Policy Tag: Independence

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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 191st WMA Council Session, Prague, April 2012
and rescinded and archived by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

Introduction

The WMA is extremely concerned about recent actions by the Turkish government that drastically reduce the self-governing authority and professional autonomy of the medical profession in Turkey. In particular, the newly enacted Government Decree 663 on the Organization and Duties of the Ministry of Health and its Associated Organizations establishes a Health Professions Board, controlled by the Ministry of Health, and delegates authority to this Board for certain critical functions that should remain with the Turkish Medical Association in keeping with the principles of professional autonomy and physician self governance. The Turkish Medical Association was established by the Turkish Parliament in 1953, while Decree 663 was passed by the government ministers of Turkey in an extraordinary process that bypassed the Parliament.

Of grave concern is the fact that the Turkish Medical Association no longer has the authority to:

  • Establish and issue ethical guidelines concerning physician conduct
  • Conduct investigations regarding alleged malpractice by physicians
  • Determine disciplinary sanctions against physicians in cases of malpractice
  • Develop core curricula for medical education, post-graduate medical specialty curricula, and content and accreditation for continuing medical education (all of which were previously done in partnership between the TMA and universities)

In addition, Decree 663 amends Article 1 of the Constituting Law of the Turkish Medical Association (originally drafted and adopted by the Parliament) by removing the following language in the TMA’s mandate: “ensuring that medical profession is practiced and promoted in line with public and individual well-being and benefit”. As a result of this restriction of its mandate, the TMA no longer has the right to legally challenge actions and regulations that adversely affect the right to health, the provision of health care, public health, and individual patient well-being. Examples might include, for instance, efforts against restrictions on which medical procedures would be reimbursed under the national health system or initiation of action to address public health hazards such as the use of cyanide in silver and gold mining and processing. The narrowing of the TMA’s mandate in this regard not only diminishes the independence of physicians, but also jeopardizes the health of their patients.

THEREFORE:

Reaffirming its unequivocal commitment to the independence and professional self-governance of the medical profession, as defined in the WMA Declaration of Madrid on Professional Autonomy and Self-Regulation, and the WMA Resolution on the Independence of National Medical Associations, the WMA Council:

  1. Urges the Turkish government to rescind Decree 663 and restore to the Turkish Medical Association its duties and responsibilities for professional autonomy and self regulation, properly established by the Parliament in 1953 through the legitimate and transparent national democratic process.
  2. Urges all physician members of Parliament, regardless of political affiliation, to recall their duties as physician leaders and support the right of the medical profession to autonomy and self-regulation.
  3. Supports and commends the Turkish Medical Association and those members of the Turkish Parliament who have challenged these recent actions and requested a legal review of this Decree by the Constitutional Court.
  4. Calls on all physicians in Turkey and around the world to join actively in advocacy efforts to promote and support professional independence, the right to health, and the health of the people of Turkey.

Adopted by the 191st WMA Council Session, Prague, April 2012

PREAMBLE

The Economic and Monetary Union of West Africa (Union Economique et Monétaire Ouest Africaine; UEMOA) brings together eight countries of West Africa using CFA Franc as a currency. This tool of integration advocates for the free circulation and settlement of physicians in the countries of UEMOA.

There is a College of the Orders of Physicians, bringing together the Orders of member countries of the Union. The Orders are often under the supervision of the health ministries. This situation often confines the technical and administrative autonomy and impedes the good management of the medical mapping of the region, undermining access to health care for the populations.

RECOMMENDATION

Reiterating its Declaration of Madrid on Professional Autonomy and Self-Regulation and its Resolution on the Independence of National Medical Associations, the WMA requests that the independence, professional autonomy and self-regulation be guaranteed within the countries of the Economic and Monetary Union of West Africa.

Adopted as a Council Resolution by the 189th WMA Council Session, Montevideo, Uruguay, October 2011, adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and reaffirmed by the 217th WMA Council Session, Seoul (online), April 2021

 

National medical associations are established to act as representatives of their physicians, and to negotiate on their behalf, sometimes as a trade union or regulatory body but also as a professional association, representing the expertise of medical doctors in relation to matters of public health and wellbeing.

They represent the views of the medical profession, including attempting to ensure the practice of ethical medicine, the provision of good quality medical care, and the adherence to high standards by all practitioners.

These associations may also campaign or advocate on behalf of their members, often in the field of public health.  Such advocacy is not always welcomed by governments who may consider the advocacy to have oppositional politics attached, when in reality it is based upon an understanding of the medical evidence and the needs of patients and populations.

