{"id":12708,"date":"2019-05-23T11:12:37","date_gmt":"2019-05-23T10:12:37","guid":{"rendered":"https:\/\/www.wma.net\/wp-content\/uploads\/2019\/05\/HB-E-Version-2019-v2.pdf"},"modified":"2019-05-23T11:12:37","modified_gmt":"2019-05-23T10:12:37","slug":"hb-e-version-2019-v2-2","status":"inherit","type":"attachment","link":"https:\/\/www.wma.net\/fr\/politique\/hb-e-version-2019-v2-2\/","title":{"rendered":"HB-E-Version-2019-v2"},"author":5,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"description":{"rendered":"

HB-E-Version-2019-v2<\/a><\/p>\n\n

Handbook\tof\tWMA\tPolicies
\nThe\tWorld\tMedical\tAssociation,\tInc.\t<\/p>\n

\tVersion\tHistory\t<\/p>\n

\u00a9\tThe\tWorld\tMedical\tAssociation,\tInc.\t<\/p>\n

Version\t2010,\tVancouver;\tPrinted\tin\tMarch\t2011
\nVersion\t2011,\tMontevideo;\tPrinted\tin\tDecember\t2011\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-2000-01-2010\tby
\nD-2000-01-2011
\nPrison\tConditions\ton\tTB\t(amended\tin\t2011)
\nS-1988-01-2005\tby
\nR-1988-01-2005
\nCorrection\tof\tmisclassified\tdocument\ttype
\nS-1988-05-2007\tby
\nS-1988-05-2011
\nTobacco\tProducts\tHealth\tHazards\t(amended\tin\t2011)
\nS-1996-05-2006\t Replacement\tdue\tto\ttypo\tin\tthe\tfooter
\nS-1997-01-2007\t Correction\t(in\t2007\tit\twas\treaffirmed,\tnot\tamended)
\nS-1997-02-2007\t Correction\tof\ttypo\tin\tthe\theader\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t62nd
\n\tWMA\tGeneral\tAssembly,
\n\t\t\t\tMontevideo,\tUruguay,\tOctober\t2011
\nD-2011-01-2011\t Disaster\tPreparedness
\nD-2011-02-2011\t End-of-Life\tMedical\tCare
\nD-2011-03-2011\t Leprosy\tControl
\nS-2011-01-2011\t Chronic\tDisease
\nS-2011-02-2011\t Monitoring\tTokyo\tDeclaration
\nS-2011-03-2011\t Protection\tand\tIntegrity\tof\tMedical\tPersonnel
\nS-2011-04-2011\t Social\tDeterminants\tof\tHealth
\nS-2011-05-2011\t Social\tMedia
\nR-2011-01-2011\t Adequate\tPain\tTreatment
\nR-2011-02-2011\t Bahrain
\nR-2011-03-2011\t Economic\tEmbargoes\tand\tHealth
\nR-2011-04-2011\t Independence\tof\tMedical\tAssociations\t<\/p>\n

Version\t2012,\tBangkok;\tPrinted\tin\tOctober\t2012\t<\/p>\n

\u2022 Replacements
\nD-2002-04-2002\tby
\nD-2002-04-2012
\nAdvanced\tTechnology\t(amended\tin\t2012)
\nS-1956-01-2006\tby
\nS-1956-01-2012
\nArmed\tConflict\t(amended\tin\t2012)
\nR-2002-05-2002\tby
\nR-2002-05-2012
\nAbuse\tof\tPsychiatry\t(amended\tin\t2012)\t<\/p>\n

\u2022 Removals\tof\tthe\tpolicies\trescinded\tand\tarchived\tby\tthe\t63rd
\n\tWMA\tGeneral\tAssembly,
\nBangkok,\tThailand,\tOctober\t2012
\nR-2002-03-2002\t Health\tCare\tServices\tin\tAfghanistan
\nR-2002-04-2002\t Pan\tAmerican\tHealth\tOrganization\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t63rd
\n\tWMA\tGeneral\tAssembly,
\nBangkok,\tThailand,\tOctober\t2012
\nS-2012-01-2012\t Electronic\tCigarettes
\nS-2012-02-2012\t Collective\tAction\tby\tPhysicians
\nS-2012-03-2012\t Forced\tand\tCoerced\tSterilisation
\nS-2012-04-2012\t Organ\tand\tTissue\tDonation
\nS-2012-05-2012\t Prioritisation\tof\tImmunisation
\nS-2012-06-2012\t Violence\tin\tthe\tHealth\tSector
\nR-2012-01-2012\t Minimum\tPrice\tfor\tAlcohol
\nR-2012-02-2012\t Plain\tPackaging\tof\tCigarettes
\nR-2012-03-2012\t Capital\tPunishment
\nR-2012-04-2012\t Professor\tCyril\tKarabus\t<\/p>\n

Version\t2013-1,\tBali;\tPrinted\tin\tApril\t2013\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-1981-02-1999\tby
\nD-1981-02-2010
\nCorrection\t(in\t2010\tit\twas\treaffirmed,\tnot\tamended)
\nS-2003-02-2003\tby
\nS-2003-02-2013
\nLiving\tWills\t(reaffirmed\tin\t2013)
\nR-2002-01-2002\tby
\nR-2002-01-2013
\nEuthanasia\t(reaffirmed\tin\t2013)
\nR-2003-01-2003\tby
\nR-2003-01-2013
\nAnnual\tMedical\tEthics\tDay\t(reaffirmed\tin\t2013)\t<\/p>\n

Version\t2013-2,\tFortaleza;\tPrinted\tin\tFebruary\t2014\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nS-2003-01-2003\tby
\nS-2003-01-2013
\nForensic\tInvestigations\tof\tthe\tMissing
\n(amended\tin\t2013)
\nR-2002-06-2002\tby
\nR-2002-06-2013
\nWomen\u2019s\tRight\tto\tHealth\tCare
\n(amended\tin\t2013)\t<\/p>\n

\u2022 Removals\tof\tthe\tpolicies\trescinded\tand\tarchived\tby\tthe\t64th
\n\tWMA\tGeneral\tAssembly,
\nFortaleza,\tBrazil,\tOctober\t2013
\nR-2003-04-2003\t SARS\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t64th
\n\tWMA\tGeneral\tAssembly,
\nFortaleza,\tBrazil,\tOctober\t2013
\nS-2013-01-2013\t Fungal\tDisease
\nS-2013-02-2013\t Human\tPapillomavirus\tVaccination
\nS-2013-03-2013\t Natural\tVariations\tof\tHuman\tSexuality
\nS-2013-04-2013\t Victims\tof\tTorture
\nS-2013-05-2013\t Death\tPenalty
\nR-2013-01-2013\t Criminalisation\tof\tMedical\tPractice
\nR-2013-02-2013\t Healthcare\tSituation\tin\tSyria
\nR-2013-03-2013\t Prohibition\tof\tChemical\tWeapons
\nR-2013-04-2013\t Standardisation\tin\tMedical\tPractice\tand\tPatient\tSafety
\nR-2013-05-2013\t Support\tof\tthe\tAMB\t<\/p>\n

Version\t2014-1,\tTokyo;\tPrinted\tin\tJune\t2014\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nR-2004-01-2004\tby
\nR-2004-01-2014
\nWFME\t(reaffirmed\tin\t2014)\t<\/p>\n

Version\t2014-2,\tDurban;\tPrinted\tin\tJanuary\t2015\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-2002-01-2003\tby
\nD-2002-01-2012
\nBiological\tWeapons\t(reaffirmed\tin\t2012)
\nD-2002-03-2002\tby
\nD-2002-03-2012
\nPatient\tSafety\t(reaffirmed\tin\t2012)
\nS-2002-01-2002\tby
\nS-2002-01-2012
\nSafe\tInjections\tin\tHealth\tCare\t(amended\tin\t2012)
\nS-2002-02-2002\tby
\nS-2002-02-2012
\nSelf-Medication\t(reaffirmed\tin\t2012)
\nS-2003-03-2003\tby
\nS-2003-03-2014
\nInternational\tMigration\tof\tHealth\tWorkers
\n(amended\tin\t2014)
\nS-2004-03-2004\tby
\nS-2004-03-2014
\nWater\tand\tHealth\t(amended\tin\t2014)
\nR-2002-02-2002\tby
\nR-2002-02-2012
\nFemale\tFoeticide\t(reaffirmed\tin\t2012)
\nR-2003-03-2003\tby
\nR-2003-03-2014
\nNon-Commercialization\tof\tHuman\tReproductive
\nMaterial\t(amended\tin\t2014)\t<\/p>\n

\u2022 Removals\tof\tthe\tpolicies\trescinded\tand\tarchived\tby\tthe\t65th
\n\tWMA\tGeneral\tAssembly,
\nDurban,\tSouth\tAfrica,\tOctober\t2014
\nS-2004-01-2004\t Health\tEmergencies\tCommunication\t&\tCoordination\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t65th
\n\tWMA\tGeneral\tAssembly,
\nDurban,\tSouth\tAfrica,\tOctober\t2014
\nD-2014-01-2014\t Protection\tof\tHealthcare\tWorkers
\nS-2014-01-2014\t Aesthetic\tTreatment
\nS-2014-02-2014\t Air\tPollution
\nS-2014-03-2014\t Solitary\tConfinement
\nR-2014-01-2014\t Ebola\tViral\tDisease\t<\/p>\n

Version\t2015-1,\tOslo;\tPrinted\tin\tJune\t2015\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-1981-01-2005\tby
\nD-1981-01-2015
\nLisbon\t(Patient\u2019s\tRights)\t\t(reaffirmed\tin\t2015)
\nD-1987-01-2005\tby
\nD-1987-01-2015
\nEuthanasia\t(reaffirmed\tin\t2015)
\nD-1989-01-2005\tby
\nD-1989-01-2015
\nHong\tKong\t(Elderly\tAbuse)\t(reaffirmed\tin\t2015)
\nS-2005-02-2005\tby
\nS-2005-02-2015
\nDrug\tSubstitution\t(reaffirmed\tin\t2015)
\nS-2005-04-2005\tby
\nS-2005-04-2015
\nMedical\tLiability\tReform\t(reaffirmed\tin\t2015)
\nR-1988-01-2005\tby
\nR-1988-01-2015
\nAcademic\tSanctions\tor\tBoycotts\t(reaffirmed\tin\t2015)\t<\/p>\n

Version\t2015-2,\tMoscow;\tPrinted\tin\tJune\t2016\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nS-2011-04-2011\tby
\nD-2011-04-2015
\nSocial\tDeterminants\tof\tHealth\t(adopted\tin\t2011\tand
\nthe\ttitle\t(S\tto\tD)\tchanged\tin\t2015)
\nS-1995-02-2006\tby
\nS-1995-02-2015
\nPatients\twith\tMental\tIllness\t(amended\tin\t2015)
\nS-1985-01-2005\tby
\nS-1985-01-2015
\nNon-Discrimination\tin\tProfessional\tMembership\tand
\nActivities\tof\tPhysicians\t(amended\tin\t2015)
\nS-1998-01-2008\tby
\nS-1998-01-2015
\nNuclear\tWeapons\t(amended\tin\t2015)
\nR-1999-01-1999\tby
\nR-1999-01-2015
\nCurriculum\tof\tMedical\tSchools\tWorld-wide\t(amended
\nin\t2015)\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t66th
\n\tWMA\tGeneral\tAssembly,
\nMoscow,\tRussia,\tOctober\t2015
\nCode\t Short\tTitle
\nD-2015-01-2015\t Alcohol
\nS-2015-01-2015\t Mobile\tHealth
\nS-2015-02-2015\t Physicians\tWell-Being
\nS-2015-03-2015\t Health\tSupport\tto\tStreet\tChildren
\nS-2015-04-2015\t Riot\tControl\tAgents
\nS-2015-04-2015\t Riot\tControl\tAgents
\nS-2015-05-2015\t Transgender\tPeople
\nS-2015-06-2015\t Vitamin\tD\tInsufficiency
\nS-2015-07-2015\t Promotional\tMass\tMedia\tAppearances\tby\tPhysicians
\nR-2015-01-2015\t Healthcare\tIn\tTurkey
\nR-2015-02-2015\t Bombing\ton\tthe\tHospital\tof\tMSF\tin\tKunduz
\nR-2015-03-2015\t Global\tRefugee\tCrisis\t<\/p>\n

Version\t2016-1,\tBuenos\tAires;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nS-1988-04-2006\tby
\nS-1988-04-2016
\nEnvironmental\tIssues\t(reaffirmed\tin\t2016)
\nS-1993-03-2006\tby
\nS-1993-03-2016
\nPatient\tAdvocacy\tand\tConfidentiality\t(reaffirmed\tin
\n2016)
\nS-1989-01-2006\tby
\nS-1989-01-2016
\nAnimal\tUse\tin\tBiomedical\tResearch\t(reaffirmed\tin
\n2016)
\nR-2006-02-2006\tby
\nR-2006-02-2016
\nChild\tSafety\tin\tAirline\tTravel\t(reaffirmed\tin\t2016)
\nR-2006-04-2006\tby
\nR-2006-04-2016
\nNuclear\tTesting\tin\tNorth\tKorea\t(reaffirmed\tin\t2016)\t<\/p>\n

Version\t2016-2,\tTaipei;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-1968-01-2006\tby
\nD-1968-01-2016
\nDetermination\tof\tDeath\tand\tthe\tRecovery\tof\tOrgans
\n(amended\tin\t2016)
\nD-1975-01-2006\tby
\nD-1975-01-2016
\nMedical\tDoctors\tconcerning\tTorture\tand\tOther\tCruel,
\nInhuman\tor\tDegrading\tTreatment\tor\tPunishment\tin
\nrelation\tto\tDetention\tand\tImprisonment\t(amended\tin
\n2016
\nD-2002-02-2002\tby
\nD-2002-02-2016
\nEthical\tConsiderations\tregarding\tHealth\tDatabases\tand
\nBiobanks\t(amended\tin\t2016)
\nS-1984-01-2006\tby
\nS-1984-01-2016
\nChild\tAbuse\tand\tNeglect\t(amended\tin\t2016)
\nS-1990-01-2006\tby
\nS-1990-01-2016
\nInjury\tControl\t(amended\tin\t2016)
\nS-1990-04-2006\tby
\nS-1990-04-2016
\nTraffic\tInjury\t(amended\tin\t2016)
\nS-1991-01-2006\tby
\nS-1991-01-2016
\nAdolescent\tSuicide\t(amended\tin\t2016)
\nS-1992-01-2006\tby
\nS-1992-01-2016
\nAlcohol\tand\tRoad\tSafety\t(amended\tin\t2016)
\nS-1993-01-2005\tby
\nS-1993-01-2016
\nBody\tSearches\tof\tPrisoners\t(amended\tin\t2016)
\nS-1993-02-2005\tby
\nS-1993-02-2016
\nFemale\tGenital\tMutilation\t(amended\tin\t2016)
\nS-1995-04-2006\tby
\nS-1995-04-2016
\nPhysicians\tand\tPublic\tHealth\t(amended\tin\t2016)
\nS-1996-05-2006\tby
\nS-1996-05-2016
\nWeapons\tof\tWarfare\tand\tTheir\tRelation\tto\tLife\tand
\nHealth\t(amended\tin\t2016)
\nS-2006-05-2006\tby
\nS-2006-05-2016
\nPhysician\u2019s\tRole\tin\tObesity\t(amended\tin\t2016)
\nS-2006-06-2006\tby
\nS-2006-06-2016
\nResponsibilities\tof\tPhysicians\tin\tPreventing\tand
\nTreating\tOpiate\tand\tPsychotropic\tDrug\tAbuse
\n(amended\tin\t2016)
\nCR-2005-05-2005\tby
\nR-2005-05-2016
\nImplementation\tof\tthe\tWHO\tFramework\tConvention
\non\tTobacco\tControl\t(amended\tin\t2016)
\nCR-2016-01-2016\tby
\nR-2016-03-2016
\nRefugees\tand\tMigrants\t(adopted\tas\ta\tCouncil
\nResolution\tin\tApril\t2016\tand\tadopted\tas\ta\tResolution\tin
\nOctober\t2016)
\nCR-2016-02-2016\tby
\nR-2016-04-2016
\nZika\tVirus\tInfection\t(adopted\tas\ta\tCouncil\tResolution\tin
\nApril\t2016\tand\tadopted\tas\ta\tResolution\tin\tOctober
\n2016)\t<\/p>\n

\u2022 Removals\tof\tthe\tpoliciers\tand\tarchived\tby\tthe\t67th
\n\tWMA\tGeneral\tassembly,
\nTaipei,\tTaiwan,\tOctober\t2016
\nCode\t Short\tTitle
\nR-2006-03-2006\t Combating\tHIV\/AIDS\t<\/p>\n

\u2022 Addition\tof\tthe\tresolution\tnewly\tadopted\tby\tthe\t67th
\n\tWMA\tGeneral\tAssembly,
\nTaipei,\tTaiwan,\tOctober\t2016
\nS-2016-01-2016\t Ageing
\nS-2016-02-2016\t Cyber-Attacks\ton\tHealth\tand\tOther\tCritical
\nInfrastructure
\nS-2016-03-2016\t Divestment\tfrom\tFossil\tFuels
\nS-2016-04-2016\t Ethical\tConsiderations\tin\tGlobal\tMedical\tElectives
\nS-2016-05-2016\t Obesity\tin\tChildren\t<\/p>\n

R-2016-01-2016\t Protection\tof\tHealth\tCare\tFacilities\tand\tPersonnel\tin
\nSyria
\nR-2016-02-2016\t Occupational\tand\tEnvironmental\tHealth\tand\tSafety\t<\/p>\n

Version\t2017-1,\tLivingstone;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nR-2007-01-2007\tby
\nR-2007-01-2017
\nHealth\tand\tHuman\tRights\tAbuses\tin\tZimbabwe
\n(reaffirmed\tin\t2017)\t<\/p>\n

Version\t2017-2,\tChicago,\tUnited\tStates;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-1948-01-2006\tby
\nD-1948-01-2017
\nDeclaration\tof\tGeneva\t(amended\tin\t2017)
\nD-1991-01-2006\tby
\nD-1991-01-2017
\nHunger\tStrikers\t(amended\tin\t2017)
\nD-1997-02-2007\tby
\nD-1997-02-2017
\nSupport\tfor\tMedical\tDoctors\tRefusing\tto\tParticipate\tin,
\nor\tto\tCondone,\tthe\tUse\tof\tTorture\tor\tOther\tForms\tof
\nCruel,\tInhuman,\tor\tDegrading\tTreatment\t(reaffirmed\tin
\n2017)
\nD-2009-01-2009\tby
\nD-2009-01-2017
\nHealth\tand\tClimate\tChange\t(amended\tin\t2017)
\nD-2015-01-2015\tby
\nD-2015-01-2017
\nAlcohol\t(amended\tin\t2017)
\nS-1983-01-2005\tby
\nS-1983-01-2017
\nBoxing\t(amended\tin\t2017)
\nS-1984-01-2016\tby
\nS-1984-01-2017
\nChild\tAbuse\tand\tNeglect\t(amended\tin\t2017)
\nS-1988-02-2006\tby
\nS-1988-01-2017
\nAccess\tto\tHealth\tCare\t(amended\tin\t2017)
\nS-1992-05-2007\tby
\nS-1992-05-2017
\nNoise\tPollution\t(reaffirmed\tin\t2017)
\nS-1994-01-2006\tby
\nS-1994-01-2017
\nMedical\tEthics\tin\tthe\tEvent\tof\tDisasters\t(amended\tin
\n2017)
\nS-1996-04-2007\tby
\nS-1996-04-2017
\nFamily\tPlanning\tand\tthe\tRight\tof\ta\tWoman\tto
\nContraception\t(reaffirmed\tin\t2017)
\nS-2004-03-2014\tby
\nS-2004-03-2017
\nWater\tand\tHealth\t(amended\tin\t2017)
\nS-2006-03-2006\tby
\nS-2006-03-2017
\nHIV\/AIDS\tand\tthe\tMedical\tProfession\t(amended\tin
\n2017)
\nS-2006-04-2006\tby
\nS-2006-04-2017
\nMedical\tEducation\t(amended\tin\t2017)
\nS-2012-04-2012\tby
\nS-2012-04-2017
\nOrgan\tand\tTissue\tDonation\t(amended\tin\t2017)
\nR-1997-02-2007\tby
\nR-1997-01-2017
\nEconomic\tEmbargoes\tand\tHealth\t(reaffirmed\tin\t2017)
\nR-2006-01-2006\tby
\nR-2006-01-2017
\nMedical\tAssistance\tin\tAir\tTravel\t(amended\tin\t2017
\nR-2006-05-2006\tby
\nR-2006-05-2017
\nTuberculosis\t(amended\tin\t2017)
\nR-2007-02-2007\tby
\nR-2007-02-2017
\nSupport\tof\tthe\tMedical\tAssociations\tin\tLatin\tAmerica
\nand\tthe\tCaribbean\t(reaffirmed\tin\t2017)\t<\/p>\n

\u2022 Removals\tof\tthe\tpolicies\trescinded\tand\tarchived\tby\tthe\t68th
\n\tWMA\tGeneral\tAssembly,
\nChicago,\tUnited\tStates,\tOctober\t2017
\nS-1997-01-2007\t Unites\tNations\tRapporteur\ton\tthe\tIndependence\tand
\nIntegrity\tof\tHealth\tProfessionals
\nS-2005-01-2005\t Reducing\tthe\tGlobal\tImpact\tof\tAlcohol\ton\tHealth\tand
\nSociety
\nR-2012-01-2012\t Minimum\tPrice\tfor\tAlcohol\t<\/p>\n

\u2022 Additions\tof\tthe\tpolicies\tnewly\tadopted\tby\tthe\t68th
\n\tWMA\tGeneral\tAssembly,\tChicago,
\nUnited\tStates,\tOctober\t2017
\nD-2017-01-2017\t Quality\tAssurance\tin\tBasic\tMedical\tEducation
\nD-2017-02-2017\t Fair\tMedical\tTrade
\nS-2017-01-2017\t Bullying\tand\tHarassment\twithin\tthe\tProfession
\nS-2017-02-2017\t Armed\tConflicts
\nS-2017-03-2017\t Medical\tCannabis
\nS-2017-04-2017\t Cooperation\tof\tNational\tMedical\tAssociations\tduring\tor
\nin\tthe\tAftermath\tof\tConflicts
\nS-2017-05-2017\t Epidemics\tand\tPandemics
\nS-2017-06-2017\t Role\tof\tPhysicians\tin\tPreventing\tExploitation\tin
\nAdoption\tPractices
\nR-2017-01-2017\t Poland
\nR-2017-02-2017\t Prohibition\tof\tForced\tAnal\tExaminations\tto
\nSubstantiate\tSame-Sex\tSexual\tActivity\t<\/p>\n

Version\t2018-1,\tRiga;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nR-1998-05-2008\tby
\nR-1998-01-2018
\nSupporting\tthe\tOttawa\tConvention\ton\tthe\tProhibition
\nof\tthe\tuse,\tstockpiling,\tproduction\tand\ttransfer\tof\tanti-
\npersonnel\tmines\tand\ton\ttheir\tdestruction\t(reaffirmed
\nin\t2018)\t<\/p>\n

Version\t2018-2,\tReykjavik,\tIceland;\tPrinted\tin\tJanuary\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nD-2008-01-2008\tby
\nD-2008-01-2018
\nProfessional\tAutonomy\tand\tClinical\tIndependence
\n(amended\tin\t2018)
\nD-1970-01-2006\tby
\nS-1970-01-2018
\nMedically-Indicated\tTermination\tof\tPregnancy\t(name
\nchanged\tand\tamended\tin\t2018)
\nS-1997-02-2007\tby
\nS-1997-02-2018
\nPhysicians\tconvicted\tof\tGenocide\tor\tCrimes\t(name
\nchanged\tand\tamended\tin\t2018)
\nS-1998-01-2015\tby
\nS-1998-01-2018
\nNuclear\tWeapons\t(amended\tin\t2018)
\nS-2006-02-2006\tby
\nS-2006-02-2018
\nAvian\tand\tPandemic\tInfluenza\t(amended\tin\t2018)
\nS-2007-02-2007\tby
\nS-2007-01-2018
\nEthics\tof\tTelemedicine\t(amended\tin\t2018)
\nS-2008-02-2008\tby
\nS-2008-02-2018
\nReducing\tthe\tGlobal\tBurden\tof\tMercury\t(reaffirmed\tin
\n2018)
\nS-2010-01-2010\tby
\nS-2010-01-2018
\nEnvironmental\tDegradation\tand\tSound\tManagement
\nof\tChemicals\t(amended\tin\t2018)
\nR-2008-03-2008\tby
\nR-2008-01-2018
\nCollaboration\tBetween\tHuman\tand\tVeterinary
\nMedicine\t(reaffirmed\tin\t2018)\t<\/p>\n

\u2022 Removals\tof\tthe\tpolicies\trescinded\tand\tarchived\tby\tthe\t69th
\n\tWMA\tGeneral\tAssembly,
\nReykjavik,\tIceland,\tOctober\t2018
\nCode\t Short\tTitle
\nS-1996-03-2006\t Professional\tResponsibility\tfor\tStandards\tof\tMedical
\nCare
\nR-1981-01-2008\t Physician\tParticipation\tin\tCapital\tPunishment
\nR-2008-01-2008\t The\tEconomic\tCrisis:\tImplications\tfor\tHealth
\nR-2008-02-2008\t Poppies\tfor\tMedicine\tProject\tfor\tAfghanistan\t<\/p>\n

\u2022 Addition\tof\tthe\tresolution\tnewly\tadopted\tby\tthe\t69th
\n\tWMA\tGeneral\tAssembly,
\nReykjavik,\tIceland,\tOctober\t2018
\nS-2018-01-2018\t Biosimilar\tMedicinal\tProducts
\nS-2018-02-2018\t Development\tand\tPromotion\tof\ta\tMaternal\tand\tChild
\nHealth\tHandbook
\nS-2018-03-2018\t Gender\tEquality\tin\tMedicine
\nS-2018-04-2018\t Medical\tTourism
\nS-2018-05-2018\t Sustainable\tDevelopment
\nR-2018-01-2018\t Migration
\nR-2018-02-2018\t Prohibition\tof\tPhysician\tParticipation\tin\tCapital
\nPunishment\t<\/p>\n

Version\t2019-1,\tSantiago,\tChile;\tPrinted\tin\tMay\t2019\t<\/p>\n

\u2022 Replacements
\nCode\t Short\tTitle
\nS-1999-01-2009\tby
\nS-1999-01-2019
\nPatenting\tMedical\tProcedures\t(reaffirmed\tin\t2019)
\nR-2009-03-2009\tby
\nR-2009-03-2019
\nTask\tShifting\tfrom\tthe\tMedical\tProfession\t(reaffirmed
\nin\t2019)\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation
\nPREFACE
\nBefore World War II came to an end, a number of medical associations gathered in Lon-
\ndon to reinvent the approach to international collaboration among the world\u2019s physicians.
\nThe old model, represented by the pre-war \u201cAssociation Professionnelle Internationale des
\nM\u00e9decins\u201d (APIM), would no longer meet the needs of the post-war medical profession.
\nIt was time to create something new.
\nAfter only two years of preparation, 27 national medical associations met in Paris on Sep-
\ntember 18th, 1947 for the inauguration of a new global physicians\u2019 association, the World
\nMedical Association (WMA). The lead-up to this first Assembly was paralleled by the
\nNuremberg trial against Nazi doctors, which was a key driver of the mission focus of the
\nnew WMA. This terrible episode in the history of medicine dictated that the organization
\nmust seek to become the authoritative voice on global standards for medical ethics and
\nprofessional conduct, rather than focus solely on protecting the interests of the profession.
\nEffectively coordinating an international organization was anything but easy in the late
\n1940s. There was no internet, e-mail, mobile phones, personal computers, fax, or even
\nphotocopiers. For many physicians, attending the Assembly required a cross-continental,
\nmulti-day journey across a deeply scarred planet, by train and ship and only in exceptional
\ncircumstances by plane. Yet the commitment of these founding WMA members to their
\nvision was even greater than the challenges they faced in achieving it. That vision, and the
\naccompanying goals, ideals, and unity of purpose, are as relevant today as they were during
\nthose early days. They are now ours to carry on.
\nThe WMA Handbook of Policies is evidence that the engagement of the world medical
\nprofession does, in fact, persist. The WMA now is bigger, stronger and more active then
\never before, and our Handbook is the product of physicians coming together for more than
\nhalf a century to provide ethical guidance, moral support and practical advice to help their
\ncolleagues serve their patients to the best of their ability. From the Declaration of Geneva,
\noften referred to as the \u201cModern Hippocratic Oath\u201d to the Declaration of Helsinki advising
\nphysicians doing medical research on human subjects, to the Declaration of Tokyo prohi-
\nbiting physicians from participating in torture and degrading treatment \u2212 to mention just a
\nfew of WMA\u2019s landmark policies \u2212 the guidance provided by the WMA is as necessary
\nnow as it has ever been.
\nThere are many other policies in this world dealing with physician conduct, many of
\nwhich try to be \u201cmodern\u201d, \u201ceasily readable\u201d and \u201cpolitically correct\u201d. The WMA has never
\ncapitulated against the \u201cZeitgeist\u201d, but has stood firm with its values, the most important
\nof which are caring, ethics and science.
\nSir William Osler said: \u201cThe most important thing is caring, so do it first, for the caring
\nphysicians best inspires hope and trust.\u201d Hope and trust are the basis for any treatment. A
\nphysician who cannot generate trust will face more challenges than the one who receives
\nthe trust of the patients. A patient with hope is far better off than one without.<\/p>\n

World\tMedical\tAssociation
\nBut caring must go hand-in-hand with medical ethics and proper conduct. Physicians are
\noften confronted with questions of life and death, resource allocations, and dual loyalties
\nwhen serving a single patient and at the same time respecting the needs of a community or
\npopulation. The questions are often too difficult and the problems too burdensome for one
\nperson alone. We are far away from having answers for all such questions, but for many,
\nthe WMA can provide the ethical guidance that protects patients, supports physicians, and
\nduly considers the interests of the communities and populations they both belong to.
\nFinally, science is what distinguishes medicine from well-intended kindness. In medicine,
\nquality care and ethical conduct cannot be separated from sound science. Still, despite our
\nsincere and continual quest for increased scientific knowledge, understanding and solu-
\ntions, we will never be protected from all mistakes. Therefore, practicing the science of
\nmedicine with faithful adherence to clear ethical guidance is the best we can do.
\nThis new handbook*
\nprovides a good part of this guidance. It is proof of our continued
\nengagement with our colleagues in the different parts of this world and our commitment to
\nour patients, wherever and whoever they may be. It is a living document and the WMA
\nwill continue to improve and expand it, in service to the profession and the health of those
\nwe serve as physicians.
\nJ. Edward Hill Otmar Kloiber
\nChairman of Council Secretary General<\/p>\n

Wonchat Subchaturas
\nPresident 2010-2011<\/p>\n

*
\nThe World Medical Association is most grateful to the Korean Medical Association for
\nseconding Ms. Seongmi LEE to the WMA Office at Ferney-Voltaire, providing valuable
\nhelp in putting this collection of policies together.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nChronological\tOrder
\nD-1948-01-2017
\nD-1949-01-2006\t\t<\/p>\n

D-1964-01-2013\t<\/p>\n

D-1968-01-2016
\nD-1970-01-2006\t<\/p>\n

D-1975-01-2016
\nD-1981-01-2015
\nD-1981-02-2010
\nD-1983-01-2006
\nD-1987-01-2015
\nD-1989-01-2015
\nD-1991-01-2017\t<\/p>\n

D-1997-01-2009\t<\/p>\n

D-1997-02-2017
\nD-1998-01-2009\t<\/p>\n

D-2000-01-2011
\nD-2002-01-2012
\nD-2002-02-2016
\nD-2002-03-2012
\nD-2002-04-2012\t<\/p>\n

D-2008-01-2018
\nD-2009-01-2017
\nTABLE\tOF\tCONTENTS
\n–\t\tChronological\tOrder\t–\t<\/p>\n

DECLARATIONS
\nDeclaration\tof\tGeneva\t\t ……………………………………………………………………………….
\nInternational\tCode\tof\tMedical\tEthics\t\t……………………………………………………………
\nDeclaration\tof\tHelsinki
\n–\tEthical\tPrinciples\tfor\tMedical\tResearch\tinvolving\tHuman\tSubjects\t\t…………….
\nDeclaration\tof\tSydney
\non\tthe\tDetermination\tof\tDeath\tand\tthe\tRecovery\tof\tOrgans\t\t………………………
\nDeclaration\tof\tOslo\ton\tTherapeutic\tAbortion\t\t………………………………………………..
\nDeclaration\tof\tTokyo\twith\tguidelines\tfor\tMedical\tDoctors\tconcerning
\nTorture\tand\tOther\tCruel,\tInhuman\tor\tDegrading\tTreatment\tor
\nPunishment\tin\trelation\tto\tDetention\tand\tImprisonment\t\t ……………………………
\nDeclaration\tof\tLisbon\ton\tthe\tRights\tof\tthe\tPatient\t\t …………………………………………
\nDeclaration\ton\tPrinciples\tof\tHealth\tCare\tfor\tSports\tMedicine\t\t………………………….
\nDeclaration\tof\tVenice\ton\tTerminal\tIllness\t\t……………………………………………………..
\nDeclaration\ton\tEuthanasia\t\t………………………………………………………………………….
\nDeclaration\tof\tHong\tKong\ton\tthe\tAbuse\tof\tthe\tElderly\t\t …………………………………..
\nDeclaration\tof\tMalta\ton\tHunger\tStrikers\t\t ………………………………………………………
\nDeclaration\ton\tGuidelines\tfor
\nContinuous\tQuality\tImprovement\tin\tHealth\tCare\t\t………………………………………
\nDeclaration\tof\tHamburg\tconcerning\tSupport\tfor\tMedical\tDoctors\tRefusing\tto
\nParticipate\tin,\tor\tto\tCondone,\tthe\tUse\tof\tTorture\tor\tOther\tForms\tof\tCruel,
\nInhuman,\tor\tDegrading\tTreatment\t\t………………………………………………………….
\nDeclaration\tof\tOttawa\ton\tChild\tHealth\t\t…………………………………………………………
\nDeclaration\tof\tEdinburgh\ton\tPrison\tConditions\tand\tthe\tSpread\tof\tTuberculosis
\nand\tOther\tCommunicable\tDiseases\t\t…………………………………………………………
\nDeclaration\tof\tWashington\ton\tBiological\tWeapons\t\t………………………………………..
\nDeclaration\ton\tEthical\tConsiderations\tregarding\tHealth\tDatabases\t…………………..
\nDeclaration\ton\tPatient\tSafety\t ………………………………………………………………………
\nDeclaration\ton\tMedical\tEthics\tand\tAdvanced\tTechnology\t\t ………………………………
\nDeclaration\tof\tSeoul\ton\tProfessional\tAutonomy\tand
\nClinical\tIndependence\t\t……………………………………………………………………………
\nDeclaration\tof\tDelhi\ton\tHealth\tand\tClimate\tChange\t\t………………………………………. \t<\/p>\n

Table\tof\tContents
\nD-2009-02-2009\t<\/p>\n

D-2011-01-2011
\nD-2011-02-2011\t\t<\/p>\n

D-2011-03-2011
\nD-2011-04-2015\t<\/p>\n

D-2014-01-2014
\nD-2015-01-2017
\nD-2017-01-2017
\nD-2017-02-2017\t<\/p>\n

S-1956-01-2012
\nS-1970-01-2018
\nS-1983-01-2017
\nS-1984-01-2017
\nS-1984-02-1984\t<\/p>\n

S-1985-01-2015
\nS-1988-01-2017
\nS-1988-04-2016\t<\/p>\n

S-1988-05-2011
\nS-1989-01-2016
\nS-1990-01-2016
\nS-1990-04-2016
\nS-1991-01-2016
\nS-1992-01-2016
\nS-1992-05-2017
\nS-1992-06-2015
\nS-1993-01-2016
\nS-1993-02-2016
\nS-1993-03-2016
\nS-1994-01-2017\t<\/p>\n

Declaration\tof\tMadrid\ton\tProfessionally-led\tRegulation\t\t …………………………………
\nDeclaration\tof\tMontevideo\ton\tDisaster\tPreparedness\tand
\nMedical\tResponse\t\t…………………………………………………………………………………
\nDeclaration\ton\tEnd-of-Life\tMedical\tCare\t\t ………………………………………………………
\nDeclaration\ton\tLeprosy\tControl\taround\tthe\tWorld\tand
\nElimination\tof\tDiscrimination\tagainst\tpersons\taffected\tby\tLeprosy\t\t ……………..
\nDeclaration\ton\tOslo\ton\tSocial\tDeterminants\tof\tHealth\t ……………………………………
\nDeclaration\ton\tthe\tProtection\tof\tHealth\tCare\tWorkers
\nin\tSituations\tof\tViolence\t\t ………………………………………………………………………..
\nDeclaration\ton\tAlcohol\t………………………………………………………………………………..
\nDeclaration\tof\tChicago\ton\tQuality\tAssurance\tin\tMedical\tEducation\t ………………….
\nDeclaration\ton\tFair\tTrade\tin\tMedical\tProducts\tand\tDevices\t…………………………….. \t<\/p>\n

STATEMENTS\t<\/p>\n

Regulations\tin\tTime\tof\tArmed\tConflict\tand\tOther\tSituations\tof\tViolence\t\t ………….
\nStatement\ton\tMedically-Indicated\tTermination\tof\tPregnancy\t………………………….
\nStatement\ton\tBoxing\t\t………………………………………………………………………………….
\nStatement\ton\tChild\tAbuse\tand\tNeglect\t\t ………………………………………………………..
\nStatement\ton\tFreedom\tto\tAttend\tMedical\tMeetings\t\t\t …………………………………….
\nStatement\ton\tNon-Discrimination\tin\tProfessional\tMembership\tand
\nActivities\tof\tPhysicians\t\t…………………………………………………………………………..
\nStatement\ton\tAccess\tto\tHealth\tCare\t\t…………………………………………………………….
\nStatement\ton\tthe\tRole\tof\tPhysicians\tin\tEnvironmental\tIssues\t\t …………………………
\nStatement\ton\tHealth\tHazards\tof\tTobacco\tProducts\tand
\nTobacco-Derived\tProducts\t\t……………………………………………………………………..
\nStatement\ton\tAnimal\tUse\tin\tBiomedical\tResearch\t\t …………………………………………
\nStatement\ton\tInjury\tControl\t\t ……………………………………………………………………….
\nStatement\ton\tTraffic\tInjury\t\t…………………………………………………………………………
\nStatement\ton\tAdolescent\tSuicide\t\t ………………………………………………………………..
\nStatement\ton\tAlcohol\tand\tRoad\tSafety\t\t ………………………………………………………..
\nStatement\ton\tNoise\tPollution\t\t……………………………………………………………………..
\nStatement\ton\tPhysician-Assisted\tSuicide\t\t………………………………………………………
\nStatement\ton\tBody\tSearches\tof\tPrisoners\t\t…………………………………………………….
\nStatement\ton\tFemale\tGenital\tMutilation\t\t ……………………………………………………..
\nStatement\ton\tPatient\tAdvocacy\tand\tConfidentiality\t\t ………………………………………
\nStatement\ton\tMedical\tEthics\tin\tthe\tEvent\tof\tDisasters\t\t ………………………………….. \t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nChronological\tOrder
\nS-1995-02-2015
\nS-1995-04-2016
\nS-1996-01-2008
\nS-1996-02-2010
\nS-1996-04-2017
\nS-1996-05-2016\t<\/p>\n

S-1997-02-2018\t<\/p>\n

S-1997-01-2007
\nS-1998-01-2018\t<\/p>\n

S-1998-02-2010
\nS-1999-01-2019\t<\/p>\n

S-1999-02-2010
\nS-2000-01-2006
\nS-2002-01-2012
\nS-2002-02-2012
\nS-2003-01-2013
\nS-2003-02-2013\t<\/p>\n

S-2003-03-2014
\nS-2003-04-2008\t<\/p>\n

S-2004-02-2009
\nS-2004-03-2017
\nS-2005-02-2015
\nS-2005-03-2009
\nS-2005-04-2015
\nS-2006-01-2006
\nS-2006-02-2018
\nS-2006-03-2017
\nS-2006-04-2017
\nStatement\ton\tEthical\tIssues\tconcerning\tPatients\twith\tMental\tIllness\t\t……………….
\nStatement\ton\tPhysicians\tand\tPublic\tHealth\t\t…………………………………………………..
\nStatement\ton\tResistance\tto\tAntimicrobial\tDrugs\t\t …………………………………………..
\nStatement\ton\tFamily\tViolence\t\t …………………………………………………………………….
\nStatement\ton\tFamily\tPlanning\tand\tthe\tRight\tof\ta\tWoman\tto\tContraception\t\t……..
\nStatement\ton\tWeapons\tof\tWarfare\tand\tTheir\tRelation\tto\tLife\tand\tHealth\t\t ………..
\nStatement\ton\tPhysicians\tconvicted\tof\tGenocide,\tWar\tCrimes\tor\tCrimes\tAgainst
\nHumanity\t\t …………………………………………………………………………………………….
\nProposal\tfor\ta\tUnited\tNations\tRapporteur\ton\tthe\tIndependence\tand
\nIntegrity\tof\tHealth\tProfessionals\t\t……………………………………………………………..
\nStatement\ton\tNuclear\tWeapons\t\t………………………………………………………………….
\nStatement\ton\tMedical\tCare\tfor\tRefugees,\tincluding\tAsylum\tSeekers,
\nRefused\tAsylum\tSeekers\tand\tUndocumented\tMigrants,\tand
\nInternally\tDisplaced\tPersons\t\t…………………………………………………………………..
\nStatement\ton\tPatenting\tMedical\tProcedures\t\t ………………………………………………..
\nStatement\ton\tthe\tRelationship\tbetween\tPhysicians\tand\tPharmacists
\nin\tMedical\tTherapy\t\t ……………………………………………………………………………….
\nStatement\ton\tHuman\tOrgan\tDonation\tand\tTransplantation\t\t……………………………
\nStatement\ton\tSafe\tInjections\tin\tHealth\tCare\t\t …………………………………………………
\nStatement\ton\tSelf-Medication\t\t…………………………………………………………………….
\nStatement\ton\tForensic\tInvestigations\tof\tthe\tMissing\t\t\t …………………………………….
\nStatement\ton\tAdvance\tDirectives\t(\u201cLiving\tWills\u201d)\t\t ………………………………………….
\nStatement\ton\tthe\tEthical\tGuidelines\tfor\tthe\tInternational\tMigration\tof
\nHealth\tWorkers\t\t…………………………………………………………………………………….
\nStatement\ton\tViolence\tand\tHealth\t\t ………………………………………………………………
\nStatement\tconcerning\tthe\tRelationship
\nbetween\tPhysicians\tand\tCommercial\tEnterprises\t\t ……………………………………..
\nStatement\ton\tWater\tand\tHealth\t\t………………………………………………………………….
\nStatement\ton\tDrug\tSubstitution\t\t ………………………………………………………………….
\nStatement\ton\tGenetics\tand\tMedicine\t\t…………………………………………………………..
\nStatement\ton\tMedical\tLiability\tReform\t\t ………………………………………………………..
\nStatement\ton\tAssisted\tReproductive\tTechnologies\t\t………………………………………..
\nStatement\ton\tAvian\tand\tPandemic\tInfluenza\t\t ………………………………………………..
\nStatement\ton\tHIV\/AIDS\tand\tthe\tMedical\tProfession\t\t………………………………………
\nStatement\ton\tMedical\tEducation\t\t………………………………………………………………… \t<\/p>\n

Table\tof\tContents
\nS-2006-05-2016\t<\/p>\n

S-2006-06-2016
\nS-2007-02-2018
\nS-2008-01-2008
\nS-2008-02-2018
\nS-2009-01-2009
\nS-2009-02-2009
\nS-2009-03-2009\t<\/p>\n

S-2009-04-2009\t<\/p>\n

S-2010-01-2018
\nS-2011-01-2011\t<\/p>\n

S-2011-02-2011\t<\/p>\n

S-2011-03-2011
\nS-2011-04-2015
\nS-2011-05-2011\t<\/p>\n

S-2012-01-2012
\nS-2012-02-2012
\n\tS-2012-03-2012
\n\tS-2012-04-2017
\n\tS-2012-05-2012\t<\/p>\n

\tS-2012-06-2012
\n\tS-2013-01-2013
\n\tS-2013-02-2013
\n\tS-2013-03-2013
\n\tS-2013-04-2013\t<\/p>\n

\tS-2013-05-2013
\nStatement\ton\tThe\tPhysician\u2019s\tRole\tin\tObesity\t\t……………………………………………….
\nStatement\ton\tthe\tResponsibilities\tof\tPhysicians\tin\tPreventing\tand
\nTreating\tOpiate\tand\tPsychotropic\tDrug\tAbuse\t\t………………………………………….
\nStatement\ton\tthe\tEthics\tof\tTelemedicine\t\t……………………………………………………..
\nStatement\ton\tReducing\tDietary\tSodium\tIntake\t\t……………………………………………..
\nStatement\ton\tReducing\tthe\tGlobal\tBurden\tof\tMercury\t\t…………………………………..
\nStatement\ton\tConflict\tof\tInterest\t\t ………………………………………………………………..
\nStatement\ton\tEmbryonic\tStem\tCell\tResearch\t\t………………………………………………..
\nStatement\ton\tInequalities\tin\tHealth\t\t …………………………………………………………….
\nStatement\ton\tGuiding\tPrinciples\tfor\tthe\tUse\tof\tTelehealth
\nfor\tthe\tProvision\tof\tHealth\tCare\t\t ……………………………………………………………..
\nStatement\ton\tEnvironmental\tDegradation\tand
\nSound\tManagement\tof\tChemicals\t\t …………………………………………………………..
\nStatement\ton\tthe\tGlobal\tBurden\tof\tChronic\tDisease\t\t………………………………………
\nRecommendation\ton\tthe\tDevelopment\tof\ta\tMonitoring\tand
\nReporting\tMechanism\tto\tpermit\tAudit\tof
\nAdherence\tof\tStates\tto\tthe\tDeclaration\tof\tTokyo\t\t………………………………………
\nStatement\ton\tthe\tProtection\tand\tIntegrity\tof\tMedical\tPersonnel
\nin\tArmed\tConflicts\tand\tOther\tSituations\tof\tViolence\t\t………………………………….
\nStatement\ton\tSocial\tDeterminants\tof\tHealth\t\t ………………………………………………..
\nStatement\ton\tthe\tProfessional\tand\tEthical\tUsage\tof\tSocial\tMedia\t\t\t…………………..
\nStatement\ton\tElectronic\tCigarettes\tand
\nOther\tElectronic\tNicotine\tDelivery\tSystems\t\t\t……………………………………………..
\nStatement\ton\tthe\tEthical\tImplications\tof\tCollective\tAction\tby\tPhysicians\t\t\t…………
\nStatement\ton\tForced\tand\tCoerced\tSterilisation\t\t\t ……………………………………………
\nStatement\ton\tOrgan\tand\tTissue\tDonation\t\t\t……………………………………………………
\nStatement\ton\tthe\tPrioritisation\tof\tImmunisation\t\t\t ………………………………………….
\nStatement\ton\tViolence\tin\tthe\tHealth\tSector\tby\tPatients\tand
\nThose\tClose\tto\tThem\t\t……………………………………………………………………………..
\nStatement\ton\tFungal\tDisease\tDiagnosis\tand\tManagement\t\t\t…………………………….
\nStatement\ton\tHuman\tPapillomavirus\tVaccination\t\t\t…………………………………………
\nStatement\ton\tNatural\tVariations\tof\tHuman\tSexuality\t\t\t ……………………………………
\nStatement\ton\tthe\tRight\tto\tRehabilitation\tof\tVictims\tof\tTorture\t\t\t………………………
\nStatement\ton\tthe\tUnited\tNations\tResolution\tfor\ta\tMoratorium\ton\tthe
\nUse\tof\tthe\tDeath\tPenalty\t\t\t ……………………………………………………………………… \t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nChronological\tOrder
\nS-2014-01-2014
\nS-2014-02-2014
\nS-2014-03-2014
\nS-2015-01-2015
\nS-2015-02-2015
\nS-2015-03-2015
\nS-2015-04-2015
\nS-2015-05-2015
\nS-2015-06-2015
\nS-2015-07-2015
\nS-2016-01-2016
\nS-2016-02-2016
\nS-2016-03-2016
\nS-2016-04-2016
\nS-2016-05-2016
\nS-2017-01-2017
\nS-2017-02-2017
\nS-2017-03-2017\t<\/p>\n

S-2017-04-2017
\nS-2017-05-2017\t<\/p>\n

S-2017-06-2017
\nS-2018-01-2018\t<\/p>\n

S-2018-02-2018
\nS-2018-03-2018
\nS-2018-04-2018
\nS-2018-05-2018\t<\/p>\n

R-1988-01-2015
\nR-1997-01-2017\t<\/p>\n

R-1997-03-2008
\nStatement\ton\tAesthetic\tTreatment\t\t\t…………………………………………………………..
\nStatement\ton\tthe\tPrevention\tof\tAir\tPollution\tand\tVehicle\tEmissions\t\t\t ………………
\nStatement\ton\tSolitary\tConfinement\t\t\t ……………………………………………………………
\nStatement\ton\tMobile\tHealth\t\t\t………………………………………………………………………
\nStatement\ton\tPhysicians\tWell-Being\t\t ……………………………………………………………
\nStatement\ton\tProviding\tHealth\tSupport\tto\tStreet\tChildren\t\t …………………………….
\nStatement\ton\tRiot\tControl\tAgents\t\t……………………………………………………………….
\nStatement\ton\tTransgender\tPeople\t\t ………………………………………………………………
\nStatement\ton\tVitamin\tD\tInsufficiency\t\t ………………………………………………………….
\nGuidelines\ton\tPromotional\tMass\tMedia\tAppearances\tby\tPhysicians\t\t………………..
\nStatement\ton\tAgeing\t\t …………………………………………………………………………………
\nStatement\ton\tCyber-Attacks\ton\tHealth\tand\tOther\tCritical\tInfrastructure\t\t………….
\nStatement\ton\tDivestment\tfrom\tFossil\tFuels\t\t ………………………………………………….
\nStatement\ton\tEthical\tConsiderations\tin\tGlobal\tMedical\tElectives\t\t…………………….
\nStatement\ton\tObesity\tin\tChildren\t\t………………………………………………………………..
\nStatement\ton\tBullying\tand\tHarassment\twithin\tthe\tProfession\t\t ………………………..
\nStatement\ton\tArmed\tConflicts\t\t…………………………………………………………………….
\nStatement\ton\tMedical\tCannabis\t\t………………………………………………………………….
\nStatement\ton\tthe\tCooperation\tof\tNational\tMedical\tAssociations
\nduring\tor\tin\tthe\tAftermath\tof\tConflicts\t\t…………………………………………………….
\nStatement\ton\tEpidemics\tand\tPandemics\t\t………………………………………………………
\nStatement\ton\tthe\tRole\tof\tPhysicians\tin\tPreventing\tExploitation
\nin\tAdoption\tPractices\t\t…………………………………………………………………………….
\nStatement\ton\tBiosimilar\tMedicinal\tProducts\t\t…………………………………………………
\nStatement\ton\tthe\tDevelopment\tand\tPromotion\tof\ta\tMaternal
\nand\tChild\tHealth\tHandbook\t\t……………………………………………………………………
\nStatement\ton\tGender\tEquality\tin\tMedicine\t\t…………………………………………………..
\nStatement\ton\tMedical\tTourism\t\t …………………………………………………………………..
\nStatement\ton\tSustainable\tDevelopment\t\t ……………………………………………………… \t<\/p>\n

RESOLUTIONS\t<\/p>\n

Resolution\ton\tAcademic\tSanctions\tor\tBoycotts\t\t……………………………………………..
\nResolution\ton\tEconomic\tEmbargoes\tand\tHealth\t\t ……………………………………………
\nResolution\ton\tAccess\tof\tWomen\tand\tChildren\tto\tHealth\tCare\tand
\nthe\tRole\tof\tWomen\tin\tthe\tMedical\tProfession\t\t…………………………………………. \t<\/p>\n

Table\tof\tContents
\nR-1998-03-2009
\nR-1998-04-2009
\nR-1998-01-2018\t<\/p>\n

R-1999-01-2015
\nR-2002-01-2013
\nR-2002-02-2012
\nR-2002-05-2012\t<\/p>\n

R-2002-06-2013
\nR-2003-01-2013\t<\/p>\n

R-2003-02-2007\t<\/p>\n

R-2003-03-2014\t<\/p>\n

R-2004-01-2014\t<\/p>\n

R-2005-01-2016
\nR-2006-01-2017
\nR-2006-02-2016
\nR-2006-04-2016
\nR-2006-05-2017
\nR-2007-01-2017\t<\/p>\n

R-2007-02-2017
\nR-2008-01-2018
\nR-2009-01-2009\t<\/p>\n

R-2009-02-2009
\nR-2009-03-2019
\nR-2010-01-2010
\nR-2010-02-2010
\nR-2011-01-2011
\nR-2011-02-2011\t<\/p>\n

Resolution\ton\tImproved\tInvestment\tin\tPublic\tHealth\t\t …………………………………….
\nResolution\ton\tthe\tMedical\tWorkforce\t\t………………………………………………………….
\nResolution\tsupporting\tthe\tOttawa\tConvention\t\t ……………………………………………..
\nResolution\ton\tthe\tInclusion\tof\tMedical\tEthics\tand
\nHuman\tRights\tin\tthe\tCurriculum\tof\tMedical\tSchools\tWorld-wide\t\t………………..
\nResolution\ton\tEuthanasia\t\t …………………………………………………………………………..
\nResolution\ton\tFemale\tFoeticide\t\t…………………………………………………………………..
\nResolution\ton\tPolitical\tAbuse\tof\tPsychiatry\t\t…………………………………………………..
\nResolution\ton\tthe\tWomen’s\tRight\tto\tHealth\tCare\tand
\nHow\tthat\tRelates\tto\tthe\tPrevention\tof\tMother-to-Child\tHIV\tInfection\t\t …………
\nResolution\ton\tthe\tDesignation\tof\tan\tAnnual\tMedical\tEthics\tDay\t\t ……………………..
\nResolution\ton\tthe\tResponsibility\tof\tPhysicians\tin\tthe\tDenunciation\tof
\nActs\tof\tTorture\tor\tCruel,\tInhuman\tor\tDegrading\tTreatment\t\t ……………………….
\nResolution\ton\tthe\tNon-Commercialization\tof
\nHuman\tReproductive\tMaterial\t\t ……………………………………………………………….
\nResolution\ton\tWFME\tGlobal\tStandards\tfor
\nQuality\tImprovement\tof\tMedical\tEducation\t\t……………………………………………..
\nResolution\ton\tImplementation\tof\tthe\tWHO\tFramework\tConvention
\n\t on\tTobacco\tControl\t\t……………………………………………………………………………….
\nResolution\ton\tMedical\tAssistance\tin\tAir\tTravel\t\t ……………………………………………..
\nResolution\ton\tChild\tSafety\tin\tAirline\tTravel\t\t…………………………………………………..
\nResolution\ton\tNorth\tKorean\tNuclear\tTesting\t\t ………………………………………………..
\nResolution\ton\tTuberculosis\t\t…………………………………………………………………………
\nResolution\ton\tHealth\tand\tHuman\tRights\tAbuses\tin\tZimbabwe\t\t ………………………..
\nResolution\tin\tSupport\tof\tthe\tMedical\tAssociations
\nin\tLatin\tAmerica\tand\tthe\tCaribbean\t\t…………………………………………………………
\nResolution\ton\tCollaboration\tBetween\tHuman\tand\tVeterinary\tMedicine\t\t…………..
\nEmergency\tResolution\ton\tLegislation\tagainst\tAbortion\tin\tNicaragua\t\t………………..
\nResolution\tsupporting\tthe\tRights\tof
\nPatients\tand\tPhysicians\tin\tthe\tIslamic\tRepublic\tof\tIran\t\t ………………………………
\nResolution\ton\tTask\tShifting\tfrom\tthe\tMedical\tProfession\t\t ……………………………….
\nResolution\ton\tDrug\tPrescription\t\t………………………………………………………………….
\nResolution\ton\tViolence\tagainst\tWomen\tand\tGirls\t\t………………………………………….
\nResolution\ton\tthe\tAccess\tto\tAdequate\tPain\tTreatment\t\t ………………………………….
\nResolution\ton\tBahrain\t\t………………………………………………………………………………..
\nResolution\treaffirming\tthe\tWMA\tResolution\ton\t\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nChronological\tOrder
\nEconomic\tEmbargoes\tand\tHealth\t\t ……………………………………………………………
\nResolution\ton\tIndependence\tof\tMedical\tAssociations\t\t ……………………………………
\nResolution\ton\tPlain\tPackaging\tof\tCigarettes\t\t………………………………………………….
\nResolution\tto\treaffirm\tthe\tWMA\u2019s\tProhibition\tof\tPhysician\tParticipation\tin
\nCapital\tPunishment\t\t……………………………………………………………………………….
\nResolution\tin\tSupport\tof\tProfessor\tCyril\tKarabus\t ……………………………………………
\nResolution\ton\tCriminalisation\tof\tMedical\tPractice\t ………………………………………….
\nResolution\ton\tthe\tHealthcare\tSituation\tin\tSyria\t ……………………………………………..
\nResolution\ton\tthe\tProhibition\tof\tChemical\tWeapons\t………………………………………
\nResolution\ton\tPatient\tSafety\tand\tStandardisation\tin\tMedical\tPractice\t………………
\nResolution\tin\tSupport\tof\tthe\tBrazilian\tMedical\tAssociation\t ……………………………..
\nResolution\ton\tEbola\tViral\tDisease\t…………………………………………………………………
\nResolution\ton\tMigrant\tWorkers’\tHealth\tand\tSafety\tin\tQatar\t ……………………………
\nResolution\ton\tUnproven\tTherapy\tand\tthe\tEbola\tVirus\t…………………………………….
\nResolution\tto\tStop\tAttacks\tAgainst\tHealthcare\tWorkers
\n\t and\tFacilities\tIn\tTurkey\t\t\t………………………………………………………………………….
\nResolution\tabout\tthe\tBombing\ton\tthe\tHospital\tof\tMSF\tin\tKunduz\t\t……………………
\nResolution\ton\tGlobal\tRefugee\tCrisis\t\t …………………………………………………………….
\nResolution\ton\tthe\tProtection\tof\tHealth\tCare\tFacilities
\n\t and\tPersonnel\tin\tSyria\t\t……………………………………………………………………………
\nResolution\ton\tOccupational\tand\tEnvironmental\tHealth\tand\tSafety\t\t………………….
\nResolution\ton\tRefugees\tand\tMigrants\t\t ………………………………………………………….
\nResolution\ton\tZika\tVirus\tInfection\t\t ……………………………………………………………….
\nResolution\ton\tPoland\t\t…………………………………………………………………………………
\nResolution\ton\tProhibition\tof\tForced\tAnal\tExaminations
\n\t to\tSubstantiate\tSame-Sex\tSexual\tActivity\t\t…………………………………………………
\nResolution\ton\tMigration\t\t …………………………………………………………………………….
\nResolution\ton\tProhibition\tof\tPhysician\tParticipation\tin\tCapital\tPunishment\t\t………
\nR-2011-03-2011
\nR-2011-04-2011
\nR-2012-02-2012\t<\/p>\n

R-2012-03-2012
\nR-2012-04-2012
\nR-2013-01-2013
\nR-2013-02-2013
\nR-2013-03-2013
\nR-2013-04-2013
\nR-2013-05-2013
\nR-2014-01-2014
\nR-2014-02-2014
\nR-2014-03-2014\t<\/p>\n

R-2015-01-2015
\nR-2015-02-2015
\nR-2015-03-2015\t<\/p>\n

R-2016-01-2016
\nR-2016-02-2016
\nR-2016-03-2016
\nR-2016-04-2016
\nR-2017-01-2017\t<\/p>\n

R-2017-02-2017
\nR-2018-01-2018
\nR-2018-02-2018
\n*\t\t\tCode\texplanation\t(sorting\tcriteria):
\nD-1948-01-2006
\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tYear\tof\tlast\taction
\nSerial\tnumber
\nYear\tof\tadoption
\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tDocument\ttype\t\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle\t<\/p>\n

R-2002-05-2012
\nR-1988-01-2015
\nS-1988-01-2017
\nR-2011-01-2011
\nS-1991-01-2016
\nD-2002-04-2012
\nS-2014-01-2014
\nS-2016-01-2016
\nS-2014-02-2014
\nR-2006-01-2017
\nD-2015-01-2017
\nS-1992-01-2016
\nS-2005-01-2005
\nS-1989-01-2016
\nR-2003-01-2013
\nS-1996-01-2008
\nS-1956-01-2012
\nS-2017-02-2017
\nS-2006-01-2006
\nS-2006-02-2018\t<\/p>\n

R-2011-02-2011
\nD-2002-01-2012
\nS-2018-01-2018
\nS-1993-01-2016
\nR-2015-02-2015
\nS-1983-01-2017
\nS-2017-01-2017\t<\/p>\n

R-2018-02-2018
\nD-2017-01-2017
\nTABLE\tOF\tCONTENTS
\n–\t\tOrder\tby\tShort\tTitle\t\t–
\n[A]
\nAbuse\tof\tPsychiatry\t\t\t…………………………………………………………………………………………………..
\nAcademic\tSanctions\tor\tBoycotts\t\t\t …………………………………………………………………………………
\nAccess\tto\tHealth\tCare\t\t\t………………………………………………………………………………………………..
\nAdequate\tPain\tTreatment\t\t\t………………………………………………………………………………………….
\nAdolescent\tSuicide\t\t\t ……………………………………………………………………………………………………
\nAdvanced\tTechnology\t…………………………………………………………………………………………………
\nAesthetic\tTreatment\t\t ………………………………………………………………………………………………….
\nAgeing\t\t ……………………………………………………………………………………………………………………..
\nAir\tPollution\t\t ……………………………………………………………………………………………………………..
\nAir\tTravel\t\t………………………………………………………………………………………………………………….
\nAlcohol\t\t …………………………………………………………………………………………………………………….
\nAlcohol\tand\tRoad\tSafety\t\t\t ……………………………………………………………………………………………
\nAlcohol\ton\tHealth\tand\tSociety\t\t\t ……………………………………………………………………………………
\nAnimal\tUse\tin\tBiomedical\tResearch\t\t\t …………………………………………………………………………….
\nAnnual\tMedical\tEthics\tDay\t\t\t…………………………………………………………………………………………
\nAntimicrobial\tResistance\t\t\t……………………………………………………………………………………………
\nArmed\tConflict\t\t\t …………………………………………………………………………………………………………
\nArmed\tConflicts\t\t…………………………………………………………………………………………………………
\nAssisted\tReproductive\tTechnologies\t\t\t……………………………………………………………………………
\nAvian\tand\tPandemic\tInfluenza\t\t…………………………………………………………………………………….\t<\/p>\n

[B]
\nBahrain\t……………………………………………………………………………………………………………………..
\nBiological\tWeapons\t(Washington)\t\t ……………………………………………………………………………….
\nBiosimilar\tMedicinal\tProducts\t\t……………………………………………………………………………………..
\nBody\tSearches\tof\tPrisoners\t\t\t………………………………………………………………………………………..
\nBombing\ton\tthe\tHospital\tof\tMSF\tin\tKunduz\t\t…………………………………………………………………..
\nBoxing\t\t\t……………………………………………………………………………………………………………………..
\nBullying\tand\tHarassment\twithin\tthe\tProfession\t\t …………………………………………………………….\t<\/p>\n

[C]
\nCapital\tPunishment\t\t\t …………………………………………………………………………………………………..
\nChicago\t(Quality\tAssurance\tin\tBasic\tMedical\tEducation)\t………………………………………………….\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nS-1984-01-2017
\nD-1998-01-2009
\nR-2006-02-2016
\nS-2011-01-2011
\nD-2009-01-2017
\nS-2012-02-2012
\nS-2009-01-2015
\nS-2017-04-2017
\nS-1997-02-2007
\nR-2013-01-2013
\nR-1999-01-2015
\nS-2016-02-2016\t<\/p>\n

S-2013-05-2013
\nD-2009-01-2017
\nR-2003-02-2007
\nD-1975-01-2016
\nD-1968-01-2016
\nS-2008-01-2008
\nD-2011-01-2011
\nS-1994-01-2017
\nS-2016-03-2016
\nR-2010-01-2010
\nS-2005-02-2015\t<\/p>\n

R-2014-01-2014
\nR-2014-03-2014
\nR-1997-01-2017
\nR-2011-03-2011
\nD-2000-01-2011
\nD-1989-01-2015
\nS-2012-01-2012
\nS-2009-02-2009
\nD-2011-02-2011
\nS-2010-01-2018
\nS-1988-04-2016
\nChild\tAbuse\tand\tNeglect\t\t\t ……………………………………………………………………………………………
\nChild\tHealth\t(Ottawa)\t\t ………………………………………………………………………………………………..
\nChild\tSafety\tin\tAirline\tTravel\t\t\t ………………………………………………………………………………………
\nChronic\tDisease\t\t\t………………………………………………………………………………………………………..
\nClimate\tChange\t(Delhi)\t\t\t………………………………………………………………………………………………
\nCollective\tAction\tby\tPhysicians\t\t\t …………………………………………………………………………………..
\nConflict\tof\tInterest\t\t\t ……………………………………………………………………………………………………
\nCooperation\tof\tNMAs\tduring\tor\tin\tthe\tAftermath\tof\tConflicts\t\t…………………………………………
\nCriminal\tOffences\tand\tLicensing\t\t\t …………………………………………………………………………………
\nCriminalisation\tof\tMedical\tPractice\t\t\t……………………………………………………………………………..
\nCurriculum\tof\tMedical\tSchools\tWorld-wide\t\t\t………………………………………………………………….
\nCyber-Attacks\ton\tHealth\t\t …………………………………………………………………………………………….\t<\/p>\n

[D]
\nDeath\tPenalty\t\t……………………………………………………………………………………………………………
\nDelhi\t(Climate\tChange)\t\t\t………………………………………………………………………………………………
\nDenunciation\tof\tActs\tof\tTorture\t\t\t………………………………………………………………………………….
\nDetention\tand\tImprisonment\t(Tokyo)\t\t ………………………………………………………………………….
\nDetermination\tof\tDeath\t(Sydney)\t\t ………………………………………………………………………………..
\nDietary\tSodium\tIntake\t\t\t……………………………………………………………………………………………….
\nDisaster\tPreparedness\t(Montevideo)\t\t …………………………………………………………………………..
\nDisasters\t\t\t………………………………………………………………………………………………………………….
\nDivestment\tfrom\tFossil\tFuels\t\t………………………………………………………………………………………
\nDrug\tPrescription\t\t\t ……………………………………………………………………………………………………..
\nDrug\tSubstitution\t\t\t ……………………………………………………………………………………………………..\t<\/p>\n

[E]
\nEbola\tViral\tDisease\t\t\t……………………………………………………………………………………………………
\nEbola\tVirus\t\t\t ………………………………………………………………………………………………………………
\nEconomic\tEmbargoes\tand\tHealth\t\t ………………………………………………………………….. -02-2007
\nEconomic\tEmbargoes\tand\tHealth\t[Revised]\t\t…………………………………………………………………..
\nEdinburgh\t(Prison\tConditions\ton\tTB)\t\t ……………………………………………………………………………
\nElderly\tAbuse\t(Hong\tKong)\t\t………………………………………………………………………………01-2005
\nElectronic\tCigarettes\t\t ………………………………………………………………………………………………….
\nEmbryonic\tStem\tCell\tResearch\t\t\t……………………………………………………………………… -02-2009
\nEnd-of-Life\tMedical\tCare\t\t…………………………………………………………………………………………….
\nEnvironmental\tDegradation\t\t\t…………………………………………………………………………. -01-2010
\nEnvironmental\tIssues\t\t\t ………………………………………………………………………………………………..\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nS-2017-05-2017
\nD-1987-01-2015
\nR-2002-01-2013\t<\/p>\n

D-2017-02-2017
\nS-1996-02-2010
\nR-2002-02-2012
\nS-1993-02-2016
\nR-2017-02-2017
\nS-2012-03-2012
\nS-2003-01-2013
\nS-1984-02-1984
\nS-2013-01-2013\t<\/p>\n

S-2005-03-2009
\nD-1948-01-2017
\nS-2018-03-2018
\nS-2016-04-2016
\nR-2015-03-2015\t<\/p>\n

D-1997-02-2017
\nR-2016-01-2016
\nR-2015-01-2015
\nR-2013-02-2013
\nD-2002-02-2016
\nD-1964-01-2013
\nS-2006-03-2017
\nD-1989-01-2015
\nS-2013-02-2013
\nR-2007-01-2017
\nD-1991-01-2017\t<\/p>\n

R-2011-04-2011
\nS-2009-03-2009
\nS-1990-01-2016
\nEpidemics\tand\tPandemics\t\t…………………………………………………………………………………………..
\nEuthanasia\t\t\t……………………………………………………………………………………………………01-2005
\nEuthanasia\t\t\t……………………………………………………………………………………………………………….\t<\/p>\n

[F]
\nFair\tMedical\tTrade\t\t …………………………………………………………………………………………………….
\nFamily\tViolence\t\t\t ………………………………………………………………………………………….. -02-2010
\nFemale\tFoeticide\t\t\t………………………………………………………………………………………… -02-2002
\nFemale\tGenital\tMutilation\t\t\t …………………………………………………………………………………………
\nForced\tAnal\tExaminations\t\t…………………………………………………………………………………………..
\nForced\tand\tCoerced\tSterilisation\t\t\t ………………………………………………………………………………..
\nForensic\tInvestigations\tof\tthe\tMissing\t\t\t…………………………………………………………… -01-2003
\nFreedom\tto\tAttend\tMedical\tMeetings\t\t\t……………………………………………………….. 84-02-1984
\nFungal\tDisease\t\t\t………………………………………………………………………………………………………….\t<\/p>\n

[G]
\nGenetics\tand\tMedicine\t\t\t…………………………………………………………………………………..03-2009
\nGeneva\t\t\t ……………………………………………………………………………………………………… -01-2006
\nGender\tEquality\tin\tMedicine\t\t……………………………………………………………………………………….
\nGlobal\tMedical\tElectives\t\t …………………………………………………………………………………………….
\nGlobal\tRefugee\tCrisis\t\t …………………………………………………………………………………………………\t<\/p>\n

[H]
\nHamburg\t(Refusing\tTorture)\t\t ……………………………………………………………………………………….
\nHealth\tCare\tFacilities\tand\tPersonnel\tin\tSyria\t\t …………………………………………………………………
\nHealthcare\tIn\tTurkey\t\t………………………………………………………………………………………………….
\nHealthcare\tSituation\tin\tSyria\t\t……………………………………………………………………………………….
\nHealth\tDatabases\t\t\t ………………………………………………………………………………………….02-2002
\nHelsinki\t(Medical\tResearch\tinvolving\tHuman\tSubjects)\t\t…………………………………………………..
\nHIV\/AIDS\tand\tthe\tMedical\tProfession\t\t\t……………………………………………………………. -03-2006
\nHong\tKong\t(Elderly\tAbuse)\t\t………………………………………………………………………………………….
\nHuman\tPapillomavirus\tVaccination\t\t\t……………………………………………………………………………..
\nHuman\tRights\tAbuses\tin\tZimbabwe\t\t\t………………………………………………………………. -01-2007
\nHunger\tStrikers\t(Malta)\t\t……………………………………………………………………………….D-01-2006\t<\/p>\n

[\tI\t]
\nIndependence\tof\tMedical\tAssociations\t\t\t………………………………………………………………………..
\nInequalities\tin\tHealth\t\t\t …………………………………………………………………………………..S03-2009
\nInjury\tControl\t\t\t …………………………………………………………………………………………………S-2006\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nS-2003-03-2014
\nR-1998-03-2009\t<\/p>\n

R-2007-02-2017
\nR-2009-01-2009
\nD-2011-03-2011
\nD-1981-01-2015
\nS-2003-02-2013\t<\/p>\n

D-2009-02-2009
\nD-1991-01-2017
\nS-2018-02-2018
\nS-2017-03-2017
\nS-2006-04-2017
\nD-1949-01-2006
\nS-2005-04-2015
\nD-1964-01-2013
\nS-2018-04-2018
\nR-1998-04-2009
\nS-2008-02-2018
\nR-2014-02-2014
\nR-2018-01-2018
\nS-2015-01-2015
\nS-2011-02-2011
\nD-2011-01-2011\t<\/p>\n

S-2013-03-2013
\nS-1992-05-2017
\nR-2003-03-2014
\nS-1985-01-2015
\nR-2006-04-2016
\nS-1998-01-2018\t<\/p>\n

S-2006-05-2016
\nS-2016-05-2016
\nInternational\tMigration\tof\tHealth\tWorkers\t\t …………………………………………………………………..
\nInvestment\tin\tPublic\tHealth\t\t\t …………………………………………………………………………. -03-2009\t<\/p>\n

[\tL\t]
\nLatin\tAmerican\tand\tthe\tCaribbean\tMedical\tAssociations\t\t\t …………………………………. -02-2007
\nLegislation\tagainst\tAbortion\tin\tNicaragua\t\t\t………………………………………………………. -01-2009
\nLeprosy\tControl\t\t…………………………………………………………………………………………………………
\nLisbon\t(Patient’s\tRights)\t\t……………………………………………………………………………………………..
\nLiving\tWills\t\t\t ………………………………………………………………………………………………… -02-2003\t<\/p>\n

[M]
\nMadrid\t(Professionally-led\tRegulation)\t\t…………………………………………………………………………
\nMalta\t(Hunger\tStrikers)\t\t………………………………………………………………………………………………
\nMaternal\tand\tChild\tHealth\tHandbook\t\t ………………………………………………………………………….
\nMedical\tCannabis\t\t………………………………………………………………………………………………………
\nMedical\tEducation\t\t\t………………………………………………………………………………………. -01-2006
\nMedical\tEthics\t\t\t ……………………………………………………………………………………………. -01-2006
\nMedical\tLiability\tReform\t\t\t ……………………………………………………………………………… -04-2005
\nMedical\tResearch\tinvolving\tHuman\tSubjects\t(Helsinki)\t\t…………………………………………………..
\nMedical\tTourism\t\t ……………………………………………………………………………………………………….
\nMedical\tWorkforce\t\t\t……………………………………………………………………………………… -04-2009
\nMercury\t\t\t…………………………………………………………………………………………………….. -02-2008
\nMigrant\tWorkers’\tHealth\tand\tSafety\tin\tQatar\t\t\t……………………………………………………………….
\nMigration …………………………………………………………………………………………………………………..
\nMobile\tHealth\t\t …………………………………………………………………………………………………………..
\nMonitoring\tTokyo\tDeclaration\t\t\t ……………………………………………………………………………………
\nMontevideo\t(Disaster\tPreparedness)\t\t …………………………………………………………………………..\t<\/p>\n

[N]
\nNatural\tVariations\tof\tHuman\tSexuality\t\t\t………………………………………………………………………..
\nNoise\tPollution\t\t\t…………………………………………………………………………………………… -05-2007
\nNon-Commercialization\tof\tHuman\tReproductive\tMaterial\t\t\t……………………………….. -03-2003
\nNon-Discrimination\tin\tProfessional\tMembership\t\t\t ………………………………………………01-2005
\nNuclear\tTesting\tin\tNorth\tKorea\t\t\t…………………………………………………………………….. -04-2006
\nNuclear\tWeapons\t\t\t……………………………………………………………………………………………..-2008\t<\/p>\n

[O]
\nObesity\t\t\t ……………………………………………………………………………………………………………………
\nObesity\tin\tChildren\t\t…………………………………………………………………………………………………….\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nR-2016-02-2016
\nS-2006-06-2016
\nS-2012-04-2017
\nD-1970-01-2006
\nD-1998-01-2009
\nR-1998-01-2018\t<\/p>\n

S-1999-01-2019
\nS-1993-03-2016
\nD-2002-03-2012
\nD-1981-01-2015
\nS-1995-02-2015
\nS-2004-02-2009
\nS-1999-02-2010
\nS-1997-02-2018
\nS-2015-02-2015
\nR-2012-02-2012
\nR-2017-01-2017
\nS-2017-06-2017
\nS-2012-05-2012
\nD-2000-01-2011
\nD-2008-01-2018
\nD-2009-02-2009
\nR-2012-04-2012
\nR-2013-03-2013
\nS-2015-07-2015
\nS-2011-03-2011
\nD-2014-01-2014
\nS-1995-04-2016\t<\/p>\n

D-1997-01-2009
\nD-2017-01-2017\t<\/p>\n

S-1998-02-2010
\nR-2016-01-2016
\nD-1997-02-2017
\nOccupational\tand\tEnvironmental\tHealth\tand\tSafety\t\t ………………………………………………………
\nOpiate\tand\tPsychotropic\tDrug\tAbuse\t\t\t…………………………………………………………….. -04-2006
\nOrgan\tand\tTissue\tDonation\t\t\t………………………………………………………………………………………..
\nOslo\t(Social\tDeterminants\tof\tHealth)\t…………………………………………………………………………….
\nOttawa\t(Child\tHealth)\t\t ………………………………………………………………………………………………..
\nOttawa\tConvention\t\t\t…………………………………………………………………………………….. -05-2008\t<\/p>\n

[P]
\nPatenting\tMedical\tProcedures\t\t\t……………………………………………………………………… -01-2009
\nPatient\tAdvocacy\tand\tConfidentiality\t\t…………………………………………………………….S-03-2006
\nPatient\tSafety\t\t\t…………………………………………………………………………………………….. -03-2002
\nPatient’s\tRights\t(Lisbon)\t\t………………………………………………………………………………D-01-2005
\nPatients\twith\tMental\tIllness\t\t\t…………………………………………………………………………. -02-2006
\nPhysicians\tand\tCommercial\tEnterprises\t\t\t…………………………………………………………S-02-2009
\nPhysicians\tand\tPharmacists\tin\tMedical\tTherapy\t\t\t……………………………………………………………
\nPhysicians\tconvicted\tof\tGenocide\tor\tCrimes\t\t………………………………………………………………….
\nPhysicians\tWell-Being\t\t ………………………………………………………………………………………………..
\nPlain\tPackaging\tof\tCigarettes\t\t\t ……………………………………………………………………………………..
\nPoland\t\t ……………………………………………………………………………………………………………………..
\nPreventing\tExploitation\tin\tAdoption\tPractices ………………………………………………… R-02-2008
\nPrioritisation\tof\tImmunisation\t\t …………………………………………………………………………………….
\nPrison\tConditions\ton\tTB\t(Edinburgh)\t\t ……………………………………………………………… -01-2000
\nProfessional\tAutonomy\tand\tClinical\tIndependence\t(Seoul)\t\t …………………………………01-2008
\nProfessionally-led\tRegulation\t(Madrid)\t\t…………………………………………………………………-2009
\nProfessor\tCyril\tKarabus\t\t ………………………………………………………………………………………………
\nProhibition\tof\tChemical\tWeapons\t\t ……………………………………………………………………………….
\nPromotional\tMass\tMedia\tAppearances\tby\tPhysicians\t\t…………………………………………………….
\nProtection\tand\tintegrity\tof\tMedical\tPersonnel\t\t ………………………………………………………………
\nProtection\tof\tHealthcare\tWorkers\t\t ……………………………………………………………………………….
\nPublic\tHealth\t\t\t ……………………………………………………………………………………………… -04-2006\t<\/p>\n

[Q]
\nQuality\tImprovement\tin\tHealth\tCare\t\t\t …………………………………………………………………………D
\nQuality\tAssurance\tin\tBasic\tMedical\tEducation\t\t……………………………………………………………….\t<\/p>\n

[R]
\nRefugees’\tMedical\tCare\t\t\t……………………………………………………………………………………………..
\nRefugees\tand\tMigrants\t\t\t ……………………………………………………………………………………………..
\nRefusing\tTorture\t(Hamburg)\t\t …………………………………………………………………………. -02-2007\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nRight\tof\tWoman\ton\tFamily\tPlanning\t\t\t……………………………………………………………..S-04-2007
\nRights\tof\tPatients\tand\tPhysicians\tin\tIran\t\t\t………………………………………………………………………
\nRiot\tControl\tAgents\t\t\t…………………………………………………………………………………………………..\t<\/p>\n

[S]
\nSafe\tInjections\tin\tHealth\tCare\t\t\t ………………………………………………………………………S-01-2002
\nSelf-Medication\t\t…………………………………………………………………………………………… -02-2002
\nSeoul\t(Professional\tAutonomy\tand\tClinical\tIndependence)\t\t …………………………………………….
\nSocial\tDeterminants\tof\tHealth\t\t\t ……………………………………………………………………………………
\nSocial\tMedia\t\t……………………………………………………………………………………………………………..
\nSolitary\tConfinemnet\t\t …………………………………………………………………………………………………
\nSports\tMedicine\t\t\t …………………………………………………………………………………………. -02-1999
\nStandardisation\tin\tMedical\tPractice\tand\tPatient\tSafety\t\t\t …………………………………………………
\nStreet\tChildren\t\t………………………………………………………………………………………………………….
\nSuicide\tPhysician-Assisted\t\t…………………………………………………………………………. 92-06-2005
\nSupport\tof\tthe\tAMB\t\t …………………………………………………………………………………………………..
\nSustainable\tDevelopment\t\t…………………………………………………………………………………………..
\nSydney\t(Determination\tof\tDeath)\t\t ………………………………………………………………………………..\t<\/p>\n

[T]
\nTask\tShifting\t\t\t ………………………………………………………………………………………………. -03-2009
\nTelehealth\t\t\t …………………………………………………………………………………………………S-04-2009
\nTelemedicine\t\t\t……………………………………………………………………………………………… -02-2007
\nTerminal\tIllness\t(Venice)\t\t………………………………………………………………………………. -01-2006
\nTherapeutic\tAbortion\t\t\t…………………………………………………………………………………….01-2006
\nTobacco\tProducts\tHealth\tHazards\t\t\t…………………………………………………………………. -05-2007
\nTobacco-WHO\tFCTC\t\t\t ……………………………………………………………………………………. -05-2005
\nTokyo\t(Detention\tand\tImprisonment)\t\t ………………………………………………………………………….
\nTraffic\tInjury\t\t\t…………………………………………………………………………………………………………….
\nTransgender\tPeople\t\t …………………………………………………………………………………………………..
\nTuberculosis\t\t\t …………………………………………………………………………………………………05-2006\t<\/p>\n

[V]
\nVenice\t(Terminal\tIllness)\t\t…………………………………………………………………………………………….
\nVeterinary\tMedicine\t\t\t………………………………………………………………………………………03-2008
\nVictims\tof\tTorture\t\t\t …………………………………………………………………………………………………….
\nViolence\tagainst\tWomen\tand\tGirls\t\t\t ……………………………………………………………………..-2010
\nViolence\tand\tHealth\t\t\t……………………………………………………………………………………. -04-2003
\nViolence\tin\tthe\tHealth\tSector\t\t\t……………………………………………………………………………………..
\nS-1996-04-2017
\nR-2009-02-2009
\nS-2015-04-2015\t<\/p>\n

S-2002-01-2012
\nS-2002-02-2012
\nD-2008-01-2018
\nS-2011-04-2015
\nS-2011-05-2011
\nS-2014-03-2014
\nD-1981-02-2010
\nR-2013-04-2013
\nS-2015-03-2015
\nS-1992-06-2015
\nR-2013-05-2013
\nS-2018-05-2018
\nD-1968-01-2016\t<\/p>\n

R-2009-03-2019
\nS-2009-04-2009
\nS-2007-02-2018
\nD-1983-01-2006
\nD-1970-01-2006
\nS-1988-05-2011
\nR-2005-01-2016
\nD-1975-01-2016
\nS-1990-04-2016
\nS-2015-05-2015
\nR-2006-05-2017\t<\/p>\n

D-1983-01-2006
\nR-2008-03-2018
\nS-2013-04-2013
\nR-2010-02-2010
\nS-2003-04-2008
\nS-2012-06-2012\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nOrder\tby\tShort\tTitle
\nVitamin\tD\tInsufficiency\t\t ………………………………………………………………………………………………\t<\/p>\n

[W]
\nWashington\t(Biological\tWeapons)\t\t ……………………………………………………………………………….
\nWater\tand\tHealth\t\t\t………………………………………………………………………………………..S03-2004
\nWeapons\tof\tWarfare\t\t\t…………………………………………………………………………………..S-05-2006
\nWFME\t\t\t……………………………………………………………………………………………………… R-01-2004
\nWomen\tand\tChildren\tto\tHealth\tCare\t\t\t…………………………………………………………………..-2008
\nWomen’s\tRight\tto\tHealth\tCare\t\t…………………………………………………………………………………….\t<\/p>\n

[Z]
\nZika\tVirus\tInfection\t\t…………………………………………………………………………………………………….\t<\/p>\n

S-2015-06-2015\t<\/p>\n

D-2002-01-2012
\n\t\tS-2004-03-2017
\nS-1996-05-2016
\nR-2004-01-2014
\nR-1997-03-2008
\nR-2002-06-2013\t<\/p>\n

R-2016-02-2016\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-1948-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tGENEVA
\nAdopted by the 2nd
\nGeneral Assembly of the World Medical Association,
\nGeneva, Switzerland, September 1948
\nand amended by the 22nd
\nWorld Medical Assembly, Sydney, Australia, August 1968
\nand the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand the 46th
\nWMA General Assembly, Stockholm, Sweden, September 1994
\nand editorially revised by the 170th
\nWMA Council Session,
\nDivonne-les-Bains, France, May 2005
\nand the 173rd
\nWMA Council Session, Divonne-les-Bains, France, May 2006
\nand amended by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nThe Physician\u2019s Pledge
\nAS A MEMBER OF THE MEDICAL PROFESSION:
\nI SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
\nTHE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
\nI WILL RESPECT the autonomy and dignity of my patient;
\nI WILL MAINTAIN the utmost respect for human life;
\nI WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender,
\nnationality, political affiliation, race, sexual orientation, social standing or any other factor to
\nintervene between my duty and my patient;
\nI WILL RESPECT the secrets that are confided in me, even after the patient has died;
\nI WILL PRACTISE my profession with conscience and dignity and in accordance with good
\nmedical practice;
\nI WILL FOSTER the honour and noble traditions of the medical profession;
\nI WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
\nI WILL SHARE my medical knowledge for the benefit of the patient and the advancement of
\nhealthcare;
\nI WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the
\nhighest standard;<\/p>\n

D-1948-01-2017\t\u23d0\tChicago
\nGeneva
\nI WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under
\nthreat;
\nI MAKE THESE PROMISES solemnly, freely, and upon my honour.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1949-01-2006
\nWMA\tINTERNATIONAL\tCODE\tOF\tMEDICAL\tETHICS
\nAdopted by the 3rd
\nGeneral Assembly of the World Medical Association,
\nLondon, England, October 1949
\nand amended by the 22nd
\nWorld Medical Assembly, Sydney, Australia, August 1968
\nand the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nDUTIES\tOF\tPHYSICIANS\tIN\tGENERAL
\nA PHYSICIAN SHALL always exercise his\/her independent professional judgment and
\nmaintain the highest standards of professional conduct.
\nA PHYSICIAN SHALL respect a competent patient’s right to accept or refuse treatment.
\nA PHYSICIAN SHALL not allow his\/her judgment to be influenced by personal profit or
\nunfair discrimination.
\nA PHYSICIAN SHALL be dedicated to providing competent medical service in full pro-
\nfessional and moral independence, with compassion and respect for human dignity.
\nA PHYSICIAN SHALL deal honestly with patients and colleagues, and report to the
\nappropriate authorities those physicians who practice unethically or incompetently or who
\nengage in fraud or deception.
\nA PHYSICIAN SHALL not receive any financial benefits or other incentives solely for
\nreferring patients or prescribing specific products.
\nA PHYSICIAN SHALL respect the rights and preferences of patients, colleagues, and
\nother health professionals.
\nA PHYSICIAN SHALL recognize his\/her important role in educating the public but
\nshould use due caution in divulging discoveries or new techniques or treatment through
\nnon-professional channels.
\nA PHYSICIAN SHALL certify only that which he\/she has personally verified.
\nA PHYSICIAN SHALL strive to use health care resources in the best way to benefit
\npatients and their community.
\nA PHYSICIAN SHALL seek appropriate care and attention if he\/she suffers from mental
\nor physical illness.
\nA PHYSICIAN SHALL respect the local and national codes of ethics.<\/p>\n

D-1949-01-2006\t\u23d0\tPilanesberg
\nMedical\tEthics
\nDUTIES\tOF\tPHYSICIANS\tTO\tPATIENTS
\nA PHYSICIAN SHALL always bear in mind the obligation to respect human life.
\nA PHYSICIAN SHALL act in the patient’s best interest when providing medical care.
\nA PHYSICIAN SHALL owe his\/her patients complete loyalty and all the scientific re-
\nsources available to him\/her. Whenever an examination or treatment is beyond the physi-
\ncian’s capacity, he\/she should consult with or refer to another physician who has the neces-
\nsary ability.
\nA PHYSICIAN SHALL respect a patient’s right to confidentiality. It is ethical to disclose
\nconfidential information when the patient consents to it or when there is a real and im-
\nminent threat of harm to the patient or to others and this threat can be only removed by a
\nbreach of confidentiality.
\nA PHYSICIAN SHALL give emergency care as a humanitarian duty unless he\/she is
\nassured that others are willing and able to give such care.
\nA PHYSICIAN SHALL in situations when he\/she is acting for a third party, ensure that
\nthe patient has full knowledge of that situation.
\nA PHYSICIAN SHALL not enter into a sexual relationship with his\/her current patient or
\ninto any other abusive or exploitative relationship.
\nDUTIES\tOF\tPHYSICIANS\tTO\tCOLLEAGUES
\nA PHYSICIAN SHALL behave towards colleagues as he\/she would have them behave
\ntowards him\/her.
\nA PHYSICIAN SHALL NOT undermine the patient-physician relationship of colleagues
\nin order to attract patients.
\nA PHYSICIAN SHALL when medically necessary, communicate with colleagues who are
\ninvolved in the care of the same patient. This communication should respect patient confi-
\ndentiality and be confined to necessary information.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1964-01-2013
\nWMA\tDECLARATION\tOF\tHELSINKI\t<\/p>\n

–\tETHICAL\tPRINCIPLES\tFOR\tMEDICAL\tRESEARCH\tINVOLVING\tHUMAN\tSUBJECTS\t–
\nAdopted by the 18th
\nWMA General Assembly, Helsinki, Finland, June 1964
\nand 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
\n53rd
\nWMA General Assembly, Washington DC, USA, October 2002
\n(Note of Clarification added)
\n55th
\nWMA General Assembly, Tokyo, Japan, October 2004
\n(Note of Clarification added)
\n59th
\nWMA General Assembly, Seoul, Republic of Korea, October 2008
\n64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\n1. The World Medical Association (WMA) has developed the Declaration of Helsinki as
\na statement of ethical principles for medical research involving human subjects,
\nincluding research on identifiable human material and data.
\nThe Declaration is intended to be read as a whole and each of its constituent para-
\ngraphs should be applied with consideration of all other relevant paragraphs.
\n2. Consistent with the mandate of the WMA, the Declaration is addressed primarily to
\nphysicians. The WMA encourages others who are involved in medical research in-
\nvolving human subjects to adopt these principles.
\nGENERAL\tPRINCIPLES
\n3. The Declaration of Geneva of the WMA binds the physician with the words, \u201cThe
\nhealth of my patient will be my first consideration,\u201d and the International Code of
\nMedical Ethics declares that, \u201cA physician shall act in the patient’s best interest when
\nproviding medical care.\u201d
\n4. It is the duty of the physician to promote and safeguard the health, well-being and
\nrights of patients, including those who are involved in medical research. The physi-
\ncian’s knowledge and conscience are dedicated to the fulfilment of this duty.<\/p>\n

D-1964-01-2013\t\u23d0\tFortaleza
\nMedical\tRsearch\tinvolving\tHuman\tSubjects\t(Helsinki)
\n5. Medical progress is based on research that ultimately must include studies involving
\nhuman subjects.
\n6. The primary purpose of medical research involving human subjects is to understand
\nthe causes, development and effects of diseases and improve preventive, diagnostic
\nand therapeutic interventions (methods, procedures and treatments). Even the best
\nproven interventions must be evaluated continually through research for their safety,
\neffectiveness, efficiency, accessibility and quality.
\n7. Medical research is subject to ethical standards that promote and ensure respect for all
\nhuman subjects and protect their health and rights.
\n8. While the primary purpose of medical research is to generate new knowledge, this
\ngoal can never take precedence over the rights and interests of individual research
\nsubjects.
\n9. It is the duty of physicians who are involved in medical research to protect the life,
\nhealth, dignity, integrity, right to self-determination, privacy, and confidentiality of
\npersonal information of research subjects. The responsibility for the protection of
\nresearch subjects must always rest with the physician or other health care pro-
\nfessionals and never with the research subjects, even though they have given consent.
\n10. Physicians must consider the ethical, legal and regulatory norms and standards for
\nresearch involving human subjects in their own countries as well as applicable
\ninternational norms and standards. No national or international ethical, legal or
\nregulatory requirement should reduce or eliminate any of the protections for research
\nsubjects set forth in this Declaration.
\n11. Medical research should be conducted in a manner that minimises possible harm to
\nthe environment.
\n12. Medical research involving human subjects must be conducted only by individuals
\nwith the appropriate ethics and scientific education, training and qualifications. Re-
\nsearch on patients or healthy volunteers requires the supervision of a competent and
\nappropriately qualified physician or other health care professional.
\n13. Groups that are underrepresented in medical research should be provided appropriate
\naccess to participation in research.
\n14. Physicians who combine medical research with medical care should involve their
\npatients in research only to the extent that this is justified by its potential preventive,
\ndiagnostic or therapeutic value and if the physician has good reason to believe that
\nparticipation in the research study will not adversely affect the health of the patients
\nwho serve as research subjects.
\n15. Appropriate compensation and treatment for subjects who are harmed as a result of
\nparticipating in research must be ensured.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tD-1964-01-2013
\nRISKS,\tBURDENS\tAND\tBENEFITS\t<\/p>\n

16. In medical practice and in medical research, most interventions involve risks and
\nburdens.
\nMedical research involving human subjects may only be conducted if the importance
\nof the objective outweighs the risks and burdens to the research subjects.
\n17. All medical research involving human subjects must be preceded by careful assess-
\nment of predictable risks and burdens to the individuals and groups involved in the
\nresearch in comparison with foreseeable benefits to them and to other individuals or
\ngroups affected by the condition under investigation.
\nMeasures to minimise the risks must be implemented. The risks must be continuously
\nmonitored, assessed and documented by the researcher.
\n18. Physicians may not be involved in a research study involving human subjects unless
\nthey are confident that the risks have been adequately assessed and can be satis-
\nfactorily managed.
\nWhen the risks are found to outweigh the potential benefits or when there is con-
\nclusive proof of definitive outcomes, physicians must assess whether to continue,
\nmodify or immediately stop the study.
\nVULNERABLE\tGROUPS\tAND\tINDIVIDUALS\t<\/p>\n

19. Some groups and individuals are particularly vulnerable and may have an increased
\nlikelihood of being wronged or of incurring additional harm.
\nAll vulnerable groups and individuals should receive specifically considered protec-
\ntion.
\n20. Medical research with a vulnerable group is only justified if the research is responsive
\nto the health needs or priorities of this group and the research cannot be carried out in
\na non-vulnerable group. In addition, this group should stand to benefit from the
\nknowledge, practices or interventions that result from the research.
\nSCIENTIFIC\tREQUIREMENTS\tAND\tRESEARCH\tPROTOCOLS
\n21. Medical research involving human subjects must conform to generally accepted
\nscientific principles, be based on a thorough knowledge of the scientific literature,
\nother relevant sources of information, and adequate laboratory and, as appropriate,
\nanimal experimentation. The welfare of animals used for research must be respected.
\n22. The design and performance of each research study involving human subjects must be
\nclearly described and justified in a research protocol.<\/p>\n

D-1964-01-2013\t\u23d0\tFortaleza
\nMedical\tRsearch\tinvolving\tHuman\tSubjects\t(Helsinki)
\nThe protocol should contain a statement of the ethical considerations involved and
\nshould indicate how the principles in this Declaration have been addressed. The pro-
\ntocol should include information regarding funding, sponsors, institutional affilia-
\ntions, potential conflicts of interest, incentives for subjects and information regarding
\nprovisions for treating and\/or compensating subjects who are harmed as a conse-
\nquence of participation in the research study.
\nIn clinical trials, the protocol must also describe appropriate arrangements for post-
\ntrial provisions.
\nRESEARCH\tETHICS\tCOMMITTEES\t<\/p>\n

23. The research protocol must be submitted for consideration, comment, guidance and
\napproval to the concerned research ethics committee before the study begins. This
\ncommittee must be transparent in its functioning, must be independent of the
\nresearcher, the sponsor and any other undue influence and must be duly qualified. It
\nmust take into consideration the laws and regulations of the country or countries in
\nwhich the research is to be performed as well as applicable international norms and
\nstandards but these must not be allowed to reduce or eliminate any of the protections
\nfor research subjects set forth in this Declaration.
\nThe committee must have the right to monitor ongoing studies. The researcher must
\nprovide monitoring information to the committee, especially information about any
\nserious adverse events. No amendment to the protocol may be made without con-
\nsideration and approval by the committee. After the end of the study, the researchers
\nmust submit a final report to the committee containing a summary of the study\u2019s find-
\nings and conclusions.
\nPRIVACY\tAND\tCONFIDENTIALITY\t\t<\/p>\n

24. Every precaution must be taken to protect the privacy of research subjects and the
\nconfidentiality of their personal information.
\nINFORMED\tCONSENT\t\t<\/p>\n

25. Participation by individuals capable of giving informed consent as subjects in medical
\nresearch must be voluntary. Although it may be appropriate to consult family mem-
\nbers or community leaders, no individual capable of giving informed consent may be
\nenrolled in a research study unless he or she freely agrees.
\n26. In medical research involving human subjects capable of giving informed consent,
\neach potential subject must be adequately informed of the aims, methods, sources of
\nfunding, any possible conflicts of interest, institutional affiliations of the researcher,
\nthe anticipated benefits and potential risks of the study and the discomfort it may
\nentail, post-study provisions and any other relevant aspects of the study. The potential
\nsubject must be informed of the right to refuse to participate in the study or to with-<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1964-01-2013
\ndraw consent to participate at any time without reprisal. Special attention should be
\ngiven to the specific information needs of individual potential subjects as well as to
\nthe methods used to deliver the information.
\nAfter ensuring that the potential subject has understood the information, the physician
\nor another appropriately qualified individual must then seek the potential subject\u2019s
\nfreely-given informed consent, preferably in writing. If the consent cannot be expressed
\nin writing, the non-written consent must be formally documented and witnessed.
\nAll medical research subjects should be given the option of being informed about the
\ngeneral outcome and results of the study.
\n27. When seeking informed consent for participation in a research study the physician
\nmust be particularly cautious if the potential subject is in a dependent relationship
\nwith the physician or may consent under duress. In such situations the informed
\nconsent must be sought by an appropriately qualified individual who is completely
\nindependent of this relationship.
\n28. For a potential research subject who is incapable of giving informed consent, the
\nphysician must seek informed consent from the legally authorised representative.
\nThese individuals must not be included in a research study that has no likelihood of
\nbenefit for them unless it is intended to promote the health of the group represented
\nby the potential subject, the research cannot instead be performed with persons
\ncapable of providing informed consent, and the research entails only minimal risk and
\nminimal burden.
\n29. When a potential research subject who is deemed incapable of giving informed con-
\nsent is able to give assent to decisions about participation in research, the physician
\nmust seek that assent in addition to the consent of the legally authorised representa-
\ntive. The potential subject\u2019s dissent should be respected.
\n30. Research involving subjects who are physically or mentally incapable of giving con-
\nsent, for example, unconscious patients, may be done only if the physical or mental
\ncondition that prevents giving informed consent is a necessary characteristic of the
\nresearch group. In such circumstances the physician must seek informed consent
\nfrom the legally authorised representative. If no such representative is available and if
\nthe research cannot be delayed, the study may proceed without informed consent
\nprovided that the specific reasons for involving subjects with a condition that renders
\nthem unable to give informed consent have been stated in the research protocol and
\nthe study has been approved by a research ethics committee. Consent to remain in the
\nresearch must be obtained as soon as possible from the subject or a legally authorised
\nrepresentative.
\n31. The physician must fully inform the patient which aspects of their care are related to
\nthe research. The refusal of a patient to participate in a study or the patient\u2019s decision
\nto withdraw from the study must never adversely affect the patient-physician
\nrelationship.<\/p>\n

D-1964-01-2013\t\u23d0\tFortaleza
\nMedical\tRsearch\tinvolving\tHuman\tSubjects\t(Helsinki)
\n32. For medical research using identifiable human material or data, such as research on
\nmaterial or data contained in biobanks or similar repositories, physicians must seek
\ninformed consent for its collection, storage and\/or reuse. There may be exceptional
\nsituations where consent would be impossible or impracticable to obtain for such
\nresearch. In such situations the research may be done only after consideration and
\napproval of a research ethics committee.
\nUSE\tOF\tPLACEBO\t<\/p>\n

33. The benefits, risks, burdens and effectiveness of a new intervention must be tested
\nagainst those of the best proven intervention(s), except in the following circums-
\ntances:
\nWhere no proven intervention exists, the use of placebo, or no intervention, is accept-
\nable; or
\nWhere for compelling and scientifically sound methodological reasons the use of any
\nintervention less effective than the best proven one, the use of placebo, or no inter-
\nvention is necessary to determine the efficacy or safety of an intervention
\nand the patients who receive any intervention less effective than the best proven one,
\nplacebo, or no intervention will not be subject to additional risks of serious or
\nirreversible harm as a result of not receiving the best proven intervention.
\nExtreme care must be taken to avoid abuse of this option.
\nPOST-TRIAL\tPROVISIONS\t<\/p>\n

