WMJ 03 2007
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WorldMMeeddiiccaall JJoouurrnnaall
Vol. No. 3, September 200753
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall 57
PPrrooffeessssiioonnaalliissmm aanndd tthhee MMeeddiiccaall AAssssoocciiaattiioonn 58
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
The Ethics of Stem Cell Research 74
Ethics and Human Rights news 75
HIV and Human Rights Handbook 76
WWMMAA CCPPDD ccoouurrssee iinn MMeeddiiccaall EEtthhiiccss–
FFuunnddaammeennttaallss iinn MMeeddiiccaall EEtthhiiccss 76
TToobbaaccccoo CCoonnttrrooll
Report on Progress made in the
Second Session of the Conference
of the Parties, WHO Framework
Convention on Tobacco Control,
Bangkok, Thailand, 30. June – 6. July 2007 77
WWHHOO
New world observatory launched with Spain 79
WHO launches ‘‘Nine patient safety solutions’’
to save lives and avoid harm 80
WHO and manufactorers move ahead
with plans for H5N1 influenza global
vaccine stockpile 81
WHO releases findings from research
project on travel and blood clots 81
Safe blood for mothers 82
Improved meningitis vaccine for Africa
could signal eventual end to deadly scourge 83
WMA General Assembly,
Copenhagen 3rd
–7th
October 2007
00_US_03_2007.qxd 19.09.2007 17:45 Seite 1
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr. J. Snaedal Dr. N. Arumagam Dr. Kgosi Letlape
Icelandic Medical Assn. Malaysian Medical Association The South African Medical Association
Hlidasmari 8 4th Floor MMA House P.O Box 74789
200 Kopavogur 124 Jalan Pahang Lynnwood Ridge 0040
Iceland 53000 Kuala Lumpur Pretoria 0153
Malaysia South Africa
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr. J. E. Hill Dr. K. Iwasa
Bundesärztekammer American Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 515 North State Street 2-28-16 Honkomagome
10623 Berlin Chicago, ILL 60610 Bunkyo-ku
Germany USA Tokyo 113-8621
Japan
Secretary General
Dr. O. Kloiber
World Medical Association
BP 63
01212 Ferney-Voltaire Cedex
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-11) 4381-1548/4384-5036
E-mail:
comra@confederacionmedica.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931/Fax: -933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-68
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 1857/Fax: 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
BMA Bhaban 5/2 Topkhana Road
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Calle Ayacucho 630
Tarija
Fax: (591) 4663569
E-mail: colmed_tjo@hotmail.com
Website: colegiomedicodebolivia.org.bo
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868-00/Fax: -31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 8610/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: rdelcastillo@colegiomedico.cl
Website: www.colegiomedico.cl
Title page: The Rigshospitalet, Copenhagen founded as King Frederik’s Hospital in 1757 celebrates its 250 anniversary this year. It became the State Hospital in 1910 and is now
integrated in the Copenhagen Hospital Corporation. With extensive resources and research activities it serves as the national specialist referral hospital for Denmark.
Below: The Headquarters of the Danish Medical Association which is hosting the General Assembly
of the World Medical Association this year, has been located in this attractive building since 1948.
U2–4_WMJ_03_07.qxd 19.09.2007 17:10 Seite U2
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Carrera 7 N° 82-66, Oficinas 218/219
Santafé de Bogotá, D.E.
Tel/Fax: (57-1) 256 8050/256 8010
E-mail: federacionmedicacol@
sky.net.co
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (243-12) 24589
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: hlz@email.htnet.hr
Website: www.hlk.hr/default.asp
CZECH REPUBLIC E
Czech Medical Association
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201-4
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association
(EsMA)Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388/Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 91/Fax-794
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel/Fax: (33) 1 45 25 22 68
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 369/Fax: -387
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, Chi-
naDuke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36 – PO.Box 145
1443 Budapest
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 23370009/23378819/
23378680
Fax: (91-11) 23379178/23379470
E-mail: inmedici@vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273Fax: (353-1)
6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: doritb@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
Website: www.lgs.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
E-mail: mld@unet.com.mk
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40413740/40411375
Association and address/Officers
ii
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Association and address/Officers
iii
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. D-107
Colonia Deportivo Obispado
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: rcantum@doctor.com
Website: www.cmm-fenacome.org
NAMIBIA E
Medical Association of Namibia
403 Maerua Park – POB 3369
Windhoek
Tel: (264) 61 22 44 55/Fax: -48 26
E-mail: man.office@iway.na
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 4225860, 231825
Fax: (977 1) 4225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 492 4179
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@cwpanama.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores, Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@cmp.org.pe
Website: www.cmp.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: medical@pma.com.ph
Website: www.pma.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24, 00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: intl@omcne.pt
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest
Tel: (40-1) 460 08 30
Fax: (40-1) 312 13 57
E-mail: AMR@itcnet.ro
Website: ong.ro/ong/amr
RUSSIA E
Russian Medical Society
Udaltsova Street 85
119607 Moscow
Tel: (7-095)932-83-02
E-mail: info@rusmed.ru
Website: www.russmed.ru
SAMOA E
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health Services
Apia
Tel: (685) 778 5858
E-mail: vialil_lameko@yahoo.com
SINGAPORE E
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road, 169850 Singapore
Tel: (65) 6223 1264
Fax: (65) 6224 7827
E-Mail: sma@sma.org.sg
www.sma.org.sg
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOMALIA E
Somali Medical Association
14 Wardigley Road – POB 199
Mogadishu
Tel: (252-1) 595 599
Fax: (252-1) 225 858
E-mail: drdalmar@yahoo.co.uk
SOUTH AFRICA E
The South African Medical Associa-
tionP.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/2063
Fax: (27-12) 481 2100/2058
E-mail: sginterim@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11, Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610, SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – C.P. 170
3000 Berne 15
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
Website: www.med.assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: www.medassocthai.org
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1002 Tunis
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary
Sehit Danis Tunaligil Sok. N° 2 Kat 4
Maltepe 06570
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
Website: www.ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Città del Vaticano
00120 Città del Vaticano
Tel: (39-06) 69879300
Fax: (39-06) 69883328
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam Medical Association
(VGAMP)68A Ba Trieu-Street
Hoau Kiem District
Hanoi
Tel/Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791553
Fax: (263-4) 791561
E-mail: zima@zol.co.zw
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OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Co-Editors
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2
D–50859 Köln
Germany
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
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The second half of the 20th
century and the beginning of this one have experienced unprece-
dented and ever increasing rapidity of technological development, scientific discovery,
research and the production of innovative diagnostic tools and therapeutic agents. All have
had enormous impact on medical practice, some have posed major ethical problems and –
not to be disregarded – increased public expectations of scientific discoveries and their
application in medicine, together with calls for, and the need of consequent changes in med-
ical practice.
In parallel, the huge expansion in the availability and accessibility of information about
medicine, medicines and medical research through the growth of communication via the
mass media and IT development, has played a major role in changes taking place in the
organisation and the conduct of medical practice. At the same time it has also, through the
instant availability on information via the media (both TV and the web) supplied com-
pelling information about the increasing instances of natural disasters and their conse-
quences. The instant availability of information has also highlighted to a wider public the
problems of disparity in the provision of health care in differing parts of the world. The
impact of information about the incidence of infectious diseases and the reality of the role
of poverty in disease, relayed through media readily accessible in the home, conveys an
even more realistic and compelling image of catastrophes, diseases and poverty, than that
previously available through the spoken or written word.
The impact of these developments has had substantial political, social and economic effects
in both developed and developing countries, leading to consequent changes in medical
practice and its organisation, as well as challenges to the nature of the role of physicians in
health care.
These developments have had far reaching impacts on the medical profession, including
effects on basic medical education, postgraduate education, licensing and regulation, con-
tinuing professional development and re-accreditation, not to mention the nature of health
care and the delivery of medical care. All of this has been accompanied by the increasing
burden of administrative, managerial functions and economic constraints.
On a number of occasions in these columns we have commented on these trends, the chal-
lenges which they are producing and the increasing need for the medical profession to
address them. Indeed, some of the issues have already been addressed in various parts of
the world (1) (2), and a Charter (3) endorsed by a number of organisations in at least 28
countries. (see annex to paper on Professionalism in this issue).
At its next meeting in October, the WMA Council will be considering these issues and with
this in mind , the current issue of WMJ is substantially devoted to a paper on the issue of
Medical Professionalism, in particular the role of the National Medical Associations. As
will be seen, this paper highlights important problems which should be considered urgent-
ly by individual physicians in whatever aspect of medical practice as well as NMA’s.
The inclusion of this substantial paper has substantial constraints on the normal contents of
the journal which we will include in the next issue. While this topic has already been
addressed in some parts of the world, we hope that it will stimulate further debate and con-
tribute to a clear affirmation of the qualities of medical professionalism in the 21st
century.
Alan J. Rowe
(1) Royal College of Physicians “Doctors’ in Society: Medical Professionalism in a changing World.
Report of a Working Party of the Royal College of Physicians, London: RCP 2005 (2) Rosen R, Dewar
S., On being a doctor Medical Professionalism in a changing world Kings Fund Publications 2004
(3) Medical Professional Project. Medical Professionalism in the new millennium. A physician charter.
Ann. Intern. Med 2002 136 (3) 243-246
Editorial
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58
“social contract” between medicine and
society. In contrast, nearly no attention has
been given to a consideration of medical
professionalism from the point of view of
organized medicine (1), in particular the
National Medical Association (NMA).
The intent of this paper is to briefly review
the current literature and thinking on med-
ical professionalism, to highlight some of
the various roles played by different med-
ical organizations, and to examine the inter-
section between medical associations and
professionalism. Finally, specific areas are
proposed where representative medical
associations might become involved in set-
ting guidelines or developing policies in
order to assist the collective profession, and
by extension its individual members, main-
tain and enhance medical professionalism
for the benefit of patients and the profession
alike.
Medical Professionalism:
Where do we stand?
Over the past few years, several articles
have been published that have helped to re-
focus the debate and discussion on medical
professionalism (2-8). The reason for this
renewed interest generally varies by situa-
tion and locality. Certainly in some
instances, it has been triggered by high-pro-
file medico-legal cases involving physician
misconduct or clinical misadventures and a
subsequent public perception that there
exists a desire by the members of the pro-
fession to “protect their own” in these situ-
ations. In other cases, the technological rev-
olution and resultant change in access to
medical information have caused physi-
cians and others to re-examine the nature of
the physician-patient relationship and the
interactions between these two parties. In
still others, discussion has focused on the
duty of physicians to society, and the need
to establish an updated and modernized
“social contract” between society and the
medical profession.
While a simple definition of medical pro-
fessionalism that satisfies everyone’s
requirements does not appear to exist, for
the purposes of this document it will be
defined generally as follows:
Medical professionalism describes the
skills, attitudes, values and behaviours com-
mon to those undertaking the practice of
medicine. It includes concepts such as the
maintenance of competence for a unique
body of knowledge and skill set, personal
integrity, altruism, adherence to ethical
codes of conduct, accountability, a dedica-
tion to self-regulation, and the exercise of
discretionary judgment. Professionalism is
also the moral understanding among med-
ical practitioners that gives reality to what is
commonly referred to as the social contract
between medicine and society. This contract
in return grants the medical profession a
monopoly over the use of its knowledge
base, the right to considerable autonomy in
practice and the privilege of self-regulation.
In February of 2002, the Annals of Internal
Medicine published an article entitled
“Medical Professionalism in the New
Millennium: A Physician Charter” (2) writ-
ten by Canadian, European and American
physicians. This document has engendered
much discussion, and the reaction to the
concepts it proposes has been both positive
and negative. The essential premise of the
Charter (2) is that professionalism is the
basis of medicine’s contract with society,
which demands placing the interests of
patients above those of the physician, set-
ting and maintaining standards of compe-
tency and integrity and providing expert
advice to society on matters of health. It
lays out 3 fundamental principles (primacy
of patient welfare, patient autonomy and
social justice) and 10 professional responsi-
bilities (commitments to: professional com-
petence, honesty with patients, patient con-
fidentiality, maintaining appropriate rela-
tions with patients, improving quality of
Professionalism and the Medical Association
Jeff Blackmer MD MHSc FRCPC
Executive Director, Office of Ethics, Canadian Medical
Association
Introduction
Medical professionalism, and an examina-
tion of exactly what it means to be a profes-
sional in today’s society, have received sig-
nificant attention in the medical, scientific
and lay press over the past few years. The
accelerated development of medical and
communication technologies, improve-
ments in access to medical information for
the public and direct to consumer advertis-
ing, have all changed the way in which
physicians and their patients interact. While
at times this change has been positive (for
example, through its empowerment of
patients to make medical decisions on their
own behalf), at other times the impact has
been negative, with many physicians feel-
ing pressured to prescribe medications or
order tests they might not have otherwise
chosen.
In some locations, the very nature of the
medical system itself forces physicians to
assume an entrepreneurial role and encour-
ages them to aggressively promote their
own medical services. These types of activ-
ity may be seen as being incompatible with
the traditional role of the physician as an
altruistic and selfless healer.
These changes and others have caused a
broad re-examination of the nature and
meaning of medical professionalism, what
it means to be a physician in today’s society
and culture, and the dynamic of the doctor-
patient relationship.
Traditionally, nearly all of the focus of the
discussion and debate in the literature on
medical professionalism has been centred
on attempts at arriving at a definition of the
concept of professionalism, the particular
obligations of individual physicians and the
WMJ_4_57-84.qxd 19.09.2007 17:07 Seite 58
59
care, improving access to care, a just distri-
bution of resources, scientific knowledge,
managing conflicts of interest and profes-
sional responsibilities including self-regula-
tion).
While several bodies and organizations
have adopted this Charter (see Appendix 1
for a complete list), others have been equal-
ly quick to point out its shortcomings (9-
10). However, few would be likely to argue
that it has not had a positive effect in renew-
ing and reinvigorating the debate and dia-
logue on the topic.
Recent developments in Britain are perhaps
especially illustrative of much of the pre-
sent public and professional discourse on
this complex issue. They also serve to high-
light the relatively large and diverse number
of relevant groups and stakeholders with an
interest in the issue, including physician
representative bodies such as National
Medical Associations. These developments
have included, among others, the following:
– The King’s Fund published a discussion
paper in 2004 entitled “On being a doc-
tor: Redefining medical professionalism
for better patient care” (11). This docu-
ment argues that the medical profession
as a whole needs to demonstrate better
its duty to serve patients’ interests in
order to show its ability to respond to
changing public expectations. It notes
that the “compact” between physicians,
the health care system and patients has
changed since the inception of the NHS
in 1948, and suggests that a new com-
pact is required that will show a higher
level of responsiveness to patient inter-
ests and a focus on identifying profes-
sional standards that are more in tune
with current values and expectations.
