Policy Type: Statement

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

 

PREAMBLE

Hypertension is the single most important risk factor for cardiovascular death globally. It accounts for more deaths from cardiovascular disease than any other modifiable risk factor. More than half of people who die from coronary heart disease and stroke had hypertension. “As populations age, adopt more sedentary lifestyles, and increase their body weight, the prevalence of hypertension worldwide will continue to rise.

Uncontrolled hypertension is a major cause of stroke and other co-morbid, chronic conditions, such as heart failure, kidney disease, vision loss, or mild cognitive impairment. Because hypertension can be asymptomatic, it may often go undiagnosed.

In 2010, hypertension emerged as the leading risk factor for disease burden in every region of the world. Moreover, elevated systolic blood pressure (SBP) is a leading global health risk. The WHO Global Plan of Action for the prevention of non-communicable diseases calls for a 25% reduction in the prevalence of elevated blood pressure by 2025.

Prevalence

Worldwide prevalence of hypertension has grown significantly over the past four decades, and most with hypertension are not achieving optimal control.

Of concern is an increasing disparity in hypertension prevalence between high-income and low/middle–income countries. Almost three times as many people with hypertension live in low/middle–income countries than in high-income countries. Low-income countries in south Asia, sub-Saharan Africa, and central and eastern Europe, are particularly impacted. Moreover, the prevalence of elevated blood pressure was highest in certain regions of Africa in both sexes.

Risk Factors

Hypertension risk factors are attributes that increase the likelihood of developing the disease. Risk factors include the following:

  • Lifestyle/Diet: Unavailability of healthy food choices, lack of access to safe neighborhoods for exercising, and unhealthy lifestyle habits can raise the risk of hypertension. Unhealthy lifestyle habits include unhealthy eating patterns such as eating too much sodium and highly processed food, drinking too much alcohol, smoking, and being physically inactive.
  • Age: Blood pressure (BP) tends to increase with age. However, the risk of hypertension is increasing for children and teens, possibly due to the rise in the number of children and teens who are overweight or obese.
  • Socioeconomic Status: In high-income countries, the greatest absolute burden of hypertension disease is in age groups 60 years and older, whereas in low/middle-income countries, the greatest absolute burden is in the middle-aged groups, such as 40 to 59 years. The age-standardized prevalence of hypertension is higher in low/middle-income countries than in high-income countries.
  • Sex: Before age 55, men are more likely than women to develop hypertension. After age 55, women are more likely than men to develop it.
  • Genetics/Family History: Research has identified many gene variations associated with small increases in the risk of developing hypertension. Some people are genetically predisposed to dietary sodium sensitivity.

Accurate blood pressure measurement

The accurate measurement of BP—both within the clinical setting and at home—is essential for the diagnosis and management of hypertension. In many countries, national clinical guidelines recommend how to achieve an accurate BP measurement and offer best practice recommendations.

Policy implications

Policies and actions at the global, national, and local levels are necessary to recognize and combat hypertension. Much effort is needed worldwide to improve awareness, treatment, and control for all populations. Current guidelines to diagnose and treat hypertension, and evidence-based guidance on the importance of proper BP measurement, offer anchors for national policies on BP measurement and control. Implementation can make significant progress towards lowering global hypertension prevalence and improving patient outcomes. To address the risk factors for hypertension, policies should also focus on addressing socioeconomic, lifestyle and dietary factors which contribute to the development of the disease.

 

RECOMMENDATIONS

  1. The World Medical Association recommends that national governments:
  • Recognize hypertension as the single most important risk factor for cardiovascular disease and death.
  • Declare hypertension control a national health priority.
  • Support campaigns to raise public awareness of hypertension, including recognition of its widespread and asymptomatic nature, and its risk of contributing to development of other serious diseases.
  • Deploy adequate resources to improve hypertension awareness, diagnosis, measurement, and management.
  • Develop country-specific strategies which address the risk factors for hypertension and advocate for improvements in awareness, diagnosis, measurement and management.
  • Promote the recommendations adopted by the WMA as stated in the Statement on Reducing Dietary Sodium Intake.
  1. The World Medical Association recommends that its constituent members:
  • Advocate at the international, national, and local levels to promote hypertension awareness, healthy lifestyles, and patient access to hypertension diagnosis and treatment including medications. This includes supporting the concept that social determinants of health are part of hypertension disease prevention.
  • Recognize and support national guidelines and strategies for measuring BP accurately.
  • Support the exchange of hypertension research, information, tools, and other resources amongst healthcare teams and patients.
  • Support the development of medical curricula that respond to societal hypertension needs with a focus on community-based primary care training and BP measurement and management skills.
  • Promote research on the causes, mechanisms and effective treatments of hypertension.
  • Advocate for sustained availability antihypertensive medications.
  1. The World Medical Association recommends that physicians:
  • Emphasize the risk factors for hypertension and ways to mitigate them, paying special attention to prevention and treatment in high-risk populations.
  • Emphasize team-based care to help prevent and, where it has been diagnosed by a physician, to treat hypertension.
  • Implement BP measurement best practices and techniques, including training and retraining of all healthcare team members.
  • Promote patient hypertension treatment adherence by facilitating ongoing patient BP self-management and involvement in the patient’s own care.

 

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

 

PREAMBLE

Genome editing, enabled by recent scientific advances, can generate targeted insertions and deletions in DNA and may even offer enough precision to modify a single base pair within the genome of an organism. Basic science research with genome editing is now underway in laboratories globally.

Human genome editing is also advancing rapidly, with clinical trials now in progress for prevention and treatment of various human diseases. These trials, which are currently in early stages, involve somatic (non-reproductive) cells, and thus are not anticipated to introduce genetic changes that will be passed on to offspring or the germline (reproductive) cells.

While genome editing holds great potential to help improve human lives, the technology raises profound safety, ethical, legal, and social concerns. These concerns are compounded by the fact that regulatory and ethical guidance often lag rapid technological developments.

Safety concerns for genome editing include the risk of unintended or unforeseen pleiotropic effects off-target effects (edits in the wrong place) unwanted on-target modifications (imprecise edits), and mosaicism (when only some cells carry the edit), and abnormal immunological responses.

Ethical issues regarding genome editing include concerns that editing may be used for non-therapeutic and enhancement purposes rather than for therapeutic purposes, i.e. improving health or curing disease. There are also concerns that germline modifications could create classes of individuals defined by the quality of their engineered genome, possibly enabling eugenics, which could exacerbate social inequalities or be used coercively.

The effect of epigenomic changes are unpredictable, and there is disquiet as to how this will affect the existing healthy biological systems, including interactions with other genetic variants, and societal norms. Once introduced into the human population, genetic alterations would be difficult to remove and would not remain within any single community or country. The effects could remain uncertain for many subsequent generations, during which time deleterious modifications could be dispersed throughout the population.

Legal issues include providing clarity for risk management and assignment of duties and liabilities, particularly when modifications can be passed to subsequent generations. There are also risks, both legal and ethical, involved in the proliferation of unvalidated direct-to-consumer CRISPR (clustered regularly interspaced short palindromic repeats) kits that allow individuals to undertake gene editing independently in a home setting.

At a social level, debates revolve around the concerns that access to beneficial genome editing will be inequitable (e.g., only the wealthy will have access) and will increase existing disparities in health and medical care.

The WMA reaffirms principles in the Declaration of Reykjavik on the  ethical considerations regarding the use of genetics in health care, the Declaration of Taipei on Ethical Considerations regarding Health Databases and Biobanks and the Declaration of Helsinki and makes the following recommendations:

 

RECOMMENDATIONS

  1. Human genome-editing, like any other medical intervention, should be implemented according to appropriate evidence that is collected via well-conducted and ethically approved research studies.
  2. When contemplating use of germline cells for research purposes, germline editing should be permitted only within a separate ethical and legal framework, distinct from an ethical and legal framework applied to somatic genome editing.
  3. Governments should:
  • Develop robust and enforceable regulatory frameworks for genome editing in their own countries.
  • Urge continued development of an international consensus, grounded in science and ethics, to determine permissible therapeutic applications of germline genome editing.
  1. WMA constituent members should:
  • Be cognisant of the advances in research in genomic medicine and inform their members on scientific advances in genome
  • Advocate for research to understand (i) the benefits and risks of human genome editing, (ii) the socio-political, ethical, and legal aspects of editing the human germline and (iii) the necessity of physician involvement in therapeutic genome editing.
  • Develop and promote ethical guidelines for genome editing for their members, taking into consideration societal perspectives, professional consensus, national laws and regulations, and international standards.
  • Advocate for the development of appropriate laws and regulations for genome editing in accordance with both international and national norms and standards.
  • Where human genome editing is safe and effective, advocate for equal patient access to the technology.
  1. Physicians should:
  • Educate themselves on the technical, ethical, social, and legal aspects of genome editing.
  • Familiarise themselves with the international and local ethical frameworks regulating genome
  • Follow all ethical standards for approved research in these areas, including appropriate informed consent.

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

 

PREAMBLE

The WHO constitution states that “the extension to all people of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health”. Access to relevant, reliable, unbiased, up-to-date and evidence-based healthcare information is crucial for the public, patients and health personnel for every aspect of health, including (but not limited to) health education, informed choice, professional development, safety and efficacy of health services, and public health policy.

Lack of access to healthcare information is a major contributor to morbidity and mortality, especially in low- and middle-income countries, and among vulnerable groups in all countries.

Healthcare information is only useful if it is relevant, appropriate, timely, updated, understandable and accurate. It covers a broad spectrum of issues and refers to diseases, treatments, services, as well as the promotion and preservation of health.

Health literacy is a key factor in understanding how health services work and how to use them. Health professionals need access to adequate training and support to communicate with patients with low health literacy or with those who have difficulty understanding healthcare information, for example because of a disability.

Globally, thousands of children and adults die needlessly because they do not receive basic life-saving interventions. Some interventions may be available locally but are simply not provided due to indecision, delays, misdiagnosis and incorrect treatment. Failure to provide basic life-saving interventions more commonly affects those who are socioeconomically disadvantaged.

In the case of children with acute diarrhea, for example, the widespread misconception among parents that they should withhold fluids, and among health workers that they should give antibiotics rather than oral rehydration, contributes to thousands of unnecessary deaths every day worldwide.

Governments have a moral obligation to ensure that the public, patients and health workers have access to the healthcare information they need to protect their own health and the health of those for whom they are responsible. This obligation includes providing adequate education, in form and content, to identify and use such information effectively.

The public, patients and healthcare workers need easy, reliable access to evidence-based, relevant healthcare information as part of a learning process throughout the life-course to enhance understanding, and to make informed and conscious decisions about their health, healthcare options and the health care they receive. These groups need information in the right language, and in a format and technical level that is understandable to them, with relevant services signposted as appropriate. This should take into account the characteristics, customs and beliefs of the population to which it is directed, and a feedback process should be established. The public, patients and families need information that is appropriate to their specific context and situation, which may change over time. They need guidance on when and how to make important health decisions, which are usually best made when there is time to consider, understand and discuss the issue at hand.

Meeting the information needs of the public, patients and healthcare providers is a prerequisite for the realisation of quality universal health coverage and the UN Sustainable Development Goals (SDGs).” UN SDG Target 3.8 on universal health coverage specifically aims to deliver ‘quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’. Achieving this requires empowerment of the public and patients, as well as health workers, with the healthcare information they need to recognize and assume their rights and responsibilities to access, use and provide appropriate services and to prevent, diagnose and manage disease.

The development and availability of evidence-based, relevant healthcare information depends on the integrity of the global healthcare information system. This system comprises researchers, publishers, systematic reviewers, producers of end-user content (including academic publishers, health education, journalists and others), information professionals, policymakers, frontline health professionals and patient representatives, among others.

