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wmj15<\/a><\/p>\n

WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No. 3, September 200753
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall 57
\nPPrrooffeessssiioonnaalliissmm aanndd tthhee MMeeddiiccaall AAssssoocciiaattiioonn 58
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nThe Ethics of Stem Cell Research 74
\nEthics and Human Rights news 75
\nHIV and Human Rights Handbook 76
\nWWMMAA CCPPDD ccoouurrssee iinn MMeeddiiccaall EEtthhiiccss–
\nFFuunnddaammeennttaallss iinn MMeeddiiccaall EEtthhiiccss 76
\nTToobbaaccccoo CCoonnttrrooll
\nReport on Progress made in the
\nSecond Session of the Conference
\nof the Parties, WHO Framework
\nConvention on Tobacco Control,
\nBangkok, Thailand, 30. June \u2013 6. July 2007 77
\nWWHHOO
\nNew world observatory launched with Spain 79
\nWHO launches \u2018\u2018Nine patient safety solutions\u2019\u2019
\nto save lives and avoid harm 80
\nWHO and manufactorers move ahead
\nwith plans for H5N1 influenza global
\nvaccine stockpile 81
\nWHO releases findings from research
\nproject on travel and blood clots 81
\nSafe blood for mothers 82
\nImproved meningitis vaccine for Africa
\ncould signal eventual end to deadly scourge 83
\nWMA General Assembly,
\nCopenhagen 3rd
\n\u20137th
\nOctober 2007
\n00_US_03_2007.qxd 19.09.2007 17:45 Seite 1
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers and Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-Elect President Immediate Past-President
\nDr. J. Snaedal Dr. N. Arumagam Dr. Kgosi Letlape
\nIcelandic Medical Assn. Malaysian Medical Association The South African Medical Association
\nHlidasmari 8 4th Floor MMA House P.O Box 74789
\n200 Kopavogur 124 Jalan Pahang Lynnwood Ridge 0040
\nIceland 53000 Kuala Lumpur Pretoria 0153
\nMalaysia South Africa
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr. J. E. Hill Dr. K. Iwasa
\nBundes\u00e4rztekammer American Medical Association Japan Medical Association
\nHerbert-Lewin-Platz 1 515 North State Street 2-28-16 Honkomagome
\n10623 Berlin Chicago, ILL 60610 Bunkyo-ku
\nGermany USA Tokyo 113-8621
\nJapan
\nSecretary General
\nDr. O. Kloiber
\nWorld Medical Association
\nBP 63
\n01212 Ferney-Voltaire Cedex
\nFrance
\nANDORRA S
\nCol\u2019legi Oficial de Metges
\nEdifici Plaza esc. B
\nVerge del Pilar 5,
\n4art. Despatx 11, Andorra La Vella
\nTel: (376) 823 525\/Fax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nARGENTINA S
\nConfederaci\u00f3n M\u00e9dica Argentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nTel\/Fax: (54-11) 4381-1548\/4384-5036
\nE-mail:
\ncomra@confederacionmedica.com.ar
\nWebsite: www.comra.health.org.ar
\nAUSTRALIA E
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nTel: (61-2) 6270-5460\/Fax: -5499
\nWebsite: www.ama.com.au
\nE-mail: ama@ama.com.au
\nAUSTRIA E
\n\u00d6sterreichische \u00c4rztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nTel: (43-1) 51406-931\/Fax: -933
\nE-mail: international@aek.or.at
\nREPUBLIC OF ARMENIA E
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nTel: (3741) 53 58-68
\nFax: (3741) 53 48 79
\nE-mail:info@armeda.am
\nWebsite: www.armeda.am
\nAZERBAIJAN E
\nAzerbaijan Medical Association
\n5 Sona Velikham Str.
\nAZE 370001, Baku
\nTel: (994 50) 328 1888
\nFax: (994 12) 315 136
\nE-mail: Mahirs@lycos.com \/
\nazerma@hotmail.com
\nBAHAMAS E
\nMedical Association of the Bahamas
\nJavon Medical Center
\nP.O. Box N999
\nNassau
\nTel: (1-242) 328 1857\/Fax: 323 2980
\nE-mail: mabnassau@yahoo.com
\nBANGLADESH E
\nBangladesh Medical Association
\nBMA Bhaban 5\/2 Topkhana Road
\nDhaka 1000
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2-9566060\/9568714
\nE-mail: bma@aitlbd.net
\nBELGIUM F
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644-12 88\/Fax: -1527
\nE-mail: absym.bras@euronet.be
\nWebsite: www.absym-bras.be
\nBOLIVIA S
\nColegio M\u00e9dico de Bolivia
\nCalle Ayacucho 630
\nTarija
\nFax: (591) 4663569
\nE-mail: colmed_tjo@hotmail.com
\nWebsite: colegiomedicodebolivia.org.bo
\nBRAZIL E
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bela Vista
\nSao Paulo SP \u2013 CEP 01333-903
\nTel: (55-11) 317868-00\/Fax: -31
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBULGARIA E
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.
\n1431 Sofia
\nTel: (359-2) 954 -11 26\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA E
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nTel: (1-613) 731 8610\/Fax: -1779
\nE-mail: monique.laframboise@cma.ca
\nWebsite: www.cma.ca
\nCHILE S
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: rdelcastillo@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nTitle page: The Rigshospitalet, Copenhagen founded as King Frederik\u2019s Hospital in 1757 celebrates its 250 anniversary this year. It became the State Hospital in 1910 and is now
\nintegrated in the Copenhagen Hospital Corporation. With extensive resources and research activities it serves as the national specialist referral hospital for Denmark.
\nBelow: The Headquarters of the Danish Medical Association which is hosting the General Assembly
\nof the World Medical Association this year, has been located in this attractive building since 1948.
\nU2–4_WMJ_03_07.qxd 19.09.2007 17:10 Seite U2
\nCHINA E
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6524 9989
\nFax: (86-10) 6512 3754
\nE-mail: suyumu@cma.org.cn
\nWebsite: www.chinamed.com.cn
\nCOLOMBIA S
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nTel\/Fax: (57-1) 256 8050\/256 8010
\nE-mail: federacionmedicacol@
\nsky.net.co
\nDEMOCRATIC REP. OF CONGO F
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (243-12) 24589
\nFax (Pr\u00e9sidente): (242) 8846574
\nCOSTA RICA S
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@sol.racsa.co.cr
\nCROATIA E
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: hlz@email.htnet.hr
\nWebsite: www.hlk.hr\/default.asp
\nCZECH REPUBLIC E
\nCzech Medical Association
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nTel: (420-2) 242 66 201-4
\nFax: (420-2) 242 66 212 \/ 96 18 18 69
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nCUBA S
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33114-1016
\nUnited States
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK E
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nTel: (45) 35 44 -82 29\/Fax:-8505
\nE-mail: er@dadl.dk
\nWebsite: www.laegeforeningen.dk
\nDOMINICAN REPUBLIC S
\nAsociaci\u00f3n M\u00e9dica Dominicana
\nCalle Paseo de los Medicos
\nEsquina Modesto Diaz Zona
\nUniversitaria
\nSanto Domingo
\nTel: (1809) 533-4602\/533-4686\/
\n533-8700
\nFax: (1809) 535 7337
\nE-mail: asoc.medica@codetel.net.do
\nECUADOR S
\nFederaci\u00f3n M\u00e9dica Ecuatoriana
\nV.M. Rend\u00f3n 923 \u2013 2 do.Piso Of. 201
\nP.O. Box 09-01-9848
\nGuayaquil
\nTel\/Fax: (593) 4 562569
\nE-mail: fdmedec@andinanet.net
\nEGYPT E
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A S
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nTel: (503) 260-1111, 260-1112
\nFax: -0324
\nE-mail: comcolmed@telesal.net
\nmarnuca@hotmail.com
\nESTONIA E
\nEstonian Medical Association
\n(EsMA)Pepleri 32
\n51010 Tartu
\nTel\/Fax (372) 7420429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nETHIOPIA E
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/
\nema@eth.healthnet.org
\nFIJI ISLANDS E
\nFiji Medical Association
\n2nd Fl. Narsey\u2019s Bldg, Renwick Road
\nG.P.O. Box 1116
\nSuva
\nTel: (679) 315388\/Fax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fj
\nFINLAND E
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nTel: (358-9) 3930 91\/Fax-794
\nE-mail: fma@fimnet.fi
\nWebsite: www.medassoc.fi
\nFRANCE F
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nTel\/Fax: (33) 1 45 25 22 68
\nGEORGIA E
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 398686 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY E
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nTel: (49-30) 400-456 369\/Fax: -387
\nE-mail: renate.vonhoff-winter@baek.de
\nWebsite: www.bundesaerztekammer.de
\nGHANA E
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I. F
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nTel: (509) 245-2060
\nFax: (509) 245-6323
\nE-mail: amh@amhhaiti.net
\nWebsite: www.amhhaiti.net
\nHONG KONG E
\nHong Kong Medical Association, Chi-
\nnaDuke of Windsor Building, 5th Floor
\n15 Hennessy Road
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nHUNGARY E
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36 \u2013 PO.Box 145
\n1443 Budapest
\nTel: (36-1) 312 3807 \u2013 311 6687
\nFax: (36-1) 383-7918
\nE-mail: motesz@motesz.hu
\nWebsite: www.motesz.hu
\nICELAND E
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 8640478
\nFax: (354) 5644106
\nE-mail: icemed@icemed.is
\nINDIA E
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nTel: (91-11) 23370009\/23378819\/
\n23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: inmedici@vsnl.com
\nINDONESIA E
\nIndonesian Medical Association
\nJalan Dr Sam Ratulangie N\u00b0 29
\nJakarta 10350
\nTel: (62-21) 3150679
\nFax: (62-21) 390 0473\/3154 091
\nE-mail: pbidi@idola.net.id
\nIRELAND E
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273Fax: (353-1)
\n6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL E
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nTel: (972-3) 6100444 \/ 424
\nFax: (972-3) 5751616 \/ 5753303
\nE-mail: doritb@ima.org.il
\nWebsite: www.ima.org.il
\nJAPAN E
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nKAZAKHSTAN F
\nAssociation of Medical Doctors
\nof Kazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nTel: (3272) 62 -43 01 \/ -92 92
\nFax: -3606
\nE-mail: sadykova-aizhan@yahoo.com
\nREP. OF KOREA E
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKUWAIT E
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA E
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga
\n1010 Latvia
\nTel: (371-7) 22 06 61; 22 06 57
\nFax: (371-7) 22 06 57
\nE-mail: lab@parks.lv
\nLIECHTENSTEIN E
\nLiechtensteinischer \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 231-1690
\nFax: (423) 231-1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLITHUANIA E
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nWebsite: www.lgs.lt
\nLUXEMBOURG F
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nDuch\u00e9 de Luxembourg
\n29, rue de Vianden
\n2680 Luxembourg
\nTel: (352) 44 40 331
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMACEDONIA E
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nMALAYSIA E
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nTel: (60-3) 40413740\/40411375
\nAssociation and address\/Officers
\nii
\nU2–4_WMJ_03_07.qxd 19.09.2007 17:10 Seite U3
\nAssociation and address\/Officers
\niii
\nFax: (60-3) 40418187\/40434444
\nE-mail: mma@tm.net.my
\nWebsite: http:\/\/www.mma.org.my
\nMALTA E
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: mfpb@maltanet.net
\nWebsite: www.mam.org.mt
\nMEXICO S
\nColegio Medico de Mexico
\nFenacome
\nHidalgo 1828 Pte. D-107
\nColonia Deportivo Obispado
\nMonterrey, Nuevo L\u00e9on
\nTel\/Fax: (52-8) 348-41-55
\nE-mail: rcantum@doctor.com
\nWebsite: www.cmm-fenacome.org
\nNAMIBIA E
\nMedical Association of Namibia
\n403 Maerua Park \u2013 POB 3369
\nWindhoek
\nTel: (264) 61 22 44 55\/Fax: -48 26
\nE-mail: man.office@iway.na
\nNEPAL E
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nTel: (977 1) 4225860, 231825
\nFax: (977 1) 4225300
\nE-mail: nma@healthnet.org.np
\nNETHERLANDS E
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nTel: (31-30) 28 23-267\/Fax-318
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: www.knmg.nl
\nNEW ZEALAND E
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472-4741
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNIGERIA E
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nTel: (234-1) 480 1569,
\nFax: (234-1) 492 4179
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\nNORWAY E
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nTel: (47) 23 10 -90 00\/Fax: -9010
\nE-mail: ellen.pettersen@
\nlegeforeningen.no
\nWebsite: www.legeforeningen.no
\nPANAMA S
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@cwpanama.net
\nPERU S
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores, Lima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@cmp.org.pe
\nWebsite: www.cmp.org.pe
\nPHILIPPINES E
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: medical@pma.com.ph
\nWebsite: www.pma.com.ph
\nPOLAND E
\nPolish Medical Association
\nAl. Ujazdowskie 24, 00-478 Warszawa
\nTel\/Fax: (48-22) 628 86 99
\nPORTUGAL E
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: intl@omcne.pt
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA F
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10
\nSect. 1, Bucarest
\nTel: (40-1) 460 08 30
\nFax: (40-1) 312 13 57
\nE-mail: AMR@itcnet.ro
\nWebsite: ong.ro\/ong\/amr
\nRUSSIA E
\nRussian Medical Society
\nUdaltsova Street 85
\n119607 Moscow
\nTel: (7-095)932-83-02
\nE-mail: info@rusmed.ru
\nWebsite: www.russmed.ru
\nSAMOA E
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag \u2013 National Health Services
\nApia
\nTel: (685) 778 5858
\nE-mail: vialil_lameko@yahoo.com
\nSINGAPORE E
\nSingapore Medical Association
\nAlumni Medical Centre, Level 2
\n2 College Road, 169850 Singapore
\nTel: (65) 6223 1264
\nFax: (65) 6224 7827
\nE-Mail: sma@sma.org.sg
\nwww.sma.org.sg
\nSLOVAK REPUBLIC E
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislava
\nTel: (421-2) 554 24 015
\nFax: (421-2) 554 223 63
\nE-mail: secretarysma@ba.telecom.sk
\nSLOVENIA E
\nSlovenian Medical Association
\nKomenskega 4, 61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOMALIA E
\nSomali Medical Association
\n14 Wardigley Road \u2013 POB 199
\nMogadishu
\nTel: (252-1) 595 599
\nFax: (252-1) 225 858
\nE-mail: drdalmar@yahoo.co.uk
\nSOUTH AFRICA E
\nThe South African Medical Associa-
\ntionP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nTel: (27-12) 481 2036\/2063
\nFax: (27-12) 481 2100\/2058
\nE-mail: sginterim@samedical.org
\nWebsite: www.samedical.org
\nSPAIN S
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11, Madrid 28014
\nTel: (34-91) 431 7780
\nFax: (34-91) 431 9620
\nE-mail: internacional1@cgcom.es
\nSWEDEN E
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610, SE – 114 86 Stockholm
\nTel: (46-8) 790 33 00
\nFax: (46-8) 20 57 18
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nSWITZERLAND F
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18 \u2013 C.P. 170
\n3000 Berne 15
\nTel: (41-31) 359 \u20131111\/Fax: -1112
\nE-mail: fmh@hin.ch
\nWebsite: www.fmh.ch
\nTAIWAN E
\nTaiwan Medical Association
\n9F No 29 Sec1
\nAn-Ho Road
\nTaipei
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@med-assn.org.tw
\nWebsite: www.med.assn.org.tw
\nTHAILAND E
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road
\nBangkok 10320
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: www.medassocthai.org
\nTUNISIA F
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1002 Tunis
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY E
\nTurkish Medical Association
\nGMK Bulvary
\nSehit Danis Tunaligil Sok. N\u00b0 2 Kat 4
\nMaltepe 06570
\nAnkara
\nTel: (90-312) 231 \u20133179\/Fax: -1952
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.ttb.org.tr
\nUGANDA E
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nTel: (256) 41 32 1795
\nFax: (256) 41 34 5597
\nE-mail: myers28@hotmail.com
\nUNITED KINGDOM E
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6710
\nE-mail: vivn@bma.org.uk
\nWebsite: www.bma.org.uk
\nUNITED STATES OF AMERICA E
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60610
\nTel: (1-312) 464 5040
\nFax: (1-312) 464 5973
\nWebsite: http:\/\/www.ama-assn.org
\nURUGUAY S
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nVATICAN STATE F
\nAssociazione Medica del Vaticano
\nStato della Citt\u00e0 del Vaticano
\n00120 Citt\u00e0 del Vaticano
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\nE-mail: servizi.sanitari@scv.va
\nVENEZUELA S
\nFederacion M\u00e9dica Venezolana
\nAvenida Orinoco
\nTorre Federacion M\u00e9dica Venezolana
\nUrbanizacion Las Mercedes
\nCaracas
\nTel: (58-2) 9934547
\nFax: (58-2) 9932890
\nWebsite: www.saludfmv.org
\nE-mail: info@saludgmv.org
\nVIETNAM E
\nVietnam Medical Association
\n(VGAMP)68A Ba Trieu-Street
\nHoau Kiem District
\nHanoi
\nTel\/Fax: (84) 4 943 9323
\nZIMBABWE E
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791553
\nFax: (263-4) 791561
\nE-mail: zima@zol.co.zw
\nU2–4_WMJ_03_07.qxd 19.09.2007 17:10 Seite U4
\n57
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nCo-Editors
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
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\nUK
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln
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\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
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\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH,
\nDieselstr. 2, P. O. Box 40 02 65,
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\nBank: Commerzbank K\u00f6ln No. 1 500 057,
\nDeutsche Apotheker- und \u00c4rztebank,
\n50670 K\u00f6ln, No. 015 13330.
\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or the World
\nMedical Association.
\nSubscription fee \u20ac 22,80 per annum (incl. 7 %
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2013 Germany
\nISSN: 0049-8122
\nThe second half of the 20th
\ncentury and the beginning of this one have experienced unprece-
\ndented and ever increasing rapidity of technological development, scientific discovery,
\nresearch and the production of innovative diagnostic tools and therapeutic agents. All have
\nhad enormous impact on medical practice, some have posed major ethical problems and \u2013
\nnot to be disregarded \u2013 increased public expectations of scientific discoveries and their
\napplication in medicine, together with calls for, and the need of consequent changes in med-
\nical practice.
\nIn parallel, the huge expansion in the availability and accessibility of information about
\nmedicine, medicines and medical research through the growth of communication via the
\nmass media and IT development, has played a major role in changes taking place in the
\norganisation and the conduct of medical practice. At the same time it has also, through the
\ninstant availability on information via the media (both TV and the web) supplied com-
\npelling information about the increasing instances of natural disasters and their conse-
\nquences. The instant availability of information has also highlighted to a wider public the
\nproblems of disparity in the provision of health care in differing parts of the world. The
\nimpact of information about the incidence of infectious diseases and the reality of the role
\nof poverty in disease, relayed through media readily accessible in the home, conveys an
\neven more realistic and compelling image of catastrophes, diseases and poverty, than that
\npreviously available through the spoken or written word.
\nThe impact of these developments has had substantial political, social and economic effects
\nin both developed and developing countries, leading to consequent changes in medical
\npractice and its organisation, as well as challenges to the nature of the role of physicians in
\nhealth care.
