19. Ethical Issues
Chapter Editor: Georges H. Coppée
Codes and Guidelines
Colin L. Soskolne
Responsible Science: Ethical Standards and Moral Behaviour in Occupational Health
Richard A. Lemen and Phillip W. Strine
Ethical Issues in Occupational Health and Safety Research
Paul W. Brandt-Rauf and Sherry I. Brandt-Rauf
Ethics in the Workplace: A Framework for Moral Judgement
Sheldon W. Samuels
Surveillance of the Working Environment
Lawrence D. Kornreich
Ethical Issues: Information and Confidentiality
Peter J. M. Westerholm
Ethics in Health Protection and Health Promotion
D. Wayne Corneil and Annalee Yassi
Case Study: Drugs and Alcohol in the Workplace - Ethical Considerations
Behrouz Shahandeh and Robert Husbands
International Code of Ethics for Occupational Health Professionals
International Commission on Occupational Health
These canons provide standards of ethical conduct for industrial hygienists as they practice their profession and exercise their primary mission, to protect the health and well-being of working people and the public from chemical, microbiological and physical health hazards present at, or emanating from, the workplace.
CANONS OF ETHICAL CONDUCT
Industrial Hygienists shall:
Practice their profession following recognized scientific principles with the realization that the lives, health and well-being of people may depend upon their professional judgement and that they are obligated to protect the health and well-being of people.
Counsel affected parties factually regarding potential health risks and precautions necessary to avoid adverse health effects.
Keep confidential personal and business information obtained during the exercise of industrial hygiene activities, except when required by law or overriding health and safety considerations.
Avoid circumstance where a compromise of professional judgment or conflict of interest may arise.
Perform services only in the areas of their competence.
Act responsibly to uphold the integrity of the profession.
Provided by the American Board of Industrial Hygiene (1995).
International Commission on Occupational Health
Codes of ethics for occupational health professionals, as distinct from Codes of ethics for medical practitioners, have been adopted during the past ten years by a number of countries. There are several reasons for the development of interest in ethics in occupational health at the national and international levels.
One is the increased recognition of the complex and sometimes competing responsibilities of occupational health and safety professionals towards the workers, the employers, the public, the competent authority and other bodies (public health and labour authorities, social security and judicial authorities). Another reason is the increasing number of occupational health and safety professionals as a result of the compulsory or voluntary establishment of occupational health services. Yet another factor is the development of a multi-disciplinary and intersectoral approach in occupational health which implies an increasing involvement in occupational health services of specialists who belong to various professions.
For the purpose of this Code, the expression “occupational health professionals” is meant to include all those who by profession carry out occupational safety and health activities, provide occupational health services or who are involved in occupational health practice, even if this happens only occasionally. A wide range of disciplines is concerned with occupational health since it is at an interface between technology and health involving technical, medical, social and legal aspects. Occupational health professionals include occupational health physicians and nurses, factory inspectors, occupational hygienists and occupational psychologists, specialists involved in ergonomics, in accident prevention and in the improvement of the working environment as well as in occupational health and safety research. The trend is to mobilise the competence of these occupational health professionals within the framework of a multi-disciplinary approach which may sometimes take the form of a multi-disciplinary team.
Many other professionals from a variety of disciplines such as chemistry, toxicology, engineering, radiation health, epidemiology, environmental health, applied sociology and health education may also be involved, to some extent, in occupational health practice. Furthermore, officials of the competent authorities, employers, workers and their representatives and first aid workers have an essential role and even a direct responsibility in the implementation of occupational health policies and programmes, although they are not occupational health specialists by profession. Finally, many other professions such as lawyers, architects, manufacturers, designers, work analysts, work organisation specialists, teachers in technical schools, universities and other institutions as well as the media personnel have an important role to play in the improvement of the working environment and of working conditions.
The aim of occupational health practice is to protect workers’ health and to promote the establishment and maintenance of a safe and healthy working environment as well as to promote the adaptation of work to the capabilities of workers, taking into account their state of health. A clear priority should be given to vulnerable groups and to underserved working populations. Occupational health is essentially preventive and should help the workers, individually and collectively, in safeguarding their health in their employment. It should thereby help the enterprise in ensuring healthy and safe working conditions and environment, which are criteria of efficient management and are to be found in well-run enterprises.
The field of occupational health is comprehensive and covers the prevention of all impairments arising out of employment, work injuries and work-related diseases, including occupational diseases as well as all aspects relating to the interactions between work and health. Occupational health professionals should be involved, whenever possible, in the design of health and safety equipment, methods and procedures and they should encourage workers’ participation in this field. Occupational health professionals have a role to play in the promotion of workers’ health and should assist workers in obtaining and maintaining employment notwithstanding their health deficiencies or their handicap. The word “workers” is used here in a broad sense and covers all employees, including management staff and the self-employed.
The approach in occupational health is multi-disciplinary and inter-sectoral. There is a wide range of obligations and complex relationships among those concerned. It is therefore important to define the role of occupational health professionals and their relationships with other professionals, with other health professionals and with social partners in the purview of economic, social and health policies and development. This calls for a clear view about the ethics of occupational health professionals and standards in their professional conduct.
In general, duties and obligations are defined by statutory regulations. Each employer has the responsibility for the health and safety of the workers in his or her employment. Each profession has its responsibilities which are related to the nature of its duties. When specialists of several professions are working together within a multi-disciplinary approach, it is important that they base their action on some common principles of ethics and that they have an understanding of each others’ obligations, responsibilities and professional standards. Special care should be taken with respect to ethical aspects, in particular when there are conflicting rights such as the right to the protection of employment and the right to the protection of health, the right to information and the right to confidentiality, as well as individual rights and collective rights.
Some of the conditions of execution of the functions of occupational health professionals and the conditions of operation of occupational health services are often defined in statutory regulations. One of the basic requirements for a sound occupational health practice is a full professional independence, i.e. that occupational health professionals must enjoy an independence in the exercise of their functions which should enable them to make judgements and give advice for the protection of the workers’ health and for their safety within the undertaking in accordance with their knowledge and conscience.
There are basic requirements for acceptable occupational health practice; these conditions of operation are sometimes specified by national regulations and include in particular free access to the work place, the possibility of taking samples and assessing the working environment, making job analyses and participating in enquiries after an accident as well as the possibility to consult the competent authority on the implementation of occupational safety and health standards in the undertaking. Occupational health professionals should be allocated a budget enabling them to carry out their functions according to good practice and to the highest professional standards. This should include adequate staffing, training and re-training, support and access to relevant information and to an appropriate level of senior management.
This code lays down general principles of ethics in occupational health practice. More detailed guidance on a number of particular aspects can be found in national codes of ethics or guidelines for specific professions. Reference to a number of documents on ethics in occupational health are given at the end of this document. The provisions of this code aim to serve as a guide for all those who carry out occupational health activities and cooperate in the improvement of the working environment and working conditions. Its purpose is to contribute, as regards ethics and professional conduct, to the development of common rules for team work and a multi-disciplinary approach in occupational health.
The preparation of this code of ethics was discussed by the Board of ICOH in Sydney in 1987. A draft was distributed to the Board members in Montreal and was subject to a process of consultations at the end of 1990 and at the beginning of 1991. The ICOH Code of Ethics for Occupational Health Professionals was approved by the Board on 29 November 1991. This document will be periodically reviewed. Comments to improve its content may be addressed to the Secretary-General of the International Commission on Occupational Health.
The three following paragraphs summarize the principles of ethics on which is based the International Code of Ethics for Occupational Health Professionals prepared by the International Commission on Occupational Health (ICOH).
Occupational health practice must be performed according to the highest professional standards and ethical principles. Occupational health professionals must serve the health and social wellbeing of the workers, individually and collectively. They also contribute to environmental and community health.
The obligations of occupational health professionals include protecting the life and the health of the worker, respecting human dignity and promoting the highest ethical principles in occupational health policies and programmes. Integrity in professional conduct, impartiality and the protection of the confidentiality of health data and of the privacy of workers are part of these obligations.
Occupational health professionals are experts who must enjoy full professional independence in the execution of their functions. They must acquire and maintain the competence necessary for their duties and require conditions which allow them to carry out their tasks according to good practice and professional ethics.
Duties and Obligations of Occupational Health Professionals
Conditions of Execution of the Functions of Occupational Health Professionals
(This article is a reprint of the ICOH published Code.)
The management of alcohol and drug problems in the workplace can pose ethical dilemmas for an employer. What course of conduct an employer takes involves a balancing of considerations with respect to individuals who have alcohol and drug abuse problems with the obligation to correctly manage the shareholder’s financial resources and safeguard the safety of other workers.
Although in a number of cases both preventive and remedial measures can be of mutual interest to the workers and the employer, in other situations what may be advanced by the employer as good for the worker’s health and well-being may be viewed by workers as a significant restriction on individual freedom. Also, employer actions taken because of concerns about safety and productivity may be viewed as unnecessary, ineffective and an unwarranted invasion of privacy.
Right to Privacy at Work
Workers consider privacy to be a fundamental right. It is a legal right in some countries, but one which, however, is interpreted flexibly according to the needs of the employer to ensure, inter alia, a safe, healthy and productive workforce, and to ensure that a company’s products or services are not dangerous to consumers and the public at large.
The use of alcohol or drugs is normally done in a worker’s free time and off-premises. In the case of alcohol, it can also occur on-premises if this is allowed by local law. Any intrusion by the employer with respect to the worker’s use of alcohol or drugs should be justified by a compelling reason, and should take place by the least intrusive method if costs are roughly comparable.
Two types of employer practices designed to identify alcohol and drug users among job applicants and workers have aroused strong controversy: testing of bodily substances (breath, blood, urine) for alcohol or drugs, and oral or written inquiries into present and past alcohol or drug use. Other methods of identification such as observation and monitoring, and computer-based performance testing, have also raised issues of concern.
Testing of Bodily Substances
The testing of bodily substances is perhaps the most controversial of all methods of identification. For alcohol, this normally involves using a breathalyser device or taking a blood sample. For drugs, the most widespread practice is urinalysis.
