Ethics – WMA – The World Medical Association

Adopted by the 229th WMA Council Session, Montevideo, Uruguay, April 2025

PREAMBLE

Pillars of medicine which were until recently considered unquestionable, such as scientific evidence, human dignity and solidarity, are being increasingly challenged by the expansion of ideologies and political positions that reject or deny them.

In this context, the ability of physicians to work ethically and to follow the rules of the profession is threatened, as is also the autonomy of the profession; the intervention of politics, of the judiciary system or of the police in the care process is increasingly becoming a reality in many parts of the world.

The pressure exists on physicians being forced by their governments to treat detained patients in an unethical manner. There is also outright violence against healthcare personnel and healthcare facilities in areas with armed conflicts and other emergencies.

Pressure put on the professional autonomy of the physicians and on their ability to follow their ethical rules can negatively impact the quality of the care provided, and can finally compromise the population’s trust in the profession.

The World Medical Association was founded with the explicit aim of setting the highest ethical and humanist standards for medicine throughout the world.

These standards are being challenged by ideologies and political stances that reject the societal achievements of the last 80 years.

These high ethical and humanist standards must, however, forcefully continue to be upheld by the medical profession with clear determination and strength.

RECOMMENDATIONS

The World Medical Association and all its Constituent Members are strongly committed to upholding the ethical standards of the medical profession, as they have been established by the profession itself during the last 80 years.
It is an essential role of the WMA and of its Constituent Members to advocate for a legal framework for healthcare in all our countries, which respects the ethical rules of our profession and allows practicing medicine according to them.
The WMA urges governments to secure the safety and lives of health care personnel whatever the actual circumstances, thereby enabling them to fulfill their duty to help any patient in need and act according to their ethical principles.
The WMA must actively advocate for the honor of the medical profession and the rights of medical personnel and of the patients wherever these are under threat.
It is the duty of the WMA and of all its Constituent Members to support individual physicians and their organizations whenever their ability to follow the ethical rules set by the WMA is threatened or limited by undue political or judiciary pressure.
The World Medical Association and all its Constituent Members strongly support and foster scientific, fact-based medicine, including evidence-based therapeutic and public health measures.
The World Medical Association calls for respect for the independence of research, in accordance with the ethical principles imbedded in its Declaration of Helsinki.

Adopted by the 18^th WMA General Assembly, Helsinki, Finland, June 1964
and amended by the:
29^th WMA General Assembly, Tokyo, Japan, October 1975
35^th WMA General Assembly, Venice, Italy, October 1983
41^st WMA General Assembly, Hong Kong, September 1989
48^th WMA General Assembly, Somerset West, Republic of South Africa, October 1996
52^nd WMA General Assembly, Edinburgh, Scotland, October 2000
53^rd WMA General Assembly, Washington DC, USA, October 2002 (Note of Clarification added)
55^th WMA General Assembly, Tokyo, Japan, October 2004 (Note of Clarification added)
59^th WMA General Assembly, Seoul, Republic of Korea, October 2008
64^th WMA General Assembly, Fortaleza, Brazil, October 2013
and by the 75^th WMA General Assembly, Helsinki, Finland, October 2024

PREAMBLE

The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of ethical principles for medical research involving human participants, including research using identifiable human material or data.

The Declaration is intended to be read as a whole, and each of its constituent paragraphs should be applied with consideration of all other relevant paragraphs.

While the Declaration is adopted by physicians, the WMA holds that these principles should be upheld by all individuals, teams, and organizations involved in medical research, as these principles are fundamental to respect for and protection of all research participants, including both patients and healthy volunteers.

GENERAL PRINCIPLES

The WMA Declaration of Geneva binds the physician with the words, “The health and well-being of my patient will be my first consideration,” and the WMA International Code of Medical Ethics declares “The physician must commit to the primacy of patient health and well-being and must offer care in the patient’s best interest.”

It is the duty of the physician to promote and safeguard the health, well-being and rights of patients, including those who are involved in medical research. The physician’s knowledge and conscience are dedicated to the fulfilment of this duty.

Medical progress is based on research that ultimately must include participants.

Even well-proven interventions should be evaluated continually through research for their safety, effectiveness, efficiency, accessibility, and quality.

Medical research involving human participants is subject to ethical standards that promote and ensure respect for all participants and protect their health and rights.

Since medical research takes place in the context of various structural inequities, researchers should carefully consider how the benefits, risks, and burdens are distributed.

Meaningful engagement with potential and enrolled participants and their communities should occur before, during, and following medical research. Researchers should enable potential and enrolled participants and their communities to share their priorities and values; to participate in research design, implementation, and other relevant activities; and to engage in understanding and disseminating results.

The primary purpose of medical research involving human participants is to generate knowledge to understand the causes, development and effects of diseases; improve preventive, diagnostic and therapeutic interventions; and ultimately to advance individual and public health.

These purposes can never take precedence over the rights and interests of individual research participants.

While new knowledge and interventions may be urgently needed during public health emergencies, it remains essential to uphold the ethical principles in this Declaration during such emergencies.

It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity, autonomy, privacy, and confidentiality of personal information of research participants. The responsibility for the protection of research participants must always rest with physicians or other researchers and never with the research participants, even though they have given consent.

Physicians and other researchers must consider the ethical, legal and regulatory norms and standards for research involving human participants in the country or countries in which the research originated and where it is to be performed, as well as applicable international norms and standards. No national or international ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research participants set forth in this Declaration.

Medical research should be designed and conducted in a manner that avoids or minimizes harm to the environment and strives for environmental sustainability.

Medical research involving human participants must be conducted only by individuals with the appropriate ethics and scientific education, training and qualifications. Such research requires the supervision of a competent and appropriately qualified physician or other researcher.

Scientific integrity is essential in the conduct of medical research involving human participants. Involved individuals, teams, and organizations must never engage in research misconduct.

Groups that are underrepresented in medical research should be provided appropriate access to participation in research.

Physicians who combine medical research with medical care should involve their patients in research only to the extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician has good reason to believe that participation in the research will not adversely affect the health of the patients who serve as research participants.

Appropriate compensation and treatment for participants who are harmed as a result of participating in research must be ensured.

Risks, Burdens, and Benefits

In medical practice and in medical research, most interventions involve risks and burdens.

Medical research involving human participants may only be conducted if the importance of the objective outweighs the risks and burdens to the research participants.

All medical research involving human participants must be preceded by careful assessment of predictable risks and burdens to the individuals and groups involved in the research in comparison with foreseeable benefits to them and to other individuals or groups affected by the condition under investigation.

Measures to minimize the risks and burdens must be implemented. The risks and burdens must be continuously monitored, assessed, and documented by the researcher.

Physicians and other researchers may not engage in research involving human participants unless they are confident that the risks and burdens have been adequately assessed and can be satisfactorily managed.

When the risks and burdens are found to outweigh the potential benefits or when there is conclusive proof of definitive outcomes, physicians and other researchers must assess whether to continue, modify or immediately stop the research.

Individual, Group, and Community Vulnerability

Some individuals, groups, and communities are in a situation of more vulnerability as research participants due to factors that may be fixed or contextual and dynamic, and thus are at greater risk of being wronged or incurring harm. When such individuals, groups, and communities have distinctive health needs, their exclusion from medical research can potentially perpetuate or exacerbate their disparities. Therefore, the harms of exclusion must be considered and weighed against the harms of inclusion. In order to be fairly and responsibly included in research, they should receive specifically considered support and protections.

Medical research with individuals, groups, or communities in situations of particular vulnerability is only justified if it is responsive to their health needs and priorities and the individual, group, or community stands to benefit from the resulting knowledge, practices, or interventions. Researchers should only include those in situations of particular vulnerability when the research cannot be carried out in a less vulnerable group or community, or when excluding them would perpetuate or exacerbate their disparities.

Scientific Requirements and Research Protocols

Medical research involving human participants must have a scientifically sound and rigorous design and execution that are likely to produce reliable, valid, and valuable knowledge and avoid research waste. The research must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as appropriate, animal experimentation.

The welfare of animals used for research must be respected.

The design and performance of all medical research involving human participants must be clearly described and justified in a research protocol.

The protocol should contain a statement of the ethical considerations involved and should indicate how the principles in this Declaration have been addressed. The protocol should include information regarding aims, methods, anticipated benefits and potential risks and burdens, qualifications of the researcher, sources of funding, any potential conflicts of interest, provisions to protect privacy and confidentiality, incentives for participants, provisions for treating and/or compensating participants who are harmed as a consequence of participation, and any other relevant aspects of the research.

In clinical trials, the protocol must also describe any post-trial provisions.

Research Ethics Committees

The protocol must be submitted for consideration, comment, guidance, and approval to the concerned research ethics committee before the research begins. This committee must be transparent in its functioning and must have the independence and authority to resist undue influence from the researcher, the sponsor, or others. The committee must have sufficient resources to fulfill its duties, and its members and staff must collectively have adequate education, training, qualifications, and diversity to effectively evaluate each type of research it reviews.

The committee must have sufficient familiarity with local circumstances and context, and include at least one member of the general public. It must take into consideration the ethical, legal, and regulatory norms and standards of the country or countries in which the research is to be performed as well as applicable international norms and standards, but these must not be allowed to reduce or eliminate any of the protections for research participants set forth in this Declaration.

When collaborative research is performed internationally, the research protocol must be approved by research ethics committees in both the sponsoring and host countries.

The committee must have the right to monitor, recommend changes to, withdraw approval for, and suspend ongoing research. Where monitoring is required, the researcher must provide information to the committee and/or competent data and safety monitoring entity, especially about any serious adverse events. No amendment to the protocol may be made without consideration and approval by the committee. After the end of the research, the researchers must submit a final report to the committee containing a summary of the findings and conclusions.

Privacy and Confidentiality

Every precaution must be taken to protect the privacy of research participants and the confidentiality of their personal information.

Free and Informed Consent

Free and informed consent is an essential component of respect for individual autonomy. Participation by individuals capable of giving informed consent in medical research must be voluntary. Although it may be appropriate to consult family members or community representatives, individuals capable of giving informed consent may not be enrolled in research unless they freely agree.

In medical research involving human participants capable of giving informed consent, each potential participant must be adequately informed in plain language of the aims, methods, anticipated benefits and potential risks and burdens, qualifications of the researcher, sources of funding, any potential conflicts of interest, provisions to protect privacy and confidentiality, incentives for participants, provisions for treating and/or compensating participants who are harmed as a consequence of participation, and any other relevant aspects of the research.

The potential participant must be informed of the right to refuse to participate in the research or to withdraw consent to participate at any time without reprisal. Special attention should be given to the specific information and communication needs of individual potential participants as well as to the methods used to deliver the information.

After ensuring that the potential participant has understood the information, the physician or another qualified individual must then seek the potential participant’s freely given informed consent, formally documented on paper or electronically. If the consent cannot be expressed on paper or electronically, the non-written consent must be formally witnessed and documented.

All medical research participants should be given the option of being informed about the general outcome and results of the research.

When seeking informed consent for participation in research the physician or other researcher must be particularly cautious if the potential participant is in a dependent relationship with them or may consent under duress. In such situations, the informed consent must be sought by an appropriately qualified individual who is independent of this relationship.

In medical research involving human participants incapable of giving free and informed consent, the physician or other qualified individual must seek informed consent from the legally authorized representative, considering preferences and values expressed by the potential participant.

Those persons incapable of giving free and informed consent are in situations of particular vulnerability and are entitled to the corresponding safeguards. In addition to receiving the protections for the particularly vulnerable, those incapable of giving consent must only be included if the research is likely to either personally benefit them or if it entails only minimal risk and minimal burden.

When a potential research participant who is incapable of giving free and informed consent is able to give assent to decisions about participation in research, the physician or other qualified individual must seek that assent in addition to the consent of the legally authorized representative, considering any preferences and values expressed by the potential participant. The potential participant’s dissent should be respected.

Research involving participants who are physically or mentally incapable of giving consent (for example, unconscious patients) may be done only if the physical or mental condition that prevents giving informed consent is a necessary characteristic of the research group. In such circumstances the physician or other qualified individual must seek informed consent from the legally authorized representative. If no such representative is available and if the research cannot be delayed, the research may proceed without informed consent provided that the specific reasons for involving participants with a condition that renders them unable to give informed consent have been stated in the research protocol and the research has been approved by a research ethics committee.

Free and informed consent to remain in the research must be obtained as soon as possible from a legally authorized representative or, if they regain capacity to give consent, from the participant.

The physician or other researcher must fully inform potential participants which aspects of their care are related to the research. The refusal of a patient to participate in research or the patient’s decision to withdraw from research must never adversely affect the patient-physician relationship or provision of the standard of care.

Physicians or other qualified individuals must obtain free and informed consent from research participants for the collection, processing, storage, and foreseeable secondary use of biological material and identifiable or re-identifiable data. Any collection and storage of data or biological material from research participants for multiple and indefinite uses should be consistent with requirements set forth in the WMA Declaration of Taipei, including the rights of individuals and the principles of governance. A research ethics committee must approve the establishment and monitor ongoing use of such databases and biobanks.