\nThese developments have had far reaching impacts on the medical profession, including
\neffects on basic medical education, postgraduate education, licensing and regulation, con-
\ntinuing professional development and re-accreditation, not to mention the nature of health
\ncare and the delivery of medical care. All of this has been accompanied by the increasing
\nburden of administrative, managerial functions and economic constraints.
\nOn a number of occasions in these columns we have commented on these trends, the chal-
\nlenges which they are producing and the increasing need for the medical profession to
\naddress them. Indeed, some of the issues have already been addressed in various parts of
\nthe world (1) (2), and a Charter (3) endorsed by a number of organisations in at least 28
\ncountries. (see annex to paper on Professionalism in this issue).
\nAt its next meeting in October, the WMA Council will be considering these issues and with
\nthis in mind , the current issue of WMJ is substantially devoted to a paper on the issue of
\nMedical Professionalism, in particular the role of the National Medical Associations. As
\nwill be seen, this paper highlights important problems which should be considered urgent-
\nly by individual physicians in whatever aspect of medical practice as well as NMA\u2019s.
\nThe inclusion of this substantial paper has substantial constraints on the normal contents of
\nthe journal which we will include in the next issue. While this topic has already been
\naddressed in some parts of the world, we hope that it will stimulate further debate and con-
\ntribute to a clear affirmation of the qualities of medical professionalism in the 21st
\ncentury.
\nAlan J. Rowe
\n(1) Royal College of Physicians \u201cDoctors\u2019 in Society: Medical Professionalism in a changing World.
\nReport of a Working Party of the Royal College of Physicians, London: RCP 2005 (2) Rosen R, Dewar
\nS., On being a doctor Medical Professionalism in a changing world Kings Fund Publications 2004
\n(3) Medical Professional Project. Medical Professionalism in the new millennium. A physician charter.
\nAnn. Intern. Med 2002 136 (3) 243-246
\nEditorial
\nWMJ_4_57-84.qxd 19.09.2007 17:07 Seite 57
\n58
\n\u201csocial contract\u201d between medicine and
\nsociety. In contrast, nearly no attention has
\nbeen given to a consideration of medical
\nprofessionalism from the point of view of
\norganized medicine (1), in particular the
\nNational Medical Association (NMA).
\nThe intent of this paper is to briefly review
\nthe current literature and thinking on med-
\nical professionalism, to highlight some of
\nthe various roles played by different med-
\nical organizations, and to examine the inter-
\nsection between medical associations and
\nprofessionalism. Finally, specific areas are
\nproposed where representative medical
\nassociations might become involved in set-
\nting guidelines or developing policies in
\norder to assist the collective profession, and
\nby extension its individual members, main-
\ntain and enhance medical professionalism
\nfor the benefit of patients and the profession
\nalike.
\nMedical Professionalism:
\nWhere do we stand?
\nOver the past few years, several articles
\nhave been published that have helped to re-
\nfocus the debate and discussion on medical
\nprofessionalism (2-8). The reason for this
\nrenewed interest generally varies by situa-
\ntion and locality. Certainly in some
\ninstances, it has been triggered by high-pro-
\nfile medico-legal cases involving physician
\nmisconduct or clinical misadventures and a
\nsubsequent public perception that there
\nexists a desire by the members of the pro-
\nfession to \u201cprotect their own\u201d in these situ-
\nations. In other cases, the technological rev-
\nolution and resultant change in access to
\nmedical information have caused physi-
\ncians and others to re-examine the nature of
\nthe physician-patient relationship and the
\ninteractions between these two parties. In
\nstill others, discussion has focused on the
\nduty of physicians to society, and the need
\nto establish an updated and modernized
\n\u201csocial contract\u201d between society and the
\nmedical profession.
\nWhile a simple definition of medical pro-
\nfessionalism that satisfies everyone\u2019s
\nrequirements does not appear to exist, for
\nthe purposes of this document it will be
\ndefined generally as follows:
\nMedical professionalism describes the
\nskills, attitudes, values and behaviours com-
\nmon to those undertaking the practice of
\nmedicine. It includes concepts such as the
\nmaintenance of competence for a unique
\nbody of knowledge and skill set, personal
\nintegrity, altruism, adherence to ethical
\ncodes of conduct, accountability, a dedica-
\ntion to self-regulation, and the exercise of
\ndiscretionary judgment. Professionalism is
\nalso the moral understanding among med-
\nical practitioners that gives reality to what is
\ncommonly referred to as the social contract
\nbetween medicine and society. This contract
\nin return grants the medical profession a
\nmonopoly over the use of its knowledge
\nbase, the right to considerable autonomy in
\npractice and the privilege of self-regulation.
\nIn February of 2002, the Annals of Internal
\nMedicine published an article entitled
\n\u201cMedical Professionalism in the New
\nMillennium: A Physician Charter\u201d (2) writ-
\nten by Canadian, European and American
\nphysicians. This document has engendered
\nmuch discussion, and the reaction to the
\nconcepts it proposes has been both positive
\nand negative. The essential premise of the
\nCharter (2) is that professionalism is the
\nbasis of medicine\u2019s contract with society,
\nwhich demands placing the interests of
\npatients above those of the physician, set-
\nting and maintaining standards of compe-
\ntency and integrity and providing expert
\nadvice to society on matters of health. It
\nlays out 3 fundamental principles (primacy
\nof patient welfare, patient autonomy and
\nsocial justice) and 10 professional responsi-
\nbilities (commitments to: professional com-
\npetence, honesty with patients, patient con-
\nfidentiality, maintaining appropriate rela-
\ntions with patients, improving quality of
\nProfessionalism and the Medical Association
\nJeff Blackmer MD MHSc FRCPC
\nExecutive Director, Office of Ethics, Canadian Medical
\nAssociation
\nIntroduction
\nMedical professionalism, and an examina-
\ntion of exactly what it means to be a profes-
\nsional in today\u2019s society, have received sig-
\nnificant attention in the medical, scientific
\nand lay press over the past few years. The
\naccelerated development of medical and
\ncommunication technologies, improve-
\nments in access to medical information for
\nthe public and direct to consumer advertis-
\ning, have all changed the way in which
\nphysicians and their patients interact. While
\nat times this change has been positive (for
\nexample, through its empowerment of
\npatients to make medical decisions on their
\nown behalf), at other times the impact has
\nbeen negative, with many physicians feel-
\ning pressured to prescribe medications or
\norder tests they might not have otherwise
\nchosen.
\nIn some locations, the very nature of the
\nmedical system itself forces physicians to
\nassume an entrepreneurial role and encour-
\nages them to aggressively promote their
\nown medical services. These types of activ-
\nity may be seen as being incompatible with
\nthe traditional role of the physician as an
\naltruistic and selfless healer.
\nThese changes and others have caused a
\nbroad re-examination of the nature and
\nmeaning of medical professionalism, what
\nit means to be a physician in today\u2019s society
\nand culture, and the dynamic of the doctor-
\npatient relationship.
\nTraditionally, nearly all of the focus of the
\ndiscussion and debate in the literature on
\nmedical professionalism has been centred
\non attempts at arriving at a definition of the
\nconcept of professionalism, the particular
\nobligations of individual physicians and the
\nWMJ_4_57-84.qxd 19.09.2007 17:07 Seite 58
\n59
\ncare, improving access to care, a just distri-
\nbution of resources, scientific knowledge,
\nmanaging conflicts of interest and profes-
\nsional responsibilities including self-regula-
\ntion).
\nWhile several bodies and organizations
\nhave adopted this Charter (see Appendix 1
\nfor a complete list), others have been equal-
\nly quick to point out its shortcomings (9-
\n10). However, few would be likely to argue
\nthat it has not had a positive effect in renew-
\ning and reinvigorating the debate and dia-
\nlogue on the topic.
\nRecent developments in Britain are perhaps
\nespecially illustrative of much of the pre-
\nsent public and professional discourse on
\nthis complex issue. They also serve to high-
\nlight the relatively large and diverse number
\nof relevant groups and stakeholders with an
\ninterest in the issue, including physician
\nrepresentative bodies such as National
\nMedical Associations. These developments
\nhave included, among others, the following:
\n– The King\u2019s Fund published a discussion
\npaper in 2004 entitled \u201cOn being a doc-
\ntor: Redefining medical professionalism
\nfor better patient care\u201d (11). This docu-
\nment argues that the medical profession
\nas a whole needs to demonstrate better
\nits duty to serve patients\u2019 interests in
\norder to show its ability to respond to
\nchanging public expectations. It notes
\nthat the \u201ccompact\u201d between physicians,
\nthe health care system and patients has
\nchanged since the inception of the NHS
\nin 1948, and suggests that a new com-
\npact is required that will show a higher
\nlevel of responsiveness to patient inter-
\nests and a focus on identifying profes-
\nsional standards that are more in tune
\nwith current values and expectations.
\n– Subsequently, the Royal College of
\nPhysicians published a working party
\nreport in December 2005 entitled
\n\u201cDoctors in society: Medical profession-
\nalism in a changing world.\u201d (12) The aim
\nof this working party was \u201cTo define the
\nnature and role of medical professional-
\nism in modern society\u201d. They define
\nmedical professionalism as a set of val-
\nues, behaviours and relationships that
\nunderpin the trust the public has in doc-
\ntors. The values identified as being of
\nparticular importance are integrity, com-
\npassion, altruism, continuous improve-
\nment, excellence and working in partner-
\nship with other members of the health
\ncare team. They suggest that these values
\nshould form the basis for a new moral
\ncontract between the profession and
\nsociety.
\n– In 2006, the British Department of
\nHealth released a report authored by the
\nChief Medical Officer, Sir Liam
\nDonaldson, entitled \u201cGood doctors, safer
\npatients: Proposals to strengthen the sys-
\ntem to assure and improve the perfor-
\nmance of doctors and to protect the safe-
\nty of patients\u201d (13). This report is aimed
\nparticularly at the topic of regulation of
\nthe medical profession, which in Britain
\nis performed under the auspices of the
\nGeneral Medical Council (GMC). It
\nnotes that in the early 1990\u2019s, a series of
\nhighly public medical scandals in the
\nUnited Kingdom gave rise to mounting
\npublic concern.
\nThe report itself was commissioned fol-
\nlowing the fairly scathing report of the
\nShipman Inquiry, chaired by Dame Janet
\nSmith (14), which was extremely critical
\nof the GMC in arguing that its culture,
\nmembership, methods of operation and
\ngovernance structures were too likely to
\nsupport the interests of doctors rather
\nthan protect patients. The Donaldson
\nreport notes that the current global trend
\nis a move away from pure self-regulation
\nto regulation in partnership between the
\nprofession and the public. The report
\nrecommends a regular assessment of
\nphysicians\u2019 clinical skills, a reshaping of
\nthe role, structure and functions of the
\nGMC and an extension of medical regu-
\nlation to the local level to create a
\nstronger interface with the health care
\nsystem.
\nFor many in the medical profession, the
\nDonaldson report represents much of the
\ncurrent angst with respect to the poten-
\ntial weakening or total loss of physician
\nself-regulation, which for the majority of
\ndoctors is one of the key pillars of med-
\nical professionalism. There appears to be
\na concerning trend in many parts of the
\nworld whereby governments and others
\nare challenging and eroding the concept
\nof physician self-regulation (and indeed
\nthe self-regulation of other professions
\nas well).
\n– The British Medical Association (BMA)
\nreleased a report on \u201cRegulation of the
\nmedical profession\u201d in March 2007 (15).
\nIt is critical of both the Donaldson report
\nand the resulting government White
\nPaper, \u201cTrust, Assurance and Safety: The
\nregulation of health professionals in the
\n21st century\u201d (16) which was published
\nin February 2007. The government doc-
\nument contains a series of proposals that,
\naccording to the BMA, would add up to
\nthe loss of professionally-led medical
\nregulation. These proposals include:
\nremoval of the adjudication function
\nfrom the GMC, having GMC Council
\nmembers appointed rather than elected ,
\nand a new composition of the GMC
\nCouncil with 50:50 lay and medical
\nmembers. The BMA argues that with a
\nstate owned medical system (the NHS),
\nand an appointed regulatory body, physi-
\ncians might find themselves compro-
\nmised in their ability to use their clinical
\nindependence to ensure optimal patient
\nmanagement, thus diminishing their
\nmedical professionalism.
\nIt is against this backdrop of recent publica-
\ntions and events, and ongoing develop-
\nments in the United States, Europe, Canada,
\nAustralia, New Zealand, Hong Kong and
\nelsewhere, that the roles of the various bod-
\nies and stakeholders in medicine and health
\ncare will be considered.
\nOrganisational roles:
\nWho does what?
\nThe number and types of organisations
\ninvolved in educating, licensing, regulating
\nand representing physicians vary signifi-
\ncantly depending on the individual country
\nor geographic region. In some locations, in
\nspite of the obvious challenges and poten-
\ntially significant conflicts of interest, the
\nsame body or organisation assumes several
\nof these roles. In general, one or more
\norganisations are involved in the following
\nareas of activity:
\nWMJ_4_57-84.qxd 19.09.2007 17:07 Seite 59
\n60
\n1) Education: Educational standards and
\ncurriculum setting are required for
\nundergraduate medical education (i.e.
\nmedical schools) and postgraduate med-
\nical education (i.e. internship and resi-
\ndency training). In some places the same
\norganization will be involved in both,
\nwhile in many places these roles are sep-
\narated. As well, many countries have
\nbodies that oversee and accredit continu-
\ning medical education (CME) initiatives
\nthat help to ensure that practicing physi-
\ncians have access to educational
\nresources throughout the life cycle of
\ntheir careers. Educational organizations
\nmay also administer examinations to
\nensure the adequacy of the knowledge
\nand clinical skills of the physician-in-
\ntraining, and may grant certificates of
\ngeneral or specialty designations on suc-
\ncessful completion of the training pro-
\ngramme and examinations.
\n2) Licensing: After physicians have com-
\npleted their training, most places require
\nthem to obtain a license for the practice
\nof medicine, usually within a specific
\nfield or area of expertise. The require-
\nments for licensure (and training back-
\nground) may vary significantly by coun-
\ntry or region. In some situations, exten-
\nsive testing and examination require-
\nments will also exist. In some countries,
\na separate license is required to practice
\nin different parts of the country, with dif-
\nferent standards in each region and no
\ntransportability of licensure.
\n3) Regulation: The licensed, practicing
\nphysician is generally held to a certain
\nstandard that they must meet in an ongo-
\ning fashion in order to continue to prac-
\ntice medicine. This standard, and the
\nway in which it is enforced, may also
\nvary significantly. The specific body
\ninvolved in regulation may also vary
\nboth between and within countries
\nTraditionally, as for many of the \u201clearned
\nprofessions\u201d, physicians have been held
\nresponsible for professionally-led self-
\nregulation, which many see as a privi-
\nlege that must be continually earned. In
\npractice, this requires physicians to form
\norganizations that will receive allega-
\ntions of professional misconduct or clin-
\nical negligence, investigate the com-
\nplaints, render a judgement and impose a
\npenalty. This activity and process is gen-
\nerally separate from the legal or civil lit-
\nigation systems of that country.
\nThe rationale for self-regulation is that
\nphysicians, by virtue of their extensive
\neducational requirements and their
\nunique grasp of a complex body of med-
\nical knowledge, obtained through years
\nof training and experience, are felt to be
\nin the best situation to be able to judge
\ntheir peers.
\nThe argument against self-regulation is
\nthat it may be perceived as being overly
\nself-serving and that the majority of the
\nmembers of a profession will inherently
\nwant to \u201cprotect their own\u201d, so that
\nphysicians who misbehave or under-per-
\nform clinically will not be properly cen-
\nsured or reprimanded by their peers. As a
\nresult, many countries have developed a
\nsystem of regulation whereby lay mem-
\nbers of the public participate actively in
\nthe process. In almost all cases, these
\npublic members make up a minority of
\nthe total membership of the regulatory
\nbodies.
\nMany regulatory bodies have also
\nassumed the role of ensuring that physi-
\ncians remain up-to-date in their clinical
\nknowledge and skills. This \u201crevalida-
\ntion\u201d activity varies significantly by
\ncountry. In some situations, it is a matter
\nof providing proof that a physician is
\nparticipating in CME activities on a reg-
\nular basis, while in others the practicing
\nphysician may be required to repeat in-
\ndepth testing and examination on a regu-
\nlar basis in order to maintain their
\nlicense to practice. Where no evidence
\nexists to link the particular standard of
\nrevalidation to quality of patient care and
\noutcomes, this activity may understand-
\nably be of some concern to physicians.
\n4) Representation: In nearly every country,
\nthere exists an association or organiza-
\ntion that represents the interests of physi-
\ncians (as exists for most professions).
\nSome countries may have one or more
\ncompeting organizations of this type.
\nMost commonly (although not always),
\nthis body takes the form of a National
\nMedical Association, whose name gen-
\nerally consists of the name of the country
\nfollowed by the Medical Association
\ndesignation (for example, Chilean
\nMedical Association, Indian Medical
\nAssociation, Russian Medical
\nAssociation and so on).
\nSome have argued that the roots of mod-
\nern representative medical associations
\ndate back to the formation of guilds in
\nthe 12th and 13th centuries (17). The
\nfeatures of guilds at that time included
\nthe power of association and self-regula-
\ntion (including training), control over the
\nmeans of production or workplace, con-
\ntrol of the market and power over rela-
\ntions with the state. However, it may be
\nmore accurate to say that today\u2019s med-
\nical associations represent the concept of
\nfreedom of coalition that evolved fol-
\nlowing Napoleon\u2019s dissolution of the
\nguilds and his introduction of a democra-
\ntic system in the early 1800\u2019s.
\nThe type and degree of specific activity
\nin today\u2019s medical association can vary.
\nIn many instances, they provide specific
\nbenefits to their members, including the
\nability to connect with a network of their
\npeers. In some countries, the NMA is
\ninvolved in advocacy activities on behalf
\nof its membership. This can include lob-
\nbying governments for improved work-
\ning conditions and health care system
\nreform, and often includes lobbying on
\nbehalf of patients to improve the level
\nand quality of the care they receive.
\nIn other countries, the NMA also acts as
\na bargaining body for its membership so
\nthat it negotiates contracts and fee struc-
\ntures on their behalf. In some situations,
\nthe association may actually have an
\nofficial \u201cunion\u201d designation. Other
\nNMA\u2019s have also assumed various edu-
\ncational and regulatory roles.
\nGiven the large number of roles undertaken
\nby the NMA\u2019s of some countries, it is not
\nsurprising that conflicts occasionally arise
\nin the course of their activities. For exam-
\nple, an association that is actively advocat-
\ning on behalf of its membership might not
\nbe seen as being able to also assume a reg-
\nulatory role that requires it on occasion to
\npublicly censure some of its members, or
\nWMJ_4_57-84.qxd 19.09.2007 17:07 Seite 60
\n61
\nremove their license to practice medicine.
\nIn the case of those NMA\u2019s that negotiate
\ncontracts on behalf of their membership,
\nsome have questioned whether they can
\nalso be legitimately involved in setting stan-
\ndards of professional behaviour and codes
\nof conduct.
