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wmj20<\/a><\/p>\n

WMA news
\nNo. 4, December 2008
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSu\ufb00olk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nCover painting : Zaza Panaskertel-Tsitsishvili
\n(XV c.).The famous Georgian
\nphysician and thinker. Author of Medical
\nMonographs.The fresco from
\nthe Kintsvisi Cathedral. A cover picture is
\nselected as a moral support of WMA for
\nGeorgian physicians.The pictures were kindly
\nprovided by Prof. Ramaz Shengelia. Chairman
\nof the Department of History of Medicine \/
\nTbilisi State Medical University
\nLayout and Artwork
\nThe Latvian Medical Publisher \u201cMedic\u012bnas
\napg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nHospit\u0101\u013cu iela 55, Riga, Latvia
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
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\nPhone (0 22 34) 70 11-0
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\nAt present rate-card No. 3 a is valid
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (inkl.
\n7%MwSt.). 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, Germany
\nISSN: 0049-8122
\nDr. Yoram BLACHAR
\nWMA President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Kazuo IWASA
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nDr. Dana HANSON
\nWMA President-Elect
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. Eva NILSSON-
\nB\u00c5GENHOLM
\nWMA Chairperson of the Medical
\nEthics Committee
\nSwedish Medical Assn.
\nP.O. Box 5610
\n11486 Stockholm
\nSweden
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. J\u00f3n SN\u00c6DAL
\nWMA Immediate Past President
\nIcelandic Medicial Assn
\nHlidasmari 8
\n200 Kopavogur
\nIceland
\nDr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Jos\u00e9 Luiz GOMES DO
\nAMARAL
\nWMA Chairperson of the Socio-
\nMedical-A\ufb00airs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nWorld Medical Association O\ufb03cers, Chairpersons and O\ufb03cials
\nO\ufb03cial Journal of The World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily re\ufb02ect WMA policy or positions
\nwww.wma.net
\n117
\nThe business of manufacturing is usually good for the consumer and
\ngood for the economy. However, not all manufactured or produced
\ngoods are safe. One of the functions of government is to regulate
\nthe safety of products.When the negative e\ufb00ects upon the economy
\nof putting a stop to a dangerous practice takes precedence over pro-
\ntecting the health of the population and the government takes no
\naction, doctors have an obligation to step in.This issue was brought
\nto light with a recent problem of melamine.
\nMelamine is an industrial chemical that is used to manufacture
\ncertain plastics. It was added to pet foods produced in China and
\nto animal feed. Because it has high nitrogen content, it was used
\nin China to increase the apparent protein content of foods when
\nsimple nutritional tests were done. Adding melamine to powdered
\nmilk changed the texture, thickness and \ufb02avor of the milk. Adding
\nmelamine was a common, though illegal practice in China.
\nThe \ufb01rst reported incident of toxicity from melamine in pets came
\nin 2007. In humans it was recently revealed that at least four infants
\nhave died, 13,000 hospitalized and about 50,000 a\ufb00ected by ingest-
\ning melamine-tainted powdered milk in China. Nephrolithiasis and
\nrenal dysfunction are the most common problems reported from
\nexcess melamine ingestion. Melamine has been found in powdered
\nbaby milk and some dairy and candy products produced in China; it
\nhas also been found in eggs, probably as a result of its being added
\nto animal feed.
\nSome of the revelations about melamine have come from Taiwan,
\nwhich imports products from China. Because of political consider-
\nations,Taiwan is not a member of the World Health Organization.
\nSince they share a common language, Taiwan can be an important
\nsource of information about health practices in China that might
\nnot otherwise be revealed.
\nJust as in the past, with issues such as alcohol use and smoking,
\ndoctors have led the battle to eliminate public health hazard in the
\nface of economic forces to the contrary. In the coming years, the
\n\ufb01ght against alcohol abuse will take center stage. It remains to be
\nseen if organizations such as the World Health Organization,which
\nreceives funding from businesses that pro\ufb01t from the sale of alcohol,
\nwill be e\ufb00ective leaders in this battle. Doctors, who put patients\u2019
\nwell-being foremost and have no con\ufb02ict of interest should be active
\nin this e\ufb00ort and help lead this campaign.
\nA bad message. On the cover of \u201cTimes\u201d 24th of November Barack
\nObama is smoking a cigatette.
\nEditorial
\nP\u0113teris Apinis, M.D.
\nEditor-in-Chief of the World Medical Journal
\nDr. Ron Davis, former Council Member of WMA, and recently Adviser, Immediate
\nPast-President of the American Medical Association and strong supported of our work,
\npassed away on November 6th
\n, 2008.
\nWe have lost a strong advocate for public health, a fantastic colleague, teacher and
\nfriend. He has been a skilled scholar, enlightening us with lectures and advice \u2013 last at
\nour seminar in Seoul, just a couple of weeks ago.
\nWorking with him until his last days, we will remember him for what he worked and
\nstood for \u2013 Health for all people.
\nOur thougts are with his family.
\n118
\nWMA news
\nDr. Yoram Blachar,
\nPresident of the World Medical Association
\nIt is an honor and privilege for me to serve as
\nthe president of this auspicious organization
\nthat unites the world\u2019s doctors and represents
\nus all. Advocating on behalf of doctors and
\npatients around the world is a pinnacle any
\nphysician committed to the public service
\ncan aspire to and I am so fortunate to be able
\nto realize my aspirations in this realm. I am
\nextremely grateful to the members of the
\nWMA who placed their trust with me and
\nallowed me the privilege of serving this very
\nvibrant and important organization.
\nThe WMA has come a long way since its es-
\ntablishment in Paris in 1947. It has grown,
\nevolved and \ufb02ourished, and it has always
\nremained true to its values and founding
\nprinciples. (Incidentally, Israeli doctors have
\nparticipated in the WMA since its establish-
\nment, initially as representatives of the Pal-
\nestine Jewish Physician Association.) The
\nneed for an international organization to
\nunite physicians around the globe existed in
\n1926 and continued to the era of the Second
\nWorld War; this need was ampli\ufb01ed by the
\nhorrendous experiences the world endured
\nthroughout that war. In light of the incon-
\nceivable events that occurred and the radical
\nbreach of any sort of humanitarian or ethi-
\ncal code, as revealed during the Nuremberg
\ntrials, it was evident that the \ufb01rst task of
\nthe WMA would be the formulation of an
\nethical code for all the world\u2019s doctors. As
\nthe world became increasingly aware of the
\nhorri\ufb01c use of human beings in experiments
\nthat held no regard for human life or basic
\nhuman rights, it became the responsibility
\nof physicians to assure we would never again
\ntake part in acts that do not bene\ufb01t people.
\nOut of this unthinkable past the Declara-
\ntion of Helsinki was created and has since
\nburgeoned to become one of the irrefutable
\ncornerstones of physician conduct.The Dec-
\nlaration has withstood the test of time and
\nscienti\ufb01c evolution because of our ability
\nto modify and adapt it to developments in
\nmedicine and society.
\nFundamental topics in medical ethics have
\nbeen at the heart of the WMA\u2019s work and
\na core component of its activities from its
\ninception. Many of the WMA\u2019s declara-
\ntions \u2013 such as the Declaration of Tokyo,
\nthe Declaration of Malta, the Declaration of
\nMadrid, and many others \u2013 have become the
\ninalienable property of the medical commu-
\nnity around the globe. Over time, with the
\nsurfacing of new dilemmas, physicians have
\nbeen faced with new challenges in the \ufb01elds
\nof medicine and health. Consequently, dis-
\ncussions within the WMA have widened to
\ninclude new ideas and changes in medicine
\nworldwide. The \ufb01eld of medicine has un-
\ndergone vast changes in the last century and
\nthese changes only accelerate as time passes.
\nFor example, penicillin was discovered less
\nthan 100 years ago and this discovery revolu-
\ntionized the face of medicine.Today, it is dif-
\n\ufb01cult for us to conceive of a reality without
\nantibiotics.
\nThere have also been prominent changes in
\nthe quality of life. Most of the world has ex-
\nperienced a great improvement in its standard
\nof living and in the quality of nutrition and
\nhygiene. Alongside these changes have been
\nsocial changes, such as the information revolu-
\ntion, electronic media and the internet, all of
\nwhich have greatly increased the amount of in-
\nformation in the public domain.These changes
\nhave all contributed to a surge in patient em-
\npowerment and an ever evolving doctor-pa-
\ntient relationship.The accessibility of informa-
\ntion and remarkable developments in medicine
\nhave brought both increased transparency and
\nincreased expectations.
\nHowever, economic factors increasingly in-
\nfringe upon the aforementioned advances in
\nmedicine. Many countries cannot a\ufb00ord to
\npay for modern medicine so the populations
\nof these countries do not bene\ufb01t from some of
\nthe most basic advances. The outcome of this
\nsituation is evident in health indices and in-
\ndicators. Additionally, it has become increas-
\ningly apparent that there is no country able to
\nthoroughly fund medical care from its public
\nbudget, and, as a result, a new reality has been
\ncreated in which di\ufb00erent levels of medical
\ncare are provided, depending on the patient\u2019s
\neconomic standing. This is true even in coun-
\ntries with public health insurance. There is a
\ngrowing trend of transferring the funding of
\nmedical services from the public account to
\nthe private pocket.Thus,whoever has the abil-
\nity to privately purchase what the state does
\nnot provide will receive excellent, up to date,
\ncare and whoever does not,will receive a lower
\nlevel of care in accordance with his or her abil-
\nity to pay. This situation creates a con\ufb02ict of
\nthe most basic medical,ethical principles with
\neconomic factors.
\nThe new reality in which we \ufb01nd ourselves
\nresults in an emphasis on disparities in the
\naccess, timeliness, and level of medical care.
\nHealth disparity is a topic that has always
\nexisted but has become more critical with
\nits e\ufb00ects becoming so profound, making it
\na topic worthy of being central to the agenda
\nof the WMA. Health disparities are evident
\nboth in comparison among di\ufb00erent coun-
\ntries as well as within di\ufb00erent regions of
\na single country. It is su\ufb03cient to measure
\nstandard parameters of health quality \u2013 such
\nas infant mortality rate,life expectancy,num-
\nber of hospital beds in relation to the popu-
\nlation, and number of modern technological
\ndevices \u2013 to realize that this phenomenon
\nwill soon become intolerable.The lower one\u2019s
\nsocio-economic status or educational level,
\nthe more extreme the phenomenon becomes.
\nThe topic of health disparities includes within
\nit ethical aspects,principles of doctor-patient
\nrelationships, the de\ufb01nition of a physician\u2019s
\nFinancial Crisis may Hasten Move to Shift
\nResponsibilities Away from Doctors
\n119
\nWMA news
\nrole in society, and the issue of human rights.
\nThis crucial topic requires us to formulate
\nan agenda. The WHO has recently declared
\nthat, \u201cHealth disparities costs lives.\u201d It is our
\nresponsibility as leaders in health to act on
\nthis crucial topic.
\nRecently, a global economic tsunami has in-
\nvaded our safe havens.It would seem that the
\nglobal outlook of a free economy completely
\nsubject to the vagaries of the market has not
\nwithstood the test of time and has collapsed.
\nThe impact of this crisis on the global lev-
\nel is still unclear, though it is clear that no
\nnational economy has been left una\ufb00ected.
\nThe vital question for us will be how this
\neconomic crisis, combined with the antici-
\npated global recession, will a\ufb00ect the world\u2019s
\nhealth systems.Especially in countries where
\nhealth insurance is an integral component of
\nemployment conditions, the recent waves of
\nlayo\ufb00s will make it di\ufb03cult to escape disas-
\ntrous consequences.It is our duty both in our
\nindividual national organizations as well as
\non the level of an international medical as-
\nsociation to be aware of these developments
\nso as to moderate their destructive impact
\nand shield the health care system as much
\nas possible. These developments will force
\ncountries without public health insurance to
\nunderstand that their health services cannot
\nbe controlled by bankrupting market forces
\nand free economy, and social-welfare states
\nwill understand that the recent inclination of
\ngovernments towards privatization threatens
\nthe equality and health of their citizens.
\nAs members of the WMA we are also social
\nleaders and, thus, we have the responsibility
\nof addressing a wider scope of issues a\ufb00ecting
\nhealth, one of which is the subject of armed
\ncon\ufb02ict. Many areas of the world are involved
\nin military con\ufb02ict; some of these are more
\nrecent while others have roots so deep that
\nall attempts to mediate between the extreme
\npositions are unsuccessful. This reality claims
\nthe lives of many victims and leaves others
\nwith physical or mental impairments. Many
\norganizations around the world,including the
\nUN and the EU, are involved in attempts to
\ntone down of the level of violence between
\nthe disputing countries. There are also hu-
\nmanitarian organizations manned by physi-
\ncians \u2013 such as Doctors Without Borders,
\nthe Taiwanese Tzu-Chi organization, and
\nPhysicians for Human Rights \u2013 that act as
\npacifying forces through the medical care they
\nprovide.The WMA is in a unique position in
\nthat it has both the ability and positioning to
\ntry to bring con\ufb02icting parties to the discus-
\nsion table via encouragement and dialogue
\nwith our organization. One of the regions
\ninvolved in an ongoing con\ufb02ict is my own.
\nThe Arab-Israeli con\ufb02ict has existed for many
\nyears. However, it is important to note that
\nIsrael does have peace agreements with two
\ncountries with which Israel had been at war
\nfor many years: Egypt and Jordan. There are
\nfull diplomatic relations between Israel and
\nEgypt and between Israel and Jordan, as well
\nas open borders. There is still much work to
\nbe done to achieve peace between Israel and
\nother countries, such as Syria, Lebanon and
\nespecially the Palestinian Authority. I plan to
\nmake every e\ufb00ort to turn health and medi-
\ncine on an organizational level into a bridging
\nforce so that maybe, as na\u00efve as it sounds, the
\npeace process in our region can be advanced as
\nit so desperately needs to be. I plan on being
\ninstrumental in the inclusion of NMAs who
\nare not yet members or active in the WMA,
\nso as to allow a dialogue to begin under the
\nauspices of the WMA,with the WMA medi-
\nating based on our common profession. This
\nprofession spans di\ufb00erent nationalities, view-
\npoints, and is common to all doctors, whose
\npurpose it is to bring help and healing.
\nThere is another topic which concerns all of
\nus as health leaders. The expected shortage
\nof physicians will almost certainly change
\nthe face of medicine. This threat is real and
\ntangible; even today the world lacks over 4
\nmillion health workers, according to WHO
\ndata.This shortage is not homogenous.There
\nare areas, such as Africa, where the shortage
\nis overwhelming, and other areas where the
\nshortage is barely felt. The genuine solution
\nto this shortage is to increase the number
\nof physicians, install solid long-lasting re-
\ntention plans for health care providers, and
\nsolve the problem of physician recruitment
\nfrom poorer areas to areas where the short-
\nage is less severe. The proposed solution of
\ntask shifting is not a real solution. Filling
\nthe positions of professionals with partially
\ntrained individuals is a temporary answer. It
\nis extremely dangerous to view task shifting
\nas a genuine solution since this will only pre-
\nvent us from \ufb01nding a real solution. As long
\nas task shifting is solely a temporary solution
\nmeant to \ufb01ll a gap that would otherwise re-
\nmain empty and provide some sort of answer
\nto the world\u2019s critical need for medical care
\nit is justi\ufb01ed. However, while implementing
\ntask shifting we must work towards a last-
\ning solution that deals with the root of the
\nproblem. We have a shared responsibility to
\nact and convince policy makers of this need
\nfor real solutions.
\nSome of the previously mentioned top-
\nics of health discrepancies, privatization of
\nhealth services, armed con\ufb02ict, and short-
\nage of health workers have already begun to
\nbe dealt with by the WMA, some of these
\ntopics have been awaiting our attention,
\nand some of these topics have just emerged.
\nSuch is the way of the WMA, with each of
\nits presidents \u201cpicking up the torch\u201dand con-
\ntinuing some of the tasks of their predeces-
\nsors, taking on new tasks, and leaving some
\ntasks to be completed by their successors. I
\nintend to continue the work of Dr. Snaedal,
\nespecially on the topics of task shifting and
\nhealth disparities, both on the policy level of
\ngovernments and NMAs as well as on the
\nlevel of the practice of doctors, with every
\nindividual doctor taking a role in the battle
\nagainst disparities in health. Additionally, I
\nintend to make attempts to engage in medi-
\ncal diplomacy. Hopefully,these attempts will
\nbe successful in making a di\ufb00erence to those
\npeople living in areas of con\ufb02ict.
\nThe issues to be addressed are large and com-
\nplex and this can not be the task of any one
\nindividual or even group of people. In order
\nto bring about a lasting contribution that
\nbrings about true change, every member of
\nthe WMA must take part. Only by working
\ntogether can we make a di\ufb00erence and in-
\nspire others to join us in working to ful\ufb01ll
\nour goals. It is not our responsibility to \ufb01nish
\nall the work that must be done, but we are
\nnot at liberty to shy away from it.
\nI conclude with a statement from Maimo-
\nnides\u2019 Physician\u2019s Prayer, which reminds us
\nall that the patient must come \ufb01rst. \u201cMay I
\nnever forget that the patient is a fellow crea-
\nture\/May I never consider him merely a vas-
\nsal of disease.\u201d
\n120
\nWMA news
\nJohn R. Williams, Ph.D., Ethics Advisor,
\nWorld Medical Association, Adjunct Professor,
\nDepartment of Medicine, University of Ot-
\ntawa, Canada
\nIntroduction
\nOn October 18, 2008 the WMA General
\nAssembly, meeting in Seoul, South Korea,
\nvoted overwhelmingly to adopt a new ver-
\nsion of the Declaration of Helsinki (DoH).
\nThe vote marked the end of an 18-month
\nrevision process that involved extensive con-
\nsultation with stakeholders and careful con-
\nsideration of their suggestions for changes.
\nThe \ufb01nal document is available for viewing
\non the WMA website: www.wma.net.
\nThis article will describe the 18-month revi-
\nsion process, the main issues that were con-
\nsidered and the \ufb01nal resolution of these is-
\nsues. It will conclude with some suggestions
\nfor future reviews of the DoH.
\nWhy Revise the DoH
\nThe DoH has been amended several times
\nsince its adoption in 1964. An extensive re-
\nvision process was begun in 1997 and con-
\ncluded with the approval of a new version
\nby the WMA General Assembly in Octo-
\nber 2000. Although the Assembly vote in
\nfavour of the new version was almost unani-
\nmous, it quickly became apparent that some
\nof the paragraphs, especially #29 dealing
\nwith the use of placebos in clinical trials and
\n#30 on access to the bene\ufb01ts of research,
\nwere unclear and\/or contentious. The addi-
\ntion of explanatory notes of clari\ufb01cation to
\nthese paragraphs in 2002 and 2004 did not
\nresolve these di\ufb03culties. Another attempt
\nwas needed.
\nA second reason for revising the DoH was
\nthe changing environment of medical re-
\nsearch. In response to widely publicized
\nscandals involving the testing, approval
\nand marketing of certain drugs that were
\nlater shown to be unsafe, there have been
\nincreased demands for greater transparency
\nin medical research and stronger protection
\nfor research subjects.The DoH\u2019s statements
\non issues such as these required clari\ufb01cation
\nand, perhaps, strengthening.
\nAn additional reason for undertaking a re-
\nvision was to see whether there were gaps
\nthat needed to be \ufb01lled, for example, ethical
\nprinciples for research on human materi-
\nals and data. A \ufb01nal reason was to remove
\ninconsistencies in terminology within the
\nDoH as well as inconsistencies among the
\nthree o\ufb03cial language versions.
\nScope of the Revision
\nThe 2000 version of the DoH was a ma-
\njor revision of the previous (1996) version
\nand included a signi\ufb01cant restructuring of
\nthe document. In contrast, the most recent
\nrevision was intended from the beginning
\nto be relatively minor in scope. In initiating
\nthe revision process at its May 2007 meet-
\ning, the WMA Council wanted to \u201cidentify
\ngaps in the content but avoid a complete re-
\nopening of the document.\u201d There had been
\ngeneral approval and acceptance of the 2000
\nversion, apart from paragraphs 29 and 30,
\nand Council felt that the remainder of the
\ndocument required at most some \ufb01ne-tun-
\ning.As for the two controversial paragraphs,
\nit seemed desirable to integrate the notes of
\nclari\ufb01cation into the body of the document
\nbut any substantive change to the 2000 po-
\nsitions would be unlikely to receive the 75%
\nmajority vote at the General Assembly that
\nis required for adoption or amendment of
\nan ethical statement.
\nProcess
\nThe previous revision took three and a half
\nyears, followed by a further four years de-
\nveloping the two notes of clari\ufb01cation. In
\ncontrast, the May 2007 Council meeting
\napproved a one and a half year timetable
\nfor this revision. It was to be guided by a
\n\ufb01ve-member workgroup and would include
\nthree rounds of stakeholder consultation.
\nThe workgroup was made up of representa-
\ntives from the National Medical Associations
\nof Brazil, Germany, Japan, South Africa and
\nSweden. The chair was Dr. Eva Nilsson-B\u00e5-
\ngenholm of Sweden, who was also the chair
\nof the WMA Medical Ethics Committee,
\nand the coordinator was Professor John Wil-
\nliams from Canada, who had recently retired
\nas WMA\u2019s Director of Ethics.
\nThe \ufb01rst consultation took place from June
\nto August 2007. It consisted of a request
\nfor suggested changes to the DoH that was
\nsent by the WMA Secretariat to National
\nMedical Associations and international re-
\nsearch, medical, health and ethics organiza-
\ntions. National Medical Associations were
\nasked to distribute the request for suggested
\nchanges to organizations in their own coun-
\ntries and to collate the responses for trans-
\nmission to the workgroup.
\n39 responses were received in response to
\nthis request, some many pages in length.
\nThey were considered by the workgroup and
\nsubsequently by the WMA Medical Ethics
\nCommittee at its meeting in Copenhagen in
\nOctober 2007.The Committee\u2019s recommen-
\ndation, subsequently endorsed by the Coun-
\ncil, was for the workgroup to prepare a draft
\nrevision of the DoH for further consultation
\nwith stakeholders and to report back to the
\nCommittee at its May 2008 meeting.
\nRevising the Declaration of Helsinki
\n121
\nWMA news
\nFollowing the Copenhagen meetings
\nthe workgroup completed its draft revi-
\nsion, which was distributed for comment
\nto stakeholders in early November. This
\nround of consultation elicited 46 responses,
\nincluding some from NMAs that repre-
\nsented the consolidated comments of nu-
\nmerous national organizations. During the
\nlast week of February the comments were
\ncollated and a list of controversial issues
\nwas developed to serve as the agenda for a
\nstakeholders\u2019workshop in Helsinki, Finland
\nin March. Immediately after the workshop,
\nthe workgroup met to decide what changes
\nto the November 2007 consultation draft
\nshould be made in consideration of the
\nwritten comments and the workshop dis-
\ncussion. A revised draft was prepared and
\ndiscussed by the Medical Ethics Committee
\nand Council at their May meetings, where
\nseveral changes to the draft were made.
\nA third round of consultation, this time on
\nthe amended revised draft, took place during
\nthe summer of 2008. It included the posting
\nof the draft and an electronic response form
\non the WMA website and stakeholder work-
\nshops in Cairo, Egypt and Sao Paulo, Brazil.
\nThe workgroup met in Sao Paulo immedi-
\nately after that workshop and during the next
\ntwo weeks it considered all the comments
\nthat had been received (80 submissions)
\nand prepared its \ufb01nal draft for the October
\nmeetings of the Medical Ethics Committee,
\nCouncil and General Assembly in Seoul.
\nIssues
\nFrom the three rounds of consultation the
\nWMA received suggestions for changes
\nto every paragraph of the DoH as well as
\nfor additional paragraphs on several topics.
\nSome respondents felt that the document
\nshould be reorganized in a more logical or-
\nder. Others wanted a preamble that would
\nclarify the scope and status of the docu-
\nment, including whether it applied only to
\nphysicians or to all researchers. Still others
\nasked for a fuller treatment of certain topics,
\nfor example,vulnerability,placebos or publi-
\ncation of research results. Terminology was
\nanother issue,for example,\u2018medical research\u2019
\nvs. \u2018biomedical research\u2019, \u2018research subject\u2019
\nvs. \u2018research participant\u2019, \u2018method\u2019 vs. \u2018inter-
\nvention\u2019, \u2018must\u2019 or \u2018should\u2019. Conversely, with
\nvery few exceptions such as paragraphs 29
\nand 30, there was general agreement among
\nrespondents that the DoH\u2019s positions were
\nbasically correct and in no need of funda-
\nmental change.
\nSuggestions for additional topics included
\nthe following: con\ufb02ict of interest; research
\ninvolving human data, including access to
\nthis data; access to participation in research
\nby previously excluded or underutilized pop-
\nulations (e.g., children and pregnant wom-
\nen); international research requirements;
\nwaiver of the consent requirement for some
\nepidemiological studies; individual limits on
\nparticipation in clinical trials; methodology
\nin prevention trials; implications of research
\nstudies for public policy; responsibilities of
\neditors; insurance coverage; consent for use
\nof personal data in publications; consent for
\nreuse of personal data in other studies; and
\naccess to the results of research.
\nOutcome
\nIn evaluating these suggestions, the work-
\ngroup considered that its mandate required
\nit to preserve the order and wording of the
\ncurrent (2004) version of the DoH except
\nwhere clari\ufb01cation was needed or where
\nsigni\ufb01cant gaps existed. Moreover, since
\nthe DoH is primarily a statement of ethical
\nprinciples and not a handbook on how these
\nprinciples should be applied, the workgroup
\ndid not consider it appropriate to make the
\ndocument too detailed. Finally, the work-
\ngroup recognized that there is no consensus
\non a few of the issues treated in the DoH,
\nespecially placebo use and post-trial access,
\nand did not make changes to the previous
\nDoH position on these issues.
\nAlthough the workgroup decided against
\nadding a preamble to the DoH, in the \ufb01rst
\ntwo paragraphs it did specify more clearly
\nthe purpose, scope and intended readership
\nof the document. It also added a sentence to
\nthe \ufb01rst paragraph cautioning against any
\ninterpretation of a paragraph that is incon-
\nsistent with the spirit and intention of the
\nentire document (as had occurred with the
\n2002 Note of Clari\ufb01cation to paragraph 29).
\nThe workgroup\u2019s \ufb01nal draft reinforces,in the
\nface of considerable opposition, the DoH\u2019s
\nlongstanding principle of the priority of the
\nindividual research subject over all other
\ninterests. Far from discouraging medical
\nresearch, however, this principle encourages
\naccess to research for both individuals and
\npopulations,especially those that are under-
\nrepresented in research (an addition in new
\nparagraph 5).
