WMJ_02_2026

Official Journal of The World Medical Association, Inc. Nr. 2, June 2026
vol. 72
Contents
Editorial   3
WMA Council Report Belgrade, Serbia, 23–25 April 2026   4
WMA Statements and Resolutions   9
Information about the 77th WMA General Assembly, Rotterdam 2026    10
Portugal’s National Health Service: Workforce Crisis, Burnout,
and the Urgent Need to Support Doctors   11
Legal Challenges of Liability for Damages in Healthcare Systems: The Case of Slovenia    14
From Precision Medicine to Precision Health:
Preventive Care and Equity in an Ageing Society   19
Interview with Experts in Patient Advocacy and Engagement   23
Constitutional Court and “Administrative Solutions”
for Physician-Assisted Suicide in Italy   27
Physician Mental Healthcare and Professional Responsibility: Lessons from PAIME   32
Bioethical Issues in Surrogacy: The Case of Greece   37
MedEdAfrica 2025 and the State of African Medical Education   41
Sustainability in Surgery: An Initiative by the Surgical Society of Bangalore   45
Renewed Ethos for the One Health Movement: A Book Review   48
www.wma.net
OFFICIAL JOURNAL OF THE WORLD
MEDICAL ASSOCIATION
Editor in Chief
Dr. Helena Chapman
Milken Institute School of Public Health, George Washington University, United States
editor-in-chief@wma.net
Assistant Editor
Mg. Health. sc. Maira Sudraba
Latvian Medical Association
lma@arstubiedriba.lv, editor-in-chief@wma.net
Journal design by
Erika Lekavica
dizains.el@gmail.com
Publisher
Latvian Medical Association
Skolas Street 3, Riga, Latvia
ISSN 0049-8122
Opinions expressed in this journal – especially those in authored contributions –
do not necessarily reflect WMA policies or positions
WORLD MEDICAL ASSOCIATION OFFICERS,
CHAIRPERSONS AND OFFICIALS
Dr. Jacqueline KITULU
President
Kenya Medical Association
KMA Centre, PO Box 48502,
Chyulu Road, 4th Floor, Upper Hill
Nairobi
Kenya
Dr. Ramin PARSA-PARSI
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Philippe CATHALA
Chairperson
Finance and Planning Committee
Conseil National de l’Ordre des
Médecins (CNOM) France
4 rue Léon Jost
75855 Paris Cedex 17
France
Dr. Jung Yul PARK
President-Elect
Korean Medical Association
37, Ichon-ro 46-gil, Yongsan-gu
04427 Seoul
Republic of Korea
Dr. Tohru KAKUTA
Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku, Tokyo
Japan
Dr. Zion HAGAY
Chairperson
Socio Medical Affairs Committee
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Ashok PHILIP
Immediate Past President
Malaysian Medical Association
4th Floor, MMA House,
124 Jalan Pahang
53000 Kuala Lumpur
Malaysia
Mr. Rudolf HENKE
Treasurer
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Julie BACQUÉ
Chairperson
Associate Members
Dr. Jack RESNECK, Jr.
Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Christofer
LINDHOLM
Chairperson
Medical Ethics Committee
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
3
Editorial
Editorial
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Over the past few months, the Artemis II mission captured
a powerful view of Earth from lunar orbit, underscoring
the interconnectedness of our planet’s ecosystems and the
importance of environmental stewardship. Simultaneously, the
global health community has navigated a complex landscape
shaped by emerging outbreaks of avian influenza, Ebola virus
disease, hantavirus, and measles, alongside constrained health
funding, geopolitical conflicts, and climate risks such as El
Niño–Southern Oscillation (ENSO). Preparations for major
international events, including the 2026 Olympic Winter
Games and FIFA World Cup, have further emphasised the
critical role of health security planning and resilient local
health systems. Amid these challenges, the World Medical
Association (WMA) issued five press releases advocating for
the protection of health personnel and facilities in conflict
settings, increased investment in the health workforce, and
stronger ethical governance of health data and biobanks.
Climate action and pandemic preparedness remain central
to the global agenda. At the 79th World Health Assembly
(WHA) in May 2026, Member States renewed commitments
to accelerate the elimination of malaria and neglected
tropical diseases, strengthen pharmacovigilance systems, and
advance key global health initiatives, including the Global
Action Plan on Antimicrobial Resistance (2026–2036),
the Immunization Agenda 2030, and the Belém Health
Action Plan. At the 93rd General Session of the World
Organization of Animal Health (WOAH), also held in May
2026, delegates approved the WOAH’s 8th Strategic Plan
(2027–2030), reaffirming animal health as a global priority
and acknowledging the veterinary profession’s role in
addressing interconnected challenges across food systems,
public health, and sustainability. Furthermore, the World
Health Statistics 2026 report highlighted substantial progress
in infectious disease control and maternal and child health,
including a 40% reduction in HIV incidence (2010–2024),
a 12% decline in tuberculosis incidence (2015–2024),
and 40% and 51% reductions in maternal and under-five
mortality, respectively (2000–2024). However, it warned
that many health indicators remain off track to meet the
2030 targets, due to workforce shortages, climate-related
risks, and persistent gaps in healthcare access. The State
of World’s Animal Health 2026 report also noted that animal
healthreceives 0.6% of global health expenditure, despite
increasing risks of zoonotic disease and antimicrobial
resistance, as well as veterinary workforce shortages that
undermine surveillance and prevention efforts.
The WMA represents 118 national medical associations,
who continue to advance medical excellence and provide
leadership in national and global health discourse. Its
members contribute to primary care and education campaigns,
inform health policy development (including mental health and
medical education topics), and support global health
observances (e.g., World Health Day on 7 April, World
Environment Day on 5 June). These leadership experiences are
illustrated through John Quincy Adam’s words: “If your actions
inspire others to dream more, learn more, do more and become
more, you are a leader.” Key issues including antimicrobial
stewardship, pandemic preparedness, and advances in artificial
intelligence will shape discussions at the 77th General
Assembly in Rotterdam, the Netherlands, from 7–10 October
2026.
In this issue, Ms. Magda Mihaila prepared a comprehensive
summary of the WMA proceedings, including two adopted
resolutions. Dr. Joana Savva-Bordalo highlighted complex
workforce challenges facing physicians in Portugal’s National
Health Service. Dr. Viktorija Žnidaršič Skubic examined
the liability challenges in Slovenia’s healthcare system. Dr.
Hamideh Frühwein emphasised the need for health systems
to shift toward precision health to improve prevention and
equity in ageing societies. Ms. Clarinda Cerejo and Ms. Caitlin
Rich, hosts of the “Not Just Patients” podcast, explored ways
physicians can strengthen physician–patient rapport, shared
decision-making, and quality of care.
As additional bioethics and medical education topics, Dr.
Marta Perin and colleagues highlighted Constitutional Court
and administrative approaches to physician-assisted suicide
in Italy. Dr. María Isabel Moya and Dr. Álvaro Cerame
shared findings from the II International Comprehensive
Care Programme for Sick Doctors (PAIME) Meeting in
Spain, which provided a platform to discuss evidence on
physicians’ mental health in a global dimension. Ms. Maria
Gatzoflia examined the bioethical considerations of surrogacy
in Greece. Dr. Abebe Bekele and colleagues presented key
outcomes from MedEdAfrica 2025 and reflections on the
current state and future of African medical education. Dr.
Bodela Sree Vidhya and Dr. Prem Kumar A. described the
Surgical Society of Bangalore’s Sustainability Initiative in
India. Finally, Dr. Bruce Kaplan and colleagues synthesised
analytical perspectives in a book review on the ethical
implementation of the One Health concept.
We are enthusiastic to join discussions and networking at the
77th WMA General Assembly in Rotterdam!
Helena Chapman, MD, MPH, PhD
Editor in Chief of the World Medical Journal
editor-in-chief@wma.net
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The 232nd Council Session of the
World Medical Association (WMA)
convened at the Metropol Palace
Hotel in Belgrade, Serbia, from
23–25 April 2026, hosted by the
Serbian Medical Chamber (Photo
1).
A Welcome from the Serbian Hosts
The session was opened by the
WMA Chair of Council, Dr.
Jack Resneck (American Medical
Association), who thanked
the Serbian hosts, including
the Chamber’s President, Dr.
Miodrag Stanić, for their hospitality.
Against a backdrop of escalating
conflict and mounting pressure
on health systems worldwide, Dr.
Resneck called on members to
continue embracing the common
values, ethics and mission that
bind the global medical profession
together.
Wednesday, 22 April
Junior Doctors Network
Ahead of the Council Session,
the WMA leadership joined the
Junior Doctors Network (JDN)
at its 2026 Spring Meeting in
Belgrade. Held in hybrid format,
the meeting brought together
junior doctors from around the
world and centred on universal
health coverage and the future of
equitable health systems, one of
global health’s defining priorities.
Beyond its thematic focus, the
gathering created valuable space for
exchange with WMA leadership
and for collaboration across
the global medical community,
reaffirming the WMA’s commitment
to supporting the leadership and
voices of junior doctors as they
help shape the future of
medicine and healthcare worldwide.
Delegates also joined the JDN for
the “Walk the Talk” initiative in
Tašmajdan Park, which brought
colleagues together in an informal
setting to connect, move, and
reinforce the importance of
physical activity and well-being.
Members of the JDN were
interviewed by Serbian media about
the initiative.
Environment Caucus
On the evening of 22 April, the
WMA Workgroup on Environment
convened the WMA Environment
Caucus in Belgrade, conducted
in a hybrid format, allowing both
on-site and remote participation.
The meeting featured a presentation
on false information related to
climate change and health, and
welcomed guest speaker, Dr. Marina
Romanello, Executive Director of
the Lancet Countdown: Tracking
Progress on Health and Climate
Change. The session offered
delegates and observers a space
to examine the intersection of
environmental policy and human
health ahead of the Council’s
deliberations on key climate and
health policies.
RTS 1 Interview with President
Kitulu
Ahead of the Council Session,
WMA President, Dr. Jacqueline
Kitulu was interviewed by
Serbia’s national broadcaster,
RTS 1, for its Health Journal
programme. The discussion focused
on the major challenges facing
health systems worldwide, the
growing importance of cross-border
cooperation and solidarity, and
the value of international medical
leaders coming together in Serbia to
exchange solutions and strengthen
global health partnerships. The
interview helped bring the work
of the WMA and the significance
of the Council Session to a wider
public audience, reflecting the
strong engagement of the Serbian
Medical Chamber in bringing
these conversations to a broader
audience.
Thursday, 23 April
Associate Members
The WMA Associate Members
held their plenary meeting under
the leadership of Dr. Julie Bacqué,
Chair of the Associate Members.
The meeting reviewed membership
developments, the activities of
the Associate Members Steering
Committee, and the growing
contribution of Associate Members
to the work of the WMA.
Members received updates from
the JDN, the Past Presidents and
Chairs of Council Network (PPCN),
and several WMA workgroups
in which they play an active role,
including those on Environment,
Medical Neutrality, Procedure
Development of Policy on Health-
related Crises, the Declaration of
Lisbon, the Declaration of Taipei,
Magda Mihaila
WMA Council Report
Belgrade, Serbia, 23–25 April 2026
WMA Council Report
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and Gender Equality within the
WMA. No new workgroups were
established in Belgrade, with the
existing workgroups continuing
their mandates. Looking ahead,
Associate Members were encouraged
to continue contributing to
forthcoming policy consultations.
Junior Doctors Network Report
The Junior Doctors Network (JDN)
presented its mid-term report
under the leadership of its 2025–
2026 Management Team, chaired
by Dr. Pablo Estrella-Porter.
With 1,236 active junior doctors
registered, the Network reported
on a busy period of external
representation, including the
World Health Summit in Berlin,
European Junior Doctors meetings
in Vienna and Copenhagen, the
158th World Health Organization
(WHO) Executive Board, the
IFMSA March Meeting, and the
UNODC Commission on Narcotic
Drugs. A major milestone was
the launch of the Global Working
Time Study of Junior Doctors
in November 2025, which had
gathered 561 responses across three
languages by March 2026. The
JDN also highlighted the work
of its eight thematic working
groups, spanning antimicrobial
resistance, planetary health, primary
healthcare, medical ethics, pandemic
preparedness, global surgery, non-
communicable diseases, and medical
education. The Network expressed
its gratitude to the WMA and the
Taiwan Medical Association for
their continued support.
Past Presidents and Chairs of
Council Network
The Past Presidents and Chairs
of Council Network (PPCN),
chaired by Dr. Kati Myllymäki
with Deputy Chair, Dr. Wonchat
Subhachaturas, and Secretary,
Dr. Jón Snædal, reported on its
activities as an advisory group
within the Associate Members.
The Network held its first-ever
in-person meeting at this Council
Session in Belgrade. It presented a
revised set of Terms of Reference
(the first revision since the
Network’s establishment in 2013)
introducing a former Secretary
General and term limits for
the Chair. Individual members
remained active across WMA
initiatives, including the Ukraine
Medical Help Fund and the
workgroups on Medical Neutrality
and the revision of the Declaration
of Taipei. The Network extended
its sincere thanks to outgoing
Secretary General Dr. Otmar
Kloiber for his longstanding
support.
Council Session
The 232nd Council Session was
called to order by the Chair of
Council, Dr. Jack Resneck. He
welcomed newly attending Council
members: Dr. Alika Lafontaine
(Canadian Medical Association),
Dr. Pedram Emami (German
Medical Association), and Dr.
Jeong Seong Seo (Korean Medical
Association).
President’s Interim Report
The WMA President, Dr. Jacqueline
Kitulu presented her report on
presidential activities from October
2025 to March 2026, a mandate
that began with a successful
General Assembly in Porto. In
October, she attended the Canadian
Conference on Global Health in
Halifax, serving as a panelist on
global health governance, financing
and trust at the opening plenary.
In November, she delivered the
keynote address at the Uganda
Medical Association’s 9th Grand
Doctors Conference, where she was
honoured with the Dr. Margaret
Mungherera Award for Leadership
in Health, named for the late Past
WMA President. In December,
together with Dr. Jack Resneck
and Dr. Otmar Kloiber, she
attended the International
Symposium on Transforming
Healthcare, co-organised by the
WMA and the Taiwan Medical
Association and honoured by
the presence of the President of
Taiwan, who presented Dr. Kloiber
with a Medal of Honour for
his service; the symposium was
followed by the First Open Expert
Meeting on the Revision of the
WMA Declaration of Taipei.
She also took part in a debrief on
the latest Lancet Countdown on
Health and Climate Change, and
delivered opening remarks at the
Panhellenic Medical Association’s
centenary celebration in Athens.
Additionally, in January, she gave
the keynote address on “Medicine,
Music and the Human Spirit”
at the 23rd Vienna Congress.
In February, she represented the
WMA at the 6th One Health
International Forum in Fukuoka,
Japan. In March, she contributed
to the Validation Workshop for
the Africa Health Professions
Education Quality Standards
in Potchefstroom, South Africa.
She closed by thanking the
WMA secretariat, the Executive
Committee, and the membership
for their support during the first
half of her mandate.
Secretary General’s Report
The Council received the WMA
Activity Report, highlighting the
Association’s extensive work in
ethics, advocacy, global health policy,
human rights and international
collaboration during the reporting
period. Among the key priorities
was the ongoing revision of the
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Declaration of Taipei, which seeks
to address the ethical challenges
posed by rapidly evolving
technologies, artificial intelligence,
health databases and biobanks.
The report also outlined the
WMA’s continued advocacy on
the protection of patients and
physicians in conflict settings,
including actions related to violence
against healthcare personnel and
violations of medical neutrality in
several countries.
Significant attention was devoted
to public health priorities, including
non-communicable diseases,
immunisation, antimicrobial
resistance, climate change, universal
health coverage, and health
workforce sustainability. The
report highlighted the WMA’s
growing engagement with
international partners, including
the WHO, the World Health
Professions Alliance (WHPA), and
United Nations agencies, as well
as its contributions to global
discussions on pandemic
preparedness, artificial intelligence
in healthcare and environmental
health. Dr. Otmar Kloiber also
called on members to extend the
same trust to the incoming WMA
Secretary General, Dr. Ramin
Parsa-Parsi, as they had shown
him when he assumed the role in
2005.
Report of the Chair of Council
The Chair of Council, Dr. Jack
Resneck, Jr., reflected on a period
of significant transition and activity
for the Association. He welcomed
the appointment of Dr. Ramin
Parsa-Parsi as the next Secretary
General following an extensive
international search process and
expressed gratitude to Dr. Otmar
Kloiber for more than two decades
of leadership and service to
the WMA. Dr. Resneck also
highlighted the ongoing revision
of the Declaration of Taipei,
noting the important contributions
made by experts during recent
Open Expert Meetings on the
Revision of the WMA Declaration
of Taipei in Taipei and São Paulo,
as the workgroup addresses the
ethical challenges posed by the
rapidly evolving use of health data
and emerging technologies. Against
a backdrop of continuing global
conflicts, humanitarian crises and
growing pressures on healthcare
systems, he reaffirmed the WMA’s
commitment to advancing policies
on medical neutrality, climate
change, health data governance,
workforce sustainability, mental
health and ethical medical practice.
Looking ahead, Dr. Resneck
expressed confidence in the future
of the WMA as it enters a new
chapter of leadership while
continuing its mission to support
physicians and improve health
worldwide.
World Medical Journal
The World Medical Journal’s
December 2025 and March 2026
issues merged contributions from
authors in 29 countries, with
thematic coverage marking the
International Day of Persons
with Disabilities in December
2025 and World Tuberculosis
Day in March 2026. These editions
also featured WMA resolutions
and statements, summary reports
on regional and international
meetings, interviews with leading
experts, and critical analyses on
medical education and ethics. As
a novelty during this session,
Editor-in-Chief, Dr. Helena
Chapman, and Assistant Editor,
Maira Sudraba-Sangoviča, hosted
a “Meet the Editors” booth during
the Council coffee breaks, where
delegates could meet the editorial
team in person and share their
article ideas.
Urgent Resolution: Global Armed
Conflict
The proposed WMA Council
Resolution on Escalating Global
Armed Conflict and Violence and
Restoring Peace was accepted as
a matter of urgency and adopted,
as amended, for immediate
publication.
Friday, 24 April
The Standing Committees (Medical
Ethics Committee, Finance and
Planning Committee, and Socio-
Medical Affairs Committee) held
their meetings. The committees’
recommendations were brought to
the Council for consideration the
following day.
Women in Medicine Lunch
Delegates gathered for the Women
in Medicine Lunch, a forum
dedicated to advancing leadership,
inclusion and practical action
across the global medical
profession. Opened by the WMA
President, Dr. Jacqueline Kitulu,
the luncheon was held under the
theme of male allyship, exploring
how active, consistent, and
intentional support from men
can help promote gender equity,
challenge systemic barriers,
and amplify women’s voices in
medicine. The programme featured
a fireside chat with Dr. Branka
Lazić, a distinguished leader in
Serbian and European medicine,
who reflected on stepping into
leadership, navigating visible
and invisible barriers, and the
importance of family, mentorship,
and institutional support throughout
her journey. Building on the
Women in Medicine working
lunch first launched in Porto,
delegates then took part in table
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discussions introduced by Dr.
Caline Mattar, focused on turning
dialogue into action and examining
how male allies can positively
influence careers, support women
in organised medicine, and
strengthen participation within the
WMA.
Saturday, 25 April
Medical Ethics Committee
The Council considered the report
of the Medical Ethics Committee,
reaching the following decisions.
The proposed revision of the WMA
Statement on Medical Neutrality
was approved for circulation
within the membership for
comments, with the workgroup
continuing its work towards an
initial draft over the summer.
The WMA Statement on Ethical
Issues Concerning Patients with
Mental Illness was approved for re-
circulation within the membership
for comments.
As part of the 2026 policy review,
the Council reaffirmed the WMA
Declaration of Sydney on the
Determination of Death and the
Recovery of Organs. It reaffirmed
with minor revision the WMA
Declaration of Tokyo on torture
and other cruel treatment in
detention, the WMA Statement
on Body Searches of Prisoners,
and the WMA Resolution on
the Non-Commercialisation of
Human Reproductive Material.
The WMA Statement on Female
Genital Mutilation and the
WMA Statement on Animal Use
in Biomedical Research were
approved for major revision.