– Subsequently, the Royal College of
Physicians published a working party
report in December 2005 entitled
“Doctors in society: Medical profession-
alism in a changing world.” (12) The aim
of this working party was “To define the
nature and role of medical professional-
ism in modern society”. They define
medical professionalism as a set of val-
ues, behaviours and relationships that
underpin the trust the public has in doc-
tors. The values identified as being of
particular importance are integrity, com-
passion, altruism, continuous improve-
ment, excellence and working in partner-
ship with other members of the health
care team. They suggest that these values
should form the basis for a new moral
contract between the profession and
society.
– In 2006, the British Department of
Health released a report authored by the
Chief Medical Officer, Sir Liam
Donaldson, entitled “Good doctors, safer
patients: Proposals to strengthen the sys-
tem to assure and improve the perfor-
mance of doctors and to protect the safe-
ty of patients” (13). This report is aimed
particularly at the topic of regulation of
the medical profession, which in Britain
is performed under the auspices of the
General Medical Council (GMC). It
notes that in the early 1990’s, a series of
highly public medical scandals in the
United Kingdom gave rise to mounting
public concern.
The report itself was commissioned fol-
lowing the fairly scathing report of the
Shipman Inquiry, chaired by Dame Janet
Smith (14), which was extremely critical
of the GMC in arguing that its culture,
membership, methods of operation and
governance structures were too likely to
support the interests of doctors rather
than protect patients. The Donaldson
report notes that the current global trend
is a move away from pure self-regulation
to regulation in partnership between the
profession and the public. The report
recommends a regular assessment of
physicians’ clinical skills, a reshaping of
the role, structure and functions of the
GMC and an extension of medical regu-
lation to the local level to create a
stronger interface with the health care
system.
For many in the medical profession, the
Donaldson report represents much of the
current angst with respect to the poten-
tial weakening or total loss of physician
self-regulation, which for the majority of
doctors is one of the key pillars of med-
ical professionalism. There appears to be
a concerning trend in many parts of the
world whereby governments and others
are challenging and eroding the concept
of physician self-regulation (and indeed
the self-regulation of other professions
as well).
– The British Medical Association (BMA)
released a report on “Regulation of the
medical profession” in March 2007 (15).
It is critical of both the Donaldson report
and the resulting government White
Paper, “Trust, Assurance and Safety: The
regulation of health professionals in the
21st century” (16) which was published
in February 2007. The government doc-
ument contains a series of proposals that,
according to the BMA, would add up to
the loss of professionally-led medical
regulation. These proposals include:
removal of the adjudication function
from the GMC, having GMC Council
members appointed rather than elected ,
and a new composition of the GMC
Council with 50:50 lay and medical
members. The BMA argues that with a
state owned medical system (the NHS),
and an appointed regulatory body, physi-
cians might find themselves compro-
mised in their ability to use their clinical
independence to ensure optimal patient
management, thus diminishing their
medical professionalism.
It is against this backdrop of recent publica-
tions and events, and ongoing develop-
ments in the United States, Europe, Canada,
Australia, New Zealand, Hong Kong and
elsewhere, that the roles of the various bod-
ies and stakeholders in medicine and health
care will be considered.
Organisational roles:
Who does what?
The number and types of organisations
involved in educating, licensing, regulating
and representing physicians vary signifi-
cantly depending on the individual country
or geographic region. In some locations, in
spite of the obvious challenges and poten-
tially significant conflicts of interest, the
same body or organisation assumes several
of these roles. In general, one or more
organisations are involved in the following
areas of activity:
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60
1) Education: Educational standards and
curriculum setting are required for
undergraduate medical education (i.e.
medical schools) and postgraduate med-
ical education (i.e. internship and resi-
dency training). In some places the same
organization will be involved in both,
while in many places these roles are sep-
arated. As well, many countries have
bodies that oversee and accredit continu-
ing medical education (CME) initiatives
that help to ensure that practicing physi-
cians have access to educational
resources throughout the life cycle of
their careers. Educational organizations
may also administer examinations to
ensure the adequacy of the knowledge
and clinical skills of the physician-in-
training, and may grant certificates of
general or specialty designations on suc-
cessful completion of the training pro-
gramme and examinations.
2) Licensing: After physicians have com-
pleted their training, most places require
them to obtain a license for the practice
of medicine, usually within a specific
field or area of expertise. The require-
ments for licensure (and training back-
ground) may vary significantly by coun-
try or region. In some situations, exten-
sive testing and examination require-
ments will also exist. In some countries,
a separate license is required to practice
in different parts of the country, with dif-
ferent standards in each region and no
transportability of licensure.
3) Regulation: The licensed, practicing
physician is generally held to a certain
standard that they must meet in an ongo-
ing fashion in order to continue to prac-
tice medicine. This standard, and the
way in which it is enforced, may also
vary significantly. The specific body
involved in regulation may also vary
both between and within countries
Traditionally, as for many of the “learned
professions”, physicians have been held
responsible for professionally-led self-
regulation, which many see as a privi-
lege that must be continually earned. In
practice, this requires physicians to form
organizations that will receive allega-
tions of professional misconduct or clin-
ical negligence, investigate the com-
plaints, render a judgement and impose a
penalty. This activity and process is gen-
erally separate from the legal or civil lit-
igation systems of that country.
The rationale for self-regulation is that
physicians, by virtue of their extensive
educational requirements and their
unique grasp of a complex body of med-
ical knowledge, obtained through years
of training and experience, are felt to be
in the best situation to be able to judge
their peers.
The argument against self-regulation is
that it may be perceived as being overly
self-serving and that the majority of the
members of a profession will inherently
want to “protect their own”, so that
physicians who misbehave or under-per-
form clinically will not be properly cen-
sured or reprimanded by their peers. As a
result, many countries have developed a
system of regulation whereby lay mem-
bers of the public participate actively in
the process. In almost all cases, these
public members make up a minority of
the total membership of the regulatory
bodies.
Many regulatory bodies have also
assumed the role of ensuring that physi-
cians remain up-to-date in their clinical
knowledge and skills. This “revalida-
tion” activity varies significantly by
country. In some situations, it is a matter
of providing proof that a physician is
participating in CME activities on a reg-
ular basis, while in others the practicing
physician may be required to repeat in-
depth testing and examination on a regu-
lar basis in order to maintain their
license to practice. Where no evidence
exists to link the particular standard of
revalidation to quality of patient care and
outcomes, this activity may understand-
ably be of some concern to physicians.
4) Representation: In nearly every country,
there exists an association or organiza-
tion that represents the interests of physi-
cians (as exists for most professions).
Some countries may have one or more
competing organizations of this type.
Most commonly (although not always),
this body takes the form of a National
Medical Association, whose name gen-
erally consists of the name of the country
followed by the Medical Association
designation (for example, Chilean
Medical Association, Indian Medical
Association, Russian Medical
Association and so on).
Some have argued that the roots of mod-
ern representative medical associations
date back to the formation of guilds in
the 12th and 13th centuries (17). The
features of guilds at that time included
the power of association and self-regula-
tion (including training), control over the
means of production or workplace, con-
trol of the market and power over rela-
tions with the state. However, it may be
more accurate to say that today’s med-
ical associations represent the concept of
freedom of coalition that evolved fol-
lowing Napoleon’s dissolution of the
guilds and his introduction of a democra-
tic system in the early 1800’s.
The type and degree of specific activity
in today’s medical association can vary.
In many instances, they provide specific
benefits to their members, including the
ability to connect with a network of their
peers. In some countries, the NMA is
involved in advocacy activities on behalf
of its membership. This can include lob-
bying governments for improved work-
ing conditions and health care system
reform, and often includes lobbying on
behalf of patients to improve the level
and quality of the care they receive.
In other countries, the NMA also acts as
a bargaining body for its membership so
that it negotiates contracts and fee struc-
tures on their behalf. In some situations,
the association may actually have an
official “union” designation. Other
NMA’s have also assumed various edu-
cational and regulatory roles.
Given the large number of roles undertaken
by the NMA’s of some countries, it is not
surprising that conflicts occasionally arise
in the course of their activities. For exam-
ple, an association that is actively advocat-
ing on behalf of its membership might not
be seen as being able to also assume a reg-
ulatory role that requires it on occasion to
publicly censure some of its members, or
WMJ_4_57-84.qxd 19.09.2007 17:07 Seite 60
61
remove their license to practice medicine.
In the case of those NMA’s that negotiate
contracts on behalf of their membership,
some have questioned whether they can
also be legitimately involved in setting stan-
dards of professional behaviour and codes
of conduct.
The next section of this paper will explore
the intersection between medical profes-
sionalism and the representative medical
association.
Professionalism and
Medical Associations
The following quote probably best summa-
rizes the concerns that most commonly
arise at the intersection of representative
medical associations and medical profes-
sionalism (1):
“ Medicine is, in essence, a moral enter-
prise, and its professional associations
should therefore be built on ethically
sound foundations. At the very least,
when physicians form associations, such
occasions should promote the interests
of those they serve. This, sadly, has not
always been the case, when economic,
commercial, and political agendas so
often take precedence over ethical oblig-
ations. The history of professional med-
ical associations reflects a constant ten-
sion between self-interest and ethical
ideals that has never been resolved.”
Most would agree that representing the eco-
nomic, commercial and political interests of
physicians and organized medicine as a
whole is a legitimate and important under-
taking, and likely one best done by a body
with democratic representation of the pro-
fession. In many cases (though certainly not
all), this representation and the resultant
advocacy also serve to further the cause of
patients and improve the care that they
receive.
The greater concern arises when the actions
(or inactions) of an NMA appear to serve
only their own self-interests. If individual
physicians have an obligation to put the
care of their patients above all else, should
this obligation extend as well to their repre-
sentative associations? If we are to say that
altruism and integrity are key values for the
medical professional, are they by extension
key values for the professional’s association
as well?
The argument has been made (1) that:
“…effacement of self-interest is the dis-
tinguishing feature of a true profession
that sets it apart from other occupa-
tions….When physicians form associa-
tions, they should make this promise col-
lectively…. Without such a commit-
ment, they easily degenerate into self-
serving trade associations, lobbies or
unions….In a properly conceived pro-
fessional association, physicians should
associate to improve the care of the sick,
to advance the health of the public, and
to ensure that their fellow associates are
faithful to that mission…Associations
should be aware of the dangers of
focussing attention on the economic con-
cerns of their members at the expense of
their more important public and profes-
sional responsibilities.”
According to this argument, physician asso-
ciations should make an active and consid-
ered decision: to represent the vested inter-
ests of their members, or of their patients,
but in general probably not both, as the
interests of the two groups will too often be
mutually exclusive.
All professions are represented in some way
by a body or organization that serves to fur-
ther their particular needs and interests.
Without this, that particular profession
would soon disappear from the horizon as
members of other more organized and more
ably represented professions, slowly (or
rapidly) eroded its place in the social order.
It is patently impossible to make the argu-
ment that physicians do not require collec-
tive representation. Like all other profes-
sions, they will be legitimately concerned
about their work environment and safety,
educational and promotional opportunities,
salary levels, and all the other things
employed persons need to care about.
However, medicine is substantively differ-
ent from most other professions, and the
fundamental difference is its commitment
to the welfare of the individual patient, and
the tradition of placing the interests of this
patient above those of the medical practi-
tioner. How can we reconcile these compet-
ing principles? Can a medical association
serve both its members and the patients they
care for?
The 1991 President’s Address to the Annual
Meeting of the House of Delegates of the
American Medical Association (AMA) (18)
by Dr. John Ring provides some direction in
this regard. The address states, inter alia:
“The new AMA has chosen the right
road for medicine: the course of profes-
sionalism, of patient advocacy, and of
personal sacrifice. It is the way of help-
ing doctors be better doctors – not neces-
sarily richer, not necessarily more pow-
erful, not necessarily more authoritative
– but better doctors…
The new AMA is a confluence of profes-
sionals whose clear agenda is the health
of the American people. …We are a doc-
tor’s organization, working for the good
of our patients, rather than a pressure
group aiming for political power as a
way to build organizational predomi-
nance, to create personal prestige, or to
line our own pockets…
Professionalism is our very identity as
doctors. And the basic act of profession-
alism is a doctor looking after a patient:
the doctor-patient relationship. We can
accept nothing that threatens this rela-
tionship by trying to turn medicine into a
mere trade, a dispassionate business ven-
ture, an impersonal public utility.”
Dr. Ring goes on to describe a new AMA
initiative examining the issue of access to
care. Clearly, the interests of both patients
and physicians are served by improving
access to care. He uses this as a prototypical
example of where the AMA should be
focusing its efforts. From this, we under-
stand that organized medicine has a legiti-
mate claim at representing its own interests,
and that this representation can and should
be done by a representative medical associ-
ation. However, these interests, like those of
the individual physician, should not super-
sede or replace the interests of patients in
the collective.
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62
Perhaps the vision statement of the
Canadian Medical Association (19) best
captures the preferred approach. In describ-
ing its vision, it lists only two aims: “A
healthy population and a vibrant medical
profession.” The promotion of both ideals
can and should coexist in the same repre-
sentative medical association. But the rank
ordering of these priorities, which is clearly
not random, should not change.
The next section will examine specific
issues and areas where medical associations
can set guidelines, policies and standards to
advance the professionalism of the associa-
tion and its members while also striving to
serve the best interests of patients and soci-
ety.
Potential areas of activity
There are several potential areas where rep-
resentative medical associations might
become actively involved in promoting and
enhancing professionalism within the asso-
ciation and for their membership. What fol-
lows is a discussion of some of these areas,
recognizing that others are likely to exist as
well.
1) Pandemic and disaster preparedness
Since the experience with the Severe Acute
Respiratory Syndrome (SARS) epidemic of
2003, there has been much discussion in the
medical literature regarding issues of pro-
fessionalism and medical care during a cri-
sis situation, be it pandemic or otherwise
(20-23). Although it is generally accepted
that physicians and other health care work-
ers have a duty to provide care in such a sit-
uation, several important questions have
been raised as part of the broader discus-
sion. These include:
– What exactly is the obligation of health
care providers during a pandemic? Is it
to provide care to all those in need
regardless of the level of personal risk?
– Do physicians and others have a right to
refuse to provide care when their own
health (or that of their family) is at risk?
– Is the provision of services during a pan-
demic based in whole or in part on the
obligation of governments and others to
provide reciprocal services to physi-
cians? If this reciprocity is not honoured,
are physicians then absolved of their
obligations?