Where consent is impossible or impracticable to obtain, secondary research on stored data or biological material may be done only after consideration and approval of a research ethics committee.

Use of Placebo

The benefits, risks, burdens, and effectiveness of a new intervention must be tested against those of the best proven intervention(s), except in the following circumstances:

If no proven intervention exists, the use of placebo, or no intervention, is acceptable; or
If for compelling and scientifically sound methodological reasons the use of any intervention other than the best proven one(s), the use of placebo, or no intervention is necessary to determine the efficacy or safety of an intervention; and the participants who receive any intervention other than the best proven one(s), placebo, or no intervention will not be subject to additional risks of serious or irreversible harm as a result of not receiving the best proven intervention.

Extreme care must be taken to avoid abuse of this option.

Post-Trial Provisions

In advance of a clinical trial, post-trial provisions must be arranged by sponsors and researchers to be provided by themselves, healthcare systems, or governments for all participants who still need an intervention identified as beneficial and reasonably safe in the trial. Exceptions to this requirement must be approved by a research ethics committee. Specific information about post-trial provisions must be disclosed to participants as part of informed consent.

Research Registration, Publication, and Dissemination of Results

Medical research involving human participants must be registered in a publicly accessible database before recruitment of the first participant.

Researchers, authors, sponsors, editors, and publishers all have ethical obligations with regard to the publication and dissemination of the results of research. Researchers have a duty to make publicly available the results of their research on human participants and are accountable for the timeliness, completeness, and accuracy of their reports. All parties should adhere to accepted guidelines for ethical reporting. Negative and inconclusive as well as positive results must be published or otherwise made publicly available. Sources of funding, institutional affiliations, and conflicts of interest must be declared in the publication. Reports of research not in accordance with the principles of this Declaration should not be accepted for publication.

Unproven Interventions in Clinical Practice

When an unproven intervention is utilized in an attempt to restore health or alleviate suffering for an individual patient because approved options are inadequate or ineffective and enrollment in a clinical trial is not possible, it should subsequently be made the object of research designed to evaluate safety and efficacy. Physicians participating in such interventions must first seek expert advice, weigh possible risks, burdens, and benefits, and obtain informed consent. They must also record and share data when appropriate and avoid compromising clinical trials. These interventions must never be undertaken to circumvent the protections for research participants set forth in this Declaration.

Disclaimer: ©2024 World Medical Association. All Rights Reserved. All intellectual property rights in the Declaration of Helsinki are vested in the World Medical Association. The WMA has granted JAMA exclusive rights to publish the English-language version of the Declaration through December 31, 2024.

Adopted by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006,
revised by the 73^rd WMA General Assembly, Berlin, Germany, October 2022,
and revised in its recommendation 14 by the 75^th WMA General Assembly, Helsinki, Finland, October 2024

PREAMBLE

Assisted Reproductive Technology [ART] encompasses a wide range of techniques designed primarily to aid individuals unable to conceive without medical assistance.

ART is defined as any fertility treatment in which either gametes or embryos are handled.

Assisted reproductive technologies may raise profound ethical and legal issues. Views and beliefs on assisted reproductive technologies vary both within and among countries and are subject to different regulations in different countries.

Central to much of the debate in this area are issues around the moral status of the embryo, the way in which ART is viewed morally, societally and religiously, the child/ren born from ART, and the rights of all participants involved, i.e. donors, surrogates, the child/ren and the intended parents are just some of the issues central to the debate in ART. Whilst consensus can be reached on some issues, there remain fundamental differences of opinion that are more difficult to resolve.

Assisted conception differs from the treatment of illness in that the inability to become a parent without medical intervention is not always regarded as an illness. Notwithstanding, the inability to conceive may also be a result of prior illness.

In many jurisdictions, the process of obtaining consent must follow a process of information giving and the offer of counselling and might also include a formal assessment of the patient in terms of the welfare of the potential child.

Faced with the progress of new technologies of assisted reproduction, physicians should keep in mind that not everything that is technically feasible is ethically acceptable. Genetic manipulation that does not have a therapeutic purpose is not ethical, nor is the manipulation on the embryo or foetus without a clear and beneficial diagnostic or therapeutic purpose.

RECOMMENDATIONS

1.Physicians involved in providing assisted reproductive technologies should always consider their ethical responsibilities towards all parties involved in a reproductive plan, which may include the future child/ren, donor, surrogate or parents. If there is compelling evidence that a future child, donor, surrogate or parent would be exposed to serious harm, treatment should not be provided.

2. As with all other medical procedures, physicians have an ethical obligation to limit their practice to areas in which they have relevant expertise, skill, and experience and to respect the autonomy and rights of patients.

3. In practice this means that informed consent is required as with other medical procedures; the validity of such consent is dependent upon the adequacy of the information offered to the patient and their freedom to make a decision, including freedom from coercion or other pressures or influences to decide in a particular way.

4. The consent process should include providing the participant/s with understandable, accurate and adequate information about the following:

The purpose, nature, procedure, and benefits of the assisted reproductive technology that will be used.
The risks, burdens and limitations of the assisted reproductive technology that will be used.
The success rates of the treatment and possible alternatives, such as adoption.
The availability of psychological support for the duration of the treatment and, in particular, if a treatment is unsuccessful.
The measures protecting confidentiality, privacy and autonomy, including data security measures.

5. The following should be discussed during the informed consent process:

Detailed medical risks;
whether or not all biological samples involved in ART, including but not limited to donor eggs, sperm, gametes and genetic information, may be used for research purposes;
The risks of multiple donations and donating at multiple clinics;
Confidentiality and privacy issues;
Compensation issues.

6. Donors, surrogates and any resulting child/ren seeking assisted reproductive technologies are entitled to the same level of confidentiality and privacy as for any other medical treatment.

7. Assisted reproductive technology involves handling and manipulation of human gametes and embryos. There are different levels of concern with the handling of such material, yet there is general agreement that such material should be subject to specific safeguards to protect from inappropriate, unethical, or illegal use.

8. Physicians should uphold the principles in the WMA Statement on Stem Cell Research, WMA Statement on Human Genome Editing, the WMA Declaration of Helsinki, and the WMA Declaration of Reykjavik – Ethical Considerations Regarding the Use of Genetics in Health Care.

9. Physicians should, where appropriate, provide ART in a non-discriminatory manner. Physicians should not withhold services based on nonclinical considerations such as marital status.

Multiple pregnancies

10. Replacement of more than one embryo will raise the likelihood of more than one embryo implanting. This is offset by the increased risk of premature labour and other complications in multiple pregnancies, which can endanger the health of both the mother and child/ren. Practitioners should follow professional guidance on the maximum number of embryos to be transferred per treatment cycle.

11. If multiple pregnancies occur, selective termination or fetus reduction will only be considered on medical grounds and with the consent of all participants involved to increase the chances of the pregnancy proceeding to term, provided this is compatible with applicable laws and codes of ethics.

Donation

12. Donation should follow counselling and be carefully controlled to avoid abuses, including coercion or undue influence of potential donors. Explicit instructions should be provided about what will be done with any donated samples if the donor is known to have died prior to implantation.

13. The WMA holds the view that gamete donation should at best not be commodified, thus serving a humanitarian benefit.

14. Appropriate controls and limits on methods used to encourage donations should be ensured. All donations must comply with national legislation and appropriate ethical guidance, including the maximum amount of gamete donations per person. Guidance on the maximum number of children allowed through donation from a single donor should be developed and adhered to, to avoid unintended incest, inbreeding and psychological harm to those involved. Physicians should advocate for and contribute to the development of such ethical guidance, if such guidance does not exist.

15. Due to the widespread use of genetic technology and registries, it has become possible to identify donors, despite clinics and donors’ attempts to maintain strict confidentiality.A child/ren born as a result of donation may in future contact donors. Potential donors must be made aware of this possibility as part of the consent process.

16. Where a child is born following donation, families should be encouraged and supported to be open with the child about this, irrespective of whether or not domestic law entitles the child to information about the donor. This may require the development of supportive materials, which should be produced to a national normative standard.

Surrogacy

17. Where a woman is unable, for medical reasons, to carry a child to term, surrogate pregnancy may be used to overcome childlessness unless prohibited by national law or the ethical rules of the National Medical Association or other relevant organizations. Where surrogacy is legally practiced, great care must be taken to protect the interests of all parties involved.

18. Prospective parents and surrogates should receive independent and appropriate legal counsel.

19. Medical tourism for surrogacy purposes should be discouraged.

20. Commercial surrogacy should be condemned. However, this must not preclude compensating the surrogate mother for necessary expenses.

21. The rights of surrogate mothers must be upheld, and great care must be taken to ensure that they are not exploited. The rights of surrogate mothers include, but are not limited to:

Having her autonomy respected;
Where appropriate, having health insurance;
Being informed about any medical procedure and the potential side effects;
Where possible, choosing her medical team if side effects develop;
Having psychological help at any point during the pregnancy;
Having medical expenses such as doctor visits, the actual birthing process, fertilization and any examinations related to the surrogacy covered by the intended parent/s;
Loss if income covered if unable to work during the pregnancy;
Receiving the compensation and/or reimbursements agreed to in any legal agreement

Pre-implantation Genetic Diagnosis (PGD)

22. Pre-implantation genetic diagnosis (PGD) and pre-implantation genetic screening (PGS) may be performed on early embryos to search for the presence of genetic or chromosomal abnormalities, especially those associated with severe illness and very premature death, and for other ethically acceptable reasons, including identifying those embryos most likely to implant successfully in women who have had multiple spontaneous abortions.

23. It is recommended to encourage screening for infectious diseases in sperm donors and to determine whether to inform donors of positive tests.

24. Physicians must never be involved with sex selection unless it is used to avoid a serious sex-chromosome related condition, such as Duchenne’s Muscular Dystrophy.

Research

25. Physicians have an ethical duty to comply with such regulation and to help inform public debate and understanding of these issues.

26. Research on human gametes and embryos should be carefully controlled and monitored and in accordance with all applicable national laws and ethical guidelines.

27. Views and legislation differ on whether embryos may be created specifically for, or in the course of, research. Physicians should act in accordance with the declarations of Taipei and Helsinki, as well as all applicable local laws and ethical and professional standards advice.

28. The principles of the Convention on Human Rights and Biomedicine should be followed.

Adopted by the 3^rd General Assembly of the World Medical Association, London, England, October 1949
Revised by the 22^nd World Medical Assembly, Sydney, Australia, August 1968,
the 35^th World Medical Assembly, Venice, Italy, October 1983,
the 57^thWMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

Preamble

The World Medical Association (WMA) has developed the International Code of Medical Ethics as a canon of ethical principles for the members of the medical profession worldwide. In concordance with the WMA Declaration of Geneva: The Physician’s Pledge and the WMA’s entire body of policies, it defines and elucidates the professional duties of physicians towards their patients, other physicians and health professionals, themselves, and society as a whole.

The physician must be aware of applicable national ethical, legal, and regulatory norms and standards, as well as relevant international norms and standards.

Such norms and standards must not reduce the physician’s commitment to the ethical principles set forth in this Code.

The International Code of Medical Ethics should be read as a whole and each of its constituent paragraphs should be applied with consideration of all other relevant paragraphs. Consistent with the mandate of the WMA, the Code is addressed to physicians. The WMA encourages others who are involved in healthcare to adopt these ethical principles.

General principles

1. The primary duty of the physician is to promote the health and well-being of individual patients by providing competent, timely, and compassionate care in accordance with good medical practice and professionalism.

The physician also has a responsibility to contribute to the health and well-being of the populations the physician serves and society as a whole, including future generations.

The physician must provide care with the utmost respect for human life and dignity, and for the autonomy and rights of the patient.

2. The physician must practise medicine fairly and justly and provide care based on the patient’s health needs without bias or engaging in discriminatory conduct on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor.

3. The physician must strive to use health care resources in a way that optimally benefits the patient, in keeping with fair, just, and prudent stewardship of the shared resources with which the physician is entrusted.

4. The physician must practise with conscience, honesty, integrity, and accountability, while always exercising independent professional judgement and maintaining the highest standards of professional conduct.

5. Physicians must not allow their individual professional judgement to be influenced by the possibility of benefit to themselves or their institution. The physician must recognise and avoid real or potential conflicts of interest. Where such conflicts are unavoidable, they must be declared in advance and properly managed.

6. Physicians must take responsibility for their individual medical decisions and must not alter their sound professional medical judgements on the basis of instructions contrary to medical considerations.

7. When medically appropriate, the physician must collaborate with other physicians and health professionals who are involved in the care of the patient or who are qualified to assess or recommend care options. This communication must respect patient confidentiality and be confined to necessary information.

8. When providing professional certification, the physician must only certify what the physician has personally verified.