Finance and Planning Committee
The Council approved the pre-
audited Financial Statement for
2025 and authorised the
continuation of the audit process.
In a show of solidarity with
associations facing financial and
operational challenges, dues
waivers and adjustments were
approved for the Royal Dutch,
Australian, Myanmar, and Indian
medical associations. The Council
confirmed future statutory
meetings, including the 244th
Council Session (2030), the 80th
General Assembly in Antwerp,
Belgium (2029), and the 81st
General Assembly in Canada
(2030), and approved the “Towards
Zero Nicotine Society” theme for
the Scientific Session of the 2027
General Assembly in Bangkok,
Thailand.
On gender equality, the Council
adopted several measures to
strengthen representation within
WMA structures: inviting
constituent members to complete
a member survey to inform
evidence-based recommendations;
introducing systematic tracking
of gender participation through
gender-disaggregated data in
Council and General Assembly
participant lists; presenting
gender participation statistics as a
visual indicator at the opening
of sessions; and encouraging
voluntary reporting of gender
composition in WMA workgroups
and committees.
Socio-Medical Affairs Committee
The Council considered the report
of the Socio-Medical Affairs
Committee, which addressed a
wide range of public health,
humanitarian, and healthcare policy
issues.
Resolutions Adopted by the Council
The WMA Council Resolution on
Childhood Vaccination Schedules
was adopted for immediate
release, reaffirming vaccination
as a cornerstone of global
public health amid concerns over
declining immunisation coverage
and renewed outbreaks of vaccine-
preventable diseases. The minor
revision of the WMA Statement
on Medical Care for Migrants
was adopted and forwarded to
the General Assembly for
information, reaffirming that access
to healthcare should be based on
clinical need and delivered without
discrimination.
Collaboration with the WHO
The WMA Advisor, Dr. Caline
Mattar, referred to the side
events being planned by the WMA
and the WHPA during the 79th
World Health Assembly (WHA)
in May 2026. These included events
on financing the health workforce
for economic resilience and
universal health coverage, the value
of investing in health professionals,
sustaining the global health and
care workforce agenda (hosted with
the German government), and
accelerating trusted digital health
transformation, co-organised with
multiple countries. She highlighted
the WHA agenda items of
particular relevance to the WMA,
including non-communicable
diseases, international ethical
recruitment of health personnel,
primary healthcare, immunisation,
mental health, and the governance
of data, digital health, and
artificial intelligence. Some side
events would be livestreamed.
The WMA Secretary General,
Dr. Otmar Kloiber, noted that the
forthcoming WHA would be one
of the most remarkable in the
history of the WHO. A pandemic
treaty, after three years of
negotiations on how to share
resources and information, was
expected to be signed, representing
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an important symbol and historic
landmark for the organisation.
He also referred to the significant
funding gap facing the WHO
following the departure of the
United States, which could
impact staff and operations
including the potential closure of
departments, and raised concern
that progress on the health
workforce and ethical issues could
be lost, a reminder, he said, that
the rest of the world needs to
contribute more to humanitarian
aid.
Other Business
Dr. Jacques de Haller reported that
Turkish courts had dropped their
case against board members of
the Turkish Medical Association,
who had been condemned to
imprisonment for protesting
against the war in Kurdistan, noting
that it is appropriate and useful
for the WMA to support colleagues
and to maintain policies that
reinforce this work.
The Past WMA Chair, Dr. Mukesh
Haikerwal (Australia), raised
awareness of traumatic brain injury,
which is not currently recognised
as a chronic non-communicable
disease, emphasising the need to
ensure such injuries are reported so
they can be properly treated.
As the session drew to a close,
the WMA Secretary General, Dr.
Otmar Kloiber, announced his
retirement following the 232nd
Council Session in Belgrade,
marking the beginning of a
major leadership transition for
the Association after 21 years of
service. He expressed his
appreciation to the Serbian
Medical Chamber, including
President, Dr. Miodrag Stanić,
their team and staff; to guests and
observers from partner organisations;
to national medical association
delegates and colleagues working
in the Associate Members, JDN,
and PPCN; to the editorial team
of the World Medical Journal; to
the technicians, photographer,
and interpreters; to the facilitator,
legal advisor, and financial advisor;
and to all WMA officers and the
office staff in Ferney-Voltaire.
Magda Mihaila
WMA Communications
and Press Manager
World Medical Association
magda.mihaila@wma.net
WMA Council Report
Photo 1. Group photo at the Metropol Palace Hotel during the 232nd Council Session in Belgrade. Credit: WMA
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WMA COUNCIL RESOLUTION ON ESCALATING
GLOBAL ARMED CONFLICT AND
VIOLENCE AND RESTORING PEACE
Adopted by the 232nd WMA Council
session, Belgrade, Serbia, April 2026
PREAMBLE
The WMA rearms its ‘Statement in Times
of Armed Conflict and Other Situations
of Violence’ and expresses its grave
concern regarding current international
developments characterised by the
escalation of multiple violent and
protracted armed conflicts, foreign policy
actions and other situations of violence
either ongoing or potential, in affected
regions – including the Middle East,
Asia, Eastern Europe, the Americas, the
Caribbean and Africa – with profound and
persistent humanitarian consequences for
civilian populations.
It further notes with alarm the reported
systematic breaches of international law
and the growing climate of impunity that
undermines global peace, security, and
protections afforded to health personnel
and civilian populations.
Defending life, protecting those who
provide care, and promoting peace are
ethical imperatives inherent to the medical
profession.
RECOMMENDATIONS
The World Medical Association:
1. Condemns the impact of escalating
armed conflicts, foreign policy actions,
and other situations of violence on
civilian populations in affected regions.
This includes the loss of human life,
physical and psychological injuries,
forced displacement, and the degradation
of the conditions necessary for a life of
dignity.
2. Condemns attacks, threats, restrictions
and any form of violence against health
personnel and facilities, as well as
violations of medical neutrality.
3. Calls for adherence to international
humanitarian and human rights law as
essential tools for protecting human life
and limiting suffering and urges actors
to fully cooperate with international
courts to strengthen accountability and
end impunity.
4. Calls for dialogue, diplomacy and
multilateral cooperation that constitute
the most legitimate, responsible and
sustainable means for the resolution of
conflicts. Therefore, the WMA urges
countries with greater political, economic
or military power to exercise their
influence and actions in strict adherence
to international law, acting with restraint
and with due consideration for the
effects that their decisions may have
on countries, people and populations in
situations of greater vulnerability.
5. Calls on United Nations agencies and
their member states to call on actors
to urgently de-escalate armed conflict
and violence and to cease attacks on
health personnel, healthcare and civilian
infrastructure.
WMA Policies
WMA COUNCIL RESOLUTION ON
CHILDHOOD VACCINATION SCHEDULES
Adopted by the 232nd WMA Council
session, Belgrade, Serbia, April 2026
PREAMBLE
The World Medical Association is concerned
by changes to childhood vaccination
schedules that are not evidence-based.
Although we recognise each country’s
independence in health matters, history
has shown us time and again how
decisions on epidemiological matters can
affect the entire world, and even more so
in today’s globalised context.
Changes to childhood vaccination schedules
that are not evidence-based can lead to
the resurgence of diseases previously on
the verge of extinction, compromising
global health and threatening the future
of the children worldwide. An outbreak of
measles or meningitis endangers the most
vulnerable populations and can spread to
other nearby countries, especially those with
very limited response capacity.
RECOMMENDATIONS
Recalling its Statement on the Priority
of Immunisation, the WMA warns
against changes to childhood vaccination
schedules that are not evidence-based
and emphasises the WMA’s commitment
to universal vaccination and its
importance as a cornerstone of progress
in a globalised world.
10
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Dear colleagues of the World
Medical Association,
On behalf of the Royal Dutch
Medical Association (RDMA), we
cordially invite you to participate
in the 77th General Assembly of
the World Medical Association
(WMA), to be held on 7-10
October 2026, in Rotterdam,
the Netherlands. The RDMA,
founded in 1849, is proud to host
this event.
Together with the WMA, we have
organised a program that we hope
will both challenge and inspire
participants, with sessions on
themes that matter most to our
profession today. We have also
planned activities to explore
Rotterdam – its world-famous
architecture, its vibrant cultural
scene, and the international
character of Europe’s largest port.
Please mark your calendar and join
us in Rotterdam for this exciting
event.
Jurriaan Penders, MD
Chairman, Royal Dutch Medical
Association (RDMA)
https://www.knmg.nl/
info@fed.knmg.nl
Information about the 77th WMA General Assembly
Information about the 77th WMA General Assembly
Rotterdam 2026
11
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Portugal’s National Health Service
Portugal’s National Health Service: Workforce Crisis,
Burnout, and the Urgent Need to Support Doctors
Since its establishment in 1979,
the Portuguese National Health
Service (Serviço Nacional de Saúde,
SNS) has served as a cornerstone
of equitable healthcare, ensuring
universal access regardless of
socioeconomic status [1]. In the
past decade, however, increasing
systemic pressures have exposed
structural weaknesses that threaten
its long-term sustainability. The
SNS currently faces a convergence
of challenges, including shortages
of healthcare professionals,
declining attractiveness of medical
careers, increasing reliance on
private providers, and growing
dissatisfaction among doctors.
These issues are further
compounded by inadequate
workforce planning and policy
decisions that fail to address long-
standing structural deficiencies.
These challenges are unfolding
at a time when health systems
across Europe are struggling to
retain healthcare professionals and
adapt to increasing demand driven
by population ageing and the
growing burden of chronic disease
[2]. Furthermore, the experience
of the coronavirus disease 2019
(COVID-19) pandemic highlighted
the importance of maintaining a
resilient public health workforce
capable of responding to future
health emergencies and unforeseen
system shocks [3]. This commentary
explores the realities faced by
Portuguese doctors and the SNS,
emphasising that without decisive
reform, the SNS risks entering a
cycle of progressive deterioration
and being unprepared to manage
emerging health risks.
Emergency Services Under Strain
Emergency care has become one
of the most visible indicators
of the crisis affecting the SNS.
During the summers of 2024
and 2025, multiple emergency
departments experienced partial
or complete closures due to a
shortage of doctors, particularly
in obstetrics and pediatric care,
leading to serious consequences
for patient safety [4,5]. Data from
the National Institute of Medical
Emergency (Instituto Nacional
de Emergência Médica, INEM)
indicate a sustained increase in
pre-hospital emergency births
since 2022 [6]. In 2025 alone, 60
births occurred in ambulances,
23 in the streets, 153 at home,
and two in primary care centers,
without access to the level of
safety and specialised care available
in hospital settings [6]. Such
events are symptomatic of systemic
fragility, as emergency departments
are increasingly dependent on
overtime work and temporary
staffing arrangements that are
neither sustainable nor conducive
to the delivery of high-quality care
[2].
Primary Care Gaps and Unequal
Access
Although primary care remains
a fundamental pillar of effective
healthcare services, however,
Portugal is currently facing a
significant shortage of family
doctors. Approximately 1.6 million
citizens (16% of the population)
do not have an assigned general
practitioner, a gap that undermines
continuity of care, increases
reliance on emergency services
for non-urgent conditions, and
exacerbates health inequalities
[7]. Regional disparities further
intensify the problem, with
underserved areas experiencing
greater difficulties in recruiting
and retaining doctors [8]. Although
training capacity has increased,
retention remains a major
challenge, as many newly qualified
specialists opt for the private
sector or opportunities abroad,
limiting the SNS’s ability to meet
population needs [9].
Burnout among Medical Residents
Burnout is driven by excessive
workloads, long working hours,
insufficient supervision, and
inadequate organisational support,
which negatively impact both
physician well-being and patient
safety [10]. A 2023 report by the
Portuguese Medical Association
(Ordem dos Médicos) identified
alarming levels of emotional
exhaustion, depersonalization, and
reduced personal accomplishment
among medical trainees, closely
linked to the demanding working
conditions experienced during
residency [11]. The study revealed
that 84.8% of respondents
performed overtime work (with an
average weekly workload of 52.8
hours), 55.1% reported monthly
shifts longer than 12 hours, and
62.1% engaged in night work.
Work–life balance was significantly
affected, with 55.9% of trainees
reporting having two or fewer
Joana Savva-Bordalo
12
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weekends off per month, 54.4%
rating their work-life balance
as poor or very poor, and
35.3% admitting initiation of
psychological or psychiatric support
during their training.
The cumulative burden of long
working hours, combined with
independent study requirements
and the pressure to meet curricular
objectives, was confirmed as a
major contributor to stress and
burnout. These findings illustrate
the scale and structural
determinants of burnout among
medical residents in Portugal,
underscoring the urgent need for
interventions addressing working
conditions, overall workload, and
institutional support services. As
burnout contributes to attrition
within the profession, physicians
exposed to these conditions early
in their careers are more likely
to leave the SNS or seek
opportunities abroad, exacerbating
workforce shortages [12].
Shift Toward the Private Sector
Recent policy decisions have
accelerated the transfer of
healthcare provision and public
funding from the SNS to the
private and social (e.g., non-
profit, religious or charitable
organisations) sectors. Instead of
prioritizing investment in healthcare
professionals, infrastructure, and
organisational capacity within the
public service, governments have
increasingly resorted to outsourcing
consultations and surgical
procedures to private providers
when maximum waiting time
guarantees are exceeded. This trend
has been accompanied by attempts
to reintroduce private management
models in healthcare facilities, the
transfer of some public services
to local charitable organisations
(e.g., Misericórdias). Public funds
for vaccination programs have
been directed to pharmacies that
could otherwise be delivered within
primary care centers [13].
The SNS24 online portal, which
offers real-time communication with
patients to schedule appointments,
access prescriptions and test
results, and manage health
information, serves as a gateway
to healthcare services [14]. This
portal grants access to external
providers, raising questions about
whether available public sector
capacity is being fully utilised.
While public-private collaboration
may have a role, such practices
can lead to inefficiencies,
fragmentation of care, and the
gradual weakening of the SNS
infrastructure. These challenges
have been identified at both
national and regional levels,
including the increasing reliance
on alternative service delivery
models and the potential
underutilisation of existing public
healthcare capacity [6].
Workforce Exodus and Retention
Challenges
Portugal has experienced a steady
outflow of physicians to the
private sector and to other
countries offering better working
conditions and remuneration,
reflecting structural issues such
as high workloads, comparatively
low salaries, and limited career
progression opportunities [15].
Policy responses have largely relied
on short-term measures, such as
increased overtime, rather than
addressing root causes, creating a
self-reinforcing cycle in which
workforce shortages intensify
workloads, leading to burnout
and further attrition. This
trend is particularly concerning
given the ageing of the
medical workforce and the
increasing difficulty in
attracting and retaining younger
physicians within the SNS,
especially in underserved regions
and in medical specialties facing
workforce shortages.
The Role of FNAM in Defending
Doctors and the SNS
The National Federation of
Doctors (Federação Nacional dos
Médicos, FNAM), as the trade
union structure representing the
largest number of doctors within the
SNS, has played a central role in
defending the medical profession
and advocating for a strong public
health service. The FNAM has
actively promoted measures to
strengthen medical careers and
reinforce the SNS, while safeguarding
collective labor agreements and
workers’ rights. Key achievements
include maintaining collective
agreements without setbacks,
preserving age limits for night
shifts (age 50) and emergency
duties (age 55), guaranteeing
compensatory rest for shifts
during nights, weekends, and
public holidays, and prohibiting
time-bank schemes and
other detrimental shift work
arrangements.
Faced with limited progress in
negotiations, the FNAM has used
all available legal and trade union
mechanisms, including strikes
and public demonstrations, to
advance its demands, particularly
in response to government-
led labour reform perceived as
a setback. Proposed measures
include extending standard working
hours to up to 50 hours per week,
increasing schedule deregulation,
introducing imposed time-bank
systems, expanding precarious
employment arrangements, and
weakening protections related
to parental rights, collective
Portugal’s National Health Service
13
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bargaining, the right to strike,
and trade union activity. The
FNAM maintains its independence,
representing both medical
professionals and the public
interest, and continues to advocate
for structural reforms, improved
working conditions, and better
healthcare delivery.
Conclusion
Portugal’s SNS stands at a
critical juncture, facing workforce
shortages, burnout, and policy
misalignment that threaten
high-quality care delivery and
sustainability. These structural
challenges require comprehensive
responses, including long-term
workforce planning and retention
strategies, strengthened primary
care access, reduced burnout
through improved salaries and
working conditions, and better
resource allocation within a
reinforced public service. Without
such measures, the SNS risks
losing its defining characteristics
as a universal and equitable
healthcare service. Supporting
Portuguese doctors is essential
for promoting professional well-
being and sustaining a functioning
healthcare service, making the
strengthening of medical careers,
working conditions, and the SNS
as crucial steps to safeguard
healthcare for future generations.
AI Disclosure Statement
The author used artificial
intelligence tools for language
editing and proofreading to
improve grammar, structure, and
clarity. The intellectual content,
analysis, and conclusions remain
entirely those of the author.
References
1. Varela R. História do Serviço
Nacional de Saúde em Portugal:
a saúde e a força de trabalho, do
Estado Novo aos nossos dias. Lisbon:
Âncora Editora; 2019. Portuguese.
2. Organisation for Economic Co-
operation and Development. Health
at a Glance: Europe 2024. Paris:
OECD Publishing; 2024.
3. World Health Organization. Health
and Care Workforce in Europe:
Time to Act. Geneva: WHO;
2022. Available from: https://www.
who.int/europe/publications/i/
item/9789289058339
4. Central Administration of the
Health System (Portugal). Relatório
de atividade dos serviços de urgência
2024. Lisbon: Administração
Central do Sistema de Saúde; 2025.
Portuguese.
5. Ministry of Health (Portugal). Plano
de contingência verão 2025. Lisbon:
Government of Portugal; 2025.
Portuguese.
6. National Institute of Medical
Emergency (Portugal). Annual
report (provisional data) 2025.
Lisbon: Instituto Nacional de
Emergência Médica; in press.
Portuguese.
7. Health Regulatory Authority
(Portugal). Informação de
monitorização sobre cuidados
de saúde primários (2021–2023).
Porto: Entidade Reguladora da
Saúde; 2024. Portuguese.
8. Costa C, Tenedório JA, Santana P.
Disparities in geographical access to
hospitals in Portugal. ISPRS Int J
Geo-Inf. 2020;9(10):567.
9. European Commission, OECD.
Portugal: Country Health
Profile 2023. Brussels: European
Commission; 2023.
10. West CP, Dyrbye LN,
Shanafelt TD. Physician burnout:
contributors and consequences. J
Intern Med. 2018;283:516-29.
11. Ordem dos Médicos. Avaliação
do burnout no internato médico
português. Lisbon: Ordem dos
Médicos; 2023. Portuguese.
12. European Parliament. The health
workforce crisis in the European
Union. Brussels: European
Parliament; 2025. Available from:
https://www.europarl.europa.eu/
RegData/etudes/BRIE/2025/
772481/ECTI_BRI(2025)772481_
EN.pdf
13. Ministry of Health (Portugal).
Despacho n.º 7433/2023. Porto:
Diário da República; 2023. Portu-
guese.
14. Executive Directorate, National
Health Service (Portugal). Relatório
da Direção Executiva do Serviço
Nacional de Saúde, I.P. Lisboa:
DE-SNS; 2024. Portuguese.
15. Organisation for Economic Co-
operation and Development. Health
workforce migration. Paris: OECD;
2023. Available from: https://doi.
org/10.1787/7a7afb35-en
Joana Savva-Bordalo, MD, MSc
Medical Oncologist Consultant,
Northern Doctors’ Union (Sindicato
dos Médicos do Norte), National
Federation of Doctors (FNAM)
Porto, Portugal
joana.savva@sindicatomedicosnorte.pt
Portugal’s National Health Service
14
Liability for Healthcare Damages in Slovenia
Legal Challenges of Liability for Damages in Healthcare Systems:
The Case of Slovenia
An appropriate legal framework
governing liability for damages
incurred by healthcare professionals
and organizations is a key
component of a high-quality
healthcare system, as it establishes
that no human activity is free
from error. The healthcare sector
is particularly sensitive in this
regard, as any irregularities can have
severe or even fatal consequences
for patients. Therefore, for every
patient who has suffered harm to
their health (or for their relatives,
in cases where the patient has
died) as a result of a medical error,
access to appropriate compensation
is a fundamental, and potentially
existential concern. The need to
provide fair compensation has
extended beyond the strict civil
law boundaries.