The WMA is aware that because of those advocacy efforts some governments attempt to silence the medical association by placing it’s own nominated representatives into positions of authority, to subvert the message into one they are better able to tolerate.

The WMA denounces such action and demands that no government interferes with the independent functioning of national medical associations.  It encourages governments to understand better the reasons behind the work of their national medical association, to consider the medical evidence and to work with physicians to improve the health and well being of their populations.

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and editorially revised by the 201st WMA Council Session, Moscow, Russia, October 2015 

PREAMBLE

This policy is intended to identify areas where a conflict of interest might occur during the day-to-day practice of medicine, and to assist physicians in resolving such conflicts in the best interests of their patients. A conflict of interest is understood to exist when professional judgement concerning direct patient care might be unduly influenced by a secondary interest.

In some cases, it may be enough to acknowledge that a potential or perceived conflict exists. In others, specific steps to resolve the conflict may be required. Some conflicts of interest are inevitable and there is nothing inherently unethical in the occurrence of conflicts of interest in medicine but it is the manner in which they are addressed that is crucial.

In addition to the clinical practice of medicine and direct patient care, physicians have traditionally served in several different roles and pursued various other interests, such as participation in research, the education of future physicians and physicians in training and the occupation of administrative or managerial positions. As private interests within medicine have expanded in many locales, physicians have occasionally provided their expertise to these endeavours as well, acting as consultants (and sometimes employees) for private enterprise.

Although the participation of physicians in many of these activities will ultimately serve the greater public good, the primary obligation of the individual physician continues to be the health and well-being of his or her patients. Other interests must not be allowed to influence clinical decision-making (or even have the potential to do so).

Each doctor has a moral duty to scrutinise his or her own behaviour for potential conflicts of interest, even if the conflicts fall outside the kinds of examples or situations addressed in this document. If unacknowledged, conflicts of interest can seriously undermine patient trust in the medical profession as well as in the individual practitioner.

Physicians may also wish to avail themselves of additional resources such as specialty societies, national medical associations or regulatory authorities, and should be aware of applicable national regulations and laws.

RECOMMENDATION

Research

The interests of the clinician and the researcher may not be the same. If the same individual is assuming both roles, as is often the case, the potential conflict should be addressed by ensuring that appropriate steps are put in place to protect the patient, including disclosure of the potential conflict to the patient.

As stated in the Declaration of Helsinki:

  • The Declaration of Geneva of the World Medical Association states that, “The health of my patient will be my first consideration,” and the International Code of Medical Ethics declares that, “A physician shall act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient.”
  • The Declaration of Helsinki states that  “While the primary purpose of medical research is to generate new knowledge, this goal can never take precedence over the rights and interests of individual research subjects.”

Research should be conducted primarily for the advancement of medical science. A physician should never place his or her financial interests above the welfare of his or her patient. Patient interests and scientific integrity must be paramount.

All relevant and material physician-researcher relationships and interests must be disclosed to potential research participants, research ethics boards, appropriate regulatory oversight bodies, medical journals, conference participants and the medical centre where the research is conducted.

All hypothesis-testing research trials should be registered with a publicly-accessible research registry.

A clear contract should be signed by all parties, including sponsors, investigators and program participants, clarifying terms relating to, at a minimum:

  • financial compensation for the physician-researcher (which should approximate lost clinical earnings)
  • ownership of research results (which should rest with the investigator)
  • the right of the investigator to publish negative results
  • the right of the investigator to release relevant information to trial participants at any point during the study.

Physician-researchers should retain control of and should have full access to all trial data, and should decline non-disclosure clauses.

Physician-researchers should ensure that, regardless of the trial results, the presentation or publication of the results of hypothesis-testing trials will not be unduly delayed or otherwise obstructed.

Referral fees should not be accepted for providing the names of potential trial participants, and patient information should not be released without the consent of the patient, except where required by legislation or regulatory authorities.

Any compensation received from trial sponsors should approximately replace lost clinical income and should be commensurate with the efforts and responsibilities of the physician performing the research. When enrolment is particularly challenging and time-consuming, reasonable additional payments may be made to compensate the clinical investigator or institution specifically for time and effort spent on extra recruiting efforts to enrol appropriate research participants. Escalating bonuses designed to increase trial enrolment should not be accepted.

Physician-researchers should decline requests to review grant applications or research paper submissions from colleagues or competitors where their relationship would have the potential to influence their judgment on the matter.

Payments or compensation of any sort should not be tied to the outcome of clinical trials.  Physician-researchers should not have a financial interest in a company sponsoring a trial or a product being studied in a clinical trial if this financial interest could be affected positively or negatively by the results of the trial; they should have no direct financial stake in the results of the trial. They should not purchase, buy or sell stock (shares) in the company while the trial is ongoing and until the results have been made public. This might not apply for those physicians who have developed a medication but are not part of the enrolment process.