\nThe workgroup was aware that in the 2004
\nversion the paragraphs dealing with the re-
\nsearch protocol and the responsibilities of
\nresearch ethics committees went beyond
\nstatements of principle to include many de-
\ntails, but they decided not to delete any of
\nthese requirements because that might be
\ninterpreted as if the WMA no longer con-
\nsiders them to be important. Instead, these
\ntwo paragraphs were reorganized to distin-
\nguish clearly between what should go in the
\nprotocol (new paragraph 14) and what is
\nrequired of the research ethics committee
\n(new paragraph 15).
\nSince medical research is conducted by
\nother health professionals, e.g., nurses and
\ndentists, as well as by scientists who are not
\nhealth professionals,the role of physicians in
\nsuch research, as described in old paragraph
\n15, needed clari\ufb01cation. The workgroup re-
\nvised this paragraph (new #16) to separate
\nand distinguish two issues: (1) who may
\nconduct medical research \u2013 since medical
\nresearch includes research on human mate-
\nrials and data, some of it can be done by in-
\ndividuals who are not members of a health
\nprofession, as long as they have the appro-
\npriate scienti\ufb01c training and quali\ufb01cations;
\n(2) what research requires supervision by a
\nphysician or other health professional \u2013 re-
\nsearch on patients or healthy volunteers but
\nnot research on human materials or data.
\nA new paragraph 19 has been added that
\nrequires every clinical trial to be registered
\nin a publicly accessible database before re-
\n122
\nWMA news
\ncruitment of the \ufb01rst subject.The workgroup
\ndeclined to elaborate on this principle since
\ntrial registries are still under development.
\nAnother topic on which the previous ver-
\nsion of the DoH goes into considerable
\ndetail is informed consent. Because of the
\ngreat importance of this topic for research
\nethics, the workgroup did not omit any of
\nthe requirements in the previous version
\nand even added some additional ones. It
\nalso distinguished more clearly the consent
\nprocedures for competent and incompetent
\nresearch subjects.
\nOne of the most di\ufb03cult issues facing the
\nworkgroup was whether the requirements for
\nresearch on human material and data should
\nbe the same as for other types of research on
\nhuman subjects. It decided that the DoH
\nshould deal only with identi\ufb01able material
\nor data and that consent for such research
\nmay sometimes be impossible or impracti-
\ncal to obtain or would pose a threat to the
\nvalidity of the research. However, it is not up
\nto researchers to decide this issue; they must
\njustify their request for an exemption to the
\nconsent requirement to the research ethics
\ncommittee (new paragraph 25).
\nAs noted above, the most contentious is-
\nsues during this revision process, as well as
\nthe previous one, were the use of placebos
\nin clinical trials and access to the bene\ufb01ts
\nof research once it is completed. The work-
\ngroup\u2019s \ufb01rst concern was to integrate the
\n2002 and 2004 notes of clari\ufb01cation on these
\nparagraphs in the text of the DoH. It also
\nwanted to preserve the substance of the pre-
\nvious version while clarifying the wording.
\nIts proposed revision achieved both these
\nobjectives but did not resolve the deeply
\nfelt con\ufb02icting views on the two issues that
\nwere expressed in the written comments,
\nat the stakeholders\u2019 workshops and, for the
\nplacebo issue,in the October 2008 meetings
\nof the Medical Ethics Committee and Gen-
\neral Assembly. The General Assembly ad-
\nopted an amendment to the new paragraph
\n32 stating that \u201cExtreme care must be taken
\nto avoid abuse of this option\u201d, i.e., the use of
\nplacebos to determine the e\ufb03cacy or safety
\nof a new intervention where there is already
\na proven intervention.However,this did not
\nsatisfy all the delegates and the new version
\ndid not receive unanimous approval.
\nConclusion
\nThe DoH is regarded as \u201ca living document\u201d
\nand will undoubtedly undergo further review
\nand revision in the future. Although it is too
\nearly to determine the success of the latest
\nrevision,some lessons from this exercise may
\nbe valuable, not just for the WMA but for
\nany organization engaged in policy review.
\nThe three rounds of consultation were very
\nuseful both for soliciting input from those
\na\ufb00ected by the DoH\u2019s provisions and for
\nmaking the document known to a wider au-
\ndience. By considering carefully the sugges-
\ntions of the respondents and sending them
\neach new draft, the WMA demonstrated
\nthat the DoH is not just an internal policy
\nbut rather a universal statement of medical
\nresearch ethics.
\nSetting a tight deadline for the completion
\nof a project such as this revision prevents
\nit from being extended inde\ufb01nitely. This is
\nespecially important for organizations such
\nas the WMA whose policy making bodies
\nmeet just once a year.
\nIn a short document such as the DoH, ev-
\nery word is important. In their discussions
\nof the workgroup\u2019s drafts the WMA Medi-
\ncal Ethics Committee and Council wisely
\nfocussed on the principles and left it to the
\nworkgroup to come up with appropriate
\nwording.The workgroup was able to do this
\ne\ufb03ciently through email exchanges.
\nFinally, since \u201cthe perfect is the enemy of the
\ngood,\u201d it is better to settle for incremental
\nimprovements than to try to achieve the ab-
\nsolute best.Both the structure and the word-
\ning of the revised DoH could undoubtedly be
\nfurther improved but the workgroup felt,and
\nthe General Assembly agreed, that it is good
\nenough for the time being,and is certainly an
\nimprovement over the previous version.
\nDeclaration of Helsinki
\nEthical Principles for Medical Research Involving Human Subjects
\nAdopted by the 18th
\nWMA General Assembly,Helsinki,Finland,June 1964,and amended by the:
\n29th
\nWMA General Assembly,Tokyo, Japan, October 1975
\n35th
\nWMA General Assembly, Venice, Italy, October 1983
\n41st
\nWMA General Assembly, Hong Kong, September 1989
\n48th
\nWMA General Assembly, Somerset West, Republic of South Africa, October 1996
\n52nd
\nWMA General Assembly, Edinburgh, Scotland, October 2000
\n53th
\nWMA General Assembly, Washington, United States, October 2002
\n(Note of Clari\ufb01cation on paragraph 29 added)
\n55th
\nWMA General Assembly,Tokyo, Japan, October 2004
\n(Note of Clari\ufb01cation on Paragraph 30 added)
\nWMA General Assembly, Seoul, Korea, October 2008
\nA. Introduction
\n1. The World Medical Association
\n(WMA) has developed the Declaration
\nof Helsinki as a statement of ethical
\nprinciples for medical research involv-
\ning human subjects, including research
\non identi\ufb01able human material and
\ndata.
\nThe Declaration is intended to be read
\nas a whole and each of its constituent
\nparagraphs should not be applied with-
\nout consideration of all other relevant
\nparagraphs.
\n123
\nWMA news
\n2. Although the Declaration is addressed primarily to physicians,
\nthe WMA encourages other participants in medical research in-
\nvolving human subjects to adopt these principles.
\n3. It is the duty of the physician to promote and safeguard the
\nhealth of patients, including those who are involved in medical
\nresearch. The physician\u2019s knowledge and conscience are dedi-
\ncated to the ful\ufb01lment of this duty.
\n4. The Declaration of Geneva of the WMA binds the physician
\nwith the words, \u201cThe health of my patient will be my \ufb01rst con-
\nsideration,\u201d and the International Code of Medical Ethics de-
\nclares that, \u201cA physician shall act in the patient\u2019s best interest
\nwhen providing medical care.\u201d
\n5. Medical progress is based on research that ultimately must in-
\nclude studies involving human subjects. Populations that are
\nunderrepresented in medical research should be provided ap-
\npropriate access to participation in research.
\n6. In medical research involving human subjects, the well-being
\nof the individual research subject must take precedence over all
\nother interests.
\n7. The primary purpose of medical research involving human sub-
\njects is to understand the causes, development and e\ufb00ects of dis-
\neases and improve preventive, diagnostic and therapeutic inter-
\nventions (methods, procedures and treatments). Even the best
\ncurrent interventions must be evaluated continually through re-
\nsearch for their safety, e\ufb00ectiveness, e\ufb03ciency, accessibility and
\nquality.
\n8. In medical practice and in medical research, most interventions
\ninvolve risks and burdens.
\n9. Medical research is subject to ethical standards that promote re-
\nspect for all human subjects and protect their health and rights.
\nSome research populations are particularly vulnerable and need
\nspecial protection.These include those who cannot give or refuse
\nconsent for themselves and those who may be vulnerable to co-
\nercion or undue in\ufb02uence.
\n10. Physicians should consider the ethical, legal and regulatory
\nnorms and standards for research involving human subjects in
\ntheir own countries as well as applicable international norms
\nand standards. No national or international ethical, legal or
\nregulatory requirement should reduce or eliminate any of the
\nprotections for research subjects set forth in this Declaration.
\nB. Principles for all Medical Research
\n11. It is the duty of physicians who participate in medical research
\nto protect the life, health, dignity, integrity, right to self-deter-
\nmination, privacy, and con\ufb01dentiality of personal information of
\nresearch subjects.
\n12. Medical research involving human subjects must conform to
\ngenerally accepted scienti\ufb01c principles, be based on a thorough
\nknowledge of the scienti\ufb01c literature, other relevant sources of
\ninformation, and adequate laboratory and, as appropriate, ani-
\nmal experimentation. The welfare of animals used for research
\nmust be respected.
\n13. Appropriate caution must be exercised in the conduct of medi-
\ncal research that may harm the environment.
\n14. The design and performance of each research study involving
\nhuman subjects must be clearly described in a research protocol.
\nThe protocol should contain a statement of the ethical consid-
\nerations involved and should indicate how the principles in this
\nDeclaration have been addressed. The protocol should include
\ninformation regarding funding, sponsors, institutional a\ufb03lia-
\ntions, other potential con\ufb02icts of interest, incentives for subjects
\nand provisions for treating and\/or compensating subjects who
\nare harmed as a consequence of participation in the research
\nstudy.The protocol should describe arrangements for post-study
\naccess by study subjects to interventions identi\ufb01ed as bene\ufb01cial
\nin the study or access to other appropriate care or bene\ufb01ts.
\n15. The research protocol must be submitted for consideration,
\ncomment, guidance and approval to a research ethics committee
\nbefore the study begins. This committee must be independent
\nof the researcher, the sponsor and any other undue in\ufb02uence.
\nIt must take into consideration the laws and regulations of the
\ncountry or countries in which the research is to be performed as
\nwell as applicable international norms and standards, but these
\nmust not be allowed to reduce or eliminate any of the protec-
\ntions for research subjects set forth in this Declaration. The
\ncommittee must have the right to monitor ongoing studies.The
\nresearcher must provide monitoring information to the com-
\nmittee, especially information about any serious adverse events.
\nNo change to the protocol may be made without consideration
\nand approval by the committee.
\n16. Medical research involving human subjects must be conduct-
\ned only by individuals with the appropriate scienti\ufb01c training
\nand quali\ufb01cations. Research on patients or healthy volunteers
\nrequires the supervision of a competent and appropriately quali-
\n\ufb01ed physician or other health care professional.The responsibil-
\nity for the protection of research subjects must always rest with
\nthe physician or other health care professional and never the
\nresearch subjects, even though they have given consent.
\n17. Medical research involving a disadvantaged or vulnerable popu-
\nlation or community is only justi\ufb01ed if the research is responsive
\nto the health needs and priorities of this population or commu-
\nnity and if there is a reasonable likelihood that this population or
\ncommunity stands to bene\ufb01t from the results of the research.
\n18. Every medical research study involving human subjects must be
\npreceded by careful assessment of predictable risks and burdens
\nto the individuals and communities involved in the research in
\ncomparison with foreseeable bene\ufb01ts to them and to other indi-
\nviduals or communities a\ufb00ected by the condition under investi-
\ngation.
\n19. Every clinical trial must be registered in a publicly accessible
\ndatabase before recruitment of the \ufb01rst subject.
\n124
\nWMA news
\n20. Physicians may not participate in a research study involving hu-
\nman subjects unless they are con\ufb01dent that the risks involved
\nhave been adequately assessed and can be satisfactorily man-
\naged. Physicians must immediately stop a study when the risks
\nare found to outweigh the potential bene\ufb01ts or when there is
\nconclusive proof of positive and bene\ufb01cial results.
\n21. Medical research involving human subjects may only be con-
\nducted if the importance of the objective outweighs the inherent
\nrisks and burdens to the research subjects.
\n22. Participation by competent individuals as subjects in medical
\nresearch must be voluntary. Although it may be appropriate to
\nconsult family members or community leaders, no competent
\nindividual may be enrolled in a research study unless he or she
\nfreely agrees.
\n23. Every precaution must be taken to protect the privacy of re-
\nsearch subjects and the con\ufb01dentiality of their personal infor-
\nmation and to minimize the impact of the study on their physi-
\ncal, mental and social integrity.
\n24. In medical research involving competent human subjects, each
\npotential subject must be adequately informed of the aims,
\nmethods, sources of funding, any possible con\ufb02icts of interest,
\ninstitutional a\ufb03liations of the researcher, the anticipated ben-
\ne\ufb01ts and potential risks of the study and the discomfort it may
\nentail, and any other relevant aspects of the study.The potential
\nsubject must be informed of the right to refuse to participate
\nin the study or to withdraw consent to participate at any time
\nwithout reprisal. Special attention should be given to the spe-
\nci\ufb01c information needs of individual potential subjects as well
\nas to the methods used to deliver the information. After ensur-
\ning that the potential subject has understood the information,
\nthe physician or another appropriately quali\ufb01ed individual must
\nthen seek the potential subject\u2019s freely-given informed consent,
\npreferably in writing.If the consent cannot be expressed in writ-
\ning, the non-written consent must be formally documented and
\nwitnessed.
\n25. For medical research using identi\ufb01able human material or data,
\nphysicians must normally seek consent for the collection, analy-
\nsis, storage and\/or reuse.There may be situations where consent
\nwould be impossible or impractical to obtain for such research
\nor would pose a threat to the validity of the research. In such
\nsituations the research may be done only after consideration and
\napproval by a research ethics committee.
\n26. When seeking informed consent for participation in a research
\nstudy the physician should be particularly cautious if the poten-
\ntial subject is in a dependent relationship with the physician or
\nmay consent under duress. In such situations the informed con-
\nsent should be sought by an appropriately quali\ufb01ed individual
\nwho is completely independent of this relationship.
\n27. For a potential research subject who is incompetent, the physi-
\ncian must seek informed consent from the legally authorized
\nrepresentative. These individuals must not be included in a re-
\nsearch study that has no likelihood of bene\ufb01t for them unless it is
\nintended to promote the health of the population represented by
\nthe potential subject, the research cannot instead be performed
\nwith competent persons, and the research entails only minimal
\nrisk and minimal burden.
\n28. When a potential research subject who is deemed incompetent
\nis able to give assent to decisions about participation in research,
\nthe physician must seek that assent in addition to the consent
\nof the legally authorized representative. The potential subject\u2019s
\ndissent should be respected.
\n29. Research involving subjects who are physically or mentally inca-
\npable of giving consent, for example, unconscious patients, may
\nbe done only if the physical or mental condition that prevents
\ngiving informed consent is a necessary characteristic of the re-
\nsearch population. In such circumstances the physician should
\nseek informed consent from the legally authorized representa-
\ntive.If no such representative is available and if the research can-
\nnot be delayed,the study may proceed without informed consent
\nprovided that the speci\ufb01c reasons for involving subjects with a
\ncondition that renders them unable to give informed consent
\nhave been stated in the research protocol and the study has been
\napproved by a research ethics committee. Consent to remain in
\nthe research should be obtained as soon as possible from the
\nsubject or a legally authorized representative.
\n30. Authors, editors and publishers all have ethical obligations with
\nregard to the publication of the results of research. Authors have
\na duty to make publicly available the results of their research on
\nhuman subjects and are accountable for the completeness and
\naccuracy of their reports.They should adhere to accepted guide-
\nlines for ethical reporting. Negative and inconclusive as well as
\npositive results should be published or otherwise made publicly
\navailable. Sources of funding, institutional a\ufb03liations and con-
\n\ufb02icts of interest should be declared in the publication. Reports
\nof research not in accordance with the principles of this Decla-
\nration should not be accepted for publication.
\nC. Additional Principles for Medical Research
\nCombined With Medical Care
\n31. The physician may combine medical research with medical care
\nonly to the extent that the research is justi\ufb01ed by its potential
\npreventive, diagnostic or therapeutic value and if the physician
\nhas good reason to believe that participation in the research
\nstudy will not adversely a\ufb00ect the health of the patients who
\nserve as research subjects.
\n32. The bene\ufb01ts, risks, burdens and e\ufb00ectiveness of a new interven-
\ntion must be tested against those of the best current proven in-
\ntervention, except in the following circumstances:
\nThe use of placebo, or no treatment, is acceptable in studies\u2022
\nwhere no current proven intervention exists; or
\nWhere for compelling and scienti\ufb01cally sound methodological\u2022
\nreasons the use of placebo is necessary to determine the e\ufb03cacy
\n125
\nWMA news
\nMore than 200 delegates from 42 Na-
\ntional Medical Associations attended the
\n2008 General Assembly held at The Shilla,
\nSeoul,in the Republic Korea from 15th
\n-18th
\nOctober 2008.
\nThe four-day event, hosted by the Korean
\nMedical Association in its centennial year,
\ncomprised three committee meetings, two
\nCouncil meetings, the General Assembly,
\nreceptions, luncheon and evening seminars.
\nDuring the event there were visits at vari-
\nous stages from the President and the Prime
\nMinister of Korea, as well as the Minister
\nfor Health, Welfare and Family A\ufb00airs.The
\nagenda for the formal meetings was one of
\nthe longest ever and inevitably the debates
\nin committee, Council and Assembly were
\ndominated by discussion on revisions to the
\nDeclaration of Helsinki.
\nWhen the Assembly met on the \ufb01nal day,
\nunder the brisk, but avuncular chairman-
\nship of Dr. Edward Hill, it adopted a host
\nof new and revised policies. In addition to
\nthe revised Declaration of Helsinki, there
\nwere documents on autonomy, on antimi-
\ncrobial agents, mercury, sodium, the access
\nof women to health, on capital punishment,
\nnuclear weapons and anti-personnel mines,
\non the economic crisis, poppies and veteri-
\nnary medicine.
\nMedical Ethics
\nThe Assembly adopted three documents
\nfrom the Medical Ethics Committee,
\nwhich had been chaired by Dr. Eva B\u00e5gen-
\nholm.In addition to the revised Declaration
\nof Helsinki, it adopted a new Declaration
\non Professional Autonomy and Clinical
\nIndependence and decided to name it the
\nDeclaration of Seoul. The document is a
\nsuccessor to the 1987 Declaration of Ma-
\ndrid, incorporating new issues based on
\na document written by Dr. Je\ufb00 Blackmer
\nfrom the Canadian Medical Association.
\nThe new policy states that unreasonable re-
\nstraints on physicians\u2019clinical independence
\nimposed by governments and administrators
\nare not in the best interests of patients and
\ncan damage the trust which is an essential
\ncomponent of the patient\u2013physician rela-
\ntionship. However the document adds that
\nphysicians recognize they must take into ac-
\ncount the structure of the health system and
\navailable resources. It declares that the cen-
\ntral element of professional autonomy and
\nclinical independence is the assurance that
\nindividual physicians have the freedom to
\nor safety of an intervention and the patients who receive pla-
\ncebo or no treatment will not be subject to any risk of serious or
\nirreversible harm. Extreme care must be taken to avoid abuse
\nof this option.
\n33. At the conclusion of the study, patients entered into the study
\nare entitled to be informed about the outcome of the study and
\nto share any bene\ufb01ts that result from it, for example, access to
\ninterventions identi\ufb01ed as bene\ufb01cial in the study or to other ap-
\npropriate care or bene\ufb01ts.
\n34. The physician must fully inform the patient which aspects of
\nthe care are related to the research. The refusal of a patient to
\nparticipate in a study or the patient\u2019s decision to withdraw from
\nthe study must never interfere with the patient-physician rela-
\ntionship.
\n35. In the treatment of a patient, where proven interventions do not
\nexist or have been ine\ufb00ective, the physician, after seeking ex-
\npert advice, with informed consent from the patient or a legally
\nauthorized representative, may use an unproven intervention
\nif in the physician\u2019s judgement it o\ufb00ers hope of saving life, re-
\nestablishing health or alleviating su\ufb00ering. Where possible, this
\nintervention should be made the object of research, designed
\nto evaluate its safety and e\ufb03cacy. In all cases, new information
\nshould be recorded and, where appropriate, made publicly avail-
\nable.
\nWMA General Assembly, Seoul 2008
\n126
\nWMA news
\nexercise their professional judgment in the
\ncare and treatment of their patients without
\nundue in\ufb02uence by outside parties or indi-
\nviduals. Patients expected their physicians
\nto be free to make clinically appropriate rec-
\nommendations.Hospital administrators and
\nthird-party payers may consider physician
\nprofessional autonomy to be incompatible
\nwith prudent management of health care
\ncosts. However, the restraints that adminis-
\ntrators and third-party payers attempted to
\nplace on clinical independence might not be
\nin the best interests of patients.
\nIn a press statement, Dr. Edward Hill said:
\n\u201cIn this new Declaration we are rea\ufb03rming
\nthe importance of professional autonomy and
\nclinical independence.We see this not only as
\nan essential component of high quality medi-
\ncal care and therefore a bene\ufb01t to the patient
\nthat must be preserved,but also as an essential
\nprinciple of medical professionalism.\u201d
\nThe Assembly also adopted revisions to the
\nWMA Statement on Physician Participa-
\ntion in Capital Punishment, which was
\n\ufb01rst adopted in 1981 and then amended in
\n2000. The revised document urges NMA
\nmembers to lobby actively their national
\ngovernments and legislators against any
\nparticipation of physicians in capital pun-
\nishment. The Statement states that it is un-
\nethical for physicians to participate in capi-
\ntal punishment in any way, including the
\nplanning and instruction and\/or training of
\npeople to perform executions.
\nSocio-Medical A\ufb00airs
\nNo fewer than eight policy documents ema-
\nnating from the Socio-Medical A\ufb00airs Com-
\nmittee, chaired by Dr. J.L. Gomes do Ama-
\nral, were adopted by the Assembly.
\nThe Statement on Antimicrobial Drugs
\nupdates Association policy adopted in 1996
\nfollowing revisions prepared by the Ameri-
\ncan Medical Association. The new State-
\nment declares that antimicrobial agents
\nshould be available only through a pre-
\nscription provided by licensed and quali\ufb01ed
\nhealth care or veterinary professionals. It
\nwarns that the global increase in resistance
\nto antimicrobial drugs has created a multi-
\nfaceted public health problem of crisis pro-
\nportions with signi\ufb01cant economic and hu-
\nman implications. It also says that the use
\nof antimicrobial agents as feed additives
\nfor animals should be strictly restricted to
\nthose antimicrobials that do not have a hu-
\nman public health impact. The Statement
\ncontains a warning that there is substan-
\ntial misuse and overuse of antimicrobial
\nagents, inappropriate prescribing, and poor
\ncompliance with antimicrobial regimens by
\npatients. The Association plans to continue
\nto work with George Mason University in
\nVirginia, USA to monitor and develop this
\nissue.
\nThree new Statements were adopted. The
\nStatement on Reducing the Global Bur-
\nden of Mercury, initiated by the American
\nMedical Association and based on work by
\nDr. Peter Orris, Professor of Occupational
\nand Environmental Medicine at the Uni-
\nversity of Illinois, Chicago Medical Cen-
\ntre. The Statement calls for the phasing
\nout of mercury use in the health care sec-
\ntor. It says hospitals and medical facilities
\nshould switch to non-mercury equivalents.
\nThis would involve eliminating mercury-
\ncontaining products such as thermometers,
\nsphygmomanometers,gastrointestinaltubes,
\nbatteries, lamps, electrical supplies, thermo-
\nstats, pressure gauges, and other laboratory
\nreagents and devices. The Statement urges
\nphysicians to counsel patients about \ufb01sh
\nconsumption in order to emphasise those
\n\ufb01sh high in omega 3 fatty acids for their
\nvalue to heart and brain health and low in
\nmercury contamination. This was particu-
\nlarly necessary for children and women of
\nchildbearing age.
\nA new Statement on Reducing Dietary
\nSodium Intake calls for a \ufb01fty per cent re-
\nduction in the sodium content of processed
\nfoods, fast food products and restaurant
\nmeals over the next decade. Citing over-
\nwhelming evidence that excessive sodium\/
\nsalt intake is a risk factor for the worsening
\nof hypertension and cardiovascular diseases,
\nit urges physicians to advise patients on how
\nto reduce sodium\/salt intake, including re-
\nducing the amount of salt used in cooking
\nat home.
\nA new Statement was also adopted on
\nCollaboration between Human and Vet-
\nerinary Medicine encouraging NMAs to
\nengage in a dialogue with their veterinary
\ncounterparts to discuss strategies for en-
\nhancing collaboration between human and
\nveterinary medical professions within their
\nown countries.
\n127
\nWMA news
\nThe revised Resolution on The Prohibition
\nofAccessofWomentoHealthCareandthe
\nProhibition of Practice by Female Doctors
\nsupports the rights of women and children
\nto full and adequate medical care, especially
\nwhere religious and cultural restrictions
\nhinder access to such medical care. It urges
\nNMAs to condemn violations of the basic
\nhuman rights of women and children. It says
\nthat for years women and girls worldwide
\nhave been su\ufb00ering increasing violations of
\ntheir human rights, including restrictions to
\naccess to employment, education and health
\ncare. In many countries female doctors and
\nnurses have been prevented from exercising
\ntheir profession, leading to female patients
\nand their children not having access to health
\ncare. Finally the Resolution urges NMAs to
\nincrease the e\ufb00ective participation of women
\nin the medical profession.
\nThe Assembly also adopted a Resolu-
\ntion on Poppies for Medicine Project for
\nAfghanistan, which supports calls for in-
\nvestigating the controlled production of
\nopium for medical purposes in Afghanistan.
\nThe Resolution urges governments to sup-
\nport a scienti\ufb01c pilot project to investigate
\nwhether certain areas of Afghanistan could
\nprovide the right conditions for the strictly
\ncontrolled production of morphine and di-
\namorphine for medical purposes.
\nThe Assembly adopted the revised State-
\nment on Nuclear Weapons, asking NMAs
\nto urge their respective governments to
\nwork towards the elimination of nuclear
\nweapons, and a Resolution Supporting the
\nOttawa Convention on Prohibition of the
\nUse, Stockpiling, Production and Trans-
\nfer of Anti-Personnel Mines and on their
\nDestruction.