34. In advance of a clinical trial, sponsors, researchers and host country governments
\nshould make provisions for post-trial access for all participants who still need an
\nintervention identified as beneficial in the trial. This information must also be dis-
\nclosed to participants during the informed consent process.
\nRESEARCH\tREGISTRATION\tAND\tPUBLICATION\tAND\tDISSEMINATION\tOF\tRESULTS
\n35. Every research study involving human subjects must be registered in a publicly
\naccessible database before recruitment of the first subject.
\n36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with
\nregard to the publication and dissemination of the results of research. Researchers
\nhave a duty to make publicly available the results of their research on human subjects
\nand are accountable for the completeness and accuracy of their reports. All parties
\nshould adhere to accepted guidelines for ethical reporting. Negative and inconclusive
\nas well as positive results must be published or otherwise made publicly available.
\nSources of funding, institutional affiliations and conflicts of interest must be declared<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1964-01-2013
\nin the publication. Reports of research not in accordance with the principles of this
\nDeclaration should not be accepted for publication.
\nUNPROVEN\tINTERVENTIONS\tIN\tCLINICAL\tPRACTICE
\n37. In the treatment of an individual patient, where proven interventions do not exist or
\nother known interventions have been ineffective, the physician, after seeking expert
\nadvice, with informed consent from the patient or a legally authorised representative,
\nmay use an unproven intervention if in the physician’s judgement it offers hope of
\nsaving life, re-establishing health or alleviating suffering. This intervention should
\nsubsequently be made the object of research, designed to evaluate its safety and effi-
\ncacy. In all cases, new information must be recorded and, where appropriate, made
\npublicly available.<\/p>\n

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\nD-1968-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tSYDNEY
\nON
\nTHE\tDETERMINATION\tOF\tDEATH\tAND\tTHE\tRECOVERY\tOF\tORGANS
\nAdopted by the 22nd
\nWorld Medical Assembly, Sydney, Australia, August 1968
\nand amended by the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nDetermination of death can be made on the basis of the irreversible cessation of all functions
\nof the entire brain, including the brain stem, or the irreversible cessation of circulatory and
\nrespiratory functions. This determination will be based on clinical judgment according to
\naccepted criteria, supplemented, if necessary, by standard diagnostic procedures, and it will
\nbe made by a physician.
\nEven without intervention, cell, organ and tissue activity in the body may continue
\ntemporarily after a determination of death. Cessation of all life at the cellular level is not a
\nnecessary criterion for determination of death.
\nThe use of deceased donor organs for transplantation has made it important for physicians to
\nbe able to determine when mechanically-supported patients have died.
\nAfter death has occurred, it may be possible to maintain circulation to the organs and tissues
\nof the body mechanically. This may be done to preserve organs and tissues for
\ntransplantation.
\nPrior to post-mortem transplantation, the determination that death has occurred shall be
\nmade by a physician who is in no way immediately involved in the transplantation
\nprocedure.
\nFollowing the determination of death, all treatment and resuscitation attempts may be ceased
\nand donor organs may be recovered, provided that prevailing requirements of consent and
\nother relevant ethical and legal requirements have been fulfilled. Physicians should follow
\nthe protocol on organ donation for deceased donors as outlined in the WMA Statement on
\nOrgan and Tissue Donation.<\/p>\n

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\nD-1975-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tTOKYO\t<\/p>\n

–\tGUIDELINES\tFOR\tPHYSICIANS\tCONCERNING\tTORTURE\tAND\tOTHER\tCRUEL,
\nINHUMAN\tOR\tDEGRADING\tTREATMENT\tOR
\nPUNISHMENT\tIN\tRELATION\tTO\tDETENTION\tAND\tIMPRISONMENT\t–
\nAdopted by the 29th
\nWorld Medical Assembly, Tokyo, Japan, October 1975
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand the 173rd
\nWMA Council Session, Divonne-les-Bains, France, May 2006
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t<\/p>\n

It is the privilege of the physician to practise medicine in the service of humanity, to
\npreserve and restore bodily and mental health without distinction as to persons, to comfort
\nand to ease the suffering of his or her patients. The utmost respect for human life is to be
\nmaintained even under threat, and no use made of any medical knowledge contrary to the
\nlaws of humanity.
\nFor the purpose of this Declaration, torture is defined as the deliberate, systematic or
\nwanton infliction of physical or mental suffering by one or more persons acting alone or
\non the orders of any authority, to force another person to yield information, to make a
\nconfession, or for any other reason.
\nDECLARATION\t\t<\/p>\n

1. The physician shall not countenance, condone or participate in the practice of torture
\nor other forms of cruel, inhuman or degrading procedures, whatever the offense of
\nwhich the victim of such procedures is suspected, accused or guilty, and whatever the
\nvictim\u2019s beliefs or motives, and in all situations, including armed conflict and civil
\nstrife.
\n2. The physician shall not provide any premises, instruments, substances or knowledge to
\nfacilitate the practice of torture or other forms of cruel, inhuman or degrading
\ntreatment or to diminish the ability of the victim to resist such treatment.
\n3. When providing medical assistance to detainees or prisoners who are, or who could
\nlater be, under interrogation, physicians should be particularly careful to ensure the<\/p>\n

Detention\tand\tImprisonment
\nD-1975-01-2006\t\u23d0\tDivonne-les-Bains
\nconfidentiality of all personal medical information. A breach of the Geneva
\nConventions shall in any case be reported by the physician to relevant authorities.
\n4. As stated in WMA Resolution on the Responsibility of Physicians in the
\nDocumentation and Denunciation of Acts of Torture or Cruel or Inhuman or
\nDegrading Treatment and as an exception to professional confidentiality, physicians
\nhave the ethical obligation to report abuses, where possible with the subject\u2019s consent,
\nbut in certain circumstances where the victim is unable to express him\/herself freely,
\nwithout explicit consent.
\n5. The physician shall not use nor allow to be used, as far as he or she can, medical
\nknowledge or skills, or health information specific to individuals, to facilitate or
\notherwise aid any interrogation, legal or illegal, of those individuals.
\n6. The physician shall not be present during any procedure during which torture or any
\nother forms of cruel, inhuman or degrading treatment is used or threatened.
\n7. A physician must have complete clinical independence in deciding upon the care of a
\nperson for whom he or she is medically responsible. The physician\u2019s fundamental role
\nis to alleviate the distress of his or her fellow human beings, and no motive, whether
\npersonal, collective or political, shall prevail against this higher purpose.
\n8. Where a prisoner refuses nourishment and is considered by the physician as capable of
\nforming an unimpaired and rational judgment concerning the consequences of such a
\nvoluntary refusal of nourishment, he or she shall not be fed artificially, as stated in
\nWMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the
\nprisoner to form such a judgment should be confirmed by at least one other
\nindependent physician. The consequences of the refusal of nourishment shall be
\nexplained by the physician to the prisoner.
\n9. Recalling the Declaration of Hamburg concerning Support for Medical Doctors
\nRefusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel,
\nInhuman or Degrading Treatment, the World Medical Association supports, and
\nencourages the international community, the National Medical Associations and
\nfellow physicians to support, the physician and his or her family in the face of threats
\nor reprisals resulting from a refusal to condone the use of torture or other forms of
\ncruel, inhuman or degrading treatment.
\n10. The World Medical Association calls on National Medical Associations to encourage
\nphysicians to continue their professional development training and education in human
\nrights.\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-1981-01-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tLISBON
\nON
\nTHE\tRIGHTS\tOF\tTHE\tPATIENT
\nAdopted by the 34th
\nWorld Medical Assembly, Lisbon, Portugal,
\nSeptember\/October 1981
\nand amended by the 47th
\nWMA General Assembly, Bali, Indonesia, September 1995
\nand editorially revised by the 171st
\nWMA Council Session, Santiago, Chile, October 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nPREAMBLE\t\t<\/p>\n

The relationship between physicians, their patients and broader society has undergone
\nsignificant changes in recent times. While a physician should always act according to his\/
\nher conscience, and always in the best interests of the patient, equal effort must be made
\nto guarantee patient autonomy and justice. The following Declaration represents some of
\nthe principal rights of the patient that the medical profession endorses and promotes.
\nPhysicians and other persons or bodies involved in the provision of health care have a joint
\nresponsibility to recognize and uphold these rights. Whenever legislation, government
\naction or any other administration or institution denies patients these rights, physicians
\nshould pursue appropriate means to assure or to restore them.
\nPRINCIPLES\t\t<\/p>\n

1. Right to medical care of good quality
\na. Every person is entitled without discrimination to appropriate medical care.
\nb. Every patient has the right to be cared for by a physician whom he\/she knows to
\nbe free to make clinical and ethical judgements without any outside interference.
\nc. The patient shall always be treated in accordance with his\/her best interests. The
\ntreatment applied shall be in accordance with generally approved medical princi-
\nples.
\nd. Quality assurance should always be a part of health care. Physicians, in parti-
\ncular, should accept responsibility for being guardians of the quality of medical
\nservices.
\ne. In circumstances where a choice must be made between potential patients for a
\nparticular treatment that is in limited supply, all such patients are entitled to a fair
\nselection procedure for that treatment. That choice must be based on medical cri-
\nteria and made without discrimination.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-1981-01-2015\t\u23d0\tWorld\tMedical\tAssociation
\nf. The patient has the right to continuity of health care. The physician has an obli-
\ngation to cooperate in the coordination of medically indicated care with other
\nhealth care providers treating the patient. The physician may not discontinue treat-
\nment of a patient as long as further treatment is medically indicated, without
\ngiving the patient reasonable assistance and sufficient opportunity to make alter-
\nnative arrangements for care.
\n2. Right to freedom of choice
\na. The patient has the right to choose freely and change his\/her physician and hospi-
\ntal or health service institution, regardless of whether they are based in the private
\nor public sector.
\nb. The patient has the right to ask for the opinion of another physician at any stage.
\n3. Right to self-determination
\na. The patient has the right to self-determination, to make free decisions regarding
\nhimself\/herself. The physician will inform the patient of the consequences of his\/
\nher decisions.
\nb. A mentally competent adult patient has the right to give or withhold consent to
\nany diagnostic procedure or therapy. The patient has the right to the information
\nnecessary to make his\/her decisions. The patient should understand clearly what
\nis the purpose of any test or treatment, what the results would imply, and what
\nwould be the implications of withholding consent.
\nc. The patient has the right to refuse to participate in research or the teaching of
\nmedicine.
\n4. The unconscious patient
\na. If the patient is unconscious or otherwise unable to express his\/her will, informed
\nconsent must be obtained whenever possible, from a legally entitled represen-
\ntative.
\nb. If a legally entitled representative is not available, but a medical intervention is
\nurgently needed, consent of the patient may be presumed, unless it is obvious and
\nbeyond any doubt on the basis of the patient’s previous firm expression or con-
\nviction that he\/she would refuse consent to the intervention in that situation.
\nc. However, physicians should always try to save the life of a patient unconscious
\ndue to a suicide attempt.
\n5. The legally incompetent patient
\na. If a patient is a minor or otherwise legally incompetent, the consent of a legally
\nentitled representative is required in some jurisdictions. Nevertheless the patient
\nmust be involved in the decision-making to the fullest extent allowed by his\/her
\ncapacity.<\/p>\n

Patient\u2019s\tRight\t(Lisbon)
\nOslo\t\u23d0\tD-1981-01-2015
\nb. If the legally incompetent patient can make rational decisions, his\/her decisions
\nmust be respected, and he\/she has the right to forbid the disclosure of information
\nto his\/her legally entitled representative.
\nc. If the patient’s legally entitled representative, or a person authorized by the pa-
\ntient, forbids treatment which is, in the opinion of the physician, in the patient’s
\nbest interest, the physician should challenge this decision in the relevant legal or
\nother institution. In case of emergency, the physician will act in the patient’s best
\ninterest.
\n6. Procedures against the patient’s will
\nDiagnostic procedures or treatment against the patient’s will can be carried out only in
\nexceptional cases, if specifically permitted by law and conforming to the principles of
\nmedical ethics.
\n7. Right to information
\na. The patient has the right to receive information about himself\/herself recorded
\nin any of his\/her medical records, and to be fully informed about his\/her health
\nstatus including the medical facts about his\/her condition. However,
\nconfidential information in the patient’s records about a third party should not be
\ngiven to the patient without the consent of that third party.
\nb. Exceptionally, information may be withheld from the patient when there is good
\nreason to believe that this information would create a serious hazard to his\/her
\nlife or health.
\nc. Information should be given in a way appropriate to the patient’s culture and in
\nsuch a way that the patient can understand.
\nd. The patient has the right not to be informed on his\/her explicit request, unless
\nrequired for the protection of another person’s life.
\ne. The patient has the right to choose who, if anyone, should be informed on his\/
\nher behalf.
\n8. Right to confidentiality
\na. All identifiable information about a patient’s health status, medical condition,
\ndiagnosis, prognosis and treatment and all other information of a personal kind
\nmust be kept confidential, even after death. Exceptionally, descendants may have
\na right of access to information that would inform them of their health risks.
\nb. Confidential information can only be disclosed if the patient gives explicit con-
\nsent or if expressly provided for in the law. Information can be disclosed to other
\nhealth care providers only on a strictly \u00ab\u00a0need to know\u00a0\u00bb basis unless the patient
\nhas given explicit consent.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-1981-01-2015\t\u23d0\tWorld\tMedical\tAssociation
\nc. All identifiable patient data must be protected. The protection of the data must be
\nappropriate to the manner of its storage. Human substances from which identifi-
\nable data can be derived must be likewise protected.
\n9. Right to health education
\nEvery person has the right to health education that will assist him\/her in making
\ninformed choices about personal health and about the available health services. The
\neducation should include information about healthy lifestyles and about methods of
\nprevention and early detection of illnesses. The personal responsibility of everybody
\nfor his\/her own health should be stressed. Physicians have an obligation to participate
\nactively in educational efforts.
\n10. Right to dignity
\na. The patient’s dignity and right to privacy shall be respected at all times in medical
\ncare and teaching, as shall his\/her culture and values.
\nb. The patient is entitled to relief of his\/her suffering according to the current state
\nof knowledge.
\nc. The patient is entitled to humane terminal care and to be provided with all avail-
\nable assistance in making dying as dignified and comfortable as possible.
\n11. Right to religious assistance
\nThe patient has the right to receive or to decline spiritual and moral comfort including the
\nhelp of a minister of his\/her chosen religion\t<\/p>\n

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\nD-1981-02-2010\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION
\nON
\nPRINCIPLES\tOF\tHEALTH\tCARE\tFOR\tSPORTS\tMEDICINE
\nAdopted by the 34th
\nWorld Medical Association General Assembly, Lisbon, Portugal,
\nSeptember\/October 1981
\nand revised by the 39th
\nWorld Medical Association General Assembly, Madrid, Spain,
\nOctober 1987
\nthe 45th
\nWorld Medical Association General Assembly, Budapest, Hungary,
\nOctober 1993
\nand the 51st
\nWorld Medical Association General Assembly, Tel Aviv, Israel, October 1999
\nand reaffirmed by the 185th
\nWMA Council Session, Evian-les-Bains, France, May 2010
\nConsidering the involvement of physicians in sports medicine, the WMA recommends the
\nfollowing ethical guidelines for physicians in order to help meet the needs of athletes, rec-
\nognizing special circumstances in which their medical care and health guidance is given.
\nConsequently,
\n1. The physician who cares for athletes has an ethical responsibility to recognize the
\nspecial physical and mental demands placed upon them by their performance in sports
\nactivities.
\n2. When the sports participant is a child or an adolescent, the physician must give first
\nconsideration to the participant’s growth and stage of development.
\n1. The physician must ensure that the child’s state of growth and development, as
\nwell as his or her general condition of health can absorb the rigors of the training
\nand competition without jeopardizing the normal physical or mental development
\nof the child or adolescent.
\n2. The physician must oppose any sports or athletic activity that is not appropriate to
\nthe child’s stage of growth and development or general condition of health. The
\nphysician must act in the best interest of the health of the child or adolescent,
\nwithout regard to any other interest or pressure from any other source.
\n3. When the sports participant is a professional athlete and derives livelihood from that
\nactivity, the physician should pay due regard to the occupational medical aspects
\ninvolved.
\n4. The physician should be aware that the use of doping practices1
\nby a physician is a
\nviolation of the medical oath and the basic principles of the WMA’s Declaration of<\/p>\n

D-1981-02-2010\t\u23d0\tEvian-les-Bains
\nSports\tMedicine
\nGeneva, which states: \u00ab\u00a0My patient’s health will always be my first consideration.\u00a0\u00bb The
\nWMA considers the problem of doping to be a threat to the health of athletes and
\nyoung people in general, as well as being in conflict with the principles of medical
\nethics. The physician must thus oppose and refuse to administer or condone any such
\nmeans or method which is not in accordance with medical ethics, and\/or which might
\nbe harmful to the athlete using it, especially:
\n1. Procedures which artificially modify blood constituents or biochemistry.
\n2. The use of drugs or other substances whatever their nature and route of adminis-
\ntration, including central-nervous-system stimulants or depressants and procedures
\nwhich artificially modify reflexes.
\n3. Pharmacological interventions that may induce alterations of will or general men-
\ntal outlook.
\n4. Procedures to mask pain or other protective symptoms if used to enable the athlete
\nto take part in events when lesions or signs are present which make his participa-
\ntion inadvisable.
\n5. Measures which artificially change features appropriate to age and sex.
\n6. Training and taking part in events when to do so would not be compatible with
\npreservation of the individual’s fitness, health or safety.
\n7. Measures aimed at an unnatural increase or maintenance of performance during
\ncompetition. Doping to improve an athlete’s performance is unethical.
\n5. The physician should inform the athlete, those responsible for him or her, and other
\ninterested parties, of the consequences of the procedures the physician is opposing,
\nguard against their use, enlist the support of other physicians and other organizations
\nwith the same aim, protect the athlete against any pressures which might induce him
\nor her to use these methods and help with supervision against these procedures.
\n6. The sports physician has the duty to give his or her objective opinion on the athlete’s
\nfitness or unfitness clearly and precisely, leaving no doubt as to his or her conclu-
\nsions.
\n7. In competitive sports or professional sports events, it is the physician’s duty to decide
\nwhether the athlete is medically fit to remain on the field or return to the game. This
\ndecision cannot be delegated to other professionals or to other persons. In the physi-
\ncian’s absence these individuals must adhere strictly to the instructions he or she has
\ngiven them, with priority always being given to the best interests of the athlete’s
\nhealth and safety, and not the outcome of the competition.
\n8. In order to carry out his or her ethical obligations the sports physician must see his or
\nher authority fully recognized and upheld, particularly wherever it concerns the
\nhealth, safety and legitimate interests of the athlete, none of which can be prejudiced<\/p>\n

Sports\tMedicine
\nEvian-les-Bains\t\u23d0\tD-1981-02-2010
\nto favour the interests of any third party whatsoever. These principles and obligations
\nshould be supported by an agreement between the sports physician and the athletic
\norganization involved, recognizing that the physician is obligated to uphold the ethical
\nprinciples determined in national and international statements to which the medical
\nprofession has subscribed and by which it is bound.
\n9. The sports physician should endeavour to keep the patient’s personal physician fully
\ninformed of facts relevant to his or her treatment. If necessary the sports physician
\nshould collaborate to ensure that the athlete does not exert himself or herself in ways
\ndetrimental to his or her health and does not use potentially harmful techniques to im-
\nprove performance.
\n10. In sports medicine, as in all other branches of medicine, professional confidentiality
\nmust be observed. The right to privacy over medical attention the athlete has received
\nmust be protected, especially in the case of professional athletes.
\n11. The sports doctor must not be party to any contract which obliges him or her to re-
\nserve particular forms of therapy solely and exclusively for any one athlete or group
\nof athletes.
\n12. It is desirable that sports physicians from foreign countries, when accompanying a
\nteam in another country, should enjoy the right to carry out their specific functions.
\n13. The participation of a sports physician is desirable when sports regulation are being
\ndrawn up.
\n1
\ncf, The Olympic Charter Against Doping in Sport and the Lausanne Declaration on Dopping in
\nSport adopted by the World Committee on Doping in Sport (February 1999)<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1983-01-2006
\nWMA\tDECLARATION\tOF\tVENICE
\nON
\nTERMINAL\tILLNESS
\nAdopted by the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nPREFACE\t\t<\/p>\n

1. When addressing the ethical issues associated with end-of-life care, questions regard-
\ning euthanasia and physician-assisted suicide inevitably arise. The World Medical
\nAssociation condemns as unethical both euthanasia and physician-assisted suicide. It
\nshould be understood that WMA policy on these issues is fully applicable in the con-
\ntext of this Statement on Terminal Illness.
\nPREAMBLE\t<\/p>\n

1. When a patient’s medical diagnosis precludes the hope of health being restored or
\nmaintained, and the death of the patient is inevitable, the physician and the patient are
\noften faced with a complex set of decisions regarding medical interventions. Ad-
\nvances in medical science have improved the ability of physicians to address many
\nissues associated with end-of-life care. However, it is an area of medicine that histori-
\ncally has not received the attention it deserves. While the priority of research to cure
\ndisease should not be compromised, more attention must be paid to developing pallia-
\ntive treatments and improving the ability of physicians to assess and address the medi-
\ncal and psychological components of symptoms in terminal illness. The dying phase
\nmust be recognized and respected as an important part of a person’s life. As public
\npressure increases in many countries to consider physician assisted suicide and eutha-
\nnasia as acceptable options to end suffering in terminal patients, the ethical imperative
\nto improve palliative treatment in the terminal phase of life comes into sharp focus.
\n2. The World Medical Association recognizes that attitudes and beliefs toward death and
\ndying vary widely from culture to culture and among different religions. In addition,
\nmany palliative and life-sustaining measures require technologies and\/or financial
\nresources that are simply not available in many places. The approach to medical care
\nof the terminally ill will be influenced significantly by these factors, and thus at-
\ntempting to developing detailed guidelines on terminal care that can be universally
\napplied is neither practical nor wise. Therefore, the World Medical Association arti-
\nculates the following core principles to assist physicians and National Medical As-
\nsociations with decision-making related to terminal care.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1983-01-2006
\nPRINCIPLES\t<\/p>\n

1. The duty of physicians is to heal, where possible, to relieve suffering and to protect
\nthe best interests of their patients. There shall be no exception to this principle even in
\nthe case of incurable disease.
\n2. In the care of terminal patients, the primary responsibilities of the physician are to
\nassist the patient in maintaining an optimal quality of life through controlling symp-
\ntoms and addressing psychosocial needs, and to enable the patient to die with dignity
\nand in comfort. Physicians should inform patients of the availability, benefits and
\nother potential effects of palliative care.
\n3. The patient’s right to autonomy in decision-making must be respected with regard to
\ndecisions in the terminal phase of life. This includes the right to refuse treatment and
\nto request palliative measures to relieve suffering but which may have the additional
\neffect of accelerating the dying process. However, physicians are ethically prohibited
\nfrom actively assisting patients in suicide. This includes administering any treatments
\nwhose palliative benefits, in the opinion of the physician, do not justify the additional
\neffects.
\n4. The physician must not employ any means that would provide no benefit for the pa-
\ntient.
\n5. Physicians should recognise the right of patients to develop written advance directives
\nthat describe their wishes regarding care in the event that they are unable to commu-
\nnicate and that designate a substitute decision-maker to make decisions that are not
\nexpressed in the advance directive. In particular, physicians should discuss the pa-
\ntient’s wishes regarding the approach to life-sustaining interventions as well as pal-
\nliative measures that might have the additional effect of accelerating death. When-
\never possible, the patient’s substitute decision-maker should be included in these con-
\nversations.
\n6. Physicians should endeavour to understand and address the psychosocial needs of
\ntheir patients, especially as they relate to patients’ physical symptoms. Physicians
\nshould try to ensure that psychological and spiritual resources are available to patients
\nand their families to help them deal with the anxiety, fear and grief associated with
\nterminal illness.
\n7. The clinical management of pain in terminal patients is of paramount importance in
\nterms of alleviating suffering. Physicians and National Medical Associations should
\npromote the dissemination and sharing of information regarding pain management to
\nensure that all physicians involved in terminal care have access to best practice guide-
\nlines and the most current treatments and methods available. Physicians should be
\nable to pursue clinically appropriate aggressive pain management without undue fear
\nof regulatory or legal repercussions.
\n8. National Medical Associations should encourage governments and research institu-
\ntions to invest additional resources in developing treatments to improve end-of-life
\ncare. Medical school curricula should include the teaching of palliative medical care.
\nWhere it does not exist, the establishment of palliative medicine as a medical special-
\nty should be considered.<\/p>\n

D-1983-01-2006\t\u23d0\tPilanesberg
\nTerminal\tIllness\t(Venice)
\n9. National Medical Associations should advocate for the development of networks
\namong institutions and organizations involved in palliative care in order to foster com-
\nmunication and collaboration.
\n10. Physicians may, when the patient cannot reverse the final process of cessation of vital
\nfunctions, apply such artificial means as are necessary to keep organs active for trans-
\nplantation provided that they act in accordance with the ethical guidelines established
\nin the World Medical Association Declaration of Sydney on the Determination of Death
\nand the Recovery of Organs.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-1987-01-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION
\nON
\nEUTHANASIA
\nAdopted by the 39th
\nWorld Medical Assembly, Madrid, Spain, October 1987
\nand reaffirmed by the 170th
\nWMA Council Session, Divonne-les-Bains, France, May 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nEuthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s
\nown request or at the request of close relatives, is unethical. This does not prevent the phy-
\nsician from respecting the desire of a patient to allow the natural process of death to follow
\nits course in the terminal phase of sickness.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1989-01-2015
\nWMA\tDECLARATION\tOF\tHONG\tKONG
\nON
\nTHE\tABUSE\tOF\tTHE\tELDERLY
\nAdopted by the 41st
\nWorld Medical Assembly, Hong Kong, September 1989
\nand editorially revised by the 126th
\nWMA Council Session, Jerusalem, Israel, May 1990
\nand the 170th
\nWMA Council Session, Divonne-les-Bains, France, May 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nElderly people may suffer pathological problems such as motor disturbances and psychic
\nand orientation disorders. As a result of such problems, elderly patients may require assis-
\ntance with their daily activities that can lead to a state of dependence. This may cause their
\nfamilies and the community to consider them to be a burden and to subsequently limit or
\ndeny care and services.
\nAbuse or neglect of the elderly can be manifested in a variety of ways: physical, psycho-
\nlogical, financial and\/or material, and medical. Variations in the definition of elder abuse
\npresent difficulties in comparing findings on the nature and causes of the problem. A num-
\nber of preliminary hypotheses have been proposed on the etiology of elder abuse includ-
\ning: dependency on others to provide services; lack of close family ties; family vio-
\nlence; lack of financial resources; psychopathology of the abuser; lack of community sup-
\nport, and institutional factors such as low pay and poor working conditions that contribute
\nto pessimistic attitudes of caretakers.
\nThe phenomenon of elder abuse is becoming increasingly recognized by both medical
\nfacilities and social agencies. The first step in preventing elder abuse and neglect is to in-
\ncrease levels of awareness and knowledge among physicians and other health profes-
\nsionals. Once high-risk individuals and families have been identified, physicians can parti-
\ncipate in the primary prevention of maltreatment by making referrals to appropriate com-
\nmunity and social service centres. Physicians may also participate by providing support
\nand information on high-risk situations directly to patients and their families. At the same
\ntime, physicians should employ care and sensitivity to preserve patient trust and confiden-
\ntiality, particularly in the case of competent patients.
\nThe World Medical Association therefore adopts the following general principles relating
\nto abuse of the elderly.<\/p>\n

GENERAL\tPRINCIPLES
\n1. The elderly have the same rights to care, welfare and respect as other human beings.
\n2. Physicians have a responsibility to help prevent the physical and psychological abuse
\nof elderly patients.<\/p>\n

Elderly\tAbuse
\nOslo\t\u23d0\tD-1989-01-2015
\n3. Whether consulted by an aged person directly, a nursing home or the family, phy-
\nsicians should see that the patient receives the best possible care.
\n4. If physicians verify or suspect ill treatment, as defined in this statement, they should
\ndiscuss the situation with those in charge, be it the nursing home or the family. If ill
\ntreatment is confirmed, or if death is considered to be suspicious, they should report
\nthe findings to the appropriate authorities.
\n5. To guarantee protection of the elderly in any environment there should be no restric-
\ntions on their right of free choice of a physician. National Medical Associations should
\nstrive to make certain that such free choice is preserved within the socio-medical sys-
\ntem.
\nThe World Medical Association also makes the following recommendations to physicians
\ninvolved in treating the elderly, and urges all National Medical Associations to publicize
\nthis Declaration to their members and the public.
\nRECOMMENDATIONS
\nPhysicians involved in treating the elderly should:
\n\u2022 make increased attempts to establish an atmosphere of trust with elderly patients in
\norder to encourage them to seek medical care when necessary and to feel comfort-
\nable confiding in the physician;
\n\u2022 provide medical evaluation and treatment for injuries resulting from abuse and\/or
\nneglect;
\n\u2022 attempt to establish or maintain a therapeutic alliance with the family (often the
\nphysician is the only professional who maintains long-term contact with the patient
\nand the family), while preserving to the greatest extent possible the confidentiality
\nof the patient;
\n\u2022 report all suspected cases of elder abuse and\/or neglect in accordance with local
\nlegislation;
\n\u2022 utilize a multidisciplinary team of caretakers from the medical, social service,
\nmental health, and legal professions, whenever possible; and
\n\u2022 encourage the development and utilization of supportive community resources that
\nprovide in-home services, respite care, and stress reduction with high-risk families.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1991-01-2017
\nWMA\tDECLARATION\tOF\tMALTA
\nON
\nHUNGER\tSTRIKERS
\nAdopted by the 43rd
\nWorld Medical Assembly, St. Julians, Malta, November 1991
\nand editorially revised by the 44th
\nWorld Medical Assembly, Marbella, Spain, September 1992
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE\t\t<\/p>\n

1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in
\nsettings where people are detained (prisons, jails and immigration detention
\ncentres). They are usually a form of protest by people who lack other ways of
\nmaking their demands known. In refusing nutrition for a significant period,
\nprisoners and detainees may hope to obtain certain goals by inflicting negative
\npublicity on the authorities. Short-term food refusals rarely raise ethical problems.
\nProlonged fasting risks death or permanent damage for hunger strikers and can
\ncreate a conflict of values for physicians. Hunger strikers rarely wish to die but
\nsome may be prepared to do so to achieve their aims.
\n2. Physicians need to ascertain the individual\u2019s true intention, especially in collective
\nstrikes or situations where peer pressure may be a factor. An emotional challenge
\narises when hunger strikers who have apparently issued clear instructions not to be
\nresuscitated reach a stage of cognitive impairment. The principle of beneficence
\nurges physicians to resuscitate them but respect for individual autonomy restrains
\nphysicians from intervening when a valid and informed refusal has been made.
\nThis has been well worked through in many other clinical situations including
\nrefusal of life saving treatment. An added difficulty arises in custodial settings
\nbecause it is not always clear whether the hunger striker\u2019s advance instructions
\nwere made voluntarily and with appropriate information about the consequences.
\nPRINCIPLES\t<\/p>\n

3. Duty to act ethically. All physicians are bound by medical ethics in their
\nprofessional contact with vulnerable people, even when not providing therapy.
\nWhatever their role, physicians must try to prevent coercion or maltreatment of
\ndetainees and must protest if it occurs.
\n4. Respect for autonomy. Physicians should respect individuals\u2019 autonomy. This can
\ninvolve difficult assessments as hunger strikers\u2019 true wishes may not be as clear as
\nthey appear. Any decisions lack moral force if made by use of threats, peer
\npressure or coercion. Hunger strikers should not forcibly be given treatment they
\nrefuse. Applying, instructing or assisting forced feeding contrary to an informed
\nand voluntary refusal is unjustifiable. Artificial feeding with the hunger striker\u2019s
\nexplicit or necessarily implied consent is ethically acceptable.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1991-01-2017
\n5. \u2018Benefit\u2019 and \u2018harm\u2019. Physicians must exercise their skills and knowledge to
\nbenefit those they treat. This is the concept of \u2018beneficence\u2019, which is
\ncomplemented by that of \u2018non-maleficence\u2019 or primum non nocere. These two
\nconcepts need to be in balance. \u2018Benefit\u2019 includes respecting individuals\u2019 wishes as
\nwell as promoting their welfare. Avoiding \u2018harm\u2019 means not only minimising
\ndamage to health but also not forcing treatment upon competent people nor
\ncoercing them to stop fasting. Beneficence does not necessarily involve prolonging
\nlife at all costs, irrespective of other determinants.
\nPhysicians must respect the autonomy of competent individuals, even where this
\nwill predictably lead to harm. The loss of competence does not mean that a
\nprevious competent refusal of treatment, including artificial feeding should be
\nignored.
\n6. Balancing dual loyalties. Physicians attending hunger strikers can experience a
\nconflict between their loyalty to the employing authority (such as prison
\nmanagement) and their loyalty to patients. In this situation, physicians with dual
\nloyalties are bound by the same ethical principles as other physicians, that is to say
\nthat their primary obligation is to the individual patient. They remain independent
\nfrom their employer in regard to medical decisions.
\n7. Clinical independence. Physicians must remain objective in their assessments and
\nnot allow third parties to influence their medical judgement. They must not allow
\nthemselves to be pressured to breach ethical principles, such as intervening
\nmedically for non medical reasons.
\n8. Confidentiality. The duty of confidentiality is important in building trust but it is
\nnot absolute. It can be overridden if non-disclosure seriously and imminently
\nharms others. As with other patients, hunger strikers\u2019 confidentiality and privacy
\nshould be respected unless they agree to disclosure or unless information sharing is
\nnecessary to prevent serious harm. If individuals agree, their relatives and legal
\nadvisers should be kept informed of the situation.
\n9. Establishing trust. Fostering trust between physicians and hunger strikers is often
\nthe key to achieving a resolution that both respects the rights of the hunger strikers
\nand minimises harm to them. Gaining trust can create opportunities to resolve
\ndifficult situations. Trust is dependent upon physicians providing accurate advice
\nand being frank with hunger strikers about the limitations of what they can and
\ncannot do, including situations in which the physician may not be able to maintain
\nconfidentiality.
\n10. Physicians must assess the mental capacity of individuals seeking to engage in a
\nhunger strike. This involves verifying that an individual intending to fast is free of
\nany mental conditions that would undermine the person\u2019s ability to make informed
\nhealth care decisions. Individuals with seriously impaired mental capacity may not
\nbe able to appreciate the consequences of their actions should they engage in a
\nhunger strike. Those with treatable mental health problems should be directed
\ntowards appropriate care for their mental conditions and receive appropriate
\ntreatment. Those with untreatable conditions, including severe learning disability<\/p>\n

D-1991-01-2017\t\u23d0\tChicago
\nHunger\tStrikers\t(Malta)
\nor advanced dementia should receive treatment and support to enable them to make
\nsuch decisions as lie within their competence.
\n11. As early as possible, physicians should acquire a detailed and accurate medical
\nhistory of the person who is intending to fast. The medical implications of any
\nexisting conditions should be explained to the individual. Physicians should verify
\nthat hunger strikers understand the potential health consequences of fasting and
\nforewarn them in plain language of the disadvantages. Physicians should also
\nexplain how damage to health can be minimised or delayed by, for example,
\nincreasing fluid and thiamine intake. Since the person\u2019s decisions regarding a
\nhunger strike can be momentous, ensuring full patient understanding of the
\nmedical consequences of fasting is critical. Consistent with best practices for
\ninformed consent in health care, the physician should ensure that the patient
\nunderstands the information conveyed by asking the patient what he or she
\nunderstands.
\n12. A thorough examination of the hunger striker should be made at the start of the fast
\nincluding measuring body weight. Management of future symptoms, including
\nthose unconnected to the fast, should be discussed with hunger strikers. Also, the
\nperson\u2019s values and wishes regarding medical treatment in the event of a prolonged
\nfast should be noted. If the hunger striker consents, medical examinations should
\nbe carried out regularly in order to determine necessary treatments. The physical
\nenvironment should be evaluated in order to develop recommendations for
\npreventing negative effects.
\n13. Continuing communication between the physician and hunger strikers is essential.
\nPhysicians should ascertain on a daily basis whether individuals wish to continue a
\nhunger strike and what they want to be done when they are no longer able to
\ncommunicate meaningfully. The clinician should identify whether the individual is
\nwilling, in the absence of their demands being met, to continue the fast even until
\ndeath. These findings must be appropriately recorded.
\n14. Sometimes hunger strikers accept an intravenous solution transfusion or other
\nforms of medical treatment. A refusal to accept certain interventions must not
\nprejudice any other aspect of the medical care, such as treatment of infections or of
\npain.
\n15. Physicians should talk to hunger strikers in privacy and out of earshot of all other
\npeople, including other detainees. Clear communication is essential and, where
\nnecessary, interpreters unconnected to the detaining authorities should be available
\nand they too must respect confidentiality.
\n16. Physicians need to satisfy themselves that food or treatment refusal is the
\nindividual\u2019s voluntary choice. Hunger strikers should be protected from coercion.
\nPhysicians can often help to achieve this and should be aware that coercion may
\ncome from the authorities, the peer group, or others, such as family members.
\nPhysicians or other health care personnel may not apply undue pressure of any sort
\non the hunger striker to suspend the strike. Treatment or care of the hunger striker
\nmust not be conditional upon suspension of the hunger strike. Any restraint or
\npressure including but not limited to hand-cuffing, isolation, tying the hunger<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1991-01-2017
\nstriker to a bed or any kind of physical restraint due to the hunger strike is not
\nacceptable.
\n17. If a physician is unable for reasons of conscience to abide by a hunger striker\u2019s
\nrefusal of treatment or artificial feeding, the physician should make this clear at the
\noutset, and must be sure to refer the hunger striker to another physician who is
\nwilling to abide by the hunger striker\u2019s refusal.
\n18. When a physician takes over the case, the hunger striker may have already lost
\nmental capacity so that there is no opportunity to discuss the individual\u2019s wishes
\nregarding medical intervention to preserve life. Consideration and respect must be
\ngiven to any advance instructions made by the hunger striker. Advance refusals of
\ntreatment must be followed if they reflect the voluntary wish of the individual
\nwhen competent. In custodial settings, the possibility of advance instructions
\nhaving been made under pressure needs to be considered. Where physicians have
\nserious doubts about the individual\u2019s intention, any instructions must be treated
\nwith great caution. If well informed and voluntarily made, however, advance
\ninstructions can only generally be overridden if they become invalid because the
\nsituation in which the decision was made has changed radically since the
\nindividual lost competence.
\n19. If no discussion with the individual is possible and no advance instructions or any
\nother evidence or note in the clinical records of a discussion exist, physicians have
\nto act in what they judge to be in the person\u2019s best interests. This means
\nconsidering the hunger strikers\u2019 previously expressed wishes, their personal and
\ncultural values as well as their physical health. In the absence of any evidence of
\nhunger strikers\u2019 former wishes, physicians should decide whether or not to provide
\nfeeding, without interference from third parties.
\n20. Physicians may rarely and exceptionally consider it justifiable to go against
\nadvance instructions refusing treatment because, for example, the refusal is thought
\nto have been made under duress. If, after resuscitation and having regained their
\nmental faculties, hunger strikers continue to reiterate their intention to fast, that
\ndecision should be respected. It is ethical to allow a determined hunger striker to
\ndie with dignity rather than submit that person to repeated interventions against his
\nor her will. Physicians acting against an advanced refusal of treatment must be
\nprepared to justify that action to relevant authorities including professional
\nregulators.
\n21. Artificial feeding, when used in the patient\u2019s clinical interest, can be ethically
\nappropriate if competent hunger strikers agree to it. However, in accordance with
\nthe WMA Declaration of Tokyo, where a prisoner refuses nourishment and is
\nconsidered by the physician as capable of forming an unimpaired and rational
\njudgment concerning the consequences of such a decision, he or she shall not be
\nfed artificially. Artificial feeding can also be acceptable if incompetent individuals
\nhave left no unpressured advance instructions refusing it, in order to preserve the
\nlife of the hunger striker or to prevent severe irreversible disability. Rectal
\nhydration is not and must never be used as a form of therapy for rehydratation or
\nnutritional support in fasting patients.<\/p>\n

D-1991-01-2017\t\u23d0\tChicago
\nHunger\tStrikers\t(Malta)
\n22. When a patient is physically able to begin oral feeding, every caution must be
\ntaken to ensure implementation of the most up to date guidelines of refeeding.
\n23. All kinds of interventions for enteral or parenteral feeding against the will of the
\nmentally competent hunger striker are \u201cto be considered as \u201cforced feeding\u201d.
\nForced feeding is never ethically acceptable. Even if intended to benefit, feeding
\naccompanied by threats, coercion, force or use of physical restraints is a form of
\ninhuman and degrading treatment. Equally unacceptable is the forced feeding of
\nsome detainees in order to intimidate or coerce other hunger strikers to stop
\nfasting.
\nTHE\tROLE\tOF\tNATIONAL\tMEDICAL\tASSOCIATIONS\t(NMAS)\tAND\tTHE\tWMA\t<\/p>\n

24. NMAs should organize and provide educational programmes highlighting the
\nethical dimensions of hunger strikes, appropriate medical approaches, treatments,
\nand interventions. They shall make efforts to update physicians\u2019 professional
\nknowledge and skills.
\nNMAs should work to provide mechanisms for supporting physicians working in
\nprisons\/jails\/immigration detention centers, who may often find themselves in
\nconflict situations and, as stated in the WMA Declaration of Hamburg, shall
\nsupport any physicians experiencing pressure to compromise their ethical
\nprinciples.
\nNMAs have a responsibility to make efforts to prevent unethical practices, to take
\na position and speak out against ethical violations, and to investigate them
\nproperly.
\n25. The World Medical Association will support physicians and NMAs confronted
\nwith political pressures as a result of defending an ethically justifiable position, as
\nstated in the WMA Declaration of Hamburg.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1997-01-2009
\nWMA\tDECLARATION
\nON
\nGUIDELINES\tFOR\tCONTINUOUS\tQUALITY\tIMPROVEMENT\tIN
\nHEALTH\tCARE
\nAdopted by the 49th
\nWorld Medical Assembly, Hamburg, Germany, November 1997
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009<\/p>\n

PREAMBLE\t<\/p>\n

The purpose of health care is to prevent, diagnose and treat illness and to maintain and to
\npromote the health of the population. The goal of quality review in health care is conti-
\nnuous improvement of the quality of services provided for patients and the population, and
\nof the ways and means of producing these services. The ultimate goal is to improve both
\nindividual patient outcomes and population health.
\nThe obligation to continuously improve one\u2019s professional ability and to rigorously eval-
\nuate the methods one uses has long been a fundamental tenet of the ethical codes of physi-
\ncians. According to these codes, a physician must always strive to maintain and increase
\nhis\/her knowledge and skills. The physician shall recommend only examinations and treat-
\nments that are believed to be effective and appropriate according to the best available evi-
\ndence-based medicine.
\nPhysicians and health care institutions have an ethical and professional obligation to strive
\nfor continuous quality improvement of services and patient safety. These guidelines are in-
\ntended to articulate the ethical grounds for these obligations and to strengthen quality re-
\nview practices.
\nEthical guidelines for health care quality improvement matter to all physicians, as well as
\nto institutions providing health care services for patients, those providing continuous
\nquality improvement services to assist physicians and organizations, health care payers
\nand regulators, patients, and every other stakeholder in the health care system.<\/p>\n

THE\tOBLIGATION\tTO\tESTABLISH\tSTANDARDS\tFOR\tGOOD\tQUALITY\tWORK\t<\/p>\n

Professionals, by definition, are responsible for specifying the standards that constitute
\ngood quality in their work and the processes needed for the evaluation of that quality.
\nHealth professionals, therefore, must define high quality health care and determine the
\nbest methods of measuring the quality of care delivered.<\/p>\n

D-1997-01-2009\t\u23d0\tNew\tDelhi
\nQuality\tImprovement\tin\tHealth\tCare
\nTHE\tOBLIGATION\tTO\tCOLLECT\tDATA\t<\/p>\n

In order to assess quality of care, it is necessary to obtain reliable data on the patients and
\npopulations served as well as on care processes and outcomes. Patient records, whether
\nrecorded on paper, digitally or in any other way, must be created written and preserved
\nwith care and, with attention to confidentiality requirements. Procedures, decisions and
\nother matters connected with patients should be recorded in a format that will allow infor-
\nmation for measuring specific standards to be available on a timely basis when needed.<\/p>\n

THE\tROLE\tOF\tPROFESSIONAL\tEDUCATION\t<\/p>\n

Health care professionals should have adequate opportunities to maintain and develop
\ntheir knowledge and skills by participating in continuing medical education and\/or conti-
\nnuing professional development. Clinical guidelines based on professional standards for
\nhigh quality care should be created and made easily available to those requiring
\nthem. Health care training should include specific instruction in quality improvement
\ntechniques, including opportunities for hands-on practice in measuring and improving
\nquality. Health care institutions should create quality improvement systems for their own
\nuse and to en-sure that instructions concerning such systems are followed.
\nGood quality work requires resources. Every effort should be made to make sure that ade-
\nquate time and economic means are available for quality work.<\/p>\n

ATTENTION\tTO\tINAPPROPRIATE\tUSE\tOF\tSERVICES\t<\/p>\n

Inappropriate use of health care services includes overuse, underuse and misuse. Quality
\nmeasurement in health care should include a balanced set of measures in all three areas.
\nOveruse of services occurs when health care services are provided under circumstances in
\nwhich the potential for harm exceeds the possible benefit. Physicians can improve quality
\nby reducing overuse, thus sparing patients the unnecessary risk that results from inappro-
\npriate health services.
\nUnderuse of services is the failure to provide health care services that would be likely to
\nproduce a favourable outcome for the patient. Physicians should strive to expand the use
\nof beneficial health care services that are underused.
\nMisuse of services occurs when an incorrect diagnosis is made or when an appropriate
\nservice has been selected for a correct diagnosis but the patient does not receive the full
\npotential benefit of the service because of a preventable adverse event. Misuse of services
\ncan be greatly reduced by using risk management and error prevention strategies.
\nMONITORING\tQUALITY:\tCLINICAL\tAUDITS
\nActive participation in critical self-evaluation, usually through clinical audit programs, is a
\nuseful mechanism for healthcare professionals, including healthcare administrators and
\nphysicians, and the institutions in which they work, to improve the quality of their work.
\nExternal independent examination and accreditation of the institution can also be of use,
\nwhen carried out appropriately and with due attention to potential unintended effects.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1997-01-2009
\nINTERNAL\tAND\tEXTERNAL\tQUALITY\tASSESSMENT
\nAt the individual level, a physician should continuously update their knowledge and skills
\nand subject their level of ability to critical self-appraisal.
\nIn organizations, the quality of health care can be assessed by both internal and external
\nmethods.
\nHealth care institutions should create internal quality improvement systems for their own
\nuse and ensure that instructions concerning such systems are followed. These systems
\nshould include continuous conducting of internal clinical peer review, review examination
\nand treatment methods and their attendant results, tracking of the organization\u2019s ability to
\nreact to quality data, and monitoring of patient feedback.
\nExternal quality review initiatives, such as external peer review and audit, should be car-
\nried out regularly and with a frequency corresponding to the evolution of the field or when
\nthere is special reason for external assessment. Any review should take into account risk
\nadjustment of the patient population under consideration.
\nWhether internal or external, if the results of any quality assessment carry significant op-
\nportunities for benefit or threats of harms for the organization or individual being
\nassessed, special attention must be paid to potential unintended and dangerous
\nconsequences of such quality assessments. It is especially important to monitor the results
\nof quality improve-ment measurement and intervention strategies over time, with attention
\nto their effects on especially vulnerable patient populations.
\nProtocols to be used for quality review should be replicable and transparent. Appeals me-
\nchanisms should be built into the protocols.
\nCONFIDENTIALITY\tOF\tPATIENT\tRECORDS
\nPatient records are an invaluable source of data for quality improvement. As with other uses
\nof individually-identifiable patient based information, consent is usually required from the
\npatient prior to use. If consent cannot reasonably be obtained, then all attempts should be
\nmade to ensure that medical records are anonymised or pseudonimised for use in quality
\nimprovement efforts. In every case, patient records used for quality improvement must
\nonly be accessible to those who need to see them for the purposes of quality improvement.
\nCONFIDENTIALITY\tOF\tPEER\tREVIEW
\nFor peer review to be most effective, all parties involved must participate and recognize its
\nimportance. It is recommended that informed voluntary consent be obtained from those to
\nbe reviewed. Within a healthcare team, the work of each physician must be able to be eval-
\nuated. Information regarding an individual physician’s evaluation should not be pu-blished
\nwithout the consent of the physician concerned. It is recommended that consent be ob-
\ntained prior to publishing information regarding an individual physician\u2019s evaluation.<\/p>\n

D-1997-01-2009\t\u23d0\tNew\tDelhi
\nQuality\tImprovement\tin\tHealth\tCare
\nA provider of services may inform his\/her patients about the results of quality review.
\nIf reviews are made available to the public, careful monitoring must be undertaken to track
\nthe effects, intended and unintended, of such public reporting of performance data.
\nETHICAL\tREVIEW\tOF\tQUALITY\tIMPROVEMENT\tACTIVITIES
\nNational codes of medical ethics and ethical principles and guidelines that relate to conti-
\nnuous quality improvement, audit and clinical review must be followed.
\nQuality improvement should be an ongoing and integral part of the operations of every
\nhealth care organization. As such, the majority of quality improvement projects will not
\nrequire specific review by an ethics committee. If there are doubts about specific issues or
\nif a project poses more than minimal risk compared to the existing processes for care, then
\nthe project should be referred to an appropriate ethics committee or institutional review
\nboard. When such formal ethical review is needed, it should be undertaken by a commit-
\ntee with members who are knowledgeable about quality improvement techniques.
\nCOMPETENCE\tAND\tIMPARTIALITY\tOF\tTHE\tREVIEWER
\nThose who conduct performance reviews must be competent in quality improvement tech-
\nniques and in clinical audit as well as experienced in the clinical field relating to the re-
\nview. Where medical care is being reviewed, the reviewer should be a physician whose
\nknowledge and experience is accepted by those being reviewed.
\nThe reviewer should be impartial and independent. Whilst he\/she must be aware of the
\nactivities under review, he\/she must be objective in the report and base conclusions on
\ncritical evaluation of observation and facts. Commercial or competitive matters should not
\nbe allowed to influence the content of the reviewer’s report.
\nSEPARATION\tOF\tQUALITY\tREVIEWS\tAND\tSUPERVISION\tBY\tAUTHORITIES
\nQuality improvement of services and of health care systems is a requirement for every
\nphysician and health care institution. It is not supervision of professional activities by au-
\nthorities and it must be kept independent of this. The results of performance reviews or au-
\ndits of physician activities should be used by supervising authorities only subject to a se-
\nparate agreement between them and the physicians concerned unless national legislation
\nmandates an alternative approach. These activities must be fully cognizant of the local le-
\ngal framework and must not expose participating physicians to litigation.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1997-02-2017
\nWMA\tDECLARATION\tOF\tHAMBURG
\nCONCERNING\tSUPPORT\tFOR\tMEDICAL\tDOCTORS
\nREFUSING\tTO\tPARTICIPATE\tIN,\tOR\tTO\tCONDONE,
\nTHE\tUSE\tOF\tTORTURE\tOR\tOTHER\tFORMS\tOF\tCRUEL,
\nINHUMAN\tOR\tDEGRADING\tTREATMENT
\nAdopted by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nand reaffirmed by the 176th
\nWMA Council Session, Berlin, Germany, May 2007
\nand reaffirmed with minor revision by the 207th
\nWMA Council session, Chicago, United
\nStates, October 2017
\nPREAMBLE\t<\/p>\n

1. On the basis of a number of international ethical declarations and guidelines subs-
\ncribed to by the medical profession, medical doctors throughout the world are
\npro-hibited from countenancing, condoning or participating in the practice of
\ntorture or other forms of cruel, inhuman or degrading procedures for any reason.
\n2. Primary among these declarations are the World Medical Association’s
\nInternational Code of Medical Ethics, Declaration of Geneva, Declaration of
\nTokyo, and Resolu-tion on Physician Participation in Capital Punishment; the
\nStanding Committee of European Doctors’ Statement of Madrid; the Nordic
\nResolution Concerning Physician Involvement in Capital Punishment; and, the
\nWorld Psychiatric Association’s Decla-ration of Hawaii.
\n3. However, none of these declarations or statements addresses explicitly the issue of
\nwhat protection should be extended to medical doctors if they are pressured, called
\nupon, or ordered to take part in torture or other forms of cruel, inhuman or
\ndegrading treatment or punishment. Nor do these declarations or statements
\nexpress explicit sup-port for, or the obligation to protect, doctors who encounter or
\nbecome aware of such procedures.
\nRESOLUTION\t\t<\/p>\n

4. The World Medical Association (WMA) hereby reiterates and reaffirms the
\nresponsibility of the organised medical profession:
\n4.1 To encourage physicians to honour their commitment as physicians to serve
\nhumanity and to resist any pressure to act contrary to the ethical principles
\ngoverning their dedication to this task;
\n4.2 To support physicians experiencing difficulties as a result of their resistance to
\nany such pressure or as a result of their attempts to speak out or to act against
\nsuch inhuman procedures; and,<\/p>\n

D-1997-02-2017\t\u23d0\tChicago
\nRefusing\tTorture\t(Hamburg)
\n4.3 To extend its support and to encourage other international organisations, as
\nwell as the constituent members of the World Medical Association (WMA), to
\nsupport physicians encountering difficulties as a result of their attempts to act
\nin accordance with the highest ethical principles of the profession.
\n4.4 To encourage physicians to report and document any acts of torture and other
\ncruel, inhuman or degrading treatment or punishment they are aware of.
\n5. Furthermore, in view of the continued employment of such inhumane procedures
\nin many countries throughout the world, and the documented incidents of pressure
\nupon physicians to act in contravention to the ethical principles subscribed to by
\nthe profession, the WMA finds it necessary:
\n5.1 To protest internationally against any involvement of, or any pressure to
\ninvolve, physicians in acts of torture and or other forms of cruel, inhuman or
\ndegrading treatment or punishment;
\n5.2 To support and protect, and to call upon its constituent members NMAs to
\nsupport and protect, physicians who are resisting involvement in such
\ninhuman procedures or who are documenting and reporting these procedures,
\nor who are working to treat and rehabilitate victims thereof, as well as to
\nsecure the right to uphold the highest ethical principles including medical
\nconfidentiality;
\n5.3 To publicize information about and to support physicians reporting evidence
\nof torture and to make known proven cases of attempts to involve physicians
\nin such procedures; and,
\n5.4 To encourage its constituent members to take action so that physicians are
\nheld accountable before the law in case of complicity in acts of torture and
\nother cruel, inhuman or degrading treatment or punishment;
\n5.5 To encourage its constituent members to ask corresponding academic
\nauthorities to teach and investigate in all schools of medicine and hospitals the
\nconsequences of torture and its treatment, the rehabilitation of the survivors,
\nthe documentation of torture, and the professional protection described in this
\nDeclaration.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-1998-01-2009
\nWMA\tDECLARATION\tOF\tOTTAWA
\nON
\nCHILD\tHEALTH
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

Science has now proven that to reach their potential, children need to grow up in a place
\nwhere they can thrive – spiritually, emotionally, mentally, physically and intellectually1
\n. That
\nplace must have four fundamental elements:
\n\u2022 a safe and secure environment;
\n\u2022 the opportunity for optimal growth and development;
\n\u2022 health services when needed; and
\n\u2022 monitoring & research for evidence-based continual improvement into the future2
\n.
\nPhysicians know that the future of our world depends on our children: their education,
\ntheir employability, their productivity, their innovation, and their love and care for one
\nanother and for this planet. Early childhood experiences strongly influence future develop-
\nment including basic learning, school success, economic participation, social citizenry,
\nand health3
\n. In most situations, parents and caregivers alone cannot provide strong nur-
\nturing environments without help from local, regional, national and international organi-
\nzations1
\n. Physicians therefore join with parents, and with world leaders to advocate for
\nhealthy children.
\nThe principles of this Declaration apply to all children in the world from birth to 18 years
\nof age, regardless of race, age, ethnicity, nationality, political affiliation, creed, language,
\ngender, disease or disability, physical ability, mental ability, sexual orientation, cultural
\nhistory, life experience or the social standing of the child or her\/his parents or legal guard-
\nian. In all countries of the world, regardless of resources, meeting these principles should
\nbe a priority for parents, communities and governments. The United Nations Con-vention
\non the Rights of Children (1989) sets out the wider rights of all children and young people,
\nbut those rights cannot exist without health.
\nGENERAL\tPRINCIPLES\t<\/p>\n

1. A place with a safe and secure environment includes:
\na. Clean water, air and soil;
\nb. Protection from injury, exploitation, discrimination and from traditional practices
\nprejudicial to the health of the child, and
\nc. Healthy families, homes and communities<\/p>\n

D-1998-01-2009\t\u23d0\tNew\tDelhi
\nChild\tHealth\t(Ottawa)
\n2. A place where a child can have good health and development offers:
\na. Prenatal and maternal care for the best possible health at birth
\nb. Nutrition for proper growth, development and long-term health
\nc. Early learning opportunities and high quality care at home and in the community
\nd. Opportunities and encouragement for physical activity
\ne. Affordable & accessible high quality primary & secondary education
\n3. A full range of health resources available to all means:
\na. The best interests of the child shall be the primary consideration in the provision of
\nhealth care;
\nb. Those caring for children shall have the special training and skills necessary to
\nenable them to respond appropriately to the medical, physical, emotional and de-
\nvelopmental needs of children & their families
\nc. Basic health care including health promotion, recommended immunization, drugs
\n& dental health
\nd. Mental health care and prompt referral to intervention when problems identified
\ne. Priority access to drugs for life- or limb-threatening conditions for all mothers and
\nchildren
\nf. Hospitalization only if the care and treatment required cannot be provided at home,
\nin the community or on an outpatient basis
\ng. Access to specialty diagnostic and treatment services when needed
\nh. Rehabilitation services and supports within community
\ni. Pain management and care and prevention (or minimization) of suffering
\nj. Informed consent is necessary before initiating any diagnostic, therapeutic, re-
\nhabilitative, or research procedure on a child. In the majority of cases, the consent
\nshall be obtained from the parent(s) or legal guardian, or in some cases, by ex-
\ntended family, although the wishes of a competent child should be taken into ac-
\ncount before consent is given.
\n4. Research4
\n& monitoring for continual improvement includes:
\na. All infants will be officially registered within one month of birth
\nb. All children will be treated with dignity and respect
\nc. Quality care is ensured through on-going monitoring of services, including collec-
\ntion of data, and evaluation of outcomes
\nd. Children will share in the benefits from scientific research relevant to their needs
\ne. The privacy of a child patient will be respected
\n1
\nIrwin LG, Siddiqi A, Hertzman C. \u201cEarly Child Development: A Powerful Equalizer. Final Re-
\nport\u201d. World Health Organization Commission on the Social Determinants of Health June 2007
\n2
\nWHO Commission on Social Determinants of Health (Closing the Gap in a Generation) 2008
\n3
\nCanadian Charter for Child and Youth Health
\n4
\nProposed WMA statement on ethical principles for medical research on child subjects
\n* Please refer the background document for specific principles.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2000-01-2011
\nWMA\tDECLARATION\tOF\tEDINBURGH
\nON
\nPRISON\tCONDITIONS\tAND\tTHE\tSPREAD\tOF\tTUBERCULOSIS\tAND
\nOTHER\tCOMMUNICABLE\tDISEASES
\nAdopted by the 52nd
\nWorld Medical Association General Assembly, Edinburgh, Scotland,
\nOctober 2000
\nand revised by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nPREAMBLE\t<\/p>\n

Prisoners enjoy the same health care rights as all other people. This includes the right to
\nhumane treatment and appropriate medical care. The standards for the treatment of pri-
\nsoners have been set down in a number of Declarations and Guidelines adopted by various
\nbodies of the United Nations.
\nThe relationship between physician and prisoner is governed by the same ethical princi-
\nples as that between the physician and any other patient. There are specific tensions within
\nthe patient\/physician relationship, which do not exist in other settings, in particular the
\nrelationship of the physician with his\/her employer, the prison service, and the general
\nattitude of society to prisoners.
\nThere are also strong public health reasons for reinforcing the importance of these rules.
\nThe high incidence of tuberculosis amongst prisoners in a number of countries reinforces
\nthe need for considering public health as an important element when designing new prison
\nregimens, and for reforming existing penal and prison systems.
\nIndividuals facing imprisonment are often from the most marginalised sections of society,
\nmay have had limited access to health care before imprisonment, may suffer worse health
\nthat many other citizens and may enter prison with undiagnosed, undetected and untreated
\nhealth problems.
\nPrisons can be breeding grounds for infection. Overcrowding, lengthy confinement within
\ntightly enclosed, poorly lit, badly heated and consequently poorly ventilated and often hu-
\nmid spaces are all conditions frequently associated with imprisonment and all of which
\ncontribute to the spread of disease and ill-health. Where these factors are combined with
\npoor hygiene, inadequate nutrition and limited access to adequate health care, prisons can
\nrepresent a major public health challenge.
\nKeeping prisoners in conditions, which expose them to substantial medical risk, poses a
\nhumanitarian challenge. An infectious prisoner is a risk to other prisoners, prison person-
\nnel, relatives and other prison visitors and the wider community – not only when the pri-
\nsoner is released, but also because prison bars do not keep Tuberculosis bacilli from
\nspreading into the outside world. The most effective and efficient way of reducing disease<\/p>\n

D-2000-01-2011\t\u23d0\tMontevideo
\nPrison\tConditions\ton\tTB\t(Edinburgh)
\ntransmission is to improve the prison environment, by putting together an efficient medi-
\ncal service that is capable of detecting and treating the disease, and by targeting prison
\novercrowding as the most urgent action.
\nThe increase in active Tuberculosis in prison populations and the development within
\nsome of these populations of resistant and especially \u00ab\u00a0multi-drug\u00a0\u00bb and \u00ab\u00a0extremely-drug\u00a0\u00bb
\nresistant forms of TB, as recognised by the World Medical Association in its Statement on
\nDrug Treatment of Tuberculosis, is reaching very high prevalence and incidence rates in
\nprisons in some parts of the world.
\nOther conditions, such as Hepatitis C and HIV Disease, do not have as high a risk of per-
\nson-to- person communicability as TB but pose transmission risks from blood to blood
\nborne spread, or sharing and exchange of body fluids. Overcrowded prison conditions also
\npromote the spread of sexually transmitted diseases. Intravenous drug use will also contri-
\nbute to the spread of HIV as well as the more contagious Hepatitis B and C. These need
\nspecific solutions that are not dealt with in this statement. However the principles set out
\nbelow will also be helpful in reducing the risk from such infective agents.
\nACTIONS\tREQUIRED
\nThe World Medical Association considers it essential both for public health and humani-
\ntarian reasons that careful attention is paid to:
\n1. Protecting the rights of prisoners according to the various UN instruments relating
\nto conditions of imprisonment. Prisoners should enjoy the same rights as other pa-
\ntients, as outlined in the WMA Declaration of Lisbon;
\n2. Not allowing the rights of prisoners to be ignored or invalidated because they have
\nan infectious illness;
\n3. Ensuring that the conditions in which detainees and prisoners are kept, whether
\nthey are held during the investigation of a crime, whilst waiting for trial, or as pu-
\nnishment once sentenced, do not contribute to the development, worsening or trans-
\nmission of disease.
\n4. Ensuring that persons being held while going through immigration procedures, are
\nkept in conditions which do not encourage the spread of disease, although prisons
\nshould not normally be used to house such persons;
\n5. Ensuring the coordination of health services within and outside prisons to facilitate
\ncontinuity of care and epidemiological monitoring of inmate patients when they
\nare released;
\n6. Ensuring that prisoners are not isolated, or placed in solitary confinement, as a res-
\nponse to their infected status without adequate access to health care and the appro-
\npriate medical treatment of their infected status;
\n7. Ensuring that, upon admission to or transfer to a different prison, inmates’ health
\nstatus is reviewed within 24 hours of arrival to assure continuity of care;<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2000-01-2011
\n8. Ensuring the provision of follow-up treatment for prisoners who, on their release,
\nare still ill, particularly with TB or any other infectious disease. Because erratic treat-
\nments or interruptions of treatment may be particularly hazardous epidemiolo-
\ngically and to the individual, planning for and providing continuing care are essen-
\ntial elements of prison health care provision;
\n9. Recognising that the public health mechanisms, which may in the rarest and most
\nexceptional cases involve the compulsory detention of individuals who pose a se-
\nrious risk of infection to the wider community must be efficacious, necessary and
\njustified, and proportional to the risks posed. Such steps should be exceptional and
\nmust follow careful and critical questioning of the need for such constraints and
\nthe absence of any effective alternative. In such circumstances detention should be
\nfor as short a time as possible and be as limited in restrictions as feasible. There
\nmust also be a system of independent appraisal and periodic review of any such
\nmeasures, including a mechanism for appeal by the patients themselves. Wherever
\npossible alternatives to such detention should be used;
\n10. This model should be used in considering all steps to prevent cross infection and to
\ntreat existing infected persons within the prison environment.
\n11. Physicians working in prisons have a duty to report to the health authorities and
\nprofessional organisations of their country any deficiency in health care provided
\nto the inmates and any situation involving high epidemiological risk. NMAs are
\nobliged to attempt to protect those physicians against any possible reprisals.
\n12. Physicians working in prisons have a duty to follow national public health guide-
\nlines, where these are ethically appropriate, particularly concerning the mandatory
\nreporting of infectious and communicable diseases.
\nANNEX\t\t<\/p>\n

International texts relating to medical care in prisons:
\nUniversal Declaration of Human Rights (Articles 4, 9, 10 and 11). Adopted by the United Nations
\nGeneral Assembly on 16 December 1948.
\nStandard Minimum Rules for the Treatment of Prisoners (Rules 22-26). Approved by the United
\nNations Economic and Social Council on 31 July 1957.
\nInternational Covenant on Economic, Social and Cultural Rights (Article 12). Adopted by the
\nUnited Nations General Assembly on 16 December 1966. Entry into force: 3 January 1976.
\nInternational Covenant on Civil and Political Rights (Articles 6, 7 and 10). Adopted by the United
\nNations General Assembly on 16 December 1966. Entry into force: 23 March 1976.
\nPrinciples of Medical Ethics Relevant to the Protection of Prisoners Against Torture (Principle 1).
\nAdopted by the United Nations General Assembly on 18 December 1982.<\/p>\n

D-2000-01-2011\t\u23d0\tMontevideo
\nPrison\tConditions\ton\tTB\t(Edinburgh)
\nBody of Principles for the Protection of All Persons Under Any Forms of Detention or
\nImprisonment (Principle 24). Adopted by the United Nations General Assembly on 9 December
\n1988.
\nBasic Principles for the Treatment of Prisoners (Article 9). Adopted by the United Nations General
\nAssembly on 14 December 1990.
\nUnited Nations Rules for the Protection of Juveniles Deprived of Their Liberty (Principles 50-54).
\nAdopted by the United Nations General Assembly on 14 December 1990.
\nWHO Guidelines on HIV Infection and AIDS in Prison. Issued in March 1993, Geneva
\n(Document WHO\/GPA\/DIR\/93.3).<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-01-2012
\nWMA\tDECLARATION\tOF\tWASHINGTON
\nON
\nBIOLOGICAL\tWEAPONS
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand editorialiy revised by the 164th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2003
\nand reaffirmed by the 191st
\nWMA Council Session, Prague, Czech Republic, April 2012
\nA.\t\tINTRODUCTION
\n1. The World Medical Association recognizes the growing threat that biological wea-
\npons might be used to cause devastating epidemics that could spread internationally.
\nAll countries are potentially at risk. The release of organisms causing smallpox,
\nplague, anthrax or other diseases could prove catastrophic in terms of the resulting
\nillnesses and deaths compounded by the panic such outbreaks would generate. At
\nthe same time, there is a growing potential for production of new microbial agents,
\nas expertise in biotechnology grows and methods for genetic manipulation of
\norganisms become simpler. These developments are of special concern to medical
\nand public health professionals because it is they who best know the potential
\nhuman suffering caused by epidemic disease and it is they who will bear primary
\nresponsibility for dealing with the victims of biological weapons. Thus, the World
\nMedical Association believes that medical associations and all who are concerned
\nwith health care bear a special responsibility to lead in educating the public and
\npolicy makers about the implications of biological weapons and to mobilize uni-
\nversal support for condemning research, development, or use of such weapons as
\nmorally and ethically unacceptable.
\n2. Unlike the use of nuclear, chemical, and conventional weapons, the consequences
\nof a biological attack are likely to be insidious. Their impact might continue with
\nsecondary and tertiary transmission of the agent, weeks or months after the initial
\nepidemic. The consequences of a successful biological attack, especially if the
\ninfection were readily communicable, could far exceed those of a chemical or even
\na nuclear event. Given the ease of travel and increasing globalization, an outbreak
\nanywhere in the world could be a threat to all nations.
\n3. A great many severe, acute illnesses occurring over a short span of time would
\nalmost certainly overwhelm the capacities of most health systems in both the
\ndeveloping and industrialized world. Health services throughout the world are
\nstruggling to meet the demands created by HIV\/AIDS and antimicrobial-resistant
\norganisms, the problems created by civil strife, refugees and crowded, unsanitary
\nurban environments as well as the increased health needs of aging populations.
\nCoping over a short period of time with large numbers of desperately ill persons
\ncould overwhelm entire health systems.<\/p>\n

D-2002-01-2012\t\u23d0\tPrague
\nBiological\tWeapons\t(Washington)
\n4. Actions can be taken to diminish the risk of biological weapons as well as the
\npotentially harmful consequences of serious epidemics whatever their origin. Inter-
\nnational collaboration is needed to build a universal consensus that condemns the
\ndevelopment, production, or use of biological weapons. Programs of surveillance
\nare needed in all countries for the early detection, identification, and response to
\nserious epidemic disease; health education and training is needed for professionals,
\ncivic leaders, and the public alike; and collaborative programs of research are
\nneeded to improve disease diagnosis, prevention, and treatment.
\n5. The proliferation of technology and scientific progress in biochemistry, biotech-
\nnology, and the life sciences provides the opportunity to create novel pathogens
\nand diseases and simplified production methods for bioweapons. The technology is
\nrelatively inexpensive and, because production is similar to that used in biological
\nfacilities such as vaccine manufacturing, it is easy to obtain. Capacity to produce
\nand effectively disperse biological weapons exists globally, allowing extremists
\n(acting collectively or individually) to threaten governments and endanger peoples
\naround the world. Nonproliferation and arms control measures can diminish but
\ncannot completely eliminate the threat of biological weapons. Thus, there is a need
\nfor the creation of and adherence to a globally accepted ethos that rejects the
\ndevelopment and use of biological weapons.
\nB. STRENGTHENING\tPUBLIC\tHEALTH\tAND\tDISEASE\tSURVEILLANCE\tSYSTEMS
\n2.
\n1. A critical component in dealing with epidemic disease is a strong public health
\ninfrastructure. Investment in public health systems will enhance capacity to detect
\nand to contain expeditiously, rare or unusual disease outbreaks, whether deli-
\nberately induced or naturally occurring. Core public health functions (disease sur-
\nveillance and supporting laboratory services) are needed as a foundation for detec-
\ntion, investigation, and response to all epidemic threats. A more effective global
\nsurveillance program will improve response to naturally occurring infectious dis-
\neases and will permit earlier detection and characterization of new or emerging
\ndiseases.
\n2. It is especially important that physicians be alert to the occurrence of cases or
\nclusters of unusual infectious diseases, to seek help from infectious disease
\nspecialists in diagnosis, and to report cases promptly to public health authorities.
\nBecause any physician may see only one or a few cases and may not recognize that
\nan outbreak is occurring, cooperation between primary care physicians and public
\nhealth authorities is especially important.
\n3. Public health officials, dealing with an epidemic, will require the cooperation of
\nemergency management agencies, law enforcement officials, healthcare facilities,
\nand a variety of community service organizations. For these different groups to work
\ntogether effectively, advance planning will be important. In addition to developing
\nsurveillance activities for early detection and reporting, public health efforts should
\nbe directed toward educating primary caregivers and public health staff about
\npotential agents that might be used, building laboratory capacity for rapid identifi-
\ncation of biological agents, providing medical and hospital services as well as
\nvaccines and drugs to control the epidemic.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-01-2012
\n4. C.\t\tENHANCEMENT\tOF\tMEDICAL\tPREPAREDNESS\tAND\tRESPONSE\tCAPACITY
\na.
\n1. The first indication that a biological weapon may have been disseminated is likely
\nto be the appearance of patients in the offices of practicing physicians, especially
\nthose in acute care settings. Physicians thus play a critical role in early detection of
\nan outbreak and must be prepared to recognize and deal with diseases resulting
\nfrom the use of biological weapons as well as other infectious disease agents and to
\npromptly report suspicious illnesses and diseases to public health officials.
\n2. In the course of an epidemic, physicians will be directly involved with mass patient
\ncare, with mass immunization and antibiotic prophylaxis, with providing informa-
\ntion to the public, and in a variety of hospital and community efforts to control the
\nepidemic. Thus, physicians should participate with local and national health
\nauthorities to develop and implement disaster preparedness and response plans for
\nintentional and natural infectious disease outbreaks.
\n5. D.\t\tBIOWEAPONS\tRESEARCH\tAND\tMEDICAL\tETHICS
\na.
\n1. Rapid advances in microbiology, molecular biology, and genetic engineering have
\ncreated extraordinary opportunities for biomedical research and hold great promise
\nfor improving human health and the quality of life. Better and more rapid diag-
\nnostic tools, novel vaccines, and therapeutic drugs can be foreseen. At the same
\ntime, there is concern about the possible misuse of research for the development of
\nmore potent biological weapons and the spread of new infectious diseases. It may
\nbe difficult to distinguish legitimate biomedical research from research by un-
\nscrupulous scientists with the malign purpose of producing more effective biologi-
\ncal weapons.
\n2. All who participate in biomedical research have a moral and ethical obligation to
\nconsider the implications of possible malicious use of their findings. Through
\ndeliberate or inadvertent means, genetic modification of microorganisms could
\ncreate organisms that are more virulent, are antibiotic-resistant, or have greater
\nstability in the environment. Genetic modification of microorganisms could alter
\ntheir immunogenicity, allowing them to evade natural- and vaccine-induced im-
\nmunity. Advances in genetic engineering and gene therapy may allow modification
\nof the immune response system of the target population to increase or decrease
\nsusceptibility to a pathogen or disrupt the functioning of normal host genes.
\n3. Research specifically for the purposes of creating biological weapons is to be
\ncondemned. As scientists and humanitarians, physicians have a societal respon-
\nsibility to decry scientific research for the development and use of biological wea-
\npons and to express abhorrence for the use of biotechnology and information
\ntechnologies for potentially harmful purposes.
\n4. Physicians and medical organizations have important societal roles in demanding a
\nglobal prohibition on biological weapons and stigmatizing their use, guarding
\nagainst unethical and illicit research, and mitigating civilian harm from use of
\nbiological weapons.<\/p>\n

D-2002-01-2012\t\u23d0\tPrague
\nBiological\tWeapons\t(Washington)
\n6. E.\t\tRECOMMENDATIONS
\na.
\n1. That the World Medical Association and National Medical Associations world-
\nwide take an active role in promoting an international ethos condemning the
\ndevelopment, production, or use of toxins and biological agents that have no justi-
\nfycation for prophylactic, protective, or other peaceful purposes.
\n2. That the World Medical Association, National Medical Associations and health-
\ncare workers worldwide promote, with the World Health Organization, the United
\nNations, and other appropriate entities, the establishment of an international con-
\nsortium of medical and public health leaders to monitor the threat of biological
\nweapons, to identify actions likely to prevent bioweapons proliferation, and to
\ndevelop a coordinated plan for monitoring the worldwide emergence of infectious
\ndiseases. This plan should address: (a) international monitoring and reporting sys-
\ntems so as to enhance the surveillance and control of infectious disease outbreaks
\nthroughout the world; (b) the development of an effective verification protocol
\nunder the UN Biological and Toxin Weapons Convention; (c) education of physi-
\ncians and public health workers about emerging infectious diseases and potential
\nbiological weapons; (d) laboratory capacity to identify biological pathogens; (e)
\navailability of appropriate vaccines and pharmaceuticals; and (f) financial, tech-
\nnical, and research needs to reduce the risk of use of biological weapons and other
\nmajor infectious disease threats.
\n3. That the World Medical Association urge physicians to be alert to the occurrence
\nof unexplained illnesses and deaths in the community and knowledgeable of
\ndisease surveillance and control capabilities for responding to unusual clusters of
\ndiseases, symptoms, or presentations.
\n4. That the World Medical Association encourage physicians, National Medical
\nAssociations and other medical societies to participate with local, national, and
\ninternational health authorities in developing and implementing disaster prepared-
\nness and response protocols for acts of bioterrorism and natural infectious disease
\noutbreaks. These protocols should be used as the basis for physician and public
\neducation.
\n5. That the World Medical Association urge all who participate in biomedical
\nresearch to consider the implications and possible applications of their work and to
\nweigh carefully in the balance the pursuit of scientific knowledge with their ethical
\nresponsibilities to society.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-02-2016
\nWMA\tDECLARATION
\nON
\nETHICAL\tCONSIDERATIONS\tREGARDING\tHEALTH\tDATABASES\tAND
\nBIOBANKS
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\n1. The Declaration of Helsinki lays down ethical principles for medical research involving
\nhuman subjects, including the importance of protecting the dignity, autonomy, privacy
\nand confidentiality of research subjects, and obtaining informed consent for using
\nidentifiable human biological material and data.
\n2. In health care provision, health information is gathered by physicians or other members
\nof the medical team to record health care events and to aid physicians in the on-going
\ncare of their patient.
\n3. This Declaration is intended to cover the collection, storage and use of identifiable data
\nand biological material beyond the individual care of patients. In concordance with the
\nDeclaration of Helsinki, it provides additional ethical principles for their use in Health
\nDatabases and Biobanks.
\nThis Declaration should be read as a whole and each of its constituent paragraphs should
\nbe applied with consideration of all other relevant paragraphs.
\n4. A Health Database is a system for collecting, organizing and storing health information.
\nA Biobank is a collection of biological material and associated data. Biological material
\nrefers to a sample obtained from an individual human being, living or deceased, which
\ncan provide biological information, including genetic information, about that individual.
\nHealth Databases and Biobanks are both collections on individuals and population, and
\nboth give rise to the similar concerns about dignity, autonomy, privacy, confidentiality
\nand discrimination.
\n5. Research using Health Databases and Biobanks can often significantly accelerate the
\nimprovement in the understanding of health, diseases, and the effectiveness, efficiency,
\nsafety and quality of preventive, diagnostic and therapeutic interventions. Health
\nresearch represents a common good that is in the interest of individual patients, as well<\/p>\n

D-2002-02-2016\u23d0\tTaipei
\nHealth\tDatabases\tand\tBiobanks
\nas the population and the society.
\n6. Physicians must consider the ethical, legal and regulatory norms and standards for
\nHealth Database and Biobanks in their own countries as well as applicable international
\nnorms and standards. No national or international ethical, legal or regulatory
\nrequirement should reduce or eliminate any of the protections for individuals and
\npopulation set forth in this Declaration.
\nWhen authorized by a national law adopted through a democratic process in respect of
\nhuman rights, other procedures could be adopted to protect the dignity, autonomy and
\nprivacy of the individuals. Such procedures are only acceptable when strict rules on data
\nprotection are implemented.
\n7. Consistent with the mandate of WMA, the Declaration is addressed primarily to
\nphysicians. The WMA encourages others who are involved in using data or biological
\nmaterial in Health Databases and Biobanks to adopt these principles.
\nETHICAL\tPRINCIPLES
\n8. Research and other Health Databases and Biobanks related activities should contribute
\nto the benefit of society, in particular public health objectives.
\n9. Respecting the dignity, autonomy, privacy and confidentiality of individuals, physicians
\nhave specific obligations, both ethical and legal, as stewards protecting information
\nprovided by their patients. The rights to autonomy, privacy and confidentiality also
\nentitle individuals to exercise control over the use of their personal data and biological
\nmaterial.
\n10. Confidentiality is essential for maintaining trust and integrity in Health Databases and
\nBiobanks. Knowing that their privacy will be respected gives patients and donors the
\nconfidence to share sensitive personal data. Their privacy is protected by the duty of
\nconfidentiality of all who are involved in handling data and biological material.
\n11. The collection, storage and use of data and biological material from individuals capable
\nof giving consent must be voluntary. If the data and biological material are collected for
\na given research project, the specific, free and informed consent of the participants must
\nbe obtained in accordance with the Declaration of Helsinki.
\n12. If the data or biological material are collected and stored in a Health Database or a
\nBiobank for multiple and indefinite uses, consent is only valid if the concerned
\nindividuals have been adequately informed about:
\n\u2022 The purpose of the Health Database or Biobank;
\n\u2022 The risks and burdens associated with collection, storage and use of data and<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-02-2016
\nmaterial;
\n\u2022 The nature of the data or material to be collected;
\n\u2022 The procedures for return of results including incidental findings;
\n\u2022 The rules of access to the Health Database or Biobank;
\n\u2022 How privacy is protected;
\n\u2022 The governance arrangements as stipulated in paragraph 21;
\n\u2022 That in case the data and material are made non-identifiable the individual may
\nnot be able to know what is done with their data\/material and that they will not
\nhave the option of withdrawing their consent;
\n\u2022 Their fundamental rights and safeguards established in this Declaration; and
\n\u2022 When applicable, commercial use and benefit sharing, intellectual property
\nissues and the transfer of data or material to other institutions or third countries.
\n13. In addition to the requirements set forth in the Declaration of Helsinki, when persons
\nwho were not able to consent, whose data and biological materials have been stored for
\nfuture research, attain or regain the capacity to consent, reasonable efforts should be
\nmade to seek the consent of those persons for continued storage and research use of their
\ndata and biological materials.
\n14. Individuals have the right to request for and be provided with information about their
\ndata and its use as well as to request corrections of mistakes or omissions. Health
\nDatabases and Biobanks should adopt adequate measures to inform the concerned
\nindividuals about their activities.
\n15. Individuals have the right, at any time and without reprisal, to alter their consent or to
\nask for their identifiable data to be withdrawn from the Health Database and their
\nbiological material to be withdrawn from a Biobank. This applies to future use of the
\ndata and biological materials.
\n16. In the event of a clearly identified, serious and immediate threat where anonymous data
\nwill not suffice, the requirements for consent may be waived to protect the health of the
\npopulation. An independent ethics committee should confirm that each exceptional case
\nis justifiable.
\n17. The interests and rights of the communities concerned, in particular when vulnerable,
\nmust be protected, especially in terms of benefit sharing.
\n18. Special considerations should be given to the possible exploitation of intellectual
\nproperty. Protections for ownership of materials, rights and privileges must be
\nconsidered and contractually defined before collecting and sharing the material.<\/p>\n

D-2002-02-2016\u23d0\tTaipei
\nHealth\tDatabases\tand\tBiobanks
\nIntellectual property issues should be addressed in a policy, which covers the rights of all
\nstakeholders and communicated in a transparent manner.
\n19. An independent ethics committee must approve the establishment of Health Databases
\nand Biobanks used for research and other purposes. In addition the ethics committee
\nmust approve use of data and biological material and check whether the consent given at
\nthe time of collection is sufficient for the planned use or if other measures have to be
\ntaken to protect the donor. The committee must have the right to monitor on-going
\nactivities. Other ethical review mechanisms that are in accordance to par 6 can be
\nestablished.
\nGOVERNANCE
\n20. In order to foster trustworthiness, Health Databases and Biobanks must be governed by
\ninternal and external mechanisms based on the following principles:
\n\u2022 Protection of individuals: Governance should be designed so the rights of
\nindividuals prevail over the interests of other stakeholders and science;
\n\u2022 Transparency: any relevant information on Health Databases and Biobanks must
\nbe made available to the public;
\n\u2022 Participation and inclusion: Custodians of Health Databases and Biobanks must
\nconsult and engage with individuals and their communities.
\n\u2022 Accountability: Custodians of Health Databases and Biobanks must be accessible
\nand responsive to all stakeholders.
\n21. Governance arrangements must include the following elements:
\n\u2022 The purpose of the Health Database or Biobank;
\n\u2022 The nature of health data and biological material that will be contained in the
\nHealth Database or Biobank;
\n\u2022 Arrangements for the length of time for which the data or material will be stored;
\n\u2022 Arrangements for regulations of the disposal and destruction of data or material;
\n\u2022 Arrangement for how the data and material will be documented and traceable in
\naccordance with the consent of the concerned persons;
\n\u2022 Arrangement for how the data and material will be dealt with in the event of
\nchange of ownership or closure;
\n\u2022 Arrangement for obtaining appropriate consent or other legal basis for data or
\nmaterial collection;
\n\u2022 Arrangements for protecting dignity, autonomy, privacy and preventing
\ndiscrimination;<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-02-2016
\n\u2022 Criteria and procedures concerning the access to and the sharing of the health
\ndata or biological material including the systematic use of Material Transfer
\nAgreement (MTA) when necessary;
\n\u2022 The person or persons who are responsible for the governance;
\n\u2022 The security measures to prevent unauthorized access or inappropriate sharing;
\n\u2022 The procedures for re-contacting participants where relevant;
\n\u2022 The procedures for receiving and addressing enquiries and complaints.
\n22. Those professionals contributing to or working with Health Databases and Biobanks
\nmust comply with the appropriate governance arrangements.
\n23. Health Databases and Biobanks must be operated under the responsibility of an
\nappropriately qualified professional assuring compliance with this Declaration.
\n24. The WMA urges relevant authorities to formulate policies and law that protect health
\ndata and biological material on the basis of the principles set forth in this document.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-03-2012
\nWMA\tDECLARATION
\nON
\nPATIENT\tSAFETY
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand reaffirmed by the 191st
\nWMA Council Session, Prague, Czech Republic, April 2012
\nPREAMBLE
\n1.
\n1. Physicians strive to provide the highest quality health and medical care to patients.
\nPatient safety is one of the core elements of quality in health and medical care.
\n2. Progress in medical and allied science and technology has transformed modern
\nmedicine into an advanced and complex health system.
\n3. Inherent risks have always existed in clinical medicine. Developments in modern
\nmedicine have resulted in new and sometimes greater risks – some avoidable, others
\ninherent.
\n4. Physicians should attempt to foresee these risks and manage them in the treatment of
\npatients.
\nPRINCIPLES
\n1.
\n1. Physicians must ensure that patient safety is always considered during medical
\ndecision-making.
\n2. Individuals and processes are rarely solely responsible for producing errors. Rather,
\nseparate elements combine and together produce a high-risk situation. Therefore,
\nthere should be a non-punitive culture for confidential reporting healthcare errors that
\nfocuses on preventing and correcting systems failures and not on individual or organi-
\nzation culpability.
\n3. A realistic understanding of the risks inherent in modern medicine requires that
\nphysicians must go beyond the professional boundaries of health care and cooperate
\nwith all relevant parties, including patients, to adopt a proactive systems approach to
\npatient safety.
\n4. To create such a systems approach, physicians must continuously absorb a wide range
\nof advanced scientific knowledge and continuously strive to improve medical practice.
\n5. All information that concerns a patient’s safety must be shared with all relevant
\nparties, including the patient. However, patient confidentiality must be strictly pro-
\ntected.<\/p>\n

Patient\tSafety
\nWashington,\tDC\t\u23d0\tD-2002-03-2002
\nRECOMMENDATIONS
\n1.
\n1. Hence, the WMA recommends the following to national medical associations:
\n1.
\n1. National medical associations should promote policies on patient safety to all
\nphysicians in their countries;
\n2. National medical associations should encourage individual physicians, other
\nhealth care professionals, patients and other relevant individuals and organiza-
\ntions to work together to establish systems that secure patient safety;
\n3. National medical associations should encourage the development of effective
\nmodels to promote patient safety through continuing medical education\/con-
\ntinuing professional development;
\n4. National medical associations should cooperate with one another and exchange
\ninformation about adverse events, including errors, their solutions, and \u00ab\u00a0lessons
\nlearned\u00a0\u00bb to improve patient safety.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2002-04-2012
\nWMA\tDECLARATION
\nON
\nMEDICAL\tETHICS\tAND\tADVANCED\tMEDICAL\tTECHNOLOGY
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand revised by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nIt is essential to balance the benefits and risks for persons inherent in the development and
\napplication of advanced medical technology. Maintaining this balance is entrusted to the
\njudgment of the physician.
\nTherefore:
\nMedical technology should be used to promote health. Patient safety should be fully
\nconsidered by the physician in the development and application of medical technology.
\nIn order to foster physicians’ ability to provide appropriate medical care and having
\nsufficient knowledge of medical technology efforts must be made to ensure the provision
\nof comprehensive medical education focusing on the safe and effective use and develop-
\nment of medical technology.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2008-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION
\nOF\tSEOUL\tON
\nPROFESSIONAL\tAUTONOMY
\nAND\tCLINICAL\tINDEPENDENCE
\nAdopted by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nAnd amended by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nThe WMA reaffirms the Declaration of Madrid on professionally-led regulation.
\nThe World Medical Association recognises the essential nature of professional autonomy
\nand physician clinical independence, and states that:
\n1. Professional autonomy and clinical independence are essential elements in
\nproviding quality health care to all patients and populations. Professional
\nautonomy and independence are essential for the delivery of high quality health
\ncare and therefore benefit patients and society.
\n2. Professional autonomy and clinical independence describes the processes under
\nwhich individual physicians have the freedom to exercise their professional
\njudgment in the care and treatment of their patients without undue or inappropriate
\ninfluence by outside parties or individuals.
\n3. Medicine is highly complex. Through lengthy training and experience, physicians
\nbecome medical experts weighing evidence to formulate advice to patients.
\nWhereas patients have the right to self-determination, deciding within certain
\nconstraints which medical interventions they will undergo, they expect their
\nphysicians to be free to make clinically appropriate recommendations.
\n4. Physicians recognize that they must take into account the structure of the health
\nsystem and available resources when making treatment decisions. Unreasonable
\nrestraints on clinical independence imposed by governments and administrators are
\nnot in the best interests of patients because they may not be evidence based and
\nrisk undermining trust which is an essential component of the patient-physician
\nrelationship.
\n5. Professional autonomy is limited by adherence to professional rules, standards and
\nthe evidence base.
\n6. Priority setting and limitations on health care coverage are essential due to limited
\nresources. Governments, health care funders (third party payers), administrators
\nand Managed Care organisations may interfere with clinical autonomy by seeking
\nto impose rules and limitations. These may not reflect evidence-based medicine
\nprinciples, cost-effectiveness and the best interest of patients. Economic evaluation
\nstudies may be undertaken from a funder\u2019s not a users\u2019 perspective and emphasise
\ncost-savings rather than health outcomes.
\n7. Priority setting, funding decision making and resource allocation\/limitations<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2002-02-2002\t\u23d0\tWorld\tMedical\tAssociation
\nprocesses are frequently not transparent. A lack of transparency further perpetuates
\nhealth inequities.
\n8. Some hospital administrators and third-party payers consider physician
\nprofessional autonomy to be incompatible with prudent management of health care
\ncosts. Professional autonomy allows physicians to help patients make informed
\nchoices, and supports physicians if they refuse demands by patients and family
\nmembers for access to inappropriate treatments and services.
\n9. Care is given by teams of health care professionals, usually led by physicians. No
\nmember of the care team should interfere with the professional autonomy and
\nclinical independence of the physician who assumes the ultimate responsibility for
\nthe care of the patient. In situations where another team member has clinical
\nconcerns about the proposed course of treatment, a mechanism to voice those
\nconcerns without fear of reprisal should exist.
\n10. The delivery of health care by physicians is governed by ethical rules, professional
\nnorms and by applicable law. Physicians contribute to the development of
\nnormative standards, recognizing that this both regulates their work as
\nprofessionals and provides assurance to the public.
\n11. Ethics committees, credentials committees and other forms of peer review have
\nlong been established, recognised and accepted by organised medicine as ways of
\nscrutinizing physicians\u2019 professional conduct and, where appropriate, may impose
\nreasonable restrictions on the absolute professional freedom of physicians.
\n12. The World Medical Association reaffirms that professional autonomy and clinical
\nindependence are essential components of high quality medical care and the
\npatient-physician relationship that must be preserved. The WMA also affirms that
\nprofessional autonomy and clinical independence are core elements of medical
\nprofessionalism.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2009-01-2017
\nWMA\tDECLARATION\tOF\tDELHI
\nON
\nHEALTH\tAND\tCLIMATE\tCHANGE
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nand amended by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE\t<\/p>\n

1. Human influence on the climate system is clear, and recent emissions of green-
\nhouse gases are the highest in history. Recent climate changes have had
\nwidespread impacts on human and natural systems.
\n2. Compelling evidence substantiates the numerous health risks posed by climate
\nchange, which threaten all countries. These include more frequent and potentially
\nmore severe heatwaves, droughts, floods and other extreme weather events
\nincluding storms and bushfires. Climate change, especially warming, is already
\nleading to changes in the environment in which disease vectors flourish. There is
\nreduced availability and quality of potable water, and worsening food insecurity
\nleading to malnutrition and population displacement. Climate Change is universal
\nbut its effects are uneven and many of the areas most affected are least able to
\nmanage the challenges it poses.
\n3. Tackling climate change offers opportunities to improve health and wellbeing both
\nbecause of the health co-benefits of low carbon solutions and because mitigation
\nand adaptation may allow action on all the social determinants of health.
\nTransition to renewable energy, the use of active transport, and dietary change
\nincluding a reduction in consumption of beef and other animal products, may all
\ncontribute to improving health and wellbeing.
\n4. The social determinants of health are those factors that correlate to health through
\nexposure before and after people are born and as they grow live, and work. They
\nvary between and within countries. Those with generally the poorest health and
\nlowest life and health expectancy will be least able to adapt to the adverse effects
\nof climate change thereby exacerbating adverse social determinants of health.
\n5. Climate change research and surveillance is important. The WMA supports studies
\nthat describe the patterns of disease attributed to climate change, including the
\nimpacts of climate change on communities and households; the burden of known
\nand emergent disease caused by climate change, and those diseases projected to<\/p>\n

D-2009-01-2017\t\u23d0\tChicago
\nClimate\tChange
\noccur with new development activities (Health Impacts Assessment). Such studies
\nshould also define the most vulnerable populations.
\n6. The Paris Agreement highlights a transition to a new model of global collaboration
\nto address climate change and is an opportunity for the health sector to contribute
\nto climate action. It includes a series of actions to be undertaken by each party to
\nachieve a long-term goal of keeping the increase in global average temperature to
\nless than 1.5 C above pre-industrial levels. Whether or not individual states are
\nparties to the Paris agreement, NMAs have an obligation to consider the effects of
\nclimate change on the planet and on human, animal, and environmental
\nsustainability and to take action as follows.
\nRECOMMENDATIONS
\n7. The World Medical Association and its Constituent Members:
\n\u2022 Urge national governments and non-state actors to recognize the serious health
\nconsequences of climate change and to adopt strategies to adapt to and mitigate
\nits effects;
\n\u2022 Urge national governments to ensure the fulfilment of national commitments to
\ninternational agreements, including both mitigation and adaptation measures as
\nwell as action on losses and damage;
\n\u2022 Urges national governments to provide climate financing that includes
\ndesignated funds to support the strengthening of health systems, and health and
\nclimate co-benefit policies and, provide sufficient global, regional and local
\nfinancing for climate mitigation, adaptation measures, disaster risk reduction,
\nand the attainment of the Sustainable Development Goals (SDGs);
\n\u2022 Urge national governments to facilitate the active participation of health sector
\nrepresentatives in the creation and implementation of climate change
\npreparedness plans and emergency planning and response on local, national
\nand international levels;
\n\u2022 Urge national governments to provide for the health and wellbeing of people
\ndisplaced by environmental causes including those becoming refugees due to
\nthe consequences of climate change;
\n\u2022 Asks national governments to invest in public health and climate change
\nresearch to ensure of better understanding of adaptation needs and health co-
\nbenefits at national level;
\n\u2022 Urge national governments to facilitate collaboration between Ministry of
\nHealth and other ministries to ensure that health is considered in their national
\ncommitments and sustainable strategies.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2009-01-2017
\n8. National Medical Associations and their physician members should:
\n\u2022 Advocate for sustainable, environmentally responsible low-carbon practices
\nacross the health sector to reduce the environmental impact of health care
\nfacilities and practices;
\n\u2022 Prepare for the infrastructure disruptions that accompany health emergencies,
\nin particular by planning in advance for the delivery of services and increased
\npatient care demands during these crisis situations;
\n\u2022 Encourage and support advocacy for environmental protection and greenhouse
\ngas emissions reductions including through emissions trading systems and\/or
\ncarbon taxes;
\n\u2022 Become educated as to the health effects of climate change and be prepared to
\ntreat and manage them in individual patients;
\n\u2022 Promote medical research into improved use of antibiotherapy to be able to
\nrespond, in the future, to the new infectious diseases linked to climate change.
\n9. The WMA and its Constituent Members should:
\n\u2022 Encourage sustainable low-carbon living respectful of planetary limits
\nincluding active lifestyle and sustainable production and consumption patterns;
\n\u2022 Seek to build professional and public awareness of the importance of the
\nenvironment and climate change to personal, community and societal health;
\n\u2022 Work towards the integration of key climate change concepts and
\ncompetencies in undergraduate, graduate and continuing medical education
\ncurricula;
\n\u2022 Collaborate with the WHO and other stakeholders as appropriate, to produce
\neducational and advocacy materials on climate change for national medical
\nassociations, physicians, other health professionals, as well as the general
\npublic;
\n\u2022 Advocate for their respective governments to finance, promote research into
\nthe effects of climate change on health and collaborate with NGOs and other
\nhealth professionals;
\n\u2022 Work collaboratively with government, NGOs, businesses, civil societies and
\nothers to create alert systems to ensure that health care systems and physicians
\nare aware of climate-related events as they unfold, and receive timely accurate
\ninformation regarding the management of emerging health events;
\n\u2022 Have climate change as a priority issue on their agendas and actively
\nparticipate in the creation of policies and initiatives that mitigate the effects of<\/p>\n

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\nClimate\tChange
\nclimate change on health.
\n10. The WMA urges National Medical Associations to:
\n\u2022 Work with health-care institutions, and individual physicians to adopt climate
\npolicies and act as role models by reducing their carbon emissions;
\n\u2022 Recognize environmental factors as a key social determinants of health (SDH),
\nand encourage governments to foster collaboration between the health and non-
\nhealth sectors in addressing these determinants.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2009-02-2009\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tMADRID
\nON
\nPROFESSIONALLY-LED\tREGULATION
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nThe collective action by the medical profession seeking for the benefit of patients, in
\nassuming responsibility for implementing a system of professionally-led regulation will
\nenhance and assure the individual physician’s right to treat patients without interference,
\nbased on his or her best clinical judgment. Therefore, the WMA urges the national medical
\nassociations and all physicians to take the following actions.
\n1. Physicians have been granted by society a high degree of professional autonomy and
\nclinical independence, whereby they are able to make recommendations based on the
\nbest interests of their patients without undue outside influence.
\n2. As a corollary to the right of professional autonomy and clinical independence, the
\nmedical profession has a continuing responsibility to be self-regulating. Ultimate con-
\ntrol and decision-making authority must rest with physicians, based on their specific
\nmedical training, knowledge, experience and expertise.
\n3. Physicians in each country are urged to establish, maintain and actively participate in
\na legitimate system of professionally-led regulation. This dedication is to ultimately
\nassure full clinical independence in patient care decisions.
\n4. To avoid being influenced by the inherent potential conflicts of interest that will arise
\nfrom assuming both representational and regulatory duties, National Medical Associa-
\ntions must do their utmost to promote and support the concept of professionally-led
\nregulation amongst their membership and the public.
\n5. Any system of professionally-led regulation must ensure
\na) the quality of the care provided to patients,
\nb) the competence of the physician providing that care and
\nc) the professional conduct of physician.
\nTo ensure the patient quality continuing care, physicians must participate actively in
\nthe process of Continuing Professional Development in order to update and maintain
\ntheir clinical knowledge, skills and competence.
\n6. The professional conduct of physicians must always be within the bounds of the Code
\nof Ethics governing physicians in each country. National Medical Associations must
\npromote professional and ethical conduct among physicians for the benefit of their
\npatients. Ethical violations must be promptly recognized and reported. The physicians
\nwho have erred must be appropriately disciplined and where possible be rehabilitated.<\/p>\n

D-2009-01-2017\t\u23d0\tChicago
\nClimate\tChange
\n7. National Medical Associations are urged to assist each other in coping with new and
\ndeveloping problems, including potential inappropriate threats to professionally-led
\nregulation. The ongoing exchange of information and experiences between National
\nMedical Associations is essential for the benefit of patients.
\n8. An effective and responsible system of professionally-led regulation by the medical
\nprofession in each country must not be self serving or internally protective of the pro-
\nfession, and the process must be fair, reasonable and sufficiently transparent to ensure
\nthis. National Medical Associations should assist their members in understanding that
\nself-regulation cannot only be perceived as being protective of physicians, but must
\nmaintain the safety, support and confidence of the general public as well as the ho-
\nnour of the profession itself.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-01-2011\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tMONTEVIDEO
\nON
\nDISASTER\tPREPAREDNESS\tAND\tMEDICAL\tRESPONSE
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nIn the last decade, the attention of the world has been drawn to a number of severe events
\nwhich seriously tested and overwhelmed the capacity of local healthcare and emergency
\nmedical response systems. Armed conflicts, terrorist attacks and natural distasters such as
\nearthquakes, floods and tsunamies in various parts of the world have not only affected the
\nhealth of people living in these areas but have also drawn the support and response of the
\ninternational community. Many National Medical Associations have sent groups to assist
\nin such disaster situations.
\nAccording to the World Health Organization (WHO) Center for Research on the Epide-
\nmiology of Disasters (CRED), the frequency, magnitude, and toll of natural disasters and
\nterrorism have increased throughout the world. In the previous century, about 3.5 million
\npeople were killed worldwide as a result of natural disasters; about 200 million were killed
\nas a result of human-caused disasters (e.g., wars, terrorism, genocides). Each year, dis-
\nasters cause hundreds of deaths and cost billions of dollars due to disruption of commerce
\nand destruction of homes and critical infrastructure.
\nPopulation vulnerability (e.g., due to increased population density, urbanization, aging)
\nhas increased the risk of disasters and public health emergencies. Globalization, which
\nconnects countries through economic interdependencies, has led to increased international
\ntravel and commerce. Such activity has also led to increased population density in cities
\naround the world and increased movement of people to coastal areas and other disaster-
\nprone regions. Increases in international travel may speed the rate at which an emerging
\ninfectious disease or bioterrorism agent spreads across the globe. Climate change and ter-
\nrorism have emerged as important global factors that can influence disaster trends and thus
\nrequire continued monitoring and attention.
\nThe emergence of infectious diseases, such as H1N1 influenza A and severe acute respi-
\nratory syndrome (SARS), and the recent arrival of West Nile virus and monkey pox in the
\nWestern hemisphere, reinforces the need for constant vigilance and planning to prepare for
\nand respond to new and unexpected public health emergencies.
\nThe growing likelihood of terrorist-related disasters affecting large civilian populations
\naffects all nations. Concern continues about the security of the worldwide arsenal of nu-
\nclear, chemical, and biological agents as well as the recruitment of people capable of manu-
\nfacturing or deploying them. The potentially catastrophic nature of a \u00ab\u00a0successful\u00a0\u00bb terrorist
\nattack configures an event that may demand a disproportionate amount of resources and
\nhealthcare professionals preparedness. Natural disasters such as tornadoes, hurricanes,<\/p>\n

