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The International Code of Medical Ethics of the World Medical Association

• 1 German Medical Association, Berlin, Germany
• 2 Chair, World Medical Association (WMA) International Code of Medical Ethics Workgroup, member of the WMA Medical Ethics Committee, and member of the WMA Council
• Special Communication World Medical Association Declaration of Helsinki World Medical Association JAMA
• Viewpoint The Revised Declaration of Geneva: The Modern-Day Physician’s Pledge Ramin Walter Parsa-Parsi, MD, MPH JAMA

One of the central missions of the World Medical Association (WMA) in its role as the global organization of physicians is to ensure the highest possible standard of ethical practice of the medical profession. Since its establishment in 1947 in the aftermath of one of the most egregious breaches of medical ethical principles, the WMA has adopted a comprehensive range of declarations, resolutions, and statements aimed at providing ethical and other guidance to the global medical profession.

At the heart of the WMA’s body of policies are 3 core documents: the Declaration of Geneva: The Physician’s Pledge (DoG), 1 the Declaration of Helsinki (DoH), 2 and the International Code of Medical Ethics (ICoME).

The inaugural DoG, which was initially adopted by the second General Assembly of the WMA in 1948 and most recently revised in 2017, concisely lays out the basic ethical principles for the medical profession in the form of a physician’s pledge. Although the DoG has undergone regular revisions over the years, the basic principles have remained consistent. 3

To address the specific ethical challenges of medical research involving human research participants, the WMA drafted and adopted the DoH in 1964. The DoH was last revised in 2013 and will undergo another revision starting in 2022. While geared primarily toward the medical profession, the DoH has proven to be a practical tool for nonphysician researchers as well. 4

The third and perhaps least well-known—at least to this point—core document of the WMA is the ICoME, which was adopted in 1949 following the DoG. The ICoME outlines the ethical principles and professional duties of the medical profession, including the physician’s responsibilities toward patients and society, as well as toward other physicians, students, and other health professionals and personnel.

As with all of the WMA policies, these 3 documents are reviewed and revised regularly to ensure their continued relevance.

In 2018, the Council of the WMA installed an international workgroup to review the ICoME, which had last been revised in 2006. The workgroup comprised WMA constituent members and observers from 19 countries representing all the WMA’s geographic regions. (The WMA’s global membership is categorized according to the following 7 geographic regions: Africa, Asia, Europe, Latin America, North America, the Pacific, and Eastern Mediterranean.) Each member of the workgroup was encouraged to consult with local ethics committees and experts, and to review the existing ethical guidelines and professional codes in their respective countries and determine which ethical principles might be outdated or missing from the most recently revised ICoME.

The representative nature of the workgroup led to extensive discussions not only about the content of the revised ICoME, but also about the linguistic subtleties of the document and how certain concepts and terminology might be understood or interpreted differently from region to region. The workgroup invested great effort to ensure that the ICoME could be applicable to different cultures and political systems by carefully and transparently assessing proposals and comments from the different world regions.

Following a substantial revision of the existing Code, a revised ICoME was unanimously adopted by the WMA General Assembly in October 2022 in Berlin, Germany ( Box ).

WMA International Code of Medical Ethics

Adopted by the 3rd General Assembly of the World Medical Association, London, England, October 1949 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968 and the 35th World Medical Assembly, Venice, Italy, October 1983 and the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006 and the 73rd WMA General Assembly, Berlin, Germany, October 2022

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 WMA Declaration of Geneva: The Physician’s Pledge and the WMA’s entire body of policies, it defines and elucidates the professional duties of physicians towards their patients, other physicians and health professionals, themselves, and society as a whole.

The physician must 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 the physician’s commitment to the ethical principles set forth in this Code.

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 ethical principles.

General Principles

1. The primary duty of the physician is to promote the health and well-being of individual patients by providing competent, timely, and compassionate care in accordance with good medical practice and professionalism.

The physician also has a responsibility to contribute to the health and well-being of the populations the physician serves and society as a whole, including future generations.

