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I swear, on my honour and conscience, that as a physician I shall strive to serve my fellow man and to respect humanity. My goals shall be to maintain and promote health, to prevent disease and to heal the ill and ease their pain. In my work I shall comply with medical ethics and only make use of treatments which have been proven useful by medical research or experience. When recommending a test or a treatment, I shall take the benefit and the possible harm to the patient equally into account. I shall continuously maintain a high level of professional competence and assess the quality of my work. I shall respect my colleagues and provide them with the help they request when treating patients. Where necessary, I shall encourage my patient to seek a second opinion. I shall respect the will of my patient. I shall keep secret all confidential information that I have been trusted with when treating my patients. I shall fulfil my duty as a physician to everyone without discrimination. I shall not, even under threat, use my skills against my professional ethics.
Code of Medical Ethics
Approved by the Delegate Committee 6 May 1988 A person working as a physician has undertaken a great and demanding task, which cannot be fulfilled unless there is, in addition to proper knowledge, a serious desire to meet the ethical responsibilities acknowledged by the medical profession for thousands of years. A physician gains trust on the basis of personality, knowledge and proficiency. In accordance with these principles, the Delegate Committee of the Finnish Medical Association has adopted the following code to be observed by physicians in their profession. I It is a physician's duty to protect human life and alleviate suffering, with the promotion and establishment of health as the principal aim. II A physician shall serve his fellowmen charitably and show himself by his behaviour and actions to be worthy of the trust and respect that his task requires. He shall never participate in torture, the implementation of a death sentence or any other inhuman actions or preparation thereof. III A physician shall treat patients as equals and not allow race, religion, political views or social status to have any effect on his actions towards them. IV A physician shall not use his authority to undermine a patient's right to make decisions concerning himself. Even where the patient cannot convey his own will, it is incumbent upon the physician to act in the patient's best interest. If a physician is compelled to make decisions concerning examinations or therapy irrespective of the patient's will, such decisions shall always be made on medical grounds. V A physician shall maintain and further his knowledge and skills, and shall recommend only those examinations and therapy that are considered effective and purposeful on the basis of medical knowledge and experience. VI Should a physician wish for his patient to participate in a clinical trial in which the examinations and therapy deviate from the normal procedure for the disease, he shall obtain the patient's freely-given consent without pressure, the patient being aware of the trial and of the additional strain and risks involved. Generally accepted declarations and instructions issued by the authorities shall be observed during the trial.
VII A physician shall maintain medical confidentiality and encourage his subordinates to do so. VIII A physician may not seek unfounded tangible interest. He shall treat patients according to their need and collect a fee on the basis of the work carried out. IX When issuing certificates and statements a physician shall bear in mind that he is an impartial witness or expert whose statement must be based on the objective findings of a thorough examination, on their critical evaluation and on other facts observed. X A physician must observe strict consideration and avoid selfemphasis when appearing in public. When advertising, a physician shall observe instructions on the advertising of physicians and medical services. XI A physician shall nor become involved in medical care in which he does not have the freedom to act according to his duties and the principles of this code.
