Paragraph 12 of the revised International Code of Medical Ethics (ICoME) states that ‘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.’1 This emphasis on environmental sustainability is in line with popular discourse as well growing scholarly attention in medical ethics for healthcare’s contribution to climate change. Recent research analyses, for instance, the ‘greening’ of informed consent and related bioethical principles.2 3 It is (...) unclear what the duty of practising sustainable healthcare means at the level of doctor–patient interaction. Parsa-Parsi et al flag the potential conflict in the ICoME’s provisions if ‘the actions of physicians are influenced by environmental considerations to the detriment of patients’ (p. 2), noting that the ICoME does not provide a handhold to improve understanding of such tensions. The code ‘does not go into extensive detail, does not include comprehensive explanations nor any rules or guidance on how to reconcile its principles when they conflict’ (p. 4). For Parsa-Parsi et al, not codes, but textbooks have a crucial role to play in resolving this conflict. It is rife that professional codes can lead to internal inconsistencies and …. (shrink)

Parsa-Parsi et al assert that the International Code of Medical Ethics (ICoME) provides a professional standard that overrides conflicting national legal norms.1 While this claim is made in the context of laws that require doctors to participate in ‘acts of torture, or other cruel, inhuman, or degrading practices and punishments’ (para10 of ICoME), the underlying premise that medical ethics supersedes law requires scrutiny. It is clear that medical ethics and law are linked inextricably, but there is unresolved debate about the (...) sequence of this interaction: should ethics shape law; or is it the converse? Important principles, notably respect for patients’ autonomy, have arisen from case law and subsequently been adopted into medical ethics. As pointed out by Beauchamp and Childress, it is only ‘since the mid-1970s (that) the primary justification advanced for requirements of informed consent has been to protect autonomous choice’ (pg.118).2 Whereas, the legal obligation to respect autonomy can be traced to the early 1900s, in the landmark US case of Schloendorff v Society of New York Hospital : ‘Every human being of adult years and sound mind has a right to determine what shall be done with his own body’.1 Moreover, the term informed consent was born in law: it was coined …. (shrink)

We thank our commentators for their thoughtful responses to our paper1 covering among other issues the relationships of ethics law and professional codes, the tensions between ethical universalism and cultural relativism and the phenomenon of moral judgement required when ethical norms conflict, including the norms of patient care versus obligations to others both now and in the future. Although the comments deserve more extensive discussion, in what follows we respond briefly to specific aspects of each commentary and remind readers that (...) professional codes of ethics are necessarily brief and that the International Code of Medical Ethics (ICoME) explicitly refers to the World Medical Association’s (WMA) mutually concordant and far more extensive ‘body of policies’.2 Sarela raises a fundamental and, as stated in the commentary, unresolved debate: ‘should ethics shape law or is it the converse’?3 We understand the ‘global medical ethos’ represented in the WMA’s revised ICoME to be firmly embedded in the assumption that ethics should shape law and that only where laws are so shaped do people governed by them have an ethical obligation to obey them. For the medical profession, laws permitting participation in torture or other cruel, inhuman or degrading practices and punishments are categorically unethical, and therefore, doctors must not facilitate or participate in them—difficult as it may be for some doctors in some regions or environments to act accordingly. Schantz and Mansoori claim that ‘if a code of ethics is an act of professional self-regulation and professional self-regulation is community-dependent, then a code of ethics cannot be …. (shrink)

Health will feature more prominently at this year’s United Nations Conference of the Parties (COP) to the Framework Convention on Climate Change. COP281 will include a ‘Health/Relief/Recovery and Peace’ day on the 3 December. The health day inevitably engages issues of equity and justice. It includes perspectives on identifying and scaling up adaption measures to address health impacts of climate change, acknowledging ‘findings that climate-sensitive health risks are disproportionately felt by the most vulnerable and disadvantaged, including women, children, ethnic minorities, (...) lower-income communities, migrants or displaced persons, older populations, and those with underlying health conditions’; reflections on what is known and not understood about the impacts of climate change on mental health, and potential ways to address this; ‘action-oriented’ look at responses to the ‘unprecedented levels of climate and disaster displacement, including on those communities already facing multiple crisis’; and an opportunity to share best practice approaches to advocacy and action at the intersection of climate and health. The full programme for the ‘health/relief/recovery and peace’ day can be found at www.cop28.com/en/health-events. A political declaration is anticipated on the day as ministers of health, environment, finance and other related sectors meet and set out a ‘roadmap’ and seek to embed health in the climate agenda. In the lead up to COP28, the WHO called on Ministers of Health ‘to …. (shrink)

After an intensive 4-year process, the World Medical Association (WMA) has revised its International Code of Medical Ethics (ICoME). In their report outlining this process, Parsa-Parsi et al not only describe how the WMA sought to ‘cultivat[e] international agreement’ on a ‘global medical ethos’, but also outline the philosophical framework of the ICoME: how the WMA, as the ‘global representation of the medical profession’, created and revised the ICoME through the process of international professional self-regulation.1 However, there is a significant (...) tension to be found in this framework—one which contrasts the international scope of the ICoME with the supposed source of its legitimacy. Here, we seek to characterise this tension and the doubt which it casts on the legitimacy of the ICoME. (shrink)

Parsa-Parsi et al bring attention to the World Medical Association (WMA) and transparency to its International Code of Medical Ethics (ICoME) revisions.1 We value their report and the revised ICoME but explain here that the ICoME cannot reflect consensus among all WMA members, or the wider medical profession, given structural and epistemic injustices that restrain low-income and middle-income country (LMIC) physicians from participating in activities such as WMA revisions. Such injustices overlook experiences and contributions of those from LMICs and marginalised (...) groups, hindering their access to and influence within medicine.2 They also undermine access to information about, and from, the WMA. Recruiting new members from, and better engaging members in, LMICs would strengthen the WMA and its influence across the medical profession, and better elevate environmental sustainability as a biomedical and bioethical concern. This would be beneficial because there is controversy among physicians, bioethicists and other stakeholders about the relevance of environmental sustainability to medicine.3 4 That its addition to the ICoME was ‘uncontentious’ hints at structural and epistemic injustices in the revision process and homogeneity of those most involved in the revisions. Based on our observations as medical educators, it appears that few medical students and physicians at our institution, and few across the Caribbean and …. (shrink)