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WMA news
No. 4, December 2008
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suﬀolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Cover painting : Zaza Panaskertel-Tsitsishvili
(XV c.).The famous Georgian
physician and thinker. Author of Medical
Monographs.The fresco from
the Kintsvisi Cathedral. A cover picture is
selected as a moral support of WMA for
Georgian physicians.The pictures were kindly
provided by Prof. Ramaz Shengelia. Chairman
of the Department of History of Medicine /
Tbilisi State Medical University
Layout and Artwork
The Latvian Medical Publisher “Medicīnas
apgāds”, President Dr. Maija Šetlere,
Hospitāļu iela 55, Riga, Latvia
Publisher
The World Medical Association, Inc. BP 63
01212 Ferney-Voltaire Cedex, France
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ISSN: 0049-8122
Dr. Yoram BLACHAR
WMA President
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Kazuo IWASA
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
Dr. Dana HANSON
WMA President-Elect
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Dr. Eva NILSSON-
BÅGENHOLM
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Assn.
P.O. Box 5610
11486 Stockholm
Sweden
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. Jón SNÆDAL
WMA Immediate Past President
Icelandic Medicial Assn
Hlidasmari 8
200 Kopavogur
Iceland
Dr. Jörg-Dietrich HOPPE
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. José Luiz GOMES DO
AMARAL
WMA Chairperson of the Socio-
Medical-Aﬀairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
World Medical Association Oﬃcers, Chairpersons and Oﬃcials
Oﬃcial Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reﬂect WMA policy or positions
www.wma.net
117
The business of manufacturing is usually good for the consumer and
good for the economy. However, not all manufactured or produced
goods are safe. One of the functions of government is to regulate
the safety of products.When the negative eﬀects upon the economy
of putting a stop to a dangerous practice takes precedence over pro-
tecting the health of the population and the government takes no
action, doctors have an obligation to step in.This issue was brought
to light with a recent problem of melamine.
Melamine is an industrial chemical that is used to manufacture
certain plastics. It was added to pet foods produced in China and
to animal feed. Because it has high nitrogen content, it was used
in China to increase the apparent protein content of foods when
simple nutritional tests were done. Adding melamine to powdered
milk changed the texture, thickness and ﬂavor of the milk. Adding
melamine was a common, though illegal practice in China.
The ﬁrst reported incident of toxicity from melamine in pets came
in 2007. In humans it was recently revealed that at least four infants
have died, 13,000 hospitalized and about 50,000 aﬀected by ingest-
ing melamine-tainted powdered milk in China. Nephrolithiasis and
renal dysfunction are the most common problems reported from
excess melamine ingestion. Melamine has been found in powdered
baby milk and some dairy and candy products produced in China; it
has also been found in eggs, probably as a result of its being added
to animal feed.
Some of the revelations about melamine have come from Taiwan,
which imports products from China. Because of political consider-
ations,Taiwan is not a member of the World Health Organization.
Since they share a common language, Taiwan can be an important
source of information about health practices in China that might
not otherwise be revealed.
Just as in the past, with issues such as alcohol use and smoking,
doctors have led the battle to eliminate public health hazard in the
face of economic forces to the contrary. In the coming years, the
ﬁght against alcohol abuse will take center stage. It remains to be
seen if organizations such as the World Health Organization,which
receives funding from businesses that proﬁt from the sale of alcohol,
will be eﬀective leaders in this battle. Doctors, who put patients’
well-being foremost and have no conﬂict of interest should be active
in this eﬀort and help lead this campaign.
A bad message. On the cover of “Times” 24th of November Barack
Obama is smoking a cigatette.
Editorial
Pēteris Apinis, M.D.
Editor-in-Chief of the World Medical Journal
Dr. Ron Davis, former Council Member of WMA, and recently Adviser, Immediate
Past-President of the American Medical Association and strong supported of our work,
passed away on November 6th
, 2008.
We have lost a strong advocate for public health, a fantastic colleague, teacher and
friend. He has been a skilled scholar, enlightening us with lectures and advice – last at
our seminar in Seoul, just a couple of weeks ago.
Working with him until his last days, we will remember him for what he worked and
stood for – Health for all people.
Our thougts are with his family.
118
WMA news
Dr. Yoram Blachar,
President of the World Medical Association
It is an honor and privilege for me to serve as
the president of this auspicious organization
that unites the world’s doctors and represents
us all. Advocating on behalf of doctors and
patients around the world is a pinnacle any
physician committed to the public service
can aspire to and I am so fortunate to be able
to realize my aspirations in this realm. I am
extremely grateful to the members of the
WMA who placed their trust with me and
allowed me the privilege of serving this very
vibrant and important organization.
The WMA has come a long way since its es-
tablishment in Paris in 1947. It has grown,
evolved and ﬂourished, and it has always
remained true to its values and founding
principles. (Incidentally, Israeli doctors have
participated in the WMA since its establish-
ment, initially as representatives of the Pal-
estine Jewish Physician Association.) The
need for an international organization to
unite physicians around the globe existed in
1926 and continued to the era of the Second
World War; this need was ampliﬁed by the
horrendous experiences the world endured
throughout that war. In light of the incon-
ceivable events that occurred and the radical
breach of any sort of humanitarian or ethi-
cal code, as revealed during the Nuremberg
trials, it was evident that the ﬁrst task of
the WMA would be the formulation of an
ethical code for all the world’s doctors. As
the world became increasingly aware of the
horriﬁc use of human beings in experiments
that held no regard for human life or basic
human rights, it became the responsibility
of physicians to assure we would never again
take part in acts that do not beneﬁt people.
Out of this unthinkable past the Declara-
tion of Helsinki was created and has since
burgeoned to become one of the irrefutable
cornerstones of physician conduct.The Dec-
laration has withstood the test of time and
scientiﬁc evolution because of our ability
to modify and adapt it to developments in
medicine and society.
Fundamental topics in medical ethics have
been at the heart of the WMA’s work and
a core component of its activities from its
inception. Many of the WMA’s declara-
tions – such as the Declaration of Tokyo,
the Declaration of Malta, the Declaration of
Madrid, and many others – have become the
inalienable property of the medical commu-
nity around the globe. Over time, with the
surfacing of new dilemmas, physicians have
been faced with new challenges in the ﬁelds
of medicine and health. Consequently, dis-
cussions within the WMA have widened to
include new ideas and changes in medicine
worldwide. The ﬁeld of medicine has un-
dergone vast changes in the last century and
these changes only accelerate as time passes.
For example, penicillin was discovered less
than 100 years ago and this discovery revolu-
tionized the face of medicine.Today, it is dif-
ﬁcult for us to conceive of a reality without
antibiotics.
There have also been prominent changes in
the quality of life. Most of the world has ex-
perienced a great improvement in its standard
of living and in the quality of nutrition and
hygiene. Alongside these changes have been
social changes, such as the information revolu-
tion, electronic media and the internet, all of
which have greatly increased the amount of in-
formation in the public domain.These changes
have all contributed to a surge in patient em-
powerment and an ever evolving doctor-pa-
tient relationship.The accessibility of informa-
tion and remarkable developments in medicine
have brought both increased transparency and
increased expectations.
However, economic factors increasingly in-
fringe upon the aforementioned advances in
medicine. Many countries cannot aﬀord to
pay for modern medicine so the populations
of these countries do not beneﬁt from some of
the most basic advances. The outcome of this
situation is evident in health indices and in-
dicators. Additionally, it has become increas-
ingly apparent that there is no country able to
thoroughly fund medical care from its public
budget, and, as a result, a new reality has been
created in which diﬀerent levels of medical
care are provided, depending on the patient’s
economic standing. This is true even in coun-
tries with public health insurance. There is a
growing trend of transferring the funding of
medical services from the public account to
the private pocket.Thus,whoever has the abil-
ity to privately purchase what the state does
not provide will receive excellent, up to date,
care and whoever does not,will receive a lower
level of care in accordance with his or her abil-
ity to pay. This situation creates a conﬂict of
the most basic medical,ethical principles with
economic factors.
The new reality in which we ﬁnd ourselves
results in an emphasis on disparities in the
access, timeliness, and level of medical care.
Health disparity is a topic that has always
existed but has become more critical with
its eﬀects becoming so profound, making it
a topic worthy of being central to the agenda
of the WMA. Health disparities are evident
both in comparison among diﬀerent coun-
tries as well as within diﬀerent regions of
a single country. It is suﬃcient to measure
standard parameters of health quality – such
as infant mortality rate,life expectancy,num-
ber of hospital beds in relation to the popu-
lation, and number of modern technological
devices – to realize that this phenomenon
will soon become intolerable.The lower one’s
socio-economic status or educational level,
the more extreme the phenomenon becomes.
The topic of health disparities includes within
it ethical aspects,principles of doctor-patient
relationships, the deﬁnition of a physician’s
Financial Crisis may Hasten Move to Shift
Responsibilities Away from Doctors
119
WMA news
role in society, and the issue of human rights.
This crucial topic requires us to formulate
an agenda. The WHO has recently declared
that, “Health disparities costs lives.” It is our
responsibility as leaders in health to act on
this crucial topic.
Recently, a global economic tsunami has in-
vaded our safe havens.It would seem that the
global outlook of a free economy completely
subject to the vagaries of the market has not
withstood the test of time and has collapsed.
The impact of this crisis on the global lev-
el is still unclear, though it is clear that no
national economy has been left unaﬀected.
The vital question for us will be how this
economic crisis, combined with the antici-
pated global recession, will aﬀect the world’s
health systems.Especially in countries where
health insurance is an integral component of
employment conditions, the recent waves of
layoﬀs will make it diﬃcult to escape disas-
trous consequences.It is our duty both in our
individual national organizations as well as
on the level of an international medical as-
sociation to be aware of these developments
so as to moderate their destructive impact
and shield the health care system as much
as possible. These developments will force
countries without public health insurance to
understand that their health services cannot
be controlled by bankrupting market forces
and free economy, and social-welfare states
will understand that the recent inclination of
governments towards privatization threatens
the equality and health of their citizens.
As members of the WMA we are also social
leaders and, thus, we have the responsibility
of addressing a wider scope of issues aﬀecting
health, one of which is the subject of armed
conﬂict. Many areas of the world are involved
in military conﬂict; some of these are more
recent while others have roots so deep that
all attempts to mediate between the extreme
positions are unsuccessful. This reality claims
the lives of many victims and leaves others
with physical or mental impairments. Many
organizations around the world,including the
UN and the EU, are involved in attempts to
tone down of the level of violence between
the disputing countries. There are also hu-
manitarian organizations manned by physi-
cians – such as Doctors Without Borders,
the Taiwanese Tzu-Chi organization, and
Physicians for Human Rights – that act as
pacifying forces through the medical care they
provide.The WMA is in a unique position in
that it has both the ability and positioning to
try to bring conﬂicting parties to the discus-
sion table via encouragement and dialogue
with our organization. One of the regions
involved in an ongoing conﬂict is my own.
The Arab-Israeli conﬂict has existed for many
years. However, it is important to note that
Israel does have peace agreements with two
countries with which Israel had been at war
for many years: Egypt and Jordan. There are
full diplomatic relations between Israel and
Egypt and between Israel and Jordan, as well
as open borders. There is still much work to
be done to achieve peace between Israel and
other countries, such as Syria, Lebanon and
especially the Palestinian Authority. I plan to
make every eﬀort to turn health and medi-
cine on an organizational level into a bridging
force so that maybe, as naïve as it sounds, the
peace process in our region can be advanced as
it so desperately needs to be. I plan on being
instrumental in the inclusion of NMAs who
are not yet members or active in the WMA,
so as to allow a dialogue to begin under the
auspices of the WMA,with the WMA medi-
ating based on our common profession. This
profession spans diﬀerent nationalities, view-
points, and is common to all doctors, whose
purpose it is to bring help and healing.
There is another topic which concerns all of
us as health leaders. The expected shortage
of physicians will almost certainly change
the face of medicine. This threat is real and
tangible; even today the world lacks over 4
million health workers, according to WHO
data.This shortage is not homogenous.There
are areas, such as Africa, where the shortage
is overwhelming, and other areas where the
shortage is barely felt. The genuine solution
to this shortage is to increase the number
of physicians, install solid long-lasting re-
tention plans for health care providers, and
solve the problem of physician recruitment
from poorer areas to areas where the short-
age is less severe. The proposed solution of
task shifting is not a real solution. Filling
the positions of professionals with partially
trained individuals is a temporary answer. It
is extremely dangerous to view task shifting
as a genuine solution since this will only pre-
vent us from ﬁnding a real solution. As long
as task shifting is solely a temporary solution
meant to ﬁll a gap that would otherwise re-
main empty and provide some sort of answer
to the world’s critical need for medical care
it is justiﬁed. However, while implementing
task shifting we must work towards a last-
ing solution that deals with the root of the
problem. We have a shared responsibility to
act and convince policy makers of this need
for real solutions.
Some of the previously mentioned top-
ics of health discrepancies, privatization of
health services, armed conﬂict, and short-
age of health workers have already begun to
be dealt with by the WMA, some of these
topics have been awaiting our attention,
and some of these topics have just emerged.
Such is the way of the WMA, with each of
its presidents “picking up the torch”and con-
tinuing some of the tasks of their predeces-
sors, taking on new tasks, and leaving some
tasks to be completed by their successors. I
intend to continue the work of Dr. Snaedal,
especially on the topics of task shifting and
health disparities, both on the policy level of
governments and NMAs as well as on the
level of the practice of doctors, with every
individual doctor taking a role in the battle
against disparities in health. Additionally, I
intend to make attempts to engage in medi-
cal diplomacy. Hopefully,these attempts will
be successful in making a diﬀerence to those
people living in areas of conﬂict.
The issues to be addressed are large and com-
plex and this can not be the task of any one
individual or even group of people. In order
to bring about a lasting contribution that
brings about true change, every member of
the WMA must take part. Only by working
together can we make a diﬀerence and in-
spire others to join us in working to fulﬁll
our goals. It is not our responsibility to ﬁnish
all the work that must be done, but we are
not at liberty to shy away from it.
I conclude with a statement from Maimo-
nides’ Physician’s Prayer, which reminds us
all that the patient must come ﬁrst. “May I
never forget that the patient is a fellow crea-
ture/May I never consider him merely a vas-
sal of disease.”
120
WMA news
John R. Williams, Ph.D., Ethics Advisor,
World Medical Association, Adjunct Professor,
Department of Medicine, University of Ot-
tawa, Canada
Introduction
On October 18, 2008 the WMA General
Assembly, meeting in Seoul, South Korea,
voted overwhelmingly to adopt a new ver-
sion of the Declaration of Helsinki (DoH).
The vote marked the end of an 18-month
revision process that involved extensive con-
sultation with stakeholders and careful con-
sideration of their suggestions for changes.
The ﬁnal document is available for viewing
on the WMA website: www.wma.net.
This article will describe the 18-month revi-
sion process, the main issues that were con-
sidered and the ﬁnal resolution of these is-
sues. It will conclude with some suggestions
for future reviews of the DoH.
Why Revise the DoH
The DoH has been amended several times
since its adoption in 1964. An extensive re-
vision process was begun in 1997 and con-
cluded with the approval of a new version
by the WMA General Assembly in Octo-
ber 2000. Although the Assembly vote in
favour of the new version was almost unani-
mous, it quickly became apparent that some
of the paragraphs, especially #29 dealing
with the use of placebos in clinical trials and
#30 on access to the beneﬁts of research,
were unclear and/or contentious. The addi-
tion of explanatory notes of clariﬁcation to
these paragraphs in 2002 and 2004 did not
resolve these diﬃculties. Another attempt
was needed.
A second reason for revising the DoH was
the changing environment of medical re-
search. In response to widely publicized
scandals involving the testing, approval
and marketing of certain drugs that were
later shown to be unsafe, there have been
increased demands for greater transparency
in medical research and stronger protection
for research subjects.The DoH’s statements
on issues such as these required clariﬁcation
and, perhaps, strengthening.
An additional reason for undertaking a re-
vision was to see whether there were gaps
that needed to be ﬁlled, for example, ethical
principles for research on human materi-
als and data. A ﬁnal reason was to remove
inconsistencies in terminology within the
DoH as well as inconsistencies among the
three oﬃcial language versions.
Scope of the Revision
The 2000 version of the DoH was a ma-
jor revision of the previous (1996) version
and included a signiﬁcant restructuring of
the document. In contrast, the most recent
revision was intended from the beginning
to be relatively minor in scope. In initiating
the revision process at its May 2007 meet-
ing, the WMA Council wanted to “identify
gaps in the content but avoid a complete re-
opening of the document.” There had been
general approval and acceptance of the 2000
version, apart from paragraphs 29 and 30,
and Council felt that the remainder of the
document required at most some ﬁne-tun-
ing.As for the two controversial paragraphs,
it seemed desirable to integrate the notes of
clariﬁcation into the body of the document
but any substantive change to the 2000 po-
sitions would be unlikely to receive the 75%
majority vote at the General Assembly that
is required for adoption or amendment of
an ethical statement.
Process
The previous revision took three and a half
years, followed by a further four years de-
veloping the two notes of clariﬁcation. In
contrast, the May 2007 Council meeting
approved a one and a half year timetable
for this revision. It was to be guided by a
ﬁve-member workgroup and would include
three rounds of stakeholder consultation.
The workgroup was made up of representa-
tives from the National Medical Associations
of Brazil, Germany, Japan, South Africa and
Sweden. The chair was Dr. Eva Nilsson-Bå-
genholm of Sweden, who was also the chair
of the WMA Medical Ethics Committee,
and the coordinator was Professor John Wil-
liams from Canada, who had recently retired
as WMA’s Director of Ethics.
The ﬁrst consultation took place from June
to August 2007. It consisted of a request
for suggested changes to the DoH that was
sent by the WMA Secretariat to National
Medical Associations and international re-
search, medical, health and ethics organiza-
tions. National Medical Associations were
asked to distribute the request for suggested
changes to organizations in their own coun-
tries and to collate the responses for trans-
mission to the workgroup.
39 responses were received in response to
this request, some many pages in length.
They were considered by the workgroup and
subsequently by the WMA Medical Ethics
Committee at its meeting in Copenhagen in
October 2007.The Committee’s recommen-
dation, subsequently endorsed by the Coun-
cil, was for the workgroup to prepare a draft
revision of the DoH for further consultation
with stakeholders and to report back to the
Committee at its May 2008 meeting.
Revising the Declaration of Helsinki
121
WMA news
Following the Copenhagen meetings
the workgroup completed its draft revi-
sion, which was distributed for comment
to stakeholders in early November. This
round of consultation elicited 46 responses,
including some from NMAs that repre-
sented the consolidated comments of nu-
merous national organizations. During the
last week of February the comments were
collated and a list of controversial issues
was developed to serve as the agenda for a
stakeholders’workshop in Helsinki, Finland
in March. Immediately after the workshop,
the workgroup met to decide what changes
to the November 2007 consultation draft
should be made in consideration of the
written comments and the workshop dis-
cussion. A revised draft was prepared and
discussed by the Medical Ethics Committee
and Council at their May meetings, where
several changes to the draft were made.
A third round of consultation, this time on
the amended revised draft, took place during
the summer of 2008. It included the posting
of the draft and an electronic response form
on the WMA website and stakeholder work-
shops in Cairo, Egypt and Sao Paulo, Brazil.
The workgroup met in Sao Paulo immedi-
ately after that workshop and during the next
two weeks it considered all the comments
that had been received (80 submissions)
and prepared its ﬁnal draft for the October
meetings of the Medical Ethics Committee,
Council and General Assembly in Seoul.
Issues
From the three rounds of consultation the
WMA received suggestions for changes
to every paragraph of the DoH as well as
for additional paragraphs on several topics.
Some respondents felt that the document
should be reorganized in a more logical or-
der. Others wanted a preamble that would
clarify the scope and status of the docu-
ment, including whether it applied only to
physicians or to all researchers. Still others
asked for a fuller treatment of certain topics,
for example,vulnerability,placebos or publi-
cation of research results. Terminology was
another issue,for example,‘medical research’
vs. ‘biomedical research’, ‘research subject’
vs. ‘research participant’, ‘method’ vs. ‘inter-
vention’, ‘must’ or ‘should’. Conversely, with
very few exceptions such as paragraphs 29
and 30, there was general agreement among
respondents that the DoH’s positions were
basically correct and in no need of funda-
mental change.
Suggestions for additional topics included
the following: conﬂict of interest; research
involving human data, including access to
this data; access to participation in research
by previously excluded or underutilized pop-
ulations (e.g., children and pregnant wom-
en); international research requirements;
waiver of the consent requirement for some
epidemiological studies; individual limits on
participation in clinical trials; methodology
in prevention trials; implications of research
studies for public policy; responsibilities of
editors; insurance coverage; consent for use
of personal data in publications; consent for
reuse of personal data in other studies; and
access to the results of research.
Outcome
In evaluating these suggestions, the work-
group considered that its mandate required
it to preserve the order and wording of the
current (2004) version of the DoH except
where clariﬁcation was needed or where
signiﬁcant gaps existed. Moreover, since
the DoH is primarily a statement of ethical
principles and not a handbook on how these
principles should be applied, the workgroup
did not consider it appropriate to make the
document too detailed. Finally, the work-
group recognized that there is no consensus
on a few of the issues treated in the DoH,
especially placebo use and post-trial access,
and did not make changes to the previous
DoH position on these issues.
Although the workgroup decided against
adding a preamble to the DoH, in the ﬁrst
two paragraphs it did specify more clearly
the purpose, scope and intended readership
of the document. It also added a sentence to
the ﬁrst paragraph cautioning against any
interpretation of a paragraph that is incon-
sistent with the spirit and intention of the
entire document (as had occurred with the
2002 Note of Clariﬁcation to paragraph 29).
The workgroup’s ﬁnal draft reinforces,in the
face of considerable opposition, the DoH’s
longstanding principle of the priority of the
individual research subject over all other
interests. Far from discouraging medical
research, however, this principle encourages
access to research for both individuals and
populations,especially those that are under-
represented in research (an addition in new
paragraph 5).