\nFinally the Assembly adopted an emergency
\nResolution from Council on The Econom-
\nic Crisis: Implications for Health urging
\nNMAs to work with their governments to
\ninitiate programmes for families and indi-
\nviduals needing medical and psychological
\nsupport because of the current economic
\ncrisis and to preserve at least the current ex-
\npenditure on health.
\nNew work groups were set up on stem cell
\nresearch, con\ufb02ict of interest, the placebo
\nissue and the development of Associate
\nMembers\u2019meetings.Dr.G.Dumont was re-
\nelected Chair of the Associates Committee.
\nApplications for membership were accepted
\nfrom no less than eight national medical as-
\nsociations – Albania, Angola, Cote d\u2019Ivoire,
\nCyprus, Mali, Senegal, Poland and Ukraine,
\nbringing the total number of NMA mem-
\nbers to 94.
\nIn relation to future General Assemblies,
\nit was agreed that next year\u2019s scienti\ufb01c ses-
\nsion in Mumbai, India should be on \u2018Multi-
\nDrug Resistant Tuberculosis and Lessons
\nLearned from this Epidemic\u2019 and that the
\nscienti\ufb01c session in Vancouver in 2010
\nshould be \u2018Health and the Environment\u2019.
\nIt was agreed that the 2011 General As-
\nsembly should be held in Uruguay and the
\n2012 Assembly in Thailand.
\nPresidential addresses
\nDuring the Assembly, Dr. Yoram Blachar,
\nPresident of the Israeli Medical Association,
\nwas installed as President for 2008\/9. In his
\ninaugural address he issued a plea for action
\nto shield the world\u2019s health care systems as
\nmuch as possible from the aftershock of the
\nglobal \ufb01nancial turmoil and the economic
\nrecession. He said the WMA and National
\nMedical Associations must act to moderate
\nthe destructive impact of the \ufb01nancial crisis.
\nHe spoke about the intolerable phenom-
\nenon of health disparities. They had always
\nexisted both among and within countries,
\nbut the gaps were widening.The WMA and
\nindividual physicians had a role to play in
\ncombating this problem.
\nHe said that doctors as social leaders had a
\nresponsibility to address a wider scope of is-
\nsues a\ufb00ecting health, such as armed con\ufb02ict.
\nThe WMA had a unique opportunity, with
\nboth ability and positioning to try to bring
\ncon\ufb02icting parties to the discussion table by
\nencouragement and dialogue within its or-
\nganization. In his own region of the Middle
\nEast, he said he would use his Presidency to
\nmake every e\ufb00ort to turn health and medi-
\ncine on an organizational level to a bridging
\nforce and to advance the peace process the
\nregion so desperately needed.
\nDr. Jon Snaedal, in his valedictory address
\nas President for 2007\/8 warned that the
\nglobal economic crisis could lead to health
\nauthorities saving costs by shifting tasks
\naway from doctors to other health profes-
\nsionals. He said that the WMA was now
\ndiscussing this whole issue with the World
\nHealth Organisation and with the other
\nhealth professions. Unity among the health
\nprofessions would result in more e\ufb00ective
\nchanges. He announced that the WMA
\nwould be organising a meeting in Iceland
\nnext March, to look in further detail at hu-
\nman resources for health, task shifting and
\ninterprofessional relations.
\nDr. Dana Hanson, a dermatologist from
\nNew Brunswick in Canada, was elected un-
\nopposed as President for 2009\/10, the \ufb01rst
\nCanadian to be elected President. Dr. Han-
\nson, a former president of the Canadian
\nMedical Association, has practiced as a
\ndermatologist in Fredericton, the capital
\nof New Brunswick, since 1980. He said he
\nplanned to focus his Presidency on advoca-
\ncy, both for patients and physicians, and on
\n128
\nWMA news
\nhealth and the environment.The last Cana-
\ndian President of the WMA was Dr.Arthur
\nPeart, secretary general of the Canadian
\nMedical Association, in 1971, although it is
\nnot thought he was elected to the post.
\nIn an Open session at the conclusion of the
\nAssembly, Michael Maves, Executive Vice
\nPresident of the American Medical Associa-
\ntion,spoke about the work on task shifting in
\nthe US,which in America,he said,was called
\nscope of practice. What the AMA and other
\nmedical organisations were trying to do was
\nrestrict inappropriate expansion of scope of
\npractice by allied health personnel through
\nlegislative activities, regulatory activities and
\njudicial advocacy.He said they were trying to
\nput together a campaign to highlight for the
\npublicthosecharacteristicsthatdistinguished
\nphysicians from other health personnel.
\nIn addition to the formal business of the
\nAssembly,there were three important fringe
\nevents.
\nAt an evening seminar, the launch was an-
\nnounced of the WMA Physicians Leader-
\nship Course, a global, annual programme to
\nenhance physician leadership skills in advo-
\ncating for health care reform and achieving
\nimproved patient care. Nominated through
\ntheir NMAs, 32 top physician leaders rep-
\nresenting 20 countries are to be selected by
\nthe WMA to participate in the high-level
\ntraining conducted by INSEAD, one of the
\nworld\u2019s leading and largest graduate busi-
\nness schools. The six-day intensive curricu-
\nlum will focus on pro\ufb01ciency in decision-
\nmaking, participation in public debate and
\npreparation to serve as spokespersons on key
\nhealth care policy issues.The Course was de-
\nveloped from a pilot programme created last
\nyear and is sponsored by a grant from the
\nP\ufb01zer Medical Partnerships Initiative.
\nThe seminar heard a welcome speech by
\nDr. Yank D. Coble Jr., Past President of the
\nWMA, and presentations by Dr. Robert
\nMiglani, Senior Director, P\ufb01zer, and
\nDr. Ruth Collins-Nakai, Alumni of 1st
\nIN-
\nSEAD Leadership Course, who reviewed
\ncontent and participants ratings.
\nA lunchtime event was held to launch a
\nnew speaking book,designed to explain the
\nrights and responsibilities of people enter-
\ning into clinical trials in Africa.The book is
\naimed at patients and their relatives who do
\nnot read and write su\ufb03ciently well to un-
\nderstand what a clinical trial is for and how
\nit works. The project has been developed by
\nBooks of Hope together with the World
\nMedical Association, the Steve Biko Cen-
\ntre of Bioethics, the South African Medi-
\ncal Association and funded by P\ufb01zer. It is
\nplanned to distribute 4,500 books in South
\nAfrica and three other Sub-Saharan coun-
\ntries before the end of 2008.
\nA second lunchtime symposium was held on
\nsmoking cessation under the title \u2018The Criti-
\ncal Role of Physicians in Helping Smokers
\nQuit\u2019. With tobacco use projected to cause
\none billion premature deaths in the 21st cen-
\ntury, speakers spoke about the importance
\nof the global health community \ufb01ghting to
\nreduce the tobacco death toll by implement-
\ning the Framework Convention on Tobacco
\nControl (FCTC), whose provisions call for
\ncountries to take strong action against to-
\nbacco use. The symposium, supported by an
\nunrestricted educational grant from GlaxoS-
\nmithKline Consumer Healthcare, heard pre-
\nsentations from Dr. Il Suh, Dean of Yonsei
\nUniversity College of Medicine,Korea,on the
\nsuccess story of an anti-smoking campaign in
\na developing country with high prevalence of
\ncigarette smoking,Dr.Ron Davis,Immediate
\npast president of the American Medical As-
\nsociation, on physician intervention and how
\nto make a di\ufb00erence, and Dr. Chi Pang We,
\nProfessor at the National Health Research
\nInstitutes, in Taiwan on overcoming barriers
\nto smoking cessation.
\nThe all-day Scienti\ufb01c Session on the topic
\nof \u2018Health and Human Rights\u2019 included
\npresentations on Health and Human
\nRights from the Social Perspective, Health
\nand Human Rights from the Environmen-
\ntal Perspective and Medical Ethics and Hu-
\nman Rights Advocacy.
\nOne notable absentee from the meeting in
\nSeoul was Dr. Mukesh Haikerwal, Chair of
\nthe Finance and Planning Committee, who
\nwas recovering at home in Australia after
\nbeing the victim of a street attack in his
\nhome city of Melbourne. He had su\ufb00ered
\nserious head injuries and was now recuper-
\nating. Delegates sent their good wishes to
\nDr. Haikerwal and in support the meeting
\nrea\ufb03rmed the WMA\u2019s 2003 Statement on
\nViolence and Health.
\nNigel Duncan
\nThe full texts of all the Declarations,
\nStatments and Resolutions my be accessed on
\nthe WMA website wma@wma.net
\nAdopted by the WMA General Assembly, Seoul, Korea, October 2008
\nThe current global economic crisis is a\ufb00ecting individuals as well
\nas national and global economies and will have implications for
\nhealth. Individuals face uncertainties about their future and psy-
\nchological consequences are beginning to emerge. Governments
\nfacing economic downturns have to respond by cutting down na-
\ntional expenses. There is a risk that expenditure on health care will
\ndecrease nominally and proportionally in the coming years. Experi-
\nence has shown that this response can have serious consequences on
\nthe health of individuals and on their contribution to the national
\neconomy. Any savings will therefore be reduced.
\nThe WMA therefore urges NMAs to work with their governments
\nto:
\nInitiate programs for families and individuals needing medical\u2022
\nand psychological support because of the current economic crisis.
\nPreserve at least the current expenditure on health.\u2022
\nResolution on the Economic
\nCrisis: Implications for Health
\n129
\nWMA news
\nAdopted by the WMA General Assembly, Seoul, Korea, October 2008
\nThe World Medical Association, having explored the importance of
\nprofessional autonomy and physician clinical independence, hereby
\nadopts the following principles:
\nThe central element of professional autonomy and clinical in-\u2022
\ndependence is the assurance that individual physicians have the
\nfreedom to exercise their professional judgment in the care and
\ntreatment of their patients without undue in\ufb02uence by outside
\nparties or individuals.
\nMedicine is a highly complex art and science.Through lengthy train-\u2022
\ning and experience, physicians become medical experts and healers.
\nWhereas patients have the right to decide to a large extent which
\nmedical interventions they will undergo,they expect their physicians
\nto be free to make clinically appropriate recommendations.
\nAlthough physicians recognize that they must take into account\u2022
\nthe structure of the health system and available resources, unrea-
\nsonable restraints on clinical independence imposed by govern-
\nments and administrators are not in the best interests of patients,
\nnot least because they can damage the trust which is an essential
\ncomponent of the patient\u2013physician relationship.
\nHospital administrators and third-party payers may consider\u2022
\nphysician professional autonomy to be incompatible with prudent
\nmanagement of health care costs. However, the restraints that ad-
\nministrators and third-party payers attempt to place on clinical
\nindependence may not be in the best interests of patients. Fur-
\nthermore,restraints on the ability of physicians to refuse demands
\nby patients or their families for inappropriate medical services are
\nnot in the best interests of either patients or society.
\nThe World Medical Association rea\ufb03rms the importance of\u2022
\nprofessional autonomy and clinical independence not only as an
\nessential component of high quality medical care and therefore
\na bene\ufb01t to the patient that must be preserved, but also as an
\nessential principle of medical professionalism. The World Medi-
\ncal Association therefore re-dedicates itself to maintaining and
\nassuring the continuation of professional autonomy and clinical
\nindependence in the care of patients.
\nDeclaration of Seoul on
\nProfessional Autonomy and
\nClinical Independence
\nA new speaking book, designed to explain the rights and responsi-
\nbilities of people entering into clinical trials, has been launched for
\nuse in Africa.
\nThe book to be launched at the World Medical Association\u2019s Gen-
\neral Assembly in Seoul, South Korea, is aimed at patients and their
\nrelatives who do not read and write su\ufb03ciently well to understand
\nwhat a clinical trial is for and how it works.
\nThe \u2018speaking book\u2019 has an audio component that corresponds to
\ntext and illustrations in the book. A simple button on the book be-
\ngins a conversation on rights,roles and responsibilities of patients in
\nrelation to their potential participation in a clinical trial. The book
\ncan be used by patients, social workers and community based health
\nworkers involved in clinical trials.
\nThe project has been developed by Books of Hope together with the
\nWorld Medical Association,the Steve Biko Centre of Bioethics,the
\nSouth African Medical Association and funded by P\ufb01zer.
\nDr. Kgosi Letlape, Chair of the South African Medical Association,
\nsaid: \u2018Animation and cartoons help to break down the barriers of com-
\nmunication and most people feel comfortable with educational material
\npresented in this form.If you cannot understand the words,you can get
\nthe meaning from the pictures.\u2019
\nDr. Edward Hill, Chair of Council, WMA, said: \u2018More than ever it
\nis necessary to do research, with, in and \u2013 most important – for poor
\npopulations.I applaud the production of the speaking book,because
\nit means paying more attention to the poorer communities of this
\nworld instead of abandoning them or just ignoring their needs.\u2019
\nIt is planned to distribute 4,500 books in South Africa and three
\nother Sub-Saharan countries before the end of 2008. Following the
\nlaunch,the book will be presented to internal and external organiza-
\ntions with the aim of assessing additional international need.
\nP\ufb01zer\u2019s vice president Dr. Jack Watters, said: \u201cIt is absolutely crucial
\nthat all people involved in clinical research \u2013 whether as a health
\nprofessional, an ethics committee member or as a patient – have the
\nnecessary knowledge and\/or skills to play their role. That e\ufb00ort is
\nsigni\ufb01cantly supported by this book.\u2019
\nNew Speaking Book on Clinical
\nTrials Aimed at African Populations
\nwith low Literacy Level
\n130
\nWMA news
\nFinance and Planning Committee
\nThe committee was opened by the Chair,Dr.
\nHaikerwal, who commented that the Exec-
\nutive had met monthly, following which the
\nminutes of the last meeting were adopted.
\nFinance
\nThe reports on membership dues and the
\noral report on dues areas were received.
\nThe pre-audited \ufb01nancial statement for
\n2007 was presented by Mr. Halmayr; he in-
\ndicated that improvement over the 2006-7
\nposition was sustained and referred to the
\nincrease in sta\ufb00 which had now returned to
\nits normal level, commenting that in rela-
\ntion to the Advocacy adviser the generous
\nassistance of the AMA had reduced the
\ncost. He further said that the costs of the
\nCouncil meeting in Berlin, despite the in-
\ncreased size of the council, were less than
\nthe benchmark set for meetings not held in
\nDivonne. The committee received a report
\nfrom the Business Development Group in-
\ncluding a report on the development of the
\nWeb Portal and the Secretary General ex-
\npressed his special thanks to the CMA for
\ntheir work on this.
\nBusiness Development Group
\nThe committee received a report from the
\nBusiness Development Group on the Seoul
\nGeneral Assembly.
\nFuture meetings
\nThe committee received reports on future
\nplans for meetings as follows:
\n2008 General Assembly:
\nThe committee heard a report on the forth-
\ncoming General Assembly in Seoul outlin-
\ning the scienti\ufb01c programme on Health and
\nHuman Rights, which was considered to be
\nvery exciting.
\n182nd
\nCouncil:
\n2009 GeneralAssemblyinMumbai,India,
\non which Dr. Desai gave a presentation &
\n\ufb01lm. The IMA proposal that the Scienti\ufb01c
\nSession be Multi Drug Resistant Tubercu-
\nlosis was recommended to and approved by
\nCouncil
\n2010 General Assembly, Vancouver, Can-
\nada.The CMA proposed the Scienti\ufb01c Ses-
\nsion to be on Human Health and the En-
\nvironment which was recommended to and
\napproved by Council.
\nIndications were given of o\ufb00ers to host the
\nGeneral Assembly from Uruguay in 2011
\nand from Australia in 2012.
\nWMA O\ufb03ce
\nThe Secretary General gave an oral report
\non necessary renovation and possible rent-
\ning\/selling of part of the o\ufb03ce space surplus
\nto needs following which there was a gen-
\neral discussion.It was made clear the appro-
\npriate expert advice would be sought which
\nwould be passed to the Executive commit-
\ntee and Chair of Council.
\nConduct of business
\nDuring a discussion of the conduct of busi-
\nness introduced by Dr. Waikerwal, he re-
\nported to council a number of points had
\nbeen made which could improve the con-
\nduct of business.
\nMembership
\nThe following applications for membership
\nof the WMA were recommended and later
\napproved by Council to be forwarded to
\nthe General Assembly
\nUkrainian Medical Association\u2022
\nNational Order of Physicians of C\u00f4te\u2022
\nd\u2019Ivoire
\nNational Order of Physicians of Sen-\u2022
\negal
\nNational Order of Physicians of Mali\u2022
\nCyprus Medical Association (pending\u2022
\nlegal approval of the statutes)
\nThe Secretary reported on the Albanian Or-
\nder of Physicians whose statutes conformed
\nwith the requirements and from whom an
\napplication would be received for the next
\nmeeting.
\nThe committee received a report on the As-
\nsociate Membership and the Chair of Coun-
\ncil reported that Drs. Ishii and Johnson had
\nagreed to undertake a thorough analysis of
\nthe associate membership and report to the
\nnext meeting of the committee.
\nWMJ
\nThe committee had an oral report from the
\nnew Editor of the WMJ Dr. Peteris Api-
\nnis, explaining his new presentation and
\nthe changed design. He again encouraged
\nNMAs to write about themselves, called
\nfor cooperation with those responsible for
\nnational association publications and also
\nsought cooperation with regional medical
\nassociation organisations such as Confermel
\netc. Speaking of design and layout he had
\nintroduced pictures of countries relating to
\nthe country to be presented each issue. The
\nkey words for policy were \u201cInformative\u201dand
\n\u201cInterdisciplinary\u201d
\nDr.Kloiber reported that the Business Group
\nhad recommended and discussed the content
\nand development of the WMJ and provided
\nits guidance.It suggested that there would be
\nvalue in exploring the niche for this publica-
\ntion and considered that a full scienti\ufb01c peer
\nreviewed publication was not the preferred
\noption for the WMJ. Dr. Kloiber thanked
\nDr. Apinis, Dr. Rowe and Professor Dop-
\npelfeld for their work on the Journal.
\nThe committee received the report of the
\nPress O\ufb03cer, Nigel Duncan who requested
\n179th
\nCouncil meeting
\n(Part 2) [continued from WMJ54 (3)]
\n131
\nWMA news
\nmember associations to mention the WMA
\nin their Press releases when appropriate to
\nincrease the visibility of the WMA.
\nSocio-Medical A\ufb00airs Committee
\nThe Chairman Dr. J.L Gomes do Amaral
\nopened the meeting,welcomed a new mem-
\nber. The minutes of the Copenhagen meet-
\ning were considered and approved.
\nAntimicrobial Drugs
\nThe committee recommended that a revi-
\nsion of the Statement on Antimicrobial
\nDrugs, a recommendation subsequently ad-
\nopted and approved by council.
\nContinuous Quality Assurance
\nThe revision of a Continuous Quality As-
\nsurance statement provoked considerable
\ndiscussion. This arose from concerns in the
\nAMA relating to governmental interpreta-
\ntion of medical research and what consti-
\ntutes \u201cevidence\u201d. The committee recom-
\nmended to council that the document be
\nreferred back to NMAs with an explanation
\nof the new concerns. The recommendation
\nwas subsequently accepted by Council.
\nAccess of Women to Healthcare
\nFollowing interventions from the BMA,
\nCanada and the AMA,a number of amend-
\nments were suggested and the amended
\ndocument recommended to council who
\napproved its adoption and forwarding to
\nthe General Assembly.
\nDietary Sodium
\nThe AMA moved the adoption of this
\ndocument. The Indian Medical Associa-
\ntion questioned whether reducing sodium
\nincreased the risk of cardiovascular disease,
\nreferring to a literature review of 450 pa-
\npers and proposed that in the light of this,
\na working group be established to review
\nthe proposed document. It was pointed
\nout that the paragraph referred to uses the
\nwords \u201ccan have an e\ufb00ect\u201d. Numerous other
\nspeakers observed that the proposal agrees
\nwith other bodies which have made such
\nrecommendations and did not refer to a di-
\nrect link.The Japanese Medical Association
\ncommented that while there was no direct
\nlink with all cardiovascular disease, there
\nwas one with hypertension and thus with
\napoplexy.
\nThe motion to refer to a working group was
\nlost.
\nA motion to recommend approval to council
\nfor forwarding the document to the Gen-
\neral Assembly was agreed and subsequently
\nadopted by Council.
\nResolution on Task Shifting
\nThe President referred to the press release
\nat the Addis Ababa conference.The concept
\nof Task shifting had positive and negative
\naspects, it moves tasks which were initially
\ncomplicated and have become simpli\ufb01ed.
\nNow however, we are dealing with task
\nshifting determined by other authorities,
\nwith governments and legislation moving
\ntasks to other professions and lay persons.
\nHis article on the Kampala meeting in
\nMarch \u201cHuman Resources for Health\u201d was
\nin the May WMJ (seeWMJ54 (2), 34-35)
\nwhich the council had before them and
\naddressed the problems facing 55 coun-
\ntries, mostly in Africa. The Executive on
\nthe previous day had recommended that
\ncouncil should adopt a statement based
\non the World Health Professions\u2019 Joint
\nStatement at the Kampala meeting. Dr.
\nBlachar (President-elect) said the proposal
\nwas that the WMA council endorse the
\nWHPA Kampala document and recom-
\nmends that WMA engage in further study
\nof this issue Responding to a question as
\nto whether actions taken by the executive
\nrequire endorsement by the council. The
\nSecretary General observed that this was
\na special situation. Normally strategy was
\ndetermined by council and passed to oth-
\ners. In Kampala, action had to be taken on
\nthe spot in the WHPA of which WHO
\nwas a member. We don\u2019t have a policy on
\nTask Shifting and therefore endorsement
\nof the action taken by an organisation of
\nwhich WMA is a member was necessary.
\nDr. Snaedel (President) observed that
\nthis was a problem also a\ufb00ecting other
\nhealth professionals. It was important that
\nthe council should make a statement on
\nthis occasion. This was a problem for the
\nhealth professions. Dr. Letlape (Immedi-
\nate Past President) commended the Execu-
\ntive. What we had here was a new cadre of
\nhealth worker. He also had a concern about
\nnomenclature. The President commented
\nthat the wording was correct, namely \u201ctask
\nshifting\u201d and that Dr. Letlape was raising a
\nSouth African issue.
\nThe President-elect felt that the WHPA
\ndocument should be endorsed.We were not
\nconcerned about losing work, but work was
\nbeing placed elsewhere due to the shortage
\nof health personnel.
\nDr. Vilmar (Germany) considered that we
\nshould think of the relationship between
\nTask shifting and Quality. In our daily work
\nas Health Professionals we delegate tasks to
\nothers e.g.ECGs to technicians.Delegation
\nof other tasks could be disastrous. However
\nwe now have other professions claiming
\nmore prerogatives. We must work with
\nother Health Professions to ensure safety
\nand quality. However, to ensure quality and
\nsafety, diagnosis must remain with Physi-
\ncians.
\nDr. Call\u2019och supported the Executive\u2019s ac-
\ntion. Some time we must produce a sup-
\nplementary motion to extend the WHPA
\nstatement to ensure safety and quality. Task
\nshifting in French is translated as Task
\nTransferring. In France protocols are now
\nbeing written for doctors transferring tech-
\nnical tasks (including drug substitution) to
\nother professions.
\nA comment from Bolivia sought assistance
\nto deal with the problem of inadequately
\ntrained Cuban doctors. The Chair com-
\nmented that we had to consider the e\ufb00ects
\nof task shifting not only in relation to a phy-
\n132
\nWMA news
\nsician shortage, but also in relation to other
\nhealth professionals
\nDr. Letlape proposed a two part decision.
\nFirst that the executive action be endorsed \u2013
\nthis was agreed. Secondly, that a study be
\nundertaken. It was observed that the issues
\nraised by task shifting clearly had major
\nmedical workforce implications, on which
\na work group already existed. It was \ufb01nally
\nagreed to recommend that this group under-
\ntake the study to de\ufb01ne the issues and rec-
\nommend long term viable solutions. Council
\nlater endorsed this recommendation
\nGlobal Problem of Mercury
\nA Statement on the Global Burden of Mer-
\ncury was recommended for approval by
\ncouncil and forwarding to the General As-
\nsembly. This recommendation was adopted
\nby Council.
\nPoppies for Medicine
\nIn connection with the proposed motion it
\nwas pointed out that the Standing Com-
\nmittee of Doctors had recommended the
\nproject.
\nThe proposal was recommended for ap-
\nproval and referral to General Assembly by
\ncouncil and later adopted by Council.
\nAction on classi\ufb01cation of 1998 policies.
\nThe following recommendation were\u2022
\nmade and adopted by council:
\nDeclaration on Nuclear Weapons to be\u2022
\nrea\ufb03rmed with minor revisions
\nResolution on Medical Workforce to un-\u2022
\ndergo major revision
\nResolution on Improved Investment in\u2022
\nHealth Care to undergo a major revi-
\nsion
\nResolution on the Hague Appeal for\u2022
\nPeace to be rescinded and archived
\nResolution supporting the Ottawa Con-\u2022
\nvention of Anti-Personnel Landmines
\nand their destruction to undergo a major
\nrevision
\nResolution on Medical Care for Refugees\u2022
\nto be rea\ufb03rmed with minor revisions.
\nHealth and the Environment.
\nDr. Hansen said that a document was be-
\ning prepared by CMA on \u201cHealth and
\nEnvironment\u201d a topic which we should be
\naddressing, rather than \u201cclimate change\u201d.
\nFirm facts are needed. It is possible to ad-
\ndress e\ufb00ects such as those of Mercury (as
\nin the WMA document) and the CMA has
\nsome projects in mind. They would try to
\nmake the document relate to physicians.
\nAdvocacy and research are important in this
\narea \u2013 such advocacy would \ufb01t into Advo-
\ncacy for patients. This work would prepare
\nthe way for a General Assembly which was
\nproposed to be held in Canada in 2010. He
\nsuggested a task Force with a mandate to
\nlook at Health and the Environment, using
\nexpertise as necessary.
\nThe Chair of Council called for nominations
\nfor a force to develop policy on Environ-
\nment and Health to which Canada, France,
\nKorea, UK and Switzerland responded. As
\nthe UN policy conference would take place
\nin Copenhagen on 2009 Denmark also of-
\nfered to join the group.
\nDr. Wilks (Chair of Standing Committee
\nof European Doctors) reported that as the
\nEU was doing work on Climate change and
\nthe CPME is developing policy.This will be
\nshared with WMA.
