the patient, including detainees and alleged criminals. This duty is often expressed through the notion of professional independence, requiring doctors to adhere to best medical practices despite any pressure that might be applied. The World Medical Association’s International Code of Medical Ethics emphasizes doctors’ duty to provide care “in full technical and moral independence, with compassion and respect for human dignity”. It also stresses the duty to act only in the patient’s interest and says that doctors owe their patients complete loyalty. The World Medical Association’s Tokyo Declaration and Declaration on Physician Independence and Professional Freedom61 make unambiguously clear that doctors must insist on being free to act in patients’ interests, regardless of other considerations, including the instructions of employers, prison authorities or security forces. The latter declaration requires doctors to ensure that they “have the professional independence to represent and defend the health needs of patients against all who would deny or restrict needed care for those who are sick or injured”. Similar principles are prescribed for nurses in the International Council of Nurses Code of Ethics. obligations expressed in their shared professional values but also that they implement them in a manner that reflects the basic duty to avoid harm to their patients. C. Principles common to all codes of health-care ethics 57. The principle of professional independence requires health professionals always to concentrate on the core purpose of medicine, which is to alleviate suffering and distress and avoid harm, despite other pressures. Several other ethical principles are so fundamental that they are invariably found in all codes and ethical statements. The most basic are the injunctions to provide compassionate care, do no harm and to respect patients’ rights. These are central requirements for all health professionals. 1. The duty to provide compassionate care 58. The duty to provide care is expressed in a variety of ways in national and international codes and declarations. One aspect of this duty is the medical duty to respond to those in medical need. This is reflected in the World Medical Association’s International Code of Medical Ethics,59 which recognizes the moral obligation of doctors to provide emergency care as a humanitarian duty. The duty to respond to need and suffering is echoed in traditional statements in virtually all cultures. 62. Another way in which duty to provide care is expressed by the World Medical Association is through its recognition of patient rights. Its Declaration of Lisbon on the Rights of the Patient62 recognizes that every person is entitled, without discrimination, to appropriate health care and reiterates that doctors must always act in a patient’s best interest. Patients must be guaranteed autonomy and justice, according to the Declaration, and both doctors and providers of medical care must uphold patient’s rights. “Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.” Individuals are entitled to appropriate health care, regardless of factors such as their ethnic origin, political beliefs, nationality, gender, religion or individual merit. People accused or convicted of crimes have an equal moral entitlement to appropriate medical and nursing care. The World Medical Association’s Declaration of Lisbon emphasizes that the only acceptable criterion for discriminating between patients is the relative urgency of their medical need. 59. Underpinning much of modern medical ethics are the principles established in the earliest statements of professional values that require doctors to provide care even at some risk to themselves. For example, the Caraka Samhita, a Hindu code dating from the first century AD, instructs doctors to “endeavour for the relief of patients with all thy heart and soul. Thou shall not desert or injure thy patient for the sake of thy life or thy living”. Similar instructions were given in early Islamic codes and the modern Declaration of Kuwait requires doctors to focus on the needy, be they “near or far, virtuous or sinner, friend or enemy”. 60. Western medical values have been dominated by the influence of the Hippocratic oath and similar pledges, such as the Prayer of Maimonides. The Hippocratic oath represents a solemn promise of solidarity with other doctors and a commitment to benefit and care for patients while avoiding harming them. It also contains a promise to maintain confidentiality. These four concepts are reflected in various forms in all modern professional codes of health-care ethics. The World Medical Association’s Declaration of Geneva60 is a modern restatement of the Hippocratic values. It is a promise by which doctors undertake to make the health of their patients their primary consideration and vow to devote themselves to the service of humanity with conscience and dignity. 2. Informed consent 63. While the declarations reflecting a duty of care all emphasize an obligation to act in the best interests of the individual being examined or treated, this presupposes that health professionals know what is in the patient’s best interest. An absolutely fundamental precept of modern medical ethics is that patients themselves are the best judge of their own interests. This requires health professionals to give normal precedence to a competent adult patient’s wishes rather than to the views of any person in authority about what would be best for that individual. Where the patient is unconscious or otherwise incapable of giving valid consent, health professionals must make a judgement about how that person’s best interests can be 61. Aspects of the duty to care are reflected in many of the World Medical Association’s declarations, which make clear that doctors must always do what is best for 61 Adopted by the World Medical Association in 1986. Adopted by the World Medical Association in 1981; amended by its General Assembly at its forty-seventh session in September 1995. 59 Adopted in 1949. 60 Adopted in 1948. 62 13