Adopted by the 46th WMA General Assembly Stockholm, Sweden, September 1994 and
Revised by the WMA General Assembly, Pilanesberg, South Africa, October 2006

1. The definition of a disaster for the purpose of this document focuses particularly on the medical aspects.
   A disaster is the sudden occurrence of a calamitous, usually violent, event resulting in substantial material damage, considerable displacement of people, a large number of victims and/or significant social disruption. 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. From the medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between the capacity and resources of the medical profession and the needs of survivors who are injured whose health is threatened, over a given period of time.
2. Disasters, irrespective of cause, share several features:
   1. their sudden and unexpected occurrence, demanding prompt action;
      
   2. material or natural damage making access to the survivors difficult and/or dangerous;
      
   3. adverse effects on health due to pollution, and the risks of epidemics, and emotional and psychological factors;
      
   4. a context of insecurity requiring police or military measures to maintain order;
      
   5. media coverage.
   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 an exceptional situation in which their normal professional ethics must be brought to the situation to ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not influenced by other motivations. Ethical rules defined and taught beforehand should complement the individual ethics of physicians.
   Inadequate and/or disrupted medical resources on site and the large number of people injured in a short time present specific ethical challenges.
   The World Medical Association therefore recommends the following ethical principles and procedures with regard to the physician's role in disaster situations.
3. TRIAGE
   1. Triage is a medical action of prioritizing treatment and management based on a rapid diagnosis and prognosis for each patient. Triage must be carried out systematically, taking into account the medical needs, medical intervention capabilities and available resources. Vital acts of reanimation may have to be carried out at the same time as triage. Triage may pose an ethical problem owing to the limited treatment resources immediately available in relation to the large number of injured persons in varying states of health.
      
   2. Ideally, triage should be entrusted to authorized, experienced physicians or to physician teams, assisted by a competent staff.
      
   3. The physician should separate patients into categories and then treat them in the following order, subject to national guidelines:
      1. patients who can be saved but whose lives are in immediate danger should be given treatment straight away or as a matter of priority within the next few hours;
         
      2. patients whose lives are not in immediate danger and who are in need of urgent but not immediate medical care should be treated next;
         
      3. injured persons requiring only minor treatment can be treated later or by relief workers;
         
      4. psychologically traumatized individuals who do not require treatment for bodily harm but might need reassurance or sedation if acutely disturbed;
         
      5. patients whose condition exceeds the available therapeutic resources, who suffer from extremely severe injuries such as irradiation or burns to such an extent and degree that they cannot be saved in the specific circumstances of time and place, or complex surgical cases requiring a particularly delicate operation which would take too long, thereby obliging the physician to make a choice between them and other patients. Such patients may be classified as "beyond emergency care".
         
      6. Since cases may evolve and thus change category, it is essential that the situation be regularly reassessed by the official in charge of the triage.
   4. The following statements apply to treatment beyond emergency care:
      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 a 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.
         
      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.
4. RELATIONS WITH THE PATIENTS
   In selecting the patients who may be saved, the physician should consider only their medical status, and should exclude any other consideration based on non-medical criteria.
   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. However, it should be recognized that in a disaster response there may not be enough time for informed consent to be a realistic possibility.
5. AFTERMATH OF DISASTER
   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.
      
   2. The physician must respect the customs, rites and religions of the patients and act in all impartiality.
      
   3. If possible, the difficulties encountered and the identification of the patients should be reported for medical follow-up.
6. MEDIA AND OTHER THIRD PARTIES
   The physician has a duty to each patient to exercise discretion and ensure confidentiality when dealing with third parties, and to exercise caution and objectivity and act with dignity with respect to the emotional and political atmosphere surrounding disaster situations. This implies that physicians are empowered to restrict the entrance of reporters to the medical premises. Media relations should always be handled by appropriately trained personnel.
   
7. DUTIES OF PARAMEDICAL PERSONNEL
   The ethical principles that apply to physicians also apply to personnel under the physician's direction.
   
8. TRAINING
   The World Medical Association recommends that disaster medicine training be included in the curricula of university and post-graduate courses in medicine.
   
9. RESPONSIBILITY
   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.
   The WMA requests that governments:
   1. accept the presence of foreign physicians and, where demonstrably qualified, their participation, without discrimination on the basis of factors such as affiliation (e.g. Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or religion.
      
   2. give priority to the rendering of medical services over visits of dignitaries.

14.10.2006