Employers argue that testing is useful to promote safety and prevent liability for accidents; to determine medical fitness for work; to enhance productivity; to reduce absenteeism and tardiness; to control health costs; to promote confidence among the public that a company’s products or services are being produced or delivered safely and properly, to prevent embarrassment to the employer’s image, to identify and rehabilitate workers, to prevent theft and to discourage illegal or socially unbecoming conduct by workers.
Workers argue that testing is objectionable because taking samples of bodily substances is very invasive of privacy; that the procedures of taking samples of bodily substances can be humiliating and degrading, particularly if one must produce a urine sample under the watchful eye of a controller to prevent cheating; that such testing is an inefficient way to promote safety or health; and that better prevention efforts, more attentive supervision and the introduction of employee assistance programmes are more efficient ways to promote safety and health.
Other arguments against screening include that testing for drugs (as opposed to alcohol) does not give an indication of current impairment, but only prior use, and therefore is not indicative of an individual’s present ability to perform the job; that testing, particularly drug testing, requires sophisticated procedures; that in case such procedures are not observed, misidentification having dramatic and unfair job consequences may occur; and that such testing can create morale problems between management and labour and an atmosphere of distrust.
Others argue that testing is designed to identify behaviour that is morally unacceptable to the employer, and that there is no persuasive empirical basis that many workplaces have alcohol or drug problems that require pre-employment, random or periodic screening, which constitute severe intrusions into a worker’s privacy because these forms of testing are done in the absence of reasonable suspicion. It has also been asserted that testing for illegal drugs is tantamount to the employer assuming a law enforcement role which is not the vocation or role of an employer.
Some European countries, including Sweden, Norway, the Netherlands and the United Kingdom, allow alcohol and drug testing, although usually in narrowly defined circumstances. For example, in many European countries statutes exist which allow the police to test workers engaged in road, aviation, rail and sea transport, normally based on reasonable suspicion of intoxication on the job. In the private sector, testing has also been reported to occur, but it is usually on the basis of reasonable suspicion of intoxication on the job, in post-accident or post-incident circumstances. Some pre-employment testing and, in very limited cases, periodic or random testing, has been reported in the context of safety-sensitive positions. However, random testing is relatively rare in European countries.
In the United States, different standards apply depending on whether alcohol and drug testing is carried out by the public- or private-sector establishments. Testing conducted by the government or by companies pursuant to legal regulation must satisfy constitutional requirements against unreasonable state action. This has led the courts to allow testing only for safety- and security-sensitive jobs, but to allow virtually all types of testing including pre-employment, reasonable cause, periodic, post-incident or post-accident, and random testing. There is no requirement that the employer demonstrate a reasonable suspicion of drug abuse in a given enterprise or administrative unit, or on the basis of individual use, before engaging in testing. This has led some observers to claim such an approach is unethical because there is no requirement for the demonstration of even a reasonable suspicion of a problem at the enterprise or individual level before any type of testing, including random screening, occurs.
In the private sector, there are no federal constitutional restrictions on testing, although a small number of American states have some procedural and substantive legal restrictions on drug testing. In most American states, however, there are few if any legal restrictions on alcohol and drug testing by private employers and it is performed on an unprecedented scale compared to European private employers, who test principally for reasons of safety.
Inquiries or Questionnaires
Although less intrusive than testing of bodily substances, employer inquiries or questionnaires designed to elicit prior and current use of alcohol and drugs are invasive of workers’ privacy and irrelevant to the requirements of most jobs. Australia, Canada, a number of European countries, and the United States have privacy laws applicable to the public and/or private sectors which require that inquiries or questionnaires be directly relevant to the job in question. In most cases, these laws do not explicitly restrict inquiries about substance abuse, although in Denmark, for example, it is prohibited to collect and store information about excessive use of intoxicants. Similarly, in Norway and Sweden, alcohol and drug abuse are characterized as sensitive data which in principle cannot be collected unless deemed necessary for specific reasons and approved by the data inspectorate authority.
In Germany, the employer can ask questions only to judge the abilities and competence of the candidate with regard to the job in question. A job applicant may answer untruthfully to inquiries of a personal character that are irrelevant. For example, it has been held by court decision that a woman can legally answer that she is not pregnant when in fact she is. Such privacy issues are judicially decided on a case-by-case basis, and whether one could answer untruthfully about one’s present or prior alcohol or drug consumption would probably depend on whether such inquiries were reasonably relevant to performance of the job in question.
Observation and Monitoring
Observation and monitoring are the traditional methods of detection of alcohol and drug problems in the workplace. Simply put, if a worker shows clear signs of intoxication or its after-effects, then he or she can be identified on the basis of such behaviour by the person’s supervisor. This reliance on management supervision to detect alcohol and drug problems is the most widespread, the least controversial and the most favoured by workers’ representatives. The doctrine that holds that treatment of alcohol and drug problems has a higher chance of success if it is based on early intervention, however, raises an ethical issue. In applying such an approach to observation and monitoring, supervisors might be tempted to note signs of ambiguous behaviour or decreased work performance, and speculate about a worker’s private alcohol or drug use. Such minute observation combined with a certain degree of speculation could be characterized as unethical, and supervisors should confine themselves to instances where a worker is clearly under the influence, and hence cannot function in the job at an acceptable level of performance.
The other question that arises is what a supervisor should do when a worker shows clear signs of intoxication. A number of commentators previously felt that the worker should be confronted by the supervisor, who should play a direct role in assisting the worker. However, most observers currently are of the view that such confrontation can be counterproductive and possibly aggravate a worker’s alcohol or drug problems, and that the worker should be referred to an appropriate health service for assessment and, if required, counselling, treatment and rehabilitation.
Computer-Based Performance Tests
Some commentators have suggested computer-based performance tests as an alternative method of detecting workers under the influence of alcohol or drugs at work. It has been argued that such tests are superior to other identification alternatives because they measure current impairment rather than previous use, they are more dignified and less intrusive of personal privacy, and persons can be identified as impaired for any reason, for example, lack of sleep, illness, or alcohol or drug intoxication. The main objection is that technically these tests may not accurately measure the job skills that they purport to measure, that they may not detect low amounts of alcohol and drugs which could potentially affect performance, and that the most sensitive and accurate tests are also those which are the most costly and difficult to set up and administer.
Ethical Issues in Choosing between Discipline and Treatment
One of the most difficult issues for an employer is when discipline should be imposed as a response to an incident of alcohol or drug use at work; when counselling, treatment and rehabilitation should be the appropriate response; and under what circumstances both alternatives—discipline and treatment—should be undertaken concurrently. Bound up in this is the question as to whether alcohol and drug use is essentially behavioural in nature, or an illness. The view that is advanced here is that alcohol and drug use is essentially behavioural in nature, but that consumption of inappropriate quantities over a period of time can lead to a condition of dependence which can be characterized as an illness.
From the employer’s point of view, it is conduct—the worker’s job performance—that is of primary interest. An employer has the right and, in certain circumstances where the worker’s misconduct has implications for the safety, health or economic well-being of others, the duty to impose disciplinary sanctions. Being under the influence of alcohol or drugs at work can be correctly characterized as misconduct, and such a situation can be characterized as serious misconduct if the person occupies a safety-sensitive position. However, a person experiencing problems at work connected to alcohol or drugs may also have a health problem.
For ordinary misconduct involving alcohol or drugs, an employer should offer the worker assistance to determine if the person has a health problem. The decision to refuse an offer of assistance may be a legitimate choice for workers who may choose not to expose their health problems to the employer, or who may not have a health problem at all. Depending on the circumstances, the employer may wish to impose a disciplinary sanction as well.
The response of an employer to a situation involving serious misconduct connected with alcohol or drugs, such as being under the influence of alcohol or drugs in a safety-sensitive position, should probably be different. Here the employer is confronted with both the ethical duty to maintain safety for other workers and the public at large, and the ethical obligation to be fair to the worker concerned. In such a situation, the employer’s principal ethical concern should be to safeguard public safety and immediately remove the worker from the job. Even in the case of such serious misconduct, the employer should assist the worker to obtain health care as appropriate.
Ethical Issues in Counselling, Treatment and Rehabilitation
Ethical issues can also arise with regard to assistance extended to workers. The initial problem that can arise is one of assessment and referral. Such services may be undertaken by the occupational health service in an establishment, by a health care provider associated with an employee assistance programme, or by the worker’s personal physician. If none of the above possibilities exists, an employer may need to identify professionals who specialize in alcohol and drug counselling, treatment and rehabilitation, and suggest that the worker contact one of them for assessment and referral, if necessary.
An employer should also make attempts to reasonably accommodate a worker during absence for treatment. Paid sick leave and other types of appropriate leave should be put at the disposition of the worker to the extent possible for in-patient treatment. If out-patient treatment requires adjustments to the person’s work schedule or transfer to part-time status, then an employer should make reasonable accommodation to such requests, particularly as the individual’s continued presence in the workforce may be a stabilizing factor in recovery. The employer should also be supportive and monitor the worker’s performance. To the extent that the working environment may have contributed initially to the alcohol or drug problem, the employer should make appropriate changes in the working environment. If this is not possible or practical, the employer should consider transferring the worker to another position with reasonable retraining if necessary.
One difficult ethical question which arises is to what extent an employer should continue to support a worker who is absent from work for health reasons due to alcohol and drug problems, and at what stage an employer should dismiss such a worker for reasons of illness. As a guiding principle, an employer should treat absence from work associated with alcohol and drug problems as any absence from work for health reasons, and the same considerations that apply to any dismissal for reasons of health should also be applicable to dismissal for absence due to alcohol and drug problems. Moreover, employers should keep in mind that relapse can occur and is, in fact, part of a process towards complete recovery.
