Policy Tag: Professional Autonomy

Adopted by the 59th WMA General Assembly, Seoul, Korea, October 2008
And amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

The WMA reaffirms the Declaration of Madrid on professionally-led regulation.

The World Medical Association recognises the essential nature of professional autonomy and physician clinical independence, and states that:

  1. Professional autonomy and clinical independence are essential elements in providing quality health care to all patients and populations. Professional autonomy and independence are essential for the delivery of high quality health care and therefore benefit patients and society.
  2. Professional autonomy and clinical independence describes the processes under which individual physicians have the freedom to exercise their professional judgment in the care and treatment of their patients without undue or inappropriate influence by outside parties or individuals.
  3. Medicine is highly complex. Through lengthy training and experience, physicians become medical experts weighing evidence to formulate advice to patients. Whereas patients have the right to self-determination, deciding within certain constraints which medical interventions they will undergo, they expect their physicians to be free to make clinically appropriate recommendations.
  4. Physicians recognize that they must take into account the structure of the health system and available resources when making treatment decisions. Unreasonable restraints on clinical independence imposed by governments and administrators are not in the best interests of patients because they may not be evidence based and risk undermining trust which is an essential component of the patient-physician relationship.
  5. Professional autonomy is limited by adherence to professional rules, standards and the evidence base.
  6. Priority setting and limitations on health care coverage are essential due to limited resources. Governments, health care funders (third party payers), administrators and Managed Care organisations may interfere with clinical autonomy by seeking to impose rules and limitations. These may not reflect evidence-based medicine principles, cost-effectiveness and the best interest of patients. Economic evaluation studies  may be undertaken from a funder’s not a users’ perspective and emphasise cost-savings rather than health outcomes.
  7. Priority setting, funding decision making and resource allocation/limitations processes are frequently not transparent. A lack of transparency further perpetuates health inequities.
  8. Some hospital administrators and third-party payers consider physician professional autonomy to be incompatible with prudent management of health care costs. Professional autonomy allows physicians to help patients make informed choices, and supports physicians if they refuse demands by patients and family members for access to inappropriate treatments and services.
  9. Care is given by teams of health care professionals, usually led by physicians. No member of the care team should interfere with the professional autonomy and clinical independence of the physician who assumes the ultimate responsibility for the care of the patient. In situations where another team member has clinical concerns about the proposed course of treatment, a mechanism to voice those concerns without fear of reprisal should exist.
  10. The delivery of health care by physicians is governed by ethical rules, professional norms and by applicable law. Physicians contribute to the development of normative standards, recognizing that this both regulates their work as professionals and provides assurance to the public.
  11. Ethics committees, credentials committees and other forms of peer review have long been established, recognised and accepted by organised medicine as ways of scrutinizing physicians’ professional conduct and, where appropriate, may impose reasonable restrictions on the absolute professional freedom of physicians.
  12. The World Medical Association reaffirms that professional autonomy and clinical independence are essential components of high quality medical care and the patient-physician relationship that must be preserved. The WMA also affirms that professional autonomy and clinical independence are core elements of medical professionalism.

Adopted by the 66th General Assembly, Moscow, Russia, October 2015
and rescinded and archived by the 75th WMA General Assembly, Helsinki, Finland, October 2024

PREAMBLE 

Several media report that over the last two months of conflict in Turkey, healthcare workers have been killed, wounded or threatened with guns. Some physicians have been taken out of ambulances and beaten. Access to wounded people is prevented by security forces, and ambulances as well as health facilities are regularly targeted. A rather comprehensive study conducted by the Turkish Medical Association confirms these facts.

There are indications that attacks on healthcare workers and the obstructions of service delivery are used as a deliberate political instrument to intimidate people, depriving them of their democratic rights.

Parties in armed conflict have the obligation to protect health care provision to wounded and sick and to prevent attack on or threat to medical activities, healthcare workers and facilities. Physicians and other healthcare workers should not be impeded to perform their duties. Such attacks constitute blatant violation of international human rights law, in particular the inherent right to life that shall be protected by law, and the right to enjoy the highest attainable standard of health[1].

These attacks undermine gravely as well fundamental medical ethics principles, in particular WMA international Code of Medical Ethics and the Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies endorsed by civilian and military health-care organisations[2], stating that: “Health-care personnel, as well as health-care facilities and medical transports, whether military or civilian, must be respected by all. They are protected while performing their duties and the safest possible working environment shall be provided to them » (article 10).