\nThe next section of this paper will explore
\nthe intersection between medical profes-
\nsionalism and the representative medical
\nassociation.
\nProfessionalism and
\nMedical Associations
\nThe following quote probably best summa-
\nrizes the concerns that most commonly
\narise at the intersection of representative
\nmedical associations and medical profes-
\nsionalism (1):
\n\u201c Medicine is, in essence, a moral enter-
\nprise, and its professional associations
\nshould therefore be built on ethically
\nsound foundations. At the very least,
\nwhen physicians form associations, such
\noccasions should promote the interests
\nof those they serve. This, sadly, has not
\nalways been the case, when economic,
\ncommercial, and political agendas so
\noften take precedence over ethical oblig-
\nations. The history of professional med-
\nical associations reflects a constant ten-
\nsion between self-interest and ethical
\nideals that has never been resolved.\u201d
\nMost would agree that representing the eco-
\nnomic, commercial and political interests of
\nphysicians and organized medicine as a
\nwhole is a legitimate and important under-
\ntaking, and likely one best done by a body
\nwith democratic representation of the pro-
\nfession. In many cases (though certainly not
\nall), this representation and the resultant
\nadvocacy also serve to further the cause of
\npatients and improve the care that they
\nreceive.
\nThe greater concern arises when the actions
\n(or inactions) of an NMA appear to serve
\nonly their own self-interests. If individual
\nphysicians have an obligation to put the
\ncare of their patients above all else, should
\nthis obligation extend as well to their repre-
\nsentative associations? If we are to say that
\naltruism and integrity are key values for the
\nmedical professional, are they by extension
\nkey values for the professional\u2019s association
\nas well?
\nThe argument has been made (1) that:
\n\u201c\u2026effacement of self-interest is the dis-
\ntinguishing feature of a true profession
\nthat sets it apart from other occupa-
\ntions\u2026.When physicians form associa-
\ntions, they should make this promise col-
\nlectively\u2026. Without such a commit-
\nment, they easily degenerate into self-
\nserving trade associations, lobbies or
\nunions\u2026.In a properly conceived pro-
\nfessional association, physicians should
\nassociate to improve the care of the sick,
\nto advance the health of the public, and
\nto ensure that their fellow associates are
\nfaithful to that mission\u2026Associations
\nshould be aware of the dangers of
\nfocussing attention on the economic con-
\ncerns of their members at the expense of
\ntheir more important public and profes-
\nsional responsibilities.\u201d
\nAccording to this argument, physician asso-
\nciations should make an active and consid-
\nered decision: to represent the vested inter-
\nests of their members, or of their patients,
\nbut in general probably not both, as the
\ninterests of the two groups will too often be
\nmutually exclusive.
\nAll professions are represented in some way
\nby a body or organization that serves to fur-
\nther their particular needs and interests.
\nWithout this, that particular profession
\nwould soon disappear from the horizon as
\nmembers of other more organized and more
\nably represented professions, slowly (or
\nrapidly) eroded its place in the social order.
\nIt is patently impossible to make the argu-
\nment that physicians do not require collec-
\ntive representation. Like all other profes-
\nsions, they will be legitimately concerned
\nabout their work environment and safety,
\neducational and promotional opportunities,
\nsalary levels, and all the other things
\nemployed persons need to care about.
\nHowever, medicine is substantively differ-
\nent from most other professions, and the
\nfundamental difference is its commitment
\nto the welfare of the individual patient, and
\nthe tradition of placing the interests of this
\npatient above those of the medical practi-
\ntioner. How can we reconcile these compet-
\ning principles? Can a medical association
\nserve both its members and the patients they
\ncare for?
\nThe 1991 President\u2019s Address to the Annual
\nMeeting of the House of Delegates of the
\nAmerican Medical Association (AMA) (18)
\nby Dr. John Ring provides some direction in
\nthis regard. The address states, inter alia:
\n\u201cThe new AMA has chosen the right
\nroad for medicine: the course of profes-
\nsionalism, of patient advocacy, and of
\npersonal sacrifice. It is the way of help-
\ning doctors be better doctors \u2013 not neces-
\nsarily richer, not necessarily more pow-
\nerful, not necessarily more authoritative
\n\u2013 but better doctors\u2026
\nThe new AMA is a confluence of profes-
\nsionals whose clear agenda is the health
\nof the American people. \u2026We are a doc-
\ntor\u2019s organization, working for the good
\nof our patients, rather than a pressure
\ngroup aiming for political power as a
\nway to build organizational predomi-
\nnance, to create personal prestige, or to
\nline our own pockets\u2026
\nProfessionalism is our very identity as
\ndoctors. And the basic act of profession-
\nalism is a doctor looking after a patient:
\nthe doctor-patient relationship. We can
\naccept nothing that threatens this rela-
\ntionship by trying to turn medicine into a
\nmere trade, a dispassionate business ven-
\nture, an impersonal public utility.\u201d
\nDr. Ring goes on to describe a new AMA
\ninitiative examining the issue of access to
\ncare. Clearly, the interests of both patients
\nand physicians are served by improving
\naccess to care. He uses this as a prototypical
\nexample of where the AMA should be
\nfocusing its efforts. From this, we under-
\nstand that organized medicine has a legiti-
\nmate claim at representing its own interests,
\nand that this representation can and should
\nbe done by a representative medical associ-
\nation. However, these interests, like those of
\nthe individual physician, should not super-
\nsede or replace the interests of patients in
\nthe collective.
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\n62
\nPerhaps the vision statement of the
\nCanadian Medical Association (19) best
\ncaptures the preferred approach. In describ-
\ning its vision, it lists only two aims: \u201cA
\nhealthy population and a vibrant medical
\nprofession.\u201d The promotion of both ideals
\ncan and should coexist in the same repre-
\nsentative medical association. But the rank
\nordering of these priorities, which is clearly
\nnot random, should not change.
\nThe next section will examine specific
\nissues and areas where medical associations
\ncan set guidelines, policies and standards to
\nadvance the professionalism of the associa-
\ntion and its members while also striving to
\nserve the best interests of patients and soci-
\nety.
\nPotential areas of activity
\nThere are several potential areas where rep-
\nresentative medical associations might
\nbecome actively involved in promoting and
\nenhancing professionalism within the asso-
\nciation and for their membership. What fol-
\nlows is a discussion of some of these areas,
\nrecognizing that others are likely to exist as
\nwell.
\n1) Pandemic and disaster preparedness
\nSince the experience with the Severe Acute
\nRespiratory Syndrome (SARS) epidemic of
\n2003, there has been much discussion in the
\nmedical literature regarding issues of pro-
\nfessionalism and medical care during a cri-
\nsis situation, be it pandemic or otherwise
\n(20-23). Although it is generally accepted
\nthat physicians and other health care work-
\ners have a duty to provide care in such a sit-
\nuation, several important questions have
\nbeen raised as part of the broader discus-
\nsion. These include:
\n– What exactly is the obligation of health
\ncare providers during a pandemic? Is it
\nto provide care to all those in need
\nregardless of the level of personal risk?
\n– Do physicians and others have a right to
\nrefuse to provide care when their own
\nhealth (or that of their family) is at risk?
\n– Is the provision of services during a pan-
\ndemic based in whole or in part on the
\nobligation of governments and others to
\nprovide reciprocal services to physi-
\ncians? If this reciprocity is not honoured,
\nare physicians then absolved of their
\nobligations?
\nClearly, these are questions not easily
\nanswered. While some have argued that
\nphysicians and other health care workers
\nappear to have an absolute obligation to
\nprovide care regardless of the circum-
\nstances in which they find themselves (24,
\n25), others have argued that this obligation
\nmay vary depending on the particular situa-
\ntion and circumstances (26-28). There are
\nclearly compelling arguments to be made
\non both sides. The professional obligations
\nof physicians in this situation are also well
\nset out in various codes of ethics and regu-
\nlatory documents.
\nTraditionally, physicians have respected the
\nprinciple of altruism, whereby, throughout
\nhistory, they have set aside concern for their
\nown health and well-being in order to serve
\ntheir patients. While this has generally man-
\nifested itself primarily as long hours away
\nfrom home and family, and a benign neglect
\nof personal health issues, at times more
\ndrastic sacrifices have been required.
\nDuring previous pandemics, physicians
\nhave served selflessly in the public interest,
\noften at great risk to their own well-being
\n(although it should be noted that there are
\nalso isolated historical exceptions of physi-
\ncians who have fled from such situations;
\nGalen and Sydenham both fled from
\npatients with contagious epidemic diseases)
\n(29).
\nSince the experience of SARS, the concepts
\nof reciprocity and reciprocal obligations
\nhave received significant attention from
\nphysicians and others both in and outside of
\nthe health care field. During this crisis,
\nmany health care workers found themselves
\nassuming great personal risk, sometimes
\nwith very little support and assistance from
\ngovernments, hospitals, health districts and
\nothers. Several physicians and nurses con-
\ntracted the virus, and some of these died as
\na result. It has become increasingly clear
\nthat more support will be expected during
\nthe next public health crisis, particularly in
\ndeveloped countries that have the necessary
\nresources to provide this support.
\nAs the University of Toronto Joint Centre
\nfor Bioethics report, \u201cWe stand on guard for
\nthee\u201d (30), states:
\n\u201c(The substantive value of) reciprocity
\nrequires that society support those who
\nface a disproportionate burden in pro-
\ntecting the public good, and take steps to
\nminimize burdens as much as possible.
\nMeasures to protect the public good are
\nlikely to impose a disproportionate bur-
\nden on health care workers, patients and
\ntheir families.\u201d
\nSome of these reciprocal obligations, which
\nshould be undertaken by governments, hos-
\npitals, and others, might include:
\n– Physicians and the associations that rep-
\nresent them should be more involved in
\nplanning and decision making at the
\nlocal, national and international levels.
\nIn turn, physicians and the associations
\nthat represent them have an obligation to
\nparticipate in these discussions.
\n– Physicians should be made aware of a
\nclear plan for resource utilization,
\nincluding:
\n– clearly defined physician roles and
\nexpectations, especially for those
\npracticing outside of their area of
\nexpertise;
\n– vaccination\/treatment plans \u2013 clarifi-
\ncation of whether health care workers
\n(and their families) will have prefer-
\nential access based on the need to
\nkeep caregivers healthy and on the
\njob;
\n– triage plans, including how the triage
\nmodel might be altered and plans to
\ninform the public of such.
\n– Physicians and health care providers
\nshould have access to the best equipment
\nneeded and should be able to undergo
\nextra training in its use if required.
\n– Physicians and health care providers
\nshould have access to up-to-date, real
\ntime information. They should be kept
\ninformed about developments locally
\nand globally.
\n– Resources should be provided for back-
\nup and relief of physicians and health
\ncare workers.
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 62
\n63
\n– Physicians and health care providers
\nshould receive financial compensation to
\ncover expenses such as lost wages, lost
\ngroup earnings, overhead, medical care,
\nmedications, rehabilitative therapy, and
\nother relevant expenses in case of quar-
\nantine, clinic cancellations or illness.
\n– Families should receive financial com-
\npensation in the case of a physician fam-
\nily member who dies as a result of pro-
\nviding care during a health care crisis.
\n– Physicians should be given expanded
\nliability coverage as required, particular-
\nly for those practicing outside of their
\narea of expertise.
\n– Psychological and emotional counselling
\nand support should be provided in a
\ntimely fashion for physicians, health care
\nproviders, their staff and family mem-
\nbers.
\nIt should be noted that meeting these recip-
\nrocal obligations might not be possible in
\nless developed countries which lack suffi-
\ncient resources to do so. For example, in
\ncountries with few resources and poor infra-
\nstructure, even providing soap for all health
\ncare workers might be difficult. In this case,
\nsituational reciprocity must be ensured; that
\nis, health care workers should be provided
\nwith whatever resources are available in
\norder to optimise patient care and the safety
\nof the workers.
\nWhat NMA\u2019s can do on the issue of disaster
\nand pandemic preparedness
\nNational Medical Associations can develop
\nguidelines on disaster and pandemic pre-
\nparedness that will specifically outline for
\ntheir membership exactly what is expected
\nof them in such a situation, and what their
\nprofessional obligations entail. They can
\nalso assist their members, and the public, by
\nhelping ensure that governments, hospitals
\nand others understand and meet the recipro-
\ncal obligations (as outlined above) that will
\nbe critically important for ensuring the care
\nand safety of patients and physicians alike
\nduring a pandemic or other public health
\nemergency.
\n2) Conscientious objection
\nIn this context, conscientious objection is a
\nterm generally used to refer to a situation
\nwhere a physician or other health care
\nworker refuses to provide treatment or ther-
\napy on the grounds that such provision
\nwould violate their strongly held moral
\nprinciples. The concept originated during
\nwartime tension between religious freedom
\nand patriotic obligations (31) and was sub-
\nsequently co-opted during the reproductive
\nrights debates of the 1960 and \u201870s
\nThe most common examples in the litera-
\nture and in day-to-day medical practice con-
\ntinue to involve reproductive medicine:
\nspecifically, the provision of therapeutic
\nabortion services and access to contracep-
\ntive devices and medication. More recently,
\nthe issue of access to post-coital contracep-
\ntion and abortifacient options has garnered
\nmuch attention, from both the physician and
\npharmacist perspective, with reports of
\npharmacists refusing to dispense emergency
\ncontraception dating back to 1991 (32). The
\npast several years have seen an increase in
\nlegislative initiatives, particularly in the
\nUnited States under the current Republican
\nadministration, designed to protect health
\ncare providers who refuse to participate in
\nspecific reproductive procedures or prac-
\ntices (33).
\nOther less common issues sometimes
\nreferred to during a discussion of conscien-
\ntious objection include euthanasia, physi-
\ncian assisted suicide, assisted reproductive
\ntechnologies, assistance during executions
\nand experimentation on human embryos
\n(34).
\nA recent New England Journal of Medicine
\narticle has served to highlight the scope of
\nthe issue, at least in the United States (35).
\nAccording to a survey of 1144 physicians,
\nmost physicians (63%) believe that it is eth-
\nically permissible for physicians to outline
\ntheir moral beliefs and objections to their
\npatients. The majority (86%) also agree that
\nphysicians must present all options regard-
\ning specific therapies and treatments to their
\npatients \u2013 which of course means that a
\nsizeable minority of 14% of physicians are
\nnot providing all the information required
\nby their patients. In addition, 71% of physi-
\ncians feel that a doctor has an obligation to
\nrefer a patient to another clinician to obtain
\na service to which the referring physician is
\nmorally opposed.
\nThere are several possible advantages in
\nallowing physicians to invoke the concept
\nof conscientious objection as a reason for
\nrefusing to participate in certain procedures
\nor therapies. It allows the physician to stay
\ntrue to their morals and values; in general,
\nsociety does not require professionals to
\nforsake their morals upon entry into a par-
\nticular profession. It allows medical profes-
\nsionals to exercise their independent judge-
\nment. And the right to refuse to participate
\nin acts that conflict with personal, ethical,
\nmoral or religious convictions is generally
\naccepted as an essential element of a free
\nand democratic society (33).
\nThere are also several possible downsides
\nwhen physicians invoke the right of consci-
\nentious objection. This practice may limit
\naccess to care and consequently have a
\ndetrimental impact on the health of patients.
\nIt can serve to impose the values and per-
\nsonal morals of the physician on the patient.
\nIt may be in direct opposition with the
\nobligation of the physician to provide care
\nwithout discrimination. Furthermore, pro-
\nfessional autonomy is not without its limits
\nand the interests of the patients are general-
\nly held to take precedence over those of the
\nphysician. Finally, the practice can intro-
\nduce elements of inefficiency, inequity and
\ninconsistency into a medical system (36).
\nWhile there are clearly arguments to be
\nmade on both sides of the issue, some
\nauthors have particularly strongly held
\nbeliefs. In a recent article in the British
\nMedical Journal, Savulescu (36) claims
\nthat:
\n\u201cA doctor\u2019s conscience has little place in
\nthe delivery of modern medical care.
\nWhat should be provided is defined by
\nthe law and consideration of the just dis-
\ntribution of finite medical resources,
\nwhich requires a reasonable conception
\nof the patient\u2019s good and the patient\u2019s
\ninformed desires. If people are not pre-
\npared to offer legally permitted, effi-
\ncient, and beneficial care because it con-
\nflicts with their values, they should not
\nbe doctors.\u201d
\nThere seems to be general agreement in the
\nmedical and ethics literature, current Codes
\nof Medical Ethics and legislative approach-
\nes on several issues. First, it would appear
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 63
\n64
\nthat physicians and other health care
\nproviders have at least a limited right to
\nrefuse to participate in certain procedures or
\ntherapies if these are in opposition to their
\nvalues and beliefs. However, one needs to
\ndistinguish this right from the right to refuse
\nto refer a patient to a clinician who will pro-
\nvide these services. While there is some
\ndebate about this issue, the majority of the
\ncurrent literature, if not current policy and
\nlegislation, appears to support the obliga-
\ntion to refer (33, 36, 37, 38).
\nFrom the perspective of the National
\nMedical Association, this issue would
\nappear to provide fertile ground for policy
\ndevelopment and professional guidance.
\nWhat NMA\u2019s can do on the issue of consci-
\nentious objection
\nIt is suggested that policy development in
\nthis area should consider and address at
\nleast 6 aspects of the issue:
\n1) The concept of conscientious objection,
\nits history and its current use should be
\ncarefully and comprehensively outlined.
\n2) In general terms, there appears to be
\nagreement that physicians have a right to
\nstay true to their personal values and
\nmorals and to exercise their independent
\nprofessional judgement. They also have
\nthe right to inform their patients of such,
\nbut not in a way that is unduly coercive
\nor argumentative.
\n3) Physicians should understand that they
\nshould not refuse to provide urgently
\nneeded care by using the concept of con-
\nscientious objection. A distinction must
\nbe made between an acute situation
\nwhere immediate care is required to save
\na life or maintain health, as opposed to a
\nless acute situation where there is time
\nfor a patient to seek medical services
\nelsewhere.
\n4) Physicians should not obstruct, actively
\nor passively, patients from receiving care
\nfrom another clinician. Although health
\nprofessionals may have a right to object,
\nthey do not have a right to obstruct (33).
\n5) Physicians should provide their patients
\nwith all the information they require
\nregardless of the personal values of the
\nphysician. For patients to give valid
\ninformed consent, they have to be
\ninformed of the relevant alternatives and
\ntheir risks and benefits in a reasonable,
\ncomplete and unbiased way. This con-
\ncept is one of the central tenets of mod-
\nern medical ethics and cannot be under-
\nmined based on conscientious objection.
\n6) NMA\u2019s should address the issue of
\nwhether or not the conscientious objec-
\ntor has a duty to refer the patient to
\nanother clinician for services the objec-
\ntor will not provide. Clearly worded
\nguidance in this area will be of benefit to
\npatients and physicians alike.
\nWhile some NMA\u2019s may elect to include
\nthis information within the context of a
\nrelated policy (for example, a policy on
\ntherapeutic abortion), because the concept
\nof conscientious objection can apply in sev-
\neral different types of clinical situations, it
\nis suggested that it is preferable to develop
\na separate policy that can be used in multi-
\nple circumstances.