Ethical Issues in Dealing with Illegal Drug Users
An employer is faced with difficult ethical choices when dealing with a worker who uses, or who in the past has used, illegal drugs. The question, for example, has been raised as to whether an employer should dismiss a worker who is arrested or convicted for illegal drug offences. If the offence is of such a serious nature that the person must serve time in prison, evidently the person will not be available for work. However, in many cases consumers or small-time pushers who sell just enough to support their own habit may be given only suspended sentences or fines. In such a case, an employer should ordinarily not consider disciplinary sanctions or dismissal for such off-duty and off-premises conduct. In some countries, if the person has a spent conviction, i.e., a fine that has been paid or a suspended or actual prison sentence that has been completed in full, there may be an actual legal bar against employment discrimination towards the person in question.
Another question that is sometimes posed is whether a previous or current user of illegal drugs should be subject to job discrimination by employers. It is argued here that the ethical response should be that no discrimination should take place against either previous or current users of illegal drugs if it occurs during off-duty time and off the establishment’s premises, as long as the person is otherwise fit to perform the job. In this respect, the employer should be prepared to make a reasonable accommodation in the arrangement of work to a current user of illegal drugs who is absent for purposes of counselling, treatment and rehabilitation. Such a view is recognized in Canadian federal human rights law, which prohibits job discrimination on the basis of disability and qualifies alcohol and drug dependence as a disability. Similarly, French labour law prohibits job discrimination on the basis of health or handicap unless the occupational physician determines the person is unfit for work. American federal law, on the other hand, protects previous illegal drug users from discrimination, but not current users.
As a general principle, if it comes to the attention of an employer that a job applicant or worker uses or is suspected of using illegal drugs off-duty or off-premises, and such use does not materially affect the functioning of the establishment, then there should be no duty to report this information to the law enforcement authorities. Provisions of American law which require testing by government agencies mandate that job applicants and workers who test positive for illegal drugs are not to be reported to law enforcement authorities for criminal prosecution.
If, on the other hand, a worker engages in activity involving illegal drugs on-duty or on-premises, an employer may have an ethical obligation to act either in terms of imposing disciplinary sanction or reporting the matter to law enforcement authorities or both.
An important consideration that employers should keep in mind is that of confidentiality. It may come to the employer’s attention that a job applicant or worker uses illegal drugs because the person may voluntarily disclose such information for health reasons—for example, to facilitate a rearrangement of work during counselling, treatment and rehabilitation. An employer has a strict ethical obligation, and frequently a legal obligation as well, to keep any information of a health character strictly confidential. Such information should not be disclosed to law enforcement authorities or to anyone else without the concerned person’s express consent.
In many cases, the employer may not be aware of whether a worker uses illegal drugs, but the occupational health service will know as a result of examinations to determine fitness for work. The health professional is bound by an ethical duty to maintain the confidentiality of health data, and may also be bound by medical confidentiality. In such circumstances, the occupational health service may report to the employer only whether the person is medically fit or not for work (or fit with reservations), and may not disclose the nature of any health problem or the prognosis to the employer, or to any third-parties such as law enforcement authorities.
Other Ethical Issues
Sensitivity to the working environment
Employers normally have a legal duty to provide a safe and healthy working environment. How this is applied in the context of alcohol and drugs, however, is frequently left to the discretion of employers. Workers’ representatives have argued that many alcohol and drug problems are principally the result of work-related factors such as long hours of work, isolated work, night work, boring or dead-end work, situations involving strained interpersonal relations, job insecurity, poor pay, job functions with high pressure and low influence, and other circumstances resulting in stress. Other factors such as easy access to alcohol or drugs, and corporate practices which encourage drinking on- or off-premises, may also result in substance abuse problems. Employers should be sensitive to such factors and take appropriate remedial actions.
Restrictions on the consumption of alcohol and drugs in the workplace
There is little debate that alcohol and drugs should not be consumed during actual working time in virtually all occupations. However, the more subtle question is whether an establishment should prohibit or restrict the availability of alcohol, for example, in an establishment’s canteen, cafeteria or dining room. Purists would argue that an absolute ban is the appropriate course to take, that the availability of alcohol on an establishment’s premises might actually encourage workers who would not otherwise drink to consume, and that any amount of alcohol consumption can have adverse health effects. Libertarians would argue that such restrictions on a legal activity are unwarranted, and that in one’s free time during meal breaks one should be free to relax and to consume alcohol in moderation if one so desires.
An adequate ethical response, however, lies somewhere between these two extremes and depends heavily on social and cultural factors, as well as the occupational setting. In some cultures, drinking is such a part of the fabric of social and business life that employers have found that making available certain types of alcohol during meal breaks is better than prohibiting it altogether. A prohibition may drive workers off the establishment’s premises to bars or pubs, where actual drinking behaviour may be more extreme. Consumption of greater quantities of alcohol, or of distilled alcohol as opposed to beer or wine, may be the result. In other cultures where drinking is not such an integrated feature of social and business life, a ban on any kind of alcohol being served on company premises may be readily accepted, and not lead to counterproductive results in terms of off-premises consumption.
Prevention through information, education and training programmes
Prevention is perhaps the most important component of any workplace alcohol and drug policy. Although problem drinkers and drug abusers certainly merit special attention and treatment, the majority of workers are moderate drinkers or consume legal drugs such as tranquillizers as a means of coping. Because they constitute the majority of workers, even a small impact on their conduct can have a substantial impact on the potential number of accidents at work, productivity, absenteeism and tardiness.
One can question whether the workplace is an appropriate place to conduct prevention activities through information, education and training programmes. Such prevention efforts have an essentially public health focus on the health risks associated with alcohol and drug consumption generally, and they are aimed at a captive audience of workers who are economically dependent on their employer. The response to these concerns is that such programmes also contain valuable and useful information concerning the risks and consequences of alcohol and drug consumption that are particular to the workplace, that the workplace is perhaps the most structured part of a person’s daily environment and may be a suitable forum for public health information, and that workers tend not to be offended by public health campaigns as a general proposition if they are persuasive but not coercive in terms of recommending a change in behaviour or lifestyle.
Although employers should be sensitive to concerns that public health programmes have a persuasive rather than a coercive orientation, the appropriate ethical choice mitigates in favour of initiating and supporting such programmes not only for the potential good of the establishment in terms of economic benefits associated with fewer alcohol and drug problems, but also for the general well-being of workers.
It should also be remarked that workers have ethical responsibilities with respect to alcohol and drugs in the workplace. Among these ethical responsibilities one could include a duty to be fit for work and to abstain from use of intoxicants immediately before or during work, and a duty to be vigilant with respect to substance use when one exercises safety-sensitive functions. Other ethical precepts could include an obligation to assist colleagues who appear to be having alcohol or drug problems as well as to provide a supportive and friendly work environment for those trying to overcome these problems. Also, workers should cooperate with the employer with respect to reasonable measures taken to promote safety and health in the workplace with respect to alcohol and drugs. However, workers should not be obligated to accept an invasion of their privacy when there is no compelling work-related justification or when the measures requested by the employer are disproportionate to the end to be attained.
In 1995, an ILO international meeting of experts, composed of 21 experts drawn equally from governments, employers’ groups and workers’ organizations, adopted a Code of Practice on the Management of Alcohol- and Drug-related Issues in the Workplace (ILO 1996). This Code of Practice addresses many of the ethical considerations that should be examined when dealing with workplace-related issues concerning alcohol and drugs. The Code of Practice is particularly useful as a reference because it also makes practical recommendations concerning how to manage potential alcohol- and drug-related problems that may arise in the employment context.
While occupational health services are becoming more prevalent throughout the world, resources to develop and sustain these activities often do not keep pace with growing demands. Meanwhile, the boundaries of private and work life have been shifting, raising the issue of what can be, or should be, legitimately encompassed by occupational health. Workplace programmes that screen for drugs or HIV seropositivity, or provide counselling for personal problems, are obvious manifestations of the blurring of the boundary between private and work life.
From a public health viewpoint there are good arguments as to why health behaviours should not be compartmentalized into lifestyle factors, workplace factors and broader environmental factors. While the goals of eliminating drug abuse and other deleterious activities are laudable, there are ethical dangers in how these issues are addressed at the workplace. It will also be necessary to ensure that measures against such activities do not displace other health protection measures. The purpose of this article is specifically to examine the ethical issues in health protection and health promotion in the workplace.
Individual and collective protection of workers
While ethical behaviour is essential to all aspects of health care, the definition and promotion of ethical behaviour is often more complex in occupational health settings. The primary care clinician must prioritize the needs of the individual patient, and the community health professional must prioritize the health needs of the collective. The occupational health professional, on the other hand, has a duty to both the individual patient and the collective—the worker, the workforce and the public at large. Sometimes this multiple obligation presents conflicting responsibilities.
In most countries workers have an undeniable legal right to be protected from workplace hazards, and the focus of occupational health programmes should be precisely to address this right. Ethical issues associated with the protection of workers from unsafe conditions are generally those related to the fact that often the employer’s financial interests, or at least perceived financial interests, militate against undertaking the activities needed to protect workers’ health. The ethical stance that the occupational health professional must adopt, however, is clear-cut. As noted in the International Code of Ethics for Occupational Health Professionals (reprinted in this chapter): “Occupational health professionals must always act, as a matter of priority, in the interests of the health and safety of the workers.”
The occupational health professional, whether an employee or a consultant, often experiences pressures to compromise on ethical practice in worker health protection. The professional may even be asked by an employee to serve as an advocate against the organization when legal issues arise or when the employee, or the professional him- or herself, feels that health protection measures are not being provided.
To minimize such real-life conflicts it is necessary to establish societal expectations, market incentives and infrastructural mechanisms to counteract the employer’s real or perceived financial disadvantages in providing worker health protection measures. These may consist of clear regulations that require safe practices, with steep fines for violation of these standards; this, in turn, requires adequate compliance and enforcement infrastructure. It may also comprise a system of workers’ compensation premiums designed to promote prevention practices. Only when societal factors, norms, expectations and legislation reflect the importance of workplace health protection will ethical practice be truly allowed to flourish.
