Submission to the World Medical Association Re: WMA International Code of Medical Ethics. Revised Draft for Public Consulation (April, 2021)
Appendix "A"
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Contents
Full Text
WMA International Code of Medical Ethics
Current revised text (as of April 2021) SUBJECT TO CHANGE
Preamble
1. The World Medical Association (WMA) has developed the International Code of Medical Ethics as a canon of ethical principles for the members of the medical profession worldwide. In concordance with the Declaration of Geneva and the WMA's entire policy apparatus, it defines and elucidates the professional duties of physicians toward their patients, other physicians and healthcare professionals, themselves, and society as a whole. The International Code of Medical Ethics should be read as a whole and each of its constituent paragraphs should be applied with consideration of all other relevant paragraphs. Consistent with the mandate of the WMA, the Code is addressed to physicians. The WMA encourages others who are involved in healthcare to adopt these principles.
General principles
2. The primary duty of the physician is to promote the health and well-being of individual patients by providing competent, compassionate care in accordance with good medical practice. The physician also has a responsibility to contribute to the health of the populations they serve and society as a whole. In providing medical care, the physician must respect the dignity and rights of the patient.
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2. The primary duty of the physician is to promote the health and well-being of individual patients by providing competent, compassionate
medical treatment and care in accordance with good medical practice. The physician also has a responsibility to contribute to the health of the populations they serve and society as a whole.
In providing medical care, the physician must respect the dignity and rights of the patient.
[Paragraph 2 reflects the unifying ethical principle of the Code expressed in Paragraph 14].
Reasoning/comments
The primary duty of a physician
qua physician is to provide medical treatment and ancillary care, not simply care. The revision elucidates this point and is also desirable for the reasons given in relation to recommended revisions to Paragraphs
14 and
21.
Paragraphs 13 and 15 set out the obligation to respect the dignity and rights of the patient, so there is no need to refer to the obligation in Paragraph 2. Dropping the final sentence keeps the emphasis in Paragraph 2 on the primary duty of physicians, which appears to be its focus.
3. The physician must practise with conscience, honesty, and integrity, while always exercising independent professional judgment and maintaining the highest standards of professional conduct.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]
4. Physicians must not allow their professional judgment to be influenced by the possibility of benefit to themselves or their institution. They must recognise and avoid, whenever possible, or otherwise declare and manage real or potential conflicts of interest.
5. The physician must practise medicine fairly and justly and provide care without engaging in discriminatory conduct or bias on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor. Care should be provided based on the patient's medical needs.
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. . . Care Treatment and recommendations should be provided based on the patient's medical needs.
Reasoning/comments
The revision is meant to be consistent with recommended revisions to Paragraphs
2,
14 and
21.
6. The physician is obliged to be aware of applicable national ethical, legal, and regulatory norms and standards, as well as relevant international norms and standards. Such norms and standards must not reduce or eliminate the physician's commitment to the ethical principles set forth in this document.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]
7. The physician must strive to use health care resources in a way that optimally benefits the patient, in keeping with fair, just, and prudent stewardship of the shared resources with which the physician is entrusted.
8. When providing professional certification, physicians must only certify what they have personally verified.
9. Physicians must take responsibility for their medical decisions and must not alter their sound professional medical judgments on the basis of instructions from non-physicians. However, physicians should consult with other health care professionals when appropriate.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]
10. Physicians should offer help in medical emergencies, while considering their own safety and competence, and the availability of other options for care.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context because the help a physician is competent and able to provide may not be a medical treatment or intervention. Cf Paragraphs 2, 5, 14, 21]
11. Physicians must engage in continuous learning throughout their professional lives in order to maintain and develop their professional knowledge and skills.
12. Physicians should strive always to practise medicine in ways that are environmentally sustainable with a view to minimising environmental health risks to current and future generations.
Duties to the patient
13. A physician must always provide medical treatment with the utmost respect for human dignity and life.
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A physician must always provide medical treatment with demonstrate the utmost respect for human dignity and life in practising medicine.
Reasoning/comments
Practising medicine entails interactions with people that involve more than providing medical treatment. The suggested revision counters a reductionist emphasis on technique or function. It directs attention to the need to respect all persons
per se, distinct but not derogating from their autonomy and rights (
Paragraph 15).
14. The physician must commit to the primacy of patient health and well-being and must offer care in the patient's best interest.