Clearly, these are questions not easily
answered. While some have argued that
physicians and other health care workers
appear to have an absolute obligation to
provide care regardless of the circum-
stances in which they find themselves (24,
25), others have argued that this obligation
may vary depending on the particular situa-
tion and circumstances (26-28). There are
clearly compelling arguments to be made
on both sides. The professional obligations
of physicians in this situation are also well
set out in various codes of ethics and regu-
latory documents.
Traditionally, physicians have respected the
principle of altruism, whereby, throughout
history, they have set aside concern for their
own health and well-being in order to serve
their patients. While this has generally man-
ifested itself primarily as long hours away
from home and family, and a benign neglect
of personal health issues, at times more
drastic sacrifices have been required.
During previous pandemics, physicians
have served selflessly in the public interest,
often at great risk to their own well-being
(although it should be noted that there are
also isolated historical exceptions of physi-
cians who have fled from such situations;
Galen and Sydenham both fled from
patients with contagious epidemic diseases)
(29).
Since the experience of SARS, the concepts
of reciprocity and reciprocal obligations
have received significant attention from
physicians and others both in and outside of
the health care field. During this crisis,
many health care workers found themselves
assuming great personal risk, sometimes
with very little support and assistance from
governments, hospitals, health districts and
others. Several physicians and nurses con-
tracted the virus, and some of these died as
a result. It has become increasingly clear
that more support will be expected during
the next public health crisis, particularly in
developed countries that have the necessary
resources to provide this support.
As the University of Toronto Joint Centre
for Bioethics report, “We stand on guard for
thee” (30), states:
“(The substantive value of) reciprocity
requires that society support those who
face a disproportionate burden in pro-
tecting the public good, and take steps to
minimize burdens as much as possible.
Measures to protect the public good are
likely to impose a disproportionate bur-
den on health care workers, patients and
their families.”
Some of these reciprocal obligations, which
should be undertaken by governments, hos-
pitals, and others, might include:
– Physicians and the associations that rep-
resent them should be more involved in
planning and decision making at the
local, national and international levels.
In turn, physicians and the associations
that represent them have an obligation to
participate in these discussions.
– Physicians should be made aware of a
clear plan for resource utilization,
including:
– clearly defined physician roles and
expectations, especially for those
practicing outside of their area of
expertise;
– vaccination/treatment plans – clarifi-
cation of whether health care workers
(and their families) will have prefer-
ential access based on the need to
keep caregivers healthy and on the
job;
– triage plans, including how the triage
model might be altered and plans to
inform the public of such.
– Physicians and health care providers
should have access to the best equipment
needed and should be able to undergo
extra training in its use if required.
– Physicians and health care providers
should have access to up-to-date, real
time information. They should be kept
informed about developments locally
and globally.
– Resources should be provided for back-
up and relief of physicians and health
care workers.
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63
– Physicians and health care providers
should receive financial compensation to
cover expenses such as lost wages, lost
group earnings, overhead, medical care,
medications, rehabilitative therapy, and
other relevant expenses in case of quar-
antine, clinic cancellations or illness.
– Families should receive financial com-
pensation in the case of a physician fam-
ily member who dies as a result of pro-
viding care during a health care crisis.
– Physicians should be given expanded
liability coverage as required, particular-
ly for those practicing outside of their
area of expertise.
– Psychological and emotional counselling
and support should be provided in a
timely fashion for physicians, health care
providers, their staff and family mem-
bers.
It should be noted that meeting these recip-
rocal obligations might not be possible in
less developed countries which lack suffi-
cient resources to do so. For example, in
countries with few resources and poor infra-
structure, even providing soap for all health
care workers might be difficult. In this case,
situational reciprocity must be ensured; that
is, health care workers should be provided
with whatever resources are available in
order to optimise patient care and the safety
of the workers.
What NMA’s can do on the issue of disaster
and pandemic preparedness
National Medical Associations can develop
guidelines on disaster and pandemic pre-
paredness that will specifically outline for
their membership exactly what is expected
of them in such a situation, and what their
professional obligations entail. They can
also assist their members, and the public, by
helping ensure that governments, hospitals
and others understand and meet the recipro-
cal obligations (as outlined above) that will
be critically important for ensuring the care
and safety of patients and physicians alike
during a pandemic or other public health
emergency.
2) Conscientious objection
In this context, conscientious objection is a
term generally used to refer to a situation
where a physician or other health care
worker refuses to provide treatment or ther-
apy on the grounds that such provision
would violate their strongly held moral
principles. The concept originated during
wartime tension between religious freedom
and patriotic obligations (31) and was sub-
sequently co-opted during the reproductive
rights debates of the 1960 and ‘70s
The most common examples in the litera-
ture and in day-to-day medical practice con-
tinue to involve reproductive medicine:
specifically, the provision of therapeutic
abortion services and access to contracep-
tive devices and medication. More recently,
the issue of access to post-coital contracep-
tion and abortifacient options has garnered
much attention, from both the physician and
pharmacist perspective, with reports of
pharmacists refusing to dispense emergency
contraception dating back to 1991 (32). The
past several years have seen an increase in
legislative initiatives, particularly in the
United States under the current Republican
administration, designed to protect health
care providers who refuse to participate in
specific reproductive procedures or prac-
tices (33).
Other less common issues sometimes
referred to during a discussion of conscien-
tious objection include euthanasia, physi-
cian assisted suicide, assisted reproductive
technologies, assistance during executions
and experimentation on human embryos
(34).
A recent New England Journal of Medicine
article has served to highlight the scope of
the issue, at least in the United States (35).
According to a survey of 1144 physicians,
most physicians (63%) believe that it is eth-
ically permissible for physicians to outline
their moral beliefs and objections to their
patients. The majority (86%) also agree that
physicians must present all options regard-
ing specific therapies and treatments to their
patients – which of course means that a
sizeable minority of 14% of physicians are
not providing all the information required
by their patients. In addition, 71% of physi-
cians feel that a doctor has an obligation to
refer a patient to another clinician to obtain
a service to which the referring physician is
morally opposed.
There are several possible advantages in
allowing physicians to invoke the concept
of conscientious objection as a reason for
refusing to participate in certain procedures
or therapies. It allows the physician to stay
true to their morals and values; in general,
society does not require professionals to
forsake their morals upon entry into a par-
ticular profession. It allows medical profes-
sionals to exercise their independent judge-
ment. And the right to refuse to participate
in acts that conflict with personal, ethical,
moral or religious convictions is generally
accepted as an essential element of a free
and democratic society (33).
There are also several possible downsides
when physicians invoke the right of consci-
entious objection. This practice may limit
access to care and consequently have a
detrimental impact on the health of patients.
It can serve to impose the values and per-
sonal morals of the physician on the patient.
It may be in direct opposition with the
obligation of the physician to provide care
without discrimination. Furthermore, pro-
fessional autonomy is not without its limits
and the interests of the patients are general-
ly held to take precedence over those of the
physician. Finally, the practice can intro-
duce elements of inefficiency, inequity and
inconsistency into a medical system (36).
While there are clearly arguments to be
made on both sides of the issue, some
authors have particularly strongly held
beliefs. In a recent article in the British
Medical Journal, Savulescu (36) claims
that:
“A doctor’s conscience has little place in
the delivery of modern medical care.
What should be provided is defined by
the law and consideration of the just dis-
tribution of finite medical resources,
which requires a reasonable conception
of the patient’s good and the patient’s
informed desires. If people are not pre-
pared to offer legally permitted, effi-
cient, and beneficial care because it con-
flicts with their values, they should not
be doctors.”
There seems to be general agreement in the
medical and ethics literature, current Codes
of Medical Ethics and legislative approach-
es on several issues. First, it would appear
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64
that physicians and other health care
providers have at least a limited right to
refuse to participate in certain procedures or
therapies if these are in opposition to their
values and beliefs. However, one needs to
distinguish this right from the right to refuse
to refer a patient to a clinician who will pro-
vide these services. While there is some
debate about this issue, the majority of the
current literature, if not current policy and
legislation, appears to support the obliga-
tion to refer (33, 36, 37, 38).
From the perspective of the National
Medical Association, this issue would
appear to provide fertile ground for policy
development and professional guidance.
What NMA’s can do on the issue of consci-
entious objection
It is suggested that policy development in
this area should consider and address at
least 6 aspects of the issue:
1) The concept of conscientious objection,
its history and its current use should be
carefully and comprehensively outlined.
2) In general terms, there appears to be
agreement that physicians have a right to
stay true to their personal values and
morals and to exercise their independent
professional judgement. They also have
the right to inform their patients of such,
but not in a way that is unduly coercive
or argumentative.
3) Physicians should understand that they
should not refuse to provide urgently
needed care by using the concept of con-
scientious objection. A distinction must
be made between an acute situation
where immediate care is required to save
a life or maintain health, as opposed to a
less acute situation where there is time
for a patient to seek medical services
elsewhere.
4) Physicians should not obstruct, actively
or passively, patients from receiving care
from another clinician. Although health
professionals may have a right to object,
they do not have a right to obstruct (33).
5) Physicians should provide their patients
with all the information they require
regardless of the personal values of the
physician. For patients to give valid
informed consent, they have to be
informed of the relevant alternatives and
their risks and benefits in a reasonable,
complete and unbiased way. This con-
cept is one of the central tenets of mod-
ern medical ethics and cannot be under-
mined based on conscientious objection.
6) NMA’s should address the issue of
whether or not the conscientious objec-
tor has a duty to refer the patient to
another clinician for services the objec-
tor will not provide. Clearly worded
guidance in this area will be of benefit to
patients and physicians alike.
While some NMA’s may elect to include
this information within the context of a
related policy (for example, a policy on
therapeutic abortion), because the concept
of conscientious objection can apply in sev-
eral different types of clinical situations, it
is suggested that it is preferable to develop
a separate policy that can be used in multi-
ple circumstances.
3) Self-regulation
The general concept of self-regulation has
been outlined above in the section on orga-
nizational roles. In some parts of the world,
the term “self-governance” is used inter-
changeably with self-regulation, while in
other areas the regulatory function is felt to
be one part of the overall governance func-
tion. For ease of understanding, the term
“self-regulation” will be used in this docu-
ment.
It is fair to say that the vast majority of rep-
resentative medical associations, if not all
of them, support and encourage the concept
of self-regulation of the medical profession.
From a physician standpoint, it would not
be advantageous to have their actions or
clinical decisions evaluated by lay people
and members of the public who are not like-
ly to have the necessary training or experi-
ence to make those judgements. In addition,
this is an area where individual physicians
can demonstrate their collective sense of
responsibility rather than through some-
times abstract principles or declarations.
From the standpoint of the general public,
they need to have confidence that the regu-
lation of physicians is fair, open and trans-
parent and that physicians are held liable for
any clinical or professional transgressions
in a significant and meaningful way so that
such transgressions will not be repeated in
the future. They need to be confident that
self-regulation does not mean self-protec-
tion. Some degree of public involvement in
regulatory bodies is now generally well
accepted, but physicians usually become
concerned when consideration is given to
having these organizations constituted with
a public majority, meaning that decision
making will then be outside the control of
the profession.
According to the website of the College of
Physicians and Surgeons of Ontario (39),
the self-regulatory body for physicians
practicing in this Canadian province, the
relationship between the College, the pro-
fession and the public is as follows:
“The College of Physicians and
Surgeons of Ontario governs the practice
of medicine in the public interest. It does
not exist to protect the medical profes-
sion. The profession’s interests are well
represented by other bodies, including
the Canadian Medical Association.
The medical profession has been permit-
ted by legislation to play a leading role in
the protection of the public. It does this
through the College. This is what is
meant by „self-regulation.“ Self-regula-
tion should never be confused with pro-
fessional autonomy. The profession,
through the College, is always account-
able to the public.”
It is not uncommon for there to be a some-
what strained relationship between repre-
sentative medical associations and those
organizations involved in physician self-
regulation. While the public may see regu-
latory bodies as occasionally overly protec-
tive of physicians and not always acting in
the best interests of the public, some physi-
cians find them unnecessarily intrusive,
interventionist and restrictive when it
comes to regulating the day-to-day practice
of medicine. However, in order to preserve
the privilege of self-regulation, the medical
profession must be clearly seen to be acting
in the best interests of the public and not of
the profession itself.
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65
The concept of self-regulation of the med-
ical profession presents a situation where
representative medical associations may
find themselves with a choice to make,
between representing the desire of their
membership for more freedom to practice
medicine in a fully autonomous way with
little “unnecessary” regulatory intrusion,
versus supporting the public desire to
strengthen the regulatory oversight of
physicians and increase the transparency of
the system. As suggested previously, and
for reasons outlined above, the interests of
the public and patients should take prece-
dence in this type of situation.
What NMA’s can do on the issue of self-
regulation
This does not mean that NMA’s should
acquiesce to any and all demands of regula-
tors and the public. It does mean that they
should support, through policy, advocacy
and action, legitimate efforts to improve the
quality of medical care and outcomes
through regulatory oversight of their physi-
cian members.
Unduly intrusive activities that have not
been shown to improve the quality of
patient care are not necessarily appropriate.
Efforts at revalidation of physicians should
not simply be exercises intended to reassure
the public and legislators, but should truly
strive to improve the quality of medical
practice, and should be based on solid evi-
dence demonstrating that the means used
will be efficient and effective. It may be up
to NMA’s to help ensure that this evidence
exists and is incorporated in a meaningful
way.
NMA’s should develop policy or position
statements clarifying their support for self-
regulation and outlining the importance of
this concept to the maintenance of medical
professionalism. They should assist their
members in understanding that self-regula-
tion cannot be perceived as being protective
of physicians, but must maintain the sup-
port and confidence of the general public.
4) Interactions between physicians and
industry
Perhaps nowhere in medicine today is the
potential for conflict of interest greater than
in the interaction between physicians and
private industry. These industries can
include pharmaceutical companies, medical
device manufacturers and makers of other
products like baby formulas. In short, any
private interest whose income generation
depends on physician prescription or
approval of their product.
From a business standpoint, the model is
fairly simple. In most businesses, the prod-
uct is marketed directly to the public
through means such as advertising and
word of mouth campaigns. However, in
medicine, the companies must go through
the “middle man”, the physician. The physi-
cian must prescribe a product, usually a
medication, which is then purchased by the
consumer, their patients. Sound and accept-
ed business practice means that the compa-
nies will mount marketing and advertising
campaigns to influence physician prescrib-
ing patterns in favour of their company,
thereby increasing their income and market
share.