In theory, long-standing debate
persists over whether classical tort
liability systems adequately address
contemporary challenges, and
whether they should be reformed
in a narrow or broad sense,
potentially including more radical
shifts toward no-fault compensation
schemes. Comparative law offers
a wide range of solutions, from
traditional compensation systems,
which are gradually reformed
through legislative amendments
or evolving judicial practice, to
models introducing targeted
no-fault compensation schemes
in selected healthcare areas (e.g.,
mandatory vaccination), and to
systems that extend no-fault
compensation across the entire
healthcare sector. In the latter
case, a fundamental shift occurs
(mainly for serious injury claims),
as the system moves away from
establishing blame and proving
fault on part of the medical
practitioner, and instead on
compensating individuals who have
suffered avoidable harm. It usually
means that patients must only
demonstrate that they experienced
a preventable adverse event, without
needing to prove fault on the part
of the medical practitioner.
Liability for damages in the
healthcare sector, which is already
a complex and multifaceted issue,
has been further complicated by
the emergence and growing use
of artificial intelligence (AI) in
medical practice. While determining
liability for damages in healthcare
has long posted legal and practical
difficulties, the integration of AI
systems has significantly further
complicated the attribution of
responsibility for patient harm.
As a result, some legal experts
argue that traditional fault-based
liability may be inadequate in
cases of AI-related medical harm,
prompting the consideration of a
no-fault compensation system to
ensure patient compensation.
In Slovenia, the new act on
healthcare quality assurance was
adopted at the end of 2024, with
the primary aim of regulating
the healthcare quality system and
establishing the Public Agency
of the Republic of Slovenia for
Healthcare Quality. As part of
this reform process, the legal
framework governing liability
for damages in healthcare is
also expected to be revised. This
article therefore examines various
considerations regarding possible
approaches for regulating this
area. These considerations may
also be useful for other national
legal systems seeking to modernise
traditional regulation of liability
for damages in healthcare.
Current Legal Framework
Slovenia, a Central European
nation of 2.1 million residents,
belongs to a group of jurisdictions
with a classic fault-based liability
system for damages, where
healthcare professionals or
institutions may be held liable
in accordance with the general
rules of contract law. Liability
for damages is based either on
breach of the treatment contract
or on tort, where no contractual
relationship exists between
the patient and the healthcare
institution (e.g., in cases of
emergency treatment where the
patient is unable to give consent).
In this system, unless an agreement
is reached, patients must pursue
compensation through civil
litigation against healthcare
providers in court. As in many
other countries with similar
systems, the procedure can be
stressful, lengthy, and burdensome
for patients – physically, mentally,
and financially – given the need
for legal assistance and costs of
expert evidence and related expenses.
It has also been noted that the
number of compensation claims
against healthcare institutions is
increasing, placing a significant
strain on public healthcare funds.
Viktorija Žnidaršič Skubic
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15
The Slovenian legislature has so
far made only limited responses
to the aforementioned issues. The
only notable exceptions are two
provisions in the Patient Rights
Act [1], with one provision
requiring courts to give priority
to cases involving serious bodily
injury or death occurring
during medical treatment, and
another provision obligating the
Ministry of Health to monitor
developments in such cases and
intervene appropriately. The latter
provision, however, has never been
implemented in practice.
Slovenian jurisprudence has
addressed the vulnerable position
of patients as injured parties in
litigation by adopting certain
measures [2]:
1. Informative medical expert
evidence (contrary to the
general rule) is admissible. Its
purpose is to determine whether
the patient’s harm resulted
from medical malpractice or a
medical complication.
2. Factual allegations may be
supplemented after receiving an
expert opinion, as lay plaintiffs
are generally unable to make
such assessments independently.
3. The standard of proof has been
relaxed. In establishing a causal
link between the physician’s
conduct and the harmful
outcome, the balance of
probabilities is accepted as
sufficient, rather than the stricter
standard of clear and convincing
evidence.
Reform Efforts
In Slovenia, during the current
government’s term (2022–2026)
and as part of broader efforts
to ensure quality in healthcare,
consideration has also been given
to reforming the area of tort
liability. In this context, a working
group was established to review
the field and propose de lege
ferenda solutions. Although the
working group has not yet
completed its work, it has
identified two potential directions
for reform:
1. The reform could be relatively
limited in scope, following the
approach of countries that have
introduced targeted amendments
and updates to the existing
classical tort system. In this
context, it is possible to consider:
a) reform in a narrower sense,
involving the modernisation and
simplification of legislation with
the aim of facilitating patients’
access to compensation, similar to
approaches adopted in Germany
and England; and
b) reform in a broader sense, where
the above-mentioned measures
(under a) could be complemented
by a specific form of no-fault
compensation scheme or a scheme
that operates alongside a fault-
based compensation system,
similar to approaches adopted in
France, Belgium, and Wales [3-6].
2. The reform could entail a more
radical solution, as seen in
countries that have introduced
a no-fault compensation system
covering the entire healthcare
sector (e.g., Norway, Denmark,
Finland, Sweden, New Zealand)
[7].
In order to reach a meaningful
conclusion on the most
appropriate approach for Slovenia,
it is not sufficient merely to
compare the advantages and
disadvantages of different solutions.
The potential impact of reforms
must be assessed in light of
specific circumstances of
contemporary society. The
Slovenian healthcare system
faces various challenges, such as
physician shortages, long waiting
times, and increasing privatisation,
while the state budget appears
to have limited capacity to further
increase healthcare expenditure. It
is important to recognise that the
direct transposition of legal solutions
from comparative law contexts,
where the political, economic, and
legal conditions differ significantly
from our own, is not appropriate.
A more radical reform, such as
the introduction of a no-fault
compensation system, could
undoubtedly yield numerous
positive effects, including:
1. These systems are, in principle,
designed primarily to benefit
injured patients, as they offer a
“patient-friendly” procedure for
obtaining compensation that is
informal, fast, and cost-effective.
2. Healthcare staff are generally
willing to assist patients in
claiming compensation, and
patients do not, in principle,
require costly legal assistance.
3. Compensation amounts are
generally standardised or tariff-
based and therefore lower than
what an individual patient
could obtain through litigation
under a full compensation
approach. However, in practice,
patients are generally satisfied
with this solution, as
compensation is paid more
quickly and through a far more
accessible and straightforward
procedure.
4. The system is perceived as more
socially just than traditional
models, as more victims report
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Liability for Healthcare Damages in Slovenia
16
harm and compensation is
actually awarded to more people.
5. The system helps preserve a
strong doctor-patient relationship,
encourages physicians to openly
report their own or systemic
errors, and also reduces the
practice of defensive medicine.
The advantages of a less radical
reform proposal, namely, the
introduction of amendments and
additions to the traditional tort
liability system, are as follows:
1. It is a proven system of gradual
improvements that has yielded
positive results in practice in
countries with similar tort law
systems (e.g., Germany).
2. Such a reform is less demanding
in terms of time, organisation,
and financial resources than
more radical changes and better
addresses the relatively complex
current situation in the Slovenian
healthcare system.
3. It involves the implementation
of a set of targeted measures
across specific areas, including
improvements to both substantive
and procedural rules, primarily
aimed at strengthening the
patient’s position through a
simplified, affordable, and rapid
decision-making process for
compensation claims.
4. Such a reform could be
implemented in two phases:
a) after the initial changes are
introduced, their effects would
be closely monitored over a
defined period; and b) depending
on the outcomes, more radical
changes could be adopted.
5. It is largely supported by
experience and comparative legal
data, as relatively few countries
worldwide have opted to introduce
a no-fault compensation system
covering the entire healthcare
sector.
AI in Medical Practice and
Liability for Damages
When reforming liability for
damages in healthcare, the specific
features of liability arising from
the use of AI cannot be
overlooked. While AI offers
significant potential for innovation
and efficiency, it also raises distinct
legal challenges, particularly
regarding accountability and
compensation for harm caused
by AI systems. As the use of AI
systems becomes increasingly
widespread, the number of
cases involving harm in which
establishing fault is difficult or
nearly impossible is likely to
increase. For this reason, many
legal experts view the introduction
of no-fault compensation systems
as a potential solution to this
problem.
The use of AI in medical
practice has introduced numerous
challenges, including the need
to redefine the duty to inform,
informed consent, and professional
standards of care (lege artis). The
key requirements for the
responsible use of AI in medical
decision-making process place a
significant burden of responsibility
on physicians, entailing a range of
corresponding duties. A physician
should therefore: 1) protect
health data and respect medical
confidentiality; 2) obtain informed
consent regarding the use of AI;
3) acquire sufficient technical
knowledge; 4) appropriately use the
output generated by AI systems;
and 5) detect and address bias.
Both at the national and
international levels, a wide range
of binding and non-binding
legal acts have been adopted to
date that address the use of AI
in healthcare. In the European
Union (EU), the most important
legal source is the Artificial
Intelligence Act (hereinafter, the
AI Act), whose primary objective
is to promote human-centric and
trustworthy AI, while ensuring
a high level of protection for
health, safety, and fundamental
rights [8]. The AI Act operates
on the principle of risk
classification, whereby the level of
regulatory requirements depends
on the degree of risk posted in
each specific context. AI systems
used to support decision-making
in healthcare are classified as
high-risk, where the strictest
safeguards and highest level of
protection are required. This
primarily means that a risk
assessment must be conducted
before their deployment, and
that the use of reliable and
non-discriminatory input data is
crucial. Key elements also include
ensuring traceability, human
oversight, and a high level of
cybersecurity.
In relation to liability for damages
in the field of AI, two directives
have been developed. First, the
Revised Product Liability Directive
(hereinafter, rPLD), adopted in
October 2024, establishes strict
liability for defective products,
and now clarifies that the directive
also applies to software (including
AI systems) [9]. Specifically,
patients who can prove that they
have suffered harm caused by a
defective AI system are entitled
to compensation. The Directive
changes the definition of a defect,
which arises where the safety of
the product does not meet the
expectations of the general public,
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Liability for Healthcare Damages in Slovenia
17
and requires manufacturers to
disclose relevant evidence of any
defective product. It follows that,
in cases where a product uses
machine learning, a failure to meet
reasonable expectations that its
underlying algorithm is designed
to prevent dangerous behaviour
may be considered a safety defect.
The Directive also expands the
range of factors that courts must
consider when determining
whether a product is defective,
including the self-learning
capabilities of products. In certain
complex cases, it reduces the
burden of proof on the injured
party by introducing rebuttable
presumptions of defectiveness or
causation.
Second, the AI Liability Directive
(hereinafter, AILD), the proposal
of which the European
Commission decided to withdraw
in February 2025 due to a lack of
agreement among stakeholders,
sought to harmonise national
fault-based liability systems by
reducing the burden of proof for
injured parties [10]. In particular,
it proposed the application of
rules on the disclosure of evidence
and a rebuttable presumption of
causation. Under the rules on the
disclosure, courts could order the
disclosure of evidence relating
specific high-risk AI systems
suspected of having caused harm.
The request should be addressed
to the provider or user of the
AI system. If the defendant fails
to comply with the disclosure
request, a presumption of breach
of the duty of care would arise.
The rebuttable presumption of
causation was designed to address
the plaintiffs’ difficulties in
proving a causal link between a
breach of the duty of care and
the output generated by the AI
system, or between the absence
of such output and the resulting
damage. To establish a (rebuttable)
presumption of causation, the
following three conditions should
be met:
1. The plaintiff has proven a
breach of the duty of care, or
the court has established fault
arising from a breach of the duty
of care, regarding the duty to
disclose evidence.
2. Based on the circumstances of
the case, it can reasonably be
inferred that the wrongful
conduct influenced the output
generated by the AI system.
3. The plaintiff has demonstrated
that the output generated by
the AI system caused the
damage. In the case of high-
risk AI systems, an exception
to the presumption of causation
would be permissible only if
the defendant proves that the
plaintiff had sufficient evidence
and expertise to establish
causation. If the case does not
involve a high-risk AI system,
the presumption of causation
applies only if the court
determines that the plaintiff
would face difficulties in proving
the causal link.
Conclusion
Appropriate legal regulation of
liability for healthcare-related
damages is more crucial than
ever. At the EU level, achieving
consensus is likely to be
challenging, given the diversity
of interests among stakeholders.
There is likely some truth to
the notion that AILD was
removed from the agenda primarily
for pragmatic reasons, namely to
preserve the EU’s competitiveness
in the field of AI. Notably, this
may prove to be a strategic misstep,
as Member States are likely to
adopt divergent national laws,
which may complicate compliance
and operations for companies
within the EU. AI system
manufacturers, however, welcomed
this development, as they consider
that the AI Act already provides
sufficient mechanisms for the
protection of users.
In my view, ensuring safe
healthcare delivery in the future
requires establishing clear
conditions and safeguards so that
only AI tools suitable for medical
use are deployed. These systems
should be safe, rigorously assessed,
and properly certified before
being placed on the market.
Furthermore, it is crucial that
healthcare professionals use these
systems responsibly, not only
in accordance with the specific
requirements of the AI tools,
but also in accordance with the
fundamental principles of the
doctor-patient relationship and
the standards of safe, appropriate,
and effective care. Liability for
damages (and other forms of
liability) should be appropriately
allocated among the various
stakeholders in the healthcare
ecosystem. It is particularly
important to ensure appropriate
evaluation, oversight, and
supervision of the implementation
of such practices, as this is the
only way to enhance patient
safety without stifling technical
innovation.
Above all, it must be recognised
that despite its high effectiveness,
AI cannot replace human judgment
and responsibility in healthcare.
Only healthcare professionals can
provide patients with compassionate
care and emotional support during
treatment and, in partnership with
patients, make shared decisions
regarding their care. Scientific
BACK TO CONTENTS
Liability for Healthcare Damages in Slovenia
18
progress should therefore never be
placed above humanity and empathy.
AI Disclosure Statement
The author confirms that no artificial
intelligence tools were used in the
preparation of this manuscript.
References
1. Republic of Slovenia. Official
Gazette of the Republic of
Slovenia: No. 15/08, 11 February
2008. Ljubljana: Government of
the Republic of Slovenia; 2008.
Slovenian. Available from: https://
pisrs.si
2. Žnidaršič Skubic V. Nekrivdna
odškodninska odgovornost:
primerno zdravilo za slovensko
zdravstvo ali njegova stranpot?
Podjetje in delo. 2024;6-7:949-62.
Slovenian.
3. Stauch M. The Law of
Medical Negligence in England
and Germany. Oxford: Hart
Publishing; 2008.
4. Jackson E. Medical Law. Oxford:
Oxford University Press; 2022.
5. Watson K, Kottenhagen R.
Patient’s rights, medical error
and harmonisation of
compensation mechanisms in
Europe. Eur J Health Law.
2018;25:10-2.
6. Taylor S. Providing redress for
medical accidents in France:
conflicting aims, effective
solutions? JETL. 2011;2:57-76.
7. Dute J, Faure MG, Koziol H,
ed. No-fault compensation in
the health care sector. Vienna:
Springer Vienna; 2004.
8. European Commission.
Regulation (EU) 2024/1689 of
the European Parliament and
of the Council of 13 June 2024
laying down harmonised rules
on artificial intelligence and
amending Regulations (EC) No
300/2008, (EU) No 167/2013,
(EU) No 168/2013, (EU)
2018/858, (EU) 2018/1139 and
(EU) 2019/2144 and Directives
2014/90/EU, (EU) 2016/797
and (EU) 2020/1828 (Artificial
Intelligence Act) [Internet]. 2024
[cited 2026 Apr 17]. Available from:
http://data.europa.eu/eli/reg/2024/
1689/oj
9. European Commission. Directive
(EU) 2024/2853 of the European
Parliament and of the Council of
23 October 2024 on liability for
defective products and repealing
Council Directive 85/374/EEC
[Internet]. 2024 [cited 2026 Apr 17].
Available from: https://eur-lex.euro­
pa.eu/eli/dir/2024/2853/oj
10. European Commission. Liability
rules for artificial intelligence
[Internet]. 2026 [cited 2026
Apr 17]. Available from: https://
c o m­m i s s i o n . e u ro p a . e u / t o p –
ics/business-and-industry/do-
ing-business-eu/contract-rules/
digital-contracts/liability-rules-arti-
ficial-intelligence_en
Viktorija Žnidaršič Skubic, PhD
Faculty of Law,
University of Ljubljana
Ljubljana, Slovenia
viktorija.znidarsic@pf.uni-lj.si
BACK TO CONTENTS
Liability for Healthcare Damages in Slovenia
19
Precision medicine has become
one of the defining ambitions of
contemporary health policy: to refine
diagnosis and treatment so that
interventions are more effective, less
toxic, and better aligned to individual
biology. Its scientific achievements
are real and impactful for patient
care. Yet Europe’s most consequential
health pressures over the coming
decades will be shaped less by
insufficient therapeutic precision
than by predictable demography,
unequal exposure to modifiable risks,
and persistent failures to deliver
prevention at scale. A recurring
problem in prevention policy is
that failure is often attributed
mainly to individuals. People may
decline screening or laboratory
tests, parents may withhold consent
for childhood vaccination, and
many do not follow health advice
or change behaviours associated
with higher risk.
This is the rationale for a shift
toward precision health. Properly
understood, precision health is an
orientation of the health system
towards anticipatory prevention and
early action. In an ageing society,
the sustainability of advanced
treatment pathways may depend
on whether preventive and early-
detection systems can meaningfully
reduce avoidable burden upstream
[1,2].
Cancer prevention is a strong test
of that approach. Cancer rates
are shaped by ageing populations,
unequal access to care, and the
growing strain on health systems.
At the same time, treatment costs
are likely to rise as more people
live longer and survive cancer,
even though much of the cancer
burden is still associated with risk
factors that can be reduced or
prevented. In 2019, risk factors
included in the Global Burden
of Disease analysis accounted for
44.4% of all cancer deaths globally,
underlining how much burden is
addressable upstream [3,4]. The
decisive barrier is not ignorance
of what works; it is the design and
governance of delivery. Recent
European Union (EU)’s modelling
suggests that meeting tobacco
reduction targets alone could
prevent around 1.9 million new
cancer cases in the EU between
2023 and 2050, illustrating the
scale of preventable burden when
prevention is treated as system
infrastructure [4].
Why Ageing makes Prevention an
Ethical and Operational Necessity
Europe is moving into a
demographic configuration in which
multimorbidity becomes the norm
rather than the exception. Ageing
increases cancer incidence even if
age-specific risks remain stable,
while improved survival expands
the population living with cancer
and requiring follow-up and long-
term care. In such a context, the
opportunity cost of prevention failure
grows. When systems over-invest
in late-stage rescue while under-
building prevention capacity, they
do not merely become inefficient.
Instead, they institutionalise
avoidable morbidity and distribute
these rates along predictable lines of
social advantage and disadvantage
[5].
This distributional point matters
significantly to health systems.
Health equity is commonly framed
as ensuring that everyone has a fair
and just opportunity to be as healthy
as possible; achieving it requires
removing obstacles to health that
are unequally distributed [5]. A
recurring problem in prevention
policy is that failure is often
attributed mainly to individuals.
People may decline screening
or laboratory tests, parents may
withhold consent for childhood
vaccination, and many do not
follow health advice or change
behaviours associated with
higher risk. This explanation is
incomplete and, in policy terms,
unhelpful. It obscures the fact
that participation is shaped by
predictable constraints ‒ time
scarcity, insecure employment,
language barriers, administrative
friction, fear or stigma, prior
negative experiences, and mistrust
‒ many of which are socially
patterned. If a programme
assumes that everyone is informed,
confident, and able to make time,
it will mostly benefit the people
who already meet those conditions.
The result is an equity failure
produced by design [6]. Precision
health, therefore, requires what
can be called an ethics of design,
where prevention is built in such
a way that the most constrained
individuals can still realistically
participate.