Code of Medical Collegiality
Approved by the Delegate Committee on 6 May 1988 Modified in the Delegate Committee meeting on 11 December 1999 It is the aim of the code of medical collegiality drawn up by the Finnish Medical Association to maintain an appropriate spirit and good fellowship among the country's medical profession. The code of medical collegiality provides guidelines for behaviour according to collegial principles in mutual relationships between physicians. The code does not aim to protect physicians against the consequences of poor proficiency, misconduct or misuse. I The behaviour of a physician towards colleagues shall be tolerant and show good will. Disagreements can usually be settled by listening to one another's views. Whenever possible, professional disagreements shall be settled directly by the physicians involved. II A physician shall not offend other groups of the medical profession or transgress their rights. III In his/her actions and decisions and by his/her example, a physician shall maintain and promote professional ethics and collegiality. As a superior and teacher in particular, a physician must pay attention to medical ethics and collegial behaviour. This must not, however, prevent him/her from supervising the activities of his/her subordinates and students, nor from investigating errors and violations committed by them and taking the necessary measures. IV Should a physician by way of illness or use of intoxicants or for some other reason become incapable of treating patients and possibly even endanger them, it is the duty of every colleague to intervene by discussing the matter with the physician and offering help in arranging for the necessary treatment. If this does not succeed, the colleague must inform the physician's superior or the Finnish Medical Association of his/her findings. A physician shall act in the same manner irrespective of whether an apparent error committed by a colleague in the medical profession or in an official position was unintentional or deliberate. V A physician shall not circulate or supply an erroneous view of his/her own or his/her colleagues' proficiency, research or therapeutic facilities or other such facts that may affect the choice of physician by patients or the selection of a physici-an for a post. VI
It is inappropriate for a physician to criticise the actions of a colleague to a patient. Should he/she find the diagnosis, treatment or other action of another physician to be erroneous he/she must inform both the patient and the colleague in question in an appropriate manner. A physician should always bear in mind that he/she is also liable to err. VII When recommending a patient to another doctor, a physician must always provide appropriate information about the patient. With the patient's consent, the referring doctor and the physician in charge of further treatment must always be provided with the necessary information about the patient and guidelines for further treatment. It is recommended that when discontinuing his/her private consultancy, a physician shall hand over any patient documentation with the patient's consent to the physician who will continue the treatment. VIII If the patient or his/her families wish to seek a second opinion, a physician shall approach the matter in a positive manner, and his/her duty is to provide the physician to be consulted with appropriate information about the patient. If necessary, a physician shall also seek another physician's expert advice unprompted. In the event that the consulted doctor finds a notable contradiction between his/her and his/her colleague's views with regard to the patient, he/she shall discuss the situation directly with the colleague with the patient's consent. IX When starting a medical research project, it is recommended that the members of the team agree in advance on each individual's responsibilities and duties, and the principles of publishing the results. A physician shall not in his/her actions or publications attribute exclusively to him/herself a research result that has crucially depended on the work or expertise of one or more of his/her colleagues. X Disagreements about collegiality that cannot be otherwise settled shall be brought to the Finnish Medical Association to be settled or solved. No information on the matter shall be given to outsiders.
Doctors and the medical industry - A guidance for doctors
Confirmed by the Board of Finnish Medical Association 18th February 1993 The goal of the cooperation between doctors and the medical industry is to improve the health care system. This cooperation is indispensable in the development of medicines. The medical industry also has a significant role in supporting doctors'
complementary training. In the relations between doctors and the medical industry, however, it is important for doctors to maintain their independence and professional autonomy. In the intercourse between doctors and medical industry, the basic rules of Finnish society should be observed, concerning incapacity and hospitality. Training programmes supported by the medical industry have to meet the professional needs of the doctors. The training programme has to be prepared together with the participating doctors, and it has to be approved of by an authority outside the medical industry, for instance, by the Faculty of Medicine, a subsection of the Medical Association, or a specialist union. A written programme of the training occasion should be drawn up. In congress and training trips, the medical programme or training has to form the main part of the programme time. The programme has to improve the professional abilities of the participants. The medical industry and doctors work together in research and product development, in order to achieve better medicines for patients. The research for product development has to be medically justified, and research outlines have to be approved of in ethical boards. In informative presentations hospitality has to be moderate and secondary in regard to the product presentation. Advertisement gifts given by the medical industry have to be primarily associated with the doctor's work, and of little value to the receiver.