\nDrug Prescription
\nA resolution on Drug Prescription was
\nintroduced to the committee. In present-
\ning this, a plea was made that prescribing
\nshould only be done by physicians and
\nbased on the clinical history and diagnosis
\n\u2013 information which is private and cannot
\nbe shared – which implied that physicians
\nwith the scienti\ufb01c and human training were
\nrequired. Advocacy only thinks of Safety of
\nthe patient whereas the Pharmaceutical In-
\ndustry tends to separate this form of medi-
\ncal practice.
\nIn a general debate it was suggested that
\nthis trend was part of Task Shifting. In its
\ncurrent form however, the motion would
\nmake WMA a laughing stock. This motion
\nwas relevant to the 20th
\ncentury, but not the
\n21st
\nwhere many other professionals were
\ntrained to prescribe drugs.It was pointed out
\nthat in the UK nurses and pharmacists were
\nable to prescribe drugs. While expressing
\nsympathy with the Spanish, it was pointed
\nout that prescribing by a physician was not
\nnecessary on every occasion e.g. OTCs.The
\nmotion needed substantial rephrasing. The
\nPresident reported that the Annual meeting
\nof the Pharmacists were already working on
\nthis issue. WMA is waiting see the guide-
\nlines on this topic in relation to physicians
\nand pharmacists.
\nThe Spanish replying to the debate agreed
\nthat work on this topic should start at once
\nand said that patients need guarantees. In
\nSpain the European Society of Patients
\nsupport prescribing by Physicians only. He
\nspoke of the problem of Adverse Drug Re-
\nactions and patients tending to take drugs
\nblindly e.g. OTC preparations. Physicians
\nwere not superior, but should be at the head
\nof prescribing.
\nAfter agreeing that the work should be done
\nby a working group,it was agreed that a new
\nworking group should be set up, with a re-
\nmit to examine the draft proposal, as well as
\nthe authority to prescribe, and report back
\nto the committee. This recommendation
\nwas later accepted by Council.
\nHuman and Veterinary Medicine
\nFollowing the presentation of a proposed
\nStatement on this issue by the American
\nMedical Association the committee recom-
\nmended and the council approved the doc-
\nument being sent to NMAs for comment.
\nAdvocacy Advisory Group
\nIt was reported that the mandate of the
\ngroup had been clari\ufb01ed, namely that it
\nwould produce an advocacy plan for the
\nyear, including a strategy highlighting areas
\nfor NMAs.
\nDr. Alan J. Rowe
\n133
\nWMA news
\nYank D. Coble, MD, Chair, WMA Caring
\nPhysicians of the World Initiative
\n\u201cThe most important thing is caring, so do it
\n\ufb01rst, for the caring Physician best inspires
\nhope and trust.\u201d Sir William Osler
\nCaring, Ethics and Science are the three
\nfundamental and enduring traditions that
\nunite medical professionals and their pa-
\ntients around the world. Because of these
\nuniversal traditions, we \ufb01nd global similar-
\nity in physicians\u2019 and patients\u2019 desires and
\nconcerns, despite the enormously disparate
\nenvironments and circumstances in which
\nphysicians care for patients.
\nThe Caring Physicians of the World Ini-
\ntiative (CPWI) was designed to restore
\nenthusiasm and optimism in medicine,
\nthrough medical and social leadership based
\non the enduring traditions of the medical
\nprofession: Caring, Ethics and Science. The
\ninitiative was conceived in Helsinki,Finland
\nat the 2003 General Assembly of the World
\nMedical Association.
\nThe World Medical Association (WMA)
\nrepresents physicians around the world and
\nprovides a global forum for physicians to
\ncommunicate, cooperate and promote high
\nstandards and professionalism. The WMA
\nis a federation of National Medical Asso-
\nciations (NMAs) representing over eight
\nmillion physicians in more than 90 coun-
\ntries around the world. It was founded in
\n1947 with the mission to \u201cserve humanity
\nby endeavoring to achieve the highest in-
\nternational standards in medical education,
\nmedical science, medical care, and medical
\nethics, and health care for all the people of
\nthe world\u201d.This unique partnership of phy-
\nsicians enhances the health and quality of
\nlife for people all over the world.
\nAs part of its work to achieve high standards
\nin medicine, the WMA conducted a survey
\nof physicians in over 40 countries around
\nthe globe in 2003. Survey results revealed
\nphysicians\u2019 concerns about access to quality
\nsafe medical care, appropriate professional
\nautonomy to provide that care,and adequate
\nresources and facilities to deliver care. Phy-
\nsicians were also seriously concerned about
\nthe regulatory, legal, political, and other
\nbarriers to providing care, as well as gov-
\nernmental attitudes regarding medical care
\nas an expense, rather than an investment
\nwith positive return. To a large degree, phy-
\nsicians across the world felt marginalized,
\nthreatened, and demeaned. They requested
\nthat the WMA provide increased informa-
\ntion on health systems and facilitate greater
\nexchange of experience between physicians
\nthroughout the world. Physicians requested
\nvigorous communication of the professional
\nvalues of the medical and health professions
\nand the well-documented value in relieving
\ndistress, despair, disease, disability, and pre-
\nmature death, and the extraordinary return
\non investment in medical care and public
\nhealth. Physicians also felt they needed to
\nenhance their own knowledge and skills in
\nleadership and advocacy for patients, public
\nhealth, and the medical profession.
\nThe WMA resolved to address these global
\nconcerns in 2004, and formed a partnership
\nwith an experienced sponsor, P\ufb01zer, Inc.
\nThey developed the Caring Physicians of
\nthe World Initiative (CPWI), chaired by
\nWMA President-elect Yank D.Coble,MD.
\nThrough this initiative, the WMA would
\nunite NMAs around the world, implement-
\ning a multipart program to address the
\nidenti\ufb01ed global concerns of physicians.
\nPhaseIoftheCPWInitiative: Connecting
\nThe goal of Phase 1 was to connect with
\nNMAs around the world, enhancing global
\ncommunication. The WMA reached out
\nto NMAs and regional associations such
\nas the Medical Association of Southeast
\nAsian Nations (MASEAN) and the Medi-
\ncal Confederation of Latin America and
\nthe Caribbean (CONFEMEL), building
\nrelationships and increasing participation
\nand leadership in the World Health Orga-
\nnization (WHO) and World Health Pro-
\nfessions Alliance (WHPA). WMA o\ufb03cers
\nvisited Africa, Europe, Latin America, the
\nMiddle East and North America, and made
\nmultiple visits to India and China. These
\noutreach visits by WMA o\ufb03cers enabled
\nThe WMA Caring Physicians of the
\nWorld Initiative
\nOtmar Kloiber, MD, Secretary General, World
\nMedical Association
\n134
\nWMA news
\nthem to learn more directly about circum-
\nstances, needs, and desires, and to obtain
\nsupport and increase advocacy for the values
\nof the medical profession.
\nPhase II of the CPW Initiative: Inspiring
\nThe goal of Phase II was to inspire, building
\nenthusiasm and optimism for the medical
\nprofession, by showcasing exemplary physi-
\ncians from around the world in a compila-
\ntion of \u201cCaring Physicians of the World.\u201d
\nThis publication featured 65 physicians
\nfrom 58 countries: heroes and social lead-
\ners who were nominated by their NMAs as
\nexemplifying the enduring traditions of car-
\ning, ethics, and science.
\nPlans for the book were announced at the
\nWMA General Assembly in Tokyo, 2004.
\nNMAs nominated over 200 physicians; 65
\nphysicians were interviewed, photographed
\non site, and memorialized in the publica-
\ntion. The book was presented at the 2005
\nWMA General Assembly in Santiago,
\nChile and the regional conference of CON-
\nFEMEL. Subsequently, the message of the
\nCaring Physicians of the World was com-
\nmunicated to NMAs, medical schools and
\nspecialty societies,government,media,busi-
\nnesses, philanthropies, and multiple other
\npublic and private associations and organi-
\nzations around the
\nworld. In May 2006
\nthe Caring Physi-
\ncians of the World
\nBook and Initiative
\nwere featured at a
\nluncheon reception
\nof over 200 Minis-
\nters of Health and
\nother health and
\nmedical leaders fol-
\nlowing the opening
\nsessions of the 2004
\nWorld Health As-
\nsembly. The preface,
\ndescribing the rel-
\nevance, importance
\nand power of caring, ethics and science.
\nPhase III of the CPW Initiative: Col-
\nlaborating The goal of Phase III was to
\nimprove collaboration, forming regional
\npartnerships in areas around the world, to
\nenhance communication, collegiality, and
\nadvocacy for patients, public health, and the
\nmedical profession. With WMA o\ufb03cers\u2019
\nparticipation, and the P\ufb01zer partnership
\nand support, Dr. Otmar Kloiber, Secretary
\nGeneral of the WMA, and host NMAs or-
\nganized highly successful regional meetings
\nin Johannesburg, Prague, Santiago, Tokyo,
\nBangkok, Shanghai, and Amelia Island,
\nFlorida. These regional meetings focused
\non e\ufb00ective ways to address the primary
\nissues for patients, physicians, and public
\nhealth. During these meetings it emerged
\nthat there was a growing desire for improv-
\ning physicians\u2019 advocacy and leadership
\nskills.
\nPhase IV of the CPW Initiative: Devel-
\noping The goal of Phase IV was to address
\nthe emergent need for development of
\nphysicians\u2019 advocacy and leadership skills.
\nThroughout 2006 and 2007 the WMA,
\nin collaboration with INSEAD and again
\nwith the partnership of P\ufb01zer, Inc., devel-
\noped the WMA\/CPWLeadershipCourse.
\nThe program was designed to develop the
\nskills and knowledge needed for medical
\nand social leadership, enhancing the abili-
\nties of medical professionals to advocate
\nmore e\ufb00ectively for medical care, education,
\nresearch, ethics, and the medical profession.
\nThe \ufb01rst course was held from 2-9 Decem-
\nber, 2007, at INSEAD in Fontainebleau,
\nFrance. Thirty three colleagues, selected by
\ntheir NMAs in 22 countries, participated in
\nthe course. Feedback from this inaugural
\ncourse has been extraordinarily positive, as
\nhas the increased communication between
\nthe \u201cAlumni\u201dof the course. The next course
\nis planned for INSEAD, Fontainebleau,
\n1-6 December, 2008. INSEAD Singapore
\nis under consideration as the site for the
\ncourse in 2009.
\nPhase V of the CPW Initiative: Apply-
\ning and Achieving Phase V is an enduring
\nphase in which WMA will explore appli-
\ncation of the CPW principles and achieve-
\nment of the CPWI goals. One of the \ufb01rst
\nexamples of CPWI Application can be
\nfound in Indonesia.
\nTwo Indonesian Medical Association
\n(IMA) leaders, Dr. Fachmi Idris and Dr.
\nTau\ufb01k Jaaman, participated in the Decem-
\nber 2007 WMA\/CPW Leadership Course.
\nThey proposed an Indonesian Caring Phy-
\nsicians Initiative for their IMA Centennial
\nAnnual meeting in May 2008. They began
\nplanning,and by early 2008 had the support
\nof the President of the Indonesian Republic,
\ncollaboration of the Minister of Health,and
\nadditional support.
\nWMA\/CPW Leadership Course 2007
\n135
\nWMA news
\nThe IMA created a video documentary of
\n100 years of Indonesian history, and a new
\nbook, Indonesian Caring Physicians, edited
\nby Dr.Tau\ufb01k Jaaman. This book pro\ufb01les 112
\nIndonesian physicians, nominated as heroes
\nand social leaders, exemplifying the endur-
\ning medical traditions of caring, ethics, and
\nscience. The publication includes messages
\nfrom the Indonesian President, and the
\nMinister of Health, and the WMA. Both
\nbooks, the Caring Physicians of the World
\nand the Indonesian Caring Physicians, were
\npresented to the Indonesian President and
\nMinister of Health at the IMA Centen-
\nnial Anniversary at a large event held at the
\nPresident\u2019s Palace, May 28, 2008, and to
\nthe faculty and students of the Indonesian
\nUniversity School of Medicine by IMA and
\nWMA o\ufb03cers with presentation addresses.
\nThe opening of the IMA Centennial Meet-
\ning and exposition featured the ICP book,
\nvideo, and initiative.
\nThe WMA is proud of the growth and
\nachievements of the CPW Initiative. How-
\never much remains to be accomplished in,
\nby and for the medical profession. Global
\nthreats of communicable and non-commu-
\nnicable disease persist despite unparalleled
\nprogress in biomedical science,public health
\nand medical care. Barriers to care \ufb02ourish,
\ncreated by ine\ufb00ective, ine\ufb03cient, and some-
\ntimes even corrupt governments. The pub-
\nlic is confused by terms such as providers
\ninstead of professionals, customers instead
\nof patients, health care instead of medical
\ncare, the pollution of scienti\ufb01c information
\nby media, and distortion by legal and regu-
\nlatory systems. They are understandably
\ndistrustful. However there is good reason
\nto be optimistic: the justi\ufb01able enthusiasm
\nphysicians have for the value and values of
\ntheir profession, and the ability to be useful.
\nThe CPW Initiative has helped to clarify
\nthe assertion of physicians around the world
\nthat e\ufb00ective leadership, hard work, a clear
\nde\ufb01nition of responsibilities and rights as a
\nprofession, and a mission beyond self, will
\nresult in signi\ufb01cant and measurable success.
\nThe CPWI has a\u2022 focus on Patients:
\nworking to inspire hope and trust, as well
\nas to reduce disease,despair,disability and
\npremature death.
\nThe CPWI has a\u2022 focus on Rights: pro-
\nmoting the right of all patients to choose
\nphysicians providing care based on a sin-
\ngular ethical commitment to them, us-
\ning the best available science, in a caring
\nmanner.To provide this level of care,phy-
\nsicians require the right to appropriate
\nautonomy, self regulation and advocacy
\nfor patient health.
\nThe CPWI has a\u2022 focus on Responsibil-
\nity: endorsing ethical and science-based
\ncare, and social leadership in advocacy for
\npatient care and public health.
\nFinally, the CPWI has a\u2022 focus on the
\nValue of Medicine: both economic and
\nhumanitarian. The Economic Value rep-
\nresents the positive \ufb01nancial return of
\ninvestment in medical care and biomedi-
\ncal research. The Humanitarian Value
\nrepresents the immeasurable worth of
\nreducing disease, despair, disability and
\npremature death.
\nThe goal of the CPWI is to restore enthu-
\nsiasm and optimism in the \ufb01eld of medi-
\ncine, through medical and social leader-
\nship based on the enduring traditions of
\nthe medical profession: Caring, Ethics
\nand Science. The CPW Initiative exem-
\npli\ufb01es the triad of medical traditions, Car-
\ning, Ethics and Science, emphasizing that
\ncaring physicians of the world are commit-
\nted to and e\ufb00ective at medical and social
\nleadership. The CPWI mission is to help
\nphysicians throughout the world, despite
\nthe diversity and adversity of circumstances,
\nto communicate Caring and Compassion,
\nwith the best Science and highest Ethics, in
\nevery professional interaction.
\nCeremonial Event at the Presidential Palace.
\n(L\u2013R) Dr. Fachmi Idris, President of Indo-
\nnesian Medical Association; Dr. Siti Fadilah
\nSupari, Health Minister of Indonesian Repub-
\nlic; Dr. Susilo Bambang Yudhoyono, President
\nof Indonesian Republic; Dr Yank Coble, Past
\nPresident of WMA
\nPresentation of the Caring Physicians of the
\nWorld. Dr. Fachmi Idris, President of Indo-
\nnesian Medical Association, presents the book
\nof Caring Physicians of the World to Susilo
\nBambang Yudhoyono, President of Indonesian
\nRepublic
\n136
\nMedical Ethics, Human Rights and Socio-medical affairs
\nLouis M. Guenin, Department of
\nMicrobiology and Molecular Genetics,
\nHarvard Medical School
\nOn occasion, discretionary actions preclude
\ntransfer of extracorporeal embryos into the
\nwomb. Such actions constitute an over-
\nlooked and crucial ground for the moral
\njusti\ufb01cation of embryo use in regenerative
\nmedicine.
\nIn the \ufb01rst instance, we encounter the situ-
\nation, which often arises with fertility pa-
\ntients, in which the one person in the world
\nwho, together with the co-progenitor, is
\nempowered to decide about intrauterine
\ntransfer of an embryo formed from her oo-
\ncyte decides that neither does she wish to
\nbear the embryo, nor does she wish to give
\nit to anyone else. Whereupon she and the
\nco-progenitor may decide to donate the
\nembryo to medical research and therapy. In
\nthe second case, embryos may originate in
\nresearch from cells donated to medicine for
\nthat purpose.
\nIf progenitors, while fully-informed and
\nacting of their own volition, donate an em-
\nbryo, either before or after the embryo\u2019s
\ncreation, on the condition that the em-
\nbryo shall be used in medical research and
\ntherapy, and may never be transferred into a
\nuterus, such embryo constitutes what I have
\ncalled an \u201cepidosembryo.\u201d I have taken this
\nname from the Greek epidosis for a citizen\u2019s
\nbene\ufb01cence to the common weal.
\nAs a moral justi\ufb01cation for the use of epi-
\ndosembryos in accordance with donor in-
\nstructions, I have o\ufb00ered the \u201cargument
\nfrom nonenablement.\u201d This proceeds as
\nfollows. A woman does not have a duty to
\nundergo a transfer into her of an embryo
\nlying outside her. There does not obtain a
\nduty of intrauterine embryo transfer into
\noneself. We, most of us, regard the decision
\nto undergo such a medical procedure as re-
\nserved to a woman\u2019s autonomous discretion.
\nA separate question is whether a woman
\nand the co-progenitor lie under a duty to
\nsurrender for adoption any embryo that she
\ndeclines to bear. Imposition of such a duty
\nwould likely present such adverse incentives
\nand consequences for fertility patients, in-
\ncluding compelled remote parenthood, that
\nwe are hard pressed to \ufb01nd any moral view
\nthat would support such imposition. For
\nreasons developed in the full account of this
\nargument, the decision whether to surren-
\nder an embryo for adoption also lies within
\nprogenitor discretion.
\nSuppose, then, that a woman forbids intra-
\nuterine transfer of an embryo. She, with the
\nco-progenitor, donates to medicine either
\nan epidosembryo created during her fertil-
\nity treatment, or an epidosembryo that will
\nbe created by a scientist from their donated
\ncells. This decision is \ufb01nal. The epidosem-
\nbryo has left progenitor control. A distinc-
\ntion now obtains between the developmen-
\ntal potential of this epidosembryo, lying in
\na petri dish where it will remain, and an
\nembryo that lies in a uterus, however it got
\nthere. In consequence of the prohibition
\non intrauterine transfer, the epidosembryo
\nwill not complete gastrulation. If not ear-
\nlier sacri\ufb01ced, the epidosembryo will begin
\nto disintegrate by about day 10. During its
\nremaining life,it cannot acquire any morally
\nsigni\ufb01cant property that it does not already
\npossess. To put the matter in language that
\nI owe to Richard Hare, no possible person
\ncorresponds to an epidosembryo. We also
\nknow that no embryo is sentient. It can
\nneither form preferences nor adopt ends.
\nNothing that we might do concerning it
\ncan cause it discomfort or frustrate it. We
\ncannot gain anything \u2013 neither for it nor for
\nany other being \u2013 by classifying it as a per-
\nson for purposes of the duty not to harm.By
\nforgoing its use in research, we could only
\nassure that the epidosembryo dies in vain.
\nScientists maintain the reasonable, though
\nnot certain,belief that embryo experimenta-
\ntion could contribute to the relief of human
\nsu\ufb00ering. Use of donated embryos remains
\ncrucial in research even as techniques de-
\nvelop for reprogramming somatic cells into
\npluripotent or specialized cells. Embryonic
\nstem cell research has been the fountainhead
\nof emerging knowledge of reprogramming,
\nand the embryonic stem cell remains the
\ngold standard of pluripotency. In this situa-
\ntion, the duty of mutual aid \u2013 the duty, rec-
\nognized across moral views, to aid those in
\nneed when one may do so without imposing
\nan unreasonable burden \u2013 bids us undertake
\nsuch research. Hence not only is it permis-
\nsible to use epidosembryos in medicine, but
\nto do so will help to ful\ufb01l a collective duty.
\nAccording to this argument, the permissi-
\nbility and virtuousness of epidosembryo use
\nrests on the autonomous decisions of people
\nfrom whose cells such embryos originate.
\nThe moral analysis \ufb02ows entirely from what
\nit is that they decide.Developmental poten-
\ntial matters, but it is human decisions that
\ndetermine its situation-dependent extent. If
\nit is permissible for progenitors to donate
\nepidosembryos, then it is permissible for
\nrecipient scientists to use the donations as
\ninstructed.
\nSome discussants seem to suppose that the
\njusti\ufb01cation of embryonic stem cell research
\nlies in the circumstance that the embryos
\ndonated were created with procreative in-
\ntent. The argument from nonenablement
\ndoes not invoke procreative intent. The
\nargument applies to any donated embryo,
\nwhether left over from an attempt at preg-
\nnancy, or created in experiment. The use of
\nsurplus embryos and the nonprocreative
\nBuilding a Consensus in Regenerative Medicine
\n137
\nMedical Ethics, Human Rights and Socio-medical affairs
\nformation of embryos by fertilization, non-
\nreprocloning, and parthenogenesis rest on
\none and the same moral ground.
\nThe argument from nonenablement is a
\nconsensus argument insofar as it does not
\ninvoke any premise peculiar to one or an-
\nother moral or religious view. The bounded
\ndevelopmental potential of an embryo in the
\ndish is a biological circumstance. The duty
\nof bene\ufb01cence and respect for the discre-
\ntion of persons to elect whether they shall
\nundergo medical procedures are common to
\nall leading moral and religious views. Some
\nform of the Golden Rule is found in virtu-
\nally every major moral and religious view
\nsince Confucius.
\nIn this analysis, I accord a wide berth to re-
\nligious views across diverse cultures, provid-
\ned only that when moral verdicts are urged
\non religious grounds, support for them can
\nbe given on the basis of reasonable nonre-
\nligious premises. As we all know, many re-
\nligious believers condemn the sacri\ufb01ce of
\nembryonic lives in aid of other lives. Hence
\na further task presents itself. It remains to
\nbe shown, if it can be, that if the argument
\nfrom nonenablement is introduced in the
\ncourse of sympathetically reinterpreting
\none or more views presumptively opposed
\nto all embryo use, such views will issue in
\napproval for epidosembryo use. I illustrate
\nhow that task may be accomplished as to
\nthe most in\ufb02uential presumptively contrary
\nview, the magisterium of the Roman Cath-
\nolic Church.
\nIn condemning all manner of embryo de-
\nstruction, the Catholic magisterium speaks
\nconsistently. Just as it condemns destruction
\nof embryos as research subjects,it condemns
\nthe practice of assisted reproduction be-
\ncause that practice brings about destruction
\nof surplus embryos. (Other discussants who
\napprove in vitro fertilization as practiced,
\nbut oppose embryo use in research fall into
\ninconsistency: they condone destruction
\nof surplus embryos as waste, but condemn
\nsacri\ufb01ce of surplus embryos for bene\ufb01cent
\nends.) On what ground does the magiste-
\nrium\u2019s condemnation of embryo sacri\ufb01ce
\nrest?
\nOne will often hear it asserted that an em-
\nbryo is a person and that killing a person
\nis murder. To say that a being is a person
\nis to recite the conclusion that the being
\nfalls within the category of beings protected
\nby the duty not to harm. It remains to ask
\nwhat reasoning supports that conclusion.
\nConceding that the Bible does not assert
\npersonhood of an extracorporeal embryo \u2013
\nin antiquity, people did not even know that
\nthere existed oocytes, hence never thought
\nabout embryos outside the body \u2013 the
\nmagisterium allows that personhood of an
\nembryo is a philosophical question. Con-
\ncerning this, the magisterium\u2019s argument in
\nchief is the following: fertilization creates a
\nnew genome, therefore fertilization creates
\na person. This argument\u2019s premise is true \u2013
\nfertilization produces a new genome \u2013 but
\nthe conclusion doesn\u2019t follow. To identify a
\nperson with a genome is to practice genetic
\nreductionism with a vengeance. That view
\ncontradicts the bedrock belief that a person
\nis a corpore et anima unus, a union of body
\nand soul. On pain of internal contradiction,
\nthe argument cannot stand.
\nA defender of zygotic personhood might
\nplead that precisely because embryos can-
\nnot form preferences, it is our obligation to
\nact according to their advantage, hence to
\nclassify them as persons. But we cannot fos-
\nter any advantage of epidosembryos. Entry
\ninto the only kind of environment by which
\nthey could attain the ability to experience
\nbene\ufb01t has been forbidden by the only per-
\nsons in the world empowered to decide such
\nmatters. It is from this recognition that the
\nargument from nonenablement builds a
\nprima facie justi\ufb01cation within Catholicism,
\nas within other views,for epidosembryo use.
\nIs there a countervailing argument?
\nOne argument is that if we do not know
\nwhether an embryo is a person in God\u2019s
\neyes, we should exercise caution and act as
\nif it were. But from within a view holding
\nthat divine will is the arbiter of morality,
\nsuppose that we could have a conversation
\nwith God. We report that in 1998, we dis-
\ncovered how to culture human embryonic
\nstem cells. We describe hopes of relieving
\nhuman su\ufb00ering by using embryos that will
\nnever enter a womb. Is it plausible that He
\nwould tell us that He regards such embryos
\nas persons in the sense that He includes
\nthem in a universe of beings that He never
\nwishes us to use as means? I do not know
\nof a tenable argument according to which
\nan all-merciful and omniscient God would
\nassert that preference. He would know that
\nunenabled embryos would never become
\nsentient if not used in research.
\nAn objection peculiar to nonreprocloning
\nmight be this. An oocyte is created for a
\npurpose, namely to issue in o\ufb00spring, and
\nit is wrong to divert an oocyte to any other
\npurpose. This objection presupposes with
\nAristotle that everything has a \ufb01xed pur-
\npose and that we know what it is. After
\nDarwin, that notion has lost its grip on our
\nthought. We have learned from the history
\nof medicine how mistaken we humans have
\noften been in inferring purposes of various
\ncells and structures of the body. Our for-
\nbears would have said that bones are what
\nhold us up; today we think of the marrow
\nas a blood factory. We think it appropri-
\nate to transfer marrow from one patient to
\nanother. We know that many cells perform
\nmultiple functions, and we are learning to
\nredirect proteins and cellular processes to
\nserve chosen ends. It seems arbitrary to say
\nthat an oocyte can or should serve only one
\npurpose. Such a rule would seem puzzling
\ninsofar as every human female possesses
\nfrom birth a quarter million or more oo-
\ncytes.