The pharmaceutical industry has tradition-
ally denied that they attempt to influence
physician prescribing behaviour, instead
insisting that their marketing efforts are
simply intended to educate physicians on
new products in order to ensure that their
prescribing choices are well-informed and
based on the latest available scientific liter-
ature. However, there is now much evi-
dence to the contrary.
To start with, the information presented to
physicians is usually extremely biased,
often inaccurate, and intended to portray the
target product in a favourable light. A
Spanish study revealed that 44.5% of the
information provided by pharmaceutical
representatives to family physicians is fac-
tually erroneous and is biased towards their
own products (40). An Argentinean study
(41) concluded that 46% of references
given in literature distributed by industry
representatives did not concur with the
claims made in the company’s literature. A
German study (42) found that 94% of the
information in brochures for doctors had no
basis in scientific evidence; while many
brochures had cited publications that could
not be found, the majority of information
found in them did not accurately reflect the
publications that they cited.
This mounting body of evidence hardly
supports the industry argument that physi-
cian education is the true intent of its infor-
mation dissemination. Clearly the purpose
is instead to provide information in such a
way that physicians will view the product in
a more favourable light and be more likely
to prescribe it to their patients.
Secondly, a significant number of former
pharmaceutical representatives and industry
insiders have recently come forward to
reveal the internal machinations of the busi-
ness. One states: “An unofficial, and more
accurate, job description for a sales rep
would be: Change the prescribing habits of
physicians.” (43). Another says: “It is my
job to figure out what a physician’s price
is…everything is for sale and everything is
an exchange” and “It’s my job to constantly
sway the doctors. Doctors are neither
trained nor paid to negotiate. Most of the
time they don’t even realize that’s what
they’re doing.” Perhaps most concerning,
this same former representative (43) went
on to write:
“The concept that reps provide necessary
services to physicians and patients is a
fiction. Pharmaceutical companies spend
billions of dollars annually to ensure that
physicians most susceptible to marketing
prescribe the most expensive, most pro-
moted drugs to the most people possible.
If detailing were an educational service,
it would be provided to all physicians,
not just those who affect market share.
Every piece of information provided is
carefully crafted, not to assist doctors or
patients, but to increase market share for
targeted drugs.”
Finally, an increasing number of studies are
revealing that pharmaceutical marketing
does impact physician prescribing habits
(44-48). The old argument that “it just does-
n’t affect me” does not hold water anymore,
nor does the assertion that “It may influence
my colleagues, but it does not influence
me”.
Given the current lack of public funding for
CME events and medical research, and the
resulting reliance of these important activi-
ties on private industry funding, most
physicians seem to be in agreement that
banning all forms of contact between physi-
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66
cians and industry is not feasible or perhaps
even desirable. However, there is clearly a
need to develop policies and guidelines in
this area to help regulate the relationship in
order to avoid the appearance or presence of
real or perceived conflicts of interest.
The bodies setting these policies can vary
and may include some or all of the follow-
ing:- government and legislators, medical
regulators, physician representative associ-
ations, medical specialty groups, and the
industry itself. The argument is made here
that these policies should be developed and
led by the profession, should be clear and
transparent and should ensure that any
interactions taking place between physi-
cians and industry will be only for the clear
benefit of patients, not of for physicians or
industry.
What NMA’s can do on the issue of interac-
tions between physicians and industry
National medical associations can and
should develop clear and comprehensive
policy in this area to ensure that their mem-
bers do not find themselves in a position of
conflict of interest. They should widely dis-
tribute these policies to their membership
and others, and undertake educational ini-
tiatives to clarify their importance, intent
and content. They should use their advoca-
cy capabilities to help ensure that these
physician-led guidelines become the
accepted standard for all the other partici-
pants involved, including industry.
At a minimum, these guidelines should
address the following topics:
– a clear explanation of the issue and the
concept of conflicts of interest
– gifts to physicians, including social sci-
ence literature on gift giving
– drug samples and their impact on pre-
scribing behaviour and drug costs
– educational and promotional materials
aimed at physicians
– CME events (including electronically-
delivered CME) and sponsorship,
including physician payment for partici-
pation
– physician participation and patient enrol-
ment in industry-sponsored research tri-
als, including physician payment for par-
ticipation
– disclosure obligations for physicians
submitting research or providing educa-
tional sessions
– physician participation as medical advi-
sors or on advisory boards, and the dis-
tinction between these activities and
marketing
-peer selling and direct physician promotion
of individual products or companies
– how medical students and residents
should approach the issue
Those NMA’s without sufficient resources
to develop their own policy in this area may
wish to adopt the policy of other NMA’s or
of the World Medical Association (49).
Physician representative associations
should also give careful consideration to
developing stringent internal policy for
governing relationships between the organi-
zation and third parties. This will serve to
set an example for the membership and
ensure that the association itself is able to
avoid situations of conflict of interest (a les-
son learned painfully by the American
Medical Association during a brief sponsor-
ship deal with Sunbeam in the 1990’s).
5) Interprofessionalism
Traditionally, and until relatively recently,
health care had been delivered in what can
best be described as a multidisciplinary
model of teamwork. In this model, each
member of the health care team fulfilled a
certain well-defined and predetermined role
with little or no overlap between the activi-
ties of the team members. Ultimate deci-
sion-making authority rested nearly always
with the physician.
More recently, this model has evolved into
one of interdisciplinary team care (or “inter-
professionalism”) whereby the members of
the team work collaboratively together to
help ensure optimum patient care and out-
comes. In this model, there may be some
overlap between the roles and responsibili-
ties of the team members, based on what is
in the best interests of the individual patient
at that particular point in time. For example,
a speech and language pathologist might
prescribe a specific dysphagia diet based on
their clinical assessment, or a pharmacist
might renew a prescription without consult-
ing the physician. Unfortunately, studies
have shown that even in this model the pro-
vision of health services is still often
fraught with interprofessional conflict, dis-
sension and misunderstandings (50).
In the current context of limited health
human resources, and particularly limited
physician resources, it makes inherent sense
to take full advantage of the abilities of each
member of the health care team. These
members can include, but are not limited to,
physicians, physician assistants, nurses,
nurse practitioners, pharmacists, occupa-
tional and physical therapists, psycholo-
gists, speech and language pathologists,
social workers and dieticians.
In general terms, the move towards inter-
professionalism has particularly impacted
on the role and responsibilities of the physi-
cian, as many of the expanded roles of team
members have been into areas traditionally
occupied by the physician on the team.
While physicians have by and large accept-
ed and sometimes actively embraced such
changes, particularly where they have been
shown to impact positively on patient care
and outcomes (although it should be noted
that such an impact has not been conclu-
sively proven) (51), they have also shown
well-placed concern when warranted.
Although physicians have been often criti-
cized as “defending their turf” or being
unwilling to relinquish complete control
over patient care, there are justifiable rea-
sons to approach interprofessionalism with
caution. It should also be noted that the
assumption of traditional physician duties
by other professions is not a new concept,
as witnessed by the undertaking of surgery
by barbers and the medical treatment of
patients by apothecaries.
It is at times unclear as to who has ultimate
responsibility for patient care. If everyone
is responsible, then no one is truly responsi-
ble. In addition, when physicians provide
direct medical care and there is a mishap,
then medico-legal liability, once estab-
lished, is usually fairly straightforward. In
an interprofessional model of care, the
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67
physician may not be constantly aware of
services or recommendations being provid-
ed by other team members, yet the patient
and their lawyers may expect the physician
to assume ultimate liability for this care if
harm occurs. Where individual liability
ends and group liability begins might not
always be clear.
Different professions may have different
Codes of Ethics with different values, stan-
dards and priorities. As a recent example,
while the American Psychiatric Association
(52) has clearly stated that sharing clinical
knowledge for the purpose of using this
information to torture or gain admissions
from terrorism suspects is unprofessional
and unacceptable behaviour, the American
Psychological Association has elected not
to take this stance (53, 54). When compet-
ing principles of various team members
occur during patient care, how are we to
determine which one will win out?
There are professional divisions based on
demographics, gender composition, class of
origin of members, educational attainment,
status and relative size and source of prima-
ry income; these have all been cited as
obstacles to the development of interdisci-
plinary collaboration in the health field
(51). Medicine is a long-established and
fairly large profession whose members
come mostly from a well-educated, small,
upper class and earn a high income. Thus, it
is argued that:
“The raw power of medicine, combined
with a high degree of professional self-
confidence developed by doctors and
consciousness of these differences in
prestige among other occupational
groups, contributes to a degree of mutu-
al wariness and defensiveness as each
occupation attempts to defend its own
territory. For most of the twentieth cen-
tury the health division of labour has
been organised and hierarchically struc-
tured around the dominant profession of
medicine. However, over recent decades
medicine’s claims to autonomy and
dominance have been increasingly chal-
lenged by non-medical groups.” (51)
Interdisciplinary relationships are also often
political. Different occupational groups
attempt to establish clear professional
demarcations and demand that their exper-
tise be recognized. They construct their own
distinct codes and standards and advance
what they deem to be their own ethical the-
ories (for example, “medical ethics” versus
“nursing ethics”) (55).
Different professions may use different
standards to judge the acuity of a case or sit-
uation. When other professionals then apply
their own frames of reference to make sense
of a situation, they may differ intensely over
the priority the case is assigned (51). This
may be a source of significant conflict
amongst team members.
Professional differences may also have
been reinforced by various court decisions.
For example, decisions by the English
courts in the early twentieth century empha-
sized the responsibility of medical practi-
tioners and the subservient nature of nurses
(56). Although more recent court decisions
have not been quite as harsh, there are those
who feel that the earlier approach still has
some influence on attitudes to the responsi-
bilities of those offering care to patients
(51).
Unfortunately, relationships between health
care professionals remain fraught with
organizational, status and value differences
(55). An Australian survey of hospital
admissions reported that problems with pro-
fessional interactions were the most com-
mon cause of preventable disability or death
in the intensive care unit, and were twice as
common as those due to poor medical skill
(57).
There is a significant body of work on the
topic of interprofessional education and
training at the medical school and under-
graduate level (58 – 61) but relatively little
guidance when it comes to educating post-
graduate trainees or practicing physicians.
While tomorrow’s physicians may be well
equipped to work in collaborative practice
models, today’s physicians may require
extra guidance and training in this area, as
many of the skills and concepts required are
not necessarily inherently known.
What NMA’s can do on the issue of inter-
professionalism
In spite of the many challenges of interpro-
fessionalism and interdisciplinary models
of care, it is clearly a concept that is becom-
ing firmly entrenched in today’s patient care
settings. In order to optimise patient care
and outcomes, physicians must be able to
work collaboratively with a wide variety of
health professionals in different settings.
Representative medical associations can
assist their members (as well as their
patients and other health care professionals)
by developing policy and guidance in this
complex area. Such policy should ideally
include:
– a review and definition of the concept of
interprofessionalism with attention given
to both the medical and non-medical lit-
erature
– a clarification of the relevant medico-
legal liability issues, including the need
for all team members (and not just physi-
cians) to carry liability insurance; this
may need to be done in partnership with
local and/or national medical malprac-
tice insurance carriers where appropriate
– an approach towards education in this
area for medical students, postgraduate
medical trainees and physicians in prac-
tice, as well as other health care profes-
sionals who will be working in the team
setting
– an integrated or separate policy or docu-
ment outlining the issue of scopes of
practice for the various health care pro-
fessions, including the fact that roles and
scopes must be in keeping with the rele-
vant training and expertise and should
not exceed the capabilities of a given
field (for example, professionals not
trained to provide a diagnosis should not
be licensed to do so; this is not in keep-
ing with clinical or ethical standards and
is a potential threat to patient care and
well-being)
– a clarification on potentially competing
ethical principles and Codes of Ethics to
ensure that physicians understand their
individual obligations in this regard
6) Clinical practice guidelines (CPGs)
Clinical practice guidelines or CPG’s, are
systematically developed statements that
aim to help physicians and patients reach
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68
the best possible health care decisions (62).
While they have been in existence for a
long time, recent years have seen an explo-
sion in their numbers. They go beyond sys-
tematic reviews of the literature by recom-
mending what should and should not be
done in specific clinical circumstances.
Generally, CPG’s are developed by a group
of writers with representatives from clinical
medicine, research, and epidemiology,
among other disciplines. The body or orga-
nization sponsoring their development may
vary significantly, from an uninterested
third party (rare), to a medical society or
association (more common) to a disease
specific organization (perhaps increasingly
common). The funding for each type of
group may also vary, with differing degrees
of private and public sponsorship. Private
sponsorship usually comes from parties
with a vested interest in the outcome of the
process, particularly the pharmaceutical
industry (and less commonly the insurance
industry). Pharmaceutical companies can
benefit from the outcome of a CPG either
through the recommendation of a specific
therapeutic agent or a lowering of the
threshold required before the use of an
agent. Sometimes the source of financial
sponsorship is made transparent, but it is
not uncommon for it to remain relatively
anonymous (or hidden).
Not only the process itself, but also the
actual participants in the process, may also
be subject to potential conflicts of interest.
This has been the focus of much debate in
the medical and scientific literature as of
late (63-65). Two recent publications have
helped to outline the scope of this problem.
One study (66) notes that 87% of authors of
CPG’s had some form of interaction with
the pharmaceutical industry. Fifty eight per-
cent had received financial support to per-
form research and 38% had served as
employees or consultants for a pharmaceu-
tical company. Only 2 published CPG’s out
of 44 examined made declarations regard-
ing the personal financial interactions of
individual authors with drug companies.
Another report (67) on more than 200
CPG’s from various countries deposited in
2004 with the United States National
Guideline Clearinghouse found that more
than one third of the authors declared finan-
Potential area of activity What NMA’s can do
1) Pandemic and disaster
preparedness
– develop guidelines on disaster and pandemic preparedness
that will specifically outline for their membership exactly
what is expected of them in such a situation, and what their
professional obligations entail
– assist their members, and the public, by helping ensure that
governments, hospitals and others understand and meet the
reciprocal obligations that will be critically important for
ensuring the care and safety of patients and physicians
alike during a pandemic or other public health emergency
2) Conscientious objection – outline the concept of conscientious objection, its history
and its current use
– assist members to understand that they should not refuse to
provide urgently needed care by using the concept of con-
scientious objection
– assist members to understand that they should not obstruct,
actively or passively, patients from receiving care from
another clinician
– address the issue of whether or not the conscientious objec-
tor has a duty to refer the patient to another clinician for
services the objector will not provide
3) Physician self
regulation
– support, through policy, advocacy and action, legitimate
efforts to improve the quality of medical care and out-
comes through regulatory oversight of their physician
members
– help ensure that efforts at revalidation of physicians are not
simply exercises intended to reassure the public and legis-
lators, but truly strive to improve the quality of medical
practice, and are be based on solid evidence demonstrating
that the means used will be efficient and effective
– develop policy or position statements clarifying their sup-
port for self-regulation and outlining the importance of this
concept to the maintenance of medical professionalism
– assist their members in understanding that self-regulation
cannot be perceived as being protective of physicians, but
must maintain the support and confidence of the general
public.