9. The physician should provide help in medical emergencies, while considering the physician’s own safety and competence, and the availability of other viable options for care.

10. The physician must never participate in or facilitate acts of torture, or other cruel, inhuman, or degrading practices and punishments.

11. The physician must engage in continuous learning throughout professional life in order to maintain and develop professional knowledge and skills.

12. The physician should strive to practise medicine in ways that are environmentally sustainable with a view to minimising environmental health risks to current and future generations.

Duties to the patient

13. In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient. The physician must respect the patient’s right to freely accept or refuse care in keeping with the patient’s values and preferences.

14. The physician must commit to the primacy of patient health and well-being and must offer care in the patient’s best interests. In doing so, the physician must strive to prevent or minimise harm for the patient and seek a positive balance between the intended benefit to the patient and any potential harm.

15. The physician must respect the patient’s right to be informed in every phase of the care process. The physician must obtain the patient’s voluntary informed consent prior to any medical care provided, ensuring that the patient receives and understands the information needed to make an independent, informed decision about the proposed care. The physician must respect the patient’s decision to withhold or withdraw consent at any time and for any reason.

16. When a patient has substantially limited, underdeveloped, impaired, or fluctuating decision-making capacity, the physician must involve the patient as much as possible in medical decisions. In addition, the physician must work with the patient’s trusted representative, if available, to make decisions in keeping with the patient’s preferences, when those are known or can reasonably be inferred. When the patient’s preferences cannot be determined, the physician must make decisions in the patient’s best interests. All decisions must be made in keeping with the principles set forth in this Code.

17. In emergencies, where the patient is not able to participate in decision making and no representative is readily available, the physician may initiate an intervention without prior informed consent in the best interests of the patient and with respect for the patient’s preferences, where known.

18. If the patient regains decision-making capacity, the physician must obtain informed consent for further intervention.

19. The physician should be considerate of and communicate with others, where available, who are close to the patient, in keeping with the patient’s preferences and best interests and with due regard for patient confidentiality.

20. If any aspect of caring for the patient is beyond the capacity of a physician, the physician must consult with or refer the patient to another appropriately qualified physician or health professional who has the necessary capacity.

21. The physician must ensure accurate and timely medical documentation.

22. The physician must respect the patient’s privacy and confidentiality, even after the patient has died. A physician may disclose confidential information if the patient provides voluntary informed consent or, in exceptional cases, when disclosure is necessary to safeguard a significant and overriding ethical obligation to which all other possible solutions have been exhausted, even when the patient does not or cannot consent to it. This disclosure must be limited to the minimal necessary information, recipients, and duration.

23. If a physician is acting on behalf of or reporting to any third parties with respect to the care of a patient, the physician must inform the patient accordingly at the outset and, where appropriate, during the course of any interactions. The physician must disclose to the patient the nature and extent of those commitments and must obtain consent for the interaction.

24. The physician must refrain from intrusive or otherwise inappropriate advertising and marketing and ensure that all information used by the physician in advertising and marketing is factual and not misleading.

25. The physician must not allow commercial, financial, or other conflicting interests to affect the physician’s professional judgement.

26. When providing medical care remotely, the physician must ensure that this form of communication is medically justifiable and that the necessary medical care is provided. The physician must also inform the patient about the benefits and limitations of receiving medical care remotely, obtain the patient’s consent, and ensure that patient confidentiality is upheld. Wherever medically appropriate, the physician must aim to provide care to the patient through direct, personal contact.

27. The physician must maintain appropriate professional boundaries. The physician must never engage in abusive, exploitative, or other inappropriate relationships or behaviour with a patient and must not engage in a sexual relationship with a current patient.

28. In order to provide care of the highest standards, physicians must attend to their own health, well-being, and abilities. This includes seeking appropriate care to ensure that they are able to practise safely.

29. This Code represents the physician’s ethical duties. However, on some issues there are profound moral dilemmas concerning which physicians and patients may hold deeply considered but conflicting conscientious beliefs.

The physician has an ethical obligation to minimise disruption to patient care. Physician conscientious objection to provision of any lawful medical interventions may only be exercised if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered.

The physician must immediately and respectfully inform the patient of this objection and of the patient’s right to consult another qualified physician and provide sufficient information to enable the patient to initiate such a consultation in a timely manner.

Duties to other physicians, health professionals, students, and other personnel

30. The physician must engage with other physicians, health professionals and other personnel in a respectful and collaborative manner without bias, harassment, or discriminatory conduct. The physician must also ensure that ethical principles are upheld when working in teams.

31. The physician should respect colleagues’ patient-physician relationships and not intervene unless requested by either party or needed to protect the patient from harm. This should not prevent the physician from recommending alternative courses of action considered to be in the patient’s best interests.

32. The physician should report to the appropriate authorities conditions or circumstances which impede the physician or other health professionals from providing care of the highest standards or from upholding the principles of this Code. This includes any form of abuse or violence against physicians and other health personnel, inappropriate working conditions, or other circumstances that produce excessive and sustained levels of stress.

33. The physician must accord due respect to teachers and students.

Duties to society

34. The physician must support fair and equitable provision of health care. This includes addressing inequities in health and care, the determinants of those inequities, as well as violations of the rights of both patients and health professionals.

35. Physicians play an important role in matters relating to health, health education, and health literacy. In fulfilling this responsibility, physicians must be prudent in discussing new discoveries, technologies, or treatments in non-professional, public settings, including social media, and should ensure that their own statements are scientifically accurate and understandable.

Physicians must indicate if their own opinions are contrary to evidence-based scientific information.

36. The physician must support sound medical scientific research in keeping with the WMA Declaration of Helsinki and the WMA Declaration of Taipei.

37. The physician should avoid acting in such a way as to weaken public trust in the medical profession. To maintain that trust, individual physicians must hold themselves and fellow physicians to the highest standards of professional conduct and be prepared to report behaviour that conflicts with the principles of this Code to the appropriate authorities.

38. The physician should share medical knowledge and expertise for the benefit of patients and the advancement of health care, as well as public and global health.

Duties as a member of the medical profession

39. The physician should follow, protect, and promote the ethical principles of this Code. The physician should help prevent national or international ethical, legal, organisational, or regulatory requirements that undermine any of the duties set forth in this Code.

40. The physician should support fellow physicians in upholding the responsibilities set out in this Code and take measures to protect them from undue influence, abuse, exploitation, violence, or oppression.

©2022 World Medical Association. All Rights Reserved. All intellectual property rights in the International Code of Medical Ethics are vested in the World Medical Association.

Croatian translation

Portuguese translation

Adopted as Council Resolution by the 220^th WMA Council Session, Paris (hybrid), France, April 2022
and as Resolution by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Reminding that the World Medical Association was founded on the backdrop of the atrocities of war and how the medical profession was abused for violation of human rights and dignity;

Reaffirming the WMA Declaration of Geneva as a beacon of fundamental principles to which the world’s physicians are committed;

Deeply shocked by the Russian army’s bombing of Ukrainian civilians and hospitals, including maternity wards, thus infringing on medical neutrality in conflict zones. The WMA and its members express their solidarity with the Ukrainian people and provide their support for Ukrainian and international healthcare workers mobilized under extremely difficult conditions;

Recalling the WMA’s Statements on the Cooperation of National Medical Associations during or in the Aftermath of Conflicts, on Armed Conflicts, the Regulations in Times of Armed Conflict and Other Situations of Violence, the Statement on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations of Violence, the Declaration on the protection of healthcare workers in emergency situations and the Statement on Medical Care for Migrants;

Emphasizing the need to respect the Geneva Conventions and their protocols as the core of international humanitarian law, as well as the United Nations Security Council Resolution 2286;

Considering the suffering and human tragedy caused by the Russian invasion of Ukraine, including a refugee crisis on a massive scale;

RECOMMENDATIONS

The Constituent Members of the WMA stand in solidarity with the Ukrainian Medical Association and all healthcare professionals.
The WMA condemns Russia’s invasion of Ukraine and calls for an end to hostilities.
The WMA considers that Russia’s political leadership and armed forces bear responsibility for the human suffering caused by the conflict.
The WMA calls on Russian and Ukrainian doctors to hold high the principles in the WMA Declaration of Geneva and other documents that serve as guidance for medical personnel during times of conflict.
The WMA demands that the parties to the conflict respect relevant Humanitarian Law and do not use health facilities as military quarters, nor target health institutions, workers and vehicles, or restrict the access of wounded persons and patients to healthcare, as set out in the WMA Declaration on the Protection of Health Workers in Situations of Violence.
The WMA stresses that the parties to the conflict must strive to protect the most vulnerable populations.
The WMA underlines that it is essential that access to medical care be guaranteed to all victims, civil or military, of this conflict, without distinction.
Physicians and all other medical personnel, both Ukrainian and international, involved in NGOs, must not under any circumstances be hindered in the exercise of their unwavering duty, in accordance with the international recommendations provided in the WMA declaration on the protection of healthcare workers in emergency situations, the WMA’s position on the protection and integrity of medical personnel in armed conflicts and other violent situations and in the declaration of the United Nations General Assembly on the rights and responsibility of individuals, groups and organs of society to promote and protect human rights and universally recognized fundamental freedoms.
The WMA calls on the parties to ensure that essential services are provided to those within areas damaged and disrupted by conflict.
The WMA calls on the international community and governments to come to the aid of all persons displaced by this conflict who may choose their country as a destination following their departure from Ukraine.
The WMA urges all nations receiving persons fleeing the conflict to ensure access to safe and adequate living conditions and essential services to all migrants, including appropriate medical care, as needed.
The WMA calls on the parties to the conflict as well as the international community to ensure that when the conflict ends, priority must be given to rebuilding the essential infrastructure necessary for a healthy life, including shelter, sewerage, fresh water supplies, and food provision, followed by the restoration of educational and occupational opportunities.

Adopted by the 70^th WMA General Assembly, Tbilisi, Georgia, October 2019

The WMA reiterates its strong commitment to the principles of medical ethics and that utmost respect has to be maintained for human life. Therefore, the WMA is firmly opposed to euthanasia and physician-assisted suicide.

For the purpose of this declaration, euthanasia is defined as a physician deliberately administering a lethal substance or carrying out an intervention to cause the death of a patient with decision-making capacity at the patient’s own voluntary request. Physician-assisted suicide refers to cases in which, at the voluntary request of a patient with decision-making capacity, a physician deliberately enables a patient to end his or her own life by prescribing or providing medical substances with the intent to bring about death.

No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end.

Separately, the physician who respects the basic right of the patient to decline medical treatment does not act unethically in forgoing or withholding unwanted care, even if respecting such a wish results in the death of the patient.

Adopted by the 24^th World Medical Assembly, Oslo, Norway, August 1970
and revised by the 35^th World Medical Assembly, Venice, Italy, October 1983,
the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006,
and the 69^th WMA General Assembly, Reykjavik, Iceland, October 2018

Preamble

Medically-indicated termination of pregnancy refers only to interruption of pregnancy due to health reasons, in accordance with principles of evidence-based medicine and good clinical practice. This Declaration does not include or imply any views on termination of pregnancy carried out for any reason other than medical indication.
Termination of pregnancy is a medical matter between the patient and the physician. Attitudes toward termination of pregnancy are a matter of individual conviction and conscience that should be respected.
A circumstance where the patient may be harmed by carrying the pregnancy to term presents a conflict between the life of the foetus and the health of the pregnant woman. Diverse responses to resolve this dilemma reflect the diverse cultural, legal, traditional, and regional standards of medical care throughout the world.

Recommendations

Physicians should be aware of local termination of pregnancy laws, regulations and reporting requirements. National laws, norms, standards, and clinical practice related to termination of pregnancy should promote and protect women’s health, dignity and their human rights, voluntary informed consent, and autonomy in decision-making, confidentiality and privacy. National medical associations should advocate that national health policy upholds these principles.
Where the law allows medically-indicated termination of pregnancy to be performed, the procedure should be performed by a competent physician and only in extreme cases by another qualified health care worker, in accordance with evidence-based medicine principles and good medical practice in an approved facility that meets required medical standards.
The convictions of both the physician and the patient should be respected.
Patients must be supported appropriately and provided with necessary medical and psychological treatment along with appropriate counselling if desired.
Physicians have a right to conscientious objection to performing an abortion; therefore, they may withdraw while ensuring the continuity of medical care by a qualified colleague. In all cases, physician must perform those procedures necessary to save the woman’s life and to prevent serious injury to her health.
Physicians must work with relevant institutions and authorities to ensure that no woman is harmed because medically-indicated termination of pregnancy services are unavailable.