\n3) Self-regulation
\nThe general concept of self-regulation has
\nbeen outlined above in the section on orga-
\nnizational roles. In some parts of the world,
\nthe term \u201cself-governance\u201d is used inter-
\nchangeably with self-regulation, while in
\nother areas the regulatory function is felt to
\nbe one part of the overall governance func-
\ntion. For ease of understanding, the term
\n\u201cself-regulation\u201d will be used in this docu-
\nment.
\nIt is fair to say that the vast majority of rep-
\nresentative medical associations, if not all
\nof them, support and encourage the concept
\nof self-regulation of the medical profession.
\nFrom a physician standpoint, it would not
\nbe advantageous to have their actions or
\nclinical decisions evaluated by lay people
\nand members of the public who are not like-
\nly to have the necessary training or experi-
\nence to make those judgements. In addition,
\nthis is an area where individual physicians
\ncan demonstrate their collective sense of
\nresponsibility rather than through some-
\ntimes abstract principles or declarations.
\nFrom the standpoint of the general public,
\nthey need to have confidence that the regu-
\nlation of physicians is fair, open and trans-
\nparent and that physicians are held liable for
\nany clinical or professional transgressions
\nin a significant and meaningful way so that
\nsuch transgressions will not be repeated in
\nthe future. They need to be confident that
\nself-regulation does not mean self-protec-
\ntion. Some degree of public involvement in
\nregulatory bodies is now generally well
\naccepted, but physicians usually become
\nconcerned when consideration is given to
\nhaving these organizations constituted with
\na public majority, meaning that decision
\nmaking will then be outside the control of
\nthe profession.
\nAccording to the website of the College of
\nPhysicians and Surgeons of Ontario (39),
\nthe self-regulatory body for physicians
\npracticing in this Canadian province, the
\nrelationship between the College, the pro-
\nfession and the public is as follows:
\n\u201cThe College of Physicians and
\nSurgeons of Ontario governs the practice
\nof medicine in the public interest. It does
\nnot exist to protect the medical profes-
\nsion. The profession\u2019s interests are well
\nrepresented by other bodies, including
\nthe Canadian Medical Association.
\nThe medical profession has been permit-
\nted by legislation to play a leading role in
\nthe protection of the public. It does this
\nthrough the College. This is what is
\nmeant by \u201eself-regulation.\u201c Self-regula-
\ntion should never be confused with pro-
\nfessional autonomy. The profession,
\nthrough the College, is always account-
\nable to the public.\u201d
\nIt is not uncommon for there to be a some-
\nwhat strained relationship between repre-
\nsentative medical associations and those
\norganizations involved in physician self-
\nregulation. While the public may see regu-
\nlatory bodies as occasionally overly protec-
\ntive of physicians and not always acting in
\nthe best interests of the public, some physi-
\ncians find them unnecessarily intrusive,
\ninterventionist and restrictive when it
\ncomes to regulating the day-to-day practice
\nof medicine. However, in order to preserve
\nthe privilege of self-regulation, the medical
\nprofession must be clearly seen to be acting
\nin the best interests of the public and not of
\nthe profession itself.
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\n65
\nThe concept of self-regulation of the med-
\nical profession presents a situation where
\nrepresentative medical associations may
\nfind themselves with a choice to make,
\nbetween representing the desire of their
\nmembership for more freedom to practice
\nmedicine in a fully autonomous way with
\nlittle \u201cunnecessary\u201d regulatory intrusion,
\nversus supporting the public desire to
\nstrengthen the regulatory oversight of
\nphysicians and increase the transparency of
\nthe system. As suggested previously, and
\nfor reasons outlined above, the interests of
\nthe public and patients should take prece-
\ndence in this type of situation.
\nWhat NMA\u2019s can do on the issue of self-
\nregulation
\nThis does not mean that NMA\u2019s should
\nacquiesce to any and all demands of regula-
\ntors and the public. It does mean that they
\nshould support, through policy, advocacy
\nand action, legitimate efforts to improve the
\nquality of medical care and outcomes
\nthrough regulatory oversight of their physi-
\ncian members.
\nUnduly intrusive activities that have not
\nbeen shown to improve the quality of
\npatient care are not necessarily appropriate.
\nEfforts at revalidation of physicians should
\nnot simply be exercises intended to reassure
\nthe public and legislators, but should truly
\nstrive to improve the quality of medical
\npractice, and should be based on solid evi-
\ndence demonstrating that the means used
\nwill be efficient and effective. It may be up
\nto NMA\u2019s to help ensure that this evidence
\nexists and is incorporated in a meaningful
\nway.
\nNMA\u2019s should develop policy or position
\nstatements clarifying their support for self-
\nregulation and outlining the importance of
\nthis concept to the maintenance of medical
\nprofessionalism. They should assist their
\nmembers in understanding that self-regula-
\ntion cannot be perceived as being protective
\nof physicians, but must maintain the sup-
\nport and confidence of the general public.
\n4) Interactions between physicians and
\nindustry
\nPerhaps nowhere in medicine today is the
\npotential for conflict of interest greater than
\nin the interaction between physicians and
\nprivate industry. These industries can
\ninclude pharmaceutical companies, medical
\ndevice manufacturers and makers of other
\nproducts like baby formulas. In short, any
\nprivate interest whose income generation
\ndepends on physician prescription or
\napproval of their product.
\nFrom a business standpoint, the model is
\nfairly simple. In most businesses, the prod-
\nuct is marketed directly to the public
\nthrough means such as advertising and
\nword of mouth campaigns. However, in
\nmedicine, the companies must go through
\nthe \u201cmiddle man\u201d, the physician. The physi-
\ncian must prescribe a product, usually a
\nmedication, which is then purchased by the
\nconsumer, their patients. Sound and accept-
\ned business practice means that the compa-
\nnies will mount marketing and advertising
\ncampaigns to influence physician prescrib-
\ning patterns in favour of their company,
\nthereby increasing their income and market
\nshare.
\nThe pharmaceutical industry has tradition-
\nally denied that they attempt to influence
\nphysician prescribing behaviour, instead
\ninsisting that their marketing efforts are
\nsimply intended to educate physicians on
\nnew products in order to ensure that their
\nprescribing choices are well-informed and
\nbased on the latest available scientific liter-
\nature. However, there is now much evi-
\ndence to the contrary.
\nTo start with, the information presented to
\nphysicians is usually extremely biased,
\noften inaccurate, and intended to portray the
\ntarget product in a favourable light. A
\nSpanish study revealed that 44.5% of the
\ninformation provided by pharmaceutical
\nrepresentatives to family physicians is fac-
\ntually erroneous and is biased towards their
\nown products (40). An Argentinean study
\n(41) concluded that 46% of references
\ngiven in literature distributed by industry
\nrepresentatives did not concur with the
\nclaims made in the company\u2019s literature. A
\nGerman study (42) found that 94% of the
\ninformation in brochures for doctors had no
\nbasis in scientific evidence; while many
\nbrochures had cited publications that could
\nnot be found, the majority of information
\nfound in them did not accurately reflect the
\npublications that they cited.
\nThis mounting body of evidence hardly
\nsupports the industry argument that physi-
\ncian education is the true intent of its infor-
\nmation dissemination. Clearly the purpose
\nis instead to provide information in such a
\nway that physicians will view the product in
\na more favourable light and be more likely
\nto prescribe it to their patients.
\nSecondly, a significant number of former
\npharmaceutical representatives and industry
\ninsiders have recently come forward to
\nreveal the internal machinations of the busi-
\nness. One states: \u201cAn unofficial, and more
\naccurate, job description for a sales rep
\nwould be: Change the prescribing habits of
\nphysicians.\u201d (43). Another says: \u201cIt is my
\njob to figure out what a physician\u2019s price
\nis\u2026everything is for sale and everything is
\nan exchange\u201d and \u201cIt\u2019s my job to constantly
\nsway the doctors. Doctors are neither
\ntrained nor paid to negotiate. Most of the
\ntime they don\u2019t even realize that\u2019s what
\nthey\u2019re doing.\u201d Perhaps most concerning,
\nthis same former representative (43) went
\non to write:
\n\u201cThe concept that reps provide necessary
\nservices to physicians and patients is a
\nfiction. Pharmaceutical companies spend
\nbillions of dollars annually to ensure that
\nphysicians most susceptible to marketing
\nprescribe the most expensive, most pro-
\nmoted drugs to the most people possible.
\nIf detailing were an educational service,
\nit would be provided to all physicians,
\nnot just those who affect market share.
\nEvery piece of information provided is
\ncarefully crafted, not to assist doctors or
\npatients, but to increase market share for
\ntargeted drugs.\u201d
\nFinally, an increasing number of studies are
\nrevealing that pharmaceutical marketing
\ndoes impact physician prescribing habits
\n(44-48). The old argument that \u201cit just does-
\nn\u2019t affect me\u201d does not hold water anymore,
\nnor does the assertion that \u201cIt may influence
\nmy colleagues, but it does not influence
\nme\u201d.
\nGiven the current lack of public funding for
\nCME events and medical research, and the
\nresulting reliance of these important activi-
\nties on private industry funding, most
\nphysicians seem to be in agreement that
\nbanning all forms of contact between physi-
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\n66
\ncians and industry is not feasible or perhaps
\neven desirable. However, there is clearly a
\nneed to develop policies and guidelines in
\nthis area to help regulate the relationship in
\norder to avoid the appearance or presence of
\nreal or perceived conflicts of interest.
\nThe bodies setting these policies can vary
\nand may include some or all of the follow-
\ning:- government and legislators, medical
\nregulators, physician representative associ-
\nations, medical specialty groups, and the
\nindustry itself. The argument is made here
\nthat these policies should be developed and
\nled by the profession, should be clear and
\ntransparent and should ensure that any
\ninteractions taking place between physi-
\ncians and industry will be only for the clear
\nbenefit of patients, not of for physicians or
\nindustry.
\nWhat NMA\u2019s can do on the issue of interac-
\ntions between physicians and industry
\nNational medical associations can and
\nshould develop clear and comprehensive
\npolicy in this area to ensure that their mem-
\nbers do not find themselves in a position of
\nconflict of interest. They should widely dis-
\ntribute these policies to their membership
\nand others, and undertake educational ini-
\ntiatives to clarify their importance, intent
\nand content. They should use their advoca-
\ncy capabilities to help ensure that these
\nphysician-led guidelines become the
\naccepted standard for all the other partici-
\npants involved, including industry.
\nAt a minimum, these guidelines should
\naddress the following topics:
\n– a clear explanation of the issue and the
\nconcept of conflicts of interest
\n– gifts to physicians, including social sci-
\nence literature on gift giving
\n– drug samples and their impact on pre-
\nscribing behaviour and drug costs
\n– educational and promotional materials
\naimed at physicians
\n– CME events (including electronically-
\ndelivered CME) and sponsorship,
\nincluding physician payment for partici-
\npation
\n– physician participation and patient enrol-
\nment in industry-sponsored research tri-
\nals, including physician payment for par-
\nticipation
\n– disclosure obligations for physicians
\nsubmitting research or providing educa-
\ntional sessions
\n– physician participation as medical advi-
\nsors or on advisory boards, and the dis-
\ntinction between these activities and
\nmarketing
\n-peer selling and direct physician promotion
\nof individual products or companies
\n– how medical students and residents
\nshould approach the issue
\nThose NMA\u2019s without sufficient resources
\nto develop their own policy in this area may
\nwish to adopt the policy of other NMA\u2019s or
\nof the World Medical Association (49).
\nPhysician representative associations
\nshould also give careful consideration to
\ndeveloping stringent internal policy for
\ngoverning relationships between the organi-
\nzation and third parties. This will serve to
\nset an example for the membership and
\nensure that the association itself is able to
\navoid situations of conflict of interest (a les-
\nson learned painfully by the American
\nMedical Association during a brief sponsor-
\nship deal with Sunbeam in the 1990\u2019s).
\n5) Interprofessionalism
\nTraditionally, and until relatively recently,
\nhealth care had been delivered in what can
\nbest be described as a multidisciplinary
\nmodel of teamwork. In this model, each
\nmember of the health care team fulfilled a
\ncertain well-defined and predetermined role
\nwith little or no overlap between the activi-
\nties of the team members. Ultimate deci-
\nsion-making authority rested nearly always
\nwith the physician.
\nMore recently, this model has evolved into
\none of interdisciplinary team care (or \u201cinter-
\nprofessionalism\u201d) whereby the members of
\nthe team work collaboratively together to
\nhelp ensure optimum patient care and out-
\ncomes. In this model, there may be some
\noverlap between the roles and responsibili-
\nties of the team members, based on what is
\nin the best interests of the individual patient
\nat that particular point in time. For example,
\na speech and language pathologist might
\nprescribe a specific dysphagia diet based on
\ntheir clinical assessment, or a pharmacist
\nmight renew a prescription without consult-
\ning the physician. Unfortunately, studies
\nhave shown that even in this model the pro-
\nvision of health services is still often
\nfraught with interprofessional conflict, dis-
\nsension and misunderstandings (50).
\nIn the current context of limited health
\nhuman resources, and particularly limited
\nphysician resources, it makes inherent sense
\nto take full advantage of the abilities of each
\nmember of the health care team. These
\nmembers can include, but are not limited to,
\nphysicians, physician assistants, nurses,
\nnurse practitioners, pharmacists, occupa-
\ntional and physical therapists, psycholo-
\ngists, speech and language pathologists,
\nsocial workers and dieticians.
\nIn general terms, the move towards inter-
\nprofessionalism has particularly impacted
\non the role and responsibilities of the physi-
\ncian, as many of the expanded roles of team
\nmembers have been into areas traditionally
\noccupied by the physician on the team.
\nWhile physicians have by and large accept-
\ned and sometimes actively embraced such
\nchanges, particularly where they have been
\nshown to impact positively on patient care
\nand outcomes (although it should be noted
\nthat such an impact has not been conclu-
\nsively proven) (51), they have also shown
\nwell-placed concern when warranted.
\nAlthough physicians have been often criti-
\ncized as \u201cdefending their turf\u201d or being
\nunwilling to relinquish complete control
\nover patient care, there are justifiable rea-
\nsons to approach interprofessionalism with
\ncaution. It should also be noted that the
\nassumption of traditional physician duties
\nby other professions is not a new concept,
\nas witnessed by the undertaking of surgery
\nby barbers and the medical treatment of
\npatients by apothecaries.
\nIt is at times unclear as to who has ultimate
\nresponsibility for patient care. If everyone
\nis responsible, then no one is truly responsi-
\nble. In addition, when physicians provide
\ndirect medical care and there is a mishap,
\nthen medico-legal liability, once estab-
\nlished, is usually fairly straightforward. In
\nan interprofessional model of care, the
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 66
\n67
\nphysician may not be constantly aware of
\nservices or recommendations being provid-
\ned by other team members, yet the patient
\nand their lawyers may expect the physician
\nto assume ultimate liability for this care if
\nharm occurs. Where individual liability
\nends and group liability begins might not
\nalways be clear.
\nDifferent professions may have different
\nCodes of Ethics with different values, stan-
\ndards and priorities. As a recent example,
\nwhile the American Psychiatric Association
\n(52) has clearly stated that sharing clinical
\nknowledge for the purpose of using this
\ninformation to torture or gain admissions
\nfrom terrorism suspects is unprofessional
\nand unacceptable behaviour, the American
\nPsychological Association has elected not
\nto take this stance (53, 54). When compet-
\ning principles of various team members
\noccur during patient care, how are we to
\ndetermine which one will win out?
\nThere are professional divisions based on
\ndemographics, gender composition, class of
\norigin of members, educational attainment,
\nstatus and relative size and source of prima-
\nry income; these have all been cited as
\nobstacles to the development of interdisci-
\nplinary collaboration in the health field
\n(51). Medicine is a long-established and
\nfairly large profession whose members
\ncome mostly from a well-educated, small,
\nupper class and earn a high income. Thus, it
\nis argued that:
\n\u201cThe raw power of medicine, combined
\nwith a high degree of professional self-
\nconfidence developed by doctors and
\nconsciousness of these differences in
\nprestige among other occupational
\ngroups, contributes to a degree of mutu-
\nal wariness and defensiveness as each
\noccupation attempts to defend its own
\nterritory. For most of the twentieth cen-
\ntury the health division of labour has
\nbeen organised and hierarchically struc-
\ntured around the dominant profession of
\nmedicine. However, over recent decades
\nmedicine\u2019s claims to autonomy and
\ndominance have been increasingly chal-
\nlenged by non-medical groups.\u201d (51)
\nInterdisciplinary relationships are also often
\npolitical. Different occupational groups
\nattempt to establish clear professional
\ndemarcations and demand that their exper-
\ntise be recognized. They construct their own
\ndistinct codes and standards and advance
\nwhat they deem to be their own ethical the-
\nories (for example, \u201cmedical ethics\u201d versus
\n\u201cnursing ethics\u201d) (55).
\nDifferent professions may use different
\nstandards to judge the acuity of a case or sit-
\nuation. When other professionals then apply
\ntheir own frames of reference to make sense
\nof a situation, they may differ intensely over
\nthe priority the case is assigned (51). This
\nmay be a source of significant conflict
\namongst team members.
\nProfessional differences may also have
\nbeen reinforced by various court decisions.
\nFor example, decisions by the English
\ncourts in the early twentieth century empha-
\nsized the responsibility of medical practi-
\ntioners and the subservient nature of nurses
\n(56). Although more recent court decisions
\nhave not been quite as harsh, there are those
\nwho feel that the earlier approach still has
\nsome influence on attitudes to the responsi-
\nbilities of those offering care to patients
\n(51).
\nUnfortunately, relationships between health
\ncare professionals remain fraught with
\norganizational, status and value differences
\n(55). An Australian survey of hospital
\nadmissions reported that problems with pro-
\nfessional interactions were the most com-
\nmon cause of preventable disability or death
\nin the intensive care unit, and were twice as
\ncommon as those due to poor medical skill
\n(57).
\nThere is a significant body of work on the
\ntopic of interprofessional education and
\ntraining at the medical school and under-
\ngraduate level (58 – 61) but relatively little
\nguidance when it comes to educating post-
\ngraduate trainees or practicing physicians.
\nWhile tomorrow\u2019s physicians may be well
\nequipped to work in collaborative practice
\nmodels, today\u2019s physicians may require
\nextra guidance and training in this area, as
\nmany of the skills and concepts required are
\nnot necessarily inherently known.
\nWhat NMA\u2019s can do on the issue of inter-
\nprofessionalism
\nIn spite of the many challenges of interpro-
\nfessionalism and interdisciplinary models
\nof care, it is clearly a concept that is becom-
\ning firmly entrenched in today\u2019s patient care
\nsettings. In order to optimise patient care
\nand outcomes, physicians must be able to
\nwork collaboratively with a wide variety of
\nhealth professionals in different settings.