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\nClimate\tChange
\nfloods, and earthquakes, as well as industrial and transportation-related catastrophes, are
\nfar more common and can also severely stress existing medical, public health, and emer-
\ngency response systems.
\nIn light of recent world events, it is increasingly clear that all physicians need to become
\nmore proficient in the recognition, diagnosis, and treatment of mass casualties under an
\nall-hazards approach to disaster management and response. They must be able to recog-
\nnize the general features of disasters and public health emergencies, and be knowledgeable
\nabout how to report them and where to get more information should the need arise. Physi-
\ncians are on the front lines when dealing with injury and disease-whether caused by mi-
\ncrobes, environmental hazards, natural disasters, highway collisions, terrorism, or other
\ncalamities. Early detection and reporting are critical to minimize casualties through astute
\nteamwork by public- and private-sector health and emergency response personnel.
\nThe WMA, representing the doctors of the world, calls upon its members to advocate for
\nthe following:
\n\u2022 To promote a standard competency set to ensure consistency among disaster
\ntraining programs for physicians across all specialties. Many NMAs have dis-
\naster courses and previous experiences in disaster response. These NMAs can
\nshare this knowledge and advocate for the integration of some standardized
\nlevel of training for all physicians, regardless of specialty or nationality.
\n\u2022 To work with national and local governments to establish or update regional
\ndatabases and geographic mapping of information on health system assets, ca-
\npacities, capabilities, and logistics to assist medical response efforts, domesti-
\ncally and worldwide, when needed. This could include information on local
\nresponse organizations, the condition of local hospitals and health system infra-
\nstructures, endemic and emerging diseases, and other important public health
\nand clinical information to assist medical response in the event of a disaster. In
\naddition, systems for communicating directly with physicians and other front
\nline health care providers should be identified and strengthened.
\n\u2022 To work with national and local governments to ensure the developing and
\ntesting of disaster management plans for clinical care and public health includ-
\ning the ethical basis for delivering such plans.
\n\u2022 To encourage governments at national and local levels to work across normal
\ndepartmental and other boundaries in developing the necessary planning.
\nThe WMA could serve as a channel of communication for NMAs during such times of
\ncrisis, enabling them to coordinate activities and work together.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-02-2011\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION
\nON
\nEND-OF-LIFE\tMEDICAL\tCARE
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nINTRODUCTION\t<\/p>\n

All people have the right to high-quality, scientifically-based, and humane healthcare.
\nTherefore, receiving appropriate end-of-life medical care must not be considered a pri-
\nvilege but a true right, independent of age or any other associated factors. The WMA reaf-
\nfirms the principles articulated in the WMA Declaration on Terminal illness and the
\nWMA Declaration on Euthanasia. These Declarations support and complement the Decla-
\nration on End of Life Medical Care.
\nPalliative care at the end of life is part of good medical care. The need for access to
\nimproved quality palliative care is great, especially in resource-poor countries. The objec-
\ntive of palliative care is to achieve the best possible quality of life through appropriate
\npalliation of pain and other distressing physical symptoms, and attention to the social, psy-
\nchological and spiritual needs of the patient.
\nPalliative care may be provided at home as well as in various levels of health care insti-
\ntutions.
\nThe physician must adopt an attitude to suffering that is compassionate and humane, and
\nact with empathy, respect and tact. Abandonment of the patient when he or she needs such
\ncare is unacceptable medical practice.
\nRECOMMENDATIONS\t<\/p>\n

1.\t\tPain\tand\tsymptom\tmanagement\t<\/p>\n

1.1 It is essential to identify patients approaching the end of life as early as possible so
\nthat the physician can perform a detailed assessment of their needs. A care plan for
\nthe patient must always be developed; whenever possible, this care plan will be de-
\nveloped in direct consultation with the patient.
\nFor some this process may begin months or a year before death is anticipated. It
\nincludes recognising and addressing the likelihood of pain and other distressing
\nsymptoms and providing for patients’ social, psychological and spiritual needs in
\nthe time remaining to them. The primary aim is to maintain patients’ dignity and
\ntheir freedom from distressing symptoms. Care plans pay attention to keeping them
\nas comfortable and in control as possible and recognise the importance of sup-
\nporting the family and treating the body with respect after death.<\/p>\n

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\nD-2011-02-2011\t\u23d0\tWorld\tMedical\tAssociation
\n1.2 Important advances in the relief of pain and other distressing symptoms have been
\nmade. The appropriate use of morphine, new analgesics, and other measures can
\nsuppress or relieve pain and other distressing symptoms in the majority of cases.
\nThe appropriate health authorities must make necessary medications accessible and
\navailable to physicians and their patients. Physician groups should develop guide-
\nlines on their appropriate use, including dose escalation and the possibility of unin-
\ntended secondary effects.
\n1.3 In a very limited number of cases, generally in the very advanced stages of a phy-
\nsical illness, some symptoms may arise that are refractory to standard therapy. In
\nsuch cases, palliative sedation to unconsciousness may be offered when life ex-
\npectancy is a few days, as an extraordinary measure in response to suffering which
\nthe patient and clinician agree is intolerable. Palliative sedation must never be used
\nto intentionally cause a patient’s death or without the agreement of a patient who
\nremains mentally competent. The degree and timing of palliative sedation must be
\nproportionate to the situation. The dosage must be carefully calculated to relieve
\nsymptoms but should still be the lowest possible to achieve a benefit.
\n2.\t\tCommunication\tand\tconsent;\tethics\tand\tvalues\t<\/p>\n

2.1 Information and communication among the patient, their family and members of
\nthe health care team is one of the fundamental pillars of quality care at the end of
\nlife. The patient should be encouraged to express his or her preferences regarding
\ncare, and his or her emotions and existential angst must be taken into considera-
\ntion.
\n2.2 Ethically-appropriate care at the end of life should routinely promote patient auto-
\nnomy and shared decision-making, and be respectful of the values of the patient
\nand his or her family.
\n2.3 Physicians should directly discuss a patient’s preferences with the patient and\/or
\nthe patient’s substitute health care decision maker, as appropriate. These discus-
\nsions should be initiated early and routinely offered to all patients and should be
\nrevisited regularly to explore any changes patients may have in their wishes, espe-
\ncially as their clinical conditions change. Physicians should encourage their pa-
\ntients to formally document their goals, values and treatment preferences and to
\nappoint a substitute health care decision maker with whom the patient can discuss
\nin advance his or her values regarding health care and treatment. Patients who are
\nin denial about the implications of their condition may not want to engage in such
\ndiscussion at some stages of their illness, but should know that they can change
\ntheir minds. Because documented advance directives are often not available in
\nemergency situations, physicians should emphasize to patients the importance of
\ndiscussing treatment preferences with individuals who are likely to act as substitute
\nhealth care decision makers.
\n2.4 If a patient is capable of giving consent, care should be based on the patient’s wishes
\nas long as preferences can be justified medically, ethically and legally. Consent
\nneeds to be based on sufficient information and dialogue, and it is the physician’s<\/p>\n

Montevideo\t\u23d0\tD-2011-02-2011
\nEnd-of-Life\tMedical\tCare
\nobligation to make sure that the patient is adequately treated for pain and dis-
\ncomfort before consent is obtained in order to assure that unnecessary physical and
\nmental suffering do not interfere with the decision-making process.
\n2.5 The patient’s next-of-kin or family should be informed and involved in the deci-
\nsion-making process, provided the patient is not opposed to this. If the patient is
\nunable to express consent and an advance directive is not available, the views of
\nthe health care substitute decision maker, appointed by the patient on care and
\ntreatment, must be considered.
\n3.\t\tMedical\trecords\tand\tmedico-legal\taspects
\n3.1 Physicians caring for a patient in the final stages of life must carefully document
\ntreatment decisions and the reasons for choosing particular procedures, including
\nthe patient’s and family’s wishes and consent, in the progress notes of the medical
\nrecords. An adequate medical record is of the utmost importance for continuity and
\nquality of medical care in general and palliative care in particular.
\n3.2 The physician must also take into account that these notes may serve a medico-
\nlegal purpose, e.g., in determining the patient’s decision-making capacity.
\n4.\t\tFamily\tmembers
\nIt is necessary to acknowledge the importance of the family and the emotional environ-
\nment of the patient. The needs of the family and other close caregivers throughout the
\ncourse of the illness must be recognized and attended to. The heath care team should pro-
\nmote collaboration in the care of the patient and provide bereavement support, when re-
\nquired, after the patient’s death. Children’s and families’ needs may require special atten-
\ntion and competence, both when children are patients and dependents.
\n5.\t\tTeamwork\t<\/p>\n

Palliative care is usually provided by multiprofessional and interdisciplinary teams of
\nhealthcare and non-healthcare professions. The physician must be the leader of the team,
\nbeing responsible, amongst other obligations, for diagnosis and medical treatment. Conti-
\nnuity of care is very important. The team should do all it can to facilitate a patient’s wish
\nto die at home, if applicable and possible.
\n6.\t\tPhysician\ttraining
\nThe increasing number of people who require palliative care and the increased availability
\nof effective treatment options mean that end-of-life care issues should be an important part
\nof undergraduate and postgraduate medical training.
\n7.\t\tResearch\tand\teducation
\nMore research is needed to improve palliative care. This includes, but is not limited to, ge-
\nneral medical care, specific treatments, psychological implications and organization. The
\nWMA will support efforts to better educate physicians in the skills necessary to increase
\nthe prevalence and quality of meaningful advance care planning.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-02-2011\t\u23d0\tWorld\tMedical\tAssociation
\nCONCLUSION\t<\/p>\n

The care that a people give to dying patients, within available resources, is an indication of
\ntheir degree of civilisation. As physicians representing the best humanitarian tradition, we
\nshould always commit ourselves to delivering the best possible end-of-life care.
\nThe WMA recommends that all National Medical Associations develop a national policy
\non palliative care and palliative sedation based on the recommendations in this declara-
\ntion.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-03-2011\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION
\nON
\nLEPROSY\tCONTROL\tAROUND\tTHE\tWORLD\tAND
\nELIMINATION\tOF\tDISCRIMINATION
\nAGAINST\tPERSONS\tAFFECTED\tBY\tLEPROSY
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nLeprosy is a widespread public health problem, with approximately 250,000 new cases
\ndiagnosed annually worldwide. It is a curable disease and after starting treatment, the
\nchain of transmission is interrupted. Leprosy is a disease that have been inadequately ad-
\ndressed from the point of view of investments in research and medical treatment.
\nThe World Medical Association recommends to all National Medical Associations to de-
\nfend the right of the people affected with leprosy and members of their families, that they
\nshould be treated with dignity and free from any kind of prejudice or discrimination. Phy-
\nsicians, health professionals and civil society should be engaged in combating all forms of
\nprejudice and discrimination. Research centers should acknowledge leprosy as a major
\npublic health problem, and continue to research this disease since there are still gaps in
\nunderstanding its patho-physiological mechanisms. These gaps in knowledge may be over-
\ncome through the allocation of resources to new research, which will contribute to more
\nefficient control worldwide. Medical schools, especially in countries with high preval-
\nence of leprosy, should enhance its importance in the curriculum. The public, private, and
\ncivil sectors should unify their best efforts in order to disseminate information that would
\ncounteract prejudice towards leprosy and that acknowledges its curability.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-04-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tOSLO
\nON
\nSOCIAL\tDETERMINANTS\tOF\tHEALTH
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nand the title (Statement to Declaration) changed by the 66th
\nWMA General Assembly,
\nMoscow, Russia, October 2015
\nThe social determinants of health are: the conditions in which people are born, grow, live,
\nwork and age; and the societal influences on these conditions. The social determinants of
\nhealth are major influences on both quality of life, including good health, and length of
\ndisability-free life expectancy. While health care will attempt to pick up the pieces and
\nrepair the damage caused by premature ill health, it is these social, cultural, environ-
\nmental, economic and other factors that are the major causes of rates of illness and, in
\nparticular, the magnitude of health inequalities.
\nHistorically, the primary role of doctors and other health care professionals has been to
\ntreat the sick – a vital and much cherished role in all societies. To a lesser extent, health
\ncare professionals have dealt with individual exposures to the causes of disease – smoking,
\nobesity, and alcohol in chronic disease, for example. These familiar aspects of life style
\ncan be thought of as \u2018proximate’ causes of disease.
\nThe work on social determinants goes far beyond this focus on proximate causes and
\nconsiders the \u00ab\u00a0causes of the causes\u00a0\u00bb. For example, smoking, obesity, alcohol, sedentary
\nlife style are all causes of illness. A social determinants approach addresses the causes of
\nthese causes; and in particular how they contribute to social inequalities in health. It
\nfocuses not only on individual behaviours but seeks to address the social and economic
\ncircumstances that give rise to premature ill health, throughout the life course: early child
\ndevelopment, education, work and living conditions, and the structural causes that give
\nrise to these living and working conditions. In many societies, unhealthy behaviours fol-
\nlow the social gradient: the lower people are in the socioeconomic hierarchy, the more
\nthey smoke, the worse their diet, and the less physical activity they engage in. A major,
\nbut not the only, cause of the social distribution of these causes is level of education.
\nOther specific examples of addressing the causes of the causes: price and availability,
\nwhich are key drivers of alcohol consumption; taxation, package labeling, bans on
\nadvertising, and smoking in public places, which have had demonstrable effects on
\ntobacco consumption. The voice of the medical profession has been most important in
\nthese examples of tackling the causes of the causes.
\nThere is a growing movement, globally, that seeks to address gross inequalities in health
\nand length of life through action on the social determinants of health. This movement has
\ninvolved the World Health Organisation, several national governments, civil society organi-
\nzation, and academics. Solutions are being sought and learning shared. Doctors should be\t<\/p>\n

Moscou\t\u23d0\tD-2011-04-2015
\nSocial\tDeterminants\tof\tHealth
\nwell informed participants in this debate. There is much that can happen within the prac-
\ntice of medicine that can contribute directly and through working with other sectors. The
\nmedical profession can be advocates for action on those social conditions that have im-
\nportant effects on health.
\nThe WMA could add significant value to the global efforts to address these social deter-
\nminants by helping doctors, other health professionals and National Medical Associations
\nunderstand what the emerging evidence shows and what works, in different
\ncircumstances. It could help doctors to lobby more effectively within their countries and
\nacross interna-tional borders, and ensure that medical knowledge and skills are shared.
\nThe WMA should help to gather data of examples that are working, and help to engage
\ndoctors and other health professionals in trying new and innovative solutions. It should
\nwork with national associations to educate and inform their members and put pressure on
\nnational governments to take the appropriate steps to try to minimise these root causes of
\npremature ill health. In Britain, for example, the national government has issued a public
\nhealth white paper that has at its heart reduction of health inequalities through action on
\nthe social determinants of health; several local areas have drawn up plans of action; there
\nare good examples of general practice that work across sectors improve the quality of
\npeople’s lives and hence reduce health inequalities. The WMA should gather examples of
\ngood practice from its members and promote further work in this area.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tD-2014-01-2014
\nWMA\tDECLARATION
\nON
\nTHE\tPROTECTION\tOF\tHEALTH\tCARE\tWORKERS
\nIN\tSITUATION\tOF\tVIOLENCE
\nAdopted by the 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nPREAMBLE
\nThe right to health is a fundamental element of human rights which does not change in
\nsituations of conflict and violence. Access to medical assistance for the sick and wounded,
\nwhether they have been engaged in active combat or not, is guaranteed through various
\ninternational agreements, including the Geneva Convention and the Basic Principles on
\nthe Use of Force and Firearms by Law Enforcement Officials of the United Nations.
\nThe primary obligation of physicians is always to their patients, and physicians have the
\nsame ethical responsibilities to preserve health and save life in situations of violence or
\narmed conflicts as in peacetime. These are as set out in the WMA Regulations in Times of
\nArmed Conflict and Other Situations of Violence.
\nIt is essential to ensure the safety and personal security of healthcare workers in order to
\nenable the provision of the highest standard of care to patients. If healthcare workers are
\nnot safe, they might not be able to provide care, and patients will suffer.
\nIn situations of violence, the delivery of healthcare is frequently obstructed and the sick
\nand wounded deprived of essential treatment through:
\n1. Medical workers being prevented from attending to the injured;
\n2. Interference by the state or others in positions of power through intimidation, de-
\ntention or other legal measures;
\n3. Patients being denied access to medical facilities;
\n4. Targeted attacks upon medical facilities and medical transport;
\n5. Targeted attacks upon medical personnel, including kidnapping;
\n6. Non-targeted violent acts which result in the damage to or destruction of facilities
\nor vehicles, or cause injury or death to medical personnel.
\nSuch actions have serious humanitarian implications and violate international standards of
\nmedical neutrality as set out in the provisions of international human rights and human-
\nitarian law and codes of medical ethics.<\/p>\n

Durban\u23d0\tD-2014-01-2014
\nProtection\tof\tHealthcare\tWorkers
\nAttacks on the fundamental ethical principles of the medical profession, such as attempts
\nto coerce medical professionals into providing details regarding those under their care, can
\nundermine the confidence of patients and discourage injured people from seeking neces-
\nsary treatment.
\nRECOMMENDATIONS
\nThe WMA calls upon governments and all parties involved in situations of violence to:
\n1. Ensure the safety, independence and personal security of healthcare personnel at
\nall times, including during armed conflicts and other situations of violence, in ac-
\ncordance with the Geneva Conventions and their additional protocols;
\n2. Enable healthcare personnel to attend to injured and sick patients, regardless of
\ntheir role in a conflict, and to carry out their medical duties freely, independently
\nand in accordance with the principles of their profession without fear of punish-
\nment or intimidation;
\n3. Safe access to adequate medical facilities for the injured and others in need of
\nmedical aid should not be unduly impeded;
\n4. Protect medical facilities, medical transport and the people being treated in them
\nand provide the safest possible working environment for healthcare workers and
\nprotect them from interference and attack;
\n5. Respect and promote the principles of international humanitarian and human rights
\nlaw which safeguard medical neutrality in situations of conflict;
\n6. Establish reporting mechanisms to document violence against medical personnel
\nand facilities as set out in the WMA Statement on the Protection and Integrity of
\nMedical Personnel in Armed Conflicts and Other Situations of Violence.
\n7. Raise awareness of international norms on the protection of healthcare workers and
\ncooperate with different actors to identify strategies to tackle threats to healthcare.
\nThe collaboration between the WMA and the International Committee of the Red
\nCross on the Health Care in Danger project provides one example of this.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2015-01-2017
\nWMA\tDECLARATION
\nON
\nALCOHOL
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nand revised by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\n1. The burden of disease and injury associated with alcohol consumption is a critical
\nchallenge to global public health and development around the world. The World
\nMedical Association offers this declaration on alcohol as its commitment to
\nreducing excessive alcohol consumption and as a means to support its members in
\npromulgating harm-reduction policies and other measures.
\n2. There are significant health, social and economic problems associated with
\nexcessive alcohol use. Overall, there are causal relationships between alcohol
\nconsumption and more than 200 types of disease and injury including traffic
\nfatalities. The harmful use of alcohol kills approximately 3.3 million people every
\nyear (5.9 % of all deaths worldwide), and is the third leading risk factor for poor
\nhealth globally, accounting for 5.1 % of disability-adjusted life years lost. Beyond
\nthe numerous chronic and acute health effects, alcohol use is associated with
\nwidespread social, mental and emotional consequences. The problem has a special
\nmagnitude among young people and adolescents who are beginning to consume
\nalcohol at earlier ages, and the risk to their physical, mental and social health is of
\nconcern.
\n3. Although alcohol consumption is deeply rooted in many societies, alcohol cannot
\nbe considered an ordinary beverage or consumer commodity. It is a substance that
\ncauses extensive medical, psychological and social harm by means of physical
\ntoxicity, intoxication and dependence.
\nThere is increasing evidence that genetic vulnerability to alcohol dependence is a
\nrisk factor for some individuals. Foetal alcohol syndrome and foetal alcohol
\neffects, preventable causes of intellectual disability, result from alcohol
\nconsumption during pregnancy.
\nAdolescence is a stage of significant vulnerability because the neurological
\ndevelopment is not complete and alcohol has a negative impact on it. Growing
\nscientific evidence has demonstrated the harmful effects of consumption prior to
\nadulthood on the brains, mental, cognitive and social functioning of youth and
\nincreased likelihood of adult alcohol dependence and alcohol related problems
\namong those who drink before full physiological maturity. Regular alcohol<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tD-2015-01-2017
\nconsumption and binge drinking in adolescents can negatively affect school
\nperformance, increase participation in crime and adversely affect sexual
\nperformance and behaviour.
\n4. Effective alcohol harm-reduction policies and measures will include legal and
\nregulatory measures that target overall alcohol consumption in the population, as
\nwell as health and social policy interventions that specifically target high-risk
\ndrinkers, vulnerable groups and harms to people affected by those who consume
\nalcohol, e.g. domestic violence.
\nWhen developing policies it should be taken into account that the majority of
\nalcohol-related problems in a population are associated with harmful or hazardous
\ndrinking by non-dependent \u2018social\u2019 drinkers, particularly when intoxicated. This is
\nparticularly a problem of young people in many regions of the world who drink
\nwith the intent of becoming intoxicated.
\n5. There are many evidence-based alcohol policies and prevention programmes that
\nare effective in reducing the health, safety and socioeconomic problems
\nattributable to harmful use of alcohol. International public health advocacy and
\npartnerships are needed to strengthen and support the ability of governments and
\ncivil society worldwide to commit to, and deliver on, reducing the harmful use of
\nalcohol through effective interventions, including action on social determinants of
\nhealth.
\nHealth professionals in general and physicians in particular have an important role
\nto play in preventing, treating and mitigating alcohol-related harm, and in using
\neffective preventive and therapeutic interventions.
\nThe World Medical Association encourages and supports the development and
\nimplementation of evidence-based national alcohol policies by promoting and
\nfacilitating partnerships, information exchange and health policy capacity building.<\/p>\n

POLICY\tOBJECTIVES
\nIn developing alcohol policies, the WMA recommends the following broad objectives:
\n6. Strengthen health systems to identify and improve a country\u2019s capacity to develop
\npolicy and lead actions that target excessive alcohol consumption.
\n7. Promote the development and evaluation in all countries of national alcohol
\nstrategies which are comprehensive, evidence-based and include measures to
\naddress the supply, distribution, sale, advertising, sponsorship and promotion of
\nalcohol. The WHO \u2018best buys\u2019 cost effective policies should be particularly
\npromoted, such as (i) increasing alcoholic beverage taxes, (ii) regulating the
\navailability of alcoholic beverages, (iii) restricting marketing of alcoholic
\nbeverages and (iv) drink-driving countermeasures. Strategies should be routinely
\nreviewed and updated.<\/p>\n

D-2015-01-2017\t\u23d0\tChicago
\nAlcohol
\n8. Through government health departments, accurately measure the health burden
\nassociated with alcohol consumption through the collection of sales data,
\nepidemiological data, and per capita consumption figures.
\n9. Support and promote the role of health and medical professionals in early
\nidentification, screening and treatment of harmful alcohol use.
\n10. Dispel myths and dispute alcohol control strategies that are not evidence-based.
\n11. Reduce the impact of harmful alcohol consumption in at risk populations.
\n12. Foster multi-disciplinary collaboration and coordinated inter-sectoral action.
\n13. Raise awareness of alcohol-related harm through public education and information
\ncampaigns.
\n14. Promote social determinants of health approach in fighting harmful alcohol
\nconsumption.
\nREOMMENDATIONS
\nhe following priorities are suggested for WMA members, National Medical Associations
\nand governments when developing integrated and comprehensive policy and legislative
\nresponses.
\n15. Regulate affordability, accessibility and availability
\n15.1 Pricing policies
\nEvidence from epidemiological and other research demonstrates a clear link between the
\nprice of alcohol and levels of consumption, especially amongst young drinkers and those
\nwho are heavy alcohol users.
\nTherefore, action is needed to increase alcohol prices, through volumetric taxation of
\nproducts based on their alcohol strength, and other proven pricing mechanisms, to reduce
\nalcohol consumption, particularly in heavy drinkers and high risk groups.
\nSetting a minimum unit price at a level that will reduce alcohol consumption is a strong
\npublic health measure, which will both reduce average alcohol consumption throughout
\nthe population and be especially effective in heavy drinkers and young drinkers.
\n15.2 Accessibility and availability
\nRegulate access to, and availability of, alcohol by limiting the hours and days of sale, the
\nnumber and location of alcohol outlets and licensed premises, and the imposition of a
\nminimum legal drinking age. Governments should tax and control the production and<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tD-2015-01-2017
\nconsumption of alcohol, with licensing that emphasises public health and safety and
\nempowers licensing authorities to control the total availability of alcohol in their
\njurisdictions. Governments should also control importation and sale of illegal alcohol
\nacross borders.
\nPublic authorities must strengthen the prohibition of selling to and by minors and must
\nsystematically request proof of age before alcohol can be purchased in shops or bars.
\n16. Regulation of non-commercial alcohol
\nThe production and consumption of non-commercial forms of alcohol, such as home
\nbrewing, illicit distillation, and illegal diversion alcohol to avoid taxes, should be curtailed
\nusing appropriate taxing and pricing mechanisms.
\n17. Regulation of alcohol marketing
\nAlcohol marketing should be restricted to prevent the early adoption of drinking by young
\npeople and to minimise their alcohol consumption. Regulatory measures range from
\nwholesale bans and restrictions on measures that promote excessive consumption, to
\nrestrictions on the placement and content of alcohol advertising and sponsorship that are
\nattractive to young people. There is evidence that industry self-regulation and voluntary
\ncodes are ineffective at protecting vulnerable populations from exposure to alcohol
\nmarketing and promotion.
\nIncrease public awareness of harmful alcohol consumption through mandatory product
\nlabelling that clearly states alcoholic content in units, advice on recommended drinking
\nlevels and a health warning, supported by public awareness campaigns.
\nIn conjunction with other measures, social marketing campaigns should be implemented
\ntogether with the media to educate the public about harmful alcohol use, to adopt driving
\nwhile intoxicated policies, and to target the behaviour of specific populations at high risks
\nof harm.
\n18. The role of health and medical services in prevention
\nHealth, medical and social services professionals should be provided with the training,
\nresources and support necessary to prevent harmful use of alcohol and treat people with
\nalcohol dependence, including routinely providing brief interventions to motivate high-
\nrisk drinkers to moderate their consumption. Health professionals also play a key role in
\neducation, advocacy and research.
\nSpecialised treatment and rehabilitation services should be available in due time and
\naffordable for alcohol dependent individuals and their families.
\nTogether with national and local medical societies, specialty medical organizations,
\nconcerned social, religious and economic groups (including governmental, scientific,
\nprofessional, nongovernmental and voluntary bodies, the private sector, and civil society)
\nphysicians and other health and social professionals can work to:<\/p>\n

D-2015-01-2017\t\u23d0\tChicago
\nAlcohol
\n18.1 Reduce harmful use of alcohol, especially among young people and pregnant
\nwomen, in the workplace, and when driving;
\n18.2 Increase the likelihood that everyone will be free of pressures to consume alcohol
\nand free from the harmful and unhealthy effects of drinking by others;
\n18.3 Promote evidence-based prevention strategies in schools and communities;
\n18.4 Assist in informing the public of alcohol related harm and demystifying the myth of
\nhealth enhancing properties of alcohol.
\nPhysicians have an important role in facilitating epidemiologic and health service data
\ncollection on the impact of alcohol with the aim of prevention and promotion of public
\nhealth. Data collection must respect the confidentiality of health data of individual
\npatients.
\n19. Driving while intoxicated measures
\nKey deterrents should be implemented for driving while intoxicated, which include a
\nstrictly enforced legal maximum blood alcohol concentration for drivers of no more than
\n50mg\/100ml, supported by social marketing campaigns and the power of authorities to
\nimpose immediate sanctions.
\nThese measures should also include active enforcement of traffic safety measures, random
\nbreath testing, and legal and medical interventions for repeat intoxicated drivers.
\n20. Limit the role of the alcohol industry in alcohol policy development
\nThe commercial priorities of the alcohol industry are in direct conflict with the public
\nhealth objective of reducing overall alcohol consumption. Internationally, the alcohol
\nindustry is frequently included in alcohol policy development by national authorities, but
\nthe industry is often active in opposing and weakening effective alcohol policies.
\nIneffective and non-evidence-based alcohol control strategies promoted by the alcohol
\nindustry and the social organisations that the industry sponsors should be countered. The
\nrole of the alcohol industry in the reduction of alcohol-related harm should be confined to
\ntheir roles as producers, distributors and marketers of alcohol, and not include alcohol
\npolicy development or health promotion.
\n21. Convention on Alcohol Control
\nPromote consideration of a Framework Convention on Alcohol Control similar to that of
\nthe WHO Framework Convention on Tobacco Control.
\n22. Exclude alcohol from trade agreements
\nFurthermore, in order to protect current and future alcohol control measures, advocate for
\nalcohol to be classified as an extra-ordinary commodity and that measures affecting the<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2015-01-2017
\nsupply, distribution, sale, advertising, sponsorship, promotion of or investment in
\nalcoholic beverages be excluded from international trade agreements.
\n23. Action against positive media messaging
\nIt is important to act on the impact of media messages on beliefs, intentions, attitudes and
\nsocial norms. Well-designed media campaigns can have direct effects on behavior. The
\nmedia also influence the social conception of a problem, and indirectly influence political
\ndecision-making on measures for intervention on alcohol.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2017-01-2017
\nWMA\tDECLARATION
\nOF\tCHICAGO\tON
\nQUALITY\tASSURANCE\tIN\tMEDICAL\tEDUCATION
\nAdopted by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\nhe goals of medical education are to prepare practitioners to apply the latest scientific
\nknowledge to promote health, to prevent and cure human diseases, and to impart the
\nethical standards governing the thought and behavior of physicians. All physicians have a
\nresponsibility to themselves, the profession, and their patients to maintain high standards
\nfor basic medical education.
\nWell-planned and well-executed quality assurance programs are essential to ensuring that
\nmedical schools meet these goals and expectations. There are many threats to the quality
\nof basic medical education. The ability to deliver a high standard of education can be
\naffected by the availability of infrastructure, clinical resources, faculty, and finances. Also,
\nthe growth of basic medical education globally, with a rapid increase in the number of
\nmedical schools in some countries, raises concerns about the quality of graduates. A well-
\ndeveloped quality assurance program allows schools to identify and address conditions
\nthat threaten the quality of their basic medical education. Such programs need to be
\nimplemented as far as possible at medical schools around the world.<\/p>\n

BACKGROUND
\nStandards developed by and for a medical school are designed to reflect what the school
\nbelieves to be important quality measures. Institutional reviews using such internally-
\ndeveloped standards can ensure that the school\u2019s missions are being met and that students
\nare being prepared to achieve the desired outcomes. The presence of an institutional
\nquality assurance program that uses its own defined criteria and is supported by
\nknowledgeable personnel can be important to ensure educational program quality over
\ntime.
\nHowever, a better outcome will more likely be achieved by also including a second
\ndimension of review that includes an external perspective. A national quality assurance
\nsystem includes the use of standards of quality that are developed and approved at the
\nnational or regional level. Evaluating a medical school based on what a country or region
\nexpects of its basic medical educational programs leads to a higher and more consistent
\nlevel of student preparation.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2017-01-2017
\nUnless compliance with standards set by a national evaluation system is required of
\nmedical schools, there is no guarantee that schools will undertake an internal evaluation or
\ncorrect problems that interfere with educational quality. The World Medical Association
\n(WMA) recognises the need for and importance of sound global standards for assuring the
\nquality of basic medical education programs.
\nAn accreditation\/recognition system is a quality assurance mechanism that is increasingly
\ncommon around the world. Accreditation\/recognition systems are based on standards of
\neducational quality that are developed to meet national needs and that use valid, reliable,
\nand widely-accepted processes to assess the attainment of these standards by schools.
\nAfter evaluating compliance with standards, cooperation and coordination among various
\nstakeholder groups within and external to a medical school is needed to implement
\nsolutions to the problems identified.
\nPRINCIPLES\tFOR\tACCREDITATION\tSYSTEMS
\nAn accreditation system reviews educational programs or institutions using a pre-
\ndetermined (typically national) set of process and outcome standards. The accreditation
\nsystems that exist around the world differ in several ways. In some countries,
\naccreditation of medical schools has been occurring for decades; in other countries,
\naccreditation is relatively new. Participation in accreditation is either mandatory or
\nvoluntary for medical schools and reviews take place over different intervals.
\nAccreditation is defined as the evaluation of educational programs or institutions based on
\na clear and specific set of standards. Accreditation guidelines should be articulated as
\nstandards that have been created with national needs in mind and with the input of relevant
\nstakeholder groups within the country.
\nCertain general principles should form the basis for an accreditation system to ensure that
\nthe process is valid and decisions related to educational program quality are trustworthy.
\nThese principles include transparency, absence of conflict of interest, and
\nreliability\/consistency. Transparency means that the accreditation standards and processes
\nare known to and understood by schools, evaluators, and decision-makers. To reduce the
\npotential for conflict of interest, evaluators and decision-makers should have no ties to the
\ninstitution being evaluated or to other institutions that may affect their ability to make a
\njudgment free from positive or negative bias. Reliability and consistency require a
\ncommon understanding of what constitutes compliance with standards and that, as far as
\npossible, this understanding is applied consistently in reviews and decisions across
\nschools.
\nAccreditation standards are measurable, but need not be quantitative. Standards are
\nnormally developed for both the process and the outcomes of a medical education
\nprogram. Specific information should be identified to evaluate compliance. For example,
\nthe standards related to process could address the objectives for and structure of the
\ncurriculum; the qualifications of entering students and teaching faculty; and the
\navailability of resources for program support, including adequate finances, sufficient
\nfaculty, and an appropriate educational infrastructure for the scientific and clinical phases
\nof training. The outcomes of the medical education program are then evaluated to<\/p>\n

D-2017-01-2017\t\u23d0\tChicago
\nQuality\tAssurance\tin\tBasic\tMedical\tEducation
\ndetermine if graduates have been adequately prepared based on the school\u2019s objectives.
\nIn order to be most effective, standards used in accreditation need to be widely
\ndisseminated and thoroughly explicated so that medical schools, evaluators, and decision-
\nmakers share a common understanding of their meaning and the expectations for
\ncompliance. For the sake of process effectiveness and transparency, the medical school
\nfaculty, the evaluators who review the medical schools\u2019 compliance with accreditation
\nstandards, and the decision-makers who determine accreditation status will require
\ntraining.
\nInstitutions will have achieved their objectives if they have continually complied with
\naccreditation standards and when internal monitoring becomes a formal responsibility for
\none or more individuals within the medical school who have access to relevant quality-
\nlinked information (e.g., the results of student satisfaction surveys and student
\nperformance data). Ongoing review of some or all accreditation standards allows schools
\nto correct problem areas before they are identified as part of the formal accreditation
\nreview and ensures that educational program quality remains high.
\nIf an accreditation review identifies areas where improvement is needed, a medical school
\nshould promptly correct the deficiencies. The accreditation\/recognition body normally sets
\na timeline for follow-up by the end of which the educational program should be able to
\ndemonstrate the actions that have been taken and the outcomes that have been achieved.
\nThis may require the medical school\/university to provide financial resources and to
\nprovide faculty time, effort, and adequate infrastructure, to make the needed corrections.
\nTo assist schools in addressing identified deficiencies, support and consultation could be
\nprovided by the staff of the accrediting body or other trained individuals. To avoid
\nconflict of interest, those who provide consultation should not take part in accreditation
\nreviews or in decisions about accreditation status.
\nRESPONSIBILITIES\t OF\t STAKEHOLDERS\t GROUPS\t WITHIN\t AND\t EXTERNAL\t TO\t MEDICAL
\nSCHOOLS
\nThe creation of an accreditation system that meets the principles for validity and
\ntrustworthiness requires actions by a variety of stakeholder groups, such as:
\n\u2022 Entities that sponsor accrediting bodies (e.g., governments, medical associations)
\nneed to ensure that the accrediting body is appropriately funded and staffed for its
\nactivities. Funding may come from the sponsors and\/or from the accrediting
\nbody\u2019s ability to generate its own funding from accreditation review fees.
\nAccrediting bodies in certain countries may require additional funding and staffing
\nto address the increase in the number of medical schools.
\n\u2022 It is advisable for school leadership to encourage an environment that values
\neducational quality assurance activities. Faculty should be given time and
\nrecognition for their participation in program evaluation and accreditation
\nactivities, and medical students should be prepared and encouraged to provide
\nfeedback on all relevant aspects of the medical education program.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2017-01-2017
\nRECOMMENDATIONS
\nThe WMA calls upon National Medical Associations (NMAs)to encourage medical
\nschools to develop quality assurance programs regarding ongoing review of educational
\nprogram quality.
\nThe WMA urges NMAs to support and promote the ongoing development of national and
\nregional accreditation\/recognition systems for medical schools. These systems should be
\ndesigned and led by physicians in collaboration with experienced medical educators and
\nwith input from other relevant experts.
\nThe WMA calls upon NMAs to urge national governmental and private-sector policy-
\nmakers to ensure that the national accreditation system has adequate and appropriate
\nresources for its activities. This includes sufficient and consistent funding to support the
\ninfrastructure and staffing of the accrediting body.
\nThe WMA recommends that accreditation systems use nationally-relevant standards
\napplied consistently by trained evaluators and decision-makers when reviewing medical
\nschools.
\nThe WMA encourages NMAs to advocate to policy-makers that participation in the
\nnational accreditation system should be required for all medical schools within a country.
\nThe WMA calls upon NMA\u2019s to urge national accreditation systems to participate in
\nexternal reviews of their policies, practices, and standards. This may include seeking
\nrecognition by the World Federation for Medical Education (WFME). Recognised
\naccrediting bodies and similar organisations are urged to establish a forum for discussion
\nand collaboration among national accrediting bodies to share best practices and
\nmechanisms to overcome challenges.
\nPhysicians should be encouraged to lead and actively participate in national accreditation
\nactivities as evaluators and decision-makers and in quality assurance activities at their own
\nmedical schools.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tD-2017-02-2017
\nWMA\tDECLARATION
\nON
\nFAIR\tTRADE\tIN\tMEDICAL\tPRODUCTS\tAND\tDEVICES
\nAdopted by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\n1. Every year trillions of dollars are spent on medical supplies globally. Little
\nconsideration is given to the conditions in which they are made, nor to the impact on
\nthe people who make them.
\n2. Abuses of labour standards, evidence of modern slavery, and unethical working
\nconditions have been uncovered in the manufacture of many medical products bound
\nfor health systems around the world. Evidence shows that many supplies used in the
\nhealthcare sector are produced in unhealthy, unsafe and unfair working conditions.
\nWidescale abuses have been reported in numerous manufacturing sites \u2013 from
\nuniforms, to latex gloves, to disposable surgical instruments \u2013 international labour core
\nconventions are persistently disregarded, and the use of child labour is widespread.
\n3. The global healthcare community should not condone unethical trade practices that are
\ndetrimental to global health and encourage modern slavery. Healthcare organisations
\nand professionals around the world must insist that the goods they use are not
\nproduced at the expense of the health of workers in the global community.
\n4. It is important to maintain trading with developing countries to ensure jobs and
\nlivelihoods, and commitment to the UN sustainable development goals. These goals
\nprovide an overarching opportunity for sustained action to be taken by health
\nprofessionals in protecting human health globally.
\n5. As enshrined in the UN Guiding Principles on Business and Human rights (June 2011)
\n\u2013 applicable to all States- businesses have a responsibility to minimise human rights
\nviolations in their supply and procurement chains, irrespective of whether the business
\ncontributed directly to the violation, and a duty to adequately address any abuses that
\ndo occur.
\n6. Introduction of fair and ethical trade in health service purchasing should be used to
\nsecure improvement in the health system supply chains. Modern approaches to
\naddressing labour rights abuses focus on models of \u2018ethical procurement\u2019.
\n7. Ethical procurement refers to the steps that purchasing organisations, such as hospitals,
\ntake to improve the pay and conditions of people involved in the supply of goods and
\nservices. It asks purchasers to systematically assess the risk of labour rights abuses in
\nthe goods they procure, and to push for improvement where necessary. This includes<\/p>\n

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\nFair\tMedical\tTrade\t<\/p>\n

working with companies throughout the supply chain to help workers exercise
\nfundamental rights such as the right to safe and decent working conditions. This model
\naims to make international trade work better for poor and otherwise disadvantaged
\npeople.<\/p>\n

RECOMMANDATIONS
\n8. Recognizing this, the World Medical Association and its national medical association
\nmembers on behalf of their physician members, support and commit to the following
\nactions:
\n\u2022 Call upon purchasing bodies, to develop a fair and ethical purchasing policy for
\nmedical goods to promote good working conditions and eradicate modern
\nslavery throughout the supply chains of the products purchased within the
\nhealth sector.
\n\u2022 Promote multiple health product production sources throughout the world.
\nNational medical associations
\n9. National medical associations should advocate for labour\/ human rights to be protected
\nthroughout the global supply chains of products used in their healthcare systems.
\n10. National medical associations should work with their members to promote fair and
\nethical trade in the health sector.
\n11. National medical associations should support community action and initiatives with to
\npromote ethical working conditions across the health sector as a whole.
\n12. National medical associations should harness government support to formulate
\nnational guidance and\/or policy on fair and ethical trade in healthcare purchasing.
\nPhysicians
\n13. Physicians should play a leadership role in integrating considerations of labour
\nstandards into purchasing decisions within healthcare organisations.
\n14. Physicians should raise awareness of the issues, and promote the development of fair
\nand ethically produced medical goods, amongst colleagues and those working with
\nhealth systems.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1956-01-2012
\nWMA\tREGULATIONS
\nIN
\nTIMES\tOF\tARMED\tCONFLICT\tAND\tOTHER\tSITUATIONS\tOF\tVIOLENCE
\nAdopted by the 10th
\nWorld Medical Assembly, Havana, Cuba, October 1956
\nand edited by the 11th
\nWorld Medical Assembly, Istanbul, Turkey, October 1957
\nand revised by the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand the 55th
\nWMA General Assembly, Tokyo, Japan, October 2004
\nand editorially revised by the 173rd
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2006
\nand revised by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nGENERAL\tGUIDELINES\t<\/p>\n

Medical ethics in times of armed conflict is identical to medical ethics in times of peace,
\nas stated in the International Code of Medical Ethics of the WMA. If, in performing their
\nprofessional duty, physicians have conflicting loyalties, their primary obligation is to their
\npatients; in all their professional activities, physicians should adhere to international con-
\nventions on human rights, international humanitarian law and WMA declarations on medi-
\ncal ethics.
\nThe primary task of the medical profession is to preserve health and save life. Hence it is
\ndeemed unethical for physicians to:
\n\u2022 Give advice or perform prophylactic, diagnostic or therapeutic procedures that are
\nnot justifiable for the patient’s health care;
\n\u2022 Weaken the physical or mental strength of a human being without therapeutic
\njustification;
\n\u2022 Employ scientific knowledge to imperil health or destroy life;
\n\u2022 Employ personal health information to facilitate interrogation;
\n\u2022 Condone, facilitate or participate in the practice of torture or any form of cruel, in-
\nhuman or degrading treatment.
\nDuring times of armed conflict and other situations of violence, standard ethical norms
\napply, not only in regard to treatment but also to all other interventions, such as research.
\nResearch involving experimentation on human subjects is strictly forbidden on all persons
\ndeprived of their liberty, especially civilian and military prisoners and the population of
\noccupied countries.
\nThe medical duty to treat people with humanity and respect applies to all patients. The
\nphysician must always give the necessary care impartially and without discrimination on
\nthe basis of age, disease or disability, creed, ethnic origin, gender, nationality, political af-
\nfiliation, race, sexual orientation, or social standing or any other similar criterion.<\/p>\n

S-1956-01-2012\t\u23d0\tBangkok
\nArmed\tConflict
\nGovernments, armed forces and others in positions of power should comply with the
\nGeneva Conventions to ensure that physicians and other health care professionals can
\nprovide care to everyone in need in situations of armed conflict and other situations of
\nviolence. This obligation includes a requirement to protect health care personnel and
\nfacilities.
\nWhatever the context, medical confidentiality must be preserved by the physician. However,
\nin armed conflict or other situations of violence, and in peacetime, there may be cir-
\ncumstances in which a patient poses a significant risk to other people and physicians will
\nneed to weigh their obligation to the patient against their obligation to other individuals
\nthreatened.
\nPrivileges and facilities afforded to physicians and other health care professionals in times
\nof armed conflict and other situations of violence must never be used other than for health
\ncare purposes.
\nPhysicians have a clear duty to care for the sick and injured. Physicians should recognise
\nthe special vulnerability of some groups, including women and children. Provision of such
\ncare should not be impeded or regarded as any kind of offence. Physicians must never be
\nprosecuted or punished for complying with any of their ethical obligations.
\nPhysicians have a duty to press governments and other authorities for the provision of the
\ninfrastructure that is a prerequisite to health, including potable water, adequate food and
\nshelter.
\nWhere conflict appears to be imminent and inevitable, physicians should, as far as they are
\nable, ensure that authorities are planning for the protection of the public health infra-
\nstructure and for any necessary repair in the immediate post-conflict period.
\nIn emergencies, physicians are required to render immediate attention to the best of their
\nability. Whether civilian or combatant, the sick and wounded must receive promptly the
\ncare they need. No distinction shall be made between patients except those based upon
\nclinical need.
\nPhysicians must be granted access to patients, medical facilities and equipment and the
\nprotection needed to carry out their professional activities freely. Such access must include
\npatients in detention centres and prisons. Necessary assistance, including unimpeded
\npassage and complete professional independence, must be granted.
\nIn fulfilling their duties and where they have the legal right, physicians and other health
\ncare professionals shall be identified and protected by internationally recognized symbols
\nsuch as the Red Cross, Red Crescent or Red Crystal.
\nHospitals and health care facilities situated in areas where there is either armed conflict or
\nother situations of violence must be respected by all combatants and media personnel.
\nHealth care given to the sick and wounded, civilians or combatants, cannot be used for
\npublicity or propaganda. The privacy of the sick, wounded and dead must always be res-<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1956-01-2012
\npected. This includes visits from important political figures for media purposes and also
\nwhen important political figures are among the wounded and the sick.
\nPhysicians must be aware that, during armed conflict or other situations of violence, health
\ncare becomes increasingly susceptible to unscrupulous practice and the distribution of
\npoor quality \/ counterfeit materials and medicines, and attempt to take action on such
\npractices.
\nThe WMA supports the collection and dissemination of data related to assaults on phy-
\nsicians, other health care personnel and medical facilities, by an international body. Such
\ndata are important to understand the nature of such attacks and to set up mechanisms to
\nprevent them. Assaults against medical personnel must be investigated and those res-
\nponsible must be brought to justice.
\nCODE\t OF\t CONDUCT:\t DUTIES\t OF\t PHYSICIANS\t WORKING\t IN\t ARMED\t CONFLICT\t AND
\nOTHER\tSITUATIONS\tOF\tVIOLENCE
\nPhysicians must in all circumstances:
\n\u2022 Neither commit nor assist violations of international law (international humanitarian
\nlaw or human rights law);
\n\u2022 Not abandon the wounded and sick;
\n\u2022 Not take part in any act of hostility;
\n\u2022 Remind authorities of their obligation to search for the wounded and sick and to
\nensure access to health care without unfair discrimination;
\n\u2022 Advocate and provide effective and impartial care to the wounded and sick
\n(without reference to any ground of unfair discrimination, including whether they
\nare the \u00ab\u00a0enemy\u00a0\u00bb);
\n\u2022 Recognise that security of individuals, patients and institutions are a major
\nconstraint to ethical behaviour and not take undue risk in the discharge of their
\nduties;
\n\u2022 Respect the individual wounded or sick person, his \/ her will, confidence and his \/
\nher dignity;
\n\u2022 Not take advantage of the situation and the vulnerability of the wounded and sick
\nfor personal financial gain;
\n\u2022 Not undertake any kind of experimentation on the wounded and sick without their
\nreal and valid consent and never where they are deprived of liberty;
\n\u2022 Give special consideration to the greater vulnerability of women and children in
\narmed conflict and other situations of violence and to their specific health-care
\nneeds;
\n\u2022 Respect the right of a family to know the fate and whereabouts of a missing family
\nmember whether or not that person is dead or receiving health care;
\n\u2022 Provide health care for anyone taken prisoner;
\n\u2022 Advocate for regular visits to prisons and prisoners by physicians, if such a me-
\nchanism is not already in place;
\n\u2022 Denounce and act, where possible, to put an end to any unscrupulous practices or
\ndistribution of poor quality\/counterfeit materials and medicines;<\/p>\n

S-1956-01-2012\t\u23d0\tBangkok
\nArmed\tConflict
\n\u2022 Encourage authorities to recognise their obligations under international humani-
\ntarian law and other pertinent bodies of international law with respect to protection
\nof health care personnel and infrastructure in armed conflict and other situations of
\nviolence;
\n\u2022 Be aware of the legal obligations to report to authorities the outbreak of any noti-
\nfiable disease or trauma;
\n\u2022 Do anything within their power to prevent reprisals against the wounded and sick
\nor health care;
\n\u2022 Recognise that there are other situations where health care might be compromised
\nbut in which there are dilemmas.
\nPhysicians should to the degree possible:
\n\u2022 Refuse to obey an illegal or unethical order;
\n\u2022 Give careful consideration to any dual loyalties that the physician may be bound
\nby and discuss these dual loyalties with colleagues and anyone in authority;
\n\u2022 As an exception to professional confidentiality, and in line with WMA Resolution
\non the Responsibility of Physicians in the Documentation and Denunciation of
\nActs of Torture or Cruel or Inhuman or Degrading Treatment and the Istanbul Pro-
\ntocol1
\n, denounce acts of torture or cruel, inhuman or degrading treatment of which
\nphysicians are aware, where possible with the subject’s consent, but in certain
\ncircumstances where the victim is unable to express him\/herself freely, without
\nexplicit consent;
\n\u2022 Listen to and respect the opinions of colleagues;
\n\u2022 Reflect on and try to improve the standards of care appropriate to the situation;
\n\u2022 Report unethical behaviour of a colleague to the appropriate superior;
\n\u2022 Keep adequate health care records;
\n\u2022 Support sustainability of civilian health care disrupted by the context;
\n\u2022 Report to a commander or to other appropriate authorities if health care needs are
\nnot met;
\n\u2022 Give consideration to how health care personnel might shorten or mitigate the
\neffects of the violence in question, for example by reacting to violations of interna-
\ntional humanitarian law or human rights law.
\n1
\nManual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or
\nDegrading Treatment or Punishment, OHCHR, 1999<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1970-01-2018
\nWMA\tSTATEMENT
\nON
\nMEDICALLY-INDICATED\tTERMINATION\tOF\tPREGNANCY
\nAdopted by the 24th
\nWorld Medical Assembly, Oslo, Norway, August 1970
\nand amended by the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018<\/p>\n

PREAMBLE
\n1. Medically-indicated termination of pregnancy refers only to interruption of pregnancy
\ndue to health reasons, in accordance with principles of evidence-based medicine and
\ngood clinical practice. This Declaration does not include or imply any views on
\ntermination of pregnancy carried out for any reason other than medical indication.
\n2. Termination of pregnancy is a medical matter between the patient and the physician.
\nAttitudes toward termination of pregnancy are a matter of individual conviction and
\nconscience that should be respected.
\n3. A circumstance where the patient may be harmed by carrying the pregnancy to term
\npresents a conflict between the life of the foetus and the health of the pregnant woman.
\nDiverse responses to resolve this dilemma reflect the diverse cultural, legal, traditional,
\nand regional standards of medical care throughout the world.
\nRECOMMENDATIONS
\n1. Physicians should be aware of local termination of pregnancy laws, regulations and
\nreporting requirements. National laws, norms, standards, and clinical practice related
\nto termination of pregnancy should promote and protect women\u2019s health, dignity and
\ntheir human rights, voluntary informed consent, and autonomy in decision-making,
\nconfidentiality and privacy. National medical associations should advocate that
\nnational health policy upholds these principles.
\n2. Where the law allows medically-indicated termination of pregnancy to be performed,
\nthe procedure should be performed by a competent physician and only in extreme
\ncases by another qualified health care worker, in accordance with evidence-based
\nmedicine principles and good medical practice in an approved facility that meets
\nrequired medical standards.
\n3. The convictions of both the physician and the patient should be respected.
\n4. Patients must be supported appropriately and provided with necessary medical and
\npsychological treatment along with appropriate counselling if desired.<\/p>\n

S-1970-01-2018\t\u23d0\tReykjavik
\nMedically-Indicated\tTermination\tof\tPregnancy
\n5. Physicians have a right to conscientious objection to performing an abortion;
\ntherefore, they may withdraw while ensuring the continuity of medical care by a
\nqualified colleague. In all cases, physician must perform those procedures necessary to
\nsave the woman\u2019s life and to prevent serious injury to her health.
\n6. Physicians must work with relevant institutions and authorities to ensure that no
\nwoman is harmed because medically-indicated termination of pregnancy services are
\nunavailable.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1983-01-2017
\nWMA\tSTATEMENT
\nON
\nBOXING
\nAdopted by the 35th
\nWorld Medical Assembly, Venice, Italy, October 1983
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand revised by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\n1. Boxing is a dangerous sport. Unlike other sports, its basic intent is to produce
\nbodily harm by specifically targeting the head. The main medical argument against
\nboxing is the risk of chronic traumatic encephalopathy (CTE), also known as
\nchronic traumatic brain injury (CTBI), and dementia pugilistica or \u201cpunch-drunk\u201d
\nsyndrome. Other injuries caused by boxing can lead to loss of sight, loss of
\nhearing, and fractures. Studies show that boxing is associated with devastating
\nshort-term injuries and chronic neurological damage on the participants in the long
\nterm.
\n2. The past few decades have witnessed vigorous campaigns by national medical
\nbodies to have all forms of boxing abolished. In the absence of such a ban, a series
\nof boxing tragedies worldwide has pressured various sports regulatory bodies to
\nadopt a variety of rules and standards to enhance the safety of boxers.
\n3. Despite regulation of boxing in various countries, injuries and death still occur as a
\nresult of boxing related head trauma, indicating that regulation does not provide
\nadequate protection to participants.
\n4. In addition to regulated boxing, unchecked and unsupervised boxing competitions
\n(bareknuckle battles or \u201cstreet fights\u201d) still take place in many parts of the world.
\nThis underground boxing puts at risk the lives and health of a significant number
\nof persons who participate in these fights.
\n5. Health and safety concerns in boxing extend to other professional sports where
\nboxing is a component, such as mixed martial arts (MMA), kickboxing etc. For
\nthis reason, the recommendations in this statement should be applied to these
\nsports as well.
\n6. The WMA believes that boxing is qualitatively different from other sports because
\nof the injuries it causes and that it should be banned.
\n7. Until a full ban is achieved the WMA urges that the following measures be
\nimplemented:<\/p>\n

S-1983-01-2017\t\u23d0\tChicago
\nBoxing
\n7.1 Boxing must be regulated and all boxers licensed. Boxers should be provided
\nwith written information on the risks of participating in boxing.
\n7.2 No children (as per country-specific definition) should be permitted to
\nparticipate in boxing.
\n7.3 A national registry of all amateur and professional boxers, including sparring
\npartners, should be established in each country where boxing is allowed. The
\nregistry should record the results of all matches, including technical
\nknockouts, knockouts, and other boxing injuries, and compile injury records
\nfor individual boxers. All boxers should be followed up for a period of at least
\ntwenty years to document long-term outcomes.
\n7.4 All boxers should undergo a baseline medical examination, which should
\ninclude neurological assessment, including brain imaging, at the beginning of
\ntheir careers. Medical and neurological assessments should also be performed
\nbefore and after each event. Boxers who do not pass the examination must be
\nreported to the national registry and must not be allowed to participate in
\nfuture matches.
\n7.5 Personal protective equipment recommendations (such as size and weight of
\ngloves, head gear and gum shields) should take into consideration medical
\nrecommendations.
\n7.6 A physician serving at a boxing match has a professional responsibility to
\nprotect the health and safety of the contestants. To that end, the physician
\nshould receive specialized training in athlete evaluation, especially traumatic
\nbrain injury assessment. The physician\u2019s judgment should be governed only by
\nmedical considerations, and the physician must be allowed to stop any match
\nin progress to examine a contestant and to terminate a match that, in the
\nphysician\u00b4s opinion, could result in serious injury.
\n7.7 Funding and sponsorship of boxing should be discouraged, and TV coverage of
\nboxing events should be age restricted and include a warning statement on the
\nrisks of boxing.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1984-01-2017
\nWMA\tSTATEMENT
\nON
\nCHILD\tABUSE\tAND\tNEGLECT
\nAdopted by the 36th
\nWorld Medical Assembly, Singapore, October 1984
\nand amended by the 41st
\nWorld Medical Assembly, Hong Kong, September 1989
\n42nd
\nWorld Medical Assembly, Rancho Mirage, CA., USA, October 1990
\n44th
\nWorld Medical Assembly, Marbella, Spain, September 1992
\n47th
\nWMA General Assembly, Bali, Indonesia, September 1995
\nand the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nand revised by the 68th
\nWMA General Assembly, Chicago, United States, October 2017<\/p>\n

PREAMBLE\t<\/p>\n

1. The welfare of children[1] is of paramount importance. Health professionals should
\nput the welfare of children at the centre of all decision-making related to the child and
\nact in the best interests of children in all of their interactions with children, young
\npeople, families, policy-makers and other professionals.
\nINTRODUCTION
\n2. One of the most destructive manifestations of family violence and upheaval is child
\nabuse[2] in all its forms. Prevention, protection, early identification, suitable
\ninterventions and comprehensive treatment of child abuse victims remain challenging
\nfor the world medical community. The World Medical Association (WMA) has called
\nfor increased health support of children living on the streets in its Statement on
\nSupporting Health Support to Street Children, but it is also important to address the
\nroot causes of child abuse in all its forms.[3]
\n3. Definitions of child abuse vary from culture to culture. Unfortunately, cultural
\nrationalizations for harmful behaviour toward children may be accepted all too readily
\nas proof that the treatment of children is neither abusive nor harmful. For instance, the
\nwork contribution of children in the everyday lives of families and in society should be
\nrecognized and encouraged only as long as it also contributes to the child\u2019s own
\ndevelopment. In contrast, exploitation of children in the labour market deprives them
\nof their childhood and of educational opportunities and endangers their present and
\nfuture health. The WMA considers such exploitation of children a serious form of
\nchild abuse in all its forms.
\n4. For the purposes of this Statement, the various forms of child abuse include emotional
\nabuse, physical abuse, sexual abuse, child trafficking, child exploitation and child
\nneglect. Child neglect represents a failure of a parent, or other person legally
\nresponsible for a child\u2019s welfare, to provide for the child\u2019s basic needs and an adequate
\nlevel of care.<\/p>\n

S-1984-01-2017\t\u23d0\tChicago
\nChild\tAbuse\tand\tNeglect\t<\/p>\n

RECOMMENDATIONS
\nThe WMA recognizes that child abuse in all its forms is a world health problem and
\nrecommends that National Medical Associations adopt the following guidelines for
\nphysicians:
\n5. Physicians have both a unique and special role in identifying and helping abused
\nchildren and their families.
\n6. All physicians should be educated about the paramount importance of the welfare of
\nchildren.
\n7. Physicians must be aware of and observe local laws regarding consent to undertake
\nexaminations of children. Physicians must act in the best interests of children in all of
\ntheir interactions with children, young people, families, policy-makers and other
\nprofessionals.
\n8. Collaboration with an experienced multidisciplinary team is strongly recommended for
\nthe physician. Such a team is likely to include physicians, social workers, child and
\nadult psychiatrists, developmental specialists, psychologists and attorneys. When
\nparticipation in a team is not possible or such a team is not available, the physician
\nmust consult with other medical, social, law enforcement and mental health personnel
\nas appropriate.
\n9. Primary care physicians, family practitioners, internists, paediatricians, emergency
\nmedicine specialists, surgeons, psychiatrists and other specialists who treat children
\nmust acquire knowledge and skills in the physical, psychological and emotional
\nassessment of child abuse in all its forms, the assessment of child development and
\nparenting skills, the utilization of community resources, and the physician\u2019s legal
\nresponsibilities.
\n10. All physicians who treat children, and those adults with caring responsibilities for
\nchildren, should be aware of the principles of the UN Convention on the Rights of the
\nChild as well as relevant national protective legal provisions applying to children and
\nyoung people.
\n11. The medical evaluation of children who are suspected of having been abused should
\nbe performed by physicians skilled in both paediatrics and abuse evaluation. The
\nmedical evaluation needs to be tailored to the child\u2019s age, injuries, and condition and
\nmay include blood testing, a trauma radiographic survey, and developmental and
\nbehavioural screenings. Follow up radiographs are strongly urged in some children
\nwho present with serious, apparently abusive injuries.
\n12. The medical assessment and management of sexually abused children includes a
\ncomplete history and physical examination, as physical and sexual abuses often occur
\ntogether; examination of the genitalia and anus; the collection and processing of
\nevidence, including photographs; and the treatment and\/or prevention of pregnancy
\nand venereal disease. Specific attention should be paid to the child\u2019s right to privacy.
\n13. It is essential for the physician to understand and be sensitive to the following: the
\nquality of relationships between care-givers; disciplinary actions or styles used within
\nthe child\u2019s home; economic stresses on the family; emotional stresses or issued<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1984-01-2017
\nexperienced by members of the family; mental health problems exhibited by any
\nmembers of the family; violence between the care-givers or other members of the
\nfamily; substance use and abuse, including alcohol and legal and illegal drugs; and any
\nother forms of stress that could relate to child abuse in all its forms.
\n14. All physicians need to be aware that all forms of abuse of children by other children
\ncan occur. Recognition that this may be a result of prior or current abuse of the
\nalleged abuser must be at the forefront of the physician\u2019s mind when such situations
\nare suspected or encountered.
\n15. The signs of abuse are often subtle, and the diagnosis may require comprehensive,
\ncareful interviews with the child, parent(s), care-givers, and siblings. Inconsistencies
\namong explanation(s) and characteristics of the injury(s), such as the severity, type and
\nage, should be documented and further investigated.
\n16. In any child presenting to a medical facility, the emergent medical and mental health
\nneeds should be addressed first. If abuse is suspected, safety needs must be addressed
\nprior to discharge from the facility. These measures should include:
\n\u2022 Reporting all suspected cases to child protective services;
\n\u2022 Hospitalizing any abused child needing protection during the initial evaluation
\nperiod;
\n\u2022 Informing the parents of the suspicion of abuse or diagnosis of abuse if it is
\nsafe to do so; and
\n\u2022 Reporting the child\u2019s injuries to child protective services or other relevant
\nauthorities.
\n17. If hospitalization is required, a prompt evaluation of the child\u2019s physical, emotional
\nand developmental problems is necessary. This comprehensive assessment should be
\nconducted by physicians with expertise or through a multidisciplinary team of experts
\nwith specialized training in child abuse.
\n18. If child abuse is suspected, the physician should discuss with the parent(s) the fact that
\nchild abuse is in the differential diagnosis of their child\u2019s problem. Advice may be
\nrequired from child protective services.
\n19. During discussions with the parent(s), guardians, or care-givers it is essential that the
\nphysician maintain objectivity and avoid accusatory or judgmental statements in
\ninteractions with the parent(s) or individual(s) responsible for the child\u2019s care.
\n20. It is essential that the physician record the history and examination findings in the
\nmedical chart contemporaneously during the evaluation process. Injuries should be
\ndocumented using photographs, illustrations, and detailed descriptions. The medical
\nrecord often provides critical evidence in court proceedings.
\n21. Physicians should participate at all levels of prevention by providing prenatal and
\npostnatal family counselling, identifying problems in child rearing and parenting, and
\nadvising about family planning and birth control.
\n22. Public health measures such as home visits by nurses and other health professionals,
\nanticipatory guidance by parents, and well-infant and well-child examinations should
\nbe encouraged by physicians. Programs that improve the child\u2019s general health also
\ntend to prevent child abuse in all its forms and should be supported by physicians and<\/p>\n

S-1984-01-2017\t\u23d0\tChicago
\nChild\tAbuse\tand\tNeglect
\ntheir representative bodies.
\n23. Physicians should recognize that child abuse and neglect is a complex problem and
\nmore than one type of treatment or service may be needed to help abused children and
\ntheir families. The development of appropriate treatment requires contributions from
\nmany professions, including medicine, law, nursing, education, psychology and social
\nwork.
\n24. Physicians should promote the development of innovative programs that will advance
\nmedical knowledge and competence in the field of child abuse and neglect. Inclusion
\nof on-going reviews of knowledge, skills and competency in relation to protecting the
\nrights of children and young people, promoting their health and well-being and the
\nrecognition of and response to suspected cases of child abuse and neglect is crucial in
\nprofessional educational programs. Physicians should obtain education on child
\nneglect and abuse in all its forms during training as medical students.
\n25. In the interests of the child, patient confidentiality may be waived in cases of child
\nabuse. The first duty of a doctor is to protect his or her patient if victimization is
\nsuspected. No matter what the type of abuse (including physical abuse, emotional
\nabuse, sexual abuse, trafficking, exploitation or neglect), an official report must be
\nmade to the appropriate authorities.
\n26. Inclusion of on-going reviews of knowledge, skills and competency in relation to
\nprotecting the rights of children and young people, promoting their health and well-
\nbeing and the recognition of and response to suspected cases of child abuse in all its
\nforms and neglect is crucial in professional educational programmes.
\n27. The undergraduate medical curriculum must include a mandatory course on child
\nabuse, in all its forms, within the paediatrics program, that can be developed within
\npostgraduate and continuing medical education for those intending to work within this
\nfield.
\n[1] The United Nations Convention on the Rights of the Child defines a child as anyone who
\nhas not reached their 18th birthday.
\n[2] Child abuse and Child maltreatment are used synonymously in this Statement.
\n[3] Neglect is the persistent failure to meet a child\u2019s basic needs, likely to result in the serious
\nimpairment of a child\u2019s health, well-being or development.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1984-02-1984\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nFREEDOM\tTO\tATTEND\tMEDICAL\tMEETINGS
\nAdopted by the 36th
\nWorld Medical Assembly, Singapore, October 1984
\nProfessional independence and professional freedom are indispensable to physicians to
\nenable them to give appropriate health care to their patients. Therefore, there should be no
\nbarriers, whether philosophical, religious, racial, political, geographic, physical or of any
\nother nature to prevent physicians from participating in professional activities that will
\nenable them to acquire the information, knowledge, skills and techniques required to pro-
\nvide appropriate health care to their patients.
\nIn as much as the purpose of the WMA is to serve humanity by endeavoring to achieve the
\nhighest international standards in medical education, medical science, medical art and
\nmedical ethics, and health care for all people of the world, there should accordingly be no
\nbarriers which will prevent physicians from attending meetings of the WMA, or other
\nmedical meetings, wherever such meetings are convened.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1985-01-2015
\nWMA\tSTATEMENT
\nON
\nNON-DISCRIMINATION\tIN\tPROFESSIONAL\tMEMBERSHIP
\nAND\tACTIVITIES\tOF\tPHYSICIANS
\nAdopted by the 37th
\nWorld Medical Assembly, Brussels, Belgium, October 1985
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand revised by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nThe World Medical Association is in favour of equality of opportunity in medical associa-
\ntion activities, medical education and training, employment, and all other medical profess-
\nsional endeavours regardless of any factors of discrimination.
\nThe World Medical Association is unalterably opposed to the denial of membership pri-
\nvileges and responsibilities in National Medical Associations to any duly registered physi-
\ncian because of any factors of discrimination.
\nThe World Medical Association calls upon the medical profession and all individual
\nmembers of National Medical Associations to exert every effort to prevent any instance in
\nwhich such equal rights, privileges or responsibilities are denied.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1988-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nACCESS\tTO\tHEALTH\tCARE
\nAdopted by the 40th
\nWorld Medical Assembly, Vienna, Austria, September 1988
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 68th
\nWMA General Assembly, Chicago, United States, October 2017<\/p>\n

PREAMBLE\t<\/p>\n

1. Health is not simply the absence of illness, but is also more than a state of physical,
\npsychological and social flourishing, and includes an individual\u2019s ability to adapt to
\nphysical, social and mental adversity. It is affected by many factors, including
\naccess to health care and especially the Social Determinants of Health (SDH), and
\nits restoration is similarly multidimensional. Society has an obligation to make
\naccess to an adequate level of care available to all its members, regardless of ability
\nto pay.
\n2. Health care professionals regularly confront the effects of lack of access to adequate
\ncare and health inequality and have a corresponding responsibility to contribute their
\nexpertise to work with governments at local, regional and national levels to ensure
\nthey understand the Social Determinants of Health and integrate reduction of factors
\nleading to inequality into all policies. Health care policies should suggest ways to
\neliminate health inequality.
\n3. Access to health care is an important factor in reducing the short, medium and long
\nterm consequences of poor health, caused by adverse social and other conditions.
\nAccess is itself multidimensional, and is constrained by factors including health
\nhuman resources, training, finance, transportation, geographical availability,
\nfreedom of choice, public education, quality assurance and technology.<\/p>\n

GUIDELINES\t\t<\/p>\n

Health\tHuman\tResources\t\t<\/p>\n

4. The delivery of health care is highly dependent upon the availability of trained
\nhealth care workers. The training should not only include socio-medical
\ncompetencies, but particularly emphasize an understanding of how the social
\ndeterminants of health affect people\u2019s health outcomes.
\nThe distribution of health care workers varies widely as do the demographics in
\nmost countries, where an ageing population forms a huge challenge for the years to
\ncome. There is global mal-distribution. While all countries train health care workers,
\nglobal movement, especially from less to better developed countries, is leading to
\ncontinuing shortages. The development of ethical recruitment codes may help to
\nreduce inappropriate recruitment activities by states. Ethical recruitment codes
\nshould also be applied to commercial recruitment agencies.<\/p>\n

S-1988-01-2017\t\u23d0\tChicago
\nAccess\tto\tHealth\tCare
\n5. Research is needed to determine the best mix of different health care workers for
\ndifferent clinical settings to meet the needs of populations. Mal-distribution within
\ncountries should be addressed by seeking methods of attracting health care workers
\nto rural and remote areas, or other underserved regions, at least for a part of their
\ncareers. Innovative concepts should be explored to make working in underserved
\nareas interesting; punitive and coercive recruiting methods must not be used.
\nRecruiting students who express a wish to return to their home area may help to
\nalleviate this problem.<\/p>\n

Training\t<\/p>\n

6. Primary training of health care workers has to be appropriate, accessible and of good
\nquality, which makes the training costly, with the country of origin meeting this
\ncost. Workers move to continue with secondary training, including higher
\nprofessional training and specialisation for physicians, and also to earn more money
\nthat may be remitted home to support the family and community.
\n7. The ambition for self-improvement is understandable; efforts to increase retention of
\nhealth care workers should include consideration of encouraging a return to the
\nhome country, with use of the new skills and knowledge to improve health care
\naccess.
\n8. Countries should not actively recruit from other states. Even when they do so
\npassively, this recruitment should take place in accordance with ethical standards
\nand the WMA Statement on Ethical Guidelines for the International Migration of
\nHealth Care workers.
\nFinance\t<\/p>\n

9. Access to care is essential for the whole population. Methods of financing care are
\nfor each country to decide, according to their own resources, health and social
\npriorities, and health needs. Countries should develop revenue systems that reduce
\nreliance on out-of-pocket payments and private health insurance as these increase
\ninequalities between population groups.
\n10. No single system of finance is ideal for every country; the exact balance needs to be
\nlocally decided. In making decision about financing systems governments must
\nunderstand the essential nature of health care, the absolute requirement that it be
\navailable to all, based upon clinical need and not on the ability to pay, and that
\naccess can be constrained by financial fears. Eligibility for care does not ensure
\naccess, especially if co-payment schemes exclude those with the fewest financial
\nresources.
\n11. Innovative means should be used to provide comprehensive health care, including
\npartnerships with private providers and commercial entities, who may be able to
\nprovide elements of specialised care. In doing so states must ensure that this does
\nnot limit specialised care to the wealthiest proportion of their population nor should
\nthis be seen as a preference for a private health care model.
\n12. Decisions to limit access to elements of health care should be done on the basis of
\nobjective information, based on the best available scientific data about the efficacy<\/p>\n

Chicago\u23d0\tS-1988-01-2017
\nAccess\tto\tHealth\tCare
\nand safety of health care services. It must include public debate about, and
\nacceptance of, the concepts involved. Nothing should be introduced which
\ndiscriminates against the elderly or vulnerable populations.
\n13. The public should have access to clear information on the health care resources
\navailable to them and how they may be accessed. Specific processes should be
\nestablished to ensure that poverty or illiteracy will never be a barrier to access care.<\/p>\n

Vulnerable\tand\thard\tto\treach\tpeople\t<\/p>\n

14. There are groups of people in every country who are hard to reach with health care
\nmessages, and who often seek health care late in the progress of disease.
\n15. A variety of methods should be used to ensure hard to reach people are aware of the
\navailability of health care, without direct cost, including methods to reduce fear and
\nother barriers to access.
\n16. Where specific vulnerabilities such as learning disabilities or sensory impairments
\nexist, solutions should include identifying and dealing with those vulnerabilities.
\n17. Health care workers have a duty to provide care that is free from any form of unfair
\ndiscrimination.
\nTransportation\t<\/p>\n

18. Health care facilities should be situated in locations that are easy to access. This may
\nmean working with local transportation providers to ensure formal and informal
\npublic transport routes pass the facilities. Consideration should be made to making
\nhealth care facilities more accessible by active transport methods. Especially in rural
\nand remote locations, patients may travel considerable distances to attend the
\nfacilities.
\n19. Patients who need referral to secondary and specialized care should be provided
\nwith access to transportation. Those needing help with accessing primary care
\nshould also receive support. Transportation should also be offered to isolated rural
\npatients who require a level of care that can be found only in metropolitan medical
\ncentres. Telemedicine can sometimes be an acceptable substitute for transportation
\nof patients.<\/p>\n

Geographical\tavailability\t<\/p>\n

20. Working with other health providers, including traditional birth attendants, may
\nprovide assistance. They should be integrated into the health care system, offered
\ntraining, and be assisted to offer care that is safe and effective and that includes
\nreferral where necessary. This does not extend to the state health care system
\nproviding or funding care which is not evidence based, including so-called
\ncomplementary therapies.
\nFreedom\tof\tchoice
\n21. The freedom to choose care providers, and the options of care they offer is an
\nessential element of care in every system. It requires the ability to understand that<\/p>\n

S-1988-01-2017\t\u23d0\tChicago
\nAccess\tto\tHealth\tCare
\nchoice, and the freedom to choose a provider from among alternatives.
\n22. Barriers to freedom of choice may lie in access to financial resources, understanding
\nof the options, and in cultural geographic, or other factors. Access to information
\nabout the available options is crucial in making an appropriately informed choice.
\n23. The health authorities should ensure that all populations understand how to access
\ncare, and should seek to ensure that populations have access to objective information
\nabout the availability of different health care suppliers.
\n24. Once individuals access care through a particular provider or physician they should
\nbe given opportunities to consider the clinical options open to them; access to
\nsystematically available information resources is an essential element supporting
\nchoice.
\nPublic\teducation
\n25. General education is a determinant of health; the better educated a person is,
\ngenerally the better their health likelihood. When ill-health presents, prior education
\nmay be a determinant of the speed at which the person accesses health care.
\nEducation also aids individuals to make appropriate choices about the care options
\nthey access.
\n26. Specific education about health matters can be an important adjunct to lifestyle
\nplanning. While education alone does not, for example, stop people from smoking,
\nusing drugs or alcohol, it can aid in decision making about risk behaviour.
\n27. A general level of health literacy assists patients to make choices among different
\noptions for treatment, and to comply or co-operate with the requirements of that
\ntreatment. It will also improve self-care and the appropriateness of self-referral.
\n28. Educational programs that assist people in making informed choices about their
\npersonal health and about the appropriate uses of both self-care and professional
\ncare should be established. These programs should include information about the
\ncosts and benefits associated with alternative courses of treatment within the context
\nof modern medicine; the use of professional services that permit early detection and
\ntreatment or prevention of illnesses; personal responsibilities in preventing illnesses;
\nand the effective use of the health care system. Physicians should actively
\nparticipate, wherever appropriate, in such educational efforts and must be provided
\nwith adequate resources to enable them to undertake such education.
\n29. Public education also assists governments by increasing understanding of public
\nhealth measures, including taxation of tobacco, banning of human consumption of
\nsome products, and restrictions on individual freedoms because of health concerns.
\nWhen legislative or other regulatory mechanisms are to be imposed by governments,
\na campaign of public education and explanation must be undertaken to gain public
\nunderstanding and voluntary compliance.
\nQuality\tassurance
\n30. Quality assurance mechanisms should be part of every system of health care<\/p>\n

Chicago\u23d0\tS-1988-01-2017
\nAccess\tto\tHealth\tCare
\ndelivery. Physicians share responsibility for assuring the quality of health care and
\nmust not allow other considerations to jeopardize the quality of care provided.
\nTechnology
\n31. Technology is playing an increasing role in the provision of health care services.
\nCapital purchase prices are high because of the need for specific logistical services,
\nincluding skilled technicians and adequate facilities. Advanced technologies are not
\navailable in all locales; access to their benefits must be well planned to ensure they
\nbenefit all patients in need, not simply those local to advanced technology centres.
\nExtraordinary\tcircumstances
\n32. In extraordinary circumstances, including armed conflicts and major natural events
\nsuch as earthquakes, physicians have a specific duty to ensure that policy makers
\nprotect access to care, especially for those most vulnerable and least able to move to
\nmore secure areas.
\nRECOMMENDATIONS
\n33. Social Determinants of Health greatly affect access to health care as well as directly
\nimpacting on health. Physicians should work with governments to ensure they are
\nable to take effective action on SDH.
\n34. Access to health care requires systematic consideration to ensure appropriate
\nconditions are met. These include:
\n34.1 Having an appropriate, universal, solidaristic and equitable health system,
\nadequately resourced facilities, being available throughout a country, providing
\nhealth centers and their professional staff with sufficient and sustainable
\nfinancing, with individuals being treated on the basis of need and not on the
\nability to pay.
\n34.2 Patient choice should include which facility to access.
\n34.3 Access to adequate information for all is essential for making choices and for co-
\noperating with health care providers.
\n34.4 Education is both a social determinant and a key factor in co-operation with
\nhealth care provision, fostering responsible self-care with accessible support.
\n34.5 Health care professionals should be free to move around the world, especially to
\naccess educational and professional opportunities. This mobility must not
\ndamage resource availability, especially in resource poor countries.
\n34.6 Physicians must be provided with transparent and efficient ethical criteria for
\nworking in overcrowded or underserved areas.
\n34.7 Provision of health care requires action by government at all levels, working
\nwith populations to ensure that people understand the benefit of this care and are
\nable to access it.<\/p>\n

S-1988-01-2017\t\u23d0\tChicago
\nAccess\tto\tHealth\tCare
\n34.8 Physicians have an important role in ensuring that health care planning makes
\nclinical sense, is communicated well to the population being served, and that
\npatients are not endangered by inadequate resources, poor planning or other
\nsystem flaws.
\n34.9 Physicians are aware of the health system and this forces them to play a socially
\nconscious role regarding the social determinants of health and access to health
\ncare by themselves or through their representative medical associations.
\n34.10 Medical associations should work with their members to promote access to
\nhealth care systems that equitably support the needs of populations.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1988-04-2016
\nWMA\tSTATEMENT
\nON
\nTHE\tROLE\tOF\tPHYSICIANS\tIN\tENVIRONMENTAL\tISSUES
\nAdopted by the 40th
\nWorld Medical Assembly, Vienna, Austria, September 1988
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand reaffirmed by the 203rd
\nWMA Council Session, Buenos Aires, Argentina, April 2016
\nINTRODUCTION\t<\/p>\n

1. The effective practice of medicine increasingly requires that physicians and their pro-
\nfessional associations turn their attention to environmental issues that have a bearing
\non the health of individuals and populations.
\n2. More than ever, due to diminishing natural resources, these problems relate to the
\nquality and protection of resources necessary to maintain health and indeed sustain
\nlife itself. In concrete terms, the key environmental issues are as follow:
\na. The degradation of the environment, which must be halted as a matter of urgency
\nso that resources essential to life and health – water and pure air – remain accessi-
\nble to all.
\nb. The ongoing contamination of our reserves of fresh water with hydrocarbons and
\nheavy metals, along with the contamination of ambient and indoor health by
\ntoxic agents, which have serious medical consequences, especially in the poorest
\nsegments of the globe. Moreover, the greenhouse effect with its concomitant pro-
\nven rise in temperature should drive our discussions forward and prepare us for
\nincreasingly serious environmental and public health consequences.
\nc. The need to control the use of non-renewable resources such as topsoil, which
\nshould constantly be at the forefront of our minds, as should the importance of
\nsafeguarding this vital heritage so that it can be passed on to future generations.
\nd. The need to mobilise resources beyond national frontiers and to co-ordinate
\nglobal solutions for the planet as a whole, so as to formulate a unified strategy to
\nconfront these worldwide medical and economic problems.
\ne. The foremost objective is to increase awareness of the vital balance between
\nenvironmental resources on the one hand, and on the other, biological essentials
\nfor the health of everyone everywhere.
\n3. Our growing awareness of these issues today has, however, failed to prevent an in-<\/p>\n

S-1988-04-2016\t\u23d0\tBuenos\tAires
\nEnvironmental\tIssues
\ncrease in our societies’ negative impact on the environment, e.g., melting of glaciers
\nand increasing desertification, nor has it halted the over-exploitation of natural re-
\nsources, e.g. pollution of rivers and seas, air pollution, deforestation and diminishing
\narable land. In this context, the migration of people from disadvantaged or developing
\ncountries, together with the emergence of new diseases, exacerbates the lack of socio-
\neconomic policies in many parts of the world. From a medical point of view, growth
\nof the population and irresponsible destruction of the environment are unacceptable,
\nand medical organisations throughout the world should redouble their efforts, not only
\nto speak out about these problems, but also to suggest solutions.
\nPRINCIPLES\t<\/p>\n

1. In their role as representatives of physicians, medical associations are duty bound to
\ngrapple with these environmental issues. They have a duty to produce analytical stu-
\ndies that include the identification of problems and current international regulations
\non environmental issues, as well as their impact on the field of health.
\n2. As physicians operate within the framework of ethics and medical deontology, the
\nenvironmental regulations advocated should not seek to limit individual autonomy,
\nbut rather to enrich the quality of life for all and to perpetuate life-forms on the planet.
\n3. The WMA should therefore act as an international platform for research, education,
\nand advocacy to help further sustain the environment and its potential to promote
\nhealth.
\n4. Thus, when new environmental diseases or syndromes are identified, the WMA
\nshould help coordinate the scientific\/medical discussions on the available data and
\ntheir implications for human health. It should foster the development of consensus
\nthinking within medicine, and help to stimulate preventive measures, accurate diagno-
\nsis and treatment of these emerging disorders.
\n5. The WMA should therefore provide a framework for the international co-ordination
\nof medical associations, NGOs, research clinicians, international health organisations,
\ndecision-makers and funding providers, in their examination of the human health ef-
\nfects of environmental problems, their prevention, remediation and treatment for indi-
\nviduals and communities.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1988-05-2011
\nWMA\tSTATEMENT
\nON
\nHEALTH\tHAZARDS\tOF\tTOBACCO\tPRODUCTS\tAND
\nTOBACCO-DERIVED\tPRODUCTS
\nAdopted by the 40th
\nWMA General Assembly, Vienna, Austria, September 1988
\nand amended by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nand the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nand the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nPREAMBLE
\nMore than one in three adults worldwide (more than 1.1 billion people) smokes, 80 per-
\ncent of whom live in low- and middle-income countries. Smoking and other forms of
\ntobacco use affect every organ system in the body, and are major causes of cancer, heart
\ndisease, stroke, chronic obstructive pulmonary disease, fetal damage, and many other con-
\nditions. Five million deaths occur worldwide each year due to tobacco use. If current
\nsmoking patterns continue, it will cause some 10 million deaths each year by 2020 and 70
\npercent of these will occur in developing countries. Tobacco use was responsible for 100
\nmillion deaths in the 20th century and will kill one billion people in the 21st century unless
\neffective interventions are implemented. Furthermore, secondhand smoke – which contains
\nmore than 4000 chemicals, including more than 50 carcinogens and many other toxins –
\ncauses lung cancer, heart disease, and other illnesses in nonsmokers.
\nThe global public health community, through the World Health Organization (WHO), has
\nexpressed increasing concern about the alarming trends in tobacco use and tobacco-
\nattributable disease. As of 20 September 2007, 150 countries had ratified the Framework
\nConvention on Tobacco Control (FCTC), whose provisions call for ratifying countries to
\ntake strong action against tobacco use by increasing tobacco taxation, banning tobacco
\nadvertising and promotion, prohibiting smoking in public places and worksites, imple-
\nmenting effective health warnings on tobacco packaging, improving access to tobacco
\ncessation treatment services and medications, regulating the contents and emissions of
\ntobacco products, and eliminating illegal trade in tobacco products.
\nExposure to secondhand smoke occurs anywhere smoking is permitted: homes, work-
\nplaces, and other public places. According to the WHO, some 200,000 workers die each
\nyear due to exposure to smoke at work, while about 700 million children, around half the
\nworld’s total, breathe air polluted by tobacco smoke, particularly in the home. Based on the
\nevidence of three recent comprehensive reports (the International Agency for Research on
\nCancer’s Monograph 83, Tobacco Smoke and Involuntary Smoking; the United States
\nSurgeon General’s Report on The Health Consequences of Involuntary Exposure to
\nTobacco Smoke; and the California Environmental Protection Agency’s Proposed Identifi-<\/p>\n

S-1988-05-2011\t\u23d0\tMontevideo
\nTobacco\tProducts\tHealth\tHazards
\ncation of Environmental Tobacco Smoke as a Toxic Air Contaminant), on May 29, 2007,
\nthe WHO called for a global ban on smoking at work and in enclosed public places.
\nThe tobacco industry claims that it is committed to determining the scientific truth about
\nthe health effects of tobacco, both by conducting internal research and by funding external
\nresearch through jointly funded industry programs. However, the industry has consistently
\ndenied, withheld, and suppressed information concerning the deleterious effects of tobacco
\nsmoking. For many years the industry claimed that there was no conclusive proof that
\nsmoking tobacco causes diseases such as cancer and heart disease. It has also claimed that
\nnicotine is not addictive. These claims have been repeatedly refuted by the global medical
\nprofession, which because of this is also resolutely opposed to the massive advertising
\ncampaigns mounted by the industry and believes strongly that the medical associations
\nthemselves must provide a firm leadership role in the campaign against tobacco.
\nThe tobacco industry and its subsidiaries have for many years supported research and the
\npreparation of reports on various aspects of tobacco and health. By being involved in such
\nactivities, individual researchers and\/or their organizations give the tobacco industry an
\nappearance of credibility even in cases where the industry is not able to use the results
\ndirectly in its marketing. Such involvement also raises major conflicts of interest with the
\ngoals of health promotion.
\nRECOMMENDATIONS
\nThe WMA urges the national medical associations and all physicians to take the following
\nactions to help reduce the health hazards related to tobacco use:
\n1. Adopt a policy position opposing smoking and the use of tobacco products, and
\npublicize the policy so adopted.
\n2. Prohibit smoking, including use of smokeless tobacco, at all business, social,
\nscientific, and ceremonial meetings of the National Medical Association, in line
\nwith the decision of the World Medical Association to impose a similar ban at all
\nits own such meetings.
\n3. Develop, support, and participate in programs to educate the profession and the
\npublic about the health hazards of tobacco use (including addiction) and exposure
\nto secondhand smoke. Programs aimed at convincing and helping smokers and
\nsmokeless tobacco users to cease the use of tobacco products and programs for
\nnon-smokers and non-users of smokeless tobacco products aimed at avoidance are
\nboth important.
\n4. Encourage individual physicians to be role models (by not using tobacco products)
\nand spokespersons for the campaign to educate the public about the deleterious
\nhealth effects of tobacco use and the benefits of tobacco-use cessation. Ask all
\nmedical schools, biomedical research institutions, hospitals, and other health care
\nfacilities to prohibit smoking, use of smokeless tobacco on their premises.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1988-05-2011
\n5. Introduce or strengthen educational programs for medical students and physicians
\nto prepare them to identify and treat tobacco dependence in their patients.
\n6. Support widespread access to evidence-based treatment for tobacco dependence –
\nincluding counseling and pharmacotherapy – through individual patient encounters,
\ncessation classes, telephone quit-lines, web-based cessation services, and other ap-
\npropriate means.
\n7. Develop or endorse a clinical practice guideline on the treatment of tobacco use
\nand dependence.
\n8. Join the WMA in urging the World Health Organization to add tobacco cessation
\nmedications with established efficacy to the WHO’s Model List of Essential Medi-
\ncines.
\n9. Refrain from accepting any funding or educational materials from the tobacco
\nindustry, and to urge medical schools, research institutions, and individual re-
\nsearchers to do the same, in order to avoid giving any credibility to that industry.
\n10. Urge national governments to ratify and fully implement the Framework Conven-
\ntion on Tobacco Control in order to protect public health.
\n11. Speak out against the shift in focus of tobacco marketing from developed to less
\ndeveloped nations and urge national governments to do the same.
\n12. Advocate the enactment and enforcement of laws that:
\n\u2022 provide for comprehensive regulation of the manufacture, sale, distribution,
\nand promotion of tobacco and tobacco-derived products, including the specific
\npro-visions listed below.
\n\u2022 require written and pictorial warnings about health hazards to be printed on all
\npackages in which tobacco products are sold and in all advertising and pro-
\nmotional materials for tobacco products. Such warnings should be prominent
\nand should refer those interested in quitting to available telephone quit-lines,
\nwebsites, or other sources of assistance.
\n\u2022 prohibit smoking in all enclosed public places (including health care facilities,
\nschools, and education facilities), workplaces (including restaurants, bars and
\nnightclubs) and public transport. Mental health and chemical dependence treat-
\nment centers should also be smoke-free. Smoking in prisons should not be per-
\nmitted.
\n\u2022 ban all advertising and promotion of tobacco and tobacco-derived products.
\n\u2022 encourage the development of plain packaging legislation
\n\u2022 prohibit the sale, distribution, and accessibility of cigarettes, and other tobacco
\nproducts to children and adolescents. Ban the production, distribution and sale
\nof candy products that depict or resemble tobacco products.
\n\u2022 prohibit smoking on all commercial airline flights within national borders and
\non all international commercial airline flights, and prohibit the sale of tax-free
\ntobacco products at airports and all other locations.<\/p>\n

S-1988-05-2011\t\u23d0\tMontevideo
\nTobacco\tProducts\tHealth\tHazards
\nprohibit all government subsidies for tobacco and tobacco-derived products.
\nprovide for research into the prevalence of tobacco use and the effects of tobac-co
\nproducts on the health status of the population.
\nprohibit the promotion, distribution, and sale of any new forms of tobacco pro-
\nducts that are not currently available.
\nincrease taxation of tobacco products, using the increased revenues for preven-tion
\nprograms, evidence-based cessation programs and services, and other health care
\nmeasures.
\ncurtail or eliminate illegal trade in tobacco products and the sale of smuggled
\ntobacco products.
\nhelp tobacco farmers switch to alternative crops.
\nurge governments to exclude tobacco products from international trade agree-
\nments.
\n13. Recognize that tobacco use may lead to pediatric disease because of the harm done
\nto children caused by tobacco use and second-hand smoke exposure, the relation-
\nship of tobacco use by children and exposure to adult tobacco use, and the existence
\nof effective interventions to reduce tobacco use. Special efforts should be made by
\nphysicians to:
\n\u2022 provide tobacco-free environments for children
\n\u2022 target parents who smoke for tobacco cessation interventions
\n\u2022 promote programs that contribute to the prevention and decrease of tobacco use
\nby youth
\n\u2022 control access to and marketing of tobacco products, and
\n\u2022 make pediatric tobacco-control research a high priority
\n14. Refuse to invest in companies or firms producing or promoting the use or sale of
\ntobacco.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1989-01-2016
\nWMA\tSTATEMENT
\nON
\nANIMAL\tUSE\tIN\tBIOMEDICAL\tRESEARCH
\nAdopted by the 41st
\nWorld Medical Assembly, Hong Kong, September 1989
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand reaffirmed by the 203rd
\nWMA Council Session, Buenos Aires, Argentina, April 2016
\nPREAMBLE\t<\/p>\n

1. Biomedical research is essential to the health and well-being of our society. Advances
\nin biomedical research have dramatically improved the quality and prolonged the
\nduration of life throughout the world. However, the ability of the scientific commu-
\nnity to continue its efforts to improve personal and public health is being threatened
\nby a movement to eliminate the use of animals in biomedical research. This move-
\nment is spearheaded by groups of radical animal rights activists whose views are
\nconsidered to be far outside mainstream public attitudes and whose tactics range from
\nsophisticated lobbying, fund-raising, propaganda and misinformation campaigns to
\nviolent attacks on biomedical research facilities and individual scientists. These violent
\nattacks are carried out by a relatively small number of activists compared with those
\nwho use peaceful means of protest, but they have profound and wide-ranging effects.
\n2. The magnitude of violent animal rights activities is staggering, and these activities
\ntake place in many different parts of the world. Various animal rights groups have
\nclaimed responsibility for the bombing of cars, institutions, stores, and the private
\nhomes of researchers.
\n3. Animal rights violence has had a chilling effect on the scientific community inter-
\nnationally. Scientists, research organizations, and universities have been intimidated
\ninto altering or even terminating important research efforts that depend on the use of
\nanimals. Laboratories have been forced to divert thousands of research dollars for the
\npurchase of sophisticated security equipment. Young people who might otherwise
\npursue a career in biomedical research are turning their sights to alternative profes-
\nsions.
\n4. Despite the efforts of many groups striving to protect biomedical research from
\nradical animal activism, the response to the animal rights movement has been frag-
\nmented, underfunded, and primarily defensive. Many groups within the biomedical
\ncommunity are hesitant to take a public stand about animal activism because of fear of
\nreprisal. As a result, the research establishment has been backed into a defensive pos-
\nture. Its motivations are questioned, and the need for using animals in research is re-<\/p>\n

S-1989-01-2016\t\u23d0\tBuenos\tAires
\nAnimal\tUse\tin\tBiomedical\tResearch
\npeatedly challenged.
\n5. While properly designed and executed research involving animals is necessary to
\nenhance the medical care of all persons, we recognize also that humane treatment of
\nresearch animals must be ensured. Appropriate training for all research personnel
\nshould be prescribed and adequate veterinary care should be available. Experiments
\nmust comply with any rules or regulations promulgated to govern humane handling,
\nhousing, care, treatment and transportation of animals.
\n6. International medical and scientific organizations must develop a stronger and more
\ncohesive campaign to counter the growing threat to public health posed by animal
\nactivists. Leadership and coordination must be provided. In addition, there must be a
\nclear understanding of the rights of animals who are part of medical research, and the
\nobligations of those who undertake it.
\nThe World Medical Association therefore affirms the following principles:
\n1. Animal use in biomedical research is essential for continued medical progress.
\n2. The WMA Declaration of Helsinki requires that biomedical research involving human
\nsubjects should be based, where appropriate, on animal experimentation, but also re-
\nquires that the welfare of animals used for research be respected.
\n3. Humane treatment of animals used in biomedical research is essential and research
\nfacilities should be required to comply with all guiding principles for humane treat-
\nment. Education about these principles should be provided to all researchers in train-
\ning.
\n4. Animals should only be used in biomedical research when it is clear that their use is
\nrequired to achieve an important outcome, and where no other feasible method is
\navailable.
\n5. Duplication of animal experiments should not occur unless scientifically justified.
\n6. The use of animals for the futile testing of cosmetic products and their ingredients,
\nalcohol and tobacco should not be supported.
\n7. Although rights to free speech should not be compromised, the anarchistic element
\namong animal right activists should be condemned.
\n8. The use of threats, intimidation, violence, and personal harassment of scientists and
\ntheir families should be condemned internationally.
\n9. A maximum coordinated effort from international law enforcement agencies should
\nbe sought to protect researchers and research facilities from activities of a terrorist
\nnature.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1990-01-2016
\nWMA\tSTATEMENT
\nON
\nINJURY\tCONTROL
\nAdopted by the 42nd
\nWorld Medical Assembly, Rancho Mirage, CA., USA, October 1990
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nnjuries are the leading cause of death and disability in children and young adults,
\ndestroying the health, livelihoods and lives of millions of people each year. Causes of
\ninjury include, among others, acts of violence against oneself or others, traffic crashes,
\nfalls, poisonings, drowning, and burns. Yet many injuries are preventable. Injury control
\nshould be recognized as a public health priority requiring coordination among health,
\ntransportation and social service agencies in each country. Physician participation and
\nleadership through medicine, education and advocacy is necessary to ensure the success of
\nsuch injury control programmes.
\nAs the World Health Organization states in Injuries and Violence: The Facts, the rate of
\ninjury is far from uniform around the world. Indeed, about 90% of injury-related deaths
\noccur in low- and middle-income countries. Within countries, injury rates vary by social
\nclass as well. The impoverished face more dangerous living and working conditions than
\nthe more affluent. For example, buildings in poorer communities are more likely to be
\nolder and in need of repair. Poor communities are also plagued by much higher rates of
\nhomicide. What\u2019s more, people living in poverty also have less access to quality
\nemergency care and rehabilitation services. Greater attention must be given to these root
\ncauses of injuries.
\nThe World Medical Association urges National Medical Associations to work with
\nappropriate public and private agencies to develop and implement programmes to prevent
\nand treat injuries. Included in the programmes must be efforts to improve medical
\ntreatment and rehabilitation of injured patients. Research and education on injury control
\nmust be increased, and international cooperation is a vital and necessary component of
\nsuccessful programmes.
\nNational Medical Associations should recommend that the following basic elements be
\nincorporated in their countries\u2019 programmes:<\/p>\n

EPIDEMIOLOGY\t<\/p>\n

The initial activity of such programmes must be the acquisition of more adequate data on
\nwhich to base priorities, interventions and research. An effective injury surveillance
\nsystem should be implemented in each country to gather and integrate information. A
\nconsistent and accurate system for coding injuries must be implemented by hospitals and
\nhealth agencies. There should also be international uniformity in the coding of injury
\nseverity.<\/p>\n

S-1990-01-2006\t\u23d0\tPilanesberg
\nInjury\tControl
\nPREVENTION\t<\/p>\n

Injury prevention requires education and training to teach and persuade people to alter
\ntheir behaviour in order to reduce their risk of injury. Laws and regulations based on
\nscientifically sound methods of preventing injuries may be appropriate for effecting
\nchanges in behaviour (for example, the use of seatbelts and protective helmets). These
\nlaws must in turn be strictly enforced. An effective injury surveillance system as
\nmentioned above will help determine how to target further preventive efforts. Urban and
\ntraffic planning should support safe environments for the residents.
\nBIOMECHANICS\t<\/p>\n

A better understanding of the biomechanics of injury and disability could inform the
\ndevelopment of improved safety standards and regulations of products and their designs.
\nTREATMENT\t<\/p>\n

Injury management at the scene of the occurrence must be enhanced by an effective
\nsystem of communication between first responders and health professionals at hospitals to
\nfacilitate decision-making. Rapid and safe transportation to the hospital should be
\nprovided. An experienced team of trauma practitioners should be available at the hospital.
\nThere should also be adequate equipment and supplies available for the care of the injured
\npatient, including immediate access to a blood bank. Education and training of medical
\npractitioners in trauma care must be encouraged to assure optimal technique by an
\nadequate number of physicians at all times.
\nREHABILITATION\t<\/p>\n

Trauma victims need continuity of care emphasizing not only survival but also the
\nidentification and preservation of residual functions. Rehabilitation to restore biological,
\npsychological and social functions must be undertaken in an effort to allow the injured
\nperson to achieve maximal personal autonomy and an independent lifestyle. Where
\nfeasible, community integration is a desirable goal for people chronically disabled by
\ninjury. Rehabilitation may also require changes in the patient\u2019s physical and social
\nenvironment.\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1990-04-2016
\nWMA\tSTATEMENT
\nON
\nTRAFFIC\tINJURY
\nAdopted by the 42nd
\nWorld Medical Assembly, Rancho Mirage, CA., USA, October 1990
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t<\/p>\n

Serious injuries and mortality in road collisions are a public health problem with
\nconsequences similar to those of major diseases such as cancer and cardiovascular disease.
\nWorldwide, about 1.2 million persons are killed each year on the roads, and an additional
\n20-50 million are injured. By 2020, road traffic injuries are expected to be the third largest
\ncontributor to the global burden of disease and injury.
\nIn addition to the immeasurable personal and social price paid by road crash victims and
\ntheir relatives, traffic injury has a significant economic impact. The economic costs of
\ntraffic injury and disability, including emergency and rehabilitative health care, costs of
\ndisability and disability adjusted life years (DALYs), amount to 1% of the GDP of poorer
\ncountries and 1.5-2% of wealthier countries. Much of this burden is borne by the health
\nsector.
\nRoad injuries continue to increase in many countries, particularly in low- and middle-
\nincome nations which currently account for 85% of all road traffic deaths, and are the
\nsecond leading cause of death among youth worldwide.
\nMost traffic injuries could be prevented by better countermeasures. Combating traffic
\ninjury is the shared responsibility of groups and individuals at the international, national,
\nand community levels, including governments, NGOs, industry, public health
\nprofessionals, engineers and law enforcement personnel.
\nSpeed is widely recognized as the most important determinant of road safety, affecting
\nboth the likelihood that a crash will occur and the severity of a crash. On average, an
\nincrease in speed of 1 km\/h is associated with a 3% higher risk of a crash involving injury
\nand a 5% higher risk of serious or fatal injury.
\nHowever, efforts to decrease road crashes and injury also require a \u201csystems approach\u201d
\nthat recognizes and addresses the many factors that contribute to the risk of traffic crashes
\nand resulting injury, including human, vehicle and road design variables.
\nPreventing traffic injury requires addressing the social determinants of health\u2014the social,
\neconomic, environmental, and political factors in society that influence a population\u2019s<\/p>\n

