Doctors worldwide have been urged to become more active in political dialogue so that the interests of their patients are put high enough on the national and international agenda.

Dr Anders Milton, chairman of the World Medical Association, told a medical conference in Malta: "To be quiet in the face of an obscenely skewed distribution of resources or a squandering of a nation's wealth is not acceptable. We must take the side of our patients and send a clear message to our governments so that the suffering and the pain can be prevented and alleviated".

The medical profession had a duty to speak out, particularly in those countries where resources were spent not on education or health care but on arms and luxury goods for the national elite.

"We have a duty to raise our voice when health is not given a sufficient priority in the national budget or when health care resources are spent not on what will raise the health status of the majority of the population but what will be of marginal benefit to the very few in the elite".

Dr Milton said that in those countries where taxes or compulsory insurance schemes were used to fund health care, doctors must influence the political majorities in such a way that the needs of the health care system and the patients were met.

Speaking about the debate in many countries about what public health care should cover, he asked: "Should the most expensive forms of treatment for unusual diagnoses be provided for by the public service? Or should very common and banal diseases be seen as something that the patients will have to take care of outside of the public system?

"My belief is that in our democratic societies it is not possible to have a well functioning public system paid for through fairly high taxes which for too long places people in queues or declares important diseases or illnesses not covered by the public system.

"People in industrialised countries expect that the hard earned money they have paid in compulsory insurance premiums or taxes will cover them when they are ill or in need."

He asked how doctors could accept priorities that led to a number of their patients going unhelped when new remedies and therapies became available.

"Personally I believe that we have a right and a duty to speak out and to inform our patients of the possible therapeutic alternatives that exist".

Dr Milton spoke of the changing relationship between doctors and patients. The information gap between them had now narrowed and the paternalism of yesteryear had gone. Patients often knew more about their particular problem than the doctor and had the right to be informed about their disease, about different diagnostic possibilities and about the existing therapeutic procedures available.

"This empowerment of the patient has come to stay and it is good".

Patients were less prepared to accept waiting times and queues and yet in not a few countries the health care system had primarily been organised according to the wishes and demands of the owners and the professionals working in the system.

"The changed role of the patient means that the focus of the systems now has to be more on the needs and the expectations of the patient. To change a traditional way of organising, to change a lived in way of doing things is not easy or without some pain. But if we want to serve our patients in a way that they appreciate and have a right to demand, the medical profession and the other health professions must listen to the voice of the patients".

The full text of the speech is available on request to Nigel Duncan.