April 2007 - Sex and Gender

The Universal Declaration of Human Rights proclaims in Article 1 that "All human beings are born free and equal in dignity and rights" and in Article 2, "Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex…." Unfortunately, the prohibition of discrimination on the basis of sex is widely disregarded. Health care in general and medicine in particular are not exempt from such discrimination. However, efforts are underway to identify and address it wherever it is found.

Recognizing the equality of women and men does not mean treating them exactly the same in every respect. There is a necessary and important distinction between sex, which refers to the biological differences between females and males, and gender, which refers to the social characteristics attributed, often arbitrarily, to males and females respectively. In health care, it would seem that there is often insufficient recognition of sexual differences and unwarranted belief in gender differences.

That male and female anatomies and hormones are different is obvious. However, there is much less recognition of other physiological differences between the sexes. In both medical research and clinical practice, standard treatments are often tailored to males and are applied to females without taking account of potential differences in their therapeutic effects. Women have traditionally been underrepresented in clinical trials. One commonly stated reason for this is to protect fetuses and nursing infants from experimental drugs that could harm them. However legitimate this objective, it does not justify the failure to conduct adequate testing of drugs for safety, efficacy and effectiveness for women. This is an example of wrongful discrimination against women by not attending to relevant differences between the sexes.

Whereas such sexual discrimination is often latent and unnoticed, gender discrimination in health care is usually quite blatant. Here, too, women are more likely to experience such discrimination, which is just one aspect of their more general devaluation. Such gender differences often have deep cultural roots and are therefore difficult to address, much less overcome. Still, there are reasons for optimism. For instance, opposition to female genital mutilation seems to be gaining ground in many countries. Access to contraceptives has improved in much of the world, with a resulting drop in the birth rate and improvement in women's health. And women have achieved and even surpassed equality in medical school enrolment in many countries.

The medical profession has a mixed record with regard to the sex and gender requirements for optimal health care. The WMA advocates for equal treatment of females and males in its Declaration of Geneva and Declaration of Lisbon on the Rights of the Patient. It has condemned female foeticide and female genital mutilation and promoted family planning and the right of a woman to contraception and women's rights to health care and how that relates to the prevention of mother-to-child HIV infection. With regard to the inclusion of women in clinical trials, however, the WMA's Declaration of Helsinki is silent. And the WMA has not provided guidance to physicians on the need to attend to both sex and gender when diagnosing and treating their patients.

There is also room for improvement in the elimination of gender discrimination in the medical profession. Female medical students are not always encouraged or made to feel welcome in certain specialties such as surgery. Female physicians are subject to similar barriers to career advancement as their counterparts in other fields. And the governing bodies of the WMA and many National Medical Associations need a significant increase in female members in order to achieve adequate gender representation of their membership and attention to the needs of female patients and physicians.

February 2007 - International Code of Medical Ethics

A profession's code of ethics is a summary of the duties and responsibilities of the members of that profession. It serves to educate present and future professionals about these duties and responsibilities and to inform the recipients of their services and the general public about what they can expect in their dealings with the members of the profession.

The forerunners of medical codes of ethics were the ethical precepts of illustrious physicians such as Hippocrates in Greece, Caraka in India, Sun Szu-miao in China, Haly Abbas in Persia, Maimonides in Egypt and Thomas Percival in England. The first modern code of ethics was probably that of the newly-founded American Medical Association in 1847. Since then, many, if not most, National Medical Associations (NMAs) have their own codes. In some jurisdictions these codes are part of the legislation or regulations that govern the practice of medicine, whereas in other places the NMA is responsible for developing its own code.

When the WMA was established in 1947, its members agreed that a top priority was the development of an International Code of Medical Ethics that would articulate a set of duties and responsibilities for all physicians worldwide. Despite the great cultural, geographical and economic variations among the countries then represented in the WMA, the task was achieved just two year later. This document has been revised just three times since its adoption, in 1968, 1983 and most recently at the WMA General Assembly in October 2006.

There has been no change in the format of the International Code throughout its six decades of existence. It still consists of three sections: duties of physicians (a terminological change from "doctors") in general, duties of physicians to patients (a terminological change from "to the sick") and duties of physicians to colleagues (changed from "to each other" to encompass non-physician colleagues). Each revision resulted in a slightly lengthier document than its predecessor, but the Code remains a succinct statement of ethical precepts; it does not provide the ethical reasoning behind the precepts. Many of the topics covered in the Code are treated at greater length in WMA policy statements.

In contrast to its format, the Code's contents have changed over the years, reflecting developments in medical science, societal values and ethics. Among the more significant changes are the following:

• In the 2006 version there is a new paragraph: "A physician shall respect a competent patient's right to accept or refuse treatment.
• The 2006 version warns physicians not to allow their judgment "to be influenced by personal profit" (as in previous versions) "or unfair discrimination" (new).
• The previous admonition against self-advertising by physicians has been deleted in the 2006 version.
• New paragraph: "A physician shall strive to use health care resources in the best way to benefit patients and their community."
• New paragraph: "A physician shall seek appropriate care and attention if he/she suffers from mental or physical illness.
• New paragraph: "A physician shall respect the local and national codes of ethics."
• Regarding abortion, the 1949 Code stated: "A doctor must always bear in mind the obligation of preserving human life from conception. Therapeutic abortion may only be performed if the conscience of the doctors and the national laws permit." This was changed in the 1983 version to: "A physician shall always bear in mind the obligation of preserving human life." The new version reads: "A physician shall always bear in mind the obligation to respect human life."
• Regarding confidentiality, the 1949 Code required physicians to "preserve absolute secrecy on all he knows about his patient because of the confidence entrusted in him." In 1983 this was changed to: "preserve absolute confidentiality on all he knows about his patient even after the patient has died." The 2006 version reads: "A physician shall respect a patient's right to confidentiality. It is ethical to disclose confidential information when the patient consents to it or when there is a real and imminent threat of harm to the patient or to others and this threat can only be removed by a breach of confidentiality."
• New paragraph: "A physician shall, in situations when he/she is acting for a third party, ensure that the patient has full knowledge of that situation."
• New paragraph: "A physician shall not enter into a sexual relationship with his/her current patient or into any other abusive or exploitative relationship."
• The previous requirement that "A physician shall not entice patients from his colleagues" has been modified as follows: "A physician shall not undermine the patient-physician relationship of colleagues in order to attract patients."
• New paragraph: "A physician shall, when medically necessary, communicate with colleagues who are involved in the care of the same patient. This communication should respect patient confidentiality and be confined to necessary information."

The WMA invites all NMAs to review their codes of ethics to ensure that they are consistent with the revised International Code. The WMA is ready to dialogue with other health professional associations and patient organizations to explore shared understandings of the respective rights and responsibilities of all those involved in health care.