The right to be protected from unsafe conditions and acts of others
Occasionally, another ethical issue arises with respect to health protection: that is the situation in which an individual worker may him- or herself pose a workplace hazard. In keeping with the multiple responsibilities of the occupational health professional, the right of members of the collective (the workforce and the public) to be protected from the acts of others must always be considered. In many jurisdictions “fitness to work” is defined not only in terms of the worker’s ability to do the job, but also to do the job without posing an undue risk to co-workers or the public. It is unethical to deny someone a job (i.e., declare the worker unfit to work) on the basis of a health condition when no scientific evidence exists to substantiate the claim that this condition impairs the worker’s ability to work safely. However, sometimes clinical judgement suggests that a worker may pose a hazard to others, even when the scientific documentation to support a declaration of unfit is weak or even completely lacking. The repercussions, for example, of allowing a worker with undiagnosed dizzy spells to drive a crane, can be extremely serious. Indeed it may be unethical to allow an individual to assume special responsibilities in these cases.
The need to balance individual rights with collective rights is not unique to occupational health. In most jurisdictions it is legally required that a health practitioner report to the public health authorities conditions such as sexually transmitted diseases, tuberculosis or child abuse, even if this requires the breaching of confidentiality of the individuals involved. While there are often no concrete guidelines to assist the occupational health practitioner when formulating such opinions, ethical principles require that the practitioner utilize the scientific literature as thoroughly as possible in combination with his or her best professional judgement. Thus public health and safety considerations must be combined with concerns for the individual worker when performing medical and other exams for jobs with special responsibilities. Indeed screening for drugs and alcohol, if it is to be justified at all as a legitimate occupational health activity, could be justified only on this basis. The International Code of Ethics for Occupational Health Professionals states:
Where the health condition of the worker and the nature of the tasks performed are such as to be likely to endanger the safety of others, the worker must be clearly informed of the situation. In the case of a particularly hazardous situation, the management and, if so required by national regulations, the competent authority, must also be informed of the measures necessary to safeguard other persons.
The emphasis on the individual tends to overlook and indeed ignore the professional’s obligations to the overall good of society or even specific collective groups. For example, when the behaviour of the individual becomes a danger either to self or others, at what point should the professional act on behalf of the collective and override individual rights? Such decisions can have important ramifications for providers of employee assistance programmes (EAPs) who work with impaired workers. The duty to warn co-workers or clients who may use the impaired person’s services, as opposed to the obligation to protect the confidentiality of the person, has to be clearly understood. The professional cannot hide behind confidentiality or the protection of individual rights, as was discussed above.
Health Promotion Programmes
The assumptions and the debate
The assumptions generally underlying lifestyle change promotion activities in the workplace are that:
(l) employees’ daily lifestyle decisions regarding exercise, eating, smoking and stress management have a direct impact on their present and future health, the quality of their lives, and their job performance and (2) a company-sponsored positive lifestyle change programme, administered by full-time personnel but voluntary and open to all employees, will motivate employees to make positive lifestyle changes sufficient to affect both health and quality of life (Nathan 1985).
How far can the employer go in attempting to modify a behaviour such as off-hours drug use, or a condition such as overweight, which does not directly affect others or employee job performance. In health promotion activities, enterprises commit themselves to a role of reformer of those aspects of employees’ lifestyles that are, or are perceived to be, harmful to their health. In other words, the employer may wish to become an agent of social change. The employer may even strive to become the health inspector with regard to those conditions which are deemed to be favourable or unfavourable to health, and implement disciplinary action to keep employees in good health. Some have specific restrictions which prohibit employees from exceeding set body weights. Incentive measures are in place which reduce insurance or other benefits to employees who care for their bodies, especially through exercise. Policies may be used to encourage certain sub-groups, i.e., smokers, to give up practices that are harmful to their health.
Many organizations contend that they do not intend to direct the personal lives of employees, but rather are seeking to influence the workers to act sensibly. However, some question whether employers should intervene in an area that is recognized as private behaviour. Opponents argue that such activities are an abuse of employers’ power. What is rejected is less the legitimacy of the health proposals than the motivation behind them, which appears to be paternalistic and elitist. The health promotion programme may also be perceived to be hypocritical where the employer does not make changes to organizational factors that contribute to ill health, and where the principal motive appears to be cost containment.
Cost containment as the primary motivator
A central feature of the context of worksite-based health services is that the “main” business of the organization is not to provide health care, though services to employees may be seen as an important contribution to the achievement of the organization’s goals, such as efficient operation and cost containment. In most cases, health promotion EAPs and rehabilitation services are provided by employers seeking to meet organizational goals—i.e., a more productive work force, or the reduction of costs of insurance and workers’ compensation. While corporate rhetoric has emphasized the humanitarian motives underlying EAPs, the major rationale and impetus usually involves the organization’s concerns about the costs, absenteeism and loss of productivity associated with mental health problems and abuse of alcohol and drugs. These goals are substantially different from the traditional goals of health practitioners, since they take into consideration the goals of the organization as well as the needs of the patient.
When employers pay directly for the services, and services are provided at the worksite, professionals delivering services must, by necessity, take into account the organizational goals of the employer and the specific culture of the workplace involved. Programmes may be framed in terms of “bottom line impact”; and compromises on goals for health services may need to be made in the face of cost containment realities. The choice of action recommended by the professional may be influenced by these considerations, sometimes presenting an ethical dilemma as to how to balance what would be best for the individual worker with what would be most cost-effective for the organization. Where the professional’s primary responsibility is managed care with a stated goal of cost containment, conflicts may be exacerbated. Considerable caution must therefore be exercised in managed care approaches to ensure that health care objectives are not compromised by efforts to limit or reduce costs.
Which employees are entitled to EAP services, which types of problem should be considered and should the programme be extended to family members or retirees? It would appear that many decisions are based not on the stated intent of improved health but rather the limit of benefit coverage. Part-time staff who have no benefit coverage tend not to have access to EAP services so that the organization does not have to pay additional costs. However, part-time staff may also have problems which affect performance and productivity.
In the trade-off between quality care and lowered costs, who should decide how much quality is required and at what price—the patient, who uses the services but is not accountable for the payment or price, or the EAP gatekeeper, who does not pay the bill but whose job may depend upon the success of the treatment? Should the provider or the insurer, the ultimate payer, take the decision?
Similarly, who should decide when an employee is expendable? And, if insurance and treatment costs dictate such a decision, when is it more cost-efficient to fire an employee—for example, because of mental illness—and then recruit and train a new employee? More discussion of the role of occupational health professionals in addressing such decisions is certainly warranted.
Voluntarism or coercion?
The ethical problems created by unclear client allegiance are immediately evident in EAPs. Most EAP professionals would argue from their clinical training that their legitimate focus is the individual for whom they are the advocates. This concept depends on the notion of voluntarism. That is, the client seeks out assistance voluntarily and consents to the relationship, which is maintained only with his or her active participation. Even where the referral is made by a supervisor or management, the argument is made that participation is still fundamentally voluntary. Similar arguments are made for health promotion activities.
This contention of EAP practitioners that clients are operating on their own free will often falls apart in practice. The notion that participation is entirely voluntary is largely an illusion. Client perceptions of choice are sometimes much less than proclaimed, and supervisory referrals can well be based on confrontation and coercion. So are the majority of so-called self-referrals, which occur after a strong suggestion has been given by a powerful other. While the language is one of choice, it is clear that choices are indeed limited and there is only one right way to proceed.
When health care costs are paid by the employer or through the employer’s insurance, the boundaries between public and private life become less distinct, further increasing the potential for coercion. The current ideology of programmes is one of voluntarism; but can any activity be completely voluntary in the work setting?
Bureaucracies are not democracies and any so-called voluntary behaviour in organizational setting is likely to be open to challenge. Unlike the community setting, the employer has a fairly long term contractual relationship with most employees, which in many cases is dynamic with the possibility of raises, promotions, as well as overt and covert demotions. This may result in deliberate or inadvertent impressions that participation in a particular active preventive programme is normative and expected (Roman 1981).
Health education too must be cautious about claims of voluntarism as this fails to recognize the subtle forces which have great potency in the workplace on shaping behaviour. The fact that health promotion activities receive considerable positive publicity and are also provided free of cost, can lead to the perception that participation is not only supported but highly desired by management. There may be expectations of rewards for participation beyond those related to health. Participation may be seen as necessary to advancement or at least to maintaining one’s profile in the organization.
There may also be a subtle deception on the part of management, which promotes health activities as part of its sincere interest in the well-being of staff, while burying its real concerns related to cost containment expectations. Overt incentives such as higher insurance premiums for smokers or overweight employees may increase participation but at the same time be coercive.
Individual and collective risk factors
The overwhelming focus of work-based health promotion on individual lifestyle as the unit of intervention distorts the complexities underlying social behaviours. Social factors, such as racism, sexism and class bias, are generally overlooked by programmes which focus solely on changing personal habits. This approach takes behaviour out of context and assumes “that personal habits are discrete and independently modifiable, and that individuals can voluntarily choose to alter such behaviour” (Coriel, Levin and Jaco 1986).
Given the influence of social factors, what is the true extent to which people have control over modifying health risks? Certainly behavioural risk factors do exist, but the effects of social structure, the environment, heredity or simple chance must also be taken into account. The individual is not solely responsible for the development of disease, yet this is precisely what many work-site health promotion efforts assume.
A health promotion programme in which individual responsibility can be overstated, leads to moralizing.
Although personal responsibility is undeniably a factor in smoking for example, social influences such as class, stress, education and advertising are also involved. Deeming that only individual factors are causally responsible facilitates blaming the victim. Employees who smoke, are overweight, have high blood pressure, and so on, are blamed, albeit sometimes implicitly, for their condition. This absolves the organization and society from any responsibility for the problem. Employees may be blamed both for the condition and for not doing something about it.