\nTurning to public policy, we observe that
\nthere obtains no practical scheme by which
\na government may fund use of embryonic
\nderivatives without complicity in their
\nderivation. Downstream demand induces
\nsupply, and complicity transmits through
\nthe channel of inducement. Our collective
\ndeliberations would bene\ufb01t from moral rea-
\nsoning generally overlooked in the policy
\narena. That is the reasoning adduced in the
\nargument from nonenablement beginning
\n138
\nMedical Ethics, Human Rights and Socio-medical affairs
\nwith the premises that intrauterine embryo
\ntransfer is discretionary and that when pro-
\ngenitors forbid such transfer, developmental
\npotential is permissibly bounded. The key
\nto assuring that legislation endorses mor-
\nally permissible activity is what it says about
\nprogenitors. Progenitors possess unique
\npower: each is the only person in the world
\n(with the co-progenitor) privileged to de-
\ncide what will happen to an embryo. It is
\nbecause a progenitor-donor decides that an
\nembryo will never enter a uterus that a do-
\nnee may experiment on it.
\nHence the most compelling justi\ufb01cation for
\na donee in performing experiments, and for
\na legislature in endorsing experiments, con-
\nsists in the donee\u2019s \ufb01delity to permissible do-
\nnative instructions bounding potential.This
\nbring us to the following public policy:
\nThe government shall support biomedical
\nresearch using human embryos that, before
\nor after formation, have been donated to
\nmedicine under donor instructions forbid-
\nding intrauterine transfer.
\nThis policy wears its moral justi\ufb01cation on
\nits sleeve. That attribute avails for public
\ndiscussion. There the policy may be de-
\nscribed as one that assures that the scope
\nof the publicly-supported is congruent with
\nthe scope of the morally permissible.
\nThere arise various other ethical questions
\nabout embryo use, including fair compensa-
\ntiontooocytecontributors,andtheformation
\nof hybrids and chimeras.In the foregoing,we
\nhave canvassed a ground for consensus on
\nthe most fundamental question.
\nMaksut K. Kulzhanov,
\nSaltanat A. Yegeubaeva,
\nKazakhstan School of Public Health
\nIntroduction
\nKazakhstan is an independent republic lo-
\ncated in the central Asian steppe. Covering
\n2.7 million square kilometres (about the size
\nof the 15 states constituting the European
\nUnion up to 2004),the country is the largest
\nof the former Soviet republics after Russia.
\nKazakhstan has a long border with Russia
\nto the north, adjoins China to the east, and
\nKyrgyzstan, Uzbekistan and Turkmenistan
\nto the south. Kazakhstan is a land-locked
\ncountry which borders on two large inland
\nseas: the Aral Sea and the Caspian Sea.The
\nterrain stretches across steppes and deserts
\nto the high mountains in the south east
\nincluding the Tian Shan and Altai ranges.
\nThe capital, formerly Almaty (previously
\nAlma-Ata), was moved in December 1997
\nto Astana (Aqmola) in the north.
\nWhen Kazakhstan became independent in
\n1991, it faced many of the same challenges
\nas other countries from the former Soviet
\nUnion, including an oversized and inpa-
\ntient-oriented system of health facilities, a
\ndrop of health \ufb01nancing in the early years of
\ntransition and many other challenges that
\nare the similar to world health care prob-
\nlems such as human recourse development
\nand bioethics. While the country has em-
\nbarked on several major health reforms in
\nthe second half of the 1990s, these often
\nlacked consistency and clear directions. In
\nthe wake of the economic upswing fuelled
\nby oil revenues in recent years, Kazakhstan
\nin 2004 embarked on a comprehensive na-
\ntional health reform programme for the pe-
\nriod 2005-2010.
\nHuman resourses in health care
\nsystem and public health
\nKazakhstan has a high level of public sector
\nemployment. In the mid-1990s, the country
\nhad one of the highest levels of government
\nemployment in the world, when health per-
\nsonnel accounted for about 40% of govern-
\nment employees (WB 1996b). The number
\nof active personnel is di\ufb03cult to ascertain,
\nas there is no accurate and comprehensive
\ninformation system on the actual number of
\nactive health care workers.In addition,health
\ncare workers who have moved to the private
\nsector, such as many dentists and pharma-
\ncists, are not counted in public \ufb01gures.
\nThe area of human resources in the health
\nsector is mainly related through the Law
\non the Health System of 4th
\nJune 2003. Ac-
\ncording to this law, the Ministry of Health
\nis responsible for:
\ndeveloping an overall human resources\u2022
\npolicy in the health sector;
\napprovingformsandtrainingprogrammes\u2022
\nfor medical specialties, and developing
\nand approving typical sta\ufb03ng and sta\ufb00-
\ning standards of health organizations;
\nconducting the attestation of managers of\u2022
\nhealth organizations and health depart-
\nments;
\nde\ufb01ning standards for the training of\u2022
\nspecialists with higher and postgraduate
\neducation, for continuous education and
\nthe retraining of health professionals.
\nOblast health departments are responsible for:
\nensuring the provision of human resourc-\u2022
\nes in health organizations and assessing
\nthe expertise of health workers;
\nplanning the training and retraining of\u2022
\nmedical specialists;
\nensuring the continuous education and\u2022
\nretraining of medical and pharmaceutical
\nspecialists.
\nHuman Resources and Bioethics in Palliative
\nCare as an Example of Human Resource and
\nBioethics Development in Kazakhstan
\nMaksut K. Kulzhanov
\n139
\nMedical Ethics, Human Rights and Socio-medical affairs
\nIn 2007, there were 57, 387 medical doc-
\ntors working in Kazakhstan\u2019s health sys-
\ntem, equivalent to a ratio of 3.68 physicians
\n(physical persons) per 1000 population,
\nwhich was close to EU-15 and CIS aver-
\nages (WHO 2007a).
\nThe decline in the ratio of health care work-
\ners to population since 1990 is due to a num-
\nber of factors, including a shift to the private
\nsector, health care workers leaving the health
\nsector, the outmigration of ethnic Russians,
\nand the dismissal of health personnel.
\nThere is a huge gap between rural and ur-
\nban areas. Primary health care facilities are
\nfacing problems in recruiting quali\ufb01ed sta\ufb00,
\nespecially in remote and rural areas. This is
\nin large part due to an insu\ufb03cient number
\nof new graduates. Enrolment to medical
\nschools \ufb01nanced by state grants or credits has
\nincreased annually by about 10% since 1999,
\nbut the need in human resources is still high
\n(President of Kazakhstan 2004). Kazakhstan
\nis facing a serious problem with the ageing
\nof health personnel and the understa\ufb03ng of
\nhealth facilities, in particular in rural areas.
\nThere is also an urgent need for certain
\ncategories of health professionals, such as
\nspecialists in health management or health
\neconomics. The lack of properly trained
\nmanagers translates into poor management
\nand ine\ufb03cient use of resources. Often, the
\nmanager of a health facility has a number of
\nsimultaneous functions: acting as manager,
\nadministrator and chief physician (Presi-
\ndent of Kazakhstan 2004).
\nKazakhstan has inherited the Soviet system of
\ntraining and retraining of health profession-
\nals and there have hardly been any changes
\nin this area in the years since independence
\n(President of Kazakhstan 2004), although it
\nshould be noted that there has been signi\ufb01-
\ncant postgraduate training in family medicine
\nand priority programmes including mother
\nand child health and tuberculosis.
\nOverall, the quality of training and retrain-
\ning remains poor, which is partly due to an
\nunderdeveloped regulatory system with re-
\ngard to university entry and the quality of
\nmedical and pharmaceutical teaching, but
\nalso to years of underinvestment in educa-
\ntional buildings and facilities. The limited
\nfunds allocated to medical training in the
\npublic sector do not allow the purchase of
\nup-to-date technical equipment or visual
\naids (President of Kazakhstan 2004).
\nIn addition to state-funded students, uni-
\nversities try to attract additional funds by
\naccepting medical students who pay for the
\ntuition themselves. The number of students
\npaying for their studies has increased in re-
\ncent years.
\nThe Concept for the Educational Develop-
\nment of Kazakhstan until 2015 envisaged
\nchanges to the training of all profession-
\nals with higher education that also have an
\nimpact on medical education. In line with
\nthis concept, new obligatory standards for
\nmedical and pharmaceutical education were
\nintroduced in 2003 that place greater em-
\nphasis on continuity between di\ufb00erent edu-
\ncational levels.
\nKazakhstan had nine medical schools (three
\nof which were private), 26 nursing colleges,
\nan Institute of Continuing Training, a na-
\ntional School of Public Health, and 65 re-
\nsearch enterprises. The Kazakhstan School
\nof Public Health was established by the
\nMinistry of Health together with the WHO
\nRegional O\ufb03ce for Europe in 1997.
\nThere are four streams in medical educa-
\ntion. Physicians are trained for six years and
\nspecialize in their sixth year. Paediatricians
\nare trained in an entirely separate course.
\nSanitary-epidemiological service physicians
\nare trained for \ufb01ve years in separate facul-
\nties. Dentists are also trained in a separate
\n\ufb01ve-year course.
\nA one year internship based on six major
\nspecialties (residency), which in similar form
\nexisted in the Soviet period, has recently been
\nreintroduced to improve the quality of medi-
\ncal graduates.Following the internship,physi-
\ncians can specialize in more than 80 specialties
\nwith a training duration of 2-4 years.
\nA family practice specialty was introduced
\nin 1995 as a four-month short course at the
\npostgraduate medical institute and other
\nshort courses are being mounted at approved
\nsites. Training in general practice (both for
\nundergraduates and for practicing physi-
\ncians) has been supported with both tech-
\nnical assistance and funding from USAID,
\nthe United Kingdom Department for Inter-
\nnational Development and the World Bank.
\nIn 2005, the government spent 2% of the
\ntotal health care budget on the training of
\ngeneral practitioners and health managers.
\nFurther education is conducted at the Post-
\ngraduate Medical Institute or at one of the
\nmedical research institutes. Physicians must
\ndo a short retraining course every \ufb01ve years
\nand clinical lecturers every three years. This
\nrequirement has faltered, however, with
\nbudget cuts and the di\ufb03culties of taking
\nleave from employment.
\nA postgraduate course in public health com-
\nmenced in 1997 at the Kazakhstan School
\nof Public Health in Almaty. Management
\ncourses are also available at the Kazakh-
\nstan Institute of Management, Economics
\nand Strategic Research and at the Centre
\nfor Medical and Economic Research. The
\nnumber of new physicians graduating has
\ncontinued to rise during the 1990s although
\nthere are few available jobs. Unemployment
\nis said to be a problem among new medi-
\ncal graduates, and this is likely to continue,
\ngiven the unwillingness of new graduates to
\nwork in rural areas.
\nHealth care personnel per 10 000 population, 1990-2007
\n1990 2000 2001 2002 2003 2004 2005 2006 2007
\nPhysicians (PP) 39.6 33.0 34.6 36.1 36.5 36.3 36.5 37.6 36.8
\nDentists (PP) 2.6 2.1 2.3 2.7 2.8 2.9 2.7 2.9 2.9
\nNurses (PP) 44.7 46.5 48.9 49.1 50.0 51.1 54.2
\nMidwives (PP) 5.2 5.5 5.4 5.4 5.5 5.5 5.7
\nNote: PP: physical persons
\n140
\nMedical Ethics, Human Rights and Socio-medical affairs
\nNursing education consists 2 years basic
\ntraining, followed by one year of specializa-
\ntion in general medicine, emergency care,
\nobstetrics, or management. However, the
\ncurricula are outdated and fail to re\ufb02ect the
\nrequirements of health service provision
\nand many nurses are poorly trained.
\nAt present, nursing education is being re-
\nformed with the aim of upgrading it to
\npostgraduate level, strengthening the status
\nof nurses as an independent health profes-
\nsion, and providing continuing education.
\nMore attention is also paid to the training
\nand retraining of managerial and adminis-
\ntrative sta\ufb00, including nurse managers, in
\nline with the increased importance of pri-
\nmary health care, where most nurse spe-
\ncialists are expected to work in the future.
\nAt Almaty Medical College for example, a
\n4-year training programme for nurse man-
\nagers has been introduced.
\nFeldshers receive nurse\/midwife training
\nwith additional training in diagnosis and
\nprescribing. They carry out clinical respon-
\nsibilities that are mid-way between doctors
\nand nurses. In rural areas, feldshers work in
\ne\ufb00ect as primary care physicians.
\nIn the former Soviet Union, the health sec-
\ntor was not regarded as productive compared
\nto other sectors such as mining. Therefore,
\nwages for health care personnel were set be-
\nlow the workforce average.Despite repeated
\nincreases in the salaries for health care work-
\ners in Kazakhstan, with an increase by 20%
\nin 2004 alone, the o\ufb03cial average salary in
\nthe health sector in 2004 was only half the
\nnational average for all sectors combined
\n(President of Kazakhstan 2004). At present,
\nthe remuneration of health workers is regu-
\nlated through the Government decree No.
\n41 on the System of Labour Remuneration
\nof Public Employees who are not Civil Ser-
\nvants of 11th
\nJanuary 2002. Health workers
\nare remunerated according to seniority and
\nquali\ufb01cation, with no regard to outcomes or
\nthe quality of services provided.
\nThe prestige and \ufb01nancial reimbursement
\nof nurses continues to be very low. While
\nthe o\ufb03cial salary of physicians is not much
\nhigher than that of nurses, they can gain
\nvarious o\ufb03cial bonus payments and infor-
\nmal \u2018under-the-table\u2019 payments from pa-
\ntients. Physicians might also be appointed
\nto more than one position, with a respective
\nincrease in income. The skill mix of health
\ncare workers is being adjusted in many Eu-
\nropean countries with the aim of increasing
\nthe number of trained nurses in relation to
\nthe number of doctors (Rechel, Dubois et
\nal. 2006). In Kazakhstan, doctors often per-
\nform tasks that in western European coun-
\ntries would be performed by nurses, while
\nnurses perform many tasks that elsewhere
\nwould be performed by auxiliary or support
\nsta\ufb00. The di\ufb00erence in Kazakhstan is that
\nthe salary di\ufb00erential is not as large and that
\nnurses receive far less training than doctors.
\nHuman resource development
\nfor successful palliative care
\nOne of the developing \ufb01elds in public
\nhealth in the country is palliative care.There
\nare a lot of problems that need to be decided
\nat the di\ufb00erent managerial levels including
\nhuman recourse development issues and
\nbioethics.
\nPalliative care in Kazakhstan has developed
\nsince 1990s. Such \ufb01gures as morbidity rate
\nincreasing, high mortality rate from onco-
\nlogical diseases, high rate of people with IV
\nstage of tumour are evidence about neces-
\nsity of this service in Kazakhstan. Six pal-
\nliative care centres have been established
\nin Kazakhstan. All of them get \ufb01nancial
\nsupport from governmental budget. By pa-
\ntient and physicians\u2019 opinion palliative care
\nservice is a very important and helpful part
\nin oncological service providing, and during
\nlast ten years Kazakhstan achieves real posi-
\ntive results in organization of this care.
\nAt the same time there are a lot of challeng-
\nes in this \ufb01eld. By medical experts\u2019 opinion
\nonly in Almaty already today there should
\nbe a minimum of four palliative care centres
\nto satisfy population needs in this service.
\nMoreover, if today most of the patients in
\nthe palliative care centres (80%) are with
\noncological diseases, and only 20% of them
\nwith internal diseases, so in near future pa-
\ntients with such diseases as tuberculosis and
\nHIV\/AIDS will also need palliative care.
\nThis will lead to another big challenge for
\npalliative care – human resources develop-
\nment. Currently there is lack of specialists
\nin general oncology that should provide ser-
\nvices as in oncological clinics, so in pallia-
\ntive care centres; lack of trained specialists
\nin palliative care; psychologists and social
\nworkers. There is lack of uni\ufb01ed training
\nprograms in palliative medicine to prepare
\nquali\ufb01ed professionals.
\nKazakhstan School of Public Health has
\nconducted a study on palliative care needs
\nassessment in Kazakhstan including human
\nrecourse development aspects. Results of
\nthe survey explored the necessity of pallia-
\ntive care development in the country for the
\ngrowing number of patients of both genders
\nand di\ufb00erent ages. Due to study conducted
\namong medical workers and population in
\n10 cities (10 di\ufb00erent oblasts) of Kazakh-
\nstan demonstrated following results. 24.5%
\nof medical workers (n=357) noted about dif-
\nferent problems in palliative care including
\nlack of professionals with good knowledge
\nof palliative care concept. Only 49.9% of
\nrespondents have regularly training. Other
\nproblem is emotional aspects of palliative
\ncare. 65.0% of population in di\ufb00erent ages
\n(n=453) noted that they have a relative who
\nhas needed palliative care service. 60.3%
\nof them know where to receive palliative
\ncare service and got it, 39.7% are not. Only
\n38.4% of respondents have had emotional
\nsupport from palliative care clinics sta\ufb00.
\nEmotional support was provided by medi-
\ncal workers in 37.6% and social workers in
\n13.8% cases. 21.6% of medical workers not-
\ned that they have positions for workers who
\nmay provide emotional and social support,
\n13.7% of medical workers noted that they
\nhave social workers and 13.1% – voluntaries
\nfrom religion organizations.
\nThis shows another challenge \u2013 the prob-
\nlem regarding the training and retraining of
\nspecialists on palliative care in new concept,
\norganization and management issues. To-
\n141
\nMedical Ethics, Human Rights and Socio-medical affairs
\nday there are no separate training courses
\non palliative care provision, on quality of
\nservices in palliative care for patients and
\ntheir families to reduce the gap in profes-
\nsional development and this is an option to
\nimprove the situation.
\nThus, there are a lot of problems regarding
\nthe organization and management of pal-
\nliative care in the country, including the
\nprovision of medical, psychological and
\nsocial services for patients and their fami-
\nlies. Palliative care is in a transition stage in
\nKazakhstan. Decisions regarding these is-
\nsues would further the development of this
\nservice. It is necessary to work on modern
\norganizational, economic, and managerial
\nmechanisms and standards to establish ap-
\npropriate centres. Also, it is important to
\nwork on workforce development to provide
\nqualitative palliative care. One of the main
\nexpected results following the study would
\nbe curriculum development for specialists of
\npalliative care services.
\nBioethics
\nHealth care is an extremely complex and
\ncomplicated \ufb01eld. Ethics is integral to health
\ncare: to its clinical practice,governmental and
\norganizational policy development, payment
\nsystem, legislation development, and \ufb01nally
\nto the national economy. Bioethics principles
\nbroadly integrated with its directions start-
\ning from research and continuing by national
\npolicy and economics of the country. Bioeth-
\nics in Kazakhstan is in a developing stage.The
\nMedical Society started to introduce modern
\ninternational bioethics concepts, approaches
\nand instruments.At the present time there are
\na few committees that could revise the ethical
\nissues of research. One of them, the Institu-
\ntional Research Board, is located in the Ka-
\nzakh National Medical University in Almaty.
\nThis Board works in line with international
\nrequirements. The Ministry of Health plans
\nto develop a similar committee at the national
\nlevel and this process is in progress. There is
\nstill a big challenge in the development of the
\nlegislation base in this \ufb01eld. The Kazakhstan
\nSchool of Public Health in collaboration with
\ninternational experts has developed a curricu-
\nlum on bioethics for researchers. This course
\nhas been conducted during the last \ufb01ve years
\nand helped to form a critical mass of health
\nprofessionals who are capable of developing
\nand implementing the bioethics concepts in
\nthe country.
\nIn respect of public health research among
\nelderly people it is necessary to remember
\nthat bioethics principles help correctly and
\nin-depth to collect data on pertinent infor-
\nmation. In particular in this direction such
\nprinciples as \u201crespect for human persons\u201d,
\n\u201chuman control of life\u201d, \u201cculture, behaviour,
\nand interpersonal relationships\u201d, \u201cjustice\u201d,
\nand \u201callocation of resources\u201dare very impor-
\ntant. In research with the elderly it is neces-
\nsary to keep in mind that elderly people are
\nmore vulnerable in the psychological and
\nsocial spheres. Con\ufb01dentiality, honesty, au-
\ntonomy are very important components in
\nethical research among the elderly popula-
\ntion. During the planning of such research
\nthe investigator needs to think about such
\npoints as the value of conducted research
\nand the results of the research, the climate
\nor the environment of conducting the study,
\nissues of the in\ufb02uence of culture and country
\npolicy to planning research, the prevention
\nof potential con\ufb02icts of interest between
\nclients and professionals and the compen-
\nsation strategy for the research.
\nAnother important approach to ethical re-
\nsearch among the elderly is equitable dis-
\ntribution of bene\ufb01ts and burdens during
\nthe study. It is necessary to understand the
\nformal and material principles of justice and
\nthe possibility for establishing (saving) bal-
\nance of justice with other principles of bio-
\nethics such as mercy, bene\ufb01cence, nonma-
\nle\ufb01cence, allocation of scarce resources and
\nthe fair opportunity principles.
\nAlso very important are such aspects in
\nconducting research among the elderly as
\ndi\ufb00erences between the de\ufb01nitions of \u201cright
\nto the life\u201d, \u201cquality of life\u201d, \u201cright to health
\ncare\u201d and \u201cresource allocation\u201d according to
\nethics positions, and also the contrast be-
\ntween \u201callocation of resources\u201d with \u201cim-
\nplicit and explicit rationing\u201d.
\nThus, conducting research among the elder-
\nly, the study of the peculiarities of ageing,
\nhealth status, quality of life, and providing
\nhealth, prevention, psychological and social
\nservices become more actual for all countries
\nin the world, and that is why such research
\nshould be conducted to modern require-
\nments and held due to bioethics principles.
\nReferences
\nHighlights on health in Kazakhstan. World Health
\nOrganization, 2006.
\nKulzhanov M, Rechel B. Kazakhstan: Health system
\nreview. Health System in transition, 2007; 9(7):
\n1-158.
\nKulzhanov M., Yegeubaeva S., Dosmailova
\nA. Palliative care in Kazakhstan: Current Status and
\nPerspectives for Development. Journal of Central Asian
\nHealth Services Research, 2007; 6(4): 35-40.
\nSchick I.C., Porter R., Chaiken M. Domains and Core
\nCompetencies in Ethics
\nProf. Gia Lobzhanidze \u2013 President of
\nGeorgian Medical Association
\nDr. Levan Labauri \u2013 Secretary General of
\nGeorgian Medical Association
\nIn August, 2008, during an armed con\ufb02ict
\nbetween Georgia and Russia,the infrastruc-
\nture of the Georgian Healthcare system was
\nseverely damaged, including a loss of hu-
\nman resources. During the war, Georgian
\nhealth professionals continued working in
\nspecial teams, organizing specialists groups
\nto deal with the critical situation. Emergen-
\ncy medical centers were entirely overloaded.
\nHealth system and personnel losses have
\nnot yet been de\ufb01nitively assessed however
\nthere are trends and medical perspectives of
\nthe disaster that can be discussed.
\nGeorgian Health Care System
\nin the Time of Armed Con\ufb02ict
\n(Georgian \u2013 Russian War of August 2008)
\n142
\nMedical Ethics, Human Rights and Socio-medical affairs
\nAt the beginning of the war, medical insti-
\ntutions located in the con\ufb02ict region were
\nable to support entirely the \ufb02ow of the in-
\njured military personnel and civilians. From
\nthe con\ufb02ict zone, patients were taken to
\nthe Tkhviavi and Nikozi medical centres.
\nMobile military hospitals were also e\ufb00ec-
\ntive and saved many lives. After receiving
\nemergency medical support in the above-
\nmentioned centres or mobile hospitals,
\npatients were transported to Gori Central
\nHospital and Gori City Hospital,where pa-
\ntients received quali\ufb01ed medical aid. When
\nneeded, patients were taken directly to vari-
\nous (mostly Tbilisi) clinical settings. Civil-
\nians, particularly those injured during war
\nin areas far beyond the con\ufb02ict zone, were
\nconcentrated in local medical centers by
\ngeographical principle. The system of the
\nmedical support described above worked
\nwell in the \ufb01rst days of the war. Later, Rus-
\nsian military forces attacked medical centres
\nand the medical support strategy had to be
\nchanged.
\nResults from the Georgian Hospitals
\nshowed that the number of injured and
\nkilled civilians was many times more than
\nthe number of military casualties. As
\nfrom the military-medical experience, the
\nratio of bullet-related injuries to missile-
\nrelated injuries was 43\/57; in the Geor-
\ngian-Russian war the ratio was 7\/93. It
\nmeans, that the gunshot wounds from au-
\ntomatic weapon were not observed during
\nthe military operations. The \ufb01rst \ufb02ow of
\nwounded was received by the Gori Hos-
\npital on August 09, 2008. The Chief Sur-
\ngeon reported that the absolute majority
\nof injuries were missile wounds, fragment
\nwounds and blast injuries. There was no
\ncase of bullet-related (automatic weapon)
\nwounds among the 65 patients admitted
\non this day. The absolute majority of the
\npatients were peaceful civilian population.
\nIn all cases life stress events have severe
\nconsequences such as acute stress disor-
\nder and PTSD symptoms.
\nOn August 8, 2008 Gori emergency medi-
\ncal centre was bombed just after that mo-
\nbile military hospital, Tkhviavi and Nikozi
\nmedical centres\u2019 infrastructure were also
\nparalyzed and destroyed. In the next phase,
\nwhen Gori was bombed, the Gori military
\nhospital was also practically paralyzed. Be-
\ncause of high level of risk, medical sta\ufb00 was
\nevacuated. This e\ufb00ectively broke the second
\ncircle of medical aid. Although the medical
\nsta\ufb00 was evacuated several times,doctors re-
\nturned repeatedly to work in this high-risk
\nzone. The Gori Hospital provided emer-
\ngency medical service to Russian soldiers as
\nwell. Excellent work by the ambulance cars
\nmust also be mentioned. Both, Gori and
\nTbilisi emergency aid systems were work-
\ning hard and the coordinated work of this
\ncircle saved lots of lives. During the war
\nemergency aid vehicles have driven up to
\n2000 times from Tbilisi to Gori and back,
\nin order to transport all the patients. Dur-
\ning the transportation none of the patients
\nhave died.
\nThe Georgian Medical Association has
\ntrying to inform doctors in other coun-
\ntries about the situation since the begin-
\nning of the war. We are very grateful to
\nthe World Medical Association, which re-
\nacted promptly. On 11th
\nSeptember 2008,
\nthe WMA Secretary General, Dr. Otmar
\nKloiber, issued a press release on behalf of
\nthe WMA calling on both parties of the
\ncon\ufb02ict to respect the professional indepen-
\ndence of physicians. The WMA reiterated
\nthe principle in its policy on Regulations
\nin Armed Con\ufb02ict that physicians must be
\ngranted access to patients, medical facilities
\nand equipment and the protection needed to
\ncarry out their professional activities freely.