4) Physician-industry
interactions
– develop clear and comprehensive policy in this area to
ensure that their members do not find themselves in a posi-
tion of conflict of interest
– widely distribute these policies to their membership and
others, and undertake educational initiatives to clarify their
importance, intent and content
– use their advocacy capabilities to help ensure that these
physician-led guidelines become the accepted standard for
all the other participants involved, including industry
– give careful consideration to developing stringent internal
policy for governing relationships between the organiza-
tion and third parties
Table 1 – Summary of potential areas of NMA activity
WMJ_4_57-84.qxd 19.09.2007 17:08 Seite 68
69
cial links to relevant drug companies with
nearly 70% of panels being involved, and
almost half of the CPG’s providing no
information about conflicts of interest.
It is increasingly clear that the problem of
conflicts of interest in the development of
CPG’s is widespread and under-reported.
While there are those who argue that it is
not possible to develop CPG’s without
using authors linked to industry, since these
authors are experts in the field and are
sought both by the companies and the bod-
ies producing the CPG’s, some organiza-
tions have taken steps to remedy this situa-
tion. Various guidelines have been devel-
oped to ensure that any possible conflicts
are declared to all those involved in the
process of CPG development and that those
with conflicts are given reduced or modi-
fied roles. For example, since 1999 the
National Institute for Health and Clinical
Excellence (NICE) has provided guidance
on appropriate clinical practice within
Britain’s National Health Service. NICE
has taken steps to avoid situations arising
from potential conflicts of interest, requir-
ing members of its advisory bodies to
declare financial and other interests. If a
conflict is identified, the individual will be
required to step down and not take part in
the decision-making process (68).
Other criticisms of CPG’s have included the
fact that some leave little room for devia-
tion in the case of individual patients whose
needs may differ, that they may present
physicians with difficult medico-legal situ-
ations if CPG’s are held to be the standard
of care, and that they may provide reasons
for insurers to deny coverage.
While National Medical Associations have
not been traditionally involved in the actual
development of CPG’s, there may well be
an important role for them to play in the
process of ensuring the highest standards of
care based on the use of recent, high quali-
ty, unbiased CPG’s by practicing clinicians.
There are some good examples of NMA’s
who have become involved in this area.
The American Medical Association, togeth-
er with the Agency for Healthcare Research
and Quality and the American Association
of Health Plans, initially assisted in the
development of the National Guideline
Clearinghouse in the United States
(www.guideline.gov). The National
Guideline Clearinghouse is a comprehen-
sive database of evidence-based clinical
practice guidelines and related documents.
Its mission is “to provide physicians, nurs-
es, and other health professionals, health
care providers, health plans, integrated
delivery systems, purchasers and others an
accessible mechanism for obtaining objec-
tive, detailed information on clinical prac-
tice guidelines and to further their dissemi-
nation, implementation and use” (69).
The Canadian Medical Association, on its
website at www.cma.ca, provides its mem-
bership with access to a service called CMA
Infobase. This site provides access to CPG’s
which are produced or endorsed in Canada
by a national, provincial/territorial or
regional medical or health organization,
professional society, government agency or
expert panel. In addition, the CMA and one
of its provincial divisions, the Ontario
Medical Association, have combined with
Potential area of activity What NMA’s can do
5) Interprofessionalism – develop policy and guidance in this complex area, includ-
ing:
– a review and definition of the concept of interprofessional-
ism
– a clarification of the relevant medico-legal liability issues
– an approach towards education in this area for medical stu-
dents, postgraduate medical trainees and physicians in
practice, as well as other health care professionals who will
be working in the team setting
– an integrated or separate policy or document outlining the
issue of scopes of practice for the various health care pro-
fessions
– a clarification on potentially competing ethical principles
and Codes of Ethics to ensure that physicians understand
their individual obligations in this regard
6) Clinical practice
guidelines
– provide physicians with access to recent, high quality,
unbiased CPG’s by:
– actively screening guidelines for their membership
– providing a quality rating for each guideline
– organizing the many thousands of CPG’s into areas of clin-
ical content and relevancy
– selecting the most appropriate and relevant guidelines for
use by their members
– providing a clearinghouse for the screened and selected
CPG’s with membership access on its website or other
location
7) Organizational ethics – develop thoughtful and well-articulated mission, vision
and values statements that are produced with input from
association staff
– develop internal organizational policies and codes which
address specific ethical and professional issues
– make efforts to promote the above policies and documents
– measure and evaluate the impact of these policies, and
keep them updated in an ongoing fashion
– ensure that the physician membership of the association is
aware of these internal policies
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70
the Ontario Ministry of Health and Long
Term Care to form the Guidelines Advisory
Committee (GAC) (70). For selected topics
relevant to clinicians, patients and the
health care system, the GAC identifies,
rates and endorses the best available guide-
line (71). The GAC uses the Appraisal of
Guidelines, Research and Evaluation
(AGREE) tool to assess the quality of
CPG’s. The AGREE tool was created and
validated for physicians to use in rating
guidelines according to their process of
development by identifying the factors that
are considered important in judging their
quality (72). On the CMA website, a rating
of the quality of the guideline development
process for those guidelines that have been
reviewed by the GAC is included.
What NMA’s can do on the issue of clinical
practice guidelines
Providing physicians with access to recent,
high quality, unbiased CPG’s will enhance
medical professionalism by increasing the
quality of patient care and outcomes and
ensuring that patients everywhere receive
the same high standard of care. Although it
is probably not reasonable to expect NMA’s
to participate in the production of the guide-
lines themselves, given the relative intensi-
ty of resources required to do so, they can
assist in the process by:
– actively screening guidelines for their
membership using a validated tool such
as AGREE
– providing a quality rating for each guide-
line based on a validated tool such as
AGREE
– organizing the many thousands of CPG’s
into areas of clinical content and rele-
vancy
– selecting the most appropriate and rele-
vant guidelines for use by their members
(for example, there are over 300 English
CPG’s on the management of high cho-
lesterol, and NMA’s could review these
and choose the highest quality 2 or 3
CPG’s)
– providing a clearinghouse for the
screened and selected CPG’s with mem-
bership access on its website or other
location (which also provides a direct
benefit of membership in the associa-
tion)
7) Organizational ethics and profession-
alism
Organizational ethics has been defined as
“the articulation and application of the con-
sistent values and moral positions of an
organization by which it is defined, both
internally and externally” (73). It is general-
ly articulated via values statements, mission
and vision statements, organizational codes
of ethics, policies addressing specific ethi-
cal issues, and especially through its effects
on the attitudes and activities of everyone
associated with the organization.
This represents in many cases a relatively
new approach to the consideration of ethics
in organizations, particularly healthcare
organizations. With the Enron scandal (74)
and other recent developments in the busi-
ness world and elsewhere, organizational
ethics have become increasingly important
both in practice and to reassure stakeholders
and others that an ethics framework is in
place.
While the medical literature in this area
focuses on healthcare organizations such as
hospitals, health care districts and health
maintenance organizations (HMO’s) (74-
76), the general principles of this approach
can be applied to representative medical
associations as well. While these associa-
tions serve an important role in helping to
guide their individual member physicians in
professional and ethical standards, as out-
lined in previous sections of this paper, hav-
ing robust internal policies will also help to
set a high standard of behavior and provide
an example of professionalism from within
the organization.
There are four important strategies that can
be used to help build a solid ethics infra-
structure in a medical organization (77).
These include:
1) Conducting a formal process to clarify
and articulate the organization’s values
and link them to the mission and vision
statements. This should include building
the mission, vision and values statements
into the introduction of the strategic
plan, involving all employees in the
design of the mission, vision and values
statements, using facilitated group
approaches to discuss these statements
and using team building strategies to
enhance organizational values.
2) Facilitating communication and learning
about ethics and professionalism.
Specific strategies include:
a. placing mission and vision statements in
highly visible locations throughout the
organization
b. offering training programmes that
encourage interaction about the organi-
zation’s values
c. using role playing, case studies and
lunchtime educational sessions to facili-
tate communication about ethics and
professionalism
d. engaging employees in values clarifica-
tion techniques
3) Creating structures that encourage and
support the culture. These structures
should be multiple, interconnected and
diffused throughout the organization,
and ideally should include an ethics
infrastructure with sufficient dedicated
staff and resources.
4) Creating processes to monitor and offer
feedback on ethical performance.
Specific strategies include:
a. using ethics and professionalism audits
b. examining processes and/or outcomes of
ethical decision making
c. regular evaluation of the organization’s
mission, vision and values statements
The American Medical Association has
published a document entitled
“Organizational ethics in healthcare: toward
a model for ethical decision-making by
provider organizations” (78). While the
document specifically notes that its focus is
on organizations that provide health care to
individual patients, and not other organiza-
tions such as associations of health care
professionals, several of the principles
reviewed are of relevance. For example, the
document discusses in some detail the pri-
oritization of competing principles to help
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71
organizations understand that patient health
is their ultimate priority, regardless of other
competing considerations. The paper also
provides an overview of various sources of
organizational ethics for provider organiza-
tions, including business ethics, profession-
al accountability and law and social con-
text.
What NMA’s can do on the issue of organi-
zational ethics
It is very important that a representative
medical association exhibit strong organiza-
tional ethics. Not only does this assist with
ensuring the proper prioritisation of associ-
ation objectives and strategies, it also helps
demonstrate to the physician membership
the importance the organization places on
ethics and professionalism. An NMA can-
not expect its membership to respect and
follow the ethical codes and policies it pro-
duces without first setting the same high
standards for the NMA itself. Associations
can do this by:
– developing thoughtful and well-articu-
lated mission, vision and values state-
ments that are produced with input from
association staff and physicians
– developing internal organizational poli-
cies and codes which address specific
ethical and professional issues (for
example, harassment in the workplace,
individual and organizational conflict of
interest, and professional interactions
with outside third parties)
– making efforts to promote the above
policies and documents, including them
both during orientation of new staff, and
in an ongoing manner through retreats
and educational sessions
– measuring and evaluating the impact of
these policies, and keeping them updated
in an ongoing fashion
– ensuring that the physician membership
of the association is aware of these inter-
nal policies via mailings, journals and
websites
Summary
In many respects, medical professionalism
is currently at a crossroads. The nature of
the physician-patient relationship continues
to evolve, as physicians struggle to redefine
their role in an ever-changing society that is
in the midst of a technological revolution.
Threats to medical self-regulation and
evolving physician scopes of practice have
caused many practicing doctors to question
whether the profession itself will ever be
the same.
At the same time, change often represents
opportunity. Many have seized this chance
to try to redefine the concept of medical
professionalism and refocus attention on the
sanctity of the physician-patient relation-
ship. New social contracts have been
devised to help physicians understand how
to balance their competing priorities and
roles. Task forces have been formed, reports
have been written and hands have been
wrung. Whether all this activity will have a
lasting impact remains to be seen.
Representative physician organizations are
in a unique position. They serve in many
instances as the public face of the profes-
sion, and help make known and understood
the views of physicians on important mat-
ters. They also have the opportunity to be
standard-setters for the profession, to help
shape and mould the ongoing evolution and
development of medical professionalism.
While the literature to date focuses with
near exclusivity on the roles and obligations
of individual physicians, there is much that
medical associations can do, both internally
and externally, to advance and promote the
concept. Whether this is done in isolation
from, or together with, other relevant med-
ical and non-medical bodies will vary
depending on individual circumstances.
The objective of this paper has been to
examine medical professionalism through
the lens of the representative medical asso-
ciation rather than the individual clinician.
Through providing both general and specif-
ic, concrete suggestions and examples of
current and future potential activities which
might be undertaken, it is hoped that it will
add in a positive and constructive way to
the preservation of what most doctors con-
sider to be at the core of medicine: the role
of the physician as healer and professional.
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Appendix 1
Organizations that have endorsed the
Physician Charter:
Accreditation Council for Graduate Medical
Education
Administrators of Internal Medicine
Alliance for Academic Internal Medicine
American Academy of Allergy, Asthma and
Immunology
American Academy of Dermatology
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology–Head
and Neck Surgery
American Academy of Pediatrics
American Academy of Physical Medicine and
Rehabilitation
American Board of Medical Specialties
American Board of Allergy and Immunology
American Board of Anesthesiology
American Board of Colon and Rectal Surgery
American Board of Dermatology
American Board of Emergency Medicine
American Board of Family Practice
American Board of Internal Medicine
American Board of Medical Genetics
American Board of Neurological Surgery
American Board of Nuclear Medicine
American Board of Obstetrics and Gynecology
American Board of Ophthalmology
American Board of Orthopedic Surgery
American Board of Otolaryngology
American Board of Pathology
American Board of Pediatrics
American Board of Physical Medicine and
Rehabilitation
American Board of Plastic Surgery
American Board of Preventive Medicine
American Board of Psychiatry and Neurology
American Board of Radiology
American Board of Surgery
American Board of Thoracic Surgery
American Board of Urology
ABIM Foundation
American College of Dentists
American College of Medical Genetics
American College of Obstetricians and
Gynecologists
American College of Physicians
American College of Radiology
American College of Surgeons
ACP Foundation
American Orthopaedic Association
American Osteopathic Association
American Psychiatric Association
American Society of Anesthesiologists
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Medical Ethics and Human Rights
74
American Society of Clinical Pathologists
American Society of Plastic Surgeons
American Urological Association
Association of Academic Physiatrists
Association of American Medical Colleges
Association of Physicians of Ireland
Association of Physicians of Malta
Association of Professors of Medicine
Association of Program Directors in Internal
Medicine
Association of Subspecialty Professors
Austrian Society of Internal Medicine
Belgian Society of Internal Medicine
Clerkship Directors in Internal Medicine
Chinese Medical Doctors Association
College of Physicians and Surgeons of British
Columbia
Council of Deans, Association of Canadian
Medical Colleges
Council of Medical Specialty Societies
Czech Society of Internal Medicine
Danish Society of Internal Medicine
Estonian Society of Internal Medicine
European Federation of Internal Medicine
Federation of Royal Colleges of Physicians of
United Kingdom
Federation of State Medical Boards
Finnish Society of Internal Medicine
French Society of Internal Medicine
German Society of Internal Medicine
Hellenic Society of Internal Medicine
Hungarian Society of Internal Medicine
Icelandic Society of Internal Medicine
Israeli Society of Internal Medicine
Italian Society of Internal Medicine
Latvian Society of Internal Medicine
Lithuanian Society of Internal Medicine
Luxembourg Society of Internal Medicine
Medical Council of Canada
Ministero della Salute
Netherlands Society of Internal Medicine
North American Society of Radiologists
Polish Society of Internal Medicine
Portuguese Society of Internal Medicine
Residency Review Committee for Internal
Medicine
Royal Australasian College of Physicians and
Surgeons
Royal College of Physicians of Edinburgh
Royal College of Physicians of Ireland
Royal College of Physicians of London
Royal College of Physicians and Surgeons of
Canada
Slovak Society of Internal Medicine
Slovenian Society of Internal Medicine
Society of Neurological Surgeons ociety of
Nuclear Medicine
Society of Thoracic Surgeons
Spanish Society of Internal Medicine
Swedish Society of Internal Medicine
Swiss Society of Internal Medicine
Turkish Society of Internal Medicine
embryos for research is usually very rigor-
ous. Some countries restrict the embryonic
cell lines that their researchers are allowed
to use to ones that have been derived in
accordance with strict ethical requirements.