The tendency to assign responsibility solely to the individual ignores a large body of scientific data. Evidence suggests that the physiological sequelae of work may have an impact on health which continues after the workday is done. It has been widely demonstrated that linkages between organizational factors (such as participation in decision making, social interaction and support, pace of work, work overload, etc.), and health outcomes, particularly cardiovascular disease, exist. Implications for organizational interventions, rather than or in addition to individual behaviour change, are quite clear. Nonetheless, most health promotion programmes aim to change individual behaviour but rarely consider such organizational factors.
The focus on individuals is less surprising when it is recognized that most professionals in health promotion, wellness and EAP programmes are clinicians who do not have a background in occupational health. Even when clinicians do identify workplace factors of concern, they are seldom equipped to recommend or carry out organizationally oriented interventions.
Diverting attention from health protection
Rarely have wellness programmes proposed interventions in the corporate culture or included alterations in work organization such as stressful management styles, the content of boring work or noise levels. By ignoring the contribution of the work environment to the health outcomes, popular programmes such as stress management may have a negative impact on health. For example, by focusing on individual stress reduction rather than altering stressful working conditions, workplace health promotion may be helping workers to adapt to unhealthy environments and in the long term increasing disease. Moreover, the research conducted has not provided much support for the clinical approaches. For example, in one study, individual stress management programmes had smaller effects on catecholamine production than did the manipulation of pay systems (Ganster et al. 1982).
In addition, Pearlin and Schooler (1978) found that while various problem-solving, coping responses were effective in one’s personal and family life, this type of coping is not effective in dealing with work-related stressors. Other studies further suggested that some personal coping behaviours actually increase distress if applied in the workplace (Parasuramen and Cleek 1984).
The advocates of wellness programmes are generally uninterested in the traditional concerns of occupational health and, consciously or otherwise, turn attention away from workplace hazards. As wellness programmes generally ignore the risk of occupational disease or hazardous working conditions, health protection advocates fear that individualizing the problem of employee health is an expedient way for some companies to deflect attention from costly but risk-reducing changes in the structure and content of workplace or jobs.
Employers sometimes feel they have the right to have access to clinical information about workers who receive services from the professional. Yet the professional is bound by the ethics of the profession and by the practical need to maintain the trust of the worker. This problem becomes particularly troublesome if legal proceedings are at issue or if the problem at hand is surrounded by emotionally charged issues, such as disability from AIDS.
Professionals may also become involved in confidential issues related to the employer’s business practices and operations. If the industry in question is highly competitive, the employer may wish to keep secret such information as organizational plans, reorganizations and downsizing. Where business practices may have an impact on the health of employees, how does the professional prevent the occurrence of such adverse effects without jeopardizing the proprietary or competitive secrets of the organization?
Roman and Blum (1987) argue that confidentiality serves to protect the practitioner from extensive scrutiny. Citing client confidentiality, many oppose quality review or peer case review, which might reveal that the practitioner has exceeded the bounds of professional training or expertise. This is an important ethical consideration given the power of the counsellor to influence the health and well-being of clients. The issue is the need to clearly identify for the client the nature of the intervention in terms of what it can or cannot do.
The confidentiality of information collected by programmes which focus on individuals rather than systems of work may be prejudicial to the worker’s job security. Health promotion information can be misused to influence the employee’s status with health insurance or personnel issues. When aggregate data are available, it may be difficult to ensure that such data will not be used to identify individual employees, especially in small work groups.
Where the clinical utilization patterns of the EAP draw attention to a particular work unit or site, practitioners have been loath to bring this to management’s attention. Sometimes the citation of confidentiality issues in reality masks an inability to make reasonable recommendations for intervention due to fears that management will not be receptive to negative feedback about their behaviour or organizational practices. Unfortunately, clinicians sometimes lack the research and epidemiological skills which allow them to present solid data in support of their observations.
Other concerns relate to the misuse of information by a variety of different interest groups. Insurance companies, employers, trade unions, client groups and health professionals may misuse both collective and individual information gathered in the course of a health promotion activity.
Some may use data to deny services or coverage to employees or their survivors in legal or administrative proceedings dealing with compensation or insurance claims. Participants in programmes may believe that the “guarantee of confidentiality” provided by such programmes is inviolate. Programmes need to clearly advise employees that under certain circumstances (i.e., legal or administrative inquiries) personal information gathered by the programme may be made available to other parties.
Aggregate data may be misused so as to shift the burden from one party to another. Access to such information may not be equitable, in that collective information may be available only to organizational representatives and not those individuals seeking benefits. While releasing data on workers focusing on the individual lifestyle contributions to a condition, organizations may be able to restrict information about corporate practices which also created the problem.
Epidemiological data about patterns of conditions or work-related factors should not be gathered in such a manner as to facilitate exploitation by the employer, the insurer, the compensation system or by the clients.
Conflict with other professional or service standards
Professional standards and values may be in conflict with practices already in place in a given organization. Confrontational methods used by occupational alcoholism programmes may be unproductive or in conflict with professional values when dealing with other disorders or disabilities, yet the professional working in this context may be pressured to participate in the use of such methods.
Ethical relationships with outside providers must also be considered. While EAPs have clearly articulated the need for practitioners to avoid referrals to treatment services with which they are closely affiliated, health promotion providers have not been as resolute in defining their relationships with external providers of services that may be attractive to employees for personal lifestyle counselling. Arrangements between EAPs and particular providers which lead to referrals to treatment based on economic advantages to the providers rather than clinical needs of clients present an obvious conflict of interest.
There is also the temptation to engage unqualified individuals in health promotion. EAP practitioners do not normally have the training in health education techniques, physiology or fitness instruction to qualify them to provide such activities. When programmes are provided and administered by management and cost is of primary concern, there is less motivation to scrutinize skills and expertise and to invest in the best qualified professionals, as this will change the cost-benefit outcomes.
The use of peers to provide services raises other concerns. It has been shown that social support from one’s co-workers could buffer the health effects of certain job stressors. Many programmes have capitalized on the positive influence of social support by the use of peer counsellors or self-help support groups. However, while peers can be used as a supplement to some extent, they do not eliminate the need for qualified health professionals. Peers need to have a strong orientation programme, which includes content on ethical practices and not exceeding one’s personal limits or qualifications whether overtly or through misrepresentation.
Drug screening and testing
Drug testing has become a quagmire of regulations and legal interpretation and has not proven to be an effective avenue to either treatment or prevention. The recent report from the National Research Institute (O’Brien 1993) has concluded that drug testing is not a strong deterrent to alcohol and drug abuse. Further evidence suggests that it does not have a significant impact on work performance.
A positive drug test may reveal much about an employee’s lifestyle but nothing about his or her level of impairment or ability to perform work.
Drug testing has been seen as the thin edge of the wedge with which employers drive out all but the most invulnerable employee—the super-resilient person. The trouble is how far does the organization go? Can one test for compulsive behaviours such as gambling or for mental disorders, such as depression?
There is also a concern that organizations may use screening to identify undesirable traits (e.g., predisposition to heart disease or back injury) and to make personnel decisions based on this information. At present this practice appears to be limited to health insurance coverage, but how long can it be resisted by management attempting to reduce cost?
The government-stimulated practice of screening for drugs, and the future possibility of screening for defective genes and excluding whole classes of high-cost employees from health insurance coverage, advances the old presumption that characteristics of workers, not work, explain disabilities and dysfunctions; and this becomes a justification for making workers bear the social and economic costs. This leads again to a perspective in which factors based on the individual, not work, become the focus of health promotion activities.
Exploitation by the client
On occasion it may be clear to the professional that workers are attempting to take improper advantage of the system of services provided by an employer or by its insurance carrier or by workers’ compensation. Problems may include clearly unrealistic rehabilitation demands or outright malingering for financial gain. Appropriate methods of confronting such behaviour, and for taking action as needed, have to be balanced against other clinical realities, such as psychological reactions to disability.
Promotion of activities with questionable effectiveness
Despite the broad claims for worksite health promotion, the scientific data available to evaluate them are limited. The profession as a whole has not addressed the ethical issues of promoting activities which do not have a strong scientific support, or of choosing to engage in services which produce more revenue rather than focusing on ones which have a demonstrated impact.
Ironically, what is being sold is based upon little conclusive evidence of cost reduction, decreased absenteeism, reduced health care expenditures, reductions in employee turnover or increased productivity. Studies are poorly designed, seldom having comparison groups or long-term follow-up. The few that meet the standards of scientific rigour have provided little evidence of a positive return on investment.
There is also some evidence that the participants in worksite health promotion activities tend to be relatively healthy individuals:
Overall it appears participants are likely to be nonsmokers, more concerned with health matters, perceive themselves in better health, and be more interested in physical activities, especially aerobic exercise, than nonparticipants. There is also some evidence that participants may use less health services and be somewhat younger than nonparticipants (Conrad 1987).
Individuals at risk may not be using the health services.
Even where there is evidence to support particular activities and all of the professionals agree on the necessity for such services as follow-up, in practice services are not always provided. Generally EAPs concentrate on finding new cases while devoting little time to workplace prevention. Follow-up services are either non-existent or limited to one or two visits after return to work. With the chronic relapse potential of alcohol and drug cases, it would appear that EAPs are not devoting energies to continuing care, which is very costly to provide, but rather emphasize activities which generate new revenues.
Health examinations for insurance purposes and determination of benefits
Just as the boundary between private life and work factors affecting health has become increasingly blurred, so too has the distinction between fit and unfit or healthy and sick. Thus instead of examinations for insurance or benefits focusing on whether or not a worker is ill or disabled, and therefore “deserving” of benefits, there is an increasing realization that with workplace changes and health promotion activities, the worker, even with his or her illness or disability, can be accommodated. Indeed “adaptation of work to the capabilities of workers in the light of their state of physical and mental health” has been enshrined in the ILO Occupational Health Services Convention, 1985 (No. 161).
The linking of health protection measures and health promotion activities is nowhere as important as it is in addressing workers with special health needs. Just as an indexed patient may reflect pathology in a group, a worker with special health needs may reflect needs in the workforce as a whole. Alteration of the workplace to accommodate such workers very often results in improvements in the workplace that benefit all workers. Providing treatment and health promotion to workers with special health needs may decrease costs to the organization, by containing insurance or workers’ compensation benefits; more importantly, it is the ethical way to proceed.