Adopted by the 69^th WMA General Assembly, Reykjavik, Iceland, October 2018

PREAMBLE

Medical tourism is an expanding phenomenon, although to date it has no agreed upon definition and, as a result, practices and protocols in different countries can vary substantially. For purposes of this statement, medical tourism is defined as a situation where patients travel voluntarily across international borders to receive medical treatment, most often at their own cost. Treatments span a range of medical services, and commonly include: dental care, cosmetic surgery, elective surgery, and fertility treatment (OECD, 2011).
This statement does not cover cases where a national health care system or treating hospital sends a patient abroad to receive treatment at its own cost or where, as in the European Union, patients are allowed to seek care in another EU Member State according to legally defined criteria, and their home health system bears the costs. Also not covered is a situation in which people are in a foreign country when they become ill and need medical care.
If not regulated appropriately, medical tourism may have medico-legal and ethical ramifications and negative implications, including but not limited to: internal brain drain, establishment of a two-tiered health system, and the spread of antimicrobial resistance. Therefore, it is imperative that there are clear rules and regulation to govern this growing phenomenon.
Medical tourism is an emerging global industry, with health service providers in many countries competing for foreign patients, whose treatment represents a significant potential source of income. The awareness of health as a potential economic benefit and the willingness to invest in it rise with the economic welfare of countries, and billions of dollars are invested each year in medical tourism all over the world. The key stakeholders within this industry include patients, brokers, governments, health care providers, insurance providers, and travel agencies. The proliferation of medical tourism websites and related content raise concerns about unregulated and inaccurate on-line health information.
A medical tourist is in a more fragile and vulnerable situation than that of a patient in his or her home country. Therefore, extra sensitivity on the part of caretakers is needed at every stage of treatment and throughout the patient’s care, including linguistic and cultural accommodation wherever possible. When medical treatment is sought abroad, the normal continuum of care may be interrupted and additional precautions should therefore be taken.
Medical tourism bears many ethical implications that should be considered by all stakeholders. Medical tourists receive care in both state-funded and private medical institutions and regulations must be in place in both scenarios. These recommendations are addressed primarily to physicians. The WMA encourages others who are involved in medical tourism to adopt these principles.

RECOMMENDATIONS

General

The WMA emphasises the importance of developing health care systems in each country in order to prevent excessive medical tourism resulting from limited treatment options in a patient´s home country. Financial incentives to travel outside a patient’s home country for medical care should not inappropriately limit diagnostic and therapeutic alternatives in the patient’s home country, or restrict treatment or referral options.
The WMA calls on governments to carefully consider all the implications of medical tourism to the healthcare system of a country by developing comprehensive, coordinated national protocols and legislation for medical tourism in consultation and cooperation with all relevant stakeholders. These protocols should assess the possibilities of each country to receive medical tourists, to agree on necessary procedures, and to prevent negative impacts to the country´s health care system.
The WMA calls on governments and service providers to ensure that medical tourism does not negatively affect the proper use of limited health care resources or the availability of appropriate care for local residents in hosting countries. Special attention should be paid to treatments with long waiting times or involving scarce medical resources. Medical tourism must not promote unethical or illegal practices, such as organ trafficking. Authorities, including government, should be able to stop elective medical tourism where it is endangering the ability to treat the local population.
The acceptance of medical tourists should never be allowed to distort the normal assessment of clinical need and, where appropriate, the development of waiting lists, or priority lists for treatment. Once accepted to treatment by a health care provider, medical tourists should be treated in accordance with the urgency of their medical condition. Whenever possible patients should be referred to institutions that have been approved by national authorities or accredited by appropriately recognised accreditation bodies.

Prior to travel

Patients should be made aware that treatment practices and health care laws may be different than in their home country and that treatment is provided according to the laws and practices of the host country. Patients should be informed by the physician/service provider of their rights and legal recourse prior to travelling outside their home country for medical care, including information regarding legal recourse in case of patient injury and possible compensation mechanisms.
The physician in the host country should establish a treatment plan, including a cost estimate and payment plan, prior to the medical tourist’s travel to the host country. In addition, the physician and the medical tourism company (if any) should collaborate in order to ensure that all arrangements are made in accordance with the patient´s medical needs. Patients should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
Medical tourists should be informed that privacy laws are not the same in all countries and, in the context of the supplementary services they receive, it is possible that their medical information will be exposed to individuals who are not medical professionals (such as interpreters). If a medical tourist nonetheless decides to avail him or herself of these services, he or she should be provided with documentation specifying the services provided by non-medical practitioners (including interpreters) and an explanation as to who will have access to his or her medical information, and the medical tourist should be asked to consent to the necessary disclosure.
All stakeholders (clinical and administrative) involved in the care of medical tourists must be made aware of their ethical obligations to protect confidentiality. Interpreters, and other administrative staff with access to health information of the medical tourist should sign confidentiality agreements.
The medical tourist should be informed that a change in his or her clinical condition might result in a change in the cost estimate and in associated travel plans and visa requirements.
If the treatment plan is altered because of a medical need that becomes clear after the initial plan has been established, the medical tourist should be notified of the change and why it was necessary. Consent should be obtained from the patient for any changes to the treatment plan.
When a patient is suffering from an incurable condition, the physician in the host country shall provide the patient with accurate information about his or her medical treatment options, including the limitations of the treatment, the ability of the treatment to alter the course of the disease in an appreciable manner, to increase life expectancy and to improve the quality of life. If, after examining all the data, the physician concludes that it is not possible to improve the patient’s medical condition, the physician should advise the patient of this and discourage the patient from travelling.

Treatment

Physicians are obligated to treat every individual accepted for treatment, both local and foreigner, without discrimination. All the obligations detailed in law and international medical ethical codes apply equally to the physician in his or her encounter with medical tourists.
Medical decisions concerning the medical tourist should be made by physicians, in cooperation with the patient, and not by non-medical personnel.
At the discretion of the treating physicians, and where information is available and of good quality, the patient should not be required to undergo tests previously performed, unless there is a clinical need to repeat tests.
The patient should receive information about his or her treatment in a language he or she understands. This includes the right to receive a summary of the treatment progress and termination by the treating physician and a translation of the documents, as needed.
Agreement should be reached before treatment begins, on the transfer of test results and diagnostic images, back to the home country of the patient.
Where possible, communication between the physicians in the host and home country should be established in order to ensure appropriate aftercare and clinical follow-up of the medical problems for which the patient was treated.
The physician who prepares the treatment plan for the patient should confirm the diagnosis, the prognosis and the treatments that the medical tourist has received.
The patient should receive a copy of his or her medical documents for the purpose of continuity of care and follow-up in his or her home country. Where necessary, the patient should be given a detailed list of medical instructions and recommendations for the period following his or her departure. This information should include a description of the expected recovery time and the time required before travelling back to his or her home is possible.

Advertising

Advertising for medical tourism services, whether via the internet or in any other manner, should comply with accepted principles of medical ethics and include detailed information regarding the services provided. Information should address the service provider’s areas of specialty, the physicians to whom it refers the benefits of its services, and the risks that may accompany medical tourism. Access to licensing/accreditation status of physicians and facilities and the facility’s outcomes data should be made readily available. Advertising material should note that all medical treatment carries risks and specific additional risks may apply in the context of medical tourism.
National Medical Associations should do everything in their power to prevent improper advertising or advertising that is in violation of medical ethical principles, including advertising that contains incorrect or partial information and/or any information that is liable to mislead patients, such as overstatement of potential benefits.
Advertising that notes the positive attributes of a specific medical treatment should also present the risks inherent in such treatment and should not guarantee treatment results or foster unrealistic expectations of benefits or treatment results.

Transparency and the prevention of conflicts of interest

Possible conflicts of interest may be inevitable for physicians treating medical tourists, including at the behest of their employing institution. It is essential that all clinical circumstances and relationships are managed in an open and transparent manner.
A physician shall exercise transparency and shall disclose to the medical tourist any personal, financial, professional or other conflict of interest, whether real or perceived, that may be connected to his or her treatment.
A physician should not accept any benefit, other than remuneration for the treatment, in the context of the medical treatment, and should not offer the medical tourist nor accept from him or her any business or personal offer, as long as the physician-patient relationship exists. Where the physician is treating the medical tourist as another fee paying patient, the same rules should apply as with his/her other fee paying patients.
A physician should ensure that any contract with a medical tourism company or medical tourist does not constitute a conflict of interest with his or her current employment, or with his or her ethical and professional obligations towards other patients.

Transparency in payment and in the physician’s fees

A treatment plan and estimate should include a detailed report of all costs, including a breakdown of physician’s fees, such as: consultancy and surgery and additional fees the patient might incur, such as: hospital costs, surgical assistance, prosthesis (if separate), and costs for post-operative care.
The cost estimate may be changed after the treatment plan has been given only in the event that the clinical condition of the patient has changed, or where circumstances have changed in a way that it was impossible to anticipate or prevent. If the pricing was thus changed, the patient must be informed as to the reason for the change in costs in as timely a fashion as possible.

Adopted by the 53^rd WMA General Assembly, Washington, DC, USA, October 2002, and
revised by the 63^rd WMA General Assembly, Bangkok, Thailand, October 2012 and
by the 74^th WMA General Assembly, Kigali, Rwanda, October 2023, and
renamed “Declaration of Kigali” by the 75^th WMA General Assembly, Helsinki, Finland, October 2024

PREAMBLE

Medical technology has come to play a key role in modern medicine. It has helped provide significantly more effective means of prevention, diagnosis, treatment and rehabilitation of illness, for example through the development and use of information technology, such as telehealth, digital platforms and large-scale data collection and analyses, or the use of advanced machinery and software in areas like medical genetics and radiology, including assistive, artificial, and augmented intelligences.

The importance of technology for medical care will continue to grow and the WMA welcomes this progress. The continuous development of medical technologies – and their use in both clinical and research settings – will create enormous benefits for the medical profession, patients, and society.

However, as for all other activities in the medical profession, the use of medical technology for any purpose, must take place within the framework provided by the basic principles of medical ethics as stated in the WMA Declaration of Geneva: The Physician’s Pledge, the International Code of Medical Ethics and the Declaration of Helsinki.

Respect for human dignity and rights, patient autonomy, beneficence, confidentiality, privacy and fairness must be the key guiding points when medical technology is developed and used for medical purposes.

The rapidly developing use of big data has implications for confidentiality and privacy. Using data in ways which would damage patients’ trust in how health services handle confidential data would be counterproductive. This must be borne in mind when introducing new data driven technology. It is essential to preserve high ethical standards and achieve the right balance between protecting confidentiality and using technology to improve patient care.

Additionally, bias through for example social differences in the collection of data may skew the intended benefits of data driven medical treatment innovations.

As medical technology advances and the potential for commercial involvement grows, it is important to protect professional and clinical independence.

RECOMMENDATIONS

Beneficence

The use of medical technology should have as its primary goal benefit for patients’ health and well-being. Medical technology should be based on sound scientific evidence and appropriate clinical expertise. Foreseeable risks and any increase in costs should be weighed against the anticipated benefits for the individual as well as for society, and medical technology should be tested or applied only if the anticipated benefits justify the risks.

Confidentiality and privacy

Protecting confidentiality and respecting patient privacy are central tenets of medical ethics and must be respected in all uses of medical technology.

Patient autonomy

The use of medical technology must respect patient autonomy, including the right of patients to make informed decisions about their health care and control access to their personal information. Patients must be given the necessary information to evaluate the potential benefits and risks involved, including those generated by the use of medical technology.

Justice

To ensure informed choices and avoid bias or discrimination, the basis and impact of medical technology on medical decisions and patient outcomes should be transparent to patients and physicians. In support of fair and equitable provision of health care, the benefits of medical technology should be available to all patients and prioritized based upon clinical need and not on the ability to pay.

Human rights

Medical technology must never be used to violate human rights, such as use in discriminatory practices, political persecution or violation of privacy.

Professional independence

To guarantee professional and clinical independence, physicians must strive to maintain and update their expertise and skills, i.e., by developing the necessary proficiency with medical technology. Medical curricula for students and trainees as well as continuing education opportunities for physicians must be updated to meet these needs. Physicians shall be included in contributions to research and development. Physicians shall remain the expert during shared decision making and not be replaced by medical technology.
Health care institutions and the medical profession should:

help ensure that innovative practices or technologies that are made available to physicians meet the highest standards for scientifically sound design and clinical value;
require that physicians who adopt innovations into their practice have relevant knowledge and skills;
provide meaningful professional oversight of innovation in patient care;
encourage physician-innovators to collect and share information about the resources needed to implement their innovations safely, effectively, and equitably; and
assure that medical technologies are applied and maintained appropriately in accordance with their intended purpose.

The relevance of these general principles is stated in detail in several existing WMA policies. Of particular importance are:

The WMA encourages all relevant stakeholders to embody the ethics guidance provided by these documents.

Adopted by the 10^th World Medical Assembly, Havana, Cuba, October 1956,
edited by the 11^th World Medical Assembly, Istanbul, Turkey, October 1957,
revised by the 35^th World Medical Assembly, Venice, Italy, October 1983 and the 55^th WMA General Assembly, Tokyo, Japan, October 2004,
editorially revised by the 173^rd WMA Council Session, Divonne-les-Bains, France, May 2006, and
revised by the 63^rd WMA General Assembly, Bangkok, Thailand, October 2012 and the 74^th WMA General Assembly, Kigali, Rwanda, October 2023*

*The WMA Regulations of the WMA in times of armed conflict and other situations of violence adopted in 1956 were reclassified as a ‘Statement’ by the 63^rd General Assembly, Kigali, Rwanda, October 2023.