Human papillomavirus (HPV)
vaccination and cervical screening
are well suited to illustrate the
governance problem, with strong
evidence bases, clear target groups,
and measurable outcomes. The
World Health Organization has
Hamideh Frühwein
Preventive Care and Equity in an Ageing Society
From Precision Medicine to Precision Health:
Preventive Care and Equity in an Ageing Society
BACK TO CONTENTS
20
set explicit 90-70-90 targets for
cervical cancer elimination by
2030: 90% HPV vaccination
coverage among girls by age 15,
70% screening coverage with
a high‑performance test by
age 35 and again by age 45, and
90% treatment for those with
disease [7]. The existence of
targets, however, does not guarantee
delivery. When vaccination or
screening rates remain low, the
problem is usually not the clinical
evidence. More commonly, it is
one or more of the following:
fragmented accountability (no
single actor owns equitable
coverage), weak data-to-action
loops (under-uptake is measured
but not actively corrected),
insufficient integration with trusted
delivery sites (schools, primary
care, community services), and
underestimation of trust and
misinformation dynamics. Across
many areas of prevention, services
are available but participation
is uneven, especially among the
people who stand to benefit most.
Europe’s Beating Cancer Plan
represents an important recognition
that prevention and early detection
must sit at the core of cancer
policy. As it emphasises prevention,
screening, and equity as strategic
priorities, it provides a European
framework for national action
[8]. A high-level plan, however,
cannot substitute for local delivery
capacity, stable financing, and
practical access design, leading
to the consideration of three
operational implications.
First, equity cannot remain a post-
hoc metric. If performance is
reported only as a national average,
inequities may remain invisible or
politically tolerable. Precision health
requires routine disaggregation
(e.g., by deprivation, geography,
and relevant sociodemographic
indicators) and explicit
accountability for closing gaps.
Second, prevention capacity needs
to be sustained over time. It is
especially vulnerable to political
change and budget pressure because
its benefits emerge gradually and
are often less visible than those of
clinical care. Yet that is precisely why
prevention must be financed and
governed as infrastructure. Short-
term campaigns and pilot programs
do not create the institutional
muscle needed for sustained
uptake. Third, delivery must be
designed around real behaviour.
Booking complexity, inconvenient
appointment times, low-
quality risk communication,
and lack of navigational
support create friction that
disproportionately affects
disadvantaged groups. By contrast,
participation often improves
when access is made easier. Clear
invitations, simple scheduling,
reminders, and supportive follow-
up can improve uptake without
coercion while preserving respect for
autonomy.
What Precision Health Requires in
Practice
For precision health to work in
practice, it needs a clear model for
delivery, with clear responsibilities,
measurable outcomes, and systems
for feedback. Five requirements are
especially important in real-world
use: governance and accountability,
infrastructure that can turn data
into action, workforce and funding
capacity, trust-building engagement,
and service design that makes
participation easy.
1. Equity-sensitive accountability.
Health leaders should assess
programmes not only by overall
coverage, but also by whether
they reduce gaps between groups.
Prevention indicators should
be published routinely by age,
sex, geography, socioeconomic
position, migration status, and
other locally relevant factors.
Responsibility for investigating
low participation and addressing
it should be clearly assigned,
rather than limiting oversight to
reporting alone.
2. Data-to-action loops. Where
possible and legally permitted,
health leaders can connect
registries, immunisation records,
screening data, and primary
care systems to identify people
who are overdue and contact
them directly. Where that is
not possible, they can rely on
practical alternatives such as
call-recall systems, prompts in
primary care, and partnerships
with community organisations.
In either case, the process
should be clear and complete:
identify, contact, follow up, and
record the result.
3. Stable prevention financing and
workforce capacity. Prevention
needs stable long-term funding
and clear workforce planning.
Capacity has to be planned, not
assumed. Staffing, time, and task
allocation, especially in primary
care and community settings,
should match the goals of the
programme and the needs of
the groups it is meant to reach.
Asa service design and clinical
issue, it should be taken
seriously in commissioning and
performance management.
4. Trust as a governance outcome.
Health leaders can view
trust as a key measure of
effective governance. Trust
affects prevention uptake and
can be undermined by weak
communication, low institutional
credibility, or processes perceived
as opaque. HPV vaccination
Preventive Care and Equity in an Ageing Society
BACK TO CONTENTS
21
showed how easily participation
can be affected by public
controversy and concerns about
how a programme is run. Trust
is stronger when health
authorities are open about
benefits and harms, respond
quickly to concerns, and adapt
outreach to communities with
lower access or lower trust in
institutions.
5. Behavioural and psycho-cognitive
design as a quality domain.
Programme quality should
include the cognitive and
logistical demands placed on
participants (e.g., number of
steps, clarity of information, ease
of rescheduling, privacy, stigma
considerations). Behavioural
interventions (reminders, prompts,
navigation support, default
scheduling) can improve uptake,
but effects are context-dependent
and should be implemented as
testable components within a
continuous quality-improvement
approach rather than as a
universally effective solution [9].
Ethical acceptability depends on
transparent intent, proportionality,
and easy opt-out/refusal
processes – not on the absence of
design.
The Role of Medical Associations
Medical associations and clinicians
can strengthen precision health
by aligning with how prevention
works in practice and whether
it reaches different groups fairly.
First, they can help define
and disseminate benchmarks
for prevention delivery that
include equity-sensitive indicators,
not solely aggregate coverage.
Second, they can advocate
for prevention as enabling
infrastructure: stable financing,
interoperable information systems
where feasible, and delivery
capacity commensurate with
stated targets. Third, they can
support credible, evidence-based
communication by equipping
clinicians to address misinformation
in a non-stigmatising manner
and by promoting culturally
competent approaches to consent
and counselling. Fourth, they
can normalise equity auditing
as routine professional practice.
Systematic prevention gaps are
generally patterned rather than
random; treating them as remediable
performance issues links professional
ethics with accountability
mechanisms.
Conclusion
This text presents the case that
prevention is one of the clearest
ways to make precision health
meaningful in practice. In ageing
societies, this matters not only
for sustainability, but also for
equity. Cancer prevention brings
this concept into focus because
effective interventions already exist
and progress can be measured.
The central challenge is therefore
not the absence of evidence,
but whether health systems can
deliver prevention in ways that
people can realistically access and
use. This approach requires trust,
stable funding, sufficient workforce
capacity, and services designed to
reduce barriers to participation,
especially for underserved groups.
From this perspective, precision
health should be judged by its
ability to reduce preventable
illness, death, and avoidable
inequality.
AI Disclosure Statement
The author confirms that no artificial
intelligence tools were used in the
preparation of this manuscript.
References
1. Organisation for Economic Co-oper-
ation and Development. Tackling the
impact of cancer on health, the econ-
omy and society. OECD Health Poli-
cy Studies. Paris: OECD Publishing;
2024. Available from: https://www.
oecd.org/en/publications/tackling-
the-impact-of-cancer-on-health-the-
economy-and-society_85e7c3ba-en.
html
2. Organisation for Economic Co-op-
eration and Development & Europe-
an Commission. Health at a glance:
Europe 2024: state of health in the
EU cycle. Paris: OECD Publishing;
2024. Available from: https://www.
oecd.org/en/publications/health-at-
a-glance-europe-2024_b3704e14-en.
html
3. GBD 2019 Cancer Risk Factors
Collaborators. The global burden of
cancer attributable to risk factors,
2010–19: a systematic analysis for the
Global Burden of Disease Study 2019.
2022;400(10352):563-91.
4. Organisation for Economic Co-op-
eration and Development & Eu-
ropean Commission. EU country
cancer profiles synthesis report 2025.
EU Country Cancer Profiles. Paris:
OECD Publishing; 2025. Available
from: https://www.oecd.org/en/pub-
lications/eu-country-cancer-profiles-
synthesis-report-2025_20ef03e1-en.
html
5. Braveman P. Defining health equity.
J Natl Med Assoc. 2022;114(6):593-
600.
6. De Marchi C, Di Lullo F, Ferrari C,
Pettinicchio V, Sinopoli A, Lombardo
P, et al. Interventions to improve can-
cer screening adherence in migrants
and ethnic minorities in the European
Region: a systematic review. J Cancer
Policy. 2025;47:100677.
Preventive Care and Equity in an Ageing Society
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22
7. World Health Organization. World
cervical cancer elimination day 2025
[Internet]. 2025 [cited 2026 Jan 23].
Available from: https://www.who.
int/campaigns/world-cervical-can-
cer-elimination-day/2025
8. European Commission. A cancer plan
for Europe [Internet]. 2025 [cited
2026 Jan 23]. Available from: https://
commission.europa.eu/topics/pub-
lic-health/european-health-union/
cancer-plan-europe_en
9. Wang F, Li Y, Zhang C, Arbing R,
Chen WT, Huang F. Evaluating dig-
ital nudge interventions for the pro-
motion of cancer screening behavior:
a systematic review and meta-analysis.
BMC Med. 2025;23(1):214.
Hamideh Frühwein, PhD
Institute for History, Philosophy
and Ethics of Medicine,
University Medical Center Mainz
Mainz, Germany
h.mahdiani@uni-mainz.de
Preventive Care and Equity in an Ageing Society
BACK TO CONTENTS
23
Interview with Experts in Patient Advocacy and Engagement
Interview with Experts
in Patient Advocacy and Engagement
For this interview, Clarinda Cerejo
and Caitlin Rich, hosts of the “Not
Just Patients” podcast, describe
the need to reinforce patient
engagement and shared decision-
making in physician-patient
interactions. Their award-winning
podcast aims to break barriers to
meaningful patient involvement in
healthcare, by challenging patient
stereotypes, highlighting successful
collaborations in healthcare,
and sharing energising tales of
turning adversity into advocacy.
In this interview with Dr. Helena
Chapman, the WMJ Editor in
Chief, they comment on how their
lived experiences and training
facilitated their podcast leadership,
describe systemic gaps in health
systems, and propose how physicians
can advance efforts to ensure
physician-patient rapport and better
quality of care.
Tell us more about the “Not Just
Patients” podcast and how your
collective roles as podcast co-
hosts have created an inclusive
and informed community.
Clarinda Cerejo: We started the
“Not Just Patients” podcast in
April 2024, shortly after we met
at the Patient Expert Training
programme run by the European
Patients Academy for Therapeutic
Innovation (EUPATI). During the
programme, we learned about the
value of patient involvement across
various stages of the medicines
development process. We started
the podcast as a way to continue
our learning and highlight for
a broad audience the value that
patient perspectives can add to
all aspects of healthcare, even
beyond medicines development.
This mission holds deep
significance for us, both as
patients living with rare and
chronic diseases, and as
professionals working in healthcare
communications and stakeholder
engagement. The “Not Just
Patients” podcast aims to break
down barriers to meaningful
patient involvement in healthcare.
By talking about the barriers
and opportunities to patient
engagement from different
stakeholders’ lenses, we highlight
the infinite possibilities for
patients to bring value and create
impact throughout the healthcare
continuum.
Caitlin Rich: Patient engagement
should be implemented across all
facets of the healthcare system, and
therefore requires collaboration
from all stakeholders. The “Not
Just Patients” podcast lives up to
its name: it is for everyone, not
just patients! Our guests and
audience represent a diverse variety
of stakeholders from across the
healthcare ecosystem and around
the world, including physicians;
patient advocates; pharma
representatives; regulatory, policy,
medical publishing experts; and
healthcare agency leaders. As
hosts, we also bring our unique
perspectives and experiences: I
live in London and have been
living with cystic fibrosis since
birth, while Clarinda lives in
Mumbai and was diagnosed with
neuromyelitis optica spectrum
disorder in her 20s.
While we interview globally
recognised experts on highly
technical topics, we break them
down with practical advice and
real-world examples, making each
episode accessible and actionable
for all. We recognise that no one
expert holds all the answers on any
topic, so while our guests share
deep knowledge, the conversations
are designed to spark reflection
and challenge assumptions. We
encourage listeners to share their
stories, successes, and questions,
fostering collective learning for
everyone. While this journey
started as a passion project to
champion patient engagement,
we have led this podcast for two
years, releasing over 24 monthly
episodes, ensuring steady audience
growth, and receiving two business
awards.
Clarinda Cerejo
Caitlin Rich
BACK TO CONTENTS
24
From the patient’s perspective,
can you describe three primary
systemic gaps in health systems
that challenge physician‒patient
rapport and quality of care?
Clarinda Cerejo: In my experience,
some systemic and cultural issues
can undermine shared decision-
making from the outset. One
gap is the inherent power
imbalance between physicians
and patients, where doctors are
viewed as superior authorities. If
physicians do not actively work to
rebalance this dynamic, patients
have little chance of achieving
true parity. A second gap stems
from the paternalistic “doctor-
knows-best” attitude, which flows
directly from the power asymmetry.
When physicians overuse jargon or
adopt a patronising or dismissive
tone, even unintentionally, patients
feel unwelcome to ask questions or
voice differing opinions.
A third gap lies in viewing patients
as cases, rather than unique
individuals. With artificial
intelligence (AI) and digital tools
providing better on-demand access
to medical information, patients
can become more informed and
willing to partner in their treatment
decisions. However, not all patients
want to be partners, which is why
physicians must view patients as
individuals and meet them where
they are. As Dr. Victor Montori
commented in one of our podcast
episodes on shared decision-
making, “Treating all patients with
the same condition as cases rather
than as individuals with distinct
preferences and life circumstances
does not allow physicians to see
patients in high definition.”
Caitlin Rich: First, although
physicians endure years of
gruelling, intense training in science,
medicine, and clinical practice,
they receive little instruction in key
“softer skills” (e.g., communication,
empathy, conflict management).
It is encouraging to see growing
education on these topics for
medical students and practising
physicians, but we still have a long
way to go until it is ubiquitous.
Second, consultations face strict
time constraints with little
flexibility to extend appointments.
This makes it difficult for
physicians to build rapport and
trust, confirm patient understanding,
field questions, and obtain a
holistic view of patients’ history
and lifestyle. While systemic changes
are not always feasible, tangible
strategies can help overcome these
time constraints. For example,
physicians can ask patients to
complete pre-appointment surveys,
share resources for self-paced
learning, and offer access to the
wider clinical team (e.g., nurses,
pharmacists, psychologists) for
ongoing questions and concerns.
Third, as physicians experience
burnout, and patients experience
emotional distress, this dynamic can
create tension between physicians
and patients, requiring empathy
from both sides to bridge the gap.
Clarinda Cerejo and Caitlin Rich:
Although we initially answered
these questions independently,
we recognise that our comments
reflect our distinct cultural contexts
and healthcare systems. These
differences often arise in our
podcast discussions, uniquely
positioning “Not Just Patients”
to highlight health inequities
and compare patient engagement
practices across regions.
How can physicians best
evaluate patients’ health and
digital literacy to ensure their
equitable access to care and
understanding of medical
information?
Clarinda Cerejo: Once again, it
starts with meeting patients
where they are. The best way for
physicians to evaluate comfort levels
is to ask patients whether they
would like additional reading
materials, whether they are
comfortable reading in the
consultation’s language, and if they
have access to a device for viewing
online videos. Having accessible
medical information tailored to
grade-school (age 11-14 years)
reading levels can be invaluable
for addressing common patient
questions and information needs. In
countries where multiple languages
are spoken, localising this material
can further enhance its effectiveness.
In some of my own consultations,
I have found it extremely beneficial
when physicians have shared
videos or photos directly on their
computer screen and explained
relevant details in real-time.
This model offers an immediate
education opportunity, allowing
physicians to gauge patients’ ability
to comprehend, while opening
up space for questions during the
consultation. The key is avoiding
a one-size fits-all approach and
rather keeping various options
available to best suit patients’
needs.
Caitlin Rich: My advice is to treat
every patient as an individual, ask
questions, and listen attentively.
Avoid assumptions based on
stereotypes, such as assuming
a person’s tech-savviness from
age or language fluency from
appearance. Every consultation
requires sharing a bare minimum
of essential information so patients
can understand their condition
and follow health recommendations.
Interview with Experts in Patient Advocacy and Engagement
BACK TO CONTENTS
25
After sharing this information,
invite further questions or
deeper discussions on specific
topics, as patients’ responses will
reveal comprehension levels and
desired detail. At the end of an
appointment, ask patients to repeat
back the next steps, which will
confirm if they fully understand
the information discussed.
Remember that most people can
only absorb limited information
in one meeting, especially during
emotional or distressing medical
circumstances. Sending patients
home with accessible resources
to review at their own pace can
be incredibly helpful. Patient
organisations and advocacy groups
often provide resources specifically
designed for patients. Physicians
can consider their patients’ needs
and prepare a range of resources
with different topics, depths, and
formats (e.g., larger fonts, child-
friendly layout, multiple languages)
for patients to choose from.
How can physicians’ sustainable
engagement in shared decision-
making with patients in clinical
practice improve patients’
satisfaction, adherence to
treatment, and overall health
outcomes?
Clarinda Cerejo: Shared decision-
making is the process whereby
patients and physicians work
together to make informed
decisions related to patient care,
considering the best available
evidence alongside patients’ values
and preferences. As a science
communication professional newly
diagnosed with a rare disease, I
was dismayed to find the scarcity
of research publications on my
rare disease. I brought all relevant
research papers I could find to my
medical consultations, expecting
physicians to engage with me as
someone deeply invested in the
science behind their decisions.
Unfortunately, I perceived that
my actions made physicians
uncomfortable, and I was frequently
dismissed.
The physician I eventually chose as
my primary consultant embraced
my research-oriented mind,
answered my questions thoroughly,
and collaborated with me on
treatment decisions. Now, 15 years
later, I often share this interaction
as life-changing, because it not
only brought positive medical
outcomes but also served as the
pivotal event that led me to pursue
patient advocacy. In this sense,
my first experience of true shared
decision-making had a profound,
snowballing positive impact on my
life.
Caitlin Rich: When I first left
home for my university studies,
I suddenly found the burden
of managing all my treatments,
alongside self-care, studying, and
socialising, to be overwhelming. As
a result, I avoided all treatments
that required anything more than
swallowing a pill. While it made
life easier and more fun, my
health declined over time,
eventually leading to hospitalisation.
My doctor scolded me and
insisted that I resume all
medications, while adding new
treatments due to my worsened
condition.
Unfortunately, behaviour change is
not that simple, and I lacked time
in my daily schedule to manage all
treatments, continue my academic
routine (e.g., studying, socialising),
and recommended health
behaviours (e.g., adequate sleep,
physiotherapy, exercise, consuming
over 3000 calories a day). Although
I agreed to adhere to these
recommendations, I was unable to
follow through. During my next
consultation, I was honest about
my situation with a different
physician I already trusted, and
together, we developed a care
plan that incorporated the most
important treatments while suiting
my lifestyle. This physician invited
a nurse and psychologist to discuss
habit stacking to support behaviour
change, switched me from a
nebuliser (requiring 15 minutes,
refrigeration, and cleaning) to a
portable inhaler (taking 2 minutes
before brushing my teeth). Though
not the absolute best treatment
per data guidelines, it improved
adherence (some medication vs none)
and health outcomes significantly.
As demonstrated by my own
personal experiences, shared
decision-making empowers
patients with the knowledge,
confidence, skills, and motivation to
manage their own health. This is
particularly important for chronic
conditions, where care must
seamlessly integrate into daily
life over the long-term. If you
would like to learn more about
shared decision-making from the
physician and patient perspectives,
I highly recommend two “Not
Just Patients” episodes: one
with Victor Montori (physician
perspective) and one with Estelle
Jobson (patient perspective), offering
practical tools for individual and
systemic implementation.
How can physicians empower the
global community to collectively
address patient engagement and
advocacy efforts?
Clarinda Cerejo: Physicians have
a powerful and unique role in
the healthcare ecosystem. Among
all healthcare stakeholders‒
drug manufacturers, hospital
administrators, payers, and
policymakers‒physicians are the
Interview with Experts in Patient Advocacy and Engagement
BACK TO CONTENTS
26
ones who have maximum direct
and meaningful access to patients.
In fact, as their perspectives are
often used as a proxy for patient
perspectives, they hold significant
power to influence patient
engagement and advocacy across
multiple levels.
The beauty of patient engagement
and advocacy lies in its flexibility,
differing in scale and form based on
objectives and available resources,
from in-clinic to community and
then to global engagement. First,
in-clinic engagement and advocacy
require that physicians see the
patient as a whole person, ask
the right questions and actively
listen, simplify complex medical
information, and encourage
shared decision-making. Second,
community advocacy and
engagement might involve activities
like sharing more patient stories,
raising awareness of healthcare
issues (via podcasts, lectures, social
media, editorials, blogs), reducing
stigma through seminars at schools
and workplaces, and supporting
local advocacy efforts (e.g.,
amplifying messages on social
media, donating to advocacy
groups, participating in fundraiser
events). Finally, national and
global advocacy and engagement
incorporate partnering with
patient authors for research
publications, integrating patient
voices into programming for
medical conferences, serving on
regulatory committees that matter
to patients, and becoming involved
in international projects (e.g.,
World Health Organization, United
Nations) related to meaningful
patient engagement.