\nRepresentative medical associations can
\nassist their members (as well as their
\npatients and other health care professionals)
\nby developing policy and guidance in this
\ncomplex area. Such policy should ideally
\ninclude:
\n– a review and definition of the concept of
\ninterprofessionalism with attention given
\nto both the medical and non-medical lit-
\nerature
\n– a clarification of the relevant medico-
\nlegal liability issues, including the need
\nfor all team members (and not just physi-
\ncians) to carry liability insurance; this
\nmay need to be done in partnership with
\nlocal and\/or national medical malprac-
\ntice insurance carriers where appropriate
\n– an approach towards education in this
\narea for medical students, postgraduate
\nmedical trainees and physicians in prac-
\ntice, as well as other health care profes-
\nsionals who will be working in the team
\nsetting
\n– an integrated or separate policy or docu-
\nment outlining the issue of scopes of
\npractice for the various health care pro-
\nfessions, including the fact that roles and
\nscopes must be in keeping with the rele-
\nvant training and expertise and should
\nnot exceed the capabilities of a given
\nfield (for example, professionals not
\ntrained to provide a diagnosis should not
\nbe licensed to do so; this is not in keep-
\ning with clinical or ethical standards and
\nis a potential threat to patient care and
\nwell-being)
\n– a clarification on potentially competing
\nethical principles and Codes of Ethics to
\nensure that physicians understand their
\nindividual obligations in this regard
\n6) Clinical practice guidelines (CPGs)
\nClinical practice guidelines or CPG\u2019s, are
\nsystematically developed statements that
\naim to help physicians and patients reach
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 67
\n68
\nthe best possible health care decisions (62).
\nWhile they have been in existence for a
\nlong time, recent years have seen an explo-
\nsion in their numbers. They go beyond sys-
\ntematic reviews of the literature by recom-
\nmending what should and should not be
\ndone in specific clinical circumstances.
\nGenerally, CPG\u2019s are developed by a group
\nof writers with representatives from clinical
\nmedicine, research, and epidemiology,
\namong other disciplines. The body or orga-
\nnization sponsoring their development may
\nvary significantly, from an uninterested
\nthird party (rare), to a medical society or
\nassociation (more common) to a disease
\nspecific organization (perhaps increasingly
\ncommon). The funding for each type of
\ngroup may also vary, with differing degrees
\nof private and public sponsorship. Private
\nsponsorship usually comes from parties
\nwith a vested interest in the outcome of the
\nprocess, particularly the pharmaceutical
\nindustry (and less commonly the insurance
\nindustry). Pharmaceutical companies can
\nbenefit from the outcome of a CPG either
\nthrough the recommendation of a specific
\ntherapeutic agent or a lowering of the
\nthreshold required before the use of an
\nagent. Sometimes the source of financial
\nsponsorship is made transparent, but it is
\nnot uncommon for it to remain relatively
\nanonymous (or hidden).
\nNot only the process itself, but also the
\nactual participants in the process, may also
\nbe subject to potential conflicts of interest.
\nThis has been the focus of much debate in
\nthe medical and scientific literature as of
\nlate (63-65). Two recent publications have
\nhelped to outline the scope of this problem.
\nOne study (66) notes that 87% of authors of
\nCPG\u2019s had some form of interaction with
\nthe pharmaceutical industry. Fifty eight per-
\ncent had received financial support to per-
\nform research and 38% had served as
\nemployees or consultants for a pharmaceu-
\ntical company. Only 2 published CPG\u2019s out
\nof 44 examined made declarations regard-
\ning the personal financial interactions of
\nindividual authors with drug companies.
\nAnother report (67) on more than 200
\nCPG\u2019s from various countries deposited in
\n2004 with the United States National
\nGuideline Clearinghouse found that more
\nthan one third of the authors declared finan-
\nPotential area of activity What NMA\u2019s can do
\n1) Pandemic and disaster
\npreparedness
\n\u2013 develop guidelines on disaster and pandemic preparedness
\nthat will specifically outline for their membership exactly
\nwhat is expected of them in such a situation, and what their
\nprofessional obligations entail
\n\u2013 assist their members, and the public, by helping ensure that
\ngovernments, hospitals and others understand and meet the
\nreciprocal obligations that will be critically important for
\nensuring the care and safety of patients and physicians
\nalike during a pandemic or other public health emergency
\n2) Conscientious objection \u2013 outline the concept of conscientious objection, its history
\nand its current use
\n\u2013 assist members to understand that they should not refuse to
\nprovide urgently needed care by using the concept of con-
\nscientious objection
\n\u2013 assist members to understand that they should not obstruct,
\nactively or passively, patients from receiving care from
\nanother clinician
\n\u2013 address the issue of whether or not the conscientious objec-
\ntor has a duty to refer the patient to another clinician for
\nservices the objector will not provide
\n3) Physician self
\nregulation
\n\u2013 support, through policy, advocacy and action, legitimate
\nefforts to improve the quality of medical care and out-
\ncomes through regulatory oversight of their physician
\nmembers
\n\u2013 help ensure that efforts at revalidation of physicians are not
\nsimply exercises intended to reassure the public and legis-
\nlators, but truly strive to improve the quality of medical
\npractice, and are be based on solid evidence demonstrating
\nthat the means used will be efficient and effective
\n\u2013 develop policy or position statements clarifying their sup-
\nport for self-regulation and outlining the importance of this
\nconcept to the maintenance of medical professionalism
\n\u2013 assist their members in understanding that self-regulation
\ncannot be perceived as being protective of physicians, but
\nmust maintain the support and confidence of the general
\npublic.
\n4) Physician-industry
\ninteractions
\n\u2013 develop clear and comprehensive policy in this area to
\nensure that their members do not find themselves in a posi-
\ntion of conflict of interest
\n\u2013 widely distribute these policies to their membership and
\nothers, and undertake educational initiatives to clarify their
\nimportance, intent and content
\n\u2013 use their advocacy capabilities to help ensure that these
\nphysician-led guidelines become the accepted standard for
\nall the other participants involved, including industry
\n\u2013 give careful consideration to developing stringent internal
\npolicy for governing relationships between the organiza-
\ntion and third parties
\nTable 1 \u2013 Summary of potential areas of NMA activity
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 68
\n69
\ncial links to relevant drug companies with
\nnearly 70% of panels being involved, and
\nalmost half of the CPG\u2019s providing no
\ninformation about conflicts of interest.
\nIt is increasingly clear that the problem of
\nconflicts of interest in the development of
\nCPG\u2019s is widespread and under-reported.
\nWhile there are those who argue that it is
\nnot possible to develop CPG\u2019s without
\nusing authors linked to industry, since these
\nauthors are experts in the field and are
\nsought both by the companies and the bod-
\nies producing the CPG\u2019s, some organiza-
\ntions have taken steps to remedy this situa-
\ntion. Various guidelines have been devel-
\noped to ensure that any possible conflicts
\nare declared to all those involved in the
\nprocess of CPG development and that those
\nwith conflicts are given reduced or modi-
\nfied roles. For example, since 1999 the
\nNational Institute for Health and Clinical
\nExcellence (NICE) has provided guidance
\non appropriate clinical practice within
\nBritain\u2019s National Health Service. NICE
\nhas taken steps to avoid situations arising
\nfrom potential conflicts of interest, requir-
\ning members of its advisory bodies to
\ndeclare financial and other interests. If a
\nconflict is identified, the individual will be
\nrequired to step down and not take part in
\nthe decision-making process (68).
\nOther criticisms of CPG\u2019s have included the
\nfact that some leave little room for devia-
\ntion in the case of individual patients whose
\nneeds may differ, that they may present
\nphysicians with difficult medico-legal situ-
\nations if CPG\u2019s are held to be the standard
\nof care, and that they may provide reasons
\nfor insurers to deny coverage.
\nWhile National Medical Associations have
\nnot been traditionally involved in the actual
\ndevelopment of CPG\u2019s, there may well be
\nan important role for them to play in the
\nprocess of ensuring the highest standards of
\ncare based on the use of recent, high quali-
\nty, unbiased CPG\u2019s by practicing clinicians.
\nThere are some good examples of NMA\u2019s
\nwho have become involved in this area.
\nThe American Medical Association, togeth-
\ner with the Agency for Healthcare Research
\nand Quality and the American Association
\nof Health Plans, initially assisted in the
\ndevelopment of the National Guideline
\nClearinghouse in the United States
\n(www.guideline.gov). The National
\nGuideline Clearinghouse is a comprehen-
\nsive database of evidence-based clinical
\npractice guidelines and related documents.
\nIts mission is \u201cto provide physicians, nurs-
\nes, and other health professionals, health
\ncare providers, health plans, integrated
\ndelivery systems, purchasers and others an
\naccessible mechanism for obtaining objec-
\ntive, detailed information on clinical prac-
\ntice guidelines and to further their dissemi-
\nnation, implementation and use\u201d (69).
\nThe Canadian Medical Association, on its
\nwebsite at www.cma.ca, provides its mem-
\nbership with access to a service called CMA
\nInfobase. This site provides access to CPG\u2019s
\nwhich are produced or endorsed in Canada
\nby a national, provincial\/territorial or
\nregional medical or health organization,
\nprofessional society, government agency or
\nexpert panel. In addition, the CMA and one
\nof its provincial divisions, the Ontario
\nMedical Association, have combined with
\nPotential area of activity What NMA\u2019s can do
\n5) Interprofessionalism \u2013 develop policy and guidance in this complex area, includ-
\ning:
\n\u2013 a review and definition of the concept of interprofessional-
\nism
\n\u2013 a clarification of the relevant medico-legal liability issues
\n\u2013 an approach towards education in this area for medical stu-
\ndents, postgraduate medical trainees and physicians in
\npractice, as well as other health care professionals who will
\nbe working in the team setting
\n\u2013 an integrated or separate policy or document outlining the
\nissue of scopes of practice for the various health care pro-
\nfessions
\n\u2013 a clarification on potentially competing ethical principles
\nand Codes of Ethics to ensure that physicians understand
\ntheir individual obligations in this regard
\n6) Clinical practice
\nguidelines
\n\u2013 provide physicians with access to recent, high quality,
\nunbiased CPG\u2019s by:
\n\u2013 actively screening guidelines for their membership
\n\u2013 providing a quality rating for each guideline
\n\u2013 organizing the many thousands of CPG\u2019s into areas of clin-
\nical content and relevancy
\n\u2013 selecting the most appropriate and relevant guidelines for
\nuse by their members
\n\u2013 providing a clearinghouse for the screened and selected
\nCPG\u2019s with membership access on its website or other
\nlocation
\n7) Organizational ethics \u2013 develop thoughtful and well-articulated mission, vision
\nand values statements that are produced with input from
\nassociation staff
\n\u2013 develop internal organizational policies and codes which
\naddress specific ethical and professional issues
\n\u2013 make efforts to promote the above policies and documents
\n\u2013 measure and evaluate the impact of these policies, and
\nkeep them updated in an ongoing fashion
\n\u2013 ensure that the physician membership of the association is
\naware of these internal policies
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 69
\n70
\nthe Ontario Ministry of Health and Long
\nTerm Care to form the Guidelines Advisory
\nCommittee (GAC) (70). For selected topics
\nrelevant to clinicians, patients and the
\nhealth care system, the GAC identifies,
\nrates and endorses the best available guide-
\nline (71). The GAC uses the Appraisal of
\nGuidelines, Research and Evaluation
\n(AGREE) tool to assess the quality of
\nCPG\u2019s. The AGREE tool was created and
\nvalidated for physicians to use in rating
\nguidelines according to their process of
\ndevelopment by identifying the factors that
\nare considered important in judging their
\nquality (72). On the CMA website, a rating
\nof the quality of the guideline development
\nprocess for those guidelines that have been
\nreviewed by the GAC is included.
\nWhat NMA\u2019s can do on the issue of clinical
\npractice guidelines
\nProviding physicians with access to recent,
\nhigh quality, unbiased CPG\u2019s will enhance
\nmedical professionalism by increasing the
\nquality of patient care and outcomes and
\nensuring that patients everywhere receive
\nthe same high standard of care. Although it
\nis probably not reasonable to expect NMA\u2019s
\nto participate in the production of the guide-
\nlines themselves, given the relative intensi-
\nty of resources required to do so, they can
\nassist in the process by:
\n– actively screening guidelines for their
\nmembership using a validated tool such
\nas AGREE
\n– providing a quality rating for each guide-
\nline based on a validated tool such as
\nAGREE
\n– organizing the many thousands of CPG\u2019s
\ninto areas of clinical content and rele-
\nvancy
\n– selecting the most appropriate and rele-
\nvant guidelines for use by their members
\n(for example, there are over 300 English
\nCPG\u2019s on the management of high cho-
\nlesterol, and NMA\u2019s could review these
\nand choose the highest quality 2 or 3
\nCPG\u2019s)
\n– providing a clearinghouse for the
\nscreened and selected CPG\u2019s with mem-
\nbership access on its website or other
\nlocation (which also provides a direct
\nbenefit of membership in the associa-
\ntion)
\n7) Organizational ethics and profession-
\nalism
\nOrganizational ethics has been defined as
\n\u201cthe articulation and application of the con-
\nsistent values and moral positions of an
\norganization by which it is defined, both
\ninternally and externally\u201d (73). It is general-
\nly articulated via values statements, mission
\nand vision statements, organizational codes
\nof ethics, policies addressing specific ethi-
\ncal issues, and especially through its effects
\non the attitudes and activities of everyone
\nassociated with the organization.
\nThis represents in many cases a relatively
\nnew approach to the consideration of ethics
\nin organizations, particularly healthcare
\norganizations. With the Enron scandal (74)
\nand other recent developments in the busi-
\nness world and elsewhere, organizational
\nethics have become increasingly important
\nboth in practice and to reassure stakeholders
\nand others that an ethics framework is in
\nplace.
\nWhile the medical literature in this area
\nfocuses on healthcare organizations such as
\nhospitals, health care districts and health
\nmaintenance organizations (HMO\u2019s) (74-
\n76), the general principles of this approach
\ncan be applied to representative medical
\nassociations as well. While these associa-
\ntions serve an important role in helping to
\nguide their individual member physicians in
\nprofessional and ethical standards, as out-
\nlined in previous sections of this paper, hav-
\ning robust internal policies will also help to
\nset a high standard of behavior and provide
\nan example of professionalism from within
\nthe organization.
\nThere are four important strategies that can
\nbe used to help build a solid ethics infra-
\nstructure in a medical organization (77).
\nThese include:
\n1) Conducting a formal process to clarify
\nand articulate the organization\u2019s values
\nand link them to the mission and vision
\nstatements. This should include building
\nthe mission, vision and values statements
\ninto the introduction of the strategic
\nplan, involving all employees in the
\ndesign of the mission, vision and values
\nstatements, using facilitated group
\napproaches to discuss these statements
\nand using team building strategies to
\nenhance organizational values.
\n2) Facilitating communication and learning
\nabout ethics and professionalism.
\nSpecific strategies include:
\na. placing mission and vision statements in
\nhighly visible locations throughout the
\norganization
\nb. offering training programmes that
\nencourage interaction about the organi-
\nzation\u2019s values
\nc. using role playing, case studies and
\nlunchtime educational sessions to facili-
\ntate communication about ethics and
\nprofessionalism
\nd. engaging employees in values clarifica-
\ntion techniques
\n3) Creating structures that encourage and
\nsupport the culture. These structures
\nshould be multiple, interconnected and
\ndiffused throughout the organization,
\nand ideally should include an ethics
\ninfrastructure with sufficient dedicated
\nstaff and resources.
\n4) Creating processes to monitor and offer
\nfeedback on ethical performance.
\nSpecific strategies include:
\na. using ethics and professionalism audits
\nb. examining processes and\/or outcomes of
\nethical decision making
\nc. regular evaluation of the organization\u2019s
\nmission, vision and values statements
\nThe American Medical Association has
\npublished a document entitled
\n\u201cOrganizational ethics in healthcare: toward
\na model for ethical decision-making by
\nprovider organizations\u201d (78). While the
\ndocument specifically notes that its focus is
\non organizations that provide health care to
\nindividual patients, and not other organiza-
\ntions such as associations of health care
\nprofessionals, several of the principles
\nreviewed are of relevance. For example, the
\ndocument discusses in some detail the pri-
\noritization of competing principles to help
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 70
\n71
\norganizations understand that patient health
\nis their ultimate priority, regardless of other
\ncompeting considerations. The paper also
\nprovides an overview of various sources of
\norganizational ethics for provider organiza-
\ntions, including business ethics, profession-
\nal accountability and law and social con-
\ntext.
\nWhat NMA\u2019s can do on the issue of organi-
\nzational ethics
\nIt is very important that a representative
\nmedical association exhibit strong organiza-
\ntional ethics. Not only does this assist with
\nensuring the proper prioritisation of associ-
\nation objectives and strategies, it also helps
\ndemonstrate to the physician membership
\nthe importance the organization places on
\nethics and professionalism. An NMA can-
\nnot expect its membership to respect and
\nfollow the ethical codes and policies it pro-
\nduces without first setting the same high
\nstandards for the NMA itself. Associations
\ncan do this by:
\n– developing thoughtful and well-articu-
\nlated mission, vision and values state-
\nments that are produced with input from
\nassociation staff and physicians
\n– developing internal organizational poli-
\ncies and codes which address specific
\nethical and professional issues (for
\nexample, harassment in the workplace,
\nindividual and organizational conflict of
\ninterest, and professional interactions
\nwith outside third parties)
\n– making efforts to promote the above
\npolicies and documents, including them
\nboth during orientation of new staff, and
\nin an ongoing manner through retreats
\nand educational sessions
\n– measuring and evaluating the impact of
\nthese policies, and keeping them updated
\nin an ongoing fashion
\n– ensuring that the physician membership
\nof the association is aware of these inter-
\nnal policies via mailings, journals and
\nwebsites
\nSummary
\nIn many respects, medical professionalism
\nis currently at a crossroads. The nature of
\nthe physician-patient relationship continues
\nto evolve, as physicians struggle to redefine
\ntheir role in an ever-changing society that is
\nin the midst of a technological revolution.
\nThreats to medical self-regulation and
\nevolving physician scopes of practice have
\ncaused many practicing doctors to question
\nwhether the profession itself will ever be
\nthe same.
\nAt the same time, change often represents
\nopportunity. Many have seized this chance
\nto try to redefine the concept of medical
\nprofessionalism and refocus attention on the
\nsanctity of the physician-patient relation-
\nship. New social contracts have been
\ndevised to help physicians understand how
\nto balance their competing priorities and
\nroles. Task forces have been formed, reports
\nhave been written and hands have been
\nwrung. Whether all this activity will have a
\nlasting impact remains to be seen.
\nRepresentative physician organizations are
\nin a unique position. They serve in many
\ninstances as the public face of the profes-
\nsion, and help make known and understood
\nthe views of physicians on important mat-
\nters. They also have the opportunity to be
\nstandard-setters for the profession, to help
\nshape and mould the ongoing evolution and
\ndevelopment of medical professionalism.
\nWhile the literature to date focuses with
\nnear exclusivity on the roles and obligations
\nof individual physicians, there is much that
\nmedical associations can do, both internally
\nand externally, to advance and promote the
\nconcept. Whether this is done in isolation
\nfrom, or together with, other relevant med-
\nical and non-medical bodies will vary
\ndepending on individual circumstances.
\nThe objective of this paper has been to
\nexamine medical professionalism through
\nthe lens of the representative medical asso-
\nciation rather than the individual clinician.
\nThrough providing both general and specif-
\nic, concrete suggestions and examples of
\ncurrent and future potential activities which
\nmight be undertaken, it is hoped that it will
\nadd in a positive and constructive way to
\nthe preservation of what most doctors con-
\nsider to be at the core of medicine: the role
\nof the physician as healer and professional.
