UN – WMA – The World Medical Association

Adopted by the 62^nd WMA General Assembly, Montevideo, Uruguay, October 2011
and revised by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

The right to health and medical assistance is a basic human right that should be guaranteed at all times; ethical principles of healthcare remain the same in times of emergencies and in times of peace. Healthcare personnel must be duly protected.

Various international agreements, including the Geneva Conventions (1949), Additional Protocols to the Geneva Conventions (1977, 2005) and the Basic Principles on the Use of Force and Firearms by Law Enforcement Officials of the United Nations, must guarantee safe access to medical assistance as well as the protection of healthcare personnel.

The United Nations Security Council Resolution 2286 (2016) condemns attacks and threats against health care personnel, demands an end to impunity for those responsible, and that all parties to armed conflict comply fully with their obligations under international law.

Despite recognized international standards and the mobilization of humanitarian and human rights stakeholders over the last years denouncing the surge of violence against healthcare worldwide, the WMA notes with great concerns persistent attacks and misuses of hospitals and other medical facilities, as well as threats, killings and other violence against patients and healthcare personnel in emergency contexts.

The WMA condemns in the strongest terms this scourge of violence against healthcare personnel and facilities, which has disastrous humanitarian implications with critical impacts on the capacity of the health system to provide the care needed, resulting in unjustifiable suffering and death. Violence against healthcare personnel constitutes an international emergency, requiring urgent actions.

Recalling its Statement on Armed Conflicts, the WMA reaffirms that armed conflicts should always be a last resort and that States and other authorities who enter into armed conflict must accept responsibility for the consequences of their actions.

The safety and personal security of physicians and other healthcare personnel are essential in enabling them to provide care and save lives in situations of conflicts. They must always be respected as neutral and should never be prevented from fulfilling their duties. Healthcare personnel and facilities should never be instrumentalised as means of war.

Recalling its Regulations in Times of Armed Conflict and Other Situations of Violence, the WMA reaffirms that the primary obligation of physicians and other healthcare personnel is always to their patients; they have the same ethical responsibilities in situation of violence or armed conflicts as in peacetime, the same duty of preserving health and saving lives; they shall at all times act in accordance with the ethical principles of the profession, relevant international and national law, and their conscience.

RECOMMENDATIONS

The WMA calls upon all parties involved in situations of violence to:

1.Fully comply with their obligations under international law, including human rights law and international humanitarian law, in particular with their obligations under the Geneva Conventions of 1949 and the obligations applicable to them under the Additional Protocols of 1977 and 2005;

2. Ensure the safety, independence and personal security of healthcare personnel at all times, including during armed conflicts and other situations of violence, in accordance with the Geneva Conventions and their additional protocols;

3. Respect and promote the principles of international humanitarian and human rights law which safeguard medical neutrality in situations of conflict;

4. Protect medical facilities, medical transport and the people being treated in them, provide the safest possible working environment for healthcare personnel, and protect them from threats, interference and attack;

5. Never misuse hospitals and other health facilities for military purposes and dedicate them exclusively to health care;

6. Enable healthcare personnel to treat injured and sick patients, regardless of their role in a conflict, and to carry out their medical duties freely, independently and in accordance with the principles of their profession without fear of punishment or intimidation;

7. Ensure that safe access to adequate medical facilities for the injured and others in need of medical aid is not unduly impeded;

8. Ensure that the equipment, including personal protection equipment, necessary for the safety of healthcare workers, is available to them as needed, and that the staffing is adequate;

9. Support and strictly respect the ethical rules of the medical profession as defined, among other documents, in the Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies and in the WMA Regulations in Times of Armed Conflict and Other Situations of Violence, and to never require from physicians or force them to breach or renounce these rules, in particular:

privileges and facilities afforded to physicians and other health care professionals in times of armed conflict and other situations of violence must never be used for purposes other than health care;
physicians must at all times show appropriate respect for medical confidentiality;
physicians must never accept acts of torture or any other form of cruel, inhuman or degrading treatment under any circumstances; they must never be present at nor take part in such acts;
physicians have a duty to recognize and support vulnerable populations, including women, children, refugees, the disabled and displaced persons;
physicians and WMA constituent members should alert governments and non-state actors of the human consequences of warfare;
where conflict appears to be imminent and inevitable, physicians should ensure that authorities are planning for the protection of the public health infrastructure and for any necessary repair in the immediate post-conflict period.