In recognition that prompt rehabilitation and accommodation of injured workers is “good business,” many employers have introduced early intervention, rehabilitation and return to modified work programmes. Sometimes these programmes are offered through workers’ compensation boards, which have come to realize that both the employer and the individual worker suffer if the benefit system provides an incentive to maintain “the sick role,” rather than an incentive towards physical, mental and vocational rehabilitation.
The International Code of Ethics for Occupational Health Professionals (reprinted in this chapter) provides guidelines to ensure that health promotion activities do not divert attention from health protection measures, and to promote ethical practice in such activities. The Code states:
Occupational health professionals may contribute to public health in different ways, in particular by their activities in health education, health promotion and health screening. When engaging in these programmes, occupational health professionals must seek the participation ... of both employers and workers in their design and in their implementation. They must also protect the confidentiality of personal health data of the workers.
Finally, it is necessary to reiterate that the ethical practice of occupational health could best be promoted by addressing the workplace and societal infrastructure that must be designed to promote the interests of both the individual and the collective. Thus stress management, health promotion and EAPs, which until now have focused almost exclusively on individuals, must address institutional factors in the workplace. It will also be necessary to ensure that such activities do not displace health protection measures.
This article deals with the ethical issues that arise in the practice of occupational health activities, including occupational health research, with respect to the handling of information on individual employees, not in terms of practicality or efficiency but by referring to what may be regarded as right or wrong. It does not provide a universal formula for decisions on whether or not practices in handling information or in dealing with issues of confidentiality are ethically justified or defensible. It describes the cornerstone ethical principles of autonomy, beneficence, non-maleficence and equity and their implications for these human rights issues.
The basic principles used in ethical analyses can be used in examining the ethical implications in the generation, communication and utilization of other types of information as well as, for example, the conduct of occupational health research. Since this article is an overview, specific applications will not be discussed in great detail.
On the labour market, in an enterprise, or at a workplace, health issues involve, first and foremost, free-living and economically active people. They may be healthy or experience health disturbances which are, in their causation, manifestation and consequences, more or less related to work and workplace conditions. Furthermore, a broad range of professionals and persons with various roles and responsibilities may become involved in the health issues concerning individuals or groups at the workplace, such as:
Information arising in the practice or science of occupational health and the issues of need-to-know involve all these groups and their interaction. This means that the question of openness or confidentiality of information with regard to human rights, individual workers’ rights and the needs of employers or the needs of society at large is of broad scope. It may also be of high complexity. It is, in reality, an area of core importance in occupational health ethics.
The underlying assumption of this article is that people have a need and also a prima facie right to privacy. This means a need, and a right, to conceal and to reveal, to know as well as to be left in ignorance on various aspects of life in society and one’s own relations with the outer world. Likewise a collective, or a society, needs to know some things about individual citizens. With regard to other things there may be no such need. At the workplace or on the enterprise level, the issues of productivity and health involve the employer and those employed, both as a collective and as individuals. There are also situations where public interests are involved, represented by government agencies or other institutions claiming a legitimate need to know.
The question which immediately arises is how these needs are to be reconciled and what conditions should be satisfied before the needs to know of the enterprise or society can legitimately override the individual’s right to privacy. There are ethical conflicts needing to be resolved in this reconciliation process. If the needs to know of the enterprise or employer are not compatible with the needs to protect the privacy of the employees, a decision has to be made as to which need, or right to information, is paramount. The ethical conflict arises from the fact that the employer is usually responsible for taking preventive action against occupational health hazards. To exercise this responsibility the employer needs information on both working conditions and the health of the employees. The employees may wish some types of information about themselves to be kept confidential or secret, even while accepting the need for preventive measures.
The ethical issues and conflicts in the occupational health sphere may be approached using the two classical ethical paradigms—consequentialist ethics or deontological ethics. Consequentialist ethics focuses on what is good or bad, harmful or useful in its consequences. As an example, the social ambition expressed as the principle of maximizing benefits for the greatest number in a community is a reflection of consequentialist ethics. The distinctive feature of deontological ethics is to regard certain actions or human behaviour as obligatory, such as for example the principle of always telling the truth—the principle of veracity—regardless of its consequences. The deontologist holds moral principles to be absolute, and that they impose an absolute duty on us to obey them. Both these paradigms of basic moral philosophy, separately or in combination, may be used in ethical assessments of activities or behaviours of humans.
When discussing ethics in occupational health, the impact of ethical principles on human relationships and the questions of needs to know at the workplace, it is necessary to clarify the main underlying principles. These can be found in international human rights documents and in recommendations and guidelines stemming from decisions adopted by international organizations. They are also reflected in professional codes of ethics and conduct.
Both individual and social human rights play a role in health care. The right to life, the right to physical integrity, and the right to privacy are of particular relevance. These rights are included in:
Of particular relevance for occupational health service personnel are the codes of conduct formulated and adopted by the World Medical Association. These are:
Individual human rights are in principle unrelated to economic conditions. Their foundation lies in the right of self determination, which involves human autonomy as well as human liberty.
The principle of autonomy focuses on the individual’s right to self-determination. According to this principle all human beings have a moral obligation to respect the human right to self- determination so long as it does not infringe on the rights of others to determine their own actions on matters concerning themselves. One important consequence of this principle for the practice of occupational health is the moral duty to regard some types of information on individuals as confidential.
The second principle, the principle of care, is a combination of two ethical principles—the non-maleficence principle and the beneficence principle. The first prescribes a moral obligation for all humans not to cause human suffering. The beneficence principle is the duty to do good. It dictates that all humans are under a moral obligation to prevent and to eliminate suffering or harm and also to some extent to promote well-being. One practical consequence of this in the practice of occupational health is the obligation to seek in a systematic way to identify health risks at the workplace, or instances where health or life quality are disturbed as a result of workplace conditions, and to take preventive or remedial action wherever such risks or risk factors are found. The beneficence principle may also be evoked as a basis for occupational health research.
The principle of equity implies the moral obligation of all human beings to respect each other’s rights in an impartial way and to contribute to a distribution of burdens and benefits in such a way that the least privileged members of the community or the collective are given particular attention. The important practical consequences of this principle lie in the obligation to respect the right to self-determination of everyone concerned, with the implication that priority should be given to groups or individuals at the workplace or in the labour market who are most vulnerable or most exposed to health risks at the workplace.
In considering these three principles it is proper to re-emphasize that in the health services the autonomy principle has in the course of time largely superseded beneficence as the first principle of medical ethics. This in fact constitutes one of the most radical re-orientations in the long history of the Hippocratic tradition. The emergence of autonomy as a sociopolitical, legal and moral concept has profoundly influenced medical ethics. It has shifted the centre of decision-making from the physician to the patient and thereby re-oriented the whole physician-patient relationship in a revolutionary way. This trend has obvious implications for the whole field of occupational health. Within the health services and biomedical research it is related to a range of factors which have an impact on the labour market and industrial relations. Among these should be mentioned the attention given to participatory approaches involving workers in decision processes in many countries, the expansion and advance of public education, the emergence of civil rights movements of many types and the rapidly accelerating technological changes in production techniques and work organization.
These trends have supported the emergence of the concept of integrity as an important value, intimately related to autonomy. Integrity in its ethical meaning signifies the moral value of wholeness, constituting all human beings as persons and ends in themselves, independent in all functions and demanding respect for their dignity and moral value.
The concepts of autonomy and integrity are related in the sense that the integrity is expressing a fundamental value equivalent to the dignity of the human person. The concept of autonomy rather expresses the principle of freedom of action directed towards safeguarding and promoting this integrity. There is an important difference between these concepts in that the value of integrity admits no degrees. It may be either intact or violated or even lost. Autonomy has degrees and is variable. In that sense autonomy can be more or less restricted, or, conversely, expanded.
Privacy and Confidentiality
Respect for the privacy and confidentiality of persons follows from the principle of autonomy. Privacy may be invaded and confidentiality violated by revealing or releasing information that can be used to identify or expose a person to unwanted or even hostile reactions or responses from others. This means that there is a need to protect such information from being disseminated. On the other hand, in the event the information is essential to discover or prevent health risks at the workplace, there is a need to protect the health of individual employees and indeed sometimes the health of a larger collective of employees who are exposed to the same workplace risks.
It is important to examine whether the need to protect information on individuals and the need to protect the health of the employee collective and to improve working conditions are compatible. It is a question of weighing the needs of the individual versus the benefits of the collective. Conflicts may therefore arise between the principles of autonomy and beneficence, respectively. In such situations it is necessary to examine the questions of who should be authorized to know what and for what purposes.
It is important to explore both these aspects. If information derived from the individual employees could be used to improve working conditions for the benefit of the whole collective, there are good ethical reasons to examine the case in depth.
Procedures have to be found to deny unauthorized access to information and to use of the information for purposes other than those stated and agreed on in advance.
In an ethical analysis it is essential to proceed step by step in identifying, clarifying and solving ethical conflicts. As has been mentioned earlier, vested interests of various kinds, and of various actors at the workplace or in the labour market, can present themselves as ethical interests or stakeholders. The first elementary step is therefore to identify the main parties involved and to describe their rational interests and to locate potential and manifest conflicts of interests. It is an essential prerequisite that such conflicts of interests between the different stakeholders are made visible and are explained instead of being denied. It is also important to accept that such conflicts are quite common. In every ethical conflict there are one or several agents and one or several subjects concerned by the action undertaken by the agent or agents.
The second step is to identify the relevant ethical principles of autonomy, beneficence, non-maleficence and equity. The third step consists in identifying ethical advantages or benefits and costs or disadvantages for those persons or bodies who are involved in or affected by the problem or the occupational health issue. The expressions ethical gains or ethical costs are here given a rather broad meaning. Anything which may reasonably be judged to be beneficial or to have a positive impact from an ethical point of view is a gain. Anything which may affect the group in a negative way is in an analogous way an ethical cost.