Although physicians often refrain
from engaging in patient advocacy
due to perceived time and resource
constraints, advocacy is inherently
scalable and can be adapted to
available capacity. Notably, in-clinic
efforts can be just as powerful as
global advocacy. What matters most
is for physicians to leverage their
strengths and skills to try and bring
more patient voices into rooms
where they have influence.
Caitlin Rich: As a first step,
physicians can explore patient
engagement and advocacy efforts in
their own space. They can research
patient advocacy organisations
and events related to their disease
expertise, region, or interests,
learn about their activities, and
identify how they might become
involved. They can review advice
on supporting patient care and
then implement one small change
in their clinical practice and
monitor improvements. They can
explore ways to support patient
engagement beyond the clinic;
patients can (and should!) also
be invited to help shape research,
regulations, reimbursement, policy,
and healthcare systems. “Not Just
Patients” episodes are available on
a range of healthcare topics if any
health professional would like to
learn more.
Once health professionals gain
experience in patient engagement
and advocacy, they can share
insights with their peers. For
example, what did they do, why
did they do it, and what was the
impact? Their stories and example
scan motivate and empower others.
Change at a personal level can
drive change at the department
level, and then locally, regionally,
nationally, and ultimately worldwide.
AI Disclosure Statement
The authors confirm that no
artificial intelligence tools were
used in the preparation of this
manuscript.
Authors
Clarinda Cerejo
Co-host, “Not Just Patients” podcast
Mumbai, India
clarinda.cerejo@gmail.com
Caitlin Rich
Co-host, “Not Just Patients” podcast
London, United Kingdom
caitlin169@hotmail.com
Interview with Experts in Patient Advocacy and Engagement
BACK TO CONTENTS
27
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Medical Assistence in Dying
(MAiD) is a regulated process
where a physician or nurse
practitioner helps a mentally
competent patient intentionally
end their life at their own request.
This practice involves either the
direct administration of a drug
by the clinician (euthanasia) or
the prescription of a medication
for patient self-administration
(physician-assisted suicide, PAS).
The right to die is among the
most ethically and legally complex
issues in bioethical discourse since
the discipline’s origins.
Numerous ethical arguments
supporting the right to die are
grounded in the principles of
dignity, bodily integrity (particularly
in the context of suffering), and
autonomy (freedom of choice).
Together, these principles support
a broader understanding of
personal self-determination that
includes the possibility of choosing
to anticipate one’s own death. In
sharp contrast, arguments such
as the slippery-slope objection,
protection of vulnerable groups,
dignity of life, and related concerns
have been invoked to oppose the
legal recognition of the right to die
[1].
Despite ethical debates, MAiD
remains a central to the social,
clinical, and cultural landscape of
many Western countries, where
research consistently shows
generally favorable stakeholder
attitudes [2]. Over the past decade,
MAiD legalization has expanded
globally, with countries adopting
different regulatory frameworks
governing eligibility, assessments,
and integration with health, social
care, and end-of-life systems [1].
MAiD remains highly debated
in several countries, with Italy
representing one of the most
controversial cases.
MAiD and Italy: A Complex
Landscape
Under Italian law, PAS and
euthanasia are prohibited by
Article 580 and Article 579,
respectively, of the 1933 Penal
Code. Article 580 establishes
criminal liability for anyone
who “instigates another to commit
suicide, or reinforces another’s
intention to commit suicide, or
facilitates its execution in any way,’’
while Article 579 criminalizes the
act of directly causing a person’s
death, even with their consent
(consensual homicide). Specifically,
regarding ‘’incitement or aiding
suicide,’’ Article 580 states that
“Anyone who instigates another
to commit suicide, or reinforces
another’s intention to commit suicide,
or facilitates its execution in any
way, shall be punished, if the
suicide occurs, with imprisonment
from five to twelve years. If the
suicide does not occur, but an attempt
is made, the penalty shall be
imprisonment from one to five
years, provided that the attempt
results in serious or very serious
bodily injury. No punishment shall
be applied if the suicide attempt does
not result in injury.”
In parallel, the right to self-
determination has gained an
increasingly central role within
Italian jurisprudence, particularly
with the Law 219/2017 (“Law
on informed consent and advance
healthcare directives”). It draws
on Article 32 of the Italian
Constitution – which states that
“no one may be obliged to undergo
any given medical treatment” – and
the principles of dignity, autonomy,
relationship of care, and respect
for bodily integrity. The law
affirms the right to self-
determination in healthcare
decisions, including those made
at the end-of-life, marking a
significant milestone in the
protection of patients’ rights. It
ensures access to comprehensive
information, effective pain
management, and palliative
care, while promoting active
participation in clinical
decision-making.
The Law 219/2017 provides a clear
legal framework for expressing
advance directives and advance
care planning regarding life-
sustaining treatment, including
the possibility of refusing or
discontinuing such treatment, such
Marta Perin
Physician-Assisted Suicide in Italy
Constitutional Court and “Administrative Solutions”
for Physician-Assisted Suicide in Italy
Carlo Botrugno
28
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as artificial ventilation, artificial
nutrition, and artificial hydration.
The law incorporates four key
ethical, clinical, and legal concepts
as follows:
• Appropriate care: The obligation
of healthcare professionals
to provide treatment and
interventions are clinically
justified, proportionate, and
aligned with patients’ values and
goals.
• Prohibition of unreasonable
treatments: Patients cannot be
subjected to treatments that
are futile, disproportionate, or
excessively burdensome relative to
the expected benefits. It protects
individuals from interventions
that prolong suffering without
offering meaningful improvement
in their quality of life.
• Withholding or withdrawing
treatment: Patients have the
right to refuse or discontinue
medical treatments, even when
such treatments are necessary to
sustain life. Withholding
treatment (not initiating a
treatment) and withdrawing
treatment (stopping an ongoing
intervention) are ethically and
legally recognised as expressions
of patient autonomy, rather than
acts intended to cause death.
• Palliative care (e.g., palliative
deep and continuous sedation):
Patients’ right to care are
focused on relieving suffering
and improving quality of life
(e.g., symptom management,
psychosocial support), especially
for patients with serious and/
or terminal illness. Deep and
continuous palliative sedation
may be used in cases of
refractory symptoms, which
consists of reducing consciousness
to alleviate intolerable suffering
while providing basic care.
Furthermore, four tools can help
ensure personal autonomy across
present and future contexts,
including:
• Informed consent: A competent
individual agrees to a medical
intervention (treatment,
procedure or trial) after receiving,
understanding, and considering
all relevant information. It
requires disclosure of the
diagnosis, nature of the
intervention, risks, benefits, and
alternatives.
• Advance directives: Legal
documents (e.g., living wills,
durable powers of attorney for
healthcare) allow individuals
to specify in advance their
preferences for medical treatment,
including life-sustaining care.
They only take effect if a person
becomes unable to communicate
their own decisions.
• Shared care planning: This
collaborative, patient-centred
process involves patients and
clinicians, together with families
and other healthcare professionals,
jointly planning future care
pathway by defining treatment
options and supportive measures.
• Surrogate decision-maker: A
legally or informally appointed
person who makes healthcare
or financial decisions on behalf
of an individual who lacks the
capacity to make their own
decisions. They act based on
the patient’s known wishes,
values, and preferences
(substituted judgment), or if
unknown, in their best interest.
The Case of DJ Fabo
In 2019, the Italian Constitutional
Court – Italy’s highest authority
after Parliament – ruled on the
case of Fabiano Antoniani, a
young man who was tetraplegic
and who, under Law 219/2017,
could have accessed the withdrawal
of life-sustaining treatments and
deep palliative sedation. Since
he was not fully dependent on
artificial ventilation, discontinuing
treatment would have led to death
within a few days. However, in
Fabiano’s view, this perspective
did not represent a dignified way
to end his life, and he requested
“a different way of departing
from life,” one that would be
faster and entail less suffering for
himself and his family.
The Italian Constitutional Court
recognised that, “The absolute
prohibition of assisted suicide
ultimately limits the patient’s freedom
of self-determination in choosing
therapies, including those aimed at
relieving suffering (…) by imposing,
in the final analysis, a single way
to take leave of life (…) thereby
violating the principle of human
dignity as well as the principles
of reasonableness and equality in
relation to different subjective
conditions” [2] Then, it confirms
that under certain circumstances,
those who assist a person in
pursuing their suicidal intent may
not be punishable.
The Italian Constitutional Court’s
ruling explicitly refers to the
ethical – not the normative
framework established by Law
219/2017 – highlighting several
points of ethical convergence.
Both the ruling and the law
respond to the concern that the
dignity of individuals at the
end-of-life may be jeopardized by
changing conditions of dying. They
Physician-Assisted Suicide in Italy
29
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share a focus on the relationship
between care and dignity,
emphasising the need to safeguard
both. Moreover, they are grounded
in a patient-centred approach that
prioritises respect for personal
dignity through the protection
of both self-determination and
vulnerability, ensuring that
individuals are never abandoned in
moments of fragility [3].
New Insight from Italian
Constitutional Court
The Italian Constitutional Court
ruling highlights the need to
understand specific issues related
to access to PAS. First, PAS
is initiated by patients’ explicit
request rather than serving as a
proposed treatment by healthcare
professionals. Second, the ruling
establishes specific eligibility
criteria that patients must meet in
order to access the PAS. Finally,
the lack of uniform and immediate
implementation of PAS across
all Italian regions resulted in
significant variability in
organizational responses [4]. The
five criteria governing access to
PAS include:
• Irreversible pathology: The patient
must suffer from an irreversible
medical condition that cannot be
cured or significantly improved.
• Intolerable suffering: The
condition must cause physical
or psychological suffering that
the patient personally considers
intolerable.
• Dependence on life-sustaining
treatments: The patient must
be kept alive by life-sustaining
treatments (e.g., mechanical
ventilation, artificial nutrition/
hydration, other vital support
systems).
• Full decision-making capacity: The
patient must be fully capable
of making free and informed
decisions.
• Clinical and ethical assessment:
These conditions must be
verified by the National Health
Service following a formal
procedure, including medical
assessments and ethical committee
review.
Since the enactment of the
Italian Constitutional Court
sentence, developments in Italy
have proceeded at two markedly
different speeds. First, the Italian
Parliament has approved a national
law regulating medically assisted
suicide. Second, opened by
constitutional jurisprudence, citizens
have requested that healthcare
institutions assess whether they
meet the required criteria,
highlighting the legal and ethical
need to provide clear answers to
patients. Consequently, some Italian
regions have started adopting
internal procedures that promote
justice, respect for self-determination,
and the protection of vulnerable
individuals faced with deciding
upon PAS.
The Emilia-Romagna Regional
Experience: Policy Addressing
PAS
Emilia-Romagna (ER) became
the first Italian region to issue a
regional deliberation in 2024,
establishing a clearly defined and
uniformly applied pathway across
all its healthcare facilities.
Subsequently, Tuscany and
Sardinia regions adopted regional
laws in 2025 [5]. The regional
deliberation implies the creation of
two dedicated bodies – the “Area
Vasta’’ Evaluation Commission
and the Regional Clinical Ethics
Committee (Comitato Regionale
per l’Etica nella clinica, COREC)
– and delineates their respective
role and responsibilities in PAS
criteria assessment [6]. The “Area
Vasta’’ Evaluation Commission,
consisting of seven health experts
in law, psychiatry, palliative care,
and psychology, is responsible
for assessing whether the PAS
criteria are met and for providing
a preliminary written response.
The COREC, composed of 22
health experts in clinical practice,
healthcare assistance, and bioethics,
provides a second evaluation of
the PAS criteria, highlighting
the ethical issues and vulnerable
situations.
In addition to “Area Vasta’’
Evaluation Commissions and
the COREC, the ER regional
deliberation was the first to
establish a clear internal pathway
with the procedural steps for
assessing patient requests, which set
a timeline that the Commissions,
COREC, and healthcare
organisations must follow. This
framework offers a structured
model for defining responsibilities
and outlines the procedures for
the request evaluations related to
managing PAS assessment and
implementation (Figure 1).
Focus on the COREC Activity
Between February 2024 and
November 2025, a total of 11
PAS requests were submitted to
the Healthcare Directorate of the
ER region three in 2024 and eight
in 2025 – related to neurological
conditions, cancer, and psychiatric
and other chronic illness. As
these requests were assessed by
the COREC, four of these cases
met the PAS criteria and were
subsequently completed. The
ER regional pathway safeguards
vulnerabilities in the context of
PAS request, as it guarantees a
Physician-Assisted Suicide in Italy
30
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clear timeline to patients and
families for multidisciplinary
care management, as well as
supports healthcare institutions in
addressing this complex issue
without national regulation.
The COREC evaluation addresses
the vulnerability of patients and
their family members, offering
an ethical (rather than purely
document-based) assessment, in
close collaboration with the
Evaluation Commission. Working
together can expose challenges,
particularly regarding complex
definitions such as life-sustaining
treatments and unbearable suffering,
while raising broader ethical
questions concerning the balance
between self-determination and
vulnerability in such contexts.
Moreover, several practical
challenges remain, including
supporting patients who cannot self-
administer medicine, the need for
specialised staff and standardised
protocols, concerns about territorial
inequality, insufficient time to
meet patients’ needs, infrastructural
limitations, and limited training to
strengthen clinical competencies in
palliative care.
Conclusion
The introduction of PAS
requires the development of new
ethical guidelines for healthcare
professionals, clearly delineating
the moral responsibilities and
implications from clinical
assessment to implementation.
In Italy, the ER regional pathway
represents a practical solution for
providing healthcare professionals
and citizens with a clear procedure
for accessing PAS, in accordance
with the principles of autonomy
and equity. Furthermore, the
pathway is particularly important
given the absence of a national
law regulating PAS.
Investing in evidence-based
research on the practices and
implementation processes can
generate timely empirical evidence
to assess the impact of the process
and deepen understanding of the
experiences of the actors involved.
This information can help guide
the development of high-quality
recommendations to increase
the acceptability of PAS within
Italian society and the medical
community. Since administrative
solutions are alone insufficient,
regulatory frameworks that ensure
national uniformity and equitable
access are needed to uphold
the principles of justice and respect
for self-determination.
Author Contribution Statement
MP, CB, and LDP conceptualised
the study, MP prepared the
original manuscript draft, and
LDP critically reviewed the
manuscript. All authors contributed
to the manuscript revisions and
approved the final version for
publication.
AI Disclosure Statement
The authors used artificial
intelligence tools for language
editing to improve grammar and
clarity. The intellectual content,
analysis, and conclusions remain
entirely those of the authors.
Figure 1. Procedural steps for managing patient requests for medically assisted suicide. Adapted by authors [7]. Abbreviations: Regional Clinical Ethics Committee, COREC; medically
assisted suicide, MAS.
Physician-Assisted Suicide in Italy
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References
1. Mroz S, Daenen F, Dierickx S,
Mortier F, De Panfilis L, Downar J,
et al. Associations between physi-
cians’ personal preferences for end-of-
life decisions and their own clinical
practice: PROPEL survey study
in Europe, North America, and
Australia. Palliat Med. 2025;39(2):
266-76.
2. Corte Costituzionale (Italy). N. 242
del 2019 [Internet]. 2019 [cited 2026
May 28]. Italian. Available from:
https://www.cortecostituzionale.it/
scheda-pronuncia/2019/242
3. De Panfilis L.Riflessioni etiche a mar-
gine del suicidio medicalmente assisti-
to: un dialogo tra principi [Internet].
2020 [cited 2026 Feb 20]. Italian.
Available from: https://www.ricp.it/
archivio/3322/articoli/32928/
4. Turillazzi E, Maiese A, Frati P, Sco-
petti M, Di Paolo M. Physician–pa-
tient relationship, assisted suicide and
the Italian Constitutional Court. J
Bioethical Inq. 2021;18(4):671-81.
5. Busatta L. Come dare forma alla
sostanza? Il ruolo delle Regioni nella
disciplina del suicidio medicalmente
assistito? [Internet]. 2024. Italian.
Available from: https://www.oss-
er vatorioaic.it/images/rivista/
pdf/2024_3_15_Busatta.pdf
6. De Panfilis L. I Comitati per l’et-
ica nella clinica di fronte alle
richieste di aiuto medico a morire:
l’organizzazione della Regione
Emilia-Romagna. BioLaw J – Riv
BioDiritto. 2026;(4):473-80. Italian.
7. Emilia Romagna Region. Istruzioni
tecnico-operative per la verifica
dei requisiti previsti dalla sentenza
della Corte Costituzionale n. 242/
2019 e delle modalità per la sua
applicazione [Internet]. Bologna:
Bollettino Ufficiale della Regione
Emilia-Romagna (BURERT); 2024.
Italian. Available from: https://
bur.regione.emilia-romagna.it/
area-bollettini/n-43-del-13-02-
2024-parte-seconda/istruzio-
ni-tecnico-operative-per-la-ver-
ifica-dei-requisiti-previsti-dal-
la-sentenza-della-corte-costituzi-
onale-n-242-2019-e-delle-modali-
ta-per-la-sua-applicazione/allegato-1
Authors
Marta Perin, PhD
Legal medicine and Bioethics, Azienda
USL-IRCCS di Reggio Emilia
Reggio Emilia, Italy
marta.perin@ausl.re.it
Carlo Botrugno, PhD,
BSW, LLM, LLB
Research Unit on Everyday Bioethics
and Ethics of Science, Department of
Legal Sciences, University of Florence
Florence, Italy
carlo.botrugno@unifi.it
Ludovica De Panfilis, PhD
Department of Medical
and Surgical Sciences,
Alma Mater Studiorum-
University of Bologna
IRCCS Azienda Ospedaliero-
Universitaria di Bologna, Italy
Bologna, Italy
ludovica.depanfilis@unibo.it
Physician-Assisted Suicide in Italy
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Physician Mental Healthcare and Professional Responsibility
Physician Mental Healthcare and Professional Responsibility:
Lessons from PAIME
Physicians’ mental health has
ceased to be a private matter,
often silenced, and has become
a central issue of professional,
institutional, and healthcare
organisational responsibility. For
far too long, physicians’
psychological suffering has been
interpreted through an individual
lens: personal fragility, clinical
disorder, addiction or deterioration
of professional competence [1].
Although this perspective remains
necessary when illness is present,
the accumulated evidence compels
us to recognise that a significant
part of physician’s distress has
organisational, occupational, and
cultural roots [2-4].
The II International Comprehensive
Care Programme for Sick Doctors
(Programa de Atención Integral al
Médico Enfermo, PAIME) Meeting
was held on 19 February 2026, in
Alicante, Spain, offering a platform
to discuss physicians’ mental
health within a global dimension.
Using the “From Evidence to
Action: Physicians’ Mental Health
Worldwide” theme, the event
highlighted findings from the
Mental Health of Nurses and
Doctors survey in the European
Union, Iceland, and Norway
(MeND) survey conducted by the
World Health Organization (WHO)
Regional Office for Europe, as
well as recent studies on physicians’
mental health in Brazil and Spain,
European experiences with specific
care resources, and an international
panel on sustainable support
systems [5]. The underlying
message was clear: it is no
longer enough merely describe
the problem, as the weight of the
evidence now demands action.
Compelling Evidence for Action
Data presented at the II
International PAIME Meeting,
alongside the wider international
literature on physician mental
health, reinforced that view that
healthcare professionals’ mental
health constitutes a critical
indicator of healthcare system
functioning. The association
of burnout with on-call duties,
sleep disturbance, poorer quality
of life, the use of psychotropic
medication, and other indicators
of personal deterioration reinforces
the idea that the problem cannot
be attributed solely to individual
vulnerabilities [3]. This evidence
shifts the focus from individual
vulnerability to systemic and
organizational determinants of
physicians’ mental health, shaped
by work conditions, professional
culture, health policy, and
occupational health.