S-1990-04-2016\t\u23d0\tTaipei
\nTraffic\tInjury
\nhealth. Low- and middle-income countries, where there is less safe infrastructure, fewer
\nminimum standards on vehicle safety, and poorer quality emergency care, experience the
\ngreatest number of traffic injuries. In this way, human, vehicular and environmental
\nfactors interact before, during and after a collision. Intervention at each of these stages will
\nhelp reduce crashes and injury. Effective intervention requires public education as well as
\nprofessional involvement in the fields of engineering, law enforcement and medical care.
\nPre-collision intervention is aimed at preventing crashes and reducing risk factors.
\nExamples include preventing drivers from driving when fatigued (especially drivers of
\nheavy vehicles), distracted or under the influence of drugs or alcohol. Necessary policies
\nmay include prohibiting the use of hand-held cellular phones and night curfews or
\ngraduated licensing for young drivers. Pre-collision intervention also includes setting
\nvehicle design standards that ensure that vehicles are roadworthy and cannot be driven at
\nexcessive speeds. Other interventions include setting and enforcing appropriate speed
\nlimits, installing speed cameras, and optimizing road design and layout to prevent crashes.
\nA second level of intervention is aimed at preventing or reducing injury during the crash.
\nSuch interventions include: enforcing the use of seat belts and child restraints; requiring
\nhelmets for cyclists; manufacturing vehicles equipped with safety devices and crash-
\nprotective design; lowering and enforcing speed limits; and removing heavy, rigid objects
\nsuch as concrete or metal dividers, light posts and abutments from the sides of roads.
\nPost-crash intervention is aimed at maximizing life-saving and injury-reducing treatment
\nand includes improved pre-hospital and emergency trauma care and rehabilitation.
\nRECOMMENDATIONS
\n1. The WMA supports the findings and key recommendations of the WHO\u2019s 2015
\nReport on road traffic injury prevention and calls for their implementation by its
\nmember National Medical Associations and their governments and relevant bodies.
\n2. Physicians must view traffic injury as a public health problem and recognize their
\nresponsibility in fighting this global problem.
\n3. National Medical Associations and their member physicians should work to
\npersuade governments and policy makers of the importance of this issue and
\nshould assist in adapting empirical and scientific information into workable
\npolicies.
\n4. National Medical Associations and physicians should be key players in public
\neducation and should include road safety in health promotion activities.
\n5. Physicians should be involved in the collection and analysis of data regarding road
\ncrashes and concomitant injuries, including injury surveillance systems.
\n6. Physicians should work toward changing the public attitude of road travel,
\nincluding pressing for improved public transportation, bicycle paths and proper
\nsidewalks to encourage less car use and the adoption of healthier options such as
\nwalking and cycling.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1990-04-2016
\n7. Physicians should address the human factor and medical reasons for road crashes,
\nincluding, but not limited to, the use of prescription drugs or medical conditions
\nthat may impair driving ability, and explore ways to prevent and reduce the
\nseverity of injuries.
\n8. Physicians should lobby for the implementation and enforcement of the measures
\nlisted above, which have been shown to decrease the risk and severity of vehicle
\ncrashes, and the evaluation of their impact.
\n9. National Medical Associations and their member physicians should encourage the
\nresearch and development of improved training systems and medical care at all
\nstages, including effective communication and transport systems to locate and
\nevacuate the victims, emergency medical care systems to provide life-saving first
\naid services, and expert trauma and rehabilitative care, and should lobby for
\nincreased resources to help provide these services.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1991-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nADOLESCENT\tSUICIDE
\nAdopted by the 43rd
\nWorld Medical Assembly, Malta, November 1991
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\nThe past several decades have witnessed a dramatic change in causes of adolescent
\nmortality. Previously, adolescents mostly died of natural causes, whereas they now more
\nlikely die from preventable causes. Part of this change has been a worldwide rise in
\nadolescent suicide rates in both developed and developing countries. In the adolescent
\npopulation, suicide is currently one of the leading causes of death. Suicides are probably
\nunder-reported due to cultural and religious stigma attached to self-destruction and to an
\nunwillingness to recognize certain traumas, such as some automobile accidents, as self-
\ninflicted.
\nAdolescent suicide is a tragedy that affects not only the individual but also the family,
\npeers and larger community in which the adolescent lived. Suicide is often experienced as
\na personal failure by parents, friends and physicians who blame themselves for not
\ndetecting warning signs. It is also viewed as a failure by the community, serving as a vivid
\nreminder that modern society often does not provide a nurturing, supportive and healthy
\nenvironment in which children can grow and develop.
\nFactors contributing to adolescent suicide are varied and include: affective disorders,
\ntrauma, emotional isolation, low self-esteem, excessive emotional stress, eating disorders,
\nharassment (school bullying, cyber bullying and sexual harassment), romantic fantasies,
\nthrill-seeking, drug and alcohol abuse, the availability of firearms and other agents of self-
\ndestruction, and media reports of other adolescent suicides, which may inspire copycat
\nacts. In addition, the prolonged exposure to electronic media, which predominantly affects
\nadolescents through their use of computer games and social media, can contribute to social
\nisolation, school failure and malaise amongst young people.
\nYouth within correctional facilities are at a higher risk for suicide than the general
\npopulation, yet they have fewer resources available to them. The lack of resources makes
\nit difficult to identify those at risk for suicide.
\nThe incidence of adolescent suicide is observed to be greater in the \u201cfirst peoples\u201d of some
\nnations. The reasons for this are complex.
\nThe health care of adolescents is best achieved when physicians provide comprehensive<\/p>\n

Taipei\u23d0\tS-1991-01-2016
\nAdolescent\tSuicide
\nservices, including both medical and psychosocial evaluation and treatment. Continuous,
\ncomprehensive care provides the physician the opportunity to obtain the information
\nnecessary to detect adolescents at risk for suicide or other self-destructive behaviour. This
\nservice model also helps to build a socially supportive patient-physician relationship that
\nmay moderate adverse influences adolescents experience in their environment.
\nIn working to prevent adolescent suicide, the World Medical Association recognizes the
\ncomplex nature of adolescent bio-psycho-social development; the changing social world
\nfaced by adolescents; and the introduction of new, more lethal, agents of self-destruction.
\nIn response to these concerns, the World Medical Association recommends that National
\nMedical Associations adopt the following guidelines for physicians. In doing so, we
\nrecognise that many other players \u2013 parents, governmental agencies, schools,
\ncommunities, social services \u2013 also have important roles in this area.
\nRECOMMENDATIONS\t<\/p>\n

1. All physicians should receive, during medical school and postgraduate training,
\neducation in child psychiatry and adolescent bio-psycho-social development,
\nincluding education in the risk factors for suicide.
\n2. Physicians should be trained to identify early signs and symptoms of physical,
\nemotional, and social distress of adolescent patients. They should also be trained to
\nidentify the signs and symptoms of psychiatric disorders, like depression, bipolar
\ndisorder and substance use disorders, that may contribute to suicide as well as
\nother self-destructive behaviours.
\n3. Physicians should be taught how and when to assess suicidal risk in their
\nadolescent patients.
\n4. Physicians should be taught and keep up-to-date on the treatment and referral
\noptions appropriate for all levels of self-destructive behaviours of their adolescent
\npatients. The physicians with the most significant training in adolescent suicide are
\nchild and adolescent psychiatrists, so the patient should be referred to one if
\navailable.
\n5. Physicians should also collaborate with other relevant stakeholders, such as social
\nworkers, school officials, and psychologists who bear expertise in child and
\nadolescent behavior.
\n6. When caring for adolescents with any type of trauma, physicians should consider
\nthe possibility that the injuries might have been self-inflicted.
\n7. When caring for adolescents who demonstrate deterioration in thinking, feeling or
\nbehaviour, the possibility of substance abuse and addiction should be considered,
\nand the threshold should be low for urine toxicology assessment.
\n8. Health care systems should facilitate the establishment of mental health
\nconsultation services aimed at preventing suicide and should pay for the socio-
\nmedical care given to patients who have attempted suicide. Services should be
\ntailored to the specific needs of adolescent patients.<\/p>\n

Adolescent\tSuicide
\nS-1991-01-2016\t\u23d0\tTaipei
\n9. Epidemiological studies on suicide, its risk factors and methods of prevention
\nshould be conducted, and physicians should keep up-to-date with such studies.
\n10. When caring for adolescents with psychiatric disorders or risk factors for suicide,
\nphysicians should educate parents or guardians to watch for the signs of suicide
\nand educate them about the options for evaluation.
\n11. Physicians should advocate for the identification of at risk groups of adolescents
\nwith the mobilization of specifically targeted resources directed at prevention and
\nrisk reduction.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1992-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nALCOHOL\tAND\tROAD\tSAFETY
\nAdopted by the 44th
\nWorld Medical Assembly, Marbella, Spain, September 1992
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General ssembky, Taipei, Taiwan, October 2016
\nINTRODUCTION\t<\/p>\n

Deaths and injuries resulting from road crashes and collisions are a major public health
\nproblem. The World Health Organization\u2019s 2015 Global status report on road safety
\nindicates that the total number of road traffic deaths per year has reached 1.25 million
\nworldwide, with the highest road traffic fatality rates in low-income countries.
\nDriving while under the influence of alcohol has caused a large number of the deaths and
\ninjuries resulting from road crashes. The prevalence of drinking and driving is increasing
\nworldwide each year.
\nA change in the behaviour of road users with regard to alcohol consumption would appear
\nto be the most promising approach to preventing traffic deaths and injuries. Measures
\nforbidding driving while under the influence of alcohol will lead to a considerable
\nimprovement in road safety and an appreciable reduction in the number of dead and
\ninjured.
\nCONSEQUENCES\tOF\tDRINKING\tAND\tDRIVING
\nDriving a vehicle implies the acceptance of a certain number of risks. The careful driver
\nwill always be aware of the risks but also ensure that the level of risk never rises to an
\nunacceptable level. Alcohol not only impairs one\u2019s ability to drive, but it also alters a
\ndriver\u2019s subjective assessment of risk so that he or she drives more recklessly.
\nIrrespective of the amount of alcohol consumed, the maximum concentration of alcohol in
\nthe body is reached:After half an hour when taken
\n\u2022 on an empty stomach;
\n\u2022 After an hour when taken with a meal.
\nOn the other hand, it takes the body a long time to eliminate alcohol. An individual in
\ngood health eliminates alcohol at a rate that reduces blood alcohol concentration by 0.1 to
\n0.15 gram\/litre\/hour. Thus, one\u2019s driving ability remains impaired long after he or she has
\nstopped drinking.
\nAlcohol abuse has both short- and long-term neurological and psychiatric consequences
\nthat can endanger road safety.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1992-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nCertain drugs interact negatively with alcohol, and in particular some combinations are
\nknown to reduce alertness. When drugs, whether legal or illegal, are taken with alcohol,
\nthe effect of the latter is intensified. This mixture can trigger mental dysfunctions that are
\nextremely dangerous for road users. Physicians should be educated and informed about
\nthese pharmacological facts.
\nRECOMMENDATIONS\t<\/p>\n

1. The WMA reaffirms its commitments to work for reducing excessive alcohol
\nconsumption and for fostering harm-reduction policies and other measures (WMA
\nDeclaration on Alcohol, October 2015.)
\n2. Physicians and National Medical Associations should play an active role in promoting
\nand advocating for the development of evidence-based government policies to reduce
\nalcohol use and driving:
\nPolicy\tinterventions
\n3. At the present time, permitted blood alcohol levels while driving vary from country to
\ncountry. Even small amounts of alcohol have a direct effect on the brain, with
\ndisturbances noted at levels as low as 0.3 grams per litre. Therefore, it would be
\ndesirable to lower the maximum permissible level of blood alcohol to a minimum, but
\nnot above 0.5 grams per litre, which is low enough to allow the average driver to retain
\nthe ability to assess risk.
\n4. The especially high prevalence in certain countries of driving while under the
\ninfluence of alcohol may justify more coercive policies, which physicians and
\nNational Medical Associations should play an active role in supporting. For example,
\nthe driver may be declared unfit to drive for a period of time sufficient to ensure he or
\nshe will no longer be a threat to road safety in the future.
\n5. Government officials should consider implementing restrictions on the sale or
\naffordability of alcohol, perhaps through taxation, licensing systems, and\/or limits on
\nthe days and hours of sale. Restrictions on the promotion of alcoholic beverages,
\nincluding advertising and event sponsorship, should also be considered.
\n6. A minimum legal age for alcohol purchase and consumption should be adopted in each
\ncountry. Government officials should consider implementing a separate, lower or zero
\nblood alcohol content law for young drivers.
\n7. There should be strict consequences to selling alcoholic beverages to individuals under
\nthe age to purchase and consume alcohol. These laws should be properly enforced.
\n8. Any driver who has been in a road traffic crash must undergo a blood alcohol
\nconcentration test or a breath test.
\n9. The practice of random driver testing for breath alcohol levels should become more
\nwidespread, and there should be further research into other ways to test urine, breath<\/p>\n

Taipei\t\u23d0\tS-1992-01-2016
\nAlcohol\tand\tRoad\tSafety
\nand saliva to identify impaired drivers and prevent subsequent operation of motor
\nvehicles.
\n10. Devices that prevent individuals with an unauthorised level of blood alcohol from
\nstarting the engine of or operating the vehicle should be developed and experimented
\nwith.
\nEducational\tinterventions
\n11. Educational interventions should promote moderation and responsibility in the
\nconsumption of alcohol and seek to reduce the likelihood that someone will consume
\nalcohol and drive afterwards.
\n12. The information dispensed by physicians and other health professionals should be
\naimed at making everyone aware of the dangers of driving under the influence of
\nalcohol. When physicians and other health professionals issue fitness-to-drive
\ncertificates, they can use this opportunity to educate road users and pass on a message
\nof prevention and personal responsibility.
\n13. In most countries, road crashes linked to alcohol consumption affect adolescents and
\nyoung adults to a disproportionately high degree, and every available resource should
\nbe mobilised to reduce their consumption of alcohol. The problem of alcohol
\nconsumption in adolescents and young adults and its relation to road safety should be
\naddressed in the school curricula so that a responsible attitude becomes the norm.
\nClinical\tand\trehabilitative\tinterventions
\n14. Physicians should also be involved in reducing the likelihood of impaired driving by
\nparticipating in the detoxification and rehabilitation of drunk drivers. These initiatives
\nshould be based on a detailed analysis of the problem as it manifests itself within each
\ncountry or culture. Generally speaking, however, alcoholism is a medical condition
\nwith concomitant psychological or social and interpersonal difficulties that affect the
\nfamily, work or social environment.
\n15. Alcoholic subjects should be given access to rehabilitation services. When drivers are
\nfound to have excess alcohol in their blood (or their breath), other factors linked to
\ntheir excessive drinking should be examined and included in a rehabilitation
\nprogramme. These rehabilitation programmes should be publicly funded.
\n16. Road crashes linked to the consumption of alcohol can be considered as possible
\npredictors of other addictive and violent behaviours. This should be taken into
\nconsideration in the medical treatment of the patient.
\nCommunity\tinterventions
\n17. Strategies should be developed by relevant stakeholders to ensure safe transportation
\nhome in situations where alcohol consumption occurs.
\n18. Eliminating alcohol from the workplace and in situations where consumers must drive
\nshould be a goal of organizational policies. The promotion of non-alcoholic drinks is
\nan important tool to facilitate these policies.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1992-05-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nNOISE\tPOLLUTION
\nAdopted by the 44th
\nWorld Medical Assembly, Marbella, Spain, September 1992
\namended by the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nand reaffirmed with minor revision by the 207th
\nWMA Council session, Chicago, United
\nStates, October 2017
\nPREAMBLE\t<\/p>\n

Given growing environmental awareness and knowledge of the impact of noise on health,
\nthe psyche, performance and well-being, environmental noise is becoming a serious public
\nhealth threat. The World Health Organization (WHO) describes noise as the principal
\nenvironmental nuisance in industrial nations.
\nNoise affects people in various ways. Its effects relate to hearing, the vegetative nervous
\nsystem, the psyche, spoken communication, sleep and performance. Since noise acts as a
\nstressor, an increased burden on the body leads to higher energy consumption and greater
\nwear. It is thus suspected that noise can primarily favour diseases in which stress plays a
\ncontributory role, such as cardiovascular diseases, which can then be manifested in the
\nform of hypertension, myocardial infarction, angina pectoris, or even apoplexy.
\nThe effects in the psychosocial field are likewise dramatic. The stress caused by
\nenvironmental noise is a central concern, not only in the industrial nations, but
\nincreasingly also in the developing countries. Owing to the continuous and massive
\ngrowth of traffic volumes, both on the roads and in the air, the stress caused by
\nenvironmental noise has increased steadily in terms of both its duration and the area
\naffected.
\nSimilarly, occupational noise generates increasingly work-related hearing impairment.
\nDamage to hearing caused by leisure-time noise is also of growing concern. The most
\ncommon source of noise in this context is music, to which the ear is exposed by different
\naudio media at different places (portable music players, stereo systems, discotheques,
\nconcerts). The risk of suffering hearing damage is underestimated by most people, or even
\nconsciously denied. The greatest issue (or aspect) lies in creating awareness of the
\nproblem in the high-risk group \u2013 which generally means young people. In this respect, the
\nlegislature is called upon to intervene and reduce the potential for damage by introducing
\nsound level limiters in audio playback units and maximum permissible sound levels at
\nmusic events, or by banning children\u2019s toys that are excessively loud or produce excessive
\nnoise levels.
\nIn keeping with its socio-medical commitment, the World Medical Association is issuing a
\nstatement on the problem of noise pollution with the aim of making a contribution to the
\nfight against environmental noise through more extensive information and more acute
\nawareness.<\/p>\n

Chicago\t\u23d0\tS-1992-05-2017
\nNoise\tPollution
\nRECOMMENDATIONS\t<\/p>\n

The World Medical Association calls upon the National Medical Associations to:
\n1. Inform the public, especially persons affected by environmental noise, as well as poli-
\ncy and decision makers, of the dangers of noise pollution.
\n2. Call upon ministers of transport and urban planners to develop alternative concepts
\nthat are capable of countering the growing level of environmental noise pollution.
\n3. Advocate appropriate statutory regulations for combating environmental noise pollu-
\ntion.
\n4. Support enforcement of noise pollution legislation and monitor the effectiveness of
\ncontrol measures.
\n5. Inform young people of the risks associated with listening to excessively loud music,
\nsuch as that which emanates, for example, from portable music players, use of stereo
\nsystems with earphones, audio systems in cars, and attendance at rock concerts and
\ndiscotheques.
\n6. Prompt the educational authorities to inform pupils at an early stage regarding the
\neffects of noise on people, how stress due to environmental noise can be counteracted,
\nthe role of the individual in contributing to noise pollution, and the risks associated
\nwith listening to excessively loud music.
\n7. Provide information about risks of damage to hearing that arise in the private sector as
\na result of working with power tools or operating excessively loud motor vehicles.
\n8. Emphasize to those individuals who are exposed to excessive levels of noise in the
\nworkplace the importance of protecting themselves against irreducible noise.
\n9. Call upon the persons responsible for occupational safety and health in businesses to
\ntake further action to reduce noise emission, in order to ensure protection of the health
\nof employees at the workplace.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1992-06-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nPHYSICIAN-ASSISTED\tSUICIDE
\nAdopted by the 44th
\nWorld Medical Assembly, Marbella, Spain, September 1992
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nPhysician-assisted suicide, like euthanasia, is unethical and must be condemned by the
\nmedical profession. Where the assistance of the physician is intentionally and deliberately
\ndirected at enabling an individual to end his or her own life, the physician acts unethically.
\nHowever the right to decline medical treatment is a basic right of the patient and the phy-
\nsician does not act unethically even if respecting such a wish results in the death of the
\npatient.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1993-01-2016
\nWMA\tSTATEMENT
\nON
\nBODY\tSEARCHES\tOF\tPRISONERS
\nAdopted by the 45th
\nWorld Medical Assembly, Budapest, Hungary, October 1993
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand revised by the 67th
\nWMA General Assembky, Taipei, Taiwan, October 2016
\n1. The World Medical Association adopts this statement for the purpose of providing
\nguidance for National Medical Associations as they develop guidelines for their
\nmembers.
\n2. Physician participation in body cavity searches for purposes of law enforcement or
\npublic safety involves complex issues of patient rights, informed consent,
\nphysicians\u2019 fiduciary obligations (dual loyalty matters) and their responsibilities to
\ncontribute to public health. A request to conduct a body cavity search puts the
\nphysician in the untenable position of potentially violating the ethical standards of
\nhis\/her profession. Physician participation should be in exceptional cases only.
\n3. There are several types of searches of prisoners carried out within the detention
\nsystem. These will include searches for contraband and searches for items
\nimmediately dangerous to the prisoner and those around him\/her. Searches range
\nfrom the least invasive \u201cpat-down\u201d searches to the most invasive strip searches
\n(including examination of the mouth) and body cavity searches.
\n4. The prison systems in many countries mandate body cavity searches of prisoners.
\nSuch searches, which include rectal and pelvic (vaginal) examination, may be
\nperformed when an individual initially enters the prison population and thereafter
\nwhenever the individual is permitted to have direct personal contact with someone
\noutside the prison population. They may also be undertaken when there is a reason
\nto believe a breach of security or of prison regulations has occurred. For example,
\nwhen a prisoner is taken to Court for a hearing, or to the hospital for treatment, or
\nto work outside the prison, the prisoner, upon returning to the institution, may be
\nsubjected to a body cavity search that will include all body orifices. Where
\nprisoners have direct contact with visitors \u2013 family members or otherwise \u2013 prison
\nrules may also require body cavity searches. The purpose of the search is primarily
\nsecurity-related, to prevent contraband, such as weapons or drugs, from entering
\nthe prison.
\n5. These searches are performed for security reasons and not for medical or health-<\/p>\n

S-1993-01-2016\t\u23d0\tTaipei
\nBody\tSearches\tof\tPrisoners
\nrelated reasons. They should only be done by someone with appropriate training.
\nIn most cases this will mean someone working within the detention system who
\nhas been trained to perform safely such searches. This person should not be a
\nphysician except under unusual and specific circumstances.
\n6. A physician\u2019s obligation to provide medical care to the prisoner can be
\ncompromised by an obligation to participate in the prison\u2019s security system. A
\nphysician should seek to be as far removed from performing body searches as
\npossible. Any directive to search should be separated from the physician\u2019s broad
\ngeneral medical care duties in order to protect the patient\/physician relationship.
\n7. In exceptional cases the detaining authority, may indicate that a search be
\nperformed by a physician. The physician, will decide whether medical
\nparticipation is necessary, and act accordingly and ethically.
\n8. If the search could, if carried out by someone with lesser skills, cause harm, for
\nexample if the prisoner is a pregnant, or has severe haemorrhoids, then this non-
\nmedical procedure may be performed by a physician to protect the prisoner from
\nharm. In such a case the physician should explain this to the prisoner. The
\nphysician should also explain to the prisoner that s\/he is performing this search not
\nas a physician caring for the patient, but for patient safety and as required by the
\ndetention authorities for which the normal patient\/doctor relationship does not
\nexist. The physician should inform the prisoner that the usual conditions of
\nmedical confidentiality do not apply during this procedure and the results of the
\nsearch will be revealed to the authorities. If a physician is properly mandated by an
\nauthority and agrees to perform a body cavity search on a prisoner for reasons of
\npatient safety, the authority should be informed that it is necessary for this
\nprocedure to be done in a humane manner.
\n9. If the search is conducted by a physician, it should not be done by any physician
\nwho will subsequently provide medical care to the prisoner.
\n10. Forced examinations are not ethically acceptable, and physicians must not perform
\nthem. If the prisoner acquiesces to a search, the doctor, or other individual carrying
\nout the body cavity search, should ensure that the prisoner is fully aware of what
\nwill be done, including the facilities in which the search will be performed.
\n11. Searches should be performed humanely, and, where possible, in a private,
\nconfidential setting respecting the prisoner. The person performing the search
\nshould be of the same gender as the prisoner being searched. When applicable,
\ntransgender persons should be asked first with which gender they identify.
\n12. The World Medical Association urges all governments and public officials with
\nresponsibility for public safety to recognize that invasive searches are serious
\nassaults on a person\u2019s privacy and dignity, and they also carry some risk of
\nphysical and psychological injury. The World Medical Association urges that, to<\/p>\n

Body\tSearches\tof\tPrisoners
\nTaipei\t\u23d0\tS-1993-01-2016
\nthe extent feasible without compromising public security, the following
\nrecommendations be followed:
\n\u2022 Alternate methods be used for routine screening of prisoners, including
\nultrasound and other scans, and body cavity searches be used only as a last
\nresort;
\n\u2022 Squatting over mirrors to examine the anus while making the prisoner bear
\ndown, a degrading procedure with questionable reliability, must be banned;
\n\u2022 If a body cavity search must be conducted, the responsible public official must
\nensure that the search is conducted humanely by personnel who are of the same
\ngender as the prisoner and who possess sufficient medical and skills to safely
\nperform the search;
\n\u2022 The same responsible authority must ensure that the individual\u2019s privacy and
\ndignity be guaranteed.
\n\u2022 Physician participation in body cavity searches should be in exceptional cases
\nonly. In these cases, the duty to search should be separated from the
\nphysician\u2019s delivery of medical care.
\n13. Finally, the World Medical Association urges all governments and responsible
\npublic officials to provide body searches that are performed by a qualified
\nphysician whenever warranted by the individual\u2019s physical condition. A specific
\nrequest by a prisoner for a physician shall be respected, so far as possible.
\n14. In specific cases, it may be the detaining authority, which requires a search be
\nperformed by a physician, for the well-being of this prisoner. The physician, in
\nsuch a case, will decide whether medical participation is indeed necessary, and act
\naccordingly and ethically.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1993-02-2016
\nWMA\tSTATEMENT
\nON
\nFEMALE\tGENITAL\tMUTILATION
\nAdopted by the 45th
\nWorld Medical Assembly, Budapest, Hungary, October 1993
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t<\/p>\n

The World Medical Association joins with other international agencies in condemning the
\npractice of genital mutilation or cutting of women and girls, regardless of the level of
\nmutilation, and opposes the participation of physicians in these practices.
\nStopping female genital mutilations (FGM) requires action on strict enforcement of laws
\nprohibiting the practice, medical and psychological care for women who are victims and
\nprevention of FGM by education, risk assessment, early detection and engagement with
\ncommunity leaders.
\nFGM is a common practice in more than 30 countries of the world, including some in
\nAfrica, Asia and the Middle East. The phrase FGM is used to convey a number of
\ndifferent forms of surgery, mutilation or cutting of the female external genitalia. The term
\nfemale circumcision is no longer used as it suggests equivalence with male circumcision,
\nwhich is both inaccurate and counterproductive. Most girls undergo FGM\/C between the
\nages of 7 and 10. There is no medical necessity for any such cutting, which is often
\nperformed by an unqualified individual in un-hygienic surroundings.
\nFGM of any type is a violation of the human rights of girls and women, as it is a harmful
\nprocedure performed on a child who cannot give valid consent. As a result of migration a
\ngrowing number of girls living outside countries where the practice is common are being
\naffected.
\nRespecting the social norms of immigrants is increasingly posing problems for physicians
\nand the wider community.
\nBecause of its impact on the physical and mental health of women and children, and
\nbecause it is a violation of human rights, FGM is a matter of concern to physicians.
\nPhysicians worldwide are confronted with the effects of this traditional practice. They
\nmay be asked to perform this mutilating procedure or to restore the result of mutilating
\n\u201csurgery\u201d on women after childbirth has reopened the introitus.<\/p>\n

Female\tGenital\tMutilation
\nTaipei\t\u23d0\tS-1993-02-2016
\nThere are various forms of FGM, classified by WHO.[1] It can be a primary procedure for
\nyoung girls, usually between 5 and 12 years of age, or a secondary one, e.g., after
\nchildbirth. The extent of a primary procedure may vary: from an incision in the foreskin of
\nthe clitoris, up to the maximally mutilating so-called pharaonic infibulation which
\ninvolves partly removing the clitoris and labia minora and stitching up of the labia majora
\nso that only a small opening remains to allow the passage of urine and menstrual blood.
\nThe majority of procedures performed are somewhere in between these two extremes.
\nWhile the term female circumcision is no longer used it remains useful, familiar and
\nreadily accessible in the context of physician\/patient consultations in some cases.
\nFGM has no health benefits and harms girls and women in many ways, regardless of
\nwhich procedure is performed. Research shows grave permanent damage to health,
\nincluding: haemorrhage, infections, urinary retention, injury to adjacent organs, shock and
\nvery severe pain. Long-term complications include severe scarring, chronic bladder and
\nurinary tract infections, urologic and obstetric complications, and psychological and social
\nproblems. FGM has serious consequences for sexuality and how it is experienced,
\nincluding the loss of capacity for orgasm. There are also many complications during
\nchildbirth including expulsion disturbances, formation of fistulae, and traumatic tears of
\nvulvar tissue.
\nThere are a number of reasons given for the continuation of the practice of FGM: custom,
\ncommunity tradition (preserving the virginity of young girls and limiting the sexual
\nexpression of women) and as part of a girl\u2019s initiation into womanhood. These reasons do
\nnot justify the considerable damages to physical and mental health.
\nNone of the major religions supports this practice, which is otherwise often wrongly
\nlinked to religious beliefs. FGM is a form of violence usually perpetuated on young
\nwomen and girls and represents a lack of respect for their individuality, freedom and
\nautonomy.
\nPhysicians may be faced with parents seeking a physician to perform FGM, or they may
\nbecome aware of parents who seek to take girls to places where the practice is commonly
\navailable. They must be prepared to intervene to protect the girl.
\nMedical associations should prepare guidance on how to manage these requests which
\nmay include invoking local laws that protect children from harm and may include
\ninvolving police and other agencies.
\nWhen patients who have undergone FGM give birth, physicians may receive requests to
\nrestore the results of the FGM. They should be confident in handling such requests and
\nsupported with appropriate educational material that will enable them to discuss with the
\npatient the medically approved option of repairing the damage done by FGM and by
\nchildbirth. Physicians also have a responsibility to have a discussion with the spouse of the
\npatient, with the consent of the patient, who might otherwise seek \u201crestoration\u201d of the
\nFGM, if not given a full explanation of the harm that is done by FGM.
\nThere is a growing tendency for physicians and other health care professionals in some<\/p>\n

S-1993-02-2016\t\u23d0\tTaipei
\nFemale\tGenital\tMutilation
\ncountries to perform FGM because of a wish to reduce the risks involved. Some
\npractitioners may believe that medicalization of the procedure is a step towards its
\neradication. Performing FGM is a breach of medical ethics and human rights, and
\ninvolvement by physicians may give it credibility. In most countries performing this
\nprocedure is a violation of the law.
\nGovernments in several countries have developed legislation, such as prohibiting FGM in
\ntheir criminal codes.
\nRECOMMENDATIONS\t\t<\/p>\n

1. Taking into account the psychological needs and \u2018cultural identity\u2019 of the people
\ninvolved, physicians should explain the dangers and consequences of FGM and
\ndiscourage performing or promoting FGM. Physicians should integrate women\u2019s
\nhealth promotion and counselling against FGM into their work.
\n2. Physicians should assist in educating health professionals and work with local
\ncommunity, cultural and social leaders to educate them about the adverse
\nconsequences of FGM. They should support persons who want to end FGM and
\nthe establishment of community programmes designed to outlaw the practice,
\noffering medical information about its damaging effects as necessary.
\n3. There are active campaigns against FGM that are led by women leaders and heads
\nof state in Africa and elsewhere. These campaigns have issued strong statements
\nagainst the practice.
\n4. Physicians should work with groups such as these and others who manage
\npregnant women including midwives, nurses and traditional birth attendants, to
\nensure all practitioners have standardized and sensitive information about FGM.
\n5. Physicians should cooperate with any preventive legal strategy when a child is at
\nrisk of undergoing FGM.
\n6. National Medical Associations should stimulate public and professional awareness
\nof the damaging effects of FGM.
\n7. National Medical Associations should ensure that FGM education and awareness
\nare part of its advocacy to prevent violence against women and girls.
\n8. National Medical Associations should work with opinion leaders, encouraging
\nthem to become active advocates against FGM.
\n9. National Medical Associations should stimulate government action in preventing
\nthe practice of FGM. This should include sustained advocacy programmes and the
\ndevelopment of legislation prohibiting FGM.
\n10. NMAs must prohibit involvement by physicians in the practice of FGM, including
\nre-infibulation after childbirth. Physicians should be encouraged to perform
\nreconstructive surgery on women who have undergone FGM. Physicians should
\nseek to ensure the provision of adequate (and non-judgemental) medical and
\npsychological care for women who have undergone FGM.<\/p>\n

Female\tGenital\tMutilation
\nTaipei\t\u23d0\tS-1993-02-2016
\n11. Physicians should be aware that the risk of FGM might be a justification for
\noverriding patient confidentiality, and allow disclosure to social or other relevant
\nservices to protect a child from serious harm.
\n[1] FGM can be classified into four types: clitoridectomy, excision, infibulation and other
\nharmful procedures such as pricking, piercing, incising, scraping and cauterizing the
\ngenital area.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1993-03-2016
\nWMA\tSTATEMENT
\nON
\nPATIENT\tADVOCACY\tAND\tCONFIDENTIALITY
\nAdopted by the 45th
\nWorld Medical Assembly, Budapest, Hungary, October 1993
\nrevised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006 and
\nreaffirmed by the 203rd
\nWMA Council Session, Buenos Aires, Argentina, April 2016
\nPREAMBLE\t<\/p>\n

Medical practitioners have an ethical duty and a professional responsibility to act in the
\nbest interests of their patients without regard to age, gender, sexual orientation, physical
\nability or disability, race, religion, culture, beliefs, political affiliation, financial means or
\nnationality.
\nThis duty includes advocating for patients, both as a group (such as advocating on public
\nhealth issues) and as individuals.
\nOccasionally, this duty may conflict with a physician’s other legal, ethical and\/or pro-
\nfessional duties, creating social, professional and ethical dilemmas for the physician.
\nPotential conflicts with the physician’s obligation of advocacy on behalf of his or her pa-
\ntient may arise in a number of contexts:
\n1. Conflict between the obligation of advocacy and confidentiality – A physician is
\nethically and often legally obligated to preserve in confidence a patient’s personal
\nhealth information and any information conveyed to the physician by the patient
\nin the course of his or her professional duties. This may conflict with the
\nphysician’s obligation to advocate for and protect patients where the patients may
\nbe incapable of doing so themselves.
\n2. Conflict between the best interest of the patient and employer or insurer dictates –
\nOften there exists potential for conflict between a physician’s duty to act in the best
\ninterest of his or her patients, and the dictates of the physician’s employer or the in-
\nsurance body, whose decision may be shaped by economic or administrative factors
\nunrelated to the patient’s health. Examples of such might be an insurer’s instructions
\nto prescribe a specific drug only, where the physician believes a different drug
\nwould better suit a particular patient, or an insurer’s denial of coverage for
\ntreatment that a physician believes is necessary.
\n3. Conflict between the best interests of the individual patient and society – Although
\nthe physician’s primary obligation is to his or her patient, the physician may, in
\ncertain circumstances, have responsibilities to a patient’s family and\/or to society<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1993-03-2016
\nas well. This may arise in cases of conflict between the patient and his or her
\nfamily, in the case of minor or incapacitated patients, or in the context of limited
\nresources.
\n4. Conflict between the patient’s wishes and the physician’s professional judgment or
\nmoral values – Patients are presumed to be the best arbiters of their best interests
\nand, in general, a physician should advocate for and accede to the wishes of his or
\nher pa-tient. However, in certain instances such wishes may be contrary to the
\nphysician’s professional judgment or personal values.
\nRECOMMENDATION\t<\/p>\n

1. The duty of confidentiality must be paramount except in cases where the physician
\nis legally or ethically obligated to disclose such information in order to protect the
\nwel-fare of the individual patient, third parties or society. In such cases, the
\nphysician must make a reasonable effort to notify the patient of the obligation to
\nbreach confi-dentiality, and explain the reasons for doing so, unless this is clearly
\ninadvisable (such as where telling the patient would exacerbate a threat). In certain
\ncases, such as gene-tic or HIV testing, physicians should discuss with their
\npatients, prior to performing the test, instances in which confidentiality might need
\nto be breached.
\nA physician should breach confidentiality in order to protect the individual patient
\nonly in cases of minor or incompetent patients (such as certain cases of child or
\nelder abuse) and only where alternative measures are not available. In all other
\ncases, confidentiality may be breached only with the specific consent of the patient
\nor his\/ her legal representative or where necessary for the treatment of the patient,
\nsuch as in consultations between medical practitioners.
\nWhenever confidentiality must be breached, it should be done so only to the extent
\nnecessary and only to the relevant party or authority.
\n2. In all cases where a physician’s obligation to his or her patient conflicts with the
\nadministrative dictates of the employer or the insurer, a physician must strive to
\nchange the decision of the employing\/insuring body. His or her ultimate obligation
\nmust be to the patient.
\nMechanisms should be in place to protect physicians who wish to challenge
\ndecisions of employers\/insurers without jeopardizing their jobs, and to resolve
\ndisagreements between medical professionals and administrators with regard to
\nallocation of re-sources.
\nSuch mechanisms should be embodied in medical practitioners’ employment con-
\ntracts. These employment contracts should acknowledge that medical practitioners’
\nethical obligations override purely contractual obligations related to employment.
\n3. A physician should be aware of and take into account economic and other factors
\nbefore making a decision regarding treatment. Nonetheless, a physician has an
\nobliga-tion to advocate on behalf of his or her patient for access to the best<\/p>\n

S-1993-03-2016\t\u23d0\tBuenos\tAires
\nPatient\tAdvocacy\tand\tConfidentiality
\navailable treat-ment.
\nIn all cases of conflict between a physician’s obligation to the individual patient
\nand the obligation to the patient’s family or to society, the obligation to the
\nindividual pa-tient should typically take precedence.
\n4. Competent patients have the right to determine, on the basis of their needs, values
\nand preferences, what constitutes for them the best course of treatment in any given
\nsitua-tion. Unless it is an emergency situation, physicians should not be required to
\nparticipate in any procedures that conflict with their personal values or professional
\njudgment. In such non-emergency cases, the physician should explain to the patient
\nhis or her in-ability to carry out the patient’s wishes, and the patient should be
\nreferred to another physician, if required.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1994-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nMEDICAL\tETHICS\tIN\tTHE\tEVENT\tOF\tDISASTERS
\nAdopted by the 46th
\nWMA Gener al Assembly, Stockholm, Sweden, September 1994
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\n1. According to International Federation of Red Cross and Red Crescent Societies (IFRC)
\na disaster is a sudden, calamitous event that seriously disrupts the functioning of a
\ncommunity or society and causes human, material, and economic or environmental
\nlosses that exceed the community\u2019s or society\u2019s ability to cope using its own resources.
\nThough often caused by nature, disasters can have human origins.
\nThis definition excludes situations arising from conflicts and wars, whether international
\nor internal, which give rise to other problems in addition to those considered in this
\npaper.
\n2. Disasters often result in substantial material damage, considerable displacement of
\npeople, many victims and significant social disruptions. Adequate preparation would
\nmake major consequences less likely and less severe and protect people especially the
\nmost vulnerable.
\nThis document will focus particularly on the medical aspects of disasters. From a
\nmedical standpoint, disaster situations are characterized by an acute and unforeseen
\nimbalance between resources and the capacity of medical professionals, and the needs of
\nsurvivors who are injured whose health is threatened, over a given period of time.
\n3. Disasters, irrespective of cause, share several common features:
\n3.1. Their sudden and unexpected but often predictable occurrence, demanding prompt
\naction;
\n3.2. Material or natural damage making access to the survivors difficult and\/or
\ndangerous;
\n3.3. Displacement or movement of often large numbers of people;
\n3.4. Adverse effects on health due to various reasons such as physical injuries and high<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1994-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\nenergy trauma, direct and indirect consequences of pollution, the risks of epidemics and
\nemotional and psychological factors as well as factors such as reduced access to food,
\npotable water, shelter, health care and other health determinants;
\n3.5. A context of insecurity sometimes requiring police or military measures to maintain
\norder; and
\n3.6. Media coverage, and the use of social media.
\n4. Disasters require multifaceted responses involving many different types of relief ranging
\nfrom transportation and food supplies to medical services. Physicians are likely to be
\npart of coordinated operations involving other responders such as law enforcement
\npersonnel. These operations require an effective and centralized authority to coordinate
\npublic and private efforts.
\nRescue workers and physicians are confronted with exceptional circumstances, which
\nrequire the continued need of a professional and ethical standard of care. This is to
\nensure that the treatment of disaster survivors conforms to basic ethical tenets and is not
\ninfluenced by other motivations. Inadequate and\/or disrupted medical resources on site
\nand a large number of people injured in a short time present specific ethical challenges.
\nRECOMMENDATIONS
\n5. Medical profession is at the service of the patients and society at all times and in all
\ncircumstances. Therefore, the physicians should be firmly committed to addressing the
\nhealth consequences of disasters, without excuse or delay.
\n6. The World Medical Association (WMA) reaffirms its Declaration of Montevideo on
\nDisaster Preparedness and Medical Response (2011) recommending the development of
\nadequate training of physicians, accurate mapping of information on health system
\nassets and advocacy towards governments to ensure planning for clinical care.
\n7. The WMA recalls the primary necessity to ensure the personal safety of physicians and
\nother responders during the event of disasters (Declaration on the Protection of Health
\nCare Workers in situation of Violence, 2014).
\nPhysicians and other responders must have access to appropriate and functional
\nequipment, both medical and protective.
\n8. Furthermore, the WMA recommends the following ethical principles and procedures
\nwith regard to the physician\u2019s role in disaster situations:
\n8.1 A system of triage may be necessary to determine treatment priorities. Despite triage
\noften leading to some of the most seriously injured receiving only symptom control<\/p>\n

Chicago\t\u23d0\tS-1994-01-2017
\nDisasters
\nsuch as analgesia, such systems are ethical provided they adhere to normative
\nstandards. Demonstrating care and compassion despite the need to allocate limited
\nresources is an essential aspect of triage.
\nIdeally, triage should be entrusted to authorized, experienced physicians or to
\nphysician teams, assisted by a competent staff. Since cases may evolve and thus
\nchange category, it is essential that the official in charge of the triage regularly
\nassesses the situation.
\n8.2 The following statements apply to treatment beyond emergency care:
\n8.2.1 It is ethical for a physician not to persist, at all costs, in treating individuals
\n\u201cbeyond emergency care\u201d, thereby wasting scarce resources needed else-
\nwhere. The decision not to treat an injured person on account of priorities
\ndictated by the disaster situation cannot be considered an ethical or medical
\nfailure to come to the assistance of a person in mortal danger. It is justified
\nwhen it is intended to save the maximum number of individuals. However, the
\nphysician must show such patients compassion and respect for their dignity,
\nfor example by separating them from others and administering appropriate
\npain relief and sedatives, and if possible ask somebody to stay with the patient
\nand not to leave him\/her alone.
\n8.2.2 The physician must act according to the needs of patients and the resources
\navailable. He\/she should attempt to set an order of priorities for treatment that
\nwill save the greatest number of lives and restrict morbidity to a minimum.
\n8.3 Relation with the patients
\n8.3.1 In selecting the patients who may be saved, the physician should consider only
\ntheir medical status and predicted response to the treatment, and should
\nexclude any other consideration based on non-medical criteria.
\n8.3.2 Survivors of a disaster are entitled to the same respect as other patients, and the
\nmost appropriate treatment available should be administered with the patient\u2019s
\nconsent.
\n8.4 Aftermath of disaster
\n8.4.1 In the post-disaster period the needs of survivors must be considered. Many
\nmay have lost family members and may be suffering psychological distress.
\nThe dignity of survivors and their families must be respected.
\n8.4.2 The physician must make every effort to respect the customs, rites and
\nreligions of the patients and act in impartiality.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1994-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\n8.4.3 As far as possible, detailed records should be kept, including details of any
\ndifficulties encountered. Identification of patients, including the deceased
\nshould be recorded.
\n8.5 Media and other third parties
\nPhysicians should take into consideration that in any disaster media is present. The work
\nof the media should be respected and facilitated as appropriate in the circumstances. If
\nneeded, physicians should be empowered to restrict the entrance of reporters and other
\nmedia representatives to the medical premises. Appropriately trained personnel should
\nhandle media relations.
\nThe physician has a duty to each patient to exercise discretion and to seek to ensure
\nconfidentiality when dealing with third parties. The physician must also exercise caution
\nand objectivity and respect the often emotional and politicized atmosphere surrounding
\ndisaster situations. Any and all media especially filming must only occur with the
\nexplicit consent of each patient who is filmed. With regard to social media use,
\nphysicians must adhere to these same standards of discretion and respect for patient
\nprivacy.
\n8.6 Duties of paramedical personnel
\nThe ethical principles that apply to physicians in disaster situations should also apply to
\nother health care workers.
\n8.7 Training
\nThe World Medical Association recommends that disaster medicine training be included
\nin the curricula of university and post-graduate courses in medicine.
\n8.8 Responsibility
\n8.8.1 The World Medical Association calls upon governments and insurance
\ncompanies to cover both civil liability and any personal damages to which
\nphysicians might be subject when working in disaster or emergency situations.
\nThis should also include life and disability coverage for physicians who die or
\nare harmed in the line of duty.
\n8.8.2 The WMA requests that governments:
\n\u2022 Ensure the preparedness of healthcare system to serve in disaster settings.
\n\u2022 Share all information related to public health timely and accurately.
\n\u2022 Accept the participation of demonstrably qualified foreign physicians, where<\/p>\n

Chicago\t\u23d0\tS-1994-01-2017
\nDisasters
\nneeded, without discrimination on the basis of factors such as affiliation (e.g.
\nRed Cross, Red Crescent, ICRC, and other qualified organizations), race, or
\nreligion.
\n\u2022 Give priority to the rendering of medical services over anything else that
\nmight delay necessary treatment of patients.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1995-02-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nETHICAL\tISSUES\tCONCERNING\tPATIENTS\tWITH\tMENTAL\tILLNESS
\nAdopted by the 47th
\nWMA General Assembly, Bali, Indonesia, September 1995
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE\t\t<\/p>\n

Historically, many societies have regarded patients with mental illness as a threat to those
\naround them rather than as people in need of support and care. In the absence of effective
\ntreatment, to prevent self-destructive behaviour or harm to others, many persons with
\nmental illness were confined to asylums for all or part of their lives.
\nToday, progress in psychiatric treatment allows for better care of patients with mental ill-
\nness. Efficacious drugs and psychosocial interventions offer outcomes ranging from
\ncomplete recovery to remission for varying lengths of time.
\nThe adoption in 2006 of the United Nations Convention on the Rights of Persons with
\nDisabilities constituted a major step towards viewing them as full members of society with
\nthe same rights as everyone else. It is the first comprehensive human rights treaty of the
\n21st
\ncentury. It aims to promote, protect and reinforce the human rights and dignity of all
\npersons with disabilities, including those with mental impairments.
\nPersons with major mental illnesses and those with learning disability have the same right
\nto preventive services and interventions to promote health as others members of the com-
\nmunity, for which they often have greater need because they are more likely to live
\nunhealthy lifestyles.
\nPatients with psychiatric morbidity may also experience non- psychiatric illness. Persons
\nwith mental illness have the same right to health care as any other patient. Psychiatrists
\nand health care professionals who provide mental health services should refer patients to
\nother appropriate professionals when patients need medical care. Health care professionals
\nshould never decline to provide needed medical care solely because the patient has a
\nmental illness.
\nPhysicians have the same obligations to all patients, including patients with mental illness.
\nPsychiatrists or other physicians who treat patients with mental illness must adhere to the
\nsame ethical standards as any physician.
\nThe physician\u2019s primary obligation is to the patient and not to serve as agents of society,<\/p>\n

Moscow\t\u23d0\tS-1995-02-2015
\nPatients\twith\tMental\tIllness
\nexcept in circumstances when a patient presents clear danger to himself\/ herself or others
\ndue to mental illness.
\nPHYSICIANS\u2019\tETHICAL\tPRINCIPLES\t<\/p>\n

The stigma and discrimination associated with psychiatry and the mentally ill should be
\neliminated. Stigma and discrimination may discourage people in need from seeking
\nmedical care, thereby aggravating their situation and placing them at risk of emotional or
\nphysical harm.
\nPhysicians have a responsibility to respect the autonomy of all patients. When patients
\nwho are being treated for mental illness have decision-making capacity, they have the
\nsame right to make decisions about their care as any other patient. Because decision-
\nmaking capacity is specific to the decision to be made and can vary over time, including as
\na result of treatment, physicians must continually evaluate the patient\u2019s capacity. When a
\npatient lacks decision-making capacity, physicians should seek consent from an
\nappropriate surrogate in accordance with applicable law.
\nThe therapeutic relationship between physician and patient is founded on mutual trust, and
\nphysicians have a responsibility to seek patients\u2019 informed consent to treatment, including
\npatients who are being treated for mental illness. Physicians should inform all patients of
\nthe nature of the psychiatric or other medical condition, and the expected benefits,
\noutcomes and risks of treatment alternatives.
\nPhysicians should always base treatment recommendations on their best professional
\njudgment and treat all patients with solicitude and respect, regardless of the setting of care.
\nPhysicians who practice in mental health facilities, the military, or correctional institutions
\nmay have concurrent responsibilities to society that create conflicts with the physician\u2019s
\nprimary obligation to the patient. In such situations, physicians should disclose the conflict
\nof interest to minimize possible feelings of betrayal on the patient\u2019s part.
\nInvoluntary treatment or hospitalization of persons with mental illness is ethically
\ncontroversial. While laws regarding involuntary hospitalization and treatment vary
\nworldwide, it is generally acknowledged that this treatment decision without the patient\u2019s
\ninformed consent or against the patient\u2019s will is ethically justifiable only when: (a) a
\nsevere mental disorder prevents the individual from making autonomous treatment
\ndecisions; and\/or (b) There is significant likelihood that the patient may harm him\/her self
\nor others. Involuntary treatment or hospitalization should be exceptional and physicians
\nshould utilize it only when there is good evidence that it is medically appropriate and
\nnecessary and should ensure that the individual is hospitalized for the shortest duration
\nfeasible under the circumstances. Wherever possible and in accordance with local laws,
\nphysicians should include an advocate for the rights of that patient in the decision process.
\nPhysicians must protect the confidentiality and privacy of all patients. When legally
\nrequired to disclose patient information, the physician should disclose only the minimum
\nrelevant information necessary and only to an entity legally authorized to request or
\nrequire the information. When databanks allow access to or transfer of information from<\/p>\n

Patients\twith\tMental\tIllness
\nS-1995-02-2015\t\u23d0\tMoscow
\none authority to another confidentiality must be respected and such access or transfer must
\ncomply fully with applicable law.
\nThe participation of individuals with psychiatric illness in research needs to be in full
\naccordance with the Declaration of Helsinki\u2019s recommendations.
\nPhysicians must never use their professional position to violate the dignity or human rights
\nof any individual or group, and should never allow their personal desires, needs, feelings,
\nprejudices or beliefs to interfere with a patient\u2019s treatment. Physicians must never abuse
\ntheir authority or take advantage of a patient\u2019s vulnerability.
\nRECOMMENDATION\t<\/p>\n

The World Medical Association and National Medical Associations are encouraged to:
\n\u2022 Publicize this Statement and affirm the ethical foundations for treatment of patients
\nwith mental illness;
\n\u2022 While doing so, call for full respect \u2013 at all times \u2013 of the dignity and human rights
\nof patients with mental illness;
\n\u2022 Raise awareness of physicians\u2019 responsibilities to support the well-being and rights
\nof patients with mental illness;
\n\u2022 Promote recognition of the privileged relationship between patient and physician
\nbased on trust, professionalism and confidentiality;
\n\u2022 Advocate for appropriate resources to meet the needs of persons with mental
\nillness.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1995-04-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nPHYSICIANS\tAND\tPUBLIC\tHEALTH
\nAdopted by the 47th
\nWMA General Assembly, Bali, Indonesia, September 1995
\nand revised by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nThe health of a community or population is determined by several factors that go beyond
\ntraditionally understood causes of disease. Social determinants of health include factors
\nthat affect behavioural lifestyle choices; the physical, psychosocial and economic
\nenvironments in which individuals live; and the health services available to people. Public
\nhealth involves monitoring, assessing and planning a variety of programs and activities
\ntargeted to the identified needs of the population, and the public health sector should have
\nthe capacity to carry out those functions effectively to optimise community health. A key
\ntenet of public health policy should be inclusivity and health equity; public health agencies
\nmust pay specific attention to populations and communities whose social, economic, and
\npolitical conditions put them at greater risk of poor health than the general population.
\nPhysicians and their professional associations have an ethical and professional
\nresponsibility to act in the best interests of patients at all times. This involves collaboration
\nwith public health agencies to integrate medical care of individual patients with a broader
\npromotion of the health of the public.
\nThe key functions of public health agencies are:
\n1. Health promotion:
\n\u2022 Working with health care providers to inform and enable the general public to take
\nan active role in preventing and controlling disease, adopting healthful lifestyles,
\nand using medical services appropriately;
\n\u2022 Assuring that conditions contributing to good health, including high-quality
\nmedical services, safe water supplies, good nutrition, an unpolluted atmosphere,
\nand opportunities for exercise and recreation are accessible for the entire
\npopulation;
\n\u2022 Working with the responsible public authorities to create healthy public policy and
\nsupportive environments in which healthy behavioural choices are the easy
\nchoices, and to develop human and social capital.
\n\u2022 Prevention: assuring access to screening and other preventive services and curative
\ncare to the entire population.
\n2. Protection: monitoring and protecting the health of communities against
\ncommunicable diseases and exposure to toxic environmental pollutants, occupational<\/p>\n

S-1995-04-2016\t\u23d0\tTaipei
\nPublic\tHealth
\nhazards, harmful products, and poor quality health services. This function includes the
\nneed to set priorities, establish essential programs, obtain requisite resources and
\nassure the availability of necessary public health laboratory services.
\n3. Surveillance: identifying outbreaks of infectious disease and patterns of chronic
\ndisease and injury and establishing appropriate control or prevention programs;
\n4. Population Health Assessment: assessing community health needs and marshalling the
\nresources for responding to them, and developing health policy in response to specific
\ncommunity and national health needs.
\nThe specific programs and activities carried out in each jurisdiction (local or national)
\nwill depend on the problems and needs identified, the organization of the health care
\ndelivery system, the types and scope of the partnerships developed and the resources
\navailable to address the identified needs.
\nPublic health agencies benefit greatly from the support and close cooperation of
\nphysicians and their professional associations. The health of a community or a nation
\nis measured by the health of all its residents, and the preventable health problems that
\naffect an individual person affect the health and resources of the community. The
\neffectiveness of many public health programs, therefore, depends on the active
\ncollaboration of physicians and their professional associations with public health
\nagencies and other governmental and nongovernmental agencies.
\nThe medical sector and the public health sector should effectively co-operate on the
\ndissemination of public health information and education programs that promote
\nhealthful lifestyles and reduce preventable risks to health, including those from the use
\nof tobacco, alcohol and other drugs; sexual activities that increase the risk of HIV
\ntransmission and sexually transmitted diseases; poor diet and physical inactivity; and
\ninadequate childhood immunization levels. For example, health education can
\nsubstantially reduce infant morbidity and mortality (e.g. through the promotion of
\nbreast-feeding and providing nutrition education to parents together with providing
\nsupportive conditions, both at work and in the community).
\nThe formal responsibility of public health agencies is primarily disease surveillance,
\ninvestigation and control. These activities cannot be conducted effectively, however,
\nwithout the active cooperation and support of physicians at the community level who
\nare aware of individual and community illness patterns and can notify health
\nauthorities promptly of problems that might require further investigation and action.
\nFor example, physicians can help identify populations at high risk for particular
\ndiseases, such as tuberculosis, and report cases of communicable diseases such as
\nmeasles, whooping cough, or infectious causes of diarrhoea, as well as cases of
\nexposure to lead or other toxic chemicals and substances in the community or work
\nplace. Close collaboration between public health agencies and physicians as well as
\nother health professionals is critical for an efficient disease monitoring system.
\nRegardless of the effectiveness of existing public health programs in a jurisdiction,
\nprofessional medical associations should be aware of unmet health needs in their<\/p>\n

Taipei\t\u23d0\tS-1995-04-2016
\nPublic\tHealth
\ncommunities and nations and advocate for activities, programs and resources to meet
\nthose needs. These efforts might be in areas of public education for health promotion
\nand disease prevention; monitoring and controlling environmental hazards; identifying
\nand publicising adverse health effects resulting from social problems, such as
\ninterpersonal violence or social practices that affect health; or identifying and
\nadvocating for services such as improvements in emergency treatment preparedness.
\nIn jurisdictions in which basic public health services are not being provided
\nadequately, medical associations must work with other health agencies and groups to
\nestablish priorities for advocacy and action. For example, in a country or area with
\nlimited resources in which potable water and sewage facilities are not available to
\nmost residents, these needs should be given priority over medical technologies that
\nwould provide service to only a small portion of the population.
\nSome health-related issues are extremely complex and involve multiple levels of
\nresponse. For example, those diagnosed with high blood lead levels need not only
\nappropriate medical treatment, but the source of contamination must also be
\ndetermined, and measures need to be taken to eliminate the danger. At times policies
\nthat promote public health create concern because of their potential economic impact.
\nFor example, strong opposition to the potential economic impact of tobacco control
\npolicies could come from regions or groups that derive significant revenue from
\ngrowing or processing tobacco. However, economic concerns should not deter a strong
\npublic health advocacy program against the use of tobacco products. The promotion of
\ntobacco products should be rigorously opposed, and every effort should be made to
\nreduce tobacco consumption in both developed and developing countries.
\nPhysicians and their associations should collaborate with political authorities and other
\norganizations to encourage the media to send positive messages for health education
\nregarding diet, drug use, sexually transmitted diseases, cardiovascular risk, etc.
\nMedical associations should ask their members to educate their patients on the
\navailability of public health services.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1996-01-2008
\nWMA\tSTATEMENT
\nON
\nRESISTANCE\tTO\tANTIMICROBIAL\tDRUGS
\nAdopted by the 48th
\nWMA General Assembly, Somerset West, South Africa, October 1996
\nand amended by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nPREAMBLE\t<\/p>\n

The global increase in resistance to antimicrobial drugs, including the emergence of bac-
\nterial strains resistant to all available antibacterial agents, has created a multi-faceted
\npublic health problem of crisis proportions with significant economic and human implica-
\ntions. The development of resistant microorganisms is a problem whenever antimicrobial
\nagents are used. The increase in high-risk populations who frequently require antimicro-
\nbial therapy, including immunocompromised patients, those undergoing invasive medical
\ninterventions, those with implanted medical devices and patients with chronic debilitating
\ndiseases, has amplified the problem. The fact that certain infectious diseases have been
\nlinked to the development of chronic disease and cancer adds another dimension to the
\nproblem.
\nA renewed effort to increase awareness of antimicrobial resistance is needed in order to
\ncontain and slow its development. International cooperation is essential in accomplishing
\nthis objective, including global, national, and local components. In particular, implement-
\ntation of national and global efforts to contain the development and spread of antimicro-
\nbial resistance is vital; policy statements without international will to accomplish results
\nare not enough. Given the dynamics of antimicrobial resistance, the need for continuing
\ndevelopment of new antimicrobials by the pharmaceutical industry can be anticipated.
\nSubstantial misuse and overuse of antimicrobial agents have exacerbated the problem by
\nadding selection pressures to microbial populations that favor mutation to antibiotic resist-
\nance. These include inappropriate prescribing of antibacterial prophylactics and\/or treat-
\nment of bacterial infections by physicians and poor compliance with antimicrobial regi-
\nmens by patients. Thus, there is a need for enhanced training and education to improve the
\nappropriate clinical use of antimicrobials and prevent the development of resistance. There
\nis a need at every level to educate the public about the appropriate use of antimicrobials
\nand the problem of antimicrobial resistance.
\nThe availability of antimicrobial agents without a prescription in many developing coun-
\ntries is escalating antibiotic resistance, and this practice must be discontinued. The in-
\ncreasing prevalence of counterfeit medications is another critical and expanding risk fac-
\ntor. Successfully addressing this problem will require substantial cooperation among
\nnations and the development and use of better technologies to verify the authenticity of
\npharmaceutical products and assure the security of deployment from point of manufacture
\nto the point of need. Similarly, the inappropriate use of antibiotics in veterinary medicine
\nand livestock production in many countries needs to be controlled.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1996-01-2008
\nRECOMMENDATIONS\t<\/p>\n

Global\t<\/p>\n

Individual governments should work to create cross-sectional national task forces to col-
\nlect national data on the use of antibiotics and antimicrobial resistance and to prioritize
\nregulation, intervention, and other measures to reduce antimicrobial resistance.
\nThe World Medical Association and its member national medical associations should
\nadvocate for:
\n\u2022 Individual governments to cooperate with the World Health Organization (WHO)
\nto enhance the effectiveness of the WHO’s global network of antimicrobial resist-
\nance surveillance. This will foster the collection, quality and sharing of data; the
\nmonitoring of progress in combating antimicrobial resistance; the establishment of
\nappropriate formularies; and scientific support for interventions.
\n\u2022 The WHO to examine the role of international travel and trade agreements on the
\ndevelopment of antimicrobial resistance.
\n\u2022 The widespread application of verifiable technology to ensure the authenticity of
\npharmaceutical products.
\nThe World Medical Association and its national medical associations should encourage
\ntheir governments to:
\n\u2022 Fund more basic and applied research directed toward the development of inno-
\nvative antimicrobial agents and vaccines, and on the appropriate and safe use of
\nsuch therapeutic tools.
\n\u2022 Create incentives for the pharmaceutical industry to pursue research and develop-
\nment programs leading to the availability of innovative antimicrobial agents, vac-
\ncines, and rapid diagnostic methods.
\nNational\t<\/p>\n

National medical associations should:
\n\u2022 urge their governments to require that antimicrobial agents be available only
\nthrough a prescription provided by licensed and qualified health care and\/or veteri-
\nnary professionals.
\n\u2022 urge their governments to initiate a national media campaign explaining to the pu-
\nblic the harmful consequences of overuse and misuse of antibiotics.
\n\u2022 actively pursue the development of a national surveillance system for antimicrobial
\nresistance that will provide physicians with the information necessary to deliver
\ntimely, evidence-based, high-quality care. Data from this system should be linked
\nwith, or at minimum, fed into, the WHO’s global network of antimicrobial resist-
\nance surveillance.
\n\u2022 create guidelines on the appropriate use of antibiotics for common medical con-
\nditions, such as respiratory infections, tonsillitis, pneumonia and urinary tract in-
\nfection; pursue the development of a national surveillance system for sales of anti-
\nmicrobials.<\/p>\n

S-1996-01-2008\t\u23d0\tSeoul
\nAntimicrobial\tResistance
\n\u2022 encourage medical schools and continuing medical education programs to renew
\ntheir efforts to educate physicians about the appropriate use of antimicrobial agents
\nand appropriate infection control practices, including antibiotic use in the out-
\npatient setting.
\n\u2022 in collaboration with veterinary authorities, encourage their governments to restrict
\nthe use of antimicrobial agents as feed additives for animals strictly to those anti-
\nmicrobials that do not have a human public health impact.
\nLocal\t<\/p>\n

Physicians should:
\n\u2022 assume leadership roles in their local hospitals, clinics, and communities regarding
\nappropriate antiseptic habits, antimicrobial agent usage, and antimicrobial resist-
\nance prevention and control programs. This applies especially to those trained in
\ninfectious diseases and clinical microbiology.
\n\u2022 raise awareness amongst their patients about antimicrobial therapy, its risks and
\nbenefits, the importance of compliance with the prescribed regimen, optimal hy-
\ngienic practices, and the problem of antimicrobial drug resistance.
\n\u2022 herever possible, explore strategies for reducing the use of antibiotics that do not
\ncompromise the quality of patient care, such as \u00ab\u00a0wait-and-see\u00a0\u00bb prescriptions for the
\ntreatment of acute otitis media.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1996-02-2010\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nFAMILY\tVIOLENCE
\nAdopted by the 48th
\nWMA General Assembly, Somerset West, South Africa, October 1996
\neditorially revised by the 174th
\nWMA Council Session, Pilanesberg, South Africa,
\nOctober 2006
\nand amended by the 61st
\nWMA General Assembly, Vancouver, Canada, October 2010
\nPREAMBLE\t<\/p>\n

Recalling the World Medical Association Declaration of Hong Kong on the Abuse of the
\nElderly and the World Medical Association Statement on Child Abuse and Neglect, and
\nprofoundly concerned with violence as a public health issue, the World Medical Associa-
\ntion calls upon National Medical Associations to intensify and broaden their efforts to
\naddress the universal problem of family violence.
\nFamily violence is a term applied to physical and\/or emotional mistreatment of a person
\nby someone in an intimate relationship with the victim. The term includes domestic vio-
\nlence (sometimes referred to as partner, spouse, or wife battering), child physical abuse
\nand neglect, child sexual abuse, maltreatment of older people, and many cases of sexual
\nassault. Family violence can be found in every country in the world, cutting across gender
\nand all racial, ethnic, religious and socio-economic lines. Although case definitions vary
\nfrom culture to culture, family violence represents a major public health problem by virtue
\nof the many deaths, injuries, and adverse psychological consequences that it causes. The
\nphysical and emotional harm may represent chronic or even lifetime disabilities for many
\nvictims. Family violence is associated with increased risk of depression, anxiety, sub-
\nstance abuse, and self-injurious behaviour, including suicide. Victims often become per-
\npetrators or become involved in violent relationships later on. Although the focus of this
\ndocument is the welfare of the victim, the needs of the perpetrator should not be over-
\nlooked.
\nAlthough the causes of family violence are complex, a number of contributing factors are
\nknown. These include poverty, unemployment, other exogenous stresses, attitudes of ac-
\nceptance of violence for dispute resolution, substance abuse (particularly alcohol), rigid
\ngender roles, poor parenting skills, ambiguous family roles, unrealistic expectations of
\nother family members, interpersonal conflicts within the family, actual or perceived physi-
\ncal or psychological vulnerability of victims by perpetrators, perpetrator pre-occupation
\nwith power and control, and familial social isolation, among others.
\nPOSITION\t<\/p>\n

There is a growing awareness of the need to think about and take action against family<\/p>\n

S-1996-02-2010\t\u23d0\tVancouver
\nFamily\tViolence
\nviolence in a unified way, rather than focusing on the particular type of victim or com-
\nmunity affected. In many families where partner battering occurs, for example, there may
\nbe abuse of children and\/or of older people as well, often carried out by a single perpe-
\ntrator. In addition, there is substantial evidence that children who are victimized or who
\nwitness violence against others in the family are later at increased risk as adolescents or
\nadults of being re-victimized and\/or becoming perpetrators of violence themselves. Final-
\nly, more recent data suggest that victims of family violence are more likely to become
\nperpetrators of violence against non-intimates as well. All of this suggests that each in-
\nstance of family violence may have implications not only for further family violence, but
\nalso for the broader spread of violence throughout a society.
\nPhysicians and NMAs should oppose violent practices such as dowry killings and honour
\nkillings.
\nPhysicians and NMAs should oppose the practice of child marriage.
\nPhysicians have important roles to play in the prevention and treatment of family violence.
\nOf course they will manage injuries, illnesses, and psychiatric problems deriving from the
\nabuse. The therapeutic relationships physicians have with patients may allow victims to
\nconfide in them about current or past victimization. Physicians should inquire about vio-
\nlence routinely, as well as when they see particular clinical presentations that may be as-
\nsociated with abuse. They can help patients to find methods of achieving safety and access
\nto community resources that will allow protection and\/or intervention in the abusive rela-
\ntionship. They can educate patients about the progression and adverse consequences of
\nfamily violence, stress management and availability of relevant mental health treatment,
\nand parenting skills as ways of preventing the violence before it occurs. Finally, physi-
\ncians as citizens and as community leaders and medical experts can become involved in
\nlocal and national activities designed to decrease family violence.
\nPhysicians recognise that victims of violence may find it difficult to trust their physician at
\nfirst. Physicians must be prepared to develop a trusting relationship with their patient over
\ntime until s\/he is ready to accept advice, help and intervention.
\nRECOMMENDATION\t<\/p>\n

The World Medical Association recommends that National Medical Associations adopt
\nthe following guidelines for physicians:
\n\u2022 All physicians should receive adequate training in the medical, sociological, psy-
\nchological and preventive aspects of all types of family violence. This would in-
\nclude medical school training in the general principles, specialty-specific infor-
\nmation during postgraduate training, and continuing medical education about
\nfamily violence. Trainees must receive adequate instruction in the role of gender,
\npower and other issues of family dynamics in contributing to family violence. The
\ntraining should also include adequate collecting of evidence, documentation and
\nreporting in cases of abuse.
\n\u2022 Physicians should know how to take an appropriate and culturally sensitive history
\nof current and past victimization.<\/p>\n

Vancouver\t\u23d0\tS-1996-02-2010
\nFamily\tViolence
\n\u2022 Physicians should routinely consider and be sensitive to signs indicating the need
\nfor further evaluations about current or past victimization as part of their general
\nhealth screen or in response to suggestive clinical findings.
\n\u2022 Physicians should be encouraged to provide pocket cards, booklets, videotapes,
\nand\/or other educational materials in reception rooms and emergency departments
\nto offer patients general information about family violence as well as to inform
\nthem about local help and services.
\n\u2022 Physicians should be aware of social, community and other services of use to vic-
\ntims of violence, and refer to and use these routinely.
\n\u2022 Physicians have the obligation to consider reporting to appropriate protection
\nservices suspected violence against children and other family members without
\nlegal capacity.
\n\u2022 Physicians should be acutely aware of the need for maintaining confidentiality in
\ncases of family violence.
\n\u2022 Physicians should be encouraged to participate in coordinated community acti-
\nvities that seek to reduce the amount and impact of family violence.
\n\u2022 Physicians should be encouraged to develop non-judgemental attitudes toward
\nthose involved in family violence so their ability to influence victims, survivors
\nand perpetrators is enhanced. For example, the behaviour should be judged but not
\nthe person.
\n\u2022 National Medical Associations should encourage and facilitate coordination of
\naction against family violence between and among components of the health care
\nsystem, criminal justice systems, law enforcement authorities, family and juvenile
\ncourts, and victims’ services organizations. They should also support public aware-
\nness and community education.
\n\u2022 National Medical Associations should encourage and facilitate research to under-
\nstand the prevalence, risk factors, outcomes and optimal care for victims of family
\nviolence.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1996-04-2017
\nWMA\tSTATEMENT
\nON
\nFAMILY\tPLANNING\tAND\tTHE\tRIGHT\tOF\tA\tWOMAN
\nTO\tCONTRACEPTION
\nAdopted by the 48th
\nWMA General Assembly, Somerset West, South Africa, October 1996
\namended by the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nand reaffirmed with minor revision by the 207th WMA Council session, Chicago, United
\nStates, October 2017
\nPREAMBLE
\nThe WMA recognizes that unwanted pregnancies and pregnancies that are too closely
\nspaced can have a serious adverse effect on the health of a woman and of her children.
\nThese adverse effects can include the premature deaths of women. Existing children in the
\nfamily can also suffer starvation, neglect or abandonment resulting in their death or
\nimpaired health, when families are unable to provide for all their children. Social
\nfunctioning and the ability to reach their full potential can also be impaired.
\nThe WMA recalls its Declaration of Ottawa on Child Health, and supports the universal
\nhealth rights of all children worldwide.
\nThe WMA recognizes the benefits for women who are able to control their fertility. They
\nshould be helped to make such choices themselves, as well as in discussion with their
\npartners. The ability to do so by choice and not chance is a principal component of
\nwomen\u2019s physical and mental health and social well-being.
\nAccess to adequate fertility control methods is not universal; many of the poorest women
\nin the world have the least access. Knowledge about how their bodies work, information
\non how to control their fertility and the materials necessary to make those choices are
\nuniversal and basic human rights for all women.
\nThe Sustainable Development Goals 5, target 6 calls for the \u201cuniversal access to sexual
\nand reproductive health and reproductive rights\u2026\u201d.
\nRECOMMENDATIONS
\nThe WMA recommends that National Medical Associations:
\n\u2022 Promote family planning education by working with governments, NGOs and others
\nto provide secure and high-quality services and assistance;
\n\u2022 Demand from governments to ensure that such information, materials, products and
\nservices are available without regard to nationality, creed, race, religion or
\nsocioeconomic status.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1996-05-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nWEAPONS\tOF\tWARFARE\tAND
\nTHEIR\tRELATION\tTO\tLIFE\tAND\tHEALTH
\nAdopted by the 48th
\nWMA General Assembly, Somerset West, South Africa, October 1996
\nand editorially revised by the 174th
\nWMA Council Session, Pilanesberg, South Africa,
\nOctober 2006
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t<\/p>\n

Recalling its Declaration of Washington on Biological Weapons, its Resolution on the
\nProhibition of chemical weapons and its Statement on Nuclear Weapons, the World
\nMedical Association condemns the use of any forms of weapons \u2013 conventional,
\nbiological, chemicals and nuclear weapons \u2013 which has the potential to bring immense
\nhuman suffering and substantial death together with catastrophic effects on the earth\u2019s
\necosystem, a reduction of the world food supply and increased poverty. The use of such
\nweapons against human beings is in opposition with physicians\u2019 duties and responsibilities
\nto preserve life.
\nWhen nations enter into warfare or into weapons development, they do not usually
\nconsider the effects of the use of weapons on the health of individual non-combatants and
\non public health in general, either in the short or in the longer term.
\nNevertheless the medical profession is required to deal with both the immediate and long
\nterm health effects of warfare, and in particular with the effects of different forms of
\nweaponry including the threat of nuclear, chemical and biological warfare.
\nThe potential for scientific and medical knowledge to contribute to the development of
\nnew weapons systems, targeted against specific individuals, specific populations or
\nagainst body systems, is considerable. This includes the development of weapons designed
\nto target anatomical or physiological systems, including vision, or which use knowledge
\nof human genetic similarities and differences to target weapons.
\nThere are no current and commonly used criteria to measure weapons effects on health.
\nInternational Humanitarian Law states that weapons that cause injuries, which would
\nconstitute \u201cunnecessary suffering or superfluous injury\u201d, are illegal. These terms are not
\ndefined and require interpretation against objective criteria for the law to be effective.
\nPhysicians can aid in developing criteria for weapons that cause injury or suffering so
\nextreme as to invoke the terms of International Humanitarian Law.
\nSuch criteria could aid lawyers in the use of International Humanitarian Law, allow
\nassessment of the legality of new weapons currently in development against an agreed,<\/p>\n

Weapons\tof\tWarfare\tand\tTheir\tRelation\tto\tLife\tand\tHealth
\nS-1996-05-2006\t\u23d0\tPilanesberg
\nobjective system of assessment of their medical effects, and identify breaches of the Law
\nonce it is developed.
\nPhysician involvement in the delineation of such objective criteria is essential if it is to
\nbecome part of the legal process. However, it must be recognised that physicians are
\nfirmly opposed to any use of weapons against human beings.
\nRECOMMENDATIONS\t<\/p>\n

The WMA believes that the development, manufacture and sale of weapons for use
\nagainst human beings are abhorrent. To support the prevention and reduction of weapons
\ninjuries, the WMA:
\n\u2022 Supports international efforts to define objective criteria to measure the effects of
\ncurrent and future weapons, which could be used to stop the development,
\nmanufacture, sale and use of those weapons;
\n\u2022 Calls on National Medical Associations to urge national governments to cooperate
\nwith the collection of such data as are necessary for establishing objective criteria;
\n\u2022 Calls on National Medical Associations to support and encourage research into the
\nglobal public health effects of weapons use, and to publicise the results of that
\nresearch, both nationally and internationally. This will ensure that both governments
\nand the public are aware of the long-term health consequences of weapons use on
\nnon-combatant individuals and populations.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1997-01-2007\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tPROPOSAL
\nFOR
\n\tA\tUNITED\tNATIONS\tRAPPORTEUR\tON\tTHE\tINDEPENDENCE
\nAND\tINTEGRITY\tOF\tHEALTH\tPROFESSIONALS
\nAdopted by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nand reaffirmed by the 176th
\nWMA Council Session, Berlin, Germany, May 2007
\nThe British Medical Association (BMA) requests that the World Medical Association
\n(WMA) supports a proposal, put forward by a network of medical organizations*
\ncon-
\ncerned with human rights issues, for the establishment of a new UN post of rapporteur on
\nthe independence and integrity of health professionals.
\nIt is envisaged that the role of the rapporteur will supplement the work already done by a
\nseries of existing UN rapporteurs on issues such as torture, arbitrary execution, violence
\nagainst women, etc. The new rapporteur would be charged with the task of monitoring that
\ndoctors are allowed to move freely and that patients have access to medical treatment,
\nwithout discrimination as to nationality or ethnic origin, in war zones or in situations of
\npolitical tension. The role of the proposed rapporteur is detailed on pages two, three and
\nfour of this submission.
\nThe original proposal was drawn up by a lawyer, Cees Flinterman, who is a professor of
\nconstitutional and international law at the University of Limburg, Maastricht, in The
\nNetherlands. It has the support of a range of doctors’ organizations listed below*
\n, whose
\ninterests are in protection of human rights and protection of doctors who act impartially in
\nconflict situations. This group will be consulting widely and acting with the help of the
\nInternational Commission of Jurists to interest the United Nations in this proposal.
\nThe Council of the BMA supported this proposal after debate in 1996. It would lend con-
\nsiderable weight to the campaign if the WMA would also support this concept whose
\nfundamental aim is to protect doctors and their patients in war situations and other cases
\nwhere medical independence may come under threat from political or military factions.
\nPROPOSAL\tFOR\tA\tRAPPORTEUR
\nON\tTHE\tINDEPENDENCE\tAND\tINTEGRITY\tOF\tHEALTH\tPROFESSIONALS\t\t<\/p>\n

Goals
\naccepting that in many situations of political conflict (such as civil or international war) or
\npolitical tension (such as during suspension of civil rights in a government-declared state
\nof emergency), health professionals are often the first people outside military of govern-
\nment circles to have detailed knowledge of human rights violations, including viola-tions
\nof the right of populations to access medical treatment, a network of physicians is anxious
\nthat a range of national and international reporting mechanisms be established to achieve
\nthe following goals:<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1997-01-2007\t\u23d0\tWorld\tMedical\tAssociation
\n1. To monitor the role of health professionals working in situations where either their
\nrights to give, or the rights of their patients to receive, treatment are threatened;
\n2. To make appeals for the protection of health professionals when they are in danger
\nsolely because of their professional or human rights activities;
\n3. To defend patients who are in danger of suffering human rights violations solely be-
\ncause of seeking medical treatment;
\n4. To encourage reporting of human rights violations by health professionals;
\n5. To analyse information about health professionals voluntarily adopting discriminatory
\npractices. The group consider that existing UN reporting mechanisms need expansion.
\nKey among proposals for new mechanisms is the development of a new UN rap-
\nporteur’s post which would link together relevant information emerging from other
\nexisting UN mechanisms and also suggest where other useful local and national
\nreporting networks could be developed in the long-term. Therefore, on the basis of
\nmaterials prepared by the Law Department at the University of Limburg, Maastricht
\nand circulated by the Dutch medical group, the Johannes Wier Foundation, the group
\nis campaigning for a new post of UN Rapporteur of the Independence and Integrity of
\nHealth Professionals.
\nDefining\tthe\tRole
\nThe potential role of a UN Rapporteur need not be exhaustively defined in advance since
\nthe experience of the individual and the practical applicability of the goals must have an
\ninfluence.
\nIt should include the following:
\n\u2022 Receive, evaluate, investigate and report allegations of repression directed at health
\nprofessionals or intended to prevent individuals receiving medical care. The rap-
\nporteur should be a clearing house for reports from individuals, groups of doctors,
\nNGOs etc. and as well as simply receiving information, should pro-actively seek
\nour information, including on-site visits.
\n\u2022 To build upon existing principles as found in humanitarian lay and the codes of
\nmedical ethics applicable in armed conflicts to develop specific guidelines on the
\nsubject of medical impartiality in relation to the treatment of patients in situations
\nof political or armed conflict.
\nThe World Medical Association and national medical association should be en-
\ncouraged to disseminate such information to health professionals during their train-
\ning. Arising also form such guidance should be the institution of mechanisms to
\nhelp health professionals protect themselves in situations where human rights are
\nat risk.
\n\u2022 The rapporteur should also have a consultative role, seeking the views of interna-
\ntional and national professional associations, human rights bodies and humani-
\ntarian organizations with regards to the protection of health professionals and the
\ndefence of the right to treat patients impartially.
\n\u2022 The rapporteur should investigate reports of health professionals voluntarily trans-
\ngressing guidelines about impartiality and non-discrimination.<\/p>\n

Berlin\t\u23d0\tS-1997-01-2007
\nUN\tRapporteur\ton\tthe\tIndependence\tand\tIntegrity\tof\tHealth\tProfessionals
\nIssues\twithin\tthe\tRemit
\n\u2022 The fundamental concern is to protect the nature of the doctor-patient relationship
\nfrom unjustified external interference although it will also include voluntary trans-
\ngressing of impartiality by health professionals. The rapporteur’s role will be to en-
\nsure the independence, integrity and impartiality of health professionals.
\nEnsuring these aims requires analysis of whether:
\n\u2022 the treatment decisions of health professionals can be carried out without coming
\ninto conflict with improper pressure from authorities;
\n\u2022 the physical integrity and ability of health professionals to act in accordance
\nwith their professional principles are both protected;
\n\u2022 health professionals are able to provide treatment on the basis of patient need;
\n\u2022 people in need of medical treatment are able to access it safely;
\n\u2022 health professionals are ensured their freedom of movement, in the capacity as
\nmedical care providers, and be able to have access to people in need of medical
\nservices.
\nMonitoring the degree to which external pressures influence negatively the provision
\nof medical treatment will be within the remit of the rapporteur.
\n\u2022 The remit will be global.
\n\u2022 For lack of a reporting mechanism, health professionals are often disempowered
\nform taking action on violations of patient rights. One of the issues of the rap-
\nporteur to monitor would be the introduction of national or local legislation, civil
\nor military regulations or other rules prohibiting or limiting the provision of medi-
\ncal or nursing care to certain categories of patient.
\n\u2022 It will be within the remit of the rapporteur to bring the evidence or reports of viola-
\ntions of medical impartiality, including those in health professionals cooperating
\nvoluntarily, to responsible bodies in the medical field and to the governments
\nconcerned.
\n\u2022 Blanket restrictions on the medical or nursing services to be provided to members
\nof vulnerable groups, such as refugees, asylum seekers, prisoners, minority ethnic
\ngroups, should be among the issues monitored by the rapporteur. The rapporteur
\nshould contribute to the empowerment of the health professionals to resist col-
\nlectively the erosion of such patients’ rights.
\n\u2022 Threats, intimidation or pressures on health professionals to discriminate against
\npatients on the basis solely of non-medical related considerations such as ethics,
\nreligious or racial affiliation should be investigated even if the threats do not ma-
\nterialize into action.
\n\u2022 Reports of health professionals being harassed or detained simply because of their
\nprofession or because of the exercise of professional skills will be investigated by
\nthe rapporteur. Similarly repressive measures designed to prevent health profes-
\nsionals reporting infringements of medical integrity will be investigated. Measures
\nto encourage health professionals actively to document and report such violations
\nshould be put forward by the rapporteur in consultation with other bodies.
\n\u2022 Reports of patients being impeded or discouraged from gaining access to the avail-
\nable medical treatment will be investigated.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1997-01-2007\t\u23d0\tWorld\tMedical\tAssociation
\nIssues\tOutside\tthe\tRemit
\nJust as important as defining what is within the rapporteur’s remit is the matter of
\nclarifying those issues which fall outside it. We anticipate that this too will become clearer
\nas practice and experience develop. In the meantime, however, we suggest that:
\n\u2022 health professionals in every country should be educated about the ethical res-
\nponsibilities they owe to patients and potential patients. Whereas such education is
\nnot within the remit of the rapproteur, acting as a resource for advice about medi-
\ncal impartiality would be within the rapporteur’s remit. In the long term this func-
\ntion should ideally be dealt with by delegation through medical schools, profes-
\nsional bodies and voluntary national networks;
\n\u2022 while government measures to regulate aspects of care, (such as the equitable dis-
\ntribution of medical resources of the prioritizing of treatment on basis of need)
\nwould not generally be a matter for monitoring for the rapporteur, extreme meas-
\nures likely to result in the disenfranchising of groups of patients from medical or
\nnursing services would be monitored and investigated;
\n\u2022 governments’ indiscriminate failure to provide health promotion or treatment to
\nmany or all sectors of the community does not fall within the remit of the rappor-
\nteur;
\n\u2022 since a principal concern is to ensure access to medical treatment by patients who
\nneed and want it, the voluntary decision of some individuals or patient groups to
\nexclude themselves (for example on religious or cultural grounds) from orthodox
\nmedicine does not fall within the remit of the rapporteur.
\n*
\norganizations participating in the network include: Amnesty International; British Medical Asso-
\nciation; Centre for Enquiry into Health & Allied Themes (Bombay); Graza Community Mental
\nHealth; International Committee of the Red Cross; Physicians for Human Rights (in Denmark,
\nIsrael, South Africa, the UK, & the USA); Turkish Medical Association; and, the Johannes Weir
\nFoundation.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1997-02-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nPHYSICIANS\tCONVICTED\tOF\tGENOCIDE,\tWAR\tCRIMES\tOR\tCRIMES
\nAGAINST\tHUMANITY
\nAdopted by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nreaffirmed by the 176th
\nWMA Council Session, Berlin, Germany, May 2007
\nand amended by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018<\/p>\n

SCOPE\tAND\tDEFINITIONS
\nThe scope of this Statement includes the following specified crimes: genocide, war
\ncrimes, and crimes against humanity, as defined by the Rome Statute of the International
\nCriminal Court.
\nPREAMBLE
\n\u2022 Physicians are bound by medical ethics to dedicate themselves to the good of their
\npatients. Physicians who have been convicted of genocide, war crimes or crimes
\nagainst humanity1, have violated medical ethics, human rights and international
\nlaw and are therefore unworthy of practising medicine.
\n\u2022 In accordance with the principle of the presumption of innocence, only physicians
\nwho have been convicted of the specified crimes should be declared unworthy of
\npractising medicine.<\/p>\n

DISCUSSION
\n1. Physicians seeking to work in any country are subject to the regulations of that
\ncountry\u2019s relevant authorities or jurisdiction. The duty to demonstrate suitability to
\npractice medicine rests with the person seeking licensure.
\n2. Physicians who have been convicted of genocide, war crimes or crimes against
\nhumanity must not be allowed to practise in another country or jurisdiction.
\n3. The relevant licensing authorities must ensure both that physicians have the
\nrequired qualifications and that they have not been convicted of genocide, war
\ncrimes or crimes against humanity.
\n4. Physicians who have been convicted of the specified crimes have sometimes been
\nable to leave the country in which these crimes were committed and obtain a
\nlicence to practise medicine from the relevant licensing authority in another<\/p>\n

Physicians\tconvicted\tof\tGenocide\tor\tCrimes
\nS-1997-02-2018\t\u23d0\tReykjavik
\ncountry.
\n5. This practice is contrary to the public interest, damaging to the reputation of the
\nmedical profession, and may be detrimental to patient safety.<\/p>\n

RECOMMENDATIONS
\n1. The WMA recommends that physicians who have been convicted of the specified
\ncrimes be denied a license to practice medicine and membership to national
\nmedical associations by the relevant regulatory and licensing authority of that
\njurisdiction.
\n2. The WMA recommends that relevant regulatory and licensing authorities use their
\nown authority to inform themselves, in so far as is possible, if verifiable allegations
\nof participation in genocide, war crimes or crimes against humanity have been
\nmade against physicians, while at the same time respecting the presumption of
\ninnocence.
\n3. National Medical Associations must be sure that a thorough investigation into
\nthose allegations is performed by an appropriate authority.
\n4. The WMA recommends that national medical associations ensure that there is
\nefficient communication amongst themselves and that where possible and
\nappropriate they inform relevant national regulatory and licensing authorities of
\nphysicians\u2019 convictions of genocide, war crimes, or crimes against humanity.
\n1 As defined by the Rome Statute of the International Criminal Court.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1998-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nNUCLEAR\tWEAPONS
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nand amended by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nand by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nand revised by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\nThe WMA Declarations of Geneva, of Helsinki and of Tokyo make clear the duties and
\nresponsibilities of the medical profession to preserve and safeguard the health of the
\npatient and to dedicate itself to the service of humanity. Therefore, and in light of the
\ncatastrophic humanitarian consequences that any use of nuclear weapons would have, and
\nthe impossibility of a meaningful health and humanitarian response, the WMA considers
\nthat it has a duty to work for the elimination of nuclear weapons. To achieve a world free
\nof nuclear weapons is a necessity.<\/p>\n

RECOMMENDATIONS
\nTherefore, the WMA:
\n1. Condemns the development, testing, production, stockpiling, transfer, deployment,
\nthreat and use of nuclear weapons;
\n2. Requests all governments to refrain from the development, testing, production,
\nstockpiling, transfer, deployment, threat and use of nuclear weapons and to work in
\ngood faith towards the elimination of nuclear weapons;
\n3. Advises all governments that even a limited nuclear war would bring about immense
\nhuman suffering and substantial death toll together with catastrophic effects on the
\nearth\u2019s ecosystem, which could subsequently decrease the worlds food supply and
\nwould put a significant portion of the world\u2019s population at risk of famine;
\n4. Is deeply concerned by plans to retain indefinitely and modernize nuclear arsenals; the
\nabsence of progress in nuclear disarmament by nuclear-armed states; and the growing
\ndangers of nuclear war, whether by intent, including cyberattack, inadvertence or
\naccident;
\n5. Welcomes the Treaty on the Prohibition of Nuclear Weapons, and joins with others in<\/p>\n

Nuclear\tWeapons
\nS-1998-01-2018\t\u23d0\tReykjavik
\nthe international community, including the Red Cross and Red Crescent movement,
\nInternational Physicians for the Prevention of Nuclear War, the International
\nCampaign to Abolish Nuclear Weapons, and a large majority of UN member states, in
\ncalling, as a mission of physicians, on all states to promptly sign, ratify or accede to,
\nand faithfully implement the Treaty on the Prohibition of Nuclear Weapons; and
\n6. Requests that all National Medical Associations join the WMA in supporting this
\nDeclaration, use available educational resources to educate the general public and to
\nurge their respective governments to work urgently to prohibit and eliminate nuclear
\nweapons, including by joining and implementing the UN Treaty on the Prohibition of
\nNuclear Weapons.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1998-02-2010
\nWMA\tSTATEMENT
\nON
\nMEDICAL\tCARE\tFOR\tREFUGEES,\tINCLUDING\tASYLUM\tSEEKERS,
\nREFUSED\tASYLUM\tSEEKERS\tAND\tUNDOCUMENTED\tMIGRANTS,
\nAND\tINTERNALLY\tDISPLACED\tPERSONS
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nreaffirmed by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nand amended by the 61st
\nWMA General Assembly, Vancouver, Canada, October 2010
\nPREAMBLE\t<\/p>\n

International and civil conflicts as well as poverty and hunger result in large numbers of
\nrefugees, including asylum seekers, refused asylum seekers and undocumented migrants,
\nas well as internally displaced persons (IDPs) in all regions. These persons are among the
\nmost vulnerable in society.
\nInternational codes of human rights and medical ethics, including the WMA Declaration
\nof Lisbon on the Rights of the Patient, declare that all people are entitled without discrimi-
\nnation to appropriate medical care. However, national legislation varies and is often not in
\naccordance with this important principle.
\nSTATEMENT\t<\/p>\n

Physicians have a duty to provide appropriate medical care regardless of the civil or poli-
\ntical status of the patient, and governments should not deny patients the right to receive
\nsuch care, nor should they interfere with physicians’ obligation to administer treatment on
\nthe basis of clinical need alone.
\nPhysicians cannot be compelled to participate in any punitive or judicial action involving
\nrefugees, including asylum seekers, refused asylum seekers and undocumented migrants,
\nor IDPs or to administer any non-medically justified diagnostic measure or treatment, such
\nas sedatives to facilitate easy deportation from the country or relocation.
\nPhysicians must be allowed adequate time and sufficient resources to assess the physical
\nand psychological condition of refugees who are seeking asylum.
\nNational Medical Associations and physicians should actively support and promote the
\nright of all people to receive medical care on the basis of clinical need alone and speak out
\nagainst legislation and practices that are in opposition to this fundamental right.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-1999-01-2019\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nPATENTING\tMEDICAL\tPROCEDURES
\nAdopted by the 51st
\nWorld Medical Assembly, Tel Aviv, Israel, October 1999
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nand reaffirmed by the 212th
\nWMA Council Session, Santiago, Chile, April 2019
\nPREAMBLE\t<\/p>\n

1. Under the law of some jurisdictions medical procedures are patentable. Patents on
\nmedical procedures are often called medical procedure patents. A medical procedure
\npatent or patent claim is one that only confers rights over procedural steps and does
\nnot confer rights over any new devices.
\n2. Over 80 countries prohibit medical procedure patents. The practice of excluding
\nmedical procedures from patentability is consistent with the Uruguay Round of
\nAmendments to the General Agreements on Tariffs and Trade Agreement on Trade
\nRelated Aspects of International Property Rights (GATT-TRIPs), which states:
\n\u00ab\u00a0Members may also exclude from patentability: (a) diagnostic, therapeutic and surgical
\nmethods for the treatment of humans or animals\u00a0\u00bb (Article 27).
\n3. The purpose of patents is to encourage private investment in research and
\ndevelopment. However, physicians, particularly those who work in research
\ninstitutions, already have incentives to innovate and improve their skills. These
\nincentives include professional reputation, professional advancement, and ethical and
\nlegal obligations to provide competent medical care (International Code of Medical
\nEthics, 17.A). Physicians are already paid for these activities, and public funding is
\nsometimes available for medical research. The argument that patents are necessary to
\nspur invention of medical procedures, and that without procedure there would be fewer
\nbeneficial medical procedures for patients, is not particularly persuasive when these
\nother incentives and financing mechanisms are available.
\n4. Another argument is that patents are necessary, not so much for invention but for
\nproduct development. This argument also is not persuasive in the case of medical
\nprocedure patents. Unlike device development, which requires investment in
\nengineers, production processes, and factories, development of medical procedures
\nconsists of physicians attain-ing and perfecting manual and intellectual skills. As
\ndiscussed above, physicians already have both obligations to engage in these
\nprofessional activities as well as rewards for doing so.
\n5. Whether or not it is ethical to patent medical devices does not bear directly on whether
\nit is ethical for physicians to patent medical procedures. Devices are manufactured and
\ndisseminated by companies, whereas medical procedures are \u00ab\u00a0produced and
\ndisseminated\u00a0\u00bb by physicians. Physicians have ethical or legal obligations to patients
\nand professional obligetions towards each other, which companies do not have.
\nHaving particular ethical obliga-tions is part of what defines medicine as a profession.<\/p>\n

Santiago\t\u23d0\tS-1999-01-2019
\nPatenting\tMedical\tProcedures
\n6. There is no a priori reason to believe that those holding medical procedure patents
\nwould make patented medical procedures widely available. Patentees might attempt to
\nmaximize their profits by making the procedure widely available through
\nnonexclusive licensing with low fees. Alternatively, they might attempt to maximize
\nprofits by limiting avail-ability of the procedure and charging higher prices to those
\nfor whom the procedure is extremely important and who have the means to pay.
\n7. Competition between organizations providing health care could provide incentives
\nfor some organizations to negotiate exclusive licenses, or licenses which sharply limit
\nwho else could practice the procedure. Such a license might provide the organization
\nwith an advantage in attracting patients, if the organization could advertise that it was
\nthe only organization in a region which could provide a particularly desirable service.
\nThus, at least some of the time patentees will probably limit access to patented medical
\nprocedures.
\n8. Medical procedure patents may negatively affect patient care. If medical procedure
\npatents are obtained, then patients’ access to necessary medical treatments might
\ndiminish and thereby undermine the quality of medical care. Access could diminish for
\nthe following reasons:
\n\u2022 the cost of medical practice would likely increase because of licensing and royalty
\nfees, and because the cost of physicians’ insurance would likely increase to cover
\npatent litigation expenses.
\n\u2022 some physicians capable of performing the patented procedure might not obtain
\nlicenses to perform it. The number of licensed physicians might be restricted be-
\ncause certain physicians cannot or will not pay the licensing fees or royalties, or
\nbecause the patentee refuses to make the license widely available. Limiting the
\nnumber of licenses would, in some circumstances, limit patients’ choice of physi-
\ncians.
\n\u2022 The presence of patents may prevent physicians from undertaking even those pro-
\ncedures which do not infringe. It may also deter a physician from introducing new
\nor modified procedures into his or her practice. Devices can be labelled if they are
\npatented, but procedures cannot, and therefore it is not immediately obvious
\nwhether what one is doing infringes somebody else’s medical procedure patent.
\nHowever, lack of knowledge is no defence against patent infringement, so if a
\nphysician is uncertain he or she may simply refrain from performing the procedure.
\n9. Enforcement of medical procedure patents can also result in invasion of patients’
\nprivacy or in the undermining of physicians’ ethical obligation to maintain the
\nconfidentiality of patients’ medical information. Where physicians practice in small
\ngroups or as sole practi-tioners, the most expedient methods for a patentee to identify
\ninstances of infringement might be to look through patients’ medical records or to
\ninterview patients. Removing obvious identifiers for the record review would not
\nguarantee confidentiality, because identity can often be \u00ab\u00a0reconstructed\u00a0\u00bb with very few
\npieces of information. This would be parti-cularly true in small towns or small
\npractices.
\n10. Physicians have ethical obligations both to teach skills and techniques to their<\/p>\n

S-1999-01-2019\t\u23d0\tSantiago
\nPatenting\tMedical\tProcedures
\ncolleagues, and to continuously learn and update their own skills. Medical procedure
\npatents can undermine these obligations. Once a patent has issued on a procedure,
\nthe procedure would be fully disclosed (this is one requirement for obtaining a patent);
\nhowever, those without licenses would not be able to practice it. Limiting who can
\npractice the procedure undermines the spirit of the ethical mandate to teach and
\ndisseminate knowledge. It also undermines the obligation to update one’s skills,
\nbecause it does not do much good to acquire skills which cannot be used legally.
\n11. The obligation to teach and impart skills may also be impaired if the possibility of
\npatents causes physicians to delay publishing new results or presenting them at
\nconferences. Physicians may be inclined to keep new techniques secret while waiting
\nto complete a patent application. This is because public use of a procedure, or
\npublication of a description of the procedure, prior to applying for a patent may
\ninvalidate the application.
\n12. Physicians also have an ethical obligation not to permit profit motives to influence
\ntheir free and independent medical judgment (International Code of Medical Ethics,
\n17.A). For physicians to pursue, obtain, or enforce medical procedure patents could
\nviolate this requirement. Physicians holding patents or licenses for procedures might
\nadvocate for the use of those procedures even when they are not indicated, or not the
\nbest procedure under the circumstances. Physicians who are not licensed to perform a
\nparticular procedure might advocate against that procedure, even when it is the best
\nprocedure under the circumstances.
\n13. Finally, physicians’ professional obligations to practice their profession with
\nconscience and dignity (Declaration of Geneva) might be violated by the enforcement
\nof medical procedure patents. The spectacle of physicians suing each other on a
\nregular basis is unlikely to enhance the standing of the profession.
\nPOSITION\t<\/p>\n

14. The World Medical Association
\n\u2022 states that physicians have an ethical responsibility to make relevant scientific in-
\nformation available to colleagues and the public, when possible.
\n\u2022 states that the patenting of medical procedures poses serious risks to the effective
\npractice of medicine by potentially limiting the availability of new procedures to
\npatients.
\n\u2022 considers that the patenting of medical procedures is unethical and contrary to the
\nvalues of the medical profession that should guide physicians’ service to their pa-
\ntients and relations with their colleagues.
\n\u2022 encourages national medical associations to make every effort to protect physi-
\ncians’ incentives to advance medical knowledge and develop new medical proce-
\ndures.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1999-02-2010
\nWMA\tSTATEMENT
\nON
\nTHE\tRELATIONSHIP\tBETWEEN\tPHYSICIANS\tAND\tPHARMACISTS
\nIN\tMEDICINAL\tTHERAPY
\nAdopted by the 51st
\nWorld Medical Assembly, Tel Aviv, Israel, October 1999
\nand amended by the 61st
\nWMA General Assembly, Vancouver, Canada, October 2010
\nINTRODUCTION\t<\/p>\n

The goal of pharmacological treatment is to improve patients\u00b4 health and quality of life.
\nOptimal pharmacological treatment should be safe, effective and efficient. There should
\nbe equity of access to this kind of treatment and an accurate and up-to-date information
\nbase that meets the needs of patients and practitioners.
\nPharmacological treatment has become increasingly complex, often requiring the input of
\na multi-disciplinary team to administer and monitor the chosen therapy. In the hospital set-
\nting the inclusion of a clinical pharmacist in such a team is increasingly common and help-
\nful. The right to prescribe medicine should be competency based and ideally the responsi-
\nbility of the physician.
\nPhysicians and pharmacists have complementary and supportive responsibilities in
\nachieving the goal of providing optimal pharmacological treatment. This requires com-
\nmunication, respect, trust and mutual recognition of each other’s professional competence.
\nAccess by both physicians and pharmacists to the same accurate and up-to-date informa-
\ntion base is important to avoid providing patients with conflicting information.
\nPhysicians and pharmacists must provide quality service to their patients and ensure safe
\nuse of drugs. Therefore collaboration between these professions is imperative, including
\nwith respect to the development of training and in terms of information sharing with one
\nanother and with patients. It is necessary to keep an open and continued dialogue between
\nphysicians\u2019 and pharmacists\u2019 representative organizations in order to define each profes-
\nsion\u2019s respective functions and promote the optimal use of drugs within a framework of
\ntransparency and cooperation, all in the best interests of patients.
\nTHE\tPHYSICIAN’S\tRESPONSIBILITIES\t<\/p>\n