The introduction of human stem cells into
animals is either forbidden or severely lim-
ited.
The ethical issues of stem cell research have
been widely discussed by medical associa-
tions and scientific organizations, including
the following:
• In 2006 the WMA Assembly adopted a
Statement on Assisted Reproductive
Technologies that deals in part with stem
cell research:
– Due to the special nature of human
embryos, research should be carefully
controlled and should be limited to
areas in which the use of alternative
materials will not provide an adequate
alternative.
– Views, and legislation, differ on
whether embryos may be created
specifically for, or in the course of,
research. Physicians should act in
accordance with national legislation
and local ethical advice.
– Cell nuclear replacement may also be
used to develop embryonic stem cells
for research and ultimately, it is hoped,
for therapy for many serious diseases.
Views on the acceptability of such
research differ and physicians wishing
to participate in such research should
ensure that they are acting in accor-
dance with national laws and local eth-
ical guidance.
• The WMA is currently considering a
Proposed Statement on Stem Cell
Research for possible adoption at its
October 2007 Assembly in Copenhagen.
• In 2003 the American Medical
Association adopted a policy on
Cloning-for-Biomedical-Research that
reads in part: „While the pluralism of
moral visions that underlie this debate
must be respected, physicians collective-
ly must continue to be guided by their
paramount obligation to the welfare of
their patients. In this light, cloning-for-
The Ethics of Stem Cell Research
Dr. John Williams
(from WMA Ethical issues of the month)
During the past decade a great deal of scien-
tific research activity has been devoted to
human stem cells. Considerable progress
has been made in deriving and replicating
cell lines and in understanding cell biology.
The ultimate goal of this activity is to devel-
op therapeutic applications of this knowl-
edge, but it is still uncertain how successful
this quest will be.
From the outset stem cell research has
raised ethical issues over and above those
associated with other types of medical
research. The principal cause of ethical
uncertainty and conflict has been the use of
human embryos as the source of stem cells
for research. Despite claims that adult stem
cells may be equally suitable for therapeutic
purposes, there is a strong consensus among
scientists working in this field that embryo
stem cells are better suited for research pur-
poses. However, since the derivation of
these cells requires the destruction of the
embryo, the question arises whether or not
such research is fundamentally unethical.
Proponents of embryo stem cell research
are not insensitive to the special ethical sta-
tus of the human embryo and there has been
substantial agreement on certain limitations
to such research. Ethical guidelines and
national legislation generally prohibit the
creation of embryos for research, allowing
research only on embryos created but no
longer wanted for reproductive purposes.
The consent process for the donation of
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Medical Ethics and Human Rights
75
biomedical-research is consistent with
medical ethics. Every physician remains
free to decide whether to participate in
stem cell research or to use its products.“
• The Australian Medical Association has
expressed support for embryonic stem
cell research.
• The British Medical Association is like-
wise in favour of embryonic stem cell
research: „The BMA supports the use of
carefully controlled research, including
research using human embryos where
necessary for the development of tissue
for transplantation and the development
of methods of therapy for mitochondrial
diseases.“
• The International Society for Stem Cell
Research website includes a number of
ethics-related documents, such as The
Ethics of Human Embryonic Stem Cell
Research.
• The U.S. National Institutes of Health
website provides a useful set of
resources on this topic: Bioethics
Resources on the Web – Stem Cell
Research.
Presumed Consent for removal
of organs from dead patients
While “presumed consent” for the removal
of organs from dead patients for transplant
purposes exists in a number of countries,
this does not apply in the United Kingdom.
The U.K Chief Medical Officer, Sir Liam
Donaldson, in his annual report (1) has
raised the issue again. Commenting that in
the UK it is estimated that of the total 7234
on the UK waiting list for transplants one
person dies each day, he proposes that in
view of the shortage of donated organs the
principle of “presumed consent“ should be
introduced. This would mean that organs
“donated” for transplant would at least dou-
ble to meet present demands. He further
suggest that those wishing to “opt out” of
donation in the event of their death should
be specifically registered (a system which
in a number of countries is implemented in
so – called ”hard” and “soft” ways – see
below).
The report comments on the experience of
other countries. Acknowledging “there have
been concerns that such an approach would
be viewed as totalitarian” the report contin-
ues “However, as long as the option to vol-
untarily opt out from the system is both
available and easily accessible and strict
measures are applied to protect vulnerable
groups, the experience shows that such a
system can command public confidence.”
In the “hard“ version presumed consent
allows organs to be removed unless the
individual had formally registered an objec-
tion during his lifetime and no account
would be taken of the views of relatives.
In the “soft” version presumed consent
would permit removal of organs unless:
– the person had registered an objection
during their lifetime;
– it is clear form information provided by
the relatives that the individual had
expressed an objection to donation but
had not officially registered this;
– it is clear that removal of organs would
cause major distress to the relatives.
“On the State of the Public Health: Annual
report of the Chief Medical Officer 2007”
HMSO com 7093
UK Human Fertilisation and
Embryology Authority (HFEA)
issues statement on licensing of
human-animal hybrids.
The UK HFEA, following a detailed and
comprehensive consultation on the licens-
ing of human animal hybrids and chimera
research which involved both scientists and
the wider public issued a statement on its
decision taken at its recent meeting.
“Having looked at all the evidence, the
Authority has decided that there is no fun-
damental reason to prevent cytoplasmic
hybrid research. However, public opinion is
very finely divided with people generally
opposed to this research unless it is tightly
regulated and is likely to lead to scientific
or medical advancements. It continues
”This is not a total green light to cytoplas-
mic hybrid research, but recognition that his
area of research can, with caution and care-
ful scrutiny, be permitted. Individual
research teams should be able to undertake
research projects involving the creation of
cytoplasmic hybrid embryos if they can
demonstrate, to the satisfaction of the
HFEA licence committee, that their planned
research project is both necessary and desir-
able and meets the standards required by the
HFEA for any embryo research.”
The authority indicated that its licence com-
mittee will now look at the details of the
two research application referred to it earli-
er this year and hope to have a decision in
November.
Currently Stem Cell Nuclear Transfer using
animal eggs is permitted in some countries,
often under special conditions, whereas in
other its is specifically forbidden.
www.hfea.gov.uk/en/1581.html accessed
11/09/2007
Ethics and Human Rights news
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Medical Ethics and Human Rights / WMA CPD
76
WMA CPD course in Medical Ethics-Fundamentals
in Medical Ethics
The World Medical Association, in cooperation with the Norwegian Medical Association has developed a web-
based continuing professional development course on Medical Ethics.
Working through the course should enable participants to:
– understand the role of ethics in medicine;
– recognise ethical issues when the arise in practice;
– deal with these issues in a systematic manner
The course, which is now online has been accredited by the Norwegian Medical Association with 8 hours/points
in post-graduate and continuing education. On completion of the course, the tests and evaluation an accredi-
tation/certificate will be issued if desired.
Further details of the WMA courses are accessible through the WMA website www.wma.net. More courses and
versions of existing courses are being developed.
Current courses:
– Doctors working in Prison: human rights and ethical dilemmas.
– Fundamentals of Medical Ethics
Medical Ethics and Human Rights
HIV and Human Rights Handbook
A new Handbook on HIV and Human
Rights was launched by the Office of the
High Commissioner for Human Rights
OHCR) and the Joint UN Programme on
HIV/AIDS (UNAIDS) at the Eighth
International Congress on AIDS in Asia and
the Pacific held in Sri Lanka 19-23 August
2007. This is intended to help national
human rights institutions to include HIV in
their human rights mandates, providing an
overview of the role of human rights in
responding to the HIV epidemic. It includes
suggestions for activities which could be
carried out by national human rights institu-
tions in their existing work and collaborat-
ing with national AIDS programmes.
UNAIDS Executive Director Peter Piot is
reported as saying that “ This is a critical
time for national human rights institutions
to engage in the AIDS response. W e has
learned that we will not succeed unless we
address discrimination, gender inequality
and other human rights abuses that drive the
epidemic”.
UN Human Rights Commissioner for
Human Rights Louise Arbour referred to
the Handbook as” an essential guide for
nationals institutions in their efforts to
ensure that States are held accountable for
protecting the rights of people living with
HIV.
In 2006, countries committed themselves to
achieve universal access to HIV prevention,
treatment, care and support by 2010.As they
scale up their efforts towards this goal it is
essential that they deal with the stigma, dis-
crimination and gender inequality that have
been identified as major obstacles to univer-
sal access.
Copies of the Handbook are available from
OHCR and UNAIDS
UN press release and OHCHR media
release 27/28.08.07
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Tobacco Control
77
Tobacco Control – new guideline
Report on Progress made in the Second Session of the Conference
of the Parties, WHO Framework Convention on Tobacco Control,
Bangkok, Thailand, 30. June – 6. July 2007
Dr. Song Lih Huang, MD, MSc.
Secretary General
Taiwan International Medical Alliance
Each year tobacco use causes approximate-
ly 5 million deaths worldwide. Because of
the increasing prevalence of tobacco use in
many developing countries, it is estimated
that by the year 2030, the death toll will
increase to 10 million per year, with 70%
coming from middle- and low-income
countries. Although deaths associated with
tobacco use are preventable, it would take
society an extraordinary effort for the pre-
vention to be effective. In view of the cross-
border nature of tobacco trade, and the vast
differences among governments on the con-
cept and practice of tobacco control, it was
recognized in the late 1990s that a global
health treaty could help individual countries
to strengthen legislative and regulatory
measures
The WHO Framework Convention on
Tobacco Control (FCTC) was adopted
unanimously by the 56th World Health
Assembly on 21 May 2003, and the FCTC
entered into force in February 2005 after 40
countries had ratified it. Two Conferences
of the Parties (COP) have been held, the
first in February 2006 (Geneva) and the sec-
ond in 30 June – 6 July, 2007 (Bangkok).
At the second COP, the parties:
adopted a guideline on protection
from exposure to tobacco smoke
(Article 8 of FCTC); see also annex.
• set up an international negotiating body
to prepare a protocol on illicit trade with
a timetable which envisages its readiness
for adoption at the fourth COP in 2010;
• agreed to ask the secretariat to work on
guidelines on Article 11 (packaging and
labeling of tobacco products) and Article
13 (regulations on domestic and cross-
border tobacco advertising, promotion
and sponsorship) with the aim of adopt-
ing these guidelines at the third COP in
2008;
• agreed to work on guidelines on Article
5.3 (protection from tobacco industry
interference), Article 12 (education,
communication, training and public
awareness) and Article 14 (cessation);
• agreed to continue with work on Article
9 and 10 (product testing, measurement
and disclosure) and 17 (economically
viable alternative activities); and
• agreed to set aside funding for all these
activities.
The official documents about FCTC and
COP can be found on WHO websites
(http://www.who.int/tobacco/framework/en
and http://www.who.int/gb/fctc/). Useful
information is also available at the
Framework Convention Alliance website
(http://www.fctc.org/).
It was quite remarkable to be able to make
such progress during any international
meeting, reflecting the fact that most coun-
tries have begun to realize the magnitude of
damage done by tobacco use. However, the
challenges for medical professionals in each
country still lie ahead. Three types of effort
will require medical professionals to take
actions in order to save millions of lives.
First, not all countries have ratified the
FCTC. There are currently 148 parties
(including the European Community) to the
FCTC. Understandably, several African
countries which rely on the exportation of
tobacco leaves as their major revenue will
certainly need to find ways for alternative
agricultural or other income-generating
activities before the governments will com-
ply with the goals of reducing world tobac-
co consumption. On the other hand, almost
all industrialized countries have ratified the
FCTC, with the notable exceptions of USA
and Russia. The health professionals in
these countries have to exert their utmost
influence on the government to give priori-
ty to the health of people both domestic and
abroad.
Secondly, the FCTC and its associated
agreements are instruments meant to assist
individual government in the legislative and
implementation processes towards tobacco
control. Take “the guideline for the protec-
tion from exposure to tobacco smoke” for
example. This guideline will be helpful to
people exposed to secondhand smoke only
if the governments are willing and able to
make effective laws or policies to restrict
smoking in public places. The health pro-
fessionals in each country should try to con-
vince law makers of the necessity, urgency,
and feasibility of taking effective measures,
citing the international health treaty and the
examples of successes from many countries
with various cultural characteristics. The
FCTC has been very helpful in moving
countries forward in tobacco control as the
international treaty makes the issue more
prominent on the political agenda and
health professionals should take advantage
of this.
The third challenge is for medical profes-
sionals of the rich countries which benefit
from the tobacco industry. One of the major
issues during the third COP was Article 13
(Tobacco advertising, promotion and spon-
sorship). As the barriers to international
trade are diminishing, cross-border adver-
tising and promotion are becoming more
difficult to regulate. This is particularly so
in developing countries which have limited
resources and capability for monitoring and
law enforcement. Another formidable chal-
lenge for these countries is the need to enact
strong legislation controlling foreign com-
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Tobacco Control
78
panies, and facing the possibility of dire
consequences involving international trade
arbitration. Cross-border advertising and
promotion do not come out of thin air. They
are sophisticated products of tobacco com-
panies (often based in rich countries) with
the sole purpose of addicting boys and girls
of less privileged countries. Medical profes-
sionals in rich countries have the moral duty
to try to limit the political power of the
tobacco industry. It is an act that can protect
the future lives and fortunes of people.