The MeND report, produced by
the WHO Regional Office for
Europe, is a cross-sectional survey
conducted across 27 European Union
countries, Iceland, and Norway,
with 122,048 responses (including
90,171 valid responses) [5]. The
study identified a high prevalence
of anxiety and depression
symptoms, thoughts of death or
self-harm, impaired psychological
well-being, and exposure to adverse
working conditions. Researchers
estimated that one in three
physicians and nurses reported
symptoms consistent with anxiety
or depression, while more than
10% reported thoughts of death
or self-harm. Furthermore, perhaps
the report’s most important
contribution is its recognition
that physicians’ mental health
cannot be separated from working
conditions. Violence, harassment,
excessive workload, long hours,
night shifts, job insecurity, limited
support and autonomy, and poor
work-life balance are consistently
associated with worse mental
health outcomes [6].
Similarly, data presented by the
Brazilian Medical Association
reinforced the idea that suicidal
behaviour among physicians
cannot be interpreted exclusively
as an individual problem, with
researchers estimating that one
in 10 physicians will, at some
point in their lives, experience
a situation of high suicide risk.
The high prevalence of suicidal
María Isabel Moya
Álvaro Cerame
33
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ideation, plans, and attempts, as
well as their association with
emotional exhaustion, occupational
frustration, self-prescribing,
substance use, and cultural
barriers to seeking help, highlight
the need for specific, confidential,
and non-punitive programmes
[7]. Finally, findings from the
IKERBURN study, promoted by
the Spanish General Medical
Council (OMC)’s National Section
of Young Doctors, showed a
particularly high prevalence of
burnout among young physicians
in Spain, with more than half
meeting the criteria for full
burnout [8]. Burnout among young
physicians represents a structural
risk to healthcare system
sustainability, underscoring the need
to integrate prevention, occupational
health, and psychological support
into human resources policies [8,9].
From Illness to Occupational
Psychological Suffering
For years, physician support
programmes have focused mainly
on mental illness, addiction or
deterioration in professional
capacity that may compromise
medical practice and patient
safety. While this scope of action
remains essential, another profile
has become increasingly visible
in recent years: physicians who
remain functional and clinically
competent, but who experience
persistent burnout, moral
distress, emotional exhaustion or
occupational psychological suffering
[2,3]. These highly committed and
competent professionals may endure
chronic stress, anxiety, emotional
exhaustion, moral fatigue or loss
of meaning for years without
initially identifying themselves as
unwell, continuing to work under
overload and normalising distress
as an inevitable part of medical
practice. When suffering becomes
chronic and begins to affect
clinical judgement, empathy,
personal life, professional safety or
the desire to leave the profession,
it ceases to be solely an individual
problem and becomes an indicator
of systemic risk [9].
For PAIME, this changing context
highlights the need to urgently
address the transformation by
identifying mental health risks and
implementing timely preventive
interventions to reduce risk
of occupational psychological
suffering. The classic profile of
the “sick” physician is increasingly
accompanied by a broader
framework that recognises burnout,
moral distress, and work-related
psychological suffering as risk
markers requiring preventive,
organizational, and professional
responses, without reducing all
work-related suffering to psychiatric
diagnosis [3,9].
PAIME as a High-value
Professional Response
PAIME was influenced by
North American physician
health programmes, particularly
state-based programs in the United
States, and adapted to the Spanish
medical and institutional context
[10-13]. For almost three decades,
PAIME has represented one
of the strongest responses of
the Spanish medical profession
to mental illness and addiction
among physicians. Its value lies
not only in the care resources
it offers, but also in its ethical
architecture. PAIME is grounded
in the premise that physicians can
also become ill and must be able
to ask for help without fear of
stigma, automatic sanction or loss
of professional dignity. Its pillars –
confidentiality, trust, voluntariness,
specialised care, and professional
reintegration – have been essential
in enabling physicians to seek
help during periods of significant
vulnerability [4].
While supporting professional
careers, protecting patients, and
restoring dignity to physicians
experiencing severe suffering,
PAIME has also helped shift
professional culture by breaking
the silence that for decades
surrounded physicians’ mental
illness. The programme extends
beyond a care service, representing
an expression of the medical
profession’s deontological
responsibility, which is why it
was created and is currently
managed by the OMC [10,11].
With its high value and major
impact, PAIME must not remain
static, but should be preserved
while also adapting to current
evidence.
Evolving toward Occupational
Health and Prevention
In the coming years, the challenge
is to redefine PAIME beyond a
care service for sick physicians,
as a structural component of
policies that protect physicians’
health. Integrating PAIME into
the occupational health ecosystem
should not dilute its identity or
turn it into an administrative
human resources tool [3,5]
Its independence, professional
legitimacy, and confidentiality
must be preserved, while ensuring
that independence does not imply
isolation. As a safe space for
physicians, PAIME can contribute
to identifying risks, anticipating
issues, and informing prevention
policies through aggregated data,
clinical experience, and professional
knowledge. Physicians’ mental
health requires a strategy combining
prevention, early intervention,
specialised care, follow-up,
professional reintegration, and
institutional learning [12,13].
Physician Mental Healthcare and Professional Responsibility
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An Ethical, Systemic and Global
Commitment
Caring for physicians’ mental
health is both an ethical obligation
and a necessary condition for
patient safety, quality of care and
public trust in medicine, as noted
in global documents like the
WMA International Code of
Medical Ethics and WMA
Declaration of Geneva [14,15].
Patients need physicians who
are competent, clear-headed,
empathetic, and adequately
protected to practise safely.
Institutions need professionals who
can remain in medical practice
without being overwhelmed by
the demands of the profession.
Society needs healthcare systems
that do not rely on the silent
deterioration of those who sustain
them. The medical vocation
should not justify working
conditions that harm physicians’
health, nor should professional
resilience be equated with an
obligation to endure excessive
stressors. A mature profession
does not hide its suffering,
but recognises, addresses, and
transforms stressors into collective
responsibility. Notably, junior
physicians attending the II
International PAIME Meeting
underscored that new generations
are clearly expressing that
professional excellence must
be compatible with health and
personal dignity – a voice that
represents one of the most
necessary cultural corrections in
contemporary medicine.
The II International PAIME
Meeting demonstrated that
physicians’ mental health remains
a global priority for the medical
profession, highlighting shared
experiences from the WHO and
selected European and Latin
American institutions. Physicians
worldwide should have access
to dedicated mental health
programmes that address the issue
from a healthcare, social, and
professional perspectives, ensuring
confidentiality and non-
stigmatization, while promoting
physical and psychological
rehabilitation, return to work,
and quality of care. This consensus
is consistent with the WMA
Statement on Physician Mental
Health Care, adopted in October
2025 in Porto, Portugal, which
establishes a clear international
framework for recognising
physicians’ mental health as a
professional, ethical, and health
policy priority and calls for
prevention, access to confidential
care, support during treatment and
safe return-to-work processes [16].
Furthermore, the French Medical
Association (Conseil National de
l’Ordre des Médecins) shared its
experience promoting physicians’
mental health, describing how its
national and regional structures
organise listening, guidance, and
psychological and social support
services under strict confidentiality
for physicians and residents facing
difficulties. Among these resources,
a free and confidential telephone
helpline offers 24/7 psychological
support, as well as social assistance
during working hours. Like
PAIME, this experience illustrates
that professional medical
associations can play an active
role in regulating the medical
profession and protecting
physicians’ mental health. It
also underscores the value of
programmes that support physicians
through treatment, recovery, and
safe return to professional practice
[10,16].
Conclusion
The II International PAIME
Meeting was timely and effectively
demonstrated that physicians’
mental health is closely shaped
by the environments in which
they practise. Understanding
the risk of anxiety, depression,
burnout, suicidal ideation, and
substance use beyond the individual
is essential, as these outcomes
are consistently linked to work-
related factors such as excessive
workload, prolonged on-call duties,
lack of rest, violence, harassment,
precarious employment, limited
autonomy, and weak institutional
support. This evidence calls for a
shift beyond exclusively reactive
models toward integrating
confidential care for physicians
with prevention, early detection,
occupational health, and improved
working conditions to ensure safe,
high quality patient care.
The PAIME programme of the
21st century must preserve its
care function, while advancing
towards prevention, early detection,
integration with occupational
health, outcomes evaluation,
knowledge generation and
institutional influence. Resources
such as PAIME will remain
crucial for caring for physicians
with mental health problems and
addictions, with a model based on
confidentiality, trust, and specialised
care that constitutes an asset of
considerable professional and social
value. The new context requires
a strategic evolution of these
programmes, with international
evidence pointing to the future of
PAIME, which cannot be limited
to addressing harm once it has
already occurred, but must establish
itself as a fundamental tool of
public health and professional
responsibility. Protecting physicians’
mental health requires preserving
Physician Mental Healthcare and Professional Responsibility
35
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quality of care, patient safety, and
the human dimension of medicine,
calling on medical associations,
health authorities, and healthcare
organisations to assume an
unavoidable responsibility.
Author Contribution Statement
MIM and AC conceptualised the
study and prepared the original
manuscript draft. All authors
critically reviewed and revised
the manuscript and approved the
final version for publication.
AI Disclosure Statement
The authors used artificial
intelligence tools for language
editing and proofreading to
improve grammar, structure, and
clarity. The intellectual content,
analysis, and conclusions remain
entirely those of the authors.
References
1. Harvey SB, Epstein RM, Glozier
N, Petrie K, Strudwick J, Gayed
A, et al. Mental illness and
suicide among physicians. Lancet.
2021;398(10303):920-30.
2. West CP, Dyrbye LN, Shanafelt
TD. Physician burnout: contribu-
tors, consequences and solutions. J
Intern Med. 2018;283(6):516-29.
3. Saddawi-Konefka D, Moutier CY,
Ehrenfeld JM. Reducing barriers
to mental health care for physicians:
an overview and strategic
recommendations. JAMA. 2025;334
(10):886-93.
4. Petrie K, Crawford J, Baker STE,
Dean K, Robinson J, Veness BG,
et al. Interventions to reduce
symptoms of common mental
disorders and suicidal ideation in
physicians: a systematic review and
meta-analysis. Lancet Psychiatry.
2019;6(3):225-34.
5. World Health Organization
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Mental Health of Nurses and
Doctors survey in the Europe-
an Union, Iceland and Norway.
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7. Luz LS, Cassenote AJF, Va-
lente EP, Mariani I, Lazzerini M,
Lima CVTC, et al. Mental
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2024;46:e20233393.
8. Sánchez-Martínez DA, Cruz-
Núñez A, Carrasco JP, Sanmiguel
Zabala JI, Pujol de Castro A,
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9. Azzopardi Muscat N, Lazëri L,
Zapata T, Kluge H. Protecting the
mental health of the health and care
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10. Fundación para la Protección
Social de la Organización Médi-
ca Colegial. Programa de Atención
Integral al Médico Enfermo
(PAIME) [Internet]. Madrid: FP-
SOMC; n.d. [cited 2026 May 20].
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gral-al-medico-enfermo-paime
11. Braquehais MD, Valero S, Bel MJ,
Navarro MC, Matalí JL, Nasillo
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12. McLellan AT, Skipper GS,
Campbell M, DuPont RL. Five
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BMJ. 2008;337:a2038.
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WL, Merlo LJ, Gold MS. Setting
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14. World Medical Association. WMA
International Code of Medical
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May 20]. Available from: https://
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cies-post/wma-statement-on-physi-
cian-mental-health-care/
Physician Mental Healthcare and Professional Responsibility
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Authors
María Isabel Moya, MD
First Vice-President, Spanish
General Medical Council
First Vice-President, Foundation for
the Social Protection, Spanish General
Medical Council (FPSOMC)
National Coordinator, PAIME
Madrid, Spain
mimoya@cgcom.es
Álvaro Cerame, MD
President, European Junior Doctors
International Advisor, Spanish General
Medical Council (OMC)
Madrid, Spain
alv.cerame@gmail.com
Physician Mental Healthcare and Professional Responsibility
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Our existence as humans and the
continuity of our species rely on
reproduction. Throughout history,
people have expressed a strong
desire to have children, driven
not only by biological instinct
but also by social, cultural, moral,
and psychological factors. This
aspiration reflects a fundamental
human impulse to create, nurture,
and ensure the legacy of future
generations. Nowadays, this desire
is increasingly challenged by rising
infertility rates. Consequently, the
pursuit of parenthood has become
both a significant individual
objective and an important issue at
the global level, influencing ethical
discussions, policy development,
and progress in medical science.
Surrogacy raises a range of
bioethical considerations relating
to human dignity, individual
autonomy, self-determination,
principles of beneficence and non-
maleficence, and the commercial
aspects of the practice and
equality. Far from being a modern
phenomenon, surrogacy is as old
as recorded human civilisation. Its
earliest documented trace appears
in the Old Testament (Genesis
16:15–16), describing the birth of
Ishmael to Hagar (Sarah’s slave),
due to Sarah’s infertility. This
arrangement was closely mirrored
in the contemporaneous Code of
Hammurabi (c. 1754 BC), which
contained provisions for a childless
wife to offer her husband a female
slave to bear children on her
behalf, with any offspring legally
considered to belong to the wife.
Similar practices persisted across the
ancient world, as Homer’s Odyssey
(Book IV) referenced Megapenthes,
Menelaus’ son by a slave, born
after his wife Helena could no
longer bear children as a divine
punishment. However, in the modern
world, the first widely publicised
surrogacy birth occurred in the
United States in 1976, marking the
beginning of surrogacy as a formally
arranged and legally contested
practice.
According to the World Health
Organization (WHO), infertility
affects one in six adults worldwide,
leading to increased reliance on
medically assisted reproduction
technology (ART) [1]. Globally,
around 30,000 children are born
through surrogacy each year,
with the global surrogacy market
valued at US $22.4 billion in
2024 here projected to reach US
$201.8 billion by 2034 [2]. These
data underscore the increasing
significance of surrogacy in
addressing infertility and the
evolving family structures on a
global scale.
Greece, a nation of 10 million
residents, faces low birth rates,
an ageing population, and rising
infertility [3]. According to the
Hellenic Authority for Medically
Assisted Reproduction, 194
embryo transfers to surrogates (81
births) occurred in 2022 and 192
transfers (51 births) in 2023 [4].
Although ART began in Greece
in the 1980s, a comprehensive
legal framework focused on
protecting the child was later
established with two of the most
liberal policies in Europe: Law
3089/2002 (amending the Greek
Civil Code) and Law 3305/2005
(describing the Application of
Medically Assisted Reproduction,
MAR). The current Greek
Civil Code clearly separates
biological from legal motherhood,
acknowledging that the woman
who gives birth is not necessarily
the legal mother.
In Greece, the legislative
framework governing surrogacy is
comprehensive. First and foremost,
Article 5 §1 of the Constitution
of Greece guarantees the right of
every person to develop their
personality freely, their personal
autonomy, and the right to natural
reproduction [5]. An unrestricted
right to access ART methods is
not granted, as it remains subject
to strict legal conditions. Second,
the Article 3 §9 of Law 3305/2005
declares that surrogacy for legal
purposes refers to “the case in
which a woman becomes pregnant
and gives birth (carrier, surrogate),
after in vitro fertilization and
transfer of fertilized eggs, using
an egg foreign to herself, on behalf
of another woman, who wishes
to have a child but is unable to
conceive for medical reasons.”
Third, the Law 3089/2022
introduced the first comprehensive
framework for MAR and
incorporated surrogacy procedures
and safeguards into the Greek
Civil Code. Finally, the Article
46 of Law 5197/2025, which
amended Article 1458 of the
Greek Civil Code and replaced
Article 8 of Law 3089/2002, set
stricter frameworks regarding
surrogacy, where the acquisition
of a child through surrogacy in
Greece requires: 1) gestational
Maria Gatzoflia
Bioethics of Surrogacy in Greece
Bioethical Issues in Surrogacy: The Case of Greece
38
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surrogacy, 2) applicant’s medical
inability to conceive, 3) judicial
permission granted at the request
of the intended mother with an
irrevocable court decision, 4) written
agreement that participation is
voluntary and unpaid, and 5) both
the surrogate and applicant residing
in Greece [6].
Conditions for MAR Access
In Greece, only gestational
surrogacy is legal, meaning that the
surrogate has no genetic link to
the child, and that the egg comes
from the intended mother or donor.
Surrogacy is permitted in clearly
defined medical circumstances,
such as cases of hysterectomy
or uterine agenesis, as well as in
cases of unexplained infertility.
The Greek Civil Code protects
surrogates from being separated
from their biological children,
which would raise ethical concerns
and resemble infant trafficking,
and permits MAR if natural
conception is a) not possible, b)
prevents serious disease transmission,
or (c) preserves fertility. MAR,
however, is not considered as an
alternative route to parenthood,
as the applicant must prove her
inability in court with medical
evidence, and it is sufficient if one
partner in a couple is infertile.
Gender Suitability
A recent amendment, through
Article 46 of Law 5197/2025,
clarifies that the inability to
conceive due to gender does not
constitute a medical inability, as
it aims to restrict surrogacy to
medically necessary limits and
prevent illegal practices. This
amendment thereby excludes
male same-sex couples and single
men from eligibility for surrogacy.
Although the Greek law recognizes
gender-neutral civil marriage and
adoption by same-sex spouses,
surrogacy laws only refer to
women, raising constitutional
concerns related to equality and
non-discrimination, as well as
broader ethical and social debates.
For example, does allowing a single
man to become a parent cause
harm? Why should society object
if a man is willing and capable to
raise a child alone? If medicine
is intended to benefit everyone,
should certain ART procedures be
restricted to women? The debate
ultimately concerns the bioethical
principle of justice: whether access
to parenthood should be equal and
whether restricting surrogacy to
women constitutes discrimination.
However, future judicial decisions by
Greek Courts may determine that
denying men access to surrogacy
solely on the basis of gender
violates equality rights, or even
find the existing legal framework
unconstitutional.
Furthermore, it remains unclear
whether the Greek law applies
only to primary infertility (e.g.,
following hysterectomy) or also
extends to subsequent infertility
(e.g., after childbirth). A Greek
Court viewed surrogacy addressing
childlessness as an exceptional
measure, not an alternative route
to expand a family, with infertility
falling outside the scope of the
law [7]. In my view, limiting
surrogacy to individuals who do not
already have children raises serious
concerns under the bioethical
principle of justice and equal
treatment. Denying access to
MAR because a first child already
exists undermines equal access to
medical treatment and restricts
reproductive autonomy. Medical
inability should therefore be
assessed based on the individual’s
health condition at the time of
evaluation, regardless of prior
fertility.
Age Limit
Article 1455 of the Greek Civil
Code permits surrogacy up to the
age that corresponds to a woman’s
natural reproductive capacity,
which Law 4958/2022 defines as
54 years. Hence, women (including
surrogates) aged 50 years and 1
day up to 54 years may access
ART, only upon authorisation
from the Hellenic Authority for
Medically Assisted Reproduction.
The current age limit in Greece
raises concerns about older parents’
ability to stay current with social,
scientific, and technological
changes and provide sustained
care. Children’s welfare could be
affected if age-related issues prevent
proper supervision, support, and
safety. Considering the inherent
physical risks of pregnancy, and
documented increased complication
rates among surrogate mothers,
allowing surrogacy up to age 54
may heighten these risks [8-10].
Hence, a serious dilemma remains:
the need to protect surrogates’
health versus the altruistic desire
to help others become parents,
although such altruism should never
endanger the surrogate’s life or
health.
According to Article 1458 of the
Greek Civil Code, the surrogate
must be medically suitable for
pregnancy, although the law offers
no detailed criteria. Even though
Article 13 §2 of Law 3305/2005
requires her to undergo medical
and psychological evaluations of
her health condition at the time
of examination, these findings
cannot predict the psychological
impact of pregnancy, hormonal
changes, or environmental
pressures. Surrogacy requires
judicial authorisation, with courts
reviewing legality rather than
suitability, which establishes the
legal mother as the woman
Bioethics of Surrogacy in Greece
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who received permission. This
authorization is valid only when
the court’s decision is irrevocable,
which can cause delays and stress,
especially for the intended mother.
Altruistic Agreement
According to Greek law, surrogacy
requires a written agreement of
no compensation between the
intended parent(s) and the
surrogate, as well as her spouse or
civil partner. If the surrogate is a
foreign national, the agreement
must also be provided in a
language she understands. In cases
where the intended parent is a
single woman or an unmarried
couple, the agreement must
be executed as a notarial deed,
enabling voluntary recognition
of the child and ensuring a fully
informed decision. In practice,
agreements may attempt to
regulate the surrogate’s lifestyle
(e.g., diet, exercise, social activities).