 

RECOMMENDATIONS

Recognizing this, the World Medical Association and its constituent members on behalf of their physician members, will support and commit to the following actions:

  1. Promote initiatives to improve access to timely, current, evidence-based healthcare information for health professionals, patients and the public to support appropriate decision-making, lifestyle changes, care-seeking behaviour and improved quality of care – thereby upholding the right to health.
  2. Promote standards of good practice and ethics to be met by information providers, guaranteeing reliable and quality information that is produced with the participation of physicians, other health professionals, and patient representatives.
  3. Support research to identify enablers and barriers to the availability of healthcare information, including how to improve the production and dissemination of evidence-based information for the public, patients and health professionals, and measures to increase health literacy and the ability to find and interpret such information.
  4. Ensure that health professionals have access to evidence-based information on diagnosis and treatment of diseases, including unbiased information on medicines. Particular attention should be paid to those working in primary care in low- and middle-income countries.
  5. Combat myths and misinformation around healthcare through validated scientific and clinical evidence, and by urging the media to report responsibly on health issues. This includes the study of health-related beliefs stemming from cultural or sociological differences. This will improve the effectiveness of health promotion activities and allow the dissemination of healthcare information to be adequately targeted to different segments of the population.
  6. Urge governments to recognize their moral obligation to take measures to improve the availability and use of evidence-based healthcare information. This includes:
    • resources to select, compile, integrate and channel scientifically validated information and knowledge. This should be adapted to target various different recipients;
    • measures to increase availability of healthcare information for healthcare workers and patients at health centres;
    • leveraging modern communication technology and social media;
    • policies that support efforts to increase the availability and use of reliable healthcare information.
  7. Urge governments to provide the political and financial support needed for ‘WHO’s function to ensure access to authoritative and strategic information on matters that affect peoples’ health’, based on the WHO General Programme of Work 2019-23.

 

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

 

PREAMBLE

Non-communicable diseases (NCDs) are the leading causes of death worldwide. Every year 40 million people die from NCDs [1]. The most common causes of these diseases are poorly balanced diet and physical inactivity. A high level of free sugar consumption has been associated with NCDs because of its association with obesity and poor dietary quality.

According to the World Health Organization (WHO), free sugar is sugar that is added to foods and beverages by the manufacturer, cook or consumer that results in excess energy intake which in turn may lead to parallel changes in body weight.

WHO defines free sugar as ‘all sugars that are added during food manufacturing and preparation as well as sugars that are naturally present in honey, syrups, fruit juices, and fruit concentrates.’

Sugar has become widely available and its global consumption has grown from about 130 to 178 million tonnes over the last decade.

Excess free sugar intake, particularly in the form of sugar-sweetened beverages, threatens the nutrient quality of the diet by contributing to the overall energy density but without adding specific nutrients. This can lead to unhealthy weight gain and increases the risk of dental disease, obesity and NCDs. Sugar-sweetened beverages are defined as all types of beverages containing free sugars (include monosaccharides and disaccharide) including soft drinks, fruit/vegetables juices and drinks, liquid and powder concentrates, flavored water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee and flavored milk drinks.

The World Health Organization recommends reducing sugar intake to a level that comprises 5% of total energy intake (that is around 6 teaspoons per day) and not to exceed 10% of total energy intake [2].

The price elasticity of sugar-sweetened beverages according to a meta-analysis published in USA, is -1.21. This means that for each 10% increase in the price of sugar-sweetened beverages, there is a -12.1% decrease in consumption. Successful examples of price elasticity were seen in Mexico as the consumption of sugar-sweetened beverages decreased after imposing the sugar tax.

Data and experience from across the world demonstrate that a tax on sugar works best as part of a comprehensive set of interventions to address obesity and related chronic diseases. Such interventions include food advertising regulations, food labelling, educational campaigns, and subsidy on healthy foods.

 

RECOMMENDATIONS

The World Medical Association (WMA) and its constituent members should:

  • call upon the national governments to reduce the affordability of free sugar and sugar-sweetened beverages through sugar taxation. The tax revenue collected should be used for health promotion and public health preventive programs aimed at reducing obesity and NCDs in their countries;
  • encourage food manufacturers to clearly label sugar, if present, in their products and urge governments to mandate such labeling;
  • urge governments to strictly regulate the advertising of sugar containing food and beverages targeted especially at children;
  • urge national governments to restrict availability of sugar-sweetened beverages and products that are highly concentrated with free sugar from educational and healthcare institutions and replace with healthier alternatives.

Constituent members of the WMA and their physician members should work with national stakeholders to:

  • advocate for healthy sustainable food with limited free sugar intake that is less than 5% of total energy intake;
  • encourage nutrition education and skills programs toward preparing healthy meals from foods without added sugar;
  • initiate and/or support campaigns focused on healthy diets to reduce sugars intake;
  • advocate for an inter-sectoral, multidisciplinary and comprehensive approach to reducing free sugar intake.

 

References

[1] http://www.who.int/fr/news-room/fact-sheets/detail/noncommunicable-diseases

[2] WHO Guideline: Sugars Intake for Adults and Children 2015

Adopted by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019
and rescinded and archived by the 76th WMA General Assembly, Porto, Portugal, October 2025

 

PREAMBLE

Artificial Intelligence (AI) is the ability of a machine to simulate intelligent behavior, a quality that enables an entity to function appropriately and with foresight in its environment. The term AI covers a range of methods, techniques and systems. Common examples of AI systems include, but are not limited to, natural language processing (NLP), computer vision and machine learning. In health care, as in other sectors, AI solutions may include a combination of these systems and methods.

(Note: A glossary of terms appears as an appendix to this statement.)

In health care, a more appropriate term is “augmented intelligence”, an alternative conceptualization that more accurately reflects the purpose of such systems because they are intended to coexist with human decision-making (1). Therefore, in the remainder of this statement, AI refers to augmented intelligence.

An AI system utilizing machine learning employs an algorithm programmed to learn (“learner algorithm”) from data referred to as “training data.” The learner algorithm will then automatically adjust the machine learning model based on the training data. A “continuous learning system” updates the model without human oversight as new data is presented, whereas “locked learners” will not automatically update the model with new data. In health care, it is important to know whether the learner algorithm is eventually locked or whether the learner algorithm continues to learn once deployed into clinical practice in order to assess the systems for quality, safety, and bias. Being able to trace the source of training data is critical to understanding the risk associated with applying a health care AI system to individuals whose personal characteristics are significantly different than those in the training data set.

Health care AI generally describes methods, tools and solutions whose applications are focused on health care settings and patient care. In addition to clinical applications, there are many other applications of AI systems in health care including business operations, research, health care administration, and population health.

The concepts of AI and machine learning have quickly become attractive to health care organizations, but there is often no clear definition of terminology used. Many see AI as a technological panacea; however, realizing the promise of AI may have its challenges, since it might be hampered by evolving regulatory oversight to ensure safety and clinical efficacy, lack of widely accepted standards, liability issues, need for clear laws and regulations governing data uses, and a lack of shared understanding of terminology and definitions.

Some of the most promising uses for health care AI systems include predictive analytics, precision medicine, diagnostic imaging of diseases, and clinical decision support. Development in these areas is underway, and investments in AI have grown over the past several years [1]. Currently, health care AI systems have started to provide value in the realm of pattern recognition, NLP, and deep learning. Machine learning systems are designed to identify data errors without perpetuating them. However, health care AI systems do not replace the need for the patient-physician relationship. Such systems augment physician-provided medical care and do not replace it.

Health care AI systems must be, transparent, reproducible, and be trusted by both health care providers and patients. Systems must focus on users’ needs. Usability should be tested by participants who reflect similar needs and practice patterns of the end user, and systems must work effectively with people. Physicians will be more likely to accept AI systems that can be integrated into or improve their existing practice patterns, and also improve patient care.

Opportunities

Health care AI can offer a transformative set of tools to physicians and patients and has the potential to make health care safer and more efficient. By automating hospital and office processes, physician productivity would improve. The use of data mining to produce accurate useful data at the right time may improve electronic health records. and access to relevant patient information. Results of data mining may also provide evidence for trends that may serve to inform resource allocation and utilization decisions. New insights into diagnosis and best practices for treatment may be produced because of analyzing all known data about a patient. The potential also exists to improve the patient experience, patient safety, and treatment adherence.

Applications of health care AI to medical education include continuing medical education, training simulations, learning assistance, coaching for medical students and residents, and may provide objective assessment tools to evaluate competencies. These applications would help customize the medical education experience and facilitate independent individual or group learning.

There are a number of stakeholders and policy makers involved in shaping the evolution of AI in health care besides physicians. These include medical associations, businesses, governments, and those in the technology industry. Physicians have an unprecedented opportunity to positively inform and influence the discussions and debates currently taking place around AI. Physicians should proactively engage in these conversations in order to ensure that their perspectives are heard and incorporated into this rapidly developing technology.

Challenges

Developers and regulators of health care AI systems must ensure proper disclosure and note the benefits, limitations, and scope of appropriate use of such systems.  In turn, physicians will need to understand AI methods and systems in order to rely upon clinical recommendations. Instruction in the opportunities and limitations of health care AI systems must take place both with medical students and practicing physicians, as physician involvement is critical to successful evolution of the field. AI systems must always adhere to professional values and ethics of the medical profession.

Protecting confidentiality, control and ownership of patient data is a central tenet of the patient-physician relationship. Anonymization of data does not provide enough protection to a patient’s information when machine-learning algorithms can identify an individual from among large complex data sets when provided with as few as three data points, which could put patient data privacy at risk. Current expectations patients have for confidentiality of their personal information must be addressed, and new models that include consent and data stewardship developed.  Viable technical solutions to mitigate these risks are being explored and will be critical to widespread adoption of health care AI systems.

Data structure, and integrity are major challenges that need to be addressed when designing health care AI systems. The data sets on which machine learning systems are trained are created by humans and may reflect bias and contain errors. Because of this, these data sets will normalize errors and the biases inherent in their data sets. Minorities may be disadvantaged because there is less data available about minority populations. Another design consideration is how a model will be evaluated for accuracy and involves very careful analysis of the training data set and its relationship to the data set used to evaluate the algorithms.

Liability concerns present significant challenges to adoption. As existing and new oversight models develop health care AI systems, the developers of such systems will typically have the most knowledge of risks and be best positioned to mitigate the risk. As a result, developers of health care AI systems and those who mandate use of such systems must be accountable and liable for adverse events resulting from malfunction(s) or inaccuracy in output. Physicians are often frustrated with the usability of electronic health records. Systems designed to support team-based care and other workflow patterns but often fall short. In addition to human factors in the design and development of health care AI systems, significant consideration must be given to appropriate system deployment. Not every system can be deployed to every setting due to data source variations.

Work is already underway to advance governance and oversight of health care AI, including standards for medical care, intellectual property rights, certification procedures or government regulation, and ethical and legal considerations.

 

RECOMMENDATIONS

That the WMA:

  • Recognize the potential for improving patient outcomes and physicians’ professional satisfaction through the use of health care AI, provided they conform to the principles of medical ethics, confidentiality of patient data, and non-discrimination.
  • Support the process of setting priorities for health care AI.
  • Encourage the review of medical curricula and educational opportunities for patients, physicians, medical students, health administrators and other health care professionals to promote greater understanding of the many aspects, both positive and negative, of health care AI.

The WMA urges its member organizations to:

  • Find opportunities to bring the practicing physician’s perspective to the development, design, validation and implementation of health care AI.
  • Advocate for direct physician involvement in the development and management of health care AI and appropriate government and professional oversight for safe, effective, equitable, ethical, and accessible AI products and services.
  • Advocate that all healthcare AI systems be transparent, reproducible, and be trusted by both health care providers and patients.
  • Advocate for the primacy of the patient-physician relationship when developing and implementing health care AI systems. 

 

(1) For purposes of this statement, the term “health care AI” will be used to refer to systems that augment, not replace, the work of clinicians.

 

APPENDIX: GLOSSARY OF TERMS USED IN HEALTH CARE AUGMENTED INTELLIGENCE

Algorithm is a set of detailed, ordered instructions that are followed by a computer to solve a mathematical problem or to complete a computer process.

Artificial intelligence consists of a host of computational methods used to produce systems that perform tasks which exhibit intelligent behavior that is indistinguishable from human behavior.

Augmented intelligence (AI) is a conceptualization of artificial intelligence that focuses on artificial intelligence’s assistive role, emphasizing that its design enhances human intelligence rather than replaces it.