Ethical guidelines for the quality assessment of health care
Accepted by the board of the Finnish Medical Association March 28, 1996 The purpose of health care is to treat illnesses and to maintain and promote the health of the population. The goal of quality assessment in health care is continuous improvement of the quality of services provided for patients and population and of the ways and means to produce these services. The obligation to continuously improve ones professional ability and to evaluate the methods used is included in the ethical codes of physicians. According to them a physician has to maintain and increase his/her knowledge and skills. He/she shall recommend only examinations and treatments that are known to be effective and appropriate based on medical knowledge and experience. Quality aspects are included also in the act concerning patient´s statutes and rights. The act takes for granted patient´s right for high quality health care. The act concerning health care professionals includes provision according to which a health care professional must maintain and improve his\her professional skills required to engage in his\her professional activity. Employers of health care professionals shall according to the same act create opportunities for a health care professional for participation in necessary professional further education. The fulfilment of these prerequisites has to be followed by assessment. Purpose of the guidelines Physicians and health care institutions have to strive for continuous improvement of services. The purpose of these guidelines is to strengthen this pursuit by means of quality assessment practices and to create ethical grounds for audit. Application of the guidelines Ethical guidelines for quality assessment concern all physicians, institutions providing health care services for patients and producers of audit services. Obligation for quality assessment Every physician involved in patient work, other health care professionals and institutions and the whole health service sector have to aspire for continuos development of their work. A physician and an institution have to evaluate the quality of their work, activities of their unit and the level of staff´s ability and to be ready to set them under independent external audit. Preconditions for good quality work and its assessment Those involved in patient work have to look after necessary preconditions for good quality work and evaluation of the quality of the work. The equipment of an institution and the dimension of staff have to meet requirements of good quality activities. Patient records have to be written and preserved with care taking into consideration the obligations for secrecy. Procedures, decisions and other matters connected with patients have to be recorded in due form so that information and events can be traced back.
The personnel of institutions have to have adequate possibilities to maintain and develop their knowledge and skills. Recommendations and guidelines have to be available for those needing them. It is recommended that institutions would create quality manuals for their own use and supervise that instructions included in them are followed. Realization of assessment Every physician has to continuously evaluate the quality of his/her work and the level of ability by self-assessment methods. The quality of health care has to be assessed by both internal and external methods. The methods have to be generally approved and they have to be based on research or sufficient knowledge. Internal audit, observation of examination and treatment methods, comparison with others, observation of organisation´s ability to act and observation of the feedback from patients have to be continuous activities belonging to every service provider. External audit, such as external peer review and audit, has to be carried out with a frequency corresponding to the evolution of the field and always when there is special reason for that. Secrecy of patient records The patient records can be used in quality assessment. This requires that patient information to be kept in secrecy shall not reach inappropriate persons. All reports and comparative data have to be presented in such a form that patients under assessment cannot be identified. Confidentiality of assessment A precondition for successful assessment is the free will of institutions and physicians to be assessed and their commitment to assessment. It is recommended that an informed voluntary consent is acquired from those to be assessed. The results of assessment belong to those subscribing the assessment. They can be used for comparisons and general purposes only with the approval of the subscriber and those involved in assessment. A provider of services can inform its customers about the results of quality assessment and use them in marketing its services. The assessment of the work of an individual physician is the responsibility of the physician him/herself and his/her superior. Information regarding individual physicians should not be published without the consent of the physician concerned. An external assessor shall not give the results of assessment or other information revealed during assessment to others without a permit from the subscriber of assessment. Ethical committees Generally approved ethical principals of health care and the ethical codes and
collegiality codes of the Finnish Medical Association have to be followed in quality assessment. If ethical issues in an assessment project raise doubts can an ethical committee be asked to give a statement. Submitting assessment projects for approval by ethical committees is, however, mainly not necessary. Competence of the assessor The assessor has to be competent and experienced in the field that the assessment concerns. He/she has to be accepted by those to be assessed whenever possible. Impartiality of the assessment The chosen assessor has to be impartial and independent. He/she has to be well acquainted with the activities of those to be assessed. In his/her statement the assessor has to be objective, the conclusions have to be based on observations and their critical evaluation and to other facts that he/she has acquired. The assessor must not allow e.g. commercial or competitive matters influence the content of his/her statement. Assessment and supervision by authorities Quality assessment of health care and continuous quality improvement of services is a part of the activity of every physician and institution. The supervision of professional activities made by health care authorities is a distinct activity and should be kept separate from health care assessment. The results of assessment can be used for the purposes of supervising authorities only by a separate mutual agreement. Supervision of ethical guidelines for health quality assessment The Finnish Medical Association supervises the compliance the ethical guidelines for health care quality assessment. The quality board of the Finnish Medical Association develops the guidelines and interprets them when necessary and gives statements about complying with the guidelines. If a physician notices deficiencies in the quality of services of his\her colleagues or institutions it is his responsibility to take action by discussion with the physician involved, his/her superior or representatives of the unit. If this does not lead to a result, the physician should inform the Finnish Medical Association about the matter.