\nShortly after receiving the message from
\nWMA, the Georgia Medical Association
\nreceived supporting letters from Germany,
\nBelgium, Austria, Great Britain, Hong-
\nKong, Estonia, Finland, Ireland, and other
\ncountries\u2019 medical organizations.The letters
\nincluded suggestions for helping injured
\npeople. We have also received thousands of
\nletters of condolence from our foreign col-
\nleagues.
\nMany Georgian physicians indicated that
\ntheir Russian colleagues had no wish to
\ncommunicate. The Georgian Medical As-
\nsociation called on the medical profes-
\nsion of Georgia to unite their e\ufb00ort and
\nstrongly follow to the WMA policy state-
\nments.The Georgian Medical Association
\ncon\ufb01rms the death of 4 healthcare pro-
\nfessionals during the war: 1. Goga Abra-
\nmishvili \u2013 the Trauma Surgeon from Gori
\nhospital; 2. Marina Gogiashvili \u2013 nurse of
\nemergency aid; 3. Leri Lagurashvili \u2013 mil-
\nitary doctor; 4. S.B. \u2013 military doctor. One
\nphysician (Zurab Begiashvili) is still miss-
\ning. The Georgian Medical Association
\nalso attempted to identify injured health
\n143
\nMedical Ethics, Human Rights and Socio-medical affairs
\nGuri Spilhaug, MD, Head of Unit for
\nPrimary Health Care and Psychiatry.
\nNorwegian Medical Association
\nThe consumption of alcohol in Norway has
\nbeen relatively low for the last 150 years.The
\ndrinking pattern has been dominated by
\nweek-end drinking \u2013 relatively few drink-
\ning occasions, but drinking to intoxication
\n(binge drinking). Lately the pattern has
\nchanged towards more continental habits,
\nhowever, heavy drinking during week-ends
\nstill continues. More people drink alcohol,
\nespecially women, they drink more when
\nthey drink and they drink more often than
\nbefore. Many people also seem to use more
\nalcohol in work related situations. It is an
\nimportant issue to prevent alcohol abuse in
\nNorwegian workplaces and also to make sure
\nemployees with abuse problems get help.
\nMeasured as pure alcohol each person 15
\nyears or older drank an average of 5.66 litres
\nin 2000, and in 2007 this had increased to
\n6.60 litres.The data of quantity of alcoholic
\nbeverages consumed during the last year
\nshows that men consume on average 2.5
\ntimes more than women. The alcohol con-
\nsumption decreases by age, while it seems to
\nincrease with income and education. People
\nwho live in the Oslo area consume more al-
\ncohol than people living in small towns and
\nrural areas. The popularity of wine and beer
\nhas shown a strong increase over time while
\nliquor consumption has decreased. A key
\nelement in Norwegian alcohol policy has
\nbeen to remove the private pro\ufb01t motive
\nfrom sales of wine, spirits and strong beer.
\nThe business became subject to a special
\nVinmonopol (Wine and Spirits Monopo-
\nly) Act on 19 June 1931, removing alcohol
\nfrom the scope of the regular Joint Stock
\nCompanies Act. Directors and the presi-
\ndent are appointed by the government. The
\nboard is also bound to observe directives is-
\nsued by the Ministry of Health and Social
\nA\ufb00airs. After the private interests had been
\ngradually bought out, Vinmonopolet be-
\ncame wholly state-owned in 1939.
\nVinmonopolet has the exclusive right to re-
\ntail wine, spirits and strong beer in Norway.
\nVinmonopolet purchases the products from
\nimporters holding the required licence and
\nwho have signed a purchase agreement with
\nVinmonopolet.
\nNorwegian alcohol policy has changed in
\nrecent times. Keywords are cuts in alcohol
\ntaxation, an expanding hospitality sector
\n\u2013 especially restaurants and bars \u2013 and in-
\ncreasing numbers of Vinmonopol outlets.
\nThe development in the EU and Nordic
\narea is also feeding this growth along with
\ngrowing public disa\ufb00ection with traditional
\nalcohol policy mechanisms. Higher import
\nquotas and lower taxation on alcohol in oth-
\ner Nordic countries made Norway\u2019s stance
\nincreasingly untenable.
\nThe Norwegian Institute for Alcohol and
\nDrug Research (SIRUS) is an indepen-
\ndent research institute with the purpose of
\nresearch concerning the use and abuse of
\nintoxicants and other addictive substances,
\nwith a particular stress on questions relating
\nAlcohol use in Norway
\nArne Johannesen, MD, Head of section,
\nDep. for Service Development. South-East
\nRegional Health Board
\nworkers. We have collected information
\nabout 18 of them. Most injured doctors
\nwere taken to Tbilisi hospitals for further
\ntreatment.Through the initiative of Geor-
\ngian Medical Association, a special fund
\nwas created to help and support medical
\nsta\ufb00 harmed by the war. GMA represen-
\ntatives personally met with injured physi-
\ncians and received the alarming news that
\nnearly each of them claims that medical
\nsta\ufb00 and hospitals were attacked directly
\nand intentionally.
\nDuring the war, the medical infrastructure
\nwas seriously harmed. In such a situation,
\nthe main public health threat is the spread
\nof infectious diseases.There was a high risk
\nof this in the con\ufb02ict zone because there
\nwere no medical sta\ufb00 and facilities avail-
\nable there. There was also no possibility
\nof maintaining sanitary conditions in the
\ncollective living places of refugees. As from
\nthe WHO release, \u201cin South-Ossetia peo-
\nple are in need of water, food and medi-
\ncal support, although no communicable
\ndisease outbreaks\u201d. WHO also stated that
\nthere have been no reported outbreaks of
\ncommunicable diseases in areas a\ufb00ected by
\nthe con\ufb02ict.
\nThe Georgian healthcare system has en-
\ndured the \ufb01rst wave of crisis, and although
\nthere are some losses, the system keeps op-
\nerating. In the next stage, some problems
\nmay emerge and our main objective is to an-
\nticipate what they will be and develop strat-
\negies and solutions to overcoming them.
\n144
\nMedical Ethics, Human Rights and Socio-medical affairs
\nto social studies.The institute monitors both
\nconsumption and the consequences of such
\nand has played an important role in the pol-
\nicy formation on alcohol in Norway. Alco-
\nhol is a risk factor to more than 60 di\ufb00erent
\nillnesses, like for example cancer, heart and
\nvascular diseases and psychiatric conditions.
\nWe also know that violence,tra\ufb03c and other
\naccidents and self-harm are related to use of
\nalcohol. In Norway the amount of patients
\nhospitalised because of alcohol intoxication
\nwas doubled from 1999 to 2003. More re-
\nsearch on alcohol use and alcohol related
\nhealth problems is necessary to increase our
\nknowledge about risks and treatment. Prior
\nto the Drug Reform in Norway in 2004,
\ntreatment for addiction was primarily a so-
\ncial service, and it was the social services in
\nthe municipalities who referred patients to
\ndrug treatment. The Drug Reform made
\nspecialised treatment a health service and
\ndoctors obtained the right to refer patients
\nto treatment. As a consequence the number
\nof referrals has risen. General practitioners
\naccount for a large portion of this increase,
\nwhile there are small changes in the number
\nof referrals from social services.
\nThe Norwegian Medical Association has
\nwatched the increase in alcohol consump-
\ntion with growing concern, and in 2004 the
\norganisation wrote a report about addiction
\nand health problems. The report concludes
\nwith several recommendations, amongst
\nthese are to increase doctors\u2019 and other
\nhealth workers\u2019 knowledge about alcohol
\naddiction and alcohol related health prob-
\nlems, and how to discover it. It is important
\nto employ more brief interventions that can
\nhelp to reduce the risk of alcohol problems
\namong persons with high-risk consumption.
\nSuch intervention usually consists of ascer-
\ntaining alcohol consumption and a moti-
\nvational interview or conversation. These
\ninterventions are not frequently used today.
\nThere is also a lack of routines for follow-up
\nafter detection of alcohol problems.
\nThe Norwegian Medical Association rec-
\nommends to maintain a restrictive alcohol
\npolicy in Norway,where price and access are
\nthe main factors to in\ufb02uence alcohol con-
\nsumption. From a public health perspective
\nit is important to keep the total consump-
\ntion of alcohol in the country low. Doctors,
\nand especially the general practitioners have
\na special responsibility to inform about
\nthe dangers of risk drinking and resulting
\nhealth problems.
\nThis year the Norwegian Medical Associa-
\ntion has established an expert group to write
\nthe organisation\u2019s strategy document on al-
\ncohol policy.
\nHeikki P\u00e4lve MD, Ph.D., CEO, Finnish
\nMedical Association, Specialist in Anaesthesia
\nand Intensive Care, Special Competency in
\nEmergency care
\nThe developed countries all face the same
\nchallenges to their health care system.
\nBecause of the advanced treatment pos-
\nsibilities o\ufb00ered by modern medicine and
\nincreasing health demand of the citizens,
\nwhich is partially a result of an ageing pop-
\nulation, health care providers are faced with
\nbudgetary pressures. There are several dif-
\nferent ways how the authorities have tried
\nto diminish these problems.
\nThe health care systems in nearly every
\ndeveloped economy are on the move away
\nfrom current organisational models in a
\nquest for cost-e\ufb00ectiveness. As a result the
\nautonomy of doctors is often restricted and
\ntask shifting is considered as one possible
\nsolution to the lack of resources. Legisla-
\ntive action is taken to cut down the health
\ncare expenses. Gate keeping roles for doc-
\ntors are often also proposed to cut down the
\ndemand of hospital care, but simultaneously
\ndoctors are often expected to treat their
\npatients not according to the best proven
\ntherapeutic or diagnostic method. Doctors
\nand their organisations all over the world
\nhave to work in a very stormy environment
\nfacing constant system changes. The case
\nis no di\ufb00erent in Finland and the situation
\nrequires increasing involvement and action
\nfrom the Finnish Medical Association. It
\nseems that Finland is the world in miniature
\nsize and we are facing all these challenges at
\nthe same time.
\nThe Finnish health care system
\nIn Finland, the health care system is \ufb01-
\nnanced mainly through taxation and run
\nby the municipalities, which are responsible
\nfor providing the services.The treatment re-
\nsults of many diseases are globally on top
\nlevel and all the citizens have equal access to
\nhealth care regardless of their wealth.
\nThe satisfaction of the population with
\nthe system is very high and the total
\nhealth care spending represents only eight
\npercent of the GDP, which can be consid-
\nered to be cheap. Even though it is dif-
\n\ufb01cult to measure the total e\ufb00ectiveness of
\nhealth care, the international comparisons
\nthat have been made have proven that the
\nFinnish system is cost-e\ufb00ective. In spite
\nof this the representatives of local and
\ncentral government judge Finnish health
\ncare as expensive. Therefore many major
\nChallenges in Health Care Unite the
\nMedical Associations
\n145
\nMedical Ethics, Human Rights and Socio-medical affairs
\nchanges to the system are either ongoing
\nor being prepared.
\nNew legislation to salvage primary care
\nPrimary care, which in Finland is organised
\nin the municipal health centres, has increas-
\ning di\ufb03culties to attract doctors. The situa-
\ntion is especially di\ufb03cult in rural areas, but
\nproblems occur even in major cities that
\nhave their own medical faculties. The cur-
\nrent law separates primary and specialist
\ncare into two di\ufb00erent organizations.
\nThis total division of primary and special-
\nist care and lack of coordination between
\nthem is one reason for increased spending
\nin health care. Therefore the Finnish gov-
\nernment is preparing new legislation that
\nwould cover both specialist and primary
\ncare and increase their joint organisation
\nas well. The bill would increase the free-
\ndom of the patient to choose between dif-
\nferent doctors and hospitals, which is not
\na right that the patients in Finland enjoy
\nat the moment. Another aim is to increase
\ncompetition and cost control to achieve
\nsavings. There is an increasing tendency
\nto encourage private entrepreneurship on
\nthe health market. Currently municipali-
\nties spend only 3% of their health care re-
\nsources to buy services from the private
\nsector. The public sector is thus managed
\npractically in a monopolistic manner.
\nHowever, people use the private sector in
\nan increasing frequency since it can o\ufb00er
\ncare without undue delay and the patient
\ncan choose the doctor freely and see a spe-
\ncialist directly without turning to a general
\npractitioner \ufb01rst.
\nUntil now it has been politically impos-
\nsible to liberate the services, which has led
\ntowards di\ufb00erent methods of rationing the
\ncare. Because the local o\ufb03cials hold the
\npurse strings of service production in a mo-
\nnopolistic manner, the central government
\nhas already earlier taken legislative action to
\nincrease pressure on the local level. In 2005
\na treatment guarantee law was introduced.
\nIt requires the local authorities to see to it
\nthat necessary treatment in hospitals has to
\nbe given within six months from the mo-
\nment the need has been diagnosed.
\nThe Finnish Medical Association has as
\none of its basic values the enhancement the
\nbest for the patient.Therefore the FMA has
\nadvocated strongly both for the treatment
\nguarantee and the free choice of the doc-
\ntor, as well as the possibility of patients to
\ntravel abroad for their treatment when and
\nif necessary. The latter choice is included in
\na new framework law proposal that is under
\npreparation in the European Union to unify
\npatient care within the boarders of the EU.
\nIt is expected to raise some opposition from
\nthe governments of EU Member States,
\nwho want to keep the grip on their citizens\u2019
\nrights and possibilities to choose between
\ndi\ufb00erent caregivers in order to safeguard
\ntheir own health care budgets.
\nNon-doctors as managers
\nFinnish doctors have traditionally \ufb01nished
\ntheir professional careers as leading admin-
\nistrators in hospitals and health centres.
\nTheir experience of the health care system
\nas a whole together with accumulated man-
\nagerial experience and education has made
\nthem highly capable to \ufb01ll these positions.
\nEven though the international comparisons
\nhave shown that the Finnish system is run
\nvery cost-e\ufb00ectively, doctors are now being
\ncharged for being responsible to the cost in-
\ncreases during the last decade and therefore
\njudged to be bad managers.
\nIf doctors are considered un\ufb01t leaders it
\nserves as a good excuse to actively diminish
\nthe role of the medical profession in run-
\nning the system. Process management is
\npreferred instead of professional manage-
\nment, and being a doctor is turning out to
\nbe a disadvantage instead of being a virtue.
\nKey indicators used to measure the suc-
\ncess in health care \u2013 such as time spent and
\nnumber of patients met \u2013 are secondary to
\nits real goals and e\ufb00ects. This mechanistic
\nview of measuring the \u201chealth industry\u201d
\nrarely takes into account real health bene\ufb01ts
\nto the patients and their level of satisfaction
\nwith the system or their treatment results. It
\nalso totally ignores the central tasks of our
\nprofession: always comfort, often alleviate
\nand when possible heal.
\nWhen we lose medical professionalism in
\nthe management of health care we also lose
\nvaluable insight how to develop patient care
\nand how to advance medicine in the best
\npossible way. Undoubtedly this trend will
\n\ufb01rst worsen the working conditions of doc-
\ntors and as a result of that also patient care.
\nForcing the doctors to step aside from their
\nadministrative role has already led into seri-
\nous problems in Finland, especially in the
\nhealth centres. Doctors feel their voice is
\nnot heard when primary care work is re-
\norganised. In many cases they have sought
\nnew positions elsewhere and even whole
\nmunicipalities have lost their all doctors in
\na very short time.The FMA tries actively to
\nlobby the local politicians and administra-
\ntors to understand the importance of pro-
\nfessional experience and leadership when
\nmeddling with the structures in order to
\ncontain costs.
\nHelsinki University Hospital, by far the
\nbiggest hospital in the country, is in the
\nmiddle of serious crises at the moment. A
\nnew CEO was appointed to the hospital
\nand he introduced a new managerial leader-
\nship model into the hospital leaving doctors
\nout of the organisation\u2019s strategy work and
\ntop leader positions. This was justi\ufb01ed by
\narguing that doctors are not educated and
\nexperienced leaders. It resulted in an open
\ncon\ufb02ict, which made front page news. In
\nthe end the united doctors\u2019 front got their
\nopinion approved, setting a good example
\nto the profession in the country and world-
\nwide: united we are strong and able to de-
\nfend our possibilities to treat the patients.
\nIn Finland there was a special educational
\nprogram for doctors on health care man-
\nagement, but it has been abolished recently.
\nNo new program has been introduced even
\nthough it was promised. This has lead into
\nmistrust between the profession and the
\ngovernment and increasing numbers of doc-
\ntors are moving from the public sector to
\n146
\nMedical Ethics, Human Rights and Socio-medical affairs
\nthe private sector and occupational health,
\nthus leaving the health centres and hospitals
\nin resource crises. It is important that edu-
\ncational programs for doctors in health care
\nmanagement exist. Doctors should be en-
\ncouraged to participate in these courses and
\nmake use of the quali\ufb01cations accordingly
\nwhen seeking positions. There is certainly
\na need for international cooperation in this
\narea as well and the FMA welcomes the
\ne\ufb00orts of the World Medical Association
\nwith its INSEAD training program which
\nwill take place for the second time in France
\nin December 2008.
\nWorking time
\nOther current topics related to the organi-
\nsation of medical services in Finland are the
\nquestions of working time and on-call work.
\nThe European Union is at the moment try-
\ning to renew the framework legislation that
\nregulates the maximum daily and weekly
\nworking hours of most employees, includ-
\ning doctors.The FMA understands well the
\nrisks for patient safety that are caused by
\nexcessively long working hours. At the same
\ntime it is clear that emergency care requires
\ndoctors to be on call when needed and they
\nalso must be properly remunerated for the
\ninconvenience caused by these abnormal
\nhours of work. The proposed ceilings to the
\nmaximum weekly working hours are not
\na major problem in Finland. However the
\nattempt to limit the active daily working
\nhours will a\ufb00ect the on-call work in hospi-
\ntals substantially and require a much higher
\nnumber of doctors.
\nTask shifting
\nThe Finnish government has promised to
\npropose a bill on task shifting later this year.
\nThe aim is to give restricted right to some
\n200 nurses to prescribe. According to the
\ngovernment this is justi\ufb01ed because it allows
\nthe patients to get their medication easier.
\nThe Finnish Medical Association feels that
\nprescriptions are a part of the treatment
\ndecisions that should be restricted to medi-
\ncal profession only and sees any attempt to
\nchange this as a substantial violation of the
\nautonomy of the medical profession. Doc-
\ntors have the knowledge, training and com-
\npetence to diagnose and determine the best
\nand most e\ufb00ective medication. They also
\nknow how to take into consideration the
\noverall condition and possible other illness-
\nes of the patient, as well as eventual interac-
\ntions between di\ufb00erent drugs.Therefore the
\nresponsibility of the pharmacotherapy must
\nalways lie on the profession and individual
\nprofessionals that are responsible of the pa-
\ntient\u2019s treatment as a whole. It is certain
\nthat the debate in the parliament about this
\nissue will be vivid, but the political pressure
\nis unfortunately towards the medically un-
\nacceptable result.
\nIn Finland there is one working-age doc-
\ntor for every 300 inhabitants. In our system
\nit is therefore not plausible that nurses are
\nneeded for prescribing. Even if there was
\na problem it could not be solved by train-
\ning some 200 nurses trained to prescribe,
\nas has been suggested. It is evident that
\nthe real reasons for these changes di\ufb00er
\nfrom the ones that have been expressed in
\npublic. Factors like cost-containment have
\nbeen stated to play a role. Unfortunately
\nit is probable that this policy will increase
\nthe medication costs even though the salary
\nof prescribers would be lower. Savings are
\nnot easily attained since the more there are
\nprescribers the more there will be prescrip-
\ntions \u2013 but not necessarily more health. Es-
\npecially antimicrobial resistance may easily
\nincrease and lead into more dangerous and
\ncostly infections.
\nThe lack of human resources (physicians)
\nand immaterial resources (time) should not
\nbe used to justify shifting the therapeutic de-
\ncision upon other non-medical professions.
\nHealth care is teamwork.The patient\u2019s inte-
\ngral health care requires a multidisciplinary
\ne\ufb00ort by all health professions, taking into
\nconsideration each other\u2019s \ufb01eld of compe-
\ntence. Other health professionals may con-
\nsiderably help the workload of the doctor
\nin their quest for the best of the patient.
\nHowever, in low-income countries that suf-
\nfer from an extreme shortage of doctors, it
\nis understandable that some tasks \u2013 such
\nas the practical delivery of drugs \u2013 may be
\npartially delegated to other health profes-
\nsionals, but even in those cases always in a
\nclearly de\ufb01ned manner.
\nClinical autonomy
\nA physician should always act in the best
\ninterests of the patient. Respecting the will
\nof the patient must however not result in
\navoiding responsibility. A physician must
\nsupport the decision-making of the patient
\nby providing factual, evidence-based infor-
\nmation in a clearly understandable manner.
\nThe patient must always be able to trust the
\nhonesty and professionalism of the physi-
\ncian. This trust from the patients and the
\nsupport of colleagues are the cornerstones
\nof our everyday work.They must be supple-
\nmented by an agreement with society that
\nresults in a health care system which gives
\nus the necessary clinical autonomy.
\nA Finnish patient was recently let down
\nby the false promises of a quack. Later, the
\npatient was quoted in a newspaper saying
\n\u2019I trusted him like a doctor\u2019. This trust that
\nwe now enjoy from the patients, from col-
\nleagues and from the society at large must be
\nregained and reinforced every day. The only
\nway to do that is to always act for the best
\ninterest of the patient in an ethical way.
\nOur profession faces major challenges to-
\nday. The patients have been empowered
\ninto demanding customers, the politicians
\nlike to see us as any other group of workers
\nand not as highly trained experts in medi-
\ncine who can and should bear the respon-
\nsibility of medical care in every health care
\norganisation. We must insist that organi-
\nsations based on medical expertise require
\nmedical experts to lead them. For all of us,
\nthere is much work to be done. Like the
\ndoctors in the Helsinki University Hospital,
\nthe National Medical Associations should
\nface these challenges united and prepared.
\nTogether we are strong and can best serve
\nour members and their patients.That is why
\nthere is an increasing need for WMA and
\nregional co-operation of the NMAs.
\n147
\nInternational, Regional and NMA news
\nDr.Federico Marin, President Elect 2009- 2011
\nI would like to talk about \u201cM\u00e9xico M\u00e1gico\u201d.
\nLet me preface by saying that Mexico is a
\nCountry of many contrasts; we have lived,
\nas was described by a Latin American writ-
\ner, in the Country of the \u201cperfect dictatorial
\nstate\u201d. It only lasted 77 years, until the year
\n2000. Then, after the treacherous murder of
\nthe \u201co\ufb03cial\u201dcandidate to the presidency,the
\nruling party lost control, and thanks to their
\nlast president the system changed bringing
\nus to the dawn of a new era, the beginning
\nof a democracy. It is said that we are living
\nin the midst of a political system that does
\nnot seem to end, and one that has not yet
\nbeen established. Theoretically, we live in a
\ndemocracy,in a republic,\u201cThe United States
\nof Mexico\u201d. It consists of 32 states and one
\nFederal District, (Mexico City) with the
\ngeography of a horn, the \u201cCornucopia\u201d, but
\nwith the opening to the north that just so
\nhappens to be to the USA.The truth is that
\nthe northern states of Mexico, mainly ag-
\nricultural and with cheap labor, (they have
\nmany labor plants) have exported their pro-
\nduction to the United States, hence their
\nwealth. And since NAFTA was created,
\ntheir growth has been 10 times as much as
\nthat of the southern states, thus, one-third
\nof the northernmost part of the country,
\nclose to the USA, are the rich estates. The
\ncentral part is where the Capitol is, as well
\nas most of the Government o\ufb03ces; and
\nthe southernmost part is where the poorer
\nstates are located and civilization seems to
\nhave stalled. (We cannot but wonder if it
\never arrived.) But then again the contrasts;
\nCancun is almost at the tip, or the south-
\nernmost part of the country, as are Oaxaca
\nand Chiapas with their natural wonders and
\nif that were not enough, all the Mayan Cul-
\nture. A paradox one might think?
\nThis is a country where o\ufb03cial data shows
\nthat half the population is below the pov-
\nerty line. (The Mexican population in 2008
\nis 106,600,000). 13.8% of the population is
\nincapable of even buying their own food.
\nIn contrast, the wealth is in a small group
\nof families, comprising less than 5%. We
\nare still wondering how it is possible that
\nthe World Bank de\ufb01ned our Country as a
\nrich Country, with high income. Perhaps
\nwe should tell the World Bank to go and
\nask the 13.8% people who are starving.
\nThe Mexican Constitution was signed on
\nFebruary 5, 1917. Within its 136 Sections,
\nit talks about the right to food, housing,
\nhealth and education for all. That has not
\nyet been the realized and nobody knows
\nwho is supposed to foot the bill. Still, feu-
\ndal lords rule each in their own reign, do-
\ning and deciding for others, on their own
\nfree will and for their own bene\ufb01t. We
\ncould say that health is the hostage to the
\nlords and they use it as ransom. We are a
\ncountry with huge proven oil reserves, but
\nwith the lack of technology to produce or
\nre\ufb01ne gasoline, the gas is burned right in
\nits extraction site, and then we import gas
\nfrom other countries.
\nThe Health System
\nNational Social Security, IMSS, ISSSTE,
\nPEMEX (equivalent to Medicare and
\nMedicaid in the United States), serve 58.7
\nmillion people, except that their inventories,
\nmaterials and physicians, are roughly at a
\n50% capacity to achieve this. Waiting time
\nfor a doctor appointment is more than two
\nhours and surgical procedures are deferred
\nup to 6 months.
\nAround 20 million people are not protected
\nby any kind of system (\u201cout-of-pocket).The
\nother 22 million people are in a prepaid sys-
\ntem, or so they say, but again, I doubt it.The
\ngovernment insurance policy called \u201cSeguro
\nPopular\u201d, (Popular Insurance or Popular
\nSecurity) was established in a way to cope
\nwith the text. Su\ufb03ce it to say that \u201creality\u201d
\ndid not read the terms and conditions of the
\ncontract. With the same health institutions,
\nthe government is trying to provide Social
\nServices \u2013 in exchange for payment \u2013 as a
\nway of insurance. We, the physicians, never
\nagreed, but we were never asked either.
\nMedical Schools
\nLegally there are 106 schools of medicine.
\nEvery year, before starting any specializa-
\ntion, an evaluation examination is required.
\nSome 25,000 new physicians attempt it, but
\nfewer than 5,000 are admitted. That means
\nthat we have a surplus of 20,000 general
\npractitioners every year. With this number
\nof schools,one can imagine how many asso-
\nciations, councils, colleges, boards, etc., ex-
\nist.We have talked about the atomization of
\nphysicians, meaning that the authorities, by
\nallowing this, have created such confusion
\nthat the possibility of doing anything in an
\norderly manner is quite minimized.