Computer vision is an interdisciplinary scientific field that deals with how computers can be made to gain high-level understanding from digital images or videos and seeks to automate tasks that the human visual system can do.

Data mining is an interdisciplinary subfield of computer science and statistics whose overall goal is to extract information (with intelligent methods) from a data set and transform the information into a comprehensible structure for further use.

Machine learning (ML) is the scientific study of algorithms and statistical models that computer systems use to effectively perform specific tasks with minimal human interaction and without using explicit instructions, by learning from data and identification of patterns.

Natural language processing (NLP) is a subfield of computer science, information engineering, and artificial intelligence concerned with the interactions between computers and human (natural) languages, in particular how to program computers to process and analyze large amounts of natural language data.

Training data is used to train an algorithm; it generally consists of a certain percentage of an overall dataset along with a testing set. As a rule, the better the training data, the better the algorithm performs. Once an algorithm is trained on a training set, it’s usually evaluated on a test set. The training set should be labelled or enriched to increase an algorithm’s confidence and accuracy.

 

Reference

[1] CB Insights. The Race for AI: Google, Baidu, Intel, Apple in a Rush to Grab Artificial Intelligence Startups. https://www.cbinsights.com/research/top-acquirers-ai-startups-ma-timeline/.

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

 

PREAMBLE

Population displacement resulting from war, violence or persecution has wide-ranging implications for the entire global community. Refugees – that is, individuals who have been forced to flee their respective countries of origin for these reasons – generally must undergo rigorous procedures for determining their legal status according to the national legislation of the country in which they are seeking asylum.

An increasing number of refugees fall under the category of unaccompanied minors, which are defined as people under the age of 18 who have been separated from or who have fled their countries of origin without their families. In light of their unique vulnerability, unaccompanied minor refugees are eligible for special protections, as outlined in the United Nations’ Convention on the Rights of the Child, which states that the best interests of the child must be the primary consideration in all stages of the displacement cycle.

Given the differences in how adults and unaccompanied minors are processed and protected when seeking asylum, recipient countries have an interest in verifying the age of applicants outside the context of criminal proceedings. However, some asylum seekers either do not have access to documentation confirming their age or originate from countries in which there is no central birth registry. In cases where there is doubt as to whether an asylum seeker is a child or an adult, e.g. if the authenticity of available documentation is called into question or if there is reason to believe the applicant’s physical appearance suggests a discrepancy between the reported age and the actual age, the competent authorities may resort to medical and/or non-medical methods for assessing the applicant’s age.

Medical age assessments carried out by medical professionals may take the form of X-ray scans of the jaw, hand or wrist; CT scans of the collarbone; MRI scans of the knee; or the examination of secondary sex characteristics to determine the applicant’s stage of puberty. However, ethical concerns have been raised about these and other forms of examination, as they can potentially endanger the health of those being examined and violate the privacy and dignity of young people who may already be severely traumatized [1]. Furthermore, there is conflicting evidence about the accuracy and reliability of the available methods of medical age assessment, which may generate significant margins of error [2]. For example, some available studies do not appear to take into account potential delays in skeletal maturation caused by malnutrition, which is just one factor that could translate into a risk of age misclassification among asylum seekers [3]. Comparative assessments are further impeded by a lack of standard images from certain world regions and limited representation in age assessment reference data, much of which was compiled on the basis of European and North American populations [4]. An imprecise assessment of an individual’s age can have far-reaching administrative, ethical, psychological and other significant consequences, including potential breaches of children’s rights.

The following recommendations apply explicitly and exclusively to cases outside the context of the criminal justice system.

 

RECOMMENDATIONS

  1. The WMA recognizes that there is sometimes a need to assess the age of asylum seekers to ensure that all unaccompanied minors receive the protections afforded them under international and national law. 
  2. The WMA recommends that medical age assessments only be carried out in exceptional cases and only after all non-medical methods have been exhausted. The WMA recognizes that non-medical methods, e.g. questioning children about traumatic events, may also have a negative impact and must therefore be carried out with great care. Each case must be evaluated carefully based on the totality of circumstances and the preponderance of available evidence.
  3. The WMA asserts that, in cases where medical age assessment is unavoidable, the health and safety and dignity of the young asylum seeker must be the highest priority. Physical examinations must be carried out by a qualified physician with appropriate pediatric examination experience in accordance with the highest medical and ethical standards, in observance of the principles of proportionality, in adherence to the standards of prior informed consent and with consideration of cultural and religious sensitivities and potential language barriers. The asylum seeker must always be made aware that the examination is carried out as part of the age assessment procedure and not to provide healthcare.
  4. The WMA underscores that any medical methods that could involve a health risk for the applicant, e.g. radiological examinations without medical indication, or that infringe upon the dignity or privacy of an already potentially traumatized asylum seeker, e.g. genital examinations, must be avoided.
  5. The WMA stresses that medical certificates indicating the results of medical age assessment examinations should include information concerning the accuracy and reliability of the methods used and the relevant margins of error.
  6. The WMA urges constituent members to develop or promote the development of internationally accepted interdisciplinary guidelines which outline the scientific basis, as well as ethical and legal or regulatory principles of medical age assessment of asylum seekers, including the potential health risks and psychological impact of specific procedures.
  7. The WMA emphasizes that, in cases where doubts regarding the age of an asylum seeker cannot be resolved or confirmed with absolute certainty, any remaining uncertainty should be interpreted in favor of the asylum seeker.

 

References:

[1] Zentrale Ethikkommission der Bundesärztekammer (2016): Stellungnahme “Medizinische Altersschätzung bei unbegleiteten jungen Flüchtlingen. Deutsches Ärzteblatt 2016; A1-A6. / German Medical Association’s Central Ethics Committee: Statement on Medical Age Assessment of Unaccompanied Minor Refugees.

[2] Separated Children in Europe Programme (2012): Position Paper on Age Assessment in the Context of Separated Children in Europe. Online http://www.separated-children-europe-programme.org/separated_children/good_practice/index.html. Last accessed 03.07.2018.

[3] Sauer PJJ, Nicholson A, Neubauer D, On behalf of the Advocacy and Ethics Group of the European Academy of Paediatrics (2016): Age determination in asylum seekers: physicians should not be implicated. European Journal of Pediatrics 175, (3): 299-303.

[4] Aynsley-Green et al. (2012): Medical, statistical, ethical and human rights considerations in the assessment of age in children and young people subject to immigration control. British Medical Bulletin 2012; 102: 39.

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

PREAMBLE

1.     The WMA notes the increasing trend around the world for women to enter medical schools and the medical profession, and believes that the study and the practice of medicine must be transformed to a greater or lesser extent in order to support all people who study to become or practice as physicians, of whatever gender. This is an essential process of modernization by which inclusiveness is promoted by gender equality. This statement proposes mechanisms to identify and address barriers causing discrimination between genders.

2.     In many countries around the world, the number of women studying and practicing medicine has steadily risen over the past decades, surpassing 50% in many places.

3.     This development offers opportunities for action, including in the following areas:

  • Greater emphasis on a proper balance of work and family life, while supporting the professional development of individual physicians.
  • Encouragement and actualization of women in academia, leadership and managerial roles.
  • Equalization of pay and employment opportunities for men and women, the elimination of gender pay gaps in medicine, and the removal of barriers negatively affecting the advancement of female physicians.

4.     The issue of women in medicine was previously recognized in the WMA Resolution on Access of Women and Children to Health Care and the Role of Women in the Medical Profession which, among other things, called for increased representation and participation in the medical profession, especially in light of the growing enrolment of women in medical schools. It also called for a higher growth rate of membership of women in National Medical Associations (NMAs)  through empowerment, career development, training and other strategic initiatives.

RECOMMENDATIONS

Increased presence of women in academia, leadership and management roles.

5.     National Medical Associations/Medical Schools/Employers are urged to facilitate the establishment of mentoring programs, sponsorship, and active recruitment to provide medical students and physicians with the necessary guidance and encouragement necessary to undertake leadership and management roles.

6.     NMAs should explore opportunities and incentives to encourage both men and women to pursue diverse careers in medicine and apply for fellowships, academic, senior leadership and management positions.

7.     NMAs should lobby for gender equal medical education and work policies.

8.     NMAs should encourage the engagement of both men and women in health policy organizations and professional medical organizations.

Work-Life Balance

9.     Physicians should recognize that an appropriate work-life balance is beneficial to all physicians, but that women may face unique challenges to work-life balance imposed by societal expectations concerning gender roles that must be addressed to solve the issue. Healthcare employers can show leadership and help tackle this imbalance by:

  • Ensuring women who go on maternity leave are able to access all their rights and entitlements;
  • Introducing programmes which encourage men as well as women to take parental leave, so that women are able to pursue their careers and men are able to spend important time with their families.

10.  Hospitals and other places of employment should strive to provide and promote access to high quality, affordable, flexible childcare for working parents, including the provision of onsite housing and childcare where appropriate. These services should be available to both male and female physicians, recognizing the need for a better work-life balance. Employers should provide information on available services which support the compatibility of work and family.

11.  Hospitals and other places of employment should be receptive to the possibility of flexible and family-friendly working hours, including part-time residencies, posts, and professional appointments.

12.  There is a need for increased research on alternative work schedules and telecommunication opportunities that will allow flexibility in balancing work-life demands.

13.  NMAs should advocate for the enforcement and, where necessary, the introduction of policy mandating appropriate paid parental leave and rights in their respective countries.

14.  Medical workplaces and professional organisations should have fair, impartial and transparent policies and practices to give all physicians and medical students equal access to employment, education and training opportunities in medicine.

Pregnancy and Parenthood

15.  It should be illegal for employers to ask applicants about pregnancy and/or family planning in relation to work.

16.  Employers should assess the risks to pregnant physicians and their unborn children, when a physician has recently given birth and when she is breastfeeding.  Where it is found, or a medical practitioner considers, that an employee or her child would be at risk were she to continue with her normal duties, the employer should provide suitable alternative work for which the physician should receive her normal rate of pay. Physician should have the right to not work night shifts or on-call shifts during the later part of pregnancy, without negative consequences on salary, employment or progression in residency.

17.  Pregnant physicians should have equal training opportunities in post-graduate training.

18.  Parents should have the right to take adequate parental leave without negative consequences on their employment, training or career opportunities.

19.  Parents should have the right to return to the same position after parental leave, without the fear of termination.

20.  Employers and training bodies should provide necessary support to any physician returning after a prolonged period of absence including parental, maternity and elder-care leave.

21.  Mothers should be able to breastfeed (or be given protected time for breast pumping) during work hours, within the current guidelines from the WHO.

22.  Workplaces should provide adequate accommodation for women who are breastfeeding including designated areas for breastfeeding, breast pumping, and milk storage, which are quiet, hygienic, and private.

Changes in organisational culture

23.  The medical profession and employers should work to eliminate discrimination and harassment on the basis of gender and create a supportive environment that allows equal opportunities for training, employment and advancement.

24.  Family friendliness should be part of the organizational culture of hospitals and other places of employment.

Workforce planning and research

25.  NMAs should encourage governments to take the increasing number of women entering medicine into consideration in the context of long-term workforce planning. A diverse workforce is beneficial to the health care system and to patients. Organizations delivering healthcare should focus on ensuring systems are appropriately resourced to ensure that all those working within them are able to deliver safe care to patients and are appropriately and equitably rewarded. Governments should also work to counteract negative attitudes and behaviour, bias, and/or outdated norms and values from organizations and individuals.

26.  NMAs should encourage governments to invest in research to identify those factors that drive women and men to choose certain fields of specialization early on in their medical education and training and strive to address any identified barriers in order to achieve equal representation of men and women in all fields of medicine.

27.  NMAs should encourage governments and employers to ensure that men and women receive equal compensation for commensurate work and strive to eliminate the gender pay gap in medicine.