Ethical guidelines in telemedicine
Approved by the Executive Board of the Finnish Medical Association in 1997. Adopted by the Commité Permanent the 12th of April 1997 CP 97/033 EN Definition The term telemedicine refers to the practice of medicine over a distance. In telemedicine, interventions, diagnostic and treatment decisions and recommendations are based on data, documents and other information transmitted through telecommunication systems. Authorisation - competence Telemedicine is one way of practising medicine which may provide opportunities and increase possibilities to effectively use available human and material resources The possibilities offered by telemedicine must be open to all doctors over geographical borders. Physicians practising telemedicine must be authorised to practise medicine in the country or state in which they are located and must be competent in the field of medicine in which they are practising it. When practising telemedicine directly with the patient, the doctor must be authorised to practice medicine in the state where the patient is normally resident or the service must be internationally approved. Patient - doctor relationship The use of telemedicine must not adversely affect the individual patient-doctor relationship which, as in all fields of medicine, must be based on mutual respect, the independence of judgement of the doctor, autonomy of the patient and professional confidentiality. It is essential that the doctor and the patient can reliably identify each other in a telemedicine consultation. Preferably, all patients seeking medical advice should see a doctor in a face to face consultation, and telemedicine should be restricted to situations in which a doctor can not be physically present within acceptable time. The major application of telemedicine is the situation in which the treating doctor seeks another doctor´s opinion or advice, at the request of or with the permission of the patient. Where a direct telemedicine consultation is sought by the patient, it should normally only take place when the doctor has an existing professional relationship with the patient, or has adequate knowledge of the presenting problem, such that the doctor will be able to exercise proper and justifiable clinical judgement. In an emergency, such judgements may have to be based on less than complete information, but in these instances the danger to the health of the patient will be the determinant factor in providing advise or treatment. The responsible physician The doctor asking for another doctor´s advice remains responsible for treatment and
other decisions and recommendations given to the patient. When practising telemedicine directly with the patient, the doctor assumes responsibility for the case in question. The doctor performing medical interventions via telemedical techniques is responsible for those interventions. Quality, security and safety in telemedicine A doctor practising telemedicine is responsible for the appropriate quality of his/her services. He/she must not practise telemedicine without ensuring that the equipment necessary for the telemedical services rendered is of sufficiently high standard and adequately operational. The doctor must carefully evaluate the data and other information he/she has received. Medical opinions and recommendations can only be given and medical decisions made if the quality and quantity of data or other information received is sufficient and relevant for the case in question. When performing medical interventions over distance, the doctor must secure the presence of sufficient and adequately trained personnel assisting the patient and his/her continuing care. Patient documents All doctors practising telemedicine must keep adequate patient records and all cases have to be properly documented. The manner of patient identification shall be recorded, as well as the quantity and quality of data and other information received. Findings, recommendations and telemedical services delivered shall be adequately documented. Medical ethics, patient consent and confidentiality The principles of medical ethics which are binding upon the profession shall also be followed in the practice of telemedicine. Normal rules of confidentiality and security also apply to telemedicine documentations Storing or transmission methods may be used only where confidentiality and security can be guaranteed. Patient data and other information may only be transmitted to a doctor or other health professional on the request or with the informed consent (permission) of the patient and to the extent approved by him/her. The data transmitted must be relevant to the problem in question.