In my opinion, any terms that
unreasonably restrict the surrogate’s
autonomy or personal rights are
inappropriate and unacceptable.
Under Article 1458 of the Greek
Civil Code, which is in line with
the Oviedo Convention, surrogacy
must be altruistic, and payments
are limited strictly to: a) expenses
related to achieving pregnancy,
childbirth, and postpartum care,
and b) compensation for lost
income due to absence from work.
Altruism requirements pose major
bioethical challenges, as genuine
altruism is likely among relatives
and friends than among unrelated
individuals. Online advertisements
in Greece, including advertised
availability, expectations, and fees,
already reveal the existence of a
clear surrogacy market. Although
the law permits reimbursement
of medical and pregnancy-related
expenses, lost income (€10,000 or
equivalent of US $11,600), and a
fixed amount (€10,000-15,000 or
equivalent of US $11,600-17,400)
for physical strain, the actual
financial burden on intended parents
is extremely high (€100,000 or
equivalent of US $116,000). In fact,
this amount surpasses the annual
income of the majority in Greece,
raising concerns about surrogates
who may have compromised
autonomy when faced with
economic or social pressures or
coercion.
Under the recent amendment,
Article 46 § 2 of Law 5197/2025,
surrogacy is allowed only when
both the intended parent and the
surrogate reside in Greece, which
aims to reduce commercialization
and prevent illegal practices such
as trafficking. This change may
create significant obstacles for
Greek citizens living abroad who
retain Greek nationality, as it
raises questions of its
constitutionality related to equal
treatment between Greek residents
and Greek citizens abroad. The
residency requirement rises
bioethical concerns regarding
the principle of equal access to
reproductive rights, as it ties legal
surrogacy to location rather than
citizenship. Furthermore, restricting
surrogacy arrangements to residents
may inadvertently drive Greek
nationals abroad to seek surrogacy
in less regulated jurisdictions
increasing risks of exploitation and
commercialization.
Surrogacy and Criminological
Issues
Although current forensic data
in Greece do not allow a precise
assessment of human trafficking
linked to surrogacy, documented
cases have shown that crime
rings have exploited women by
trafficking eggs and coercing them
into surrogacy. The trafficking of
illegal genetic material used in
surrogacy procedures is considered
as a form of human trafficking
and is prohibited under Law
3984/2011. Accordingly, the
question arises as to whether
the strict ban on compensation
may inadvertently encourage the
emergence of illegal markets.
Some argue that regulated payment
could reduce exploitation, while
others fear that it would merely
shift criminal activity into more
concealed forms. As Article 26 §§5,
8 of Law 3305/2005 sets penalties
for violating surrogacy rules,
unauthorised MAR practices, and
illegal brokerage, stricter sanctions,
especially targeting intermediaries,
may be necessary to enhance
deterrence of violations.
Conclusion
Since surrogacy is regarded as a
prominent reproductive option,
the growing commercialization
of surrogacy has led to ongoing
ethical debates regarding dignity
and potential exploitation. The
surrogacy process has both physical
and psychological impacts on all
parties involved, making clinical
care, psychological support, and
transparency essential to minimise
potential harm. Greece, as one of
the few countries to have
legislatively regulated altruistic
surrogacy, stands at a critical
juncture. The recent amendment
of Article 46 of Law 5197/2025,
which excludes male same-
sex couples and single men on
the ground that the inability to
conceive due to gender does not
constitute a medical inability,
raises profound concerns regarding
equality, non-discrimination, and
reproductive autonomy. By linking
eligibility to biological capacity
rather than reproductive need,
the Greek law risks transforming
Bioethics of Surrogacy in Greece
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surrogacy from a right into a
privilege determined by gender.
Clear and ethically informed
policies are therefore essential as
frameworks that shape clinical
practice, psychological care, and
the dignity of all parties involved.
Responsible and robust regulation
and ethical oversight are needed
to ensure that surrogacy remains
a pathway to parenthood without
compromising the dignity and
well-being of surrogates, intended
parents, and children. By
prioritising these values, surrogacy
can fulfill its true promise of
expanding reproductive possibilities
while fostering empathy, autonomy,
and respect for all parties.
AI Disclosure Statement
The author used artificial intelligence
tools for language editing and
proofreading only. The intellectual
content, structure, analysis, and
conclusions remain entirely those of
the author.
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7. Government (Greece). Court
Decision nr. 487/2023 of the
Patras Multi-Member Court
[Internet]. 2023 [cited 2026 Feb
20]. Greek. Available from: https://
www.sakkoulas-online.gr/reader/
d61fbdb9b8e0aeab5152
8. Wise J. Surrogates have higher
risk of pregnancy complications,
research finds. BMJ. 2024;386:
q2100.
9. Science Media Exchange.
Surrogates may face higher risks
of complications in pregnancy
and after birth [Internet]. 2024
[cited 2026 Feb 20]. Available
from: https://www.scimex.org/news
feed/surrogates-may-face-higher-
r i s k s – o f – c o m p l i c a t i o n s – i n –
pregnancy-and-after-birth
10. Ahmari Tehran H, Tashi S,
Mehran N, Eskandari N, Dadkhah
Tehrani T. Emotional experiences
in surrogate mothers: a qualitative
study. Iran J Reprod Med.
2014;12(7):471-80.
Maria Gatzoflia, MSc (Bioethics)
Attorney at Law & Medical
and AI Ethicist,
Member of the Athens Bar Association
Accredited Mediator (MoJ)
Athens, Greece
gatzoflia@gmail.com
Bioethics of Surrogacy in Greece
41
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MedEdAfrica 2025 and the State of African Medical Education
MedEdAfrica 2025 and African Medical Education
Africa continues to face a persistent
health workforce paradox, with
approximately 25% of the global
disease burden but only 3-4% of
the global health workforce [1].
Between 2010 and 2023, the number
of medical schools across the
continent grew from around 165 to
444, and Africa now produces over
225,000 health graduates annually
from more than 4,000 training
institutions [2,3]. Despite this
growth, Africa still faces a projected
shortfall of 6.1 million health
professionals by 2030 [3], one that
is further compounded by
fragmented education systems,
misaligned curricula, and an
outmigration rate estimated
between 20% and 40% of
physicians trained on the continent
[4].
To address this workforce and
training challenge, a unified
continental and interdisciplinary
platform, including medical
education leaders, researchers,
policymakers, faculty, and students,
is needed for African medical
schools to collectively identify,
deliberate on, and respond
effectively. In March 2025,
African leaders took a significant
step toward realising this vision
through the inaugural Advancing
Medical Education in Africa
Conference (MedEdAfrica 2025).
This commentary summarizes
the key scientific outputs and
outcomes of the MedEdAfrica 2025
and leaders’ reflections about the
present state and future trajectory
of African medical education.
Abebe Bekele
Jacqueline Kitulu
Amal Saleh Nour
Bisola Olubiyi
Menelas Nkeshimana
Lionel Green-Thompson
Kara L. Neil Barnabas Tobi Alayande
42
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Scope and Scale
Held in Kigali, Rwanda, the initial
plan of MedEdAfrica 2025 grew
from a 500-person gathering to
over 750 attendees, including 117
medical school deans from 34
African countries, 195 student
delegates, 64 speakers, and
representatives from the World
Health Organization Regional
Office for Africa (WHO-
AFRO), the World Federation
for Medical Education (WFME),
the Association of Medical
Councils of Africa (AMCOA), and
the World Medical Association
(WMA) [5]. Participants attended
from all five African Union
regions, reflecting both the scale of
geographic engagement, as well as
the practical reality that proximity
reduces the structural barriers
(e.g., cost, visa accessibility, travel
logistics) that typically exclude
African scholars from Global
North conferences [5,6]. The
conference featured 86 abstracts,
including 32 oral and 56 poster
presentations, spanning topics
from artificial intelligence (AI)-
driven simulation and competency-
based education to social medicine,
medical humanities, medical
education during crises, and the
role of the African diaspora. The
digital reach was substantial, with
over 123,000 total social media
impressions and strong engagement
across X, Facebook, and LinkedIn,
underscoring the historically unmet
demand for a continental platform
for scholarly exchange among
African medical schools.
Scientific Agenda
The intellectual quality and breadth
of the program distinguished
MedEdAfrica 2025 from a standard
convening, with three sessions
particularly standing out in the
scientific agenda. First, the opening
plenary entitled, “2050 in Our
Vision: Embracing Technology
and Innovation in Medical
Education,” convened four
panellists who were deans and
faculty from institutions across the
continent, to examine how African
medical education systems must
evolve to remain relevant. There
was consensus that AI, virtual
simulation, and digital learning
platforms must become embedded
in teaching and assessment, rather
than added as supplementary or
ad hoc modules. The panelists
also explicitly cautioned against
importing uncontextualised models
of innovation, calling instead for
African-led approaches that are
grounded in local infrastructure
realities and disease contexts [5].
This framing around embracing
transformative technologies, while
insisting they be contextualised
and African-owned, set the tone
for other sessions throughout the
conference.
Second, one presentation described
an innovative district hospital
clerkship model that was designed
to train medical students in under-
resourced settings, where they
could develop relevant clinical
competencies and were more
likely to stay and practice in those
communities after graduation. As
a result, participants called for
competency mapping in alignment
with the local community needs.
Finally, one interactive session
entitled, “Competency-Based
Medical Education (CBME)
is Feasible and Essential for
Undergraduate and Postgraduate
Medical Education in Africa,”
incorporated presentations and a
structured debate on the feasibility
of CBME in medical education.
The majority sided with the
opposing argument (CBME is not
feasible), citing that it demands
infrastructure, faculty capacity,
and functional health systems
that remain out of reach for many
African institutions [5]. This
outcome was not a rejection of
educational quality standards,
but rather a claim by participants
that externally developed CBME
frameworks require African
interrogation and contextualisation.
The debate format will serve as
a model for MedEdAfrica 2026,
which will examine the question of
global versus African-contextualised
accreditation systems.
Consortium of Medical Schools-
Africa (COMS-A) Foundation from
Convening to Institution
At the heart of MedEdAfrica
2025, a historical moment
occurred when the 117 deans in
attendance separately convened,
debated, and adopted the
COMS-A constitution, establishing
the governance structure for a
continent-wide platform dedicated
to transforming health professions
education [5,7]. The following
day, an inaugural Executive
Committee of eight members was
elected, overseen by an independent
electoral commission comprising
representatives from the WMA,
WHO-AFRO, and WFME [5].
COMS-A provides a grassroots
platform for collective ownership,
grounded in the principle that
African medical schools must
lead (not just receive) the
transformation of their education
and health systems [7]. The
strategic goals included the
standardisation and harmonisation
of health professions education
curricula, development of
continent-wide quality assurance
benchmarks co-designed with
national accreditation bodies, and
support for collaborative research
and faculty development across
multi-lingual member institutions
[8]. During the first year, the
MedEdAfrica 2025 and African Medical Education
43
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COMS-A expanded to over 180
member institutions, with the
University of Global Health Equity
mandated to host a full-time
secretariat in Rwanda. Its design
addressed structural vulnerabilities
that undermined previous African
medical school associations including
the absence of a permanent
secretariat and governance gaps [5].
What MedEdAfrica 2025 Revealed
MedEdAfrica 2025 revealed three
key findings that reflect the path
forward for medical education
across Africa. First, the high
attendance and engagement data
reflect the significant demand
for peer-to-peer African medical
education exchange, which has
been systemically suppressed by
the structural barriers of hosting
events in the Global North. Over
90% of global health conferences
take place in high-income
countries, imposing cost-prohibitive
registration fees, visa barriers,
and travel expenses that exclude
professionals whose contexts are
central to the discussions [6]. This
convening drew 750 participants
from 46 countries, 50% above its
initial projections, representing the
predictable outcome of removing
those barriers.
Second, the scientific program
demonstrated that medical
educators across the continent
exhibit the expertise and
determination to engage rigorously
with challenging questions in
health professions education.
The scientific sessions reflect
this prepared workforce through
interactive debates on workforce
migration and CBME, plenary
on the history of African medical
schools, and breakout sessions on
AI, simulation, and social medicine.
The missing element remains
expanding the visibility of this
COMS-A platform to a continental
scale with institutional legitimacy.
Third, the unanimous adoption
of the COMS-A constitution by
deans from across the continent’s
linguistic, regional, and institutional
divides demonstrated that collective
African governance of medical
education is structurally possible.
Looking Ahead to MedEdAfrica
2026
MedEdAfrica 2026 will convene
on 6-8 July 2026 in Addis Ababa,
Ethiopia, co-hosted by the
COMS-A and the Ministry of
Health of the Federal Democratic
Republic of Ethiopia. Under the
theme, “Preparing Africa’s Health
Workforce for an Uncertain
Future: Harnessing Partnerships,
Technology, Innovation, and
Leadership”, the program is
structured around four thematic
tracks: (1) leadership, governance,
and African ownership; (2)
transformative technologies, AI, and
simulation; (3) maternal, newborn,
and child health alignment; and (4)
learner-centered systems, including
assessment and accreditation. With
over 800 participants expected, the
convening in Addis Ababa – as
the seat of the African Union and
a continental policy hub – signals
an intentional effort to engage
the regulatory and governmental
actors needed to translate COMS-
A’s commitments translating into
workforce and health system
outcomes.
Conclusion
MedEdAfrica 2025 provides
structural evidence that a
continental platform for African-
led medical education reform is
feasible, timely, and capable of
producing long-lasting institutional
and systemic outcomes. The
establishment of the COMS-A,
the high-quality scientific program,
and participation across all five
African regions constitute a
foundation for continued scale-up.
The challenge now is to sustain
the momentum by adequately
resourcing governance structures,
publishing MedEdAfrica research
in peer-reviewed literature, and
advancing policy discussions
initiated in Kigali through Addis
Ababa and beyond. The WMA
and its member organisations
are well-positioned to engage in
this work, with initial dialogue
already underway with COMS-A
as a key platform for African
medical education. These early
interactions reflect a shared interest
in recognising Africa-led convenings
as hubs for knowledge exchange
and in exploring future collaboration.
Author Contribution Statement
AB, KLN, and BO prepared
the original manuscript draft.
JK, ASN, BTA, MN, and LG-T
conceptualised the paper. All authors
critically reviewed and edited the
final manuscript.
AI Disclosure Statement
The authors used artificial
intelligence tools for language
editing and proofreading only.
The intellectual content, structure,
analysis, and conclusions remain
entirely those of the authors.
MedEdAfrica 2025 and African Medical Education
44
BACK TO CONTENTS
References
1. Asamani JA, Bediakon KSB, Bo-
niol M, Munga’tu JK, Christmals
CD, Okoroafor SC, et al. State of
the health workforce in the WHO
African Region: decade review of
progress and opportunities for policy
reforms and investments. BMJ Glob
Health. 2024;7:e015952.
2. World Health Organization, Re-
gional Office for Africa. Report of
Africa health professions education
dialogue. Brazzaville: WHO; 2024.
3. Rosenberg J, Juvonen M, Ng MZ,
Arinzeh N, Adanu TSA, Ninsiima
H, et al. Medical schools in Afri-
ca: seeing momentum. BMJ Glob
Health. 2024;9:e014468.
4. Talib Z, Narayan L, Harrod T.
Postgraduate medical education
in Sub-Saharan Africa: a scoping
review spanning 26 years and les-
sons learned. J Grad Med Educ.
2019;11:34-46.
5. University of Global Health Equity.
MedEdAfrica Conference Summary
Report 2025: Inaugural Advancing
Medical Education in Africa – col-
laborative leadership conference. Ki-
gali: UGHE; 2025. Available from:
https://coms-africa.org/wp-content/
uploads/2025/05/New-Short-Med-
EdAfrica-2025-Report.pdf
6. Velin L, Lartigue J, Johnson SA,
Zorigtbaatar A, Kanmounye US,
Truche P, et al. Conference equity
in global health: a systematic re-
view of factors impacting LMIC
representation at global health
conferences. BMJ Global Health.
2021;6:e003455.
7. Bekele A, Neil KL, Dei-Adomakoh
Y, Abdi Mahmoud S, Frank-Briggs
A, Atwoli L, et al. African solutions
for African medical education: the
strategic establishment of the Con-
sortium of Medical Schools in Africa.
BMJ Glob Health.2025;10:e020145.
Authors
Abebe Bekele, MD, PhD
University of Global Health Equity
Butaro, Rwanda
abekele@ughe.org
Jacqueline Kitulu,
MBS, OGW, MD, MBA, FCMA
President, World Medical Association
Ferney-Voltaire, France
jkitulu@gmail.com
Kara L. Neil, EdD
University of Global Health Equity
Butaro, Rwanda
Africa Health Sciences University
Kigali, Rwanda
kneil@coms-africa.org
Amal Saleh Nour, MD
Addis Ababa University
Ethiopian Medical Association
Addis Ababa, Ethiopia
salehamal12@gmail.com
Bisola Olubiyi, MBBS, MSc
University of Global Health Equity
Butaro, Rwanda
bolubiyi@ughe.org
Barnabas Tobi Alayande,
MBBS, MBA, MPH
University of Global Health Equity
Butaro, Rwanda
balayande@ughe.org
Menelas Nkeshimana, MMed
Ministry of Health Rwanda
Kigali, Rwanda
menelas.nkeshimana@moh.gov.rw
Lionel Green-Thompson, MD, PhD
University of Cape Town
Cape Town, South Africa
lionel.green-thompson@uct.ac.za
MedEdAfrica 2025 and African Medical Education
45
Sustainability in Surgery: An Initiative by
the Surgical Society of Bangalore
Sustainability in Surgery
Climate change is one of the
most significant global threats to
human health, with healthcare
systems contributing substantially
to environmental degradation.
The health sector is responsible
for approximately 4.6% of global
greenhouse gas emissions, and
surgical services are among the
most resource-intensive components
[1,2]. Operating theatres function
as high-intensity clinical
environments, characterised by
continuous energy demand and
dependence on disposable resources,
making them a critical focus area
for sustainability interventions as
surgical volumes expand globally.
Addressing sustainability in
healthcare is increasingly recognised
as a global priority and aligns closely
with major international policy
frameworks, including the United
Nations Sustainable Development
Goals (SDGs). In particular,
SDG 3 (Good health and well-
being), SDG 12 (Responsible
consumption and production), and
SDG 13 (Climate action) underscore
the need for health systems that are
both environmentally responsible
and socially equitable [3]. Building
on these frameworks, the global
surgical triple goal emphasises
that surgical innovation must now
be driven by sustainability to ensure
that the expansion of essential
care does not exacerbate global
healthcare inequities [4]. This
perspective shifts the focus from
merely increasing surgical volume
to ensuring that such growth
is environmentally sustainable
and ethically sound. The World
Health Organization has further
highlighted the urgent necessity
of developing low-carbon, climate-
resilient healthcare systems,
especially in low- and middle-
income countries where rapid
expansion of medical services is
occurring [5].
In this context, surgical practice
warrants particular attention as a
focal point for operational change.
Operating theatres concentrate
energy consumption, material
use and waste generation within
a single clinical setting, allowing
targeted interventions to deliver
measurable environmental benefits
without compromising patient safety
or clinical outcomes. This focus
is particularly pertinent in India,
where high surgical volumes,
constrained public sector resources,
and marked infrastructure variability
mean that even incremental gains
in efficiency can yield substantial
environmental benefits and enhance
healthcare system resilience.
Sustainability Strengths of the
Indian Healthcare System
In India, the healthcare system
serves a population of approximately
1.47 billion people, characterised
by a high and heterogeneous
disease burden, substantial reliance
on resource-intensive hospital-
based care, and pronounced
urban–rural disparities in access
and infrastructure. Consequently,
healthcare delivery contributes to
an estimated 2% of the national
climate footprint, a proportion
expected to increase with
urbanisation, population growth,
and rising demand for surgical
care [2]. The heterogeneity of
healthcare infrastructure across
India provides a natural setting
to assess the scalability and
adaptability of sustainability
initiatives across diverse clinical
environments.