Recommendations

The WMA urges all parties to:

  1. Stop attacks on healthcare workers and patients, health care facilities, and ambulances and ensure their safety,
  2. Respect the professional autonomy and impartiality of healthcare workers,
  3. Comply fully with international human rights law as well as other relevant international regulations that Turkey is a State Party to, and
  4. Document and record all violations and duly prosecute their perpetrators.

[1] International Covenant on Economic, Social and Cultural Rights, article 12 – December 1966

[2] Adopted by the ICRC, the WMA, the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP)  – June 2015

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

 

PREAMBLE

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

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

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

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

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

RECOMMENDATION

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

Adopted by the 48th WMA General Assembly, Somerset West, South African, October 1996
and editorially revised by the 174th WMA Council Session, Pilanesberg, South Africa, October 2006
and rescinded at the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

Recognising that:

  1. The physician has an obligation to provide his or her patients with competent medical service and to report to the appropriate authorities those physicians who practice unethically and incompetently or who engage in fraud or deception (International Code of Medical Ethics); and
  2. The physician should be free to make clinical and ethical judgements without inappropriate outside interference; and
  3. Ethics committees, credentials committees and other forms of peer review have been long established, recognised and accepted by organised medicine to scrutinise physicians’ professional conduct and, where appropriate, impose reasonable restrictions on the absolute professional freedom of physicians; and

Reaffirming that:

  1. Professional autonomy and the duty to engage in vigilant self-regulation are essential requirements for high quality care and therefore are patient benefits that must be preserved;
  2. And, as a corollary, the medical profession has a continuing responsibility to support, participate in, and accept appropriate peer review activity that is conducted in good faith;

POSITION

  1. A physician’s professional service should be considered distinct from commercial goods and services, not least because a physician is bound by specific ethical duties, which include the dedication to provide competent medical practice (International Code of Medical Ethics).
  2. Whatever judicial or regulatory process a country has established, any judgement on a physician’s professional conduct or performance must incorporate evaluation by the physician’s professional peers who, by their training and experience, understand the complexity of the medical issues involved.
  3. Any procedure for considering complaints from patients which fails to be based upon good faith evaluation of the physician’s actions or omissions by the physician’s peers is unacceptable. Such a procedure would undermine the overall quality of medical care provided to all patients.

Adopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975
Editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016

 

PREAMBLE

It is the privilege of the physician to practise medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, and to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use is to be made of any medical knowledge contrary to the laws of humanity.

For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.

 

DECLARATION

1. The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives, and in all situations, including armed conflict and civil strife.

2. The physician shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment.

3. When providing medical assistance to detainees or prisoners who are, or who could later be, under interrogation, physicians should be particularly careful to ensure the confidentiality of all personal medical information. A breach of the Geneva Conventions shall in any case be reported by the physician to relevant authorities.

4. As stated in WMA Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment and as an exception to professional confidentiality, physicians have the ethical obligation to report abuses, where possible with the subject’s consent, but in certain circumstances where the victim is unable to express him/herself freely, without explicit consent.

5. The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.

6. The physician shall not be present during any procedure during which torture or any other forms of cruel, inhuman or degrading treatment is used or threatened.

7. A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose.

8. Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.

9. Recalling the Declaration of Hamburg concerning Support for Medical Doctors Refusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman or Degrading Treatment, the World Medical Association supports, and encourages the international community, the National Medical Associations and fellow physicians to support, the physician and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

10. The World Medical Association calls on National Medical Associations to encourage physicians to continue their professional development training and education in human rights.

Adopted by the 36th World Medical Assembly, Singapore, October 1984
and reaffirmed with minor revision by the 215th WMA Council Session (online), Cordoba, Spain, October 2020

Professional independence and professional freedom are indispensable to physicians to enable them to give appropriate health care to their patients. Therefore, there should be no barriers based on disease or disability, creed, ethic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to prevent physicians from participating in professional activities that will enable them to acquire the information, knowledge, skills and techniques required to provide appropriate health care to their patients.

In as much as the purpose of the WMA is to serve humanity by endeavoring to achieve the highest international standards in medical education, medical science, medical art and medical ethics, and health care for all people of the world, there should accordingly be no barriers which will prevent physicians from attending meetings of the WMA, or other medical meetings, wherever such meetings are convened.