-06-2017 Role of Physicians in Preventing Exploitation in
Adoption Practices
R-2017-01-2017 Poland
R-2017-02-2017 Prohibition of Forced Anal Examinations to
Substantiate Same-Sex Sexual Activity
Version 2018-1, Riga; Printed in January 2019
• Replacements
Code Short Title
R-1998-05-2008 by
R-1998-01-2018
Supporting the Ottawa Convention on the Prohibition
of the use, stockpiling, production and transfer of anti-
personnel mines and on their destruction (reaffirmed
in 2018)
Version 2018-2, Reykjavik, Iceland; Printed in January 2019
• Replacements
Code Short Title
D-2008-01-2008 by
D-2008-01-2018
Professional Autonomy and Clinical Independence
(amended in 2018)
D-1970-01-2006 by
S-1970-01-2018
Medically-Indicated Termination of Pregnancy (name
changed and amended in 2018)
S-1997-02-2007 by
S-1997-02-2018
Physicians convicted of Genocide or Crimes (name
changed and amended in 2018)
S-1998-01-2015 by
S-1998-01-2018
Nuclear Weapons (amended in 2018)
S-2006-02-2006 by
S-2006-02-2018
Avian and Pandemic Influenza (amended in 2018)
S-2007-02-2007 by
S-2007-01-2018
Ethics of Telemedicine (amended in 2018)
S-2008-02-2008 by
S-2008-02-2018
Reducing the Global Burden of Mercury (reaffirmed in
2018)
S-2010-01-2010 by
S-2010-01-2018
Environmental Degradation and Sound Management
of Chemicals (amended in 2018)
R-2008-03-2008 by
R-2008-01-2018
Collaboration Between Human and Veterinary
Medicine (reaffirmed in 2018)
• Removals of the policies rescinded and archived by the 69th WMA General Assembly,
Reykjavik, Iceland, October 2018
Code Short Title
S-1996-03-2006 Professional Responsibility for Standards of Medical
Care
R-1981-01-2008 Physician Participation in Capital Punishment
R-2008-01-2008 The Economic Crisis: Implications for Health
R-2008-02-2008 Poppies for Medicine Project for Afghanistan
• Addition of the resolution newly adopted by the 69th WMA General Assembly,
Reykjavik, Iceland, October 2018
S-2018-01-2018 Biosimilar Medicinal Products
S-2018-02-2018 Development and Promotion of a Maternal and Child
Health Handbook
S-2018-03-2018 Gender Equality in Medicine
S-2018-04-2018 Medical Tourism
S-2018-05-2018 Sustainable Development
R-2018-01-2018 Migration
R-2018-02-2018 Prohibition of Physician Participation in Capital
Punishment
Version 2019-1, Santiago, Chile; Printed in May 2019
• Replacements
Code Short Title
S-1999-01-2009 by
S-1999-01-2019
Patenting Medical Procedures (reaffirmed in 2019)
R-2009-03-2009 by
R-2009-03-2019
Task Shifting from the Medical Profession (reaffirmed
in 2019)
Version 2019-2, Tbilisi, Georgia; Printed in November 2019
• Replacements
Code Short Title
D-1997-01-2009 by
D-1997-01-2019
Continuous Quality Improvement in Health Care
(reaffirmed with minor revision in 2019)
D-2009-02-2009 by
D-2009-02-2019
Professionally-led Regulation (amended in 2019)
S-1996-01-2008 by
S-1996-01-2019
Antimicrobial Resistance (name changed and amended
in 2019)
S-2003-04-2008 by
S-2003-04-2019
Violence and Health (amended in 2019)
S-2005-03-2009 by
D-2005-01-2019
Ethical considerations regarding the use of genetics in
health care (name and title changed (S to D) and
amended in 2019)
S-2008-01-2008 by
S-2008-01-2019
Reducing Dietary Sodium Intake (amended in 2019)
S-2014-03-2014 by
S-2014-03-2019
Solitary Confinement (amended in 2019)
R-1997-03-2008 by
S-1997-03-2019
Access of Women and Children to Health Care (title
changed (R to S) and amended in 2019)
R-2002-02-2012 by
S-2002-03-2019
Sex Selection Abortion and Female Foeticide (name
and title changed (R to S) and amended in 2019)
R-2009-01-2009 by