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

PREAMBLE

  1. The expiry of patents for original biotherapeutics has led to the development and approval of copies, called ‘similar biological medicinal products’ or ‘biosimilars’ that are highly similar to a previously approved biological product, known as the originator or reference product.
  2. In light of the fact that biosimilars are made in living organisms, there may be some minor differences from the reference medicine, as minor variability is a characteristic attribute of all biological medicines. The manufacture of biosimilars is generally more complex than the manufacture of chemically derived molecules. Therefore, the active substance in the final biosimilar can have an inherent degree of minor variability. Innovator biologics also have inherent batch-to-batch variability, and for that reason biosimilars are not always interchangeable with the reference products, even after regulatory approval.
  3. Biosimilars are not the same as generics. A generic drug is an identical copy of a currently licenced pharmaceutical product that has an expired patent protection and must contain the ‘same active ingredients as the original formulation’. A biosimilar is a different product with a similar, but not identical, structure that elicits a similar clinical response. As a result, biosimilar medicines have the potential to cause an unwanted immune response. Whereas generics are interchangeable, biosimilars are not always interchangeable.
  4. Biosimilars have been available in Europe for almost a decade following their approval by the European Medicines Agency (EMA) in 2005. The first biosimilar was approved by the Food and Drug Administration (FDA) for use in the United States in 2015.
  5. Biosimilar medicines have transformed the outlook for patients with chronic and debilitating conditions, as it is possible to obtain similar efficacy as that of the reference product at a lower cost.
  6. Biosimilars will also increase availability for patients without access to the bio-originator. Greater global access to effective biopharmaceuticals can reduce disability, morbidity, and mortality associated with various chronic diseases.
  7. Nonetheless, the potentially lower cost of biosimilars raises the risk that insurers and health care providers  may favor them over the originator product, even when they may not be appropriate for an individual patient or in situations when they have not demonstrated adequate clinical equivalence to an original biological product. The decision to prescribe biosimilars or to switch patients from reference medicine to a biosimilar must be made by the attending physicians, not by health insurance companies. 

RECOMMENDATIONS

  1. National medical associations should work with their governments to develop national guidance on safety of biosimilars.
  2. National medical associations should advocate for delivering biosimilar therapies that are as safe and effective as their reference products.
  3. National medical associations should strive to ensure that physician autonomy is preserved in directing which biologic product is dispensed.
  4. Where appropriate, national medical associations should lobby against allowing insurers and health funds to require biosimilar and originator product’s interchangeability, and for safe regulations of interchanging biosimilar medicines where this is allowed.
  5. Physicians must ensure that patient medical records accurately reflect the biosimilar medicine that is being prescribed and taken.
  6. Physicians shouldn’t prescribe a biosimilar to patients already showing success with the originator product, unless clinical equivalence has been clearly demonstrated and established and patients are adequately informed and have given consent. There should be no substitution between biosimilars and other drugs without the attending physcian’s permission.
  7. Physicians should seek to improve their understanding of the distinctions between biosimilar products that are highly similar to or are interchangeable with an originator product; raise awareness of the issues surrounding biosimilars and interchangeability; and promote clearly delineated labelling of biosimilar products.
  8. Physicians should remain vigilant and report to the manufacturer, as well as through the designated regulatory pathways, any adverse events suffered by patients using originator biological products or biosimilars.

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

PREAMBLE

The WMA believes that both a continuum of care and family empowerment is necessary to improve the health and wellbeing of the mother and child. The reduction of maternal mortality ratio and infant deaths was an important objective of the Millennium Development Goals (MDGs). The reductions of the maternal mortality ratio, neonatal mortality rate and the under-five mortality rate are important targets to be achieved under the Sustainable Development Goals (SDGs).

The maternal and child health (MCH) handbook is a comprehensive home-based booklet designed to provide relevant health information and include integrated mother and child health records. The MCH handbook covers health records and information on pregnancy, delivery, neonatal and childhood periods, and child growth and immunizations. The MCH handbook supports the integration of maternal, neonatal and child health services. The MCH handbook is not only about health education, but about creating ownership with women and families.

In 1948, Japan became the first country in the world to create and distribute a maternal and child health (MCH) handbook, in order to protect and improve the health and wellbeing of the mother and child.

There are now approximately 40-country versions of the MCH handbook, all adapted to the local culture and socio-economic context. There are a variety of handbooks and educational materials concerned to MCH in many countries. The use of MCH handbooks has helped improve the knowledge of mothers on maternal and child health issues, and has contributed to changing behaviors during pregnancy, delivery and post-delivery period.

The MCH handbook can promote the health of pregnant women, neonates and children by using it as a tool for strengthening a continuum of care. Physicians can make better care decisions, by referring to the patient’s medical history and health-check data recorded in the MCH handbook. The MCH handbook alone has not been shown to improve health indicators. The benefits are maximized when women and children have access to relevant healthcare services based on information recorded in the handbook. Such benefits of the handbook could be shared globally.

In Japan, a digital handbook is spreading progressively. The digital handbook is expected to be utilized in a way that protects confidentiality of the patient’s health information. Some private kindergarten and primary schools request access to the MCH as part of their admission process, placing pressure on parents and physicians to modify the answers to questions in the handbook.

RECOMMENDATIONS

  1. The WMA recommends that the constituent member associations encourage their health authorities and health institutions to provide accessible and easy to understand information regarding maternal and child health. The MCH handbook, or equivalents, can be an important tool to improve continuity of care and benefit health promotion for mothers, neonates and children.
  2. The WMA recommends that the constituent member associations and medical professionals promote the adaptation to local setting and the utilization of MCH handbooks, or equivalents, in order to leave no one behind with respect to SDGs, especially for non-literate people, migrant families, refugees, minorities, people in underserved and remote areas.
  3. When using a MCH handbook or similar documentation, in either digital or print form, the confidentiality of the individual health information and the privacy of mothers and children should be strictly protected. It should be used exclusively to improve health and wellbeing of mothers, neonates, and children. It should not be used in the admission procedures of schools.
  4. The constituent member associations should promote local research to evaluate the utilization of the MCH handbooks, or equivalents, and make recommendations to improve the quality of care in the local setting.

Adopted by the 49th WMA General Assembly, Hamburg, Germany, November 1997
and reaffirmed by the WMA Council Session, Berlin, Germany, May 2007
and amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018

 

SCOPE AND DEFINITIONS

The scope of this Statement includes the following specified crimes: genocide, war crimes, and crimes against humanity, as defined by the Rome Statute of the International Criminal Court.

PREAMBLE

  • Physicians are bound by medical ethics to dedicate themselves to the good of their patients. Physicians who have been convicted of genocide, war crimes or crimes against humanity1, have violated medical ethics, human rights and international law and are therefore unworthy of practising medicine.
  • In accordance with the principle of the presumption of innocence, only physicians who have been convicted of the specified crimes should be declared unworthy of practising medicine.

DISCUSSION

  1. Physicians seeking to work in any country are subject to the regulations of that country’s relevant authorities or jurisdiction. The duty to demonstrate suitability to practice medicine rests with the person seeking licensure.
  2. Physicians who have been convicted of genocide, war crimes or crimes against humanity must not be allowed to practise in another country or jurisdiction.
  3. The relevant licensing authorities must ensure both that physicians have the required qualifications and that they have not been convicted of genocide, war crimes or crimes against humanity.
  4. Physicians who have been convicted of the specified crimes have sometimes been able to leave the country in which these crimes were committed and obtain a licence to practise medicine from the relevant licensing authority in another country.
  5. This practice is contrary to the public interest, damaging to the reputation of the medical profession, and may be detrimental to patient safety.

RECOMMENDATIONS

  1. The WMA recommends that physicians who have been convicted of the specified crimes be denied a license to practice medicine and membership to national medical associations by the relevant regulatory and licensing authority of that jurisdiction.
  2. The WMA recommends that relevant regulatory and licensing authorities use their own authority to inform themselves, in so far as is possible, if verifiable allegations of participation in genocide, war crimes or crimes against humanity have been made against physicians, while at the same time respecting the presumption of innocence.
  3. National Medical Associations must be sure that a thorough investigation into those allegations is performed by an appropriate authority.
  4. The WMA recommends that national medical associations ensure that there is efficient communication amongst themselves and that where possible and appropriate they inform relevant national regulatory and licensing authorities of physicians’ convictions of genocide, war crimes, or crimes against humanity.

1 As defined by the Rome Statute of the International Criminal Court

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

 

Preamble

  1. 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.
  2. 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.
  3. 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

  1. 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.
  2. 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.
  3. The convictions of both the physician and the patient should be respected.
  4. Patients must be supported appropriately and provided with necessary medical and psychological treatment along with appropriate counselling if desired.
  5. 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.
  6. 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 69th WMA General Assembly, Reykjavik, Iceland, October 2018

Preamble

1. The WMA believes that health and well-being are dependent upon social determinants of health (SDHs), the conditions in which people are born, grow, live, work and age. These social determinants will directly influence the achievement of the United Nations Sustainable Development Goals (SDGs).  Many of the SDG goals, targets and indicators that have been developed to measure progress towards them, will also be useful measures of the impact of action is having on improving the SDH and, in particular, on reducing health inequities.

2. This statement builds upon WMA policy on Social Determinants of Health as set out in the Declaration of Oslo, and upon the basic principles of medical ethics set out in the Declaration of Geneva.

3. The WMA recognizes the important efforts undertaken by the United Nations with the adoption on 25 September 2015 of the resolution “Transforming our world: the 2030 Agenda for Sustainable Development”. The Sustainable Development Agenda is based upon five key themes: people, planet, prosperity, peace and partnership and the principle of leaving no one behind. The WMA affirms the importance of global efforts on sustainable development and the impact that they can bring to humanity.

4. SDGs are built on the lessons learned from successes and failures in achieving the Millennium Development Goals (MDGs), including inequity in many areas of life. While there is no overarching concept unifying the SDGs, the WMA believes that inequity in health and wellbeing encapsulates much of the 2030 Agenda. The WMA notes that while only SDG 3 is overtly about health, many of the goals have major health components.

5. The WMA recognizes all governments must commit and invest to fully implement the goals by 2030, in alignment with the Addis Ababa Action Agenda. The WMA also recognizes the risk that the SDGs might be considered unaffordable due to their estimated potential cost of between US$ 3.3 and US$ 4.5 trillion a year.

6. The WMA emphasises the need for cross and inter-sectoral work to achieve the goals and believes that health must be addressed in all SDGs and not only under health specific SDG 3.

Policy priorities:

7. Recognition of Health in All Policies and the Social Determinants of Health / Whole of Society approach.

8. Policy areas that are essential to achieving the SDG 3:

  • Patient Empowerment and Patient Safety
  • Continuous Quality Improvement in Health Care
  • Overcoming the Impact of Aging on Health Care
  • Addressing Antimicrobial Resistance
  • The safety and welfare of Health care staff

9. Ensuring policy alignment among all the UN Agencies and the work of regional governmental organizations such as EU, African Union, Arab League, ASEAN, and Organization of American States.

10. The WMA commits to support implementation of the other three global agreements regarding the sustainable development process:

  • The Addis Ababa Action Agenda as the mechanism that will provide the financial support for the 2030 Agenda.
  • The Paris Agreement is the binding mechanism of the sustainable development process that sets out a global action plan to put the world on track to avoid dangerous climate change by limiting global warming to well below 2°C above pre-industrial levels.
  • The Sendai Framework for Disaster Risk Reduction as the agreement which recognizes that the State has the primary role to reduce disaster risk but that responsibility should be shared with local government, the private sector and other stakeholders.

Recommendations and Commitments

11. The WMA commits to work with other intergovernmental organizations, including the UN, the WHO, healthcare professionals’ organizations and other stakeholders, for the implementation and follow-up of this Agenda and related international agreements, and for policy and advocacy alignment.

12. The WMA commits to collaborate with its constituent member Associations to support their work at regional and national levels, and with their governments on the 2030 Agenda implementation.

13. The WMA recommends that NMAs create strategies regarding data collection, implementation, capacity building and advocacy, to enhance policy coherence and to maximise the 2030 Agenda implementation at national and global levels.

14. The WMA also recommends that NMAs collaborate with development banks, NGOs, intergovernmental organisations and other stakeholders who are also working to implement of the 2030 Agenda, especially in their own countries.

15. The WMA encourages the UN and the WHO to develop guidelines on how financing for health will be implemented to reach the targets established by the 2030 Agenda and the economic implications of NCDs, aging and antimicrobial resistance.