The WMA calls upon governments to:

10. Establish efficient, secure and unbiased reporting mechanisms with sufficient resources to collect and disseminate data regarding assaults on physicians, other healthcare personnel and medical facilities;

11. Provide to the WHO the necessary support to fulfil its leadership role in documenting attacks on healthcare personnel and facilities[1];

12. Foster the mechanisms of investigating and bringing to justice those responsible for reported violations of the international agreements pertaining to the protection of healthcare personnel in armed conflicts and other situations of violence, and of enforcing the sanctions when such have been decided;

13. Develop and implement more efficient legal protection for medical and other healthcare personnel, so that whoever attacks a nurse, physician or another healthcare personnel knows that such actions will be severely penalised.

The WMA calls upon governments, its member organisations and the appropriate international bodies to:

14. Raise awareness of international norms on the protection of healthcare personnel and cooperate with different actors to identify strategies to tackle threats to healthcare and strengthen the mechanism of investigating the reported violations;

15. Raise awareness at both national and local level of the fundamental importance of protecting the healthcare personnel and of upholding their neutrality in times of conflict;

16. Support the development of pregraduate, postgraduate and continuous education for the healthcare personnel to ensure their competencies and their security and to minimize the psychological toll when confronted with armed conflicts and other situations of violence.

[1] The WMA recognizes that in some circumstances, documenting and denouncing acts of torture or other violence may put the physician, and those close to him or her, at great risk. Doing so may have excessive personal consequences. Physicians must avoid putting individuals in danger while assessing, documenting or reporting signs of torture and cruel, inhuman and degrading treatment and punishments.

Adopted by the 60^th WMA General Assembly, New Delhi, India, October 2009
and amended by the 68th WMA General Assembly, Chicago, United States, October 2017

PREAMBLE

1. Human influence on the climate system is clear, and recent emissions of green-house gases are the highest in history. Recent climate changes have had widespread impacts on human and natural systems.

2. Compelling evidence substantiates the numerous health risks posed by climate change, which threaten all countries. These include more frequent and potentially more severe heatwaves, droughts, floods and other extreme weather events including storms and bushfires. Climate change, especially warming, is already leading to changes in the environment in which disease vectors flourish. There is reduced availability and quality of potable water, and worsening food insecurity leading to malnutrition and population displacement. Climate Change is universal but its effects are uneven and many of the areas most affected are least able to manage the challenges it poses.

3. Tackling climate change offers opportunities to improve health and wellbeing both because of the health co-benefits of low carbon solutions and because mitigation and adaptation may allow action on all the social determinants of health. Transition to renewable energy, the use of active transport, and dietary change including a reduction in consumption of beef and other animal products, may all contribute to improving health and wellbeing.

4. The social determinants of health are those factors that correlate to health through exposure before and after people are born and as they grow live, and work. They vary between and within countries. Those with generally the poorest health and lowest life and health expectancy will be least able to adapt to the adverse effects of climate change thereby exacerbating adverse social determinants of health.

5. Climate change research and surveillance is important. The WMA supports studies that describe the patterns of disease attributed to climate change, including the impacts of climate change on communities and households; the burden of known and emergent disease caused by climate change, and those diseases projected to occur with new development activities (Health Impacts Assessment). Such studies should also define the most vulnerable populations.

6. The Paris Agreement highlights a transition to a new model of global collaboration to address climate change and is an opportunity for the health sector to contribute to climate action. It includes a series of actions to be undertaken by each party to achieve a long-term goal of keeping the increase in global average temperature to less than 1.5 C above pre-industrial levels. Whether or not individual states are parties to the Paris agreement, NMAs have an obligation to consider the effects of climate change on the planet and on human, animal, and environmental sustainability and to take action as follows.

RECOMMENDATIONS

7. The World Medical Association and its Constituent Members:

· Urge national governments and non-state actors to recognize the serious health consequences of climate change and to adopt strategies to adapt to and mitigate its effects;

· Urge national governments to ensure the fulfilment of national commitments to international agreements, including both mitigation and adaptation measures as well as action on losses and damage;

· Urges national governments to provide climate financing that includes designated funds to support the strengthening of health systems, and health and climate co-benefit policies and, provide sufficient global, regional and local financing for climate mitigation, adaptation measures, disaster risk reduction, and the attainment of the Sustainable Development Goals (SDGs);

· Urge national governments to facilitate the active participation of health sector representatives in the creation and implementation of climate change preparedness plans and emergency planning and response on local, national and international levels;

· Urge national governments to provide for the health and wellbeing of people displaced by environmental causes including those becoming refugees due to the consequences of climate change;

· Asks national governments to invest in public health and climate change research to ensure of better understanding of adaptation needs and health co-benefits at national level;

· Urge national governments to facilitate collaboration between Ministry of Health and other ministries to ensure that health is considered in their national commitments and sustainable strategies.