These basic principles of ethics (autonomy, beneficence and equity) and associated steps of analysis apply both for handling of information in the day-to-day practice of professional occupational health work and for handling and communication of scientific information. Seen in this perspective, the confidentiality of medical records or results of occupational health research projects may be analysed on the principal grounds outlined above.
Such information may for instance concern suspected or potential health hazards at work, and it may be of varying quality and practical value. Obviously the use of such information involves ethical issues.
It is to be emphasized that this model for ethical analyses is intended primarily for structuring of a complex pattern of relationships involving the individual employee, the employees at the enterprise as a collective and vested interests at the workplace and in the community at large. Basically, in the present context, it is a pedagogic exercise. It is fundamentally based on the assumption, from some quarters regarded as controversial in moral philosophy, that the objective and correct solution in an ethical conflict simply does not exist. To cite Bertrand Russell:
(We) are ourselves the ultimate and irrefutable arbiters of values and in the world of value nature is only a part. Thus, in this world we are greater than Nature. In the world of values, nature itself is neutral, neither good nor bad, deser- ving neither admiration nor censure. It is we who create values and our desires which confer value. In this realm we are kings, and we debase kingship if we bow down to Na- ture. It is for us to determine the good life, not for Nature—not even nature personified as God (Russell 1979).
This is another way of saying that the authority of ethical principles, as referred to earlier in this text, is determined by the individual person or group of persons, who may or may not agree as to what is intellectually or emotionally acceptable.
This means that in solving ethical conflicts and problems the dialogue between the different interests involved assumes significant importance. It is essential to create a possibility for everyone concerned to exchange views with the others involved in mutual respect. If it is accepted as a fact of life that there are no objectively correct solutions for ethical conflicts, it does not follow that the definition of ethical positioning is entirely based on subjective and unprincipled thinking. It is important to keep in mind that issues related to confidentiality and integrity may be approached by various groups or individuals with points of departure based on widely differing norms and values. One of the important steps in an ethical analysis is therefore to design the procedure for contacts with and between the persons and collective interests concerned, and the steps to be taken to initiate the process ending in agreement or disagreement with respect to the handling or transfer of sensitive information.
Lastly, it is emphasized that ethical analysis is a tool for examination of practices and optional strategies of action. It does not provide blueprint answers to what is right or wrong, or to what is thought to be acceptable or not acceptable from an ethical point of view. It provides a framework for decisions in situations involving the basic ethical principles of autonomy, beneficence, maleficence and equity.
Ethics and Information in Occupational Health
The ethical questions and dilemmas arising in the practice and science of occupational health derive from the collection, storage, analyses and use of information about individual persons. Such processes may be carried out on a routine or ad hoc basis with the objective of improving the health and life quality of employees or the working conditions at the workplace. These are, in themselves, motives which are of fundamental importance in all occupational health work. The information may, however, also be used for selective practices, even of a discriminatory nature, if used for instance in hiring or making work assignments. Information collected from health records or personnel files has, therefore, in principle a potential to be used against the individual in a way which may be unacceptable or regarded as a violation of basic ethical principles.
The information may consist of data and recorded observations from pre-employment medical examinations or periodic screening or health monitoring programmes. Such programmes or routines are often initiated by the employer. They may also be motivated by legal requirements. It may also include information collected at medical consultations initiated by the person concerned. One data source of particular relevance in the occupational health field is the biological monitoring of workplace exposures.
In occupational health practice and in occupational health research many different types of data and observations are collected, documented and, to varying extents, eventually used. The information may concern past health conditions and health-related behaviours, such as absence due to sickness. It may also include observations of symptoms and findings at clinical examinations or results of laboratory examinations of many kinds. The latter type of information may concern functional capacity, muscle strength, physical stamina, cognitive or intellectual abilities, or it may include judgements of performance in various regards. The information may also contain, at the opposite end of the health spectrum, information on health deficiencies; handicaps; extremes of lifestyle; use of alcohol, drugs and other toxicants; and so on. Even if many single items of information of this kind are in themselves relatively trivial or innocuous, combinations of them and the continuous collection of them over time may provide a very detailed and comprehensive description of the characteristics of a person.
The information may be recorded and stored in various forms. Manual records are most common in files containing information on individual persons. Computer databases may also be used with information carriers such as magnetic tapes and floppy discs. Since the memory capacity of such computerized personnel files commonly is of huge dimensions, the databases constitute in themselves potential threats to personal integrity. The information in such data banks and registers and files may, in the hands of less scrupulous persons, constitute a tool of power, which may be used contrary to the interests of the person concerned.
It is beyond the scope of this article to define what type of information is sensitive and what is not. Nor is it the intention in this context to give an operational definition of the concept of personal integrity or to provide a blueprint for judgements on what information is to be regarded as more or less sensitive with respect to basic ethical principles. This is simply not possible. The sensitivity of information in this regard is contextually determined and dependent on many factors. The important consideration lies in applying basic ethical principles in dealing with questions of how, by whom and under what circumstances such data and information are handled.
Risk Analysis and Research Information
In explaining the principles of an ethical analysis the focus has been set on health information and health-related information in individual records such as health records and personnel files. There are, however, both in the practice and in the science of occupational health, other types of information which may, in their generation, processing and use, involve ethical considerations and even conflicts of ethical principles. Such information can, however, usually be analysed using the ethical principles of autonomy, beneficence and equity as points of departure. This applies, for example, in hazard assessments and risk analysis. In a situation where, for instance, relevant information on a health hazard at work is deliberately withheld from the employees, it is to be expected that ethical analysis will demonstrate clearly that all three basic ethical principles are violated. This applies regardless of whether or not the information is judged to be confidential by one of the stakeholding partners involved. The difficulty arises when the information involved is uncertain, insufficient or even inaccurate. Widely differing judgements may also be at hand concerning the strength of the evidence. This, however, does not alter the fundamental structure of the ethical issues involved.
In occupational health research it is quite common to have situations where information on past, present or future research projects is to be communicated to employees. If research is undertaken involving employees as research subjects without explaining the motives and full implications of the project and without seeking proper informed consent by everyone concerned, ethical analysis will demonstrate that the basic tenets of autonomy, beneficence and equity have been violated.
Obviously, the technical and complex nature of the subject matter may cause practical difficulties in the communication between researchers and others concerned. This, in itself, does not change the structuring of the analysis and the ethical issues involved.
There are various administrative safeguards which may be applied to protect sensitive information. Common methods are:
1. Secrecy and confidentiality. Contents of medical records and other items labelled as health information may be regarded as confidential or secret, in legal terms. It is to be observed though that not all contents of such documents are necessarily of a sensitive nature. They also contain items of information which could be communicated freely without causing harm to anyone.
Another aspect is the obligation imposed on members of selected professional groups to keep secret the information given them in confidence. This may be the case in consultations in the types of relationship which may be referred to as fiduciary. This may for instance apply to health information or other information dealt with in a physician-patient relationship. Such information may be protected in legislation, in collective-bargaining agreements or in professional codes.
It should, however, be observed that the concept of health information has—just as the concept of health—no practical operational definition. This means that the term may be given different interpretations.
2. Authorization for access to information. This requirement may for instance apply to researchers seeking information in health records or in social security files of individual citizens.
3. Informed consent as a condition for data collection and access to records containing information on individual persons. The principle of informed consent, implying right to co-decision by the person concerned, is a legally established practice in many countries in all questions regarding collection and access to personal information.
The principle of informed consent is being increasingly recognized as important in handling of personal information. It implies that the concerned subject has a prima facie right to decide what information is acceptable or permissible to be collected, for what purposes, by whom, by using what methods, on what conditions and with which administrative or technical safeguards against unauthorized or unwanted access.
4. Technical safeguards to protect computerized information. This may for instance concern introduction of coding and ciphering routines for prevention of unauthorized access to records containing information on persons or—if access is legitimate—prevention of identification of persons in the data base (protection of anonymity). It should however be observed that anonymity, meaning coding or concealment of name and other identity particulars, such as social security numbers, may not provide reliable protection against identification. The other information contained in the personal file may often be sufficient to allow individual persons to be identified.
5. Legal regulation, including prohibition, authorization and control for establishing and operating computerized data sources containing personnel files or records.
6. Professional ethical code. Principles of ethical standards in professional performance may be adopted by professional bodies and organizations in the form of codes of professional ethics. Such documents exist both on the national level in many countries and also on the international level. For further reference the following international documents are recommended:
In concluding this section it is appropriate to emphasize that an elementary principle in planning or establishing practices for data collection is to avoid collection of data without a carefully considered motive and occupational health relevance. The ethical hazards inherent in collecting information which is not utilized for the benefit, including health benefit, of the employee or person concerned, are obvious. In principle, the options and strategies at hand in planning for collection and processing of information on employees are amenable to ethical analyses in terms of autonomy, beneficence and equity.
Computerized Personnel Files
The development of computer technology has created possibilities for employers to collect, store and process information about employees on many diverse aspects relevant to their behaviour and functioning at the workplace. The use of such advanced computer systems has increased significantly during recent years and has led to concerns for the risks of intrusion into individual integrity. It is reasonable to predict that such risks will be still more common in the future. There will be a growing need to use data protection and various measures to guard against violations of integrity.
At the same time it is obvious that new technology brings significant benefits for production in an enterprise or in the public sector, as well as providing means to improve work organization or eliminate such problems as monotonous and short-cycled work tasks. The fundamental question is how to achieve reasonable balance between the benefits in the use of computer techniques and the legitimate rights and needs of the employees to be protected against intrusions into their personal integrity.
The Council of Europe has in 1981 adopted a recommendation (No. R 81–1) on medical databases and a convention on Protection of Individuals with Regard to Automatic Processing of Personal Data. The Council of the European Union has in a directive (95/46/EC)—On the Protection of Individuals with Regard to the Processing of Personal Data and on the Free Movement of such Data dealt with these issues. It should be observed that the implementation of such regulations on computerized personal data is in many countries regarded as issues of industrial relations.
