Advocacy – WMA – The World Medical Association

Adopted by the 63^rd WMA General Assembly, Bangkok, Thailand, October 2012
and revised by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Violence in the health sector has increased substantially in the new millennium, especially in time of COVID-19 pandemic. All persons have the right to work in a safe environment without the threat of violence. Workplace violence includes both physical and non-physical, such as (psychological) violence, intimidation and cyber harassment, among others.

Cyber and social media harassment particularly includes online threats and intimidation towards physicians who take part in a public debate in order to give adequate information and fight disinformation. These physicians are increasingly confronted with, amongst others, malicious messages on social media, death threats and intimidating home visits.

For the purposes of this document, the broad WHO definition of workplace violence will be used: “The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation”.

In addition to the numerous consequences on victims’ health, violence against health personnel has potentially destructive social effects. It affects the entire healthcare system and undermines the quality of the working environment, ultimately impacting the quality of patient care. Furthermore, violence can affect the availability of health care, particularly in impoverished areas.

While workplace violence is indisputably a global issue, various cultural differences among countries must be taken into consideration in order to accurately understand the concept of violence on a universal level. Significant differences exist in terms of what defines various levels of violence and what specific forms of workplace violence are most likely to occur. This may create tolerance for some levels of violence in those places. However, threats and other forms of psychological violence are widely recognized to be more prevalent than physical violence.

Causes of violence in the healthcare setting are extremely complex. Several studies have identified common triggers for acts of violence by patients and relatives to be delays in receiving treatment, dissatisfaction with the treatment provided, aggressive patient behavior caused by the patient’s medical condition, the medication they take or the use of alcohol and other drugs. Additionally, individuals may threaten or perpetrate violence against health personnel because they oppose a specific area of medical practice, based on their social, political or religious beliefs. Cases of violence from the bystanders are reported as well. Co-worker violence, such as bullying, including initiation ceremonies and practical jokes, or harassment, constitutes another important pattern of workplace violence in the health sector.

Collaboration among various stakeholders (including governments, medical associations, hospitals, general health services, management, insurance companies, trainers, preceptors, researchers, media, police and legal authorities) together with a multi-faceted approach encompassing the areas of legislation, security, data collection, training/education, environmental factors, public awareness and financial incentives is required in order to successfully address this issue. As the representatives of physicians, medical associations should take a proactive role in combating violence in the health sector and also encourage other key stakeholders to act, thus further protecting the quality of the working environment for health personnel and the quality of patient care.

RECOMMENDATIONS

The WMA condemns in the strongest terms any forms of violence against healthcare personnel and facilities, which may include coworker violence, aggressive behavior exhibited by patients or family members, as well as acts of malicious intent from individuals in the general public, and calls on its constituent members, the health authorities and other relevant stakeholders to act through a collaborative, coordinated and effective strategy approach:

Policy-making

The state has obligations to ensure the safety and security of patients, physicians, and other health personnel. This includes providing an appropriate physical environment.
Governments should provide the necessary framework so that the prevention and elimination of workplace violence in the health sector be an essential part of national/regional/local policies on occupational health and safety, human rights protection, healthcare-facility management standards and gender equality.

Financial

Governments should allocate appropriate and sustainable funds in order to effectively tackle violence in the health sector.

Protocols for situation of violence in healthcare facilities

Healthcare facilities should adopt a zero-tolerance policy towards workplace violence eliminating its “normalization” through the development and implementation of adequate protocols including the following:

A predetermined plan for maintaining security in the workplace; including recognition of non-physical abuse as a risk factor for physical abuse.
A designated plan of action for health personnel when violence takes place.
A strengthened internal communication strategy, involving the staff in decisions concerning their security.
A system for reporting and recording acts of violence, which may include reporting to legal and/or police authorities.
A means to ensure that employees who report violence do not face reprisals.