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

PREAMBLE

  1. 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).
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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

  1. 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.
  2. Medical decisions concerning the medical tourist should be made by physicians, in cooperation with the patient, and not by non-medical personnel.
  3. 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.
  4. 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.
  5. Agreement should be reached before treatment begins, on the transfer of test results and diagnostic images, back to the home country of the patient.
  6. 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.
  7. 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.
  8. 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

  1. 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.
  2. 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.
  3. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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

  1. 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.
  2. 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 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018 

Preamble

Pandemic influenza occurs approximately three or four times every century. It usually occurs when a novel influenza A virus emerges that can easily be transmitted from person-to-person, to which humans have little or no immunity. Infection control and social distancing practices can help slow down the spread of the virus. Vaccine development can be challenging as the pandemic strain may not be accurately predicted. Adequate supplies of antivirals are key for treatment of specific at-risk populations and controlling further spread of the outbreak.

Avian influenza is a zoonotic infection of birds and poultry, and can cause sporadic human infections. Birds act as reservoir and shed the virus in their feces, mucous and saliva. In addition, a new pandemic virus could develop if a human became simultaneously infected with avian and human influenza viruses, resulting in gene swapping and a new virus strain for which there may be no immunity. Humans are infected if they are exposed through the mouth, eyes, or from the inhalation of virus particles. Limited evidence of human to human transmission has been reported as well.

This statement alongside with WMA Statement on Epidemics and Pandemics provides guidance to National Medical Associations and physicians on how they should be involved in their respective country’s pandemic influenza planning and how to respond to Avian Influenza or pandemic influenza.

Recommendations

Avian Influenza

In the event of an avian influenza outbreak, the following measures should be taken:

  • Sources of exposure should be avoided when possible as this is the most effective prevention measure.
  • Personal protective equipment should be used and hand hygiene practices emphasized for personnel handling poultry as well as members of the healthcare team.
  • All infected/exposed birds should be destroyed with proper disposal of carcasses, and rigorous disinfection or quarantine of farms.
  • Stockpiles of vaccines and antivirals should be maintained for use during an outbreak.
  • Antiviral medications such as neuraminidase inhibitors may be used for treatment.

Pandemic Influenza Preparedness

WHO and National Public Health Officials:

  • The coordination of the international response to an influenza pandemic is the responsibility of the World Health Organization (WHO). The WHO currently uses an all-hazards risk based approach, to allow for a coordinated response based on varying degrees of severity of the pandemic.

The WHO should:

  • Offer technical and laboratory assistance to affected countries if needed and continuously monitor activity levels of potential pandemic influenza strains continuously, ensuring that the designation of “Public Health Emergency of International Concern” is done in a timely manner if needed.
  • Monitor and coordinate processes by which governments share biological materials including virus strains, to facilitate the production of and ensure access to vaccines globally.
  • Communicate available information on influenza activity of concern as early as possible to allow for a timely response.

National governments are urged to develop National Action plans to address the following points:

  • Ensure that there is adequate local capacity for diagnosis and surveillance to allow continuous monitoring of influenza activity around the country.
  • Consider the surge capacity of hospitals, laboratories, and public health infrastructure and improve them if necessary.
  • Identify legal and ethical frameworks as well as governance structures in relation to the pandemic planning.
  • Identify the mechanisms and the relevant authorities to initiate and escalate interventions to slow the spread of the virus in the community such as school closures, quarantine, border closures etc.
  • Prepare risk and crisis communication strategies and messages in anticipation of public and media fear and anxiety.
  • Governments are also urged to share biological materials namely virus strains and others, to facilitate the production and ensure access to vaccines globally.
  • Ensure that diagnostics and surveillance efforts are continued and that adequate vaccine and antiviral stockpiles are established.
  • Establish protocols to manage patients in the community, carry out triage in healthcare facilities, provide ventilation management, and handle infectious waste.
  • Allocation of vaccine doses, antivirals and hospital beds should be coordinated with experts.
  • Priority for vaccination should be given to the highest risk groups including those required to maintain essential services, including health care services.
  • Guidance and timely information to regional health departments, health care organizations, and physicians.
  • Preparation for an increase in demand for healthcare services and absences of health care providers especially if clinical severity of the illness is high. In such cases prioritization and coordination of available resources is essential. This may include tapping into private sector capacity where state resources are insufficient.
  • Ensure adequate funding is allocated for pandemic preparedness and response as well as its health and social consequences.
  • Make sure that mechanisms are in place to ensure the safety of healthcare facilities, personnel and the supply chains for vaccines and antivirals
  • Promote and fund research to develop vaccines and effective treatments with lasting effects against influenza.
  • Encourage collaboration between human and veterinary medicine in the prevention, research and control of avian influenza.

National Medical Associations are urged to:

  • Delineate their involvement in the national pandemic influenza preparedness plan, which may include increasing capacity building amongst physicians, participating in guideline development and communication with healthcare professionals.
  • Help educate the public about avian and pandemic influenza.
  • When feasible, coordinate with other healthcare professionals’ organizations as well as other NMAs to identify common issues and congruent policies related to pandemic influenza preparedness and response.
  • Consider implementing support strategies for members involved in the response including mental health services, facilitation of health emergency response teams, and locum relief.
  • Advocate before and during a pandemic, for allocation of adequate resources to meet foreseeable and emerging needs of healthcare, patients and the general public.
  • Encourage health personnel to protect themselves by vaccination.
  • Develop their own organization-specific business contingency plans to ensure continued support of their members.

Physicians:

  • Must be sufficiently knowledgeable about pandemic influenza and transmission risks, including local, national and international epidemiology.
  • Should implement infection control practices and vaccination, to protect themselves as well as other staff members during seasonal and pandemic influenza outbreaks.
  • Must participate in local/regional pandemic influenza preparedness planning and training.
  • Should develop contingency plans to deal with possible disruptions in essential services and personnel shortages.

Adopted by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007
amended by the 69th WMA General Assembly, Reykjavik, Iceland, October 2018
and rescinded and archived by the 73rd WMA General Assembly, Berlin, Germany, October 2022

DEFINITION

Telemedicine is the practice of medicine over a distance, in which interventions, diagnoses, therapeutic decisions, and subsequent treatment recommendations are based on patient data, documents and other information transmitted through telecommunication systems.

Telemedicine can take place between a physician and a patient or between two or more physicians including other healthcare professionals.

PREAMBLE 

  • The development and implementation of information and communication technology are creating new and different ways for of practicing medicine. Telemedicine is used for patients who cannot see an appropriate physician timeously because of inaccessibility due to distance, physical disability, employment, family commitments (including caring for others), patients’ cost and physician schedules. It has capacity to reach patients with limited access to medical assistance and have potential to improve health care.
  • Face-to-face consultation between physician and patient remains the gold standard of clinical care.
  • The delivery of telemedicine services must be consistent with in-person services and supported by evidence.
  • The principles of medical ethics that are mandatory for the profession must also be respected in the practice of telemedicine.

PRINCIPLES

Physicians must respect the following ethical guidelines when practicing telemedicine:

1. The patient-physician relationship should be based on a personal examination and sufficient knowledge of the patient’s medical history. Telemedicine should be employed primarily in situations in which a physician cannot be physically present within a safe and acceptable time period. It could also be used in management of chronic conditions or follow-up after initial treatment where it has been proven to be safe and effective.

2. The patient-physician relationship must be based on mutual trust and respect. It is therefore essential that the physician and patient be able to identify each other reliably when telemedicine is employed. In case of consultation between two or more professionals within or between different jurisdictions, the primary physician remains responsible for the care and coordination of the patient with the distant medical team.

3. The physician must aim to ensure that patient confidentiality, privacy and data integrity are not compromised. Data obtained during a telemedicine consultation must be secured to prevent unauthorized access and breaches of identifiable patient information through appropriate and up to date security measures in accordance with local legislation. Electronic transmission of information must also be safeguarded against unauthorized access.

4. Proper informed consent requires that all necessary information regarding the distinctive features of telemedicine visit be explained fully to patients including, but not limited to:

  • explaining how telemedicine works,
  • how to schedule appointments,
  • privacy concerns,
  • the possibility of technological failure including confidentiality breaches,
  • protocols for contact during virtual visits,
  • prescribing policies and coordinating care with other health professionals in a clear and understandable manner, without influencing the patient’s choices.

5. Physicians must be aware that certain telemedicine technologies could be unaffordable to patients and hence impede access. Inequitable access to telemedicine can further widen the health outcomes gap between the poor and the rich.

Autonomy and privacy of the Physician

6. A physician should not to participate in telemedicine if it violates the legal or ethical framework of the country.

7. Telemedicine can potentially infringe on the physician privacy due to 24/7 virtual availability. The physician needs to inform patients about availability and recommend services such as emergency when inaccessible.

8. The physician should exercise their professional autonomy in deciding whether a telemedicine versus face-to-face consultation is appropriate.

9. A physician should exercise autonomy and discretion in selecting the telemedicine platform to be used.

Responsibilities of the Physician

10. A physician whose advice is sought through the use of telemedicine should keep a detailed record of the advice he/she delivers as well as the information he/she received and on which the advice was based in order to ensure traceability.

11. If a decision is made to use telemedicine it is necessary to ensure that the users (patients and healthcare professionals) are able to use the necessary telecommunication system.

12. The physician must seek to ensure that the patient has understood the advice and treatment suggestions given and take steps in so far as possible to promote continuity of care.

13. The physician asking for another physician’s advice or second opinion remains responsible for treatment and other decisions and recommendations given to the patient.

14. The physician should be aware of and respect the special difficulties and uncertainties that may arise when he/she is in contact with the patient through means of tele-communication. A physician must be prepared to recommend direct patient-doctor contact when he/she believes it is in the patient’s best interests.

15. Physicians should only practise telemedicine in countries/jurisdictions where they are licenced to practise. Cross-jurisdiction consultations should only be allowed between two physicians.

16. Physicians should ensure that their medical indemnity cover include cover for telemedicine.

Quality of Care

17. Healthcare quality assessment measures must be used regularly to ensure patient security and the best possible diagnostic and treatment practices during telemedicine procedures. The delivery of telemedicine services must follow evidence-based practice guidelines to the degree they are available, to ensure patient safety, quality of care and positive health outcomes. Like all health care interventions, telemedicine must be tested for its effectiveness, efficiency, safety, feasibility and cost-effectiveness.

18. The possibilities and weaknesses of telemedicine in emergencies must be duly identified. If it is necessary to use telemedicine in an emergency situation, the advice and treatment suggestions are influenced by the severity of the patient´s medical condition and the competency of the persons who are with the patient. Entities that deliver telemedicine services must establish protocols for referrals for emergency services.

RECOMMENDATIONS

  1. Telemedicine should be appropriately adapted to local regulatory frameworks, which may include licencing of telemedicine platforms in the best interest of patients.
  2. Where appropriate the WMA and National Medical Associations should encourage the development of ethical norms, practice guidelines, national legislation and international agreements on subjects related to the practice of telemedicine, while protecting the patient-physician relationship, confidentiality, and quality of medical care.
  3. Telemedicine should not be viewed as equal to face-to-face healthcare and should not be introduced solely to cut costs or as a perverse incentive to over-service and increase earnings for physicians.
  4. Use of telemedicine requires the profession to explicitly identify and manage adverse consequences on collegial relationships and referral patterns.
  5. New technologies and styles of practice integration may require new guidelines and standards.
  6. Physicians should lobby for ethical telemedicine practices that are in the best interests of patients.

Adopted by the 41st World Medical Assembly Hong Kong, September 1989
and rescinded at the WMA General Assembly, Santiago 2005

Preamble

Present requirements of health reporting fails to provide an accurate estimate of the incidence and prevalence of worldwide individuals in a persistent vegetative state (PVS). Ten years ago, a prevalence of 2 to 3 per 100,000 was estimated for Japan. It seems likely that the absolute number of such cases has risen appreciably as a consequence of current practices in critical medicine, cardiorespiratory support, parenteral feeding, and control of infections in severely brain damaged patients. How to deal with this emotionally painful, financially costly, and generally unwanted outcome of modern medical treatment is an increasing problem.