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14. The physician must commit to the primacy of patient health and well-being and must offer
care only recommendations and treatment the physician believes in good faith to be in the patient's best interest.
[Note that the terms "health", "well-being" and "best interest" are unhelpful when the meanings of the terms are disputed. See accompanying submission.]
[Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.
Reasoning/comments
"Care" is an overbroad and loaded term. In Canada and elsewhere it includes euthanasia; physicians who refuse to collaborate are accused of failing to provide "care." The suggested revision is more precise and less open to polemical misuse.
Physicians' fiduciary obligations require them to independently and in good faith determine what is in a patient's best interest, even if the patient or others disagree. The suggested revision incorporates these key elements and ensures that an evaluation of "best interest" cannot be forced upon a physician who disagrees. See II.8 to II.12 in this submission.
15. The physician must respect the autonomy and rights of the patient, including the right to accept or refuse treatment in keeping with the patient's values and preferences.
16. Physicians must obtain patients' voluntary informed consent prior to treatment, ensuring that patients receive and understand the information they need to make independent, well-informed decisions about their care.
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. . .well-informed decisions about their care. When presenting an opinion that is contrary to the generally held opinion of the profession, they must so indicate.
Reasoning/comments
Patients typically assume that a physician's recommendations are consistent with the general view of the profession. They seldom know if they are not. Disclosure ensures patient decision-making is properly informed. The same recommendation is made in relation to Paragraph
35, which addresses public statements by physicians rather than physician-patient consultations. The recommended addition is from the 2004 version of the Canadian Medical Association
Code of Ethics.
17. In emergencies, where the patient is not able to participate in decision making, physicians may initiate treatment in the best interests of the patient without prior informed consent.
18. When a patient has substantially limited, undeveloped, impaired or fluctuating decision-making capacity, the physician must work with the patient's trusted surrogate, if available, to make decisions in keeping with the patient's preferences, when those are known or can reasonably be inferred, or in the patient's best interests, when the individual's preferences cannot be determined, always in keeping with the principles set forth in this Code.
19. Physicians should be considerate of and collaborate with others, where available, who are central to the patient's care, including family members, significant others, or other health care professionals in keeping with the patient's preferences and best interest.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context. Cf Paragraphs 2, 5, 14, 21]
20. When medically necessary, the physician must communicate with other physicians and health professionals who are involved in the care of the patient or who are qualified to assess or recommend treatment options. This communication must respect patient confidentiality and be confined to necessary information.
21. If any aspect of caring for the patient is beyond the capacity of a physician, the physician must consult with or refer the patient to another physician or health professional who has the necessary ability.
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If any aspect of caring for medical treatment needed by the patient is beyond the capacity ability of a physician, the physician must consult with or refer the patient to another physician or health professional who has the necessary ability.
Reasoning/comments
"Caring" is overbroad. In Canada and elsewhere, "care" includes lawful killing of patients by lethal injection.
"Capacity" is also overbroad. This paragraph is apparently meant to refer to specific knowledge or technical expertise or skill in relation to medical treatment the physician believes is necessary for the health of the patient. Suggested revisions achieve the purpose of the paragraph with greater precision and less likelihood of misunderstanding or misinterpretation.
22. The physician must respect a patient's right to confidentiality, even after a patient has died. It may be ethical to disclose confidential information when the patient consents to it or, in exceptional cases, when disclosure is necessary to safeguard a significant and overriding ethical obligation and the patient does not or cannot consent to that disclosure. This disclosure must be limited to the minimal necessary information.
23. If a physician is acting on behalf of or reporting to any third parties with respect to the care of a patient, the physician must inform the patient accordingly.
At the outset of an interaction, the physician must disclose to the patient the nature and extent of those commitments and must obtain prior consent for the interaction with the patient to continue.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context. Cf Paragraphs 2, 5, 14, 21]
24. Physicians must refrain from intrusive advertising and marketing and ensure that all information used by them in advertising and marketing is correct and not misleading. Physicians may not participate in advertising or marketing of products related to their professional activity.
25. The physician should not allow commercial, financial, or other conflicting interests to take precedence over the physician's professional judgment.
26. When providing medical consultation or treatment in the form of telemedicine, the physician must ensure that this form of communication is medically justifiable and that the necessary medical care is guaranteed, particularly through the manner in which diagnostic assessment, medical consultation, treatment and documentation are carried out. The physician is also obligated to inform the patient about the particularities of receiving medical consultation and treatment via communications media. Wherever helpful, physicians must aim to provide medical consultation and treatment to patients through direct, personal contact.