The workgroup was aware that in the 2004
version the paragraphs dealing with the re-
search protocol and the responsibilities of
research ethics committees went beyond
statements of principle to include many de-
tails, but they decided not to delete any of
these requirements because that might be
interpreted as if the WMA no longer con-
siders them to be important. Instead, these
two paragraphs were reorganized to distin-
guish clearly between what should go in the
protocol (new paragraph 14) and what is
required of the research ethics committee
(new paragraph 15).
Since medical research is conducted by
other health professionals, e.g., nurses and
dentists, as well as by scientists who are not
health professionals,the role of physicians in
such research, as described in old paragraph
15, needed clariﬁcation. The workgroup re-
vised this paragraph (new #16) to separate
and distinguish two issues: (1) who may
conduct medical research – since medical
research includes research on human mate-
rials and data, some of it can be done by in-
dividuals who are not members of a health
profession, as long as they have the appro-
priate scientiﬁc training and qualiﬁcations;
(2) what research requires supervision by a
physician or other health professional – re-
search on patients or healthy volunteers but
not research on human materials or data.
A new paragraph 19 has been added that
requires every clinical trial to be registered
in a publicly accessible database before re-
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WMA news
cruitment of the ﬁrst subject.The workgroup
declined to elaborate on this principle since
trial registries are still under development.
Another topic on which the previous ver-
sion of the DoH goes into considerable
detail is informed consent. Because of the
great importance of this topic for research
ethics, the workgroup did not omit any of
the requirements in the previous version
and even added some additional ones. It
also distinguished more clearly the consent
procedures for competent and incompetent
research subjects.
One of the most diﬃcult issues facing the
workgroup was whether the requirements for
research on human material and data should
be the same as for other types of research on
human subjects. It decided that the DoH
should deal only with identiﬁable material
or data and that consent for such research
may sometimes be impossible or impracti-
cal to obtain or would pose a threat to the
validity of the research. However, it is not up
to researchers to decide this issue; they must
justify their request for an exemption to the
consent requirement to the research ethics
committee (new paragraph 25).
As noted above, the most contentious is-
sues during this revision process, as well as
the previous one, were the use of placebos
in clinical trials and access to the beneﬁts
of research once it is completed. The work-
group’s ﬁrst concern was to integrate the
2002 and 2004 notes of clariﬁcation on these
paragraphs in the text of the DoH. It also
wanted to preserve the substance of the pre-
vious version while clarifying the wording.
Its proposed revision achieved both these
objectives but did not resolve the deeply
felt conﬂicting views on the two issues that
were expressed in the written comments,
at the stakeholders’ workshops and, for the
placebo issue,in the October 2008 meetings
of the Medical Ethics Committee and Gen-
eral Assembly. The General Assembly ad-
opted an amendment to the new paragraph
32 stating that “Extreme care must be taken
to avoid abuse of this option”, i.e., the use of
placebos to determine the eﬃcacy or safety
of a new intervention where there is already
a proven intervention.However,this did not
satisfy all the delegates and the new version
did not receive unanimous approval.
Conclusion
The DoH is regarded as “a living document”
and will undoubtedly undergo further review
and revision in the future. Although it is too
early to determine the success of the latest
revision,some lessons from this exercise may
be valuable, not just for the WMA but for
any organization engaged in policy review.
The three rounds of consultation were very
useful both for soliciting input from those
aﬀected by the DoH’s provisions and for
making the document known to a wider au-
dience. By considering carefully the sugges-
tions of the respondents and sending them
each new draft, the WMA demonstrated
that the DoH is not just an internal policy
but rather a universal statement of medical
research ethics.
Setting a tight deadline for the completion
of a project such as this revision prevents
it from being extended indeﬁnitely. This is
especially important for organizations such
as the WMA whose policy making bodies
meet just once a year.
In a short document such as the DoH, ev-
ery word is important. In their discussions
of the workgroup’s drafts the WMA Medi-
cal Ethics Committee and Council wisely
focussed on the principles and left it to the
workgroup to come up with appropriate
wording.The workgroup was able to do this
eﬃciently through email exchanges.
Finally, since “the perfect is the enemy of the
good,” it is better to settle for incremental
improvements than to try to achieve the ab-
solute best.Both the structure and the word-
ing of the revised DoH could undoubtedly be
further improved but the workgroup felt,and
the General Assembly agreed, that it is good
enough for the time being,and is certainly an
improvement over the previous version.
Declaration of Helsinki
Ethical Principles for Medical Research Involving Human Subjects
Adopted by the 18th
WMA General Assembly,Helsinki,Finland,June 1964,and amended by the:
29th
WMA General Assembly,Tokyo, Japan, October 1975
35th
WMA General Assembly, Venice, Italy, October 1983
41st
WMA General Assembly, Hong Kong, September 1989
48th
WMA General Assembly, Somerset West, Republic of South Africa, October 1996
52nd
WMA General Assembly, Edinburgh, Scotland, October 2000
53th
WMA General Assembly, Washington, United States, October 2002
(Note of Clariﬁcation on paragraph 29 added)
55th
WMA General Assembly,Tokyo, Japan, October 2004
(Note of Clariﬁcation on Paragraph 30 added)
WMA General Assembly, Seoul, Korea, October 2008
A. Introduction
1. The World Medical Association
(WMA) has developed the Declaration
of Helsinki as a statement of ethical
principles for medical research involv-
ing human subjects, including research
on identiﬁable human material and
data.
The Declaration is intended to be read
as a whole and each of its constituent
paragraphs should not be applied with-
out consideration of all other relevant
paragraphs.
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WMA news
2. Although the Declaration is addressed primarily to physicians,
the WMA encourages other participants in medical research in-
volving human subjects to adopt these principles.
3. It is the duty of the physician to promote and safeguard the
health of patients, including those who are involved in medical
research. The physician’s knowledge and conscience are dedi-
cated to the fulﬁlment of this duty.
4. The Declaration of Geneva of the WMA binds the physician
with the words, “The health of my patient will be my ﬁrst con-
sideration,” and the International Code of Medical Ethics de-
clares that, “A physician shall act in the patient’s best interest
when providing medical care.”
5. Medical progress is based on research that ultimately must in-
clude studies involving human subjects. Populations that are
underrepresented in medical research should be provided ap-
propriate access to participation in research.
6. In medical research involving human subjects, the well-being
of the individual research subject must take precedence over all
other interests.
7. The primary purpose of medical research involving human sub-
jects is to understand the causes, development and eﬀects of dis-
eases and improve preventive, diagnostic and therapeutic inter-
ventions (methods, procedures and treatments). Even the best
current interventions must be evaluated continually through re-
search for their safety, eﬀectiveness, eﬃciency, accessibility and
quality.
8. In medical practice and in medical research, most interventions
involve risks and burdens.
9. Medical research is subject to ethical standards that promote re-
spect for all human subjects and protect their health and rights.
Some research populations are particularly vulnerable and need
special protection.These include those who cannot give or refuse
consent for themselves and those who may be vulnerable to co-
ercion or undue inﬂuence.
10. Physicians should consider the ethical, legal and regulatory
norms and standards for research involving human subjects in
their own countries as well as applicable international norms
and standards. No national or international ethical, legal or
regulatory requirement should reduce or eliminate any of the
protections for research subjects set forth in this Declaration.
B. Principles for all Medical Research
11. It is the duty of physicians who participate in medical research
to protect the life, health, dignity, integrity, right to self-deter-
mination, privacy, and conﬁdentiality of personal information of
research subjects.
12. Medical research involving human subjects must conform to
generally accepted scientiﬁc principles, be based on a thorough
knowledge of the scientiﬁc literature, other relevant sources of
information, and adequate laboratory and, as appropriate, ani-
mal experimentation. The welfare of animals used for research
must be respected.
13. Appropriate caution must be exercised in the conduct of medi-
cal research that may harm the environment.
14. The design and performance of each research study involving
human subjects must be clearly described in a research protocol.
The protocol should contain a statement of the ethical consid-
erations involved and should indicate how the principles in this
Declaration have been addressed. The protocol should include
information regarding funding, sponsors, institutional aﬃlia-
tions, other potential conﬂicts of interest, incentives for subjects
and provisions for treating and/or compensating subjects who
are harmed as a consequence of participation in the research
study.The protocol should describe arrangements for post-study
access by study subjects to interventions identiﬁed as beneﬁcial
in the study or access to other appropriate care or beneﬁts.
15. The research protocol must be submitted for consideration,
comment, guidance and approval to a research ethics committee
before the study begins. This committee must be independent
of the researcher, the sponsor and any other undue inﬂuence.
It must take into consideration the laws and regulations of the
country or countries in which the research is to be performed as
well as applicable international norms and standards, but these
must not be allowed to reduce or eliminate any of the protec-
tions for research subjects set forth in this Declaration. The
committee must have the right to monitor ongoing studies.The
researcher must provide monitoring information to the com-
mittee, especially information about any serious adverse events.
No change to the protocol may be made without consideration
and approval by the committee.
16. Medical research involving human subjects must be conduct-
ed only by individuals with the appropriate scientiﬁc training
and qualiﬁcations. Research on patients or healthy volunteers
requires the supervision of a competent and appropriately quali-
ﬁed physician or other health care professional.The responsibil-
ity for the protection of research subjects must always rest with
the physician or other health care professional and never the
research subjects, even though they have given consent.
17. Medical research involving a disadvantaged or vulnerable popu-
lation or community is only justiﬁed if the research is responsive
to the health needs and priorities of this population or commu-
nity and if there is a reasonable likelihood that this population or
community stands to beneﬁt from the results of the research.
18. Every medical research study involving human subjects must be
preceded by careful assessment of predictable risks and burdens
to the individuals and communities involved in the research in
comparison with foreseeable beneﬁts to them and to other indi-
viduals or communities aﬀected by the condition under investi-
gation.
19. Every clinical trial must be registered in a publicly accessible
database before recruitment of the ﬁrst subject.
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WMA news
20. Physicians may not participate in a research study involving hu-
man subjects unless they are conﬁdent that the risks involved
have been adequately assessed and can be satisfactorily man-
aged. Physicians must immediately stop a study when the risks
are found to outweigh the potential beneﬁts or when there is
conclusive proof of positive and beneﬁcial results.
21. Medical research involving human subjects may only be con-
ducted if the importance of the objective outweighs the inherent
risks and burdens to the research subjects.
22. Participation by competent individuals as subjects in medical
research must be voluntary. Although it may be appropriate to
consult family members or community leaders, no competent
individual may be enrolled in a research study unless he or she
freely agrees.
23. Every precaution must be taken to protect the privacy of re-
search subjects and the conﬁdentiality of their personal infor-
mation and to minimize the impact of the study on their physi-
cal, mental and social integrity.
24. In medical research involving competent human subjects, each
potential subject must be adequately informed of the aims,
methods, sources of funding, any possible conﬂicts of interest,
institutional aﬃliations of the researcher, the anticipated ben-
eﬁts and potential risks of the study and the discomfort it may
entail, and any other relevant aspects of the study.The potential
subject must be informed of the right to refuse to participate
in the study or to withdraw consent to participate at any time
without reprisal. Special attention should be given to the spe-
ciﬁc information needs of individual potential subjects as well
as to the methods used to deliver the information. After ensur-
ing that the potential subject has understood the information,
the physician or another appropriately qualiﬁed individual must
then seek the potential subject’s freely-given informed consent,
preferably in writing.If the consent cannot be expressed in writ-
ing, the non-written consent must be formally documented and
witnessed.
25. For medical research using identiﬁable human material or data,
physicians must normally seek consent for the collection, analy-
sis, storage and/or reuse.There may be situations where consent
would be impossible or impractical to obtain for such research
or would pose a threat to the validity of the research. In such
situations the research may be done only after consideration and
approval by a research ethics committee.
26. When seeking informed consent for participation in a research
study the physician should be particularly cautious if the poten-
tial subject is in a dependent relationship with the physician or
may consent under duress. In such situations the informed con-
sent should be sought by an appropriately qualiﬁed individual
who is completely independent of this relationship.
27. For a potential research subject who is incompetent, the physi-
cian must seek informed consent from the legally authorized
representative. These individuals must not be included in a re-
search study that has no likelihood of beneﬁt for them unless it is
intended to promote the health of the population represented by
the potential subject, the research cannot instead be performed
with competent persons, and the research entails only minimal
risk and minimal burden.
28. When a potential research subject who is deemed incompetent
is able to give assent to decisions about participation in research,
the physician must seek that assent in addition to the consent
of the legally authorized representative. The potential subject’s
dissent should be respected.
29. Research involving subjects who are physically or mentally inca-
pable of giving consent, for example, unconscious patients, may
be done only if the physical or mental condition that prevents
giving informed consent is a necessary characteristic of the re-
search population. In such circumstances the physician should
seek informed consent from the legally authorized representa-
tive.If no such representative is available and if the research can-
not be delayed,the study may proceed without informed consent
provided that the speciﬁc reasons for involving subjects with a
condition that renders them unable to give informed consent
have been stated in the research protocol and the study has been
approved by a research ethics committee. Consent to remain in
the research should be obtained as soon as possible from the
subject or a legally authorized representative.
30. Authors, editors and publishers all have ethical obligations with
regard to the publication of the results of research. Authors have
a duty to make publicly available the results of their research on
human subjects and are accountable for the completeness and
accuracy of their reports.They should adhere to accepted guide-
lines for ethical reporting. Negative and inconclusive as well as
positive results should be published or otherwise made publicly
available. Sources of funding, institutional aﬃliations and con-
ﬂicts of interest should be declared in the publication. Reports
of research not in accordance with the principles of this Decla-
ration should not be accepted for publication.
C. Additional Principles for Medical Research
Combined With Medical Care
31. The physician may combine medical research with medical care
only to the extent that the research is justiﬁed by its potential
preventive, diagnostic or therapeutic value and if the physician
has good reason to believe that participation in the research
study will not adversely aﬀect the health of the patients who
serve as research subjects.
32. The beneﬁts, risks, burdens and eﬀectiveness of a new interven-
tion must be tested against those of the best current proven in-
tervention, except in the following circumstances:
The use of placebo, or no treatment, is acceptable in studies•
where no current proven intervention exists; or
Where for compelling and scientiﬁcally sound methodological•
reasons the use of placebo is necessary to determine the eﬃcacy
125
WMA news
More than 200 delegates from 42 Na-
tional Medical Associations attended the
2008 General Assembly held at The Shilla,
Seoul,in the Republic Korea from 15th
-18th
October 2008.
The four-day event, hosted by the Korean
Medical Association in its centennial year,
comprised three committee meetings, two
Council meetings, the General Assembly,
receptions, luncheon and evening seminars.
During the event there were visits at vari-
ous stages from the President and the Prime
Minister of Korea, as well as the Minister
for Health, Welfare and Family Aﬀairs.The
agenda for the formal meetings was one of
the longest ever and inevitably the debates
in committee, Council and Assembly were
dominated by discussion on revisions to the
Declaration of Helsinki.
When the Assembly met on the ﬁnal day,
under the brisk, but avuncular chairman-
ship of Dr. Edward Hill, it adopted a host
of new and revised policies. In addition to
the revised Declaration of Helsinki, there
were documents on autonomy, on antimi-
crobial agents, mercury, sodium, the access
of women to health, on capital punishment,
nuclear weapons and anti-personnel mines,
on the economic crisis, poppies and veteri-
nary medicine.
Medical Ethics
The Assembly adopted three documents
from the Medical Ethics Committee,
which had been chaired by Dr. Eva Bågen-
holm.In addition to the revised Declaration
of Helsinki, it adopted a new Declaration
on Professional Autonomy and Clinical
Independence and decided to name it the
Declaration of Seoul. The document is a
successor to the 1987 Declaration of Ma-
drid, incorporating new issues based on
a document written by Dr. Jeﬀ Blackmer
from the Canadian Medical Association.
The new policy states that unreasonable re-
straints on physicians’clinical independence
imposed by governments and administrators
are not in the best interests of patients and
can damage the trust which is an essential
component of the patient–physician rela-
tionship. However the document adds that
physicians recognize they must take into ac-
count the structure of the health system and
available resources. It declares that the cen-
tral element of professional autonomy and
clinical independence is the assurance that
individual physicians have the freedom to
or safety of an intervention and the patients who receive pla-
cebo or no treatment will not be subject to any risk of serious or
irreversible harm. Extreme care must be taken to avoid abuse
of this option.
33. At the conclusion of the study, patients entered into the study
are entitled to be informed about the outcome of the study and
to share any beneﬁts that result from it, for example, access to
interventions identiﬁed as beneﬁcial in the study or to other ap-
propriate care or beneﬁts.
34. The physician must fully inform the patient which aspects of
the care are related to the research. The refusal of a patient to
participate in a study or the patient’s decision to withdraw from
the study must never interfere with the patient-physician rela-
tionship.
35. In the treatment of a patient, where proven interventions do not
exist or have been ineﬀective, the physician, after seeking ex-
pert advice, with informed consent from the patient or a legally
authorized representative, may use an unproven intervention
if in the physician’s judgement it oﬀers hope of saving life, re-
establishing health or alleviating suﬀering. Where possible, this
intervention should be made the object of research, designed
to evaluate its safety and eﬃcacy. In all cases, new information
should be recorded and, where appropriate, made publicly avail-
able.
WMA General Assembly, Seoul 2008
126
WMA news
exercise their professional judgment in the
care and treatment of their patients without
undue inﬂuence by outside parties or indi-
viduals. Patients expected their physicians
to be free to make clinically appropriate rec-
ommendations.Hospital administrators and
third-party payers may consider physician
professional autonomy to be incompatible
with prudent management of health care
costs. However, the restraints that adminis-
trators and third-party payers attempted to
place on clinical independence might not be
in the best interests of patients.
In a press statement, Dr. Edward Hill said:
“In this new Declaration we are reaﬃrming
the importance of professional autonomy and
clinical independence.We see this not only as
an essential component of high quality medi-
cal care and therefore a beneﬁt to the patient
that must be preserved,but also as an essential
principle of medical professionalism.”
The Assembly also adopted revisions to the
WMA Statement on Physician Participa-
tion in Capital Punishment, which was
ﬁrst adopted in 1981 and then amended in
2000. The revised document urges NMA
members to lobby actively their national
governments and legislators against any
participation of physicians in capital pun-
ishment. The Statement states that it is un-
ethical for physicians to participate in capi-
tal punishment in any way, including the
planning and instruction and/or training of
people to perform executions.
Socio-Medical Aﬀairs
No fewer than eight policy documents ema-
nating from the Socio-Medical Aﬀairs Com-
mittee, chaired by Dr. J.L. Gomes do Ama-
ral, were adopted by the Assembly.
The Statement on Antimicrobial Drugs
updates Association policy adopted in 1996
following revisions prepared by the Ameri-
can Medical Association. The new State-
ment declares that antimicrobial agents
should be available only through a pre-
scription provided by licensed and qualiﬁed
health care or veterinary professionals. It
warns that the global increase in resistance
to antimicrobial drugs has created a multi-
faceted public health problem of crisis pro-
portions with signiﬁcant economic and hu-
man implications. It also says that the use
of antimicrobial agents as feed additives
for animals should be strictly restricted to
those antimicrobials that do not have a hu-
man public health impact. The Statement
contains a warning that there is substan-
tial misuse and overuse of antimicrobial
agents, inappropriate prescribing, and poor
compliance with antimicrobial regimens by
patients. The Association plans to continue
to work with George Mason University in
Virginia, USA to monitor and develop this
issue.
Three new Statements were adopted. The
Statement on Reducing the Global Bur-
den of Mercury, initiated by the American
Medical Association and based on work by
Dr. Peter Orris, Professor of Occupational
and Environmental Medicine at the Uni-
versity of Illinois, Chicago Medical Cen-
tre. The Statement calls for the phasing
out of mercury use in the health care sec-
tor. It says hospitals and medical facilities
should switch to non-mercury equivalents.
This would involve eliminating mercury-
containing products such as thermometers,
sphygmomanometers,gastrointestinaltubes,
batteries, lamps, electrical supplies, thermo-
stats, pressure gauges, and other laboratory
reagents and devices. The Statement urges
physicians to counsel patients about ﬁsh
consumption in order to emphasise those
ﬁsh high in omega 3 fatty acids for their
value to heart and brain health and low in
mercury contamination. This was particu-
larly necessary for children and women of
childbearing age.
A new Statement on Reducing Dietary
Sodium Intake calls for a ﬁfty per cent re-
duction in the sodium content of processed
foods, fast food products and restaurant
meals over the next decade. Citing over-
whelming evidence that excessive sodium/
salt intake is a risk factor for the worsening
of hypertension and cardiovascular diseases,
it urges physicians to advise patients on how
to reduce sodium/salt intake, including re-
ducing the amount of salt used in cooking
at home.
A new Statement was also adopted on
Collaboration between Human and Vet-
erinary Medicine encouraging NMAs to
engage in a dialogue with their veterinary
counterparts to discuss strategies for en-
hancing collaboration between human and
veterinary medical professions within their
own countries.
127
WMA news
The revised Resolution on The Prohibition
ofAccessofWomentoHealthCareandthe
Prohibition of Practice by Female Doctors
supports the rights of women and children
to full and adequate medical care, especially
where religious and cultural restrictions
hinder access to such medical care. It urges
NMAs to condemn violations of the basic
human rights of women and children. It says
that for years women and girls worldwide
have been suﬀering increasing violations of
their human rights, including restrictions to
access to employment, education and health
care. In many countries female doctors and
nurses have been prevented from exercising
their profession, leading to female patients
and their children not having access to health
care. Finally the Resolution urges NMAs to
increase the eﬀective participation of women
in the medical profession.
The Assembly also adopted a Resolu-
tion on Poppies for Medicine Project for
Afghanistan, which supports calls for in-
vestigating the controlled production of
opium for medical purposes in Afghanistan.
The Resolution urges governments to sup-
port a scientiﬁc pilot project to investigate
whether certain areas of Afghanistan could
provide the right conditions for the strictly
controlled production of morphine and di-
amorphine for medical purposes.