Diagnosing diseases on the basis of the physician’s education and specialized skills and
\ncompetence.
\nAssessing the need for pharmacological treatment and prescribing the corresponding medi-
\ncines in consultation with patients, pharmacists and other health care professionals, when
\nappropriate.<\/p>\n

S-1999-02-2010\t\u23d0\tVancouver
\nPhysicians\tand\tPharmacists\tin\tMedical\tTherapy
\nProviding information to patients about diagnosis, indications and treatment goals, as well
\nas action, benefits, risks and potential side effects of pharmacological treatment. In the
\ncase of off-label prescriptions the patient must be informed about the character of the pre-
\nscription.
\nMonitoring and assessing response to pharmacological treatment, progress toward thera-
\npeutic goals, and, as necessary, revising the therapeutic plan in collaboration with pharma-
\ncists, other health professionals and, when appropriate, caregivers.
\nProviding and sharing information in relation to pharmacological treatment with other
\nhealth care practitioners.
\nLeading the multi-disciplinary team of health professionals responsible for managing
\ncom-plex pharmacological treatment.
\nMaintaining adequate records for each patient, according to the need for therapy and in
\ncompliance with legislation respecting confidentiality and protecting the patient\u2019s data.
\nWhere practically possible, actively participating in establishing electronic drug delivery
\nsystems within their workplace and supporting those systems with their professional
\nknowledge.
\nMaintaining a high level of knowledge of pharmacological treatment through continuing
\nprofessional development.
\nEnsuring safe procurement and storage of medicines that the physician is required to
\nsupply or permitted to dispense.
\nReviewing prescription orders to identify interactions, allergic reactions, contra-indica-
\ntions and therapeutic duplications.
\nReporting adverse reactions to medicines to health authorities, in accordance with national
\nlegislation.
\nMonitoring and limiting, where appropriate, prescriptions of medications that may have
\naddictive properties.
\nDocumenting adverse reactions to medicines in the patient\u2019s medical record.
\nTHE\tPHARMACIST’S\tRESPONSIBILITIES\t<\/p>\n

Ensuring safe procurement, adequate storage and dispensing of medicines in compliance
\nwith the relevant regulations.
\nProviding information to patients, which may include the information leaflet, name of the
\nmedicine, its purpose, potential interactions and side effects, as well as correct usage and
\nstorage.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-1999-02-2010
\nReviewing prescription orders to identify interactions, allergic reactions, contra-indica-
\ntions and therapeutic duplications. Concerns should be discussed with the prescribing phy-
\nsician but the pharmacist should not change the prescription without consulting the
\nprescriber.
\nDiscussing medicine-related problems or concerns with regard to the prescribed medicines
\nwhen appropriate and when requested by the patient.
\nAdvising patients, when appropriate, on the selection and the use of non-prescription
\nmedicines and the patient’s management of minor symptoms or ailments. Where self-
\nmedication is not appropriate, advising patients to consult their physician for diagnosis
\nand treatment.
\nParticipating in multi-disciplinary teams concerning complex pharmacological treatment
\nin collaboration with physicians and other health care providers, typically in a hospital
\nsetting.
\nReporting adverse reactions to medicines to the prescribing physician and to health au-
\nthorities in accordance with national legislation.
\nProviding and sharing general as well as specific medicine-related information and advice
\nwith the public and health care practitioners.
\nMaintaining a high level of knowledge of pharmacological treatment through continuing
\nprofessional development.
\nCONCLUSION\t<\/p>\n

The patient will best be served when pharmacists and physicians collaborate, recognizing
\nand respecting each other’s roles, to ensure that medicines are used safely and appropriately
\nto achieve the best outcome for the patient\u2019s health.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2002-01-2012\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nSAFE\tINJECTIONS\tIN\tHEALTH\tCARE
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand amended with minor resivion by the 192nd
\nWMA Council Session,
\nBangkok, Thailand, October 2012
\nPREAMBLE
\nAccording to the World Health Organization, billions of injections are administered world-
\nwide each year in health care. Of these injections, many millions are unsafe, especially
\nthose that are administered with a re-used syringe and\/or needle.
\nThe most common diseases acquired from unsafe injections are hepatitis B, hepatitis C
\nand HIV.
\nIn many countries disposable equipment is always used in health care settings, and the
\nmajor problem is the safe use and disposal of sharps.
\nPhysicians are involved in the prescription and\/or administration of injections. Therefore,
\nthey are in a prime position to bring about changes in behaviour, which could lead to the
\nappropriate and safe use of injections.
\nSafe and appropriate use of injections is a necessary component of HIV prevention. Safe
\npractices to prevent HIV infection also yield substantial spin-off benefits outside the HIV
\nprevention area, such as hepatitis B and C infections.
\nBASIC\tCONSIDERATIONS
\nUnsafe injections result from the overuse of therapeutic injections and unsafe injection
\npractices. These practices include the use of unsterilized or inadequately sterilized needles,
\nthe re-use of syringes and the inappropriate and unsafe disposal of syringes and needles.
\nSafe injection practices prevent harm to the recipient, the provider and the community.
\nUnsafe injections cause widespread harm by spreading pathogens on a large scale.
\nPhysician attitudes and inappropriate practice standards may be important determinants in
\nthe overuse of \u00ab\u00a0therapeutic\u00a0\u00bb injections in certain countries. These are a result of the as-
\nsumption that some patients only feel satisfied with a treatment if it includes an injection.
\nScientific evidence has shown that this assumption is incorrect. Patients prefer good<\/p>\n

Bangkok\t\u23d0\tS-2002-01-2012
\nSafe\tInjections\tin\tHealth\tCare
\ncommunication with physicians to receiving injections. Furthermore, the payment schemes
\nin some health care systems may be structured in a way that they provide perverse in-
\ncentives for unnecessary use of injections.
\nMost non-injectable medications are equivalent in action and efficacy to those which are
\ninjectable.
\nUnsafe injections are a waste of precious healthcare resources and can easily be prevented
\nthrough integrated interventions. For an effective national, regional or local strategy to
\npromote safe injections, the following primary elements are necessary:
\n\u2022 The use of injections should be limited to suitably trained health care professionals
\nand trained lay persons;
\n\u2022 Behaviour change among patients and health care professionals to decrease injec-
\ntion overuse and achieve injection safety;
\n\u2022 The availability of necessary equipment and supplies, preferably disposable;
\n\u2022 The use of auto-disable syringes where appropriate;
\n\u2022 The appropriate management of sharps waste.
\nIncreased availability of appropriate injection equipment and supplies, preferably dis-
\nposable, increases the safety of injections without necessarily increasing the number of
\nunnecessary injections.
\nRECOMMENDATIONS
\nThat National Medical Associations cooperate with their national governments or other
\nappropriate authorities to develop effective policies on the safe and appropriate use of
\ninjections. These policies would demand appropriate financing and include the assessment
\nof current injection practices and the development of an integrated plan. Such a plan
\nshould support the provision of adequate supplies of injection equipment, measures to
\nenforce proper standards of sterilisation where needed, the management of sharps waste
\nand training programs to deter the overuse of injections and promote safe injection prac-
\ntices.
\nThat physicians worldwide are urged to:
\n\u2022 Prescribe non-injectable medication rather than injectable medication whenever
\npossible and promote the use of non-injectable medication with patients and their
\ncolleagues;
\n\u2022 Use injectable medications only if safe and appropriate and administer injections in
\na way that does not harm the recipient, the provider and the community;<\/p>\n

S-2002-01-2012\t\u23d0\tBangkok
\nSafe\tInjections\tin\tHealth\tCare\t<\/p>\n

\u2022 Ensure that only waste disposal containers for sharp objects be used to safely dis-
\npose of used surgical material (e.g. needles, blades, etc.), and that the covers of
\nsharp instruments not be re-utilised.
\nRaise awareness regarding the risks involved with unsafe injections and help bring about
\nbehaviour changes in patients and health professionals to promote safe and appropriate
\ninjections. Training in this area should emphasise that needles should not be re-sheathed<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2002-02-2012
\nWMA\tSTATEMENT
\nON
\nSELF-MEDICATION
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand reaffirmed by the 191st
\nWMA Council Session, Prague, Czech Republic, April 2012
\nPREAMBLE
\nThe World Medical Association has developed this statement to provide guidance to phy-
\nsicians and their patients regarding responsible self-medication.
\n1. Distinction between Self-Medication and Prescription Medicine
\n1. Medicinal products can generally be divided into two separate categories: pre-
\nscription and non-prescription medicines. This classification may differ from
\ncountry to country. The national authorities must assure that medicines, cate-
\ngorized as non-prescription medicines, are sufficiently safe not to be harmful
\nto health.
\n2. Prescription medicines are those which are only available to individuals on
\nprescription from a physician following a consultation. Prescription medicines
\nare not safe for use except under the supervision of a physician because of
\ntoxicity, other potential or harmful effects (e.g. addictiveness), the method of
\nuse, or the collateral measures necessary for use.
\n3. Responsible self-medication, as used in this document, is the use of a re-
\ngistered or monographed medicine legally available without a physician’s pre-
\nscription, either on an individual’s own initiative or following advice of a
\nhealthcare professional. The use of prescription medicines without a prior me-
\ndical prescription is not part of responsible self-medication.
\n4. The safety, efficacy and quality of non-prescription medicines must be proved
\naccording to the same principles as prescription medicines.
\n2. Use of Self-Medication in conjunction with Prescription Medication A course of
\ntreatment may combine self-medication and prescription medication, either con-
\ncurrently or sequentially. The patient must be informed about possible interactions
\nbetween prescription medicines and non-prescription medicines. For this reason
\nthe patient should be encouraged to inform the physician about his \/ her self-
\nmedication.
\n3. Roles & Responsibilities in Self-Medication
\n1. In self-medication the individual bears primary responsibility for the use of
\nself-medication products. Special caution must be exercised when vulnerable
\ngroups such as children, elderly people or pregnant women use self-medication.<\/p>\n

S-2002-02-2012\t\u23d0\tPrague
\nSelf-Medication
\n2. If individuals choose to use self-medication, they should be able:
\n1. to recognize the symptoms they are treating;
\n2. to determine that their condition is suitable for self-medication;
\n3. to choose an appropriate self-medication product;
\n4. to follow the directions for use of the product as provided in the product
\nlabelling.
\n3.
\n3. In order to limit the potential risks involved in self-medication it is important
\nthat all health professionals who look after patients should provide:
\n1. Education regarding the non-prescription medicine and its appropriate use,
\nand instructions to seek further advice from a physician if they are unsure.
\nThis is particularly important where self-medication is inappropriate for
\ncertain conditions the patient may suffer from;
\n2. Encouragement to read carefully a product’s label and leaflet (if provided),
\nto seek further advice if necessary, and to recognize circumstances in which
\nself-medication is not, or is no longer, appropriate.
\n4. All parties involved in self-medication should be aware of the benefits and
\nrisks of any self-medication product. The benefit-risk balance should be com-
\nmunicated in a fair, rational manner without overemphasizing either the risks
\nor the benefits.
\n5. Manufacturers in particular are obliged to follow the various codes or regula-
\ntions already in place to ensure that information provided to consumers is
\nappropriate in style and content. This refers in particular to the labelling, ad-
\nvertising and all notices concerning non-prescription medicines.
\n6. The pharmacist has a professional responsibility to recommend, in appropriate
\ncircumstances, that medical advice be sought.
\n4. Role of Governments in Self-Medication Governments should recognize and en-
\nforce the distinction between prescription and non-prescription medicines, and
\nensure that the users of self-medication are well informed and protected from
\npossible harm or negative long-term effects.
\n5. The Promotion and Marketing of Self-Medication Products
\n1. Advertising and marketing of non-prescription medicines should be responsi-
\nble, provide clear and accurate information and exhibit a fair balance between
\nbenefit and risk information. Promotion and marketing should not encourage
\nirresponsible self-medication, purchase of medicines that are inappropriate, or
\npurchases of larger quantities of medicines than are necessary.
\n2. People must be encouraged to treat medicines (prescription and non-prescrip-
\ntion) as special products and that standard precautions should be followed in
\nterms of safe storage and usage, in accordance with professional advice.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2003-01-2013
\nWMA\tSTATEMENT
\nON
\nFORENSIC\tINVESTIGATIONS\tOF\tTHE\tMISSING
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand amended by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nOver the last three decades, forensic investigations into the whereabouts and fate of people
\nkilled and missing as a result of armed conflict, other situations of violence and catas-
\ntrophes, have made an important contribution to humanitarian action on behalf of victims,
\nincluding [the deceased and] bereaved families. Forensic investigations have also helped
\nin achieving justice and reparations for victims.
\nIn 2003 the International Conference on The Missing and their Families, organized by the
\nInternational Committee of the Red Cross (ICRC), adopted a set of recommendations to
\nhelp prevent people going missing, and resolve the cases of those already missing, as a
\nresult of armed conflicts and other situations of violence. The recommendations include
\nethical, scientific and legal principles that must apply to forensic investigations in the
\nsearch, recovery, management and identification of human remains. These principles have
\nsince been further developed by the ICRC’s forensic services and they provide a frame-
\nwork for humanitarian forensic action in situations of armed conflicts, other situations of
\nviolence and catastrophes.1
\nThe principles also ensure the proper and dignified manage-
\nment and identification of the dead, and help provide answers to the bereaved.
\nNational Medical Associations have a role in promoting these principles and encouraging
\ncompliance with them, and for ensuring the highest possible ethical, scientific and legal
\nstandards in forensic investigations aimed at addressing the humanitarian consequences of
\narmed conflicts, other situations of violence and catastrophes.
\nIn many countries NMAs will not have a role in certifying the qualifications and experi-
\nence of forensic medical practitioners. NMAs should draw the attention of practitioners to
\nthe best practice guidelines produced by the ICRC, the United Nations and Interpol, and
\nrecommend or, where possible, require compliance with those standards.
\nRECOMMENDATIONS
\nThe WMA calls upon all NMAs to help ensure that, when its members take part in
\nforensic investigations for humanitarian and human rights purposes, such investigations
\nare established with a clear mandate based upon the highest ethical, scientific and legal<\/p>\n

S-2003-01-2013\t\u23d0\tFortaleza
\nForensic\tInvestigations\tof\tthe\tMissing
\nstandards, and conform with the principles and practice of humanitarian forensic action
\ndeveloped by the ICRC.
\nThe WMA calls upon NMAs to develop expertise in the principles collated by the dif-
\nferent authorities on forensic investigations for humanitarian and human rights purposes,
\nincluding those developed by the ICRC to prevent new cases and resolve those of existing
\nmissing persons, and to assist their members in applying these principles to forensic
\ninvestigations worldwide.
\nThe WMA calls upon NMAs to disseminate the principles that should apply to such
\ninvestigations, including those developed by the ICRC, and to attempt to ensure that phy-
\nsicians refuse to take part in investigations that are ethically or otherwise unacceptable.
\nThe WMA calls upon NMAs to help ensure compliance by forensic medical practitioners
\nwith the principles enshrined in international humanitarian law for the dignified and
\nproper management, documentation and identification of the dead, and, where possible,
\nproviding answers to the bereaved.
\nThe WMA invites NMAs to be mindful of academic qualifications and ethical under-
\nstanding, ensuring that forensic doctors practice with competence and independence.<\/p>\n

1
\nThe ICRC defines catastrophes as disasters beyond expectations. See: M. Tidball-Binz, Man-
\naging the dead in catastrophes: guiding principles and practical recommendations for first
\nresponders. International review of the Red Cross, Vol 89 Number 866 June 2007; 421- 442<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2003-02-2013
\nWMA\tSTATEMENT
\nON
\nADVANCE\tDIRECTIVES\t(\u00ab\u00a0LIVING\tWILLS\u00a0\u00bb)
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand reaffirmed by the 194th
\nWMA Council Session, Bali, Indonesia, April 2013
\nA.\t\tPREAMBLE\t<\/p>\n

1. An advance directive is a written and signed document or a witnessed verbal
\nstatement whereby persons record their wishes regarding the medical care they
\nwish to receive, or not receive, if they become unconscious or otherwise unable to
\nexpress their will.
\n2. This type of document may have different names in different countries (e.g.,
\n\u00ab\u00a0living will\u00a0\u00bb or \u00ab\u00a0biological wills\u00a0\u00bb). The acceptability and legal status of such
\ndirectives may differ from one country to another, depending on social, cultural
\nand religious and other factors.
\n3. The majority of persons who draw up such directives are particularly concerned
\nabout excessive, ineffective or prolonged therapeutic interventions in the terminal
\nphases of life, in situations where there is clear and irreversible physical or mental
\ndegeneration.
\n4. The WMA Declaration of Lisbon on the Rights of the Patient states that \u00ab\u00a0If the
\npatient is unconscious and if a legally entitled representative is not available but a
\nmedical intervention is urgently needed, consent of the patient may be presumed
\nunless it is obvious and beyond any doubt on the basis of the patient’s previous
\nfirm expression or conviction that he\/she would refuse consent to the intervention
\nin that situation.\u00a0\u00bb
\nB.\t\tRECOMMENDATIONS\t<\/p>\n

1. A patient’s duly executed advance directive should be honoured unless there are
\nreasonable grounds to suppose that it is not valid because it no longer represents
\nthe wishes of the patient or that the patient’s understanding was incomplete at the
\ntime the directive was prepared. If the advance directive is contrary to the physi-
\ncian’s convictions, provisions should be made to transfer the care of the patient to
\nanother consenting physician.
\n2. If the physician is uncertain about the validity of an advance directive to terminate
\nlife-prolonging treatment, he\/she should consult family members or legal
\nguardians of the patient concerned and should seek advice from at least one other<\/p>\n

S-2003-02-2013\t\u23d0\tBali
\nLiving\tWills
\nphysician or the relevant ethics committee. The family members or legal guardians
\nshould be designated in the advance directive, be trustworthy and willing to testify
\nas to the intention(s) expressed in the advance directive by the signatory. The
\nphysician should consider any relevant legislation concerning substitute decision
\nmaking for incompetent patients.
\n3. Patients should be advised to review their advance directives periodically.
\n4. In the absence of an advance directive or a legally designated substitute decision
\nmaker, physicians should render such treatment as they believe to be in the pa-
\ntient’s best interests.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2003-03-2014
\nWMA\tSTATEMENT
\nON
\nETHICAL\tGUIDELINES\tFOR
\nTHE\tINTERNATIONAL\tMIGRATION\tOF\tHEALTH\tWORKERS
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand revised by the 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nPREAMBLE
\nThe WMA acknowledges that temporary stays of physicians in other countries help both
\nthe receiving and the sending countries to exchange medical knowledge, skills and atti-
\ntudes. The exchange of medical professionals is therefore beneficial for the development
\nof medicine and healthcare systems and in general deserves the support of national medi-
\ncal associations as well as governments.
\nThe WMA Statement on Medical Manpower – 1 (1983, 1986) called upon all National
\nMedical Associations to work with their governments towards solutions to the emerging
\nproblems related to the medical workforce.
\nThe WMA Resolution on the Medical Workforce (1998) identified the major components
\nof the medical workforce situation that need to be taken into account when developing a
\nnational workforce policy.
\nFor several decades many governments, employers and medical associations have mis-
\ninterpreted demographical data regarding the number of physicians that are required.
\nYoung people seeing employment as physicians have often been seriously affected by
\npoor medical workforce planning.
\nIn many countries, including the wealthiest ones, there is a shortage of physicians. A
\nmajor reason for the shortage is a failure to educate enough physicians to meet the needs
\nof the country. Other reasons for the net loss of physicians are the recruitment of physi-
\ncians to other professions, early retirement and emigration, and the problems of combining
\nprofessional and family responsibilities, all of which are often due to poor working con-
\nditions for physicians.
\nSome countries have traditionally solved their need for physicians by recruiting medical
\ngraduates from other countries. This practice continues today.
\nThe flow of international migration of physicians is generally from poorer to wealthier
\ncountries. The poorer countries bear the expense of educating the migrating physicians
\nand receive no recompense when they enter other countries. The receiving countries gain a
\nvaluable resource without paying for it, and in the process they save the cost of educating
\ntheir own physicians.
\nPhysicians do have valid reasons for migrating, for example, to seek better career oppor-
\ntunities and to escape poor working and living conditions, which may include the pursuit
\nof more political and personal freedoms and other benefits.<\/p>\n

S-2003-03-2014\t\u23d0\tDurban
\nInternational\tMigration\tof\tHealth\tWorkers
\nRECOMMENDATIONS
\n1.
\n1. National medical associations, governments and employers should exercise utmost
\ncare in utilizing demographic data to make projections about future requirements
\nfor physicians and in communicating these projections to young people contem-
\nplating a medical career.
\n2. Every country should do its utmost to educate an adequate number of physicians,
\ntaking into account its needs and resources. A country should not rely on immi-
\ngration from other countries to meet its need for physicians.
\n3. Every country should do its utmost to retain its physicians in the profession as well
\nas in the country by providing them with the support they need to meet their
\npersonal and professional goals, taking into account the country’s needs and re-
\nsources.
\n4. Countries that wish to recruit physicians from another country should only do so in
\nterms of and in accordance with the provisions of a Memorandum of Under-
\nstanding entered into between the countries.
\n5. Physicians should not be prevented from leaving their home or adopted country to
\npursue career opportunities in another country.
\n6. Countries that recruit physicians from other countries should ensure that recruiters
\nprovide full and accurate information to potential recruits on the nature and re-
\nquirements of the position to be filled, on immigration, administrative and con-
\ntractual requirements, and on the legal and regulatory conditions for the practice of
\nmedicine in the recruiting country, including language skills.
\n7. Physicians who are working, either permanently or temporarily, in a country other
\nthan their home country should be treated fairly in relation to other physicians in
\nthat country (for example, equal opportunity career options and equal payment for
\nthe same work).
\n8. Nothing should prevent countries from entering into bilateral agreements and
\nagreements of understanding, as provided for in international law and with due
\ncognizance of international human rights law, so as to effect meaningful co-
\noperation on health care delivery, including the exchange of physicians.
\n9. The WHO Global Code of Practice on the International Recruitment of Health
\nPersonnel (May 2010) was established to promote voluntary principles and prac-
\ntices for the ethical international recruitment of health professionals and to facilitate
\nthe strengthening of health systems. The Code takes into account the rights, obliga-
\ntions and expectations of source countries and migrant health professionals. The
\nWMA was involved in the drafting of the Code and supports its implementation.
\n10. The WHO Code states that international recruitment should be \u201cconducted in ac-
\ncordance with the principles of transparency, fairness and promotion of sustain-
\nability of health systems in developing countries.\u201d
\n11. The monitoring and information-sharing system established by the WHO should be
\nrobustly supported with the goal of international cooperation. Stakeholders should
\nregularly collate and share data, which should be monitored and anlaysed by the
\nWHO. The WHO should provide substantive critical feedback to governments.
\nInformation should be shared about how to overcome challenges encountered.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2003-04-2008
\nWMA\tSTATEMENT
\nON
\nVIOLENCE\tAND\tHEALTH
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand reaffirmed by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nINTRODUCTION\t\t<\/p>\n

In the year 2000 there were over 1.6 million people who lost their lives to violence –
\nmeaning that every day more than 4,000 people around the world die a violent death.
\nRoughly half of these deaths are due to suicide, almost a third due to homicide, and the
\nremainder arise from conflict-related violence. These fatalities are only the tip of the ice-
\nberg – available data tends to come from higher income countries with established re-
\nporting systems and it is known that many forms of violence are more prevalent in lower
\nincome settings that may not provide data to the World Health Organization. In addition to
\npotential data collection problems, a variety of different forms of violence, child abuse and
\nneglect, intimate partner violence and elder abuse, to name a few, are systematically under-
\nreported, owing to fear, shame, or cultural norms.
\nFor every young person killed by homicide, at least 20-40 other youth receive hospital
\ntreatment for violence-related injuries. One in five females and 5-10% of males report
\nbeing sexually abused during childhood. International population-based studies indicate
\nthat between 10 and 69 percent of women report having been physically assaulted by an
\nintimate partner. In addition to the direct effects of injury arising from violence there are a
\nwide range of health effects, including mental and reproductive health problems, sexually
\ntransmitted diseases, and other health problems. Health effects arising from violence can
\nlast for years, and may include permanent mental or physical disability. From a societal
\nperspective, the economic costs associated with violence are substantial, with direct costs
\nfor health services alone amounting to 5.0% of GDP in some countries.
\nNo single factor drives violence, either at the level of the community or the individual.
\nViolence arises out of a complex interplay of individual, relationship, community, societal
\nand political factors.
\nIn 1996 the World Health Assembly adopted resolution WHA49.25, which declared vio-
\nlence a global public health priority. One year later, resolution WHA50.19 was adopted,
\nwhich endorsed the World Health Organization’s integrated plan of action for a science-
\nbased public health approach to the prevention of violence and called for further work in
\nthis field.<\/p>\n

S-2003-04-2008\t\u23d0\tSeoul
\nViolence\tand\tHealth
\nINVOLVEMENT\tOF\tTHE\tINTERNATIONAL\tMEDICAL\tCOMMUNITY\t<\/p>\n

Irrespective of the diversity of factors that give rise to violence, there is one feature com-
\nmon to all forms of violence: the health effects suffered are a direct concern for the medi-
\ncal community.
\nDoctors can be victims of violence in the workplace or in other settings. In some cases
\ndoctors can be involved in committing acts of violence or neglect. Doctors of every
\ndescription also deal with the victims of violence on a daily basis. They make decisions
\nregarding referral and coordinated care across specialties and health sectors, they plan for
\nlong-term follow-up and care of disabilities, and in some settings they have contributed as
\na profession to the prevention of violence. Whether as a pediatrician assessing if a child is
\na victim of abuse, an emergency physician or surgeon tending to a shooting victim, a psy-
\nchiatrist dealing with the psychosocial impacts of intimate partner violence or any number
\nof other possible encounters, the reality is that more than any other profession the medical
\ncommunity is absolutely central in terms of responding to the health effects of violence.
\nThe manner in which the medical community can respond is varied and will depend as
\nmuch as anything else upon contextual features and realities. In some settings more struc-
\ntured forms of data collection are of paramount concern and doctors may be the only
\ngroup within such settings with the ability to lobby for health systems to adequately inte-
\ngrate systematic data collection related to violent injury. In other settings that are more
\nadvanced, clinicians and public health practitioners can play a major role in facilitating or
\nconducting focused studies that examine an aspect of violence or violence prevention. The
\nprovision of such data to policy-makers in a timely and appropriate fashion can contribute
\nto further development of evidence-based policies to reduce violence.
\nRECOMMENDATIONS\t<\/p>\n

National Medical Associations are encouraged to contribute to more systematic appro-
\naches to dealing with violence, including:
\nAdvocacy – violence is a global health problem and its victims are frequently among the
\npoorest, most powerless or otherwise most vulnerable within society. The medical profes-
\nsion should advocate at local, national and international levels for effective strategies to
\nprevent violence and limit its impact on health. Moreover, the medical profession should
\ndenounce all depictions or uses of violent behaviour as solutions for personal, societal or
\npolitical problems.
\nData collection – the medical profession should play a central role in ensuring that routine
\ndata collection occurs and is of a sufficient standard and comprehensive enough to be a
\nvaluable tool to guide public health policy. Research has shown that a large proportion of
\nvictims of violence are not reported in police statistics because they are not the victims of
\na crime (e.g. forms of family violence, bullying, etc.) or have avoided being reported to
\nthe police.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2003-04-2008
\nMedical training – in recognition of the substantial burden of global morbidity and mor-
\ntality that is related to violence and the fact that violence and injury as a threat to health is
\nlargely absent from medical training, the medical profession should take steps to ensure
\nthe integration of injury and violence prevention into medical school curricula.
\nPrevention – the medical profession should use the unique opportunity during clinical en-
\ncounters, where appropriate, to counsel patients and families with respect to creating safer,
\nless violent household environments. They can also use their clinical judgment to detect
\nvictims of violence or those at potential risk for violence and make arrangements for ap-
\npropriate care.
\nCoordination of victim assistance – whether through detecting victims that may suffer
\nfrom violence but do not know how to bring themselves to medical attention, or through
\nappropriate referral to deal with the related health conditions or the physical, psychosocial
\nor long-term disability associated with injury, doctors can play a vital role in enhancing
\nthe quality and comprehensiveness of victim assistance.
\nResearch – violence is an under-documented global public health problem. Better under-
\nstanding of causes and consequences of violence is necessary, along with an enhanced
\nunderstanding of the effectiveness of various strategies to prevent violence.
\nSocial example – the medical profession should contribute to the creation and reinforce-
\nment of social norms by not participating in or tolerating various forms of violence, such
\nas torture or mistreatment or neglect of certain populations such as prisoners, and actively
\nopposing such violence.
\nPolicy-making – many countries still lack comprehensive national or local violence pre-
\nvention policies and plans of action. The medical profession should encourage the develop-
\nment of such policies and in some cases take a leading role in developing them.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2004-02-2009\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nCONCERNING\tTHE\tRELATIONSHIP
\nBETWEEN\tPHYSICIANS\tAND\tCOMMERCIAL\tENTERPRISES
\nAdopted by the 55th
\nWMA General Assembly, Tokyo, Japan, October 2004
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

In the treatment of their patients, physicians use drugs, instruments, diagnostic tools,
\nequipment and materials developed and produced by commercial enterprises. Industry
\npossesses resources to finance expensive research and development programmes, for
\nwhich the knowledge and experience of physicians are essential. Moreover, industry sup-
\nport enables the furtherance of medical research, scientific conferences and continuing
\nmedical education that can be of benefit to patients and the entire health care system. The
\ncombination of financial resources and product knowledge contributed by industry and the
\nmedical knowledge possessed by physicians enables the development of new diagnostic
\nprocedures, drugs, therapies, and treatments and can lead to great advances in medicine.
\nHowever, conflicts of interest between commercial enterprises and physicians occur that
\ncan affect the care of patients and the reputation of the medical profession. The duty of the
\nphysician is to objectively evaluate what is best for the patient, while commercial enter-
\nprises are expected to bring profit to owners by selling their own products and competing
\nfor customers. Commercial considerations can affect the physician’s objectivity, especially
\nif the physician is in any way dependent on the enterprise.
\nRather than forbidding any relationships between physicians and industry, it is preferable
\nto establish guidelines for such relationships. These guidelines must incorporate the key
\nprinciples of disclosure, avoidance of obvious conflicts of interest and the physician’s cli-
\nnical autonomy to act in the best interests of patients.
\nThese guidelines should serve as the basis for the review of existing guidelines and the de-
\nvelopment of any future guidelines.
\nMEDICAL\tCONFERENCES\t<\/p>\n

Physicians may attend medical conferences sponsored in whole or in part by a commercial
\nentity if these conform to the following principles:
\n1. The main purpose of the conference is the exchange of professional or scientific infor-
\nmation.<\/p>\n

New\tDelhi\t\u23d0\tS-2004-02-2009
\nPhysicians\tand\tCommercial\tEnterprises
\n2. Hospitality during the conference is secondary to the professional exchange of infor-
\nmation and does not exceed what is locally customary and generally acceptable.
\n3. Physicians do not receive payment directly from a commercial entity to cover travel-
\nling expenses, room and board at the conference or compensation for their time unless
\nprovided for by law and\/or the policy of their National Medical Association.
\n4. Physicians may not accept unjustified hospitality and may not receive payment from a
\ncommercial entity to cover room and board for accompanying persons.
\n5. The name of a commercial entity providing financial support is publicly disclosed in
\norder to allow the medical community and the public to assess the information pre-
\nsented in light of the source of funding. In addition, conference organizers and lec-
\nturers disclose to conference participants any financial affiliations they may have with
\nmanufacturers of products mentioned at the event or with manufacturers of competing
\nproducts.
\n6. Presentation of material by a physician is scientifically accurate, gives a balanced
\nreview of possible treatment options, and is not influenced by the sponsoring organi-
\nzation.
\n7. A conference can be recognised for purposes of continuing medical education \/ conti-
\nnuing professional development (CME\/CPD) only if it conforms to the following
\nprinciples:
\n7.1. The commercial entities acting as sponsors, such as pharmaceutical companies,
\nhave no influence on the content, presentation, choice of lecturers, or publica-
\ntion of results.
\n7.2. Funding for the conference is accepted only as a contribution to the general
\ncosts of the meeting.
\nGIFTS\t<\/p>\n

Physicians may not receive a gift from a commercial entity unless this is permitted by law
\nand\/or by the policy of their National Medical Association and it conforms to the fol-
\nlowing conditions:
\n1. Physicians may not receive payments in cash or cash equivalents from a commercial
\nentity.
\n2. Physicians may not receive gifts for their personal benefit.
\n3. Gifts designed to influence clinical practice are always unacceptable. Promotional
\naids may be accepted provided that the gift is of minimal value and is not connected
\nto any stipulation that the physician prescribes a certain medication, uses certain
\ninstruments or materials or refers patients to a certain facility.
\n4. Cultural courtesy gifts may be received on an infrequent basis according to local
\nstandards if the gift is inexpensive and not related to the practice of medicine.<\/p>\n

S-2004-02-2009\t\u23d0\tNew\tDelhi
\nPhysicians\tand\tCommercial\tEnterprises
\nRESEARCH\t<\/p>\n

A physician may carry out research funded by a commercial entity, whether individually
\nor in an institutional setting, if it conforms to the following principles:
\n1. The physician is subject only to the law, the ethical principles and guidelines of the
\nDeclaration of Helsinki, and clinical judgment in performing research and does not
\nallow himself or herself to be subject to external pressure regarding the results of his
\nor her research or their publication.
\n2. If possible, a physician or institution wishing to undertake research approaches more
\nthan one company to request funding for the research.
\n3. Identifiable information about research patients or voluntary participants is not passed
\nto the sponsoring company without the consent of the individuals concerned.
\n4. A physician’s compensation for research is based on his or her time and effort and
\nsuch compensation is in no way connected to the results of the research.
\n5. The results of research are made public with the name of the sponsoring entity
\ndisclosed, along with a statement disclosing who requested the research. This applies
\nwhether the sponsorship is direct or indirect, full or partial.
\n6. Commercial entities do not suppress the publication of research results. If results of
\nresearch are not made public, especially if they are negative, the research may be re-
\npeated unnecessarily and thereby expose future participants to potential harm.
\nAFFILIATIONS\tWITH\tCOMMERCIAL\tENTITIES\t<\/p>\n

A physician may not enter into an affiliation with a commercial entity such as consulting
\nor membership on an advisory board unless the affiliation conforms to the following prin-
\nciples:
\n1. The affiliation does not compromise the physician’s integrity.
\n2. The affiliation does not conflict with the physician’s obligations to his or her patients.
\n3. Affiliations and\/or other relationships with commercial entities are fully disclosed in
\nall relevant situations such as lectures, articles and reports.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2004-03-2017
\nWMA\tSTATEMENT
\nON
\nWATER\tAND\tHEALTH
\nApproved by the 55th
\nWMA General Assembly, Tokyo, Japan, October 2004
\nand revised by the 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nand by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\n1. An adequate supply of fresh (i.e. clean potable and uncontaminated) water is
\nessential for individual and public health, as well as being a social determinant of
\nhealth. It is central to living a life in dignity and health and upholding human
\nrights. Many individuals, families and communities do not have access to such a
\nsupply, and even in those places where there is an abundance of fresh water, it is
\nthreatened by pollution, activities such as industry and waste, inadequate or
\nineffective sanitation and other negative forces.
\n2. A recent review of the evidence demonstrates that inadequate access to clean
\nwater, sanitation and soap for hand washing is the norm in many healthcare
\nfacilities worldwide, even in normal operating conditions. Natural and manmade
\nmajor events, including war, reduce access to clean water still further.
\n3. In keeping with its mission to serve humanity by endeavouring to achieve the
\nhighest international standards in health care for all people in the world, the World
\nMedical Association has developed this statement to encourage all those
\nresponsible for health to consider the importance and work towards achieving
\nuniversal access to of water, sanitation and hygiene for individual and public
\nhealth
\n4. Hygiene, sanitation and water (HSW) are important determinants of health. And
\nkey intervention strategies for reducing preventable morbidity, mortality and health
\ncare costs. The health sector, and physicians in particular, play a key role in
\nensuring such determinants are properly managed.
\nCONSIDERATIONS
\n5. Water-borne diseases account for a large proportion of mortality and morbidity,
\nespecially in developing countries. These problems are accentuated in times of
\ndisasters such as conflicts nuclear and man-made accidents with oil and\/or
\nchemicals, earthquakes, epidemics, droughts and floods.
\n6. Anthropogenic changes to ecosystems, lowered retention by the earth\u2019s surface,
\nand the limitation of the inherent capacity of nature to filter dirt from the water are
\ncausing increasing damage to the natural environment, especially the water<\/p>\n

S-2004-03-2017\t\u23d0\tChicago
\nWater\tand\tHealth
\nenvironment. Fracking for fossil fuels may have a significant effect on ground
\nwater as does the accumulation of micropollutant substances including
\npharmaceuticals and pesticides.
\n7. The commodification of water, whereby it is provided for profit rather than as a
\npublic service, has potentially significant negative implications for access to an
\nadequate supply of drinking water.
\n8. The development of sustainable infrastructure for the provision of safe water and
\nadequate sanitation contributes greatly to sound public health and national well-
\nbeing. Curtailing infectious diseases and other ailments that are caused by unsafe
\nwater lowers the burden of health care costs and improves productivity. This
\ncreates a positive ripple effect on national economies
\n9. Water as a vital and necessary resource for life has become scarce in many parts of
\nthe world and therefore must be used reasonably and with care.
\n10. Water and effective sanitation are assets that are shared by humanity and the earth.
\nThus, water-related issues should be addressed collaboratively by the global
\ncommunity.
\n11. Water, sanitation and hygiene are essential to the safe and effective provision of
\nhealth care services, and are fundamental to public health.
\nRECOMMENDATIONS
\n12. The WMA encourages National Medical Associations, health authorities and
\nphysicians to support all measures related to improving access to adequate, safe
\nwater and health including:
\n12.1. International and national programmes to provide ready access to safe
\ndrinking water at low cost, or free, to every human on the planet and to prevent the
\npollution of water supplies.
\n12.2. International, national, local and regional programmes to provide access to
\nsanitation and to prevent the degradation of water resources.
\n12.3. Research on the relationship between water pollution, water supply systems,
\nincluding wastewater treatment, and health.
\n12.4. The development of plans for providing potable water and proper wastewater
\ndisposal during emergencies. These will vary according to the nature of the
\nemergency, but may include on-site water disinfection, identifying sources of
\nwater, and back-up power to run pumps.
\n12.5. Preventive measures to secure safe water, sanitation and good hygiene for all
\nhealth care institutions, including after the occurrence of natural disasters,
\nespecially earthquakes. Such measures should include the development of<\/p>\n

Chicago\t\u23d0\tS-2004-03-2017
\nWater\tand\tHealth
\ninfrastructure and training programs to help health care institutions cope with such
\ncrises. The implementation of continued emergency water supply programs should
\nbe done in conjunction with regional authorities and with community involvement.
\n12.6. More efficient use of water resources by each nation. The WMA especially
\nurges hospitals and health institutions to examine their impact on sustainable water
\nresources and to adhere to the highest safety standards for drug and medical waste
\ndisposal from healthcare settings.
\n12.7. Preventive measures and emergency preparedness to save water from
\npollution.
\n12.8. The promotion of the universal access to clean and affordable water and
\nsanitation as a human right[1] and as a common good of humanity.
\n12.9. Instruction on the link between hygiene supported by hand washing, and ill
\nhealth prevention are health promotion and health education measures and requires
\nwork by government and health agencies, especially where access to water has
\npreviously been too limited for persons to exploit it for hygiene purposes.
\n12.10. The establishment of a real-time alert system accessible to both the local
\npopulation and to tourists providing information about the risks of contamination
\nof water in a particular area.
\n1
\nIn 2010, the United Nations General Assembly and the Human Rights Council explicitly recog-
\nnized the human right to water and sanitation, derived from the right to an adequate standard of
\nliving as stipulated in article 11 of the International Covenant on Economic, Social and Cultural
\nRights and other international human rights treaties. Hence, it is part of international human
\nrights law.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-02-2015
\nWMA\tSTATEMENT
\nON
\nDRUG\tSUBSTITUTION
\nAdopted by the 56th
\nWMA General Assembly, Santiago, Chile, October 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nINTRODUCTION\t<\/p>\n

1. The prescription of a drug represents the culmination of a careful deliberative process
\nbetween physician and patient aimed at the prevention, amelioration or cure of a
\ndisease or problem. This deliberative process requires that the physician evaluate a
\nvariety of scientific and other data including costs and make an individualized choice
\nof therapy for the patient. Sometimes, however, a pharmacist is required to substitute
\na different drug for the one prescribed by the physician. The World Medical Associa-
\ntion has serious concerns about this practice.
\n2. Drug substitution can take two forms: generic substitution and therapeutic substitu-
\ntion.
\n3. In generic substitution, a generic drug is substituted for a brand name drug. However,
\nboth drugs have the same active chemical ingredient, same dosage strength, and same
\ndosage form.
\n4. Therapeutic substitution occurs when a pharmacist substitutes a chemically different
\ndrug for the drug that the physician prescribed. The drug substituted by the pharmacist
\nbelongs to the same pharmacologic class and\/or to the same therapeutic class. How-
\never since the two drugs have different chemical structures, adverse outcomes for the
\npatient can occur.
\n5. The respective roles of physicians and pharmacists in serving the patient’s need for
\noptimal drug therapy are outlined in the WMA Statement on the Working Relation-
\nship between Physicians and Pharmacists in Medicinal Therapy.
\n6. The physician should be assured by national regulatory authorities of the bioequi-
\nvalence and the chemical and therapeutic equivalence of prescription drug products
\nfrom both multiple and single sources. Quality assurance procedures should be in
\nplace to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equi-
\nvalence.
\n7. Many considerations should be addressed before prescribing the drug of choice for a
\nparticular indication in any given patient. Drug therapy should be individualized
\nbased on a complete clinical patient history, current physical findings, all relevant
\nlaboratory data, and psychosocial factors. Once these primary considerations are met,
\nthe physician should then consider comparative costs of similar drug products avail-
\nable to best serve the patient’s needs. The physician should select the type and quan-
\ntity of drug product that he or she considers to be in the best medical and financial
\ninterest of the patient.<\/p>\n

Santiago\t\u23d0\tS-2005-02-2005
\nDrug\tSubstitution
\n8. Once the patient gives his or her consent to the drug selected, that drug should not be
\nchanged without the consent of the patient and his or her physician. Failure to follow
\nthis principle can result in harm to patients. On behalf of patients and physicians alike,
\nNational Medical Associations should do everything possible to ensure the imple-
\nmentation of the following recommendations:
\nRECOMMENDATIONS\t<\/p>\n

1. Physicians should become familiar with specific laws and\/or regulations governing
\ndrug substitution where they practise.
\n2. Pharmacists should be required to dispense the exact chemical, dose, and dosage form
\nprescribed by the physician. Once medication has been prescribed and begun, no drug
\nsubstitution should be made without the prescribing physician’s permission.
\n3. If substitution of a drug product occurs, the physician should carefully monitor and
\nadjust the dose to ensure therapeutic equivalence of the drug products.
\n4. If drug substitution leads to serious adverse drug reaction or therapeutic failure, the
\nphysician should document this finding and report it to appropriate drug regulatory
\nauthorities.
\n5. National Medical Associations should regularly monitor drug substitution issues and
\nkeep their members advised on developments that have special relevance for patient
\ncare. Collection and evaluation of information reports on significant developments in
\nthis area is encouraged.
\n6. Appropriate drug regulatory bodies should evaluate and ensure the bioequivalence
\nand the chemical and therapeutic equivalence of all similar drug products, whether
\ngeneric or brand-name, in order to ensure safe and effective treatment.
\n7. National Medical Associations should oppose any action to restrict the freedom and
\nthe responsibility of the physician to prescribe in the best medical and financial
\ninterest of the patient.
\n8. National Medical Associations should urge national regulatory authorities to declare
\ntherapeutic substitution illegal, unless such substitution has the immediate prior con-
\nsent of the prescribing physician.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-03-2009
\nWMA\tSTATEMENT
\nON
\nGENETICS\tAND\tMEDICINE
\nAdopted by the 56th
\nWMA General Assembly, Santiago, Chile, October 2005
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

1. In recent years, the field of genetics has undergone rapid change and development.
\nThe areas of gene therapy and genetic engineering and the development of new tech-
\nnology have presented possibilities inconceivable only decades ago.
\n2. The Human Genome Project opened new spheres of research. Its applications also
\nproved useful to clinical care, by allowing physicians to utilize knowledge of the
\nhuman genome in order to diagnose future disease as well as to individualize drug
\ntherapy (pharmacogenomics).
\n3. Because of this, genetics has become an integral part of primary care medicine.
\nWhereas at one time, medical genetics was devoted to the study of relatively rare
\ngenetic disorders, the Human Genome Project has established a genetic contribution to
\na variety of common diseases. It is therefore incumbent upon all physicians to have a
\nworking knowledge of the field.
\n4. Genetics is an area of medicine with enormous medical, social, ethical and legal
\nimplications. The WMA has developed this statement in order to address some of
\nthese concerns and provide guidance to physicians. These guidelines should be up-
\ndated in accordance with developments in the field of genetics.
\nMAJOR\tISSUES:\t<\/p>\n

Genetic\ttesting\t<\/p>\n

5. The identification of disease-related genes has led to an increase in the number of
\navailable genetic tests that detect disease or an individual’s risk of disease. As the
\nnumber and types of such tests and the diseases they detect increases, there is concern
\nabout the reliability and limitations of such tests, as well as the implications of testing
\nand disclosure. The ability of physicians to interpret test results and counsel their pa-
\ntients has also been challenged by the proliferation of knowledge.
\n6. Genetic testing may be undergone prior to marriage or childbearing to detect the pre-
\nsence of carrier genes that might affect the health of future offspring. Physicians
\nshould actively inform those from populations with high incidence of certain genetic<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-03-2009
\ndiseases about the possibility of pre-marital and pre-pregnancy testing, and genetic
\ncounselling should be made available to those individuals or couples who are consi-
\ndering such testing.
\n7. Genetic counselling and testing during pregnancy should be offered as an option. In
\ncases where no medical intervention is possible following diagnosis, this should be
\nexplained to the couple prior to their decision to test.
\n8. In recent years, with the advent of IVF, genetic testing has been extended to pre-
\nimplantation genetic diagnosis of embryos (PGD). This can be a useful tool in cases
\nwhere a couple has a high chance of conceiving a child with genetic disease.
\n9. Since the purpose of medicine is to treat, in cases where no sickness or disability is
\ninvolved, genetic screening should not be employed as a means of producing children
\nwith pre-determined characteristics. For example, genetic screening should not be
\nused to enable sex selection unless there is a gender-based illness involved. Similarly,
\nphysicians should not countenance the use of such screening to promote non-health
\nrelated personal attributes.
\n10. Genetic testing should be done only with informed consent of the individual or his\/her
\nlegal guardian. Genetic testing for predisposition to disease should be performed only
\non consenting adults, unless there is treatment available for the condition and the test
\nresults would facilitate earlier instigation of this treatment.
\n11. Valid consent to genetic testing should include the following factors:
\n\u2022 The limitations of genetic testing, including the fact that the presence of a specific
\ngene may denote predisposition to disease rather than the disease itself and does
\nnot definitively predict the likelihood of developing a certain disease, particularly
\nin multi-factorial disorders.
\n\u2022 The fact that a disease may manifest itself in one of several forms and in varying
\ndegrees. Information about the nature and predictability of information received
\nfrom the tests.
\n\u2022 The benefits of testing including the relief of uncertainty and the ability to make
\ninformed choices, including the possible need to increase or reduce regular screen-
\nings and checkups and to implement risk reduction measures.
\n\u2022 The implications of a positive result and the prevention, screening and\/or
\ntreatment possibilities.
\n\u2022 The possible implications for the family members of the patient involved.
\n12. In the case of a positive test result that may have implications for third parties such as
\nclose relatives, the individual tested should be encouraged to discuss the results of the
\ntest with such third parties. In cases where not disclosing the results involves a direct
\nand imminent threat to the life or health of an individual, the physician may reveal the
\nresults to such third parties, but should usually discuss this with the patient first. If the
\nphysician has access to an ethics committee, it is preferable to consult such a com-
\nmittee prior to revealing results to third parties.<\/p>\n

S-2005-03-2009\t\u23d0\tNew\tDelhi
\nGenetics\tand\tMedicine
\nGenetic\tcounselling\t<\/p>\n

13. Genetic counselling is generally offered prior to marriage or conception, in order to
\npredict the likelihood of conceiving an affected child, during pregnancy, in order to
\ndetermine the condition of the fetus, or to an adult, in order to determine susceptibility
\nto a certain disease.
\n14. Individuals at higher risk for conceiving a child with a specific disease should be
\noffered genetic counselling prior to conception or during pregnancy. In addition,
\nadults at higher risk for various diseases such as cancer, mental illness or neuro-
\ndegenerative diseases in which the risk can be tested for, should be made aware of the
\navailability of genetic counselling.
\n15. Because of the scientific complexity involved in genetic testing as well as the prac-
\ntical and emotional implications of the results, the WMA sees great importance in
\neducating and training medical students and physicians in genetic counselling, parti-
\ncularly counselling related to pre-symptomatic diagnosis of disease. Independent ge-
\nnetic counsellors also have an important role to play. The WMA acknowledges that
\nthere can be very complex situations requiring the involvement of medical genetics
\nspecialists.
\n16. In all cases where genetic counselling is offered, it should be non-directive and
\nprotect the individual’s right not to be tested.
\n17. In cases of counselling prior to or during pregnancy, the prospective parents should be
\ngiven information to provide the basis for an informed decision regarding child-
\nbearing, but should not be influenced by the physicians’ personal views in this matter
\nand physicians should be careful not to substitute their own moral judgment for that
\nof the prospective parents. In cases where a physician is morally opposed to
\ncontracep-tion or abortion, he\/she may choose not to provide these services but should
\nalert pro-spective parents that a potential genetic problem exists and make note of the
\noption of contraception or abortion as well as treatment alternatives, relevant genetic
\ntests, and the availability of genetic counselling.
\nConfidentiality\tof\tresults\t<\/p>\n

18. Like all medical records, the results of genetic testing should be kept strictly
\nconfidential, and should not be revealed to outside parties without the consent of the
\nindividual tested. Third parties to whom results may in certain circumstances be
\nreleased are identified in paragraph 12.
\n19. Physicians should support the passage of laws guaranteeing that no individual shall be
\ndiscriminated against on the basis of genetic makeup in the fields of human rights,
\nemployment and insurance.
\nGene\ttherapy\tand\tgenetic\tresearch\t<\/p>\n

20. Gene therapy represents a combination of techniques used to correct defective genes
\nthat cause disease, especially in the fields of oncology, hematology and immune dis-
\norders. Gene therapy is not yet an active current therapy but is still in a stage of clini-<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-03-2009
\ncal investigation. However, with the continued development of this field, it should
\nproceed according to the following guidelines:
\n\u2022 Gene therapy performed in a research context should conform to the requirements
\nof the Declaration of Helsinki while therapy performed in a treatment context
\nshould conform to standards of medical practice and professional responsibility.
\n\u2022 Informed consent should always be obtained from the patient undergoing the
\ntherapy. This informed consent should include disclosure of the risks of gene
\ntherapy, including the fact that the patient may have to undergo multiple rounds of
\ngene therapy, the risk of an immune response, and the potential problems arising
\nfrom the use of viral vectors.
\n\u2022 Gene therapy should only be undertaken after a careful analysis of the risks and
\nbenefits involved and an evaluation of the perceived effectiveness of the therapy,
\nas compared to the risks, side effects, availability and effectiveness of other treat-
\nments.
\n21. It is currently possible to undertake screening of an embryo in order to provide stem
\ncell or other therapies for an existing sibling with a genetic disorder. This may be
\nconsidered acceptable medical practice where no evidence exists that the embryo is
\nbeing created exclusively for this purpose.
\n22. Genetic discoveries should be shared as much as possible between countries so as to
\nbenefit humankind and reduce duplication of research and the risk inherent in research
\nin this area.
\n23. The mapping of human genomes must be anonymous but the information acquired
\nwill apply to every human being. The genetic information should be general property.
\nTherefore, no patents should be given for the human genome or parts of it.
\n24. In the case of genetic research performed on large, defined population groups, efforts
\nshould be made to avoid potential stigmatization.
\nCloning\t<\/p>\n

25. Recent developments in science have led to the cloning of a mammal and raise the
\npossibility of such cloning techniques being used in humans.
\n26. Cloning includes both therapeutic cloning, namely the cloning of individual stem cells
\nin order to produce a healthy copy of a diseased tissue or organ for transplant, and re-
\nproductive cloning, namely the cloning of an existing mammal to produce a duplicate
\nof such mammal. The WMA currently opposes reproductive cloning, and in many
\ncountries it is considered to pose more of an ethical problem than therapeutic cloning.
\n27. Physicians should act in accordance with the codes of medical ethics in their countries
\nregarding the use of cloning and be mindful of the law governing this activity<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-04-2015
\nWMA\tSTATEMENT
\nON
\nMEDICAL\tLIABILITY\tREFORM
\nAdopted by the 56th
\nWMA General Assembly, Santiago, Chile, October 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\n1. A culture of litigation is growing around the world that is adversely affecting the
\npractice of medicine and eroding the availability and quality of health care services.
\nSome National Medical Associations report a medical liability crisis whereby the
\nlawsuit culture is increasing health care costs, restraining access to health care ser-
\nvices, and hindering efforts to improve patient safety and quality. In other countries,
\nmedical liability claims are less rampant, but National Medical Associations in those
\ncountries should be alert to the issues and circumstances that could result in an in-
\ncrease in the frequency and severity of medical liability claims brought against physi-
\ncians.
\n2. Medical liability claims have greatly increased health care costs, diverting scarce
\nhealth care resources to the legal system and away from direct patient care, research,
\nand physician training. The lawsuit culture has also blurred the distinction between
\nnegligence and unavoidable adverse outcomes, often resulting in a random determi-
\nnation of the standard of care. This has led to the broad perception that anyone can
\nsue for almost anything, betting on a chance to win a big award. Such a culture breeds
\ncynicism and distrust in both the medical and legal systems with damaging conse-
\nquences to the patient-physician relationship.
\n3. In adopting this Statement, the World Medical Association makes an urgent call to all
\nNational Medical Associations to demand the establishment of a reliable system of
\nmedical justice in their respective countries. Legal systems should ensure that patients
\nare protected against harmful practices, physicians are protected against unmeritorious
\nlawsuits, and standard of care determinations are consistent and reliable so that all
\nparties know where they stand.
\n4. In this Statement the World Medical Association wishes to inform National Medical
\nAssociations of some of the facts and issues related to medical liability claims. The
\nlaws and legal systems in each country, as well as the social traditions and the econo-
\nmic conditions of the country, will affect the relevance of some portions of this State-
\nment to each National Medical Association but do not detract from the fundamental
\nimportance of such a Statement.
\n5. An increase in the frequency and severity of medical liability claims may result, in
\npart, from one or more of the following circumstances:
\na. Increases in medical knowledge and medical technology that have enabled phy-
\nsicians to accomplish medical feats that were not possible in the past, but that
\ninvolve considerable risks in many instances.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2005-04-2015
\nb. Pressures on physicians by private managed care organizations or government-
\nmanaged health care systems to limit the costs of medical care.
\nc. Confusing the right to access to health care, which is attainable, with the right to
\nachieve and maintain health, which cannot be guaranteed.
\nd. The role of the media in fostering mistrust of physicians by questioning their
\nability, knowledge, behaviour, and management of patients, and by prompting pa-
\ntients to submit complaints against physicians.
\n6. A distinction must be made between harm caused by medical negligence and an un-
\ntoward result occurring in the course of medical care and treatment that is not the fault
\nof the physician.
\na. Injury caused by negligence is the direct result of the physician’s failure to con-
\nform to the standard of care for treatment of the patient’s condition, or the physi-
\ncian’s lack of skill in providing care to the patient.
\nb. An untoward result is an injury occurring in the course of medical treatment that
\nwas not the result of any lack of skill or knowledge on the part of the treating
\nphysician, and for which the physician should not bear any liability.
\n7. Compensation for patients suffering a medical injury should be determined differently
\nfor medical liability claims than for the untoward results that occur during medical
\ncare and treatment, unless there is an alternative system in place such as a no-fault
\nsystem or alternate resolution system.
\na. Where an untoward result occurs without fault on the part of the physician, each
\ncountry must determine if the patient should be compensated for the injuries suf-
\nfered, and if so, the source from which the funds will be paid. The economic con-
\nditions of the country will determine if such solidarity funds are available to com-
\npensate the patient without being at the expense of the physician.
\nb. The laws of each jurisdiction should provide the procedures for deciding liability
\nfor medical liability claims and for determining the amount of compensation
\nowed to the patient in those cases where negligence is proven.
\n8. National Medical Associations should consider some or all of the following activities
\nin an effort to provide fair and equitable treatment for both physicians and patients:
\na. Establish public education programs on the risks inherent in some of the new
\nadvances in treatment modalities and surgery, and professional education pro-
\ngrams on the need for obtaining the patient’s informed consent to such treatment
\nand surgery.
\nb. Implement public advocacy programs to demonstrate the problems in medicine
\nand health care delivery resulting from strict cost containment limitations.<\/p>\n

S-2005-04-2015\t\u23d0\tOslo
\nMedical\tLiability\tReform
\nc. Enhance the level and quality of medical education for all physicians, including
\nimproved clinical training experiences.
\nd. Develop and participate in programs for physicians to improve the quality of
\nmedical care and treatment.
\ne. Develop appropriate policy positions on remedial training for physicians found to
\nbe deficient in knowledge or skills, including policy positions on limiting the
\nphysician’s medical practice until the deficiencies are corrected.
\nf. Inform the public and government of the dangers that various manifestations of
\ndefensive medicine may pose (the multiplication of medical acts or, on the con-
\ntrary, the abstention of the physicians, the disaffection of young physicians for
\ncertain higher risk specialties or the reluctance by physicians or hospitals to treat
\nhigher-risk patients).
\ng. Educate the public on the possible occurrence of injuries during medical treat-
\nment that are not the result of physician negligence, and establish simple proce-
\ndures to allow patients to receive explanations in the case of adverse events and
\nto be informed of the steps that must be taken to obtain compensation, if avail-
\nable.
\nh. Advocate for legal protection for physicians when patients are injured by un-
\ntoward results not caused by any negligence, and participate in decisions relating
\nto the advisability of providing compensation for patients injured during medical
\ntreatment without any negligence.
\ni. Participate in the development of the laws and procedures applicable to medical
\nliability claims.
\nj. Develop active opposition to meritless or frivolous claims and to contingency
\nbilling by lawyers.
\nk. Explore innovative alternative dispute resolution procedures for handling medical
\nliability claims, such as arbitration, rather than court proceedings.
\nl. Encourage self-insurance by physicians against medical liability claims, paid by
\nthe practitioners themselves or by the employer if the physician is employed.
\nm. Encourage the development of voluntary, confidential, and legally protected sys-
\ntems for reporting untoward outcomes or medical errors for the purpose of analy-
\nsis and for making recommendations on reducing untoward outcomes and im-
\nproving patient safety and health care quality.
\nn. Advocate against the increasing criminalization or penal liability of medical acts
\nby the courts.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2006-01-2006\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nASSISTED\tREPRODUCTIVE\tTECHNOLOGIES
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nPREAMBLE\t<\/p>\n

1. Assisted reproductive technology encompasses a wide range of techniques designed
\nprimarily to aid couples unable to conceive without medical assistance. Since the birth
\nof the first so-called ‘test-tube baby’ in 1978, more than 1.5 million children world-
\nwide have been born following IVF treatment.
\n2. The term ‘assisted reproductive technology’ includes techniques such as in-vitro fer-
\ntilisation (IVF) and intra-cytoplasmic sperm injection (ICSI). It can be defined as in-
\ncluding all treatments that include medical and scientific manipulation of human gam-
\netes and embryos in order to produce a term pregnancy. Although some legislatures
\nhave considered artificial insemination, whether using donor semen or semen from the
\npatient’s partner, as different, many of the issues about regulation in relation to obtain-
\ning, storing, using and disposing of gametes and embryos are closely inter-linked. In
\nthis statement treatments such as artificial insemination are excluded.
\n3. Assisted reproductive technologies raise profound moral issues. Views and beliefs
\nabout the moral status of the embryo, which are central to much of the debate in this
\narea, vary both within and among countries. Assisted conception is also regulated dif-
\nferently in various countries. Whilst consensus can be reached on some issues, there
\nremain fundamental differences of opinion that cannot be resolved. This statement
\nidentifies areas of agreement and also highlights those matters on which agreement
\ncannot be reached. Physicians faced with such situations should comply with applica-
\nble laws and regulations as well as the ethical requirements and professional standards
\nestablished by their National Medical Association and other appropriate organisations
\nin the community.
\n4. Physicians involved in providing assisted reproductive technologies should always
\nconsider their ethical responsibilities towards any child who may be born as a result of
\nthe treatment. If there is evidence that a future child would be exposed to serious
\nharm, treatment should not be provided.
\n5. As with all other medical procedures, physicians also have an ethical obligation to
\nlimit their practice to areas in which they have relevant expertise and experience and
\nto respect the rights of patients. These rights include that of personal bodily integrity
\nand freedom from coercion. In practice this means that valid or real consent is re-
\nquired as with other medical procedures; the validity of such consent is dependent
\nupon the adequacy of the information offered to the patient and their freedom to make
\na decision, including freedom from coercion or other pressures to decide in a parti-
\ncular way.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2006-01-2006\t\u23d0\tWorld\tMedical\tAssociation
\n6. Assisted conception differs from the treatment of illness in that the inability to be-
\ncome a parent without medical intervention is not always regarded as an illness.
\nWhile it may have profound psychosocial, and thus medical, consequences, it is not in
\nitself life limiting. It is, however, a significant cause of major psychological illness
\nand its treatment is clearly medical.
\n7. Obtaining informed consent from those considering undertaking treatment must in-
\nclude consideration of the alternatives, including accepting childlessness or pursuing
\nadoption, the risks associated with the various techniques, and the possibility of failure.
\nIn many jurisdictions the process of obtaining consent must follow a process of infor-
\nmation giving and the offer of counselling and might also include a formal assessment
\nof the patient in terms of the welfare of the potential child.
\n8. Patients seeking assisted reproductive technologies are entitled to the same level of
\nconfidentiality and privacy as for any other medical treatment.
\n9. Assisted reproductive technology always involves handling and manipulation of hu-
\nman gametes and embryos. Different individuals regard this with different levels of
\nconcern but there is general agreement that these special concerns should be met by
\nspecific safeguards to protect from abuse. In some jurisdictions all centres handling
\nsuch materials require a licence and must demonstrate compliance with high norma-
\ntive standards.
\nSUCCESS\tOF\tTHE\tTECHNIQUES\t<\/p>\n

1. The success of different techniques may differ widely from centre to centre. Physi-
\ncians have an obligation to give realistic information about success rates to potential
\npatients. If their success rates are widely different from the current norm they should
\ndisclose this fact to patients. They also have an obligation to consider the reasons for
\nthis as they might relate to poor practice, and if so, to correct their deficiencies.
\nMULTIPLE\tPREGNANCIES\t<\/p>\n

1. Replacement of more than one embryo may raise the likelihood of at least one embryo
\nimplanting. This is offset by the increased risk, especially of premature labour, in
\nmultiple pregnancies. The risk of twin pregnancies, while higher than that of singleton
\npregnancies, is considered acceptable by most people. Practitioners should follow pro-
\nfessional guidance on the maximum number of embryos to be transferred per treat-
\nment cycle. If multiple pregnancies occur, selective termination might be considered
\non medical grounds to increase the chances of the pregnancy proceeding to term
\nwhere this is compatible with the national law and code of ethics.
\nDONATION\t<\/p>\n

1. Some patients are unable to produce usable gametes. They require ova or sperm from
\ndonors. Donation should follow counselling and be carefully controlled to avoid
\nabuses, including coercion of potential donors. It is inappropriate to offer money or
\nbenefits in kind (for example free or lower cost treatment cycles) to encourage dona-
\ntion but donors may be reimbursed for reasonable expenses.<\/p>\n

Pilanesberg\t\u23d0\tS-2006-01-2006
\nAssisted\tReproductive\tTechnologies
\n2. Where a child is born following donation, families should be encouraged to be open
\nwith him\/her about this, irrespective of whether domestic law entitles the child to
\ninformation about the donor. Keeping secrets within families is difficult and can be
\nharmful to children if information about donor conception is disclosed inadvertently
\nand without appropriate support.
\nPRE-IMPLANTATION\tGENETIC\tDIAGNOSIS\t(PGD)\t<\/p>\n

1. Pre-implantation genetic diagnosis (PGD) may be performed on early embryos to
\nsearch for the presence of genetic or chromosomal abnormalities, especially those
\nassociated with severe illness and very premature death and for other reasons, includ-
\ning identifying those embryos most likely to implant successfully in women who have
\nhad multiple spontaneous abortions. Embryos carrying the abnormality are discarded;
\nonly embryos with apparently normal genetic and chromosomal complements are im-
\nplanted.
\n2. Neither this powerful technique nor simpler means should be used for trivial reasons
\nsuch as sex selection for reasons of gender preference. The WMA holds that physi-
\ncians should only be involved with sex selection where it is used to avoid a serious
\nsex-chromosome related condition such as Duchenne’s Muscular Dystrophy.
\n3. PGD can also be combined with HLA matching to select embryos on the basis that
\nstem cells from the resulting child’s umbilical cord blood could be used to treat a
\nseriously ill sibling. Views on the acceptability of this practice vary and physicians
\nshould follow national laws and local ethical and professional standards if confronted
\nwith such requests.
\nUSE\tOF\tSPARE\tGAMETES\tAND\tEMBRYOS
\nAND\tDISPOSAL\tOF\tUNUSED\tGAMETES\tAND\tEMBRYOS\t<\/p>\n

1. In most cases, assisted conception results in the production of gametes and embryos
\nthat will not be used to treat those from whom they are procured. Such so-called spare
\ngametes and embryos may be stored, cryo-preserved for future use, donated to other
\npatients or disposed of. One alternative to disposal, in countries that permit embryo
\nresearch, is donation to a research facility. The available options must be explained
\nclearly and precisely to individuals before donations are made or retrievals performed.
\nSURROGACY\t<\/p>\n

1. Where a woman is unable, for medical reasons, to carry a child to term, surrogacy
\nmay be used to overcome childlessness, unless prohibited by national law or the ethi-
\ncal rules of the National Medical Association or other relevant organisation. Where
\nsurrogacy is practised, great care must be taken to protect the interests of all parties
\ninvolved.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2006-01-2006\t\u23d0\tWorld\tMedical\tAssociation
\nRESEARCH\t<\/p>\n

1. Physicians should promote the importance of research using tissues obtained during
\nassisted conception procedures. Because of the special status of the material being
\nused, research on human gametes and especially on human embryos is, in many juris-
\ndictions, specifically regulated. Physicians have an ethical duty to comply with such
\nregulation and to help inform public debate and understanding of the issues.
\n2. Due to the special nature of human embryos, research should be carefully controlled
\nand should be limited to areas in which the use of alternative materials will not pro-
\nvide an adequate alternative.
\n3. Views, and legislation, differ on whether embryos may be created specifically for, or
\nin the course of, research. Physicians should act in accordance with national legisla-
\ntion and local ethical advice.
\nCELL\tNUCLEAR\tREPLACEMENT\t<\/p>\n

1. The WMA opposes the use of cell nuclear replacement with the aim of cloning human
\nbeings.
\n2. Cell nuclear replacement may also be used to develop embryonic stem cells for
\nresearch and ultimately, it is hoped, for therapy for many serious diseases. Views on
\nthe acceptability of such research differ and physicians wishing to participate in such
\nresearch should ensure that they are acting in accordance with national laws and local
\nethical guidance.
\nRECOMMENDATIONS\t<\/p>\n

1. Assisted reproductive technology is a dynamic, rapidly developing field of medical
\npractice. Developments should be subject to careful ethical consideration alongside
\nthe scientific monitoring.
\n2. Human gametes and embryos are accorded a special status. Their use, including for
\nresearch, donation to others and disposal, should be carefully explained to potential
\ndonors and subject to local regulation.
\n3. Embryo research should only be carried out if local law and ethical standards permit it
\nand should be limited to areas where the use of alternative materials or computer
\nmodelling does not provide an adequate alternative.
\n4. Physicians should follow professional guidance on the maximum number of embryos
\nto transfer in any treatment cycle.
\n5. It is inappropriate to offer money or benefits in kind (for example free or lower cost
\ntreatment cycles) to encourage donation but donors may be reimbursed for reasonable
\nexpenses.<\/p>\n

Pilanesberg\t\u23d0\tS-2006-01-2006
\nAssisted\tReproductive\tTechnologies
\n6. Families using donated embryos or gametes should be encouraged and supported to
\nbe open with the child about this.
\n7. Sex selection should only be carried out to avoid serious, including life threatening,
\nmedical conditions.
\n8. Physicians have an important role in ensuring that public debate about the
\npossibilities of assisted conception, and the limits to be applied to its practice, is
\ninformed.
\n9. Physicians should comply with national legislation and should demonstrate com-
\npliance with high normative standards.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-02-2018
\nWMA\tSTATEMENT
\nON
\nAVIAN\tAND\tPANDEMIC\tINFLUENZA
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand amended by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018<\/p>\n

PREAMBLE
\nPandemic influenza occurs approximately three or four times every century. It usually
\noccurs when a novel influenza A virus emerges that can easily be transmitted from person-
\nto-person, to which humans have little or no immunity. Infection control and social
\ndistancing practices can help slow down the spread of the virus. Vaccine development can
\nbe challenging as the pandemic strain may not be accurately predicted. Adequate supplies
\nof antivirals are key for treatment of specific at-risk population and controlling further
\nspread of the outbreak.
\nAvian influenza is a zoonotic infection of birds and poultry, and can cause sporadic human
\ninfections. Birds act as reservoir and shed the virus in their feces, mucous and saliva. In
\naddition, a new pandemic virus could develop if a human became simultaneously infected
\nwith avian and human influenza viruses, resulting in gene swapping and a new virus strain
\nfor which there may be no immunity. Humans are infected if they are exposed through the
\nmouth, eyes, or from the inhalation of virus particles. Limited evidence of human to
\nhuman transmission has been reported as well.
\nThis statement alongside with WMA Statement on Epidemics and Pandemics provides
\nguidance to National Medical Associations and physicians on how they should be
\ninvolved in their respective country\u2019s pandemic influenza planning and how to respond to
\nAvian Influenza or pandemic influenza.
\nRECOMMENDATIONS
\nAvian Influenza
\n\u2022 In the event of an avian influenza outbreak, the following measures should be
\ntaken:
\n\u2022 Sources of exposure should be avoided when possible as this is the most effective
\nprevention measure.
\n\u2022 Personal protective equipment should be used and hand hygiene practices
\nemphasized for personnel handling poultry as well as members of the healthcare<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-02-2018
\nteam.
\n\u2022 All infected\/exposed birds should be destroyed with proper disposal of carcasses,
\nand rigorous disinfection or quarantine of farms.
\n\u2022 Stockpiles of vaccines and antivirals should be maintained for use during an
\noutbreak.
\n\u2022 Antiviral medications such as neuraminidase inhibitors may be used for treatment.
\nPandemic Influenza Preparedness
\nWHO and National Public Health Officials:
\n\u2022 The coordination of the international response to an influenza pandemic is the
\nresponsibility of the World Health Organization (WHO). The WHO currently uses
\nan all-hazards risk based approach, to allow for a coordinated response based on
\nvarying degrees of severity of the pandemic.
\nThe WHO should:
\n\u2022 Offer technical and laboratory assistance to affected countries if needed and
\ncontinuously monitor activity levels of potential pandemic influenza strains
\ncontinuously, ensuring that the designation of \u201cPublic Health Emergency of
\nInternational Concern\u201d is done in a timely manner if needed.
\n\u2022 Monitor and coordinate processes by which governments share biological
\nmaterials including virus strains, to facilitate the production of and ensure access to
\nvaccines globally.
\n\u2022 Communicate available information on influenza activity of concern as early as
\npossible to allow for a timely response.
\nNational governments are urged to develop National Action plans to address the following
\npoints:
\n\u2022 Ensure that there is adequate local capacity for diagnosis and surveillance to allow
\ncontinuous monitoring of influenza activity around the country.
\n\u2022 Consider the surge capacity of hospitals, laboratories, and public health
\ninfrastructure and improve them if necessary.
\n\u2022 Identify legal and ethical frameworks as well as governance structures in relation
\nto the pandemic planning.
\n\u2022 Identify the mechanisms and the relevant authorities to initiate and escalate
\ninterventions to slow the spread of the virus in the community such as school
\nclosures, quarantine, border closures etc.
\n\u2022 Prepare risk and crisis communication strategies and messages in anticipation of<\/p>\n

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\nAvian\tand\tPandemic\tInfluenza
\npublic and media fear and anxiety.
\n\u2022 Governments are also urged to share biological materials namely virus strains and
\nothers, to facilitate the production and ensure access to vaccines globally.
\n\u2022 Ensure that diagnostics and surveillance efforts are continued and that adequate
\nvaccine and antiviral stockpiles are established.
\n\u2022 Establish protocols to manage patients in the community, carry out triage in
\nhealthcare facilities, provide ventilation management, and handle infectious waste.
\n\u2022 Allocation of vaccine doses, antivirals and hospital beds should be coordinated
\nwith experts.
\n\u2022 Priority for vaccination should be given to the highest risk groups including those
\nrequired to maintain essential services, including health care services.
\n\u2022 Guidance and timely information to regional health departments, health care
\norganizations, and physicians.
\n\u2022 Preparation for an increase in demand for healthcare services and absences of
\nhealth care providers especially if clinical severity of the illness is high. In such
\ncases prioritization and coordination of available resources is essential. This may
\ninclude tapping into private sector capacity where state resources are insufficient.
\n\u2022 Ensure adequate funding is allocated for pandemic preparedness and response as
\nwell as its health and social consequences.
\n\u2022 Make sure that mechanisms are in place to ensure the safety of healthcare facilities,
\npersonnel and the supply chains for vaccines and antivirals
\n\u2022 Promote and fund research to develop vaccines and effective treatments with
\nlasting effects against influenza.
\n\u2022 Encourage collaboration between human and veterinary medicine in the
\nprevention, research and control of avian influenza.
\nNational Medical Associations are urged to:
\n\u2022 Delineate their involvement in the national pandemic influenza preparedness plan,
\nwhich may include increasing capacity building amongst physicians, participating
\nin guideline development and communication with healthcare professionals.
\n\u2022 Help educate the public about avian and pandemic influenza.
\n\u2022 When feasible, coordinate with other healthcare professionals\u2019 organizations as
\nwell as other NMAs to identify common issues and congruent policies related to
\npandemic influenza preparedness and response.
\n\u2022 Consider implementing support strategies for members involved in the response
\nincluding mental health services, facilitation of health emergency response teams,
\nand locum relief.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-02-2018
\n\u2022 Advocate before and during a pandemic, for allocation of adequate resources to
\nmeet foreseeable and emerging needs of healthcare, patients and the general
\npublic.
\n\u2022 Encourage health personnel to protect themselves by vaccination.
\n\u2022 Develop their own organization-specific business contingency plans to ensure
\ncontinued support of their members.
\nPhysicians:
\n\u2022 Must be sufficiently knowledgeable about pandemic influenza and transmission
\nrisks, including local, national and international epidemiology.
\n\u2022 Should implement infection control practices and vaccination, to protect
\nthemselves as well as other staff members during seasonal and pandemic influenza
\noutbreaks.
\n\u2022 Must participate in local\/regional pandemic influenza preparedness planning and
\ntraining.
\n\u2022 Should develop contingency plans to deal with possible disruptions in essential
\nservices and personnel shortages.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-03-2017
\nWMA\tSTATEMENT
\nON
\nHIV\/AIDS\tAND\tTHE\tMEDICAL\tPROFESSION
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand amended by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nINTRODUCTION\t\t<\/p>\n

1. HIV\/AIDS, a chronic manageable disease, is a global pandemic that has created
\nunprecedented challenges for physicians and health infrastructures.
\nIn addition to representing a staggering public health crisis, HIV\/AIDS is also
\nfundamentally a human rights issue.
\nMany factors drive the spread of the disease, such as poverty, homelessness, illiteracy,
\nprostitution, human trafficking, drug (substance) abuse, stigma, discrimination and
\ngender-based inequality.
\nThese social, economic, legal and human rights factors affect not only the public
\nhealth dimension of HIV\/AIDS but also individual physicians\/health workers and
\npatients, their decisions and relationships.
\nEfforts to tackle the disease are also constrained by the lack of human and financial
\nresources available in health care systems.
\n2. Discrimination against HIV \/ AIDS patients by physicians is unacceptable and must be
\neliminated completely from the practice of medicine.
\n2.1 All persons with HIV\/AIDS are entitled to adequate and timely support,
\ntreatment and care with compassion and respect for human dignity.
\n2.2 It is unethical for a physician to refuse to treat a patient whose condition is
\nwithin his or her current realm of competence, solely because the patient is
\nseropositive.
\n2.3 National Medical Associations should work with respective governments,
\npatient groups and relevant national and international organizations to ensure
\nthat national health policies clearly and explicitly prohibit discrimination
\nagainst people infected with or affected by HIV\/AIDS, including vulnerable
\ngroups such as males having sex with males and transgender persons.
\n2.4 Woman and man having sex with same sex partners are at a higher risk of
\ndiscrimination at all levels. National Medical organizations shall work with
\nGovernment, Non-Governmental Organizations, and Community based
\norganizations to remove the discrimination for these under-privileged
\ndisadvantaged groups.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-03-2017
\nAPPROPRIATE\t\/\tCOMPETENT\tMEDICAL\tCARE\t<\/p>\n

3. Patients with HIV\/AIDS must be provided with competent and appropriate medical
\ncare at all stages of the disease.
\n4. A physician who is not able to provide the care and services required by patients with
\nHIV\/AIDS must make an appropriate timely referral to those physicians or facilities
\nthat are equipped to provide such services. Unless or until the referral can be
\naccomplished, the physician must take care for the patient.
\n5. All physicians should be able to timely suspect and identify common opportunistic
\ninfections such as tuberculosis, fungal infections in HIV-AIDs patients and also
\nsuspect HIV-AIDS in presence of these infections especially in high risk individuals
\nlike IV drug users.
\nThey must timely counsel these patient about the nexus of these infections with HIV
\ninfection.
\n6. Physicians and other appropriate professional bodies must ensure that patients have
\naccurate information regarding transmission of HIV\/AIDS and strategies to protect
\nthemselves against infection.
\nProactive measures should be taken to ensure that all members of the population,
\nparticularly at-risk groups, are educated to this effect.
\nPublic information and related strategies should recognise that everyone is at risk, and
\nattempt to spell out methods of risk reduction.
\n7. Physicians must effectively counsel all seropositive patients regarding responsible
\nbehaviour to prevent the spread of the infection to their partners and prevention of
\nopportunistic infections.
\n8. Physicians must recognize that many people still believe HIV\/AIDS to be an
\nautomatic and immediate death sentence and therefore will not seek testing.
\nPhysicians must ensure that patients have accurate information regarding the treatment
\noptions available to them.
\nPatients should understand the potential and need of starting early antiretroviral
\ntreatment (ART) to improve not only their medical condition but also the quality of
\ntheir lives. The new strategy is test and treat strategy.
\nEffective ART can greatly extend the period that patients are able to lead healthy
\nproductive lives, functioning socially and in the workplace and maintaining their
\nindependence.
\nHIV\/AIDS is now manageable chronic condition.
\nFor ART country \u2013 specific WHO evidence based practice guidelines should be<\/p>\n

S-2006-03-2017\t\u23d0\tChicago
\nHIV\/AIDS\tand\tthe\tMedical\tProfession
\nfollowed and promoted by all NMAs.
\n9. Physicians should be aware that misinformation regarding the negative aspects of ART
\nhas created resistance toward treatment by patients in some areas. Where
\nmisinformation is being spread about ART, physicians and medical associations must
\nmake it an immediate priority to publicly challenge the source of the misinformation
\nand to work with the HIV\/AIDS community to counteract the negative effects of the
\nmisinformation.
\n10. Physicians should encourage the involvement of support networks to assist patients in
\nadhering to ART regimens. With the patient\u2019s consent, counselling and training should
\nbe available to family members to assist them in providing care.
\n11. Physicians must be aware of the discriminatory attitudes toward HIV\/AIDS that are
\nprevalent in society and local culture. Because physicians are the first, and sometimes
\nthe only, people who are informed of their patients\u2019 HIV status, physicians should be
\nable to counsel them about their basic social and legal rights and responsibilities or
\nshould refer them to counsellors who specialize in the rights of persons living with
\nHIV\/AIDS.
\n12. Physicians should be aware of the current availability and prescribing guidelines for
\npre-exposure and post-exposure prophylaxis for any patient and health care providers
\nwho may have been exposed to HIV.<\/p>\n

TESTING\t\t<\/p>\n

13. Mandatory testing for HIV must be required of donated blood and blood fractions
\ncollected for donation or to be used in the manufacture of blood products; organs and
\nother tissues intended for transplantation; and semen or ova collected for assisted
\nreproduction procedures.
\nNewer technologies which are more sensitive, specific, and reduce the window period
\nof HIV detection, such as nuclear acid testing (NAT), should be encouraged for such
\nscreening.
\n14. Mandatory HIV testing of an individual against his or her will is a violation of medical
\nethics and human rights.
\n15. Physicians must clearly explain the purpose of an HIV test, the reasons it is
\nrecommended and the implications of a positive test result.
\nBefore a test is administered, the physician should have an action plan in place in case
\nof a positive test result. Informed consent must be obtained from the patient prior to
\ntesting.
\n16. While certain groups are labeled \u201chigh risk\u201d, anyone who has had unprotected sex
\nshould be considered at risk.
\nPhysicians must become increasingly proactive about recommending testing to
\npatients, based on a mutual understanding of the level of risk and the potential to
\nbenefit from testing. Pregnant women and her partner should routinely be offered<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-03-2017
\ntesting for HIV, and those pregnant women found to be HIV positive should be offered
\nimmediate counseling and offered timely ART (at diagnosis) in order to prevent
\ntransmission of the virus to the fetus and treatment of the fetus if seropositive.
\n17. Counselling and voluntary anonymous testing for HIV should be available to all
\npersons who request it, along with adequate post-testing support mechanisms.
\nPROTECTION\tFROM\tHIV\tIN\tTHE\tHEALTH\tCARE\tENVIRONMENT\t\t<\/p>\n

18. Physicians and all health care workers have the right to a safe work environment.
\nEspecially in developing countries, the problem of occupational exposure to HIV has
\ncontributed to high attrition rates of the health labour force. In some cases, employees
\nbecome infected with HIV, and in other cases fear of infection causes health care
\nworkers to leave their jobs voluntarily. Fear of infection among health workers can
\nalso lead to refusal to treat HIV\/AIDS patients. Likewise, patients have the right to be
\nprotected to the greatest degree possible from transmission of HIV from health
\nprofessionals and in health care institutions.
\n18.1 Proper infection control procedures and universal precautions consistent with
\nthe most current national or international standards, as appropriate, should be
\nimplemented in all health care facilities. This includes procedures for the use
\nof preventive and timely bART for health professionals who have been
\nexposed to HIV.
\n18.2 If the appropriate safeguards for protecting physicians or patients against
\ninfection are not in place, physicians and National Medical Associations
\nshould take action to correct the situation.
\n18.3 Physicians who are infected with HIV should not engage in any activity that
\ncreates a risk of transmission of the disease to others.
\nIn the context of possible exposure to HIV, the activity in which the physician
\nwishes to engage will be the determining factor.
\nThere may be nationally agreed standards but if not a determination should be
\nmade by a suitable expert panel or committee of health workers.
\n18.4 In the provision of medical care, if a risk of transmission of an infectious
\ndisease from a physician to a patient exists, disclosure of that risk to patients is
\nnot enough; patients are entitled to expect that their physicians will not
\nincrease their exposure to the risk of contracting an infectious disease.
\n18.5 If no risk exists, disclosure of the physician\u2019s medical condition to his or her
\npatients will serve no rational purpose.
\n18.6 Physicians should be aware of current professional guidelines for post-<\/p>\n

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\nHIV\/AIDS\tand\tthe\tMedical\tProfession
\nexposure prophylaxis of health care workers in case of any accidental
\nexposure to HIV.<\/p>\n

PROTECTING\tPATIENT\tPRIVACY\tAND\tISSUES\tRELATED\tTO\tNOTIFICATION\t\t<\/p>\n

19. Fear of stigma and discrimination is a driving force behind the spread of HIV\/AIDS.
\nThe social and economic repercussions of being identified as infected can be
\ndevastating and can include violence, rejection by family and community members,
\nloss of housing and loss of employment.
\nNormalizing the presence of HIV\/AIDS in society through public education is the only
\nway to reduce discriminatory attitudes and practices. Until that can be universally
\nachieved, or a cure is developed, potentially infected individuals may refuse testing to
\navoid these consequences.
\nThe result of individuals not knowing their HIV status is not only disastrous on a
\npersonal level in terms of not receiving treatment, but may also lead to high rates of
\navoidable transmission of the disease. Fear of unauthorized disclosure of information
\nalso provides a disincentive to participate in HIV\/AIDS research and generally thwarts
\nthe efficacy of prevention programs. Lack of confidence in protection of personal
\nmedical information regarding HIV status is a threat to public health globally and a
\ncore factor in the continued spread of HIV\/AIDS. At the same time, in certain
\ncircumstances, the right to privacy must be balanced with the right of partners (sexual
\nand injection drug) of persons with HIV\/AIDS to be informed of their potential
\ninfection. Failure to inform partners not only violates their rights but also leads to the
\nhealth problems of avoidable transmission and delay in treatment.
\n20. All standard ethical principles and duties related to confidentiality and protection of
\npatients\u2019 health information, as articulated in the WMA Declaration of Lisbon on the
\nRights of the Patient, apply equally in the context of HIV\/AIDS. In addition, National
\nMedical Associations and physicians should take note of the special circumstances and
\nobligations (outlined below) associated with the treatment of HIV\/AIDS patients.
\n20.1 National Medical Associations and physicians must, as a matter of priority,
\nensure that HIV\/AIDS public education, prevention and counselling programs
\ncontain explicit information related to protection of patient information as a
\nmatter not only of medical ethics but of their human right to privacy.
\n20.2 Special safeguards are required when HIV\/AIDS care involves a physically
\ndispersed care team that includes home-based service providers, family
\nmembers, counsellors, case workers or others who require medical information
\nto provide comprehensive care and assist in adherence to treatment regimens. In
\naddition to implementing protection mechanisms regarding transfer of
\ninformation, ethics training regarding patient privacy should be given to all
\nteam members.
\nMany countries have specific legislation to protect the privacy of those who are
\nHIV positive. Others may consider the same.
\n20.3 Physicians must make all efforts to convince HIV\/AIDS patients to take action
\nto notify all partners (sexual and\/or injection drug) about their exposure and<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-03-2017
\npotential infection. Physicians must be competent to counsel patients about the
\noptions for notifying partners. These options should include:
\n20.3.1 Notification of the partner(s) by the patient. In this case, the patient should
\nreceive counselling regarding the information that must be provided to the
\npartner and strategies for delivering it with sensitivity and in a manner that
\nis easily understood. A timetable for notification should be established and
\nthe physician should follow-up with the patient to ensure that notification
\nhas occurred.
\n20.3.2 Notification of the partner(s) by a third party. In this case, the third party
\nmust make every effort to protect the identity of the patient.
\n20.4 When all strategies to convince the patient to take such action have been
\nexhausted, and if the physician knows the identity of the patient\u2019s partner(s), the
\nphysician is compelled, either by law or by moral obligation, to take action to
\nnotify the partner(s) of their potential infection. Depending on the system in
\nplace, the physician will either notify directly the person at risk or report the
\ninformation to a designated authority responsible for notification. Physicians
\nmust be aware of the laws and regulations in the jurisdiction in which they are
\npracticing. In cases where a physician must disclose the information regarding
\nexposure, the physician must:
\n20.4.1 inform the patient of his or her intentions,
\n20.4.2 to the extent possible, ensure that the identity of the patient is protected,
\n20.4.3 take the appropriate measures to protect the safety of the patient, especially
\nin the case of a female patient vulnerable to domestic violence.
\n20.5 Regardless of whether it is the patient, the physician or a third party who
\nundertakes notification, the person learning of his or her potential infection
\nshould be offered support and assistance in order to access testing and
\ntreatment.
\n20.6 National Medical Associations should develop guidelines to assist physicians in
\ndecision-making related to notification. These guidelines should help physicians
\nunderstand the legal requirements and consequences of notification decisions as
\nwell as the medical, psychological, social and ethical considerations.
\n20.7 As per local and national laws and guidelines requiring the reporting of new
\nHIV infections, sexually transmitted diseases, and opportunistic infections,
\nphysicians must protect the privacy and confidentiality of all patients and
\nmaintain the highest ethical standards.
\n20.8 National Medical Associations should work with governments to ensure that
\nphysicians who carry out their ethical obligation to notify individuals at risk,
\nand who take precautions to protect the identity of their patient, are afforded
\nadequate legal protection.
\nMEDICAL\tEDUCATION\t<\/p>\n

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\nHIV\/AIDS\tand\tthe\tMedical\tProfession\t<\/p>\n

21. National Medical Associations should assist in ensuring that there is training and
\neducation of physicians in the most current prevention strategies and medical
\ntreatments available for all stages of HIV\/AIDS and associated infections, including
\nprevention and support.
\n22. National Medical Associations should, when appropriate, collaborate with NGOs and
\ncommunity based organizations, insist upon, and when possible assist with, the
\neducation of physicians in the relevant psychological, legal, cultural and social
\ndimensions of HIV\/AIDS.
\n23. National Medical Associations should fully support the efforts of physicians wishing
\nto concentrate their expertise in HIV\/AIDS care, even where HIV\/AIDS is not
\nrecognized as an official specialty or sub-specialty within the medical education
\nsystem.
\n24. The WMA encourages its national medical associations to promote the inclusion of
\ndesignated, comprehensive courses on HIV\/AIDS in undergraduate and postgraduate
\nmedical education programs, as well as continuing medical education.
\nINTEGRATION\tof\tHIV\/AIDS\tSERVICES\twith\tother\tSTDs\tMANAGEMENT\tACTIVITES
\n25. The National Medical Associations should support governments to integrate
\nHIV\/AIDS preventive and curative services with other STD management activities in
\na comprehensive manner.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-04-2017
\nWMA\tSTATEMENT
\nON
\nMEDICAL\tEDUCATION
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand revised by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE\t<\/p>\n

1. Medical education consists of basic medical education, postgraduate medical
\neducation, and continuing professional development. Medical education is a dynamic
\nprocess that commences at the start of basic medical education (medical school) and
\ncontinues until a physician retires from active practice. Its goal is to prepare physicians
\nto apply the latest scientific knowledge to promote health, prevent and cure human
\ndisease and mitigate symptoms. All physicians have a responsibility to themselves, the
\nprofession and their patients to maintain a high standard for medical education.
\nBASIC\tPRINCIPLES\tOF\tMEDICAL\tEDUCATION\t<\/p>\n

2. Medical education consists of training aimed at ensuring physicians acquire the
\ncompetencies, skills and aptitudes that that allow them to practice professionally and
\nethically at the highest level. All physicians, the profession as a whole, medical
\nfaculties, educational institutions, and governments share the responsibility for
\nguaranteeing that medical education meets a high quality standard throughout the
\nmedical education continuum.
\nI.\tBASIC\tMEDICAL\tEDUCATION\t<\/p>\n

3. The goal of basic medical education is to ensure that medical students have acquired
\nthe knowledge, skills, and professional behaviors that prepare them for a spectrum of
\ncareer choices, including, but not limited to, patient care, public health, clinical or
\nbasic research, leadership and management, or medical education. Each of these career
\nchoices will require additional education beyond the first professional degree.
\n4. At a medical school, the knowledge, skills and professional behavior that students
\nshould acquire should be based on the professional judgment of the faculty and
\naccreditation councils, and be responsive to the healthcare needs of the region and\/or
\nthe country. These decisions will inform the selection of students, the curriculum
\ndesign and content, the student assessment system, and the evaluation of whether the
\nschool has achieved its goals. Such decisions should also be subject to relevant
\nstandards, the needs of fairness and accessibility, and diversity and inclusion in the
\nmedical workforce.
\nII.\tSELECTION\tOF\tSTUDENTS\t<\/p>\n

S-2006-04-2017\t\u23d0\tChicago
\nMedical\tEducation
\n5. Prior to their entry to medical school, medical students should have acquired a broad
\neducation, ideally including background in the arts, humanities, and social sciences, as
\nwell as biological and physical sciences. Students should be chosen for the study of
\nmedicine based on their intellectual ability, motivation for medicine, previous relevant
\nexperiences, and character and integrity. The selection process for students must not
\nbe discriminatory and should reflect the importance of increasing diversity in the
\nmedical workforce. A medical school should also consider its mission when
\ndeveloping admission requirements.
\n6. Within a given country or region, there should be enough medical students to meet
\nlocal and regional needs. National medical associations (NMAs) and national
\ngovernments should collaborate to mitigate the economic barriers that prevent
\nqualified individuals from entering and completing medical school.<\/p>\n

7. Curriculum\tand\tAssessment<\/p>\n

7.1 A medical school\u2019s educational program should be based on educational program
\nobjectives developed in response to the healthcare needs of the region and\/or
\ncountry. These educational program objectives must be used in the selection of
\ncurriculum content, the development of the system for student assessment, and the
\nevaluations of whether the school has achieved its educational goals, subject to
\nrelevant regulatory and educational standards.
\n7.2 The medical curriculum should equip the student with a broad base of general
\nmedical knowledge. This includes the biological and behavioral sciences, as well
\nas the socio-economics of health care, the social determinants of health, and
\npopulation and public health. These disciplines, together with basic medical
\nscience, are central to an understanding and practice of clinical medicine. The
\nWMA recommends that content related to medical ethics and human rights should
\nbe a core requirement in the medical curriculum.1 The student should also be
\nintroduced to the principles and methodology of medical research and how the
\nresults of research are used in clinical practice. Students should have opportunities,
\nif desired or required by the medical school, to participate in research. The
\ncognitive skills of self-directed learning, critical thinking, and medical problem
\nsolving should be introduced early in the medical curriculum to prepare students for
\nclinical training.
\n7.3 Before beginning independent practice, every physician should complete a formal
\nprogram of supervised clinical education. Within basic medical education, clinical
\nexperiences should range from primary to tertiary care in a variety of inpatient and
\noutpatient settings, such as university hospitals, community hospitals, clinics,
\nphysician practices, and other health care facilities. The clinical component of
\nbasic medical education should use an apprenticeship model of teaching using
\ndefined objectives and must involve direct experiences in the diagnosis and
\ntreatment of disease, with a gradual increase in the student\u2019s responsibility based on
\nhis\/her demonstration of the relevant knowledge and skills. Experiences and
\ntraining in interprofessional teams providing collaborative care to patients is
\nimportant in preparing medical students for practice.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-04-2017
\n7.4 The medical school faculty have the responsibility to ensure that students who have
\ngraduated and received the \ufb01rst professional degree have acquired a basic
\nunderstanding of clinical medicine, have the basic skills needed to evaluate clinical
\nproblems and take appropriate action, and exhibit the attitudes and character to be
\nan ethical physician. The assessment system within a medical school should
\ninclude appropriate and valid methods to ensure that all graduates have met each of
\nthese expectations. It would be useful for medical schools to have access to
\nindividuals with expertise in student assessment, either from within the medical
\nschool or from external sources.
\n8. Sudent\tSupport<\/p>\n

8.1 Medical students should receive academic and social support, such as counselling
\nfor personal problems and programs to support well-being, to assist them in meeting
\nthe demands of medical school. Academic support includes tutoring and advice for
\nstudy and time management skills. Social support includes access to activities to
\npromote their physical and mental well-being, as well as access to general and
\nmental health services. Mentors and advisors to assist students in specialty choice
\nand career planning also should be available.
\n9. Faculty\tand\tInstitutional\tResources<\/p>\n

9.1 Basic medical education must be taught by appropriate staff including faculty who
\npossess the appropriate qualifications that can only be achieved through formal
\ntraining and experience. There should be a sufficient number of faculty to meet the
\neducational, research, and other missions of the medical school. The selection
\nprocess for faculty must be not be discriminatory. The faculty should have a formal
\ncommitment to the medical school, such as a faculty appointment, and be part of
\nand subject to the medical school\u2019s governance and departmental structures.
\n9.2 The faculty of a medical school are accountable for developing the medical
\ncurriculum and the student assessment system. As such, the educational program
\nobjectives, curriculum content and format, and evaluation of the curriculum are the
\nresponsibility of the faculty. The faculty should review the curriculum frequently,
\nideally utilizing statistics on student achievement and input from students,
\ngraduates, and the practicing community. Furthermore, the faculty must regularly
\nevaluate the quality of each component of the educational program and the program
\nas a whole through the utilization of student and peer feedback. Medical schools
\nshould provide opportunities for faculty development to support the acquisition and
\nmaintenance of teaching and assessment, and curriculum development skills so that
\nthey can meet their responsibilities for the medical education program and
\ncurriculum design skills.
\n9.3 Medical schools must provide an academic environment which encourages learning
\nand inquiry by faculty including an active institutional research program to advance
\nthe body of medical knowledge and the quality of care. Medical schools should<\/p>\n

S-2006-04-2017\t\u23d0\tChicago
\nMedical\tEducation
\nprovide support for faculty to acquire research skills and to engage in independent
\nor collaborative research.
\n9.4 In addition to sufficient numbers of well-prepared faculty, medical schools must
\nensure that there are adequate library and information technology resources,
\nclassrooms, research laboratories, clinical facilities, and study areas for students in
\nsufficient quantity to meet the needs of all learners. There must be an administrative
\nsupport structure for things such as academic records maintenance and registrar
\nfunctions.
\n10. Financing\tMedical\tEducation
\n10.1 National governments and medical schools should collaborate to develop financing
\nmechanisms to support basic medical education. Support is needed for individual
\nstudents and for the medical schools themselves. There should be sufficient financial
\nresources for medical schools to educate the number of medical students required to
\nmeet national or regional health care system needs.<\/p>\n

III.\tPOSTGRADUATE\tMEDICAL\tEDUCATION\t<\/p>\n

11. A graduate from a basic medical education institution must participate in a clinically-
\nbased advanced training program prior to being legally authorized to enter independent
\nmedical practice and, if required, obtaining a license to practice. Postgraduate medical
\neducation, the second phase of medical education continuum, prepares physicians for
\npractice in a medical discipline or specialty and focuses on specific competencies
\nneeded for practice in that specialty area.
\n12. Postgraduate medical education programs, also termed residency programs, include
\neducational experiences that support the resident\u2019s acquisition of the knowledge and
\nskills characteristic of the specialty area. Depending on the specialty, postgraduate
\nprograms will use a variety of inpatient and ambulatory clinical settings, including
\ncommunity-based clinics, hospitals or other health care institutions. The education of
\nresidents should combine a structured didactic curriculum with clinical activity that
\nincludes the diagnosis and management of patients under appropriate and supportive
\nlevels of supervision. A residency program must ensure that each resident has
\nopportunities to care for an adequate number of patients in order to gain experience in
\nthe range of conditions that characterize the specialty. These clinical experiences
\nshould occur in settings where high quality care is delivered, since educational quality
\nand patient care quality are interdependent and must be pursued in a manner so that
\nthey enhance one another.
\n13. A proper balance must be maintained so that residents are not required to meet clinical
\nservice needs at the expense of their education. The residency program should further
\nthe resident\u2019s teaching and leadership skills and ability to contribute to continuous
\nimprovement. The program should also provide opportunities for scholarly activity
\naimed at enhancing scientific and critical thinking, clinical problem-solving, and life-
\nlong learning skills. These opportunities will have been introduced during basic<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-04-2017
\nmedical education and should be reinforced during residency to prepare and motivate
\nthe resident to exercise these skills during practice. Additionally, a proper balance
\nmust be maintained among clinical work, education, and personal life.
\n14. During the residency program, a resident takes on progressively greater responsibility
\nfor patient care based on his or her individual growth in clinical experience,
\nknowledge, and skill. Allowing the resident to assume increased responsibility
\nrequires a system of assessment to monitor the resident\u2019s increase in knowledge and
\nskills over time. There also needs to be a process in place to conclusively determine
\nthat the resident is prepared to undertake independent medical practice.
\n15. Postgraduate medical education should take place in institutions that are accredited or
\nhave been reviewed for quality.
\nIV.\tCONTINUING\tPROFESSIONAL\tDEVELOPMENT\t<\/p>\n

16. Continuing professional development* (CPD) is defined as the activities that maintain,
\ndevelop, or increase the knowledge, skills, and professional performance and
\nrelationships a physician uses on a daily basis to provide services for patients, the
\npublic, or the profession. CPD can include activities such as involvement in national or
\nregional medical associations; committee work in hospitals or group practices; and
\nteaching, mentoring and participating in education within his or her chosen specialty
\nor more broadly within medicine.
\n17. One of the components of CPD is continuing medical education (CME), in which the
\nphysician participates in medically-related educational activities. Physicians should
\nfurther their medical education throughout their careers, including acquiring new
\nknowledge and skills in response to scientific discoveries and the introduction of new
\ntreatments. Such educational experiences are essential to for the physician to keep
\nabreast of developments in clinical medicine and the health care delivery environment,
\nand to continue to maintain the knowledge and skills necessary to provide high quality
\ncare. In many jurisdictions, CME is specialty-defined and may be required for
\nmaintaining a medical license.
\n18. The goal of continuing professional development is to broadly sustain and enhance the
\ncompetent physician. Medical schools, hospitals and professional societies all share a
\nresponsibility for developing and making available to all physicians effective
\nopportunities for continuing professional development, including continuing medical
\neducation.
\nRECOMMENDATIONS
\n19. The demand for physicians to provide medical care, prevent disease, and give advice
\nin health matters to patients, the public, and policy-makers calls for the highest
\nstandards of basic, postgraduate, and continuing professional development.
\nRecommendations are as follows:<\/p>\n