Persistent Vegetative State

Pathologic loss of consciousness may follow a variety of insults to the brain including, among others, nutritional insufficiency, poisoning, stroke, infections, direct physical injury, or degenerative disease. Abrupt loss of consciousness usually consists of an acute sleep-like state of unarousability called coma that may be followed either by varying degrees of recovery or severe, chronic neurologic impairment. Persons with overwhelming damage to the cerebral hemispheres commonly pass into a chronic state of unconsciousness called the vegetative state in which the body cyclically awakens and sleeps but expresses no behavioral or cerebral metabolic evidence of possessing cognitive function or of being able to respond in a learned manner to external events or stimuli. This condition of total cognitive loss can follow acute injuries causing coma or can develop more slowly as an end result of progressive structural disorders, such as Alzheimer’s disease, that in their end stages also can destroy the phychological function of the cerebrum. When such cognitive loss lasts for more than a few weeks, the condition has been termed a persistent vegetative state (PVS) because the body retains the functions necessary to sustain vegetative survival. Recovery from the vegetative state is possible, especially during the first few days or weeks after onset, but the tragedy is that many persons in PVS live for many months or years if provided with nutritional and other supportive measures.

Recovery

Once qualified clinicians have determined that a person is awake but unaware, the permanence of the vegetative state depends on the nature of the brain injury, the duration of the period of unawareness, and the estimated prognosis. Some persons less than 35 years old with coma after head trauma, as well as an occasional patient with coma after intracranial hemorrhage, may recover very slowly; thus, what appears to be a PVS at one to three months after an event causing coma may in rare cases evolve into a lesser degree of impairment by six months. On the other hand, the chances of regaining independence after being vegetative for three months are vanishingly small. Rare exceptions are claimed, but some of these may have represented patients who entered an unrecognized locked-in state shortly after reawakening from a coma-causing injury. Ultimately, all have been severely disabled.

Guidelines

These rare examples notwithstanding, the data indicate that unawareness for six months predicts nonrecovery or overwhelming disability with a high degree of certainty regardless of the nature of the insult to the brain. Therefore, a conservative criterion for the diagnosis of PVS would be observed unawareness for at least 12 months although cognitive recovery after six months is exceedingly rare in patients over 50.

The risk of prognostic error from widespread use of the above criterion is so small that a decision that incorporates it as a prognostic conclusion seems fully justifiable. A physician’s determination that a person is unlikely to regain consciousness is the usual prelude to deliberations about withdrawing or withholding life support. Although the family may be the first to raise the issue, until a physician has ventured an opinion about prognosis, the matter of withholding treatment is not generally considered. Once the question of withholding or withdrawing life support has been raised, its legal and ethical dimensions must be considere.

Adopted by the 18th World Medical Assembly Helsinki, Finland, June 1964,
amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Santiago 2005

  1. Rural populations have the same entitlement to medical care as people living in urban areas. Although there may be economic and other factors affecting the quantity of medical services available in rural areas, there should be no disparity in the quality of medical services. Persistent efforts should be made to elevate the qualifications of all persons rendering medical service to the highest level in the nation.
  2. Studies and analysis of factual data are useful for rural communities and regions in providing information for planning and developing suitable health services in rural areas.
  3. Education and socio-economic levels in rural communities are mutually dependent. Health education of the public is most effectively achieved when agencies, organizations, the health professions and the community share in the development and maintenance of the highest level of health practices that can be mutually effected.
  4. The physician-patient relationship should be preserved in the development of health services in rural areas.
  5. It is the duty of the State to ensure that conditions offered in Public Health appointments are sufficiently attractive to enable rural health services to develop to the same extent as those in urban areas.
  6. Proper integration of the program and facilities for preventive and therapeutic medicine, sanitation and health education should be ensured in both rural and urban areas.
  7. Every effort should be made to ensure that only qualified physicians should have ultimate clinical responsibility in rural, as well as urban, health services. Medical auxiliaries should be employed only temporarily to perform the duties of qualified physicians. The number of rural health personnel should be adequate and should receive training well adapted to medical needs of the rural population. Their technical knowledge should be kept up to date.
  8. The training of medical auxiliaries especially nurses, male nurses and mid-wives should be based on and correspond to the cultural and educational level of the country in order that a sufficient number may be available for the rural areas. The medical profession should in every way possible assist in providing basic as well as post-graduate and refresher courses to this group.
  9. The special diseases of rural areas require cooperation of physicians with professionals of related fields.
  10. The medical profession should provide leadership in health education of rural populations. It is essential that there be cooperation between the physician and the rural population in order to achieve the highest possible standard of health education.
  11. National medical associations should do everything possible to ensure that rural physicians practice under conditions no less favourable than urban physicians.
  12. National medical associations should take an active part in the development of plans for improving health conditions in rural areas.

Adopted by the 42nd World Medical Assembly Rancho Mirage, CA., USA, October 1990
and rescinded at the WMA General Assembly, Santiago 2005

  • THE WORLD MEDICAL ASSOCIATION recognizes that tobacco products are hazardous to human health (See WMA Statement on Health Hazards of Tobacco Products, adopted September, 1988).
  • THE WORLD MEDICAL ASSOCIATION therefore urges all nations to protect the public health by adopting prohibitions or restrictions on the manufacture, import, export, sale or advertisement of tobacco products
  • THE WORLD MEDICAL ASSOCIATION further urges all national medical associations to take such actions as may be appropriate to advocate the adoption of prohibitions or restrictions on the manufacture, import, export, sale or advertisement of tobacco products by the governments of their respective nations.

Adopted by the 39th World Medical Assembly Madrid, Spain, October 1987
and rescinded at the WMA General Assembly, Santiago 2005

Preface

Recognizing the high infant mortality rate (IMR) in various areas of the world, the WMA and its national medical association members are embarked on a program to reduce unnecessary morbidity and mortality in developing countries.

The concept for the program was initiated by the AMA which collaborated with the Centers for Disease Control (CDC) in the development of what is now known as “WMA Infant Health Program”. The AMA is responsible for implementation of the program on behalf of WMA with CDC serving as the technical consultant.

The Indonesian Medical Association and the Medical Association of Thailand were selected to implement pilot projects in their respective countries. Funding for these projects has been provided by the United States Agency for International Development (USAID).

WMA’s Role

The World Medical Association (WMA) Infant Health Program, a private sector endeavor, involves the WMA in an initiative that is highly relevant to Third World countries. The hope is to contribute significantly to the overall goal of reducing unnecessary morbidity and mortality among children in Third World countries – a goal which is integral, as well, to efforts by other international and governmental bodies.

The main thrust of this initiative is to seek active involvement of physicians in Third World countries in measures such as the use of oral rehydration therapy (ORT), immunization, and nutrition programs which will significantly improve infant health. It recognizes the importance of mobilizing physicians, in their professional and private capacities and as influential citizens, around goals of improved infant health. The national medical association (NMA) is the ideal vehicle for such an approach.

The WMA and its member associations will work cooperatively with ministries of health and other governmental and private organizations in countries where the infant health program will be implemented. Private sector initiatives are increasingly being recognized as an essential force to accomplish national goals of improving the quality of health care and lowering infant mortality.

The WMA through its world-wide membership of NMAs representing more than two million physicians, will reach a wide audience with publications and information on interventions to enhance child survival. The WMA will be the catalyst to motivate NMAs in developing countries to participate in child survival programs focused on ORT immunization against the six vaccine-preventable diseases and other key interventions. NMAs in developed countries will join in the effort. Cooperating together under the auspices of the WMA, NMAs will develop the necessary resources to carry on the work into the future.

Goals and Objectives

The program components of the pilot projects, which will be developed fo replication in other countries, are as follows:

  • Full immunization of children against the six vaccine-preventable diseases
  • Use of ORT for the treatment of diarrhea
  • Immunization of all pregnant women with tetanus toxoid
  • Two-year interval between births
  • Exclusive breastfeeding of infants for at least four to six months and the introduction of weaning foods at an appropriate age
  • Prenatal examination of all pregnant women
  • Delivery of all newborns by trained personnel
  • Birthweight of at least 2500 grams

Strategies

The WMA joins with other private and public sector organizations in the battle to save lives and prevent the deaths each year of some 14 to 15 million children under five who die from disease and malnutrition. Millions of these children die needlessly since relatively low-cost disease prevention and life-saving interventions are available. The WMA Infant Health pilot programs will develop strategies for interventions that can be replicated and become selfsustaining and institutionalized within each country.

It is of paramount importance that physicians and their NMAs understand and support the delivery of relatively inexpensive vaccines for immunization against the six vaccine-preventable diseases (diphteria, pertussis, tetanus, measles, polio and tuberculosis). The WMA programs will be a part of the world-wide goal to immunize 80% of the world’s children by the end of this decade in countries where this is achievable and, shortly thereafter, in those countries with the most severe problems in accomplishing this goal.

In tandem with immunization, the WMA strategy will be to lower the IMR with the use of ORT in the treatment of diarrheal disease which kills five millions children every year. ORT is effective against dehydration – the complication of diarrhea which is most often lethal. If fluids and chemicals are not replenished, children who are already underweight or malnourished rapidly weaken and die.

Through lessons learned in the development of ORT, scientists determined the role of glucose in accelerating the absorption of salt and water through the wall of the intestine permitting rapid replacement of essential fluids. According to USAID:

It is now known that a simple combination of sugar, salts and water in specific ratios (along with bicarbonate or trisodium citrate), given by mouth in frequent small doses, will reverse dehydration in all but about 5 per cent of cases, usually within three to seven hours. Just sugar, salt and water, in the right proportions, will usually prevent dehydration if given soon enough. This ORT is not only far cheaper than the IVS and drugs it replaces, it is also better for the child and can be used in the home and outpatient clinic as well as in the hospital.

As a child’s most important health care provider, mothers must be taught how to mix fluids in the correct proportions, how to administer them, what other nourishment to provide the child, and when to seek outside help for a desperately ill child. In designing education and training programs, the cultural milieu prevailing in different societies must be taken into account.

In order to educate mothers to the need for ORT and to have the requisite knowledge to administer it, physicians must understand and support the therapy. Their acceptance will make ORT credible to health workers and to mothers. However, since many physicians have been trained to utilize anti-diarrheal drugs and IV therapy, NMAs can play a pivotal role in child survival by educating their physician members and non members to the efficacy of ORT in saving the lives of millions of children worldwide. Informed and trained physicians can educate health workers and most importantly, mothers, to use ORT in the home. It is clear from the continued high IMR in many countries that government programs cannot do the job alone. Governments, in turn, are increasingly aware of the need for more private sector involvement.

Conclusion

While recognizing that the battle against diseases is not easily nor quickly won, the WMA seizes the opportunity to save the lives of potentially millions of children through child survival action programs. WMA member NMAs in developed and developing countries have a shared responsibility to work for quality care for all people of the world, and in this spirit, to support efforts to reach child survival goals.

Adopted by the 37th World Medical Assembly Brussels, Belgium, October 1985,
amended by the 38th World Medical Assembly,Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

Those concerned with directing medical education programs in each country should communicate to their medical students the importance of obtaining actual experience in the practice of medicine in order to achieve basic medical competence, and the necessity for continuous experience to maintain such competence. Medical students should also be advised that the application of a medical education to alternative employment is extremely limited.

When it is doubtful that the medical student will have an opportunity to acquire the necessary experience to achieve basic medical competency, the medical student should be urged to reconsider the value of a medical education.

Adopted by the 36th World Medical Assembly Singapore, October 1984,
amended by the 38th World Medical Assembly Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

  • WHEREAS, the World Medical Association endeavors to serve humanity by seeking to achieve the highest international standards in medical education, and
  • WHEREAS, the World Medical Association and its National Medical Associations have always supported high quality medical education, and
  • WHEREAS, the quality of health care provided by physicians can be no better than the quality of medical education that physicians receive,
  • THEREFORE, the World Medical Association reaffirms its support for high standards of medical education that provide high quality educational experiences for all medical students, andThat only properly qualified candidates should be admitted to study medicine, andThat the number of students admitted to study medicine be no greater than the number which can be provided with high quality educational experience by the educational resources available.That the qualifications required of candidates to be admitted to medical schools be determined by the objective judgement of medical school faculties.