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\nprovider organizations. American Medical
\nAssociation, 2000. Accessed online at
\nhttp:\/\/www.ama-assn.org\/ama\/upload\/mm\/
\n369\/organizationalethics.pdf on June 6,
\n2007.
\nAppendix 1
\nOrganizations that have endorsed the
\nPhysician Charter:
\nAccreditation Council for Graduate Medical
\nEducation
\nAdministrators of Internal Medicine
\nAlliance for Academic Internal Medicine
\nAmerican Academy of Allergy, Asthma and
\nImmunology
\nAmerican Academy of Dermatology
\nAmerican Academy of Family Physicians
\nAmerican Academy of Neurology
\nAmerican Academy of Ophthalmology
\nAmerican Academy of Orthopaedic Surgeons
\nAmerican Academy of Otolaryngology\u2013Head
\nand Neck Surgery
\nAmerican Academy of Pediatrics
\nAmerican Academy of Physical Medicine and
\nRehabilitation
\nAmerican Board of Medical Specialties
\nAmerican Board of Allergy and Immunology
\nAmerican Board of Anesthesiology
\nAmerican Board of Colon and Rectal Surgery
\nAmerican Board of Dermatology
\nAmerican Board of Emergency Medicine
\nAmerican Board of Family Practice
\nAmerican Board of Internal Medicine
\nAmerican Board of Medical Genetics
\nAmerican Board of Neurological Surgery
\nAmerican Board of Nuclear Medicine
\nAmerican Board of Obstetrics and Gynecology
\nAmerican Board of Ophthalmology
\nAmerican Board of Orthopedic Surgery
\nAmerican Board of Otolaryngology
\nAmerican Board of Pathology
\nAmerican Board of Pediatrics
\nAmerican Board of Physical Medicine and
\nRehabilitation
\nAmerican Board of Plastic Surgery
\nAmerican Board of Preventive Medicine
\nAmerican Board of Psychiatry and Neurology
\nAmerican Board of Radiology
\nAmerican Board of Surgery
\nAmerican Board of Thoracic Surgery
\nAmerican Board of Urology
\nABIM Foundation
\nAmerican College of Dentists
\nAmerican College of Medical Genetics
\nAmerican College of Obstetricians and
\nGynecologists
\nAmerican College of Physicians
\nAmerican College of Radiology
\nAmerican College of Surgeons
\nACP Foundation
\nAmerican Orthopaedic Association
\nAmerican Osteopathic Association
\nAmerican Psychiatric Association
\nAmerican Society of Anesthesiologists
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 73
\nMedical Ethics and Human Rights
\n74
\nAmerican Society of Clinical Pathologists
\nAmerican Society of Plastic Surgeons
\nAmerican Urological Association
\nAssociation of Academic Physiatrists
\nAssociation of American Medical Colleges
\nAssociation of Physicians of Ireland
\nAssociation of Physicians of Malta
\nAssociation of Professors of Medicine
\nAssociation of Program Directors in Internal
\nMedicine
\nAssociation of Subspecialty Professors
\nAustrian Society of Internal Medicine
\nBelgian Society of Internal Medicine
\nClerkship Directors in Internal Medicine
\nChinese Medical Doctors Association
\nCollege of Physicians and Surgeons of British
\nColumbia
\nCouncil of Deans, Association of Canadian
\nMedical Colleges
\nCouncil of Medical Specialty Societies
\nCzech Society of Internal Medicine
\nDanish Society of Internal Medicine
\nEstonian Society of Internal Medicine
\nEuropean Federation of Internal Medicine
\nFederation of Royal Colleges of Physicians of
\nUnited Kingdom
\nFederation of State Medical Boards
\nFinnish Society of Internal Medicine
\nFrench Society of Internal Medicine
\nGerman Society of Internal Medicine
\nHellenic Society of Internal Medicine
\nHungarian Society of Internal Medicine
\nIcelandic Society of Internal Medicine
\nIsraeli Society of Internal Medicine
\nItalian Society of Internal Medicine
\nLatvian Society of Internal Medicine
\nLithuanian Society of Internal Medicine
\nLuxembourg Society of Internal Medicine
\nMedical Council of Canada
\nMinistero della Salute
\nNetherlands Society of Internal Medicine
\nNorth American Society of Radiologists
\nPolish Society of Internal Medicine
\nPortuguese Society of Internal Medicine
\nResidency Review Committee for Internal
\nMedicine
\nRoyal Australasian College of Physicians and
\nSurgeons
\nRoyal College of Physicians of Edinburgh
\nRoyal College of Physicians of Ireland
\nRoyal College of Physicians of London
\nRoyal College of Physicians and Surgeons of
\nCanada
\nSlovak Society of Internal Medicine
\nSlovenian Society of Internal Medicine
\nSociety of Neurological Surgeons ociety of
\nNuclear Medicine
\nSociety of Thoracic Surgeons
\nSpanish Society of Internal Medicine
\nSwedish Society of Internal Medicine
\nSwiss Society of Internal Medicine
\nTurkish Society of Internal Medicine
\nembryos for research is usually very rigor-
\nous. Some countries restrict the embryonic
\ncell lines that their researchers are allowed
\nto use to ones that have been derived in
\naccordance with strict ethical requirements.
\nThe introduction of human stem cells into
\nanimals is either forbidden or severely lim-
\nited.
\nThe ethical issues of stem cell research have
\nbeen widely discussed by medical associa-
\ntions and scientific organizations, including
\nthe following:
\n\u2022 In 2006 the WMA Assembly adopted a
\nStatement on Assisted Reproductive
\nTechnologies that deals in part with stem
\ncell research:
\n\u2013 Due to the special nature of human
\nembryos, research should be carefully
\ncontrolled and should be limited to
\nareas in which the use of alternative
\nmaterials will not provide an adequate
\nalternative.
\n\u2013 Views, and legislation, differ on
\nwhether embryos may be created
\nspecifically for, or in the course of,
\nresearch. Physicians should act in
\naccordance with national legislation
\nand local ethical advice.
\n\u2013 Cell nuclear replacement may also be
\nused to develop embryonic stem cells
\nfor research and ultimately, it is hoped,
\nfor therapy for many serious diseases.
\nViews on the acceptability of such
\nresearch differ and physicians wishing
\nto participate in such research should
\nensure that they are acting in accor-
\ndance with national laws and local eth-
\nical guidance.
\n\u2022 The WMA is currently considering a
\nProposed Statement on Stem Cell
\nResearch for possible adoption at its
\nOctober 2007 Assembly in Copenhagen.
\n\u2022 In 2003 the American Medical
\nAssociation adopted a policy on
\nCloning-for-Biomedical-Research that
\nreads in part: \u201eWhile the pluralism of
\nmoral visions that underlie this debate
\nmust be respected, physicians collective-
\nly must continue to be guided by their
\nparamount obligation to the welfare of
\ntheir patients. In this light, cloning-for-
\nThe Ethics of Stem Cell Research
\nDr. John Williams
\n(from WMA Ethical issues of the month)
\nDuring the past decade a great deal of scien-
\ntific research activity has been devoted to
\nhuman stem cells. Considerable progress
\nhas been made in deriving and replicating
\ncell lines and in understanding cell biology.
\nThe ultimate goal of this activity is to devel-
\nop therapeutic applications of this knowl-
\nedge, but it is still uncertain how successful
\nthis quest will be.
\nFrom the outset stem cell research has
\nraised ethical issues over and above those
\nassociated with other types of medical
\nresearch. The principal cause of ethical
\nuncertainty and conflict has been the use of
\nhuman embryos as the source of stem cells
\nfor research. Despite claims that adult stem
\ncells may be equally suitable for therapeutic
\npurposes, there is a strong consensus among
\nscientists working in this field that embryo
\nstem cells are better suited for research pur-
\nposes. However, since the derivation of
\nthese cells requires the destruction of the
\nembryo, the question arises whether or not
\nsuch research is fundamentally unethical.
\nProponents of embryo stem cell research
\nare not insensitive to the special ethical sta-
\ntus of the human embryo and there has been
\nsubstantial agreement on certain limitations
\nto such research. Ethical guidelines and
\nnational legislation generally prohibit the
\ncreation of embryos for research, allowing
\nresearch only on embryos created but no
\nlonger wanted for reproductive purposes.
\nThe consent process for the donation of
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 74
\nMedical Ethics and Human Rights
\n75
\nbiomedical-research is consistent with
\nmedical ethics. Every physician remains
\nfree to decide whether to participate in
\nstem cell research or to use its products.\u201c
\n\u2022 The Australian Medical Association has
\nexpressed support for embryonic stem
\ncell research.
\n\u2022 The British Medical Association is like-
\nwise in favour of embryonic stem cell
\nresearch: \u201eThe BMA supports the use of
\ncarefully controlled research, including
\nresearch using human embryos where
\nnecessary for the development of tissue
\nfor transplantation and the development
\nof methods of therapy for mitochondrial
\ndiseases.\u201c
\n\u2022 The International Society for Stem Cell
\nResearch website includes a number of
\nethics-related documents, such as The
\nEthics of Human Embryonic Stem Cell
\nResearch.
\n\u2022 The U.S. National Institutes of Health
\nwebsite provides a useful set of
\nresources on this topic: Bioethics
\nResources on the Web \u2013 Stem Cell
\nResearch.
\nPresumed Consent for removal
\nof organs from dead patients
\nWhile \u201cpresumed consent\u201d for the removal
\nof organs from dead patients for transplant
\npurposes exists in a number of countries,
\nthis does not apply in the United Kingdom.
\nThe U.K Chief Medical Officer, Sir Liam
\nDonaldson, in his annual report (1) has
\nraised the issue again. Commenting that in
\nthe UK it is estimated that of the total 7234
\non the UK waiting list for transplants one
\nperson dies each day, he proposes that in
\nview of the shortage of donated organs the
\nprinciple of \u201cpresumed consent\u201c should be
\nintroduced. This would mean that organs
\n\u201cdonated\u201d for transplant would at least dou-
\nble to meet present demands. He further
\nsuggest that those wishing to \u201copt out\u201d of
\ndonation in the event of their death should
\nbe specifically registered (a system which
\nin a number of countries is implemented in
\nso \u2013 called \u201dhard\u201d and \u201csoft\u201d ways \u2013 see
\nbelow).
\nThe report comments on the experience of
\nother countries. Acknowledging \u201cthere have
\nbeen concerns that such an approach would
\nbe viewed as totalitarian\u201d the report contin-
\nues \u201cHowever, as long as the option to vol-
\nuntarily opt out from the system is both
\navailable and easily accessible and strict
\nmeasures are applied to protect vulnerable
\ngroups, the experience shows that such a
\nsystem can command public confidence.\u201d
\nIn the \u201chard\u201c version presumed consent
\nallows organs to be removed unless the
\nindividual had formally registered an objec-
\ntion during his lifetime and no account
\nwould be taken of the views of relatives.
\nIn the \u201csoft\u201d version presumed consent
\nwould permit removal of organs unless:
\n– the person had registered an objection
\nduring their lifetime;
\n– it is clear form information provided by
\nthe relatives that the individual had
\nexpressed an objection to donation but
\nhad not officially registered this;
\n– it is clear that removal of organs would
\ncause major distress to the relatives.
\n\u201cOn the State of the Public Health: Annual
\nreport of the Chief Medical Officer 2007\u201d
\nHMSO com 7093
\nUK Human Fertilisation and
\nEmbryology Authority (HFEA)
\nissues statement on licensing of
\nhuman-animal hybrids.
\nThe UK HFEA, following a detailed and
\ncomprehensive consultation on the licens-
\ning of human animal hybrids and chimera
\nresearch which involved both scientists and
\nthe wider public issued a statement on its
\ndecision taken at its recent meeting.
\n\u201cHaving looked at all the evidence, the
\nAuthority has decided that there is no fun-
\ndamental reason to prevent cytoplasmic
\nhybrid research. However, public opinion is
\nvery finely divided with people generally
\nopposed to this research unless it is tightly
\nregulated and is likely to lead to scientific
\nor medical advancements. It continues
\n\u201dThis is not a total green light to cytoplas-
\nmic hybrid research, but recognition that his
\narea of research can, with caution and care-
\nful scrutiny, be permitted. Individual
\nresearch teams should be able to undertake
\nresearch projects involving the creation of
\ncytoplasmic hybrid embryos if they can
\ndemonstrate, to the satisfaction of the
\nHFEA licence committee, that their planned
\nresearch project is both necessary and desir-
\nable and meets the standards required by the
\nHFEA for any embryo research.\u201d
\nThe authority indicated that its licence com-
\nmittee will now look at the details of the
\ntwo research application referred to it earli-
\ner this year and hope to have a decision in
\nNovember.
\nCurrently Stem Cell Nuclear Transfer using
\nanimal eggs is permitted in some countries,
\noften under special conditions, whereas in
\nother its is specifically forbidden.
\nwww.hfea.gov.uk\/en\/1581.html accessed
\n11\/09\/2007
\nEthics and Human Rights news
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 75
\nMedical Ethics and Human Rights \/ WMA CPD
\n76
\nWMA CPD course in Medical Ethics-Fundamentals
\nin Medical Ethics
\nThe World Medical Association, in cooperation with the Norwegian Medical Association has developed a web-
\nbased continuing professional development course on Medical Ethics.
\nWorking through the course should enable participants to:
\n\u2013 understand the role of ethics in medicine;
\n\u2013 recognise ethical issues when the arise in practice;
\n\u2013 deal with these issues in a systematic manner
\nThe course, which is now online has been accredited by the Norwegian Medical Association with 8 hours\/points
\nin post-graduate and continuing education. On completion of the course, the tests and evaluation an accredi-
\ntation\/certificate will be issued if desired.
\nFurther details of the WMA courses are accessible through the WMA website www.wma.net. More courses and
\nversions of existing courses are being developed.
\nCurrent courses:
\n\u2013 Doctors working in Prison: human rights and ethical dilemmas.
\n\u2013 Fundamentals of Medical Ethics
\nMedical Ethics and Human Rights
\nHIV and Human Rights Handbook
\nA new Handbook on HIV and Human
\nRights was launched by the Office of the
\nHigh Commissioner for Human Rights
\nOHCR) and the Joint UN Programme on
\nHIV\/AIDS (UNAIDS) at the Eighth
\nInternational Congress on AIDS in Asia and
\nthe Pacific held in Sri Lanka 19-23 August
\n2007. This is intended to help national
\nhuman rights institutions to include HIV in
\ntheir human rights mandates, providing an
\noverview of the role of human rights in
\nresponding to the HIV epidemic. It includes
\nsuggestions for activities which could be
\ncarried out by national human rights institu-
\ntions in their existing work and collaborat-
\ning with national AIDS programmes.
\nUNAIDS Executive Director Peter Piot is
\nreported as saying that \u201c This is a critical
\ntime for national human rights institutions
\nto engage in the AIDS response. W e has
\nlearned that we will not succeed unless we
\naddress discrimination, gender inequality
\nand other human rights abuses that drive the
\nepidemic\u201d.
\nUN Human Rights Commissioner for
\nHuman Rights Louise Arbour referred to
\nthe Handbook as\u201d an essential guide for
\nnationals institutions in their efforts to
\nensure that States are held accountable for
\nprotecting the rights of people living with
\nHIV.
\nIn 2006, countries committed themselves to
\nachieve universal access to HIV prevention,
\ntreatment, care and support by 2010.As they
\nscale up their efforts towards this goal it is
\nessential that they deal with the stigma, dis-
\ncrimination and gender inequality that have
\nbeen identified as major obstacles to univer-
\nsal access.
\nCopies of the Handbook are available from
\nOHCR and UNAIDS
\nUN press release and OHCHR media
\nrelease 27\/28.08.07
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 76
\nTobacco Control
\n77
\nTobacco Control \u2013 new guideline
\nReport on Progress made in the Second Session of the Conference
\nof the Parties, WHO Framework Convention on Tobacco Control,
\nBangkok, Thailand, 30. June \u2013 6. July 2007
\nDr. Song Lih Huang, MD, MSc.
\nSecretary General
\nTaiwan International Medical Alliance
\nEach year tobacco use causes approximate-
\nly 5 million deaths worldwide. Because of
\nthe increasing prevalence of tobacco use in
\nmany developing countries, it is estimated
\nthat by the year 2030, the death toll will
\nincrease to 10 million per year, with 70%
\ncoming from middle- and low-income
\ncountries. Although deaths associated with
\ntobacco use are preventable, it would take
\nsociety an extraordinary effort for the pre-
\nvention to be effective. In view of the cross-
\nborder nature of tobacco trade, and the vast
\ndifferences among governments on the con-
\ncept and practice of tobacco control, it was
\nrecognized in the late 1990s that a global
\nhealth treaty could help individual countries
\nto strengthen legislative and regulatory
\nmeasures
\nThe WHO Framework Convention on
\nTobacco Control (FCTC) was adopted
\nunanimously by the 56th World Health
\nAssembly on 21 May 2003, and the FCTC
\nentered into force in February 2005 after 40
\ncountries had ratified it. Two Conferences
\nof the Parties (COP) have been held, the
\nfirst in February 2006 (Geneva) and the sec-
\nond in 30 June \u2013 6 July, 2007 (Bangkok).
\nAt the second COP, the parties:
\nadopted a guideline on protection
\nfrom exposure to tobacco smoke
\n(Article 8 of FCTC); see also annex.
\n\u2022 set up an international negotiating body
\nto prepare a protocol on illicit trade with
\na timetable which envisages its readiness
\nfor adoption at the fourth COP in 2010;
\n\u2022 agreed to ask the secretariat to work on
\nguidelines on Article 11 (packaging and
\nlabeling of tobacco products) and Article
\n13 (regulations on domestic and cross-
\nborder tobacco advertising, promotion
\nand sponsorship) with the aim of adopt-
\ning these guidelines at the third COP in
\n2008;
\n\u2022 agreed to work on guidelines on Article
\n5.3 (protection from tobacco industry
\ninterference), Article 12 (education,
\ncommunication, training and public
\nawareness) and Article 14 (cessation);
\n\u2022 agreed to continue with work on Article
\n9 and 10 (product testing, measurement
\nand disclosure) and 17 (economically
\nviable alternative activities); and
\n\u2022 agreed to set aside funding for all these
\nactivities.
\nThe official documents about FCTC and
\nCOP can be found on WHO websites
\n(http:\/\/www.who.int\/tobacco\/framework\/en
\nand http:\/\/www.who.int\/gb\/fctc\/). Useful
\ninformation is also available at the
\nFramework Convention Alliance website
\n(http:\/\/www.fctc.org\/).
\nIt was quite remarkable to be able to make
\nsuch progress during any international
\nmeeting, reflecting the fact that most coun-
\ntries have begun to realize the magnitude of
\ndamage done by tobacco use. However, the
\nchallenges for medical professionals in each
\ncountry still lie ahead. Three types of effort
\nwill require medical professionals to take
\nactions in order to save millions of lives.
