September 2006 - Medical Ethics and Armed Conflict

No matter what their justification, armed conflicts invariably have serious detrimental effects on health and healthcare. In addition to deaths and injuries suffered by both combatants and non-combatants, damage to healthcare facilities, environmental degradation and disruption of normal living activities all contribute to ill health and premature mortality for the survivors of conflicts.

Because of its commitment to health and health care, the medical profession is generally opposed to armed conflict as a means of settling disputes between and within nations. The WMA has repeatedly condemned armed conflict and its instruments:

• Its Resolution on The Hague Appeal for Peace 1999 supports the following goals: the strengthening of international human rights and humanitarian law and institutions; the peaceful settlement of disputes, including conflict prevention and peace building; and disarmament and the elimination of weapons of mass destruction, including nuclear, chemical and biological weapons.

• Its Statement on Weapons and Their Relation to Life and Health declares that "no weapon is medically acceptable to physicians" and that "the development, manufacture and sale of weapons for use against human beings is abhorrent." The Statement makes specific recommendations to support the prevention and reduction of weapons-related casualties.

• Its Resolution on The SIrUS Project: "Towards a Determination of which Weapons cause 'Superfluous Injury or Unnecessary Suffering'" insists that from a medical point of view neither 'necessary injury' nor 'necessary suffering' inflicted by weapons is acceptable and calls on National Medical Associations to support the International Committee of the Red Cross (ICRC)'s proposed criteria for weapons that cause 'superfluous injury or unnecessary suffering'.

• Its Declaration on Nuclear Weapons condemns the development, testing, production, deployment, threat and use of nuclear weapons; requests all governments to refrain from these activities and to work in good faith towards the elimination of nuclear weapons; and requests all National Medical Associations to join the WMA in supporting this Declaration.

• Its Resolution Supporting the Ottawa Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-personnel Mines and on their Destruction urged its member National Medical Associations to press their governments to sign and ratify the Convention.

• Its Declaration of Washington on Biological Weapons states "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 universal support for condemning research, development, or use of such weapons as morally and ethically unacceptable."

Although the elimination of armed conflicts and the weapons that make them possible is an important long-term goal, the WMA realises that harm reduction is the best that can be achieved in the present circumstances of widespread recourse to armed conflict. Therefore, it has developed Regulations in Times of Armed Conflict to help minimize the harmful effects on health of such conflicts. This statement provides advice to physicians as to how they should practise medicine during such conflicts and calls on governments, armed forces and others in positions of power to 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. This obligation includes a requirement to protect health care personnel.

July 2006 - Medical Ethics and Sports

Ethics has always been of crucial importance for sports. Unethical behaviour such as cheating is universally condemned and much effort is expended on detecting and punishing cheaters, whether before, during or after the events. In recent years, there has been increasing interaction between sports ethics and medical ethics. The development of pharmaceutical agents that enhance sports performance has created a demand for physicians to administer these agents while monitoring their effect on athletes' health. As a result, physicians have to distinguish between those medical interventions on behalf of the athlete-patient that are ethical and legal and those that are not.

Much of sports medicine, such as advice re diet and exercise, is ethically unproblematic. At the other end of the spectrum, some interventions, such as 'doping', are clearly unethical, for both the athlete and the physician. The WMA Declaration on Principles of Health Care for Sports Medicine, originally adopted in 1981 and last revised in 1999, is unambiguous on this issue:

The WMA considers the problem of doping to be a threat to the health of athletes and young people in general, as well as being in conflict with the principles of medical ethics. The physician must thus oppose and refuse to administer or condone any such means or method which is not in accordance with medical ethics, and/or which might be harmful to the athlete using it, especially:

1. Procedures which artificially modify blood constituents or biochemistry.
2. 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.
3. Pharmacological interventions that may induce alterations of will or general mental outlook.
4. Procedures to mask pain or other protective symptoms if used to enable the athlete to take part in events when lesions or signs are present which make his participation inadvisable.
5. Measures which artificially change features appropriate to age and sex.
6. Training and taking part in events when to do so would not be compatible with preservation of the individual's fitness, health or safety.
7. Measures aimed at an unnatural increase or maintenance of performance during competition.

Doping to improve an athlete's performance is unethical.

In between these two extremes, there is a grey area where the physician has to exercise his or her own judgment on possible conflicts between the athletes' desire to perform and their medical best interests. For example, physicians are often responsible for certifying athletes' fitness to participate in sports events, especially after injuries. In such situations, the right of athlete-patients to make their own decisions about their health may be superseded by the physician's duty to act in the best interests of the patients.

Besides resisting the requests of athletes for inappropriate medical interventions, physicians must also resist such demands from team officials and sponsors. As in occupational medicine, the physician's primary responsibility is for the well being of the patient, not of third parties.

The WMA has developed a specific Statement on Boxing. It states that boxing should be banned but until this happens, specific measures should be taken to minimize the physical damage to participants, including the presence of a physician authorized to stop any bout in progress, at any time, to examine a contestant and, when indicated, to terminate a bout that might, in his/her opinion, result in serious injury for either contestant.

In 1997 the International Federation of Sports Medicine developed a Code of Ethics that covers the following topics: medical ethics in general, ethics in sports medicine, special ethical issues in sports medicine, the athlete-physician relationship, training and competition, education, health promotion, injuries and athletes, therapeutic exercise, relationship with other professionals, relation to officials, clubs, etc., doping, and research.

In December 2005 the International Olympic Committee adopted a Medical Code that contains the basic guidelines regarding best medical practices in the domain of sport and the safeguarding of the rights and health of the athletes. It supports and encourages the adoption of specific measures to achieve that objective. It complements and reinforces the World Anti-Doping Code and reflects the general principles recognised in the international codes of medical ethics.

The following National Medical Associations have adopted policies on medical ethics and sports:

• The American Medical Association states: "Physicians should assist athletes to make informed decisions about their participation in amateur and professional contact sports which entail risks of bodily injury…. The professional responsibility of the physician who serves in a medical capacity at an athletic contest or sporting event is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even the injured athlete that he or she not be removed from the contest should not be controlling. The physician's judgment should be governed only by medical considerations."
  
• The Australian Medical Association's policy on Drugs in Sports "condemns as unethical the prescription or administration of medically unnecessary substances or the employment of medically inappropriate practices, including those intended to enhance performance in sport or body image." The Association has repeatedly called for a ban on boxing.
  
• The British Medical Association has developed a policy on Doctors' assistance to sports clubs & sporting events that deals with the physician's responsibility to both athletes and spectators. The Association is currently undertaking a review of the use of drugs in sport and related issues.