PREAMBLE

The primary task of the medical profession is to promote health and save life; the primary obligation of the physicians is to their patients; in all their professional activities, physicians should adhere to international conventions on human rights, to international humanitarian law and to the WMA’s Declaration of Geneva, International Code of Medical Ethics and other relevant WMA declarations on medical ethics^[1], as well as to the Ethical Principles of Health Care in Times of Conflict and Other Emergencies, elaborated by civilian and military healthcare organisations, including the WMA, under the initiative of the International Committee of the Red Cross.

In situations of armed conflict and other situations of violence, governments, belligerent armed forces and others in positions of power must comply with their obligations in accordance with international law, including, as applicable, Geneva Conventions (1949) and the Additional Protocols to the Geneva Conventions (1977, 2005).

This obligation includes a requirement to protect healthcare personnel and facilities (see e.g. the WMA Declaration on the protection and integrity of healthcare personnel in armed conflicts and other situations of violence, 2022), including any means of transportation devoted to the wounded and sick, to health personnel or medical equipment.

This obligation also includes condemning the targeting of health care facilities and personnel and using denial of medical services, including as a tactic or strategy in war, by any party, wherever and whenever it occurs.

The WMA supports efficient, secure and unbiased reporting mechanisms with sufficient resources to collect and disseminate data regarding assaults on physicians, other healthcare personnel and healthcare facilities, and to provide to the WHO and other relevant agencies the necessary support to fulfill their role in documenting attacks on healthcare personnel and facilities.

Assaults against healthcare personnel must be investigated and those responsible must be brought to justice; to this end, adequate enforcement mechanisms must be used, or where relevant, developed, and necessary resources must be guaranteed.

Physicians must be granted access to all persons in need of care, including those deprived of liberty.

Physicians have a responsibility to press governments and other authorities for the provision of the infrastructure and equipment that is a prerequisite to health and healthcare, including potable water, adequate food and shelter, proper infrastructure, clinical equipment and available healthcare personnel, and the necessary personal protection equipment (PPE).

Where conflict appears to be imminent and inevitable, relevant authorities are responsible for guaranteeing the protection of the health infrastructure and for planning any necessary repair in the immediate post-conflict period.

Respect of professional ethical rules

During times of armed conflict and other situations of violence, the ethical standards of the medical profession apply as in times of peace. The professional duty to treat people with humanity and respect applies to all patients. The physician must always act in accordance with medical neutrality and give the necessary care impartially and without discrimination.

Physicians must never be persecuted for complying with any of their ethical obligations, and may not be compelled by governments, armed forces or others in positions of power, to undertake any action that contravenes the medical profession’s ethical rules.

The privacy of the sick, wounded and dead must always be respected and confidentiality duly respected.

Health care given to the sick and wounded, civilians or combatants, cannot be used for publicity or propaganda.

Physicians must not spread disinformation, or manipulate facts for the public, for the media, or for the social media outlets.

Ethics training on the issue of medical treatment of prisoners of war and detainees should be provided in medical schools and during postgraduate training.

RECOMMENDATIONS

In situations of armed conflict and other situations of violence, the physician must:

General principles

Not take part in any act of hostility and refuse any illegal or unethical order;
Neither commit nor assist in violations of international law;
Not abandon the wounded and sick, while considering the physician’s own safety and competence and the availability of other viable options for care;
Promote medical neutrality by advocating for and providing effective and impartial patient care without discrimination; no distinction must be made between patients except based upon clinical facts;
Give special consideration to the most vulnerable or marginalized parts of the population in need of care (e.g. women, children, older persons, people with specific healthcare needs, and displaced persons) and to their specific healthcare needs while adhering to triage principles;
Respect the individual wounded or sick person´s autonomy, trust and dignity;
Respect confidentiality, in line with the Declaration of Geneva and the International Code of Medical Ethics;
Give careful consideration to any dual loyalties that the physician may be bound by or conflicts of interest that may be present.

Detention

Provide healthcare to anyone taken as a prisoner;
Advocate for regular visits to prisons and prisoners by physicians;
Never condone, facilitate or participate in the practice of torture or any form of cruel, inhuman or degrading treatment, nor in any form of abuse, including forced feeding, human trafficking or human organ trafficking;
In line with the WMA International Code of Medical Ethics, the WMA Declaration of Tokyo, the WMA Statement on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment, the Istanbul Protocol and the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), denounce acts of torture or cruel, inhuman or degrading treatment and punishments.

Forbidden activities

Never use the situation and the vulnerability of the wounded and sick for personal advantage;
Never make use of healthcare privileges and facilities contrary to their intended purposes;

Public Health

Report to the appropriate authorities if healthcare needs are not met;
Respect the legal obligations to report to the appropriate authorities in matters of epidemiology;
Respect the WMA Declarations of Helsinki and the WMA Declaration of Taipei on research and data management;
Denounce and intervene against any unscrupulous practices, including distribution of poor quality or counterfeit medicines and materials;
Be aware of war-related mental health trauma when caring for patients, internally displaced persons and refugees.

^[1] WMA Declaration on the Protection and Integrity of Medical Personnel in Armed Conflicts and Other Situations of Violence / WMA Statement on Armed Conflicts

Adopted by the 60^th WMA General Assembly, New Delhi, India, October 2009
and revised by the 70^th WMA General Assembly, Tbilisi, Georgia, October 2019

The WMA reaffirms the Declaration of Seoul on professional autonomy and clinical independence of physicians.

The medical profession must play a central role in regulating the conduct and professional activities of its members, ensuring that their professional practice is in the best interests of citizens.

The regulation of the medical profession plays an essential role in ensuring and maintaining public confidence in the standards of care and of behaviour that they can expect from medical professionals. That regulation requires very strong independent professional involvement.

Physicians aspire to the development or maintenance of systems of regulation that will best protect the highest possible standards of care for all patients. Professionally led models can provide an environment that enhances and assures the individual physician’s right to treat patients without interference, based on his or her best clinical judgment. Therefore, the WMA urges its constituent members and all physicians to work with regulatory bodies and take appropriate actions to ensure effective systems are in place. These actions should be informed by the following principles:

Physicians are accorded a high degree of professional autonomy and clinical independence, whereby they are able to make recommendations based on their knowledge and experience, clinical evidence and their holistic understanding of the patient including his/her best interests without undue or inappropriate outside influence. This is expounded in more detail in the Declaration of Seoul.
The regulation of the profession must be proportionate and facilitative and not be burdensome, and be based on a model that applies to every physician equally and that protects and benefits patients and is based upon an ethical code. The planning and delivery of all types of health care is based upon an ethical model and current evidence-based medical knowledge by which all physicians are governed. This is a core element of professionalism and protects patients. Physicians are best qualified to judge the actions of their peers against such normative standards, bearing in mind relevant local circumstances.
The medical profession has a continuing responsibility to be strongly involved in regulation or self-regulating. Ultimate control and decision-making authority must include physicians, based on their specific medical training, knowledge, experience and expertise. In countries where Professionally led regulation is in place physicians must ensure that this retains the confidence of the public. In countries that have a mixed regulation system physicians must seek to ensure that it maintains professional and public confidence.
Physicians in each country are urged to consider establishing, maintaining and actively participating in a proportionate, fair, rigorous and transparent system of professionally-led regulation. Such systems are intended to balance physicians’ rights to exercise medical judgment freely with the obligation to do so wisely and temperately.
National Medical Associations must do their utmost to promote and support the concept of well-informed and effective regulation amongst their membership and the public. To ensure that any potential conflicts of interest between their representative and regulatory roles are avoided they must ensure separation of the two processes and pay rigorous attention to a transparent and fair system of regulation that will assure the public of its independence and fairness.
Any system of professionally-led regulation must enhance and ensure:
- the delivery of high quality safe and competent healthcare to patients
- the competence of the physician providing that care the professional, including ethical, conduct of all physicians
- the protection of society and the rights of patients
- the promotion of trust and confidence of patients, their families and the public
- the quality assurance of the regulation system
- the maintenance of trust by patients and society
- the development of solutions to potential conflicts of interest
- a commitment to wide professional responsibilities
To ensure that the patient is offered quality continuing care, physicians should participate actively in the process of Continuing Professional Development, including reflective practice, in order to update and maintain their clinical knowledge, skills and competence. Employers and management have a responsibility to enable physicians to meet this requirement.
The professional conduct of physicians must always be within the bounds of the Code of Ethics governing physicians in each country. National Medical Associations must promote professional and ethical conduct among physicians for the benefit of patients, and ethical violations must be promptly recognized, reported to the relevant regulatory authority and acted upon. Physicians are obligated to intervene in a timely manner to ensure that impaired colleagues do not put patients or colleagues at risk and receive appropriate assistance from a physician health program or appropriate training enabling a return to active practice.
The regulatory body should, when the judicial or quasi-judicial processes are complete, and assuming that a case is found against the physician, publish their findings and include details of the remedial action taken. Lessons learned from every case should, to the extent possible, be extracted and used in professional education processes.
The regulation process should ensure that the incorporation of such lessons is, as far as possible, seamless.
National Medical Associations are urged to assist each other in coping with new and developing challenges including potential threats to professionally-led regulation. The ongoing exchange of information and experiences between National Medical Associations is essential for the benefit of patients.
Whatever judicial or regulatory process a country has established, any judgment on a physician’s professional conduct or performance must incorporate evaluation by the physician’s professional peers who, by their training, knowledge and experience, understand the complexity of the medical issues involved.
An effective and responsible system of professionally-led regulation must not be self-serving or internally protective of the profession. National Medical Associations should assist their members in understanding that professionally-led regulation, in countries where that system exists, must maintain the safety, support and confidence of the general public, including their health-related rights, as well as the honour of the profession itself.

Adopted by the 182^ndWMA Council Session, Tel Aviv, Israel, May 2009

WHEREAS:

Recent international conflicts, including the Israeli-Palestinian conflict in Gaza, the conflict in Sri Lanka, the conflict in Darfur, and the conflict in the Democratic Republic of Congo, have led to loss of life and the impairment of living conditions; and International standards of medical neutrality must be upheld throughout such conflicts;

THEREFORE, the WMA

Reaffirms its policy, “Regulations in Time of Armed Conflict” and the obligations of physicians stated in this document. The WMA calls on its members to act in accordance with all internationally accepted principles of healthcare delivery in times of conflict.
Reiterates its commitment to the universal right to health, and access to the highest attainable standard of health care. This universal right is not conditional on peaceful existence, although a peaceful existence accommodates greater ability to provide health to all.
Reaffirms the obligation incumbent on all parties involved in conflict situations to abide by the rules of international medical ethics, a swell as the provisions of international humanitarian law, as expressed in the Geneva Conventions, particularly their common article 3, and, specifically, to assure the provision of medical care and/or evacuation of the trapped and wounded and to refrain from targeting medical personnel and medical facilities.

Adopted by the 182^nd WMA Council Session, Tel Aviv, Israel, May 2009

WHEREAS:

Reports worldwide have alluded to deeply unsettling practices by health professionals, including direct participation in the infliction of ill-treatment, monitoring specific methods of ill-treatment, and participation in interrogation processes;

THEREFORE, the WMA

Reaffirms its Declaration of Tokyo: Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment, which prohibits physicians from participating in, or even being present during, the practice of torture or other forms of cruel, inhuman or degrading procedures, and urges National Medical Associations to inform physicians and governments of the Declaration and its contents.
Reaffirms its Declaration of Hamburg: Support for Medical Doctors Refusing to Participate in or to Condone the use of Torture or other Forms of Cruel, Inhuman or Degrading Treatment.
Reaffirms its Resolution: Responsibility of Physicians in the Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment of Which they are Aware.
Urges national medical associations to speak out in support of this fundamental principle of medical ethics and to investigate any breach of these principles by association members of which they are aware.

Adopted by the 46^thWMA General Assembly, Stockholm, Sweden, September 1994
revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68^th WMA General Assembly, Chicago, United States, October 2017
and rescinded and archived by the 74^th WMA General Assembly, Kigali, Rwanda, October 2023

PREAMBLE

1. According to International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.

This definition excludes situations arising from conflicts and wars, whether international or internal, which give rise to other problems in addition to those considered in this paper.

2. Disasters often result in substantial material damage, considerable displacement of people, many victims and significant social disruptions. Adequate preparation would make major consequences less likely and less severe and protect people especially the most vulnerable.

This document will focus particularly on the medical aspects of disasters. From a medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between resources and the capacity of medical professionals, and the needs of survivors who are injured whose health is threatened, over a given period of time.