\nFirst, not all countries have ratified the
\nFCTC. There are currently 148 parties
\n(including the European Community) to the
\nFCTC. Understandably, several African
\ncountries which rely on the exportation of
\ntobacco leaves as their major revenue will
\ncertainly need to find ways for alternative
\nagricultural or other income-generating
\nactivities before the governments will com-
\nply with the goals of reducing world tobac-
\nco consumption. On the other hand, almost
\nall industrialized countries have ratified the
\nFCTC, with the notable exceptions of USA
\nand Russia. The health professionals in
\nthese countries have to exert their utmost
\ninfluence on the government to give priori-
\nty to the health of people both domestic and
\nabroad.
\nSecondly, the FCTC and its associated
\nagreements are instruments meant to assist
\nindividual government in the legislative and
\nimplementation processes towards tobacco
\ncontrol. Take \u201cthe guideline for the protec-
\ntion from exposure to tobacco smoke\u201d for
\nexample. This guideline will be helpful to
\npeople exposed to secondhand smoke only
\nif the governments are willing and able to
\nmake effective laws or policies to restrict
\nsmoking in public places. The health pro-
\nfessionals in each country should try to con-
\nvince law makers of the necessity, urgency,
\nand feasibility of taking effective measures,
\nciting the international health treaty and the
\nexamples of successes from many countries
\nwith various cultural characteristics. The
\nFCTC has been very helpful in moving
\ncountries forward in tobacco control as the
\ninternational treaty makes the issue more
\nprominent on the political agenda and
\nhealth professionals should take advantage
\nof this.
\nThe third challenge is for medical profes-
\nsionals of the rich countries which benefit
\nfrom the tobacco industry. One of the major
\nissues during the third COP was Article 13
\n(Tobacco advertising, promotion and spon-
\nsorship). As the barriers to international
\ntrade are diminishing, cross-border adver-
\ntising and promotion are becoming more
\ndifficult to regulate. This is particularly so
\nin developing countries which have limited
\nresources and capability for monitoring and
\nlaw enforcement. Another formidable chal-
\nlenge for these countries is the need to enact
\nstrong legislation controlling foreign com-
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 77
\nTobacco Control
\n78
\npanies, and facing the possibility of dire
\nconsequences involving international trade
\narbitration. Cross-border advertising and
\npromotion do not come out of thin air. They
\nare sophisticated products of tobacco com-
\npanies (often based in rich countries) with
\nthe sole purpose of addicting boys and girls
\nof less privileged countries. Medical profes-
\nsionals in rich countries have the moral duty
\nto try to limit the political power of the
\ntobacco industry. It is an act that can protect
\nthe future lives and fortunes of people.
\nAs stated above, agreements made at the
\nsecond COP will continue to be worked on,
\nand hopefully will yield meaningful results
\nin the third and fourth COPs. The adopted
\nguideline has started to serve the purpose of
\nprotecting people from exposure to tobacco
\nsmoke, and the protocols being developed
\nnow promise to help countries deal with
\nillicit trade and advertisement\/promotion
\nwhich are hard to control by any single
\ncountry. The progress on this international
\nhealth treaty is to be celebrated, but it
\nawaits the effort of each country to consoli-
\ndate the benefits of FCTC. Medical profes-
\nsionals should stay involved and play more
\nactive roles in this regard.
\nAnnex 1 (Extract from Guidelines on
\nprotection from tobacco smoke)
\nThe following extracts from this docu-
\nment set out the objectives and main
\nprinciples upon which the Guidelines on
\nimplementing Article 8 of the FCTC
\nadopted by the 2nd
\nFCTC COP at the
\nBangkok meeting, are based.
\n\u201cPurpose of the guidelines
\n1 Consistent with other provisions of the
\nWHO Framework Convention and the
\nintentions of the Conference of Parties
\n(COP), these guidelines are intended to
\nassist Parties (to the convention) in meet-
\ning their obligations under Article 8.
\nThey draw on the best available evi-
\ndence and the experiences of Parties that
\nhave successfully implemented effective
\nmeasures to reduce exposure to tobacco
\nsmoke.
\n2 The guidelines contain agreed upon
\nstatements of principles and definitions
\nof relevant terms, as well as agreed upon
\nrecommendations for the steps required
\nto satisfy the obligations of the
\nConvention. In addition, the guidelines
\nidentify the measures necessary to
\nachieve effective protection the hazards
\nof second-hand tobacco smoke. Parties
\nare encouraged to use these guidelines
\nnot only to fulfil their legal duties under
\nthe Convention, but also to follow best
\npractices in protecting public health.
\nObjectives of the guidelines
\nThese guidelines have two related objec-
\ntives. The first is to assist Parties in meeting
\ntheir obligations under Article 8 of the
\nWHO Framework Convention, in a manner
\nconsistent with the scientific evidence
\nregarding exposure to second hand tobacco
\nsmoke and the best practice worldwide in
\nthe implementation of smoke-free mea-
\nsures, in order to establish a high standard
\nof health. The second objective is to identi-
\nfy key elements and legislation necessary to
\neffectively protect people from exposure to
\ntobacco smoke, as required by Article 8.
\nUnderlying considerations
\nThe development of these guidelines has
\nbeen influenced by the following funda-
\nmental considerations.
\na) The duty to protect from tobacco smoke,
\nembodied in the text of Article 8, is
\ngrounded in fundamental human rights
\nand freedoms. Given the dangers of
\nbreathing second-hand tobacco smoke,
\nthe duty to protect from tobacco smoke
\nis implicit in, inter alia, the right to life
\nand the right to the highest attainable
\nstandard of health, as recognized by
\nmany international legal instruments
\n(including the Constitution of the World
\nHealth Organisation, the Convention on
\nthe Rights of the Child, the Convention
\non the elimination of all forms of
\nDiscrimination Against Women and the
\nCovenant on Economic, Social and
\nCultural Rights), as formally incorporat-
\ned into the Preamble of the WHO
\nFramework Convention and as recog-
\nnized in the constitutions of many
\nnations.
\nb) The duty to protect individuals from
\ntobacco smoke corresponds to an obliga-
\ntion by governments to enact legislation
\nto protect individuals against threats to
\ntheir fundamental rights and freedoms.
\nThis obligation extends to all persons,
\nand not merely to certain populations.
\nc) Several Authoritative scientific bodies
\nhave determined that second-hand tobac-
\nco smoke is a carcinogen. Some Parties
\nto the Framework Convention (for
\nexample Finland and Germany) have
\nclassified second-hand tobacco smoke as
\na carcinogen and included the prevention
\nof exposure to it at work in their health
\nand safety legislation. In addition to the
\nrequirements of Article 8 therefore,
\nParties may be obligated to address the
\nhazard of exposure to tobacco smoke in
\naccordance with their existing workplace
\nlaws or other laws governing exposure to
\nharmful substances, including carcino-
\ngens.
\nStatement of Principles (shortened ver-
\nsion edited by Dr. Song Lhi)*
\nPrinciple 1
\n6. Effective measures to provide protection
\nfrom exposure to tobacco smoke require the
\ntotal elimination of smoking and tobacco
\nsmoke in a particular space or environment
\nin order to create a 100% smoke-free envi-
\nronment laws. There is no safe level of
\nexposure to tobacco smoke, and approaches
\nother than 100% smoke-free environment
\nlaws, including ventilation, air filtration and
\nthe use of designated smoking areas
\n(whether with separate ventilation systems
\nor not), have repeatedly been shown to be
\nineffective.
\nPrinciple 2
\n7. All people should be protected from
\nexposure to tobacco smoke. All indoor
\nworkplaces and indoor public places should
\nbe smoke-free.
\nPrinciple 3
\n8. Legislation is necessary to protect people
\nfrom exposure to tobacco smoke. Voluntary
\nsmoke-free policies have repeatedly been
\nshown to be ineffective.
\nPrinciple 4
\n9. Good planning and adequate resources
\nare essential for successful implementation
\nand enforcement of smoke-free legislation.
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 78
\nWHO
\n79
\nPrinciple 5
\n10. Civil society has a central role in build-
\ning support for and ensuring compliance
\nwith smoke-free measures, and should be
\nincluded as an active partner.
\nPrinciple 6
\n11. The implementation of smoke-free leg-
\nislation, its enforcement and its impact
\nshould all be monitored and evaluated. This
\nshould include monitoring and responding
\nto tobacco industry activities.
\nPrinciple 7
\n12. The protection of people from exposure
\nto tobacco smoke should be strengthened
\nand expanded, if necessary; such action
\nmay include new or amended legislation,
\nimproved enforcement and other measures
\nto reflect new scientific evidence and case-
\nstudy experiences.
\nGENEVA \u2013 At the second Global
\nConsultation on Transplantation the World
\nHealth Organization presented countries
\nand other stakeholders with a blueprint for
\nupdated global guiding principles on cell,
\ntissue and organ donation and transplanta-
\ntion.
\nThose principles aim to address a number of
\nproblems: the global shortage of human
\nmaterials \u2013 particularly organs \u2013 for trans-
\nplantation; the growing phenomenon of
\n\u2018transplant tourism\u2019 partly caused by that
\nshortage; quality, safety and efficacy issues
\nrelated to transplantation procedures; trace-
\nability and accountability of human materi-
\nals crossing borders.
\nStakeholders agreed to the creation of a
\nGlobal Forum on Transplantation to be
\nspearheaded by WHO, to assist and support
\ndeveloping countries initiating transplanta-
\ntion programmes and to work towards a
\nunified global coding system for cells, tis-
\nsues and organs.
\nA central theme of the discussions was
\nWHO\u2019s concern over increasing cases of
\ncommercial exploitation of human materi-
\nals.
\n\u201cHuman organs are not spare parts,\u201c said
\nDr. Howard Zucker, WHO Assistant
\nDirector-General of Health Technology and
\nPharmaceuticals. \u201cNo one can put a price
\non an organ which is going to save some-
\none\u2019s life.\u201c
\n\u201cNon-existent or lax laws on organ dona-
\ntion and transplantation encourage com-
\nmercialism and transplant tourism,\u201c said Dr.
\nLuc Noel, in charge of transplantation at
\nWHO. \u201cIf all countries agree on a common
\napproach, and stop commercial exploita-
\ntion, then access will be more equitable and
\nwe will have fewer health tragedies.\u201c
\nTransplantation is increasingly seen as the
\nbest solution to end-stage organ failure.
\nEnd-stage kidney disease, for instance, can
\nonly be repaired with a kidney transplant.
\nWithout it, the patient will die or require
\ndialysis for years, which is an expensive
\nprocedure and often out of reach of poorer
\npatients. Transplantation is the only option
\nfor some liver conditions, such as severe
\ncirrhosis or liver cancer, and a number of
\nserious heart conditions.
\nRecent estimates communicated to WHO
\nby 98 countries show that the most sought
\nafter organ is the kidney. Sixty-six thousand
\nkidneys were transplanted in 2005 repre-
\nsenting a mere 10 % of the estimated need.
\nIn the same year, 21 000 livers and 6 000
\nhearts were transplanted. Both kidney and
\nliver transplants are on the rise but demand
\nis also increasing and remains unmatched.
\nReports on \u2018transplant tourism\u2019 show that it
\nmakes up an estimated 10 % of global trans-
\nplantation practices. The phenomenon has
\nbeen increasing since the mid-1990\u2019s, coin-
\nciding with greater acceptance of the thera-
\npeutic benefits of transplantation and with
\nprogress in the efficacy of the medicines \u2013
\nimmuno-suppressants \u2013 used to prevent the
\nbody\u2019s rejection of a transplanted organ.
\nThe principles put forward by WHO under-
\nscore that the person \u2013 whether recipient of
\nan organ or a donor \u2013 must be the main con-
\ncern both as patient and as human being;
\nthat commercial exploitation of organs
\ndenies equitable access and can be harmful
\nto both donors and recipients; that organ
\ndonation from live donors poses numerous
\nhealth risks which can be avoided by pro-
\nmoting donation from deceased donors; and
\nthat quality, safety, efficacy and transparen-
\ncy are essential if society is to reap the ben-
\nefits transplantation can offer as a therapy.
\n\u201cLive donations are not without risk,
\nwhether the organ is paid for or not. The
\ndonor must receive proper medical follow-
\nup but this is often lacking when he or she
\nis seen as a means to making a profit,\u201c
\nadded Dr. Luc Noel. \u201cDonations from
\ndeceased persons eliminate the problem of
\ndonor safety and can help reduce organ traf-
\nficking.\u201c
\nWHO action on transplantation will be
\naided by a global observatory set up in
\nMadrid under the auspices of the
\nGovernment of Spain. The observatory,
\nwhich is linked to the WHO Global
\nKnowledge Base, will provide an interface
\nfor health authorities and the general public
\nto access data on donation and transplanta-
\nWHO proposes global agenda on transplantation
\nNew world observatory launched with Spain
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 79
\nWHO
\n80
\ntion practices, legal frameworks and obsta-
\ncles to equitable access.
\nBackground
\nFigures collected by WHO and collated by
\nthe global observatory come from question-
\nnaires answered by 98 countries represent-
\ning just under 5.5 billion people, that is,
\nabout 82% of the world\u2019s population. The
\ncountries were distributed in the following
\nmanner: 41 from the European region; 21
\nfrom North and South America; 13 from the
\nWestern Pacific region; 12 from the Eastern
\nMediterranean; eight from South East Asia;
\nand three from Africa.
\nIn 2005, 66 000 kidney transplants were
\nperformed, 60 % of which in industrialized
\ncountries. Seventy-five per cent of the more
\nthan 21 000 liver transplants and 6 000 heart
\ntransplants were performed in industrial-
\nized and emerging economies.
\nObservatory link:
\nhttp:\/\/www.transplant-observatory.org
\nUsername: rticxcarmona
\nPassword: Omsmc789
\nGlobal Knowledge Base link:
\nhttp:\/\/www.who.int\/transplantation\/knowledge-
\nbase\/en\/
\nwork is addressing several vital areas of risk
\nto patients. Clear and succinct actions con-
\ntained in the nine solutions have proved to
\nbe useful in reducing the unacceptably high
\nnumbers of medical injuries around the
\nworld.\u201c
\nThe nine solutions are now being made
\navailable in an accessible form for use and
\nadaptation by WHO Member States to re-
\ndesign patient care processes and make
\nthem safer. They come under the headings
\nof: Look-Alike; Sound-Alike medication
\nnames; patient identification; communica-
\ntion during patient hand-overs; perfor-
\nmance of correct procedure at correct body
\nsite; control of concentrated electrolyte
\nsolutions; assuring medication accuracy at
\ntransitions in care; avoiding catheter and
\ntubing misconnections; single use of injec-
\ntion devices; and improved hand hygiene to
\nprevent health care-associated infection.
\nThe Patient Safety Solutions, a core pro-
\ngramme of the WHO World Alliance for
\nPatient Safety, brings attention to patient
\nsafety and best practices that can reduce
\nrisks to patients. It ensures that interven-
\ntions and actions that have solved patient
\nsafety problems in one part of the world are
\nmade widely available in a form that is
\naccessible and understandable to all. The
\nJoint Commission on Accreditation of
\nHealthcare Organizations and Joint
\nCommission International were officially
\ndesignated as a WHO Collaborating Centre
\non Patient Safety (Solutions) in 2005.
\nIn the past 12 months, the WHO
\nCollaborating Centre on Patient Safety
\n(Solutions) has brought together more than
\n50 recognized leaders and experts in patient
\nsafety from around the world to identify and
\nadapt the nine solutions to different needs.
\nAn international field review of the solu-
\ntions was conducted to gather feedback
\nfrom leading patient safety entities, accred-
\niting bodies, ministries of health, interna-
\ntional health professional organizations and
\nother experts.
\n\u2018\u2018These solutions offer to WHO Member
\nStates a major new resource to assist their
\nhospitals in avoiding preventable deaths
\nand injuries,\u201c says Dr Dennis S. O\u2019Leary,
\npresident of the Joint Commission.
\n\u201eCountries around the world now face both
\nthe opportunity and the challenge to trans-
\nlate these solutions into tangible actions that
\nactually save lives.\u201c
\nThe patient Safety Solutions focus on the
\nfollowing challenges:
\n1. Look-Alike, Sound-Alike Medication
\nNames
\n2. Patient Identification
\n3. Communication During Patient
\nHand-Overs
\n4. Performance of Correct Procedure at
\nCorrect Body Site
\n5. Control of Concentrated Electrolyte
\nSolutions
\n6. Assuring Medication Accuracy at
\ntransitions in Care
\n7. Avoiding Catheter and Tubing Mis-
\nConnections
\n8. Single Use of Injection Devices
\n9. Improved Hand Hygiene to Prevent
\nHealth Care-Associated Infection.
\nFor more Information or to view the com-
\nplete Patient Safety Solutions, please go to:
\nwww.jointcommissioninternational.org\/
\nsolutions
\nMedical Injuries
\nWHO launches \u2018\u2018Nine patient safety solutions\u2019\u2019
\nto save lives and avoid harm
\nWASHINGTON\/GENEVA \u2013 The World
\nHealth Organization has launched \u2018\u2018Nine
\npatient safety solutions\u201c to help reduce the
\ntoll of health care-related harm affecting
\nmillions of patients worldwide.
\n\u2018\u2018Recognizing that health care errors affect
\none in every 10 patients around the world,
\nthe WHO\u2019s World Alliance for Patient
\nSafety and the Collaborating Centre have
\npackaged nine effective solutions to reduce
\nsuch errors,\u201c said WHO Director-General
\nDr Margaret Chan. \u2018\u2018Implementing these
\nsolutions is a way to improve patient safe-
\nty.\u201c
\nThe most important knowledge in the field
\nof patient safety is how to prevent harm
\nfrom happening to patients during treatment
\nand care. The nine solutions are based on
\ninterventions and actions that have reduced
\nproblems related to patient safety in some
\ncountries.
\nSir Liam Donaldson, Chair of the Alliance
\nand Chief Medical Officer for England,
\nsaid: \u2018\u2018Patient safety is now recognized as a
\npriority by health systems around the world.
\nThe Patient Safety Solutions programme of
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 80
\nWHO
\n81
\nH5N1 Avian `Flu
\nWHO and manufactorers move ahead with plans for H5N1 influenza
\nglobal vaccine stockpile
\nThe World Health Organization has
\nannounced that it is working with vaccine
\nmanufacturers to move ahead on plans to
\ncreate a global stockpile of vaccine for the
\nH5N1 avian influenza virus.
\nThe announcement follows a request by the
\nWorld Health Assembly in May for WHO to
\nestablish an international stockpile of H5N1
\nvaccine.
\nWHO also welcomed the announcement by
\nGlaxoSmithKline that it will contribute to
\nthe H5N1 global vaccine stockpile.
\nOmninvest of Hungary, Baxter and Sanofi
\nPasteur have also indicated their willing-
\nness to make some of their H5N1 vaccine
\navailable.
\n\u2018\u2018This is another significant step towards
\ncreating a global resource to help the world
\nand especially to help developing countries
\nin case of a major outbreak of H5N1 avian
\ninfluenza,\u201c said Dr Margaret Chan, WHO
\nDirector-General.
\n\u2018\u2018WHO welcomes this contribution from
\nthe vaccines industry and is also working
\nwith countries to develop capacity for the
\nproduction of influenza vaccines.\u201c
\nFurther work is needed on detailed opera-
\ntional planning for the stockpile, including
\nhow and under which conditions it will be
\ndeployed, as well as regulatory aspects of
\nthe vaccine.