R-2009-01-2019
Legislation against Abortion in Nicaragua (amended in
2019)
CR-2003-01-2003 by
D-2003-01-2019
Relation of Law and Ethics (adopted as a Declaration in
2019)
• Removals of the policies rescinded and archived by the 70th WMA General Assembly, Tbilisi,
Georgia, October 2019
Code Short Title
D-1987-01-2015 Euthanasia
S-1992-06-2015 Physician-Assisted Suicide
R-1998-03-2009 Improved Investment in Public Health
R-2002-01-2013 Euthanasia
• Additions of the policies newly adopted by the 70th WMA General Assembly, Tbilisi, Georgia,
October 2019
D-2019-01-2019 Euthanasia and Physician-Assisted Suicide
S-2019-01-2019 Augmented Intelligence in Medical Care
S-2019-02-2019 Free Sugar Consumption and Sugar-sweetened
Beverages
S-2019-03-2019 Healthcare Information for All
S-2019-04-2019 Medical Age Assessment of Unaccompanied Minor
Asylum Seekers
R-2019-01-2019 Climate Emergency
R-2019-02-2019 Revocation of WHO Guidelines on Opioid Use
Version 2020, Cordoba (online), Spain; Printed in January 2021
• Replacements
Code Short Title
D-1998-01-2009 by
D-1998-01-2020
Child Health (amended in 2020)
D-2011-04-2015 by
D-2011-04-2020
Social Determinants of Health (amended in 2020)
S-1984-02-1984 by
S-1984-02-2020
Freedom to Attend Medical Meetings (reaffirmed with
minor revision in 2020)
S-1999-02-2010 by
S-1999-02-2020
Relationship between Physicians and Pharmacists in
Medical Therapy (reaffirmed with minor revision in
2020)
S-2004-02-2009 by
S-2004-02-2020
Relationship between Physicians and Commercial
Enterprises (amended in 2020)
S-2009-02-2009 by
S-2009-02-2020
Stem Cell Research (name changed and amended in
2020)
R-2003-01-2013 by
R-2003-01-2020
Designation of an Annual Medical Ethics Day
(reaffirmed in 2020)
R-2003-02-2008 by
R-2003-02-2020
Responsibility of Physicians in the Denunciation of Acts
of Torture or Cruel or Inhuman or Degrading
Treatment (amended in 2020)
R-2010-02-2010 by
S-2010-02-2020
Violence against women (name and title changed (R to
S) and amended in 2020)
R-2010-01-2010 by
R-2010-01-2020
Drug Prescription (reaffirmed with minor revision in
2020)
R-2011-01-2011 by
R-2011-01-2020
Access to adequate pain treatment (amended in 2020)
R-2013-02-2013 by
R-2013-02-2020
Healthcare Situation in Syria (reaffirmed with minor
revision in 2020)
R-2013-03-2013 by
R-2013-03-2020
Prohibition of Chemical Weapons (reaffirmed with
minor revision in 2020)
CR-2017-01-2017 by
R-2017-03-2020
Support of Dr Serdar Küni (reaffirmed as Resolution in
2020)
• Removals of the policies rescinded and archived by the 71th WMA General Assembly (online),
Cordoba, Spain, October 2020
Code Short Title
S-2009-03-2009 Inequalities in Health
CR-2012-02-2012 Professional Autonomy in Turkey
• Additions of the policies newly adopted by the 71th WMA General Assembly (online), Cordoba,
Spain, October 2020
Code Short Title
D-2020-01-2020 Patient-Physician Relationship
D-2020-02-2020 Pseudoscience and Pseudotherapies in the field of
health
S-2020-01-2020 Human Genome Editing
S-2020-02-2020 Hypertension and Cardiovascular Disease
S-2020-03-2020 Measures for the Prevention and Fight against
Transplant-Related Crimes
R-2020-01-2020 International Day of the Medical Profession
R-2020-02-2020 Turkish Medical Association
R-2020-03-2020 Equitable Global Distribution of COVID-19 Vaccine
R-2020-04-2020 Human Rights violations against Uighur people in China
R-2020-05-2020 Protecting the Future Generation’s Right to Live in a
Healthy Environment
R-2020-06-2020 Medical Profession and COVID-19
Version 2021-1, Seoul (online), South Korea; Printed in May 2021