The Assembly adopted the revised State-
ment on Nuclear Weapons, asking NMAs
to urge their respective governments to
work towards the elimination of nuclear
weapons, and a Resolution Supporting the
Ottawa Convention on Prohibition of the
Use, Stockpiling, Production and Trans-
fer of Anti-Personnel Mines and on their
Destruction.
Finally the Assembly adopted an emergency
Resolution from Council on The Econom-
ic Crisis: Implications for Health urging
NMAs to work with their governments to
initiate programmes for families and indi-
viduals needing medical and psychological
support because of the current economic
crisis and to preserve at least the current ex-
penditure on health.
New work groups were set up on stem cell
research, conﬂict of interest, the placebo
issue and the development of Associate
Members’meetings.Dr.G.Dumont was re-
elected Chair of the Associates Committee.
Applications for membership were accepted
from no less than eight national medical as-
sociations – Albania, Angola, Cote d’Ivoire,
Cyprus, Mali, Senegal, Poland and Ukraine,
bringing the total number of NMA mem-
bers to 94.
In relation to future General Assemblies,
it was agreed that next year’s scientiﬁc ses-
sion in Mumbai, India should be on ‘Multi-
Drug Resistant Tuberculosis and Lessons
Learned from this Epidemic’ and that the
scientiﬁc session in Vancouver in 2010
should be ‘Health and the Environment’.
It was agreed that the 2011 General As-
sembly should be held in Uruguay and the
2012 Assembly in Thailand.
Presidential addresses
During the Assembly, Dr. Yoram Blachar,
President of the Israeli Medical Association,
was installed as President for 2008/9. In his
inaugural address he issued a plea for action
to shield the world’s health care systems as
much as possible from the aftershock of the
global ﬁnancial turmoil and the economic
recession. He said the WMA and National
Medical Associations must act to moderate
the destructive impact of the ﬁnancial crisis.
He spoke about the intolerable phenom-
enon of health disparities. They had always
existed both among and within countries,
but the gaps were widening.The WMA and
individual physicians had a role to play in
combating this problem.
He said that doctors as social leaders had a
responsibility to address a wider scope of is-
sues aﬀecting health, such as armed conﬂict.
The WMA had a unique opportunity, with
both ability and positioning to try to bring
conﬂicting parties to the discussion table by
encouragement and dialogue within its or-
ganization. In his own region of the Middle
East, he said he would use his Presidency to
make every eﬀort to turn health and medi-
cine on an organizational level to a bridging
force and to advance the peace process the
region so desperately needed.
Dr. Jon Snaedal, in his valedictory address
as President for 2007/8 warned that the
global economic crisis could lead to health
authorities saving costs by shifting tasks
away from doctors to other health profes-
sionals. He said that the WMA was now
discussing this whole issue with the World
Health Organisation and with the other
health professions. Unity among the health
professions would result in more eﬀective
changes. He announced that the WMA
would be organising a meeting in Iceland
next March, to look in further detail at hu-
man resources for health, task shifting and
interprofessional relations.
Dr. Dana Hanson, a dermatologist from
New Brunswick in Canada, was elected un-
opposed as President for 2009/10, the ﬁrst
Canadian to be elected President. Dr. Han-
son, a former president of the Canadian
Medical Association, has practiced as a
dermatologist in Fredericton, the capital
of New Brunswick, since 1980. He said he
planned to focus his Presidency on advoca-
cy, both for patients and physicians, and on
128
WMA news
health and the environment.The last Cana-
dian President of the WMA was Dr.Arthur
Peart, secretary general of the Canadian
Medical Association, in 1971, although it is
not thought he was elected to the post.
In an Open session at the conclusion of the
Assembly, Michael Maves, Executive Vice
President of the American Medical Associa-
tion,spoke about the work on task shifting in
the US,which in America,he said,was called
scope of practice. What the AMA and other
medical organisations were trying to do was
restrict inappropriate expansion of scope of
practice by allied health personnel through
legislative activities, regulatory activities and
judicial advocacy.He said they were trying to
put together a campaign to highlight for the
publicthosecharacteristicsthatdistinguished
physicians from other health personnel.
In addition to the formal business of the
Assembly,there were three important fringe
events.
At an evening seminar, the launch was an-
nounced of the WMA Physicians Leader-
ship Course, a global, annual programme to
enhance physician leadership skills in advo-
cating for health care reform and achieving
improved patient care. Nominated through
their NMAs, 32 top physician leaders rep-
resenting 20 countries are to be selected by
the WMA to participate in the high-level
training conducted by INSEAD, one of the
world’s leading and largest graduate busi-
ness schools. The six-day intensive curricu-
lum will focus on proﬁciency in decision-
making, participation in public debate and
preparation to serve as spokespersons on key
health care policy issues.The Course was de-
veloped from a pilot programme created last
year and is sponsored by a grant from the
Pﬁzer Medical Partnerships Initiative.
The seminar heard a welcome speech by
Dr. Yank D. Coble Jr., Past President of the
WMA, and presentations by Dr. Robert
Miglani, Senior Director, Pﬁzer, and
Dr. Ruth Collins-Nakai, Alumni of 1st
IN-
SEAD Leadership Course, who reviewed
content and participants ratings.
A lunchtime event was held to launch a
new speaking book,designed to explain the
rights and responsibilities of people enter-
ing into clinical trials in Africa.The book is
aimed at patients and their relatives who do
not read and write suﬃciently well to un-
derstand what a clinical trial is for and how
it works. The project has been developed by
Books of Hope together with the World
Medical Association, the Steve Biko Cen-
tre of Bioethics, the South African Medi-
cal Association and funded by Pﬁzer. It is
planned to distribute 4,500 books in South
Africa and three other Sub-Saharan coun-
tries before the end of 2008.
A second lunchtime symposium was held on
smoking cessation under the title ‘The Criti-
cal Role of Physicians in Helping Smokers
Quit’. With tobacco use projected to cause
one billion premature deaths in the 21st cen-
tury, speakers spoke about the importance
of the global health community ﬁghting to
reduce the tobacco death toll by implement-
ing the Framework Convention on Tobacco
Control (FCTC), whose provisions call for
countries to take strong action against to-
bacco use. The symposium, supported by an
unrestricted educational grant from GlaxoS-
mithKline Consumer Healthcare, heard pre-
sentations from Dr. Il Suh, Dean of Yonsei
University College of Medicine,Korea,on the
success story of an anti-smoking campaign in
a developing country with high prevalence of
cigarette smoking,Dr.Ron Davis,Immediate
past president of the American Medical As-
sociation, on physician intervention and how
to make a diﬀerence, and Dr. Chi Pang We,
Professor at the National Health Research
Institutes, in Taiwan on overcoming barriers
to smoking cessation.
The all-day Scientiﬁc Session on the topic
of ‘Health and Human Rights’ included
presentations on Health and Human
Rights from the Social Perspective, Health
and Human Rights from the Environmen-
tal Perspective and Medical Ethics and Hu-
man Rights Advocacy.
One notable absentee from the meeting in
Seoul was Dr. Mukesh Haikerwal, Chair of
the Finance and Planning Committee, who
was recovering at home in Australia after
being the victim of a street attack in his
home city of Melbourne. He had suﬀered
serious head injuries and was now recuper-
ating. Delegates sent their good wishes to
Dr. Haikerwal and in support the meeting
reaﬃrmed the WMA’s 2003 Statement on
Violence and Health.
Nigel Duncan
The full texts of all the Declarations,
Statments and Resolutions my be accessed on
the WMA website wma@wma.net
Adopted by the WMA General Assembly, Seoul, Korea, October 2008
The current global economic crisis is aﬀecting individuals as well
as national and global economies and will have implications for
health. Individuals face uncertainties about their future and psy-
chological consequences are beginning to emerge. Governments
facing economic downturns have to respond by cutting down na-
tional expenses. There is a risk that expenditure on health care will
decrease nominally and proportionally in the coming years. Experi-
ence has shown that this response can have serious consequences on
the health of individuals and on their contribution to the national
economy. Any savings will therefore be reduced.
The WMA therefore urges NMAs to work with their governments
to:
Initiate programs for families and individuals needing medical•
and psychological support because of the current economic crisis.
Preserve at least the current expenditure on health.•
Resolution on the Economic
Crisis: Implications for Health
129
WMA news
Adopted by the WMA General Assembly, Seoul, Korea, October 2008
The World Medical Association, having explored the importance of
professional autonomy and physician clinical independence, hereby
adopts the following principles:
The central element of professional autonomy and clinical in-•
dependence is the assurance that individual physicians have the
freedom to exercise their professional judgment in the care and
treatment of their patients without undue inﬂuence by outside
parties or individuals.
Medicine is a highly complex art and science.Through lengthy train-•
ing and experience, physicians become medical experts and healers.
Whereas patients have the right to decide to a large extent which
medical interventions they will undergo,they expect their physicians
to be free to make clinically appropriate recommendations.
Although physicians recognize that they must take into account•
the structure of the health system and available resources, unrea-
sonable restraints on clinical independence imposed by govern-
ments and administrators are not in the best interests of patients,
not least because they can damage the trust which is an essential
component of the patient–physician relationship.
Hospital administrators and third-party payers may consider•
physician professional autonomy to be incompatible with prudent
management of health care costs. However, the restraints that ad-
ministrators and third-party payers attempt to place on clinical
independence may not be in the best interests of patients. Fur-
thermore,restraints on the ability of physicians to refuse demands
by patients or their families for inappropriate medical services are
not in the best interests of either patients or society.
The World Medical Association reaﬃrms the importance of•
professional autonomy and clinical independence not only as an
essential component of high quality medical care and therefore
a beneﬁt to the patient that must be preserved, but also as an
essential principle of medical professionalism. The World Medi-
cal Association therefore re-dedicates itself to maintaining and
assuring the continuation of professional autonomy and clinical
independence in the care of patients.
Declaration of Seoul on
Professional Autonomy and
Clinical Independence
A new speaking book, designed to explain the rights and responsi-
bilities of people entering into clinical trials, has been launched for
use in Africa.
The book to be launched at the World Medical Association’s Gen-
eral Assembly in Seoul, South Korea, is aimed at patients and their
relatives who do not read and write suﬃciently well to understand
what a clinical trial is for and how it works.
The ‘speaking book’ has an audio component that corresponds to
text and illustrations in the book. A simple button on the book be-
gins a conversation on rights,roles and responsibilities of patients in
relation to their potential participation in a clinical trial. The book
can be used by patients, social workers and community based health
workers involved in clinical trials.
The project has been developed by Books of Hope together with the
World Medical Association,the Steve Biko Centre of Bioethics,the
South African Medical Association and funded by Pﬁzer.
Dr. Kgosi Letlape, Chair of the South African Medical Association,
said: ‘Animation and cartoons help to break down the barriers of com-
munication and most people feel comfortable with educational material
presented in this form.If you cannot understand the words,you can get
the meaning from the pictures.’
Dr. Edward Hill, Chair of Council, WMA, said: ‘More than ever it
is necessary to do research, with, in and – most important – for poor
populations.I applaud the production of the speaking book,because
it means paying more attention to the poorer communities of this
world instead of abandoning them or just ignoring their needs.’
It is planned to distribute 4,500 books in South Africa and three
other Sub-Saharan countries before the end of 2008. Following the
launch,the book will be presented to internal and external organiza-
tions with the aim of assessing additional international need.
Pﬁzer’s vice president Dr. Jack Watters, said: “It is absolutely crucial
that all people involved in clinical research – whether as a health
professional, an ethics committee member or as a patient – have the
necessary knowledge and/or skills to play their role. That eﬀort is
signiﬁcantly supported by this book.’
New Speaking Book on Clinical
Trials Aimed at African Populations
with low Literacy Level
130
WMA news
Finance and Planning Committee
The committee was opened by the Chair,Dr.
Haikerwal, who commented that the Exec-
utive had met monthly, following which the
minutes of the last meeting were adopted.
Finance
The reports on membership dues and the
oral report on dues areas were received.
The pre-audited ﬁnancial statement for
2007 was presented by Mr. Halmayr; he in-
dicated that improvement over the 2006-7
position was sustained and referred to the
increase in staﬀ which had now returned to
its normal level, commenting that in rela-
tion to the Advocacy adviser the generous
assistance of the AMA had reduced the
cost. He further said that the costs of the
Council meeting in Berlin, despite the in-
creased size of the council, were less than
the benchmark set for meetings not held in
Divonne. The committee received a report
from the Business Development Group in-
cluding a report on the development of the
Web Portal and the Secretary General ex-
pressed his special thanks to the CMA for
their work on this.
Business Development Group
The committee received a report from the
Business Development Group on the Seoul
General Assembly.
Future meetings
The committee received reports on future
plans for meetings as follows:
2008 General Assembly:
The committee heard a report on the forth-
coming General Assembly in Seoul outlin-
ing the scientiﬁc programme on Health and
Human Rights, which was considered to be
very exciting.
182nd
Council:
2009 GeneralAssemblyinMumbai,India,
on which Dr. Desai gave a presentation &
ﬁlm. The IMA proposal that the Scientiﬁc
Session be Multi Drug Resistant Tubercu-
losis was recommended to and approved by
Council
2010 General Assembly, Vancouver, Can-
ada.The CMA proposed the Scientiﬁc Ses-
sion to be on Human Health and the En-
vironment which was recommended to and
approved by Council.
Indications were given of oﬀers to host the
General Assembly from Uruguay in 2011
and from Australia in 2012.
WMA Oﬃce
The Secretary General gave an oral report
on necessary renovation and possible rent-
ing/selling of part of the oﬃce space surplus
to needs following which there was a gen-
eral discussion.It was made clear the appro-
priate expert advice would be sought which
would be passed to the Executive commit-
tee and Chair of Council.
Conduct of business
During a discussion of the conduct of busi-
ness introduced by Dr. Waikerwal, he re-
ported to council a number of points had
been made which could improve the con-
duct of business.
Membership
The following applications for membership
of the WMA were recommended and later
approved by Council to be forwarded to
the General Assembly
Ukrainian Medical Association•
National Order of Physicians of Côte•
d’Ivoire
National Order of Physicians of Sen-•
egal
National Order of Physicians of Mali•
Cyprus Medical Association (pending•
legal approval of the statutes)
The Secretary reported on the Albanian Or-
der of Physicians whose statutes conformed
with the requirements and from whom an
application would be received for the next
meeting.
The committee received a report on the As-
sociate Membership and the Chair of Coun-
cil reported that Drs. Ishii and Johnson had
agreed to undertake a thorough analysis of
the associate membership and report to the
next meeting of the committee.
WMJ
The committee had an oral report from the
new Editor of the WMJ Dr. Peteris Api-
nis, explaining his new presentation and
the changed design. He again encouraged
NMAs to write about themselves, called
for cooperation with those responsible for
national association publications and also
sought cooperation with regional medical
association organisations such as Confermel
etc. Speaking of design and layout he had
introduced pictures of countries relating to
the country to be presented each issue. The
key words for policy were “Informative”and
“Interdisciplinary”
Dr.Kloiber reported that the Business Group
had recommended and discussed the content
and development of the WMJ and provided
its guidance.It suggested that there would be
value in exploring the niche for this publica-
tion and considered that a full scientiﬁc peer
reviewed publication was not the preferred
option for the WMJ. Dr. Kloiber thanked
Dr. Apinis, Dr. Rowe and Professor Dop-
pelfeld for their work on the Journal.
The committee received the report of the
Press Oﬃcer, Nigel Duncan who requested
179th
Council meeting
(Part 2) [continued from WMJ54 (3)]
131
WMA news
member associations to mention the WMA
in their Press releases when appropriate to
increase the visibility of the WMA.
Socio-Medical Aﬀairs Committee
The Chairman Dr. J.L Gomes do Amaral
opened the meeting,welcomed a new mem-
ber. The minutes of the Copenhagen meet-
ing were considered and approved.
Antimicrobial Drugs
The committee recommended that a revi-
sion of the Statement on Antimicrobial
Drugs, a recommendation subsequently ad-
opted and approved by council.
Continuous Quality Assurance
The revision of a Continuous Quality As-
surance statement provoked considerable
discussion. This arose from concerns in the
AMA relating to governmental interpreta-
tion of medical research and what consti-
tutes “evidence”. The committee recom-
mended to council that the document be
referred back to NMAs with an explanation
of the new concerns. The recommendation
was subsequently accepted by Council.
Access of Women to Healthcare
Following interventions from the BMA,
Canada and the AMA,a number of amend-
ments were suggested and the amended
document recommended to council who
approved its adoption and forwarding to
the General Assembly.
Dietary Sodium
The AMA moved the adoption of this
document. The Indian Medical Associa-
tion questioned whether reducing sodium
increased the risk of cardiovascular disease,
referring to a literature review of 450 pa-
pers and proposed that in the light of this,
a working group be established to review
the proposed document. It was pointed
out that the paragraph referred to uses the
words “can have an eﬀect”. Numerous other
speakers observed that the proposal agrees
with other bodies which have made such
recommendations and did not refer to a di-
rect link.The Japanese Medical Association
commented that while there was no direct
link with all cardiovascular disease, there
was one with hypertension and thus with
apoplexy.
The motion to refer to a working group was
lost.
A motion to recommend approval to council
for forwarding the document to the Gen-
eral Assembly was agreed and subsequently
adopted by Council.
Resolution on Task Shifting
The President referred to the press release
at the Addis Ababa conference.The concept
of Task shifting had positive and negative
aspects, it moves tasks which were initially
complicated and have become simpliﬁed.
Now however, we are dealing with task
shifting determined by other authorities,
with governments and legislation moving
tasks to other professions and lay persons.
His article on the Kampala meeting in
March “Human Resources for Health” was
in the May WMJ (seeWMJ54 (2), 34-35)
which the council had before them and
addressed the problems facing 55 coun-
tries, mostly in Africa. The Executive on
the previous day had recommended that
council should adopt a statement based
on the World Health Professions’ Joint
Statement at the Kampala meeting. Dr.
Blachar (President-elect) said the proposal
was that the WMA council endorse the
WHPA Kampala document and recom-
mends that WMA engage in further study
of this issue Responding to a question as
to whether actions taken by the executive
require endorsement by the council. The
Secretary General observed that this was
a special situation. Normally strategy was
determined by council and passed to oth-
ers. In Kampala, action had to be taken on
the spot in the WHPA of which WHO
was a member. We don’t have a policy on
Task Shifting and therefore endorsement
of the action taken by an organisation of
which WMA is a member was necessary.
Dr. Snaedel (President) observed that
this was a problem also aﬀecting other
health professionals. It was important that
the council should make a statement on
this occasion. This was a problem for the
health professions. Dr. Letlape (Immedi-
ate Past President) commended the Execu-
tive. What we had here was a new cadre of
health worker. He also had a concern about
nomenclature. The President commented
that the wording was correct, namely “task
shifting” and that Dr. Letlape was raising a
South African issue.
The President-elect felt that the WHPA
document should be endorsed.We were not
concerned about losing work, but work was
being placed elsewhere due to the shortage
of health personnel.
Dr. Vilmar (Germany) considered that we
should think of the relationship between
Task shifting and Quality. In our daily work
as Health Professionals we delegate tasks to
others e.g.ECGs to technicians.Delegation
of other tasks could be disastrous. However
we now have other professions claiming
more prerogatives. We must work with
other Health Professions to ensure safety
and quality. However, to ensure quality and
safety, diagnosis must remain with Physi-
cians.
Dr. Call’och supported the Executive’s ac-
tion. Some time we must produce a sup-
plementary motion to extend the WHPA
statement to ensure safety and quality. Task
shifting in French is translated as Task
Transferring. In France protocols are now
being written for doctors transferring tech-
nical tasks (including drug substitution) to
other professions.
A comment from Bolivia sought assistance
to deal with the problem of inadequately
trained Cuban doctors. The Chair com-
mented that we had to consider the eﬀects
of task shifting not only in relation to a phy-
132
WMA news
sician shortage, but also in relation to other
health professionals
Dr. Letlape proposed a two part decision.
First that the executive action be endorsed –
this was agreed. Secondly, that a study be
undertaken. It was observed that the issues
raised by task shifting clearly had major
medical workforce implications, on which
a work group already existed. It was ﬁnally
agreed to recommend that this group under-
take the study to deﬁne the issues and rec-
ommend long term viable solutions. Council
later endorsed this recommendation
Global Problem of Mercury
A Statement on the Global Burden of Mer-
cury was recommended for approval by
council and forwarding to the General As-
sembly. This recommendation was adopted
by Council.
Poppies for Medicine
In connection with the proposed motion it
was pointed out that the Standing Com-
mittee of Doctors had recommended the
project.
The proposal was recommended for ap-
proval and referral to General Assembly by
council and later adopted by Council.
Action on classiﬁcation of 1998 policies.
The following recommendation were•
made and adopted by council:
Declaration on Nuclear Weapons to be•
reaﬃrmed with minor revisions
Resolution on Medical Workforce to un-•
dergo major revision
Resolution on Improved Investment in•
Health Care to undergo a major revi-
sion
Resolution on the Hague Appeal for•
Peace to be rescinded and archived
Resolution supporting the Ottawa Con-•
vention of Anti-Personnel Landmines
and their destruction to undergo a major
revision
Resolution on Medical Care for Refugees•
to be reaﬃrmed with minor revisions.
Health and the Environment.
Dr. Hansen said that a document was be-
ing prepared by CMA on “Health and
Environment” a topic which we should be
addressing, rather than “climate change”.
Firm facts are needed. It is possible to ad-
dress eﬀects such as those of Mercury (as
in the WMA document) and the CMA has
some projects in mind. They would try to
make the document relate to physicians.
Advocacy and research are important in this
area – such advocacy would ﬁt into Advo-
cacy for patients. This work would prepare
the way for a General Assembly which was
proposed to be held in Canada in 2010. He
suggested a task Force with a mandate to
look at Health and the Environment, using
expertise as necessary.
The Chair of Council called for nominations
for a force to develop policy on Environ-
ment and Health to which Canada, France,
Korea, UK and Switzerland responded. As
the UN policy conference would take place
in Copenhagen on 2009 Denmark also of-
fered to join the group.