3. Disasters, irrespective of cause, share several common features:

3.1. Their sudden and unexpected but often predictable occurrence, demanding prompt action;

3.2. Material or natural damage making access to the survivors difficult and/or dangerous;

3.3. Displacement or movement of often large numbers of people;

3.4. Adverse effects on health due to various reasons such as physical injuries and high energy trauma, direct and indirect consequences of pollution, the risks of epidemics and emotional and psychological factors as well as factors such as reduced access to food, potable water, shelter, health care and other health determinants;

3.5. A context of insecurity sometimes requiring police or military measures to maintain order; and

3.6. Media coverage, and the use of social media.

4. Disasters require multifaceted responses involving many different types of relief ranging from transportation and food supplies to medical services. Physicians are likely to be part of coordinated operations involving other responders such as law enforcement personnel. These operations require an effective and centralized authority to coordinate public and private efforts.

Rescue workers and physicians are confronted with exceptional circumstances, which require the continued need of a professional and ethical standard of care. This is to ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not influenced by other motivations. Inadequate and/or disrupted medical resources on site and a large number of people injured in a short time present specific ethical challenges.

RECOMMENDATIONS

5. Medical profession is at the service of the patients and society at all times and in all circumstances. Therefore, the physicians should be firmly committed to addressing the health consequences of disasters, without excuse or delay.

6. The World Medical Association (WMA) reaffirms its Declaration of Montevideo on Disaster Preparedness and Medical Response (2011) recommending the development of adequate training of physicians, accurate mapping of information on health system assets and advocacy towards governments to ensure planning for clinical care.

7. The WMA recalls the primary necessity to ensure the personal safety of physicians and other responders during the event of disasters (Declaration on the Protection of Health Care Workers in situation of Violence, 2014).

Physicians and other responders must have access to appropriate and functional equipment, both medical and protective.

8. Furthermore, the WMA recommends the following ethical principles and procedures with regard to the physician’s role in disaster situations:

8.1 A system of triage may be necessary to determine treatment priorities. Despite triage often leading to some of the most seriously injured receiving only symptom control such as analgesia, such systems are ethical provided they adhere to normative standards. Demonstrating care and compassion despite the need to allocate limited resources is an essential aspect of triage.

Ideally, triage should be entrusted to authorized, experienced physicians or to physician teams, assisted by a competent staff. Since cases may evolve and thus change category, it is essential that the official in charge of the triage regularly assesses the situation.

8.2 The following statements apply to treatment beyond emergency care:

8.2.1 It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed else-where. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

8.2.2 The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum.

8.3 Relation with the patients

8.3.1 In selecting the patients who may be saved, the physician should consider only their medical status and predicted response to the treatment, and should exclude any other consideration based on non-medical criteria.

8.3.2 Survivors of a disaster are entitled to the same respect as other patients, and the most appropriate treatment available should be administered with the patient’s consent.

8.4 Aftermath of disaster

8.4.1 In the post-disaster period the needs of survivors must be considered. Many may have lost family members and may be suffering psychological distress. The dignity of survivors and their families must be respected.

8.4.2 The physician must make every effort to respect the customs, rites and religions of the patients and act in impartiality.

8.4.3 As far as possible, detailed records should be kept, including details of any difficulties encountered. Identification of patients, including the deceased should be recorded.

8.5 Media and other third parties

Physicians should take into consideration that in any disaster media is present. The work of the media should be respected and facilitated as appropriate in the circumstances. If needed, physicians should be empowered to restrict the entrance of reporters and other media representatives to the medical premises. Appropriately trained personnel should handle media relations.

The physician has a duty to each patient to exercise discretion and to seek to ensure confidentiality when dealing with third parties. The physician must also exercise caution and objectivity and respect the often emotional and politicized atmosphere surrounding disaster situations. Any and all media especially filming must only occur with the explicit consent of each patient who is filmed. With regard to social media use, physicians must adhere to these same standards of discretion and respect for patient privacy.

8.6 Duties of paramedical personnel

The ethical principles that apply to physicians in disaster situations should also apply to other health care workers.

8.7 Training

The World Medical Association recommends that disaster medicine training be included in the curricula of university and post-graduate courses in medicine.

8.8 Responsibility

8.8.1 The World Medical Association calls upon governments and insurance companies to cover both civil liability and any personal damages to which physicians might be subject when working in disaster or emergency situations. This should also include life and disability coverage for physicians who die or are harmed in the line of duty.

8.8.2 The WMA requests that governments:

Ensure the preparedness of healthcare system to serve in disaster settings.
Share all information related to public health timely and accurately.
Accept the participation of demonstrably qualified foreign physicians, where needed, without discrimination on the basis of factors such as affiliation (e.g. Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or religion.
Give priority to the rendering of medical services over anything else that might delay necessary treatment of patients.

Adopted by the 41^st World Medical Assembly, Hong Kong, September 1989
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

Biomedical research is essential to the health and well-being of our society. Advances in biomedical research have dramatically improved the quality and prolonged the duration of life throughout the world. However, the ability of the scientific community to continue its efforts to improve personal and public health is being threatened by a movement to eliminate the use of animals in biomedical research. This movement is spearheaded by groups of radical animal rights activists whose views are considered to be far outside mainstream public attitudes and whose tactics range from sophisticated lobbying, fund-raising, propaganda and misinformation campaigns to violent attacks on biomedical research facilities and individual scientists. These violent attacks are carried out by a relatively small number of activists compared with those who use peaceful means of protest, but they have profound and wide-ranging effects.
The magnitude of violent animal rights activities is staggering, and these activities take place in many different parts of the world. Various animal rights groups have claimed responsibility for the bombing of cars, institutions, stores, and the private homes of researchers.
Animal rights violence has had a chilling effect on the scientific community internationally. Scientists, research organizations, and universities have been intimidated into altering or even terminating important research efforts that depend on the use of animals. Laboratories have been forced to divert thousands of research dollars for the purchase of sophisticated security equipment. Young people who might otherwise pursue a career in biomedical research are turning their sights to alternative professions.
Despite the efforts of many groups striving to protect biomedical research from radical animal activism, the response to the animal rights movement has been fragmented, under-funded, and primarily defensive. Many groups within the biomedical community are hesitant to take a public stand about animal activism because of fear of reprisal. As a result, the research establishment has been backed into a defensive posture. Its motivations are questioned, and the need for using animals in research is repeatedly challenged.
While properly designed and executed research involving animals is necessary to enhance the medical care of all persons, we recognize also that humane treatment of research animals must be ensured. Appropriate training for all research personnel should be prescribed and adequate veterinary care should be available. Experiments must comply with any rules or regulations promulgated to govern humane handling, housing, care, treatment and transportation of animals.
International medical and scientific organizations must develop a stronger and more cohesive campaign to counter the growing threat to public health posed by animal activists. Leadership and coordination must be provided. In addition, there must be a clear understanding of the rights of animals who are part of medical research, and the obligations of those who undertake it.

The World Medical Association therefore affirms the following principles:

Animal use in biomedical research is essential for continued medical progress.
The WMA Declaration of Helsinki requires that biomedical research involving human subjects should be based, where appropriate, on animal experimentation, but also requires that the welfare of animals used for research be respected.
Humane treatment of animals used in biomedical research is essential and research facilities should be required to comply with all guiding principles for humane treatment. Education about these principles should be provided to all researchers in training.
Animals should only be used in biomedical research when it is clear that their use is required to achieve an important outcome, and where no other feasible method is available.
Duplication of animal experiments should not occur unless scientifically justified.
The use of animals for the futile testing of cosmetic products and their ingredients, alcohol and tobacco should not be supported.
Although rights to free speech should not be compromised, the anarchistic element among animal right activists should be condemned.
The use of threats, intimidation, violence, and personal harassment of scientists and their families should be condemned internationally.
A maximum coordinated effort from international law enforcement agencies should be sought to protect researchers and research facilities from activities of a terrorist nature.

Adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987,
editorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005
and rescinded and archived by the WMA General Assembly, New Delhi, India, October 2009
* This document has been replaced by the “Declaration of Seoul on Professional Autonomy and Clinical Independence” (2008) and a completely rewritten “Declaration of Madrid on Professionally-led Regulation” (2009)

The World Medical Association, having explored the importance of professional autonomy and self-regulation of the medical profession around the world, and recognizing the problems and the current challenges to professional autonomy and self-regulation, hereby adopts the following principles:

The central element of professional autonomy is the assurance that individual physicians have the freedom to exercise their professional judgement in the care and treatment of their patients.
The World Medical Association reaffirms the importance of professional autonomy as an essential component of high quality medical care and therefore a benefit to the patient that must be preserved. The World Medical Association therefore re-dedicates itself to maintaining and assuring the continuation of professional autonomy in the care of patients, which is an essential principle of medical ethics.
As a corollary to the right of professional autonomy, the medical profession has a continuing responsibility to be self-regulating. In addition to any other source of regulation that may be applied to individual physicians, the medical profession itself must be responsible for regulating the professional conduct and activities of individual physicians.
The World Medical Association urges physicians in each country to establish, maintain and actively participate in a system of self-regulation. It is this dedication to effective self-regulation that will ultimately assure professional autonomy in patient care decisions.
The quality of the care provided to patients and the competence of the physician providing that care must always be a primary concern in any system of self-regulation. Physicians have the expertise to make the necessary evaluations. These evaluations must be used for the benefit of patients to assure them continued quality care by competent physicians. Included in this area of responsibility is the need to monitor advances in scientific medicine and the use of therapeutic regimens that are safe and effective. Experimental procedures must comply with the protections required by the World Medical Association Declaration of Helsinki and other protections as may be required in each country.
Cost consciousness is an essential element of self-regulation. Again, physicians are particularly qualified to make the evaluations that are necessary for cost containment decisions. Physicians must, therefore, include cost containment activities in their respective systems of self-regulation. Common issues in cost containment activities relate to methods of delivery of medical care, access to hospital and surgery, and the appropriate use of technology. Cost containment activities must not be used to deny patients access to necessary medical care. Nor should over-utilization of medical facilities be permitted to drive the cost of medical care upwards so that it will not be available to all who may need the particular care.
Finally, the professional activities and the conduct of physicians must always be within the bounds of the professional code of ethics or the principles of medical ethics governing physicians in each country. National Medical Associations must promote ethical conduct among physicians for the benefit of their patients. Ethical violations must be promptly corrected, and the physicians guilty of ethical violations must be disciplined and rehabilitated.
There are, of course, many other areas of self-regulation for which National Medical Associations may take responsibility. National Medical Associations are urged to assist each other in coping with new and developing problems. The exchange of information and experiences between National Medical Associations is encouraged.
National Medical Associations must also educate the public generally as to the existence of an effective and responsible system of self-regulation by the medical profession in each country. The public must come to recognise that it can rely on this system of self-regulation for an honest and objective evaluation of the issues relating to the practice of medicine and the care and treatment of patients.
The collective action by the medical profession in assuming responsibility for implementing a system of professional self-regulation will enhance and assure the individual physician’s right to treat patients without interference with his or her professionally-based judgement. Responsible professional conduct by individual physicians and an effective and efficient system of self-regulation are necessary to assure the public that when they are patients they will receive quality medical care provided by competent physicians.

Adopted by the 54^th WMA General Assembly, Helsinki, Finland, September 2003,
revised by the 58^th WMA General Assembly, Copenhagen, Denmark, October 2007,
editorially revised by the 179^th WMA Council Session, Divonne-les-Bains, France, May 2008
and by the 71^st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

The dignity and value of every human being are acknowledged globally and expressed in numerous distinguished ethical codes and codifications of human rights, including the Universal Declaration of Human Rights. Any act of torture or cruel, inhuman or degrading treatment constitutes a violation of these codes and is irreconcilable with the ethical principles that lie at their core. These codes are listed at the end of this Statement (1).

However, in the medical professional codes and legal texts, there is no consistent and explicit reference to an obligation upon physicians to document cases and denounce acts of torture or cruel, inhuman or degrading treatment of which they become aware or witness.

The careful and consistent documentation and denunciation of torture or cruel, inhuman or degrading treatment by physicians contributes to the human rights of the victims and to the protection of their physical and mental integrity. The absence of documentation and denunciation of these acts may be considered as a form of tolerance thereof.

Because of the psychological sequelae from which they suffer, or the pressures brought upon them, victims are often unable or unwilling to formulate by themselves complaints against those responsible for the torture or cruel, inhuman and degrading treatment and punishments they have undergone.

By ascertaining the sequelae and treating the victims of torture, either early or late after the event, physicians witness the effects of these violations of human rights.

The WMA recognizes that in some circumstances, documenting and denouncing acts of torture may put the physician, and those close to him or her, at great risk. Consequently, doing so may have excessive personal consequences.

This statement relates to torture and other cruel, inhuman and degrading treatment and punishments as referred by the United Nations Convention against torture, excluding purposely the role of physicians in detention appraisal addressed in particular by the UN Standard Minimum Rules for the Treatment of Prisoners (Mandela rules).