27. Physicians have an ethical obligation to minimise disruption to patient care. Conscientious objection must only be considered if the individual patient is not discriminated against or disadvantaged, the patient's health is not endangered, and undelayed continuity of care is ensured through effective and timely referral to another qualified physician.*
* This paragraph will be debated in greater detail at the WMA's dedicated conference on the subject of conscientious objection in 2021 or 2022. However, comments on this paragraph are also welcome at this time.
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Physicians Individual physicians have an ethical obligation to minimise disruption to patient care. Conscientious objection must only be considered if the individual patient is not discriminated against or disadvantaged, the patient's health is not endangered, and undelayed continuity of care is ensured through effective and timely referral to another qualified physician.* refuse to provide, facilitate recommend or support interventions they reasonably consider inefficacious, harmful, discriminatory or otherwise unethical, notwithstanding contrary ethical, legal or regulatory requirements, norms or standards. They should provide information necessary to enable informed decision-making and continue to provide necessary treatment and care unrelated to a contested intervention to ensure the health of the patient is not endangered.
Reasoning/comments
Paragraphs
3,
6,
9,
14,
27, 30, 39 and
40 are functionally interdependent.
See Part III of this submission for detailed discussion of Paragraph 27.
28. Appropriate professional boundaries must be maintained. Physicians must not engage in a sexual relationship with a current patient and must never engage in abusive or exploitative relationships with a patient.
29. In order to provide care of the highest standard, physicians must attend to their own health, well-being and abilities. This includes seeking appropriate care to ensure that they are able to practise safely.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context. Cf Paragraphs 2, 5, 14, 21]
Duties to other physicians and health professionals
30. The physician must engage with other physicians and health professionals in a respectful and collaborative manner. Physicians must also ensure that ethical principles are upheld when working in teams.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]
31. The physician should respect colleagues' patient-physician relationships and not intervene unless needed to protect the patient from harm. This should not prevent the physician from recommending alternative courses of action considered to be in patients' best interests.
32. Physicians should report conditions or circumstances which impede them from providing care of the highest standards, including violence against physicians and other health personnel, inappropriate working conditions, and any other unsustainable stress factors.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context. Cf Paragraphs 2, 5, 14, 21]
33. Due respect should be granted to teachers and students of medicine and other health professionals.
Duties to society
34. Physicians must support fair and equitable provision of health care. This includes addressing inequities in health and care, the determinants of those inequities, as well as violations of the rights of patients and health care professionals.
- [Project comment only: "Care" (rather than "treatment") is appropriate in this context. Cf Paragraphs 2, 5, 14, 21]
35. Physicians play an important role in matters relating to the health and safety of the public, health education and health literacy. In fulfilling this responsibility, physicians should be prudent in discussing new discoveries, technologies, or treatments in non-professional, public venues and should ensure that their statements are scientifically accurate.
Physicians should be especially careful to distinguish in their public comments between evidence-based scientific information and their own personal opinions.
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. . .Physicians should be especially careful to distinguish in their public comments between evidence-based scientific information and their own personal opinions. When presenting an opinion that is contrary to the generally held opinion of the profession, they must so indicate.
Reasoning/comments
The same recommendation is made in relation to Paragraph 16, which addresses physician-patient consultations rather public statements by physicians. The recommended addition is from the 2004 version of the Canadian Medical Association Code of Ethics.
36. Physicians should avoid acting in such a way as to weaken public trust in the medical profession. To maintain that trust, physicians must hold themselves and fellow physicians to the highest standards of professional conduct and be prepared to report unethical or incompetent behaviour.
37. Physicians should share their medical knowledge and expertise for the benefit of patients and the advancement of healthcare.
38. Physicians have a duty to support the conduct of scientifically sound medical research in keeping with the ethical principles of the Declaration of Helsinki.
Duties of the physician as members of professional medical organisations
39. As members of professional medical organisations, physicians shall follow, protect, and promote the ethical principles of this code. They shall help prevent national or international ethical, legal, or regulatory requirements that undermine any of the duties set forth in this document.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]
40. As members of professional medical organisations, it is the task of physicians to support fellow members in upholding the responsibilities set out in this code and to take measures to protect them from undue influence, from violence and from oppression.
- [Project comment only: Paragraphs 3, 6, 9, 14, 27, 30, 39 and 40 are functionally interdependent.]