Dr. Wilks (Chair of Standing Committee
of European Doctors) reported that as the
EU was doing work on Climate change and
the CPME is developing policy.This will be
shared with WMA.
Drug Prescription
A resolution on Drug Prescription was
introduced to the committee. In present-
ing this, a plea was made that prescribing
should only be done by physicians and
based on the clinical history and diagnosis
– information which is private and cannot
be shared – which implied that physicians
with the scientiﬁc and human training were
required. Advocacy only thinks of Safety of
the patient whereas the Pharmaceutical In-
dustry tends to separate this form of medi-
cal practice.
In a general debate it was suggested that
this trend was part of Task Shifting. In its
current form however, the motion would
make WMA a laughing stock. This motion
was relevant to the 20th
century, but not the
21st
where many other professionals were
trained to prescribe drugs.It was pointed out
that in the UK nurses and pharmacists were
able to prescribe drugs. While expressing
sympathy with the Spanish, it was pointed
out that prescribing by a physician was not
necessary on every occasion e.g. OTCs.The
motion needed substantial rephrasing. The
President reported that the Annual meeting
of the Pharmacists were already working on
this issue. WMA is waiting see the guide-
lines on this topic in relation to physicians
and pharmacists.
The Spanish replying to the debate agreed
that work on this topic should start at once
and said that patients need guarantees. In
Spain the European Society of Patients
support prescribing by Physicians only. He
spoke of the problem of Adverse Drug Re-
actions and patients tending to take drugs
blindly e.g. OTC preparations. Physicians
were not superior, but should be at the head
of prescribing.
After agreeing that the work should be done
by a working group,it was agreed that a new
working group should be set up, with a re-
mit to examine the draft proposal, as well as
the authority to prescribe, and report back
to the committee. This recommendation
was later accepted by Council.
Human and Veterinary Medicine
Following the presentation of a proposed
Statement on this issue by the American
Medical Association the committee recom-
mended and the council approved the doc-
ument being sent to NMAs for comment.
Advocacy Advisory Group
It was reported that the mandate of the
group had been clariﬁed, namely that it
would produce an advocacy plan for the
year, including a strategy highlighting areas
for NMAs.
Dr. Alan J. Rowe
133
WMA news
Yank D. Coble, MD, Chair, WMA Caring
Physicians of the World Initiative
“The most important thing is caring, so do it
ﬁrst, for the caring Physician best inspires
hope and trust.” Sir William Osler
Caring, Ethics and Science are the three
fundamental and enduring traditions that
unite medical professionals and their pa-
tients around the world. Because of these
universal traditions, we ﬁnd global similar-
ity in physicians’ and patients’ desires and
concerns, despite the enormously disparate
environments and circumstances in which
physicians care for patients.
The Caring Physicians of the World Ini-
tiative (CPWI) was designed to restore
enthusiasm and optimism in medicine,
through medical and social leadership based
on the enduring traditions of the medical
profession: Caring, Ethics and Science. The
initiative was conceived in Helsinki,Finland
at the 2003 General Assembly of the World
Medical Association.
The World Medical Association (WMA)
represents physicians around the world and
provides a global forum for physicians to
communicate, cooperate and promote high
standards and professionalism. The WMA
is a federation of National Medical Asso-
ciations (NMAs) representing over eight
million physicians in more than 90 coun-
tries around the world. It was founded in
1947 with the mission to “serve humanity
by endeavoring to achieve the highest in-
ternational standards in medical education,
medical science, medical care, and medical
ethics, and health care for all the people of
the world”.This unique partnership of phy-
sicians enhances the health and quality of
life for people all over the world.
As part of its work to achieve high standards
in medicine, the WMA conducted a survey
of physicians in over 40 countries around
the globe in 2003. Survey results revealed
physicians’ concerns about access to quality
safe medical care, appropriate professional
autonomy to provide that care,and adequate
resources and facilities to deliver care. Phy-
sicians were also seriously concerned about
the regulatory, legal, political, and other
barriers to providing care, as well as gov-
ernmental attitudes regarding medical care
as an expense, rather than an investment
with positive return. To a large degree, phy-
sicians across the world felt marginalized,
threatened, and demeaned. They requested
that the WMA provide increased informa-
tion on health systems and facilitate greater
exchange of experience between physicians
throughout the world. Physicians requested
vigorous communication of the professional
values of the medical and health professions
and the well-documented value in relieving
distress, despair, disease, disability, and pre-
mature death, and the extraordinary return
on investment in medical care and public
health. Physicians also felt they needed to
enhance their own knowledge and skills in
leadership and advocacy for patients, public
health, and the medical profession.
The WMA resolved to address these global
concerns in 2004, and formed a partnership
with an experienced sponsor, Pﬁzer, Inc.
They developed the Caring Physicians of
the World Initiative (CPWI), chaired by
WMA President-elect Yank D.Coble,MD.
Through this initiative, the WMA would
unite NMAs around the world, implement-
ing a multipart program to address the
identiﬁed global concerns of physicians.
PhaseIoftheCPWInitiative: Connecting
The goal of Phase 1 was to connect with
NMAs around the world, enhancing global
communication. The WMA reached out
to NMAs and regional associations such
as the Medical Association of Southeast
Asian Nations (MASEAN) and the Medi-
cal Confederation of Latin America and
the Caribbean (CONFEMEL), building
relationships and increasing participation
and leadership in the World Health Orga-
nization (WHO) and World Health Pro-
fessions Alliance (WHPA). WMA oﬃcers
visited Africa, Europe, Latin America, the
Middle East and North America, and made
multiple visits to India and China. These
outreach visits by WMA oﬃcers enabled
The WMA Caring Physicians of the
World Initiative
Otmar Kloiber, MD, Secretary General, World
Medical Association
134
WMA news
them to learn more directly about circum-
stances, needs, and desires, and to obtain
support and increase advocacy for the values
of the medical profession.
Phase II of the CPW Initiative: Inspiring
The goal of Phase II was to inspire, building
enthusiasm and optimism for the medical
profession, by showcasing exemplary physi-
cians from around the world in a compila-
tion of “Caring Physicians of the World.”
This publication featured 65 physicians
from 58 countries: heroes and social lead-
ers who were nominated by their NMAs as
exemplifying the enduring traditions of car-
ing, ethics, and science.
Plans for the book were announced at the
WMA General Assembly in Tokyo, 2004.
NMAs nominated over 200 physicians; 65
physicians were interviewed, photographed
on site, and memorialized in the publica-
tion. The book was presented at the 2005
WMA General Assembly in Santiago,
Chile and the regional conference of CON-
FEMEL. Subsequently, the message of the
Caring Physicians of the World was com-
municated to NMAs, medical schools and
specialty societies,government,media,busi-
nesses, philanthropies, and multiple other
public and private associations and organi-
zations around the
world. In May 2006
the Caring Physi-
cians of the World
Book and Initiative
were featured at a
luncheon reception
of over 200 Minis-
ters of Health and
other health and
medical leaders fol-
lowing the opening
sessions of the 2004
World Health As-
sembly. The preface,
describing the rel-
evance, importance
and power of caring, ethics and science.
Phase III of the CPW Initiative: Col-
laborating The goal of Phase III was to
improve collaboration, forming regional
partnerships in areas around the world, to
enhance communication, collegiality, and
advocacy for patients, public health, and the
medical profession. With WMA oﬃcers’
participation, and the Pﬁzer partnership
and support, Dr. Otmar Kloiber, Secretary
General of the WMA, and host NMAs or-
ganized highly successful regional meetings
in Johannesburg, Prague, Santiago, Tokyo,
Bangkok, Shanghai, and Amelia Island,
Florida. These regional meetings focused
on eﬀective ways to address the primary
issues for patients, physicians, and public
health. During these meetings it emerged
that there was a growing desire for improv-
ing physicians’ advocacy and leadership
skills.
Phase IV of the CPW Initiative: Devel-
oping The goal of Phase IV was to address
the emergent need for development of
physicians’ advocacy and leadership skills.
Throughout 2006 and 2007 the WMA,
in collaboration with INSEAD and again
with the partnership of Pﬁzer, Inc., devel-
oped the WMA/CPWLeadershipCourse.
The program was designed to develop the
skills and knowledge needed for medical
and social leadership, enhancing the abili-
ties of medical professionals to advocate
more eﬀectively for medical care, education,
research, ethics, and the medical profession.
The ﬁrst course was held from 2-9 Decem-
ber, 2007, at INSEAD in Fontainebleau,
France. Thirty three colleagues, selected by
their NMAs in 22 countries, participated in
the course. Feedback from this inaugural
course has been extraordinarily positive, as
has the increased communication between
the “Alumni”of the course. The next course
is planned for INSEAD, Fontainebleau,
1-6 December, 2008. INSEAD Singapore
is under consideration as the site for the
course in 2009.
Phase V of the CPW Initiative: Apply-
ing and Achieving Phase V is an enduring
phase in which WMA will explore appli-
cation of the CPW principles and achieve-
ment of the CPWI goals. One of the ﬁrst
examples of CPWI Application can be
found in Indonesia.
Two Indonesian Medical Association
(IMA) leaders, Dr. Fachmi Idris and Dr.
Tauﬁk Jaaman, participated in the Decem-
ber 2007 WMA/CPW Leadership Course.
They proposed an Indonesian Caring Phy-
sicians Initiative for their IMA Centennial
Annual meeting in May 2008. They began
planning,and by early 2008 had the support
of the President of the Indonesian Republic,
collaboration of the Minister of Health,and
additional support.
WMA/CPW Leadership Course 2007
135
WMA news
The IMA created a video documentary of
100 years of Indonesian history, and a new
book, Indonesian Caring Physicians, edited
by Dr.Tauﬁk Jaaman. This book proﬁles 112
Indonesian physicians, nominated as heroes
and social leaders, exemplifying the endur-
ing medical traditions of caring, ethics, and
science. The publication includes messages
from the Indonesian President, and the
Minister of Health, and the WMA. Both
books, the Caring Physicians of the World
and the Indonesian Caring Physicians, were
presented to the Indonesian President and
Minister of Health at the IMA Centen-
nial Anniversary at a large event held at the
President’s Palace, May 28, 2008, and to
the faculty and students of the Indonesian
University School of Medicine by IMA and
WMA oﬃcers with presentation addresses.
The opening of the IMA Centennial Meet-
ing and exposition featured the ICP book,
video, and initiative.
The WMA is proud of the growth and
achievements of the CPW Initiative. How-
ever much remains to be accomplished in,
by and for the medical profession. Global
threats of communicable and non-commu-
nicable disease persist despite unparalleled
progress in biomedical science,public health
and medical care. Barriers to care ﬂourish,
created by ineﬀective, ineﬃcient, and some-
times even corrupt governments. The pub-
lic is confused by terms such as providers
instead of professionals, customers instead
of patients, health care instead of medical
care, the pollution of scientiﬁc information
by media, and distortion by legal and regu-
latory systems. They are understandably
distrustful. However there is good reason
to be optimistic: the justiﬁable enthusiasm
physicians have for the value and values of
their profession, and the ability to be useful.
The CPW Initiative has helped to clarify
the assertion of physicians around the world
that eﬀective leadership, hard work, a clear
deﬁnition of responsibilities and rights as a
profession, and a mission beyond self, will
result in signiﬁcant and measurable success.
The CPWI has a• focus on Patients:
working to inspire hope and trust, as well
as to reduce disease,despair,disability and
premature death.
The CPWI has a• focus on Rights: pro-
moting the right of all patients to choose
physicians providing care based on a sin-
gular ethical commitment to them, us-
ing the best available science, in a caring
manner.To provide this level of care,phy-
sicians require the right to appropriate
autonomy, self regulation and advocacy
for patient health.
The CPWI has a• focus on Responsibil-
ity: endorsing ethical and science-based
care, and social leadership in advocacy for
patient care and public health.
Finally, the CPWI has a• focus on the
Value of Medicine: both economic and
humanitarian. The Economic Value rep-
resents the positive ﬁnancial return of
investment in medical care and biomedi-
cal research. The Humanitarian Value
represents the immeasurable worth of
reducing disease, despair, disability and
premature death.
The goal of the CPWI is to restore enthu-
siasm and optimism in the ﬁeld of medi-
cine, through medical and social leader-
ship based on the enduring traditions of
the medical profession: Caring, Ethics
and Science. The CPW Initiative exem-
pliﬁes the triad of medical traditions, Car-
ing, Ethics and Science, emphasizing that
caring physicians of the world are commit-
ted to and eﬀective at medical and social
leadership. The CPWI mission is to help
physicians throughout the world, despite
the diversity and adversity of circumstances,
to communicate Caring and Compassion,
with the best Science and highest Ethics, in
every professional interaction.
Ceremonial Event at the Presidential Palace.
(L–R) Dr. Fachmi Idris, President of Indo-
nesian Medical Association; Dr. Siti Fadilah
Supari, Health Minister of Indonesian Repub-
lic; Dr. Susilo Bambang Yudhoyono, President
of Indonesian Republic; Dr Yank Coble, Past
President of WMA
Presentation of the Caring Physicians of the
World. Dr. Fachmi Idris, President of Indo-
nesian Medical Association, presents the book
of Caring Physicians of the World to Susilo
Bambang Yudhoyono, President of Indonesian
Republic
136
Medical Ethics, Human Rights and Socio-medical affairs
Louis M. Guenin, Department of
Microbiology and Molecular Genetics,
Harvard Medical School
On occasion, discretionary actions preclude
transfer of extracorporeal embryos into the
womb. Such actions constitute an over-
looked and crucial ground for the moral
justiﬁcation of embryo use in regenerative
medicine.
In the ﬁrst instance, we encounter the situ-
ation, which often arises with fertility pa-
tients, in which the one person in the world
who, together with the co-progenitor, is
empowered to decide about intrauterine
transfer of an embryo formed from her oo-
cyte decides that neither does she wish to
bear the embryo, nor does she wish to give
it to anyone else. Whereupon she and the
co-progenitor may decide to donate the
embryo to medical research and therapy. In
the second case, embryos may originate in
research from cells donated to medicine for
that purpose.
If progenitors, while fully-informed and
acting of their own volition, donate an em-
bryo, either before or after the embryo’s
creation, on the condition that the em-
bryo shall be used in medical research and
therapy, and may never be transferred into a
uterus, such embryo constitutes what I have
called an “epidosembryo.” I have taken this
name from the Greek epidosis for a citizen’s
beneﬁcence to the common weal.
As a moral justiﬁcation for the use of epi-
dosembryos in accordance with donor in-
structions, I have oﬀered the “argument
from nonenablement.” This proceeds as
follows. A woman does not have a duty to
undergo a transfer into her of an embryo
lying outside her. There does not obtain a
duty of intrauterine embryo transfer into
oneself. We, most of us, regard the decision
to undergo such a medical procedure as re-
served to a woman’s autonomous discretion.
A separate question is whether a woman
and the co-progenitor lie under a duty to
surrender for adoption any embryo that she
declines to bear. Imposition of such a duty
would likely present such adverse incentives
and consequences for fertility patients, in-
cluding compelled remote parenthood, that
we are hard pressed to ﬁnd any moral view
that would support such imposition. For
reasons developed in the full account of this
argument, the decision whether to surren-
der an embryo for adoption also lies within
progenitor discretion.
Suppose, then, that a woman forbids intra-
uterine transfer of an embryo. She, with the
co-progenitor, donates to medicine either
an epidosembryo created during her fertil-
ity treatment, or an epidosembryo that will
be created by a scientist from their donated
cells. This decision is ﬁnal. The epidosem-
bryo has left progenitor control. A distinc-
tion now obtains between the developmen-
tal potential of this epidosembryo, lying in
a petri dish where it will remain, and an
embryo that lies in a uterus, however it got
there. In consequence of the prohibition
on intrauterine transfer, the epidosembryo
will not complete gastrulation. If not ear-
lier sacriﬁced, the epidosembryo will begin
to disintegrate by about day 10. During its
remaining life,it cannot acquire any morally
signiﬁcant property that it does not already
possess. To put the matter in language that
I owe to Richard Hare, no possible person
corresponds to an epidosembryo. We also
know that no embryo is sentient. It can
neither form preferences nor adopt ends.
Nothing that we might do concerning it
can cause it discomfort or frustrate it. We
cannot gain anything – neither for it nor for
any other being – by classifying it as a per-
son for purposes of the duty not to harm.By
forgoing its use in research, we could only
assure that the epidosembryo dies in vain.
Scientists maintain the reasonable, though
not certain,belief that embryo experimenta-
tion could contribute to the relief of human
suﬀering. Use of donated embryos remains
crucial in research even as techniques de-
velop for reprogramming somatic cells into
pluripotent or specialized cells. Embryonic
stem cell research has been the fountainhead
of emerging knowledge of reprogramming,
and the embryonic stem cell remains the
gold standard of pluripotency. In this situa-
tion, the duty of mutual aid – the duty, rec-
ognized across moral views, to aid those in
need when one may do so without imposing
an unreasonable burden – bids us undertake
such research. Hence not only is it permis-
sible to use epidosembryos in medicine, but
to do so will help to fulﬁl a collective duty.
According to this argument, the permissi-
bility and virtuousness of epidosembryo use
rests on the autonomous decisions of people
from whose cells such embryos originate.
The moral analysis ﬂows entirely from what
it is that they decide.Developmental poten-
tial matters, but it is human decisions that
determine its situation-dependent extent. If
it is permissible for progenitors to donate
epidosembryos, then it is permissible for
recipient scientists to use the donations as
instructed.
Some discussants seem to suppose that the
justiﬁcation of embryonic stem cell research
lies in the circumstance that the embryos
donated were created with procreative in-
tent. The argument from nonenablement
does not invoke procreative intent. The
argument applies to any donated embryo,
whether left over from an attempt at preg-
nancy, or created in experiment. The use of
surplus embryos and the nonprocreative
Building a Consensus in Regenerative Medicine
137
Medical Ethics, Human Rights and Socio-medical affairs
formation of embryos by fertilization, non-
reprocloning, and parthenogenesis rest on
one and the same moral ground.
The argument from nonenablement is a
consensus argument insofar as it does not
invoke any premise peculiar to one or an-
other moral or religious view. The bounded
developmental potential of an embryo in the
dish is a biological circumstance. The duty
of beneﬁcence and respect for the discre-
tion of persons to elect whether they shall
undergo medical procedures are common to
all leading moral and religious views. Some
form of the Golden Rule is found in virtu-
ally every major moral and religious view
since Confucius.
In this analysis, I accord a wide berth to re-
ligious views across diverse cultures, provid-
ed only that when moral verdicts are urged
on religious grounds, support for them can
be given on the basis of reasonable nonre-
ligious premises. As we all know, many re-
ligious believers condemn the sacriﬁce of
embryonic lives in aid of other lives. Hence
a further task presents itself. It remains to
be shown, if it can be, that if the argument
from nonenablement is introduced in the
course of sympathetically reinterpreting
one or more views presumptively opposed
to all embryo use, such views will issue in
approval for epidosembryo use. I illustrate
how that task may be accomplished as to
the most inﬂuential presumptively contrary
view, the magisterium of the Roman Cath-
olic Church.
In condemning all manner of embryo de-
struction, the Catholic magisterium speaks
consistently. Just as it condemns destruction
of embryos as research subjects,it condemns
the practice of assisted reproduction be-
cause that practice brings about destruction
of surplus embryos. (Other discussants who
approve in vitro fertilization as practiced,
but oppose embryo use in research fall into
inconsistency: they condone destruction
of surplus embryos as waste, but condemn
sacriﬁce of surplus embryos for beneﬁcent
ends.) On what ground does the magiste-
rium’s condemnation of embryo sacriﬁce
rest?
One will often hear it asserted that an em-
bryo is a person and that killing a person
is murder. To say that a being is a person
is to recite the conclusion that the being
falls within the category of beings protected
by the duty not to harm. It remains to ask
what reasoning supports that conclusion.
Conceding that the Bible does not assert
personhood of an extracorporeal embryo –
in antiquity, people did not even know that
there existed oocytes, hence never thought
about embryos outside the body – the
magisterium allows that personhood of an
embryo is a philosophical question. Con-
cerning this, the magisterium’s argument in
chief is the following: fertilization creates a
new genome, therefore fertilization creates
a person. This argument’s premise is true –
fertilization produces a new genome – but
the conclusion doesn’t follow. To identify a
person with a genome is to practice genetic
reductionism with a vengeance. That view
contradicts the bedrock belief that a person
is a corpore et anima unus, a union of body
and soul. On pain of internal contradiction,
the argument cannot stand.
A defender of zygotic personhood might
plead that precisely because embryos can-
not form preferences, it is our obligation to
act according to their advantage, hence to
classify them as persons. But we cannot fos-
ter any advantage of epidosembryos. Entry
into the only kind of environment by which
they could attain the ability to experience
beneﬁt has been forbidden by the only per-
sons in the world empowered to decide such
matters. It is from this recognition that the
argument from nonenablement builds a
prima facie justiﬁcation within Catholicism,
as within other views,for epidosembryo use.
Is there a countervailing argument?
One argument is that if we do not know
whether an embryo is a person in God’s
eyes, we should exercise caution and act as
if it were. But from within a view holding
that divine will is the arbiter of morality,
suppose that we could have a conversation
with God. We report that in 1998, we dis-
covered how to culture human embryonic
stem cells. We describe hopes of relieving
human suﬀering by using embryos that will
never enter a womb. Is it plausible that He
would tell us that He regards such embryos
as persons in the sense that He includes
them in a universe of beings that He never
wishes us to use as means? I do not know
of a tenable argument according to which
an all-merciful and omniscient God would
assert that preference. He would know that
unenabled embryos would never become
sentient if not used in research.