\nThe challenge is to convince physicians to
\nmove to where they are needed. Southern
\nstates have a minimum of medical services,
\nwhile, on the other hand, in the capitol and
\nin the big cities, there is \u201ctop of the line\u201d
\nmedical services, with excellent hospitals
\nfor those who can a\ufb00ord it. The health sys-
\ntem is supported mainly by residents as a la-
\nbor force. Depending on the health system
\nColegio Medico de Mexico
\n148
\nInternational, Regional and NMA news
\nneeds, the number of physicians admitted
\nby the evaluation examination may increase
\nor decrease.
\nAccording to the Mexican Constitution,
\nno person can be obligated, forced or re-
\nstricted from the free exercise of work or
\nemployment; therefore, by law, good fel-
\nlowship is not stimulated, promoted or en-
\nforced.The Secretary of Education has 638
\nmedical specialties. Currently, the COLE-
\nGIO M\u00c9DICO DE M\u00c9XICO is certifying,
\nproviding continuing medical education,
\nand trying to return dignity to physicians.
\nThis dignity was lost when third parties
\nor third payers, interested in belittling the
\nprofession, intervened with the purpose
\nof having technicians who are easily and
\nrapidly trained, as opposed to educated
\nspecialists who undertake years of formal
\neducation and training.
\nOur meetings take place in di\ufb00erent states
\nwith the idea of visiting the whole country,
\npresenting new programs and setting new
\ngoals, and to try to negotiate with the dif-
\nferent departments in the government, who
\ndemonstrate unlawful management. In
\ntrying to make them modify their perfor-
\nmance \u2013 though it is a day by day battle \u2013 we
\n\ufb01nally seem to be making progress with the
\nnew government administration (demo-
\ncratic government?). Now we seem to have
\nreached a meeting place for negotiations.
\nOur comments on health issues have been
\naccepted and are beginning to in\ufb02uence the
\nhealth programs, the pharmaceutical indus-
\ntry and other health issues.
\nGordon Caruana Dingli, MD LRCP Edin
\nLRCS Edin LRCP&S Glasg, FRCS Edin
\nFRCS RCP&S Glasg, Secretary General,
\nMedical Association of Malta
\nThe Medical Association of Malta (MAM)
\nwas established in 1955. MAM represents
\nall the di\ufb00erent medical specialties in Malta
\nwith a membership of around seven hun-
\ndred doctors. MAM is both a medical asso-
\nciation and a trade union; in fact it is one of
\nthe oldest and most prestigious trade unions
\nin Malta.
\nThe founder President of MAM is the Hon-
\nourable Dr. Vincent Tabone, an ophthalmic
\nsurgeon and Emeritus President of Malta.
\nThe council of the Medical Association of
\nMalta is elected every three years and is
\ncompletely voluntary and unpaid with only
\npart-time secretarial support.
\nMAM aims to unite all medical practitio-
\nners and to safeguard their interests, pro-
\nviding advice and assistance in their mu-
\ntual relations and with the State and other
\nauthorities and organizations and provides
\nspokesmen for any member seeking assis-
\ntance.
\nMAM promotes the ethical, scienti\ufb01c, pro-
\nfessional, cultural, social and economic in-
\nterests of its members to lead to the highest
\npossible standards of education, ethics and
\npatient care.
\nMAM works with other national and inter-
\nnational partners and organizations to fur-
\nther its aims.Its local a\ufb03liations are with the
\nFederation of Professional Associations and
\nthe Confederation of Malta Trade Unions
\n(CMTU). On the international scene,
\nMAM is a\ufb03liated with the World Medical
\nAssociation (WMA), European Forum of
\nMedical Associations and WHO (EFMA),
\nPermanent Working Group of European
\nJunior Doctors (PWG), European Union
\nof Family Doctors (UEMO), Common-
\nwealth Medical Association (CMA), Euro-
\npean Union of Medical Specialists (UEMS)
\nand the Standing Committee of European
\nDoctors (CP).
\nIn 2007 the Medical Association of Malta
\nnegotiated a new agreement with the Health
\nDivision of the Malta Government which
\nimproved working conditions for hospital
\ndoctors.The new agreement promoted \ufb02ex-
\nible working times by introducing sessions
\nand also entrenched postgraduate training.
\nIn Malta the medical profession faces sev-
\neral challenges, foremost of which is the
\n\u2018brain drain\u2019 where locally trained doctors
\nare emigrating to other European countries
\nfor \ufb01nancial bene\ufb01ts and for better career
\nprospects. This new agreement will serve to
\nretain local graduates by improving training,
\nworking conditions and career prospects.
\nMAM is also conscious of the physical and
\nmental stresses of working in the profession
\nleading to early \u2018burn out\u2019.This problem will
\nbe approached by improving health care
\nservices for practicing doctors.
\nOn the other hand there are exciting new
\nprospects for the medical profession in Mal-
\nta. A brand new \u2018state of the art\u2019 hospital
\nhas recently been commissioned and there
\nare several new developments especially in
\npostgraduate training. There are plans to
\nmake Malta an international training centre
\nand also to encourage medical tourism.
\nMAM strives to improve the standard of
\nhealth care in Malta to provide the highest
\npossible levels of patient care.
\nThe Medical Association of Malta
\nXLV General Meeting, in Monterrey, Nuevo
\nLeon, Mexico, November 18, 2007 Doctors.
\nFrom the left: Reynaldo Cantu Mata, Former
\nPresident 2005-2007; Eduardo Tello, Cur-
\nrent President 2007-2009; Federico Marin
\nPresident elect 2009-2011
\n149
\nInternational, Regional and NMA news
\n149
\nDr. Din Abazaj, President
\nDr. Shaqir Krasta, General Secretary
\nThe Order of Physicians of Albania was
\ncreated in 1994,by a law of Parliament,dur-
\ning the \ufb01rst years after changes in the socio-
\neconomic and political system of Albania,
\nas a new body without any precedent in Al-
\nbanian medical practice. This entity began
\nits activities in the circumstances of a very
\ndi\ufb03cult transition in all sectors of Albanian
\nsocial life.
\nThe foundation of the Order of Physicians
\nwas a very important step for Albanian
\nmedicine as an independent link of profes-
\nsional self-regulation and e\ufb00ective support
\nwithin the framework of the reforms in
\nhealth care.
\nUntil 2000, the Order was completely de-
\npendent on the Ministry of Health; the
\nactivity and competencies of the Order was
\nvery restricted. During this year a new Law
\nNo. 1615 date 01.06.2000 \u201cOn the Order of
\nPhysicians in the Republic of Albania\u201d was
\npromulgated, which considered it a \u201cPublic
\nEntity\u201d. From this time the Order began
\nto develop, raise and enforce institutional
\ncapacities and functioning as an e\ufb00ective,
\nindependent, professional body.
\nDuring the last few years of the activity the
\nchallenges of the Order had been oriented
\nto:
\nFirstly\u2022 ,raising of capacity and institution-
\nal e\ufb00ectiveness,
\nSecondly\u2022 , raising of public credibility,
\namong the membership and in partner-
\nship with counterparts in the country and
\nabroad.
\nThirdly\u2022 , the construction and consolida-
\ntion of systems and processes for the good
\nfunctioning of all the Order\u2019s structures.
\nThe Order of Physicians is a regulatory
\nbody of medical professions and its main
\nmission is to o\ufb00er support and encourage
\nhigh standards for formation and continu-
\ning education of doctors.On the other hand,
\nit is engaged to guarantee the application of
\nthese standards in the defence of the public
\nand patients from medical malpractice and
\ntransgressions of the Code of Medical Eth-
\nics.
\nThe Order has concentrated its e\ufb00orts on:
\nRegistration of doctors\u2022
\nFitness to medical practice\u2022
\nManaging of \ufb01nancial sustainability\u2022
\nPublic involvement\u2022
\nPublic relations and communication\u2022
\nInternational relations\u2022
\nThe National Council of the Order had ap-
\nproved the Code of Deontology and Medi-
\ncal Ethics as a central document for profes-
\nsional standards, to be applied compulsorily
\nby every physician during medical practice.
\nThe establishment of the National and Re-
\ngional Register of physician\u2019s membership
\nand creation of the website (www.umsh.org)
\nwere important challenges of these years.
\nThe register was constructed as a database
\nand is open to the public and it contains
\nsome data, which belongs only to the Order,
\nregarding the Continuous Medical Educa-
\ntion for doctors, needed for the periodical
\nrevalidation of health professionals.
\nClosely associated with the National Coun-
\ncil is the National Disciplinary Judgment
\nCommission, which deals with the doctors
\nwho avoid the \ufb01tness to practice and other
\ncommissions.
\nA very important issue for the Order has
\nbeen public communication and the exami-
\nnation of public and patients complaints.
\nThe Order of Physicians of Albania is a
\nyoung body without experience and tradi-
\ntion. These conditions have led to the ex-
\npansion of relations and collaboration with
\nsimilar bodies and international organisa-
\ntions. Today the Order has relations with
\na number of European medical associa-
\ntions and is a member of IAMRA, GIPEF,
\nEFMA, ZEVA, COMEM, etc.
\nThe expansion of international relations has
\nbeen directed to the integration of Albanian
\nmedicine with European medicine.
\nThe priority challenges to the future activity
\nof the Order are:
\nFirstly: enforcement and improvement of\u2022
\nactivities related to raising the credibility
\nof the Order and consolidation of it as an
\nindependent public entity,
\nSecondly: invigoration of all the Order\u2019s\u2022
\nbranches for monitoring and control of
\ndaily medical practice standards related to
\nthe protection of the public and patients
\nfrom medical malpractice.
\nThe long term Strategy of Order of Phy-
\nsicians has been directed to the support of
\nHealth policy reform in Albania.
\n15 years after the changing of the politi-
\ncal and social regime in Albania the health
\nsystem still encounters a lot of di\ufb03culties
\nrelated to:
\nvery limited technical capacities to devel-\u2022
\nop policies, strategies and national plans,
\ninstitutional and individual professional\u2022
\naccreditation has not yet been applied.
\nAlbania does not currently enjoy either
\nexperience or tradition in this sector.
\nlack of the decentralisation of compe-\u2022
\ntencies from government authorities to
\nhealth organisations, institutions and
\npublic entities and, as result, the orders
\nand professional organisations are not
\nplaying the role which belongs to them
\nfor exercising their competencies, author-
\nity and commitment regarding Continu-
\nous Medical Education, and the accredit-
\ning and licensing of professionals.
\nlack of experience in monitoring and con-\u2022
\ntrolling the activities of private practice,
\nlack of necessary structures for monitor-\u2022
\ning and controlling the quality of health
\ncare,
\nAlbanian Order of Physicians \u2013 Progress and
\nStrategy of Development
\n150
\nInternational, Regional and NMA news
\nlack of many diagnostic equipment and\u2022
\ncurative services.
\nlack of credibility and public dissatisfac-\u2022
\ntion of the quality of medical services
\ndelivered.
\none of the more acute problems is the un-\u2022
\nequal distribution of medical sta\ufb00. Many
\ncommunities are left uncovered by the
\nhealth service.As result of free movement
\nand the migration toward big cities, phy-
\nsicians abandoned their working places in
\nremote rural areas, which make the plan-
\nning of the needs for health services very
\ndi\ufb03cult.
\ninsu\ufb03ciency in the \ufb01nancing the health\u2022
\nsystem.
\nlittle experience and weak capacities in\u2022
\nthe \ufb01eld of health management.
\nTaking into consideration the above-men-
\ntioned problems, health reform in Albania
\nhas concentrated on an ambitious strategy
\nthat introduces challenges to be faced, such
\nas:
\nStrengthening the technical capacity of\u2022
\nthe Ministry of Health in drafting poli-
\ncies,strategies or national plans for health
\nsystem development, avoiding the tra-
\nditional role of direct management of
\nhealth services,
\nImproving the stimulating policies for\u2022
\nprivate health service, as well as the
\nstrengthening of legislation, standards,
\nand monitoring structures in order to
\nprotect the public from abuses and harm-
\nful medical practices.
\nPlacing the patient in the centre of the\u2022
\nhealth system as a fundamental condition
\nfor quality service and development.
\nDecentralization of health system with\u2022
\nthe \ufb01nal aim of its autonomy, as the op-
\ntimal solution for good management and
\nthe safeguarding of system integrity.
\nEstablishing of a national system of hu-\u2022
\nman health resources, capable of achiev-
\ning its mission.
\nExtension of \ufb01nancial basic resources,\u2022
\nincrease of the \ufb01nancial and cost-e\ufb00ec-
\ntiveness of their use through increasing
\npublic funds for health, enlargement and
\nstrengthening of health insurance schemes,
\nimprovement of contracting mechanisms.
\nStrengthening of managerial capacity of\u2022
\nhealth institutions through creation of
\nmodels for their management. Establish-
\ning of the profession of health managers.
\nPreserving and improving public health\u2022
\nby adapting it to the economic, social and
\nepidemiological changes in the country.
\nStrengthening and perfecting of primary\u2022
\nhealth care service by considering it as the
\nmain pillar of health services.
\nCreating the model of an autonomous\u2022
\nhospital aiming at the improvement of
\nhealth care quality.
\nImprovement of dental and pharmaceu-\u2022
\ntical service with the aim to standardise,
\nstrengthen and monitor structures.
\nTo face and realize all these challenges
\nAlbania needs the setting up of necessary
\nstructures in the sectors of Health Insur-
\nance Policies, Mental health, Health Man-
\nagement, Quality Control, Accreditation,
\nLicensing, Monitoring. CME, Standard-
\nization and Maintenance of medical equip-
\nment and others.
\nThe human resources in the health care sys-
\ntem today in Albania are limited. The ratio
\nof physicians to population is 1.36 per 1000
\ninhabitants (among the lowest ratios in Eu-
\nrope). The ratio of mid-quali\ufb01ed sta\ufb00 is 3.7
\nper 1000 inhabitants.
\nFor resolving these issues,the reform is con-
\ncentrated in developing a medium term and
\nlong term plan for human resources in the
\nhealth system, improving the geographical
\ndistribution of medical sta\ufb00 by applying the
\nprinciples of the labour market, establish-
\ning a Centre of CME and allocating the
\nnecessary funds, establishing the School of
\nPublic Health in order to create a functional
\ntraining system for physicians and medical
\nsta\ufb00. On the other hand, it is important to
\nstrengthen the role of the family doctor. Al-
\nbania possesses an insu\ufb03cient number of
\nfamily doctors \u2013 0.5 per 1000 inhabitants.
\nThe specialty of family medicine was in-
\ntroduced only recently and is still the most
\ndiscriminated and low-esteem specialty.It is
\nvery important to strengthen the category
\nof family doctors by improving their tech-
\nnical abilities and the infrastructure of Pri-
\nmary health care.
\nThe reform in Albanian medical services
\nshould include also:
\nStrengthening the patient\u2019s role in assess-\u2022
\ning the level of health service and devel-
\nopment of health policies,
\nEncouraging the establishment of au-\u2022
\ntonomous health services (PHC and hos-
\npitals), \ufb01nanced by the health insurance
\nscheme.
\nEstablishing the School of Public Health\u2022
\nand institutionalising Continuous Medi-
\ncal Education.
\nChanging the image of family doctors\u2022
\nthrough improvement of clinical practice
\nand a new philosophy of dealing with the
\nindividual and community issues.
\nThe new Government has decided to rise\u2022
\nthe percentage of GDP for medical ser-
\nvices from 2.4 today to 3.5 during 2007-
\n2008.
\nOrganising of health promotion focusing\u2022
\non improvement of life style, prevention
\nof road accidents, drugs, alcohol, tobacco,
\netc.
\nImprove population access by primary,\u2022
\nsecondary and tertiary health services.
\nImproving the primary health care infra-\u2022
\nstructures.
\nEncouraging and supporting the enlarge-\u2022
\nment process of private practice in deliv-
\nering health care in the primary and hos-
\npital services.
\nImproving legislation to harmonise the\u2022
\nreform in medical service.
\nPrivatise the curative dental service com-\u2022
\npletely and apply the health insurance
\nscheme cover people of 0-18 years of age.
\nImproving the pharmaceutical legislation\u2022
\nbased upon EU experience.
\nStrengthening the monitoring capacities\u2022
\nin manufacturing, storage and marketing
\nof drugs.
\nStrengthen the structures, collaboration\u2022
\nand the role of public entities such as
\nthe Order of Physicians and Dentists of
\nAlbania, the Order of Pharmacists, the
\nOrder of Nurses and professional associa-
\ntions of the medical specialties.
\n151
\nInternational, Regional and NMA news
\nEric De Roodenbeke, Director General of the
\nInternational Hospital Federation.
\nThe International Hospital Federation is
\nthe successor to the International Hospital
\nAssociation, which was established in 1929
\nafter the \ufb01rst International Hospital Con-
\ngress in Atlantic City, USA. The Associa-
\ntion ceased to function during the Second
\nWorld War, but was revived under its new
\ntitle \u2013 International Hospital Federation
\n(IHF) \u2013 in 1947. The IHF is an interna-
\ntional non-governmental organisation, sup-
\nported by members from over 100 coun-
\ntries. As the worldwide body for hospitals
\nand healthcare organisations it develops
\nand maintains a spirit of co-operation and
\ncommunication among them, with the pri-
\nmary goal of improving patient safety and
\npromoting health in underserved commu-
\nnities.
\nThe IHF vision is to become a world leader
\nin facilitating the exchange of knowledge
\nand experience in health sector manage-
\nment, with its main goals being:
\nTo improve patient care quality around\u2022
\nthe globe, through the dissemination of
\nevidence-based information.
\nTo collect, collate, publish and facilitate\u2022
\nthe exchange of information and ideas on
\nbest practice in hospital and health care
\nmanagement.
\nTo assist in the creation of environments\u2022
\nthat support organisations in the promo-
\ntion and delivery of health care.
\nTo foster international partnerships that\u2022
\npromote interaction among public and
\nprivate hospitals and health care organi-
\nsations, the community and commercial
\nentities.
\nTo promote and protect the dignity,safety\u2022
\nand welfare of patients.
\nThe vision is promoted through events,
\npublications, networking and projects in
\nline with its mission and values. These ac-
\ntivities prioritize information on leadership
\nand management of hospitals and health
\nservices.
\nThe IHF publishes the journals World Hospi-
\ntals and Health Services and Building Quality
\nin Health Care launched in October 2007 in
\ncollaboration with The Methodist Hospital
\n(Texas, USA); the yearbook International
\nHospital Federation Reference Book
\nIHF events which are organized and locat-
\ned to ensure its presence in all regions of the
\nworld include the Biennial World Hospital
\nCongress, Pan-Regional Conferences. IHF
\nevents also provide both a forum and meet-
\ning place for public and corporate actors.
\nThe IHF engages in a myriad of activities
\nwhich have as their objectives prioritization
\nof information on leadership and manage-
\nment of hospitals and health services. Ex-
\namples of such activities include:
\nDevelopment of a Training Manual for\u2022
\nTuberculosis (TB) and MultiDrug Re-
\nsistant-Tuberculosis (MDR-TB) Con-
\ntrol for Hospital\/Clinic\/Health Facility
\nManagers.
\nAssessment and preparation of a report\u2022
\non water usage within hospitals and
\nhealthcare facilities, for which aspects of
\nwaste management and control of infec-
\ntious diseases were points of focus.
\nInter-professional collaborative project\u2022
\ninvolving conduct of and preparation of
\na report on smoking policies and practices
\nin hospitals and health services in select-
\ned African countries.
\nTechnical Assistance Programmes to\u2022
\nMinistry of Health (Kuwait), to review
\nrecent initiatives undertaken to improve
\nthe country\u2019s health care.
\nCollaboration with the International As-\u2022
\nsociation for Infant Food Manufacturers
\n(IFM) to develop a concept paper for a
\nsafety training programme for feeding
\npractices in hospitals.
\nThe IHF through its membership and com-
\nmunications activities acts as a bridge be-
\ntween members in order to facilitate and
\nsupport cross-fertilization of knowledge
\nand experience in management and leader-
\nship of health organizations. Through these
\nactivities, the IHF supports the creation of
\nnew national hospital associations.
\nThe IHF has o\ufb03cial relations with the
\nWorld Health Organization and also main-
\ntains good working relationships with a
\nnumber of other international organiza-
\ntions, such as:
\nthe International Council of Nurses;\u2022
\nthe World Medical Association;\u2022
\nthe Hospital Committee of the European\u2022
\nCommunity;
\nthe World Dental Federation;\u2022
\nthe International Pharmaceutical Federa-\u2022
\ntion;
\nthe Global Health Workforce Alliance;\u2022
\nWorld Alliance for Patient Safety of\u2022
\nWHO.
\nIHF secretariat is engaged in questioning
\nall of its national members to better re\ufb02ect
\ntheir priority areas of concern. This review
\nwill lead to the organization of the \ufb01rst-
\never global retreat of health-care organiza-
\ntion representative top decision-makers, in
\nMay 2009. Such a forum will energize solu-
\ntions and enhance advocacy capacities both
\nat global and national level. It will also be
\nof major importance to clarify the dialogue
\nIHF will undertake at global level with ma-
\njor health organizations.Today hospitals are
\ntrying to \ufb01nd opportunities to grow and\/or
\nsustain their activities.The hospital sector is
\ngoing to change dramatically in the com-
\ning years. It is more than ever important to
\nthink ahead relying on a better understand-
\ning of how the future is shaping up. Innova-
\ntive solutions emerge locally but they can be
\nscaled up through a bottom up – top-down
\nprocess, thereby making the global level a
\nnecessary step to accelerate responsiveness.
\nIHF is the key to this process because it
\nis the link between the hospital sector, the
\nhealth care professions and the internation-
\nal organizations.
\nInternational Hospital Federation
\n152
\nInternational, Regional and NMA news
\nDr. Hiroko Minami
\nThe International Council of Nurses (ICN)
\nis the world\u2019s \ufb01rst and widest reaching
\nforum for health professionals. As a fed-
\neration of 131 national nurses\u2019 associations,
\nICN represents more than 13 million nurses
\nworking around the globe.Our mission is to
\nrepresent and advance the nursing profes-
\nsion worldwide, and in\ufb02uence health policy.
\nOur vision is to lead our societies toward
\nbetter health. All ICN activity is guided by
\nthree strategic goals and \ufb01ve core values.
\nThe goals are:
\nto bring nursing together worldwide;\u2022
\nto advance nurses and nursing world-\u2022
\nwide;
\nto in\ufb02uence health policy.\u2022
\nFive core values form the basis of all ICN
\ndecisions: Visionary Leadership, Inclusive-
\nness, Flexibility, Partnership and Achieve-
\nment. As a federation of nursing organisa-
\ntions \u2013 professional associations, regulatory
\nbodies, and unions \u2013 ICN\u2019s work encom-
\npasses professional practice, regulation and
\nsocio-economic welfare.
\nProfessional Practice
\nIn professional practice ICN\u2019s current focus is
\nin three main areas. The \ufb01rst, leadership, fo-
\ncuses on developing nursing leadership skills
\n\u2013 to make the nursing voice heard at the pol-
\nicy level, to improve working environments
\nand,most importantly,to support quality care
\nfor patients, families and communities. As
\na speci\ufb01c example, ICN is developing nurs-
\ning skills in the area of disaster preparedness,
\nand lobbying international institutions to
\nintegrate disaster preparedness, response and
\nrecovery into their aid programmes.
\nA second focus is the development of a spe-
\nci\ufb01c language to describe nursing practice.
\nCalled the International Classi\ufb01cation of
\nNursing Practice or ICNP\u00ae
\n,it is used to doc-
\nument and describe nursing practice across
\ngeographic areas,languages and time.A third
\nfocus of ICN\u2019s work in professional practice
\nis the importance of strong linkages with na-
\ntional,regional and international nursing and
\nnon-nursing organisations. Building positive
\nrelationships internationally helps position
\nICN,nurses and nursing for now and the fu-
\nture. ICN works with a wide range of part-
\nners, including United Nations agencies, the
\nWorld Health Organization (WHO) and
\nthe International Labour Organisation. We
\nalso work with a variety of other intergovern-
\nmental agencies, non-government organisa-
\ntions and industry.
\nRegulation
\nTurning to ICN\u2019s second pillar, regulation,
\nICN has long recognised that setting and
\nenforcing standards for nursing education
\nand practice is a major responsibility of or-
\nganised nursing. ICN has established an
\nObservatory that identi\ufb01es future trends
\nand issues that require consideration and
\naction. We have produced guidance docu-
\nments, fact sheets and monographs on issues
\nas diverse as mutual recognition agreements,
\nprofessional regulation, competencies and
\na model nursing act. ICN brings the global
\nregulatory community together via a forum
\nfor Regulators and \u2018triad\u2019 meetings bringing
\ntogether NNAs, regulators and Government
\nChief Nurses. We are currently undertak-
\ning a major research study that will facilitate
\ncommunication and understanding between
\nnurse regulators. This study in addition to
\nconducting a comparative analysis of legisla-
\ntion also identi\ufb01es regulatory best practices.
\nSocio-Economic Welfare
\nIn much of the world the socio-economic
\nwelfare of nurses is inadequate. Unsafe and
\nundesirable working conditions contribute
\nto what is probably the greatest challenge
\nto nursing and health today \u2013 the shortage
\nof nurses worldwide. In 2004 ICN and the
\nFlorence Nightingale International Foun-
\ndation undertook the \ufb01rst systematic inves-
\ntigation of the nursing workforce to estab-
\nlish a global picture of the actual situation
\nand the potential solutions. This global
\nanalysis has identi\ufb01ed the policy and
\npractice issues and solutions that should
\nbe considered by all sectors in addressing
\nthe supply and utilisation of nurses.
\nOne of the solutions is the promotion of
\npositive practice environments which sup-
\nport nurses\u2019 professional identity through
\nmeaningful work, autonomy, control over
\npractice, input into decision making and
\nstrong leadership. ICN is working with
\nother health professions on a campaign for
\npositive practice environments.
\nWe are also working with other health
\nprofessions in the \ufb01ght against counterfeit
\nmedicines \u2013 a growing global threat. This is
\nan area in which nurses are well positioned
\nto monitor drug e\ufb00ects and side e\ufb00ects.
\nNurses also have a key role in educating the
\npublic about the dangers of buying medi-
\ncines through the Internet or on the streets
\nfrom unauthorized sources. ICN also works
\nin the area of HIV\/AIDS care to protect
\nnurses from the danger of occupational ex-
\nposure to HIV and to address the particu-
\nlar needs of health care workers. ICN has
\nestablished HIV and TB Wellness Centres
\nof Excellence in sub-Saharan Africa which
\ndeliver comprehensive HIV and TB treat-
\nment, health services and training for all in-
\nfected health workers and their families.