The physician must provide care with the utmost respect for human life and dignity, and for the autonomy and rights of the patient.

2. The physician must practise medicine fairly and justly and provide care based on the patient’s health needs without bias or engaging in discriminatory conduct on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor.

3. 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.

4. The physician must practise with conscience, honesty, integrity, and accountability, while always exercising independent professional judgement and maintaining the highest standards of professional conduct.

5. Physicians must not allow their individual professional judgement to be influenced by the possibility of benefit to themselves or their institution. The physician must recognise and avoid real or potential conflicts of interest. Where such conflicts are unavoidable, they must be declared in advance and properly managed.

6. Physicians must take responsibility for their individual medical decisions and must not alter their sound professional medical judgements on the basis of instructions contrary to medical considerations.

7. When medically appropriate, the physician must collaborate with other physicians and health professionals who are involved in the care of the patient or who are qualified to assess or recommend care options. This communication must respect patient confidentiality and be confined to necessary information.

8. When providing professional certification, the physician must only certify what the physician has personally verified.

9. The physician should provide help in medical emergencies, while considering the physician’s own safety and competence, and the availability of other viable options for care.

10. The physician must never participate in or facilitate acts of torture or other cruel, inhuman or degrading practices and punishments.

11. The physician must engage in continuous learning throughout professional life in order to maintain and develop professional knowledge and skills.

12. The physician should strive 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. In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient.

The physician must respect the patient’s right to freely accept or refuse care in keeping with the patient’s values and preferences.

14. The physician must commit to the primacy of patient health and well-being and must offer care in the patient’s best interests. In doing so, the physician must strive to prevent or minimise harm for the patient and seek a positive balance between the intended benefit to the patient and any potential harm.

15. The physician must respect the patient’s right to be informed in every phase of the care process. The physician must obtain the patient’s voluntary informed consent prior to any medical care provided, ensuring that the patient receives and understands the information needed to make an independent, informed decision about the proposed care. The physician must respect the patient’s decision to withhold or withdraw consent at any time and for any reason.

16. When a patient has substantially limited, underdeveloped, impaired, or fluctuating decision-making capacity, the physician must involve the patient as much as possible in medical decisions. In addition, the physician must work with the patient’s trusted representative, if available, to make decisions in keeping with the patient’s preferences, when those are known or can reasonably be inferred. When the patient’s preferences cannot be determined, the physician must make decisions in the patient’s best interests. All decisions must be made in keeping with the principles set forth in this Code.

17. In emergencies, where the patient is not able to participate in decision making and no representative is readily available, the physician may initiate an intervention without prior informed consent in the best interests of the patient and with respect for the patient’s preferences, where known.

18. If the patient regains decision-making capacity, the physician must obtain informed consent for further intervention.

19. The physician should be considerate of and communicate with others, where available, who are close to the patient, in keeping with the patient’s preferences and best interests and with due regard for patient confidentiality.

20. 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 appropriately qualified physician or health professional who has the necessary capacity.

21. The physician must ensure accurate and timely medical documentation.

22. The physician must respect the patient’s privacy and confidentiality, even after the patient has died. A physician may disclose confidential information if the patient provides voluntary informed consent or, in exceptional cases, when disclosure is necessary to safeguard a significant and overriding ethical obligation to which all other possible solutions have been exhausted, even when the patient does not or cannot consent to it.

This disclosure must be limited to the minimal necessary information, recipients, and duration.

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 and, where appropriate, during the course of any interactions. The physician must disclose to the patient the nature and extent of those commitments and must obtain consent for the interaction.

24. The physician must refrain from intrusive or otherwise inappropriate advertising and marketing and ensure that all information used by the physician in advertising and marketing is factual and not misleading.

25. The physician must not allow commercial, financial, or other conflicting interests to affect the physician’s professional judgement.

26. When providing medical care remotely, the physician must ensure that this form of communication is medically justifiable and that the necessary medical care is provided. The physician must also inform the patient about the benefits and limitations of receiving medical care remotely, obtain the patient’s consent, and ensure that patient confidentiality is upheld. Wherever medically appropriate, the physician must aim to provide care to the patient through direct, personal contact.

