Declaration of Geneva – WMA – The World Medical Association

Adopted by the 71^st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

The patient-physician relationship is part of a human relationship model that dates back to the origins of medicine. It represents a privileged bond between a patient and a physician based on trust. It is a space of creativity where information, feelings, visions, help and support are exchanged.

The patient-physician relationship is a moral activity that arises from the obligation of the physician to alleviate suffering and respect the patient’s beliefs and autonomy. It is usually initiated by mutual consent – expressed or implied – to provide quality medical care.

The patient-physician relationship is the fundamental core of medical practice. It has a universal scope and aims at improving a person’s health and wellbeing. This is made possible by knowledge sharing, common decision making, patient and physician autonomy, help, comfort and companionship in an atmosphere of trust. Trust is an inherent component of the relationship that can be therapeutic in and of itself.

The patient-physician relationship is essential to patient-centred care. It requires both the physician and the patient to be active participants in the healing process. While the relationship encourages and supports collaboration in medical care, competent patients make decisions that direct their care. The relationship may be terminated by either party. The physician must then assist the patient in securing transfer of care and refer the patient to another physician with the necessary ability to continue the care.

The patient-physician relationship is a complex issue subject to myriad cultural, technological, political, social, economic or professional influences. It has evolved throughout history, according to culture and civilisation, in the pursuit of what is most appropriate based on scientific evidence for patients by improving their mental and physical health and well-being and alleviating pain. The relationship underwent deep changes as a result of momentous milestones such as the Universal Declaration of Human Rights (1948), the WMA declarations of Geneva (1948), Helsinki (1964), and the Lisbon (1981).The relationship has slowly progressed towards the empowerment of the patient.

Today, the patient-physician relationship is frequently under threat from influences both within and outside health care systems. In some countries and health care systems, these influences risk alienating physicians from their patients and potentially harming patients. Amongst those challenges likely to undermine the therapeutic efficacy of the relationship, we note a growing trend to:

A technologization of medicine, sometimes leading to a mechanistic view of health care, neglecting human considerations;
The dilution of trustworthy relationships between people in our societies, which negatively influences healthcare relationships;
A primary focus on economic aspects of medical care to the detriment of other factors, posing sometimes difficulties to establish genuine relationships of trust between the physician and the patient.

It is of the utmost importance that the patient-physician relationship addresses these factors of influence in such a way that the relationship is enriched, and that its specificity is warranted. The relationship should never be subject to undue administrative, economic, or political interferences.

RECOMMENDATIONS

Reiterating its Declaration of Geneva, the International Code of Medical Ethics and its Lisbon Declaration on Patient Rights and given the vital importance of the relationship between physician and patient in history and in the current and future context of medicine, the WMA and its Constituent Members:

Reaffirm that professional autonomy and clinical independence are essential components of high-quality medical care and medical professionalism, protecting the right of the patients to receive the health care they need.
Urge all actors involved in the regulation of the patient-physician relationship (governments and health authorities, medical associations, physicians, and patients) to defend, protect and strengthen the patient-physician relationship, based of high-quality care, as a scientific, health, cultural and social heritage.
Call on Constituent Members and individual physicians to preserve this relationship as the fundamental core of any medical action centred on a person, to defend the medical profession and its ethical values, including compassion, competence, mutual respect, and professional autonomy, and to support patient-centred care.
Reaffirm its opposition to interference from governments, other agents and institutional administrations in the practice of medicine and in the Patient-physician
Reaffirm its dedication to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.
Commit to address emerging factors which could pose a threat to the patient-physician relationship and to take action to mitigate against those factors.

Portuguese translation

Adopted by the 67th General Assembly of the World Medical Association, Taipei, Taiwan, October 2016

PREAMBLE

Medical trainees are increasingly participating in global educational and service experiences, commonly referred to as ‘international medical electives’ (IMEs). These experiences are normally short term, i.e., less than 12 months, and are often undertaken in resource-limited settings in low-and middle-income countries.

Although IMEs can provide valuable learning experience, this must be weighed against the potential risks to the host community, the sponsor organization and the visiting trainee. Successful placements help to ensure that there are mutual benefits for all parties and are built upon an agreed understanding of concepts including non-maleficence and justice.

Published ethical guidelines, such as the Ethics and Best Practice Guidelines for Training Experiences in Global Health by the Working Group on Ethics Guidelines for Global Health Training (WEIGHT), call on sponsor institutions (i.e., universities and organizations facilitating electives) to commit to sustainable partnerships with host institutions and local communities. All parties are also called upon to work collaboratively in creating professional guidelines and standards for medical electives.

In turn, trainees undertaking IMEs must adhere to relevant ethical principles outlined in WMA ethical documents, including the WMA’s Declaration of Geneva, the WMA International Code of Medical Ethics and the WMA Statement on the Professional and Ethical Use of Social Media.

RECOMMENDATIONS

Therefore the WMA recommends that:

Sponsor institutions work closely with host institutions and local communities to create professional and ethical guidelines on best practices for international medical electives. Both institutions should be actively engaged in guideline development. The sponsor organization should evaluate the proposed elective using such standards prior to approval.
Guidelines should be appropriate to local context and endorse the development of sustainable, mutually-beneficial and just partnerships between institutions and the patients and the local community, with their health as the first consideration. These must take account of best practice guidelines, already available in many countries.
Guidelines must hold patient and community safety as paramount, and outline processes to ensure informed consent, patient confidentiality, privacy, and continuity of care as outlined in the WMA International Code of Medical Ethics.
Guidelines should also outline processes to protect the safety and health of the trainee, and highlight the obligations of the sponsor and host institutions to ensure adequate supervision of the trainee at all times. Institutions should consider means of addressing possible natural disasters, political instability, and exposure to disease. Emergency care should be available.
Sponsor and host institutions have a responsibility to ensure that IMEs are well planned, including, at a minimum, appropriate pre-departure briefings, which should include training in culture and language competency and explicit avoidance of any activity which could be exploitative, provision of language services as required, and sufficient introduction and guidance at the host institution. Post-departure debriefing should be planned on return of the trainee, including reviewing ethical situations encountered and providing appropriate emotional and medical support needed.
It is expected that the trainee will receive feedback and assessment for the experience so that he/she can receive academic credit. The trainee should have the opportunity to evaluate the quality and utility of the experience.
Trainees must be fully informed of their responsibility to follow instructions given by local supervisors, and to treat local host staff and patients with respect.
These guidelines and processes should be reviewed and updated on a regular basis as sponsor and host institutions develop more experience with one another.
National Medical Associations should develop best practices for international medical electives, and encourage their adoption as standards by national or regional accrediting bodies, as feasible, and their implementation by sponsor and host institutions.