In order for these protocols to be effective, the management and administration of healthcare facilities should communicate and take the necessary steps to ensure that all staff are aware of the protocols. Managers should be urged to verbalize a no-tolerance policy towards violence in healthcare settings.
Patients with acute, chronic or illness-induced mental health disturbances or other underlying medical conditions may act violently toward health personnel; those taking care of these patients must be adequately protected. Except in emergency cases, physicians might have the right to refuse to treat and, in such situations, they must ensure that adequate alternative arrangements are made by the relevant authorities in order to safeguard the patient’s health and treatment.

Training/Education

A well-trained and vigilant staff supported by management can be a key deterrent of violent acts. Constituent members should work with undergraduate and postgraduate education providers to ensure that health personnel are trained in the following areas: communication skills, empathy as well as recognising and handling potentially violent persons and high-risk situations in order to prevent incidents of violence.
Continuous education should include ethical principles of healthcare and the cultivation of the patient-physician relationships based on respect and mutual trust. This not only improves the quality of patient care but also fosters feelings of security resulting in a reduced risk of violence.

Communication and Social Awareness

Medical associations, health authorities and other stakeholders should work together to increase awareness of violence in the health sector, creating networks of information and expertise in this area. When appropriate, health personnel and the public should be informed of acts of violence.
Broadcasting agencies, newspapers, and other news outlets are encouraged to thoroughly verify their sources in order to keep the information shared to the highest standard of professional reporting. Social media companies and associated stakeholders should also take active steps to create a cyber-violence-free environment for its users. This includes strengthening policies to protect user data, making reporting and flagging such violence easy and accessible, and engaging law enforcement for proper legal action when warranted.

Security

Appropriate security measures should be in place in all healthcare facilities and acts of violence should be given a high priority by law-enforcement authorities. A routine violence risk audit, including a risk assessment, should be implemented in order to identify which jobs and locations are at highest risk for violence, especially in places where violence has already occurred, and to determine weaknesses in facilities’ security. Examples of high-risk areas include general practice premises, mental health treatment facilities and high traffic areas of hospitals including the emergency department.
The risk of violence may be ameliorated by a variety of means which include placing security personnel in high-risk areas and at the entrance of buildings, the installation of security cameras and alarm devices for use by health personnel, the use distinguishable items to identify the staff and by maintaining sufficient lighting in work areas, contributing to an environment conducive to vigilance and safety. The implementation of a system to screen patients and visitors for weapons upon entering certain areas, especially the high-risk ones, should be considered.

Support to victims

Adequate medical, psychological and legal support should be provided to victims of violence. Such support should be free of access for all the health personnel.

Investigation

In all cases of violence there should be investigation to better understand the causes and to aid in prevention of future violence. The investigation may lead to prosecution of perpetrators under civil or criminal codes. The procedure should be led by relevant officials in law enforcement and should not expose the victim to further physical or psychological harm.

Data Collection

Appropriate reporting systems should be established to enable health personnel to report anonymously and without reprisal, any threats or incidents of violence. Such a system should assess in terms of number, type and severity, incidents of violence within an institution and resulting injuries. The system should be used to analyse the effectiveness of preventative strategies. Aggregated data and analyses should be made available to health professional organizations and other relevant stakeholders.

Adopted by the 61^st WMA General Assembly, Vancouver, Canada, October 2010
And amended by the 71^st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

Violence against women is a worldwide phenomenon and includes violence within the family, within the community and violence perpetrated by or condoned by the state. Many excuses are given for violence generally and specifically; in cultural and societal terms, these include tradition, beliefs, customs, values and religion. Intimate partner violence, rape, sexual abuse and harassment, intimidation at work or in education, modern slavery, trafficking and forced prostitution, are all forms of violence condoned by some societies. One extreme form of such violence is sexual violence used as a weapon of war (United Nations Security Council Resolution 1820). Specific cultural practices that harm women, including female genital mutilation, forced marriages, dowry attacks and so-called “honour” killings are all practices that may occur within the family setting.

All human beings enjoy fundamental human rights. The examples listed above involve denial of many of those rights, and each abuse can be examined against the Universal Declaration of Human Rights, as well as the Convention on the Elimination of All Forms of Discrimination against Women and the Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000).