An objection peculiar to nonreprocloning
might be this. An oocyte is created for a
purpose, namely to issue in oﬀspring, and
it is wrong to divert an oocyte to any other
purpose. This objection presupposes with
Aristotle that everything has a ﬁxed pur-
pose and that we know what it is. After
Darwin, that notion has lost its grip on our
thought. We have learned from the history
of medicine how mistaken we humans have
often been in inferring purposes of various
cells and structures of the body. Our for-
bears would have said that bones are what
hold us up; today we think of the marrow
as a blood factory. We think it appropri-
ate to transfer marrow from one patient to
another. We know that many cells perform
multiple functions, and we are learning to
redirect proteins and cellular processes to
serve chosen ends. It seems arbitrary to say
that an oocyte can or should serve only one
purpose. Such a rule would seem puzzling
insofar as every human female possesses
from birth a quarter million or more oo-
cytes.
Turning to public policy, we observe that
there obtains no practical scheme by which
a government may fund use of embryonic
derivatives without complicity in their
derivation. Downstream demand induces
supply, and complicity transmits through
the channel of inducement. Our collective
deliberations would beneﬁt from moral rea-
soning generally overlooked in the policy
arena. That is the reasoning adduced in the
argument from nonenablement beginning
138
Medical Ethics, Human Rights and Socio-medical affairs
with the premises that intrauterine embryo
transfer is discretionary and that when pro-
genitors forbid such transfer, developmental
potential is permissibly bounded. The key
to assuring that legislation endorses mor-
ally permissible activity is what it says about
progenitors. Progenitors possess unique
power: each is the only person in the world
(with the co-progenitor) privileged to de-
cide what will happen to an embryo. It is
because a progenitor-donor decides that an
embryo will never enter a uterus that a do-
nee may experiment on it.
Hence the most compelling justiﬁcation for
a donee in performing experiments, and for
a legislature in endorsing experiments, con-
sists in the donee’s ﬁdelity to permissible do-
native instructions bounding potential.This
bring us to the following public policy:
The government shall support biomedical
research using human embryos that, before
or after formation, have been donated to
medicine under donor instructions forbid-
ding intrauterine transfer.
This policy wears its moral justiﬁcation on
its sleeve. That attribute avails for public
discussion. There the policy may be de-
scribed as one that assures that the scope
of the publicly-supported is congruent with
the scope of the morally permissible.
There arise various other ethical questions
about embryo use, including fair compensa-
tiontooocytecontributors,andtheformation
of hybrids and chimeras.In the foregoing,we
have canvassed a ground for consensus on
the most fundamental question.
Maksut K. Kulzhanov,
Saltanat A. Yegeubaeva,
Kazakhstan School of Public Health
Introduction
Kazakhstan is an independent republic lo-
cated in the central Asian steppe. Covering
2.7 million square kilometres (about the size
of the 15 states constituting the European
Union up to 2004),the country is the largest
of the former Soviet republics after Russia.
Kazakhstan has a long border with Russia
to the north, adjoins China to the east, and
Kyrgyzstan, Uzbekistan and Turkmenistan
to the south. Kazakhstan is a land-locked
country which borders on two large inland
seas: the Aral Sea and the Caspian Sea.The
terrain stretches across steppes and deserts
to the high mountains in the south east
including the Tian Shan and Altai ranges.
The capital, formerly Almaty (previously
Alma-Ata), was moved in December 1997
to Astana (Aqmola) in the north.
When Kazakhstan became independent in
1991, it faced many of the same challenges
as other countries from the former Soviet
Union, including an oversized and inpa-
tient-oriented system of health facilities, a
drop of health ﬁnancing in the early years of
transition and many other challenges that
are the similar to world health care prob-
lems such as human recourse development
and bioethics. While the country has em-
barked on several major health reforms in
the second half of the 1990s, these often
lacked consistency and clear directions. In
the wake of the economic upswing fuelled
by oil revenues in recent years, Kazakhstan
in 2004 embarked on a comprehensive na-
tional health reform programme for the pe-
riod 2005-2010.
Human resourses in health care
system and public health
Kazakhstan has a high level of public sector
employment. In the mid-1990s, the country
had one of the highest levels of government
employment in the world, when health per-
sonnel accounted for about 40% of govern-
ment employees (WB 1996b). The number
of active personnel is diﬃcult to ascertain,
as there is no accurate and comprehensive
information system on the actual number of
active health care workers.In addition,health
care workers who have moved to the private
sector, such as many dentists and pharma-
cists, are not counted in public ﬁgures.
The area of human resources in the health
sector is mainly related through the Law
on the Health System of 4th
June 2003. Ac-
cording to this law, the Ministry of Health
is responsible for:
developing an overall human resources•
policy in the health sector;
approvingformsandtrainingprogrammes•
for medical specialties, and developing
and approving typical staﬃng and staﬀ-
ing standards of health organizations;
conducting the attestation of managers of•
health organizations and health depart-
ments;
deﬁning standards for the training of•
specialists with higher and postgraduate
education, for continuous education and
the retraining of health professionals.
Oblast health departments are responsible for:
ensuring the provision of human resourc-•
es in health organizations and assessing
the expertise of health workers;
planning the training and retraining of•
medical specialists;
ensuring the continuous education and•
retraining of medical and pharmaceutical
specialists.
Human Resources and Bioethics in Palliative
Care as an Example of Human Resource and
Bioethics Development in Kazakhstan
Maksut K. Kulzhanov
139
Medical Ethics, Human Rights and Socio-medical affairs
In 2007, there were 57, 387 medical doc-
tors working in Kazakhstan’s health sys-
tem, equivalent to a ratio of 3.68 physicians
(physical persons) per 1000 population,
which was close to EU-15 and CIS aver-
ages (WHO 2007a).
The decline in the ratio of health care work-
ers to population since 1990 is due to a num-
ber of factors, including a shift to the private
sector, health care workers leaving the health
sector, the outmigration of ethnic Russians,
and the dismissal of health personnel.
There is a huge gap between rural and ur-
ban areas. Primary health care facilities are
facing problems in recruiting qualiﬁed staﬀ,
especially in remote and rural areas. This is
in large part due to an insuﬃcient number
of new graduates. Enrolment to medical
schools ﬁnanced by state grants or credits has
increased annually by about 10% since 1999,
but the need in human resources is still high
(President of Kazakhstan 2004). Kazakhstan
is facing a serious problem with the ageing
of health personnel and the understaﬃng of
health facilities, in particular in rural areas.
There is also an urgent need for certain
categories of health professionals, such as
specialists in health management or health
economics. The lack of properly trained
managers translates into poor management
and ineﬃcient use of resources. Often, the
manager of a health facility has a number of
simultaneous functions: acting as manager,
administrator and chief physician (Presi-
dent of Kazakhstan 2004).
Kazakhstan has inherited the Soviet system of
training and retraining of health profession-
als and there have hardly been any changes
in this area in the years since independence
(President of Kazakhstan 2004), although it
should be noted that there has been signiﬁ-
cant postgraduate training in family medicine
and priority programmes including mother
and child health and tuberculosis.
Overall, the quality of training and retrain-
ing remains poor, which is partly due to an
underdeveloped regulatory system with re-
gard to university entry and the quality of
medical and pharmaceutical teaching, but
also to years of underinvestment in educa-
tional buildings and facilities. The limited
funds allocated to medical training in the
public sector do not allow the purchase of
up-to-date technical equipment or visual
aids (President of Kazakhstan 2004).
In addition to state-funded students, uni-
versities try to attract additional funds by
accepting medical students who pay for the
tuition themselves. The number of students
paying for their studies has increased in re-
cent years.
The Concept for the Educational Develop-
ment of Kazakhstan until 2015 envisaged
changes to the training of all profession-
als with higher education that also have an
impact on medical education. In line with
this concept, new obligatory standards for
medical and pharmaceutical education were
introduced in 2003 that place greater em-
phasis on continuity between diﬀerent edu-
cational levels.
Kazakhstan had nine medical schools (three
of which were private), 26 nursing colleges,
an Institute of Continuing Training, a na-
tional School of Public Health, and 65 re-
search enterprises. The Kazakhstan School
of Public Health was established by the
Ministry of Health together with the WHO
Regional Oﬃce for Europe in 1997.
There are four streams in medical educa-
tion. Physicians are trained for six years and
specialize in their sixth year. Paediatricians
are trained in an entirely separate course.
Sanitary-epidemiological service physicians
are trained for ﬁve years in separate facul-
ties. Dentists are also trained in a separate
ﬁve-year course.
A one year internship based on six major
specialties (residency), which in similar form
existed in the Soviet period, has recently been
reintroduced to improve the quality of medi-
cal graduates.Following the internship,physi-
cians can specialize in more than 80 specialties
with a training duration of 2-4 years.
A family practice specialty was introduced
in 1995 as a four-month short course at the
postgraduate medical institute and other
short courses are being mounted at approved
sites. Training in general practice (both for
undergraduates and for practicing physi-
cians) has been supported with both tech-
nical assistance and funding from USAID,
the United Kingdom Department for Inter-
national Development and the World Bank.
In 2005, the government spent 2% of the
total health care budget on the training of
general practitioners and health managers.
Further education is conducted at the Post-
graduate Medical Institute or at one of the
medical research institutes. Physicians must
do a short retraining course every ﬁve years
and clinical lecturers every three years. This
requirement has faltered, however, with
budget cuts and the diﬃculties of taking
leave from employment.
A postgraduate course in public health com-
menced in 1997 at the Kazakhstan School
of Public Health in Almaty. Management
courses are also available at the Kazakh-
stan Institute of Management, Economics
and Strategic Research and at the Centre
for Medical and Economic Research. The
number of new physicians graduating has
continued to rise during the 1990s although
there are few available jobs. Unemployment
is said to be a problem among new medi-
cal graduates, and this is likely to continue,
given the unwillingness of new graduates to
work in rural areas.
Health care personnel per 10 000 population, 1990-2007
1990 2000 2001 2002 2003 2004 2005 2006 2007
Physicians (PP) 39.6 33.0 34.6 36.1 36.5 36.3 36.5 37.6 36.8
Dentists (PP) 2.6 2.1 2.3 2.7 2.8 2.9 2.7 2.9 2.9
Nurses (PP) 44.7 46.5 48.9 49.1 50.0 51.1 54.2
Midwives (PP) 5.2 5.5 5.4 5.4 5.5 5.5 5.7
Note: PP: physical persons
140
Medical Ethics, Human Rights and Socio-medical affairs
Nursing education consists 2 years basic
training, followed by one year of specializa-
tion in general medicine, emergency care,
obstetrics, or management. However, the
curricula are outdated and fail to reﬂect the
requirements of health service provision
and many nurses are poorly trained.
At present, nursing education is being re-
formed with the aim of upgrading it to
postgraduate level, strengthening the status
of nurses as an independent health profes-
sion, and providing continuing education.
More attention is also paid to the training
and retraining of managerial and adminis-
trative staﬀ, including nurse managers, in
line with the increased importance of pri-
mary health care, where most nurse spe-
cialists are expected to work in the future.
At Almaty Medical College for example, a
4-year training programme for nurse man-
agers has been introduced.
Feldshers receive nurse/midwife training
with additional training in diagnosis and
prescribing. They carry out clinical respon-
sibilities that are mid-way between doctors
and nurses. In rural areas, feldshers work in
eﬀect as primary care physicians.
In the former Soviet Union, the health sec-
tor was not regarded as productive compared
to other sectors such as mining. Therefore,
wages for health care personnel were set be-
low the workforce average.Despite repeated
increases in the salaries for health care work-
ers in Kazakhstan, with an increase by 20%
in 2004 alone, the oﬃcial average salary in
the health sector in 2004 was only half the
national average for all sectors combined
(President of Kazakhstan 2004). At present,
the remuneration of health workers is regu-
lated through the Government decree No.
41 on the System of Labour Remuneration
of Public Employees who are not Civil Ser-
vants of 11th
January 2002. Health workers
are remunerated according to seniority and
qualiﬁcation, with no regard to outcomes or
the quality of services provided.
The prestige and ﬁnancial reimbursement
of nurses continues to be very low. While
the oﬃcial salary of physicians is not much
higher than that of nurses, they can gain
various oﬃcial bonus payments and infor-
mal ‘under-the-table’ payments from pa-
tients. Physicians might also be appointed
to more than one position, with a respective
increase in income. The skill mix of health
care workers is being adjusted in many Eu-
ropean countries with the aim of increasing
the number of trained nurses in relation to
the number of doctors (Rechel, Dubois et
al. 2006). In Kazakhstan, doctors often per-
form tasks that in western European coun-
tries would be performed by nurses, while
nurses perform many tasks that elsewhere
would be performed by auxiliary or support
staﬀ. The diﬀerence in Kazakhstan is that
the salary diﬀerential is not as large and that
nurses receive far less training than doctors.
Human resource development
for successful palliative care
One of the developing ﬁelds in public
health in the country is palliative care.There
are a lot of problems that need to be decided
at the diﬀerent managerial levels including
human recourse development issues and
bioethics.
Palliative care in Kazakhstan has developed
since 1990s. Such ﬁgures as morbidity rate
increasing, high mortality rate from onco-
logical diseases, high rate of people with IV
stage of tumour are evidence about neces-
sity of this service in Kazakhstan. Six pal-
liative care centres have been established
in Kazakhstan. All of them get ﬁnancial
support from governmental budget. By pa-
tient and physicians’ opinion palliative care
service is a very important and helpful part
in oncological service providing, and during
last ten years Kazakhstan achieves real posi-
tive results in organization of this care.
At the same time there are a lot of challeng-
es in this ﬁeld. By medical experts’ opinion
only in Almaty already today there should
be a minimum of four palliative care centres
to satisfy population needs in this service.
Moreover, if today most of the patients in
the palliative care centres (80%) are with
oncological diseases, and only 20% of them
with internal diseases, so in near future pa-
tients with such diseases as tuberculosis and
HIV/AIDS will also need palliative care.
This will lead to another big challenge for
palliative care – human resources develop-
ment. Currently there is lack of specialists
in general oncology that should provide ser-
vices as in oncological clinics, so in pallia-
tive care centres; lack of trained specialists
in palliative care; psychologists and social
workers. There is lack of uniﬁed training
programs in palliative medicine to prepare
qualiﬁed professionals.
Kazakhstan School of Public Health has
conducted a study on palliative care needs
assessment in Kazakhstan including human
recourse development aspects. Results of
the survey explored the necessity of pallia-
tive care development in the country for the
growing number of patients of both genders
and diﬀerent ages. Due to study conducted
among medical workers and population in
10 cities (10 diﬀerent oblasts) of Kazakh-
stan demonstrated following results. 24.5%
of medical workers (n=357) noted about dif-
ferent problems in palliative care including
lack of professionals with good knowledge
of palliative care concept. Only 49.9% of
respondents have regularly training. Other
problem is emotional aspects of palliative
care. 65.0% of population in diﬀerent ages
(n=453) noted that they have a relative who
has needed palliative care service. 60.3%
of them know where to receive palliative
care service and got it, 39.7% are not. Only
38.4% of respondents have had emotional
support from palliative care clinics staﬀ.
Emotional support was provided by medi-
cal workers in 37.6% and social workers in
13.8% cases. 21.6% of medical workers not-
ed that they have positions for workers who
may provide emotional and social support,
13.7% of medical workers noted that they
have social workers and 13.1% – voluntaries
from religion organizations.
This shows another challenge – the prob-
lem regarding the training and retraining of
specialists on palliative care in new concept,
organization and management issues. To-
141
Medical Ethics, Human Rights and Socio-medical affairs
day there are no separate training courses
on palliative care provision, on quality of
services in palliative care for patients and
their families to reduce the gap in profes-
sional development and this is an option to
improve the situation.
Thus, there are a lot of problems regarding
the organization and management of pal-
liative care in the country, including the
provision of medical, psychological and
social services for patients and their fami-
lies. Palliative care is in a transition stage in
Kazakhstan. Decisions regarding these is-
sues would further the development of this
service. It is necessary to work on modern
organizational, economic, and managerial
mechanisms and standards to establish ap-
propriate centres. Also, it is important to
work on workforce development to provide
qualitative palliative care. One of the main
expected results following the study would
be curriculum development for specialists of
palliative care services.
Bioethics
Health care is an extremely complex and
complicated ﬁeld. Ethics is integral to health
care: to its clinical practice,governmental and
organizational policy development, payment
system, legislation development, and ﬁnally
to the national economy. Bioethics principles
broadly integrated with its directions start-
ing from research and continuing by national
policy and economics of the country. Bioeth-
ics in Kazakhstan is in a developing stage.The
Medical Society started to introduce modern
international bioethics concepts, approaches
and instruments.At the present time there are
a few committees that could revise the ethical
issues of research. One of them, the Institu-
tional Research Board, is located in the Ka-
zakh National Medical University in Almaty.
This Board works in line with international
requirements. The Ministry of Health plans
to develop a similar committee at the national
level and this process is in progress. There is
still a big challenge in the development of the
legislation base in this ﬁeld. The Kazakhstan
School of Public Health in collaboration with
international experts has developed a curricu-
lum on bioethics for researchers. This course
has been conducted during the last ﬁve years
and helped to form a critical mass of health
professionals who are capable of developing
and implementing the bioethics concepts in
the country.
In respect of public health research among
elderly people it is necessary to remember
that bioethics principles help correctly and
in-depth to collect data on pertinent infor-
mation. In particular in this direction such
principles as “respect for human persons”,
“human control of life”, “culture, behaviour,
and interpersonal relationships”, “justice”,
and “allocation of resources”are very impor-
tant. In research with the elderly it is neces-
sary to keep in mind that elderly people are
more vulnerable in the psychological and
social spheres. Conﬁdentiality, honesty, au-
tonomy are very important components in
ethical research among the elderly popula-
tion. During the planning of such research
the investigator needs to think about such
points as the value of conducted research
and the results of the research, the climate
or the environment of conducting the study,
issues of the inﬂuence of culture and country
policy to planning research, the prevention
of potential conﬂicts of interest between
clients and professionals and the compen-
sation strategy for the research.
Another important approach to ethical re-
search among the elderly is equitable dis-
tribution of beneﬁts and burdens during
the study. It is necessary to understand the
formal and material principles of justice and
the possibility for establishing (saving) bal-
ance of justice with other principles of bio-
ethics such as mercy, beneﬁcence, nonma-
leﬁcence, allocation of scarce resources and
the fair opportunity principles.
Also very important are such aspects in
conducting research among the elderly as
diﬀerences between the deﬁnitions of “right
to the life”, “quality of life”, “right to health
care” and “resource allocation” according to
ethics positions, and also the contrast be-
tween “allocation of resources” with “im-
plicit and explicit rationing”.
Thus, conducting research among the elder-
ly, the study of the peculiarities of ageing,
health status, quality of life, and providing
health, prevention, psychological and social
services become more actual for all countries
in the world, and that is why such research
should be conducted to modern require-
ments and held due to bioethics principles.
References
Highlights on health in Kazakhstan. World Health
Organization, 2006.
Kulzhanov M, Rechel B. Kazakhstan: Health system
review. Health System in transition, 2007; 9(7):
1-158.
Kulzhanov M., Yegeubaeva S., Dosmailova
A. Palliative care in Kazakhstan: Current Status and
Perspectives for Development. Journal of Central Asian
Health Services Research, 2007; 6(4): 35-40.
Schick I.C., Porter R., Chaiken M. Domains and Core
Competencies in Ethics
Prof. Gia Lobzhanidze – President of
Georgian Medical Association
Dr. Levan Labauri – Secretary General of
Georgian Medical Association
In August, 2008, during an armed conﬂict
between Georgia and Russia,the infrastruc-
ture of the Georgian Healthcare system was
severely damaged, including a loss of hu-
man resources. During the war, Georgian
health professionals continued working in
special teams, organizing specialists groups
to deal with the critical situation. Emergen-
cy medical centers were entirely overloaded.
Health system and personnel losses have
not yet been deﬁnitively assessed however
there are trends and medical perspectives of
the disaster that can be discussed.
Georgian Health Care System
in the Time of Armed Conﬂict
(Georgian – Russian War of August 2008)
142
Medical Ethics, Human Rights and Socio-medical affairs
At the beginning of the war, medical insti-
tutions located in the conﬂict region were
able to support entirely the ﬂow of the in-
jured military personnel and civilians. From
the conﬂict zone, patients were taken to
the Tkhviavi and Nikozi medical centres.
Mobile military hospitals were also eﬀec-
tive and saved many lives. After receiving
emergency medical support in the above-
mentioned centres or mobile hospitals,
patients were transported to Gori Central
Hospital and Gori City Hospital,where pa-
tients received qualiﬁed medical aid. When
needed, patients were taken directly to vari-
ous (mostly Tbilisi) clinical settings. Civil-
ians, particularly those injured during war
in areas far beyond the conﬂict zone, were
concentrated in local medical centers by
geographical principle. The system of the
medical support described above worked
well in the ﬁrst days of the war. Later, Rus-
sian military forces attacked medical centres
and the medical support strategy had to be
changed.
Results from the Georgian Hospitals
showed that the number of injured and
killed civilians was many times more than
the number of military casualties. As
from the military-medical experience, the
ratio of bullet-related injuries to missile-
related injuries was 43/57; in the Geor-
gian-Russian war the ratio was 7/93. It
means, that the gunshot wounds from au-
tomatic weapon were not observed during
the military operations. The ﬁrst ﬂow of
wounded was received by the Gori Hos-
pital on August 09, 2008. The Chief Sur-
geon reported that the absolute majority
of injuries were missile wounds, fragment
wounds and blast injuries. There was no
case of bullet-related (automatic weapon)
wounds among the 65 patients admitted
on this day. The absolute majority of the
patients were peaceful civilian population.
In all cases life stress events have severe
consequences such as acute stress disor-
der and PTSD symptoms.
On August 8, 2008 Gori emergency medi-
cal centre was bombed just after that mo-
bile military hospital, Tkhviavi and Nikozi
medical centres’ infrastructure were also
paralyzed and destroyed. In the next phase,
when Gori was bombed, the Gori military
hospital was also practically paralyzed. Be-
cause of high level of risk, medical staﬀ was
evacuated. This eﬀectively broke the second
circle of medical aid. Although the medical
staﬀ was evacuated several times,doctors re-
turned repeatedly to work in this high-risk
zone. The Gori Hospital provided emer-
gency medical service to Russian soldiers as
well. Excellent work by the ambulance cars
must also be mentioned. Both, Gori and
Tbilisi emergency aid systems were work-
ing hard and the coordinated work of this
circle saved lots of lives. During the war
emergency aid vehicles have driven up to
2000 times from Tbilisi to Gori and back,
in order to transport all the patients. Dur-
ing the transportation none of the patients
have died.