S-2006-04-2017\t\u23d0\tChicago
\nMedical\tEducation
\n19.1 That the WMA encourage NMAs, governments, and other relevant stakeholder
\ngroups to engage in planning for a high quality continuum of medical education
\nwithin countries that is informed by and supports the health care needs of the
\npopulation.
\n19.2 That the WMA encourage NMAs to work with medical schools to plan and deliver
\nfaculty development that enhances the skills of medical school faculty as teachers
\nand researchers.
\n19.3 That the WMA encourage NMAs and governments to engage in dialogue related to
\nmedical school and postgraduate program funding so that adequate numbers of
\nwell-trained physicians are available to meet national health care needs.
\n19.4 That NMAs and national governments collaborate to mitigate the economic barriers
\nthat prevent qualified individuals from entering and completing medical school.
\n19.5 That the WMA encourage NMAs to individually or collaboratively provide
\nopportunities for continuing physician professional development and continuing
\nmedical education.
\n* Note on terminology
\nThere are different uses of the term ‘Continuing Professional Development’ (CPD). One way to
\ndescribe it is all those activities that contribute to the professional development of a physician
\nincluding involvement in organized medicine, committee work in hospitals or group practices,
\nteaching, mentoring and reading, to name just a few. One of the components of CPD should be
\nContinuing Medical Education, which in many jurisdictions is specially defined and possibly
\nrequired for licensure.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-05-2016
\nWMA\tSTATEMENT
\nON
\nTHE\tPHYSICIAN’S\tROLE\tIN\tOBESITY
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t<\/p>\n

Obesity is one of the single most important health issues facing the world in the twenty-
\nfirst century, affecting all countries and socio-economic groups and representing a serious
\ndrain on health care resources.
\nObesity in children is of increasing concern and is emerging as a growing epidemic in
\nitself.
\nObesity has complex origins linked to economic and social changes in society including
\nthe obeso-genic environment within which much of the population lives.
\nTherefore the WMA urges physicians to use their roles as leaders to advocate for
\nrecognition by national health authorities that reduction in obesity should be a priority,
\nwith culturally and age appropriate policies involving physicians and other key
\nstakeholders.
\nTHE\tWMA\tRECOMMENDS\tTHAT\tPHYSICIANS:\t<\/p>\n

\u2022 Lead the development of societal changes that emphasize environments which
\nsupport healthy food choices and regular exercise or physical activity for all
\npeople, with a specific focus on children;
\n\u2022 Individually and through medical associations, express concern that excessive
\ntelevision viewing and video game playing are impediments to physical activity
\namong children and adolescents in many countries;
\n\u2022 Encourage individuals to make healthy choices and guide parents in helping their
\nchildren to do so;
\n\u2022 Recognise the role of personal decision making and the adverse influences exerted
\nby current environments;
\n\u2022 Recognise that collection and evaluation of data can contribute to evidence based<\/p>\n

S-2006-05-2016\t\u23d0\tTaipei
\nObesity
\nmanagement, and should be part of routine medical screening and evaluation
\nthroughout life;
\n\u2022 Encourage the development of life skills that contribute to a healthy lifestyle in all
\npersons and to better public knowledge of healthy diets, exercise and the dangers
\nof smoking and excess alcohol consumption;
\n\u2022 Advocate for appropriately trained professionals to be placed in educational
\nfacilities, highlighting the importance of education on healthy lifestyles from an
\nearly age;
\n\u2022 Contribute to the development of better assessment tools and databases to enable
\nbetter targeted and evaluated interventions;
\n\u2022 Ensure that obesity, its causes and management remain part of continuing
\nprofessional development programmes for health care workers, including
\nphysicians;
\n\u2022 Use pharmacotherapy and bariatric surgery consistent with evidence-based
\nguidelines and an assessment of the risks and benefits associated with such
\ntherapies.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-06-2016
\nWMA\tSTATEMENT
\nON
\nTHE\tRESPONSIBILITIES\tOF\tPHYSICIANS\tIN\tPREVENTING
\nAND\tTREATING\tOPIATE\tAND\tPSYCHOTROPIC\tDRUG\tABUSE
\nAdopted by the 57th
\nWMA General Assembly, Pilanesberg, South Africa, October 2006
\nand revised by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE\t\t<\/p>\n

Opiate and psychotropic drugs are valuable therapeutic tools when used as medically
\nindicated for a variety of symptoms and conditions. Indeed, the WMA has called for the
\ngreater provision of pain management treatment in its Resolution on the Access to
\nAdequate Pain Treatment (Montevideo, Uruguay, October 2011). Unfortunately, non-
\nclinical misuse of these addictive substances is an enormous problem worldwide. Drug
\naddiction is a complex social, economic and legal issue as well as a threat to public health
\nand safety globally. It affects people from all demographic and social groups and
\neconomic spheres. In addition to exposing themselves to the direct health risks related to
\nthe inappropriate use of these substances, persons addicted to drugs may engage in high
\nrisk behaviour, such as needle-sharing and unprotected sex, and many resort to criminal
\nactivity to finance their expensive addiction. These factors increase transmission of viral
\ninfections, such as Hepatitis B and C and HIV\/AIDS, among both users and non-users
\nalike. Other results of addiction include failure to maintain employment or to function in
\nsocial and family life.
\nThe legal ramifications of non-medical drug use, which is illegal in most countries,
\ngenerally do little to assist users in breaking free from their addiction. Despite the
\npresence of drug programs in many correctional facilities, illegal substances are very often
\navailable to inmates and, in fact, some users begin their addiction in these institutions.
\nAddressing addiction therefore falls largely to society and the health profession.
\nThe World Medical Association, concerned by the widespread misuse of psychotropic and
\nopiate drugs, urges physicians to prioritize this problem in the practice of medicine and to
\nadhere to the following guidelines.
\nPRINCIPLES\t<\/p>\n

Responsible prescribing practices
\nPhysicians should be aware of the addictive properties of certain psychotropic and opiate
\ndrugs. Such drugs should be prescribed with the greatest restraint, observing the strictest
\npossible generally accepted medical indications. Physicians must take all necessary
\nmeasures to ensure that they are fully informed of the effects of these drugs. This includes
\nreviewing up-to-date research regarding dosage, potential effectiveness for the specific<\/p>\n

S-2006-06-2016\t\u23d0\tTaipei
\nOpiate\tand\tPsychotropic\tDrug\tAbuse
\ncondition, potential side effects and pharmacological interactions and prevalence of
\nmisuse.
\nWhen such drugs are medically indicated, their use must be carefully monitored to ensure
\nthat the patient is following strict dosage instructions, timing and any other factors
\nassociated with the safe use of the particular drug. All appropriate measures must be taken
\nto prevent the stockpiling, resale or other illicit usage of the drug.
\nPatients must be fully informed of all potential therapeutic and non-therapeutic effects of
\npsychotropic and opiate drugs, including potential for addiction, and be fully involved in
\nthe decision to take them. No competent patient should be forced to take any psychotropic
\ndrug against his or her will.
\nPhysicians should be aware of non-medical factors that may predispose patients to
\naddiction. These may include, among others, family history, past addiction, emotional
\ntrauma, depression or other mental health conditions and peer pressure, especially among
\nyoung persons.
\nPhysicians should learn to recognize \u2018drug seekers\u2019, addicted patients who attempt to
\nobtain psychotropic and opiate drugs under false medical pretenses. Drug seekers often
\nconsult more than one physician in an effort to obtain multiple prescriptions. In extreme
\ncases, drug seekers may harm themselves to create symptoms to obtain a prescription. All
\npatient conditions and symptoms should be clinically verified, to the extent possible, and
\nmeticulous records maintained regarding the patient\u2019s drug history. If databases containing
\npatient drug records and prescribing histories are available, they should be consulted.
\nWhen prescribing any psychotropic or opiate substance to minors, physicians must ensure
\nthat the parents or guardians of the patient are fully informed of the potential misuse of the
\ndrug and encouraged to monitor the child carefully to ensure adherence to the physician\u2019s
\ninstructions. Parents or guardians should be informed that, in some countries, it is
\nincreasingly common for children to sell prescription drugs to their peers.
\nNon-drug therapy for addicts to opiate and psychotropic drugs
\nPhysicians should be aware of all non-drug treatment options for addicts to opiate and
\npsychotropic drugs, including inpatient and outpatient programs and therapeutic
\ncommunities, in which recovering addicts live in a supportive, drug-free environment.
\nMost treatment programs are focused on breaking the cycle of drug dependence through
\ndetoxification, counselling \u2013 including ongoing peer support \u2013 and permanent abstinence
\nfrom the use of any addictive opiate or psychotropic substance, including alcohol. Some
\noffer educational and\/or vocational programs to facilitate successful reintegration into
\ncommunity life.
\nPhysicians should encourage their patients to participate in drug treatment programs at the
\nearliest possible stage of addiction.
\nAll efforts should be made to respect the dignity and autonomy of addicted patients.
\nInvoluntary inpatient treatment of addicted persons should be a last resort, according to
\nestablished guidelines and, where applicable, legal requirements.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2006-06-2016
\nDrug therapy for addicts to opiate drugs
\nIn some cases, persons addicted to opiate drugs may be treated using medications that
\nrelieve withdrawal symptoms and cravings for the addictive substance without producing
\nthe \u2018high\u2019 associated with opiates. These medications also provide cross tolerance to other
\nopioids. The objective of drug treatment is the immediate cessation of the use of opiate
\ndrugs.
\nDrug therapy can assist the opiate-dependent patient to function in his or her normal
\nenvironment and activities while working to overcome the opiate addiction. However, it
\nshould always be part of a multi-disciplinary approach that includes proven non-drug
\ntreatment elements, such as counselling and peer support.
\nDrug therapy should be administered according to established evidence-based guidelines
\nand supervised by specially trained physicians with an appropriate support team.
\nAwareness raising and policy development
\nNational Medical Associations (NMAs) should engage in cross-sectoral national efforts to
\nraise awareness of the risks associated with the abuse of opiate and psychotropic drugs and
\nto ensure the availability of appropriate treatment options for addicted persons. NMAs
\nshould encourage their members to participate in similar programs at the community level.
\nNMAs should promote appropriate drug prevention programming at all levels of the
\neducational system, recognizing that experimentation with drugs is increasingly prevalent
\namong younger age groups.
\nNMAs and physicians should participate in the development of evidence-based guidelines
\nthat support a multi-disciplinary approach to the treatment of drug addiction, including
\nharm reduction strategies such as needle exchange programmes.
\nNMAs should participate in the development of legal procedures relating to illegal drug
\nuse to ensure that addicted persons are recognized as entitled to receive appropriate
\nmedical and rehabilitative care, including in correctional institutions.
\nCONCLUSION\t<\/p>\n

Physicians have an important role to play in the treatment of drug addiction, both as
\nclinicians and as advocates for the treatment, rights and dignity of persons addicted to
\nthese harmful substances. Treatment of addiction, like treatment for any disease or
\ncondition, should be undertaken in the best interests of the patient and according to
\nestablished principles of medical ethics.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2007-02-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nTHE\tETHICS\tOF\tTELEMEDICINE
\nAdopted by the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nand amended by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018<\/p>\n

DEFINITION\t<\/p>\n

Telemedicine is the practice of medicine over a distance, in which interventions,
\ndiagnoses, therapeutic decisions, and subsequent treatment recommendations are based on
\npatient data, documents and other information transmitted through telecommunication
\nsystems.
\nTelemedicine can take place between a physician and a patient or between two or more
\nphysicians including other healthcare professionals.
\nPREAMBLE\t<\/p>\n

\u2022 The development and implementation of information and communication
\ntechnology are creating new and different ways for of practicing medicine.
\nTelemedicine is used for patients who cannot see an appropriate physician
\ntimeously because of inaccessibility due to distance, physical disability,
\nemployment, family commitments (including caring for others), patients\u2019 cost and
\nphysician schedules. It has capacity to reach patients with limited access to
\nmedical assistance and have potential to improve health care.
\n\u2022 Face-to-face consultation between physician and patient remains the gold standard
\nof clinical care.
\n\u2022 The delivery of telemedicine services must be consistent with in-person services
\nand supported by evidence.
\n\u2022 The principles of medical ethics that are mandatory for the profession must also be
\nrespected in the practice of telemedicine.
\nPRINCIPLES\t<\/p>\n

Physicians\tmust\trespect\tthe\tfollowing\tethical\tguidelines\twhen\tpracticing\ttelemedicine:
\n1. The patient-physician relationship should be based on a personal examination and
\nsufficient knowledge of the patient\u2019s medical history. Telemedicine should be
\nemployed primarily in situations in which a physician cannot be physically present
\nwithin a safe and acceptable time period. It could also be used in management of
\nchronic conditions or follow-up after initial treatment where it has been proven to
\nbe safe and effective.<\/p>\n

Reykjavik\t\u23d0\tS-2007-02-2018
\nTelemedicine
\n2. The patient-physician relationship must be based on mutual trust and respect. It is
\ntherefore essential that the physician and patient be able to identify each other
\nreliably when telemedicine is employed. In case of consultation between two or
\nmore professionals within or between different jurisdictions, the primary physician
\nremains responsible for the care and coordination of the patient with the distant
\nmedical team.
\n3. The physician must aim to ensure that patient confidentiality, privacy and data
\nintegrity are not compromised. Data obtained during a telemedicine consultation
\nmust be secured to prevent unauthorized access and breaches of identifiable patient
\ninformation through appropriate and up to date security measures in accordance
\nwith local legislation. Electronic transmission of information must also be
\nsafeguarded against unauthorized access.
\n4. Proper informed consent requires that all necessary information regarding the
\ndistinctive features of telemedicine visit be explained fully to patients including,
\nbut not limited to:
\n\u2022 explaining how telemedicine works,
\n\u2022 how to schedule appointments,
\n\u2022 privacy concerns,
\n\u2022 the possibility of technological failure including confidentiality breaches,
\n\u2022 protocols for contact during virtual visits,
\n\u2022 prescribing policies and coordinating care with other health professionals in a
\nclear and understandable manner, without influencing the patient\u2019s choices.
\n5. Physicians must be aware that certain telemedicine technologies could be
\nunaffordable to patients and hence impede access. Inequitable access to
\ntelemedicine can further widen the health outcomes gap between the poor and the
\nrich.\t<\/p>\n

Autonomy\tand\tprivacy\tof\tthe\tPhysician
\n6. A physician should not to participate in telemedicine if it violates the legal or
\nethical framework of the country.
\n7. Telemedicine can potentially infringe on the physician privacy due to 24\/7 virtual
\navailability. The physician needs to inform patients about availability and
\nrecommend services such as emergency when inaccessible.
\n8. The physician should exercise their professional autonomy in deciding whether a
\ntelemedicine versus face-to-face consultation is appropriate.
\n9. A physician should exercise autonomy and discretion in selecting the telemedicine
\nplatform to be used.<\/p>\n

S-2007-02-2018\t\u23d0\tReykjavik
\nTelemedicine
\nResponsibilities\tof\tthe\tPhysician
\n10. A physician whose advice is sought through the use of telemedicine should keep a
\ndetailed record of the advice he\/she delivers as well as the information he\/she
\nreceived and on which the advice was based in order to ensure traceability.
\n11. If a decision is made to use telemedicine it is necessary to ensure that the users
\n(patients and healthcare professionals) are able to use the necessary
\ntelecommunication system.
\n12. The physician must seek to ensure that the patient has understood the advice and
\ntreatment suggestions given and take steps in so far as possible to promote
\ncontinuity of care.
\n13. The physician asking for another physician\u2019s advice or second opinion remains
\nresponsible for treatment and other decisions and recommendations given to the
\npatient.
\n14. The physician should be aware of and respect the special difficulties and
\nuncertainties that may arise when he\/she is in contact with the patient through
\nmeans of tele-communication. A physician must be prepared to recommend direct
\npatient-doctor contact when he\/she believes it is in the patient\u2019s best interests.
\n15. Physicians should only practise telemedicine in countries\/jurisdictions where they
\nare licenced to practise. Cross-jurisdiction consultations should only be allowed
\nbetween two physicians.
\n16. Physicians should ensure that their medical indemnity cover include cover for
\ntelemedicine.
\nQuality\tof\tCare
\n17. Healthcare quality assessment measures must be used regularly to ensure patient
\nsecurity and the best possible diagnostic and treatment practices during
\ntelemedicine procedures. The delivery of telemedicine services must follow
\nevidence-based practice guidelines to the degree they are available, to ensure
\npatient safety, quality of care and positive health outcomes. Like all health care
\ninterventions, telemedicine must be tested for its effectiveness, efficiency, safety,
\nfeasibility and cost-effectiveness.
\n18. The possibilities and weaknesses of telemedicine in emergencies must be duly
\nidentified. If it is necessary to use telemedicine in an emergency situation, the
\nadvice and treatment suggestions are influenced by the severity of the patient\u00b4s
\nmedical condition and the competency of the persons who are with the patient.
\nEntities that deliver telemedicine services must establish protocols for referrals for
\nemergency services.<\/p>\n

Reykjavik\t\u23d0\tS-2007-02-2018
\nTelemedicine
\nRECOMMENDATION\t<\/p>\n

1. Telemedicine should be appropriately adapted to local regulatory frameworks,
\nwhich may include licencing of telemedicine platforms in the best interest of
\npatients.
\n2. Where appropriate the WMA and National Medical Associations should encourage
\nthe development of ethical norms, practice guidelines, national legislation and
\ninternational agreements on subjects related to the practice of telemedicine, while
\nprotecting the patient-physician relationship, confidentiality, and quality of medical
\ncare.
\n3. Telemedicine should not be viewed as equal to face-to-face healthcare and should
\nnot be introduced solely to cut costs or as a perverse incentive to over-service and
\nincrease earnings for physicians.
\n4. Use of telemedicine requires the profession to explicitly identify and manage
\nadverse consequences on collegial relationships and referral patterns.
\n5. New technologies and styles of practice integration may require new guidelines
\nand standards.
\n6. Physicians should lobby for ethical telemedicine practices that are in the best
\ninterests of patients.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2008-01-2008\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nREDUCING\tDIETARY\tSODIUM\tINTAKE
\nAdopted by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nINTRODUCTION\t<\/p>\n

Cardiovascular diseases (CVD) remain a leading cause of mortality throughout the world.
\nRisk factors include high blood cholesterol, hypertension, cigarette smoking, physical
\ninactivity, obesity, and diabetes. These risk factors are largely preventable and modifiable.
\nGlobally, about 25% of all deaths from cardiovascular diseases are due to hypertension.
\nThis figure may underestimate the true impact of elevated blood pressure since the blood
\npressure cardiovascular risk continuum begins at 115\/75 mm Hg. There is overwhelming
\nevidence that excessive sodium intake is a risk factor for the development, or worsening of
\nhypertension, and it may also be an independent risk factor for cardiovascular diseases as
\nwell as all-cause mortality.
\nSubstantial overall benefits can accrue from even small reductions in the population’s
\nblood pressure. Depending upon an individual’s salt sensitivity, sodium may cause great
\ndamage to both normotensive and hypertensive populations. Therefore, population-wide
\nefforts to reduce dietary sodium intake are a cost-effective way to reduce overall hyper-
\ntension levels and subsequent cardiovascular disease.
\nBACKGROUND\t<\/p>\n

In acculturated populations, the level of blood pressure, the incremental rise in blood pres-
\nsure with age, and the prevalence of hypertension are related to salt intake. Observational
\nstudies and randomized controlled trials document a clear and consistent effect of salt con-
\nsumption on increased blood pressure. Blood pressure is also affected by other foods and
\nnutrients, and a reduced salt intake should be only one component of a comprehensive
\nstrategy to lower blood pressure. Increasing physical activity, consuming a diet high in
\nfruits and vegetables and low in saturated and total fats, maintenance of optimal body
\nweight, and moderation in alcohol intake are also recommended lifestyle approaches to
\npreventing and managing hypertension and reducing its impact on cardiovascular disease.
\nThe World Health Organization recommends that average daily sodium consumption in
\nadults should be less than 2000 mg (5 g salt). Epidemiologic evidence, including the
\nmarked reduction of either hypertension or of a progressive rise in blood pressure with
\nadvancing age in populations with an average sodium ingestion <1500 mg (3.8 g salt) per
\nday, supports the concept of such a threshold, above which the risk for harmful cardio-
\nvascular disease consequences begins to increase.<\/p>\n

Seoul\t\u23d0\tS-2008-01-2008
\nDietary\tSodium\tIntake
\nThe world's population consumes 2300-4600 mg of sodium (5.8 – 11.5 g salt) per day per
\n2000 calories. In developed countries, it is estimated that 75% to 80% of the daily intake
\nof sodium comes from processed foods and foods that are prepared outside of the home
\n(e.g., fast food or restaurant meals). Therefore, any meaningful strategy to reduce popula-
\ntion salt intake must rely on food manufacturers and preparers to reduce the amount added
\nduring preparation as well as on nutritional education programs. The largest impact on
\nsodium in the food supply of developed countries may derive from the stepwise lowering
\nof sodium in foods that are most commonly eaten and are large contributors to sodium
\nintake. In less developed countries, reductions in sodium are more likely to be achieved by
\nadding less salt during cooking inside the home.
\nRECOMMENDATIONS\t<\/p>\n

National Medical Associations should:
\n\u2022 In cooperation with national and international health organizations, work to
\neducate consumers about the effects of sodium intake on hypertension and cardio-
\nvascular disease, the benefits of long-term reductions in sodium intake, and about
\nthe dietary sources of salt\/sodium and how these can be reduced.
\n\u2022 Call for a stepwise 50% reduction in the sodium content of processed foods, "fast"
\nfood products, and restaurant meals over the next decade.
\n\u2022 Urge physicians to counsel patients about the major sources of sodium in their
\ndiets and how to reduce sodium intake, including reducing the amount of salt used
\nin cooking at home.
\n\u2022 In cooperation with the food industry and government regulators, discuss ways to
\nimprove labeling of food products and develop label markings and warnings for
\nfoods high in sodium.
\n\u2022 Encourage government authorities to create national laws and regulations that
\nenforce the reduction of sodium in processed foods to acceptable levels. Establish
\na deadline for industries to comply with new laws and regulations.
\n\u2022 Stimulate debate on the issue at conferences, symposia, and teleconferences in an
\neffort to promote awareness among the medical profession regarding sodium in
\nfood and its consequences. Doctors who are well-informed will transmit the infor-
\nmation to their patients and may be able to prescribe fewer antihypertensive medi-
\ncations.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2008-02-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nREDUCING\tTHE\tGLOBAL\tBURDEN\tOF\tMERCURY\t<\/p>\n

Adopted by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nand reaffirmed with minor revision by the 210th
\nWMA Council Session, Reykjavik, Iceland,
\nOctober 2018
\nPREAMBLE
\nMercury is a naturally occurring heavy metal that is a potent neurotoxin. The most likely
\nroutes of human exposure on a population basis are ingestion of methylmercury from
\ncontaminated fish. Less commonly, individuals are exposed via inhalation of inorganic
\nmercury vapor after a spill or during a manufacturing process.
\nMercury has been the ideal choice for use in medical devices that measure temperature
\nand pressure. Therefore, a typical large hospital may have more than a hundred pounds of
\nmercury onsite incorporated into various devices in separate locations.
\nHospitals and clinics can avoid the occupational or environmental risk of mercury by
\nusing products that don\u2019t rely on mercury-based technology. Major healthcare institutions
\naround the world have demonstrated that safe, effective alternative products exist, and can
\nbe safely used for most situations, such as electronic thermometers, recently calibrated
\naneroid devices and mercury-free batteries.
\nAlthough the rationale for instituting voluntary mercury replacement initiatives is
\ncompelling from both occupational and environmental perspectives, financial
\nconsiderations may ultimately motivate hospitals to undertake a mercury replacement
\nprogram. Hazardous waste clean-up costs, reporting requirements for spills, disruptions in
\nservices, and staff training are costly. The cost of cleaning up one significant
\ncontamination can be substantially higher than the cost of converting to mercury-free
\nalternatives.
\nBy implementing a \u201cbest practices\u201d management method for mercury use, the need for
\nincreased government regulations in the future, may be avoided. Such regulations may
\ncreate costly burdens that some facilities may not be able to meet.
\nThe World Medical Association (WMA) recalls its statement on Environmental
\nDegradation and Sound Management of Chemicals that provides recommendations for
\nadvocacy measures and capacity building in order to tackle this issue.<\/p>\n

Reykjavik\t\u23d0\tS-2008-02-2018
\nMercury
\nRECOMMENDATIONS
\nThe following recommendations are based on the urgent need to reduce both the supply
\nand demand of mercury in the health care sector:
\nGlobal
\nThe World Medical Association and its member national medical associations should:
\n\u2022 Advocate for the United Nations and individual governments to voluntarily
\ncooperate to implement key features of the United Nations Environment
\nProgramme (UNEP) Mercury Programme, which provides a framework for
\nreducing the use, release, trade and risk related to mercury.
\n\u2022 Enhance the activity of existing partnerships.
\nRegional\/National
\nNational medical associations should advocate that their governments work to reduce risks
\nrelated to mercury in the environment by:
\n\u2022 Reducing reliance on mercury mining in favor of environmentally-friendly sources
\nof mercury, such as recycled mercury.
\n\u2022 Developing options and scientifically sound plans for the long term safe storage of
\nexcess mercury supplies.
\n\u2022 Urging Member States to ratify and implement the United Nations Minamata
\nConvention on Mercury adopted in 2013 and designed to protect human health and
\nthe environment from anthropogenic emissions and releases of mercury and
\nmercury compounds.
\n\u2022 Encouraging a phase-out of mercury use in the health care sector
\n\u2022 Designing and implementing regulations and\/or requirements designed to
\nsignificantly reduce mercury emissions from coal combustion and cement
\nproduction by using specific mercury emission controls.
\nLocal
\nPhysicians should:
\n\u2022 Explore eliminating mercury-containing products in their offices and clinical
\npractices, including thermometers, sphygmomanometers, gastrointestinal tubes,
\nbatteries, lamps, electrical supplies, thermostats, pressure gauges, and other
\nlaboratory reagents and devices.
\n\u2022 Ensure that local hospitals and medical facilities have a plan to identify sources of
\nmercury in their workplace, a commitment to mercury reduction, and a mercury
\nmanagement policy regarding recycling, disposal and education.
\n\u2022 Encourage local hospitals and medical facilities to phase out mercury-containing
\nproducts and switch to non-mercury equivalents.
\n\u2022 Counsel patients about local and national advisories related to fish consumption
\ndesigned to limit exposure to mercury in children and women of childbearing age.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2009-01-2009\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nCONFLICT\tOF\tINTEREST
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

This policy is intended to identify areas where a conflict of interest might occur during the
\nday-to-day practice of medicine, and to assist physicians in resolving such conflicts in the
\nbest interests of their patients. A conflict of interest is understood to exist when profes-
\nsional judgement concerning direct patient care might be unduly influenced by a second-
\nary interest.
\nIn some cases, it may be enough to acknowledge that a potential or perceived conflict
\nexists. In others, specific steps to resolve the conflict may be required. Some conflicts of
\ninterest are inevitable and there is nothing inherently unethical in the occurrence of con-
\nflicts of interest in medicine but it is the manner in which they are addressed that is cru-
\ncial.
\nIn addition to the clinical practice of medicine and direct patient care, physicians have
\ntraditionally served in several different roles and pursued various other interests, such as
\nparticipation in research, the education of future physicians and physicians in training and
\nthe occupation of administrative or managerial positions. As private interests within medi-
\ncine have expanded in many locales, physicians have occasionally provided their expertise
\nto these endeavours as well, acting as consultants (and sometimes employees) for private
\nenterprise.
\nAlthough the participation of physicians in many of these activities will ultimately serve
\nthe greater public good, the primary obligation of the individual physician continues to be
\nthe health and well-being of his or her patients. Other interests must not be allowed to
\ninfluence clinical decision-making (or even have the potential to do so).
\nEach doctor has a moral duty to scrutinise his or her own behaviour for potential conflicts
\nof interest, even if the conflicts fall outside the kinds of examples or situations addressed
\nin this document. If unacknowledged, conflicts of interest can seriously undermine patient
\ntrust in the medical profession as well as in the individual practitioner.
\nPhysicians may also wish to avail themselves of additional resources such as specialty
\nsocieties, national medical associations or regulatory authorities, and should be aware of
\napplicable national regulations and laws.<\/p>\n

New\tDelhi\t\u23d0\tS-2009-01-2009
\nConflict\tof\tInterest
\nRECOMMENDATION\t<\/p>\n

Research\t<\/p>\n

The interests of the clinician and the researcher may not be the same. If the same indivi-
\ndual is assuming both roles, as is often the case, the potential conflict should be addressed
\nby ensuring that appropriate steps are put in place to protect the patient, including dis-
\nclosure of the potential conflict to the patient.
\nAs stated in the Declaration of Helsinki:
\n\u2022 The Declaration of Geneva of the World Medical Association states that, "The
\nhealth of my patient will be my first consideration," and the International Code of
\nMedical Ethics declares that, "A physician shall act only in the patient's interest
\nwhen providing medical care which might have the effect of weakening the phy-
\nsical and mental condition of the patient."
\n\u2022 The Declaration of Helsinki states that \u201cIn medical research involving human
\nsubjects, the well-being of the individual research subject must take precedence
\nover all other interests.\u201d
\nResearch should be conducted primarily for the advancement of medical science. A
\nphysician should never place his or her financial interests above the welfare of his or her
\npatient. Patient interests and scientific integrity must be paramount.
\nAll relevant and material physician-researcher relationships and interests must be dis-
\nclosed to potential research participants, research ethics boards, appropriate regulatory
\noversight bodies, medical journals, conference participants and the medical centre where
\nthe research is conducted.
\nAll hypothesis-testing research trials should be registered with a publicly-accessible re-
\nsearch registry.
\nA clear contract should be signed by all parties, including sponsors, investigators and
\nprogram participants, clarifying terms relating to, at a minimum:
\n\u2022 financial compensation for the physician-researcher (which should approximate
\nlost clinical earnings)
\n\u2022 ownership of research results (which should rest with the investigator)
\n\u2022 the right of the investigator to publish negative results
\n\u2022 the right of the investigator to release relevant information to trial participants at
\nany point during the study.
\nPhysician-researchers should retain control of and should have full access to all trial data,
\nand should decline non-disclosure clauses.
\nPhysician-researchers should ensure that, regardless of the trial results, the presentation or
\npublication of the results of hypothesis-testing trials will not be unduly delayed or other-
\nwise obstructed.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2009-01-2009\t\u23d0\tWorld\tMedical\tAssociation
\nReferral fees should not be accepted for providing the names of potential trial participants,
\nand patient information should not be released without the consent of the patient, except
\nwhere required by legislation or regulatory authorities.
\nAny compensation received from trial sponsors should approximately replace lost clinical
\nincome and should be commensurate with the efforts and responsibilities of the physician
\nperforming the research. When enrolment is particularly challenging and time-consuming,
\nreasonable additional payments may be made to compensate the clinical investigator or
\ninstitution specifically for time and effort spent on extra recruiting efforts to enrol appro-
\npriate research participants. Escalating bonuses designed to increase trial enrolment should
\nnot be accepted.
\nPhysician-researchers should decline requests to review grant applications or research
\npaper submissions from colleagues or competitors where their relationship would have the
\npotential to influence their judgment on the matter.
\nPayments or compensation of any sort should not be tied to the outcome of clinical trials.
\nPhysician-researchers should not have a financial interest in a company sponsoring a trial
\nor a product being studied in a clinical trial if this financial interest could be affected
\npositively or negatively by the results of the trial; they should have no direct financial
\nstake in the results of the trial. They should not purchase, buy or sell stock (shares) in the
\ncompany while the trial is ongoing and until the results have been made public. This
\nmight not apply for those physicians who have developed a medication but are not part of
\nthe enrolment process.
\nPhysician-researchers should only participate in clinical trials when they relate to their
\narea of medical expertise and they should have adequate training in the conduct of re-
\nsearch and the principles of research ethics.
\nAuthorship should be determined prior to the start of the trial and should be based on
\nsubstantive scientific contribution.
\nEducation\t<\/p>\n

The educational needs of students and the quality of their training experience must be
\nbalanced with the best interests of patients. Where these are in conflict, the interests of
\npatients will take precedence.
\nWhile recognizing that medical trainees require experience with real patients, physician-
\neducators must ensure that these trainees receive supervision commensurate with their
\nlevel of training.
\nPatients should be made aware that their medical care may be performed in part by stu-
\ndents and physicians in training, including the performance of procedures and surgery, and
\nwhere possible should give appropriate informed consent to this effect.
\nPatients should be made aware of the identity and qualifications of the individuals in-
\nvolved in their care.
\nRefusal by a patient to involve trainees in their care should not affect the amount or
\nquality of care they subsequently receive.<\/p>\n

New\tDelhi\t\u23d0\tS-2009-01-2009
\nConflict\tof\tInterest
\nSelf-referrals\tand\tfee-splitting\t<\/p>\n

All referrals and prescriptions (whether for specific goods or services) should be based on
\nan objective assessment of the quality of the service or of the physician to whom the pa-
\ntient has been referred.
\nReferral by physicians to health care facilities (such as laboratories) where they do not
\nengage in professional activities but in which they have a financial interest is called self-
\nreferral. This practice has the potential to significantly influence clinical decision-making
\nand is not generally considered acceptable unless there is a need in that particular com-
\nmunity for the facility and other ownership is not a possibility (for example, in small rural
\ncommunities). The physician in this situation should receive no more financial interest
\nthan would an ordinary investor.
\nKickbacks (or fee-splitting) occur when a physician receives financial consideration for
\nreferring a patient to a specific practitioner or for a specific service for which a fee is
\ncharged. This practice is not acceptable.
\nPhysician\toffices\t<\/p>\n

For reasons of patient convenience, many physician offices are located in close geographic
\nproximity to other medical services such as laboratories, pharmacies and opticians. The
\nphysician should not receive any financial compensation or other consideration either for
\nreferring a patient to these services, or for being located in close geographical proximity to
\nthem. Physician-owned buildings should not charge above-market or below-market rates
\nto tenants.
\nNon-medical products (those having nothing to do with patient health or the practice of
\nmedicine) and scientifically non-validated medical products should not be sold out of the
\nphysician\u2019s office. If scientifically validated medical products are sold out of the physi-
\ncian\u2019s office charges should be limited to the costs incurred in making them available and
\nthe products should be offered in such a way that the patient does not feel pressured to
\npurchase them.
\nOrganizational\/institutional\tconflicts\t<\/p>\n

Health care institutions in particular are increasingly subject to a number of pressures that
\nthreaten several of their roles, and many academic medical centres have begun to identify
\nalternate sources of revenue. Policies should be in place to ensure that these new sources
\nare not in conflict with the values and mission of the institution (for example, tobacco
\nfunding in medical schools).
\nIndividual medical organizations and institutions (including, but not limited to, medical
\nschools, hospitals, national medical associations, official\/state regulators and research in-
\nstitutions) should develop and, where possible, enforce conflict of interest guidelines for
\ntheir employees and members.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2009-01-2009\t\u23d0\tWorld\tMedical\tAssociation
\nPhysician-researchers and others will benefit from the development of institutional con-
\nflict of interest guidelines to assist them in making appropriate disclosure and clearly
\nidentifying situations where a conflict would preclude them from participating in a re-
\nsearch study or other activity.
\nAcademic health care institutions should have a clear demarcation between investment
\ndecision-making committees, technology transfer and the research arm of the institution.
\nWritten policies should provide guidelines for disclosure requirements, or for disconti-
\nnuing participation in the decision-making process, for those individuals who are con-
\nflicted due to sponsored research, consulting agreements, private holdings or licensing
\nagreements.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2009-02-2009
\nWMA\tSTATEMENT
\nON
\nEMBRYONIC\tSTEM\tCELL\tRESEARCH
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

The field of stem cell research has been developing during the last decade and is now one
\nof the fastest growing areas of biotechnology.
\nStem cells can be harvested from an established tissue (adult stem cell) or from the blood
\nof the umbilical cord and these sources, for many, create no specific ethical dilemma.
\nStem cells can also be obtained from the embryo (embryonic stem cells). Obtaining and
\nusing these stem cells raises specific ethical questions and is, for some, problematic.
\nSome legislatures have prohibited obtaining and using embryonic stem cells. Others have
\nallowed using so-called spare or excess embryos from assisted reproduction cycles for re-
\nsearch purposes, but often the production of embryos solely for research purposes is prohi-
\nbited. Many jurisdictions have no specific legislative provisions with respect to embryonic
\nstem cells.
\nThe basis of legal and ethical consideration is that human embryos have a specific and
\nspecial ethical status. This has generated debate amongst ethicists, philosophers, clini-
\ncians, scientists, health workers, the public and legislators.
\nSome assisted reproductive technology, specifically in vitro fertilisation, involves the pro-
\nduction of embryos outside of the human body. In many cases not all of these are needed
\nto achieve pregnancies. Those not used, so called \u201cspare or excess embryos\u201d, may be do-
\nnated for the treatment of others or for research or stored for some time and then des-
\ntroyed.
\nThe differing legislative approaches to the use of embryos for research, may be reflected
\nin law prohibiting the public funding of such research.
\nStem cells can be used to conduct research into human disease and basic developmental
\nbiology. There are many current research programs investigating the use of stem cells to
\ntreat human disease. Although clinical studies have not yet validated the use of stem cells
\nin therapy, the potential for therapeutic use in the future has been widely acknowledged by
\nmembers of the medical and scientific community.
\nIt is too early to assess the likelihood of success in any specific therapy and the place of
\nstem cells amongst a variety of forms of treatments.<\/p>\n

S-2009-02-2009\t\u23d0\tNew\tDelhi
\nEmbryonic\tStem\tCell\tResearch
\nPublic views of stem cell research are at least as varied as those of doctors and scientists.
\nMuch public debate centres on concerns of abuse of the technology as well as specific
\nconcerns about the use of embryos.
\nRegulation according to established ethical principles is likely to alleviate concerns for
\nmany members of the public, especially if associated with careful and credible policing of
\nthe regulations.
\nRECOMMENDATION\t<\/p>\n

Whenever possible research should be carried out using stem cells that are not of embryo-
\nnic origin. However, there will be circumstances where only embryonic stem cells will be
\nsuitable for the research model.
\nAll research on stem cells, regardless of their origin, must be carried out according to
\nagreed ethical principles. Regulation and legislation must also accord with these principles
\nto avoid confusion or conflicts between law and ethics.
\nThe ethical principles should, where possible, follow international agreement. Recogni-
\nsing that different groups have widely varying views on the use, especially, of embryonic
\nstem cells, these principles should be drafted to allow different jurisdictions to limit their
\nallowed levels of research as locally appropriate.
\nAll and any research using embryos must only occur when written informed consent has
\nbeen obtained from both donors of the genetic material that created the embryo.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2009-03-2009
\nWMA\tSTATEMENT
\nON
\nINEQUALITIES\tIN\tHEALTH
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

For over 150 years, the existence of health inequality has been acknowledged worldwide.
\nThe recently published Final Report of the WHO Commission on Social Determinants of
\nHealth has highlighted the critical importance of health equity to the health, economy and
\nsocial cohesiveness of all countries. It is clear that while there are major differences be-
\ntween countries, especially between the developing and developed countries, there are also
\nsubstantial disparities within countries with respect to various measures of socio-economic
\nand cultural diversity. Disparities in health can be defined as either disparities in access to
\nhealthcare, disparities in quality of care received, or both. The differences manifest them-
\nselves in a wide variety of health measures, such as life expectancy, infant mortality, and
\nchildhood mortality. Particularly disturbing is evidence of the gradual and ongoing widen-
\ning of specific disparities.
\nAt the core of this issue is the healthcare provided by physicians. National medical asso-
\nciations should take an active role in combating social and health inequalities in order to
\nallow their physician members the ability to provide equal, quality service to all.
\nThe Role of the Health Care System:
\nWhile the major causes of health disparities lie in the socio-economic and cultural di-
\nversity of population groups, there is a very significant role for the health care system in
\ntheir prevention and reduction. This role can be summarized as follows:
\n\u2022 To prevent the health effects of socio-economic and cultural inequality and in-
\nequity \u2013 especially by health promotion and disease prevention activities (Primary
\nPrevention)
\n\u2022 To Identify, treat and reduce existing health inequality, e.g. early diagnosis of
\ndisease, quality management of chronic disease, rehabilitation (Secondary and Ter-
\ntiary Prevention).
\nRECOMMENDATIONS\t<\/p>\n

The members of the medical profession, faced with treating the results of this inequity,
\nhave a major responsibility and call on their national medical associations to:
\n\u2022 Recognize the importance of health inequality and the need to influence national
\npolicy and action for its prevention and reduction<\/p>\n

S-2009-03-2009\t\u23d0\tNew\tDelhi
\nInequalities\tin\tHealth
\n\u2022 Identify the social and cultural risk factors to which patients and families are ex-
\nposed and to plan clinical activities (diagnostic and treatment) to counter their con-
\nsequences.
\n\u2022 Advocate for the abolishment of financial barriers to obtaining needed medical
\ncare.
\n\u2022 Advocate for equal access for all to health care services irrespective of geographic,
\nsocial, age, gender, religious, ethnic and economic differences or sexual orienta-
\ntion.
\n\u2022 Require the inclusion of health inequality studies (including the scope, severity,
\ncauses, health, economic and social implications) as well as the provision of cul-
\ntural competence tools, at all levels of academic medical training, including further
\ntraining for those already in clinical practice.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2009-04-2009
\nWMA\tSTATEMENT
\nON
\nGUIDING\tPRINCIPLES\tFOR\tTHE\tUSE\tOF\tTELEHEALTH
\nFOR\tTHE\tPROVISION\tOF\tHEALTH\tCARE
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nDEFINITION\t<\/p>\n

Telehealth is the use of information and communications technology to deliver health and
\nhealthcare services and information over large and small distances.
\nPREAMBLE\t<\/p>\n

The prevalence of telemedicine and telehealth in most countries in the world has led the
\nWorld Medical Association (WMA) to develop ethical guidelines for physicians who use
\nthis modality to provide health care services. The WMA defines telemedicine as \u201cthe prac-
\ntice of medicine over a distance, in which interventions, diagnostics and treatment deci-
\nsions and recommendations are based on data, including voice and images, documents and
\nother information transmitted through telecommunication systems\u201d. This could include
\ntelephone and internet.
\nA broader telehealth definition brings into play the entire range of activities that support
\nthe patient and the public in being healthy: prevention, promotion, diagnostics self-care
\nand treatment are all areas where physicians play an important role. It is this broader defi-
\nnition that the WMA endorses.
\nTelehealth\/telemedicine helps eliminate distance barriers and improve equity of access to
\nservices that otherwise often would not be available in remote, rural and increasingly ur-
\nban communities. It is about transmitting voice, data, images, and information rather than
\nphysically moving patients, health professionals and educators \u2013 thereby improving ac-
\ncess, timeliness and convenience and reducing travel costs. It also has the added benefit
\nthat the patients more easily can become active participants in their own health and well-
\nbeing and are able to engage in educational programs aimed at fostering wellness from the
\ncomfort, convenience and safety of their own homes. While this statement focuses mainly
\non telehealth encounters between patients and health professionals, it should be noted that
\nanother important aspect of telehealth is the use of tele-communication between health
\nprofessionals when providing health care.
\nThe telemedicine\/telehealth agenda will become an integral part of the larger eHealth
\nprograms that most countries in the developed world are pursuing, as are many countries
\nin the developing world. More and more solutions are being introduced that provide the
\nability to deliver care through an e-channel and therefore more physicians will have access
\nto this capability to provide care to their patients.<\/p>\n

S-2009-04-2009\t\u23d0\tNew\tDelhi
\nTelehealth
\nGUIDING\tPRINCIPLES\t<\/p>\n

Duty\tof\tCare\t<\/p>\n

While the practice of telehealth challenges the conventional perception of the physician-
\npatient relationship, there is a \u201cduty of care\u201d established in all telehealth encounters be-
\ntween the physician and the patient as in any healthcare encounter.
\nThe physician needs to give clear and explicit direction to the patient during the telehealth
\nencounter as to who has ongoing responsibility for any required follow-up and ongoing
\nhealth care. Physician supervision regarding protocols, conferencing and medical record
\nreview is required in all settings and circumstances. Physicians should have the capability
\nto immediately contact nonphysician providers and technicians as well as patients.
\nThe physician needs to clarify ongoing responsibility for the patient with any other health
\ncare providers who are involved in the patient\u2019s care.
\nThe legal responsibility of health professionals providing health care through means of
\ntelehealth must be clearly defined by the appropriate jurisdiction.
\nCommunication\twith\tPatients\t<\/p>\n

The physician will take steps to ensure that quality of communication during a telehealth
\nencounter is maximized. Any significant technical deficiencies should be noted in the
\ndocumentation of the consultation.
\nThe physician providing telehealth services should be familiar with the technology.
\nThe physician should be aware of and accommodate the limitations of video\/audio in the
\nprovision of telehealth health care services.
\nThe physician should receive education\/orientation in telehealth communication skills prior
\nto the initial telehealth encounter.
\nThe physician needs to determine to the best of his or her ability each patient\u2019s appropria-
\nteness for, and level of comfort with, telehealth prior to or at the encounter, while recog-
\nnizing that this will not be possible in all situations.
\nThe physician, to the extent possible, should ensure that the patient receives sufficient
\neducation\/orientation to the telehealth process and communication issues prior to their ini-
\ntial telehealth encounter.
\nStandards\tof\tPractice\/Quality\tof\tClinical\tCare\t<\/p>\n

The physician must be satisfied that the standard of care delivered via telehealth is
\n\u201creasonable\u201d and at least equivalent to any other type of care that can be delivered to the
\npatient\/client, considering the specific context, location and timing, and relative avail-
\nability of traditional care. If the \u201creasonable\u201d standard cannot be satisfied via telehealth,
\nthe physician should inform the patient and suggest an alternative type of health care
\ndelivery\/service.
\nThe physician should use existing clinical practice guidelines, whenever possible, to guide
\nthe delivery of care in the telehealth setting, recognizing that certain modifications may
\nneed to be made to accommodate specific circumstances.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2009-04-2009
\nThe physician should ensure that any modifications to clinical practice guidelines for the
\ntelehealth setting are approved by the discipline's clinical governing body or association.
\nThe physician providing telehealth services should follow all relevant protocols and pro-
\ncedures related to: informed consent (verbal, written, and recorded); privacy and confi-
\ndentiality; documentation; ownership of patient\/client record; and appropriate video\/tele-
\nphone behaviours.
\nThe physician providing telehealth services ensures compliance with the relevant legisla-
\ntion and professional guidelines of the jurisdiction from which the services are provided as
\nwell as the jurisdiction from which the service is administered.
\nThe physician providing telehealth services should possess the following: required skills
\nexpected in the professional's field of practice; competent communication skills; an under-
\nstanding of the scope of service being provided via telehealth; orientation to and ability to
\nnavigate the technology system and environment; an understanding of the telehealth
\noperational protocols and procedures; and an understanding of any limitations of the tech-
\nnology being used.
\nClinical\tOutcomes\t<\/p>\n

Organizations providing telehealth programs should monitor and continuously strive to
\nimprove the quality of services in order to achieve the best possible outcomes.
\nOrganizations providing telehealth programs should have in place a systematic method of
\ncollecting, evaluating and reporting meaningful health care outcome data and clinical ef-
\nfectiveness. Quality indicators should be identified and utilized.
\nPatient\tConfidentiality\t<\/p>\n

The confidentiality of patient information should be protected.
\nThe health care organization and physician providing telehealth services should be aware
\nof, and ensure compliance with, relevant legislation and regulations designed to protect the
\nconfidentiality of patient\/client information and have its own confidentiality guidelines.
\nThe health care organizations and the physician are encouraged to consult with legal
\ncounsel and relevant professional licensing\/regulatory bodies when determining confi-
\ndentiality policy.
\nInformed\tConsent\t<\/p>\n

Relevant legislation and regulations that relate to patient decision-making and consent
\nshould be applied.
\nTo the extent possible, informed consent shall be obtained by the physician before starting
\nany service or intervention. Where appropriate the patient\u2019s consent should be noted in the
\ndocumentation of the consultation.
\nConsent for telehealth should follow similar principles and processes as those used for
\nother health services.<\/p>\n

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\nS-2010-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nENVIRONMENTAL\tDEGRADATION
\nAND\tSOUND\tMANAGEMENT\tOF\tCHEMICALS
\nAdopted by the 61st
\nWMA General Assembly, Vancouver, Canada, October 2010
\nand amended by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018<\/p>\n

PREAMBLE\t<\/p>\n

1. This Statement focuses on one important aspect of environmental degradation, which
\nis environmental contamination by domestic and industrial substances. It emphasizes
\nthe harmful chemical contribution to environmental degradation and physicians\u2019 role
\nin promoting sound management of chemicals as part of sustainable development,
\nespecially in the healthcare environment.
\n2. Unsafe management of chemicals has potential adverse impacts on human health and
\nhuman rights, with vulnerable populations being most at risk.
\n3. Most chemicals to which humans are exposed come from industrial sources and
\ninclude, toxic gases, food additives, household consumer and cosmetic products,
\nagrochemicals, and substances used for therapeutic purposes, such as drugs and dietary
\nsupplements. Recently, attention has been concentrated on the effects of human
\nengineered (or synthetic) chemicals on the environment, including specific industrial
\nor agrochemicals and on new patterns of distribution of natural substances due to
\nhuman activity. As the number of such compounds has multiplied, governments and
\ninternational organizations have begun to develop a more comprehensive approach to
\ntheir safe regulation. The increasing amount of plastic waste in our environment is
\nanother serious concern, that needs to be addressed.
\n4. While governments have the primary responsibility for establishing a framework to
\nprotect the public\u2019s health from chemical hazards, the World Medical Association, on
\nbehalf of its members, emphasizes the need to highlight the human health risks and
\nmake recommendations for further action.
\nBACKGROUND
\nChemicals of Concern
\n5. During the last half-century, the use of chemical pesticides and fertilizers dominated
\nagricultural practice and manufacturing industries rapidly expanded their use of
\nsynthetic chemicals in the production of consumer and industrial goods.
\n6. The greatest concern relates to chemicals, which persist in the environment, have low
\nrates of degradation, bio-accumulate in human and animal tissue (concentrating as they
\nmove up the food chain), and which have significant harmful impacts on human health
\nand the environment (particularly at low concentrations). Some naturally occurring<\/p>\n

Reykjavik\t\u23d0\tS-2010-01-2018
\nEnvironmental\tDegradation
\nmetals including lead, mercury, and cadmium have industrial sources and are also of
\nconcern. Advances in environmental health research including environmental and
\nhuman sampling and measuring techniques, and better information about the potential
\nof low dose human health effects have helped to underscore emerging concerns.
\n7. Health effects from chemical emissions can be direct (occurring as an immediate effect
\nof the emission) or indirect. Indirect health effects are caused by the emissions\u2019 effects
\non water, air and food quality as well as the alterations in regional and global systems,
\nsuch as red tide in many oceans, and the ozone layer and the climate, to which the
\nemissions may contribute.
\nNational and International Actions
\n8. The model of regulation of chemicals varies widely both within and between
\ncountries, from voluntary controls to statutory legislation. It is important that all
\ncountries move to a coherent, standardized national legislated approach to regulatory
\ncontrol. Furthermore, international regulations must be coherent such that developing
\ncountries will not be forced by economic circumstances to accept elevated toxic
\nexposure levels.
\n9. Synthetic chemicals include all substances that are produced by, or result from, human
\nactivities including industrial and household chemicals, fertilizers, pesticides,
\nchemicals contained in products and in wastes, prescription and over-the-counter drug
\nproducts and dietary supplements, and unintentionally produced byproducts of
\nindustrial processes or incineration, like dioxins. Furthermore, nanomaterials may need
\nexplicit regulation beyond existing frameworks.
\nStrategic approach to international chemicals management
\n10. Worldwide hazardous environmental contamination persists despite several
\ninternational agreements on chemicals, making a more comprehensive approach to
\nchemicals essential. Reasons for ongoing contamination include persistence of
\ncompanies, absolute lack of controls in some countries, lack of awareness of the
\npotential hazards, inability to apply the precautionary principle, non-adherence to the
\nvarious conventions and treaties and lack of political will. The Strategic Approach to
\nInternational Chemicals Management (SAICM) was adopted in Dubai, on February 6,
\n2006 by delegates from over 100 governments and representatives of civil society.
\nThis is a voluntary global plan of action designed to assure the sound management of
\nchemicals throughout their life cycle so that, by 2020, chemicals are used and
\nproduced in ways that minimize significant adverse effects on human health and the
\nenvironment. The SAICM addresses both agricultural and industrial chemicals, covers
\nall stages of the chemical life cycle of manufacture, use and disposal, and includes
\nchemicals in products and in wastes.
\nPlastic waste
\n11. Plastic has been part of life for more than 100 years and is regularly used in some form
\nby nearly everyone. While some biodegradable varieties are being developed, most
\nplastics break down very slowly with the decomposition process taking hundreds of
\nyears. This means that most plastics that have ever been manufactured are still on
\nEarth, unless they have been burnt, thus polluting the atmosphere with poisonous<\/p>\n

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\nS-2010-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\nsmoke.
\n12. Concerns about the use of plastic include accumulation of waste in landfills and in
\nnatural habitats, terrestrial and marine, physical problems for wildlife resulting from
\ningestion or entanglement in plastic, the leaching of chemicals from plastic products
\nand the potential for plastics to transfer chemicals to wildlife and humans. Many
\nplastics in use today are halogenated plastics or contain other additives used in
\nproduction,\u2009that have potentially harmful effects on health (e.g. carcinogenic or
\npromoting\u2009endocrine disruption).
\n13. Our current usage of plastic is not sustainable, accumulating waste and therefore
\ncontributing to environmental degradation and potentially harmful effects on health.
\nSpecific regulation is therefore needed to counter the harmful distribution of slowly
\ndegradable plastic waste into the environment and the incineration of such waste
\nwhich often creates toxic byproducts.
\nWORLD\tMEDICAL\tASSOCIATION\t(WMA)\tRECOMMENDATIONS
\n14. Despite national and international initiatives, chemical contamination of the
\nenvironment due to inadequately controlled production and usage continues to exert
\nharmful effects on global public health. Evidence linking some chemicals to some
\nhealth issues is strong, but far from all chemicals have been tested for their health or
\nenvironmental impacts. This is especially true for newer chemicals or nano materials,
\nparticularly at low doses over long periods of time. Plastic contamination of our
\nnatural environment, including in the sea where plastic decomposes to minute
\nparticles, is an additional area of serious concern. Physicians and the healthcare sector
\nare frequently required to make decisions concerning individual patients and the public
\nas a whole based on existing data. Physicians therefore recognize that they, too, have a
\nsignificant role to play in closing the gap between policy formation and chemicals
\nmanagement and in reducing risks to human health.
\n15. The World Medical Association reaffirms its commitment to advocate for the
\nenvironment in order to protect health and life, and recommends that:
\nADVOCACY
\n16. National Medical Associations (NMAs) advocate for legislation that reduces chemical
\npollution, enhances the responsibities of chemical manufacturers, reduces human
\nexposure to chemicals, detects and monitors harmful chemicals in both humans and
\nthe environment, and mitigates the health effects of toxic exposures with special
\nattention to fertility for women and men and vulnerability during pregnancy and early
\nchildhood.
\n17. NMAs urge their governments to support international efforts to restrict chemical
\npollution through safe management, or phase out and safer substitution when
\nunmanageable (e.g. asbestos), with particular attention to developed countries aiding
\ndeveloping countries to achieve a safe environment and good health for all.
\n18. NMAs facilitate better inter-sectoral collaboration between government
\nministries\/departments responsible for the environment and public health.
\n19. NMAs promote public awareness about hazards associated with chemicals (including
\nplastics) and what can be done about it.<\/p>\n

Reykjavik\t\u23d0\tS-2010-01-2018
\nEnvironmental\tDegradation
\n20. Modern medical diagnosis and treatment relies heavily on the single use of packaged
\nclean or sterile materials with various plastic components, whether the device itself or
\nits packaging. NMAs should encourage research and the dissemination of practices
\nthat can reduce or eliminate this component of environmental degradation.
\n21. Physicians and their medical associations advocate for environmental protection,
\ndisclosure of product constituents, sustainable development, green chemistry and
\ngreen hospitals within their communities, countries and regions.
\n22. Physicians and their medical associations should support the phase out of mercury and
\npersistent bioaccumulative and toxic chemicals in health care devices and products and
\navoid incineration of wastes from these products which may create further toxic
\npollution.
\n23. Physicians and their medical associations should support the Globally Harmonized
\nSystem of Classification and Labelling of Chemicals (GHS) and legislation to require
\nan environmental and health impact assessment prior to the introduction of a new
\nchemical or a new industrial facility.
\n24. Physicians should encourage the publication of evidence of the effects of different
\nchemicals and plastics, and dosages on human health and the environment. These
\npublications should be accessible internationally and readily available to media, non-
\ngovernmental organizations (NGOs) and concerned citizens locally.
\n25. Physicians and their medical associations should advocate for the development of
\neffective and safe systems to collect and dispose of pharmaceuticals that are not
\nconsumed. They should also advocate for the introduction worldwide of efficient
\nsystems to collect and dispose of plastic waste.
\n26. Physicians and their medical associations should encourage efforts to curb the
\nmanufacture and use of plastic packaging and plastic bags, to halt the introduction of
\nplastic waste into the environment, and to phase out and replace plastics with more
\nbiocompatible materials. These efforts may include measures to enhance recycling and
\nspecific regulations limiting the use of plastic packaging and plastic bags.
\n27. Physicians and their medical associations should support efforts to rehabilitate or clean
\nareas of environmental degradation based on a \u201cpolluter pays\u201d and precautionary
\nprinciples and ensure that moving forward, such principles are built into legislation.
\n28. The WMA, NMAs and physicians should urge governments to collaborate within and
\nbetween departments to ensure coherent regulations are developed.
\nLEADERSHIP
\nThe WMA:
\n29. Supports the goals of the Strategic Approach to International Chemicals Management
\n(SAICM), which promotes best practices in the handling of chemicals by utilizing
\nsafer substitution, waste reduction, sustainable non-toxic building, recycling, as well as
\nsafe and sustainable waste handling in the health care sector.
\n30. Cautions that these chemical practices must be coordinated with efforts to reduce
\ngreenhouse gas emissions from health care and other sources to mitigate its
\ncontribution to global warming.
\n31. Urges physicians, medical associations and countries to work collaboratively to<\/p>\n

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\nS-2010-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\ndevelop systems for event alerts to ensure that health care systems and physicians are
\naware of high-risk industrial accidents as they occur, and receive timely and accurate
\ninformation regarding the management of these emergencies.
\n32. Urges local, national and international organizations to focus on sustainable
\nproduction, safer substitution, green safe jobs, and consultation with the health care
\ncommunity to ensure that damaging health impacts of development are anticipated and
\nminimized.
\n33. Emphasizes the importance of the safe disposal of pharmaceuticals as one aspect of
\nhealth care\u2019s responsibility and the need for collaborative work in developing best
\npractice models to reduce this part of the chemical waste problem.
\n34. Encourages environmental classification of pharmaceuticals in order to stimulate
\nprescription of environmentally less harmful pharmaceuticals.
\n35. Encourages local, national and international efforts to reduce the use of plastic
\npackaging and plastic bags.
\n36. Encourages ongoing outcomes research on the impact of regulations and monitoring of
\nchemicals on human health and the environment.
\nThe WMA recommends that Physicians:
\n37. Work to reduce toxic medical waste and exposures within their professional settings as
\npart of the World Health Professional Alliance\u2019s campaign for Positive Practice
\nEnvironments.
\n38. Work to provide information on the health impacts associated with exposure to toxic
\nchemicals, how to reduce patient exposure to specific agents and encourage behaviors
\nthat improve overall health.
\n39. Inform patients about the importance of safe disposal of pharmaceuticals that are not
\nconsumed.
\n40. Work with others to help address the gaps in research regarding the environment and
\nhealth (i.e., patterns and burden of disease attributed to environmental degradation;
\ncommunity and household impacts of industrial chemicals; the effects, including on
\nhealth, of distribution of plastic and of plastic waste into our natural environment; the
\nmost vulnerable populations and protections for such populations).
\nPROFESSIONAL\tEDUCATION\t&\tCAPACITY\tBUILDING
\nThe WMA recommends that:
\n41. Physicians and their professional associations assist in building professional and public
\nawareness of the importance of the environment and global chemical pollutants on
\npersonal health.
\n42. NMAs develop tools for physicians to help assess their patients\u2019 risk from chemical
\nexposures.
\n43. Physicians and their medical associations develop locally appropriate continuing
\nmedical education on the clinical signs, diagnosis, treatment and prevention of
\ndiseases that are introduced into communities as a result of chemical pollution and
\nexacerbated by climate change.<\/p>\n

Reykjavik\t\u23d0\tS-2010-01-2018
\nEnvironmental\tDegradation
\n44. Environmental health and occupational medicine should become a core theme in
\nmedical education. Medical schools should encourage the training of sufficient
\nspecialists in environmental health and occupational medicine.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2011-01-2011
\nWMA\tSTATEMENT
\nON
\nTHE\tGLOBAL\tBURDEN\tOF\tCHRONIC\tDISEASE
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nINTRODUCTION\t<\/p>\n

Chronic diseases, including cardiovascular and circulatory diseases, diabetes, cancer, and
\nchronic lung disease are the leading cause of death and disability in both the developed
\nand developing world. Chronic diseases are not replacing existing causes of disease and
\ndisability (infectious disease and trauma), but are adding to the disease burden. Develop-
\ning countries now face the triple burden of infectious disease, trauma and chronic disease.
\nThis increased burden is straining the capacity of many countries to provide adequate
\nhealth care services. This burden is also undermining these nations' efforts to increase life
\nexpectancy and spur economic growth.
\nOngoing and anticipated global trends that will lead to more chronic disease problems in
\nthe future include an aging population, urbanization and community planning,
\nincreasingly sedentary lifestyles, climate change and the rapidly increasing cost of medical
\ntechnology to treat chronic disease. Chronic disease prevalence is closely linked to global
\nsocial and economic development, globalization and mass marketing of unhealthy foods
\nand other products. The prevalence and cost of addressing the chronic disease burden is
\nexpected to rise in coming years.
\nPOSSIBLE\tSOLUTIONS\t<\/p>\n

The primary solution is disease prevention. National policies that help people achieve
\nhealthy lifestyles and behaviors are the foundation for all possible solutions.
\nIncreased access to primary care combined with well designed and affordable disease –
\ncontrol programs can greatly improve health care. Partnerships of national ministries of
\nhealth with institutions in developed countries may overcome many barriers in the poorest
\nsettings. Effective partnerships currently exist in rural Malawi, Rwanda and Haiti. In these
\nsettings where no oncologists are available, care is provided by local physicians and nurse
\nteams. These teams deliver chemotherapy to patients with a variety of treatable malig-
\nnancies.
\nMedical education systems should become more socially accountable. The World Health
\nOrganization (WHO) defines social accountability of medical schools as the obligation to
\ndirect their education, research and service activities towards addressing the priority health
\nconcerns of the community, region, or nation they have a mandate to serve. The priority
\nhealth concerns are to be identified jointly by governments, health care organizations,<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2011-01-2011
\nhealth professionals and the public. There is an urgent need to adopt accreditation stand-
\nards and norms that support social accountability. Educating physicians and other health
\ncare professionals to deliver health care that is concordant with the resources of the coun-
\ntry must be a primary consideration. Led by primary care physicians, teams of physicians,
\nnurses and community health workers will provide care that is driven by the princi-ples of
\nquality, equity, relevance and effectiveness. [see WMA Resolution on Medical Work-
\nforce]
\nStrengthening the health care infrastructure is important in caring for the increasing num-
\nbers of people with chronic disease. Components of this infrastructure include training the
\nprimary health care team, improved facilities, chronic disease surveillance, public health
\npromotion campaigns, quality assurance and establishment of national and local standards
\nof care. One of the most important components of health care infrastructure is human re-
\nsources; well-trained and motivated health care professionals led by primary care physi-
\ncians are crucial to success. International aid and development programs need to move
\nfrom "vertical focus" on single diseases or objectives to a more sustainable and effective
\nprimary care health infrastructure development.
\nFor\tWorld\tGovernments:\t<\/p>\n

1. Support global immunization strategies;
\n2. Support global tobacco and alcohol control strategies;
\n3. Promote healthy living and implement policies that support prevention and healthy
\nlifestyle behaviors;
\n4. Set aside a fixed percentage of national budget for health infrastructure develop-
\nment and promotion of healthy lifestyles.
\n5. Promote trade policy that protects public health;
\n6. Promote research for prevention and treatment of chronic disease;
\n7. Develop global strategies for the prevention of obesity.
\nFor\tNational\tMedical\tAssociations:\t<\/p>\n

1. Work to create communities that promote healthy lifestyles and prevention beha-
\nviors and to increase physician awareness of optimal disease prevention behaviors;
\n2. Offer patients smoking cessation, weight control strategies, substance abuse coun-
\nseling, self-management education and support, and nutritional counseling;
\n3. Promote a team-based approach to chronic disease management;
\n4. Advocate for integration of chronic disease prevention and control strategies in
\ngovernment-wide policies;
\n5. Invest in high quality training for more primary care physicians and an equitable
\ndistribution of them among populations;<\/p>\n

S-2011-01-2011\t\u23d0\tMontevideo
\nChronic\tDisease
\n6. Provide high quality accessible resources for continuing medical education;
\n7. Support establishing evidence-based standards of care for chronic disease;
\n8. Establish, support and strengthen professional associations for primary care physi-
\ncians
\n9. Promote medical education that is responsive to societal needs;
\n10. Promote an environment of support for continuity of care for chronic disease, in-
\ncluding patient education and self-management;
\n11. Advocate for policies and regulations to reduce factors that promote chronic dis-
\nease such as smoking cessation and blood pressure control;
\n12. Support strong public health infrastructure; and
\n13. Support the concept that social determinants are part of prevention and health care.
\nFor\tMedical\tSchools:\t<\/p>\n

1. Develop curriculum objectives that meet societal needs; e.g., social accountability;
\n2. Focus on providing primary care training opportunities that highlight the integra-
\ntive and continuity elements of the primary care specialties including family medi-
\ncine;
\n3. Provide community-oriented and community-based primary care educational ve-
\nnues so that students become acquainted with the basic elements of chronic care
\ninfrastructure and continuity care provision;
\n4. Create departments of family medicine that are of equal academic standing in the
\nuniversity; and
\n5. Promote the use of interdisciplinary and other collaborative training methodologies
\nwithin primary and continuing education programs.
\n6. Include instruction in prevention of chronic diseases in the general curriculum.
\nFor\tIndividual\tPhysicians:\t<\/p>\n

1. Work to create communities that promote healthy lifestyles and prevention beha-
\nviors;
\n2. Offer patients smoking cessation, weight control strategies, substance abuse coun-
\nseling, self-management education and support, and nutritional counseling;
\n3. Promote a team-based approach to chronic disease management;
\n4. Ensure continuity of care for patients with chronic disease;<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2011-01-2011
\n5. Model prevention behaviors to patients by maintaining personal health;
\n6. Become community advocates for positive social determinants of health and for
\nbest prevention methods;
\n7. Work with parents and the community to ensure that the parents have the best
\nadvice on maintaining the health of their children.
\n8. Physicians should collaborate with patients' associations in designing and deliver-
\ning prevention education.
\nNote: Depending on the country, different stakeholders will assume greater or lesser responsibility
\nfor change.<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2011-02-2011
\nWMA\tRECOMMENDATION
\nON
\nTHE\tDEVELOPMENT\tOF\tA\tMONITORING\tAND
\nREPORTING\tMECHANISM\tTO\tPERMIT\tAUDIT\tOF
\nADHERENCE\tOF\tSTATES\tTO\tTHE\tDECLARATION\tOF\tTOKYO
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nThe\tWMA\trecommends\tthat
\n1.
\n1. Where physicians are working in situations of dual loyalties, support must be
\noffered to ensure they are not put in positions that might lead to violations of
\nfundamental professional ethics, whether by active breaches of medical ethics or
\nomission of ethical conduct, and\/or of human rights, as laid out in the Declaration
\nof Tokyo.
\n2. National Medical Associations (NMA's) should offer support for physicians in
\ndifficult situations, including, as feasible and without endangering either patients
\nor doctors, helping individuals to report violations of patients' health rights and
\nphysicians' professional ethics in custodial settings.
\n3. The WMA should review the evidence available, in cases brought to it by its mem-
\nbers, of the violation of human rights codes by states and\/or the forcing of physi-
\ncians to violate the Declaration of Tokyo, and refer as appropriate such cases to the
\nrelevant national and international authorities.
\n4. The WMA should contact member associations and encourage them to investigate
\naccusations of physician involvement in torture and similar abuses of human rights
\nreported to it from reputable sources, and to report back in particular on whether
\nphysicians are at risk and in need of support. The WMA should provide support to
\nthe NMAs and their members to resist such violations, and as far as realistically
\npossible, stand firm in their ethical convictions.
\n5. The WMA shall encourage and support NMAs in their calls for investigations by
\nthe relevant special rapporteur (or other individual or organization) when NMAs
\nand their members raise valid concerns.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2011-03-2011\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nTHE\tPROTECTION\tAND\tINTEGRITY\tOF\tMEDICAL\tPERSONNEL
\nIN\tARMED\tCONFLICTS\tAND\tOTHER\tSITUATIONS\tOF\tVIOLENCE
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nPREAMBLE\t<\/p>\n

During wars and armed conflicts hospitals and other medical facilities have often been
\nattacked and misused and patients and medical personnel have been killed or wounded.
\nSuch attacks are a violation of the Geneva Conventions (1949), Additional Protocols to
\nthe Geneva Conventions (1977) and WMA regulations in times of war (2006).
\nThe World Medical Association (WMA) has been active in condemning documented at-
\ntacks on medical personnel and facilities in armed conflicts. The International Committee
\nof the Red Cross (ICRC) Geneva Conventions and their Additional Protocols shall protect
\nmedical personnel in international and non-international armed conflicts. The warring
\nparties have duty not to interfere with medical care for wounded or sick combatants and
\ncivilians, and not attack, threaten or impede medical functions. Physicians and other health
\ncare personnel must be considered as neutral and must not be prevented from fulfilling
\ntheir duties.
\nThe lack of systematic reporting and documentation of violence against medical personnel
\nand facilities creates threats to both civilians and military personnel. The development of
\nstrategies for protection and efforts to improve compliance with the laws of war are im-
\npeded as long as such information is not available.
\nSTATEMENT\t<\/p>\n

The World Medical Association condemns all attacks on and misuse of medical personnel,
\nfacilities and vehicles in armed conflicts. These attacks put people in need of help in great
\ndanger and can lead to the flight of physicians and other health personnel from the conflict
\nareas with a lack of available medical personnel as a result.
\nCurrently no party is responsible for collecting data regarding assaults on medical person-
\nnel and facilities. Data collection after attacks is vital to identify the reasons why medical
\npersonnel and facilities are attacked. Such data are important in order to understand the
\nnature of the attacks and to take necessary steps to prevent attacks in the future. All attacks
\nmust also be properly investigated and those responsible for the violations of the Geneva
\nConventions and Protocols must be brought to justice.<\/p>\n

S-2011-03-2011\t\u23d0\tMontevideo
\nProtection\tand\tIntegrity\tof\tMedical\tPersonnel
\nThe WMA requests that appropriate international bodies establish mechanisms with the
\nnecessary resources to collect and disseminate data regarding assaults on physicians, other
\nhealth care personnel and medical facilities in armed conflicts. Such mechanisms could in-
\nclude the establishment of a new United Nations post of Rapporteur on the independence
\nand integrity of health professionals. As stated in the WMA proposal for a United Nations
\nRapporteur on the Independence and Integrity of Health Professionals (1997), "The new
\nrapporteur would be charged with the task of monitoring that doctors are allowed to move
\nfreely and that patients have access to medical treatment, without discrimination as to na-
\ntionality or ethnic origin, in war zones or in situations of political tension".
\nWhen a reporting system is established the WMA will recommend to their member or-
\nganisations reporting armed conflicts which they become aware of.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nD-2011-04-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tDECLARATION\tOF\tOSLO
\nON
\nSOCIAL\tDETERMINANTS\tOF\tHEALTH
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay, October 2011
\nand the title (Statement to Declaration) changed by the 66th
\nWMA General Assembly,
\nMoscow, Russia, October 2015
\nThe social determinants of health are: the conditions in which people are born, grow, live,
\nwork and age; and the societal influences on these conditions. The social determinants of
\nhealth are major influences on both quality of life, including good health, and length of
\ndisability-free life expectancy. While health care will attempt to pick up the pieces and
\nrepair the damage caused by premature ill health, it is these social, cultural, environ-
\nmental, economic and other factors that are the major causes of rates of illness and, in
\nparticular, the magnitude of health inequalities.
\nHistorically, the primary role of doctors and other health care professionals has been to
\ntreat the sick – a vital and much cherished role in all societies. To a lesser extent, health
\ncare professionals have dealt with individual exposures to the causes of disease – smoking,
\nobesity, and alcohol in chronic disease, for example. These familiar aspects of life style
\ncan be thought of as \u2018proximate' causes of disease.
\nThe work on social determinants goes far beyond this focus on proximate causes and
\nconsiders the "causes of the causes". For example, smoking, obesity, alcohol, sedentary
\nlife style are all causes of illness. A social determinants approach addresses the causes of
\nthese causes; and in particular how they contribute to social inequalities in health. It
\nfocuses not only on individual behaviours but seeks to address the social and economic
\ncircumstances that give rise to premature ill health, throughout the life course: early child
\ndevelopment, education, work and living conditions, and the structural causes that give
\nrise to these living and working conditions. In many societies, unhealthy behaviours fol-
\nlow the social gradient: the lower people are in the socioeconomic hierarchy, the more
\nthey smoke, the worse their diet, and the less physical activity they engage in. A major,
\nbut not the only, cause of the social distribution of these causes is level of education.
\nOther specific examples of addressing the causes of the causes: price and availability,
\nwhich are key drivers of alcohol consumption; taxation, package labeling, bans on
\nadvertising, and smoking in public places, which have had demonstrable effects on
\ntobacco consumption. The voice of the medical profession has been most important in
\nthese examples of tackling the causes of the causes.
\nThere is a growing movement, globally, that seeks to address gross inequalities in health
\nand length of life through action on the social determinants of health. This movement has
\ninvolved the World Health Organisation, several national governments, civil society organi-
\nzation, and academics. Solutions are being sought and learning shared. Doctors should be<\/p>\n

S-2011-04-2011\t\u23d0\tMontevideo
\nSocial\tDeterminants\tof\tHealth
\nwell informed participants in this debate. There is much that can happen within the prac-
\ntice of medicine that can contribute directly and through working with other sectors. The
\nmedical profession can be advocates for action on those social conditions that have im-
\nportant effects on health.
\nThe WMA could add significant value to the global efforts to address these social deter-
\nminants by helping doctors, other health professionals and National Medical Associations
\nunderstand what the emerging evidence shows and what works, in different circumstances.
\nIt could help doctors to lobby more effectively within their countries and across interna-
\ntional borders, and ensure that medical knowledge and skills are shared.
\nThe WMA should help to gather data of examples that are working, and help to engage
\ndoctors and other health professionals in trying new and innovative solutions. It should
\nwork with national associations to educate and inform their members and put pressure on
\nnational governments to take the appropriate steps to try to minimise these root causes of
\npremature ill health. In Britain, for example, the national government has issued a public
\nhealth white paper that has at its heart reduction of health inequalities through action on
\nthe social determinants of health; several local areas have drawn up plans of action; there
\nare good examples of general practice that work across sectors improve the quality of
\npeople's lives and hence reduce health inequalities. The WMA should gather examples of
\ngood practice from its members and promote further work in this area.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2011-05-2011\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nTHE\tPROFESSIONAL\tAND\tETHICAL\tUSE\tOF\tSOCIAL\tMEDIA
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Urugay, October 2011
\nDEFINITION\t<\/p>\n

Social Media is generally understood to be a collective term for the different platforms and
\napplications that allow user-generated content to be created and shared electronically.
\nPREAMBLE\t<\/p>\n

The objectives of the proposed policy are to:
\n\u2022 Examine the professional and ethical challenges related to the increasing usage of
\nsocial media by physicians, medical students and patients.
\n\u2022 Establish a framework that protects their respective interests.
\n\u2022 Ensure trust and reputation by maintaining high professional and ethical standards.
\nThe use of social media has become a fact of life for many millions of people world wide
\nincluding physicians, medical students and patients.
\nInteractive, collaborative tools such as wikis, social networks, chat rooms and blogs have
\ntransformed passive Internet users into active participants. They are means for gathering,
\nsharing and disseminating personal information, including health information, socializing
\nand connecting with friends, relatives, professionals etc. They can be used to seek medical
\nadvice, and patients with chronic diseases can share their experiences with each other.
\nThey can also been used in research, public health, education and direct or indirect pro-
\nfessional promotion.
\nThe positive aspects of social media should be recognized such as in promoting healthy
\nlife style, in empowering patients and in reducing patients' isolation.
\nAreas, which may require special attention:
\n\u2022 Sensitive content, photographs, other personal materials posted on online social
\nforums often exists in the public domain and have the capacity to remain on the
\ninternet permanently. Individuals may not have control over the ultimate distribu-
\ntion of material they post on-line.
\n\u2022 Patient portal, blogs and tweets are not a substitute for one on one consultation
\nwith physicians but may widen engagement with health services amongst certain<\/p>\n

S-2011-05-2011\t\u23d0\tMontevideo
\nSocial\tMedia
\ngroups. Online "friendships" with patients may also alter the patient-physician
\nrelationship, and may result in unnecessary, possibly problematic physician and
\npatient self-disclosure.
\n\u2022 Each party's privacy may be compromised in the absence of adequate and con-
\nservative privacy settings or by their inappropriate use. Privacy settings are not
\nabsolute; social media sites may change default privacy settings unilaterally, without
\nthe user's knowledge. Social media sites may also make communications available
\nto third parties.
\n\u2022
\nInterested stakeholders such as current\/prospective employers, insurance companies and
\ncommercial entities may monitor these Internet web sites for various purposes such as to
\nbetter understand their customer's needs and expectations, to profile job candidates or to
\nimprove a product or a service.
\nRECOMMENDATIONS\t<\/p>\n

The WMA urges their NMA\u00b4s to establish guidelines for their physicians addressing the
\nfollowing issues:
\n1.
\n1. To maintain appropriate boundaries of the patient-physician relationship in accor-
\ndance with professional ethical guidelines just as they would in any other context.
\n2. To study carefully and understand the privacy provisions of social networking
\nsites, bearing in mind their limitations.
\n3. For physicians to routinely monitor their own Internet presence to ensure that the
\npersonal and professional information on their own sites and, to the extent possi-
\nble, content posted about them by others is accurate and appropriate.
\n4. To consider the intended audience and assess whether it is technically feasible to
\nrestrict access to the content to pre-defined individuals or groups.
\n5. To adopt a conservative approach when disclosing personal information as patients
\ncan access the profile. The professional boundaries that should exist between the
\nphysician and the patient can thereby be blurred. Physicians should acknowledge
\nthe potential associated risks of social media and accept them, and carefully select
\nthe recipients and privacy settings.
\n6. To provide factual and concise information, declare any conflicts of interest and
\nadopt a sober tone when discussing professional matters.
\n7. To ensure that no identifiable patient information be posted in any social media by
\ntheir physician. Breaching confidentiality undermines the public's trust in the medi-
\ncal profession, impairing the ability to treat patients effectively.
\n8. To draw the attention of medical students and physicians to the fact that online
\nposting may contribute also to the public perception of the profession.<\/p>\n

Montevideo\t\u23d0\tS-2011-05-2011
\nSocial\tMedia
\n9. To consider the inclusion of educational programs with relevant case studies and
\nappropriate guidelines in medical curricula and continuing medical education.
\n10. To bring their concerns to a colleague when observing his or her clearly inappro-
\npriate behavior. If the behaviour significantly violates professional norms and the
\nindividual does not take appropriate action to resolve the situation, physicians should
\nreport the conduct to appropriate authorities.
\n\u2022<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-01-2012
\nWMA\tSTATEMENT
\nON
\nELECTRONIC\tCIGARETTES\tAND
\nOTHER\tELECTRONIC\tNICOTINE\tDELIVERY\tSYSTEMS
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nINTRODUCTION
\nElectronic cigarettes (e-cigarettes) are products designed to deliver nicotine to a user in the
\nform of a vapor. They are usually composed of a rechargeable battery-operated heating
\nelement, a replaceable cartridge that contains nicotine and\/or other chemicals, and an
\natomizer that, when heated, turns the contents of the cartridge into a vapor (not smoke).
\nThis vapor is then inhaled by the user. These products are often made to look like other
\ntobacco-derived products like cigarettes, cigars, and pipes. They can also be made to look
\nlike everyday items such as pens and USB memory sticks.
\nNo standard definition of e-cigarettes exists and different manufacturers use different
\ndesigns and different ingredients. Quality control processes used to manufacture these
\nproducts are substandard or non-existent. Few studies have been done to analyze the level
\nof nicotine delivered to the user and the composition of the vapor produced.
\nManufacturers and marketers of e-cigarettes often claim that use of their products is a safe
\nalternative to smoking, particularly since they do not produce carcinogenic smoke.
\nHowever, no studies have been conducted to determine that the vapor is not carcinogenic,
\nand there are other potential risks associated with these devices: Appeal to children,
\nespecially when flavors like strawberry or chocolate are added to the cartridges. E-
\ncigarettes can increase nicotine addiction among young people and their use may lead to
\nexperimenting with other tobacco products.
\nManufacturers and distributors mislead people into believing these devices are acceptable
\nalternatives to scientifically proven cessation techniques, thus delaying actual smoking
\ncessation. E-cigarettes are not comparable to scientifically-proven methods of smoking
\ncessation. Their dosage, manufacture, and ingredients are not consistent or clearly la-
\nbelled. Brand stretching by using known cigarette logos is to be deplored.
\nUnknown amounts of nicotine are delivered to the user, and the level of absorption is
\nunclear, leading to potentially toxic levels of nicotine in the system. These products may
\nalso contain other ingredients toxic to humans.
\nHigh potential of toxic exposure to nicotine by children, either by ingestion or dermal
\nabsorption, because the nicotine cartridges and refill liquid are readily available over the
\nInternet and are not sold in child resistant packaging.<\/p>\n

S-2012-01-2012\t\u23d0\tBangkok
\nElectronic\tCigarettes
\nDue to the lack of rigorous chemical and animal studies, as well as clinical trials on com-
\nmercially available e-cigarettes, neither their value as therapeutic aids for smoking ces-
\nsation nor their safety as cigarette replacements is established. Lack of product testing
\ndoes not permit the conclusion that e-cigarettes do not produce any harmful products even
\nif they produce fewer dangerous substances than conventional cigarettes.
\nClinical testing, large population studies and full analyses of e-cigarette ingredients and
\nmanufacturing processes need to be conducted before their safety, viability and impacts
\ncan be determined as either clinical tools or as widely available effective alternatives to
\ntobacco use.
\nRECOMMENDATIONS
\nThat the manufacture and sale of e-cigarettes and other electronic nicotine delivery sys-
\ntems be subject to national regulatory bodies prior approval based on testing and research
\nas either a new form of tobacco product or as a drug delivery device.
\nThat the marketing of e-cigarettes and other electronic nicotine delivery systems as a valid
\nmethod for smoking cessation must be based on evidence and must be approved by ap-
\npropriate regulatory bodies based on safety and efficacy data.
\nThat e-cigarettes and other electronic nicotine delivery systems be included in smoke free
\nlaws.
\nPhysicians should inform their patients of the risks of using e-cigarettes even if regulatory
\nauthorities have not taken a position on the efficacy and safety of these products.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-02-2012
\nWMA\tSTATEMENT
\nON
\nTHE\tETHICAL\tIMPLICATIONS\tOF\tCOLLECTIVE\tACTION\tBY\tPHYSICIANS
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nPREAMBLE
\nIn recent years, in countries where physicians' satisfaction with their working conditions
\nhas decreased, collective action by physicians has become increasingly common.
\nPhysicians may carry out protest action and sanctions in order to improve direct and
\nindirect working conditions that also may affect patient care. Physicians must consider not
\nonly their duty to individual patients, but also their responsibility to improve the system
\nsuch that it meets the requirements of accessibility and quality.
\nIn addition to their professional obligations, physicians are often also employees. There
\nmay be tension between physicians' duty not to cause harm, and their rights as employees.
\nTherefore, physicians' strikes or other forms of collective action often give rise to public
\ndebate on ethical and moral issues. This statement attempts to address these issues.
\nRECOMMENDATIONS
\nThe World Medical Association recommends that National Medical Associations (NMAs)
\nadopt the following guidelines for physicians with regard to collective action:
\nPhysicians who take part in collective action are not exempt from their ethical or pro-
\nfessional obligations to patients.
\nEven when the action taken is not organized by or associated with the National Medical
\nAssociation, the NMA should ensure that the individual physician is aware of and abides
\nby his or her ethical obligations.
\nWhenever possible, physicians should press for reforms through non-violent public de-
\nmonstrations, lobbying and publicity or informational campaigns or negotiation or media-
\ntion.
\nIf involved in collective action, NMAs should act to minimize the harm to the public and
\nensure that essential and emergency health services, and the continuity of care, are pro-
\nvided throughout a strike. Further, NMAs should advocate for measures to review excep-
\ntional cases.If involved in collective action, NMAs should provide continuous and up-to-
\ndate information to their patients and the general public with regard to the demands of the
\nconflict and the actions being undertaken. The general public must be kept informed in a
\ntimely manner about any strike actions and the restrictions they may have on health care.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2012-03-2012\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nFORCED\tAND\tCOERCED\tSTERILISATION
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nThe WMA recognises that no person, regardless of gender, ethnicity, socio-economic
\nstatus, medical condition or disability, should be subjected to forced or coerced permanent
\nsterilisation.
\nA full range of contraceptive services, including sterilisation, should be accessible and
\naffordable to every individual. The state may have a role to play in ensuring that such ser-
\nvices are available, along with private, charitable and third sector organisations. The
\ndecision to undergo contraception, including sterilisation, must be the sole decision of the
\nindividual concerned.
\nAs with all other medical treatments, sterilisation should only be performed on a com-
\npetent patient after an informed choice has been made and the free and valid consent of the
\nindividual has been obtained. Where a patient is incompetent, a valid decision about treat-
\nment must be made in accordance with relevant legal requirements and the ethical
\nstandards of the WMA before the procedure is carried out. Sterilization of those unable to
\ngive consent would be extremely rare and done only with the consent of the surrogate
\ndecision maker.
\nSuch consent should be obtained when the patient is not facing a medical emergency, or
\nother major stressor.
\nThe WMA condemns practices where a state or any other actor attempts to bypass ethical
\nrequirements necessary for obtaining free and valid consent.
\nConsent to sterilisation should be free from material or social incentives which might
\ndistort freedom of choice and should not be a condition of other medical care (including
\nsafe abortion), social, insurance, institutional or other benefits.
\nThe WMA calls on national medical associations to advocate against forced and coerced
\nsterilisation in their own countries and globally.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-04-2017
\nWMA\tSTATEMENT
\nON
\nORGAN\tAND\tTISSUE\tDONATION
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nand revised by the 68th
\nWMA General Assembly, Chicago, United States, October 2017
\nPREAMBLE
\n1. Advances in medical sciences, especially surgical techniques, tissue typing and
\nimmuno-suppressive drugs, have made possible a significant increase in the rates of
\nsuccessful transplantation of human organs and tissue. Yet, in all countries, a shortage
\nof organ donors results in potentially avoidable loss of life. National medical
\nassociations should support attempts to maximise the number of donor organs
\navailable in their countries and to ensure that the highest ethical standards are
\nmaintained. The World Medical Association has developed this policy to assist
\nmedical associations, physicians, other health care providers and policy makers to
\nachieve this.
\nThis policy is based on a number of core ethical principles: altruism, autonomy,
\nbeneficence, equity and justice. These principles should guide those developing
\nnational policies and those operating within it, both in relation to organ procurement
\nand to the distribution and transplantation of donor organs. All systems and processes
\nshould be transparent and open to scrutiny.
\nThis statement applies to organ and tissue donation from both deceased and living
\ndonors. It does not apply to blood donation.
\nRAISING\tPUBLIC\tAWARENESS
\n2. It is important that individuals are aware of the option of donation and have the
\nopportunity to choose whether or not to donate organs and\/or tissue before and after
\ntheir death. Awareness and choice should be facilitated in a coordinated multi-faceted
\napproach by a variety of stakeholders and means, including media awareness and
\npublic campaigns. In designing such campaigns account needs to be taken of any
\nreligious or cultural sensitivities of the target audience.
\n3. Through awareness raising campaigns, individuals should be informed of the benefits
\nof transplantation, the impact on the lives of those who are waiting for a transplant and
\nthe shortage of donors available. They should be encouraged to think about their own
\nwishes about donation, to discuss their wishes with their family and friends and to use
\nestablished mechanisms to formally record them by opting into, or out of, donation.
\n4. The WMA advocates informed donor choice. National medical associations in<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-04-2017
\ncountries that have adopted or are considering a policy of \u201cpresumed consent\u201d (or opt-
\nout), in which there is an assumption that the individual wishes to donate unless there
\nis evidence to the contrary, or \u201cmandated choice\u201d, in which all persons would be
\nrequired to declare whether they wish to donate, should make every effort to ensure
\nthat these policies have been adequately publicised and do not diminish informed
\ndonor choice, including the patient\u2019s right not to donate.
\n5. Consideration should be given to the establishment of national donor registries to
\ncollect and maintain a list of citizens who have chosen either to donate or not to donate
\ntheir organs and\/or tissue. Any such registry must protect individual privacy and the
\nindividual\u2019s ability to control the collection, use, disclosure of, and access to, his or
\nher health information for other purposes. Provisions must be in place to ensure that
\nthe decision to sign up to a register is adequately informed and that registrants can
\nwithdraw from the registry easily and quickly and without prejudice.
\n6. Living organ donation is becoming an increasingly important component of
\ntransplantation programmes in many countries. Most living donation is between
\nrelated or emotionally close individuals and small but increasing numbers are donating
\nto people they do not know. Given that there are health risks associated with living
\norgan donation, proper controls and safeguards are essential. Information aimed at
\ninforming people about the possibility of donating organs as a living donor should be
\ncarefully designed so as not to put pressure on them to donate and to minimise the risk
\nof financial or other coercion. Potential donors should know where to obtain detailed
\ninformation about what is involved, should be informed of the inherent risks and
\nshould know that there are safeguards in place to protect those offering to donate.
\nPROTOCOLS\tFOR\tORGAN\tAND\tTISSUE\tDONATION\tFROM\tDECEASED\tDONORS
\n7. The WMA encourages its members to support the development of comprehensive,
\ncoordinated national protocols for deceased (also referred to as cadaveric) organ and
\ntissue procurement in consultation and cooperation with all relevant stakeholders.
\nEthical, cultural and societal issues arising in connection with donation and
\ntransplantation should be resolved, wherever possible, in an open process involving
\npublic debate informed by sound evidence.
\n8. National and local protocols should provide detailed information about the
\nidentification, referral and management of potential donors as well as communication
\nwith those close to people who have died. They should encourage the procurement of
\norgans and tissues consistent with this statement. Protocols should uphold the
\nfollowing key principles:
\n\u2022 Decisions to withhold or withdraw life-prolonging treatment should be based on an
\nassessment of whether the treatment is able to benefit the patient. Such decisions
\nmust be, and must be seen to be, completely separate from any decisions about
\ndonation.
\n\u2022 The diagnosis of death should be made according to national guidelines and as<\/p>\n

S-2012-04-2017\t\u23d0\tChicago
\nOrgan\tand\tTissue\tDonation
\noutlined in the WMA\u2019s Declaration of Sydney on the Determination of Death and
\nRecovery of Organs.
\n\u2022 There should be a clear separation between the treating team and the transplant
\nteam. In particular, the physician who declares or certifies the death of a potential
\ndonor should not be involved in the transplantation procedure. Nor should he\/she
\nbe responsible for the care of the organ recipient.
\n\u2022 Countries that carry out donation following circulatory\/cardiac death should have
\nspecific and detailed protocols for this practice.
\n\u2022 Where an individual has expressed a clear and voluntary wish to donate organs
\nand\/or tissue after death, steps should be taken to facilitate that wish wherever
\npossible. This is part of the treating team\u2019s responsibility to the dying patient.
\n\u2022 The WMA considers that the potential donor\u2019s wishes are paramount. Relatives
\nand those close to the patient should be strongly encouraged to support a deceased
\nperson\u2019s previously expressed wish to donate organs and\/or tissues. Whenever
\npossible, these conversations should occur prior to the death of the patient.
\n\u2022 Those charged with approaching the patient, family members or other designated
\ndecision maker about organ and tissue donation should possess the appropriate
\ncombination of knowledge, skill and sensitivity for engaging in such discussions.
\nMedical students and practising physicians should seek the necessary training for
\nthis task, and the appropriate authorities should provide the resources necessary to
\nsecure that training.
\n\u2022 Donation must be unconditional. In exceptional cases, requests by potential
\ndonors, or their substitute decision makers, for the organ or tissue to be given to a
\nparticular recipient may be considered if permitted by national law. Donors
\nseeking to apply conditions that could be seen as discriminatory against certain
\ngroups, however, should be declined.
\n9. Hospitals and other institutions where donation occurs should ensure that donation
\nprotocols are publicised amongst those likely to use them and that adequate resources
\nare available for their implementation. They should also foster a pro-donation culture
\nwithin the institution in which consideration of donation is the norm, rather than the
\nexception, when a patient dies.
\n10. The role of transplant coordination is critical to organ donation. Those performing
\ncoordination act as the key point of contact between the bereaved family and the
\ndonation team and usually also undertake the complex logistical arrangements to make
\ndonation happen. Their role must be recognised and supported.
\n11. Deceased organ donation must be based on the notion of a gift, freely and voluntarily
\ngiven. It should involve the voluntary and unpressured consent of the individual
\nprovided before death (by opting in or opting out of donation depending upon the<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-04-2017
\njurisdiction) or the voluntary authorisation of those close to the deceased patient if that
\nperson\u2019s wishes are unknown. The WMA is strongly opposed to the commercialisation
\nof donation and transplantation.
\n12. Prospective donors or their substitute health care decision makers should have access
\nto accurate and relevant information, including through their general practitioners.
\nNormally, this will include information about:
\n\u2022 the procedures and definitions involved in the determination of death,
\n\u2022 the testing that is undertaken to determine the suitability of the organs and\/or tissue
\nfor transplantation and that this may reveal previously unsuspected health risks in
\nprospective donors and their families,
\n\u2022 measures that may be required to preserve organ function until death is determined
\nand transplantation can occur,
\n\u2022 what will happen to the body once death has been declared,
\n\u2022 what organs and tissues can be donated,
\n\u2022 The protocol that will be followed in the event that the family objects to donation,
\nand
\n\u2022 the possibility of withdrawing consent.
\n13. Prospective donors or their substitute health care decision makers should be given the
\nopportunity to ask questions about donation and should have their questions answered
\nsensitively and intelligibly.
\n14. Where both organs and tissues are to be donated, information should be provided, and
\nconsent obtained, for both together in order to minimise distress and disruption to
\nthose close to the deceased.
\n15. In some parts of the world a contribution towards funeral costs is given to the family
\nof those who donate. This can be viewed either as appropriate recognition of their
\naltruistic act or as a payment that compromises the voluntariness of the choice and the
\naltruistic basis for donation. The interpretation may depend, in part, on the way it is set
\nup and managed. When considering the introduction of such a system, care needs to
\nbe taken to ensure that the core principles of altruism, autonomy, beneficence, equity
\nand justice are met.
\n16. Free and informed decision making requires not only the provision of information but
\nalso the absence of coercion. Any concerns about pressure or coercion must be
\nresolved before the decision to donate organs or tissue is made.
\n17. Prisoners and other people who are effectively detained in institutions should be
\neligible to donate after death where checks have been made to ensure that donation is
\nin line with the individual\u2019s prior, un-coerced wishes and, where the individual is<\/p>\n

S-2012-04-2017\t\u23d0\tChicago
\nOrgan\tand\tTissue\tDonation
\nincapable of giving consent, authorisation has been provided by a family member or
\nother authorized decision-maker. Such authorisation may not override advance
\nwithholding or refusal of consent.
\n18. Their death is from natural causes and this is verifiable.
\n19. In jurisdictions where the death penalty is practised, executed prisoners must not be
\nconsidered as organ and\/or tissue donors. While there may be individual cases where
\nprisoners are acting voluntarily and free from pressure, it is impossible to put in place
\nadequate safeguards to protect against coercion in all cases.
\nALLOCATION\tOF\tORGANS\tFROM\tDECEASED\tDONORS
\n20. The WMA considers there should be explicit policies, open to public scrutiny,
\ngoverning all aspects of organ and tissue donation and transplantation, including the
\nmanagement of waiting lists for organs to ensure fair and appropriate access.
\n21. Policies governing the management of waiting lists should ensure efficiency and
\nfairness. Criteria that should be considered in allocating organs or tissue include:
\n\u2022 Severity and urgency of medical need,
\n\u2022 Length of time on the waiting list,
\n\u2022 Medical probability of success measured by such factors as age, type of disease,
\nlikely improvements in quality of life, other complications, and histocompatibility.
\n22. There must be no discrimination based on social status, lifestyle or behaviour. Non-
\nmedical criteria must not be considered.
\nPROTOCOLS\tFOR\tORGAN\tAND\tTISSUE\tDONATION\tFROM\tLIVING\tDONORS
\n23. Living donation is becoming increasingly common as a way to overcome the shortage
\nof organs from deceased donors. In most cases donors provide organs to relatives or
\npeople to whom they are emotionally close. A small number of individuals choose to
\ndonate an organ altruistically to a stranger. Another scenario is where one or more
\ndonor and recipient pairs are incompatible with each other but donate in the form of a
\ncross-over or pooled donation system (for example, donor A donates to recipient B,
\ndonor B donates to recipient C and donor C donates to recipient A).
\n24. All potential donors should be given accurate and up to date information about the
\nprocedure and the risks of donation and have the opportunity to discuss the issue
\nprivately with a member of the healthcare team or a counsellor. Normally this
\ninformation will include:
\n\u2022 The risks of becoming a living donor,<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-04-2017
\n\u2022 The tests that are undertaken to assess suitability for donation and that this may
\nreveal previously unsuspected health problems,
\n\u2022 What will happen before, during and after donation takes place, and
\n\u2022 In the case of solid organs, the long-term implications of living without the
\ndonated organ.
\n25. Prospective donors should be given the opportunity to ask questions about donation
\nand should have their questions answered sensitively and intelligibly.
\n26. Procedures should be in place to ensure that living donors are acting voluntarily and
\nfree from pressure or coercion. In order to avoid donors being paid and then posing as
\na known donor, independent checks should also be undertaken to verify the claimed
\nrelationship and, where this cannot be proven, the donation should not proceed. Such
\nchecks should be independent of the transplant team and those who are caring for the
\npotential recipient.
\n27. Additional safeguards should be in place for vulnerable donors, including but not
\nlimited to, people who are dependent in some way (such as competent minors donating
\nto a parent or sibling).
\n28. Prisoners should be eligible to be living donors only in exceptional circumstances, to
\nfirst or second degree family members; evidence should be provided of any claimed
\nrelationship before the donation may proceed. Where prisoners are to be considered as
\nliving donors, extra safeguards are required to ensure they are acting voluntarily and
\nare not subject to coercion.
\n29. Those who lack the capacity to consent should not be considered as living organ
\ndonors because of their inability to understand and decide voluntarily. Exceptions may
\nbe made in very limited circumstances, following legal and ethical review.
\n30. Donors should not lose out financially as a result of their donation and so should be
\nreimbursed for general and medical expenses and any loss of earnings incurred.
\n31. In some parts of the world individuals are paid for donating a kidney, although in
\nvirtually all countries the sale of organs is unlawful. The WMA is strongly opposed to
\na market in organs.
\nPROTOCOLS\tFOR\tRECIPIENTS
\n32. Protocols for free and informed decision making should be followed in the case of
\nrecipients of organs or tissue. Normally, this will include providing information about:
\nThe risks of the procedure,
\nThe likely short, medium and long-term survival, morbidity, and quality-of-life<\/p>\n

S-2012-04-2017\t\u23d0\tChicago
\nOrgan\tand\tTissue\tDonation
\nprospects,
\nAlternatives to transplantation, and
\nHow organs and tissues are obtained.
\n33. In the case of a delayed diagnosis for infection, disease or malignancy in the donor,
\nthere should be a strong presumption that the recipient will be informed of any risk to
\nwhich they may have been exposed. Individual decisions about disclosure need to take
\naccount of the particular circumstances, including the level and severity of risk. In
\nmost cases disclosure will be appropriate and should be managed carefully and
\nsensitively.
\nCOSTS\tAND\tORIGIN\tOF\tORGANS\tAND\tTISSUES
\n34. Organs or tissue suspected to have been obtained through unlawful means must not be
\naccepted for transplantation.
\n35. Organs and tissues must not be sold for profit. In calculating the cost of
\ntransplantation, charges related to the organ or tissue itself should be restricted to those
\ncosts directly associated with its retrieval, storage, allocation and transplantation.
\n36. Transplant surgeons should seek to ensure that the organs and tissues they transplant
\nhave been obtained in accordance with the provisions of this policy and should refrain
\nfrom transplanting organs and tissues that they know, or suspect, have not been
\nprocured in a legal and ethical manner.
\nTRANSPARENCY\tAND\tACCOUNTABILITY
\n37. National Medical Associations should work with governments and relevant institutions
\nto ensure that appropriate, effective structures and processes are in place to:
\n\u2022 support relevant traceability and follow-up of all transplant recipients and living
\ndonors including those who require ongoing medical management receive care and
\nsupport;
\n\u2022 record information on donation and transplantation rates and outcomes;
\n\u2022 assess the short and long-term outcomes, quality, safety and efficacy of organ
\ndonation and transplantation activities;
\n\u2022 assess the adherence to ethical and clinical protocols of organ donation and
\ntransplantation activities;
\n38. The data arising from these activities should be publicly accessible and open to
\nscrutiny (notwithstanding appropriate protection of donor and recipient
\nconfidentiality).
\nFUTURE\tOPTIONS
\n39. Public health measures to reduce the demand for donated organs should be seen as a
\npriority, alongside initiatives to increase the effectiveness and success of organ<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2012-04-2017
\ndonation systems.
\n40. New developments and possibilities, such as xenotransplantation and the use of stem
\ncell technology to repair damaged organs, should be monitored. Before their
\nintroduction into clinical practice such technologies should be subject to scientific
\nreview and robust safety checks as well as ethical review. Where, as with
\nxenotransplantation, there are potential risks that go beyond individual recipients, this
\nprocess must also involve public debate.<\/p>\n