Over the past decade, three
landmark national policies have
strengthened environmental
governance within India’s healthcare
sector. First, the Bio-Medical
Waste (Management and Handling)
Rules, first adopted in 1998
and revised in 2016, established
standards for waste segregation
and disposal. Second, the National
Programme on Climate Change
and Human Health was approved
in 2019, under the National
Health Mission, integrating
environmental sustainability into
health system planning. Third,
the Health and Environment
Leadership Platform, launched
in 2017, has promoted the
adoption of sustainable practices
across Indian hospitals.
Bodela Sree Vidhya
Prem Kumar A.
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46
Linking Surgical Care with
Sustainability Principles
Surgical care is inherently resource-
intensive, requiring continuous
electricity supply, substantial water
use, energy-demanding sterilisation
processes, and extensive reliance
on single-use consumables. Life
cycle assessment studies have
shown that a single procedure is
associated with a substantial carbon
footprint, with reported emissions
ranging from approximately 6 to
over 800 kg of carbon dioxide
equivalents depending on the
type and complexity of surgery,
anesthetic practices, energy use,
and material consumption [6].
These challenges are particularly
pronounced in high-volume public
hospitals, where infrastructure
constraints and workforce
pressures limit the adoption of
environmentally responsible
practices.
In response to these challenges,
the Surgical Society of Bangalore,
under the leadership of Professor
Prem Kumar (President), developed
the Sustainability Initiative in
2025, to integrate global
sustainability principles and
practices into operating theatres
within the Indian healthcare
system. By improving sustainability
in surgery, hospitals can enhance
efficiency, reduce costs, and optimise
resource utilisation. In fact, evidence
indicates that environmentally
responsible surgical practices can be
implemented without compromising
infection control standards or
clinical outcomes [7]. Furthermore,
the Sustainability Initiative aims
to foster a culture of stewardship,
accountability, and professional
commitment across surgical
specialties as well as throughout
undergraduate medical education,
postgraduate surgical training, and
continuing professional develop
(Photo 1).
Specifically, the Sustainability
Initiative incorporated a
strategic framework to promote
environmental stewardship with
improved clinical outcomes through
improved surgical knowledge
(Sustainability in Surgery Booklet),
operational efficiency (Green
Operating Theatre Checklist), and
cultural accountability (Oath for
Sustainable Surgery).
1. Sustainability in Surgery Booklet.
This booklet outlines practical
guidance on energy optimisation,
rational use of consumables,
biomedical waste segregation,
and environmentally responsible
procurement within the Indian
healthcare system. By integrating
education, operational change,
and accountability into routine
surgical practice, it emphasises
the need for sustained system-
level transformation over
short-term interventions.
These recommendations align
with existing infection control
standards and clinical governance
standards, demonstrating that
sustainability can be embedded
into routine surgical workflows.
2. Green Operating Theatre Checklist.
This checklist supports
perioperative teams in making
environmentally responsible
decisions across all workflow
stages, focusing on high-
impact areas such as low-
global-warming anaesthetic
use and energy optimisation.
By reducing unnecessary
consumables and auditing
waste segregation, it embeds
measurable resource conservation
into surgical routines, promoting
environmental stewardship without
compromising sterility or patient
safety.
3. Oath for Sustainable Surgery. The
introduction of a professional
sustainable oath marks a
critical shift towards ethical
Sustainability in Surgery
Photo 1. Professor Prem Kumar, President (2025) of the Surgical Society of Bangalore, promoted the integration of
environmental stewardship and clinical excellence during a monthly clinical meeting at API Bhavan, Bangalore,
in September 2025. Credit: Surgical Society of Bangalore.
BACK TO CONTENTS
47
accountability and cultural
transformation in surgery. Inspired
by traditional medical ethics,
it extends the surgeon’s duty
of care to include minimising
environmental harm. As a formal
pledge to deliver high-quality
outcomes while protecting
community and ecological health,
it integrates sustainability into
surgical identify and fosters
long-term behaviour change
across healthcare systems.
Conclusion
Within the Indian healthcare
system, rising surgical demands,
combined with finite resources,
makes sustainability in surgery
both a practical necessity and
an ethical obligation. The
Surgical Society of Bangalore’s
Sustainability Initiative demonstrates
how locally led, professionally
driven programmes can align
global sustainability goals with
national policy frameworks and
routine clinical practice. By
operationalising existing guidelines
through education, structured tools,
and ethical commitments, this
model offers a scalable approach
for other urban and teaching
centres across India. Notably,
it illustrates that sustainability
initiatives can enhance efficiency
and accountability without
compromising patient safety.
As climate change increasingly
shapes population health outcomes,
surgical communities must play
an active role in reducing the
environmental footprint of
healthcare delivery.
References
1. Karliner J, Slotterback S, Boyd R,
Ashby B, Steele K. Health care’s
climate footprint: How the health
sector contributes to the global
climate crisis and opportunities for
action. Reston: Health Care Without
Harm; 2019.
2. Romanello M, Walawender M, Hsu
SC, Moskeland A, Palmeiro-Silva Y,
Scamman D, et al. The 2024 report
of the Lancet Countdown on health
and climate change: facing record-
breaking threats from delayed action.
Lancet. 2024;404(10465):1847-96.
3. United Nations. Transforming
our world: the 2030 Agenda for
Sustainable Development. New York:
UN; 2015. Available from: https://
digitallibrary.un.org/record/3923923
4. Meara JG, Greenberg SL. The glob-
al surgical triple goal: surgery must
improve health, be equitable, and
environmentally sustainable. J Clim
Chang Health. 2025;13:100458.
5. World Health Organization. Safe,
climate-resilient and environmental-
ly sustainable health care facilities:
an overview. Geneva: WHO; 2024.
Available from: https://www.who.int/
publications/i/item/B09119
6. Rizan C, Steinbach I, Nicholson
R, Lillywhite R, Reed M, Bhutta
MF. The carbon footprint of surgical
operations: a systematic review. Ann
Surg. 2020;272(6):986-95.
7. Brighton & Sussex Medical School,
Centre for Sustainable Healthcare,
and UK Health Alliance on Climate
Change. Green surgery: reducing
the environmental impact of surgical
care. London: UKHACC; 2023.
Available from: https://ukhealthal-
liance.org/sustainable-healthcare/
green-surgery-report/
Author Contribution Statement
BSV and PKA conceptualised the
design and prepared the original
manuscript draft. All authors
critically reviewed and revised the
manuscript and approved the final
version for publication.
AI Disclosure Statement
The authors used artificial
intelligence tools for language
editing and proofreading to
improve grammar, structure, and
clarity. The intellectual content,
analysis, and conclusions remain
entirely those of the authors.
Authors
Bodela Sree Vidhya, MBBS
Surgery Resident, Department of
General Surgery, Bangalore Medical
College and Research Institute
Bangalore, Karnataka, India
vidhyareddy1602@gmail.com
Prem Kumar A.,
MS, FICS, FIMSA, FACS,
FRCS (Glasg), PhD (MIS)
Professor and Head of Unit,
Department of Surgery,
Bangalore Medical College
and Research Institute
Bangalore, Karnataka, India
drpremk512@yahoo.co.in
Sustainability in Surgery
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48
Renewed Ethos for the One Health Movement: A Book Review
Book Review
The national and international One
Health movement has expanded
substantially over the past two
centuries, where four key figures (two
physicians and two veterinarians)
led the transformation of the
perceived interconnectedness of
human, animal, and environmental
health. Initially recognised as
the One Medicine concept,
Rudolf Virchow (physician)
demonstrated the value of
integrating medical and veterinary
sciences in the 19th century.
Building on these findings, William
Osler (physician), James Harlan
Steele (veterinarian), and Calvin
Schwabe (veterinarian) advanced
the One Medicine foundation to
the modern One Health concept.
Nowadays, the One Health High-
Level Expert Panel, an advisory
Bruce Kaplan
Lisa Conti
Laura Kahn
Thomas Yuill
Thomas Monath
Helena Chapman
Craig Carter Elizabeth Barrentine
Richard Seifman
Jack Woodall
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49
group to the Quadripartite
organizations (Food and Agriculture
Organization of the United
Nations, FAO; United Nations
Environment Programme, UNEP;
World Health Organization,
WHO; World Organisation for
Animal Health, WOAH) has
further refined the One Health
definition, incorporated the 4 C’s
(communication, coordination,
collaboration, capacity building),
and developed an operational guide
to support the implementation
of the One Health Joint Plan of
Action (2022-2026) [1,2].
Established in 2006, the One
Health Initiative (OHI) has played
a fundamental role in engaging
diverse stakeholders in the One
Health movement, supporting a
wide range of professional and
occupational initiatives worldwide.
Together with the One Health
Commission and the Global One
Health Community (formerly,
One Health Platform), the three
groups have supported One
Health Day celebrated annually
on 3 November. Notably, the
OHI autonomous pro bono team
contributed an interview and
prepared a historical review of the
One Health movement, describing
primary leaders in human, animal,
and environmental health from
the 1880s to present day [3,4].
In this article, the OHI team
synthesises key highlights and
offers analytical perspectives on
a timely One Health publication
for the global community, as an
opportunity to help catalyse
collective dialogue on ethical
approaches to the practical
implementation of the One Health
concept.
Discovering the One Health
Roadmap
As emerging global challenges grow
more complex and interconnected,
understanding the scientific,
social, and ethical dimensions
will be essential for effective
preparedness and response by
leaders and community members
alike. The Ethics for One Health
Approaches: A Roadmap for Future
Directions book, published by
Henrik Lerner in 2025, marks the
path for a closer look at the ethos
for the One Health movement
[5]. The author proposes an
accompanied literary journey to
review and identify frameworks
on strategically solving ethical
challenges using the One Health
approach.
In the first chapter (“Introduction
and Scope of the Book”), Lerner
presents an overview of how One
Health approaches have evolved
since the 19th
century (Rudolf
Virchow as the “Father of Modern
Pathology”), and underscores the
importance of ethical approaches
to analyze the utility of these One
Health approaches in real-world
scenarios using three concrete
examples. First, since understanding
infectious disease transmission
(including bats) can be connected
to value systems and knowledge
traditions, conflicts between
species conservation and disease
transmission or prioritising one
development goal versus all goals
may present. Second, as animal-
assisted interventions (including
therapy, learning, and coaching) are
directly aligned with human health,
promoting best hygiene practices
may not reduce all potential risks
of infectious disease spread (such
as antimicrobial resistance). Third,
compounding risks of marine
ecosystems – such as increasing
ocean temperatures (leading to
warming, acidification, and coral reef
health) or plastic waste (causing the
accumulation of microplastics and
increased health risks in humans
and animals) – bring non-living
elements of ecosystems to the
forefront of global dialogue.
In the second chapter (“Values
and Scope of One Health
Approaches”), the author highlights
that the empirical and conceptual
groundwork for a unified ethical
approach is posed by an examination
of central values and definitions
of various integrated health
frameworks. He discusses key issues
for advancing cohesive, practicable
One Health ethical principles.
The primary focus remains on
integrating or amalgamating
diverse health standpoints by
independently examining the
holistic perspectives of One
Health, EcoHealth, Planetary
Health, and One Welfare.
Consequently, this chapter
positions the book as a roadmap
for future dialogue and research
aimed at building a more robust
ethical framework for One Health
approaches.
Exploring Ethical Perspectives
In the third chapter (“Ethical
Attempts for One Health
Approaches”), the author presents
proposed ethical frameworks
within One Health approaches,
disputing some claims that One
Health approaches ignore ethics.
This chapter points out that when
participants address situations
requiring multiple disciplines,
they must recognize that actions
employed within each discipline
may reflect distinct ethical
viewpoints and norms, which
may not always be compatible.
The author cites several examples
related to animal culling in
dealing with disease outbreaks,
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50
noting that domains encompassed
by a broad One Health definition
– such as Planetary Health and
EcoHealth (e.g. biophilia, land
ethic) – may be overlooked by
biomedical experts. The Merriam-
Webster Dictionary defines ethics
as the “principles of conduct governing
an individual or a group”, as a
reminder that individual behaviors
and activities may vary substantially
from our own. The unspoken
question, however, remains:
Who holds the responsibility for
determining what elements fall
within or outside the scope of One
Health?
In the fourth chapter (“Expanding
Anthropocentric Ethics”), Lerner
evaluates the feasibility of whether
or not an anthropocentric, ethics-
based framework can meet the
needs of the One Health
movement. The author examines
the pros and cons related to issues
of anthropocentric bioethics,
principlism, and biophilia. He
stresses that a truly effective,
ethical framework for One Health
must transcend conventional public
health concerns, by incorporating
moral consideration for ecosystems
and recognising the intrinsic value
of non-human species beyond
human exploitation.
In the fifth chapter (“Animal
Ethics, Veterinarian Ethics, and
Humans”), the author highlights
the burgeoning global curiosity
and desire to better understand
the vast realm of animal ethics and
human-animal interactions and
relations. The chapter references
decades of work by Martha
Nussbaum, who avows that all
humans and wild and domesticated
animals have a straightforward
right to dignity. It also showcases
the work by David Fraser and other
well-known philosophers on animal
welfare and the ethical treatment
of animals. As Lerner’s analysis
looks closely at similarities and
differences between human and
animal species, he examines
Nussbaum’s premise that the
combined capabilities concept can
also apply to animals in various
ways. Finally, the author references
the four principles of animal
ethics, comparing and contrasting
Fraser and Fawcett et al. (Anne
Fawcett, Siobhan Mullan, and Paul
McGreevy) versions, and concludes
that all forms of ethical decision-
making (principlism) tend to be
too narrow in scope and not
inclusive enough for One Health
approaches.
In the sixth chapter (“Environmental
Ethics”), Lerner uses the lens of
Aldo Leopold’s Land Ethic
framework to discuss the importance
and the interconnectedness of
environmental ethics in the One
Health approach. He developed
the Lerner’s Land Ethic Decision
Model, influenced by the
Intergovernmental Platform on
Biodiversity and Ecosystem (IPBES)
that shifted its framework from
the Nature’s Contribution to People
(NCP) to the Nature Futures
Framework (NFF). Through
three applications of his decision
model, the author examines One
Health bioethics, emphasising the
effects on the beauty, stability, and
integrity of various biotic
communities.
In the seventh chapter (“A Need
for a Pluralistic Ethics”), the
author promotes pluralistic ethics
as an inclusive approach that
engages multiple perspectives and
fosters fair and ethical conclusions
through a two-step process. The
first stage (“pre-framing”) includes
the selection of relevant
stakeholders to identify hidden
assumptions, acknowledge cultural
differences, select values, and
set agendas. The second stage
(“ethical dialogue”) brings the first
stage results to an open-ended,
inclusive discussion with the goal
of obtaining feedback and mutual
understanding. With the frequent
omission of the role of animals
and the environment in ethical
debates, the author comments on
the important inclusion of
indigenous people’s belief systems
as well as the ethical, cultural, and
philosophical views underlying
animal rights and the moral
position of animals. Ongoing
global discourse spotlights One
Health priorities in national and
international funding, policy
development, and capacity building
activities.
Incorporating Lessons Learned
In the final chapter (“A Roadmap
for Future Directions”), Lerner
draws on the analysis developed in
the prior chapters that One Health
advocates and experts lack a shared
definition and ethical integration
to address the complex challenges
spanning human, animal, and
environmental domains. Various
One Health initiatives routinely
involve selective stakeholders
with divergent world views –
such as veterinarians, physicians,
ecologists, indigenous communities,
sociologists, agriculturists,
policymakers, and the public –
and each group brings their own
assumptions about what counts as
harm, benefit, responsibility, and
justice. Asserting ethical pluralism
as a structural requirement for
One Health, the author proposes
an inclusive, dialogical model to
manage diverse values, cultures,
and knowledge systems involved
in One Health decision-making.
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51
Conclusion
The Ethics for One Health
Approaches: A Roadmap for Future
Directions book, published by
Henrik Lerner, offers a fresh
ethical perspective about the
human-animal-environment nexus
that can broaden the scope and
enrich the One Health discourse.
The author underscores the
analysis that no single ethical
framework effectively captures
the diverse values and interests
involved in addressing complex
One Health issues. By supporting
the pluralistic two-step dialogue,
sharing multidisciplinary and
multisectoral perspectives on
pressing global health topics – like
the triple planetary crisis (climate
change, biodiversity loss, pollution)
– can lead to developing ethical
and cost-effective solutions and
sustainable change.
While this book provides a
valuable forum for debating ethical
perspectives on One Health
approaches, the author does
not share guidance on resolving
conflicts arising from different
disciplinary viewpoints. Although
conflict resolution extends beyond
the scope of this literary work,
it remains an essential critique
deserving broader attention in
One Health discussions. Future
trends that highlight One
Health ethics worldwide should
consider understanding the gap
between ethical concepts (e.g.,
anthropocentrism, biocentrism,
ecocentrism, zoocentrism),
identifying ethical decision
models, and balancing ethical
aspects among different species or
levels [6]. Furthermore, the author
recognizes that future progress
for the One Health movement
depends on ethical consensus
among diverse global stakeholder
communities.
Note: The OHI team contends
that, ceteris paribus, irrefutable
evidence underscores the critical
need to institutionalize the One
Health concept or approach
worldwide, as it will “…protect
and/or save untold millions of
lives in our generation and for
those to come.”
References
1. One Health High-Level Expert Pan-
el (OHHLEP), Adisasmito WB,
Almuhairi S, et al. One Health:
a new definition for a sustainable
and healthy future. PLoS Pathog.
2022;18(6):e1010537.
2. Food and Agriculture Organiza-
tion of the United Nations, United
Nations Environment Programme,
World Health Organization, World
Organisation for Animal Health.
Rome: FAO, UNEP, WHO, and
WOAH; 2022. Available from:
https://www.who.int/publications/i/
item/9789240059139
3. Kaplan B. Interview with the
co-founder of the One Health In-
itiative. World Medical Journal.
2023;69(1):7-9.
4. Kaplan B, Kahn LH, Monath TP,
Conti LA, Yuill TM, Chapman HJ,
Carter CN, Barrentine B, Seifman
R, Woodall JP. ‘One Medicine−One
Health’: an historic perspective.
World Medical Journal.
2023;69(2):18-27.
5. Lerner H. Ethics for One Health
approaches: a roadmap for future di-
rections. New York City: Springer;
2025.
6. Lerner H. Ethical challenges in scien-
tific studies within One Health. Curr
Environ Health Rep. 2026;13(1):3.
Author Contribution Statement
BK, LK, TM, TY, HC, CC, RS, and
EB conceptualized the design and
prepared the original manuscript
draft. All authors critically reviewed
and revised the manuscript and
approved the final version for
publication.
AI Disclosure Statement
The authors confirm that no artificial
intelligence tools were used in the
preparation of this manuscript.
Authors of the One Health
Initiative Autonomous pro bono
Team
Bruce Kaplan, DVM
Co-Founder,
One Health Initiative team
Contents Manager & Editor,
One Health Initiative website
Sarasota, Florida, United States
bruce@kaplandvm.com
Laura Kahn,
MD, MPH, MPP, FACP
Co-Founder,
One Health Initiative team
Former Research Scholar,
Program on Science
and Global Security,
Princeton School of Public
and International Affairs,
Princeton University
Bethesda, Maryland, United States
lkahn@alumni.princeton.edu
Thomas Monath, MD
Co-Founder,
One Health Initiative team/website
Managing Partner &
Chief Scientific Officer,
Quigley BioPharma LLC
Leominster, Massachusetts,
United States
tom@quigleybio.com
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52
Lisa Conti, DVM, MPH*
*Deceased 6 November 2020
Thomas Yuill, PhD
Professor Emeritus,
Pathobiological Science,
Forest and Wildlife Ecology
Director Emeritus,
Nelson Institute of
Environmental Studies,
School of Veterinary Medicine,
University of Wisconsin-Madison
Madison, Wisconsin, United States
thomas.yuill@wisc.edu
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington, DC, United States
hjchapman@gwu.edu
Craig Carter, DVM, PhD
Department of Veterinary Science,
College of Agriculture,
Food & the Environment
College of Public Health,
University of Kentucky
Lexington, Kentucky, United States
craig.carter@uky.edu
Richard Seifman, JD, MBA
World Bank Senior Health
Advisor (retired)
Washington, DC, United States
seifmanrichard@gmail.com
Elizabeth Barrentine, MBA
Vice president, Business Operations
Public Health Vaccines, LLC
Cambridge, Massachusetts,
United States
bbarrentine@phvaccines.com
Jack Woodall, PhD*
*Deceased 24 October 2016
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