\nThe health of women and girls is of par-
\nticular concern to ICN because of the dis-
\ncrimination they su\ufb00er on the basis of their
\ngender. ICN\u2019s Girl Child Education Fund
\nis helping the orphaned daughters of nurses
\nreturn to school. The education of girls and
\nwomen has a direct result on poverty reduc-
\ntion, lower maternal and infant mortality
\nrates, improved health and nutrition, higher
\nproductivity and increased likelihood that
\nthe next generation will in turn be educat-
\ned. The successes ICN has known since its
\nfounding in 1899 are a product of the com-
\nbined e\ufb00orts of the nurses of every country,
\nevery continent. Our members, the national
\nnursing associations, represent the strength
\nof ICN and nursing and are vital to health
\nand progress in every society.
\nThe International Council of Nurses
\n153
\nInternational, Regional and NMA news
\nJames Appleyard MD FRCP, Hon. Secretary
\nto the Board of Trustees, IAOMC
\nA few nations train a surplus of doctors.
\nBut most governments maintain a shortfall
\nin medical manpower. The incomes of phy-
\nsicians varies substantially throughout the
\nworld.Thus we are now witnessing an ever-
\naccelerating global migration of physicians,
\nsome of whom are poorly trained. This un-
\nderlines the urgent need for transparent
\nglobal medical accreditation standards with
\na transparent process applied by quali\ufb01ed
\nmedical educators to help insure compli-
\nance world-wide.
\nAccreditation\u2019s objective is to enhance med-
\nical education and thus medical practice.
\nIndeed the future of medicine as a profes-
\nsion depends on our teaching tomorrow\u2019s
\ndoctors with the developing medical knowl-
\nedge, skills, and ethics to an agreed standard
\nas the basis for their lifetime of learning
\nThe greatest assurance of maximum quality
\nin medical education requires an impartial,
\nexternal, open and transparent, non-polit-
\nical, global, accreditor. There are real and
\npotential di\ufb03culties when governments
\ncontrol medical standards through their po-
\nlitical processes. According to the Founda-
\ntion for the Advancement in Medical Edu-
\ncation and Research (FAIMER) directory
\nof international organizations involved in
\naccreditation of medical standards, there are
\nabout 92 nations who claim there is an ac-
\ncreditation process for their nations medical
\nschool(s). (see: http:\/\/www.faimer.org\/orgs.
\nhtml).
\nMany nations however have no adequate
\nmechanisms to maintain or improve their
\nstandards of medical education. Few of the
\nexisting national accrediting organizations
\nare open and transparent. Transparency,
\nPeer Oversight and Accreditation encour-
\nage improvement and diminish the op-
\nportunities for corruption. (see examples at:
\nhttp:\/\/www.iaomc.org\/databank1.htm#3).
\nIn times past some governments have not
\nbeen candid with their citizens.
\nThe IAOMC was founded as an indepen-
\ndent agency and speci\ufb01cally designed to
\nresolve these issues. (see: http:\/\/www.iaomc.
\norg\/begining.htm. Global standards have
\nbeen developed after public hearings were
\nheld. see: http:\/\/www.iaomc.org\/minutes1.
\nhtm. and take into account the World Fed-
\neration of Medical Education\u2019s (WFME)
\nTrilogy of Global Standards.
\nIAOMC has an independent body of site
\nvisitors whose quali\ufb01cations can be ob-
\ntained from its website; http:\/\/www.iaomc.
\norg\/svp.htm. Members elect their own
\nChair and Secretary. An independent panel
\nof regulators will accompany the site visi-
\ntor as observers. Because of the distances,
\ncommunication is electronic and via Skype.
\nBetween meetings Board members vote by
\nemail and the results are posted. see: http:\/\/
\nwww.iaomc.org\/minutes3.htm.
\nMedical Ethics provides the foundation of
\nthe trust between patients and their phy-
\nsicians. The IAOMC has established an
\nstanding Ethics Committee whose report
\nforms the basis for the standards that medi-
\ncal schools are expected to maintain. see:
\nhttp:\/\/www.iaomc.org\/ec.htm. Ethical edu-
\ncation with openness are central in prevent-
\ning any corruption
\nThe Board of Trustees are being assisted in
\ntheir appreciation of the complexity of each
\nnation or region\u2019s medical education\/prac-
\ntice, through their Advisory Council. For
\ndetails see: http:\/\/www.iaomc.org\/council1.
\nhtm#1. There are three sections: 1. Expe-
\nrienced, expert, medical administrators or
\neducators, 2. Senior government regulators\/
\nAdministrators or Medical Board members
\nand, 3. Distinguished Representatives of
\nCountries, Regions, or Organizations. Each
\nsection elects its own Chair and Secretary.
\nTo insure each section is heard its Chair
\nhas a permanent voting seat on the Board
\nof Trustees. The Board of Trustees elects
\nthe Associations O\ufb03cers. see: http:\/\/www.
\niaomc.org\/o\ufb03cers.htm#1
\nWithin Associations of Physicians and
\nMedical Academic Institutions there should
\nbe an obligation to inculcate the values and
\nattitudes required for preserving the medi-
\ncal professions standards and our \u2018social
\ncontract\u2019 with society across generations.
\nAll medical associations or individuals who
\naccept this professional responsibility, are
\ninvited, without regard for nationality, race,
\ngender, religion, or age to become a part of
\nthe International Association of Medical
\nColleges The challenges that the IAOMC
\nhave set itself are as important as they are
\nenormous.
\nBut it is in the long term interest of all med-
\nical academic and representational institu-
\ntions to develop and maintain their aca-
\ndemic standards and independence. Joining
\ntogether in the independent international
\nassociation of medical colleges will further
\ntheir aims of professionalism and academic
\nexcellence.
\nThe International Association of
\nMedical Colleges (IAOMC)
\n154
\nInternational, Regional and NMA news
\nLisetteTiddens \u2013 Engwirda, CPME Secretary
\nGeneral
\nThe CPME represents all, about 2 million,
\nmedical doctors in the EU. It is an interna-
\ntional, not-for-pro\ufb01t association under Bel-
\ngian Law composed of the National Medi-
\ncal Associations of the European Union and
\nof the European Economic Area (30 mem-
\nbers). It also has associated members (those
\ncountries that are currently negotiating with
\nthe EU), observers and 9 associated organi-
\nsations (specialised European medical asso-
\nciations and the WMA). CPME aims to
\npromote the highest standards of medical
\ntraining and medical practice in order to
\nachieve the highest quality of health care for
\nall citizens of Europe. Linked to the activi-
\nties from the EU, the CPME is also active
\nin the area of promotion of public health,
\nthe relationship between patients and doc-
\ntors and the free movement of patients and
\ndoctors within the European Union. The
\nCPME formulates its policies both in an-
\nswer to developments in Europe, as well as
\nby taking the lead in matters regarding the
\nprofession and patient care.
\nTo achieve its goals,the CPME co-operates
\nclosely and where possible proactively with
\nthe Institutions of the European Union.
\nThe CPME o\ufb00ers broad expertise in mat-
\nters related to medicine and the medical
\nprofession in its contacts with the European
\nParliament, the European Commission and
\nrelevant special European Agencies such
\nas, for example, the EMEA (the European
\nMedicines Agency) and the ECDC (the
\nEuropean Centre for Disease Control).
\nThe Standing Committee of European
\nDoctors is directed by a Board (each country
\nhas 1 Board member) that is elected by the
\nGeneral Assembly (in which each country
\nhas 1 head of delegation) for two years.The
\nPresident and the Executive Committee are
\nelected from the Board members also for a
\nperiod of two years.
\nThe CPME develops its policies in 4 sub-
\ncommittees:
\nMedical training, continuing professional\u2022
\ndevelopment and quality improvement
\nMedical ethics and professional codes\u2022
\nOrganisation of health care, social secu-\u2022
\nrity and health economics
\nPublic health, prevention and environ-\u2022
\nment
\nExperts from each national member organ-
\nisation, associate members and associated
\norganisations, as well as observers partici-
\npate in these meetings.
\nCurrent Activites
\nThe CPME is active in a very wide range of
\nissues.The following are some examples:
\nProvision of health services: patients\u2019 and
\nprofessional\u2019s mobility
\nThe CPME supports the free movement of
\npatients and health professionals within the
\nEU. High quality of care and free move-
\nment of patients and professionals are inter-
\ntwined topics that should all be addressed
\nwithin a Community framework.
\nCPME policy states that patients should
\nhave the right to receive safe and high-
\nquality care all over the Union. For this they
\nneed to be provided with a solid legal basis
\nand the required information in order to
\nmake informed choices.
\nTherefore the recently published proposal for
\na Directive on Patients rights, that is based
\non existing European Court of Justice rul-
\nings, is welcomed by the CPME although a
\nreaction in detail is still being prepared
\nIt is the CPME position that health services
\nhave speci\ufb01c characteristics that should be
\nrecognised and protected. As they deal with
\ncitizens\u2019 lives and well-being, health services
\nneedstrictercontrolsandregulationthanmost
\nother services.It is essential that the Member
\nStates take responsibility for guaranteeing the
\nquality and equal availability of healthcare for
\ntheir citizens in all circumstances. Recently
\nthe CPME organised a Round Table discus-
\nsion (under the auspices of the MEP Karas
\nand together with the Council of European
\nDentists) on the proposed directive on pa-
\ntients\u2019 rights. At this occasion the CPME
\nPresident Dr. M. Wilks warmly welcomed
\nthe draft Directive on behalf of European
\nDoctors. He pointed out that the aim of the
\nCPME as it is de\ufb01ned is very much linked to
\nthe core topic of the directive.
\nHe underlined that all the topics re\ufb02ected
\nin the draft directive, especially in article 5,
\nwhich deals with quality, safety and infor-
\nmation are core issues for the CPME.
\nPatient safety
\nThe CPME has been an initiating and
\ncentral partner in setting patient safety on
\nthe EU agenda. The o\ufb03cial launch took
\nplace in April 2005 with the Patient Safety
\nConference organised under the auspices
\nof the Luxembourg Presidency of the EU,
\nthe European Commission and the CPME
\ntogether with a large number of other rel-
\nevant EU stakeholders. The Luxembourg
\nDeclaration on Patient Safety set a number
\nof principles and objectives that marked a
\nroadmap for the years to come.
\nThe Standing Committee of European
\nDoctors (CPME)
\n155
\nInternational, Regional and NMA news
\nThe work on this issue is now continued in:
\nThe Patient Safety Working Group of the\u2022
\nHigh Level Group that is the counsel of
\nthe European Commission on the draft-
\ning of European Recommendations on
\nPatient Safety.
\nThe CPME has also been partner of\u2022
\nEuropean-wide projects on patient
\nsafety, such as the SIMPATIE (Safety
\nIMprovement for PATients In Europe)
\nproject which published its \ufb01nal report
\nin December 2007; has participated in
\nthe advisory council of the MARQUIS
\n(Methods of Assessing Response to
\nQUality Improvement Strategies) proj-
\nect and is partner of the new EUNetPaS
\n(European Union NETwork for PAtient
\nSafety) Project,which gathers all member
\nstates\u2019 and a number of stakeholders that
\nare active at EU level.
\neHealth
\nIn October 2007, the CPME adopted a
\npolicy document on Electronic Health Re-
\ncords. The CPME strongly values the use
\nof eHealth technology as a support-tool for
\nthe physician in his or her work. However
\nthere are considerable di\ufb00erences within the
\nEU regarding the approach physicians adopt
\ntowards eHealth. Because of these di\ufb00er-
\nences, the CPME has set out some essential
\nprinciples for the use and development of
\neHealth systems. It is obvious however that
\nfurther study and development is needed
\nin order to be able to establish commonali-
\nties and solutions. Electronic health records
\nshould be a support-tool in the provision
\nof optimal care that is based on face to face
\ncontact and trust between the patient and
\nthe physician. For the CPME it is clear that
\nthe bottom line needs to be that eHealth
\ntechnology must be to help support the
\nquality of care and patient safety provided
\nby healthcare professionals, in full respect of
\ncurrent ethical and legal principles. eHealth
\nwill continue to be a developing topic with-
\nin the CPME. The organisation will keep a
\nkeen eye on eHealth developments and will
\ncontinue to deliver opinions to European
\nCommission proposals, from both practical
\nand ethical points of view.
\nPharmaceuticals
\nIn December 2005, the Pharma Forum was
\nlaunched by the European Commissioners
\nfor Health and Enterprise. It was a follow
\nup to the \u201cG-10 Medicines Group\u201d. The
\nCPME was invited to take part as a full
\nmember and thus sits around the very large
\ntable with all Member States, the European
\nCommission, and 9 other EU stakehold-
\ners. The CPME has representatives in the
\n3 working groups of the Forum, which deal
\nwith information to patients, pricing and
\nrelative e\ufb00ectiveness. The CPME is often
\nencouraged to deliver its views on a number
\nof pharmaceutical issues such as pharma-
\ncovigilance, rare diseases or clinical trials.
\nEU Platform on Diet, Physical
\nActivity and Health
\nAs one of the founding members of the EU
\nPlatform on Diet, Physical Activity and
\nHealth, the CPME has been very vocal in
\nthe area of for example nutrition, physical
\nactivity, and food labelling. This Platform
\nhas been established by the EU in order to
\nco-ordinate partners that could help \ufb01nd
\nsolutions for the growing obesity prob-
\nlem in Europe. Every year, every Platform
\nmember issues commitments on the issue.
\nCPME commitments are available on the
\nEU Platform on Diet, Physical Activity and
\nHealth, EUROPA website.
\nAlcohol
\nThe CPME is a founding member of the
\nAlcohol & Health Forum which was o\ufb03-
\ncially launched in June 2007.The CPME is
\na signatory of the charter. The CPME is
\nmember of the Task Force on Youth-Spe-
\nci\ufb01c aspects of Alcohol and the Task Force
\non Marketing Communication.The CPME
\nadopted a policy on alcohol which expressed
\nits support to the EU and Member States in
\nreducing alcohol related harm.
\nWorking Time
\nThe CPME, together with the PWG and
\nFEMS is lobbying the European Parlia-
\nment and is having close contacts with
\nMember States on the current Revision
\nof the European Working Time Directive.
\nThe CPME policy defends the codi\ufb01cation
\nof the ECJ rulings stating that the inactive
\npart of on call time is to be considered to be
\nworking time.
\nEducation and training: CPD
\nTheCPMEandtheotherEuropeanMedical
\nOrganizations plus relevant EU stakehold-
\ners organised a Conference on \u201cContinuing
\nProfessional Development \u2013 Improving Pa-
\ntient Safety\u201d in December 2006, under the
\nauspices of the Finnish EU Presidency and
\nthe European Commission. A Consensus
\nStatement was adopted declaring: \u201cIn addi-
\ntion to contributing to improvements in the
\ncare of individual patients, CPD also plays
\nan important part in improving the quality
\nof healthcare systems\u201d.
\nTeaching of medical ethics and of medical
\nvalues are issues that are currently debated
\nwithin the organisation
\nRelationship with stakeholders:
\nPatients, a privileged stakeholder
\nAs of course the patient is the most im-
\nportant partner for physicians, the CPME
\nis in close contact with the EPF (Euro-
\npean Patient Forum) and has developed a
\nFramework Statement of Collaboration
\nwith them.
\nA similar exercise has been done with both
\nthe Pharmaceutical industry and the Medi-
\ncal Devices Industry.
\nOver the years, the CPME has developed
\nclose relations with all the relevant EU
\nstakeholders, including nurses, dentists,
\npharmacists, public health organisations,
\ninstitutions, and patient organisations. As
\nthis article is meant to give you an intro-
\nduction to CPME, I was only able to give
\na short impression of the organisation and
\nits activities. However you can \ufb01nd all our
\npolicies and more on the CPME website
\nwww.cpme.eu
\n156
\nInternational, Regional and NMA news
\nDr Eva Nilsson B\u00e5genholm, MD, President
\nof the Swedish Medical Association
\nGabriella Blomberg, International Coordina-
\ntor, Swedish Medical Association
\nThe Swedish Medical Association has a
\nlong tradition of international engagement
\nin the area of human rights and ethics. Dr
\nEva Nilsson B\u00e5genholm, current president
\nof the Swedish Medical Association and
\nalso chairperson of the WMA Medical
\nEthics Committee (MEC), has been ac-
\ntively involved in the work of updating the
\nHelsinki declaration during the last year. In
\nthis process the Swedish Medical Associa-
\ntion has arranged a high level conference for
\nSwedish stakeholders in order to make the
\nSwedish updating comments solid and well
\nthought-out. In pursuit of highest possible
\nstandards of ethical behaviour and care by
\nphysicians, the Swedish Medical Associa-
\ntion feels a strong responsibility to promote
\nWMA ethical policies.
\nThe role and the structure of the SMA
\nThe Swedish Medical Association is the
\nunion and the professional organisation for
\nphysicians in Sweden. Important issues dealt
\nwith include doctors\u2019work environment,sala-
\nries, working hours, medical training and re-
\nsearch.The SMA also has key role to play by
\nin\ufb02uencing the development of healthcare in
\nSweden.Over 90 per cent of the physicians in
\nSweden belong to the SMA. All members of
\nthe SMA are also registered at a local branch
\nin the area where they work.The membership
\nmoreover includes signing up for at least one
\nnational professional association, such as the
\nassociation for general practitioners, for hos-
\npital doctors, for private practitioners or the
\nnational association for junior doctors.
\nMost members are also members in one
\nof the 50 specialist associations, a number
\nwhich re\ufb02ects the amount of specialties that
\nare recognized by the National board of
\nHealth and Welfare, the regulatory body of
\nSwedish physicians.
\nThe SMA enters into collective agree-
\nments with the employers organisations
\non behalf of its members in areas such as
\ngeneral employment conditions, which in-
\ncludes salaries, working hours, holidays, sick
\nleave,parental leave and pensions.Members
\ncan get help with salary negotiations, and
\nup-to-date salary statistics, legal assistance
\non disciplinary matters, such as negligence
\nclaims or probation, and on general matters
\nof healthcare, tax and labour law. The SMA
\ncan also give peer support for doctors un-
\ndergoing a personal crisis.
\nThe Ethic Committee of the Swedish
\nMedical association (EAR)
\nThe EAR handles ethical questions in rela-
\ntion to the medical profession, as well as the
\nethical questions that are related to market-
\ning in connection with medical practice.
\nAnother task of the EAR is to review the
\nlegislation that is linked to the professional
\nresponsibility of the medical profession.The
\ncommittee also works for strengthening and
\ndeveloping the awareness of medical-ethi-
\ncal questions within the medical profession.
\nOne intermediate goal in this work is for
\nexample to collect and spread knowledge
\nabout national and international ethical
\npolicies and to put ethics on the agenda in
\nthe daily clinical work situation.
\nInternational engagement
\nThe aim of the international engagement of
\nthe SMA is to protect and to develop hu-
\nman rights, professional ethics, conditions
\nof the medical profession, patient\u2019s rights
\nand a good quality healthcare for everybody.
\nIn order to pursue these goals the SMA is
\na member of CPME, Comit\u00e9 Permanent
\ndes M\u00e9decins Europ\u00e9ens, Standing com-
\nmittee of European Doctors, which repre-
\nsent all medical doctors in the EU. SMA is
\nalso a member of the UEMS, the European
\nUnion of Medical Specialists and UEMO,
\nthe union of general practitioners in Eu-
\nrope. Already in 1947 the Swedish Medi-
\ncal Association started its international en-
\ngagement by being one of the founders of
\nthe World Medical Association.
\nThe Swedish health care system
\nIn Sweden 21 county councils and regions
\nare responsible for supplying their citizens
\nwith health care services. This includes hos-
\npital care, primary care and psychiatric care.
\nA county council tax supplemented by a
\nstate grant is the main mean of \ufb01nancing the
\nhealth care system. In addition to that small
\nuser fees are paid at the point of use. Each
\ncounty council and region is governed by a
\npolitical assembly. Within the framework of
\nnational legislation and varying health care
\npolicy initiatives from the national govern-
\nment, the county councils and regions have
\nsubstantial decision-making powers and ob-
\nligations towards their citizens.The Swedish
\nhealth care system is a decentralized system.
\nStructural changes in the
\nSwedish Primary Care system
\nSwedish primary care is in the process of
\nchanging.Recently two green books are pro-
\nposing to introduce a national system that
\ngives each citizen the possibility to choose
\nher\/his provider of primary care. There is a
\nplan of introducing the possibility of pri-
\nvately owned healthcare enterprises in order
\nto increase the competition and thereby give
\na wider choice to the citizens.
\nThe Swedish Medical Association
\nDr. Eva Nilsson B\u00e5genholm, MD, President
\nof the Swedish Medical Association
\n157
\nInternational, Regional and NMA news
\nThe search is on for more musical doctors
\nas yet another worldwide doctors\u2019 orchestra
\nhas been established. German doctor, con-
\nductor and concert pianist Wolfgang Ellen-
\nberger from Buchen has founded the Phil-
\nharmonic Doctors Orchestra (PDO) and is
\nplanning to produce an entire opera, Mo-
\nzart\u2019s \u2018Magic Flute\u2019 in the autumn of 2010.
\nHis ambitious project follows on the success
\nof the European Doctors Orchestra (www.
\nEuropeanDoctorsOrchestra.com) which was
\nfounded in November 2004 by Miki Pohl in
\nLondon. Their concerts in London, Bucha-
\nrest, Budapest and Berlin have been over-
\nbooked and led to the orchestra producing
\nseveral DVDs of their successful recitals.
\nThe orchestra\u2019s founder Miki Pohl said that
\nthe web site www.DoctorsTalents.com was
\nlargely responsible for \ufb01nding doctors for
\nthe orchestra. This was followed by the es-
\ntablishment earlier this year of the World
\nDoctors Orchestra (www.World-Doctors-
\nOrchestra.org) with 80 musical doctors
\nfrom 20 countries from all over the world.
\nNow Dr. Ellenberger is setting up the Phil-
\nharmonic Doctors Orchestra and is look-
\ning for more musical doctors to perform.
\nTogether with conductors Callista Janzing
\nand Otmar Desch, he plans to perform the
\nentire opera of \u2018The Magic Flute\u2019 in 2010
\nafter just four practice sessions.
\nCallista Janzing has studied with Sergi\u00f9
\nCelibidache and is working as a coach with
\nmusicians and orchestras. Dr. Desch is a
\ngeneral practitioner and has been a conduc-
\ntor in the theatre of Stendal in Germany for
\nthe last \ufb01ve years where he also performed
\nhis new musical \u2018The Call of Dalai Lama\u2019.
\nDr. Ellenberger said that the new orches-
\ntra is open to a range of health profession-
\nals \u2013 medical doctors,dentists,veterinarians,
\npharmacists, psychotherapists and spiritual
\nhealers \u2013 from all countries. Interested doc-
\ntors can register on the website (www.
\nPDO.name) and the \ufb01rst practice session is
\nplanned for spring 2009 in Germany.
\nThe target is to end up with a full orches-
\ntra,choir,soloists,conductors,director,stage
\nand costume designers. Many of the roles
\nwill be covered by two singers.
\nThe venue for the performances is still being
\nnegotiated,but there are hopes that it might
\nbe a signi\ufb01cant festival theatre.
\nMoney raised from the productions will go
\nto charity and members of the orchestra and
\ncast will have to cover their own travel and
\nexpenses, and play without a fee.
\nAlready Dr. Ellenberger is planning the next
\nphase of his musical developments. He has a
\nvision of extending the web site (DoctorsTal-
\nents.com) into a building which could house
\npermanent exhibitions, a library of literary
\ndoctors, piano classes and other events. One
\npossibility is having a paying membership of
\ndoctors from all over the world.
\nNew Doctors Orchestra plans to produce
\n\u2018The Magic Flute\u2019 in 2010
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
\nWMA news
\nFinancial Crisis may Hasten
\nMove to Shift Responsibilities Away from Doctors. . . . . . . . 118
\nRevising the Declaration of Helsinki . . . . . . . . . . . . . . . . . . . 120
\nDeclaration of Helsinki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
\nWMA General Assembly, Seoul 2008. . . . . . . . . . . . . . . . . . 125
\nResolution on the Economic Crisis: Implications for Health. 128
\nDeclaration of Seoul on
\nProfessional Autonomy and Clinical Independence. . . . . . . . 129
\nNew Speaking Book on Clinical Trials Aimed
\nat African Populations with low Literacy Level . . . . . . . . . . . 129
\n179th
\nCouncil meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
\nThe WMA Caring Physicians of the World Initiative. . . . . . 133
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nBuilding a Consensus in Regenerative Medicine . . . . . . . . . . 136
\nHuman Resources and Bioethics in Palliative Care
\nas an Example of Human Resourse
\nand Bioethics Development in Kazakhstan . . . . . . . . . . . . . . 138
\nGeorgian Health Care System in the Time
\nof Armed Con\ufb02ict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
\nAlcohol use in Norway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
\nChallenges in Health Care Unite the Medical Associations . 144
\nInternational, Regional and NMA news
\nColegio Medico de Mexico. . . . . . . . . . . . . . . . . . . . . . . . . . . 147
\nThe Medical Association of Malta . . . . . . . . . . . . . . . . . . . . . 148
\nAlbanian Order of Physicians \u2013
\nProgress and Strategy of Development. . . . . . . . . . . . . . . . . . 149
\nInternational Hospital Federation . . . . . . . . . . . . . . . . . . . . . 151
\nThe International Council of Nurses . . . . . . . . . . . . . . . . . . . 152
\nThe International Association
\nof Medical Colleges (IAOMC) . . . . . . . . . . . . . . . . . . . . . . . 153
\nThe Standing Committee of European Doctors (CPME) . . 154
\nThe Swedish Medical Association . . . . . . . . . . . . . . . . . . . . . 156
\nNew Doctors Orchestra plans
\nto produce \u2018The Magic Flute\u2019 in 2010 . . . . . . . . . . . . . . . . . . . 157
\nWMA news<\/p>\n"},"caption":{"rendered":"

wmj20 WMA news No. 4, December 2008 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv editorin-chief@wma.net Co-Editor Dr. Alan J. Rowe Haughley Grange, Stowmarket Su\ufb00olk IP143QT, UK Co-Editor Prof. Dr. med. Elmar Doppelfeld Deutscher \u00c4rzte-Verlag Dieselstr. 2, D-50859 K\u00f6ln, Germany Assistant Editor Velta […]<\/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\/wmj20.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3576"}],"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=3576"}]}}