RECOMMENDATIONS

The WMA recommends that its constituent members:

Promote awareness among physicians of The Istanbul Protocol, including its Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment. This should be done at the national level.
Promote training of physicians on the identification of different methods of torture and cruel, inhuman and degrading treatment and punishments, to enable them to provide high quality medical documentation that can be used as evidence in legal or administrative proceedings.
Encourage professional training to ensure that physicians include assessment and documentation of signs and symptoms of torture or cruel, inhuman and degrading treatment and punishments in the medical records, including the correlation between the allegations given and the clinical findings.
Work to ensure that physicians carefully balance potential conflicts between their ethical obligation to document and denounce acts of torture or cruel, inhuman and degrading treatment and punishments and a patient’s right to informed consent before documenting torture cases.
Work to ensure that physicians avoid putting individuals in danger while assessing, documenting or reporting signs of torture and cruel, inhuman and degrading treatment and punishments.
Promote access to immediate and independent health care for victims of torture or cruel, inhuman and degrading treatment and punishments.
Support the adoption of ethical rules and legislative provisions:

Aimed at affirming the ethical obligation on physicians to report and denounce acts of torture or cruel, inhuman and degrading treatment and punishments of which they become aware; depending on the circumstances, the report or denunciation should be addressed to the competent national or international authorities for further investigation.
Addressing that a physician’s obligation to document and denounce instances of torture and cruel, inhuman and degrading treatment and punishments may conflict with their obligations to respect patient confidentiality and autonomy.
Physicians should use their discretion in this matter, bearing in mind paragraph 69 of the Istanbul Protocol (2).
cautioning physicians to avoid putting in danger victims who are deprived of freedom, subjected to constraint or threat or in a compromised psychological situation when disclosing information that can identify them.
Work to ensure protection of physicians, who risk reprisals or sanctions of any kind due to the compliance with these guidelines.
Provide physicians with all relevant information on procedures and requirements for reporting torture or cruel, inhuman and degrading treatment and punishments, particularly to national authorities, non-governmental organizations and the International Criminal Court.

The WMA recommends that the constituent members’ codes of ethics include the physician’s obligations concerning documentation and denunciation of acts of torture and cruel, inhuman and degrading treatment and punishments as they are stated in this document.

(1) Codes and codifications:

The Preamble to the United Nations Charter of 26 June 1945 solemnly proclaiming the faith of the people of the United Nations in the fundamental human rights, the dignity and value of the human person.
The Preamble to the Universal Declaration of Human Rights of 10 December 1948 which states that disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind.
Article 5 of the Universal Declaration of Human Rights which proclaims that no one shall be subjected to torture or cruel, inhuman or degrading treatment.
The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), Adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders, held at Geneva in 1955, and approved by the Economic and Social Council by its resolutions 663 C (XXIV) of 31 July 1957 and 2076 (LXII) of 13 May 1977, revised and adopted by the General Assembly on 17 December 2015.
The American Convention on Human Rights, which was adopted by the Organization of American States on 22 November 1969 and entered into force on 18 July 1978, and the Inter-American Convention to Prevent and Punish Torture, which entered into force on 28 February 1987.
The Declaration of Tokyo, Adopted by the 29^th World Medical Assembly, Tokyo, Japan, October 1975 Editorially revised by the 170^thWMA Council Session, Divonne-les-Bains, France, May 2005 and the 173^rdWMA Council Session, Divonne-les-Bains, France, May 2006.
Revised by the 67^th WMA General Assembly, Taipei, Taiwan, October 2017.
The Declaration of Hawaii, adopted by the World Psychiatric Association in 1977.
The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by the United Nations General Assembly on 18 December 1982, and particularly Principle 2, which states: “It is a gross contravention of medical ethics… for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment…”.
The Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which was adopted by the United Nations General Assembly on December 1984 and entered into force on 26 June,1987.
The European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, which was adopted by the Council of Europe on 26 June 1987 and entered into force on 1 February 1989.
The WMA Declaration of Hamburg, adopted by the World Medical Association in November 1997 during the 49th General Assembly, and reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017 calling on physicians to protest individually against ill-treatment and on national and international medical organizations to support physicians in such actions.
The Istanbul Protocol (Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment), adopted by the United Nations General Assembly on 4 December 2000.
The Convention on the Rights of the Child, which was adopted by the United Nations on 20 November 1989 and entered into force on 2 September 1990.
The World Medical Association Declaration of Malta on Hunger Strikers, adopted by the 43rd World Medical Assembly Malta, November 1991and amended by the WMA General Assembly, Pilanesberg, South Africa, October 2006, and revised by the 68th WMA General Assembly, Chicago, United States, October 2017.

(2) Istanbul Protocol, paragraph 69: “In some cases, two ethical obligations are in conflict. International codes and ethical principles require the reporting of information concerning torture or maltreatment to a responsible body. In some jurisdictions, this is also a legal requirement. In some cases, however, patients may refuse to give consent to being examined for such purposes or to having the information gained from examination disclosed to others. They may be fearful of the risks of reprisals for themselves or their families. In such situations, health professionals have dual responsibilities: to the patient and to society at large, which has an interest in ensuring that justice is done and perpetrators of abuse are brought to justice. The fundamental principle of avoiding harm must feature prominently in consideration of such dilemmas. Health professionals should seek solutions that promote justice without breaking the individual’s right to confidentiality. Advice should be sought from reliable agencies; in some cases, this may be the national medical association or non-governmental agencies. Alternatively, with supportive encouragement, some reluctant patients may agree to disclosure within agreed parameters.”

Adopted by the 54^thWMA General Assembly, Helsinki, Finland, September 2003,
revised by 65^th WMA General Assembly, Durban, South Africa 2014
and reaffirmed by the 217^th WMA Council Session, Seoul (online), April 2021

PREAMBLE

The rapid advances in biomedical technologies have led to growth of the reproductive assistance industry, which tends to be poorly regulated. Despite the fact that many governments have laws prohibiting commercial transactions of reproductive material, most have not been successful in universally preventing the sale of human ova, sperm and embryos on the internet and elsewhere. The market value of human material, including cells, tissues, and cellular tissue can be lucrative, creating a potential conflict for physicians and others between economic interests and professional ethical obligations.

For the purposes of this resolution human reproductive material is defined as human gametes and embryos.

According to the WHO, transplant commercialism “is a policy or practice in which cells, tissues or organs are treated as a commodity, including by being bought or sold or used for material gain.” [1]

The principle that the “human body and its parts shall not, as such, give rise to financial gain”[2] is laid down in numerous international declarations and recommendations.[3] The 2006 WMA Statement on Human Organ Donation and Transplantation and the 2012 WMA Statement on Organ and Tissue Donation call for the prohibition of the sale of organs and tissues for transplantation. The WMA Statement on Assisted Reproductive Technologies (2006) also states that it is inappropriate to offer financial benefits to encourage donation of human reproductive material.

The same principles should be in place for the use of human reproductive material in the area of medical research. The International Bioethics Committee of the United Nations Educational, Scientific and Cultural Organization (UNESCO IBC) in its report on the ethical aspects of human embryonic stem cell research states that the transfer of human embryos must not be a commercial transaction and that measures should be taken to discourage any financial incentive.

It is important to distinguish between the sale of clinical assisted reproductive services, which is legal, and the sale of the human reproductive materials, which is usually illegal. Due to the special nature of human embryos, the commercialization of gametes is unlike that of other cells and tissues as sperm and eggs may develop into a child if fertilization is successful.

Before human reproductive material is donated, the donor must give informed consent that is free of duress. This requires that the individual donor is deemed fully competent and has been given all the available information regarding the procedure and its outcome. If research is to be conducted on the material, it is subject to a separate consent process that must be consistent with the provisions in the WMA’s Declaration of Helsinki. There must not be any inducement or other undue pressure to donate or offers of compensation.

Monetary compensation given to individuals for economic losses, expenses or inconveniences associated with the retrieval of donated reproductive materials should be distinguished from payment for the purchase of reproductive materials.

RECOMMENDATIONS

National Medical Associations (NMAs) should urge their governments to prohibit commercial transactions in human ova, sperm and embryos and any human material for reproductive purpose.
Physicians involved in the procurement and use of human ova, sperm, and embryos should implement protocol to ensure that materials have been acquired appropriately with the consent and authorization of the source individuals. In doing so, they can uphold the ethical principle of non-commercialization of human reproductive material.
Physicians should consult with potential donors prior to donation in order to ensure free and informed consent.
Physicians should adhere to the WMA Statement on Conflict of Interest when treating patients who seek reproductive services.

[1] Global Glossary of Terms and Definitions on Donation and Transplantation, WHO, November 2009

[2] European convention of human rights and biomedicine – Article 21 – Prohibition of financial gain

[3] Declaration of Istanbul guiding principle 5

Adopted by the 54^th WMA General Assembly, Helsinki, Finland, September 2003
revised by the 64^th WMA General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224^th WMA Council, Kigali, Rwanda, October 2023

PREAMBLE

Over the last three decades, forensic investigations into the whereabouts and fate of people killed and missing as a result of armed conflict, other situations of violence and catastrophes, have made an important contribution to humanitarian action on behalf of victims, including [the deceased and] bereaved families. Forensic investigations have also helped in achieving justice and reparations for victims.

In 2003 the International Conference on The Missing and Their Families, organized by the International Committee of the Red Cross (ICRC), adopted a set of recommendations to help prevent people going missing, and resolve the cases of those already missing, as a result of armed conflicts and other situations of violence. The recommendations include ethical, scientific and legal principles that must apply to forensic investigations in the search, recovery, management and identification of human remains. These principles have since been further developed and provide a framework for humanitarian forensic action in situations of armed conflicts, other situations of violence and catastrophes [1]. The principles also ensure the dignified and professional management of the dead [2], adherence to cultural and religious practices and help provide answers to the bereaved.

The WMA and its Constituent Members have a role in promoting these principles, encouraging compliance with them, and for ensuring the highest possible ethical, scientific and legal standards in forensic investigations aimed at addressing the humanitarian consequences of armed conflicts, other situations of violence and catastrophes.

RECOMMENDATIONS

The WMA calls upon its Constituent Members to:

- draw the attention of practitioners to the best practice guidelines produced by the ICRC, the United Nations and Interpol, and recommend or, where possible, require compliance with those standards;
- help ensure that, when its individual physicians members take part in forensic investigations for humanitarian and human rights purposes, such investigations are established with a clear mandate based upon the highest ethical, scientific and legal standards, and conform with the principles and practice of humanitarian forensic action developed by the ICRC [3] and the United Nations [4];
- acquire expertise in the principles collated by the different authorities on forensic investigations for humanitarian and human rights purposes, including those developed by the ICRC and the United Nations to prevent new cases and resolve those of existing missing persons, and to assist their members in applying these principles to forensic investigations worldwide;
- disseminate those principles and support physicians refusing to take part in investigations that are ethically or otherwise unacceptable;
- help ensure compliance by forensic medical practitioners with the principles enshrined in international humanitarian law for the dignified and professional management of the dead, including taking all measures to ensure their identification, while ensuring respect for their families.

The WMA invites its Constituent Members to be mindful of academic qualifications and ethical understanding, ensuring that forensic physicians practice with competence and independence.

[1] The ICRC defines catastrophes as disasters beyond expectations. See: M. Tidball-Binz, Managing the dead in catastrophes: guiding principles and practical recommendations for first responders. International review of the Red Cross, Vol 89 Number 866 June 2007 p.p. 421-442.

[2] Management of the deceased (MotD) refers to a process encompassing different stages that begin with the information or report of death and finalizes with the return of the body to the bereaved, issuance of death certificates and final disposition.

[3] ICRC Guiding Principles for Dignified Management of the Dead in Humanitarian Emergencies and to Prevent them Becoming Missing Persons; Forensic Identification of Human Remains; Management of dead bodies after disasters: A manual for 1st responders; Guidelines for the use of Forensic Genetics in Investigations into Human Rights and International Humanitarian Law Violations

[4] UN Minnesota protocol applicable for the MotD in context of violations of human rights and criminal investigations.

Adopted by the 53^rd WMA General Assembly, Washington, DC, USA, October 2002,
reaffirmed with minor revision by the 194^th WMA Council Session, Bali, Indonesia, April 2013 and
and rescinded and archived by the 70^th WMA General Assembly, Tbilisi, October 2019
* This document has been replaced by the completely rewritten “WMA Declaration on Euthanasia and Physician-Assisted Suicide” (2019)

The World Medical Association’s Declaration on Euthanasia, adopted by the 38^th World Medical Assembly, Madrid, Spain, October 1987 and reaffirmed by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 states:
“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.”

The WMA Statement on Physician-Assisted Suicide, adopted by the 44^th World Medical Assembly, Marbella, Spain, September 1992 and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 likewise states:
“Physicians-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.”

The World Medical Association has noted that the practice of active euthanasia with physician assistance, has been adopted into law in some countries.