The Georgian Medical Association has
trying to inform doctors in other coun-
tries about the situation since the begin-
ning of the war. We are very grateful to
the World Medical Association, which re-
acted promptly. On 11th
September 2008,
the WMA Secretary General, Dr. Otmar
Kloiber, issued a press release on behalf of
the WMA calling on both parties of the
conﬂict to respect the professional indepen-
dence of physicians. The WMA reiterated
the principle in its policy on Regulations
in Armed Conﬂict that physicians must be
granted access to patients, medical facilities
and equipment and the protection needed to
carry out their professional activities freely.
Shortly after receiving the message from
WMA, the Georgia Medical Association
received supporting letters from Germany,
Belgium, Austria, Great Britain, Hong-
Kong, Estonia, Finland, Ireland, and other
countries’ medical organizations.The letters
included suggestions for helping injured
people. We have also received thousands of
letters of condolence from our foreign col-
leagues.
Many Georgian physicians indicated that
their Russian colleagues had no wish to
communicate. The Georgian Medical As-
sociation called on the medical profes-
sion of Georgia to unite their eﬀort and
strongly follow to the WMA policy state-
ments.The Georgian Medical Association
conﬁrms the death of 4 healthcare pro-
fessionals during the war: 1. Goga Abra-
mishvili – the Trauma Surgeon from Gori
hospital; 2. Marina Gogiashvili – nurse of
emergency aid; 3. Leri Lagurashvili – mil-
itary doctor; 4. S.B. – military doctor. One
physician (Zurab Begiashvili) is still miss-
ing. The Georgian Medical Association
also attempted to identify injured health
143
Medical Ethics, Human Rights and Socio-medical affairs
Guri Spilhaug, MD, Head of Unit for
Primary Health Care and Psychiatry.
Norwegian Medical Association
The consumption of alcohol in Norway has
been relatively low for the last 150 years.The
drinking pattern has been dominated by
week-end drinking – relatively few drink-
ing occasions, but drinking to intoxication
(binge drinking). Lately the pattern has
changed towards more continental habits,
however, heavy drinking during week-ends
still continues. More people drink alcohol,
especially women, they drink more when
they drink and they drink more often than
before. Many people also seem to use more
alcohol in work related situations. It is an
important issue to prevent alcohol abuse in
Norwegian workplaces and also to make sure
employees with abuse problems get help.
Measured as pure alcohol each person 15
years or older drank an average of 5.66 litres
in 2000, and in 2007 this had increased to
6.60 litres.The data of quantity of alcoholic
beverages consumed during the last year
shows that men consume on average 2.5
times more than women. The alcohol con-
sumption decreases by age, while it seems to
increase with income and education. People
who live in the Oslo area consume more al-
cohol than people living in small towns and
rural areas. The popularity of wine and beer
has shown a strong increase over time while
liquor consumption has decreased. A key
element in Norwegian alcohol policy has
been to remove the private proﬁt motive
from sales of wine, spirits and strong beer.
The business became subject to a special
Vinmonopol (Wine and Spirits Monopo-
ly) Act on 19 June 1931, removing alcohol
from the scope of the regular Joint Stock
Companies Act. Directors and the presi-
dent are appointed by the government. The
board is also bound to observe directives is-
sued by the Ministry of Health and Social
Aﬀairs. After the private interests had been
gradually bought out, Vinmonopolet be-
came wholly state-owned in 1939.
Vinmonopolet has the exclusive right to re-
tail wine, spirits and strong beer in Norway.
Vinmonopolet purchases the products from
importers holding the required licence and
who have signed a purchase agreement with
Vinmonopolet.
Norwegian alcohol policy has changed in
recent times. Keywords are cuts in alcohol
taxation, an expanding hospitality sector
– especially restaurants and bars – and in-
creasing numbers of Vinmonopol outlets.
The development in the EU and Nordic
area is also feeding this growth along with
growing public disaﬀection with traditional
alcohol policy mechanisms. Higher import
quotas and lower taxation on alcohol in oth-
er Nordic countries made Norway’s stance
increasingly untenable.
The Norwegian Institute for Alcohol and
Drug Research (SIRUS) is an indepen-
dent research institute with the purpose of
research concerning the use and abuse of
intoxicants and other addictive substances,
with a particular stress on questions relating
Alcohol use in Norway
Arne Johannesen, MD, Head of section,
Dep. for Service Development. South-East
Regional Health Board
workers. We have collected information
about 18 of them. Most injured doctors
were taken to Tbilisi hospitals for further
treatment.Through the initiative of Geor-
gian Medical Association, a special fund
was created to help and support medical
staﬀ harmed by the war. GMA represen-
tatives personally met with injured physi-
cians and received the alarming news that
nearly each of them claims that medical
staﬀ and hospitals were attacked directly
and intentionally.
During the war, the medical infrastructure
was seriously harmed. In such a situation,
the main public health threat is the spread
of infectious diseases.There was a high risk
of this in the conﬂict zone because there
were no medical staﬀ and facilities avail-
able there. There was also no possibility
of maintaining sanitary conditions in the
collective living places of refugees. As from
the WHO release, “in South-Ossetia peo-
ple are in need of water, food and medi-
cal support, although no communicable
disease outbreaks”. WHO also stated that
there have been no reported outbreaks of
communicable diseases in areas aﬀected by
the conﬂict.
The Georgian healthcare system has en-
dured the ﬁrst wave of crisis, and although
there are some losses, the system keeps op-
erating. In the next stage, some problems
may emerge and our main objective is to an-
ticipate what they will be and develop strat-
egies and solutions to overcoming them.
144
Medical Ethics, Human Rights and Socio-medical affairs
to social studies.The institute monitors both
consumption and the consequences of such
and has played an important role in the pol-
icy formation on alcohol in Norway. Alco-
hol is a risk factor to more than 60 diﬀerent
illnesses, like for example cancer, heart and
vascular diseases and psychiatric conditions.
We also know that violence,traﬃc and other
accidents and self-harm are related to use of
alcohol. In Norway the amount of patients
hospitalised because of alcohol intoxication
was doubled from 1999 to 2003. More re-
search on alcohol use and alcohol related
health problems is necessary to increase our
knowledge about risks and treatment. Prior
to the Drug Reform in Norway in 2004,
treatment for addiction was primarily a so-
cial service, and it was the social services in
the municipalities who referred patients to
drug treatment. The Drug Reform made
specialised treatment a health service and
doctors obtained the right to refer patients
to treatment. As a consequence the number
of referrals has risen. General practitioners
account for a large portion of this increase,
while there are small changes in the number
of referrals from social services.
The Norwegian Medical Association has
watched the increase in alcohol consump-
tion with growing concern, and in 2004 the
organisation wrote a report about addiction
and health problems. The report concludes
with several recommendations, amongst
these are to increase doctors’ and other
health workers’ knowledge about alcohol
addiction and alcohol related health prob-
lems, and how to discover it. It is important
to employ more brief interventions that can
help to reduce the risk of alcohol problems
among persons with high-risk consumption.
Such intervention usually consists of ascer-
taining alcohol consumption and a moti-
vational interview or conversation. These
interventions are not frequently used today.
There is also a lack of routines for follow-up
after detection of alcohol problems.
The Norwegian Medical Association rec-
ommends to maintain a restrictive alcohol
policy in Norway,where price and access are
the main factors to inﬂuence alcohol con-
sumption. From a public health perspective
it is important to keep the total consump-
tion of alcohol in the country low. Doctors,
and especially the general practitioners have
a special responsibility to inform about
the dangers of risk drinking and resulting
health problems.
This year the Norwegian Medical Associa-
tion has established an expert group to write
the organisation’s strategy document on al-
cohol policy.
Heikki Pälve MD, Ph.D., CEO, Finnish
Medical Association, Specialist in Anaesthesia
and Intensive Care, Special Competency in
Emergency care
The developed countries all face the same
challenges to their health care system.
Because of the advanced treatment pos-
sibilities oﬀered by modern medicine and
increasing health demand of the citizens,
which is partially a result of an ageing pop-
ulation, health care providers are faced with
budgetary pressures. There are several dif-
ferent ways how the authorities have tried
to diminish these problems.
The health care systems in nearly every
developed economy are on the move away
from current organisational models in a
quest for cost-eﬀectiveness. As a result the
autonomy of doctors is often restricted and
task shifting is considered as one possible
solution to the lack of resources. Legisla-
tive action is taken to cut down the health
care expenses. Gate keeping roles for doc-
tors are often also proposed to cut down the
demand of hospital care, but simultaneously
doctors are often expected to treat their
patients not according to the best proven
therapeutic or diagnostic method. Doctors
and their organisations all over the world
have to work in a very stormy environment
facing constant system changes. The case
is no diﬀerent in Finland and the situation
requires increasing involvement and action
from the Finnish Medical Association. It
seems that Finland is the world in miniature
size and we are facing all these challenges at
the same time.
The Finnish health care system
In Finland, the health care system is ﬁ-
nanced mainly through taxation and run
by the municipalities, which are responsible
for providing the services.The treatment re-
sults of many diseases are globally on top
level and all the citizens have equal access to
health care regardless of their wealth.
The satisfaction of the population with
the system is very high and the total
health care spending represents only eight
percent of the GDP, which can be consid-
ered to be cheap. Even though it is dif-
ﬁcult to measure the total eﬀectiveness of
health care, the international comparisons
that have been made have proven that the
Finnish system is cost-eﬀective. In spite
of this the representatives of local and
central government judge Finnish health
care as expensive. Therefore many major
Challenges in Health Care Unite the
Medical Associations
145
Medical Ethics, Human Rights and Socio-medical affairs
changes to the system are either ongoing
or being prepared.
New legislation to salvage primary care
Primary care, which in Finland is organised
in the municipal health centres, has increas-
ing diﬃculties to attract doctors. The situa-
tion is especially diﬃcult in rural areas, but
problems occur even in major cities that
have their own medical faculties. The cur-
rent law separates primary and specialist
care into two diﬀerent organizations.
This total division of primary and special-
ist care and lack of coordination between
them is one reason for increased spending
in health care. Therefore the Finnish gov-
ernment is preparing new legislation that
would cover both specialist and primary
care and increase their joint organisation
as well. The bill would increase the free-
dom of the patient to choose between dif-
ferent doctors and hospitals, which is not
a right that the patients in Finland enjoy
at the moment. Another aim is to increase
competition and cost control to achieve
savings. There is an increasing tendency
to encourage private entrepreneurship on
the health market. Currently municipali-
ties spend only 3% of their health care re-
sources to buy services from the private
sector. The public sector is thus managed
practically in a monopolistic manner.
However, people use the private sector in
an increasing frequency since it can oﬀer
care without undue delay and the patient
can choose the doctor freely and see a spe-
cialist directly without turning to a general
practitioner ﬁrst.
Until now it has been politically impos-
sible to liberate the services, which has led
towards diﬀerent methods of rationing the
care. Because the local oﬃcials hold the
purse strings of service production in a mo-
nopolistic manner, the central government
has already earlier taken legislative action to
increase pressure on the local level. In 2005
a treatment guarantee law was introduced.
It requires the local authorities to see to it
that necessary treatment in hospitals has to
be given within six months from the mo-
ment the need has been diagnosed.
The Finnish Medical Association has as
one of its basic values the enhancement the
best for the patient.Therefore the FMA has
advocated strongly both for the treatment
guarantee and the free choice of the doc-
tor, as well as the possibility of patients to
travel abroad for their treatment when and
if necessary. The latter choice is included in
a new framework law proposal that is under
preparation in the European Union to unify
patient care within the boarders of the EU.
It is expected to raise some opposition from
the governments of EU Member States,
who want to keep the grip on their citizens’
rights and possibilities to choose between
diﬀerent caregivers in order to safeguard
their own health care budgets.
Non-doctors as managers
Finnish doctors have traditionally ﬁnished
their professional careers as leading admin-
istrators in hospitals and health centres.
Their experience of the health care system
as a whole together with accumulated man-
agerial experience and education has made
them highly capable to ﬁll these positions.
Even though the international comparisons
have shown that the Finnish system is run
very cost-eﬀectively, doctors are now being
charged for being responsible to the cost in-
creases during the last decade and therefore
judged to be bad managers.
If doctors are considered unﬁt leaders it
serves as a good excuse to actively diminish
the role of the medical profession in run-
ning the system. Process management is
preferred instead of professional manage-
ment, and being a doctor is turning out to
be a disadvantage instead of being a virtue.
Key indicators used to measure the suc-
cess in health care – such as time spent and
number of patients met – are secondary to
its real goals and eﬀects. This mechanistic
view of measuring the “health industry”
rarely takes into account real health beneﬁts
to the patients and their level of satisfaction
with the system or their treatment results. It
also totally ignores the central tasks of our
profession: always comfort, often alleviate
and when possible heal.
When we lose medical professionalism in
the management of health care we also lose
valuable insight how to develop patient care
and how to advance medicine in the best
possible way. Undoubtedly this trend will
ﬁrst worsen the working conditions of doc-
tors and as a result of that also patient care.
Forcing the doctors to step aside from their
administrative role has already led into seri-
ous problems in Finland, especially in the
health centres. Doctors feel their voice is
not heard when primary care work is re-
organised. In many cases they have sought
new positions elsewhere and even whole
municipalities have lost their all doctors in
a very short time.The FMA tries actively to
lobby the local politicians and administra-
tors to understand the importance of pro-
fessional experience and leadership when
meddling with the structures in order to
contain costs.
Helsinki University Hospital, by far the
biggest hospital in the country, is in the
middle of serious crises at the moment. A
new CEO was appointed to the hospital
and he introduced a new managerial leader-
ship model into the hospital leaving doctors
out of the organisation’s strategy work and
top leader positions. This was justiﬁed by
arguing that doctors are not educated and
experienced leaders. It resulted in an open
conﬂict, which made front page news. In
the end the united doctors’ front got their
opinion approved, setting a good example
to the profession in the country and world-
wide: united we are strong and able to de-
fend our possibilities to treat the patients.
In Finland there was a special educational
program for doctors on health care man-
agement, but it has been abolished recently.
No new program has been introduced even
though it was promised. This has lead into
mistrust between the profession and the
government and increasing numbers of doc-
tors are moving from the public sector to
146
Medical Ethics, Human Rights and Socio-medical affairs
the private sector and occupational health,
thus leaving the health centres and hospitals
in resource crises. It is important that edu-
cational programs for doctors in health care
management exist. Doctors should be en-
couraged to participate in these courses and
make use of the qualiﬁcations accordingly
when seeking positions. There is certainly
a need for international cooperation in this
area as well and the FMA welcomes the
eﬀorts of the World Medical Association
with its INSEAD training program which
will take place for the second time in France
in December 2008.
Working time
Other current topics related to the organi-
sation of medical services in Finland are the
questions of working time and on-call work.
The European Union is at the moment try-
ing to renew the framework legislation that
regulates the maximum daily and weekly
working hours of most employees, includ-
ing doctors.The FMA understands well the
risks for patient safety that are caused by
excessively long working hours. At the same
time it is clear that emergency care requires
doctors to be on call when needed and they
also must be properly remunerated for the
inconvenience caused by these abnormal
hours of work. The proposed ceilings to the
maximum weekly working hours are not
a major problem in Finland. However the
attempt to limit the active daily working
hours will aﬀect the on-call work in hospi-
tals substantially and require a much higher
number of doctors.
Task shifting
The Finnish government has promised to
propose a bill on task shifting later this year.
The aim is to give restricted right to some
200 nurses to prescribe. According to the
government this is justiﬁed because it allows
the patients to get their medication easier.
The Finnish Medical Association feels that
prescriptions are a part of the treatment
decisions that should be restricted to medi-
cal profession only and sees any attempt to
change this as a substantial violation of the
autonomy of the medical profession. Doc-
tors have the knowledge, training and com-
petence to diagnose and determine the best
and most eﬀective medication. They also
know how to take into consideration the
overall condition and possible other illness-
es of the patient, as well as eventual interac-
tions between diﬀerent drugs.Therefore the
responsibility of the pharmacotherapy must
always lie on the profession and individual
professionals that are responsible of the pa-
tient’s treatment as a whole. It is certain
that the debate in the parliament about this
issue will be vivid, but the political pressure
is unfortunately towards the medically un-
acceptable result.
In Finland there is one working-age doc-
tor for every 300 inhabitants. In our system
it is therefore not plausible that nurses are
needed for prescribing. Even if there was
a problem it could not be solved by train-
ing some 200 nurses trained to prescribe,
as has been suggested. It is evident that
the real reasons for these changes diﬀer
from the ones that have been expressed in
public. Factors like cost-containment have
been stated to play a role. Unfortunately
it is probable that this policy will increase
the medication costs even though the salary
of prescribers would be lower. Savings are
not easily attained since the more there are
prescribers the more there will be prescrip-
tions – but not necessarily more health. Es-
pecially antimicrobial resistance may easily
increase and lead into more dangerous and
costly infections.
The lack of human resources (physicians)
and immaterial resources (time) should not
be used to justify shifting the therapeutic de-
cision upon other non-medical professions.
Health care is teamwork.The patient’s inte-
gral health care requires a multidisciplinary
eﬀort by all health professions, taking into
consideration each other’s ﬁeld of compe-
tence. Other health professionals may con-
siderably help the workload of the doctor
in their quest for the best of the patient.
However, in low-income countries that suf-
fer from an extreme shortage of doctors, it
is understandable that some tasks – such
as the practical delivery of drugs – may be
partially delegated to other health profes-
sionals, but even in those cases always in a
clearly deﬁned manner.
Clinical autonomy
A physician should always act in the best
interests of the patient. Respecting the will
of the patient must however not result in
avoiding responsibility. A physician must
support the decision-making of the patient
by providing factual, evidence-based infor-
mation in a clearly understandable manner.
The patient must always be able to trust the
honesty and professionalism of the physi-
cian. This trust from the patients and the
support of colleagues are the cornerstones
of our everyday work.They must be supple-
mented by an agreement with society that
results in a health care system which gives
us the necessary clinical autonomy.
A Finnish patient was recently let down
by the false promises of a quack. Later, the
patient was quoted in a newspaper saying
’I trusted him like a doctor’. This trust that
we now enjoy from the patients, from col-
leagues and from the society at large must be
regained and reinforced every day. The only
way to do that is to always act for the best
interest of the patient in an ethical way.
Our profession faces major challenges to-
day. The patients have been empowered
into demanding customers, the politicians
like to see us as any other group of workers
and not as highly trained experts in medi-
cine who can and should bear the respon-
sibility of medical care in every health care
organisation. We must insist that organi-
sations based on medical expertise require
medical experts to lead them. For all of us,
there is much work to be done. Like the
doctors in the Helsinki University Hospital,
the National Medical Associations should
face these challenges united and prepared.
Together we are strong and can best serve
our members and their patients.That is why
there is an increasing need for WMA and
regional co-operation of the NMAs.
147
International, Regional and NMA news
Dr.Federico Marin, President Elect 2009- 2011
I would like to talk about “México Mágico”.
Let me preface by saying that Mexico is a
Country of many contrasts; we have lived,
as was described by a Latin American writ-
er, in the Country of the “perfect dictatorial
state”. It only lasted 77 years, until the year
2000. Then, after the treacherous murder of
the “oﬃcial”candidate to the presidency,the
ruling party lost control, and thanks to their
last president the system changed bringing
us to the dawn of a new era, the beginning
of a democracy. It is said that we are living
in the midst of a political system that does
not seem to end, and one that has not yet
been established. Theoretically, we live in a
democracy,in a republic,“The United States
of Mexico”. It consists of 32 states and one
Federal District, (Mexico City) with the
geography of a horn, the “Cornucopia”, but
with the opening to the north that just so
happens to be to the USA.The truth is that
the northern states of Mexico, mainly ag-
ricultural and with cheap labor, (they have
many labor plants) have exported their pro-
duction to the United States, hence their
wealth. And since NAFTA was created,
their growth has been 10 times as much as
that of the southern states, thus, one-third
of the northernmost part of the country,
close to the USA, are the rich estates. The
central part is where the Capitol is, as well
as most of the Government oﬃces; and
the southernmost part is where the poorer
states are located and civilization seems to
have stalled. (We cannot but wonder if it
ever arrived.) But then again the contrasts;
Cancun is almost at the tip, or the south-
ernmost part of the country, as are Oaxaca
and Chiapas with their natural wonders and
if that were not enough, all the Mayan Cul-
ture. A paradox one might think?
This is a country where oﬃcial data shows
that half the population is below the pov-
erty line. (The Mexican population in 2008
is 106,600,000). 13.8% of the population is
incapable of even buying their own food.
In contrast, the wealth is in a small group
of families, comprising less than 5%. We
are still wondering how it is possible that
the World Bank deﬁned our Country as a
rich Country, with high income. Perhaps
we should tell the World Bank to go and
ask the 13.8% people who are starving.
The Mexican Constitution was signed on
February 5, 1917. Within its 136 Sections,
it talks about the right to food, housing,
health and education for all. That has not
yet been the realized and nobody knows
who is supposed to foot the bill. Still, feu-
dal lords rule each in their own reign, do-
ing and deciding for others, on their own
free will and for their own beneﬁt. We
could say that health is the hostage to the
lords and they use it as ransom. We are a
country with huge proven oil reserves, but
with the lack of technology to produce or
reﬁne gasoline, the gas is burned right in
its extraction site, and then we import gas
from other countries.
The Health System
National Social Security, IMSS, ISSSTE,
PEMEX (equivalent to Medicare and
Medicaid in the United States), serve 58.7
million people, except that their inventories,
materials and physicians, are roughly at a
50% capacity to achieve this. Waiting time
for a doctor appointment is more than two
hours and surgical procedures are deferred
up to 6 months.