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\nS-2012-05-2012\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nTHE\tPRIORITISATION\tOF\tIMMUNISATION
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nPREAMBLE
\nVaccination use to prevent against disease was first done successfully by Jenner in 1796
\nwhen he used cowpox material for vaccination against smallpox. Since then, vaccination
\nand immunisation have been acknowledged as an effective preventive strategy for several
\ncommunicable diseases and are now being developed for the control of some non-
\ncommunicable diseases.
\nVaccine development and administration are some of the most significant interventions to
\ninfluence global health in modern times. It is estimated that immunisation currently pre-
\nvents approximately 2.5 million deaths every year, saving lives from diseases such as
\ndiphtheria, tetanus, whooping cough (pertussis) and measles. Approximately 109 million
\nchildren under the age of one are fully vaccinated with the diphtheria-tetanus-pertussis
\n(DTP3) vaccine alone.
\nMostly the ultimate goal of immunisation is the total eradication of a communicable
\ndisease. This was achieved for smallpox in 1980 and there is a realistic goal for the eradi-
\ncation of polio within the next few years.
\nThe Global Immunisation Vision Strategy (GIVS) 2006-2015 was developed by the WHO
\nand UNICEF in the hope of reaching target populations who currently do not have im-
\nmunisation services or who do not have an adequate level of coverage.
\nThe four strategies promoted in this vision are:
\n\u2022 Protecting more people in a changing world
\n\u2022 Introducing new vaccines and technologies
\n\u2022 Integrating immunisation, other linked health interventions and
\n\u2022 Surveillance in the health systems context
\n\u2022 Immunizing in the context of global interdependence1
\nVaccine research is constantly revealing new possibilities to protect populations from
\nserious health threats. Additionally, new strains of diseases emerge requiring the adapta-
\ntion of vaccines in order to offer protection.
\nThe process of immunisation requires an environment that is resourced with appropriate
\nmaterials and health workers to ensure the safe and effective administration of vaccines.<\/p>\n

Bangkok\t\u23d0\tS-2012-05-2012
\nPrioritisation\tof\tImmunisation
\nAdministration of vaccines often requires injections, and safety procedures for injections
\nmust always be followed.
\nImmunisation schedules can vary according to the type of vaccine, with some requiring
\nmultiple administrations to be effective. It is vitally important that the full schedule is
\nfollowed otherwise the effectiveness of the vaccine may be compromised.
\nThe benefits of immunisation have had a profound effect on populations, not only in terms
\nof preventing ill health but also in permitting resources previously required to treat the
\ndiseases to be redirected to other health priorities. Healthier populations are economically
\nbeneficial and can contribute more to society.
\nReducing child mortality is the fourth of the United Nation's Millennium Development
\nGoals, with immunisation of children having a significant impact on mortality rates on
\nchildren aged under five. According to the WHO, there are still more than 19 million
\nchildren who have not received the DTP3 vaccine. In addition, basic health care services
\nfor maternal health with qualified health care personnel must be established.
\nImmunisation of adults for diseases such as influenza and pneumococcal infections has
\nbeen shown to be effective, not only in decreasing the number of cases amongst those that
\nhave received immunisation but also in decreasing the disease burden in society.
\nThe medical profession denounce any claims that are unfounded and inaccurate with res-
\npect to the possible dangers of vaccine administration. Claims such as these have resulted
\nin diminished immunisation rates in some countries. The result is that the incidences of the
\ndiseases to be prevented have increased with serious consequences for a number of
\npersons.
\nCountries differ in immunisation priorities, with the prevalence and risk of diseases
\nvarying among populations. Not all countries have the same coverage rates, nor do they
\nhave the resources to acquire, coordinate, distribute or effectively administer vaccines to
\ntheir populations, often relying on non-governmental organizations to support immuni-
\nsation programmes. These organizations in turn often rely on external funding that may
\nnot be secure. In times of global financial crisis, funding for such programmes is under
\nconsiderable pressure.
\nThe risk of health complications from vaccine-preventable diseases is greatest in those
\nwho experience barriers in accessing immunisation services. These barriers could be cost,
\nlocation, lack of awareness of immunisation services and their health benefits or other
\nlimiting factors.
\nThose with chronic diseases, underlying health issues or other risk factors such as age are
\nat particular risk of major complications due to vaccine-preventable diseases and therefore
\nshould be targeted to ensure adequate immunisation.
\nSupply chains can be difficult to secure, particularly in countries that lack coordination or
\nsupport of their immunisation programmes. Securing the appropriate resources, such as
\nqualified health professionals, equipment and administrative support can present signifi-
\ncant challenges.<\/p>\n

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\nS-2012-05-2012\t\u23d0\tWorld\tMedical\tAssociation
\nData collection on vaccine administration rates, side effects of vaccines and disease sur-
\nveillance can often be difficult to achieve, particularly in isolated and under-resourced
\nareas. Nevertheless, reporting incidents and monitoring disease spread are vital tools in
\ncombating global health threats.
\nRECOMMENDATIONS
\nThe WMA supports the recommendations of the Global Immunisation Vision Strategy
\n(GIVS) 2006-2015, and calls on the international community to:
\n\u2022 Encourage governments to commit resources to immunisation programmes targeted
\nto meet country specific needs.
\n\u2022 Recognise the importance of vaccination\/immunisation through the continued sup-
\nport and adoption of measures to achieve global vaccination targets and to meet the
\nMillennium Development Goals, especially four (reduce child mortality), five (im-
\nprove maternal health) and six (combat HIV\/AIDS, malaria and other diseases).
\n\u2022 Recognise the global responsibility of immunisation against preventable diseases
\nand support work in countries that have difficulties in meeting the 2012 targets in
\nthe Global Polio Eradication Initiative2
\n.
\n\u2022 Support national governments with vulnerable populations at risk of vaccine-pre-
\nventable diseases, and the local agencies that work to deliver immunisation services
\nand to work with them to alleviate retrictions in accessing services.
\n\u2022 Support vaccine research and development and ensure commitment through the ade-
\nquate funding of vital vaccine research.
\n\u2022 Promote vaccination and the benefits of immunisation, particularly targeting those
\nat-risk and those who are difficult to reach. Comply with monitoring activities
\nundertaken by WHO and other health authorities. Promote high standards in the
\nresearch, development and administration of vaccines to ensure patient safety. Vac-
\ncines need to be thoroughly tested before implemented on a large scale and subse-
\nquently monitored in order to identify possible complications and untoward side
\neffects. In order to be successful, immunisation programmes need public trust which
\ndepends on safety.
\nIn delivering vaccination programmes, the WMA recommends that:
\n\u2022 The full immunisation schedule is delivered to provide optimum coverage. Where
\npossible, the schedule should be managed and monitored by suitably trained indi-
\nviduals to ensure consistent delivery and prompt appropriate management of adverse
\nreactions to vaccines.
\n\u2022 Strategies are employed to reach populations that may be isolated because of loca-
\ntion, race, religion, economic status, social marginalization, gender and\/or age.
\n\u2022 Ensure that qualified health professionals receive comprehensive training to safely
\ndeliver vaccinations and immunisations, and that vaccination\/immunisations are tar-
\ngeted to those whose need is greatest.
\n\u2022 Educate people on the benefits of immunisation and how to access immunisation
\nservices.<\/p>\n

Bangkok\t\u23d0\tS-2012-05-2012
\nPrioritisation\tof\tImmunisation
\n\u2022 Maintain accurate medical records to ensure that valid data on vaccine admin-
\nistration and coverage rates are available, enabling immunisation policies to be
\nbased upon sound and reliable evidence.
\n\u2022 Healthcare professionals should be seen as a priority population for the receipt of
\nimmunisation services due to their exposure to patients and to diseases.
\nThe WMA calls upon its members to advocate the following:
\n\u2022 To increase awareness of national immunisation schedules and of their own (and
\ntheir dependents) personal immunisation history.
\n\u2022 To work with national and local governments to ensure that immunisation pro-
\ngrammes are resourced and implemented.
\n\u2022 To ensure that health personnel delivering vaccines and immunisation services re-
\nceive proper education and training.
\n\u2022 To promote the evidence base and increase awareness about the benefits of im-
\nmunisation amongst physicians and the public.
\n1
\nWorld Health Organization and United Nations Children's Fund. Global Immunisation Vision and
\nStrategy, 2006-2015. Geneva, Switzerland: World Health Organization and United Nations Child-
\nren's Fund; 2005. Available at: http:\/\/www.who.int\/immunisation\/givs\/related_docs\/en\/index.html
\n2
\nWorld Health Organization. Global Polio Eradication Initiative: Strategic Plan 2010-2012.
\nGeneva, Switzerland: World Health Organization; 2010. Available at:
\nhttp:\/\/www.polioeradication.org\/Portals\/0\/Document\/StrategicPlan\/StratPlan2010_2012_ENG.pdf<\/p>\n

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\nS-2012-06-2012\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\n\tVIOLENCE\tIN\tTHE\tHEALTH\tSECTOR\tBY\tPATIENTS\tAND
\nTHOSE\tCLOSE\tTO\tTHEM
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand, October 2012
\nPREAMBLE
\nAll persons have the right to work in a safe environment without the threat of violence.
\nWorkplace violence includes both physical and non-physical (psychological) violence.
\nGiven that non-physical abuse, such as harassment and threats, can have severe psy-
\nchological consequences, a broad definition of workplace violence should be used. For
\nthe purposes of this statement we will use the widely accepted definition of workplace
\nviolence, as used by the WHO: "The intentional use of power, threatened or actual, against
\nanother person or against a group, in work-related circumstances, that either results in or
\nhas a high degree of likelihood of resulting in injury, death, psychological harm, mal-
\ndevelopment, or deprivation".
\nViolence, apart from the numerous health effects it can have on its victims, also has
\npotentially destructive social effects. Violence against health workers, including physi-
\ncians, not only affects the individuals directly involved, but also impacts the entire health-
\ncare system and its delivery. Such acts of violence affect the quality of the working
\nenvironment, which has the potential to detrimentally impact the quality of patient care.
\nFurther, violence can affect the availability of care, particularly in impoverished areas.
\nWhile workplace violence is indisputably a global issue, various cultural differences
\namong countries must be taken into consideration in order to accurately understand the
\nconcept of violence on a universal level. Significant differences exist in terms of what
\nconstitutes violence and what specific forms of workplace violence are most likely to
\noccur. Threats and other forms of psychological violence are widely recognized to be
\nmore prevalent than physical violence. Reasons and causes of violence in the healthcare
\nsetting are extremely complex.
\nSeveral studies have identified common triggers for acts of violence in the health sector to
\nbe delays in receiving treatment and dissatisfaction with the treatment provided1
\n.
\nMoreover, patients may act aggressively as a result of their medical condition, the medi-
\ncation they take or the use of alcohol and other drugs. Another important example is that
\nindividuals may threaten or perpetrate physical violence against healthcare workers
\nbecause they oppose, on the basis of their social, political or religious beliefs, a specific
\narea of medical practice.
\nA multi-faceted approach encompassing the areas of legislation, security, data collection,
\ntraining, environmental factors, public awareness and financial incentives is required in
\norder to successfully address the issue of violence in the health sector.<\/p>\n

Bangkok\t\u23d0\tS-2012-06-2012
\nViolence\tin\tthe\tHealth\tSector
\nIn addition, collaboration among various stakeholders (including governments, National
\nMedical Associations (NMAs), hospitals, general health services, management, insurance
\ncompanies, trainers, preceptors, researchers, police and legal authorities) is more effective
\nthan the individual efforts of any one party. As the representatives of physicians, NMAs
\nshould take an active role in combating violence in the health sector and also encourage
\nother key stakeholders to act, thus further protecting the quality of the working environ-
\nment for healthcare employees and the quality of patient care.
\nThis collaborative approach to addressing violence in the health sector must be promoted
\nthroughout the world.
\nRECOMMENDATIONS
\nThe WMA encourages National Medical Associations (NMAs) to act in the following areas:
\nStrategy – NMAs should encourage healthcare institutions to develop and implement a
\nprotocol to deal with acts of violence. The protocol should include the following:
\n\u2022 A zero-tolerance policy towards workplace violence.
\n\u2022 A universal definition of workplace violence.
\n\u2022 A predetermined plan for maintaining security in the workplace.
\n\u2022 A designated plan of action for healthcare professionals to take when violence
\ntakes place.
\n\u2022 A system for reporting and recording acts of violence, which may include
\nreporting to legal and\/or police authorities.
\n\u2022 A means to ensure that employees who report violence do not face reprisals.
\nIn order for this protocol to be effective, it is necessary for the management and admin-
\nistration of healthcare institutions to communicate and take the necessary steps to ensure
\nthat all staff are aware of the strategy.
\nPolicymaking – In order to help increase patient satisfaction, national priorities and limita-
\ntions on medical care should be clearly addressed by government institutions.
\nThe state has obligations to ensure the safety and security of patients, physicians, and
\nother healthcare workers. This includes providing an appropriate physical environment.
\nHence, healthcare systems should be designed to promote the safety of healthcare staff and
\npatients. An institution which has experienced an act of violence by a patient may require
\nthe provision of extra security, as all healthcare workers have the right to be protected in
\ntheir work place.
\nIn some jurisdictions, physicians might have the right to refuse to treat a violent patient.
\nIn such cases, they must ensure that adequate alternative arrangements are made by the
\nrelevant authorities in order to safeguard the patient's health and treatment.
\nPatients with acute, chronic or illness-induced mental health disturbances may act
\nviolently toward caregivers; those offering care to these patients must be adequately pro-
\ntected.
\nTraining – A well-trained and vigilant staff supported by management can be a key
\ndeterrent of violent acts. NMAs should work with undergraduate and postgraduate edu-
\ncation providers to ensure that healthcare professionals are trained in the following: com-<\/p>\n

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\nS-2012-06-2012\t\u23d0\tWorld\tMedical\tAssociation
\nmunication skills and recognising and handling potentially violent persons and high risk
\nsituations in order to prevent incidents of violence. The cultivation of physician-patient
\nrelationships based on respect and mutual trust will not only improve the quality of patient
\ncare, but will also foster feelings of security resulting in a reduced risk of violence.
\nCommunication – NMAs should work with other key stakeholders to increase awareness
\nof violence in the health sector. When appropriate, they should inform healthcare workers
\nand the public when acts of violence occur and encourage physicians to report acts of
\nviolence through the appropriate channels.
\nFurther, once an act of violence has taken place, the victim should be informed about the
\nprocedures undertaken thereafter.
\nSupport to victims – Medical, psychological and legal counselling and support should be
\nprovided to staff members who have been the victims of threats and\/or acts of violence
\nwhile at work.
\nData Collection – NMAs should lobby their governments and\/or hospital boards to
\nestablish appropriate reporting systems enabling all healthcare workers to report anony-
\nmously and without reprisal, any threats or incidents of violence. Such a system should
\nassess in terms of number, type and severity, incidents of violence within an institution
\nand resulting injuries. The system should be used to analyse the effectiveness of pre-
\nventative strategies. Aggregated data and analyses should be made available to NMAs.
\nInvestigation – In all cases of violence there should be some form of investigation to
\nbetter understand the causes and to aid in prevention of future violence. In some cases, the
\ninvestigation may lead to prosecution under civil or criminal codes. The procedure should
\nbe, as much as possible, authoritative-led and uncomplicated for the victim.
\nSecurity – NMAs should work to ensure that appropriate security measures are in place in
\nall healthcare institutions and that acts of violence in the healthcare sector are given a high
\npriority by law-enforcement institutions. A routine violence risk audit should be imple-
\nmented in order to identify which jobs and locations are at highest risk for violence.
\nExamples of high risk areas include general practice premises, mental health treatment
\nfacilities and high traffic areas of hospitals including the emergency department.
\nThe risk of violence may be ameliorated by a variety of means which could include
\nplacing security guards in these high risk areas and at the entrance of buildings, by the
\ninstallation of security cameras and alarm devices for use by health professionals, and by
\nmaintaining sufficient lighting in work areas, contributing to an environment conducive to
\nvigilance and safety.
\nFinancial – NMAs should encourage their governments to allocate appropriate funds in
\norder to effectively tackle violence in the health sector.
\n1
\nCarmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence towards hospital-
\nand community- based physicians in the Negev: an observational study BMC Health Service
\nResearch 2005; 5: 54
\nDerazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department
\n(Article in Hebrew) Harefuah. 1999 Aug; 137(3-4): 95-101, 175
\nLandua SF. Violence against medical and non-medical personnel in hospital emergency wards
\nin Israel Research Report, Submitted to the Israel National Institute for Health Policyand Health
\nServices Research, December 2004<\/p>\n

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\nWorld\tMedical\tAssociation\t\u23d0\tS-2013-01-2013
\nWMA\tSTATEMENT
\nON
\nFUNGAL\tDISEASE\tDIAGNOSIS\tAND\tMANAGEMENT
\nAdopted by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nAnnual WHO Global Burden of Disease estimates recognize that fungal diseases account
\nfor a significant proportion of health problems worldwide. These include cutaneous fungal
\ninfections which affect up to a billion persons and vulvovaginal candidiasis which affects
\ntens of millions of women, often multiple times annually.
\nEven more serious are invasive and chronic fungal diseases that lead to estimated annual
\nmorbidity rates that are similar to those caused by commonly recognized global health
\nconcerns such as malaria and tuberculosis. In addition to death, these fungal diseases
\ncommonly lead to chronic ill health, including blindness with keratitis, respiratory distress
\nwith allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensiti-
\nsation (SAFS) and chronic pulmunary aspergillosis (CPA), weight loss and nutritional
\ndeficiency with oesophageal candidiasis and CPA, and inability to engage in healthy
\nsexual activity with vulvovaginal candidiasis.
\nSerious fungal diseases are often opportunistic, occurring as a consequence of other condi-
\ntions that suppress the immune system, such as asthma, AIDS, cancer, post-transplant im-
\nmunosuppressive drugs and corticosteroid therapies. Some occur in critically ill patients.
\nDespite the fact that many fungal diseases can be treated relatively simply, in many cases,
\nthese diseases go untreated. Fungal infections alone are often not distinctive enough to
\nallow a clinical diagnosis, and as cultures are frequently falsely negative, missed diagnosis
\nis common. In addition, a relatively narrow diagnostic window to cure the patient is fre-
\nquently missed, resulting in prolonged expensive hospital stays, often with a fatal out-
\ncome. Despite the existence of effective medicine to treat fungal infections, these are often
\nnot available when and where they are needed.
\nSTATEMENT
\nThe WMA stresses the need to support the diagnosis and management of fungal diseases
\nand urges national governments to ensure that both diagnostic tests and antifungal ther-
\napies are available for their populations. Depending on the prevalence of fungal diseases
\nand their underlying conditions, specific antigen testing or microscopy and culture are
\nessential. These tests, and personnel trained to administer and interpret the tests, should be
\navailable in all countries where systemic fungal infections occur. This will likely include
\ndeveloping at least one diagnostic centre of excellence with a sufficient staff of trained
\ndiagnostic personnel. Monitoring for antifungal toxicities should be available.<\/p>\n

S-2013-01-2013\t\u23d0\tFortaleza
\nFungal\tDisease
\nPhysicians will be the first point of contact for most patients with a fungal infection and
\nshould be sufficiently educated about the topic in order to ensure an effective diagnostic
\napproach.
\nThe WMA encourages its members to undertake and support epidemiologic studies on the
\nburden of fungal disease in their country and to inform the national government of the
\nresults.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2013-02-2013
\nWMA\tSTATEMENT
\nON
\nHUMAN\tPAPILLOMAVIRUS\tVACCINATION
\nAdopted by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nHuman papillomavirus (HPV) vaccination presents a unique and valuable opportunity for
\nphysicians to substantially prevent morbidity and mortality from certain cancers in all
\npopulations, and to improve maternal health. The HPV vaccine therefore merits considera-
\ntion by the World Medical Association (WMA) separately from other vaccines.
\nHPV is a sexually transmitted virus and is so common that most sexually active adults
\nbecome infected at some point in their lives. Most infections are asymptomatic and
\nresolve without medical intervention. However, some of the 40 types of HPV can cause
\ncervical cancer. HPV is the cause of nearly 100% of cervical cancer cases and may also
\ncause cancer of the vagina, vulva, anus, penis and the head and neck. Cervical cancer
\naccounts for more than 10% of all female cancers, and the majority of cervical cancer
\ndeaths are in developing countries.
\nVaccines can protect against infection by the most common HPV types and afford pro-
\ntection against cancer. The U.S. Advisory Committee on Immunization Practices recom-
\nmends HPV vaccination for both females and males starting at age 11 years up to age 26
\nyears. Benefits of vaccinating young men include protection against genital warts and
\ncancer in addition to preventing transmission of HPV to sexual partners. The additional
\nprotection afforded by the quadrivalent vaccine against genital warts as well as cervical
\nand other cancers should be taken into consideration when developing HPV vaccination
\nprogrammes. The HPV vaccines are effective; post-marketing studies have shown decreases
\nin HPV prevalence and HPV related disorders such as genital warts and abnormal cervical
\ncytology. Studies concerning the safety of HPV vaccines have been reassuring.
\nThese vaccines should be made widely available and should be promoted by physicians as
\na matter of individual patient wellbeing and public health.
\nRECOMMANDATIONS
\nThe WMA urges physicians to educate themselves and their patients about HPV and
\nassociated diseases, HPV vaccination and routine cervical cancer screening; and encourages
\nthe development and funding of programs to make HPV vaccine available and to provide
\ncervical cancer screening in countries without organized cervical cancer screening pro-
\ngrams.<\/p>\n

S-2013-02-2013\t\u23d0\tFortaleza
\nHuman\tPapillomavirus\tVaccination
\nNational medical associations (NMAs) are encouraged to carry out intensive education of
\nand advocacy efforts toward their members to:
\n\u2022 Improve awareness and understanding of HPV and associated diseases;
\n\u2022 Understand the availability and efficacy of HPV vaccines;
\n\u2022 Understand the desirability of including HPV vaccines in national immunization
\nprograms;
\n\u2022 Understand the need for routine cervical cancer screening; and
\n\u2022 Integrate HPV cancer prevention methods, early detection and screening, diagnosis,
\ntreatment and palliative care into existing continuing professional development pro-
\ngrams and pre-service training. Such training will leverage existing support for HPV
\nprograms and help in capacity building and quality assurance efforts.
\nNMAs are also encouraged to:
\n\u2022 Integrate HPV vaccination for all adolescents and routine cervical cancer screening
\nfor young women into all appropriate health care settings and visits;
\n\u2022 Support the availability of the HPV vaccine and routine cervical cancer screening
\nfor appropriate populations that benefit most from preventive measures, including
\nbut not limited to at-risk patients such as low-income, disadvantaged and popula-
\ntions that are not yet sexually active;
\n\u2022 Recommend HPV vaccination for all appropriate populations;
\n\u2022 Promote member advocacy for HPV prevention, care and treatment; and
\n\u2022 Create a network of physicians and practitioners who are willing and able to mentor
\nand support one another and establish linkages to existing HPV vaccine and cancer
\nprevention networks.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2013-03-2013
\nWMA\tSTATEMENT
\nON
\nNATURAL\tVARIATIONS\tOF\tHUMAN\tSEXUALITY
\nAdopted by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nHealthcare professionals encounter many aspects of human diversity when providing care,
\nincluding different variations of human sexuality.
\nA large body of scientific research indicates that homosexuality is a natural variation of
\nhuman sexuality without any intrinsically harmful health effects.
\nAs a consequence homosexuality was removed from the American Psychiatric Associa-
\ntion\u2019s official diagnostic manual in 1973. The World Health Organisation (WHO) removed
\nit from the ICD in 1990 following a similar process of scientific review. The Pan
\nAmerican Health Organization (WHO) states: \u201cIn none of its individual manifestations
\ndoes homosexuality constitute a disorder or an illness, and therefore it requires no cure.\u201d
\nDirect and indirect discrimination, stigmatisation, peer rejection, and bullying continue to
\nhave a serious impact upon the psychological and physical health of people with a homo-
\nsexual or bisexual orientation. These negative experiences lead to higher prevalence rates
\nof depression, anxiety disorders, substance misuse, and suicidal ideations and attempts.
\nThe suicide rate among adolescents and young adults with a homosexual or bisexual
\norientation is, consequently, three times higher than that of their peers.
\nThis can be exacerbated by so-called \u201cconversion\u201d or \u201creparative\u201d procedures, which
\nclaim to be able to convert homosexuality into asexual or heterosexual behaviour and give
\nthe impression that homosexuality is a disease. These methods have been rejected by
\nmany professional organisations due to a lack of evidence of their effectiveness. They
\nhave no medical indication and represent a serious threat to the health and human rights of
\nthose so treated.
\nRECOMMENDATIONS
\nThe WMA strongly asserts that homosexuality does not represent a disease, but rather a
\nnatural variation within the range of human sexuality.
\nThe WMA condemns all forms of stigmatisation, criminalisation and discrimination of
\npeople based on their sexual orientation.<\/p>\n

S-2013-03-2013\t\u23d0\tFortaleza
\nNatural\tVariations\tof\tHuman\tSexuality
\nThe WMA calls upon all physicians to classify physical and psychological diseases on the
\nbasis of clinically relevant symptoms according to ICD-10 criteria regardless of sexual
\norientation, and to provide therapy in accordance with internationally recognised treat-
\nments and protocols.
\nThe WMA asserts that psychiatric or psychotherapeutic approaches to treatment must not
\nfocus upon homosexuality itself, but rather upon conflicts, which arise between homo-
\nsexuality, and religious, social and internalised norms and prejudices.
\nThe WMA condemns so-called \u201cconversion\u201d or \u201creparative\u201d methods. These constitute
\nviolations of human rights and are unjustifiable practices that should be denounced and
\nsubject to sanctions and penalties. It is unethical for physicians to participate during any
\nstep of such procedures.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2013-04-2013
\nWMA\tSTATEMENT
\nON
\nTHE\tRIGHT\tOF\tREHABILITATION\tOF\tVICTIMS\tOF\tTORTURE
\nAdopted by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nThe World Medical Association notes with grave concern the continued use of torture in
\nmany countries throughout the world.
\nThe WMA reaffirms its total condemnation of all form of torture, and other cruel, in-
\nhuman or degrading treatment or punishment, as defined by the UN Convention Against
\nTorture (CAT, 1984). Torture is one of the gravest violations of international human rights
\nlaw and has devastating consequences for victims, their families and society as a whole.
\nTorture causes severe physical and mental injuries and is a crime absolutely prohibited
\nunder international law.
\nThe WMA reaffirms its policies adopted previously, namely:
\n\u2022 The Declaration of Tokyo laying down Guidelines for Physicians Concerning Tor-
\nture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to
\nDetention and Imprisonment (1975)
\n\u2022 The Declaration of Hamburg concerning Support for Medical Doctors Refusing to
\nParticipate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman
\nor Degrading Treatment (1997)
\n\u2022 The Resolution on the Responsibility of Physicians in the Documentation and De-
\nnunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment (2003).
\nThe medical evaluation is an essential factor in pursuing the documentation of torture and
\nthe reparation of victims of torture. Physicians have a critical role to play in gathering
\ninformation about torture, documenting evidence of torture for legal purposes, as well as
\nsupporting and rehabilitating victims.
\nThe WMA recognizes the adoption, in December 2012, by the UN Committee Against
\nTorture of the General Comment on the Implementation of article 14 of Convention
\nagainst Torture relating to the right to reparation of victims of torture.
\nThe General Comment outlines the right of rehabilitation as an obligation on States and
\nspecifies the scope of these services. The WMA welcomes in particular:
\n\u2022 The obligation of State parties to adopt a \u201clong-term and integrated approach and<\/p>\n

S-2013-04-2013\t\u23d0\tFortaleza
\nVictims\tof\tTorture
\nensure that specialized services for the victim of torture or ill treatment are available,
\nappropriate and promptly accessible\u201d (paragraph 13), without making access to these
\nservices dependent on the victim pursuing judicial remedies.
\n\u2022 The recognition of the right of victims to choose a rehabilitation service provider, be
\nit a State institution, or a non-State service provider, which is funded by the State.
\n\u2022 The recognition that State parties should provide torture victims with access to
\nrehabilitation programs as soon as possible following an assessment by qualified
\nindependent healthcare professionals.
\n\u2022 The references in paragraph 18 to measures aimed at protecting health and legal
\nprofessionals who assist torture victims, developing specific training on the Istanbul
\nProtocol for health professionals, and promoting the observance of international
\nstandards and codes of conduct by public servants, including medical, psychological
\nand social service personnel.
\nRECOMMENDATIONS
\nThe WMA emphasizes the vital function of reparation for victims of torture and their
\nfamilies in rebuilding their lives and achieve redress and the important role of physicians
\nin rehabilitation.
\nThe WMA encourages its member associations to work with relevant agencies \u2013 govern-
\nmental and non-governmental \u2013 acting for the reparation of victims of torture, in particular
\nin the areas of documentation and rehabilitation, as well as prevention.
\nThe WMA encourages its members to support agencies that are under threat of \u2013 or
\nsubjected to \u2013 reprisals from state parties due to their involvement in the documentation of
\ntorture, rehabilitation and reparation of torture victims.
\nThe WMA calls on its members to use their medical experience to support torture victims
\nin accordance with article 14 of the UN Convention against Torture.
\nThe WMA calls on its member associations to support and facilitate data collection at the
\nnational level in order to monitor the implementation of the State\u2019s obligation to provide
\nrehabilitation services.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2013-05-2013
\nWMA\tSTATEMENT
\nON
\nTHE\tUNITED\tNATIONS\tRESOLUTION\tFOR\tA\tMORATORIUM\tON
\nTHE\tUSE\tOF\tTHE\tDEATH\tPENALTY
\nAdopted by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nThe WMA Resolution on Physician Participation in Capital Punishment states that it is
\nunethical for physicians to take part in capital punishment, and the WMA Declaration of
\nGeneva obliges physicians to maintain the utmost respect for human life.
\nThe WMA acknowledges that the views prevalent in the countries of some of its members
\nprevent all members unconditionally opposing the death penalty.
\nThe WMA therefore supports the suspension of the use of the death penalty through a
\nglobal moratorium.
\nThe WMA has long recognized that it cannot hold its national medical association mem-
\nbers responsible for the actions and policies of their respective governments.
\nRECOMMANDATIONS
\nThe World Medical Association supports United Nations General Assembly Resolution
\n65\/206 calling for a moratorium on the use of the death penalty.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2014-01-2014\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nAESTHETIC\tTREATMENT
\nAdopted by the 65th
\nWMA General Assembly, Durban, South Africa, Otober 2014
\nPREAMBLE
\nAesthetic treatments have become increasingly common in recent years as society appears
\nto have become more preoccupied with physical appearance. These treatments are per-
\nformed by practitioners with widely differing clinical and educational backgrounds.
\nFor the purpose of this statement, aesthetic treatment is defined as an intervention that is
\nperformed not to treat an injury, a disease or a deformity, but for non-therapeutic reasons,
\nwith the sole purpose of enhancing or changing the physical appearance of the individual
\nconcerned. In this statement, the individual undergoing treatment is referred to as the
\npatient. The treatments available include a great variety of interventions, ranging from
\nsurgical procedures to injections and different kinds of skin treatments. This statement
\nfocuses on interventions that are methodologically similar to those performed in con-
\nventional health care. Tattooing, scarring and similar interventions are therefore not con-
\nsidered in this statement.
\nBody image affects a person's self-esteem and mental health and is an integral part of a
\nperson's overall health and well-being. However, media images of \u201cperfect bodies\u201d have
\nbecome the norm, causing some people, to develop unrealistic and unhealthy body images.
\nMany aesthetic treatments involve risks and may potentially harm the health of the patient.
\nMinors1
\nare particularly vulnerable, as their bodies are often not fully developed. In order
\nto protect persons considering or undergoing aesthetic treatment the WMA has developed
\nthe following basic principles regarding aesthetic treatments.
\nReaffirming the medical ethics principles laid out in the WMA Declaration of Geneva, the
\nWMA Declaration of Lisbon on the Rights of the Patient and the WMA International
\nCode of Medical Ethics, and consistent with the mandate of the WMA, this statement is
\naddressed primarily to physicians. However, the WMA encourages other practitioners per-
\nforming aesthetic treatments to adopt these principles.
\nPRINCIPLES
\n1. The patient\u00b4s dignity, integrity and confidentiality must always be respected.
\n2. Physicians have a role in helping to identify unhealthy body images and to address
\nand treat disorders when these exist.<\/p>\n

Durban\t\u23d0\tS-2014-01-2014
\nAesthetic\tTreatment
\n3. Aesthetic treatments must only be performed by practitioners with sufficient knowl-
\nedge, skills and experience of the interventions performed.
\n4. All practitioners providing aesthetic treatments must be registered with and\/or li-
\ncensed by the appropriate regulatory authority. Ideally, the practitioner should also
\nbe authorized by this authority to provide these specific aesthetic treatments.
\n5. All aesthetic treatments must be preceded by a thorough examination of the patient.
\nThe practitioner should consider all circumstances, physical and psychological,
\nthat may cause an increased risk of harm for the individual patient and should
\nrefuse to perform the treatment if the risk is unacceptable. This is especially true in
\nthe case of minors. Practitioners should always choose the most appropriate treat-
\nment option, rather than the most lucrative one.
\n6. Minors may need or benefit from plastic medical treatments but pure aesthetic
\nprocedures should not be performed on minors. If, in exceptional cases, aesthetic
\ntreatment is performed on a minors, it should only be done with special care and
\nconsideration and only if the aim of the treatment is to avoid negative attention
\nrather than gain positive attention. All relevant medical factors, such as whether
\nthe minor is still growing or whether the treatment will need to be repeated at a
\nlater date, must be considered.
\n7. The patient must consent explicitly to any aesthetic treatment, preferably in writing.
\nBefore seeking consent the practitioner should inform the patient of all relevant
\naspects of the treatment, including how the procedure is performed, possible risks
\nand the fact that many of these treatments may be irreversible. The patient should
\nbe given sufficient time to consider the information before the treatment starts.
\nWhere the patient requesting the treatment is a minor, the informed consent of his
\nor her parents or legally authorized representative should be obtained.
\n8. All aesthetic treatments performed should be carefully documented by the practi-
\ntioner. The documentation should include a detailed description of the treatment
\nperformed, information on medications used, if any, and all other relevant aspects
\nof the treatment.
\n9. Aesthetic treatments must only be performed under strictly hygienic and medically
\nsafe conditions on premises that are adequately staffed and equipped. This must
\ninclude equipment for treating life-threatening allergic reactions and other poten-
\ntial complications.
\n10. Advertising and marketing of aesthetic treatments should be responsible and should
\nnot foster unrealistic expectations of treatment results. Unrealistic or altered pho-
\ntographs showing patients before and after treatments must not be used in adver-
\ntising.
\n11. Advertising and marketing of aesthetic treatments should never be targeted to
\nminors.
\n12. Practitioners should never offer or promote financial loans as a means of paying
\nfor aesthetic treatment.
\n1
\nFor the purpose of this statement minor is defined as a person who, according to applicable
\nnational legislation, is not an adult.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2014-02-2014\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nTHE\tPREVENTION\tOF\tAIR\tPOLLUTION\tDUE\tTO\tVEHICLE\tEMISSIONS
\nAdopted by the 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nPREAMBLE
\nThere are a number of ways in which the volume of harmful emissions can be reduced.
\nThese include encouraging fewer road traffic journeys, active transport for individuals
\nundertaking relatively short journeys, the use of mass public transit in preference to
\nindividual vehicles, and alternative energy sources for vehicles, including electric and
\nhybrid technologies. Where vehicle use is essential, means of reducing harmful emissions
\nshould be used.
\nPhysicians around the world are aware of air pollution. It impacts the quality of life for
\nhundreds of millions of people worldwide, causing both, a large burden of disease as well
\nas economic losses and increased health care costs. According to WHO estimates, in 2012,
\nurban outdoor air pollution was responsible for 3.7 million annual deaths, representing
\n6.7% of the total deaths (WHO, 2014).
\nEspecially, diesel soot is acknowledged as a proven carcinogen (IARC, 07\/2012). Further-
\nmore, it has many other toxic effects, most prominently in the cardiovascular (Brook et al.,
\n2010) and respiratory systems (ERS, 2010). Moreover, in the context of global warming,
\nsoot, along with methane, is identified as the second most important greenhouse driving
\nforce substance after CO2 (Kerr, 2013).
\nDespite the fact that new vehicles will have to comply with stricter emission standards
\nwhich take into account most harmful ultra fine particles too, a high-polluting in-use fleet,
\nincluding off-road vehicles such as construction engines and ships, will continue polluting
\nfor many more years.
\nBACKGROUND
\nIn many densely populated cities around the world, fine dust concentrations measurable as
\naerosols exceed up to 50 times the maximum WHO recommendation. High volumes of
\ntransport, power generated from coal, and pollution caused by construction machinery are
\namong the contributing factors. People living and working near major (high density
\nvolume traffic) streets are most affected by pollutants. For fighting the health risks men-
\ntioned above, there exist a variety of highly efficient and reliable filter systems on the
\nmarket (Best Available Technology (BAT) filters1
\n). They are applicable to all internal
\ncombustion engines and they reduce even most harmful ultra-fine particles by a factor of<\/p>\n

Durban\t\u23d0\tS-2014-02-2014
\nAir\tPollution
\nover one hundred. As soon as 90% of heavy duty vehicles, both, new and upgraded ones,
\nsatisfy this standard, health problems attributable to emissions of heavy duty traffic will be
\ngreatly reduced, and no further tightening of emission standards will be possible or even
\nneeded at all because of an almost total elimination of the pollutant as such.
\nIn a variety of countries on different continents and under varying conditions retrofit or
\nupgrading programs have been successfully performed. The UN\u2019s Working Party on Pol-
\nlution Prevention and Energy in Geneva has just proposed a technical standard for
\nregulation in their member states, which will be applicable worldwide.
\nThe WMA supports these efforts and calls on policy makers in all countries, especially in
\nurban regions, to introduce regulatory restrictions of access for vehicles without filter,
\nand\/or to provide financial assistance to support the retrofitting of in-use vehicles.
\nRECOMMENDATIONS
\nThe WMA therefore recommends that all NMAs should encourage their respective govern-
\nments to:
\n1. Introduce BAT standards for all new diesel vehicles (on road and off-road)
\n2. Incentivise retrofitting with BAT filters for all in-use engines
\n3. Monitor and limit the concentration of nanosize soot particles in the urban breathing
\nair
\n4. Conduct epidemiological studies detecting and differentiating the health effects of
\nultrafine particles
\n5. Build professional and public awareness of the importance of diesel soot and the
\nexisting methods of eliminating the particles
\n6. Contribute to developing strategies to protect people from soot particles in aircraft
\npassenger cabins, trains, homes and in the general environment. These strategies
\nshould include plans to develop and increase use of public transportation systems.
\nABBREVIATIONS:
\nEPA: Environmental Protection Agency (US)
\nERS: European Respiratory Society
\nIARC: International Agency for Research of Cancer
\nBAT Standards: Emission standards for passenger cars, heavy-duty vehicles and off-road
\nmachinery, based on count of ultrafine particles rather than mass and aimed at the
\nprotection of human health from the most hazardous soot particles, the lung and even cell
\nmembrane penetrating ultra-fines.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2014-02-2014\t\u23d0\tWorld\tMedical\tAssociation
\nREFERENCES:
\n\u2022 Brook, Robert D. et al. (2010): AHA Scientific Statement: Particulate Matter Air
\nPollution and Cardiovascular Disease. An Update to the Scientific Statement from
\nthe American Heart Association. Circulation 121: 2331-2378.
\n\u2022 ERS (2010): The ERS report on air pollution and public health. European
\nRespiratory Society, Lausanne, Switzerland. ISBN: 978-1-84984-008-8
\n\u2022 IARC (2012): \u201cIARC: Diesel Engine Exhaust Carcinogenic\u201d. Press Release No.
\n213.http:\/\/www.iarc.fr\/en\/media-centre\/pr\/2012\/pdfs\/pr213_E.pdf. (access: 14\/02\/14)
\n\u2022 Kerr, Richard R. (2013): \u201cSoot is Warming the World Even More Than Thought\u201d.
\nIn: Science 339(6118), p. 382.
\n\u2022 WHO (2014): \u201cBurden of disease from Ambient Air Pollution for 2012.\u201d http:\/\/
\nwww.who.int\/phe\/health_topics\/outdoorair\/databases\/AAP_BoD_results_March20
\n14.pdf?ua=1 (access: 26\/08\/14)
\n1
\nEuro 6\/VI, US\/EPA\/CARB, Chinese and equivalent standards.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2014-03-2014
\nWMA\tSTATEMENT
\nON
\nSOLITARY\tCONFINEMENT
\nAdopted by the 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nPREAMBLE
\nIn many countries substantial numbers of prisoners are held at times in solitary confine-
\nment. Prisoners are typically kept in isolation for most of the day, and are allowed out of
\ntheir cells only a short period of time of solitary exercise. Meaningful contact with other
\npeople (prisoners, prison staff, outside world) is kept to a minimum. Some countries have
\nstrict provisions on how long and how often prisoners can be kept in solitary confinement,
\nbut many countries lack clear rules on this.
\nThe reasons for the use of solitary confinement vary in different jurisdictions. It may be
\nused as a disciplinary measure when a prisoner does not respond to other sanctions in-
\ntended to address his or her behaviour, for example, in response to seriously disruptive
\nbehaviour, threats of violence or suspected acts of violence.
\nThe legal authorities in some nations allow individuals to be held in solitary confinement
\nduring an on-going criminal investigation or to be sentenced to solitary confinement, even
\nwhen the individual poses no threat to others. Individuals with mental illness may be
\nkept in high-security or super-maximum security (supermax) units or prisons. Solitary con-
\nfinement can be imposed for hours to days or even years.
\nReliable data on the use of solitary confinement are lacking. Various studies estimate that
\ntens of thousands or even hundreds of thousands of prisoners are currently held in soli-
\ntary confinement worldwide.
\nPeople react to isolation in different ways. For a significant number of prisoners, solitary
\nconfinement has been documented to cause serious psychological, psychiatric, and some-
\ntimes physiological effects, including insomnia, confusion, hallucinations and psycho-
\nsis. Solitary confinement is also associated with a high rate of suicidal behaviour. Nega-
\ntive health effects can occur after only a few days, and may in some cases persist when
\nisolation ends.
\nCertain populations are particularly vulnerable to the negative health effects of solitary
\nconfinement. For example, persons with psychotic disorders, major depression, or post-
\ntraumatic stress disorder or people with severe personality disorders may find isolation
\nunbearable and suffer health harms. Solitary confinement may complicate treating such
\nindividuals and their associated health problems successfully later in the prison environ-
\nment or when they are released back into the community.<\/p>\n

S-2014-03-2014\t\u23d0\tDurban
\nSolitary\tConfinement
\nHuman rights conventions prohibit the use of torture, cruel, inhuman or degrading treat-
\nment or punishment. The use of pronged solitary confinement against a prisoner\u00b4s own
\nwill or the use of solitary confinement during pre-trial detention or against minors can
\nbe regarded as a breach of international human rights law, and must be avoided.
\nRECOMMENDATIONS
\nThe WMA urges National Medical Associations and governments to promote the follow-
\ning principles:
\n1. Solitary confinement should be imposed only as a last resort whether to protect
\nothers or the individual prisoner, and only for the shortest period of time pos-
\nsible. The human dignity of prisoners confined in isolation must always be res-
\npected.
\n2. Authorities responsible for overseeing solitary confinement should take account of
\nthe individual\u2019s health and medical condition and regularly re-evaluate and docu-
\nment the individual\u2019s status. Adverse health consequences should lead to the im-
\nmediate cessation of solitary confinement.
\n3. All decisions on solitary confinement must be transparent and regulated by law.
\nThe use of solitary confinement should be time-limited by law. Prisoners sub-
\nject to solitary confinement should have a right of appeal.
\n4. Prolonged solitary confinement, against the will of the prisoner, must be avoided.
\nWhere prisoners seek prolonged solitary confinement, for whatever reason, they
\nshould be medically and psychologically assessed to ensure it is unlikely to lead to
\nharm.
\n5. Solitary confinement should not be imposed when it would adversely affect the
\nmedical condition of prisoners with a mental illness. If it is essential to provide
\nsafety for the prisoner or other prisoners then especially careful and frequent
\nmonitoring must occur, and an alternative found as soon as possible.
\n6. Prisoners in isolation should be allowed a reasonable amount of regular human
\ncontact. As with all prisoners, they must not be subjected to extreme physical
\nand mentally taxing conditions.
\n7. The health of prisoners in solitary confinement must be monitored regularly by a
\nqualified physician. For this purpose, a physician should be allowed to check both
\nthe documentation of solitary confinement decisions in the institution and the
\nactual health of the confined prisoners on a regular basis.
\n8. Prisoners who have been in solitary confinement should have an adjustment period
\nbefore they are released from prison. This must never extend their period of in-
\ncarceration.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2014-03-2014
\n9. Physician\u00b4s role is to protect, advocate for, and improve prisoners\u00b4 physical and
\nmental health, not to inflict punishment. Therefore, physicians should never parti-
\ncipate in any part of the decision-making process resulting in solitary confine-
\nment.
\n10. Doctors have a duty to consider the conditions in solitary confinement and to pro-
\ntest to the authorities if they believe that they are unacceptable or might amount to
\ninhumane or degrading treatment.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-01-2015
\nWMA\tSTATEMENT
\nON
\nMOBILE\tHEALTH
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nMobile health (mHealth) is a form of electronic health (eHealth) for which there is no
\nfixed definition. It has been described as medical and public health practice supported by
\nmobile devices, such as mobile phones, patient monitoring devices, personal digital
\nassistants (PDAs), and other devices intended to be used in connection with mobile
\ndevices. It includes voice and short messaging services (SMS), applications (apps), and
\nthe use of the global positioning system (GPS).
\nSufficient policies and safeguards to regulate and secure the collection, storage, protection
\nand processing of data of mHealth users, especially health data, must be implemented.
\nUsers of mHealth services must be informed about how their personal data is collected,
\nstored, protected and processed and their consent must be obtained prior to any disclosure
\nof data to third parties, e.g. researchers, governments or insurance companies.
\nThe monitoring and evaluation of mHealth should be implemented carefully to avoid
\ninequity of access to these technologies. Where appropriate, social or healthcare services
\nshould facilitate access to mHealth technologies as part of basic benefit packages, while
\ntaking all the required precautions to guarantee data security and privacy. Access to
\nmHealth technologies should not be denied to anyone on the basis of financial status or a
\nlack of technical expertise.
\nmHealth technologies cover a wide spectrum of functions. They may be used for:
\nHealth promotional (lifestyle) purposes, such as apps into which users input their calorie
\nintake or motion sensors which track exercise.
\nServices which require the medical expertise of physicians, such as SMS services
\nproviding advice to pregnant women or wearable sensors to monitor chronic conditions
\nsuch as diabetes. mHealth technologies of this nature frequently meet the definition of a
\nmedical device and should be subject to risk-based oversight and regulation with all its
\nimplications.
\nmHealth may also be used to expedite the transfer of information between health
\nprofessionals, e.g. providing physicians with free, cross network mobile phone access in
\nresource poor settings.
\nTechnological developments and the increasing prevalence and affordability of mobile
\ndevices have led to an exponential increase in the number and variety of mHealth services<\/p>\n

S-2015-01-2015\t\u23d0\tMoscow
\nMobile\tHealth
\nin use in both developed and developing countries. At the same time, this relatively new
\nand rapidly evolving sector remains largely unregulated, a fact which could have potential
\npatient safety implications.
\nmHealth has the potential to supplement and further develop existing healthcare services
\nby leveraging the increasing prevalence of mobile devices to facilitate access to
\nhealthcare, improve patient self-management, enable electronic interactions between
\npatients and their physicians and potentially reduce healthcare costs. There are significant
\nregional and demographic variations in the potential use and benefits of mHealth. The use
\nof certain mHealth services may be more appropriate in some settings than others.
\nmHealth technologies generally involve the measurement or manual input of medical,
\nphysiological, lifestyle, activity and environmental data in order to fulfil their primary
\npurpose. The large amount of data generated in this way also offers huge scope for
\nresearch into effective healthcare delivery and disease prevention. However, this
\nsecondary use of personal data also has great potential for misuse and abuse, of which
\nmany users of mHealth services are unaware.
\nThe expansion of mHealth services has been largely market driven and many technologies
\nhave been developed in an uncoordinated, experimental fashion and without appropriate
\nconsideration of data protection and security or patient safety aspects. It is often
\nimpossible for users to know whether the information provided via mHealth stems from a
\nreliable medical source. Major challenges faced by the mHealth market are the quality of
\nmHealth technologies and whether their use ultimately helps patients or physicians
\nachieve the intended purpose.
\nComprehensive regulation and evaluation of the effectiveness, quality and cost
\neffectiveness of mHealth technologies and services is currently lacking, which has
\nimplications for patient safety. These factors are crucial to the integration of mHealth
\nservices into regular healthcare provision.
\nRECOMMENDATIONS
\nThe WMA recognises the potential of mHealth to supplement traditional ways of
\nmanaging health and delivering healthcare. While mHealth may offer advantages to
\npatients otherwise unable to access services from physicians, it is not universally
\nappropriate, nor is it always an ideal form of diagnosis and treatment option. Where face-
\nto-face treatment is available this is almost always advantageous to the patient.
\nThe driving force behind mHealth must be the need to eliminate deficiencies in the
\nprovision of care or to improve the quality of care.
\nThe WMA urges patients and physicians to be extremely discerning in their use of
\nmHealth and to be mindful of potential risks and implications.
\nA clear distinction must be made between mHealth technologies used for lifestyle
\npurposes and those which require the medical expertise of physicians and meet the<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-01-2015
\ndefinition of medical devices. The latter must be appropriately regulated and users must be
\nable to verify the source of information provided. The information provided must be clear,
\nreliable and non-technical, and therefore comprehensible to lay people.
\nConcerted work must go into improving the interoperability, reliability, functionality and
\nsafety of mHealth technologies, e.g. through the development of standards and
\ncertification schemes.
\nComprehensive and independent evaluations must be carried out by competent authorities
\nwith appropriate medical expertise on a regular basis in order to assess the functionality,
\nlimitations, data integrity, security and privacy of mHealth technologies. This information
\nmust be made publicly available.
\nmHealth can only make a positive contribution towards improvements in care if services
\nare based on sound medical rationale. As evidence of clinical usefulness is developed,
\nfindings should be published in peer reviewed journals and be reproducible.
\nSuitable reimbursement models must be set up in consultation with national medical
\nassociations and healthcare providers to ensure that physicians receive appropriate
\nreimbursement for their involvement in mHealth activities
\nA clear legal framework must be drawn up to address the question of identifying potential
\nliability arising from the use of mHealth technologies.
\nPhysicians who use mHealth technologies to deliver healthcare services should heed the
\nethical guidelines set out in the WMA Statement on Guiding Principles for the Use of
\nTelehealth for the Provision of Health Care.
\nIt is important to take into account the risks of excessive or inappropriate use of mHealth
\ntechnologies and the potential psychological impact this can have on patients.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-02-2015
\nWMA\tSTATEMENT
\nON
\nPHYSICIANS\tWELL-BEING
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nPhysician well-being refers to the optimization of all factors affecting biological,
\npsychological and social health and preventing or treating acute or chronic diseases
\nexperienced by physicians including mental illness, disabilities and injuries resulting from
\nwork hazards, occupational stress and burnout.
\nPhysician\u2019s well-being could have positive impact on patient care, but more research is
\nneeded. The profession should therefore encourage and support on-going research on
\nphysician\u2019s health. Evidence that already exists should be implemented in policy and
\npractice. While physicians tend to have healthy habits, it is essential to enhance their
\nhealth as a way to improve health for the whole population.
\nPhysicians and medical students at all career stages are exposed to both positive
\nexperiences as well as a variety of stressors and work injuries The medical profession
\nshould seek to identify and revise policies and practices that contribute to these stressors
\nand collaborate with NMA\u2019s in order to develop policies and practices that have protective
\neffects. Like all human beings, physicians experience illness, and they also have family
\nobligations and other commitments outside their professional lives that should be taken
\ninto account.
\nOne reason physicians delay seeking help is their concern about confidentiality and feeling
\nill at ease in the patient role. They experience feelings of responsibility towards their
\npatients and are sensitive to external expectations on their health. Therefore, physicians
\nmust be assured of the same right of confidentiality as any other patient when seeking and
\nundergoing treatment. The health care system may need to provide special arrangements
\nfor the care of physician-patients in order to uphold its duty to provide privacy and
\nconfidentiality. Prevention, early assistance and intervention should be available
\nseparately from any disciplinary process.
\nTHREATS,\tBARRIERS\tAND\tOPPORTUNITIES\tFOR\tPHYSICIAN\tWELL-BEING\t<\/p>\n

Professional\tRoles\tand\tExpectations
\nThe medical profession often attracts highly driven individuals with a strong sense of
\nduty. Successfully completing the long and intense educational requirements often confers<\/p>\n

S-2015-02-2015\t\u23d0\tMoscow
\nPhysicians\tWell-Being
\nupon physicians a high degree of respect and responsibility in their communities.
\nWith these high levels of respect and responsibility, physicians are subject to high
\nexpectations from patients and the public. These expectations can contribute to
\nprioritizing the care of others over care of self and feelings of guilt and selfishness for
\nmanaging their own well-being.
\nThere is a direct relationship between physicians\u2019 and patients\u2019 preventive health
\npractices. This relationship should encourage healthcare systems to better support and
\nevaluate the effects on patients of improving physician and medical student health.
\nWork\tEnvironment
\nWorking conditions, including workload and working hours, affect physicians\u2019
\nmotivation, job satisfaction, personal life and psychological health during their careers.
\nPhysicians are often perceived as being immune to injury and diseases as they care for
\ntheir patients, and workplace health and safety programs may be overlooked. Physician
\nwho are employed by small organizations or who are self-employed may be at even a
\nhigher risk for occupational diseases and may not have access to health and safety
\nprograms provided by large health care establishments.
\nAs a consequence of their professional duties, physicians and physicians in postgraduate
\neducation often confront emotionally challenging and traumatic situations including
\npatients\u2019 suffering, injury and death. Physicians may also be exposed to physical hazards
\nlike radiation, noise, poor ergonomics, and biological hazards like HIV, TB and hepatitis.
\nSome healthcare systems may exacerbate stress because of the hierarchies and competition
\ninherent in them. Physicians in postgraduate education and medical students can be
\nvictims of harassment and discrimination during their medical education. Due to their
\nposition within the medical hierarchy, they may feel powerless to confront these
\nbehaviours.
\nPhysician autonomy is one of the strongest predictors of physician satisfaction. Increasing
\nexternal regulatory pressures such as undue emphasis on cost efficiencies and concerns
\nabout consequences of reporting medical errors may unduly influence medical decision-
\nmaking and diminish a physician\u2019s autonomy.
\nIllness
\nEven though medical professionals recognize that it is preferable to identify and treat
\nillness early, physicians are often adept at hiding their own illnesses and may continue to
\nfunction without seeking help until they become incapable of carrying out their duties.
\nThere are many potential obstacles to an ill physician seeking care including: denial,
\nconfidentiality issues, aversion to the patient role, practice coverage, fear of disciplinary
\naction, potential loss of practice privileges, loss of performance based payment and the
\nefficiencies of self-care. Because of these obstacles doctors are often reluctant to refer
\nthemselves or their colleagues for treatment.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-02-2015
\nIllnesses can include mental and behavioural health problems, burnout, communication
\nand interpersonal issues, physical and cognitive problems and substance use disorders.
\nThese illnesses and problems can overlap and can occur throughout the professional life
\ncycle from basic medical education to retirement. It is important to acknowledge the
\ncontinuum of physician well-being, ranging from optimal health, to minor illness, to
\ndebilitating illness.
\nSubstance abuse may disrupt a physician\u2019s personal life and may also significantly affect
\nhis or her ability to care for patients. Easy access to medications may contribute to
\nphysicians\u2019 risk for abuse of recreational drugs and prescription medications. Assistance
\nprior to impairment in the workplace is protective for physicians, their professional
\ncredentials and their patients.
\nImproved wellness promotion, prevention strategies and earlier intervention can help
\nmitigate the severity of mental and physical illnesses and help reduce incidence of suicide
\nin physicians, physicians in postgraduate education and medical students.
\nRECOMMENDATIONS
\nThe World Medical Association recommends that National Medical Associations (NMAs)
\nrecognize and, where possible, actively address the following:
\n1. In partnership with medical schools and workplaces, NMAs recognize their obligation
\nto provide education at all levels about physician well-being. NMAs should
\ncollaboratively promote research to establish best practices that promote physician
\nhealth and to determine the impact of physician well-being on patient care.
\n2. Physician well-being should be supported and provided within and outside the
\nworkplace. Support may include but is not limited to referral to medical treatment,
\ncounselling, support networks, recognized physician health programs, occupational
\nrehabilitation and primary prevention programs including resiliency training, healthy
\nlifestyles and case management.
\n3. NMA\u2019s should recognize the strong and consistent link between physicians\u2019 and
\npatients\u2019 personal health practices, providing yet another critically important reason
\nfor health systems to promote physician health.
\n4. Physician health programs can help all physicians to proactively help themselves via
\nprevention strategies and can assist physicians who are ill via assessment, referral to
\ntreatment and follow-up. Programs and resources to help promote positive
\npsychological health should be available to all physicians. Early identification,
\nintervention and special arrangements for the care of physician-patients should be
\navailable to protect the health of physicians. Fostering a supportive and accepting
\nculture is critical to successful early referral and intervention.
\n5. Physicians at risk for abuse of alcohol or drugs should have access to appropriate<\/p>\n

S-2015-02-2015\t\u23d0\tMoscow
\nPhysicians\tWell-Being
\nconfidential medical treatment and comprehensive professional support. NMAs
\nshould promote programs that help physicians re-enter medical practice with
\nappropriate ongoing supervision at the completion of their treatment programs. More
\nresearch should be conducted to determine best practices in preventing substance
\nabuse among physicians and physicians in postgraduate education.
\n6. Physicians have the right to working conditions that help limit the risk of burnout and
\nempower them to care for their personal health by balancing their professional
\nmedical commitments and their private lives and responsibilities. Optimal working
\nconditions include a safe and reasonable maximum number of consecutive and total
\nworking hours, adequate rest between shifts and appropriate number of non-working
\ndays. Relevant organizations should constructively address professional autonomy
\nand work-life balance problems and involve physicians in making decisions about
\ntheir work lives. Working conditions must not put the safety of patients or physicians
\nat risk, and ultimately physicians should be engaged in establishing optimal
\nworkplace conditions.
\n7. Workplaces should promote conditions conducive to healthy lifestyles, including
\naccess to healthy food choices, exercise, nutrition counselling and support for
\nsmoking cessation.
\n8. Physicians, physicians in postgraduate education and medical students have the right
\nto work in a harassment and violence-free workplace. This includes freedom from
\nverbal, sexual and physical abuse.
\n9. Physicians, physicians in postgraduate education and medical students have the right
\nto a collaborative safe workplace. Workplaces should promote interdisciplinary
\nteamwork, and communication between physicians and all other professionals in the
\nworkplace should be offered in a spirit of cooperation and respect. Education on
\ncommunications skills, self-awareness and team-work should be considered.
\n10. Medical staff should undergo training in recognizing, handling and communicating
\nwith potentially violent persons. Health care facilities should safeguard against
\nviolence including routine violence risk audits, especially in mental health treatment
\nfacilities and emergency departments. Staff members who are victims of violence or
\nwho report violence should be supported by management and offered medical,
\npsychological and legal counselling.
\n11. Medical schools and teaching hospitals should develop and maintain confidential
\nservices for physicians in postgraduate education and medical students and to raise
\nawareness of and access to such programs. Workplaces should consider offering
\nmedical consultations to physicians in postgraduate education in order to identify any
\nhealth issues at the outset of medical education.
\n12. Workplace support for all physicians should be easily accessible and confidential.
\nPhysicians evaluating and treating their medical colleagues should not be required to
\nreport any aspects of their physician-patients\u2019 care in any manner not required for
\ntheir non-physician patients.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-03-2015
\nWMA\tSTATEMENT
\nON
\nSUPPORTING\tHEALTH\tSUPPORT\tTO\tSTREET\tCHILDREN
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nThe WMA recognises that having children in living on the streets is unacceptable in a
\nsociety even though this phenomenon is difficult to avoid in many communities around
\nthe world.
\nThe WMA intends to raise awareness within civil and medical society about the
\nfundamental role played by medical contact in improving the situation of street children.
\nIn this regard, it is important that the initial contact with street children be based on trust.
\nTherefore, together with other healthcare professionals and social workers, medical
\ncontact should be viewed as the first step towards resocialising street children by building
\ntrust between the physician and the street child. Once achieved, a more global
\nmultidisciplinary and multidimensional approach can follow to improve the well-being of
\nstreet children.
\nChildhood and adolescence are the beginnings of a long physical, mental, cultural and
\nsocial growth process;
\nThe health of young people shapes the health of tomorrow's population;
\nYoung people play a part in social cohesion and they are an asset to any country;
\nAddressing the social determinants of health is essential to achieving equity in healthcare.
\nThe social determinants leading to the appearance and growth of the phenomenon of
\n\u201cstreet children\u201d are varied and complex;
\nThe negative health impact of living on the streets for children, both in terms of the
\nadditional health risks to which these children are exposed and their lack of access to
\nhealthcare and prevention; street children are, in particular, more vulnerable to acute
\nillnesses and traumatic injuries. In addition, preventive care and continuity of care are
\nnon-existent for street children due to frequent relocation;
\nThe health of street children remains critical and has been exacerbated by the global
\nfinancial and economic crisis, which has contributed to family break-ups, social upheaval
\nand disruptions in healthcare and education;
\nChildren may be victims of discrimination arising from their gender, ethnic origin,<\/p>\n

S-2015-03-2015\t\u23d0\tMoscow
\nHealth\tSupport\tto\tStreet\tChildren
\nlanguage, religion, political opinion, handicap, social status or population migration;
\nStreet children are especially vulnerable to abuse, violence, exploitation and manipulation,
\nincluding trafficking;
\nChild homelessness often goes unrecognised at a national and international level since it is
\ndifficult to quantify and assess.
\nRECOMMENDATIONS
\n1. The WMA strongly condemns any violations of the rights of children living on the
\nstreets and any infringements of these rights, in particular discrimination and
\nstigmatisation and their exposure to abuse, violence, exploitation and manipulation,
\nincluding trafficking.
\n2. The WMA calls upon governments to address the factors, which lead to children living
\non the streets and to take action to implement all applicable legislation and systems of
\nprotection to reduce the health implications for street children. National authorities
\nhave an obligation to provide care for all children and, where necessary, to support
\ntheir return to a living environment appropriate for a child.
\n3. Reducing health implications includes not only direct treatment of health issues but
\nalso protection of Street Children from health risks such as exposure to drugs, HIV
\ninfection, smoking and drinking.
\n4. The WMA calls upon governments, national medical associations and healthcare
\nprofessionals to acknowledge the scale of this phenomenon and to instigate prevention
\nand awareness campaigns. These children must be able to access the full range of
\nnecessary health and social protection.
\n5. The WMA urges all national medical associations to work with legal counterparts,
\ngovernments, health care professionals and public authorities to ensure the
\nfundamental rights of children, who are a particularly vulnerable population in need of
\nprotection, particularly access to healthcare and education. The right to food and
\nhousing should be guaranteed, and any form of discrimination or exploitation should
\nbe forbidden.
\n6. The WMA condemns any improper age-assessment practices that make use of
\ninsufficiently reliable clinical or paraclinical investigations. Until they reach
\nadulthood, adolescents must be able to enjoy their status as minors, as recognised by
\nthe UN International Convention on the Rights of the Child.
\n7. The WMA urges physicians to remain vigilant in terms of delivering all the support
\nrequired to provide suitable and comprehensive care for 'street children'. Physicians
\nshould be aware that homelessness is a pervasive problem. They should be
\nknowledgeable about the existence of homelessness in their own communities and are
\nencouraged to establish a relationship of trust between the physician and the street
\nchild to become involved in local relief and advocacy programs.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-03-2015
\n8. The WMA maintains that every effort should be made to provide all children, and
\nparticularly those that are homeless, with access to a suitable and balanced psycho-
\nsocial environment, in which their rights, including the right to health, are respected.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-04-2015
\nWMA\tSTATEMENT
\nON
\nRIOT\tCONTROL\tAGENTS
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nThere has been a long-standing concern regarding the use of chemical weapons. Despite
\nthis concern, poison gas was used fairly extensively during World War I, leading to a call
\nfrom the International Committee of the Red Cross (ICRC) in February 1918 for cessation
\nof its use.
\nThis led to the Geneva Protocol of 1925, the Biological and Toxin Weapons Convention
\nof 1972 (BTWC) and the Chemical Weapons Convention of 1993 (CWC).
\nAll but six countries in the world have signed and ratified the CWC; two more have
\nsigned but not yet ratified, making it a nearly universally accepted Convention.
\nThe conventions prohibit the development, production and stockpiling of chemical
\nweapons in addition to their usage in warfare and call for measures to decommission or
\ndestroy existing stores. However, the CWC allows the use of specific chemicals in
\ndomestic law enforcement including riot control situations, which means that governments
\nmight hold stockpiles of certain agents. Even so, riot control agents cannot be used in
\nwarfare; the exclusion has reached the status of customary law, which allows their use
\nonly in domestic or national jurisdictions.
\nAlthough there is academic and military interest in what is often called non-lethal
\nweapons, the incidence of morbidity and mortality caused by weapons are not criteria used
\nin prohibition. A tiered approach based upon degrees of lethality of specific weapons is
\ncontrary to the ethos of both conventions.
\nIn situations of widespread public unrest and political or other uprisings governments
\nunfortunately may choose to deploy riot control agents in a domestic setting. Although
\nthis is not in conflict with the principles of the CWC their use may still give rise to
\nspecific medical, legal and ethical challenges.
\nWhile riot control agents are designed to make remaining within the riot unpleasant and
\nimpractical, they are not expected to directly cause any injuries or deaths. As with all other
\nagents, how they are used determines the concentration to which individuals are exposed.
\nThe ability to take evasive actions, such as leaving the area, to reduce exposure may also
\nhave an impact. It is recognised that individual determinants including general health and
\nage will affect an individual\u2019s response to chemical agent.<\/p>\n

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\nRiot\tControl\tAgents
\nRelease of chemical agents such as tear gas in a small enclosed space exposes individuals
\nto concentrations far higher than those expected in normal deployment in riot situations,
\ncausing higher levels of serious morbidity and potentially death.
\nMisuse of riot control agents, leading to serious harms or deaths of demonstrators,
\nexposing individuals excessively or using them for oppressing non-violent peaceful
\ndemonstrations, may lead to a breach of the human rights of the individuals concerned, in
\nparticular the right to life (article 3), the right to freedom of expression (article 19) and of
\npeaceful assembly (article 20) of the Universal Declaration of Human Rights.
\nGovernments, who authorize the stockpiling and use of such agents by their police and
\nsecurity forces, are urged to consider that there might be fatal results of their usage.
\nGovernments are required to ensure that they are used in a manner, which minimise their
\nlikelihood of causing serious morbidity and mortality.
\nRECOMMENDATION
\nThe WMA recognises that the inappropriate use of riot control agents risks the lives of
\nthose targeted and exposes people around, amounting to a potential breach of human rights
\nstandards, in particular the right to life, the right to freedom of expression and of peaceful
\nassembly as stated in the Universal Declaration of Human Rights.
\nIn case of use of riot control agents, the WMA urges States to do so in a manner designed
\nto minimise the risk of serious harm to individuals, and to prohibit its use in the presence
\nof vulnerable populations, such as children, older people or pregnant women;
\nThe WMA insists that riot control agents should never be used in enclosed spaces where
\nchemical concentrations may reach dangerous levels, and where people cannot move away
\nfrom areas with high concentrations of the agent;
\nThe WMA insists that governments train police and other security forces in the safe and
\nlegal use of riot control agents, in order to minimise the risk of harm when they are
\ndeployed. This must include the rapid evacuation of any individual who is apparently
\nsuffering from a high level of exposure, not aiming people, and not using the agent
\nexcessively;
\nThe WMA insists that States penalise individuals who misuse riot control agents and who
\ndeliberately endanger human life and safety by using the agents. Such misuse leading to
\nserious physical harms or death of individuals should be investigated by independent
\nexperts.
\nThe WMA calls for unimpeded and protected access of healthcare personnel to allow them
\nto fulfil their duty of attending to the injured as set forth in the \u201cWMA Declaration on the
\nprotection of healthcare workers in situations of violence\u201d.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-04-2015
\nThe WMA recommends that, because of the significant difficulties and risks to health and
\nlife associated with the use of such riot control agents, States should refrain from using
\nthem in any circumstances.\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-05-2015
\nWMA\tSTATEMENT
\nON
\nTRANSGENDER\tPEOPLE
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nIn most cultures, an individual\u2019s sex is assigned at birth according to primary physical sex
\ncharacteristics. Individuals are expected to identify with their assigned sex (gender
\nidentity) and behave according to specific cultural norms strongly associated with this
\n(gender expression). Gender identity and gender expression make up the concept of
\n\u201cgender\u201d itself.
\nThere are individuals who experience different manifestations of gender that do not
\nconform to those typically associated with their sex assigned at birth. The term
\n\u201ctransgender\u201d refers to people who experience gender incongruence, which is defined as a
\nmarked mismatch between one\u2019s gender and the sex assigned at birth.
\nWhile conceding that this is a complex ethical issue, the WMA would like to acknowledge
\nthe crucial role played by physicians in advising and consulting with transgender people
\nand their families about desired treatments. The WMA intends this statement to serve as a
\nguideline for patient-physician relations and to foster better training to enable physicians
\nto increase their knowledge and sensitivity toward transgender people and the unique
\nhealth issues they face.
\nAlong the transgender spectrum, there are people who, despite having a distinct
\nanatomically identifiable sex, seek to change their primary and secondary sex
\ncharacteristics and gender role completely in order to live as a member of the opposite sex
\n(transsexual). Others choose to identify their gender as falling outside the sex\/gender
\nbinary of either male or female (genderqueer). The generic term \u201ctransgender\u201d represents
\nan attempt to describe these groups without stigmatisation or pathological characterisation.
\nIt is also used as a term of positive self-identification. This statement does not explicitly
\naddress individuals who solely dress in a style or manner traditionally associated with the
\nopposite sex (e.g. transvestites) or individuals who are born with physical aspects of both
\nsexes, with many variations (intersex). However, there are transvestites and intersex
\nindividuals who identify as transgender. Being transvestite or intersex does not exclude an
\nindividual from being transgender. Finally, it is important to point out that transgender
\nrelates to gender identity, and must be considered independently from an individual\u2019s
\nsexual orientation.
\nAlthough\t being\t transgender\t does\t not\t in\t itself\t imply\t any\t mental\t impairment,
\ntransgender\t people\t may\t require\t counseling\t to\t help\t them\t understand\t their\t gender\t<\/p>\n

S-2015-05-2015\t\u23d0\tMoscow
\nTransgender\tPeople
\nand\t to\t address\t the\t complex social and relational issues that are affected by it. The
\nDiagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
\nAssociation (DSM-5) uses the term \u201cgender dysphoria\u201d to classify people who experience
\nclinically significant distress resulting from gender incongruence.
\nEvidence suggests that treatment with sex hormones or surgical interventions can be
\nbeneficial to people with pronounced and long-lasting gender dysphoria who seek gender
\ntransition. However, transgender people are often denied access to appropriate and
\naffordable transgender healthcare (e.g. sex hormones, surgeries, mental healthcare) due to,
\namong other things, the policies of health insurers and national social security benefit
\nschemes, or to a lack of relevant clinical and cultural competence among healthcare
\nproviders. Transgender persons may be more likely to forego healthcare due to fear of
\ndiscrimination.
\nTransgender people are often professionally and socially disadvantaged, and experience
\ndirect and indirect discrimination, as well as physical violence. In addition to being denied
\nequal civil rights, anti-discrimination legislation, which protects other minority groups,
\nmay not extend to transgender people. Experiencing disadvantage and discrimination may
\nhave a negative impact upon physical and mental health.
\nRECOMMENDATION\t<\/p>\n

1. The WMA emphasises that everyone has the right to determine one\u2019s own gender
\nand recognises the diversity of possibilities in this respect. The WMA calls for
\nphysicians to uphold each individual\u2019s right to self-identification with regards to
\ngender.
\n2. The WMA asserts that gender incongruence is not in itself a mental disorder;
\nhowever it can lead to discomfort or distress, which is referred to as gender
\ndysphoria (DSM-5).
\n3. The WMA affirms that, in general, any health-related procedure or treatment
\nrelated to an individual\u2019s transgender status, e.g. surgical interventions, hormone
\ntherapy or psychotherapy, requires the freely given informed and explicit consent
\nof the patient.
\n4. The WMA urges that every effort be made to make individualised, multi-
\nprofessional, interdisciplinary and affordable transgender healthcare (including
\nspeech therapy, hormonal treatment, surgical interventions and mental healthcare)
\navailable to all people who experience gender incongruence in order to reduce or to
\nprevent pronounced gender dysphoria.
\n5. The WMA explicitly rejects any form of coercive treatment or forced behaviour
\nmodification. Transgender healthcare aims to enable transgender people to have
\nthe best possible quality of life. National Medical Associations should take action
\nto identify and combat barriers to care.
\n6. The WMA calls for the provision of appropriate expert training for physicians at<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-05-2015
\nall stages of their career to enable them to recognise and avoid discriminatory
\npractises, and to provide appropriate and sensitive transgender healthcare.
\n7. The WMA condemns all forms of discrimination, stigmatisation and violence
\nagainst transgender people and calls for appropriate legal measures to protect their
\nequal civil rights. As role models, individual physicians should use their medical
\nknowledge to combat prejudice in this respect.
\n8. The WMA reaffirms its position that no person, regardless of gender, ethnicity,
\nsocio-economic status, medical condition or disability, should be subjected to
\nforced or coerced permanent sterilisation (WMA Statement on Forced and Coerced
\nSterilisation). This also includes sterilisation as a condition for rectifying the
\nrecorded sex on official documents following gender reassignment.
\n9. The WMA recommends that national governments maintain continued interest in
\nthe healthcare rights of transgender people by conducting health services research
\nat the national level and using these results in the development of health and
\nmedical policies. The objective should be a responsive healthcare system that
\nworks with each transgender person to identify the best treatment options for that
\nindividual.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tS-2015-06-2015
\nWMA\tSTATEMENT
\nON
\nVITAMIN\tD\tINSUFFICIENCY
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nVitamin D has major role in calcium and bone metabolism. Normal values are 75-100
\nnmol\/L (30-40 ng\/ml). Vitamin D deficiency is defined if serum hydroxyvitamin D levels
\nare less than 50nmol\/L (20 ng\/ml), insufficiency as 50-75 nmol\/L (20-30 ng\/ml).
\nStudies demonstrate that vitamin D is essential also for overall health and well-being. In
\nthe body vitamin D is produced during exposure to sunlight and in lesser degree by food
\nintake.
\nVitamin D exists in two forms: vitamin D3 (cholecalciferol in humans and other
\nmammals) and vitamin D2(ergocalciferol in plants), but both are similarly metabolized.
\nVitamin D3 is more active than vitamin D2.
\nThe serum concentration of the hepatic metabolite of vitamin D3, the 25-hydroxyvitamin
\nD, is consideredas the best biomarker of vitamin D status.
\nVitamin D deficiency is an important health issue globally. About one third of the
\npopulation is estimated to have lower serum concentration of vitamin D.
\nMany studies have shown that vitamin D deficiency is linked to impaired growth and
\ndevelopment. Because vitamin D receptors are broadly distributed in tissues, vitamin D
\ndeficiency is associated with musculoskeletal disorders (osteoporosis), falls, fractures,
\nautoimmune disorders, chronic inflammatory diseases, type 2 diabetes mellitus, and
\ncardiovascular, neurologic and psychiatric disorders. High risk groups are young children,
\nthe elderly and pregnant women. Primary factors, contributing to vitamin D deficiency,
\ninclude reduced sunshine exposure, poor quality diet, availability of fortified foods and
\nsupplement use.<\/p>\n

RECOMMANDATIONS\t<\/p>\n

Because of widespread occurrence of vitamin D deficiency\/insufficiency it is desirable to
\nfocus attention on adequate preventive actions in populations at risk. Determining vitamin
\nD levels requires only a blood test, and oral supplementation is a simple treatment method.
\nSun exposure is not generally recommended because it can increase the risk of skin
\ncancer.<\/p>\n

S-2015-06-2015\t\u23d0\tMoscow
\nVitamin\tD\tInsufficiency
\nThe World Medical Association recommends that national medical associations:
\n\u2022 Support continued research in vitamin D and its metabolites
\n\u2022 Educate physicians about the evolving science of vitamin D and its impact on
\nhealth (documents, brochures, posters)
\n\u2022 Encourage physicians to consider measuring the serum concentrations of 25-
\nhydroxyvitamin D in the patients at risk of vitamin D deficiency
\n\u2022 Monitor development of dietary recommendations for vitamin D.<\/p>\n

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\nS-2015-07-2015\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tGUIDELINES
\nON\tPROMOTIONAL\tMASS\tMEDIA
\nAPPEARANCES\tBY\tPHYSICIANS
\nAdopted by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nMass media can effectively play diverse roles in medical communication. Physicians, as
\nprofessionals and experts can contribute to improved public health by providing the public
\nwith accurate health related information. Mass media provides a channel through which
\nphysicians may contribute to society by leveraging mass media appearances in positive
\nways.
\nHowever, the increase in instances of physicians\u2019 frequent appearances on mass media to
\nrecommend unproven treatments or products and to use such appearances for marketing
\npurposes is posing a serious concern. The public may readily accept groundless
\nrecommendations by physicians and may develop unrealistic expectations. The subsequent
\nconfusion and disappointment can damage the patient-physician-relationship.
\nThis issue is more serious in some countries where there are different systems of
\nmedicine, including alternative medicine.<\/p>\n

RECOMMANDATIONS\t<\/p>\n

The WMA recommends the following guidelines regarding mass media appearances by
\nphysicians to prevent them from being involved in commercial activities that may
\ncompromise professional ethics and to contribute to patient safety by ensuring physicians
\nproviding accurate, timely, and objective information.
\nAccurate and Objective Delivery of Scientifically Proven Medical Information
\nWhen appearing in media, physicians shall provide objective and evidence-based
\ninformation and shall not recommend medical procedures or products that are not
\nmedically proven or justified.
\nA physician shall not use expressions that may promote unrealistic patient expectations or
\nmislead viewers about the function and effect of medical procedures, drugs or other
\nproducts.
\nPhysicians shall include important information including possible adverse effects and risks
\nwhen explaining medical procedures, drugs, or other products.<\/p>\n

S-2015-07-2015\t\u23d0\tMoscow
\nPromotional\tMass\tMedia\tAppearances\tby\tPhysicians
\nNot Abusing Mass Media as a Means of Advertisement
\nPhysicians should not recommend specific products by either specifically introducing or
\nintentionally highlighting the name or trademark of a product.
\nPhysicians shall practice prudence regarding personal appearances on home shopping
\nprograms.. The physician should have no financial stake in the products being sold.
\nPhysicians shall not be a part of mass media advertisement on any product, which is
\nharmful to human, and\/or environment.
\nMaintaining Professional Integrity
\nPhysicians shall not require or receive economic benefits for mass media appearances
\nother than a customary appearance fee.
\nPhysicians shall not provide economic benefits to broadcasting personnel in order to
\nsecure mass media appearances.
\nPhysicians shall not engage in the promotion, sale or advertising of commercial products
\nand shall not introduce false or exaggerated statements regarding their qualifications such
\nas academic background, professional experience, medical specialty and licensure as a
\nspecialist, for the benefit of the economic interests of any commercial entity.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2016-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON\tAGEING
\nAdopted by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\nThe world is undergoing a longevity extension at an unprecedentedly rapid pace. Over the
\nlast century, some 30 years have been added to global average Life Expectancy at Birth
\n(LEB) \u2013 with more gains expected in the future. By 2050, LEB is projected to reach 74
\nyears with an ever-increasing number of countries reaching 80 years and beyond. In 1950
\nthe total number of people aged 80+ was 14 million \u2013 by 2050 the estimated number is
\n384 million, a 26-fold increase. The proportion of elderly will more than double from 10%
\nin 2015 to 22% of the total population in 2050. These improvements are very variable;
\nmany of the poorest communities in all countries and a larger percentage of the population
\nin the poorest countries have gained little in terms of life expectancy over this period of
\ntime.
\nThe increase in longevity has been paired with a decreasing number of children,
\nadolescents and younger adults as more and more countries experience Total Fertility
\nRates below replacement level, raising the average age in these countries.
\nThe challenges of aging in developing countries are complicated by the fact that basic
\ninfrastructure is not always in place. In some cases, populations in developing countries
\nare aging more quickly than infrastructure is being developed.
\nLongevity is arguably the greatest societal achievement of the 20th century but it could
\nturn into a major problem during the 21st century. The World Health Organization (WHO)
\ndefines Active Ageing as \u201cthe process of optimizing opportunities for Health, Lifelong
\nlearning, Participation and Security in order of enhancing quality of life as individuals
\nage\u201d. This definition presupposes a life course perspective as the determinants that
\ninfluence active ageing operates throughout the life course of an individual. These are
\nsocial determinants of health and include behavioral determinants (life-styles), personal
\ndeterminants (not only hereditary factors which are, overall, responsible for no more than
\n25% of the chances of ageing well but also psychological characteristics), the physical
\nenvironment where one lives as well as broad social and economic determinants. All of
\nthese act individually on the prospects of active ageing but also interact among
\nthemselves: the more they interact and overlap, the higher the chance of an individual
\nageing actively. Gender and culture are crosscutting determinants, influencing all the
\nothers.<\/p>\n

S-2016-01-2016\t\u23d0\tTaipei
\nAgeing
\nGENERAL\tPRINCIPLES
\nMedical Expenses
\nThere is strong evidence that chronic diseases increase the use (and costs) of health
\nservices rather than age per se.
\nHowever, chronic conditions and disabilities become more prevalent with advancing age \u2013
\ntherefore health care use and spending rise in tandem with age.
\nIn many countries health care spending for older persons has increased over the years as
\nmore interventions and new technologies have become available for problems common in
\nolder age.
\nEffect of Ageing on Health Systems
\nHealth care systems face two major challenges in the longevity revolution: preventing
\nchronic disease and disability and delivering high quality and cost-effective care that is
\nappropriate for individuals regardless of age.
\nIn less developed regions the disease burden in old age is higher than in more developed
\nregions.
\nSpecial Health Care Considerations
\nThe leading diseases contributing to disability in all regions are cardiovascular diseases,
\ncancers, chronic respiratory diseases, musculoskeletal disorders, and neurological and
\nmental diseases, including the dementias. Some common conditions in older age are
\nespecially disabling and require early detection and management.
\nChronic diseases common among older people include diseases preventable through
\nhealthy behaviors and\/or lifestyle interventions and effective preventive health services \u2013
\ntypically cardiovascular disease, diabetes, chronic obstructive pulmonary disease and
\nmany types of cancer. Other diseases are more closely linked to ageing processes and are
\nnot understood well enough to prevent them \u2013 such as dementia, depression and some
\nmusculoskeletal and neurological disorders.
\nWhile research may eventually lead to effective disability prevention or treatment, early
\nmanagement is key to controlling disability and\/or maintaining quality of life.
\nOlder persons may be more vulnerable to the effects of accidents within and outside the
\nhome. This will include risks when operating machinery such as road vehicles, but also
\nrisks from handling other potentially dangerous equipment. As older people continue to
\nwork these risks must be assessed and managed. Those who suffer injuries may have their
\nrecovery complicated by other medical vulnerabilities and comorbidities.<\/p>\n

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\nS-2016-01-2016\t\u23d0\tWorld\tMedical\tAssociation
\nConsiderations for Health Care Professionals
\nHealth care for elderly people usually requires a variety of professionals working as an
\narticulated team.
\nEducation and training of health professionals to treat and manage the conditions common
\nin the elderly are generally not sufficiently emphasized in undergraduate curricula.
\nReducing Impact on Health Care
\nA comprehensive continuum of health services needs to be adopted urgently as population
\nage. It should include health promotion, disease prevention, curative treatments,
\nrehabilitation, management and prevention of decline, and palliative care.
\nDifferent types of health care providers offer these services, from self and family\/informal
\ncare \u2013 sometimes in a voluntary capacity \u2013 to community-based providers and institutions.
\nEstablishing Optimal Health Care Systems
\nUniversal Health Care coverage ideally should be provided to all, including elderly
\npeople.
\nThe vast majority of health problems can and should be dealt with at the community level.
\nIn order to provide optimal community care and ensure care coordination over time it is
\ncritical to strengthen Primary Health Care (PHC) services.
\nIn order to strengthen PHC to promote active ageing, WHO advanced evidence-based
\nprinciples for age-friendly PHC in three areas which should be considered:
\ninformation\/education\/communication\/ training, health management systems and the
\nphysical environment.
\nThe health sector should encourage health systems to support all such dimensions of care
\nprovided to individuals as they age given the importance of health to ensure quality of life.
\nSpecificities of Health Care
\nMany formal systems of health care have been developed with an emphasis on \u201cacute or
\ncatastrophic care\u201d of a much younger population, often focused on communicable diseases
\nand\/or injuries. Health systems should emphasize other needs, especially chronic diseases
\nmanagement and cognitive decline, when treating the elderly.
\nWhile acute care services are essential for people of all ages, but they are not focused on
\nkeeping people healthy or providing the ongoing support and care required to manage
\nchronic conditions. A paradigm shift is needed to avoid treating chronic diseases as if they
\nwere acute conditions.
\nMedical conditions in older age often occur simultaneously with social problems and both<\/p>\n

S-2016-01-2016\t\u23d0\tTaipei
\nAgeing
\nneed to be considered by health professionals when providing health care. Doctors,
\nparticularly specialists, should bear in mind that elderly patients may have other
\nconcurrent chronic diseases or comorbidities that interact with each other and that their
\ntreatment should not lead to inadvertent and preventable induction of complications.
\nWhen initiating a pharmacologic treatment for chronic disease in an elderly patient,
\nprescribers should generally start low (doses) and go slow (increasing the doses) to
\naccommodate the specific needs of the patient.
\nIf the patient cannot decide for him\/herself, due to the high prevalence of memory and
\ncognitive problems in old age, physicians treating elderly patients should actively
\ncommunicate with the family, and frequently with the formal caretaker, to better educate
\nthem about the patient\u2019s health condition and about medication administration, in order to
\navoid complications.
\nWhen considering different therapeutic options, physicians should always seek to find out
\nthe wishes of the patient and recognize that for some patients quality of life will be more
\nimportant than the potential results of more aggressive treatment options.
\nEducation and Training for Physicians
\nAll physicians should be appropriately trained to diagnose and treat the health problems of
\nolder people, which means mainstreaming ageing in the medical curriculum.
\nSecondary health care for the elderly should be provided as necessary. It should be
\nholistic, including taking into consideration psychosocial as well as environmental
\naspects. Physicians should also be aware of the risks of elder abuse and measures to be
\ntaken when abuse is identified or suspected. (See the WMA Declaration of Hong Kong on
\nthe Abuse of the Elderly.)
\nEvery doctor, particularly general practitioners, should have access to information and
\nundergo training to identify and prevent polypharmacy and adverse drugs interactions that
\nmay be more common in elderly patients.
\nContinuing medical education on topics relevant to the ageing patient should be
\nemphasized in order to help physicians adequately diagnose, treat, and manage the
\ncomplexities of caring for an ageing population.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2016-02-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nCYBER-ATTACKS\tON\tHEALTH\tAND\tOTHER\tCRITICAL
\nINFRASTRUCTURE\t<\/p>\n

Adopted by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\n\u2022 Advancements in modern information technology (IT) pave the way for
\nimprovements in healthcare delivery and help streamline physician workflow,
\nfrom medical record keeping to patient care. At the same time, implementing new
\nand more sophisticated IT infrastructure is not without its challenges and risks,
\nincluding cyber-attacks and data breaches.
\n\u2022 Cyber security threats are an unfortunate reality in an age of digital information
\nand communication. Attacks on critical infrastructure and vital assets of public
\ninterest, including those used in the fields of energy, food and water supply,
\ntelecommunications, transportation and healthcare, are on the rise and pose a
\nserious threat to the health and well-being of the general public.
\n\u2022 With the proliferation of electronic medical records and billing systems, the
\nhealthcare sector is especially susceptible to cyber intrusions and has become a
\nprime soft target for cyber criminals. Healthcare institutions and business partners,
\nfrom the smallest of private practices to the largest of hospitals, are vulnerable not
\nonly to the theft, alteration and manipulation of patients\u2019 electronic medical and
\nfinancial records, but also to increasingly sophisticated system breaches that could
\njeopardise their ability to provide care for patients and respond to health
\nemergencies. Especially disconcerting is the threat posed to a patient\u2019s
\nfundamental right to data privacy and safety. In addition, repairing the damage
\ncaused by successful cyber-attacks can entail significant costs.
\n\u2022 Patient data also demands protection because it often contains sensitive personal
\ninformation that can be used by criminals to access bank accounts, steal identities,
\nor obtain prescriptions illegally. For this reason, it is worth far more on the black
\nmarket than credit card information alone. Alterations to or abuse of patient data in
\nthe case of a breach can be detrimental to the health, safety and material situation
\nof patients. In some cases, breaches can even have life-threatening consequences.
\n\u2022 Current security procedures and strategies in the healthcare sector have generally
\nnot kept pace with the volume and magnitude of cyber-attacks. If not adequately
\nprotected, hospital information systems, practice management systems or control
\nsystems for medical devices can become gateways for cybercriminals. Radiology<\/p>\n

S-2016-02-2016\t\u23d0\tTaipei
\nCyber-Attacks\ton\tHealth
\nimaging software, video conferencing systems, surveillance cameras, mobile
\ndevices, printers, routers and digital video systems used for online health
\nmonitoring and remote procedures are just some of the many IT structures at risk
\nof being compromised.
\n\u2022 Despite this danger, many healthcare organisations and institutions lack the
\nfinancial resources (or the will to provide them) and the administrative or technical
\nskills and personnel required to detect and prevent cyber-attacks. They may also
\nfail to adequately communicate the seriousness of cyber threats both internally and
\nto patients and external business partners.<\/p>\n

RECOMMENDATIONS
\n1. The WMA recognises that cyber-attacks on healthcare systems and other critical
\ninfrastructure represent a cross-border issue and a threat to public health. It
\ntherefore calls upon governments, policy makers and operators of health and other
\nvital infrastructure throughout the world to work with the competent authorities for
\ncyber security in their respective countries and to collaborate internationally in
\norder to anticipate and defend against such attacks.
\n2. The WMA urges national medical associations to raise awareness among their
\nmembers, health care institutions and other industry stakeholders about the threat
\nof cyber-attacks and to support an effective, consistent healthcare IT strategy to
\nprotect sensitive medical data and to assure patient privacy and safety.
\n3. The WMA underscores the heightened risk of cyber intrusions and other data
\nbreaches faced by the healthcare sector and urges medical institutions to
\nimplement and maintain comprehensive systems for preventing security breaches,
\nincluding but not limited to providing training to ensure employee compliance with
\noptimal data handling practices and to maintain security of computing devices.
\n4. In the event of a data security breach, healthcare institutions should have proven
\nresponse systems in place, including but not limited to notifying and offering
\nprotection services to victims and implementing processes to correct errors in
\nmedical records that result from malicious use of stolen data. Data breach
\ninsurance policies could be considered as a precautionary measure for defraying
\nthe costs associated with a potential cyber intrusion.
\n5. The WMA calls upon physicians, as guardians of patient safety and data
\nconfidentiality, to remain aware of the unique challenge cyber-attacks could pose
\nto their ability to practice their profession and to take all necessary measures that
\nhave been shown to safeguard patient data, patient safety and other vital
\ninformation.
\n6. The WMA recommends that undergraduate and postgraduate medical education
\ncurricula include comprehensive information on how physicians can use modern
\nIT and electronic communications systems to full advantage, while still ensuring
\ndata protection and maintaining the highest standards of professional conduct.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2016-02-2016\t\u23d0\tWorld\tMedical\tAssociation
\n7. The WMA acknowledges that physicians and healthcare providers may not always
\nhave access to the resources (including financial), infrastructure and expertise
\nrequired to establish fail-safe defence systems and stresses the need for the
\nappropriate public as well as private bodies to support them in overcoming these
\nlimitations.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2016-03-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nDIVESTMENT\tFROM\tFOSSIL\tFUELS\t\t<\/p>\n

Adopted by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\n\u2022 As\tnoted\tby\tthe\t65th\tWorld\tMedical\tAssembly\tin\tDurban\tin\t2014,\tphysicians
\naround\tthe\tworld\tare\taware\tthat\tfossil\tfuel\tair\tpollution\treduces\tquality\tof\tlife
\nfor\t millions\t of\t people\t worldwide,\t causing\t a\t substantial\t burden\t of\t disease,
\neconomic\tloss,\tand\tcosts\tto\thealth\tcare\tsystems.
\n\u2022 According\t to\t World\t Health\t Organization\t data,\t in\t 2012,\t approximately\t \u201c7
\nmillion\t people\t died,\t one\t in\t eight\t of\t total\t global\t deaths,\t as\t a\t result\t of\t air
\npollution\u201d\t(WHO,\t2014).
\n\u2022 The\tUnited\tNations\u2019\tIntergovernmental\tPanel\ton\tClimate\tChange\t(IPCC)\tnotes
\nthat\tglobal\teconomic\tand\tpopulation\tgrowth,\trelying\ton\tan\tincreased\tuse\tof
\ncoal,\tcontinues\tto\tbe\tthe\tmost\timportant\tdriver\tof\tincreases\tin\tCarbon\tDioxide
\nemissions.\t\tThese\temissions\tare\tthe\tmajor\tcomponent\tof\tan\taccelerating\tthe
\namount\t of\t human\t fossil\t fuel\t Greenhouse\t Gas\t (GHG)\t emissions\t despite\t the
\nadoption\tof\tclimate\tchange\tmitigation\tpolicies\t(IPCC,\t2014).
\n\u2022 The\t burden\t of\t disease\t arising\t from\t Climate\t Change\t will\t be\t differentially
\ndistributed\t across\t the\t globe\t and,\t while\t it\t will\t affect\t everyone,\t the\t most
\nmarginal\t populations\t will\t be\t the\t most\t vulnerable\t to\t the\t impacts\t of\t climate
\nchange\tand\thave\tthe\tleast\tcapacity\tfor\tadaptation.\t<\/p>\n

BACKGROUND
\n\u2022 In many densely settled populated cities around the world, the fine dust measurable
\nin the air is up to 50 times higher than the WHO recommendations. A high volume
\nof transport, power generated from coal, and pollution caused by construction
\nequipment are among the contributing factors (WMA, SMAC 197, Air Pollution
\nWMA Statement on the Prevention of Air pollution due to Vehicle Emissions
\n2014).
\n\u2022 Evidence from around the world shows that the effects of climate change and its
\nextreme weather are having significant and sometimes devastating impacts on
\nhuman health. Fourteen of the 15 warmest years on record have occurred in the<\/p>\n

S-2016-03-2016\t\u23d0\tTaipei
\nDivestment\tfrom\tFossil\tFuels
\nfirst 15 years of this century (World Meteorological Organization 2014). The
\nvulnerable among us including children, older adults, people with heart or lung
\ndisease, and people living in poverty are most at risk from these changes.
\n\u2022 The WMA notes the Lancet Commission\u2019s description of Climate Change as \u201cthe
\ngreatest threat to human health of the 21st century\u201d, and that the Paris agreement at
\nCOP21 on Climate calls upon governments \u201cwhen taking action on climate
\nchange\u201d to \u201crespect, promote and consider their respective obligations on human
\nrights (and) the right to health\u201d.
\n\u2022 As the WMA states in its Delhi Declaration on Health and Climate Change,
\n\u201cAlthough governments and international organizations have the main
\nresponsibility for creating regulations and legislation to mitigate the effects of
\nclimate change and to help their populations adapt to it, the World Medical
\nAssociation, on behalf of (\u2026) its physician members, feels an obligation to
\nhighlight the health consequences of climate change and to suggest solutions. (\u2026)
\nThe WMA and NMAs should develop concrete actionable plans\/practical steps\u201d to
\nboth mitigate and adapt to climate change (WMA 2009).<\/p>\n

RECOMMENDATIONS
\nThe WMA recommends that its national medical associations and all health organizations:
\n\u2022 Continue to educate health scientists, businesses, civil society, and governments
\nconcerning the benefits to health of reducing greenhouse gas emissions and
\nadvocate for the incorporation of health impact assessments into economic policy.
\n\u2022 Encourage governments to adopt strategies that emphasize strict environmental
\nregulations and standards that encourage energy companies to move toward
\nrenewable fuel sources.
\n\u2022 Begin a process of transferring their investments, when feasible without damage,
\nfrom energy companies whose primary business relies upon extraction of, or
\nenergy generation from, fossil fuels to those generating energy from renewable
\nenergy sources.
\n\u2022 Strive to invest in companies upholding the environmental principles consistent
\nwith the United Nations Global Compact (www.unglobalcompact.org), and refrain
\nfrom investing in companies that do not adhere to applicable legislation and
\nconventions regarding environmental responsibility.<\/p>\n

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\nS-2016-04-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nETHICAL\tCONSIDERATIONS\tIN\tGLOBAL\tMEDICAL\tELECTIVES\t<\/p>\n

Adopted by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\n\u2022 Medical trainees are increasingly participating in global educational and service
\nexperiences, commonly referred to as \u2018international medical electives\u2019 (IMEs).
\nThese experiences are normally short term, i.e., less than 12 months, and are often
\nundertaken in resource-limited settings in low-and middle-income countries.
\n\u2022 Although IMEs can provide valuable learning experience, this must be weighed
\nagainst the potential risks to the host community, the sponsor organization and the
\nvisiting trainee. Successful placements help to ensure that there are mutual benefits
\nfor all parties and are built upon an agreed understanding of concepts including
\nnon-maleficence and justice.
\n\u2022 Published ethical guidelines, such as the Ethics and Best Practice Guidelines for
\nTraining Experiences in Global Health by the Working Group on Ethics
\nGuidelines for Global Health Training (WEIGHT), call on sponsor institutions
\n(i.e., universities and organizations facilitating electives) to commit to sustainable
\npartnerships with host institutions and local communities. All parties are also
\ncalled upon to work collaboratively in creating professional guidelines and
\nstandards for medical electives.
\n\u2022 In turn, trainees undertaking IMEs must adhere to relevant ethical principles
\noutlined in WMA ethical documents, including the WMA\u2019s Declaration of
\nGeneva, the WMA International Code of Medical Ethics and the WMA Statement
\non the Professional and Ethical Use of Social Media.
\nRECOMMENDATIONS
\nTherefore the WMA recommends that:
\n1. Sponsor institutions work closely with host institutions and local communities to
\ncreate professional and ethical guidelines on best practices for international
\nmedical electives. Both institutions should be actively engaged in guideline
\ndevelopment. The sponsor organization should evaluate the proposed elective
\nusing such standards prior to approval.<\/p>\n

S-2016-04-2016\t\u23d0\tTaipei
\nGlobal\tMedical\tElectives
\n2. Guidelines should be appropriate to local context and endorse the development of
\nsustainable, mutually-beneficial and just partnerships between institutions and the
\npatients and the local community, with their health as the first consideration. These
\nmust take account of best practice guidelines, already available in many countries.
\n3. Guidelines must hold patient and community safety as paramount, and outline
\nprocesses to ensure informed consent, patient confidentiality, privacy, and
\ncontinuity of care as outlined in the WMA International Code of Medical Ethics.
\n4. Guidelines should also outline processes to protect the safety and health of the
\ntrainee, and highlight the obligations of the sponsor and host institutions to ensure
\nadequate supervision of the trainee at all times. Institutions should consider means
\nof addressing possible natural disasters, political instability, and exposure to
\ndisease. Emergency care should be available.
\n5. Sponsor and host institutions have a responsibility to ensure that IMEs are well
\nplanned, including, at a minimum, appropriate pre-departure briefings, which
\nshould include training in culture and language competency and explicit avoidance
\nof any activity which could be exploitative, provision of language services as
\nrequired, and sufficient introduction and guidance at the host institution. Post-
\ndeparture debriefing should be planned on return of the trainee, including
\nreviewing ethical situations encountered and providing appropriate emotional and
\nmedical support needed.
\n6. It is expected that the trainee will receive feedback and assessment for the
\nexperience so that he\/she can receive academic credit. The trainee should have the
\nopportunity to evaluate the quality and utility of the experience.
\n7. Trainees must be fully informed of their responsibility to follow instructions given
\nby local supervisors, and to treat local host staff and patients with respect.
\n8. These guidelines and processes should be reviewed and updated on a regular basis
\nas sponsor and host institutions develop more experience with one another.
\n9. National Medical Associations should develop best practices for international
\nmedical electives, and encourage their adoption as standards by national or
\nregional accrediting bodies, as feasible, and their implementation by sponsor and
\nhost institutions.<\/p>\n

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\nS-2016-05-2016\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nOBESITY\tIN\tCHILDREN\t<\/p>\n