BE IT RESOLVED that:

The World Medical Association reaffirms its strong belief that euthanasia is in conflict with basic ethical principles of medical practice, and

The World Medical Association strongly encourages all National Medical Associations and physicians to refrain from participating in euthanasia, even if national law allows it or decriminalizes it under certain conditions.

Adopted by the 51^st World Medical Assembly, Tel Aviv, Israel, October 1999,
revised by the 66^th WMA General Assembly, Moscow, Russia, October 2015
and reaffirmed by the 217^th WMA Council Session, Seoul (online), April 2021

Preamble

Medical School curricula are designed to prepare medical students to enter the profession of medicine. Increasingly, in addition to core biomedical and clinical knowledge, they teach skills including critical appraisal and reflective practice. These additional skills help to enable future doctors to understand and assess the importance of published research evidence, and how to evaluate their own practice against norms and standards set nationally and internationally.

In much the way same that anatomy, physiology and biochemistry are a solid base for understanding the human body, how it works, how it can fail or otherwise go wrong, and how different mechanisms can be used to repair damaged structure and functions, there is a clear need for physicians in training to understand the social, cultural and environmental contexts within which they will practice. This includes a solid understanding of the social determinants of health.

Medical ethics includes the social contract made between the health care professions and the societies they serve, based upon established principles, on the limits that apply to medical practice It also establishes a system or set of principles through which new treatments or other clinical interventions will be sieved before decisions are made on whether elements are acceptable within medical practice. There is a complex intermingling of medical ethics and the duties of physicians to patients, and the rights patients enjoy as citizens.

At the same time physicians face challenges and opportunities in relation to the human rights of their patients and of populations, for example occasions for imposing treatments without consent, and will also often be the first to observe and to itemize the infringement of these rights by others, including the state. This places very specific responsibilities upon the observing physician.

Physicians have a duty to use their knowledge to improve the wellbeing and health of patients and the population. This will mean considering social and societal change, including legislation and regulation, and can only be done well if doctors can take a holistic view within clinical and ethical parameters.

Physicians should press government to ensure legislation supports principled medical practice.

Given the core nature of health care ethics in establishing medical practice in a manner that is acceptable to society and that does not violate civil, political and other human rights, it is essential that all physicians are trained to perform an ethics evaluation of every clinical scenario they may encounter, while simultaneously understanding their role in protecting the rights of individuals.

Physicians’ ability to act and communicate in a way that respects the values of the individual patient is a prerequisite for successful treatment. Physicians must also be able to work effectively in teams with other health c are professionals including other physicians.

Failures of individual physicians to recognize the ethical obligations they owe patients and communities can damage the reputation of doctors both locally and globally. Therefore it is essential that all doctors are taught to understand and respect medical ethics and human rights from the beginning of their medical school careers.

In many countries ethics and human rights are an integral part of the medical curriculum, but this is not universal. Too often teaching is undertaken by volunteers, and can fail if those volunteers are unable or unavailable to teach, or if that teaching is unduly idiosyncratic or inadequately based upon clinical scenarios.

The teaching of medical ethics should become an obligatory and examined part of the medical curriculum within every medical school.

Recommendations

The WMA urges that medical ethics and human rights be taught at every medical school as obligatory and examined parts of the curriculum, and should continue at all stages of post graduate medical education and continuing professional development.
The WMA believes that medical schools should seek to ensure that they have sufficient faculty skilled at teaching ethical enquiry and human rights to make these courses sustainable.
The WMA commends the inclusion of medical ethics and human rights within post graduate and continuing medical education.

Adopted by the 34^thWorld Medical Association General Assembly, Lisbon, Portugal, September/October 1981,
revised by the 39^th World Medical Association General Assembly, Madrid, Spain, October 1987,
by the 45^thWorld Medical Association General Assembly, Budapest, Hungary, October 1993,
by the 51^stWorld Medical Association General Assembly, Tel Aviv, Israel, October 1999,
reaffirmed by the 185^th WMA Council Session, Evian-les-Bains, France, May 2010,
and revised by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

PREAMBLE

Sports medicine physicians are physicians concerned with the prevention and treatment of injuries and disorders that are related to participation in sports. In some countries, sports medicine physicians are recognized as medical specialists. They are trained to address issues associated with nutrition, sports psychology and substance misuse, and may also counsel athletes on injury prevention.

Considering the involvement of physicians in sports medicine, the World Medical Association (WMA) recommends ethical guidelines for sports medicine physicians, recognizing the special circumstances in which their medical care and health guidance is given.

Anabolic Agents and Performance Enhancing Drugs and Methods

The use of anabolic agents, performance enhancing drugs, pain killers and performance enhancing methods by athletes is contrary to the rules and ethical principles of athletic competition as set forth by most sports governing bodies. Performance enhancing drugs and methods have been associated with adverse health effects.

The sports medicine physician should be aware that methods, drugs or interventions which artificially modify blood constituents, biochemistry, genome sequence, gene expression or hormone levels and do not benefit patients, violate the basic principles of the WMA’s Declaration of Geneva, which states: “the health and wellbeing of my patient will be my first consideration.”

The WMA believes that the use of anabolic agents and performance enhancing drugs and methods is a threat to the health of athletes and is in conflict with the principles of medical ethics. The physician must oppose and refuse to administer or condone any means or method which is not in accordance with medical ethics, or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.

Examples of these drugs and methods include, but are not limited to:

The use of drugs or other substances whatever their nature and route of administration, including central-nervous-system stimulants or depressants and procedures which artificially modify reflexes, alter a sense of well-being and/or general mental outlook.
Procedures or therapeutics to mask pain or other protective symptoms if used to enable the athlete to take part in events or training activities when clinical signs make his or her participation inadvisable. This includes allowing participation in athletic activity when doing so would be dangerous to the athlete.
Procedures or therapeutics used to mask the presence of other performance enhancing drugs or to induce rapid water or weight loss.
Measures aimed at an unnatural improvement in or maintenance of endurance or oxygen carrying capacity during competition. This includes the manipulation of blood and/or blood components defined as the administration or reintroduction of blood or red blood cell products of any origin into the circulatory system, artificially enhancing the uptake, transport, or delivery of oxygen using chemicals such as erythropoietin, or other forms of intravascular manipulation to artificially increase red blood cell mass, unless medically indicated for the treatment of a documented disease or medical condition. Blood doping also exposes the athlete to unwarranted and potentially serious health risks.
Use of anabolic agents including “designer steroids”, which are substances that are undetectable through the use of standard testing methods.
Use of anabolic steroid precursors, including dietary supplements, that claim to provide “safe” steroid equivalents, but that metabolize in the body into anabolic steroids.
Use of non-approved substances which have no current approval by any governmental regulatory health authority for human therapeutic use, for example, drugs under pre-clinical or clinical development, discontinued drugs, designer drugs or substances approved only for veterinary use.
Use of peptide hormones, growth factors and related substances to increase red blood cell count, blood oxygenation or oxygen-carrying capacity.
Use of hormone and metabolic modulators, which are substances to modify hormone activity by blocking the action or increasing the activity of a hormone.

Of special concern is the use of anabolic agents and steroid precursors in adolescents. Young users are considered particularly susceptible to potentially serious health problems during this physically and emotionally vulnerable period when their own hormonal cycles are changing. In females, anabolic agents have been associated with a number of adverse effects, some of which appear to be permanent even when drug use is stopped. Physicians should strongly discourage using these products.

World Athletics Gender Rules for Classifying Female Athletes

World Athletics 2018 Eligibility Regulations for Female Classification^[1] imposes an upper hormonal limit for athletes wishing to compete in the female category in certain disciplines of international athletics competitions.

The WMA opposes World Athletics’ rules^[2] requiring female athletes with differences in sex development to take drugs to reduce and maintain their natural level of blood testosterone in order to compete. The mere existence of a condition caused by a difference in sex development, in a person who has not expressed a desire to change that condition, does not constitute a medical indication for treatment. Medical treatment solely to alter athletic performance is unethical.

RECOMMENDATIONS

Sports medicine physicians have an obligation and duty to respect and comply with the ethical standards of the medical profession.
The sports medicine physician who cares for athletes has an ethical responsibility to recognize the special physical and mental demands placed upon athletes by their participation in athletic activities. The physician’s duty is to preserve the athlete’s mental and physical health and not solely to increase athletic performance.
When the sports participant is a professional athlete and derives livelihood from that activity, the physician should understand the occupational health aspects involved.
The sports physician should give his or her objective opinion about the athlete’s state of fitness clearly and precisely, leaving no doubt as to his or her conclusions.
In all sporting events, it is the physician’s duty to decide whether the athlete is medically fit to compete in an event. This decision cannot be delegated to other non-physician professionals.
In order to carry out his or her ethical obligations, the sports medicine physician’s authority must be fully recognized and upheld, particularly when it concerns the health and safety of the athlete. Concern for the athlete’s health and safety must override the interests of any third party.
The sports medicine physician is obligated to uphold the ethical principles of the medical profession. This includes the right to privacy and respect for the confidential nature of the patient-physician relationship. These principles and obligations should be supported by an agreement between the sports medicine physician and the athletic organization involved.
The sports medicine physician must oppose and refuse to administer any substance or condone any means or treatment method which is not in accordance with medical ethics and/or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.
The sports medicine physician should be invited to participate in the design and modification of a sport’s rules and regulations in order to protect the health and safety of athletes.
The sports medicine physician, with patient consent, should work cooperatively with the patient’s personal physician, and keep him or her fully informed of the patient’s current condition.
All physicians should recognize that the desire to enhance performance, appearance, and/or well-being is not limited to elite athletes. Amateur and recreational athletes, as well as adolescents, are also at risk of and subject to sociocultural pressures to misuse anabolic agents and performance enhancing drugs and methods. A harm-reduction approach with discussions focused on risks, harm minimization, prevention strategies, and health promotion is recommended.

[1] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”

[2] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”

Adopted by the 49^th WMA General Assembly, Hamburg, Germany, November 1997,
reaffirmed by the 176^th WMA Council Session, Berlin, Germany, May 2007
And reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017

PREAMBLE

1. On the basis of a number of international ethical declarations and guidelines subscribed to by the medical profession, physicians throughout the world are prohibited from countenancing, condoning or participating in the practice of torture and other cruel, inhuman or degrading treatment or punishment for any reason.

2. Primary among these declarations are the World Medical Association’s International Code of Medical Ethics, Declaration of Geneva, the Declaration of Tokyo (1975), the Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Inhuman or Degrading Treatment (2003) and the Resolution on Physician Participation in Capital Punishment(1981); as well as the Standing Committee of European Doctors’ Statement of Madrid (1989); the Nordic Resolution Concerning Physician Involvement in Capital Punishment; and, the World Psychiatric Association’s Declaration of Hawaii.

3. However, none of these declarations or statements addresses explicitly the issue of what protection should be extended to physicians if they are pressured, called upon, or ordered to take part in torture and other cruel, inhuman or degrading treatment or punishment. Nor do these declarations or statements express explicit support for, or the obligation to protect, doctors who encounter or become aware of such procedures.

RESOLUTION

4. The World Medical Association (WMA) hereby reiterates and reaffirms the responsibility of the organised medical profession:

4.1 To encourage physicians to honour their commitment as physicians to serve humanity and to resist any pressure to act contrary to the ethical principles governing their dedication to this task;

4.2 To support physicians experiencing difficulties as a result of their resistance to any such pressure or as a result of their attempts to speak out or to act against such inhuman procedures; and,

4.3 To extend its support and to encourage other international organisations, as well as the constituent members of the World Medical Association (WMA), to support physicians encountering difficulties as a result of their attempts to act in accordance with the highest ethical principles of the profession.

4.4 To encourage physicians to report and document any acts of torture and other cruel, inhuman or degrading treatment or punishment they are aware of.

5. Furthermore, in view of the continued employment of such inhumane procedures in many countries throughout the world, and the documented incidents of pressure upon physicians to act in contravention to the ethical principles subscribed to by the profession, the WMA finds it necessary:

5.1 To protest internationally against any involvement of, or any pressure to involve, physicians in acts of torture and or other forms of cruel, inhuman or degrading treatment or punishment;

5.2 To support and protect, and to call upon its constituent members NMAs to support and protect, physicians who are resisting involvement in such inhuman procedures or who are documenting and reporting these procedures, or who are working to treat and rehabilitate victims thereof, as well as to secure the right to uphold the highest ethical principles including medical confidentiality;

5.3 To publicize information about and to support physicians reporting evidence of torture and to make known proven cases of attempts to involve physicians in such procedures; and,

5.4 To encourage its constituent members to take action so that physicians are held accountable before the law in case of complicity in acts of torture and other cruel, inhuman or degrading treatment or punishment;

5.5 To encourage its constituent members to ask corresponding academic authorities to teach and investigate in all schools of medicine and hospitals the consequences of torture and its treatment, the rehabilitation of the survivors, the documentation of torture, and the professional protection described in this Declaration.