As stated above, agreements made at the
second COP will continue to be worked on,
and hopefully will yield meaningful results
in the third and fourth COPs. The adopted
guideline has started to serve the purpose of
protecting people from exposure to tobacco
smoke, and the protocols being developed
now promise to help countries deal with
illicit trade and advertisement/promotion
which are hard to control by any single
country. The progress on this international
health treaty is to be celebrated, but it
awaits the effort of each country to consoli-
date the benefits of FCTC. Medical profes-
sionals should stay involved and play more
active roles in this regard.
Annex 1 (Extract from Guidelines on
protection from tobacco smoke)
The following extracts from this docu-
ment set out the objectives and main
principles upon which the Guidelines on
implementing Article 8 of the FCTC
adopted by the 2nd
FCTC COP at the
Bangkok meeting, are based.
“Purpose of the guidelines
1 Consistent with other provisions of the
WHO Framework Convention and the
intentions of the Conference of Parties
(COP), these guidelines are intended to
assist Parties (to the convention) in meet-
ing their obligations under Article 8.
They draw on the best available evi-
dence and the experiences of Parties that
have successfully implemented effective
measures to reduce exposure to tobacco
smoke.
2 The guidelines contain agreed upon
statements of principles and definitions
of relevant terms, as well as agreed upon
recommendations for the steps required
to satisfy the obligations of the
Convention. In addition, the guidelines
identify the measures necessary to
achieve effective protection the hazards
of second-hand tobacco smoke. Parties
are encouraged to use these guidelines
not only to fulfil their legal duties under
the Convention, but also to follow best
practices in protecting public health.
Objectives of the guidelines
These guidelines have two related objec-
tives. The first is to assist Parties in meeting
their obligations under Article 8 of the
WHO Framework Convention, in a manner
consistent with the scientific evidence
regarding exposure to second hand tobacco
smoke and the best practice worldwide in
the implementation of smoke-free mea-
sures, in order to establish a high standard
of health. The second objective is to identi-
fy key elements and legislation necessary to
effectively protect people from exposure to
tobacco smoke, as required by Article 8.
Underlying considerations
The development of these guidelines has
been influenced by the following funda-
mental considerations.
a) The duty to protect from tobacco smoke,
embodied in the text of Article 8, is
grounded in fundamental human rights
and freedoms. Given the dangers of
breathing second-hand tobacco smoke,
the duty to protect from tobacco smoke
is implicit in, inter alia, the right to life
and the right to the highest attainable
standard of health, as recognized by
many international legal instruments
(including the Constitution of the World
Health Organisation, the Convention on
the Rights of the Child, the Convention
on the elimination of all forms of
Discrimination Against Women and the
Covenant on Economic, Social and
Cultural Rights), as formally incorporat-
ed into the Preamble of the WHO
Framework Convention and as recog-
nized in the constitutions of many
nations.
b) The duty to protect individuals from
tobacco smoke corresponds to an obliga-
tion by governments to enact legislation
to protect individuals against threats to
their fundamental rights and freedoms.
This obligation extends to all persons,
and not merely to certain populations.
c) Several Authoritative scientific bodies
have determined that second-hand tobac-
co smoke is a carcinogen. Some Parties
to the Framework Convention (for
example Finland and Germany) have
classified second-hand tobacco smoke as
a carcinogen and included the prevention
of exposure to it at work in their health
and safety legislation. In addition to the
requirements of Article 8 therefore,
Parties may be obligated to address the
hazard of exposure to tobacco smoke in
accordance with their existing workplace
laws or other laws governing exposure to
harmful substances, including carcino-
gens.
Statement of Principles (shortened ver-
sion edited by Dr. Song Lhi)*
Principle 1
6. Effective measures to provide protection
from exposure to tobacco smoke require the
total elimination of smoking and tobacco
smoke in a particular space or environment
in order to create a 100% smoke-free envi-
ronment laws. There is no safe level of
exposure to tobacco smoke, and approaches
other than 100% smoke-free environment
laws, including ventilation, air filtration and
the use of designated smoking areas
(whether with separate ventilation systems
or not), have repeatedly been shown to be
ineffective.
Principle 2
7. All people should be protected from
exposure to tobacco smoke. All indoor
workplaces and indoor public places should
be smoke-free.
Principle 3
8. Legislation is necessary to protect people
from exposure to tobacco smoke. Voluntary
smoke-free policies have repeatedly been
shown to be ineffective.
Principle 4
9. Good planning and adequate resources
are essential for successful implementation
and enforcement of smoke-free legislation.
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WHO
79
Principle 5
10. Civil society has a central role in build-
ing support for and ensuring compliance
with smoke-free measures, and should be
included as an active partner.
Principle 6
11. The implementation of smoke-free leg-
islation, its enforcement and its impact
should all be monitored and evaluated. This
should include monitoring and responding
to tobacco industry activities.
Principle 7
12. The protection of people from exposure
to tobacco smoke should be strengthened
and expanded, if necessary; such action
may include new or amended legislation,
improved enforcement and other measures
to reflect new scientific evidence and case-
study experiences.
GENEVA – At the second Global
Consultation on Transplantation the World
Health Organization presented countries
and other stakeholders with a blueprint for
updated global guiding principles on cell,
tissue and organ donation and transplanta-
tion.
Those principles aim to address a number of
problems: the global shortage of human
materials – particularly organs – for trans-
plantation; the growing phenomenon of
‘transplant tourism’ partly caused by that
shortage; quality, safety and efficacy issues
related to transplantation procedures; trace-
ability and accountability of human materi-
als crossing borders.
Stakeholders agreed to the creation of a
Global Forum on Transplantation to be
spearheaded by WHO, to assist and support
developing countries initiating transplanta-
tion programmes and to work towards a
unified global coding system for cells, tis-
sues and organs.
A central theme of the discussions was
WHO’s concern over increasing cases of
commercial exploitation of human materi-
als.
“Human organs are not spare parts,“ said
Dr. Howard Zucker, WHO Assistant
Director-General of Health Technology and
Pharmaceuticals. “No one can put a price
on an organ which is going to save some-
one’s life.“
“Non-existent or lax laws on organ dona-
tion and transplantation encourage com-
mercialism and transplant tourism,“ said Dr.
Luc Noel, in charge of transplantation at
WHO. “If all countries agree on a common
approach, and stop commercial exploita-
tion, then access will be more equitable and
we will have fewer health tragedies.“
Transplantation is increasingly seen as the
best solution to end-stage organ failure.
End-stage kidney disease, for instance, can
only be repaired with a kidney transplant.
Without it, the patient will die or require
dialysis for years, which is an expensive
procedure and often out of reach of poorer
patients. Transplantation is the only option
for some liver conditions, such as severe
cirrhosis or liver cancer, and a number of
serious heart conditions.
Recent estimates communicated to WHO
by 98 countries show that the most sought
after organ is the kidney. Sixty-six thousand
kidneys were transplanted in 2005 repre-
senting a mere 10 % of the estimated need.
In the same year, 21 000 livers and 6 000
hearts were transplanted. Both kidney and
liver transplants are on the rise but demand
is also increasing and remains unmatched.
Reports on ‘transplant tourism’ show that it
makes up an estimated 10 % of global trans-
plantation practices. The phenomenon has
been increasing since the mid-1990’s, coin-
ciding with greater acceptance of the thera-
peutic benefits of transplantation and with
progress in the efficacy of the medicines –
immuno-suppressants – used to prevent the
body’s rejection of a transplanted organ.
The principles put forward by WHO under-
score that the person – whether recipient of
an organ or a donor – must be the main con-
cern both as patient and as human being;
that commercial exploitation of organs
denies equitable access and can be harmful
to both donors and recipients; that organ
donation from live donors poses numerous
health risks which can be avoided by pro-
moting donation from deceased donors; and
that quality, safety, efficacy and transparen-
cy are essential if society is to reap the ben-
efits transplantation can offer as a therapy.
“Live donations are not without risk,
whether the organ is paid for or not. The
donor must receive proper medical follow-
up but this is often lacking when he or she
is seen as a means to making a profit,“
added Dr. Luc Noel. “Donations from
deceased persons eliminate the problem of
donor safety and can help reduce organ traf-
ficking.“
WHO action on transplantation will be
aided by a global observatory set up in
Madrid under the auspices of the
Government of Spain. The observatory,
which is linked to the WHO Global
Knowledge Base, will provide an interface
for health authorities and the general public
to access data on donation and transplanta-
WHO proposes global agenda on transplantation
New world observatory launched with Spain
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80
tion practices, legal frameworks and obsta-
cles to equitable access.
Background
Figures collected by WHO and collated by
the global observatory come from question-
naires answered by 98 countries represent-
ing just under 5.5 billion people, that is,
about 82% of the world’s population. The
countries were distributed in the following
manner: 41 from the European region; 21
from North and South America; 13 from the
Western Pacific region; 12 from the Eastern
Mediterranean; eight from South East Asia;
and three from Africa.
In 2005, 66 000 kidney transplants were
performed, 60 % of which in industrialized
countries. Seventy-five per cent of the more
than 21 000 liver transplants and 6 000 heart
transplants were performed in industrial-
ized and emerging economies.
Observatory link:
http://www.transplant-observatory.org
Username: rticxcarmona
Password: Omsmc789
Global Knowledge Base link:
http://www.who.int/transplantation/knowledge-
base/en/
work is addressing several vital areas of risk
to patients. Clear and succinct actions con-
tained in the nine solutions have proved to
be useful in reducing the unacceptably high
numbers of medical injuries around the
world.“
The nine solutions are now being made
available in an accessible form for use and
adaptation by WHO Member States to re-
design patient care processes and make
them safer. They come under the headings
of: Look-Alike; Sound-Alike medication
names; patient identification; communica-
tion during patient hand-overs; perfor-
mance of correct procedure at correct body
site; control of concentrated electrolyte
solutions; assuring medication accuracy at
transitions in care; avoiding catheter and
tubing misconnections; single use of injec-
tion devices; and improved hand hygiene to
prevent health care-associated infection.
The Patient Safety Solutions, a core pro-
gramme of the WHO World Alliance for
Patient Safety, brings attention to patient
safety and best practices that can reduce
risks to patients. It ensures that interven-
tions and actions that have solved patient
safety problems in one part of the world are
made widely available in a form that is
accessible and understandable to all. The
Joint Commission on Accreditation of
Healthcare Organizations and Joint
Commission International were officially
designated as a WHO Collaborating Centre
on Patient Safety (Solutions) in 2005.
In the past 12 months, the WHO
Collaborating Centre on Patient Safety
(Solutions) has brought together more than
50 recognized leaders and experts in patient
safety from around the world to identify and
adapt the nine solutions to different needs.
An international field review of the solu-
tions was conducted to gather feedback
from leading patient safety entities, accred-
iting bodies, ministries of health, interna-
tional health professional organizations and
other experts.
‘‘These solutions offer to WHO Member
States a major new resource to assist their
hospitals in avoiding preventable deaths
and injuries,“ says Dr Dennis S. O’Leary,
president of the Joint Commission.
„Countries around the world now face both
the opportunity and the challenge to trans-
late these solutions into tangible actions that
actually save lives.“
The patient Safety Solutions focus on the
following challenges:
1. Look-Alike, Sound-Alike Medication
Names
2. Patient Identification
3. Communication During Patient
Hand-Overs
4. Performance of Correct Procedure at
Correct Body Site
5. Control of Concentrated Electrolyte
Solutions
6. Assuring Medication Accuracy at
transitions in Care
7. Avoiding Catheter and Tubing Mis-
Connections
8. Single Use of Injection Devices
9. Improved Hand Hygiene to Prevent
Health Care-Associated Infection.
For more Information or to view the com-
plete Patient Safety Solutions, please go to:
www.jointcommissioninternational.org/
solutions
Medical Injuries
WHO launches ‘‘Nine patient safety solutions’’
to save lives and avoid harm
WASHINGTON/GENEVA – The World
Health Organization has launched ‘‘Nine
patient safety solutions“ to help reduce the
toll of health care-related harm affecting
millions of patients worldwide.
‘‘Recognizing that health care errors affect
one in every 10 patients around the world,
the WHO’s World Alliance for Patient
Safety and the Collaborating Centre have
packaged nine effective solutions to reduce
such errors,“ said WHO Director-General
Dr Margaret Chan. ‘‘Implementing these
solutions is a way to improve patient safe-
ty.“
The most important knowledge in the field
of patient safety is how to prevent harm
from happening to patients during treatment
and care. The nine solutions are based on
interventions and actions that have reduced
problems related to patient safety in some
countries.
Sir Liam Donaldson, Chair of the Alliance
and Chief Medical Officer for England,
said: ‘‘Patient safety is now recognized as a
priority by health systems around the world.
The Patient Safety Solutions programme of
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81
H5N1 Avian `Flu
WHO and manufactorers move ahead with plans for H5N1 influenza
global vaccine stockpile
The World Health Organization has
announced that it is working with vaccine
manufacturers to move ahead on plans to
create a global stockpile of vaccine for the
H5N1 avian influenza virus.
The announcement follows a request by the
World Health Assembly in May for WHO to
establish an international stockpile of H5N1
vaccine.
WHO also welcomed the announcement by
GlaxoSmithKline that it will contribute to
the H5N1 global vaccine stockpile.
Omninvest of Hungary, Baxter and Sanofi
Pasteur have also indicated their willing-
ness to make some of their H5N1 vaccine
available.
‘‘This is another significant step towards
creating a global resource to help the world
and especially to help developing countries
in case of a major outbreak of H5N1 avian
influenza,“ said Dr Margaret Chan, WHO
Director-General.
‘‘WHO welcomes this contribution from
the vaccines industry and is also working
with countries to develop capacity for the
production of influenza vaccines.“
Further work is needed on detailed opera-
tional planning for the stockpile, including
how and under which conditions it will be
deployed, as well as regulatory aspects of
the vaccine.
As well as developing a stockpile of H5N1
vaccine, other measures being taken by
WHO to prepare for a potential influenza
pandemic include:
• rapid containment plans to stop a pan-
demic using public health measures (iso-
lation, quarantine of contacts, personal
hygiene and social distancing) and anti-
virals;
• assistance to countries to increase vaccine
production capacity, including research
and promoting the transfer of technology
to developing countries.
WHO releases findings from research project on travel and blood clots
Risk of VTE is higher after travel of more than four hours but is still relatively low
during travel where the passenger is seated
and immobile for over four hours, whether
in a plane, train, bus or car. However, it is
important to remember that the risk of
developing VTE when travelling remains
relatively low,“ says Dr Catherine Le
Galès-Camus, WHO Assistant Director-
General for Noncommunicable Disease and
Mental Health.