The denial of rights and the violence itself have health consequences to women. In addition to the specific and direct physical and health consequences, the general way in which women are treated can lead to an excess of mental health problems and increase of suicidal behavior. The short and long-term mental health consequences of violence may severely influence later wellbeing, enjoyment of life, function in society and the ability to provide appropriate care for dependents. Lack of good nutritional opportunities can lead to generations of women with poorer health, poorer growth and development. Denial of educational opportunities leads to poorer health for all the family members since good education of women is a major factor in the wellbeing of the family.

In addition to being unacceptable in and of itself, violence against women is also socially and economically damaging to the family and to society. There are direct and indirect economic consequences to violence against women that are far greater than the direct health sector costs. Lack of economic independence, and of basic education, also mean that women who survive abuse are more likely to be or to become dependent upon the state or society and less able to support themselves and contribute to that society.

Physicians have a unique insight into the combined effects of violence against women. The holistic view from physicians can be used to influence society and politicians. Gaining societal support for improving the rights, freedom and status of women is essential.

This Statement alongside with other WMA key related policies, including the statements on Female Genital Mutilation, Sex Selection and Female Foeticide, Medically-indicated Termination of Pregnancy, Family Violence, Violence and Health, Child Abuse and Neglect and on the Right of Rehabilitation of Victims of Torture, provide guidance to WMA Constituent Members and physicians on ways to support women who are victims of violence, and strive for eradicating violence against women.

RECOMMENDATIONS

The WMA:

Calls for zero tolerance for all forms of violence against women.
Asserts that violence against women is not only about physical, psychological and sexual violence but includes neglect and abuses such as harmful cultural and traditional practices and is a major public health issue as well as a social determinant of health.
Recognizes the linkage between better education, other women’s rights and societal health and wellbeing, and emphasizes that equality in civil liberties and human rights are health-related issue.
Calls on WHO, other United Nations agencies and relevant actors at national and international levels to accelerate actions towards ending discrimination and violence against women.
Urges the governments to implement WHO’s Global Plan of Action to Strengthen the Role of the Health System within a National Multisectoral Response to Address Interpersonal Violence, in particular Against Women and Girls, and Against Children.
Encourages the development of free educational materials online to provide guidance to front line health care personnel on abuse and its effects, and on prevention strategies.

National Medical Associations are urged to:

Use and promote the available educational materials on preventing and treating the consequences of violence against women and act as advocates within their own country.
Seek to ensure that physicians and other health care personnel are alerted on the phenomenon of violence, its consequences, and the evidence on preventative strategies that work, and place appropriate emphasis on this in undergraduate, graduate and continuing education.
Recognise the importance of more complete reporting of violence and encourage the development of education emphasising violence awareness and prevention.
Advocate for legislation against specific harmful practices including female feticide, female genital mutilation, forced marriage, and corporal punishment.
Advocate for the criminalization of intimate partner violence as well as rape in all circumstances including within marriage.
Advocate for the development of research data on the impact of violence and neglect upon primary and secondary victims and upon society, and for increased funding for such research.
Encourage medical journals to publish more of the research on the complex interactions in this area, thus keeping it in the professions’ awareness and contributing to the development of a solid research base and ongoing documentation of types and incidence of violence.
Advocate for the national implementation of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).

Physicians are encouraged to:

Use the material developed for their education to better inform themselves about the effects of violence and the successful strategies for prevention.
Treat and reverse, where possible, the complications and adverse effects of female genital mutilation and refer the patient to social support services.
Oppose the publication or broadcast of victims’ names or addresses without the explicit permission of the victim.
Assess risk of family violence in the context of taking a routine social history of a patient.
Be alert to the association between alcohol or drug dependence among women and a history of abuse.
Where appropriate, report suspected violence or ill-treatment against women to relevant protection services and take the necessary measures to ensure that victims of violence are not at risk.
Support global and local action to better understand the health consequences both of violence and of the denial of rights, and advocate for increased services for victims.