Around 20 million people are not protected
by any kind of system (“out-of-pocket).The
other 22 million people are in a prepaid sys-
tem, or so they say, but again, I doubt it.The
government insurance policy called “Seguro
Popular”, (Popular Insurance or Popular
Security) was established in a way to cope
with the text. Suﬃce it to say that “reality”
did not read the terms and conditions of the
contract. With the same health institutions,
the government is trying to provide Social
Services – in exchange for payment – as a
way of insurance. We, the physicians, never
agreed, but we were never asked either.
Medical Schools
Legally there are 106 schools of medicine.
Every year, before starting any specializa-
tion, an evaluation examination is required.
Some 25,000 new physicians attempt it, but
fewer than 5,000 are admitted. That means
that we have a surplus of 20,000 general
practitioners every year. With this number
of schools,one can imagine how many asso-
ciations, councils, colleges, boards, etc., ex-
ist.We have talked about the atomization of
physicians, meaning that the authorities, by
allowing this, have created such confusion
that the possibility of doing anything in an
orderly manner is quite minimized.
The challenge is to convince physicians to
move to where they are needed. Southern
states have a minimum of medical services,
while, on the other hand, in the capitol and
in the big cities, there is “top of the line”
medical services, with excellent hospitals
for those who can aﬀord it. The health sys-
tem is supported mainly by residents as a la-
bor force. Depending on the health system
Colegio Medico de Mexico
148
International, Regional and NMA news
needs, the number of physicians admitted
by the evaluation examination may increase
or decrease.
According to the Mexican Constitution,
no person can be obligated, forced or re-
stricted from the free exercise of work or
employment; therefore, by law, good fel-
lowship is not stimulated, promoted or en-
forced.The Secretary of Education has 638
medical specialties. Currently, the COLE-
GIO MÉDICO DE MÉXICO is certifying,
providing continuing medical education,
and trying to return dignity to physicians.
This dignity was lost when third parties
or third payers, interested in belittling the
profession, intervened with the purpose
of having technicians who are easily and
rapidly trained, as opposed to educated
specialists who undertake years of formal
education and training.
Our meetings take place in diﬀerent states
with the idea of visiting the whole country,
presenting new programs and setting new
goals, and to try to negotiate with the dif-
ferent departments in the government, who
demonstrate unlawful management. In
trying to make them modify their perfor-
mance – though it is a day by day battle – we
ﬁnally seem to be making progress with the
new government administration (demo-
cratic government?). Now we seem to have
reached a meeting place for negotiations.
Our comments on health issues have been
accepted and are beginning to inﬂuence the
health programs, the pharmaceutical indus-
try and other health issues.
Gordon Caruana Dingli, MD LRCP Edin
LRCS Edin LRCP&S Glasg, FRCS Edin
FRCS RCP&S Glasg, Secretary General,
Medical Association of Malta
The Medical Association of Malta (MAM)
was established in 1955. MAM represents
all the diﬀerent medical specialties in Malta
with a membership of around seven hun-
dred doctors. MAM is both a medical asso-
ciation and a trade union; in fact it is one of
the oldest and most prestigious trade unions
in Malta.
The founder President of MAM is the Hon-
ourable Dr. Vincent Tabone, an ophthalmic
surgeon and Emeritus President of Malta.
The council of the Medical Association of
Malta is elected every three years and is
completely voluntary and unpaid with only
part-time secretarial support.
MAM aims to unite all medical practitio-
ners and to safeguard their interests, pro-
viding advice and assistance in their mu-
tual relations and with the State and other
authorities and organizations and provides
spokesmen for any member seeking assis-
tance.
MAM promotes the ethical, scientiﬁc, pro-
fessional, cultural, social and economic in-
terests of its members to lead to the highest
possible standards of education, ethics and
patient care.
MAM works with other national and inter-
national partners and organizations to fur-
ther its aims.Its local aﬃliations are with the
Federation of Professional Associations and
the Confederation of Malta Trade Unions
(CMTU). On the international scene,
MAM is aﬃliated with the World Medical
Association (WMA), European Forum of
Medical Associations and WHO (EFMA),
Permanent Working Group of European
Junior Doctors (PWG), European Union
of Family Doctors (UEMO), Common-
wealth Medical Association (CMA), Euro-
pean Union of Medical Specialists (UEMS)
and the Standing Committee of European
Doctors (CP).
In 2007 the Medical Association of Malta
negotiated a new agreement with the Health
Division of the Malta Government which
improved working conditions for hospital
doctors.The new agreement promoted ﬂex-
ible working times by introducing sessions
and also entrenched postgraduate training.
In Malta the medical profession faces sev-
eral challenges, foremost of which is the
‘brain drain’ where locally trained doctors
are emigrating to other European countries
for ﬁnancial beneﬁts and for better career
prospects. This new agreement will serve to
retain local graduates by improving training,
working conditions and career prospects.
MAM is also conscious of the physical and
mental stresses of working in the profession
leading to early ‘burn out’.This problem will
be approached by improving health care
services for practicing doctors.
On the other hand there are exciting new
prospects for the medical profession in Mal-
ta. A brand new ‘state of the art’ hospital
has recently been commissioned and there
are several new developments especially in
postgraduate training. There are plans to
make Malta an international training centre
and also to encourage medical tourism.
MAM strives to improve the standard of
health care in Malta to provide the highest
possible levels of patient care.
The Medical Association of Malta
XLV General Meeting, in Monterrey, Nuevo
Leon, Mexico, November 18, 2007 Doctors.
From the left: Reynaldo Cantu Mata, Former
President 2005-2007; Eduardo Tello, Cur-
rent President 2007-2009; Federico Marin
President elect 2009-2011
149
International, Regional and NMA news
149
Dr. Din Abazaj, President
Dr. Shaqir Krasta, General Secretary
The Order of Physicians of Albania was
created in 1994,by a law of Parliament,dur-
ing the ﬁrst years after changes in the socio-
economic and political system of Albania,
as a new body without any precedent in Al-
banian medical practice. This entity began
its activities in the circumstances of a very
diﬃcult transition in all sectors of Albanian
social life.
The foundation of the Order of Physicians
was a very important step for Albanian
medicine as an independent link of profes-
sional self-regulation and eﬀective support
within the framework of the reforms in
health care.
Until 2000, the Order was completely de-
pendent on the Ministry of Health; the
activity and competencies of the Order was
very restricted. During this year a new Law
No. 1615 date 01.06.2000 “On the Order of
Physicians in the Republic of Albania” was
promulgated, which considered it a “Public
Entity”. From this time the Order began
to develop, raise and enforce institutional
capacities and functioning as an eﬀective,
independent, professional body.
During the last few years of the activity the
challenges of the Order had been oriented
to:
Firstly• ,raising of capacity and institution-
al eﬀectiveness,
Secondly• , raising of public credibility,
among the membership and in partner-
ship with counterparts in the country and
abroad.
Thirdly• , the construction and consolida-
tion of systems and processes for the good
functioning of all the Order’s structures.
The Order of Physicians is a regulatory
body of medical professions and its main
mission is to oﬀer support and encourage
high standards for formation and continu-
ing education of doctors.On the other hand,
it is engaged to guarantee the application of
these standards in the defence of the public
and patients from medical malpractice and
transgressions of the Code of Medical Eth-
ics.
The Order has concentrated its eﬀorts on:
Registration of doctors•
Fitness to medical practice•
Managing of ﬁnancial sustainability•
Public involvement•
Public relations and communication•
International relations•
The National Council of the Order had ap-
proved the Code of Deontology and Medi-
cal Ethics as a central document for profes-
sional standards, to be applied compulsorily
by every physician during medical practice.
The establishment of the National and Re-
gional Register of physician’s membership
and creation of the website (www.umsh.org)
were important challenges of these years.
The register was constructed as a database
and is open to the public and it contains
some data, which belongs only to the Order,
regarding the Continuous Medical Educa-
tion for doctors, needed for the periodical
revalidation of health professionals.
Closely associated with the National Coun-
cil is the National Disciplinary Judgment
Commission, which deals with the doctors
who avoid the ﬁtness to practice and other
commissions.
A very important issue for the Order has
been public communication and the exami-
nation of public and patients complaints.
The Order of Physicians of Albania is a
young body without experience and tradi-
tion. These conditions have led to the ex-
pansion of relations and collaboration with
similar bodies and international organisa-
tions. Today the Order has relations with
a number of European medical associa-
tions and is a member of IAMRA, GIPEF,
EFMA, ZEVA, COMEM, etc.
The expansion of international relations has
been directed to the integration of Albanian
medicine with European medicine.
The priority challenges to the future activity
of the Order are:
Firstly: enforcement and improvement of•
activities related to raising the credibility
of the Order and consolidation of it as an
independent public entity,
Secondly: invigoration of all the Order’s•
branches for monitoring and control of
daily medical practice standards related to
the protection of the public and patients
from medical malpractice.
The long term Strategy of Order of Phy-
sicians has been directed to the support of
Health policy reform in Albania.
15 years after the changing of the politi-
cal and social regime in Albania the health
system still encounters a lot of diﬃculties
related to:
very limited technical capacities to devel-•
op policies, strategies and national plans,
institutional and individual professional•
accreditation has not yet been applied.
Albania does not currently enjoy either
experience or tradition in this sector.
lack of the decentralisation of compe-•
tencies from government authorities to
health organisations, institutions and
public entities and, as result, the orders
and professional organisations are not
playing the role which belongs to them
for exercising their competencies, author-
ity and commitment regarding Continu-
ous Medical Education, and the accredit-
ing and licensing of professionals.
lack of experience in monitoring and con-•
trolling the activities of private practice,
lack of necessary structures for monitor-•
ing and controlling the quality of health
care,
Albanian Order of Physicians – Progress and
Strategy of Development
150
International, Regional and NMA news
lack of many diagnostic equipment and•
curative services.
lack of credibility and public dissatisfac-•
tion of the quality of medical services
delivered.
one of the more acute problems is the un-•
equal distribution of medical staﬀ. Many
communities are left uncovered by the
health service.As result of free movement
and the migration toward big cities, phy-
sicians abandoned their working places in
remote rural areas, which make the plan-
ning of the needs for health services very
diﬃcult.
insuﬃciency in the ﬁnancing the health•
system.
little experience and weak capacities in•
the ﬁeld of health management.
Taking into consideration the above-men-
tioned problems, health reform in Albania
has concentrated on an ambitious strategy
that introduces challenges to be faced, such
as:
Strengthening the technical capacity of•
the Ministry of Health in drafting poli-
cies,strategies or national plans for health
system development, avoiding the tra-
ditional role of direct management of
health services,
Improving the stimulating policies for•
private health service, as well as the
strengthening of legislation, standards,
and monitoring structures in order to
protect the public from abuses and harm-
ful medical practices.
Placing the patient in the centre of the•
health system as a fundamental condition
for quality service and development.
Decentralization of health system with•
the ﬁnal aim of its autonomy, as the op-
timal solution for good management and
the safeguarding of system integrity.
Establishing of a national system of hu-•
man health resources, capable of achiev-
ing its mission.
Extension of ﬁnancial basic resources,•
increase of the ﬁnancial and cost-eﬀec-
tiveness of their use through increasing
public funds for health, enlargement and
strengthening of health insurance schemes,
improvement of contracting mechanisms.
Strengthening of managerial capacity of•
health institutions through creation of
models for their management. Establish-
ing of the profession of health managers.
Preserving and improving public health•
by adapting it to the economic, social and
epidemiological changes in the country.
Strengthening and perfecting of primary•
health care service by considering it as the
main pillar of health services.
Creating the model of an autonomous•
hospital aiming at the improvement of
health care quality.
Improvement of dental and pharmaceu-•
tical service with the aim to standardise,
strengthen and monitor structures.
To face and realize all these challenges
Albania needs the setting up of necessary
structures in the sectors of Health Insur-
ance Policies, Mental health, Health Man-
agement, Quality Control, Accreditation,
Licensing, Monitoring. CME, Standard-
ization and Maintenance of medical equip-
ment and others.
The human resources in the health care sys-
tem today in Albania are limited. The ratio
of physicians to population is 1.36 per 1000
inhabitants (among the lowest ratios in Eu-
rope). The ratio of mid-qualiﬁed staﬀ is 3.7
per 1000 inhabitants.
For resolving these issues,the reform is con-
centrated in developing a medium term and
long term plan for human resources in the
health system, improving the geographical
distribution of medical staﬀ by applying the
principles of the labour market, establish-
ing a Centre of CME and allocating the
necessary funds, establishing the School of
Public Health in order to create a functional
training system for physicians and medical
staﬀ. On the other hand, it is important to
strengthen the role of the family doctor. Al-
bania possesses an insuﬃcient number of
family doctors – 0.5 per 1000 inhabitants.
The specialty of family medicine was in-
troduced only recently and is still the most
discriminated and low-esteem specialty.It is
very important to strengthen the category
of family doctors by improving their tech-
nical abilities and the infrastructure of Pri-
mary health care.
The reform in Albanian medical services
should include also:
Strengthening the patient’s role in assess-•
ing the level of health service and devel-
opment of health policies,
Encouraging the establishment of au-•
tonomous health services (PHC and hos-
pitals), ﬁnanced by the health insurance
scheme.
Establishing the School of Public Health•
and institutionalising Continuous Medi-
cal Education.
Changing the image of family doctors•
through improvement of clinical practice
and a new philosophy of dealing with the
individual and community issues.
The new Government has decided to rise•
the percentage of GDP for medical ser-
vices from 2.4 today to 3.5 during 2007-
2008.
Organising of health promotion focusing•
on improvement of life style, prevention
of road accidents, drugs, alcohol, tobacco,
etc.
Improve population access by primary,•
secondary and tertiary health services.
Improving the primary health care infra-•
structures.
Encouraging and supporting the enlarge-•
ment process of private practice in deliv-
ering health care in the primary and hos-
pital services.
Improving legislation to harmonise the•
reform in medical service.
Privatise the curative dental service com-•
pletely and apply the health insurance
scheme cover people of 0-18 years of age.
Improving the pharmaceutical legislation•
based upon EU experience.
Strengthening the monitoring capacities•
in manufacturing, storage and marketing
of drugs.
Strengthen the structures, collaboration•
and the role of public entities such as
the Order of Physicians and Dentists of
Albania, the Order of Pharmacists, the
Order of Nurses and professional associa-
tions of the medical specialties.
151
International, Regional and NMA news
Eric De Roodenbeke, Director General of the
International Hospital Federation.
The International Hospital Federation is
the successor to the International Hospital
Association, which was established in 1929
after the ﬁrst International Hospital Con-
gress in Atlantic City, USA. The Associa-
tion ceased to function during the Second
World War, but was revived under its new
title – International Hospital Federation
(IHF) – in 1947. The IHF is an interna-
tional non-governmental organisation, sup-
ported by members from over 100 coun-
tries. As the worldwide body for hospitals
and healthcare organisations it develops
and maintains a spirit of co-operation and
communication among them, with the pri-
mary goal of improving patient safety and
promoting health in underserved commu-
nities.
The IHF vision is to become a world leader
in facilitating the exchange of knowledge
and experience in health sector manage-
ment, with its main goals being:
To improve patient care quality around•
the globe, through the dissemination of
evidence-based information.
To collect, collate, publish and facilitate•
the exchange of information and ideas on
best practice in hospital and health care
management.
To assist in the creation of environments•
that support organisations in the promo-
tion and delivery of health care.
To foster international partnerships that•
promote interaction among public and
private hospitals and health care organi-
sations, the community and commercial
entities.
To promote and protect the dignity,safety•
and welfare of patients.
The vision is promoted through events,
publications, networking and projects in
line with its mission and values. These ac-
tivities prioritize information on leadership
and management of hospitals and health
services.
The IHF publishes the journals World Hospi-
tals and Health Services and Building Quality
in Health Care launched in October 2007 in
collaboration with The Methodist Hospital
(Texas, USA); the yearbook International
Hospital Federation Reference Book
IHF events which are organized and locat-
ed to ensure its presence in all regions of the
world include the Biennial World Hospital
Congress, Pan-Regional Conferences. IHF
events also provide both a forum and meet-
ing place for public and corporate actors.
The IHF engages in a myriad of activities
which have as their objectives prioritization
of information on leadership and manage-
ment of hospitals and health services. Ex-
amples of such activities include:
Development of a Training Manual for•
Tuberculosis (TB) and MultiDrug Re-
sistant-Tuberculosis (MDR-TB) Con-
trol for Hospital/Clinic/Health Facility
Managers.
Assessment and preparation of a report•
on water usage within hospitals and
healthcare facilities, for which aspects of
waste management and control of infec-
tious diseases were points of focus.
Inter-professional collaborative project•
involving conduct of and preparation of
a report on smoking policies and practices
in hospitals and health services in select-
ed African countries.
Technical Assistance Programmes to•
Ministry of Health (Kuwait), to review
recent initiatives undertaken to improve
the country’s health care.
Collaboration with the International As-•
sociation for Infant Food Manufacturers
(IFM) to develop a concept paper for a
safety training programme for feeding
practices in hospitals.
The IHF through its membership and com-
munications activities acts as a bridge be-
tween members in order to facilitate and
support cross-fertilization of knowledge
and experience in management and leader-
ship of health organizations. Through these
activities, the IHF supports the creation of
new national hospital associations.
The IHF has oﬃcial relations with the
World Health Organization and also main-
tains good working relationships with a
number of other international organiza-
tions, such as:
the International Council of Nurses;•
the World Medical Association;•
the Hospital Committee of the European•
Community;
the World Dental Federation;•
the International Pharmaceutical Federa-•
tion;
the Global Health Workforce Alliance;•
World Alliance for Patient Safety of•
WHO.
IHF secretariat is engaged in questioning
all of its national members to better reﬂect
their priority areas of concern. This review
will lead to the organization of the ﬁrst-
ever global retreat of health-care organiza-
tion representative top decision-makers, in
May 2009. Such a forum will energize solu-
tions and enhance advocacy capacities both
at global and national level. It will also be
of major importance to clarify the dialogue
IHF will undertake at global level with ma-
jor health organizations.Today hospitals are
trying to ﬁnd opportunities to grow and/or
sustain their activities.The hospital sector is
going to change dramatically in the com-
ing years. It is more than ever important to
think ahead relying on a better understand-
ing of how the future is shaping up. Innova-
tive solutions emerge locally but they can be
scaled up through a bottom up – top-down
process, thereby making the global level a
necessary step to accelerate responsiveness.
IHF is the key to this process because it
is the link between the hospital sector, the
health care professions and the internation-
al organizations.
International Hospital Federation
152
International, Regional and NMA news
Dr. Hiroko Minami
The International Council of Nurses (ICN)
is the world’s ﬁrst and widest reaching
forum for health professionals. As a fed-
eration of 131 national nurses’ associations,
ICN represents more than 13 million nurses
working around the globe.Our mission is to
represent and advance the nursing profes-
sion worldwide, and inﬂuence health policy.
Our vision is to lead our societies toward
better health. All ICN activity is guided by
three strategic goals and ﬁve core values.
The goals are:
to bring nursing together worldwide;•
to advance nurses and nursing world-•
wide;
to inﬂuence health policy.•
Five core values form the basis of all ICN
decisions: Visionary Leadership, Inclusive-
ness, Flexibility, Partnership and Achieve-
ment. As a federation of nursing organisa-
tions – professional associations, regulatory
bodies, and unions – ICN’s work encom-
passes professional practice, regulation and
socio-economic welfare.
Professional Practice
In professional practice ICN’s current focus is
in three main areas. The ﬁrst, leadership, fo-
cuses on developing nursing leadership skills
– to make the nursing voice heard at the pol-
icy level, to improve working environments
and,most importantly,to support quality care
for patients, families and communities. As
a speciﬁc example, ICN is developing nurs-
ing skills in the area of disaster preparedness,
and lobbying international institutions to
integrate disaster preparedness, response and
recovery into their aid programmes.
A second focus is the development of a spe-
ciﬁc language to describe nursing practice.
Called the International Classiﬁcation of
Nursing Practice or ICNP®
,it is used to doc-
ument and describe nursing practice across
geographic areas,languages and time.A third
focus of ICN’s work in professional practice
is the importance of strong linkages with na-
tional,regional and international nursing and
non-nursing organisations. Building positive
relationships internationally helps position
ICN,nurses and nursing for now and the fu-
ture. ICN works with a wide range of part-
ners, including United Nations agencies, the
World Health Organization (WHO) and
the International Labour Organisation. We
also work with a variety of other intergovern-
mental agencies, non-government organisa-
tions and industry.
Regulation
Turning to ICN’s second pillar, regulation,
ICN has long recognised that setting and
enforcing standards for nursing education
and practice is a major responsibility of or-
ganised nursing. ICN has established an
Observatory that identiﬁes future trends
and issues that require consideration and
action. We have produced guidance docu-
ments, fact sheets and monographs on issues
as diverse as mutual recognition agreements,
professional regulation, competencies and
a model nursing act. ICN brings the global
regulatory community together via a forum
for Regulators and ‘triad’ meetings bringing
together NNAs, regulators and Government
Chief Nurses. We are currently undertak-
ing a major research study that will facilitate
communication and understanding between
nurse regulators. This study in addition to
conducting a comparative analysis of legisla-
tion also identiﬁes regulatory best practices.
Socio-Economic Welfare
In much of the world the socio-economic
welfare of nurses is inadequate. Unsafe and
undesirable working conditions contribute
to what is probably the greatest challenge
to nursing and health today – the shortage
of nurses worldwide. In 2004 ICN and the
Florence Nightingale International Foun-
dation undertook the ﬁrst systematic inves-
tigation of the nursing workforce to estab-
lish a global picture of the actual situation
and the potential solutions. This global
analysis has identiﬁed the policy and
practice issues and solutions that should
be considered by all sectors in addressing
the supply and utilisation of nurses.
One of the solutions is the promotion of
positive practice environments which sup-
port nurses’ professional identity through
meaningful work, autonomy, control over
practice, input into decision making and
strong leadership. ICN is working with
other health professions on a campaign for
positive practice environments.
We are also working with other health
professions in the ﬁght against counterfeit
medicines – a growing global threat. This is
an area in which nurses are well positioned
to monitor drug eﬀects and side eﬀects.