This study did not investigate effective pre-
ventive measures against DVT and VTE.
However, experts recognize that blood cir-
culation can be promoted by exercising the
calf muscles with up-and-down movements
of the feet at the ankle joints. Moving feet in
this manner encourages blood flow in the
calf muscle veins, thus reducing blood stag-
nation. People should also avoid wearing
tight clothing during travel, as such gar-
ments may promote blood stagnation.
GENEVA – The World Health Organization
released results from Phase 1 of the World
Health Organization research into global
hazards of travel project. Findings indicate
that the risk of developing venous throm-
boembolism (VTE) approximately doubles
after travel lasting four hours or more.
However, the study points out that even
with this increased risk, the absolute risk of
developing VTE, if seated and immobile for
more than four hours, remains relatively
low at about 1 in 6000.
The two most common manifestations of
VTE are deep vein thrombosis (DVT) and
pulmonary embolism.
The study showed that plane, train, bus or
automobile passengers are at higher risk of
VTE when they remain seated and immo-
bile on journeys of more than four hours.
This is due to a stagnation of blood in the
veins caused by prolonged immobility,
which can promote blood clot formation in
veins.
One study within the project examining
flights in particular, found that those taking
multiple flights over a short period of time
are also at higher risk. This is because the
risk of VTE does not go away completely
after a flight is over, and the risk remains
elevated for about four weeks.
The report showed that a number of other
factors increase the risk of VTE during trav-
el, including obesity, being very tall or very
short (taller than 1.9 meters or shorter than
1.6 meters), use of oral contraceptives, and
inherited blood disorders leading to
increased clotting tendency.
‘‘The study does confirm that there is an
increased risk of venous thromboembolism
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82
Phase I of the research project concludes
that there is a need for travellers to be given
appropriate information regarding the risk
of VTE by transport authorities, airlines,
and medical professionals. Further studies
will be needed to identify effective preven-
tive measures. This will comprise Phase II
of the project, which requires additional
funding before it can begin.
Individuals with questions regarding pre-
vention of VTE should consult their physi-
cians before travelling.
Background to the WRIGHT project:
In 2000, following the death from pul-
monary embolism of a young English
woman who returned on a long-haul flight
from Australia. Media and public attention
was focused on the risk of thrombosis in
long-haul travellers. In the same year, a
report from the Select Committee on
Science and Technology of the United
Kingdom House of Lords recommended
research into the risk of DVT. Following a
consultation of experts convened by WHO
in March 2001, the WRIGHT project was
initiated. Phase 1 was funded by the UK
Government (Department for Transport and
Department of Health) and the European
Commission.
The objectives of Phase I were to confirm
whether the risk of VTE is increased by air
travel and to determine the magnitude of
risk.The studies were conducted under the
auspices of WHO and performed by an
international collaboration of researchers
from the Universities of Leiden, Amster-
dam, Leicester, Newcastle, Aberdeen and
Lausanne.
There were five studies:
• a population-based case control study to
investigate the risk factors of VTE;
• two retrospective cohort studies among
employees of international organizations
and Dutch commercial pilots to investi-
gate the actual risk of VTE related to air
travel; and
• two pathophysiological studies to inves-
tigate the influence of immobility on
VTE related to travel and the influence,
if any, of low oxygen and low pressure in
the cabin of aircraft on VTE related to
travel.
Safe blood for mothers
New WHO survey on blood safety and donation
GENEVA — On the occasion of World
Blood Donor Day, the theme of which this
year is Safe blood for safe motherhood, the
World Health Organization launched a new
initiative to improve the availability and use
of safe blood to save the lives of women
during and after childbirth. The initiative is
the beginning of a broader blood safety
agenda (redefined in Ottawa) aiming to
work towards universal access to safe blood
transfusion in support of the Millennium
Development Goals.
On 14 June, WHO also released data col-
lected from 172 countries on trends in blood
donation, access and testing.
Globally, more than 500 000 women die
each year during pregnancy, childbirth or in
the postpartum period – 99% of them in the
developing world – an estimated 25% of
those deaths are caused by severe bleeding
during childbirth, making this the most
common cause of maternal mortality.
Severe bleeding during delivery or after
childbirth contributes to around 34% of
maternal deaths in Africa, 31% in Asia and
21% in Latin America and the Caribbean.
As pregnant women are one of the main
groups of patients requiring blood transfu-
sion in developing countries, together with
children they are particularly vulnerable to
blood shortages and to HIV, hepatitis B and
hepatitis C infections through unsafe blood.
‘‘If current trends continue, the world will
fail to meet target 5 of the Millennium
Development Goals to reduce maternal
mortality,“ said Dr Margaret Chan, WHO
Director-General. ‘‘We must do everything
we can to improve the chances of women
during and after childbirth.“
Blood transfusion has been identified as one
of the eight key life-saving interventions in
healthcare facilities providing emergency
obstetric care. Timely, appropriate and safe
blood transfusion during and after labour
and delivery can make the difference
between life and death for many women
and their newborns.
The Global Initiative on Safe Blood for
Safe Motherhood aims to improve access to
safe blood to manage pregnancy-related
complications as part of a comprehensive
approach to maternal care. This includes
good antenatal care, prevention and timely
treatment of anaemia, assessment of the
need for transfusion and safe blood transfu-
sion given only when really required. WHO
will strengthen the capacity of blood banks
and district hospitals for improving mater-
nal health through the provision of technical
support in the areas of voluntary blood
donation, safe blood collection, quality
assured testing and best clinical practices.
WHO will train clinicians, nurses, techni-
cians and other key health personnel at dis-
trict level facilities through its regional net-
works across the world.
The lack of access to safe blood for women
reflects the general situation in developing
countries. Developing countries are home
to more than 80% of the world’s population,
yet they currently represent only 45% of the
global blood supply.
Out of 80 countries that have donation rates
of less than 1% of the population (fewer
than 10 donations per thousand people), 79
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83
are in developing regions; it is generally
recommended that 1-3% of the population
give blood to meet a country’s needs.
The WHO survey, conducted in 172 coun-
tries covering 95% of the world’s popula-
tion and based on 2004 data, shows that
some progress has been made since the
beginning of the millennium towards ensur-
ing a safer, more adequate supply of blood.
One of the survey’s indicators was the
implementation of voluntary, unpaid blood
donation, which remains a mainstay of
WHO recommendations to ensure a safe
and sufficient blood supply.
In 2004, 50 countries had achieved 100%
voluntary unpaid blood donation, compared
with 39 countries in 2002. Three of the 11
new countries achieving this are categorized
as least developed. More and more coun-
tries are moving towards voluntary blood
donation. In 2002, 63 countries were col-
lecting less than 25% of their blood from
voluntary unpaid donors. By 2004, this had
fallen to 46 countries.
Testing of blood for major infections such
as HIV/AIDS, hepatitis B and C is also
increasing, although in many countries
there are few indicators showing if the test-
ing is carried out according to quality
assured procedures. Out of 40 countries in
sub-Saharan Africa, 28 countries have yet to
establish national quality systems.
Worldwide, the highest rate of infection is
found among donors who give blood for
money or other form of payments. 41 of 148
countries (28%) that provided data on
screening for transfusion-transmissible
infections were not able to screen the donat-
ed blood for one or more of the markers.
On 9-11 June, Ottawa was the venue for a
global consultation organized by WHO with
the collaboration and support of the
Government of Canada and the Canadian
and French blood services. Around 100
experts in transfusion called on govern-
ments, international agencies and non-
governmental organizations to work togeth-
er towards universal access to safe blood
transfusion by 2015 in support of the
Millennium Development Goals to reduce
maternal and child mortality and prevent the
transmission of HIV, hepatitis and other
life-threatening infections through unsafe
blood and blood products.
Background to World Blood
Donor Day
While most countries celebrated World
Blood Donor Day on 14 June, this year’s
main event was hosted by the Government
of Canada. Festivities took place in Ottawa,
in the presence of the Canadian Minister of
Health and guests from WHO and other
international partners.
WHO works with partners internationally
and in countries to promote better blood
collection practices, 100% voluntary,
unpaid blood donation policies, quality
assured blood testing and rational use of
blood.
WHO, the International Federation of the
Red Cross and Red Crescent Societies, the
International Society of Blood Transfusion
and the International Federation of Blood
Donor Organizations joined forces in 2004
to celebrate for the first time World Blood
Donor Day — a tribute to voluntary, unpaid
blood donors who altruistically give of
themselves to improve and save lives. In
2005 the World Health Assembly voted a
resolution to make World Blood Donor Day
an annual event. Since then, the Day has
become a vehicle to launch national and
regional awareness and advocacy cam-
paigns to encourage blood donation and
safer practices in blood transfusion.
Blood safety data are collected biennially
by WHO through a comprehensive survey
addressed to national governments.
Highlights of the data available on:
http://www.who.intienity/worldblooddonor
day/resources/Data.xls
Improved meningitis vaccine for Africa could signal eventual end
to deadly scourge
Successful Vaccine Trial Promises Long-Term, Low-Cost Protection From Epidemics in Africa
GENEVA – The Meningitis Vaccine Project
(MVP) has released new data on the perfor-
mance of a meningitis vaccine in West
African children, suggesting that the new
vaccine – expected to sell initially for 40
US cents a dose – will be much more effec-
tive in protecting African children and their
communities than any vaccine currently on
the market in the region.
MVP, a partnership between the World
Health Organization and the Seattle-based
nonprofit, PATH, is collaborating with a
vaccine producer, Serum Institute of India
Limited (SIIL), to produce the new vac-
cine against serogroup A Neisseria menin-
gitidis (meningococcus). The preliminary
results of their study, a Phase 2 vaccine
trial, reveal that the vaccine could eventu-
ally slash the incidence of epidemics in the
“meningitis belt,” as 21 affected nations of
sub-Saharan Africa are collectively
known. The vaccine is expected to block
infection by the serogroup A meningococ-
cus, and therefore extend protection to the
entire population, including the unvacci-
nated, a phenomenon know as “herd
immunity.”
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84
“When it becomes part of the public health
arsenal, this vaccine will make a real differ-
ence in Africa,” said Dr. F. Marc LaForce,
MVP director. “The vaccine will allow
elimination of the meningococcal epi-
demics that have afflicted the continent for
more than 100 years.”
The new meningococcal conjugate vaccine
trial, in 12- to 23-month-olds in Mali and
The Gambia, shows that the vaccine was
safe, and that it produced antibody levels
almost 20 times higher than those obtained
with the marketed polysaccharide (un-con-
jugated) vaccine. This means that protection
from serogroup A meningococcal meningi-
tis is expected to last for several years.
‘‘This important study brings real hope that
the lives of thousands of children,
teenagers, and young adults will be saved
by immunization and that widespread suf-
fering, sickness and socioeconomic disrup-
tion can be avoided,” said Dr. Margaret
Chan, Director-General of the World Health
Organization.
“Elimination of these epidemics with wide
use of the meningococcal A conjugate vac-
cine is now a likely possibility over the next
few years,” said LaForce. “People between
the ages of 1 and 29 years of age will be
protected by receiving a single dose in large
mass vaccination campaigns. The large
campaigns are expected to create herd
immunity, and eventually, elimination of the
disease.”
As a result of the encouraging preliminary
findings of this Phase 2 clinical study, SIIL
and MVP will proceed with a Phase 2/3
study where the vaccine will be tested in 2-
to 29-year-olds—the population that will be
mostly targeted by mass vaccination cam-
paigns. Testing will take place in Mali, The
Gambia, and at least one other African
country. An additional clinical study is
planned for this summer in India, where the
vaccine will be licensed.
“Serum Institute of India is dedicated to
developing safe, effective, and affordable
products for the poorest countries in the
world,” said Dr. Cyrus Poonawalla,
Chairman of SIIL. “These results confirm
and extend the observations made last year
in our Phase 1 study in India. The new con-
jugate vaccine has an excellent safety pro-
file in young children, and it is immunolog-
ically superior to the polysaccharide vac-
cine.”
A conjugate vaccine joins (or “conjugates”)
sugars from the meningococcal bacterium
with a protein, which in turn stimulates
immune cells. These cells then produce
antibodies to meningitis, protecting the
individual from infection. A total of 600
toddlers participated in the Phase 2 study.
They were enrolled at two clinical sites in
Africa: Center for Vaccine Development
(CVD)-Mali and the Medical Research
Council (MRC) Laboratories in The
Gambia. Dr. Brown Okoko, principal inves-
tigator at the MRC site in Basse, said, “The
clinical teams at MRC and CVD-Mali iden-
tify with the vision, mission, and mandate
of the Meningitis Vaccine Project. We are
all highly motivated and very proud to be
able to contribute to the development of a
vaccine that is critically needed in Africa.”
Dr. Samba Sow, principal investigator at
CVD-Mali, said, “Some of the families who
participated in the study have lost several
members of their family to meningococcal
meningitis. Those who have not been direct-
ly affected know the terrible impact that the
disease has on the community. There is a lot
of support for the clinical study and the new
vaccine in the Bamako community.”
iGATE Clinical Research International, a
contract research company in Mumbai,
India, is providing data management ser-
vices.
“The plans for the future are quite ambi-
tious,” said LaForce. “With the successful
completion of the Phase 2 study, and once
funding is secured, we plan to do a demon-
stration study next year in a hyperendemic
country where we will take the vaccine to
public-health scale by immunizing the
entire population between the ages of 1 and
29. If all continues to go well in testing and
during the demonstration study, the new
vaccine, which will be priced at about 40
cents per dose, could be introduced in
Africa within the next two to three years.”
Meningitis is one of the world’s most dread-
ed infectious diseases. Even with antibiotic
treatment, at least 10 percent of patients die,
with up to 20 percent left with permanent
problems, such as mental retardation, deaf-
ness, epilepsy, or necrosis leading to limb
amputation.
The most prominent groups of meningococ-
ci are A, B, C, Y, and W135. While groups
A, B, and C are responsible for the majority
of cases worldwide, group A causes deadly,
explosive epidemics every 8 to 10 years
predominantly in what is known as the
African “meningitis belt,” an area that
stretches from Senegal and The Gambia in
the West to Ethiopia in the East. The belt
has an at-risk population of about 430 mil-
lion. The largest epidemic wave ever
recorded in history swept across the entire
region in 1996–1997, causing over 250,000
cases and 25,000 deaths. Africa has been
relatively spared in recent years, but last
year’s 41,526 reported cases and the 47,925
cases reported from 1 January to 6 May
2007 bring the fear that a new epidemic
wave may have begun in sub-Saharan
Africa.
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