WMA DECLARATION OF HELSINKI Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the 29th WMA General Assembly, Tokyo, Japan, October 1975 35th WMA General Assembly, Venice, Italy, October 1983 41st WMA General Assembly, Hong Kong, September 1989 48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 and the 52nd WMA General Assembly, Edinburgh, Scotland, October 2000 Note of Clarification on Paragraph 29 added by the WMA General Assembly, Washington 2002 Note of Clarification on Paragraph 30 added by the WMA General Assembly, Tokyo 2004 A.INTRODUCTION 1.The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects. Medical research involving human subjects includes research on identifiable human material or identifiable data. 2.It is the duty of the physician to promote and safeguard the health of the people. The physician's knowledge and conscience are dedicated to the fulfillment of this duty. 3.The Declaration of Geneva of the World Medical Association binds the physician with the words, "The health of my patient will be my first consideration," and the International Code of Medical Ethics declares that, "A physician shall act only in the patient's interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient." 4.Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects. 5.In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society. 6.The primary purpose of medical research involving human subjects is to improve prophylactic, diagnostic and therapeutic procedures and the understanding of the aetiology and pathogenesis of disease. Even the best proven prophylactic, diagnostic, and therapeutic methods must continuously be challenged through research for their effectiveness, efficiency, accessibility and quality. 7.In current medical practice and in medical research, most prophylactic, diagnostic and therapeutic procedures involve risks and burdens. 8.Medical research is subject to ethical standards that promote respect for all human beings and protect their health and rights. Some research populations are vulnerable and need special protection. The particular needs of the economically and medically disadvantaged must be recognized. Special attention is also required for those who cannot give or refuse consent for themselves, for those who may be subject to giving consent under duress, for those who will not benefit personally from the research and for those for whom the research is combined with care. 9.Research Investigators should be aware of the ethical, legal and regulatory requirements for research on human subjects in their own countries as well as applicable international requirements. No national ethical, legal or regulatory requirement should be allowed to reduce or eliminate any of the protections for human subjects set forth in this Declaration. B.BASIC PRINCIPLES FOR ALL MEDICAL RESEARCH 10.It is the duty of the physician in medical research to protect the life, health, privacy, and dignity of the human subject. 11.Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and on adequate laboratory and, where appropriate, animal experimentation. 12.Appropriate caution must be exercised in the conduct of research which may affect the environment, and the welfare of animals used for research must be respected. 13.The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol. This protocol should be submitted for consideration, comment, guidance, and where appropriate, approval to a specially appointed ethical review committee, which must be independent of the investigator, the sponsor or any other kind of undue
influence. This independent committee should be in conformity with the laws and regulations of the country in which the research experiment is performed. The committee has the right to monitor ongoing trials. The researcher has the obligation to provide monitoring information to the committee, especially any serious adverse events. The researcher should also submit to the committee, for review, information regarding funding, sponsors, institutional affiliations, other potential conflicts of interest and incentives for subjects. 14.The research protocol should always contain a statement of the ethical considerations involved and should indicate that there is compliance with the principles enunciated in this Declaration. 15.Medical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given consent. 16.Every medical research project involving human subjects should be preceded by careful assessment of predictable risks and burdens in comparison with foreseeable benefits to the subject or to others. This does not preclude the participation of healthy volunteers in medical research. The design of all studies should be publicly available. 17.Physicians should abstain from engaging in research projects involving human subjects unless they are confident that the risks involved have been adequately assessed and can be satisfactorily managed. Physicians should cease any investigation if the risks are found to outweigh the potential benefits or if there is conclusive proof of positive and beneficial results. 18.Medical research involving human subjects should only be conducted if the importance of the objective outweighs the inherent risks and burdens to the subject. This is especially important when the human subjects are healthy volunteers. 19.Medical research is only justified if there is a reasonable likelihood that the populations in which the research is carried out stand to benefit from the results of the research. 20.The subjects must be volunteers and informed participants in the research project. 21.The right of research subjects to safeguard their integrity must always be respected. Every precaution should be taken to respect the privacy of the subject, the confidentiality of the patient's information and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject. 22.In any research on human beings, each potential subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail. The subject should be informed of the right to abstain from participation in the study or to withdraw consent to participate at any time without reprisal. After ensuring that the subject has understood the information, the physician should then obtain the subject's freely-given informed consent, preferably in writing. If the consent cannot be obtained in writing, the non-written consent must be formally documented and witnessed. 