• Replacements
Code Short Title
R-1999-01-2015 by
R-1999-01-2021
Inclusion of Medical Ethics and Human Rights in the
Curriculum of Medical Schools World-wide (reaffirmed
in 2021)
R-2002-05-2012 by
R-2002-05-2021
Abuse of Psychiatry (reaffirmed in 2021)
R-2003-03-2014 by
R-2003-03-2021
Non-Commercialisation of Human Reproductive
Material (reaffirmed in 2021)
R-2004-01-2014 by
R-2004-01-2021
WFME Global Standards for Quality Improvement of
Medical Education (reaffirmed in 2021)
R-2011-04-2011 by
R-2011-04-2021
Independence of Medical Associations (reaffirmed in
2021)
R-2012-02-2012 by
R-2012-02-2021
Plain Packaging of Cigarettes (reaffirmed with minor
revision in 2021)
R-2013-01-2013 by
R-2013-01-2021
Criminalisation of Medical Practice (reaffirmed in
2021)
R-2013-04-2013 by
R-2013-04-2021
Standardisation in Medical Practice and Patient Safety
(reaffirmed in 2021)
R-2014-02-2014 by
R-2014-02-2021
Migrant Workers’ Health and Safety in Qatar
(reaffirmed in 2021)
Version 2021-2, London (online), United Kingdom; Printed in February 2022
• Replacements
Code Short Title
D-1981-02-2010 by
D-1981-02-2021
Principles of Health Care for Sports Medicine
(amended in 2021)
D-2011-03-2011 by
D-2011-03-2021
Leprosy Control around the World and Elimination of
Discrimination against persons affected by Leprosy
(reaffirmed with minor revisions in 2021)
S-1996-02-2010 by
S-1996-02-2021
Family Violence (amended in 2021)
S-1997-03-2019 by
S-1997-03-2021
Access of Women and Children to Health Care
(amended in 2021)
S-1998-02-2010 by
S-1998-02-2021
Medical Care for Migrants (name changed and
amended in 2021)
S-2005-04-2015 by
S-2005-04-2021
Medical Liability (name changed and amended in 2021)
S-2011-02-2011 by
S-2011-02-2021
Development of a Monitoring and Reporting
Mechanism to permit Audit of Adherence of States to
the Declaration of Tokyo (reaffirmed with minor
revisions in 2021)
R-2002-06-2013 by
S-2002-04-2021
Women’s Right to Health Care and How that Relates to
the Prevention of Mother-to-Child HIV Infection (title
changed R to S and amended in 2021)
R-2005-05-2016 by
R-2005-05-2021
Implementation of the WHO Framework Convention
on Tobacco Control (reaffirmed with minor revisions in
2021)
R-2006-02-2016 by
R-2006-02-2021
Child Safety in Airline Travel (reaffirmed with minor
revisions in 2021)
R-2006-04-2016 by
R-2006-04-2021
North Korean Nuclear Testing (reaffirmed with minor
revisions in 2021)
R-2009-02-2009 by
R-2009-02-2021
Rights of Patients and Physicians in the Islamic
Republic of Iran (amended in 2021)
R-2016-01-2016 by
R-2016-01-2021
Protection of Health Care Facilities and Personnel in
Syria (reaffirmed with minor revisions in 2021)
CR-2005-04-2005 by
R-2005-04-2021
Taiwan’s participation in all WHO Health Programs and
inclusion in the International Health Regulations (IHR)
Mechanism (adopted as a Statement and amended in
2021)
CR-2015-01-2015 by
S-2015-08-2021
Trade Agreements and Public Health (adopted as a
Statement and amended in 2021)
CR-2021-01-2021 by
R-2021-01-2021
Countries worst affected by the Covid-19 crisis
(adopted as a Resolution in 2021)
CR-2021-02-2021 by
R-2021-02-2021
Support of Medical Personnel and Citizens of Myanmar
(adopted as a Resolution in 2021)
• Additions of the policies newly adopted by the 72nd WMA General Assembly (online), London,
United Kingdom, October 2021
Code Short Title
S-2021-01-2021 Ensuring the Availability, the Quality and the Safety of
Medicines Worldwide
S-2021-02-2021 Access to Surgery and Anesthesia Care
