It was my honour to represent SMA in attending the Regional Meeting in Asia on the International Code of Medical Ethics (ICoME), held by the World Medical Association (WMA) from 7 to 8 June 2022 in Bangkok, Thailand. The Medical Association of Thailand, our host, organised this regional meeting successfully in a very short time - as soon as Thailand began welcoming international visitors again after the two years of pandemic.
The aim for this regional meeting was to have a face-to-face exchange of ideas and opinions on the draft for the revision of the ICoME. The secretary general of WMA and the chairperson of the WMA ICoME Revision Workgroup came to Bangkok and met with representatives from medical associations throughout Asia, including Bangladesh, India, Indonesia, Japan, Korea, Malaysia, Singapore and Thailand. With such a mix of countries, voices from diverse cultures reflecting common ethical challenges in clinical practice, fascinatingly, have built up a very coherent and supportive tone in this two-half-day meeting – together with plenty of smiles!
International Code of Medical Ethics
The ICoME was first adopted by the General Assembly of the WMA in London in 1949, soon after the Assembly's establishment in 1947. The WMA is in official relations with the World Health Organization.1 Both ICoME and the Declaration of Helsinki are intended to be read with the Declaration of Geneva. Since the first version in 1949, ICoME has been revised in 1968, 1983 and 2006. The current revision exercise started in 2020, and regional meetings were planned in Asia and Africa. Deferred by the COVID-19 pandemic, they were finally held in Bangkok in June 2022 and in Nigeria in August 2022. The final version of the ICoME is to be endorsed in the WMA General Assembly in Berlin in October 2022.
The ICoME consists of 40 codes that guide international physicians on medical ethics. They cover our daily practice widely in the areas of: general principles, duties to the patient, duties to other physicians and health professionals, duties to society, and physician's duties as a member of professional medical organisations. The codes are written in modern, gender-neutral English. They are normative and ontological - focusing on the duty of physicians, but not their rights. Although the ICoME is comprehensive, it is not meant to cover the details, especially taking into account its application in each country. In view of the global political and cultural diversity, regional meetings were organised to facilitate an exchange of opinions, in order to make the ICoME a widely applicable code of medical ethics.
The six roundtables
To allow for more intensive discussion, this regional meeting consisted of six roundtable sessions to cover controversial articles of the ICoME. These articles are:
- The physician's duty to help in medical emergencies: responsibilities, challenges and limits
The physician must offer help in medical emergencies, while considering the physician's own safety and competence, and the availability of other viable options for care. (Article 10, ICoME)
The attendees contended with the tension between the ethical aspiration of "must offer help" and the recognition of contemporary challenges during emergency care, including contagious diseases, workplace violence and, in some countries, death threats to doctors.
- Patient autonomy and informed consent
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, and ensure that the patient receives and understands the information needed to make an independent, well-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. (Article 16, ICoME)
The discussion focused on conditions in which a doctor may be exempted from informing the patients for consent. For example, in our region, doctors commonly encounter requests from the patient's family to keep the diagnosis hidden from the patient (also known as medical collusion). Many attendees shared this situation and related their experiences in handling this challenge in their countries. All attendees eventually agreed that, although it is not easy to get the family in line with the medical opinion, it is paramount to uphold this principle of patient autonomy in the ICoME, with the current wording.
- The ethics of remote treatment
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. (Article 27, ICoME)
With full awareness of the advantage of remote treatment (eg, telemedicine) in this pandemic, all the attendees preferred a relaxation of this article. "Medically appropriate" was suggested and will be proposed to the Revision Workgroup as replacement for "medically justifiable". This will help the development of telemedicine in the provision of medical care for rural areas.
- Duty to share knowledge: the important role physicians play in global health and in combating misinformation
Physicians play an important role in matters relating to health, 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 and understandable. Physicians must indicate if their own personal opinions are contrary to evidence-based scientific information. (Article 36, ICoME)
All the attendees expressed a vast concern with the current "infodemic" which occurred during the COVID-19 crisis. Many doctors gave their opinions on the Internet in relation to treatment and vaccination. These are experience-based, not evidence-based. While it is essential for doctors to provide medical information to the public for health promotion and disease prevention, doctors should be prudent that the information provided should not be misinformation.
- Ethical issues in advertising and marketing for physicians
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. (Article 25, ICoME)
Every attendee found it difficult to define advertising and marketing. Knowing that the border between advertising and providing medical information is blurred, focus should be placed on the information given. It must be factual and not misleading.
- Caring for oneself to provide better care to the patient: the physician's duty to report inappropriate or unsafe working conditions, violence against physicians and health personnel, and other unsustainable stress factors
The physician should report to the appropriate authorities the conditions or circumstances which impede the physician or another physician 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, and any other unsustainable stress factors. (Article 33, ICoME)
Finally, this revision of the ICoME also emphasises the physicians' well-being, which allows physicians to provide better care to the patient. Three issues are embedded in this article: the fitness and health of physicians, burnout and exploitation, and doctors to be led by good role models for development. All attendees are happy to know that, while patient safety has been emphasised greatly in the ICoME, there is an article paying attention to the physician's well-being.
Conclusion
This Bangkok trip has been very fruitful. It was a great opportunity to learn about the medico-ethical challenges faced by the physicians from our neighbouring countries and to share our experiences from Singapore. Medical ethics, importantly, are upheld by a set of ethical codes guiding the physicians' duty in the matrix of Patient-Personnel-Public. By and large, it was a very valuable experience representing SMA and connecting with medical colleagues from our neighbouring Asian countries and the rest of the WMA.