Adopted by the 65^th WMA General Assembly, Durban, South Africa, October 2014
and reaffirmed by the 217^th WMA Council Session, Seoul (online), April 2021
and rescinded and archived by the 75th WMA General Assembly, Helsinki, Finland, October 2024

PREAMBLE

Reliable reports indicate that migrant workers in Qatar suffer from exploitation and violation of their rights. Workers basic needs, e.g. access to sufficient water and food, are not met. Less than half of the workers are entitled to health care. Hundreds of workers have already died in the construction sites since 2010 as the country prepares to host the 2022 FIFA[1] World Cup. Workers are not free to leave when they see their situation hopeless or health endangered since their passports are confiscated.

Despite the pleas of international labour and human rights organizations, such as ITUC (International Trade Union Confederation) and Amnesty International, the response of the Qatar government to solve the situation has not been adequate. FIFA has been inefficient and has not taken the full responsibility to facilitate the improvements to the worker´s living and working conditions.

The World Medical Association reminds that health is a human right that should be safeguarded in all situations.

The World Medical Association is concerned that migrant workers are continuously put at risk in construction sites in Qatar, and their right to freedom of movement and right to health care and safe working conditions are not respected.

RECOMMENDATIONS

The WMA calls upon the Qatar government and construction companies to ensure the health and safety of migrant workers;
The WMA demands the FIFA as the responsible organization of the World Cup to take immediate action by changing the venue as soon as possible;
The WMA calls upon its members to approach local governments in order to facilitate international cooperation with the aim of ensuring the health and safety of migrant workers in Qatar.

[1] Fédération Internationale de Football Association

Adopted by the 45^th World Medical Assembly, Budapest, Hungary, October 1993,
revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and reaffirmed by the 203^rd WMA Council Session, Buenos Aires, Argentina, April 2016

PREAMBLE

Medical practitioners have an ethical duty and a professional responsibility to act in the best interests of their patients without regard to age, gender, sexual orientation, physical ability or disability, race, religion, culture, beliefs, political affiliation, financial means or nationality.

This duty includes advocating for patients, both as a group (such as advocating on public health issues) and as individuals.

Occasionally, this duty may conflict with a physician’s other legal, ethical and/or professional duties, creating social, professional and ethical dilemmas for the physician.

Potential conflicts with the physician’s obligation of advocacy on behalf of his or her patient may arise in a number of contexts:

Conflict between the obligation of advocacy and confidentiality – A physician is ethically and often legally obligated to preserve in confidence a patient’s personal health information and any information conveyed to the physician by the patient in the course of his or her professional duties. This may conflict with the physician’s obligation to advocate for and protect patients where the patients may be incapable of doing so themselves.
Conflict between the best interest of the patient and employer or insurer dictates – Often there exists potential for conflict between a physician’s duty to act in the best interest of his or her patients, and the dictates of the physician’s employer or the insurance body, whose decision may be shaped by economic or administrative factors unrelated to the patient’s health. Examples of such might be an insurer’s instructions to prescribe a specific drug only, where the physician believes a different drug would better suit a particular patient, or an insurer’s denial of coverage for treatment that a physician believes is necessary.
Conflict between the best interests of the individual patient and society – Although the physician’s primary obligation is to his or her patient, the physician may, in certain circumstances, have responsibilities to a patient’s family and/or to society as well. This may arise in cases of conflict between the patient and his or her family, in the case of minor or incapacitated patients, or in the context of limited resources.
Conflict between the patient’s wishes and the physician’s professional judgment or moral values – Patients are presumed to be the best arbiters of their best interests and, in general, a physician should advocate for and accede to the wishes of his or her patient. However, in certain instances such wishes may be contrary to the physician’s professional judgment or personal values.

