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.

The privileged relationship between the physician and their larger community has, since at least the 1980s, been described as a social contract. Writing in The Social Transformation of American Medicine, the sociologist Paul Starr was the first to describe the patient–physician relationship as contractual, with later authors drawing on the broader tradition of Enlightenment philosophy, developing the idea of the social contract between the physician and their community.2 On this view, the social contract engages both the physician and their community in a series of obligations: in return for the physician’s services as …