Physician-researchers should only participate in clinical trials when they relate to their area of medical expertise and they should have adequate training in the conduct of research and the principles of research ethics.

Authorship should be determined prior to the start of the trial and should be based on substantive scientific contribution.

Education

The educational needs of students and the quality of their training experience must be balanced with the best interests of patients. Where these are in conflict, the interests of patients will take precedence.

While recognizing that medical trainees require experience with real patients, physician-educators must ensure that these trainees receive supervision commensurate with their level of training.

Patients should be made aware that their medical care may be performed in part by students and physicians in training, including the performance of procedures and surgery, and where possible should give appropriate informed consent to this effect.

Patients should be made aware of the identity and qualifications of the individuals involved in their care.

Refusal by a patient to involve trainees in their care should not affect the amount or quality of care they subsequently receive.

Self-referrals and fee-splitting

All referrals and prescriptions (whether for specific goods or services) should be based on an objective assessment of the quality of the service or of the physician to whom the patient has been referred.

Referral by physicians to health care facilities (such as laboratories) where they do not engage in professional activities but in which they have a financial interest is called self-referral. This practice has the potential to significantly influence clinical decision-making and is not generally considered acceptable unless there is a need in that particular community for the facility and other ownership is not a possibility (for example, in small rural communities). The physician in this situation should receive no more financial interest than would an ordinary investor.

Kickbacks (or fee-splitting) occur when a physician receives financial consideration for referring a patient to a specific practitioner or for a specific service for which a fee is charged. This practice is not acceptable.

Physician offices

For reasons of patient convenience, many physician offices are located in close geographic proximity to other medical services such as laboratories, pharmacies and opticians. The physician should not receive any financial compensation or other consideration either for referring a patient to these services, or for being located in close geographical proximity to them. Physician-owned buildings should not charge above-market or below-market rates to tenants.

Non-medical products (those having nothing to do with patient health or the practice of medicine) and scientifically non-validated medical products should not be sold out of the physician’s office. If scientifically validated medical products are sold out of the physician’s office charges should be limited to the costs incurred in making them available and the products should be offered in such a way that the patient does not feel pressured to purchase them.

Organizational/institutional conflicts

Health care institutions in particular are increasingly subject to a number of pressures that threaten several of their roles, and many academic medical centres have begun to identify alternate sources of revenue. Policies should be in place to ensure that these new sources are not in conflict with the values and mission of the institution (for example, tobacco funding in medical schools).

Individual medical organizations and institutions (including, but not limited to, medical schools, hospitals, national medical associations, official/state regulators and research institutions) should develop and, where possible, enforce conflict of interest guidelines for their employees and members.

Physician-researchers and others will benefit from the development of institutional conflict of interest guidelines to assist them in making appropriate disclosure and clearly identifying situations where a conflict would preclude them from participating in a research study or other activity.

Academic health care institutions should have a clear demarcation between investment decision-making committees, technology transfer and the research arm of the institution.

Written policies should provide guidelines for disclosure requirements, or for discontinuing participation in the decision-making process, for those individuals who are conflicted due to sponsored research, consulting agreements, private holdings or licensing agreements.

Adopted by the 55th WMA General Assembly, Tokyo, Japan, October 2004,
amended by the 60th WMA General Assembly, New Delhi, India, October 2009
and by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

In the treatment of their patients, physicians use medicines, instruments, diagnostic tools, equipment and materials developed and produced by commercial enterprises. Industry possesses resources to finance expensive research and development programmes, for which the knowledge and experience of physicians are essential. Moreover, industry support enables the progress of medical research, scientific conferences and continuing medical education that can be of benefit to patients and the entire health care system. The combination of financial resources and product knowledge contributed by industry and the medical knowledge possessed by physicians enables the development of new diagnostic procedures, drugs, therapies, and treatments and can lead to great advances in medicine.

However, conflicts of interest between commercial enterprises and physicians occur and can affect the care of patients as well as the reputation of the medical profession. The duty of the physician is to objectively evaluate what is best for the patient and to promote the patient-physician relationship, while commercial enterprises are expected to bring profit to owners by selling their own products and competing for customers. Commercial considerations can affect the physician’s objectivity, especially if the physician is in any way dependent on the enterprise.

Rather than forbidding any relationships between physicians and industry, it is preferable to establish guidelines for such relationships. These guidelines must incorporate the key principles of disclosure, transparency, avoidance of conflicts of interest and promoting the physician’s ability to act in the best interests of patients.