27. The physician must maintain appropriate professional boundaries. The physician must never engage in abusive, exploitative, or other inappropriate relationships or behaviour with a patient and must not engage in a sexual relationship with a current patient.

28. In order to provide care of the highest standards, 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.

29. This Code represents the physician’s ethical duties. However, on some issues there are profound moral dilemmas concerning which physicians and patients may hold deeply considered but conflicting conscientious beliefs.

The physician has an ethical obligation to minimise disruption to patient care. Physician conscientious objection to provision of any lawful medical interventions may only be exercised if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered.

The physician must immediately and respectfully inform the patient of this objection and of the patient’s right to consult another qualified physician and provide sufficient information to enable the patient to initiate such a consultation in a timely manner.

Duties to Other Physicians, Health Professionals, Students, and Other Personnel

30. The physician must engage with other physicians, health professionals and other personnel in a respectful and collaborative manner without bias, harassment or discriminatory conduct. The physician must also ensure that ethical principles are upheld when working in teams.

31. The physician should respect colleagues’ patient-physician relationships and not intervene unless requested by either party or needed to protect the patient from harm. This should not prevent the physician from recommending alternative courses of action considered to be in the patient’s best interests.

32. The physician should report to the appropriate authorities conditions or circumstances which impede the physician or other health professionals from providing care of the highest standards or from upholding the principles of this Code. This includes any form of abuse or violence against physicians and other health personnel, inappropriate working conditions, or other circumstances that produce excessive and sustained levels of stress.

33. The physician must accord due respect to teachers and students.

Duties to Society

34. The physician 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 both patients and health professionals.

35. Physicians play an important role in matters relating to health, health education and health literacy. In fulfilling this responsibility, physicians must be prudent in discussing new discoveries, technologies, or treatments in non-professional, public settings, including social media, and should ensure that their own statements are scientifically accurate and understandable.

Physicians must indicate if their own opinions are contrary to evidence-based scientific information.

36. The physician must support sound medical scientific research in keeping with the WMA Declaration of Helsinki and the WMA Declaration of Taipei.

37. The physician should avoid acting in such a way as to weaken public trust in the medical profession. To maintain that trust, individual physicians must hold themselves and fellow physicians to the highest standards of professional conduct and be prepared to report behaviour that conflicts with the principles of this Code to the appropriate authorities.

38. The physician should share medical knowledge and expertise for the benefit of patients and the advancement of health care, as well as public and global health.

Duties as a Member of the Medical Profession

39. The physician should follow, protect, and promote the ethical principles of this Code. The physician should help prevent national or international ethical, legal, organisational, or regulatory requirements that undermine any of the duties set forth in this Code.

40. The physician should support fellow physicians in upholding the responsibilities set out in this Code and take measures to protect them from undue influence, abuse, exploitation, violence, or oppression.

©2022 World Medical Association. All Rights Reserved. All intellectual property rights in the International Code of Medical Ethics are vested in the World Medical Association.

However, before the revision process was concluded, it was complemented by a series of regional and international conferences, including in Sao Paulo, Brazil; Kuwait City, Kuwait; Bangkok, Thailand; Abuja, Nigeria; and Washington, DC. To gather further opinions and insights from the broader medical ethics community, the WMA presented interim drafts of the revised ICoME in special sessions at several international bioethics conferences. In addition, a highly successful online public consultation was held, resulting in hundreds of comments received from experts throughout the world. During this public consultation and the initial international meetings, it quickly became apparent that a newly added paragraph dealing with physician conscientious objection would be the most contentious issue and would therefore require the most consideration.

Conscientious objection in medicine refers to a physician’s refusal to carry out a certain medical procedure on moral or religious grounds. 5 The potential tension between the physician’s right to exercise a conscientious objection and the patient’s wish to access legally permitted procedures (including but not limited to abortion or physician-assisted suicide) led to many debates about the obligations of a physician who exercises such a right.

