The WMA Medical Ethics Manual

The WMAMedical Ethics Manual, published this year, aims to provide “a basic, universally used, curriculum for the teaching of medical ethics”. According to the secretary general of the World Medical Association (WMA), Dr Human, this book results from “a comprehensive global developmental and consultative process, guided and coordinated by the WMA Ethics Unit” since the 51st WMA Assembly in 1999, which strongly advised that “medical ethics and human rights” should be a compulsory course in the curricula of medical schools worldwide.

The manual is built on the foundation of the “physician's relationships with others” and covers a wide range of issues in medical ethics. These include an introduction to what medical ethics is and why it ought to be studied; the principal features of medical ethics, and how the WMA decides what is ethical; ethical issues arising from the physician/patient encounter; ethics concerning physicians and society; ethical issues arising from physician/colleague interactions, and medical research ethics.

In the introduction, four cases illustrate that the physician's daily work, his decision making, and his interaction with others all invite ethical reflection, and that ethics has always been an essential component of medical practice. Although professionalism has been a medical tradition since the time of Hippocrates, nowadays international human rights agreements should provide the global foundation of medical ethics for modern pluralist and multicultural societies. “Compassion, competence and autonomy” are identified as the core values of medicine in chapter one. Whether ethics is universal and how the WMA and individuals decide what is ethical are discussed. The WMA ensures that its ethical policy statements reflect a more than 75% vote consensus in annual assemblies. Then two categories of ethical reasoning are outlined: “the non‐rational approaches,” which include “feeling or desire, intuition, and habit”, and “the rational approaches,” which include “deontology, consequentialism, principlism, and virtues ethics”. Chapter one concludes that “a combination of all four (rational) approaches… is the best way to make ethical decisions rationally”.

Most of the fundamental concepts and common problems in medical ethics are discussed in chapter two, which is entitled Physicians and Patients. Topics covered include respect and equal treatment; communication and consent; decision making for incompetent patients; confidentialities, beginning of life, and end of life issues. Many of the WMA declarations and its code of ethics are referred to in this manual, which helps readers to understand the WMA's positions, policies, and recommendations regarding specific ethical problems. Chapter three explores the physician/society relationship and the social character of medicine. The ethical issues arising from dual loyalty, resource allocation, public health, and global health are introduced. It focuses on the wider social implications of medical ethics and briefly reflects upon the conceptions of “health organisation ethics”, “population and health policy ethics”, and “international health ethics”, though using different terminologies. These themes are comparatively later developments in medical ethics but have increasing and far reaching importance and influence for both medicine and society. The physician's relationship with colleagues, teachers, students, other health professionals, and the authorities are expounded in chapter four. Guidelines for “resolving conflict and disagreement between colleagues” and steps for “reporting unsafe and unethical practices” are proposed. Regarding research ethics, the Declaration of Helsinki, which is the most important international guideline for medical research and probably the most important contribution that the WMA has made to the world, forms the foundation and contents of chapter five. Topics addressed are ethics review; scientific merit; social value; risks and benefits; informed consent; confidentiality; honest reporting of results, and unresolved issues. The manual concludes by discussing the privilege of being a physician and the duties and responsibilities flowing from it. Because the environments in which medical professionals practise are becoming more challenging and frustrating in many parts of the world, the WMA asserts that the rights of physicians, as described in various WMA statements, should not be overlooked and should be protected. This manual reminds physicians that while they are bound to fulfil their responsibilities to their patients, to society and to colleagues, they still have responsibilities toward themselves and their families. To have a healthy lifestyle and not to overwork is beneficial for health professionals as well as their patients.

As a short, introductory booklet to medical ethics, this manual is succinct, modestly comprehensive, and informative, and can serves as a good start to reading in this field. It should be quite accessible for most medical students and doctors worldwide and those who are interested in medical ethics. It also gives readers a basic understanding of WMA's approaches, stances, and recommendations on some medical ethical controversies, and invites them to become familiar with more of the WMA's statements and declarations. It must be said, however, that some ethical issues, in genetic medicine, organ transplantation, medical error, public health, and health organisation administration, are not sufficiently addressed. People may also disagree with some of the opinions expressed in the manual—for example: “Perhaps a combination of all four approaches… is the best way to make ethical decisions rationally (p 30)”. Deontology and consequentialism are antithetical— they are theoretically contradictory and incompatible with each other. Principlism arises to adjudicate the “deep, and some claim untraversable, philosophical chasm separating these two types of philosophical theory” by resorting to the middle level moral principles since “utilitarianism and Kantianism can accept the relevance of the four principles but only because they see them as generated by, and secondary to, their overarching and monist moral theories (based on welfare maximisation and respect for autonomy, respectively).”¹ Virtue ethics, as an alternative ethical approach to medical situations, often provides very little help in real ethical dilemmas. Thus, to teach beginners that perhaps the best way is to combine all four approaches is probably both theoretically unsound and confusing. Furthermore, the statement that “20th century medicine witnessed the emergence of an unfortunate division between ‘public health' and other health care (presumably ‘private' or ‘individual' health)” as described on page 73 is also controversial. The definition and meaning of “public health” presented here could be problematic and needs to be clarified. Experts in the field of public health might not acknowledge the development of public health as “a division from other health care”. Also, they might not acknowledge that the development of the specialty of public health is “unfortunate”.

Nevertheless, this manual provides reliable knowledge and useful practice guidelines for readers. Although it is available on the internet (WMA website: www.wma.net/e/ethicsunit/resources.htm) and is now being translated into languages other than English, the WMA might be advised to investigate how this useful manual can be made accessible to the medical teachers, students, and physicians of those countries who are lacking in medical ethics resources, and where internet access might also be scarce.