The guidelines regulating the Physician-Commercial Enterprise relationship should be understood in the light of WMA core ethical values, as stated in particular in the Declaration of Geneva, the International Code of Medical Ethics. the Statement on Conflict of Interest, and the Declaration of Seoul on Professional Autonomy and Clinical Independence.

The autonomy and clinical independence of physicians should be foremost in all physician decisions for patients, regardless of practice setting, whether government-sponsored, private, for profit or not for profit, investor funded, insurance company employers or otherwise.

Curricula of medical schools and residency programs should include educational courses on the relation between enterprises and the medical profession in the light of ethical principles and values of the profession.

RECOMMENDATIONS

Medical conferences

  1. These guidelines related to medical conferences apply, where pertinent, to corporation events, such as educational events, and promotional activities including for items of medical utility, sponsored by a commercial enterprise.
  2. Physicians may attend medical conferences, sponsored in whole or in part by a commercial entity if these conform to the following principles:
    • The main purpose of the conference is the exchange of professional or scientific information for the benefit of patient care.
    • Hospitality during the conference is secondary to the professional exchange of information and does not exceed what is locally customary and generally acceptable.
    • Physicians do not receive payment directly from a commercial entity to cover travelling expenses, room and board at the conference for themselves or an accompanying person or compensation for their time unless provided for by law and/or the policy of their National Medical Association, or unless it is a reasonable honorarium for speaking at the conference.
    • The name of a commercial entity providing financial support is publicly disclosed in order to allow the medical community and the public to fairly evaluate the information presented. In addition, conference organizers and lecturers are transparent and disclose any financial affiliations that could potentially influence educational activities or any other substantial outcome that may result from the conference.
    • In accordance with the WMA Guidelines on Promotional Mass Media Appearances by Physicians, presentation of material by a physician should be scientifically accurate, give a balanced review of possible treatment options, and not be influenced by the sponsoring organization.
  1. In addition, a conference can be recognized for purposes of continuing medical education/ continuing professional development (CME/CPD) only if it conforms to the following principles:
    • The commercial entities acting as sponsors, such as pharmaceutical companies or enterprises in the medical devices sector, have no influence on the content, presentation, choice of lecturers, or publication of results.
    • Funding for the conference is accepted only as a contribution to the general costs of the meeting.
    • The independence of the contents of the conference is guaranteed.

Gifts

  1. To preserve the trust between patients and physicians, physicians should decline:
    • cash, cash equivalents and other gifts for personal benefit from a commercial entity
    • gifts designed to influence clinical practice, including direct prescription incentives.
  1. Physicians may accept:
    • Promotional aids provided that the gift is of minimal value and is not connected to any stipulation that the physician uses certain instruments, medications or materials or refers patients to a certain facility.
    • Cultural courtesy gifts on an infrequent basis according to local standards if the gift is of minimal value and not related to the practice of medicine.

Research

  1. A physician may carry out research funded by a commercial entity, whether individually or in an institutional setting, if it conforms to the following principles:
    • The physician is subject only to the law, the ethical principles and guidelines of the Declaration of Helsinki, and clinical judgment when undertaking research and should guard against external pressure regarding the research results or its publications.
    • If possible, a physician or institution wishing to undertake research approaches more than one commercial source for research funds.
    • Identifiable personal information about research patients or voluntary participants is not passed to the sponsoring company without the consent of the individuals concerned.
    • A physician’s compensation for research is based on his or her time and effort and such compensation must not be connected to the results of the research.
    • The results of research are made public with the name of the sponsoring entity disclosed, along with a statement disclosing who requested the research. This applies whether the sponsorship is direct or indirect, full or partial.
    • Commercial entities allow unrestricted publication of research results.
    • Where possible, research financed by commercial enterprises should be managed by interposed, non-profit entities, such as institutes or foundations.

Affiliations with Commercial Entities

  1. A physician may not enter into an affiliation with a commercial entity, such as consulting or membership on an advisory board unless the affiliation conforms to the following principles:
    • The affiliation does not compromise the physician’s integrity.
    • The affiliation does not conflict with the physician’s obligations to his or her patients.
    • The affiliation or other relationship with a commercial entity is fully disclosed in all relevant situations, such as lectures, personal appearances, articles, reports and influential contributions to the mission of medical associations or other non-profit health entities.

Adopted by the 60th WMA General Assembly, New Delhi, India, October 2009
and revised by the 70th 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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
  7. 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.
  8. 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.
  9. 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.
  10. The regulation process should ensure that the incorporation of such lessons is, as far as possible, seamless.
  11. 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.
  12. 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.
  13. 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.