To delve into the nuances of these debates, the WMA hosted a dedicated international conference on this topic in Jakarta, Indonesia, in July 2022. Experts presented a range of arguments both for and against a physician’s right to refuse to perform certain interventions on the basis of conscience. Consensus was quickly reached about the right of physicians, in principle, to exercise a conscientious objection. But the ICoME is a document detailing the duties of physicians, and therefore the ultimate objective of the conference was to address the obligations, if any, a physician has toward a patient in the case of such an objection. At issue was the question of whether a physician is obliged to provide a patient with appropriate information for pursuing the requested intervention or even to refer the patient to a colleague who does not share this objection. Weighing all these arguments, the workgroup ultimately agreed on a compromise wording that also achieved consensus in the WMA General Assembly (see item 29).

The Code was also expanded to incorporate the concepts of patient autonomy, physician well-being, and equity and justice in health care. In addition, the workgroup determined that the principles of patient confidentiality and informed consent required further elaboration. Also, references to contemporary issues such as remote treatment, environmental sustainability, and advertising and social media have been addressed.

Throughout the revision process, the ICoME was also reviewed for compatibility with the DoG and DoH to avoid any contradictions or inconsistencies. Without diminishing the interrelationships between the DoG and the ICoME, the workgroup sought to lend the ICoME the renewed standing and attention needed to fulfill its purpose as a foundation of ethical principles defining the professional duties of physicians.

In pursuit of this objective, the workgroup drafted a revised ICoME that covers the vital ethical principles and duties of physicians, but without citing specific details, descriptions, or examples. This new and comprehensive Code is bolstered by the WMA’s policy apparatus, which addresses many of the issues therein in greater detail.

The workgroup restructured the ICoME by adding a new preamble, followed by a section of general principles. The remaining ethical duties are categorized as “duties to the patient,” “duties to other physicians, health professionals, students, and other personnel,” and “duties to society.” The final section entitled “duties as a member of the medical profession” highlights the obligation to follow, protect, and promote the ethical principles of the ICoME and to support other physicians in upholding them. Throughout the document, new, more modern and gender-inclusive language has been introduced.

As stated in the preamble, each of the paragraphs of the ICoME should be applied with consideration of all other relevant paragraphs and the Code must always be read as a whole.

WMA declarations, resolutions, and statements that are ethical in nature must achieve a three-quarter majority to pass the General Assembly. The successful unanimous adoption of the revised ICoME despite this rather high threshold can be attributed to a comprehensive and inclusive revision process that was carried out with respect not only for the ethical foundation upon which the WMA was established, but also for the WMA members, ethics experts, and other stakeholders who contributed to the process.

Physicians are facing unprecedented challenges brought on and exacerbated by changing clinical, political, legal, and market forces. At the same time, the medical profession is becoming more dynamic and interconnected on a global scale, making it increasingly crucial to reaffirm the fundamental and universal principles of medical ethics as reflected in the ICoME. Through their advocacy work, the WMA and its members hope to raise awareness of this document and, in so doing, provide a common ethical language for the medical profession and strengthen professional identity.

Corresponding Author: Ramin Walter Parsa-Parsi, MD, MPH, German Medical Association, Herbert-Lewin-Platz 1, Berlin 10623, Germany ( [email protected] ).

Published Online: October 13, 2022. doi:10.1001/jama.2022.19697

Conflict of Interest Disclosures: Dr Parsa-Parsi has reported receiving nonfinancial support from the World Medical Association (WMA) in the form of coverage of travel expenses related to WMA or International Code of Medical Ethics meetings.

Additional Contributions: I thank the International Code of Medical Ethics workgroup members, advisors, and observers for their commitment and valuable contributions throughout the revision process. I also thank Siobhan O'Leary for her editorial support.

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Parsa-Parsi RW. The International Code of Medical Ethics of the World Medical Association. JAMA. 2022;328(20):2018–2021. doi:10.1001/jama.2022.19697

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