8. National Medical Associations and their physician members should:

· Advocate for sustainable, environmentally responsible low-carbon practices across the health sector to reduce the environmental impact of health care facilities and practices;

· Prepare for the infrastructure disruptions that accompany health emergencies, in particular by planning in advance for the delivery of services and increased patient care demands during these crisis situations;

· Encourage and support advocacy for environmental protection and greenhouse gas emissions reductions including through emissions trading systems and/or carbon taxes;

· Become educated as to the health effects of climate change and be prepared to treat and manage them in individual patients;

· Promote medical research into improved use of antibiotherapy to be able to respond, in the future, to the new infectious diseases linked to climate change.

9. The WMA and its Constituent Members should:

· Encourage sustainable low-carbon living respectful of planetary limits including active lifestyle and sustainable production and consumption patterns;

· Seek to build professional and public awareness of the importance of the environment and climate change to personal, community and societal health;

· Work towards the integration of key climate change concepts and competencies in undergraduate, graduate and continuing medical education curricula;

· Collaborate with the WHO and other stakeholders as appropriate, to produce educational and advocacy materials on climate change for national medical associations, physicians, other health professionals, as well as the general public;

· Advocate for their respective governments to finance, promote research into the effects of climate change on health and collaborate with NGOs and other health professionals;

· Work collaboratively with government, NGOs, businesses, civil societies and others to create alert systems to ensure that health care systems and physicians are aware of climate-related events as they unfold, and receive timely accurate information regarding the management of emerging health events;

· Have climate change as a priority issue on their agendas and actively participate in the creation of policies and initiatives that mitigate the effects of climate change on health.

10. The WMA urges National Medical Associations to:

· Work with health-care institutions, and individual physicians to adopt climate policies and act as role models by reducing their carbon emissions;

· Recognize environmental factors as a key social determinants of health (SDH), and encourage governments to foster collaboration between the health and non-health sectors in addressing these determinants.

Adopted by the 49^th WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the 176^th WMA Council Session, Berlin, Germany, May 2007
and rescinded at the 68th WMA General Assembly, Chicago, USA, October 2017

The British Medical Association (BMA) requests that the World Medical Association (WMA) supports a proposal, put forward by a network of medical organizations* concerned with human rights issues, for the establishment of a new UN post of rapporteur on the independence and integrity of health professionals.

It is envisaged that the role of the rapporteur will supplement the work already done by a series of existing UN rapporteurs on issues such as torture, arbitrary execution, violence against women, etc. The new rapporteur would be charged with the task of monitoring that doctors are allowed to move freely and that patients have access to medical treatment, without discrimination as to nationality or ethnic origin, in war zones or in situations of political tension. The role of the proposed rapporteur is detailed on pages two, three and four of this submission.

The original proposal was drawn up by a lawyer, Cees Flinterman, who is a professor of constitutional and international law at the University of Limburg, Maastricht, in The Netherlands. It has the support of a range of doctors’ organizations listed below*, whose interests are in protection of human rights and protection of doctors who act impartially in conflict situations. This group will be consulting widely and acting with the help of the International Commission of Jurists to interest the United Nations in this proposal.

The Council of the BMA supported this proposal after debate in 1996. It would lend considerable weight to the campaign if the WMA would also support this concept whose fundamental aim is to protect doctors and their patients in war situations and other cases where medical independence may come under threat from political or military factions.

PROPOSAL FOR A RAPPORTEUR ON THE INDEPENDENCE AND INTEGRITY OF HEALTH PROFESSIONALS

Goals

accepting that in many situations of political conflict (such as civil or international war) or political tension (such as during suspension of civil rights in a government-declared state of emergency), health professionals are often the first people outside military of government circles to have detailed knowledge of human rights violations, including violations of the right of populations to access medical treatment, a network of physicians is anxious that a range of national and international reporting mechanisms be established to achieve the following goals:

To monitor the role of health professionals working in situations where either their rights to give, or the rights of their patients to receive, treatment are threatened;
To make appeals for the protection of health professionals when they are in danger solely because of their professional or human rights activities;
To defend patients who are in danger of suffering human rights violations solely because of seeking medical treatment;
To encourage reporting of human rights violations by health professionals;
To analyse information about health professionals voluntarily adopting discriminatory practices. The group consider that existing UN reporting mechanisms need expansion. Key among proposals for new mechanisms is the development of a new UN rapporteur’s post which would link together relevant information emerging from other existing UN mechanisms and also suggest where other useful local and national reporting networks could be developed in the long-term. Therefore, on the basis of materials prepared by the Law Department at the University of Limburg, Maastricht and circulated by the Dutch medical group, the Johannes Wier Foundation, the group is campaigning for a new post of UN Rapporteur of the Independence and Integrity of Health Professionals.

Defining the Role

The potential role of a UN Rapporteur need not be exhaustively defined in advance since the experience of the individual and the practical applicability of the goals must have an influence.