Nurses also have a key role in educating the
public about the dangers of buying medi-
cines through the Internet or on the streets
from unauthorized sources. ICN also works
in the area of HIV/AIDS care to protect
nurses from the danger of occupational ex-
posure to HIV and to address the particu-
lar needs of health care workers. ICN has
established HIV and TB Wellness Centres
of Excellence in sub-Saharan Africa which
deliver comprehensive HIV and TB treat-
ment, health services and training for all in-
fected health workers and their families.
The health of women and girls is of par-
ticular concern to ICN because of the dis-
crimination they suﬀer on the basis of their
gender. ICN’s Girl Child Education Fund
is helping the orphaned daughters of nurses
return to school. The education of girls and
women has a direct result on poverty reduc-
tion, lower maternal and infant mortality
rates, improved health and nutrition, higher
productivity and increased likelihood that
the next generation will in turn be educat-
ed. The successes ICN has known since its
founding in 1899 are a product of the com-
bined eﬀorts of the nurses of every country,
every continent. Our members, the national
nursing associations, represent the strength
of ICN and nursing and are vital to health
and progress in every society.
The International Council of Nurses
153
International, Regional and NMA news
James Appleyard MD FRCP, Hon. Secretary
to the Board of Trustees, IAOMC
A few nations train a surplus of doctors.
But most governments maintain a shortfall
in medical manpower. The incomes of phy-
sicians varies substantially throughout the
world.Thus we are now witnessing an ever-
accelerating global migration of physicians,
some of whom are poorly trained. This un-
derlines the urgent need for transparent
global medical accreditation standards with
a transparent process applied by qualiﬁed
medical educators to help insure compli-
ance world-wide.
Accreditation’s objective is to enhance med-
ical education and thus medical practice.
Indeed the future of medicine as a profes-
sion depends on our teaching tomorrow’s
doctors with the developing medical knowl-
edge, skills, and ethics to an agreed standard
as the basis for their lifetime of learning
The greatest assurance of maximum quality
in medical education requires an impartial,
external, open and transparent, non-polit-
ical, global, accreditor. There are real and
potential diﬃculties when governments
control medical standards through their po-
litical processes. According to the Founda-
tion for the Advancement in Medical Edu-
cation and Research (FAIMER) directory
of international organizations involved in
accreditation of medical standards, there are
about 92 nations who claim there is an ac-
creditation process for their nations medical
school(s). (see: http://www.faimer.org/orgs.
html).
Many nations however have no adequate
mechanisms to maintain or improve their
standards of medical education. Few of the
existing national accrediting organizations
are open and transparent. Transparency,
Peer Oversight and Accreditation encour-
age improvement and diminish the op-
portunities for corruption. (see examples at:
http://www.iaomc.org/databank1.htm#3).
In times past some governments have not
been candid with their citizens.
The IAOMC was founded as an indepen-
dent agency and speciﬁcally designed to
resolve these issues. (see: http://www.iaomc.
org/begining.htm. Global standards have
been developed after public hearings were
held. see: http://www.iaomc.org/minutes1.
htm. and take into account the World Fed-
eration of Medical Education’s (WFME)
Trilogy of Global Standards.
IAOMC has an independent body of site
visitors whose qualiﬁcations can be ob-
tained from its website; http://www.iaomc.
org/svp.htm. Members elect their own
Chair and Secretary. An independent panel
of regulators will accompany the site visi-
tor as observers. Because of the distances,
communication is electronic and via Skype.
Between meetings Board members vote by
email and the results are posted. see: http://
www.iaomc.org/minutes3.htm.
Medical Ethics provides the foundation of
the trust between patients and their phy-
sicians. The IAOMC has established an
standing Ethics Committee whose report
forms the basis for the standards that medi-
cal schools are expected to maintain. see:
http://www.iaomc.org/ec.htm. Ethical edu-
cation with openness are central in prevent-
ing any corruption
The Board of Trustees are being assisted in
their appreciation of the complexity of each
nation or region’s medical education/prac-
tice, through their Advisory Council. For
details see: http://www.iaomc.org/council1.
htm#1. There are three sections: 1. Expe-
rienced, expert, medical administrators or
educators, 2. Senior government regulators/
Administrators or Medical Board members
and, 3. Distinguished Representatives of
Countries, Regions, or Organizations. Each
section elects its own Chair and Secretary.
To insure each section is heard its Chair
has a permanent voting seat on the Board
of Trustees. The Board of Trustees elects
the Associations Oﬃcers. see: http://www.
iaomc.org/oﬃcers.htm#1
Within Associations of Physicians and
Medical Academic Institutions there should
be an obligation to inculcate the values and
attitudes required for preserving the medi-
cal professions standards and our ‘social
contract’ with society across generations.
All medical associations or individuals who
accept this professional responsibility, are
invited, without regard for nationality, race,
gender, religion, or age to become a part of
the International Association of Medical
Colleges The challenges that the IAOMC
have set itself are as important as they are
enormous.
But it is in the long term interest of all med-
ical academic and representational institu-
tions to develop and maintain their aca-
demic standards and independence. Joining
together in the independent international
association of medical colleges will further
their aims of professionalism and academic
excellence.
The International Association of
Medical Colleges (IAOMC)
154
International, Regional and NMA news
LisetteTiddens – Engwirda, CPME Secretary
General
The CPME represents all, about 2 million,
medical doctors in the EU. It is an interna-
tional, not-for-proﬁt association under Bel-
gian Law composed of the National Medi-
cal Associations of the European Union and
of the European Economic Area (30 mem-
bers). It also has associated members (those
countries that are currently negotiating with
the EU), observers and 9 associated organi-
sations (specialised European medical asso-
ciations and the WMA). CPME aims to
promote the highest standards of medical
training and medical practice in order to
achieve the highest quality of health care for
all citizens of Europe. Linked to the activi-
ties from the EU, the CPME is also active
in the area of promotion of public health,
the relationship between patients and doc-
tors and the free movement of patients and
doctors within the European Union. The
CPME formulates its policies both in an-
swer to developments in Europe, as well as
by taking the lead in matters regarding the
profession and patient care.
To achieve its goals,the CPME co-operates
closely and where possible proactively with
the Institutions of the European Union.
The CPME oﬀers broad expertise in mat-
ters related to medicine and the medical
profession in its contacts with the European
Parliament, the European Commission and
relevant special European Agencies such
as, for example, the EMEA (the European
Medicines Agency) and the ECDC (the
European Centre for Disease Control).
The Standing Committee of European
Doctors is directed by a Board (each country
has 1 Board member) that is elected by the
General Assembly (in which each country
has 1 head of delegation) for two years.The
President and the Executive Committee are
elected from the Board members also for a
period of two years.
The CPME develops its policies in 4 sub-
committees:
Medical training, continuing professional•
development and quality improvement
Medical ethics and professional codes•
Organisation of health care, social secu-•
rity and health economics
Public health, prevention and environ-•
ment
Experts from each national member organ-
isation, associate members and associated
organisations, as well as observers partici-
pate in these meetings.
Current Activites
The CPME is active in a very wide range of
issues.The following are some examples:
Provision of health services: patients’ and
professional’s mobility
The CPME supports the free movement of
patients and health professionals within the
EU. High quality of care and free move-
ment of patients and professionals are inter-
twined topics that should all be addressed
within a Community framework.
CPME policy states that patients should
have the right to receive safe and high-
quality care all over the Union. For this they
need to be provided with a solid legal basis
and the required information in order to
make informed choices.
Therefore the recently published proposal for
a Directive on Patients rights, that is based
on existing European Court of Justice rul-
ings, is welcomed by the CPME although a
reaction in detail is still being prepared
It is the CPME position that health services
have speciﬁc characteristics that should be
recognised and protected. As they deal with
citizens’ lives and well-being, health services
needstrictercontrolsandregulationthanmost
other services.It is essential that the Member
States take responsibility for guaranteeing the
quality and equal availability of healthcare for
their citizens in all circumstances. Recently
the CPME organised a Round Table discus-
sion (under the auspices of the MEP Karas
and together with the Council of European
Dentists) on the proposed directive on pa-
tients’ rights. At this occasion the CPME
President Dr. M. Wilks warmly welcomed
the draft Directive on behalf of European
Doctors. He pointed out that the aim of the
CPME as it is deﬁned is very much linked to
the core topic of the directive.
He underlined that all the topics reﬂected
in the draft directive, especially in article 5,
which deals with quality, safety and infor-
mation are core issues for the CPME.
Patient safety
The CPME has been an initiating and
central partner in setting patient safety on
the EU agenda. The oﬃcial launch took
place in April 2005 with the Patient Safety
Conference organised under the auspices
of the Luxembourg Presidency of the EU,
the European Commission and the CPME
together with a large number of other rel-
evant EU stakeholders. The Luxembourg
Declaration on Patient Safety set a number
of principles and objectives that marked a
roadmap for the years to come.
The Standing Committee of European
Doctors (CPME)
155
International, Regional and NMA news
The work on this issue is now continued in:
The Patient Safety Working Group of the•
High Level Group that is the counsel of
the European Commission on the draft-
ing of European Recommendations on
Patient Safety.
The CPME has also been partner of•
European-wide projects on patient
safety, such as the SIMPATIE (Safety
IMprovement for PATients In Europe)
project which published its ﬁnal report
in December 2007; has participated in
the advisory council of the MARQUIS
(Methods of Assessing Response to
QUality Improvement Strategies) proj-
ect and is partner of the new EUNetPaS
(European Union NETwork for PAtient
Safety) Project,which gathers all member
states’ and a number of stakeholders that
are active at EU level.
eHealth
In October 2007, the CPME adopted a
policy document on Electronic Health Re-
cords. The CPME strongly values the use
of eHealth technology as a support-tool for
the physician in his or her work. However
there are considerable diﬀerences within the
EU regarding the approach physicians adopt
towards eHealth. Because of these diﬀer-
ences, the CPME has set out some essential
principles for the use and development of
eHealth systems. It is obvious however that
further study and development is needed
in order to be able to establish commonali-
ties and solutions. Electronic health records
should be a support-tool in the provision
of optimal care that is based on face to face
contact and trust between the patient and
the physician. For the CPME it is clear that
the bottom line needs to be that eHealth
technology must be to help support the
quality of care and patient safety provided
by healthcare professionals, in full respect of
current ethical and legal principles. eHealth
will continue to be a developing topic with-
in the CPME. The organisation will keep a
keen eye on eHealth developments and will
continue to deliver opinions to European
Commission proposals, from both practical
and ethical points of view.
Pharmaceuticals
In December 2005, the Pharma Forum was
launched by the European Commissioners
for Health and Enterprise. It was a follow
up to the “G-10 Medicines Group”. The
CPME was invited to take part as a full
member and thus sits around the very large
table with all Member States, the European
Commission, and 9 other EU stakehold-
ers. The CPME has representatives in the
3 working groups of the Forum, which deal
with information to patients, pricing and
relative eﬀectiveness. The CPME is often
encouraged to deliver its views on a number
of pharmaceutical issues such as pharma-
covigilance, rare diseases or clinical trials.
EU Platform on Diet, Physical
Activity and Health
As one of the founding members of the EU
Platform on Diet, Physical Activity and
Health, the CPME has been very vocal in
the area of for example nutrition, physical
activity, and food labelling. This Platform
has been established by the EU in order to
co-ordinate partners that could help ﬁnd
solutions for the growing obesity prob-
lem in Europe. Every year, every Platform
member issues commitments on the issue.
CPME commitments are available on the
EU Platform on Diet, Physical Activity and
Health, EUROPA website.
Alcohol
The CPME is a founding member of the
Alcohol & Health Forum which was oﬃ-
cially launched in June 2007.The CPME is
a signatory of the charter. The CPME is
member of the Task Force on Youth-Spe-
ciﬁc aspects of Alcohol and the Task Force
on Marketing Communication.The CPME
adopted a policy on alcohol which expressed
its support to the EU and Member States in
reducing alcohol related harm.
Working Time
The CPME, together with the PWG and
FEMS is lobbying the European Parlia-
ment and is having close contacts with
Member States on the current Revision
of the European Working Time Directive.
The CPME policy defends the codiﬁcation
of the ECJ rulings stating that the inactive
part of on call time is to be considered to be
working time.
Education and training: CPD
TheCPMEandtheotherEuropeanMedical
Organizations plus relevant EU stakehold-
ers organised a Conference on “Continuing
Professional Development – Improving Pa-
tient Safety” in December 2006, under the
auspices of the Finnish EU Presidency and
the European Commission. A Consensus
Statement was adopted declaring: “In addi-
tion to contributing to improvements in the
care of individual patients, CPD also plays
an important part in improving the quality
of healthcare systems”.
Teaching of medical ethics and of medical
values are issues that are currently debated
within the organisation
Relationship with stakeholders:
Patients, a privileged stakeholder
As of course the patient is the most im-
portant partner for physicians, the CPME
is in close contact with the EPF (Euro-
pean Patient Forum) and has developed a
Framework Statement of Collaboration
with them.
A similar exercise has been done with both
the Pharmaceutical industry and the Medi-
cal Devices Industry.
Over the years, the CPME has developed
close relations with all the relevant EU
stakeholders, including nurses, dentists,
pharmacists, public health organisations,
institutions, and patient organisations. As
this article is meant to give you an intro-
duction to CPME, I was only able to give
a short impression of the organisation and
its activities. However you can ﬁnd all our
policies and more on the CPME website
www.cpme.eu
156
International, Regional and NMA news
Dr Eva Nilsson Bågenholm, MD, President
of the Swedish Medical Association
Gabriella Blomberg, International Coordina-
tor, Swedish Medical Association
The Swedish Medical Association has a
long tradition of international engagement
in the area of human rights and ethics. Dr
Eva Nilsson Bågenholm, current president
of the Swedish Medical Association and
also chairperson of the WMA Medical
Ethics Committee (MEC), has been ac-
tively involved in the work of updating the
Helsinki declaration during the last year. In
this process the Swedish Medical Associa-
tion has arranged a high level conference for
Swedish stakeholders in order to make the
Swedish updating comments solid and well
thought-out. In pursuit of highest possible
standards of ethical behaviour and care by
physicians, the Swedish Medical Associa-
tion feels a strong responsibility to promote
WMA ethical policies.
The role and the structure of the SMA
The Swedish Medical Association is the
union and the professional organisation for
physicians in Sweden. Important issues dealt
with include doctors’work environment,sala-
ries, working hours, medical training and re-
search.The SMA also has key role to play by
inﬂuencing the development of healthcare in
Sweden.Over 90 per cent of the physicians in
Sweden belong to the SMA. All members of
the SMA are also registered at a local branch
in the area where they work.The membership
moreover includes signing up for at least one
national professional association, such as the
association for general practitioners, for hos-
pital doctors, for private practitioners or the
national association for junior doctors.
Most members are also members in one
of the 50 specialist associations, a number
which reﬂects the amount of specialties that
are recognized by the National board of
Health and Welfare, the regulatory body of
Swedish physicians.
The SMA enters into collective agree-
ments with the employers organisations
on behalf of its members in areas such as
general employment conditions, which in-
cludes salaries, working hours, holidays, sick
leave,parental leave and pensions.Members
can get help with salary negotiations, and
up-to-date salary statistics, legal assistance
on disciplinary matters, such as negligence
claims or probation, and on general matters
of healthcare, tax and labour law. The SMA
can also give peer support for doctors un-
dergoing a personal crisis.
The Ethic Committee of the Swedish
Medical association (EAR)
The EAR handles ethical questions in rela-
tion to the medical profession, as well as the
ethical questions that are related to market-
ing in connection with medical practice.
Another task of the EAR is to review the
legislation that is linked to the professional
responsibility of the medical profession.The
committee also works for strengthening and
developing the awareness of medical-ethi-
cal questions within the medical profession.
One intermediate goal in this work is for
example to collect and spread knowledge
about national and international ethical
policies and to put ethics on the agenda in
the daily clinical work situation.
International engagement
The aim of the international engagement of
the SMA is to protect and to develop hu-
man rights, professional ethics, conditions
of the medical profession, patient’s rights
and a good quality healthcare for everybody.
In order to pursue these goals the SMA is
a member of CPME, Comité Permanent
des Médecins Européens, Standing com-
mittee of European Doctors, which repre-
sent all medical doctors in the EU. SMA is
also a member of the UEMS, the European
Union of Medical Specialists and UEMO,
the union of general practitioners in Eu-
rope. Already in 1947 the Swedish Medi-
cal Association started its international en-
gagement by being one of the founders of
the World Medical Association.
The Swedish health care system
In Sweden 21 county councils and regions
are responsible for supplying their citizens
with health care services. This includes hos-
pital care, primary care and psychiatric care.
A county council tax supplemented by a
state grant is the main mean of ﬁnancing the
health care system. In addition to that small
user fees are paid at the point of use. Each
county council and region is governed by a
political assembly. Within the framework of
national legislation and varying health care
policy initiatives from the national govern-
ment, the county councils and regions have
substantial decision-making powers and ob-
ligations towards their citizens.The Swedish
health care system is a decentralized system.
Structural changes in the
Swedish Primary Care system
Swedish primary care is in the process of
changing.Recently two green books are pro-
posing to introduce a national system that
gives each citizen the possibility to choose
her/his provider of primary care. There is a
plan of introducing the possibility of pri-
vately owned healthcare enterprises in order
to increase the competition and thereby give
a wider choice to the citizens.
The Swedish Medical Association
Dr. Eva Nilsson Bågenholm, MD, President
of the Swedish Medical Association
157
International, Regional and NMA news
The search is on for more musical doctors
as yet another worldwide doctors’ orchestra
has been established. German doctor, con-
ductor and concert pianist Wolfgang Ellen-
berger from Buchen has founded the Phil-
harmonic Doctors Orchestra (PDO) and is
planning to produce an entire opera, Mo-
zart’s ‘Magic Flute’ in the autumn of 2010.
His ambitious project follows on the success
of the European Doctors Orchestra (www.
EuropeanDoctorsOrchestra.com) which was
founded in November 2004 by Miki Pohl in
London. Their concerts in London, Bucha-
rest, Budapest and Berlin have been over-
booked and led to the orchestra producing
several DVDs of their successful recitals.
The orchestra’s founder Miki Pohl said that
the web site www.DoctorsTalents.com was
largely responsible for ﬁnding doctors for
the orchestra. This was followed by the es-
tablishment earlier this year of the World
Doctors Orchestra (www.World-Doctors-
Orchestra.org) with 80 musical doctors
from 20 countries from all over the world.
Now Dr. Ellenberger is setting up the Phil-
harmonic Doctors Orchestra and is look-
ing for more musical doctors to perform.
Together with conductors Callista Janzing
and Otmar Desch, he plans to perform the
entire opera of ‘The Magic Flute’ in 2010
after just four practice sessions.
Callista Janzing has studied with Sergiù
Celibidache and is working as a coach with
musicians and orchestras. Dr. Desch is a
general practitioner and has been a conduc-
tor in the theatre of Stendal in Germany for
the last ﬁve years where he also performed
his new musical ‘The Call of Dalai Lama’.
Dr. Ellenberger said that the new orches-
tra is open to a range of health profession-
als – medical doctors,dentists,veterinarians,
pharmacists, psychotherapists and spiritual
healers – from all countries. Interested doc-
tors can register on the website (www.
PDO.name) and the ﬁrst practice session is
planned for spring 2009 in Germany.
The target is to end up with a full orches-
tra,choir,soloists,conductors,director,stage
and costume designers. Many of the roles
will be covered by two singers.
The venue for the performances is still being
negotiated,but there are hopes that it might
be a signiﬁcant festival theatre.
Money raised from the productions will go
to charity and members of the orchestra and
cast will have to cover their own travel and
expenses, and play without a fee.
Already Dr. Ellenberger is planning the next
phase of his musical developments. He has a
vision of extending the web site (DoctorsTal-
ents.com) into a building which could house
permanent exhibitions, a library of literary
doctors, piano classes and other events. One
possibility is having a paying membership of
doctors from all over the world.
New Doctors Orchestra plans to produce
‘The Magic Flute’ in 2010
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
WMA news
Financial Crisis may Hasten
Move to Shift Responsibilities Away from Doctors. . . . . . . . 118
Revising the Declaration of Helsinki . . . . . . . . . . . . . . . . . . . 120
Declaration of Helsinki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
WMA General Assembly, Seoul 2008. . . . . . . . . . . . . . . . . . 125
Resolution on the Economic Crisis: Implications for Health. 128
Declaration of Seoul on
Professional Autonomy and Clinical Independence. . . . . . . . 129
New Speaking Book on Clinical Trials Aimed
at African Populations with low Literacy Level . . . . . . . . . . . 129
179th
Council meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
The WMA Caring Physicians of the World Initiative. . . . . . 133
Medical Ethics, Human Rights and Socio-medical aﬀairs
Building a Consensus in Regenerative Medicine . . . . . . . . . . 136
Human Resources and Bioethics in Palliative Care
as an Example of Human Resourse
and Bioethics Development in Kazakhstan . . . . . . . . . . . . . . 138
Georgian Health Care System in the Time
of Armed Conﬂict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Alcohol use in Norway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Challenges in Health Care Unite the Medical Associations . 144
International, Regional and NMA news
Colegio Medico de Mexico. . . . . . . . . . . . . . . . . . . . . . . . . . . 147
The Medical Association of Malta . . . . . . . . . . . . . . . . . . . . . 148
Albanian Order of Physicians –
Progress and Strategy of Development. . . . . . . . . . . . . . . . . . 149
International Hospital Federation . . . . . . . . . . . . . . . . . . . . . 151
The International Council of Nurses . . . . . . . . . . . . . . . . . . . 152
The International Association
of Medical Colleges (IAOMC) . . . . . . . . . . . . . . . . . . . . . . . 153
The Standing Committee of European Doctors (CPME) . . 154
The Swedish Medical Association . . . . . . . . . . . . . . . . . . . . . 156
New Doctors Orchestra plans
to produce ‘The Magic Flute’ in 2010 . . . . . . . . . . . . . . . . . . . 157
WMA news

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