\nAs well as developing a stockpile of H5N1
\nvaccine, other measures being taken by
\nWHO to prepare for a potential influenza
\npandemic include:
\n\u2022 rapid containment plans to stop a pan-
\ndemic using public health measures (iso-
\nlation, quarantine of contacts, personal
\nhygiene and social distancing) and anti-
\nvirals;
\n\u2022 assistance to countries to increase vaccine
\nproduction capacity, including research
\nand promoting the transfer of technology
\nto developing countries.
\nWHO releases findings from research project on travel and blood clots
\nRisk of VTE is higher after travel of more than four hours but is still relatively low
\nduring travel where the passenger is seated
\nand immobile for over four hours, whether
\nin a plane, train, bus or car. However, it is
\nimportant to remember that the risk of
\ndeveloping VTE when travelling remains
\nrelatively low,\u201c says Dr Catherine Le
\nGal\u00e8s-Camus, WHO Assistant Director-
\nGeneral for Noncommunicable Disease and
\nMental Health.
\nThis study did not investigate effective pre-
\nventive measures against DVT and VTE.
\nHowever, experts recognize that blood cir-
\nculation can be promoted by exercising the
\ncalf muscles with up-and-down movements
\nof the feet at the ankle joints. Moving feet in
\nthis manner encourages blood flow in the
\ncalf muscle veins, thus reducing blood stag-
\nnation. People should also avoid wearing
\ntight clothing during travel, as such gar-
\nments may promote blood stagnation.
\nGENEVA \u2013 The World Health Organization
\nreleased results from Phase 1 of the World
\nHealth Organization research into global
\nhazards of travel project. Findings indicate
\nthat the risk of developing venous throm-
\nboembolism (VTE) approximately doubles
\nafter travel lasting four hours or more.
\nHowever, the study points out that even
\nwith this increased risk, the absolute risk of
\ndeveloping VTE, if seated and immobile for
\nmore than four hours, remains relatively
\nlow at about 1 in 6000.
\nThe two most common manifestations of
\nVTE are deep vein thrombosis (DVT) and
\npulmonary embolism.
\nThe study showed that plane, train, bus or
\nautomobile passengers are at higher risk of
\nVTE when they remain seated and immo-
\nbile on journeys of more than four hours.
\nThis is due to a stagnation of blood in the
\nveins caused by prolonged immobility,
\nwhich can promote blood clot formation in
\nveins.
\nOne study within the project examining
\nflights in particular, found that those taking
\nmultiple flights over a short period of time
\nare also at higher risk. This is because the
\nrisk of VTE does not go away completely
\nafter a flight is over, and the risk remains
\nelevated for about four weeks.
\nThe report showed that a number of other
\nfactors increase the risk of VTE during trav-
\nel, including obesity, being very tall or very
\nshort (taller than 1.9 meters or shorter than
\n1.6 meters), use of oral contraceptives, and
\ninherited blood disorders leading to
\nincreased clotting tendency.
\n\u2018\u2018The study does confirm that there is an
\nincreased risk of venous thromboembolism
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 81
\nWHO
\n82
\nPhase I of the research project concludes
\nthat there is a need for travellers to be given
\nappropriate information regarding the risk
\nof VTE by transport authorities, airlines,
\nand medical professionals. Further studies
\nwill be needed to identify effective preven-
\ntive measures. This will comprise Phase II
\nof the project, which requires additional
\nfunding before it can begin.
\nIndividuals with questions regarding pre-
\nvention of VTE should consult their physi-
\ncians before travelling.
\nBackground to the WRIGHT project:
\nIn 2000, following the death from pul-
\nmonary embolism of a young English
\nwoman who returned on a long-haul flight
\nfrom Australia. Media and public attention
\nwas focused on the risk of thrombosis in
\nlong-haul travellers. In the same year, a
\nreport from the Select Committee on
\nScience and Technology of the United
\nKingdom House of Lords recommended
\nresearch into the risk of DVT. Following a
\nconsultation of experts convened by WHO
\nin March 2001, the WRIGHT project was
\ninitiated. Phase 1 was funded by the UK
\nGovernment (Department for Transport and
\nDepartment of Health) and the European
\nCommission.
\nThe objectives of Phase I were to confirm
\nwhether the risk of VTE is increased by air
\ntravel and to determine the magnitude of
\nrisk.The studies were conducted under the
\nauspices of WHO and performed by an
\ninternational collaboration of researchers
\nfrom the Universities of Leiden, Amster-
\ndam, Leicester, Newcastle, Aberdeen and
\nLausanne.
\nThere were five studies:
\n\u2022 a population-based case control study to
\ninvestigate the risk factors of VTE;
\n\u2022 two retrospective cohort studies among
\nemployees of international organizations
\nand Dutch commercial pilots to investi-
\ngate the actual risk of VTE related to air
\ntravel; and
\n\u2022 two pathophysiological studies to inves-
\ntigate the influence of immobility on
\nVTE related to travel and the influence,
\nif any, of low oxygen and low pressure in
\nthe cabin of aircraft on VTE related to
\ntravel.
\nSafe blood for mothers
\nNew WHO survey on blood safety and donation
\nGENEVA \u2014 On the occasion of World
\nBlood Donor Day, the theme of which this
\nyear is Safe blood for safe motherhood, the
\nWorld Health Organization launched a new
\ninitiative to improve the availability and use
\nof safe blood to save the lives of women
\nduring and after childbirth. The initiative is
\nthe beginning of a broader blood safety
\nagenda (redefined in Ottawa) aiming to
\nwork towards universal access to safe blood
\ntransfusion in support of the Millennium
\nDevelopment Goals.
\nOn 14 June, WHO also released data col-
\nlected from 172 countries on trends in blood
\ndonation, access and testing.
\nGlobally, more than 500 000 women die
\neach year during pregnancy, childbirth or in
\nthe postpartum period \u2013 99% of them in the
\ndeveloping world \u2013 an estimated 25% of
\nthose deaths are caused by severe bleeding
\nduring childbirth, making this the most
\ncommon cause of maternal mortality.
\nSevere bleeding during delivery or after
\nchildbirth contributes to around 34% of
\nmaternal deaths in Africa, 31% in Asia and
\n21% in Latin America and the Caribbean.
\nAs pregnant women are one of the main
\ngroups of patients requiring blood transfu-
\nsion in developing countries, together with
\nchildren they are particularly vulnerable to
\nblood shortages and to HIV, hepatitis B and
\nhepatitis C infections through unsafe blood.
\n\u2018\u2018If current trends continue, the world will
\nfail to meet target 5 of the Millennium
\nDevelopment Goals to reduce maternal
\nmortality,\u201c said Dr Margaret Chan, WHO
\nDirector-General. \u2018\u2018We must do everything
\nwe can to improve the chances of women
\nduring and after childbirth.\u201c
\nBlood transfusion has been identified as one
\nof the eight key life-saving interventions in
\nhealthcare facilities providing emergency
\nobstetric care. Timely, appropriate and safe
\nblood transfusion during and after labour
\nand delivery can make the difference
\nbetween life and death for many women
\nand their newborns.
\nThe Global Initiative on Safe Blood for
\nSafe Motherhood aims to improve access to
\nsafe blood to manage pregnancy-related
\ncomplications as part of a comprehensive
\napproach to maternal care. This includes
\ngood antenatal care, prevention and timely
\ntreatment of anaemia, assessment of the
\nneed for transfusion and safe blood transfu-
\nsion given only when really required. WHO
\nwill strengthen the capacity of blood banks
\nand district hospitals for improving mater-
\nnal health through the provision of technical
\nsupport in the areas of voluntary blood
\ndonation, safe blood collection, quality
\nassured testing and best clinical practices.
\nWHO will train clinicians, nurses, techni-
\ncians and other key health personnel at dis-
\ntrict level facilities through its regional net-
\nworks across the world.
\nThe lack of access to safe blood for women
\nreflects the general situation in developing
\ncountries. Developing countries are home
\nto more than 80% of the world\u2019s population,
\nyet they currently represent only 45% of the
\nglobal blood supply.
\nOut of 80 countries that have donation rates
\nof less than 1% of the population (fewer
\nthan 10 donations per thousand people), 79
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 82
\nWHO
\n83
\nare in developing regions; it is generally
\nrecommended that 1-3% of the population
\ngive blood to meet a country\u2019s needs.
\nThe WHO survey, conducted in 172 coun-
\ntries covering 95% of the world\u2019s popula-
\ntion and based on 2004 data, shows that
\nsome progress has been made since the
\nbeginning of the millennium towards ensur-
\ning a safer, more adequate supply of blood.
\nOne of the survey\u2019s indicators was the
\nimplementation of voluntary, unpaid blood
\ndonation, which remains a mainstay of
\nWHO recommendations to ensure a safe
\nand sufficient blood supply.
\nIn 2004, 50 countries had achieved 100%
\nvoluntary unpaid blood donation, compared
\nwith 39 countries in 2002. Three of the 11
\nnew countries achieving this are categorized
\nas least developed. More and more coun-
\ntries are moving towards voluntary blood
\ndonation. In 2002, 63 countries were col-
\nlecting less than 25% of their blood from
\nvoluntary unpaid donors. By 2004, this had
\nfallen to 46 countries.
\nTesting of blood for major infections such
\nas HIV\/AIDS, hepatitis B and C is also
\nincreasing, although in many countries
\nthere are few indicators showing if the test-
\ning is carried out according to quality
\nassured procedures. Out of 40 countries in
\nsub-Saharan Africa, 28 countries have yet to
\nestablish national quality systems.
\nWorldwide, the highest rate of infection is
\nfound among donors who give blood for
\nmoney or other form of payments. 41 of 148
\ncountries (28%) that provided data on
\nscreening for transfusion-transmissible
\ninfections were not able to screen the donat-
\ned blood for one or more of the markers.
\nOn 9-11 June, Ottawa was the venue for a
\nglobal consultation organized by WHO with
\nthe collaboration and support of the
\nGovernment of Canada and the Canadian
\nand French blood services. Around 100
\nexperts in transfusion called on govern-
\nments, international agencies and non-
\ngovernmental organizations to work togeth-
\ner towards universal access to safe blood
\ntransfusion by 2015 in support of the
\nMillennium Development Goals to reduce
\nmaternal and child mortality and prevent the
\ntransmission of HIV, hepatitis and other
\nlife-threatening infections through unsafe
\nblood and blood products.
\nBackground to World Blood
\nDonor Day
\nWhile most countries celebrated World
\nBlood Donor Day on 14 June, this year\u2019s
\nmain event was hosted by the Government
\nof Canada. Festivities took place in Ottawa,
\nin the presence of the Canadian Minister of
\nHealth and guests from WHO and other
\ninternational partners.
\nWHO works with partners internationally
\nand in countries to promote better blood
\ncollection practices, 100% voluntary,
\nunpaid blood donation policies, quality
\nassured blood testing and rational use of
\nblood.
\nWHO, the International Federation of the
\nRed Cross and Red Crescent Societies, the
\nInternational Society of Blood Transfusion
\nand the International Federation of Blood
\nDonor Organizations joined forces in 2004
\nto celebrate for the first time World Blood
\nDonor Day \u2014 a tribute to voluntary, unpaid
\nblood donors who altruistically give of
\nthemselves to improve and save lives. In
\n2005 the World Health Assembly voted a
\nresolution to make World Blood Donor Day
\nan annual event. Since then, the Day has
\nbecome a vehicle to launch national and
\nregional awareness and advocacy cam-
\npaigns to encourage blood donation and
\nsafer practices in blood transfusion.
\nBlood safety data are collected biennially
\nby WHO through a comprehensive survey
\naddressed to national governments.
\nHighlights of the data available on:
\nhttp:\/\/www.who.intienity\/worldblooddonor
\nday\/resources\/Data.xls
\nImproved meningitis vaccine for Africa could signal eventual end
\nto deadly scourge
\nSuccessful Vaccine Trial Promises Long-Term, Low-Cost Protection From Epidemics in Africa
\nGENEVA \u2013 The Meningitis Vaccine Project
\n(MVP) has released new data on the perfor-
\nmance of a meningitis vaccine in West
\nAfrican children, suggesting that the new
\nvaccine \u2013 expected to sell initially for 40
\nUS cents a dose \u2013 will be much more effec-
\ntive in protecting African children and their
\ncommunities than any vaccine currently on
\nthe market in the region.
\nMVP, a partnership between the World
\nHealth Organization and the Seattle-based
\nnonprofit, PATH, is collaborating with a
\nvaccine producer, Serum Institute of India
\nLimited (SIIL), to produce the new vac-
\ncine against serogroup A Neisseria menin-
\ngitidis (meningococcus). The preliminary
\nresults of their study, a Phase 2 vaccine
\ntrial, reveal that the vaccine could eventu-
\nally slash the incidence of epidemics in the
\n\u201cmeningitis belt,\u201d as 21 affected nations of
\nsub-Saharan Africa are collectively
\nknown. The vaccine is expected to block
\ninfection by the serogroup A meningococ-
\ncus, and therefore extend protection to the
\nentire population, including the unvacci-
\nnated, a phenomenon know as \u201cherd
\nimmunity.\u201d
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 83
\nWHO
\n84
\n\u201cWhen it becomes part of the public health
\narsenal, this vaccine will make a real differ-
\nence in Africa,\u201d said Dr. F. Marc LaForce,
\nMVP director. \u201cThe vaccine will allow
\nelimination of the meningococcal epi-
\ndemics that have afflicted the continent for
\nmore than 100 years.\u201d
\nThe new meningococcal conjugate vaccine
\ntrial, in 12- to 23-month-olds in Mali and
\nThe Gambia, shows that the vaccine was
\nsafe, and that it produced antibody levels
\nalmost 20 times higher than those obtained
\nwith the marketed polysaccharide (un-con-
\njugated) vaccine. This means that protection
\nfrom serogroup A meningococcal meningi-
\ntis is expected to last for several years.
\n\u2018\u2018This important study brings real hope that
\nthe lives of thousands of children,
\nteenagers, and young adults will be saved
\nby immunization and that widespread suf-
\nfering, sickness and socioeconomic disrup-
\ntion can be avoided,\u201d said Dr. Margaret
\nChan, Director-General of the World Health
\nOrganization.
\n\u201cElimination of these epidemics with wide
\nuse of the meningococcal A conjugate vac-
\ncine is now a likely possibility over the next
\nfew years,\u201d said LaForce. \u201cPeople between
\nthe ages of 1 and 29 years of age will be
\nprotected by receiving a single dose in large
\nmass vaccination campaigns. The large
\ncampaigns are expected to create herd
\nimmunity, and eventually, elimination of the
\ndisease.\u201d
\nAs a result of the encouraging preliminary
\nfindings of this Phase 2 clinical study, SIIL
\nand MVP will proceed with a Phase 2\/3
\nstudy where the vaccine will be tested in 2-
\nto 29-year-olds\u2014the population that will be
\nmostly targeted by mass vaccination cam-
\npaigns. Testing will take place in Mali, The
\nGambia, and at least one other African
\ncountry. An additional clinical study is
\nplanned for this summer in India, where the
\nvaccine will be licensed.
\n\u201cSerum Institute of India is dedicated to
\ndeveloping safe, effective, and affordable
\nproducts for the poorest countries in the
\nworld,\u201d said Dr. Cyrus Poonawalla,
\nChairman of SIIL. \u201cThese results confirm
\nand extend the observations made last year
\nin our Phase 1 study in India. The new con-
\njugate vaccine has an excellent safety pro-
\nfile in young children, and it is immunolog-
\nically superior to the polysaccharide vac-
\ncine.\u201d
\nA conjugate vaccine joins (or \u201cconjugates\u201d)
\nsugars from the meningococcal bacterium
\nwith a protein, which in turn stimulates
\nimmune cells. These cells then produce
\nantibodies to meningitis, protecting the
\nindividual from infection. A total of 600
\ntoddlers participated in the Phase 2 study.
\nThey were enrolled at two clinical sites in
\nAfrica: Center for Vaccine Development
\n(CVD)-Mali and the Medical Research
\nCouncil (MRC) Laboratories in The
\nGambia. Dr. Brown Okoko, principal inves-
\ntigator at the MRC site in Basse, said, \u201cThe
\nclinical teams at MRC and CVD-Mali iden-
\ntify with the vision, mission, and mandate
\nof the Meningitis Vaccine Project. We are
\nall highly motivated and very proud to be
\nable to contribute to the development of a
\nvaccine that is critically needed in Africa.\u201d
\nDr. Samba Sow, principal investigator at
\nCVD-Mali, said, \u201cSome of the families who
\nparticipated in the study have lost several
\nmembers of their family to meningococcal
\nmeningitis. Those who have not been direct-
\nly affected know the terrible impact that the
\ndisease has on the community. There is a lot
\nof support for the clinical study and the new
\nvaccine in the Bamako community.\u201d
\niGATE Clinical Research International, a
\ncontract research company in Mumbai,
\nIndia, is providing data management ser-
\nvices.
\n\u201cThe plans for the future are quite ambi-
\ntious,\u201d said LaForce. \u201cWith the successful
\ncompletion of the Phase 2 study, and once
\nfunding is secured, we plan to do a demon-
\nstration study next year in a hyperendemic
\ncountry where we will take the vaccine to
\npublic-health scale by immunizing the
\nentire population between the ages of 1 and
\n29. If all continues to go well in testing and
\nduring the demonstration study, the new
\nvaccine, which will be priced at about 40
\ncents per dose, could be introduced in
\nAfrica within the next two to three years.\u201d
\nMeningitis is one of the world\u2019s most dread-
\ned infectious diseases. Even with antibiotic
\ntreatment, at least 10 percent of patients die,
\nwith up to 20 percent left with permanent
\nproblems, such as mental retardation, deaf-
\nness, epilepsy, or necrosis leading to limb
\namputation.
\nThe most prominent groups of meningococ-
\nci are A, B, C, Y, and W135. While groups
\nA, B, and C are responsible for the majority
\nof cases worldwide, group A causes deadly,
\nexplosive epidemics every 8 to 10 years
\npredominantly in what is known as the
\nAfrican \u201cmeningitis belt,\u201d an area that
\nstretches from Senegal and The Gambia in
\nthe West to Ethiopia in the East. The belt
\nhas an at-risk population of about 430 mil-
\nlion. The largest epidemic wave ever
\nrecorded in history swept across the entire
\nregion in 1996\u20131997, causing over 250,000
\ncases and 25,000 deaths. Africa has been
\nrelatively spared in recent years, but last
\nyear\u2019s 41,526 reported cases and the 47,925
\ncases reported from 1 January to 6 May
\n2007 bring the fear that a new epidemic
\nwave may have begun in sub-Saharan
\nAfrica.
\nWMJ_4_57-84.qxd 19.09.2007 17:08 Seite 84<\/p>\n"},"caption":{"rendered":"

wmj15 WorldMMeeddiiccaall JJoouurrnnaall Vol. No. 3, September 200753 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall 57 PPrrooffeessssiioonnaalliissmm aanndd tthhee MMeeddiiccaall AAssssoocciiaattiioonn 58 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss The Ethics of Stem Cell Research 74 Ethics and Human Rights news 75 HIV and Human Rights Handbook 76 WWMMAA CCPPDD ccoouurrssee iinn […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj15.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3561"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3561"}]}}