It should include the following:

Receive, evaluate, investigate and report allegations of repression directed at health professionals or intended to prevent individuals receiving medical care. The rapporteur should be a clearing house for reports from individuals, groups of doctors, NGOs etc. and as well as simply receiving information, should pro-actively seek our information, including on-site visits.
To build upon existing principles as found in humanitarian lay and the codes of medical ethics applicable in armed conflicts to develop specific guidelines on the subject of medical impartiality in relation to the treatment of patients in situations of political or armed conflict.The World Medical Association and national medical association should be encouraged to disseminate such information to health professionals during their training. Arising also form such guidance should be the institution of mechanisms to help health professionals protect themselves in situations where human rights are at risk.
The rapporteur should also have a consultative role, seeking the views of international and national professional associations, human rights bodies and humanitarian organizations with regards to the protection of health professionals and the defence of the right to treat patients impartially.
The rapporteur should investigate reports of health professionals voluntarily transgressing guidelines about impartiality and non-discrimination.

Issues within the Remit

The fundamental concern is to protect the nature of the doctor-patient relationship from unjustified external interference although it will also include voluntary transgressing of impartiality by health professionals. The rapporteur’s role will be to ensure the independence, integrity and impartiality of health professionals.Ensuring these aims requires analysis of whether:
- the treatment decisions of health professionals can be carried out without coming into conflict with improper pressure from authorities;
- the physical integrity and ability of health professionals to act in accordance with their professional principles are both protected;
- health professionals are able to provide treatment on the basis of patient need;
- people in need of medical treatment are able to access it safely;
- health professionals are ensured their freedom of movement, in the capacity as medical care providers, and be able to have access to people in need of medical services.
Monitoring the degree to which external pressures influence negatively the provision of medical treatment will be within the remit of the rapporteur.
The remit will be global.
For lack of a reporting mechanism, health professionals are often disempowered form taking action on violations of patient rights. One of the issues of the rapporteur to monitor would be the introduction of national or local legislation, civil or military regulations or other rules prohibiting or limiting the provision of medical or nursing care to certain categories of patient.
It will be within the remit of the rapporteur to bring the evidence or reports of violations of medical impartiality, including those in health professionals co-operating voluntarily, to responsible bodies in the medical field and to the governments concerned.
Blanket restrictions on the medical or nursing services to be provided to members of vulnerable groups, such as refugees, asylum seekers, prisoners, minority ethnic groups, should be among the issues monitored by the rapporteur. The rapporteur should contribute to the empowerment of the health professionals to resist collectively the erosion of such patients’ rights.
Threats, intimidation or pressures on health professionals to discriminate against patients on the basis solely of non-medical related considerations such as ethics, religious or racial affiliation should be investigated even if the threats do not materialize into action.
Reports of health professionals being harassed or detained simply because of their profession or because of the exercise of professional skills will be investigated by the rapporteur. Similarly repressive measures designed to prevent health professionals reporting infringements of medical integrity will be investigated. Measures to encourage health professionals actively to document and report such violations should be put forward by the rapporteur in consultation with other bodies.
Reports of patients being impeded or discouraged from gaining access to the available medical treatment will be investigated.

Issues Outside the Remit

Just as important as defining what is within the rapporteur’s remit is the matter of clarifying those issues which fall outside it. We anticipate that this too will become clearer as practice and experience develop. In the meantime, however, we suggest that:

health professionals in every country should be educated about the ethical responsibilities they owe to patients and potential patients. Whereas such education is not within the remit of the rapproteur, acting as a resource for advice about medical impartiality would be within the rapporteur’s remit. In the long term this function should ideally be dealt with by delegation through medical schools, professional bodies and voluntary national networks;
while government measures to regulate aspects of care, (such as the equitable distribution of medical resources of the prioritizing of treatment on basis of need) would not generally be a matter for monitoring for the rapporteur, extreme measures likely to result in the disenfranchising of groups of patients from medical or nursing services would be monitored and investigated;
governments’ indiscriminate failure to provide health promotion or treatment to many or all sectors of the community does not fall within the remit of the rapporteur;
since a principal concern is to ensure access to medical treatment by patients who need and want it, the voluntary decision of some individuals or patient groups to exclude themselves (for example on religious or cultural grounds) from orthodox medicine does not fall within the remit of the rapporteur.

* organizations participating in the network include: Amnesty International; British Medical Association; Centre for Enquiry into Health & Allied Themes (Bombay); Graza Community Mental Health; International Committee of the Red Cross; Physicians for Human Rights (in Denmark, Israel, South Africa, the UK, & the USA); Turkish Medical Association; and, the Johannes Weir Foundation.