RECOMMENDATION

The duty of confidentiality must be paramount except in cases where the physician is legally or ethically obligated to disclose such information in order to protect the welfare of the individual patient, third parties or society. In such cases, the physician must make a reasonable effort to notify the patient of the obligation to breach confidentiality, and explain the reasons for doing so, unless this is clearly inadvisable (such as where telling the patient would exacerbate a threat). In certain cases, such as genetic or HIV testing, physicians should discuss with their patients, prior to performing the test, instances in which confidentiality might need to be breached.A physician should breach confidentiality in order to protect the individual patient only in cases of minor or incompetent patients (such as certain cases of child or elder abuse) and only where alternative measures are not available. In all other cases, confidentiality may be breached only with the specific consent of the patient or his/her legal representative or where necessary for the treatment of the patient, such as in consultations between medical practitioners.Whenever confidentiality must be breached, it should be done so only to the extent necessary and only to the relevant party or authority.
In all cases where a physician’s obligation to his or her patient conflicts with the administrative dictates of the employer or the insurer, a physician must strive to change the decision of the employing/insuring body. His or her ultimate obligation must be to the patient.Mechanisms should be in place to protect physicians who wish to challenge decisions of employers/insurers without jeopardizing their jobs, and to resolve disagreements between medical professionals and administrators with regard to allocation of resources.Such mechanisms should be embodied in medical practitioners’ employment contracts. These employment contracts should acknowledge that medical practitioners’ ethical obligations override purely contractual obligations related to employment.
A physician should be aware of and take into account economic and other factors before making a decision regarding treatment. Nonetheless, a physician has an obligation to advocate on behalf of his or her patient for access to the best available treatment.In all cases of conflict between a physician’s obligation to the individual patient and the obligation to the patient’s family or to society, the obligation to the individual patient should typically take precedence.
Competent patients have the right to determine, on the basis of their needs, values and preferences, what constitutes for them the best course of treatment in any given situation.Unless it is an emergency situation, physicians should not be required to participate in any procedures that conflict with their personal values or professional judgment. In such non-emergency cases, the physician should explain to the patient his or her inability to carry out the patient’s wishes, and the patient should be referred to another physician, if required.

Adopted by the 54^th WMA General Assembly, Helsinki, Finland, September 2003
reaffirmed by the 59^th WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70^th WMA General Assembly, Tbilisi, Georgia, October 2019

PREAMBLE

Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.’’

Violence is multi-dimensional, has multiple driving factors, and can be physical, sexual, psychological or exerted through acts of deprivation or neglect.

The World Medical Association (WMA) has developed policies condemning different forms of violence. These include statements on Violence Against Women and Girls, Family Violence, Child Abuse and Neglect, Abuse of the Elderly, Adolescent Suicide, Violence in the Health Sector by Patients and those close to them, Protection of Health Care Workers in Situation of Violence, WMA Declaration on Alcohol and the WMA Statement on Armed-Conflicts.

Violence is a manifestation of the health, socio-economic, policy, legal, and political conditions of a country. It occurs in all social classes and is strongly associated with leadership failure and poor governance, and social determinants such as unemployment, poverty, health and gender inequality, and poor access to educational opportunities.

Despite regional and country-wide disparities in the scale and burden of violence, along with the under reporting of data, it is evident that violence results in fatal and non-fatal consequences. These include the devastation of individual, family, and community life, as well as disruption of the social, economic, and political development of nations.

Violence impacts the economy because of increased health and administrative expenditures by the criminal justice, law enforcement, and social welfare systems. It also has negative impact on a nation’s productivity because of a loss in human capital and the productivity of the workforce.

Impact on health

The effects of violence on health vary and can be life-long. Health consequences include physical disability, depression, post-traumatic stress disorder and other mental health challenges, unwanted pregnancies, miscarriages, and sexually transmitted infections.

Behavioral risk factors such as substance use, which can give rise to violent behaviour, are also risk factors for cancer, cardiovascular and cerebrovascular diseases.

Direct victims of violence are prone to traumatizing experiences such as physical, sexual and psychological abuse, and may be unwilling or unable to disclose or report their experiences to appropriate authorities due to shame, cultural taboo, fear of societal stigma or reprisal, and the justice system’s undue delay in dispensing justice.

In institutions such as healthcare facilities, violence is often interpersonal in nature, and may be perpetrated against patients by healthcare workers, or against health care workers by patients and their caregivers, or among healthcare personnel in the form of bullying, intimidation, and harassment.