Adopted by the 35th World Medical Assembly Venice, Italy, October 1983
amended by the 38th World Medical Assembly Rancho Mirage, CA, USA, October 1986
and rescinded at the WMA General Assembly, Santiago 2005

The Assembly of the World Medical Association meeting in Venice, this 28th day of October 1983, calls upon all National Medical Associations to work for a solution to the emerging problems related to medical manpower.

Recognizing the need:

  1. to provide access for all people to medical care of the highest quality, and
  2. to maintain those standards of medical care that result in the provision of quality medical care, as well as
  3. providing for the development of new knowledge, skills and techniques that will foster progress in medical science.

The Assembly urges all National Medical Associations to work with their governments within the provisions of their respective laws to accomplish these ends.

Quality medical care and the maintenance and development of a physician’s skills and techniques, as well as the discovery of new knowledge and information, are inseparably linked to the physician’s opportunity for patient care and clinical experience. This principle must be recognized in any solution to medical manpower problems, and economic and political concerns must be subordinated to this principle.

Most importantly, the foregoing principle must be recognized and applied to the laws and policies governing medical schools so that the high standards of quality medical care may be assured for future generations.

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Santiago 2005

In some countries medical malpractice claims are increasing, and National Medical Associations are seeking ways of coping with the problem. In other countries medical malpractice claims are rarely brought, but National Medical Associations in those countries should be alert to the issues and circumstances that could result in an increase in the number of claims asserted against physicians.

In this statement, the World Medical Association, Inc. seeks to inform National Medical Associations of some of the facts and issues related to medical malpractice claims. The laws and legal systems in each country, as well as the social traditions and the economic conditions of the country will affect the relevance of some portions of this statement to each National Medical Association. Nevertheless, the World Medical Association, Inc. believes that this statement should be of interest to all National Medical Associations.

  1. An increase in medical malpractice claims may result, in part, from one or more of the following circumstances:
    1. The increase in medical knowledge and the increase in medical technology has allowed physicians to accomplish medical feats that were not possible in the past, but these accomplishments involve risks of greater severity in many instances.
    2. The obligation imposed on physicians to limit the costs of medical care.
    3. Confusing the right to health care, which is attainable, with the right to achieve and maintain health, which can not be guaranteed.
    4. The pernicious role often played by the media engendering mistrust in physician by questioning his ability, knowledge, behaviour and management of the patient, and by prompting patients to submit complaints against physicians.
    5. The indirect consequences of an upsurge of a defensive medicine engendered by the increase in the number of claims.
  2. A distinction must be made between medical malpractice and an untoward result occuring in the course of medical care and treatment that is not the fault of the physician.
    1. Medical malpractice involves the physician’s failure to conform to the standard of care for treatment of the patient’s condition, or a lack of skill, or negligence in providing care to the patient, which is the direct cause of an injury to the patient.
    2. An injury occuring in the course of medical treatment which could not be foreseen and was not the result of any lack of skill or knowledge on the part of the treating physician is an untoward result, for which the physician should not bear any liability.
  3. Compensation for patients suffering a medical injury could be determined to the extent that no national laws prohibit this, differently for medical malpractice claims than for the untoward results that occur during medical care and treatment.
    1. Where un untoward result occurs without fault on the part of the physician, society must determine if the patient should be compensated for the injuries suffered, and if so, the source from which the funds will be paid. The economic conditions of the country will determine if such solidarity funds are available to compensate the patient without being at the expense of the physician.
    2. The laws of each jurisdiction will provide the procedures for deciding liability for medical malpractice claims and for determining the amount of compensation owed to the patient in those cases where malpractice is proved.
  4. National Medical Associations should consider some or all of the following activities in an effort to provide fair and equitable treatment for both physicians and patients:
    1. Public education programs on the risks inherent in some of the new advances treatment modalities and surgery, and professional education programs on the need for obtaining the patient’s informed consent to such treatment and surgery.
    2. Public advocacy programs to demonstrate the problems in medicine and the delivery of health care resulting from strict cost containment limitations.
    3. Advocating general health education programs both in school and in social settings.
    4. Enhancing the level and quality of medical education for all physicians, including improved clinical training experiences.
    5. Develop and participate in programs for physicians designed to improve the quality of medical care and treatment.
    6. Develop appropriate policy positions on remedial training for physicians found to be deficient in knowledge or skills, including policy positions on limiting the physician’s medical practice until the deficiencies are corrected.
      Inform the public and government of the danger that various manifestations of defensive medicine may appear (the multiplication of medical acts or, on the contrary, the abstention of the doctors, or even the disaffection of young physicians for certain higher risk specialties).
    7. Educate the public on the possible occurence of injuries during medical treatment which could not be foreseen and are not the result of physician malpractice.
    8. Advocate for legal protection for physicians when patients are injured by untoward results not caused by any malpractice.
    9. Participate in the development of the laws and procedures applicable to medical malpractice claims.
    10. Develop active opposition to frivolous claims and to contingency billing by lawyers.
    11. Explore innovative procedures for handling medical malpractice claims, such as arbitration rather than court proceedings.
    12. Encourage self insurance by physicians against malpractice claims, paid by the practitioner himself or by the employer if the doctor is employed.
    13. Participate in decisions relating to the advisability of providing compensation for patients injured during medical treatment without any malpractice.

Adopted by the 41st World Medical Assembly Hong Kong, September 1989
and rescinded at the WMA General Assembly, Santiago 2005

Definition

Generic substitution is herein defined as the dispensing of a different brand or an unbranded drug product for the drug product prescribed; i.e., the exact same chemical entity in the same dosage form but distributed by a different company.

Preamble

If drug products are not bioequivalent because of different manufacturing processes and/or the presence of different biologically inactive excipients, anticipated therapeutic equivalence among such drug product may also change. Therefore, when substitution occurs among drug products that are not bioequivalent and chemically and therapeutically equivalent, the patient may be adversely affected; i.e, suffer an adverse drug reaction or a therapeutic failure. For these reasons, the physician should be assured by national regulatory authorities of the bioequivalence and the chemical and therapeutic equivalence of prescription drug products from multiple sources. This principle is also desirable in the case of single-source drug products. Quality assurance procedures should be in place to ensure their lot-to-lot bioequivalence and their chemical and therapeutic equivalence.

In the drug selection process, many medical considerations should be addressed before prescribing the drug of choice for a particular indication in any given patient. Once these primary considerations are met, the physician should then consider comparative costs of similar drug products available to best serve all of the patient’s needs. The physician has both the right and the obligation to exercise his/her best judgment on behalf of the patient; therefore, the physician should select the type and quantity of drug product that he or she considers to be in the best medical and financial interest of the patient. Once the patient gives his consent on the drug selected that drug should not be changed without the consent of the patient and his or her physician. Even when third-party carriers mandate generic drug substitution, every effort must be made to preserve the prescribing authority of the physician. Failure to follow these principles can result in harm to patients, and physicians can be held liable for such harmful consequences. On behalf of patients and physicians alike, national medical associations should do everything possible to uphold these precepts.

Recommendations

  1. Physicians should become familiar with specific laws and/or regulations governing generic drug substitution in locals where they practice.
  2. On initiation of treatment, physicians should carefully determine the dose of any medication for optimum efficacy and safety, especially in patients with chronic disorders who require prolonged therapy or patients in special population groups not expected to respond to a drug in the normal manner.
  3. Once medication for chronic diseases has been prescribed and begun, no substitution of either generic or brand-name drug products should be made without the attending physician’s permission. If generic or brand-name substitution of a drug product occurs, the physician should carefully monitor and adjust the dose to ensure therapeutic equivalence of the drug products.
  4. The physician has the duty to report serious adverse drug reactions or therapeutic failures that may be related to drug substitution; the finding should be documented and reported to appropriate drug regulatory authorities, including the appropriate national medical association.
  5. National medical associations should regularly monitor generic drug substitution issues and keep their members advised on developments that have special relevance for patient’s care. When appropriate, information reports on significant developments should be made available to physicians.
  6. National medical associations, in collaboration with other appropriate drug regulatory bodies, should evaluate and ensure the bioequivalence and the chemical and therapeutic equivalence of all similar drug products, whether generic or brand-name manufactured, in order to ensure safe and effective treatment.
  7. National medical associations should oppose any action to restrict the freedom and the responsibility of the physician to prescribe in the best medical and financial interest of the patient.

Adopted by the 17th World Medical Assembly New York, USA, October 1963,
and amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

PREAMBLE

Medical care is organized throughout the world in many different ways, from the most complete laisser-faire, to medical services organized exclusively and completely by the State.

It would be impossible to describe all the systems in detail, but one may say that while some countries only help those in dire need, others have organized a system of health insurance, and others have gone even further in organizing complete medical care. Personal initiative is associated in varying degrees with government policies and action in the health care field, and this serves to multiply indefinitely the ways in which medical care is provided.

The ideal, in this field, is certainly the “provision of the most up-to-date medical care while entirely respecting the freedom of both physician and patient”.

A formula of this nature is however too imprecise to be of use in solving the problems which arise in the daily application of the various national systems (which exist whether one likes it or not).

The WMA has a duty to safeguard the basic principles of medical practice and defence of the freedom of the medical profession. In consequence it cannot be expected to produce valued judgement on the different systems, but has an overwhelming duty to decide as far as it is possible, upon what terms the medical profession can collaborate with State Health Services.

PRINCIPLES

  1. The conditions of medical practice in any system of health care shall be determined in consultation with the representatives of organizations of physicians.
  2. Any health care system should allow the patient to consult the physician of his choice, and the physician to treat only patients of his choice, without the rights of either being affected in any way. The principle of free choice also should be applied in cases where medical treatment or a part of it is provided in treatment centers. Physicians have a compelling professional and ethical duty to attend to a patient in an emergency.
  3. Any health care system should be open to all licensed physicians; neither the medical profession nor the individual physician should be forced to take part if they do not so wish.
  4. The physician should be free to practice his profession where he wishes and also to limit his practice to a given specialty in which he is qualified. The medical needs of the country concerned should be satisfied and the profession, wherever possible, should seek to orient young physicians toward the areas where they are most needed. In cases where these areas are less favorable than others, physicians who go there should be aided by appropriate incentives so that their equipment is satisfactory and their standard of living is in accordance with their professional responsibilities.
  5. The profession should be adequately represented on all official bodies dealing with problems concerning health or disease.
  6. The confidential nature of the physician-patient relationship must be recognized and must be observed by all those who collaborate at any stage of the patient’s treatment or in the control thereof. This should be duly respected by authority.
  7. The confidential nature of the physician-patient relationship must be recognized and must be observed by all those who collaborate at any stage of the patient’s treatment or in the control thereof. This should be duly respected by authority.
  8. When the remuneration for medical services in any national health care system is not fixed by direct agreement between physician and patient the remunerating authority must adequately compensate the physician.
  9. The remuneration of medical services should take into consideration the services rendered and should not entirely be fixed according to the financial status of the paying authority or as a result of unilateral government decisions and should be acceptable to the agency which represents the medical profession.
  10. The review of physician’s services for the purpose of quality safeguards or the utilization of services both as to the number and cost, should be carried out by physicians only and should be measured against local or regional rather than national standards.
  11. In the higher interest of the patient there should be no restriction of the physician’s right to prescribe drugs or any other treatment deemed appropriate by current medical standards.
  12. The physician should be encouraged to participate in any activity directed toward improving his knowledge and status in his professional life.

Adopted by the 49th WMA General Assembly Hamburg, Germany, November 1997
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

Preamble

Despite advances in therapeutics, tuberculosis (TB) is becoming an increasing cause of morbidity and mortality world-wide. Recent World Health Organisation estimates are that 30 million people could die from TB over the next ten years. While many patients with TB are not diagnosed many others are not treated effectively. There are many contributory reasons, including poor prescribing by doctors and poor patient compliance with treatment. TB is also a major threat to the health of HIV-positive persons and an increasingly common cause of death of persons with AIDS.

Furthermore, these factors also predispose to an increased likelihood of the development of drug resistant strains of M. Tuberculosis. In some closed communities, such as prisons, and amongst groups such as Hospitalised HIV-positive persons, the majority of new patients present with infection with multi-drug resistant strains.