23.When obtaining informed consent for the research project the physician should be particularly cautious if the subject is in a dependent relationship with the physician or may consent under duress. In that case the informed consent should be obtained by a well-informed physician who is not engaged in the investigation and who is completely independent of this relationship. 24.For a research subject who is legally incompetent, physically or mentally incapable of giving consent or is a legally incompetent minor, the investigator must obtain informed consent from the legally authorized representative in accordance with applicable law. These groups should not be included in research unless the research is necessary to promote the health of the population represented and this research cannot instead be performed on legally competent persons. 25.When a subject deemed legally incompetent, such as a minor child, is able to give assent to decisions about participation in research, the investigator must obtain that assent in addition to the consent of the legally authorized representative. 26.Research on individuals from whom it is not possible to obtain consent, including proxy or advance consent, should be done only if the physical/mental condition that prevents obtaining informed consent is a necessary characteristic of the research population. The specific reasons for involving research subjects with a condition that renders them unable to give informed consent should be stated in the
experimental protocol for consideration and approval of the review committee. The protocol should state that consent to remain in the research should be obtained as soon as possible from the individual or a legally authorized surrogate. 27.Both authors and publishers have ethical obligations. In publication of the results of research, the investigators are obliged to preserve the accuracy of the results. Negative as well as positive results should be published or otherwise publicly available. Sources of funding, institutional affiliations and any possible conflicts of interest should be declared in the publication. Reports of experimentation not in accordance with the principles laid down in this Declaration should not be accepted for publication. C.ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH MEDICAL CARE 28.The physician may combine medical research with medical care, only to the extent that the research is justified by its potential prophylactic, diagnostic or therapeutic value. When medical research is combined with medical care, additional standards apply to protect the patients who are research subjects. 29.The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists. See footnote
30.At the conclusion of the study, every patient entered into the study should be assured of access to
the best proven prophylactic, diagnostic and therapeutic methods identified by the study. See footnote 31.The physician should fully inform the patient which aspects of the care are related to the research. The refusal of a patient to participate in a study must never interfere with the patient-physician relationship. 32.In the treatment of a patient, where proven prophylactic, diagnostic and therapeutic methods do not exist or have been ineffective, the physician, with informed consent from the patient, must be free to use unproven or new prophylactic, diagnostic and therapeutic measures, if in the physician's judgement it offers hope of saving life, re-establishing health or alleviating suffering. Where possible, these measures should be made the object of research, designed to evaluate their safety and efficacy. In all cases, new information should be recorded and, where appropriate, published. The other relevant guidelines of this Declaration should be followed. Note: Note of clarification on paragraph 29 of the WMA Declaration of Helsinki The WMA hereby reaffirms its position that extreme care must be taken in making use of a placebo-controlled trial and that in general this methodology should only be used in the absence of existing proven therapy. However, a placebocontrolled trial may be ethically acceptable, even if proven therapy is available, under the following circumstances: - Where for compelling and scientifically sound methodological reasons its use is necessary to determine the efficacy or safety of a prophylactic, diagnostic or therapeutic method; or - Where a prophylactic, diagnostic or therapeutic method is being investigated for a minor condition and the patients who receive placebo will not be subject to any additional risk of serious or irreversible harm. All other provisions of the Declaration of Helsinki must be adhered to, especially the need for appropriate ethical and scientific review. Page back to paragraph 29. Note: Note of clarification on paragraph 30 of the WMA Declaration of Helsinki The WMA hereby reaffirms its position that it is necessary during the study planning process to identify post-trial access by study participants to prophylactic, diagnostic and therapeutic procedures identified as beneficial in the study or access to other appropriate care. Post-trial access arrangements or other care must be described in the study protocol so the ethical review committee may consider such arrangements during its review. Page back to paragraph 30. The Declaration of Helsinki (Document 17.C) is an official policy document of the World Medical Association, the global representative body for physicians. It was first adopted in 1964 (Helsinki, Finland) and revised in 1975 (Tokyo, Japan), 1983 (Venice, Italy), 1989 (Hong Kong), 1996 (Somerset-West, South Africa) and 2000 (Edinburgh, Scotland). Note of clarification on Paragraph 29 added by the WMA General Assembly, Washington 2002. 9.10.2004
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