Additionally, healthcare professionals and healthcare facilities are increasingly subjected to violent attacks. Such violence and targeted attacks on healthcare facilities, healthcare personnel, and the sick and wounded are in direct breach of medical ethics, international humanitarian and human rights laws.

Though many countries are increasingly accepting the need to institute violence prevention programs in their respective jurisdictions, the field of violence prevention and management still faces many challenges. Challenges include inadequate or non-existent reporting of data, inadequate investment in violence prevention programs and support services for victims of violence, and failure to enforce existing laws against violence, including measures to restrict access to alcohol.

Recognizing that violence remains a significant public health challenge which is multi-dimensional and preventable in nature, and affirming the pre-eminent role of physicians as role models, and in the care and support of victims of violence, the WMA commits itself to act against this global scourge.

RECOMMENDATIONS

WMA encourages its constituent members to:

Educate and advise political and public office holders at all levels of government with appropriate and adequate knowledge and scientific evidence on the benefits of investing more resources in violence prevention.
Advocate for and support good governance based on the rule of law, transparency, and accountability.
Conduct and support effective media campaigns to inform and raise the public’s awareness on the burden and consequences of violence and the need to prevent it.
Raise public awareness of international laws, norms, and ethical codes that mandate the protection of healthcare workers and facilities in times of peace and conflict.
Advocate for and promote the inclusion of courses on violence and its prevention in academic curricula, including those for undergraduate and postgraduate medical training and Continuing Medical Education (CME).
Consider organizing capacity building and CME programs for physicians on violence prevention, caring for victims of violence, emergency preparedness and response, and early recognition of signs of interpersonal and sexual violence.

The WMA urges governments to:

Work towards achieving a zero-tolerance for violence, through prevention programs, establishment of violence prevention and victim support clinics, establishment of safe domestic violence shelters, increased public and private investment in public safety, security, and strengthening of health and educational institutions.
Encourage collaborative action on violence prevention, with integrated violence prevention and victim support in health care institutions.
Promote social justice and equity by eliminating inequities and inequalities that may create the conditions for violence.
Focus on addressing social determinants of health through the creation and improvement of socio-economic, educational and health infrastructure and opportunities, and elimination of adverse and oppressive cultural attitudes and practices and all forms of inequality or discrimination on the basis of gender, creed, ethnic origin, nationality, political affiliation, race, sexual orientation, social standing, disease or disability.
Secure the enactment and enforcement of policies and laws on violence prevention, protection and support of victims of violence, and punishment of offenders.
Strengthen institutions concerned with public safety and security.
Develop policies and enforce legislations that regulate access to alcohol.
Develop and implement effective legal frameworks that protect individuals and entities that deliver healthcare. Such frameworks should guarantee the protection of physicians and other healthcare professionals, as well as the free and safe access of healthcare personnel and patients to health care facilities.
Support comprehensive research studies on the nature and character of the various forms of violence, including the effectiveness of response strategies, to assist them in the preparation and implementation of policies, laws and strategies on violence prevention, protection and support of victims, and punishment of perpetrators.
Initiate and foster multi-stakeholder involvement and collaboration among relevant bodies and organizations at global, national, state and local levels, in the development, implementation and promotion of violence prevention and management strategies, including engagement of traditional, religious, and political leaders.
Develop robust multi-sectoral partnerships at local, state and national levels with violence prevention made a priority concern in all government ministries, including health, education, labour, and defense ministries.
Institute a Safe Care Initiative that guarantees the safety and security of physicians and other healthcare workers, patients, healthcare facilities, and the uninterrupted delivery of healthcare services in times of peace and conflict.
The initiative should include the following components:
- Routine violence risk audit.
- Efficient and effective violence surveillance and reporting mechanisms.
- Transparent and timely investigation of all reported cases of violence.
- A system for protecting patients and healthcare personnel who report cases of violence.
- Legal support for physicians and other healthcare workers subjected to violence in the workplace.
- Establishment of security posts in healthcare facilities as deemed necessary.
- Financial coverage for injured medical personnel and other healthcare workers.
- Compensated time off for injured medical personnel and other healthcare workers.