Resolution

Therefore, and in accord with its Statement on Resistance to Antimicrobial Drugs (Doc. 10.120),

The World Medical Association calls on its national member associations to support the World Health Organisation in its “Directly Observed Treatment Short-Course” and “Strictly Supervised Treatment” projects, and in other work to promote the more effective management of tuberculosis.

Adopted by the 47th General Assembly Bali, Indonesia, September 1995
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

PREAMBLE

A large number of regions throughout the world currently are faced with the frequent tragedies generated by addicts to opiate drugs. These tragedies occur in the following four spheres:

  1. health: the physical and psychological condition of the addict; propagation of viral infections such as HIV and hepatitis B or C through the sharing of infected syringes and unprotected sexual intercourse;
  2. decay of the family, professional and social environment;
  3. degeneration of the individual: incitement of both sexes to prostitution to pay for the drug, hospitalization, imprisonment, etc…
  4. public safety: resorting to criminal behavior to obtain either the drug or the money to buy the drug.
    The World Medical Association, concerned by such a widespread medico-psycho-social calamity, must formulate recommendations for physicians involved in the treatment of addicts to opiate drugs. This subject has already been addressed briefly in the WMA Statement on the Use and Misuse of Psychotropic Drugs (Doc. 20.30). However, the current situation requires more specific and elaborate guidelines than those presented in that Statement.

POSITION

The addict to opiate drugs is a full citizen who has rights and duties. His/her drug dependence indicates suffering that leads to physical, psychological and social difficulties; even prolonged drug dependence should be considered a temporary situation. The help to which addicts should have access should respect their dignity. They must be cared for with the same consideration as any other patient. The objective of the treatment always should be to re-establish addicts in a free and responsible life.

Treating addiction to opiate drugs is often very difficult. Among the many programmes proposed in different countries concerned by the increase in the number of such addicts, two trends are revealed: “therapeutic communities” (external protection) and the prescription of substitute drugs (internal protection).

The use of substitute drugs in outpatient treatment is certainly not the ideal solution (which should be sought through further research and scientific evaluation) to the problem of drug dependence. However, this method as a “therapeutic tool” exists, is used in many places throughout the world, and may contribute in part – until a better solution is found – to containing the problem. The standard ambition of the method is the weaning of the patient and his/her reintegration into his/her family, professional, and social environment, without improper maintenance of his/her dependence. A decrease in dosage should always be sought by the prescribing physician.

Whatever we do, drug dependence is a phenomenon for which we know no “miracle solution”. The medical use of substitute products for heroin (diacetylmorphine), and opiate drugs of synthesis (and in particular but not only methadone, which has been known for about fifty years), creates fundamental problems (weaning, pharmacology, etc…), clinical problems (treatment programs, prescription, delivery, surveillance), legal problems (laws and regulations) and ethical problems.

Consequently, in outpatient treatment, substitute drugs should be subjected to a set of evidence-based guidelines, the formulation of which would stem from experience acquired during the last quarter of this century by those treating drug dependence, namely in North America and Europe. Many countries have established legal procedures for the treatment of addicts to opiate drugs. The National Medical Associations should seek, if necessary, to improve inadequate legal texts.

RECOMMENDATIONS

  1. The physician shall abstain from prescribing at the sole request of the patient any drug that is not medically justified by his/her condition.
  2. In the outpatient treatment of addicts to opiate drugs, substitute drugs shall be prescribed according to evidence-based guidelines.
  3. The ultimate goal of the treatment always shall be the weaning of the patient, which may be achieved only after a long period of time.
  4. The use of substitute drugs will allow the patient to be medically, psychologically or socially stabilized and therefore reintegrated without delay into his/her family and professional environments. It will also serve to reduce the risk of contracting viruses such as HIV or hepatitis B or C through the use of infected syringes. In addition, the crime induced by the use of heroin can only diminish.
  5. Any treatment using substitution drugs shall be prescribed only after accurate diagnosis. It should be supervised by a competent and trained physician with an appropriate support team.
  6. The physician shall limit the number of patients addicted to opiate drugs that he/she will treat, with a view to ensuring attentive and conscientious care to each of them. In every case, he will keep a detailed medical record concerning the treatment provided to the patient, and audit the results.
  7. The prescription and administration of substitute drugs should be organized in such a way as to avoid any stocking by the patient, resale or other illicit usage.
  8. Subject to the provisions of national law, the patient, in order to receive drug substitution must agree to comply regularly with unscheduled, supervised biological tests, (urine for instance) to ensure that he/she is not taking other drugs simultaneously and/or accepting simultaneous treatment from another physician, without the knowledge of both practitioners.

Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975
and amended by the 35th World Medical Assembly Venice, Italy, October 1983
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

  1. The use of psychotropic drugs is a complex social phenomenon and not simply a medical problem.
  2. Within society generally there is urgent need for intensive public education, presented in non-moralizing, non-punitive manner, and the development and demonstration of practical alternatives to drug use. Physicians, as knowledgeable, concerned citizens, should participate in such programs.
  3. Physicians should prescribe psychotropic drugs with the greatest restraint and observing the strictest possible medical indication ensuring that all prescribing of psychotropic drugs reflects accurate diagnosis, appropriate non-pharmacologic advice, and careful utilization of precise pharmacotherapeutic materials, mindful of the potential dangers of misuse and abuse.
  4. Physicians should accept the responsibility for collating and providing factual information regarding the health hazards of the non-medical use of all psychotropic material, including alcohol.
  5. In cooperation with governments and relevant agencies, the medical profession should ensure that such information is disseminated as widely as possible; especially within those age groups most likely to experiment with drugs to counteract peer group pressure and other factors which lead to misuse and abuse, and in order to maintain for each individual the right and the responsibility of free exercise of informed personal choice.

Adopted by the 42nd World Medical Assembly Rancho Mirage, CA., USA, October 1990
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

 

PREFACE

The care of terminally ill patients with severe chronic pain should provide treatment that permits these patients to close their lives with dignity and purpose. Analgesics, both opioid and nonopioid, are available and when properly used, can provide effective relief of pain for most terminally ill patients. It is incumbent on the physician and on all others who care for the dying patient with severe chronic pain to understand clearly the dynamics of the pain experience, the clinical pharmacology of analgesics, and the needs of the patient, family and friends. It also is imperative that governments assure that medically necessary quantities of opioid analgesics are available for appropriate application in the management of severe chronic pain.

PRINCIPLES OF THE CLINICAL MANAGEMENT OF SEVERE CHRONIC PAIN

When a patient is terminally ill, the physician must focus efforts on the relief of suffering. Pain is only one component of the patient’s suffering. However, the impact that pain can have on a patient’s life can range from tolerable discomfort to the production of a sense of crushing and exhausting defeat.

Clinical experience has demonstrated that, in general, it is not so much which opioid is used to achieve the relief of severe chronic pain in the terminally ill patient, rather it is the manner in which the drug is used that is critical.

It is imperative, however, that the physician distinguish between acute pain and pain that can be expected to be chronic, as this distinction can carry important implications for the use of opioid analgesics. The following are general principles that should guide the treatment of severe chronic pain particularly through the use of analgesic medication.

  1. Treatment must be individualized to satisfy the patient’s needs and keep him or her as comfortable as possible;
  2. It must be understood that the needs of the patient with chronic pain often differ from those of patients with acute pain.
  3. The physician must know the potency, duration of action and side effects of available analgesics to select the appropriate drug, as well as the dose, route, and schedule that will ensure delivery of optimum pain relief for the patient.
  4. Combinations of opioid and nonopioid analgesics can provide greater relief of pain to patients in whom nonopioid analgesics are no longer sufficient. This can be achieved without producing a concomitantly greater potential for undesirable side effects.
  5. The development of tolerance to the analgesic effects of an opioid agonist can be surmounted by switching the patient to an alternative opioid agonist. This is based on the lack of complete cross-tolerance among different opioid analgesics.
  6. Iatrogenic dependence should not be considered a primary problem in treating the severe pain of neoplastic disease and must never be a reason to withhold strong analgesics from patients who may benefit from them.
  7. Governments should examine the extent to which their health care systems and laws and regulations permit the use of opioids for medical purposes, identify possible impediments to such use and develop plans of action to facilitate the supply and availability of opioids for all appropriate medical indications.

Adopted by the 44th World Medical Assembly Marbella, Spain, September 1992
and rescinded at the WMA General Assembly, Pilanesberg, South Africa, 2006

Modern medical technologies and therapies have led to the treatment and control (but not cure) of many potentially fatal illnesses. Such medical successes worldwide have, in turn, led to a rapidly growing population of chronically ill and disabled people of all ages. The problem facing the world health care community is how to best care for his chronically ill and disabled population (including the need to develop new technologies and social/medical organizations).

The goal of medical care in these cases is to control the disease processes and to help the patients maintain their independence and maximum level of function within their own homes and communities.

The scope of medical care includes not only diagnosis and medical treatment but also patient education in self-care and prolonged medical monitoring and supervision.

Patients must learn to perform a wide variety of medical tasks that have only been performed by trained medical personnel in the past. Such tasks can range from that of a diabetic patient who checks his/her blood glucose level 2-4 times a day and adjusts the insulin dose appropriately, to the patient with a pacemaker who learns to use the equipment to send a electrocardiographic rhythm strip over the telephone lines to the local physician’s office or to a distant monitoring center.

Telecommunication technology has made possible new ways for physicians to collect information and manage the medical needs of their patients from a distance. A wide range of medical information can now be transmitted via telephone including electrocardiograms, encephalograms, x-rays, photographs and medical documents of all kinds. Such information can be collected and sent from a patient’s home or physician’s office to a major medical center for interpretation and advice on treatment. The rapid exchange of medical information enables the patient to remain in his/her own home and community and receive the most comprehensive and up-to-date medical care.

The World Medical Association recognizes that “tele-medicine” will undoubtedly play an increasingly important role in the practice of medicine in the future.

Developing tele-surveillance systems need to address the following issues:

  • A central station needs to be able to receive and respond to calls coming from different bio-televigilance systems.
  • There is a need for an interactive system, such as an “interphone system” which allows for dialogue and intervention.
  • The tele-medicine network must establish a medical link from the patient’s home to the most sophisticated medical center. Implementation of tele-surveillance systems includes:
  1. The utilization of communications systems (telephone, television, satellites) for visual consultation and cooperation between doctors at a distance, and for connecting facilities in high quality medical establishments to:
    1. modest medical centers
    2. private homes
    3. convalescent clinics
    4. in those areas that are geographically isolated and distant, or that are not readily accessible in case of an emergency.
  2. Transmission of documents: electrocardiographs, encephalograms, photographs, radiographies, scanners, biological analysis, echograms, magnetic resonance imaging, and a history of the patient, etc.
    • description of symptoms
    • therapeutic and medico-surgical advice
  3. Assistance to homecare (tele-vigilance network): control in cardiology, obstetrics, renal dialysis, respiratory problems, serious physical disorders, etc.

The World Medical Association recognizes that in addition to the technological difficulties involved in developing and implementing tele-medicine systems, there are many ethical and legal issues raised by these new practices. Therefore, the World Medical Association recommends that physicians utilize the following guidelines as key elements in establishing an effective “tele-medicine” network/system.

  1. The physician must determine that the patient or family are competent and well-informed before initiating a tele-medicine system. Those systems that rely on the patient or the family to collect and send the data will not be effective if patients do not understand the significance of the tests and the importance of completing them. Patient compliance psychologically as well as physically is essential.
  2. There must be close collaboration and trust between the patient and the physician who is responsible for his/her medical care. The organizations providing “tele-medicine” services should respect the right of the patient to choose his/her personal doctor.
  3. Close collaboration between the patient’s personal physician and the staff at the “tele-medicine” center is essential to ensure humane, individualized, quality care.
  4. Confidentiality of all patients records must be ensured. There must be strict control of access to records, technological safeguards and heavy legal penalties for infringement.
  5. Control of the quality of the equipment used and the information sent is essential to ensure adequacy of care. Strict monitoring systems for calibration and maintenance of equipment are necessary for patient safety.