Adopted by the 67th
\nWMA General Assembly, Taipei, Taiwan, October 2016
\nPREAMBLE
\nChildhood obesity is a serious medical condition and a major public health concern
\naffecting many children. Childhood obesity is emerging as a growing epidemic and is a
\nchallenge in both developed and developing countries. Due to its increasing prevalence
\nand its immediate and long-term impact on health, including predisposition to diabetes and
\ncardiovascular abnormalities, childhood obesity should be viewed as a serious concern for
\npublic health. The increase in childhood obesity may be attributed to many factors:
\n\u2022 Recent studies show that marketing targeted at children has a wide influence on the
\nshopping trends and food preferences of households all over the world. Special
\noffers, short-term price reductions and other price promotions and advertising on
\nsocial as well as traditional media all play a role in increasing product demand.
\n\u2022 Many advertisements are in conflict with nutritional recommendations of medical
\nand scientific bodies. TV advertisements for food and drink products with little or
\nno nutritional value are often scheduled for broadcast hours with a large
\nconcentration of child viewers and are intended to promote the desire to consume
\nthese products regardless of hunger. Advertisements increase children\u2019s emotional
\nresponse to food and exploit their trust. These methods and techniques are also
\nused in non-traditional media, such as social networks, video games and websites
\naimed at children.
\n\u2022 Unhealthy dietary patterns, together with a sedentary lifestyle and lack of exercise,
\ncontribute to childhood obesity. The sedentary lifestyle is the most predominant
\none in the developed world today. Many children typically spend more time than
\never in front of screens, rarely engaging in physical activities.
\n\u2022 International corporations and conglomerates that manufacture foods and
\nbeverages are not always subject to regional regulations that govern food labeling.
\nConcern for profits may come at the expense of corporate responsibility for
\nenvironmental and public health issues.
\n\u2022 Products containing large amounts of added sugar, fat, and salt can be addictive,
\nespecially when combined with flavor enhancers. In some countries, not all
\ningredients are required to be listed on food labels and manufacturers often refuse<\/p>\n

S-2016-05-2016\t\u23d0\tTaipei
\nObesity\tin\tChildren
\nto release data on methods employed to maximize consumption of their products.
\nGovernments should require that all ingredients in food and beverages be clearly
\nlabeled, including those proprietary ingredients intended to increase consumption
\nof the product.
\n\u2022 Socioeconomic disparities also correlate with increasing rates of childhood
\nobesity. The link between living in poverty and early childhood obesity continues
\nto negatively affect health in adult life.[1] Exposure to environmental
\ncontaminants, sporadic medical checkups, insufficient access to nutritious foods
\nand limited physical activity lead to obesity and other chronic illnesses that are all
\nmore prevalent among children living in poverty.
\nRECOMMENDATIONS
\n1. A comprehensive program is needed to prevent and address obesity in all segments
\nof the population, with a specific focus on children. The approach must include
\ninitiatives on price and availability of nutritious foods, access to education,
\nadvertising and marketing, information, labeling and other areas specific to regions
\nand countries. An approach similar to that on tobacco in the WHO Framework
\nConvention on Tobacco Control is advocated.
\n2. International studies stress the importance of adopting an integrated approach to
\neducation and health promotion. Investment in education is key to minimizing
\npoverty, improving health and providing economic benefits.
\n3. Quality education offered in formal settings to children aged 2 to 3 years,
\ncombined with enrichment activities for parents, and sufficient supply of nutritious
\nfood and beverages may help to reduce the rate of adolescent obesity and reduce its
\nhealth implications throughout the life course. Developing early healthy eating
\npractices and experiencing flavors of healthy food when very young appear to be
\npositive factors in prevention of childhood obesity.
\n4. Governments should invest in education related to menu design, food shopping
\nincluding budget setting, storage and preparation so that people are better equipped
\nto plan their food intake.
\n5. Governments should seek to regulate the availability of food and beverages of poor
\nnutritional value, by a range of methods including price. Attention should be paid
\nto the availability close to schools of establishments selling products of poor
\nnutritional quality. Governments should seek to persuade manufacturers to
\nreformulate products to reduce their obesogenic effects. Where possible
\ngovernment and local authorities should seek to manage the density of such
\nestablishments in the area.
\n6. Governments should consider imposing a tax on non-nutritious foods and sugary
\ndrinks and use the additional revenue to fund research and epidemiological studies
\naimed at preventing childhood obesity and reducing the resulting disease risk.
\n7. Ministries of health and education should regulate food and beverages that are sold<\/p>\n

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\nS-2016-05-2016\t\u23d0\tWorld\tMedical\tAssociation
\nand served at educational and healthcare facilities.
\n8. Given the scientifically proven link between the extent of media consumption and
\nadverse effects on body weight in children, the WMA recommends that the
\nadvertising of non-nutritious products be restricted during television programming
\nand other forms of media that appeal to children. Regulators should be aware that
\nchildren access television programs designed for adults and ensure that legislation
\nand regulation also limits marketing associated with such programs.
\n9. Governments should work with independent health experts to produce sound
\nguidance on food and nutrition, with no involvement of the food and drink
\nindustry.
\n10. Governments and local authorities should subsidize and encourage activities that
\npromote good health among their residents, including providing safe spaces for
\nwalking, bike riding and other forms of physical activity.
\n11. Parents have a crucial role in fostering physical activity in their children. Schools
\nshould incorporate daily physical activity into their daily routine. Participation in
\nsport activities should be possible for everyone regardless of their economic
\nsituation.
\n12. National Medical Associations should support or develop guidelines and
\nrecommendations to ensure that they reflect current knowledge of prevention and
\ntreatment of childhood obesity.
\n13. National Medical Associations should work to raise public awareness on the issue
\nof childhood obesity and highlight the need to tackle the rising prevalence of
\nobesity and its health and economic burden.
\n14. Clinics and Health Maintenance Organizations should employ appropriately
\ntrained professionals to offer classes and consultation in selecting appropriate
\namounts of nutritious foods and beverages and attaining optimal levels of physical
\nactivity for children. They should also ensure that their premises are exemplars in
\nthe provision of healthy food options.
\n15. Educational facilities should employ appropriately trained professionals who
\neducate for healthy lifestyles from an early age and allow all children, whatever
\ntheir social environment, to practice regular physical activities.
\n16. Physicians should guide parents and children in how to live healthy lives and
\nemphasize the importance of doing so, and must identify as soon as possible
\nobesity in their patients, particularly children. They should direct patients suffering
\nfrom obesity to the appropriate services at the earliest possible stage, and conduct
\nregular follow-ups.
\n17. Physicians and health professionals should be educated in nutrition assessment,
\nobesity prevention and treatment. This could be accomplished by strengthening
\nCME activities focused on nutritional medicine.<\/p>\n

S-2016-05-2016\t\u23d0\tTaipei
\nObesity\tin\tChildren
\n[1] WHO Commission on Social Determinants of Health (Closing the Gap in a
\nGeneration) 2008.<\/p>\n

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\nS-2017-01-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nBULLYING\tAND\tHARASSMENT\tWITHIN\tTHE\tPROFESSION
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. Workplace bullying has been recognised as a major occupational stressor since the
\nearly 1980s.
\n2. Workplace bullying is unreasonable and inappropriate behaviour directed towards a
\nworker or a group of workers that creates a risk to health and safety. By definition,
\nbullying is behaviour that is repeated over time or occurs as part of a pattern of
\nbehaviour, rather than a single episode. Unreasonable behaviour is what a reasonable
\nperson in the same circumstances would see as unreasonable. It includes behaviour
\nthat intimidates, offends, victimises, threatens, degrades, insults or humiliates.
\nBullying can take psychological, social and physical forms. It is not the perpetrator\u2019s
\nintention, but the victim\u2019s perception, that is key to determining whether bullying has
\noccurred.
\n3. Harassment is unwanted, unwelcome or uninvited behaviour that makes a person feel
\nhumiliated, intimidated or offended. Harassment can be related to a person\u2019s ethnicity,
\ngender, sexual orientation, disability or other factors such as whether a person has
\nmade a complaint.
\n4. Employers generally have a legal duty to ensure the health, safety and welfare of their
\nemployees. This includes identifying bullying and harassment and taking steps to
\neliminate and prevent it. Employees are generally required to take reasonable care for
\ntheir own health and safety as well as for the health and safety of others who may be
\naffected by their acts in the workplace.
\n5. In recent years, bullying and harassment have become more recognised in the medical
\nprofession; there is good evidence that disruptive behaviour, inappropriate behaviour
\nand harassment occurs in the medical workplace. International research has shown that
\nbullying in the healthcare profession is not associated with specialty or sex. It appears
\nthat bullying is widespread and occurs across all specialties and at all levels of
\nseniority, although it is fair to say that where bullying occurs it is more common to be
\ninflicted by a more senior employee upon a more junior one. The hierarchical nature of
\nmedicine and the inherent power imbalance associated with this can however create a
\nculture of bullying and harassment which, in some cases, becomes pervasive and
\ninstitutionalized.
\n6. Workplace bullying can have detrimental effects such as decreased job satisfaction,
\ndepression, anxiety, and absenteeism, all of which impact adversely on staff retention
\nand quality of patient care.<\/p>\n

S-2017-01-2017\t\u23d0\tChicago
\nBullying\tand\tHarassment\twithin\tthe\tProfession
\nRECOMMENDATIONS
\n7. The WMA condemns bullying or harassment under any circumstances. It further
\nbelieves that raising awareness of inappropriate behaviour, disruptive behaviour and
\nharassment in the medical profession is an important step in the process of eliminating
\nthe problem. The WMA is of the view that this is an issue of professionalism and it
\nencourages National Medical Associations (NMAs), medical schools, employers, and
\nmedical colleges to establish and implement anti-bullying and harassment policies.
\n8. The WMA recommends that NMAs recognise and, where possible, actively address
\nthe following:
\n8.1 Bullying in the health workplace is an entirely unprofessional and destructive
\nbehaviour and should not be tolerated.
\n8.2 Steps should be taken to prevent, confront, report and eliminate bullying at any
\nlevel.
\n8.3 Bystanders also have a responsibility to take action.
\n8.4 There can be significant barriers for junior doctors to speak out about bullying by
\nsenior colleagues, for example fear of career retribution.
\n8.5 Professionalism is not just how we treat our patients, but how we treat each other
\nas professional colleagues. Acting professionally means also being vigilant and
\nstepping in to intervene, for the good of all.
\n8.6 Bullying is unprofessional, contradicts the fundamentals of the profession and
\nraises fitness to medical practise concerns.
\n8.7 Healthcare needs good teams. Eliminating bullying ensures a safer team
\nenvironment and a safer healthcare environment for patients.
\n8.8 It is the responsibility of the management to maintain a good working
\nenvironment and address all signs of harassment and bullying. There should be
\nzero tolerance of bullying and harassment<\/p>\n

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\nS-2017-02-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nARMED\tCONFLICTS
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. The duties of physicians in times of armed conflict are set out in the WMA Statement
\non Ethical Principles of Health Care in Times of Armed Conflict and Other
\nEmergencies and WMA Regulations in Times of Armed Conflict and Other Situations
\nof Violence.
\n2. Physicians should encourage politicians, governments, and others in positions of
\npower to be more aware of the consequences, including the impact on health, of their
\ndecisions on the commencement or continuation of armed conflict.
\n3. Armed conflict damages the health of individuals and of populations as well as critical
\ninfrastructure including health care facilities, housing, potable-water supplies and
\nsewerage. It also leads to environmental degradation. Such destruction of critical
\ninfrastructure may lead to adverse health consequences including malnutrition, and
\ninfectious or waterborne diseases, such as cholera and typhoid. Warfare also destroys
\nwork-related infrastructure, including factories and manufacturing centres as well as
\nagriculture. Repair to damaged infrastructure cannot proceed until cessation of the
\nconflict.
\n4. Wars start for many different reasons. Efforts to avoid conflicts are often insufficient
\nand inadequate and country leaders may not seek all alternatives. Avoiding war and
\nseeking constructive alternatives is always desirable.
\n5. It is essential that those claiming that a war us a \u201cjust war\u201d understand that this is a
\nrare and extreme circumstance, which must not be overcited. The concept of a \u201cjust\u201d
\nwar must not be used to legitimize violence.
\n6. Warfare and other forms of armed conflict are likely to worsen the suffering of the
\npoorest and to contribute to the development of large numbers of Internally Displaced
\nPersons and refugees.
\n7. Physicians should seek, during conflicts, to influence parties in order to alleviate the
\nsuffering of populations.
\nRECOMMENDATIONS
\n8. The WMA believes that armed conflict should always be a last resort. Physicians and
\nNMAs should alert governments and non-state actors of the human consequence of<\/p>\n

S-2017-02-2017\t\u23d0\tChicago
\nArmed\tConflicts
\nwarfare.
\n9. Physicians should encourage politicians, governments, and others in positions of
\npower to be more aware of the consequence of their decisions related to armed
\nconflict.
\n10. The WMA recognizes that armed conflict always produces enormous human suffering.
\nStates and other authorities, including non-state actors, who enter into armed conflict
\nmust accept responsibility for the consequences of their actions, and be prepared to
\nanswer for their consequences including to international courts and tribunals and
\nrecommends that authorities recognize and cooperate to ensure this occurs.
\n11. The WMA recognizes that the impact of armed conflict will be most significant upon
\nwomen and vulnerable populations, including children, the young, the elderly and the
\npoorest members of society. Physicians should seek to ensure that allocation of
\nmedical care resources does not have a discriminatory impact.
\n12. Physicians must continually remind those in power of the need to provide essential
\nservices to those within areas damaged and disrupted by conflict.
\n13. After a conflict ends, priority must be given to rebuilding the essential infrastructure
\nnecessary for a healthy life, including shelter, sewerage, fresh water supplies, and food
\nprovision, followed by the restoration of educational and occupational opportunities.
\n14. The WMA demands that parties to a conflict respect relevant Humanitarian Law and
\ndo not use health facilities as military quarters, nor target health institutions, workers
\nand vehicles, and respect established International Humanitarian Law (IHL) and do not
\nuse health facilities as military quarters, nor initiate attacks against health institutions,
\nworkers and vehicles, or restrict the access of wounded persons and patients to
\nhealthcare, as set out in the WMA Declaration on the Protection of Health Workers in
\nSituations of Violence.
\n15. Physicians should work with aid and other agencies to seek to ensure that parties
\nprotect family integrity and, wherever possible, remove people from direct and
\nimmediate danger.
\n16. Physicians should be aware of the likely prevalence of Post-Traumatic Stress Disorder
\n(PTSD) and other post-conflict psychosocial and psychosomatic problems and provide
\nappropriate care and treatment to combatants and civilians.
\n17. Physicians, including forensic medicine specialists, should help families ensure that
\nefforts to identify the missing and the dead are not subverted by security forces.<\/p>\n

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\nS-2017-03-2017\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nMEDICAL\tCANNABIS
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. Cannabis is the generic term used to denote psychoactive preparations of the plant
\nCannabis sativa, which grows wild in many parts of the world and is known by
\nnumerous other names, such as: \u201cmarijuana\u201d, \u201cdagga\u201d, \u201cweed\u201d, \u201cpot\u201d, \u201chashish\u201d, or
\n\u201chemp\u201d.
\n2. Cannabis for medical use refers to the use of cannabis and its constituents, natural or
\nsynthetic, to treat disease or alleviate symptoms under professional supervision;
\nhowever, there is no single agreed upon definition.
\n3. Recreational cannabis refers to the use of cannabis to alter one\u2019s mental state in a way
\nthat modifies emotions, perceptions, and feelings regardless of medical need.
\n4. This WMA statement is intended to provide a position on legalisation of cannabis for
\nmedical use and highlight the adverse effects associated with recreational use.
\n5. Recreational cannabis use is an important health and social issue across the world.
\nCannabis is the most commonly used illicit drug in the world. The World Health
\nOrganisation estimates that about 147 million people, 2.5% of the world population,
\nuse cannabis compared with 0.2% using cocaine and 0.2% using opiates.
\n6. The WMA opposes recreational cannabis use due to serious adverse health effects
\nsuch as increased risk of psychosis, fatal motor vehicle accidents, dependency, as well
\nas deficits in verbal learning, memory and attention. Use of cannabis before the age
\nof 18 doubles the risk of psychotic disorder. The ominously growing availability of
\ncannabis or its forms in foodstuffs such as sweets and \u201cconcentrates\u201d, which have
\nenormous appeal to children and adolescent, requires intensive vigilance and policing.
\n7. National Medical Associations should support strategies to prevent and reduce
\nrecreational cannabis use.
\n8. Evidence for use of cannabis for medical use
\n8.1 Cannabinoids are chemical constituents of Cannabis sativa that contain similar
\nstructural features; some of the chemical constituents act on human cannabinoid
\nreceptor cells. Conceptually, cannabinoids that activate these receptors (1) occur
\nnaturally in the human body like other endogenous neurotransmitters
\n(endocannabinoids); (2) occur naturally in the cannabis plant<\/p>\n

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\nS-2017-03-2017\t\u23d0\tWorld\tMedical\tAssociation
\n(phytocannabinoids); or (3) are pharmaceutical preparations containing either
\nsynthetic cannabinoids, (e.g. delta9-tetrahydrocannabinol [dronabinol,
\nMarinol\u2122], or a related compound, nabilone [Cesamet\u2122], or extracts of
\nphytocannabinoids (nabiximols [Sativex\u2122]).
\n8.2 Amongst phytocannabinoids is naturally occurring Cannabis sativa, delta-9-
\ntetrahydrocannabinol (THC), the main bioactive cannabinoid and the principal
\npsychoactive constituent, while cannabidiol (CBD) is the second most
\nabundant. CBD lacks significant psychoactive properties but may possess
\nanalgesic and antiseizure properties.
\n8.3 The human endocannabinoid system is believed to mediate the psychoactive
\neffects of cannabis and is involved in a variety of physiologic processes
\nincluding appetite, pain-sensation, mood, and memory. The significant medical
\nand pharmacological therapeutic potential of influencing the endocannabinoid
\nsystem has been widely recognized.
\n8.4 The medical benefits of cannabis reported in scientific literature are widely
\ndebated globally. Cannabis has been used for the treatment of severe spasticity
\nin multiple sclerosis, chronic pain, nausea and vomiting due to cytotoxics, and
\nloss of appetite and cachexia associated with AIDS. Evidence suggest that
\ncertain cannabinoids are effective in the treatment of chronic pain, particularly
\nas an alternative or adjunct to the use of opiates when the development of opiate
\ntolerance and withdrawal can be avoided. Evidence supporting use of cannabis
\nfor medicinal purposes is of low to moderate quality, and inconsistent. The
\ninconsistency can be partially attributable to the prohibition of cannabis. Its
\nclassification as an illegal substance in some countries has constrained safe and
\nhigh-quality clinical research.
\n8.5 The short-term adverse effects of cannabis use are well documented. However,
\nthe long-term adverse effects are less well understood, particularly the risk of
\ndependence and cardiovascular disease. There are also significant public health
\nconcerns for vulnerable populations such as adolescents, and pregnant or
\nbreastfeeding women.
\n8.6 Despite weak evidence of its medical benefits, cannabis for medical use has
\nbeen legalised in some countries. In other countries medical cannabis is
\nforbidden or under debate.
\n9. Medical professionals may find themselves in a medico-legal dilemma as they try to
\nbalance their ethical responsibility to patients for whom cannabis may be an effective
\ntherapy and compliance with applicable legislation. This dilemma can manifest itself
\nboth with patients who may medically benefit from the use of cannabis, and those
\nwho are not likely to do so, but pressure the medical professionals to prescribe it.<\/p>\n

RECOMMENDATIONS
\n10. Cannabis Research<\/p>\n

S-2017-03-2017\t\u23d0\tChicago
\nMedical\tCannabis
\n10.1 In the light of the low-quality scientific evidence on the health effects and
\ntherapeutic effectiveness of cannabis, more rigorous research involving larger
\nsamples is necessary before governments decide whether or not to legalise
\nmedical cannabis for medical purposes. Comparators must include the existing
\nstandards of treatment. Expansion of such research should be supported.
\nResearch should also examine the public health, social and economic
\nconsequences of cannabis use.
\n10.2 Governments may consider reviewing laws governing access to and possession
\nof research-grade cannabis for the purpose of allowing well-designed scientific
\nresearch studies to broaden the evidence base on the health effects and
\ntherapeutic benefits of cannabis.
\n11. In countries where cannabis is legalised for medicinal purposes, the following
\nrequirements should apply:
\n11.1 Requirements for producers and products:
\n11.1.1 Provision of cannabis plant products for treatment must be in accordance
\nwith the UN Single Convention on Narcotic Drugs from 30 March 1961,
\nincluding the Convention\u2019s rules on production, trade, and distribution.
\nThus, it is essential that the cannabis included in the products delivered for
\nmedical treatment must be provided and handled in accordance with the
\nrequirements of the Convention.
\n11.1.2 Requirements must include that the cannabis plants meet appropriate
\nquality demands for growing and standardization. The produced cannabis
\nplant products must have a specific indication (interval) of ingredients,
\nincluding the content of delta-9-tetrahydrocannabinol (THC) and
\ncannabidiol (CBD) and strength indication of these.
\n11.2 Requirements for prescription and dispensing of cannabis for medical
\npurposes:
\n11.2.1 Cannabis must be prescribed by an authorised physician\/prescriber in
\naccordance with the best level of evidence and the country\u2019s regulatory
\nframeworks.
\n11.2.2 It is recommended that treatment with approved conventional drugs is
\nundertaken before cannabis products are used for treatment.
\n11.2.3 Each individual physician must take responsibility for and make a decision
\nregarding treatment with cannabis products, in accordance with the best
\navailable evidence and country specific registered indications.
\n11.2.4 Cannabis for medical purposes must only be dispensed at pharmacies or by
\nauthorised dispensers in accordance with the country\u00b4s regulatory
\nframeworks.
\n11.2.5 Effective control measures must be put in place to impede illicit use of
\nmedical cannabis.<\/p>\n

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\n11.2.6 Public health surveillance systems to monitor prevalence of cannabis use
\nand trends in utilisation patterns are necessary.
\n12. In considering policy and legislation on cannabis, governments, NMAs,
\npolicymakers, and other health stakeholders, should emphasize and examine the
\nhealth effects and therapeutic benefits based on the available evidence, while also
\nrecognizing various contextual factors such as regulatory capacity, cost-effectiveness,
\nsocietal values, social circumstances of the country, and the public health and safety
\nimpact on the wider population.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nTHE\tCOOPERATION\tOF\tNATIONAL\tMEDICAL\tASSOCIATIONS
\nDURING\tOR\tIN\tTHE\tAFTERMATH\tOF\tCONFLICTS
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. Throughout history, there have been cases of political conflict in which physicians and
\nthe professional bodies that represent them have adopted and reinforced the policies of
\ntheir respective governments in violation of medical ethical standards. There have also
\nbeen cases of physicians themselves deliberately engaging in criminal activities and
\nembracing unethical ideologies. Even today, on-going moral and political conflicts can
\nlead physicians and their representative organisations to overstep ethical boundaries.
\n2. To prevent such breaches of ethical conduct from occurring, physicians and their
\nrepresentative organisations have a responsibility to rise above national conflicts, to
\nfoster mutual professional support and to base their actions on the highest medical
\nethical standards, including the physician\u2019s primary obligation to the health of
\nindividual patients.
\n3. All national medical associations and their members have an obligation to uphold the
\nethos of medicine, to demonstrate absolute forthrightness and honesty in confronting
\nhistorical and ongoing national conflicts, as well as to preserve the lessons gleaned
\nfrom all forms of unethical behaviour. This includes maintaining a clear commitment
\nto human rights, explicitly rejecting racial, religious, gender, sexual orientation and
\nany other forms of discrimination and actively confronting moral failures of the
\nmedical profession.
\n4. Physicians have professional and ethical obligations that go beyond ethnic and
\nnational interests. Medical associations have a role to play in bridging the gap between
\ndifferent groups based on their common medical ethical codes, regardless of political,
\nreligious, ethnic and social background. Medical expertise as represented in the
\nmedical associations could be a powerful agent for re-establishing respect for human
\nrights in general at times of war and other conflicts.
\nRECOMMENDATIONS
\n5. The World Medical Association urges National Medical Associations to:
\n5.1 Meet regularly in the spirit of enduring friendship and cooperation;<\/p>\n

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\nCooperation\tof\tNMAs\tduring\tor\tin\tthe\tAftermath\tof\tConflicts
\n5.2 Take initiative to invite colleagues from medical associations from nations in
\nconflict to meetings with the intention of re-establishing the contact and
\ncooperation between the associations;
\n5.3 Engage in a meaningful exchange of experience and knowledge with the regional
\nand global medical community in order to maintain the highest levels of ethical
\nstandards and care;
\n5.4 Ensure that all generations of physicians, including those who have not been
\ninvolved in any wrongdoing, are made aware of the vital importance of medical
\nethics and the dire consequences of any departure therefrom. This can be
\naccomplished by including these principles as part of basic medical training (see
\nWMA Resolution on the Inclusion of Medical Ethics and Human Rights in the
\nCurriculum of Medical Schools Worldwide) and continuing throughout
\nphysicians\u2019 careers;
\n5.5 Recognise their obligation to work with each other and with other competent
\nauthorities to keep the memory of any deviations from medical ethics or
\nviolations of human rights alive, in order to prevent them from happening again;
\n5.6 Promote the preservation and growth of constructive relations in the medical
\nprofession, even in the aftermath of regretful pasts or on-going conflicts. To
\nachieve this, it is particularly important to engage in continuous communication
\nin an atmosphere of professional collegiality.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nEPIDEMICS\tAND\tPANDEMICS
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. History demonstrates that new diseases may emerge and old diseases re-emerge,
\nunpredictably. The rapid global movement of people and goods now means that
\ninfections spread globally at unprecedented rates, challenging health systems to
\nrespond in a timely manner. Therefore, quickly recognizing and reacting appropriately
\nto such epidemics or pandemics must be an international concern, with effective
\ncommunication and collaboration between nations.
\n2. Epidemics may be caused by a variety of infectious agents with different methods of
\ntransmission. These diseases may be self-limiting, may lead to few obvious symptoms
\nor may cause short or long term, sometimes serious, effects. Relatively minor illnesses
\nmay become life threatening in some vulnerable individuals. This may include the
\nelderly and the very young as well as those with some degree of compromised
\nimmunity.
\n3. Investment in public health systems will enhance capacity to effectively detect and to
\ncontain rare or unusual disease outbreaks. Core public health functions are needed as a
\nfoundation for detection, investigation and response to all epidemics. A more effective
\nglobal surveillance program will improve response to infectious diseases and will
\nallow earlier detection and identification of new or emerging diseases. Epidemics and
\npandemics have the potential to spread more rapidly in countries with systematically
\nunderfunded and underdeveloped public health systems.
\nRECOMMENDATIONS
\nWHO and National Governments
\n4. The World Health Organization (WHO) has the responsibility for coordinating the
\ninternational response to epidemics and pandemics. It has defined phases that allow an
\nescalating approach to preparedness planning and response as an epidemic evolves.
\nThe WMA recommends:<\/p>\n

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\n4.1 WHO should ensure that all relevant data on the development of infectious
\ndiseases and their spread is collected, including working with voluntary bodies or
\nnon-state actors as well as national and local governments who observe
\ndevelopments in areas where documentation may be limited. A global system of
\ndata capture and surveillance is essential for tracking infectious diseases and their
\nconsequences.
\n4.2 WHO should work closely with the Centers for Disease Control in Atlanta and
\nEurope (CDC and ECDC), National Centres for Disease Control and other
\napplicable regional public health agencies to examine reports of disease pattern
\nchanges and to declare epidemics and pandemics as soon as they are identified.
\nEmergence and identification may be on different time scales.
\n4.3 WHO and others should work with national governments and international
\ngovernment groups to coordinate responses to emerging and reemerging infectious
\ndiseases.
\n4.4 WHO should collaborate with national medical associations and other health
\nauthorities to ensure that accurate and timely clinical care guidelines are made
\navailable to physicians and health care providers.
\n4.5 As infections emerge or reemerge WHO and other UN agencies must ensure that
\neasy-to-understand information is made available to all people in the affected zone
\nin local languages, working with governments and other partners. This should
\ninclude information on disease prevention, including appropriate information on
\noptimal hygiene and infection control practices.
\n4.6 Where diseases lead to the development of birth defects, governments must
\nprovide support to families that are affected.
\n4.7 A cadre of public health specialists who can offer support during a developing
\nhealth emergency should be developed and supported by all national governments.
\nThey and other physicians should be prepared to make themselves available to assist in
\nepidemic control, according to their relevant skill set.
\nNational Medical Associations (NMAs)
\n5.1 NMAs should clearly identify their responsibilities during an epidemic including
\nthe extent of their participation in the national epidemic planning process. These
\nresponsibilities should include communicating vital information to the public and
\nespecially to health care professionals.
\n5.2 Where applicable, NMAs should offer training, information and clinical support
\ntools to physicians and regional medical associations, working with public health
\nand educational institutions.
\n5.3 NMAs should be prepared to advocate for adequate government funding for<\/p>\n

S-2017-05-2017\t\u23d0\tChicago
\nEpidemics\tand\tPandemics
\nsupporting the health care workforce and preparing for an epidemic.
\nPhysicians
\n6.1 Physicians should be sufficiently educated about transmission risks, infection
\ncontrol, and concurrent chronic illness management during an epidemic.
\n6.2 Since physicians will be the first responders, they must remain involved in planning
\nfor epidemics and all stages of epidemic response at the local level.
\n6.3 Physicians should take all measures necessary to protect their own health and the
\nhealth of their staff and co-workers.
\n6.4 Physicians should assist in primary data collection to monitor epidemics with due
\nregard to confidentiality and protecting the vulnerable.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nTHE\tROLE\tOF\tPHYSICIANS\tIN\tPREVENTING\tEXPLOITATION\tIN
\nADOPTION\tPRACTICES
\nAdopted by the 68th
\nGeneral Assembly, Chicago, October 2017
\nPREAMBLE
\n1. UNICEF\u2019s Convention on the Rights of the Child calls in article 21 for a transparent
\nand proper adoption process in which the best interests of the child are the principal
\nconcern.
\n2. The Hague Convention on the Protection of Children and Co-operation in Respect of
\nInter-Country Adoption (Hague Adoption Convention) establishes safeguards to
\nensure that intercountry adoptions take place in the best interests of the child. Its
\nprinciples should form the basis for global intercountry adoption practices.
\n3. Physicians may be in touch with children who are going to be adopted, with parents
\nand\/or legal guardians of those children, and with parents who are going to adopt a
\nchild. Because physicians may confront the consequences of exploitation in adoptive
\npractices, their role is crucial in seeking to ensure adherence to children\u2019s\u2019 rights, and
\nin particular to article 21 of UNICEF\u00b4s Convention on the Rights of the Child.
\nProfessional awareness of the legal adoption process is necessary to protect the rights
\nand health of the child.
\nRECOMMENDATIONS
\n4. The WMA condemns all forms of exploitation in child adoption practices.
\nUnacceptable practices may include criminal acts, including trafficking and sexual
\ncrimes.
\n5. WMA calls on National Medical Associations and physicians to actively participate in
\npreventing exploitation in adoption practices.
\n6. Physicians should be educated about the nature and importance of their role during the
\nadoption process. Physicians should become knowledgeable about exploitative
\nadoption practices and should be aware of resources to help them identify and address
\nthe needs of victims.
\n7. Physicians having contact with families who are adopting minors, should strongly<\/p>\n

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\nPreventing\tExploitation\tin\tAdoption\tPractices
\nencourage them to verify that the adoption practices meet all legal and regulatory
\nrequirements in their jurisdiction.
\n8. The WMA supports providing information to families who are considering adoption
\nabout the existence of networks that may engage in exploitation in adoption practices,
\nespecially when adoption will take place across legal jurisdictions.
\n9. Physicians who have justifiable reason to suspect that a child or adult patient may be
\ninvolved in exploitative adoption practices should, according to national regulations,
\nnotify appropriate authorities.
\n10. Physicians should be educated about the existence of tools that may help identify
\nfamily members of adopted children, including DNA identification testing.
\n11. The WMA encourages scientific and professional activities that could support local
\nauthorities\u2019 efforts to deter exploitation in adoption practices.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nBIOSIMILAR\tMEDICINAL\tPRODUCTS
\nAdopted by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\n1. he expiry of patents for original biotherapeutics has led to the development and
\napproval of copies, called \u2018similar biological medicinal products\u2019 or \u2018biosimilars\u2019
\nthat are highly similar to a previously approved biological product, known as the
\noriginator or reference product.
\n2. In light of the fact that biosimilars are made in living organisms, there may be
\nsome minor differences from the reference medicine, as minor variability is a
\ncharacteristic attribute of all biological medicines. The manufacture of biosimilars
\nis generally more complex than the manufacture of chemically derived molecules.
\nTherefore, the active substance in the final biosimilar can have an inherent degree
\nof minor variability. Innovator biologics also have inherent batch-to-batch
\nvariability, and for that reason biosimilars are not always interchangeable with the
\nreference products, even after regulatory approval.
\n3. Biosimilars are not the same as generics. A generic drug is an identical copy of a
\ncurrently licenced pharmaceutical product that has an expired patent protection and
\nmust contain the \u2018same active ingredients as the original formulation\u2019. A biosimilar
\nis a different product with a similar, but not identical, structure that elicits a similar
\nclinical response. As a result, biosimilar medicines have the potential to cause an
\nunwanted immune response. Whereas generics are interchangeable, biosimilars are
\nnot always interchangeable.
\n4. Biosimilars have been available in Europe for almost a decade following their
\napproval by the European Medicines Agency (EMA) in 2005. The first biosimilar
\nwas approved by the Food and Drug Administration (FDA) for use in the United
\nStates in 2015.
\n5. Biosimilar medicines have transformed the outlook for patients with chronic and
\ndebilitating conditions, as it is possible to obtain similar efficacy as that of the
\nreference product at a lower cost.
\n6. Biosimilars will also increase availability for patients without access to the bio-
\noriginator. Greater global access to effective biopharmaceuticals can reduce
\ndisability, morbidity, and mortality associated with various chronic diseases.
\n7. Nonetheless, the potentially lower cost of biosimilars raises the risk that insurers
\nand health care providers may favor them over the originator product, even when<\/p>\n

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\nBiosimilar\tMedicinal\tProducts
\nthey may not be appropriate for an individual patient or in situations when they
\nhave not demonstrated adequate clinical equivalence to an original biological
\nproduct. The decision to prescribe biosimilars or to switch patients from reference
\nmedicine to a biosimilar must be made by the attending physicians, not by health
\ninsurance companies.<\/p>\n

RECOMMENDATIONS
\n1. National medical associations should work with their governments to develop
\nnational guidance on safety of biosimilars.
\n2. National medical associations should advocate for delivering biosimilar therapies
\nthat are as safe and effective as their reference products.
\n3. National medical associations should strive to ensure that physician autonomy is
\npreserved in directing which biologic product is dispensed.
\n4. Where appropriate, national medical associations should lobby against allowing
\ninsurers and health funds to require biosimilar and originator product\u2019s
\ninterchangeability, and for safe regulations of interchanging biosimilar medicines
\nwhere this is allowed.
\n5. Physicians must ensure that patient medical records accurately reflect the
\nbiosimilar medicine that is being prescribed and taken.
\n6. Physicians shouldn\u2019t prescribe a biosimilar to patients already showing success
\nwith the originator product, unless clinical equivalence has been clearly
\ndemonstrated and established and patients are adequately informed and have given
\nconsent. There should be no substitution between biosimilars and other drugs
\nwithout the attending physcian\u2019s permission.
\n7. Physicians should seek to improve their understanding of the distinctions between
\nbiosimilar products that are highly similar to or are interchangeable with an
\noriginator product; raise awareness of the issues surrounding biosimilars and
\ninterchangeability; and promote clearly delineated labelling of biosimilar products.
\n8. Physicians should remain vigilant and report to the manufacturer, as well as
\nthrough the designated regulatory pathways, any adverse events suffered by
\npatients using originator biological products or biosimilars.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nTHE\tDEVELOPMENT\tAND\tPROMOTION\tOF\tA\tMATERNAL\tAND
\nCHILD\tHEALTH\tHANDBOOK
\nAdopted by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\nThe WMA believes that both a continuum of care and family empowerment is necessary
\nto improve the health and wellbeing of the mother and child. The reduction of maternal
\nmortality ratio and infant deaths was an important objective of the Millennium
\nDevelopment Goals (MDGs). The reductions of the maternal mortality ratio, neonatal
\nmortality rate and the under-five mortality rate are important targets to be achieved under
\nthe Sustainable Development Goals (SDGs).
\nThe maternal and child health (MCH) handbook is a comprehensive home-based booklet
\ndesigned to provide relevant health information and include integrated mother and child
\nhealth records. The MCH handbook covers health records and information on pregnancy,
\ndelivery, neonatal and childhood periods, and child growth and immunizations. The MCH
\nhandbook supports the integration of maternal, neonatal and child health services. The
\nMCH handbook is not only about health education, but about creating ownership with
\nwomen and families.
\nIn 1948, Japan became the first country in the world to create and distribute a maternal
\nand child health (MCH) handbook, in order to protect and improve the health and
\nwellbeing of the mother and child.
\nThere are now approximately 40-country versions of the MCH handbook, all adapted to
\nthe local culture and socio-economic context. There are a variety of handbooks and
\neducational materials concerned to MCH in many countries. The use of MCH handbooks
\nhas helped improve the knowledge of mothers on maternal and child health issues, and has
\ncontributed to changing behaviors during pregnancy, delivery and post-delivery period.
\nThe MCH handbook can promote the health of pregnant women, neonates and children by
\nusing it as a tool for strengthening a continuum of care. Physicians can make better care
\ndecisions, by referring to the patient\u2019s medical history and health-check data recorded in
\nthe MCH handbook. The MCH handbook alone has not been shown to improve health
\nindicators. The benefits are maximized when women and children have access to relevant
\nhealthcare services based on information recorded in the handbook. Such benefits of the
\nhandbook could be shared globally.
\nIn Japan, a digital handbook is spreading progressively. The digital handbook is expected
\nto be utilized in a way that protects confidentiality of the patient\u2019s health information.<\/p>\n

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\nMaternal\tand\tChild\tHealth\tHandbook
\nSome private kindergarten and primary schools request access to the MCH as part of their
\nadmission process, placing pressure on parents and physicians to modify the answers to
\nquestions in the handbook.
\nRECOMMENDATIONS
\n1. The WMA recommends that the constituent member associations encourage their
\nhealth authorities and health institutions to provide accessible and easy to
\nunderstand information regarding maternal and child health. The MCH handbook,
\nor equivalents, can be an important tool to improve continuity of care and benefit
\nhealth promotion for mothers, neonates and children.
\n2. The WMA recommends that the constituent member associations and medical
\nprofessionals promote the adaptation to local setting and the utilization of MCH
\nhandbooks, or equivalents, in order to leave no one behind with respect to SDGs,
\nespecially for non-literate people, migrant families, refugees, minorities, people in
\nunderserved and remote areas.
\n3. When using a MCH handbook or similar documentation, in either digital or print
\nform, the confidentiality of the individual health information and the privacy of
\nmothers and children should be strictly protected. It should be used exclusively to
\nimprove health and wellbeing of mothers, neonates, and children. It should not be
\nused in the admission procedures of schools.
\n4. The constituent member associations should promote local research to evaluate the
\nutilization of the MCH handbooks, or equivalents, and make recommendations to
\nimprove the quality of care in the local setting.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nGENDER\tEQUALITY\tIN\tMEDICINE
\nAdopted by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\n1. The WMA notes the increasing trend around the world for women to enter medical
\nschools and the medical profession, and believes that the study and the practice of
\nmedicine must be transformed to a greater or lesser extent in order to support all
\npeople who study to become or practice as physicians, of whatever gender. This is an
\nessential process of modernization by which inclusiveness is promoted by gender
\nequality. This statement proposes mechanisms to identify and address barriers causing
\ndiscrimination between genders.
\n2. In many countries around the world, the number of women studying and practicing
\nmedicine has steadily risen over the past decades, surpassing 50% in many places.
\n3. This development offers opportunities for action, including in the following areas:
\n\u2022 Greater emphasis on a proper balance of work and family life, while supporting
\nthe professional development of individual physicians.
\n\u2022 Encouragement and actualization of women in academia, leadership and
\nmanagerial roles.
\n\u2022 Equalization of pay and employment opportunities for men and women, the
\nelimination of gender pay gaps in medicine, and the removal of barriers
\nnegatively affecting the advancement of female physicians.
\n4. The issue of women in medicine was previously recognized in the WMA Resolution
\non Access of Women and Children to Health Care and the Role of Women in the
\nMedical Profession which, among other things, called for increased representation and
\nparticipation in the medical profession, especially in light of the growing enrolment of
\nwomen in medical schools. It also called for a higher growth rate of membership of
\nwomen in National Medical Associations (NMAs) through empowerment, career
\ndevelopment, training and other strategic initiatives.
\nRECOMMENDATIONS
\nIncreased presence of women in academia, leadership and management roles.
\n5. National Medical Associations\/Medical Schools\/Employers are urged to facilitate the<\/p>\n

S-2018-03-2018\t\u23d0\tReykjavik
\nGender\tEquality\tin\tMedicine
\nestablishment of mentoring programs, sponsorship, and active recruitment to provide
\nmedical students and physicians with the necessary guidance and encouragement
\nnecessary to undertake leadership and management roles.
\n6. NMAs should explore opportunities and incentives to encourage both men and women
\nto pursue diverse careers in medicine and apply for fellowships, academic, senior
\nleadership and management positions.
\n7. NMAs should lobby for gender equal medical education and work policies.
\n8. NMAs should encourage the engagement of both men and women in health policy
\norganizations and professional medical organizations.
\nWork-Life Balance
\n9. Physicians should recognize that an appropriate work-life balance is beneficial to all
\nphysicians, but that women may face unique challenges to work-life balance imposed
\nby societal expectations concerning gender roles that must be addressed to solve the
\nissue. Healthcare employers can show leadership and help tackle this imbalance by:
\n\u2022 Ensuring women who go on maternity leave are able to access all their rights
\nand entitlements;
\n\u2022 Introducing programmes which encourage men as well as women to take
\nparental leave, so that women are able to pursue their careers and men are able
\nto spend important time with their families.
\n10. Hospitals and other places of employment should strive to provide and promote access
\nto high quality, affordable, flexible childcare for working parents, including the
\nprovision of onsite housing and childcare where appropriate. These services should be
\navailable to both male and female physicians, recognizing the need for a better work-
\nlife balance. Employers should provide information on available services which
\nsupport the compatibility of work and family.
\n11. Hospitals and other places of employment should be receptive to the possibility of
\nflexible and family-friendly working hours, including part-time residencies, posts, and
\nprofessional appointments.
\n12. There is a need for increased research on alternative work schedules and
\ntelecommunication opportunities that will allow flexibility in balancing work-life
\ndemands.
\n13. NMAs should advocate for the enforcement and, where necessary, the introduction of
\npolicy mandating appropriate paid parental leave and rights in their respective
\ncountries.
\n14. Medical workplaces and professional organisations should have fair, impartial and
\ntransparent policies and practices to give all physicians and medical students equal
\naccess to employment, education and training opportunities in medicine.<\/p>\n

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\nPregnancy and Parenthood
\n15. It should be illegal for employers to ask applicants about pregnancy and\/or family
\nplanning in relation to work.
\n16. Employers should assess the risks to pregnant physicians and their unborn children,
\nwhen a physician has recently given birth and when she is breastfeeding. Where it is
\nfound, or a medical practitioner considers, that an employee or her child would be at
\nrisk were she to continue with her normal duties, the employer should provide suitable
\nalternative work for which the physician should receive her normal rate of pay.
\nPhysician should have the right to not work night shifts or on-call shifts during the
\nlater part of pregnancy, without negative consequences on salary, employment or
\nprogression in residency.
\n17. Pregnant physicians should have equal training opportunities in post-graduate training.
\n18. Parents should have the right to take adequate parental leave without negative
\nconsequences on their employment, training or career opportunities.
\n19. Parents should have the right to return to the same position after parental leave,
\nwithout the fear of termination.
\n20. Employers and training bodies should provide necessary support to any physician
\nreturning after a prolonged period of absence including parental, maternity and elder-
\ncare leave.
\n21. Mothers should be able to breastfeed (or be given protected time for breast pumping)
\nduring work hours, within the current guidelines from the WHO.
\n22. Workplaces should provide adequate accommodation for women who are
\nbreastfeeding including designated areas for breastfeeding, breast pumping, and milk
\nstorage, which are quiet, hygienic, and private.
\nChanges in organisational culture
\n23. The medical profession and employers should work to eliminate discrimination and
\nharassment on the basis of gender and create a supportive environment that allows
\nequal opportunities for training, employment and advancement.
\n24. Family friendliness should be part of the organizational culture of hospitals and other
\nplaces of employment.<\/p>\n

Workforce\tplanning\tand\tresearch
\n25. NMAs should encourage governments to take the increasing number of women
\nentering medicine into consideration in the context of long-term workforce planning.
\nA diverse workforce is beneficial to the health care system and to patients.
\nOrganizations delivering healthcare should focus on ensuring systems are<\/p>\n

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\nGender\tEquality\tin\tMedicine
\nappropriately resourced to ensure that all those working within them are able to deliver
\nsafe care to patients and are appropriately and equitably rewarded. Governments
\nshould also work to counteract negative attitudes and behaviour, bias, and\/or outdated
\nnorms and values from organizations and individuals.
\n26. NMAs should encourage governments to invest in research to identify those factors
\nthat drive women and men to choose certain fields of specialization early on in their
\nmedical education and training and strive to address any identified barriers in order to
\nachieve equal representation of men and women in all fields of medicine.
\n27. NMAs should encourage governments and employers to ensure that men and women
\nreceive equal compensation for commensurate work and strive to eliminate the gender
\npay gap in medicine.<\/p>\n

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\nWMA\tSTATEMENT
\nON
\nMEDICAL\tTOURISM
\nAdopted by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\n1. Medical tourism is an expanding phenomenon, although to date it has no agreed upon
\ndefinition and, as a result, practices and protocols in different countries can vary
\nsubstantially. For purposes of this statement, medical tourism is defined as a situation
\nwhere patients travel voluntarily across international borders to receive medical
\ntreatment, most often at their own cost. Treatments span a range of medical services,
\nand commonly include: dental care, cosmetic surgery, elective surgery, and fertility
\ntreatment (OECD, 2011).
\n2. This statement does not cover cases where a national health care system or treating
\nhospital sends a patient abroad to receive treatment at its own cost or where, as in the
\nEuropean Union, patients are allowed to seek care in another EU Member State
\naccording to legally defined criteria, and their home health system bears the costs.
\nAlso not covered is a situation in which people are in a foreign country when they
\nbecome ill and need medical care.
\n3. If not regulated appropriately, medical tourism may have medico-legal and ethical
\nramifications and negative implications, including but not limited to: internal brain
\ndrain, establishment of a two-tiered health system, and the spread of antimicrobial
\nresistance. Therefore, it is imperative that there are clear rules and regulation to govern
\nthis growing phenomenon.
\n4. Medical tourism is an emerging global industry, with health service providers in many
\ncountries competing for foreign patients, whose treatment represents a significant
\npotential source of income. The awareness of health as a potential economic benefit
\nand the willingness to invest in it rise with the economic welfare of countries, and
\nbillions of dollars are invested each year in medical tourism all over the world. The
\nkey stakeholders within this industry include patients, brokers, governments, health
\ncare providers, insurance providers, and travel agencies. The proliferation of medical
\ntourism websites and related content raise concerns about unregulated and inaccurate
\non-line health information.
\n5. A medical tourist is in a more fragile and vulnerable situation than that of a patient in
\nhis or her home country. Therefore, extra sensitivity on the part of caretakers is needed
\nat every stage of treatment and throughout the patient\u2019s care, including linguistic and
\ncultural accommodation wherever possible. When medical treatment is sought abroad,
\nthe normal continuum of care may be interrupted and additional precautions should<\/p>\n

S-2018-04-2018\t\u23d0\tReykjavik
\nMedical\tTourism
\ntherefore be taken.
\n6. Medical tourism bears many ethical implications that should be considered by all
\nstakeholders. Medical tourists receive care in both state-funded and private medical
\ninstitutions and regulations must be in place in both scenarios. These
\nrecommendations are addressed primarily to physicians. The WMA encourages others
\nwho are involved in medical tourism to adopt these principles.
\nRECOMMENDATIONS
\nGeneral
\n7. The WMA emphasises the importance of developing health care systems in each
\ncountry in order to prevent excessive medical tourism resulting from limited treatment
\noptions in a patient\u00b4s home country. Financial incentives to travel outside a patient\u2019s
\nhome country for medical care should not inappropriately limit diagnostic and
\ntherapeutic alternatives in the patient\u2019s home country, or restrict treatment or referral
\noptions.
\n8. The WMA calls on governments to carefully consider all the implications of medical
\ntourism to the healthcare system of a country by developing comprehensive,
\ncoordinated national protocols and legislation for medical tourism in consultation and
\ncooperation with all relevant stakeholders. These protocols should assess the
\npossibilities of each country to receive medical tourists, to agree on necessary
\nprocedures, and to prevent negative impacts to the country\u00b4s health care system.
\n9. The WMA calls on governments and service providers to ensure that medical tourism
\ndoes not negatively affect the proper use of limited health care resources or the
\navailability of appropriate care for local residents in hosting countries. Special
\nattention should be paid to treatments with long waiting times or involving scarce
\nmedical resources. Medical tourism must not promote unethical or illegal practices,
\nsuch as organ trafficking. Authorities, including government, should be able to stop
\nelective medical tourism where it is endangering the ability to treat the local
\npopulation.
\n10. The acceptance of medical tourists should never be allowed to distort the normal
\nassessment of clinical need and, where appropriate, the development of waiting lists,
\nor priority lists for treatment. Once accepted to treatment by a health care provider,
\nmedical tourists should be treated in accordance with the urgency of their medical
\ncondition. Whenever possible patients should be referred to institutions that have been
\napproved by national authorities or accredited by appropriately recognised
\naccreditation bodies.
\nPrior to travel
\n11. Patients should be made aware that treatment practices and health care laws may be
\ndifferent than in their home country and that treatment is provided according to the<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2018-04-2018\t\u23d0\tWorld\tMedical\tAssociation
\nlaws and practices of the host country. Patients should be informed by the
\nphysician\/service provider of their rights and legal recourse prior to travelling outside
\ntheir home country for medical care, including information regarding legal recourse in
\ncase of patient injury and possible compensation mechanisms.
\n12. The physician in the host country should establish a treatment plan, including a cost
\nestimate and payment plan, prior to the medical tourist\u2019s travel to the host country. In
\naddition, the physician and the medical tourism company (if any) should collaborate in
\norder to ensure that all arrangements are made in accordance with the patient\u00b4s
\nmedical needs. Patients should be provided with information about the potential risks
\nof combining surgical procedures with long flights and vacation activities.
\n13. Medical tourists should be informed that privacy laws are not the same in all countries
\nand, in the context of the supplementary services they receive, it is possible that their
\nmedical information will be exposed to individuals who are not medical professionals
\n(such as interpreters). If a medical tourist nonetheless decides to avail him or herself of
\nthese services, he or she should be provided with documentation specifying the
\nservices provided by non-medical practitioners (including interpreters) and an
\nexplanation as to who will have access to his or her medical information, and the
\nmedical tourist should be asked to consent to the necessary disclosure.
\n14. All stakeholders (clinical and administrative) involved in the care of medical tourists
\nmust be made aware of their ethical obligations to protect confidentiality. Interpreters,
\nand other administrative staff with access to health information of the medical tourist
\nshould sign confidentiality agreements.
\n15. The medical tourist should be informed that a change in his or her clinical condition
\nmight result in a change in the cost estimate and in associated travel plans and visa
\nrequirements.
\n16. If the treatment plan is altered because of a medical need that becomes clear after the
\ninitial plan has been established, the medical tourist should be notified of the change
\nand why it was necessary. Consent should be obtained from the patient for any
\nchanges to the treatment plan.
\n17. When a patient is suffering from an incurable condition, the physician in the host
\ncountry shall provide the patient with accurate information about his or her medical
\ntreatment options, including the limitations of the treatment, the ability of the
\ntreatment to alter the course of the disease in an appreciable manner, to increase life
\nexpectancy and to improve the quality of life. If, after examining all the data, the
\nphysician concludes that it is not possible to improve the patient\u2019s medical condition,
\nthe physician should advise the patient of this and discourage the patient from
\ntravelling.
\nTreatment
\n18. Physicians are obligated to treat every individual accepted for treatment, both local
\nand foreigner, without discrimination. All the obligations detailed in law and
\ninternational medical ethical codes apply equally to the physician in his or her<\/p>\n

S-2018-04-2018\t\u23d0\tReykjavik
\nMedical\tTourism
\nencounter with medical tourists.
\n19. Medical decisions concerning the medical tourist should be made by physicians, in
\ncooperation with the patient, and not by non-medical personnel.
\n20. At the discretion of the treating physicians, and where information is available and of
\ngood quality, the patient should not be required to undergo tests previously performed,
\nunless there is a clinical need to repeat tests.
\n21. The patient should receive information about his or her treatment in a language he or
\nshe understands. This includes the right to receive a summary of the treatment
\nprogress and termination by the treating physician and a translation of the documents,
\nas needed.
\n22. Agreement should be reached before treatment begins, on the transfer of test results
\nand diagnostic images, back to the home country of the patient.
\n23. Where possible, communication between the physicians in the host and home country
\nshould be established in order to ensure appropriate aftercare and clinical follow-up of
\nthe medical problems for which the patient was treated.
\n24. The physician who prepares the treatment plan for the patient should confirm the
\ndiagnosis, the prognosis and the treatments that the medical tourist has received.
\n25. The patient should receive a copy of his or her medical documents for the purpose of
\ncontinuity of care and follow-up in his or her home country. Where necessary, the
\npatient should be given a detailed list of medical instructions and recommendations for
\nthe period following his or her departure. This information should include a
\ndescription of the expected recovery time and the time required before travelling back
\nto his or her home is possible.
\nAdvertising
\n26. Advertising for medical tourism services, whether via the internet or in any other
\nmanner, should comply with accepted principles of medical ethics and include detailed
\ninformation regarding the services provided. Information should address the service
\nprovider\u2019s areas of specialty, the physicians to whom it refers the benefits of its
\nservices, and the risks that may accompany medical tourism. Access to
\nlicensing\/accreditation status of physicians and facilities and the facility\u2019s outcomes
\ndata should be made readily available. Advertising material should note that all
\nmedical treatment carries risks and specific additional risks may apply in the context
\nof medical tourism.
\n27. National Medical Associations should do everything in their power to prevent
\nimproper advertising or advertising that is in violation of medical ethical principles,
\nincluding advertising that contains incorrect or partial information and\/or any
\ninformation that is liable to mislead patients, such as overstatement of potential
\nbenefits.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2018-04-2018\t\u23d0\tWorld\tMedical\tAssociation
\n28. Advertising that notes the positive attributes of a specific medical treatment should
\nalso present the risks inherent in such treatment and should not guarantee treatment
\nresults or foster unrealistic expectations of benefits or treatment results.
\nTransparency and the prevention of conflicts of interest
\n29. Possible conflicts of interest may be inevitable for physicians treating medical tourists,
\nincluding at the behest of their employing institution. It is essential that all clinical
\ncircumstances and relationships are managed in an open and transparent manner.
\n30. A physician shall exercise transparency and shall disclose to the medical tourist any
\npersonal, financial, professional or other conflict of interest, whether real or perceived,
\nthat may be connected to his or her treatment.
\n31. A physician should not accept any benefit, other than remuneration for the treatment,
\nin the context of the medical treatment, and should not offer the medical tourist nor
\naccept from him or her any business or personal offer, as long as the physician-patient
\nrelationship exists. Where the physician is treating the medical tourist as another fee
\npaying patient, the same rules should apply as with his\/her other fee paying patients.
\n32. A physician should ensure that any contract with a medical tourism company or
\nmedical tourist does not constitute a conflict of interest with his or her current
\nemployment, or with his or her ethical and professional obligations towards other
\npatients.
\nTransparency in payment and in the physician\u2019s fees
\n33. A treatment plan and estimate should include a detailed report of all costs, including a
\nbreakdown of physician\u2019s fees, such as: consultancy and surgery and additional fees
\nthe patient might incur, such as: hospital costs, surgical assistance, prosthesis (if
\nseparate), and costs for post-operative care.
\n34. The cost estimate may be changed after the treatment plan has been given only in the
\nevent that the clinical condition of the patient has changed, or where circumstances
\nhave changed in a way that it was impossible to anticipate or prevent. If the pricing
\nwas thus changed, the patient must be informed as to the reason for the change in costs
\nin as timely a fashion as possible.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nS-2018-05-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tSTATEMENT
\nON
\nSUSTAINABLE\tDEVELOPMENT
\nAdopted by the 69th
\nWMA General Assembly, Reykjavik, Iceland, October 2018
\nPREAMBLE
\n1. The WMA believes that health and well-being are dependent upon social determinants
\nof health (SDHs), the conditions in which people are born, grow, live, work and age.
\nThese social determinants will directly influence the achievement of the United
\nNations Sustainable Development Goals (SDGs). Many of the SDG goals, targets and
\nindicators that have been developed to measure progress towards them, will also be
\nuseful measures of the impact of action is having on improving the SDH and, in
\nparticular, on reducing health inequities.
\n2. This statement builds upon WMA policy on Social Determinants of Health as set out
\nin the Declaration of Oslo, and upon the basic principles of medical ethics set out in
\nthe Declaration of Geneva.
\n3. The WMA recognizes the important efforts undertaken by the United Nations with the
\nadoption on 25 September 2015 of the resolution \u201cTransforming our world: the 2030
\nAgenda for Sustainable Development\u201d. The Sustainable Development Agenda is based
\nupon five key themes: people, planet, prosperity, peace and partnership and the
\nprinciple of leaving no one behind. The WMA affirms the importance of global efforts
\non sustainable development and the impact that they can bring to humanity.
\n4. SDGs are built on the lessons learned from successes and failures in achieving the
\nMillennium Development Goals (MDGs), including inequity in many areas of life.
\nWhile there is no overarching concept unifying the SDGs, the WMA believes that
\ninequity in health and wellbeing encapsulates much of the 2030 Agenda. The WMA
\nnotes that while only SDG 3 is overtly about health, many of the goals have major
\nhealth components.
\n5. The WMA recognizes all governments must commit and invest to fully implement the
\ngoals by 2030, in alignment with the Addis Ababa Action Agenda. The WMA also
\nrecognizes the risk that the SDGs might be considered unaffordable due to their
\nestimated potential cost of between US$ 3.3 and US$ 4.5 trillion a year.
\n6. The WMA emphasises the need for cross and inter-sectoral work to achieve the goals
\nand believes that health must be addressed in all SDGs and not only under health
\nspecific SDG 3.<\/p>\n

S-2018-05-2018\t\u23d0\tReykjavik
\nSustainable\tDevlopment
\nPolicy\tpriorities:
\n7. Recognition of Health in All Policies and the Social Determinants of Health \/ Whole
\nof Society approach.
\n8. Policy areas that are essential to achieving the SDG 3:
\n\u2022 Patient Empowerment and Patient Safety
\n\u2022 Continuous Quality Improvement in Health Care
\n\u2022 Overcoming the Impact of Aging on Health Care
\n\u2022 Addressing Antimicrobial Resistance
\n\u2022 The safety and welfare of Health care staff
\n9. Ensuring policy alignment among all the UN Agencies and the work of regional
\ngovernmental organizations such as EU, African Union, Arab League, ASEAN, and
\nOrganization of American States.
\n10. The WMA commits to support implementation of the other three global agreements
\nregarding the sustainable development process:
\n\u2022 The Addis Ababa Action Agenda as the mechanism that will provide the
\nfinancial support for the 2030 Agenda.
\n\u2022 The Paris Agreement is the binding mechanism of the sustainable development
\nprocess that sets out a global action plan to put the world on track to avoid
\ndangerous climate change by limiting global warming to well below 2\u00b0C above
\npre-industrial levels.
\n\u2022 The Sendai Framework for Disaster Risk Reduction as the agreement which
\nrecognizes that the State has the primary role to reduce disaster risk but that
\nresponsibility should be shared with local government, the private sector and
\nother stakeholders.
\nRecommendations\tand\tCommitments
\n11. The WMA commits to work with other intergovernmental organizations, including the
\nUN, the WHO, healthcare professionals\u2019 organizations and other stakeholders, for the
\nimplementation and follow-up of this Agenda and related international agreements,
\nand for policy and advocacy alignment.
\n12. The WMA commits to collaborate with its constituent member Associations to support
\ntheir work at regional and national levels, and with their governments on the 2030
\nAgenda implementation.
\n13. The WMA recommends that NMAs create strategies regarding data collection,
\nimplementation, capacity building and advocacy, to enhance policy coherence and to
\nmaximise the 2030 Agenda implementation at national and global levels.<\/p>\n

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\nS-2018-05-2018\t\u23d0\tWorld\tMedical\tAssociation\t\t<\/p>\n

14. The WMA also recommends that NMAs collaborate with development banks, NGOs,
\nintergovernmental organisations and other stakeholders who are also working to
\nimplement of the 2030 Agenda, especially in their own countries.
\n15. The WMA encourages the UN and the WHO to develop guidelines on how financing
\nfor health will be implemented to reach the targets established by the 2030 Agenda and
\nthe economic implications of NCDs, aging and antimicrobial resistance.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-1988-01-2015
\nWMA\tRESOLUTION
\nON
\nACADEMIC\tSANCTIONS\tOR\tBOYCOTTS
\nAdopted by the 40th
\nWorld Medical Assembly, Vienna, Austria, September 1988
\nand editorially revised by the 170th
\nWMA Council Session, Divonne-les-Bains, France,
\nMay 2005
\nand reaffirmed by the 200th
\nWMA Council Session, Oslo, Norway, April 2015
\nWHEREAS
\nacademic sanctions or boycotts are discriminatory restrictions on academic, professional
\nand scientific freedoms that deny or exclude physicians and others from educational, cul-
\ntural and scientific meetings and other opportunities for the exchange of information and
\nknowledge, the purpose of such restrictions being to protest the social and political poli-
\ncies of governments, and
\nWHEREAS
\nsuch restrictions are in direct conflict with the major objectives of the WMA, viz., to
\nachieve the highest international standards in medical education, medical science, medical
\nart and medical ethics, and
\nWHEREAS
\nsuch restrictions adversely affect health care, particularly of the disadvantaged, and there-
\nfore thwart the WMA's objective of obtaining the best possible health care for all people
\nof the world, and
\nWHEREAS
\nsuch restrictions discriminate against physicians and patients on grounds of political per-
\nsuasion or of political decisions taken by governments and are therefore in conflict with
\nthe WMA's Declaration of Geneva, Statement on Non-Discrimination in Professional Mem-
\nbership and Activities of Physicians and Statement on Freedom to Attend Medical Meet-
\nings, and
\nWHEREAS
\na basic rule of medical practice is "primum non nocere", i.e. first, do no harm,
\nTHEREFORE BE IT RESOLVED,
\nthat the WMA regards the application of such restrictions as arbitrary political decisions
\ndesigned to deny international scholarly exchange and to blacklist particular physicians or<\/p>\n

R-1988-01-2015\t\u23d0Oslo
\nAcademic\tSanctions\tBoycotts
\nbodies of physicians because of their nationality or because of the political policies of
\ntheir governments. The WMA is unalterably opposed to such restrictions and calls on all
\nNa-tional Medical Associations to resist the imposition of such restrictions by every
\nmeans at their disposal and to heed the WMA's Statement on Non-Discrimination in
\nProfessional Membership and Activities of Physicians and the WMA Statement on
\nFreedom to Attend Medical Meetings.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-1997-01-2017
\nWMA\tRESOLUTION
\nON
\nECONOMIC\tEMBARGOES\tAND\tHEALTH
\nAdopted by the 49th WMA General Assembly, Hamburg, Germany, November 1997
\nand reaffirmed by the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nAnd reaffirmed with minor revision by the 207th
\nWMA Council session, Chicago, United
\nStates, October 2017
\nRECOGNISING\tTHAT:\t<\/p>\n

all people have the right to the preservation of health; and,
\nthe Geneva Convention (Article 23, Number IV, 1949) requires the free passage of
\nmedical supplies intended for civilians;
\nRecalling the standards of international human rights law, specifically the Universal
\nDeclaration of Human Rights and the International Covenant on Economic, Social and
\nCultural Rights guarantees in its article 12 \u201cthe right of everyone to the enjoyment of the
\nhighest attainable standard of physical and mental health\u201d;
\nThe WMA urges national medical associations to ensure that Governments employing
\neconomic sanctions against other States respect the agreed exemptions for medicines,
\nmedical supplies and basic food items. Exemptions should not be exploited for
\ninappropriate purposes.\t\t<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-1997-03-2008\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nACCESS\tOF\tWOMEN\tAND\tCHILDREN\tTO\tHEALTH\tCARE
\nAND\tTHE\tROLE\tOF\tWOMEN\tIN\tTHE\tMEDICAL\tPROFESSION
\nAdopted by the 49th
\nWMA General Assembly, Hamburg, Germany, November 1997
\nand amended by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nPREAMBLE\t<\/p>\n

For years women and girls worldwide have been suffering increasing violations of their
\nhuman rights. These violations often arise from historically based gender bias where
\nwomen and girls are restricted in their access to, inter alia, employment, education and
\nhealth care.
\nIn many countries, due to, inter alia, religious and cultural convictions, female doctors and
\nnurses have been prevented from exercising their profession, which may lead to female
\npatients and their children not having access to health care.
\nGirls have the same rights as boys, and women have the same rights as men. Discrimina-
\nting against girls and women damages their health expectation. Education of girl children
\nis a major factor affecting their likelihood of experiencing health and well-being as adults.
\nIt also improves the chances of their children surviving infancy. Secondary discrimination
\ndue to social, religious and cultural practices – which diminishes women's freedom to
\nmake decisions for themselves and to access work and healthcare – should be condemned.
\nRECOMMANDATIONS:\t<\/p>\n

Therefore, the World Medical Association urges its constituent members to:
\n\u2022 Categorically condemn violations of the basic human rights of women and child-
\nren, including violations stemming from social, religious and cultural practices;
\n\u2022 Insist on the rights of women and children to full and adequate medical care, espe-
\ncially where religious and cultural restrictions hinder access to such medical care;
\n\u2022 Promote women's and children's health rights as human rights;
\n\u2022 Sensitize their membership on issues of gender equality and on participation of
\nwomen in decision-making and health related activities;
\n\u2022 Increase broad-based representation and effective participation of women in the
\nmedical profession, especially in light of the increased enrolment of women in
\nmedical schools;<\/p>\n

New\tDelhi\t\u23d0\tR-1997-03-2008
\nWoman\tand\tChildren\tto\tHealth\tCare
\n\u2022 Promote the achievement of the human right to equality of opportunity, equality of
\ntreatment and non-sexism;
\n\u2022 Promote a higher growth rate of membership in National Medical Associations
\namongst women through empowerment, career development, appropriate training to
\nimprove knowledge and skills, and other strategic initiatives.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-1998-01-2018\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nSUPPORTING\tTHE\tOTTAWA\tCONVENTION
\n(Convention on the prohibition of the use, stockpiling, production
\nand transfer of anti-personnel mines and on their destruction)
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nand amended by the 59th
\nWMA General Assembly, Seoul, Korea, October 2008
\nand reaffirmed by the 209th
\nWMA Council Session, Riga, April 2018
\nThe World Medical Association:
\n\u2022 expresses its support for the Ottawa Convention (also known as the landmine ban
\nconvention); and
\n\u2022 urges its member National Medical Associations to press their governments to sign
\nand ratify the Convention.
\n\u2022 urges its member National Medical Associations to press their governments to
\ncease manufacture, sale, deployment and use of landmines.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-1998-03-2009\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nIMPROVED\tINVESTMENT\tIN\tPUBLIC\tHEALTH
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nINTRODUCTION\t<\/p>\n

Each country should have a health system with enough resources to attend to the needs of
\nits population. However today, many countries across the world are suffering wide in-
\nequities and inequalities in health care and this is causing problems of access to health ser-
\nvices for the poorer segments of society [the weak or underprivileged]. The situation is
\nespecially serious in low-income countries.
\nThe international community has attempted to improve the situation. The 20\/20 initiative
\nof 1995, the 1996 Initiative for Heavily Indebted Poor Countries (HIPC), and Objectives
\nfor Millennium 2000 Development (MDGs) are all initiatives aimed at reducing poverty
\nand dealing with poor health, inequities and inequalities between the sexes, education,
\ninsufficient access to drinking water and environmental contamination.
\nThe objectives are formed as an agreement with acknowledgement of the contributions
\nwhich developed countries can make, in the shape of trade relations, development assis-
\ntance, reduction of the burden of debt, improving access to essential medication and the
\ntransfer of technology. Three of the eight objectives are directly related to health, which
\nhas a considerable influence on various other objectives that interact to support each of the
\nothers within a structural framework, these are designed to increase human development
\nglobally. The eight Millennium Development Objectives (MDO) foresee a development
\nvision based on health and education, thus affirming that development does not only refer
\n(allude) to economic growth.
\nVarious reports from the World Health Organization have underlined the opportunities
\nand skills [or techniques] which are currently involved in bringing about significant im-
\nprovements in health, as well as helping to reduce poverty and encourage growth. Addi-
\ntionally, the reports highlight the fact that it is of fundamental importance to reduce limita-
\ntions on human resources, in order to increase the achievements of the public health sys-
\ntem, a situation which requires urgent attention. These limitations are related to work, train-
\ning and payment conditions, and play a substantial role in determining capacity for sus-
\ntained growth of access to health services.
\nRECOMMENDATIONS\t<\/p>\n

The World Medical Association urges National Medical Associations to:<\/p>\n

R-1998-03-2009\t\u23d0\tNew\tDelhi
\nInvestment\tin\tPublic\tHealth
\n1. Advocate that their governments should adhere to and promote the proposals to in-
\ncrease investment in the health sector; and to adhere to and promote initiatives to re-
\nduce the debt burden for the poorest countries on the planet.
\n2. Advocate [defend] the inclusion of public health factors in all fields of policy pro-
\nvision, since health is mostly determined by factors that are external to the area of
\nhealthcare, for example, housing and education. [Health is not only medicine, it also
\ndepends on living standards].
\n3. Encourage and support countries in the planning and implementation of investment
\nplans, which invest in health for the poor; guarantee that more resources be used for
\nhealth in general, with greater efficiency and impact; and reduce limitations for the
\nmost effective use of the additional investments.
\n4. Maintain vigilance to ensure that the investment plans focus maximum attention on
\ngenerating capacity, that they promote leadership skills and promote incentives to
\nretain and place qualified personnel, whilst it is taken into consideration that the limi-
\ntations in relation to the previous matter currently constitute the greatest obstacle for
\nprogress.
\n5. Urge international financial institutions and other important donors to: i) Adopt the
\nnecessary measures to help the countries that have already organised mechanisms to
\nprepare their investment plans, and provide assistance to those countries that have be-
\ngun to take the necessary steps, with the support and participation of the international
\ncommunity; ii) Help countries to obtain funds to develop and implement their invest-
\nment plans; iii) Continue providing technical assistance to the countries for their plans.
\n6. Exchange information in order to coordinate efforts to change policies in these areas.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-1998-04-2009\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nMEDICAL\tWORKFORCE
\nAdopted by the 50th
\nWorld Medical Assembly, Ottawa, Canada, October 1998
\nand amended by the 60th
\nWMA General Assembly, New Delhi, India, October 2009
\nPREAMBLE\t<\/p>\n

The health of our countries depends upon keeping the population healthy. Health care is a
\nkey right of individuals. This care is dependent upon access to highly-trained medical and
\nother healthcare professionals. Well-functioning health care systems depend upon these
\nsufficient human resources. Comprehensive and extensive planning on a national level is
\nrequired in order to ensure that a country has a medical workforce in all fields of medicine
\nthat meets the present and future health needs of the entire population of that country.
\nThere are currently significant shortages in the area of health human resources. These
\nshortages are present in all countries but are especially pronounced in developing coun-
\ntries where health human resources are more limited.
\nThe problem is made more severe by the fact that many countries have not invested ade-
\nquately in the education, training, recruitment and retention of their medical workforce.
\nThe ageing population in developed countries has also been reflected by an ageing medi-
\ncal workforce. Many developed countries address their medical workforce shortages by
\nemploying health care professionals from developing countries to bolster their own health
\ncare systems.
\nThe migration of health care professionals from developing countries to developed coun-
\ntries has, over the past ten years, impaired the performance of health systems in develop-
\ning countries. Economic realities of insufficient investments in health care and inadequate
\nfacilities and support for health care professionals have continued to be responsible for
\nthis migration.
\nThe World Health Organization has recognized that the crisis of health workforce short-
\nages is impeding the provision of essential, life-saving interventions. It has therefore esta-
\nblished structures such as the Global Health Workforce Alliance, a partnership dedicated
\nto identifying and implementing solutions to the health workforce problems. The WHO is
\npromoting the development of a cadre of medical\/clinical assistants who propose to join
\nthe medical workforce to partially address these shortages.
\nRECOMMENDATIONS\t<\/p>\n

Recognizing that health care systems require adequate numbers of qualified and com-
\npetent health care professionals, the World Medical Association asks all National Medical
\nAssociations to participate and be active in addressing these requirements and to:<\/p>\n

R-1999-01-2015\t\u23d0\tMoscow
\nMedical\tWorkforce
\n1. Call on their respective governments to allocate sufficient financial resources for the
\neducation, training, development, recruitment and retention of physicians to meet the
\nmedical needs of the entire population in their countries.
\n2. Call on their respective governments to ensure that the education, training and develop-
\nment of healthcare professionals meets the highest possible standards including:
\n\u2022 The training and development of medical\/clinical assistants where this is applica-
\nble and appropriate and
\n\u2022 Ensuring clear definitions of scope of practice and conditions for adequate support
\nand supervision;
\n3. Call on governments to ensure that appropriate ratios are maintained between popula-
\ntion and the medical workforce at all levels, including mechanisms to address reduced
\naccess to care in rural and remote areas, based on accepted international norms and
\nstandards where these are available;
\n4. Take measures to attract and support individuals within their countries to enter the
\nmedical profession and also call on their respective governments to take such action;
\n5. Actively advocate for programs that will ensure the retention of physicians within
\ntheir respective countries and ensure governments\u2019 recognition of this need;
\n6. Call on governments to improve the health care working environment (including ac-
\ncess to appropriate facilities, equipment, treatment modalities and professional sup-
\nport), physician remuneration, physician living environment and career development
\nof the medical workforce at all levels;
\n7. Advocate for the development of transparent memoranda of understanding between
\ncountries where migration of trained health care professionals is an issue of concern
\nand enlist where possible the NMA of origin and receiving NMA\u2019s to support these
\nphysicians.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-1999-01-2015
\nWMA\tRESOLUTION
\nON
\nTHE\tINCLUSION\tOF\tMEDICAL\tETHICS\tAND\tHUMAN\tRIGHTS
\nIN\tTHE\tCURRICULUM\tOF\tMEDICAL\tSCHOOLS\tWORLD-WIDE
\nAdopted by the 51st
\nWorld Medical Assembly, Tel Aviv, Israel, October 1999
\nand revised by the 66th
\nWMA General Assembly, Moscow, Russia, October 2015
\nPREAMBLE
\nMedical School curricula are designed to prepare medical students to enter the profession
\nof medicine. Increasingly, in addition to core biomedical and clinical knowledge, they
\nteach skills including critical appraisal and reflective practice. These additional skills help
\nto enable future doctors to understand and assess the importance of published research
\nevidence, and how to evaluate their own practice against norms and standards set nation-
\nally and internationally.
\nIn much the way same that anatomy, physiology and biochemistry are a solid base for
\nunderstanding the human body, how it works, how it can fail or otherwise go wrong, and
\nhow different mechanisms can be used to repair damaged structure and functions, there is
\na clear need for physicians in training to understand the social, cultural and environmental
\ncontexts within which they will practice. This includes a solid understanding of the social
\ndeterminants of health.
\nMedical ethics includes the social contract made between the health care professions and
\nthe societies they serve, based upon established principles, on the limits that apply to
\nmedical practice It also establishes a system or set of principles through which new
\ntreatments or other clinical interventions will be sieved before decisions are made on
\nwhether elements are acceptable within medical practice. There is a complex intermingl-
\ning of medical ethics and the duties of physicians to patients, and the rights patients enjoy
\nas citizens.
\nAt the same time physicians face challenges and opportunities in relation to the human
\nrights of their patients and of populations, for example occasions for imposing treatments
\nwithout consent, and will also often be the first to observe and to itemize the infringement
\nof these rights by others, including the state. This places very specific responsibilities
\nupon the observing physician.
\nPhysicians have a duty to use their knowledge to improve the wellbeing and health of
\npatients and the population. This will mean considering social and societal change,
\nincluding legislation and regulation, and can only be done well if doctors can take a
\nholistic view within clinical and ethical parameters.<\/p>\n

R-1999-01-2015\t\u23d0\tMoscow
\nMedical\tWorkforce
\nPhysicians should press government to ensure legislation supports principled medical
\npractice.
\nGiven the core nature of health care ethics in establishing medical practice in a manner
\nthat is acceptable to society and that does not violate civil, political and other human
\nrights, it is essential that all physicians are trained to perform an ethics evaluation of every
\nclinical scenario they may encounter, while simultaneously understanding their role in
\nprotecting the rights of individuals.
\nPhysicians\u2019 ability to act and communicate in a way that respects the values of the
\nindividual patient is a prerequisite for successful treatment. Physicians must also be able to
\nwork effectively in teams with other health care professionals including other physicians.
\nFailures of individual physicians to recognize the ethical obligations they owe patients and
\ncommunities can damage the reputation of doctors both locally and globally. Therefore it
\nis essential that all doctors are taught to understand and respect medical ethics and human
\nrights from the beginning of their medical school careers.
\nIn many countries ethics and human rights are an integral part of the medical curriculum,
\nbut this is not universal. Too often teaching is undertaken by volunteers, and can fail if
\nthose volunteers are unable or unavailable to teach, or if that teaching is unduly idiosync-
\nratic or inadequately based upon clinical scenarios.
\nThe teaching of medical ethics should become an obligatory and examined part of the
\nmedical curriculum within every medical school.
\nRECOMMENDATIONS
\n1. The WMA urges that medical ethics and human rights be taught at every medical
\nschool as obligatory and examined parts of the curriculum, and should continue at all
\nstages of post graduate medical education and continuing professional development.
\n2. The WMA believes that medical schools should seek to ensure that they have
\nsufficient faculty skilled at teaching ethical enquiry and human rights to make these
\ncourses sustainable.
\n3. The WMA commends the inclusion of medical ethics and human rights within post
\ngraduate and continuing medical education.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2002-01-2013\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nEUTHANASIA
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand reaffirmed with minor revision by the 194th
\nWMA Council Session,
\nBali, Indonesia, April 2013
\nThe World Medical Association's Declaration on Euthanasia, adopted by the 38th
\nWorld
\nMedical Assembly, Madrid, Spain, October 1987 and reaffirmed by the 170th
\nWMA
\nCouncil Session, Divonne-les-Bains, France, May 2005 states:
\n"Euthanasia, that is the act of deliberately ending the life of a patient, even at the
\npatient's own request or at the request of close relatives, is unethical. This does not
\nprevent the physician from respecting the desire of a patient to allow the natural pro-
\ncess of death to follow its course in the terminal phase of sickness."
\nThe WMA Statement on Physician-Assisted Suicide, adopted by the 44th
\nWorld Medical
\nAssembly, Marbella, Spain, September 1992 and editorially revised by the 170th
\nWMA
\nCouncil Session, Divonne-les-Bains, France, May 2005 likewise states:
\n"Physicians-assisted suicide, like euthanasia, is unethical and must be condemned by
\nthe medical profession. Where the assistance of the physician is intentionally and
\ndeliberately directed at enabling an individual to end his or her own life, the physi-
\ncian acts unethically. However the right to decline medical treatment is a basic right
\nof the patient and the physician does not act unethically even if respecting such a
\nwish results in the death of the patient."
\nThe World Medical Association has noted that the practice of active euthanasia with
\nphysician assistance, has been adopted into law in some countries.
\nBE\tIT\tRESOLVED\tthat:\t<\/p>\n

The World Medical Association reaffirms its strong belief that euthanasia is in conflict
\nwith basic ethical principles of medical practice, and
\nThe World Medical Association strongly encourages all National Medical Associations
\nand physicians to refrain from participating in euthanasia, even if national law allows it or
\ndecriminalizes it under certain conditions.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-2002-02-2012
\nWMA\tRESOLUTION
\nON
\nFEMALE\tFOETICIDE
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand reaffirmed by the 191st
\nWMA Council Session, Prague, Czech Republic, April 2012
\n1. Whereas there is grave concern that in certain countries female foeticide is commonly
\npractised.
\n2. The WMA denounces female foeticide as a totally unacceptable example of gender
\ndiscrimination.
\n3. The World Medical Association calls on National Medical Associations:
\n1. To denounce the practice of female foeticide and the use of selective sex
\ndetermination for that purpose and;
\n2. To advise their governments accordingly.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2002-05-2012\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nTHE\tABUSE\tOF\tPSYCHIATRY
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand revised by the 63rd
\nWMA General Assembly, Bangkok, Thiland, October 2012
\nThe World Medical Association (WMA) notes with concern evidence from a number of
\ncountries that political dissidents, practitioners of various religions and social activists
\nhave been detained in psychiatric institutions and subjected to unnecessary psychiatric
\ntreatment as a punishment and not to treat a substantiated psychiatric illness.
\nThe WMA:
\n\u2022 Declares that such detention and unwarranted treatment is abusive, unethical and
\nunacceptable;
\n\u2022 Calls on physicians and psychiatrists to resist involvement in these abusive prac-
\ntices;
\n\u2022 Calls on member NMAs to support their physician members who resist involve-
\nment in these abuses, and
\n\u2022 Calls on governments to stop abusing medicine and psychiatry in this manner, and
\non non-governmental organizations and the World Health Organization to work to
\nend these abuses; and
\n\u2022 Calls on governments to uphold the United Nations International Covenant on
\nCivil and Political Rights, which states that "all persons are equal before the law
\nand are entitled without any discrimination to the equal protection of the law."<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-2002-06-2013
\nWMA\tRESOLUTION
\nON
\nWOMEN'S\tRIGHTS\tTO\tHEALTH\tCARE
\nAND\tHOW\tTHAT\tRELATES\tTO\tTHE\tPREVENTION
\nOF\tMOTHER-TO-CHILD\tHIV\tINFECTION
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA, October 2002
\nand amended by the 64th
\nWMA General Assembly, Fortaleza, Brazil, October 2013
\nPREAMBLE
\nIn many parts of the world the prevalence of HIV infection continues to increase. One of
\nthe Millennium Development Goals (MDG 6), specifically targets combating HIV\/AIDS,
\nmalaria and other diseases, with 2015 being its target year to halt HIV\/AIDS infection and
\nto begin reversing the spread of HIV\/AIDS. In addition, it was hoped that by 2010
\nuniversal access to treatment for HIV\/AIDS for all those requiring it would be achieved. A
\nDecember 2012 UN resolution declared that countries must develop programmes for
\nUniversal Health Access after 2015 when the MDGs end.
\nHIV\/AIDS is a disease that disproportionately affects people in their reproductive years
\nalthough today, due to better management of the condition, there are also many older
\npeople who are infected. In addition, many who were infected as infants are now reaching
\nreproductive maturity.
\nIn developed countries men who have sex with men and injection drug users constitute
\nsignificant risk groups for contracting HIV. In many developing countries, women are at
\nrisk due to heterosexual contact with HIV infected partners. In 2011 approximately 58
\npercent of people living with HIV in sub-Saharan Africa were women, equating to about
\n13.6 million women living with HIV and AIDS, compared to about 9.9 million men
\n(UNAIDS 'Global Fact Sheet 2012: World AIDS Day 2012).
\nIn the absence of HIV, maternal mortality worldwide would be significantly (20% ) lower
\n(Murray et al. Maternal mortality for 181 countries, 1980~2008: a systematic analysis of
\nprogress towards Millennium Development Goal 5).
\nHIV infection increases the risk of invasive cervical cancer 2 to 22 fold. Some evidence
\nexists that the use of antiretroviral therapy may decrease this risk. Hence, the appropriate
\nmanagement of patients infected with HIV may have a long-term impact on other aspects
\nof women\u2019s health.
\nThe WMA believes that access to healthcare, including both therapeutic and preventative
\nstrategies, is a fundamental human right. This imposes an obligation on government to<\/p>\n

Washington,\tDC\t\u23d0\tR-2002-06-2002
\nWomen\u2019s\tRight\tto\tHealth\tCare
\nensure that these human rights are fully respected and protected. Gender inequalities must
\nbe addressed and eradicated. This should impact every aspect of healthcare.
\nThe promotion and protection of the reproductive rights of women are critical to the
\nultimate success of confronting and resolving the HIV\/AIDS pandemic.
\nMany of the MDGs address empowering women and promoting their role in society and
\nspecifically in healthcare. MDG 5B, in particular, promotes universal access to repro-
\nductive health including contraceptive access, reduction in adolescent birth rate, antenatal
\ncare coverage and addressing unmet needs for family planning. In addition, MDG 3
\nwhich promotes gender equality and empowers women, and MDGs 1 and 2 will influence
\nwomen\u2019s status in society and therefore their access to healthcare and health promotion.
\nRECOMMENDATIONS\t<\/p>\n

The WMA requests all national member associations to encourage their governments to
\nundertake and promote the following actions:
\n\u2022 Develop empowerment programs for women of all ages to ensure that women are
\nfree from discrimination and enjoy universal and free access to reproductive health
\neducation and life skills training. It is recommended that campaigns be initiated and
\nactivated in the media, including social media and popular programmes on radio and
\ntelevision in order to eradicate myths, stigma and stereotypes that might degrade or
\ndehumanise women. This must include campaigns against genital mutilation and
\nforced adolescent marriages and unwanted pregnancies. In addition, promoting the
\navailability and choice of contraception for women, without necessarily having to
\nget input from their partners, and promoting the availability of HIV testing and treat-
\nment are essential for reproductive health. It is also important to provide for the eco-
\nnomic means for the infected populations in terms of prevention, treatment and
\nmedical follow-up.
\n\u2022 Women must have the same access as men, without discrimination to education,
\nemployment, economic independence, information about healthcare and health ser-
\nvices.
\n\u2022 Laws, policies and practices that facilitate the full recognition and respect of human
\nrights and the fundamental freedom of women should be initiated or reviewed and
\nrevised where appropriate. It is essential that women are empowered to make deci-
\nsions regarding their children, their financial status and their future.
\n\u2022 All governments should develop programmes to provide prophylactic treatment in
\nthe form of antiretrovirals to women who have been raped or sexually assaulted.
\nUniversal and free access to antiretroviral therapy must also be provided to all HIV
\ninfected women.
\n\u2022 HIV infected women who are pregnant should receive counselling and access to
\nanti-retroviral prophylaxis or treatment in order to prevent mother to child trans-
\nmission of HIV.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nWorld\tMedical\tAssociation\t\u23d0\tR-2003-01-2013
\nWMA\tRESOLUTION
\nON
\nTHE\tDESIGNATION\tOF\tAN\tANNUAL\tMEDICAL\tETHICS\tDAY
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand reaffirmed by the 194th
\nWMA Council Session, Bali, Indonesia, April 2013
\nWhereas the World Medical Association has a specific focus and function in the field of
\nmedical ethics, and came into being on 18 September 1947 during the first General
\nAssembly, it is resolved that NMAs are encouraged to annually observe the 18th
\nSeptember as "Medical Ethics Day".<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2003-02-2007\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nTHE\tRESPONSIBILITY\tOF\tPHYSICIANS\tIN\tTHE\tDOCUMENTATION
\nAND\tDENUNCIATION\tOF\tACTS\tOF\tTORTURE\tOR\tCRUEL
\nOR\tINHUMAN\tOR\tDEGRADING\tTREATMENT
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand amended by the 58th
\nWMA General Assembly, Copenhagen, Denmark, October 2007
\nThe World Medical Association,
\n1. Considering the Preamble to the United Nations Charter of 26 June 1945 solemnly
\nproclaiming the faith of the people of the United Nations in the fundamental human
\nrights, the dignity and value of the human person,
\n2. Considering the Preamble to the Universal Declaration of Human Rights of 10 De-
\ncember 1948 which states that disregard and contempt for human rights have re-
\nsulted in barbarous acts which have outraged the conscience of mankind,
\n3. Considering Article 5 of that Declaration which proclaims that no one shall be sub-
\njected to torture or cruel, inhuman or degrading treatment,
\n4. Considering the American Convention on Human Rights, which was adopted by the
\nOrganization of American States on 22 November 1969 and entered into force on 18
\nJuly 1978, and the Inter-American Convention to Prevent and Punish Torture, which
\nentered into force on 28 February 1987,
\n5. Considering the Declaration of Tokyo, adopted by the World Medical Association in
\n1975, which reaffirms the prohibition of any form of medical involvement or presence
\nof a physician during torture or inhuman or degrading treatment,
\n6. Considering the Declaration of Hawaii, adopted by the World Psychiatric Association
\nin 1977,
\n7. Considering the Declaration of Kuwait, adopted by the International Conference of
\nIslamic Medical Associations in 1981,
\n8. Considering the Principles of Medical Ethics Relevant to the Role of Health Person-
\nnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Tor-
\nture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by
\nthe United Nations General Assembly on 18 December 1982, and particularly Princi-
\nple 2, which states: "It is a gross contravention of medical ethics\u2026 for health person-
\nnel, particularly physicians, to engage, actively or passively, in acts which constitute
\nparticipation in, complicity in, incitement to or attempts to commit torture or other
\ncruel, inhuman or degrading treatment\u2026",<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2003-03-2014\t\u23d0\tWorld\tMedical\tAssociation
\n9. Considering the Convention Against Torture and Other Cruel, Inhuman or Degrading
\nTreatment or Punishment, which was adopted by the United Nations General Assem-
\nbly on December 1984 and entered into force on 26 June, 1987,
\n10. Considering the European Convention for the Prevention of Torture and Inhuman or
\nDegrading Treatment or Punishment, which was adopted by the Council of Europe on
\n26 June 1987 and entered into force on 1 February 1989,
\n11. Considering the Resolution on Human Rights adopted by the World Medical Asso-
\nciation in Rancho Mirage, in October 1990 during the 42nd
\nGeneral Assembly and
\namended by the 45th
\n, 46th
\nand 47th
\nGeneral Assemblies,
\n12. Considering the Declaration of Hamburg, adopted by the World Medical Association
\nin November 1997 during the 49th
\nGeneral Assembly, calling on physicians to protest
\nindividually against ill-treatment and on national and international medical organiza-
\ntions to support physicians in such actions,
\n13. Considering the Istanbul Protocol (Manual on the Effective Investigation and Docu-
\nmentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punish-
\nment), adopted by the United Nations General Assembly on 4 December 2000,
\n14. Considering the Convention on the Rights of the Child, which was adopted by the
\nUnited Nations on 20 November 1989 and entered into force on 2 September 1990,
\nand
\n15. Considering the World Medical Association Declaration of Malta on Hunger Strikers,
\nadopted by the 43rd
\nWorld Medical Assembly Malta, November 1991and amended by
\nthe WMA General Assembly, Pilanesberg, South Africa, October, 2006,
\nRECOGNIZING
\n1. That careful and consistent documentation and denunciation by physicians of cases of
\ntorture and of those responsible contributes to the protection of the physical and men-
\ntal integrity of victims and in a general way to the struggle against a major affront to
\nhuman dignity,
\n2. That physicians, by ascertaining the sequelae and treating the victims of torture, either
\nearly or late after the event, are privileged witnesses of this violation of human rights,
\n3. That the victims, because of the psychological sequelae from which they suffer or the
\npressures brought on them, are often unable to formulate by themselves complaints
\nagainst those responsible for the ill-treatment they have undergone,
\n4. That the absence of documenting and denouncing acts of torture may be considered as
\na form of tolerance thereof and of non-assistance to the victims,
\n5. That nevertheless there is no consistent and explicit reference in the professional
\ncodes of medical ethics and legislative texts of the obligation upon physicians to
\ndocument, report or denounce acts of torture or inhuman or degrading treatment of
\nwhich they are aware,<\/p>\n

Copenhagen\t\u23d0\tR-2003-02-2007
\nDenunciation\tof\tActs\tof\tTorture
\nRECOMMENDS\tTHAT\tNATIONAL\tMEDICAL\tASSOCIATIONS
\n1. Attempt to ensure that detainees or victims of torture or cruelty or mistreatment have
\naccess to immediate and independent health care. Attempt to ensure that physicians
\ninclude assessment and documentation of symptoms of torture or ill-treatment in the
\nmedical records using the necessary procedural safeguards to prevent endangering
\ndetainees.
\n2. Promote awareness of the Istanbul Protocol and its Principles on the Effective Investi-
\ngation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treat-
\nment. This should be done at country level using different methods of information
\ndis-semination; including trainings, publications and web documents.
\n3. Disseminate to physicians the Istanbul Protocol.
\n4. Promote training of physicians on the identification of different modes of torture, in
\nrecognizing physical and psychological symptoms following specific forms of torture
\nand in using the documentation techniques foreseen in the Istanbul Protocol to create
\ndocumentation that can be used as evidence in legal or administrative proceedings.
\n5. Promote awareness of the correlation between the examination findings, under-
\nstanding torture methods and the patients' allegations of abuse;
\n6. Facilitate the production of high-quality medical reports on torture victims for sub-
\nmission to judicial and administrative bodies;
\n7. Attempt to ensure that physicians observe informed consent and avoid putting indi-
\nviduals in danger while assessing or documenting signs of torture and ill-treatment;
\n8. Attempt to ensure that physicians include assessment and documentation of
\nsymptoms of torture or ill-treatment in the medical records using the necessary
\nprocedural safe-guards to prevent endangering detainees.
\n9. Support the adoption in their country of ethical rules and legislative provisions:
\n1. aimed at affirming the ethical obligation on physicians to report or denounce acts
\nof torture or cruel, inhuman or degrading treatment of which they are aware; de-
\npending on the circumstances, the report or denunciation would be addressed to
\nmedical, legal, national or international authorities, to non-governmental organiza-
\ntions or to the International Criminal Court. Doctors should use their discretion in
\nthis matter, bearing in mind paragraph 68 of the Istanbul Protocol.
\n2. establishing, to that effect, an ethical and legislative exception to professional con-
\nfidentiality that allows the physician to report abuses, where possible with the sub-
\nject's consent, but in certain circumstances where the victim is unable to express
\nhim\/herself freely, without explicit consent.
\n3. cautioning physicians to avoid putting individuals in danger by reporting on a
\nnamed basis a victim who is deprived of freedom, subjected to constraint or threat
\nor in a compromised psychological situation<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2003-03-2014\t\u23d0\tWorld\tMedical\tAssociation
\n10. Place at their disposal all useful information on reporting procedures, particularly to
\nthe national authorities, nongovernmental organizations and the International Crimi-
\nnal Court.
\nIstanbul Protocol, paragraph 68: "In some cases, two ethical obligations are in conflict.
\nInternational codes and ethical principles require the reporting of information concerning
\ntorture or maltreatment to a responsible body. In some jurisdictions, this is also a legal re-
\nquirement. In some cases, however, patients may refuse to give consent to being exa-
\nmined for such purposes or to having the information gained from examination disclosed
\nto others. They may be fearful of the risks of reprisals for themselves or their families. In
\nsuch situations, health professionals have dual responsibilities: to the patient and to society
\nat large, which has an interest in ensuring that justice is done and perpetrators of abuse are
\nbrought to justice. The fundamental principle of avoiding harm must feature prominently
\nin consideration of such dilemmas. Health professionals should seek solutions that pro-
\nmote justice without breaking the individual's right to confidentiality. Advice should be
\nsought from reliable agencies; in some cases this may be the national medical association
\nor non-governmental agencies. Alternatively, with supportive encouragement, some reluc-
\ntant patients may agree to disclosure within agreed parameters."<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2003-03-2014\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nTHE\tNON-COMMERCIALISATION\tOF
\nHUMAN\tREPRODUCTIVE\tMATERIAL
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, September 2003
\nand revised by 65th
\nWMA General Assembly, Durban, South Africa, October 2014
\nPREAMBLE
\nThe rapid advances in biomedical technologies have led to growth of the reproductive
\nassistance industry, which tends to be poorly regulated. Despite the fact that many govern-
\nments have laws prohibiting commercial transactions of reproductive material, most have
\nnot been successful in universally preventing the sale of human ova, sperm and embryos
\non the internet and elsewhere. The market value of human material, including cells, tis-
\nsues, and cellular tissue can be lucrative, creating a potential conflict for physicians and
\nothers between economic interests and professional ethical obligations.
\nFor the purposes of this resolution human reproductive material is defined as human
\ngametes and embryos.
\nAccording to the WHO, transplant commercialism \u201cis a policy or practice in which cells,
\ntissues or organs are treated as a commodity, including by being bought or sold or used for
\nmaterial gain.\u201d1
\nThe principle that the \u201chuman body and its parts shall not, as such, give rise to financial
\ngain\u201d2
\nis laid down in numerous international declarations and recommendations.3
\nThe
\n2006 WMA Statement on Human Organ Donation and Transplantation and the 2012
\nWMA Statement on Organ and Tissue Donation call for the prohibition of the sale of or-
\ngans and tissues for transplantation. The WMA Statement on Assisted Reproductive
\nTechnologies (2006) also states that it is inappropriate to offer financial benefits to en-
\ncourage donation of human reproductive material.
\nThe same principles should be in place for the use of human reproductive material in the
\narea of medical research. The International Bioethics Committee of the United Nations
\nEducational, Scientific and Cultural Organization (UNESCO IBC) in its report on the
\nethical aspects of human embryonic stem cell research states that the transfer of human
\nembryos must not be a commercial transaction and that measures should be taken to
\ndiscourage any financial incentive.
\nIt is important to distinguish between the sale of clinical assisted reproductive services,
\nwhich is legal, and the sale of the human reproductive materials, which is usually illegal.
\nDue to the special nature of human embryos, the commercialization of gametes is unlike
\nthat of other cells and tissues as sperm and eggs may develop into a child if fertilization is
\nsuccessful.<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2003-03-2014\t\u23d0\tWorld\tMedical\tAssociation
\nBefore human reproductive material is donated, the donor must give informed consent that
\nis free of duress. This requires that the individual donor is deemed fully competent and has
\nbeen given all the available information regarding the procedure and its outcome. If re-
\nsearch is to be conducted on the material, it is subject to a separate consent process that
\nmust be consistent with the provisions in the WMA's Declaration of Helsinki. There must
\nnot be any inducement or other undue pressure to donate or offers of compensation.
\nMonetary compensation given to individuals for economic losses, expenses or incon-
\nveniences associated with the retrieval of donated reproductive materials should be dis-
\ntinguished from payment for the purchase of reproductive materials.
\nRECOMMENDATIONS
\n1.
\n1. National Medical Associations (NMAs) should urge their governments to prohibit
\ncommercial transactions in human ova, sperm and embryos and any human material
\nfor reproductive purpose.
\n2. Physicians involved in the procurement and use of human ova, sperm, and em-
\nbryos should implement protocol to ensure that materials have been acquired ap-
\npropriately with the consent and authorization of the source individuals. In doing
\nso, they can uphold the ethical principle of non-commercialization of human repro-
\nductive material.
\n3. Physicians should consult with potential donors prior to donation in order to ensure
\nfree and informed consent.
\n4. Physicians should adhere to the WMA Statement on Conflict of Interest when
\ntreating patients who seek reproductive services.
\n1
\nGlobal Glossary of Terms and Definitions on Donation and Transplantation, WHO, November
\n2009
\n2
\nEuropean convention of human rights and biomedicine – Article 21 \u2013 Prohibition of financial
\ngain
\n3
\nDeclaration of Istanbul guiding principle 5<\/p>\n

Handbook\tof\tWMA\tPolicies
\nR-2004-01-2014\t\u23d0\tWorld\tMedical\tAssociation
\nWMA\tRESOLUTION
\nON
\nWFME\tGLOBAL\tSTANDARDS\tFOR\tQUALITY\tIMPROVEMENT\tOF
\nMEDICAL\tEDUCATION
\nApproved by the 55th
\nWMA General Assembly, Tokyo, Japan, October 2004
\nand reaffirmed by the 197th
\nWMA Council Session, Tokyo, Japan, April 2014
\nWhereas the WMA:
\n1. Recognizes the need and importance for sound global standards for quality improve-
\nment of medical education;
\n2. Acknowledges the WMA's special relationship with the World Federation for Medical
\nEducation (WFME) as one of the founders of the Federation;
\n3. Recognizes that it is represented in the WFME Executive Council and in this capacity
\nis co-responsible for the WFME Project on International Standards in Medical Educa-
\ntion, conducted since 1997 1
\n;
\n4. Acknowledges the recent development of the WFME Trilogy of Documents of Global
\nStandards in Medical Education for Quality Improvement, covering Basic Medical
\nEducation2
\n, Postgraduate Medical Education3
\nand the Continuing Professional De-
\nvelopment (CPD) of Medical Doctors4
\n;
\n5. Recognizes the endorsement5
\nof the WFME Global Standards at the World Confer-
\nence in Medical Education: Global Standards in Medical Education for Better Health
\nCare, in Copenhagen, Denmark, March 20036
\n;
\nIt hereby:
\n1. Expresses its encouragement and support of the ongoing work of implementing the
\nTrilogy of WFME Documents on Global Standards in Medical Education.
\n1
\nThe Executive Council, The World Federation for Medical Education: International standards in
\nmedical education: assessment and accreditation of medical schools\u00b4 educational programmes. A
\nWFME position paper. Med Ed 1998; 32: 549-558.
\n2
\nWorld Federation for Medical Education: Basic Medical Education. WFME Global Standards for
\nQuality Improvement. WFME, Copenhagen 2003. http:\/\/www.wfme.org
\n3
\nWorld Federation for Medical Education. Postgraduate Medical Education. WFME Global
\nStandards for Quality Improvement. WFME, Copenhagen 2003. http:\/\/www.wfme.org
\n4
\nWorld Federation for Medical Education: Continuing Professional Development (CPD) of Me-
\ndical Doctors. WFME Global Standards for Quality Improvement. WFME Copenhagen 2003.<\/p>\n

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