S-2021-03-2021 Solar Radiation and Photoprotection
R-2021-03-2021 Covid-19 Vaccines and International Travel
Requirements
R-2021-04-2021 Repression of Nicaraguan Doctors
• Removals of the policies rescinded and archived by the 72nd WMA General Assembly (online),
London, United Kingdom, October 2021
Code Short Title
R-2015-03-2015 Global Refugee Crisis
R-2016-03-2016 Refugees and Migrants
R-2018-01-2018 Migration
Version 2022-1, Paris (hybrid), France; Printed in May 2022
• Replacements
Code Short Title
R-1997-01-2017 by
R-1997-01-2022
Economic Embargoes and Health (reaffirmed in 2022)
Version 2022-2, Berlin, Germany; Printed in October 2022
• Replacements
Code Short Title
D-1949-01-2006 by
D-1949-01-2022
International Code of Medical Ethics (revised in 2022)
D-1983-01-2006 by
D-1983-01-2022
End of Life Medical Care (name changed and revised in
2022)
D-2000-01-2011 by
D-2000-01-2022
Prison Conditions and the Spread of Communicable
Diseases (name changed and revised in 2022)
D-2002-03-2012 by
D-2002-03-2022
Patient Safety (revised in 2022)
S-1988-05-2011 by
S-1988-05-2022
Health Hazards of Tobacco Products and Tobacco-
Derived Products (revised in 2022)
S-2002-01-2012 by
S-2002-01-2022
Safe Injections in Health Care (reaffirmed with minor
revisions in 2022)
S-2002-02-2012 by
S-2002-02-2022
Self-Medication (reaffirmed with minor revisions in
2022)
S-2006-01-2006 by
S-2006-01-2022
Assisted Reproductive Technologies (revised in 2022)
S-2009-04-2009 by
S-2009-04-2022
Digital Health (name changed and revised in 2022)
S-2011-01-2011 by
S-2011-01-2022
Global Burden of Chronic Non-Communicable Disease
(name changed and revised in 2022)
S-2011-03-2011 by
D-2011-05-2022
Protection and Integrity of Medical Personnel in Armed
Conflicts and Other Situations of Violence (title
changed (S to D) and revised in 2022)
S-2011-05-2011 by
S-2011-05-2022
Professional and Ethical Use of Social Media (revised in
2022)
S-2012-02-2012 by
S-2012-02-2022
Ethical Implications of Collective Action by Physicians
(reaffirmed with minor revisions in 2022)
S-2012-06-2012 by
S-2012-06-2022
Workplace Violence in the Health Sector (name
changed and revised in 2022)
R-2006-01-2017 by
S-2006-07-2022
Medical Assistance in Air Travel (title changed (R to S)
and reaffirmed with minor revisions in 2022)
R-2006-05-2017 by
R-2006-05-2022
Tuberculosis (reaffirmed with minor revisions in 2022)
R-2016-02-2016 by
S-2016-06-2022
Occupational and Environmental Health and Safety
(title changed (R to S) and revised in 2022)
R-2017-02-2017 by
R-2017-02-2022
Prohibition of Forced Anal Examinations to
Substantiate Same-Sex Sexual Activity (reaffirmed in
2022)
CR-2022-01-2022 by
R-2022-01-2022
Medical Personnel and Citizens of Ukraine in the face
of the Russian invasion (adopted as a Resolution in
2022)
• Additions of the policies newly adopted by the 73rd WMA General Assembly, Berlin, Germany,
October 2022
Code Short Title
D-2022-01-2022 Racism in Medicine
D-2022-02-2022 Discrimination against Elderly Individuals within
Healthcare Settings
S-2022-01-2022 Physicians Treating Relatives
R-2022-02-2022 Providing Covid-19 Vaccines for All
R-2022-03-2022 Humanitarian and Medical Aid to Ukraine
• Removals of the policies rescinded and archived by the 73rd WMA General Assembly, Berlin,
Germany, October 2022
Code Short Title
D-2011-02-2011 End-of-Life Medical Care
D-2014-01-2014 Protection of Healthcare Workers in Situations of
Violence
S-2007-02-2018 Ethics of Telemedicine
S-2015-01-2015 Mobile Health
R-2007-01-2017 Health and Human Rights Abuses in Zimbabwe
R-2017-01-2017 Poland