Practical situations involving handling of information in occupational health involve judgements by occupational health professionals and many others. Questions regarding what is right or wrong, or more or less acceptable, arise in the practice of occupational health in many contextually and culturally differing circumstances. Ethical analysis is a tool providing the basis of judgements and decisions, by using ethical principles and sets of values to help evaluate and choose between different courses of action.
Since Ramazzini published the seminal text on occupational medicine (Ramazzini 1713), we have come to realize that working at certain jobs can cause specific illnesses. At first, only observational tools were available to survey the work environment. As technology developed, we began to be able to measure the environments in which workers plied their trades. Measuring the workers’ environment has helped identify the sources of workplace stresses. However, this improved knowledge brought with it a need to set exposure limits to protect workers’ health. Indeed, we have found ways to detect the presence of toxic substances at low levels, before they can create health problems. Now we often can predict the results of exposures without waiting for the effects to appear, and thus prevent disease and permanent injury. Good health in the workplace is no accident; it requires surveillance of workers and their environments.
Workplace Exposure Limits
Early workplace exposure limits were set to prevent acute illness and death. Today, with much better information, we try to meet much lower limits in order to prevent chronic illness and subclinical health effects. The most successful systematic attempt to develop occupational exposure limits was the effort of the Committee on Threshold Limits established by the American Conference of Governmental Industrial Hygienists (ACGIH) in 1943. (The ACGIH is a US organization with no formal ties to any government regulatory agency.) The success of this effort is shown by the fact that many countries around the world have adopted the threshold limit values (TLVs) published by ACGIH, which now number more than 600, as workplace exposure standards. Their wide use as enforceable standards has invited critical examination of TLVs and the process by which they were set. Despite their usefulness, TLVs have been criticized from three sectors of the decision-making process: scientific, political and ethical. A brief review of several criticisms follows:
Scientists criticized the fact that the TLVs set on the basis of substantial data are not distinguished from those based on considerably less data.
TLVs were never intended to be “safe” exposure levels for all workers. The TLV Committee recognized that the biological variations among workers, and other factors that could not be calculated, made it impossible to set limits that would guarantee safety for all workers in all environments. Adopting TLVs as enforceable standards creates a political problem, because part of the worker population is not protected. Only zero exposure can provide this guarantee, but zero exposure and zero risk are not practical alternatives.
The data that the TLV Committee worked with were often produced and paid for by industry, and were unavailable to the public. Those protected by this limit-setting process argue that they should have access to the data upon which the limits are based. Industry’s attempts to restrict access to their data, no matter what the reason, are seen by many as unethical and self-serving.
TLVs are still widely respected as guidelines for workers’ exposures to environmental stresses, to be used by professionals who can interpret them properly.
Community Exposure Standards
There is a link between occupational and community exposures. Any adverse health effects seen in workers are a result of their total exposure to environmental contaminants. Total dose is important in selecting appropriate exposure limits. This need is already recognized for poisons that accumulate in the body, such as lead and radioactive substances.
Present exposure limits differ for workers and for the community, in part, because workers’ exposures are intermittent, not continuous. TLVs were set for a five-day work week of eight-hour days, the norm in the United States. TLVs reflect the action of human repair mechanisms. However, many argue that community and occupational exposure limits should not be different.
Without specific information about synergistic or antagonistic effects, exposure limits for both workers and the public reflect only additive interactions between multiple environmental contaminants. When setting limits for a single substance, the complexities of the environments in which we live and work make it impossible to evaluate all potential interactions among environmental contaminants. Instead, we make the following simplifying assumptions: (1) the basic mix of chemicals in our environment has not changed materially; and (2) the epidemiological information and the environmental criteria used to set standards reflect our exposure to this mix of chemicals. By making these assumptions when setting community exposure limits for individual substances, interactions can be ignored. Although it would be useful to apply the same reasoning to setting workplace exposure limits, the logic is questionable because the mix of substances in the various work environments is not uniform when compared with that in our communities.
A part of the political debate is whether to adopt enforceable international exposure standards. Should an individual country set its own priorities, as reflected in its exposure limits, or should international standards be adopted, based on the best data available? Many governments of developing countries take the position that the developed countries should have stricter community exposure standards, because the latter’s industrial and agricultural pollution has created a less healthy environment.
Health Criteria Based on the Type of Risk
Currently, we rely heavily on toxicity testing of animals to set human exposure limits. Today’s sophisticated technology makes it possible to determine both the degree and kind of toxicity that a body will suffer after exposure to a substance. We measure a substance’s ability to cause cancer, to damage a foetus, to cause even benign tumours. We also measure the degree to which that substance can affect somatic systems. Many scientists assume that there is a safe level of exposure, and this has been validated by observations of mankind’s early diseases. However, such an assumption may not be justified today, especially for cancer. Experts still argue both for the existence and absence of a no-effect or “safe” level of exposure.
We co-exist with natural carcinogens in our environment. To deal with them, we must calculate the risk associated with exposure to these substances, and then use the best available technology to reduce that risk to an acceptable level. To think we can achieve zero risk is a misleading idea, and possibly the wrong path to take. Because of the cost and complexity of animal testing, we use mathematical models to predict the risks of exposures to substances at low doses. The best we can do is compute statistically reliable predictions of what are likely to be safe levels of exposure to environmental stresses, assuming a level of risk that the community accepts.
Monitoring the Working Environment
Monitoring of the working environment is the speciality of occupational hygienists. (In North America, they are called industrial hygienists.) These professionals practice the art and science of identification, evaluation and control of occupational stresses. They are schooled in the techniques of measuring the environment in which people work. Because of their obligation to protect the health and well-being of employees and the community, occupational hygienists have a deep concern for ethical issues. As a result, the principal industrial hygiene societies in the United States recently completed a revision to their Code of Ethics, which was originally drafted in 1978 (see also “Canons of Ethical Conduct and Interpretive Guidelines”).
Problems of Secrecy
Data developed from monitoring the work environment are critical to improving exposure limits both for workers and for the community. In order to come up with the best limits, which balance risk, cost and technical feasibility, all data from industry, labour and government must be available to those who set the limits. This consensus approach seems to be growing in popularity in a number of countries, and may become the procedure of choice for setting international standards.
Regarding trade secrets and other proprietary information, the new Code of Ethics provides guidelines for industrial hygienists. As professionals, they are obliged to make sure that all parties who need to know information regarding health risks and exposures are given that information. However, hygienists must keep key business information confidential, except when overriding health and safety considerations require them to reveal it.
There is no ethical possibility of serious dialogue on moral issues without disclosing the framework of critical decision-making tools—the assumptions—of the participants. Different tools result in different decisions.
The most important critical assumptions made in labour-management relations are those which become the basis of assigning obligations or duties in the face of multiple and often conflicting paths to the protection of “rights” of workers and their employers.
How do we decide to meet different and often conflicting needs found both in natural sets of humans (such as individual, family, peer group, community) and in synthetic sets of humans (such as political party, union, corporation, nation) which may include many diverse natural sets?
How do we decide who is responsible to provide family health care and “safe” tools to design a work station? How do we choose a level of risk in setting a permissible exposure limit?
How do we allocate moral responsibility and distribute the burden of risk?
The “Ladder of Social Justice”
To allocate responsibility, we can posit a “ladder of social justice”. On this ladder, those most able to act are rationally obligated to rise to the highest rung of responsibility so that they may act first in pursuit of a moral objective. They are obligated to act before others, because they are best or uniquely able to do so. This does not mean that only they should act. When those with special obligations fail to act, or need assistance, the obligation falls on the shoulders of those on the next rung.
By rational we mean not only an action that logically follows another. We also mean actions taken to avoid pain, disability, death and loss of pleasure (Gert 1993).
An application of the ladder is found in the US Occupational Safety and Health Act of 1970. The Act provides that “employers and employees have separate but dependent responsibilities and rights with respect to achieving safe and healthful working conditions”.
An employee has a duty to comply with rules uniquely “applicable to his own actions and conduct”. The employer has duties based on a unique ability to ensure compliance with rules applicable to an entire workplace. Government has a separate duty based on its unique abilities, for example, to mandate rules if persuasion fails.
There are other assumptions in the framework common to any system of ethical values in any culture. Here, we need to highlight those having to do with the nature of our community, the meaning of “rights”, the method of moral axioms, truth or the good, risk allocation, ideals and reality, and the ethical need for worker participation.
We exist, ecologically, as a global community. In our niche, natural sets of humans (such as families or peer groups) are more meaningful than synthetic sets (such as a corporation or politically defined entity). In this community, we share necessary obligations to protect and to help everyone to act rationally in accordance with their rights, just as we should protect our own rights, regardless of differences in mores and cultural values. These obligations, when they result in actions that protect workers across an international border, are not the imposition of the synthetic values of one nation upon another synthetic set of people. They are acts of reverent recognition of natural, timeless, universal moral values.
Basic human rights, the generic rights to freedom and life (or well being) derive from needs which, if met, enable us to be human (Gewirth 1986). They are not given us by any government or enterprise. We always have had them, logically and phylogenetically. Laws governing the work environment, and rules consistent with rights they implement, are not gifts of charity or benevolence. They are expressions of morality.
The specifications of basic rights, such as personal privacy and the “rights” to know and act in the avoidance of the risks of work, while expressed differently in different cultures, fundamentally are the same among all people in every nation.
Acting on the specifications of our rights may result in conflicts between those rights which protect the individual, such as protecting the privacy of personal medical records, and those concerned with the duties of the employer, such as deriving information from medical records to protect other lives through the avoidance of health hazards thus made known.
These conflicts may be resolved, not by depending upon the ability of a lone physician or even a professional society to withstand court or company challenges, but by choosing axioms of moral behaviour that are rational for everyone collectively in the workplace. Thus, taking encompassing action through stewardship of personal medical records by agencies such as a government-supervised labour-management “neutral” entity (like Germany’s Berufgenossenschaften) may resolve this conflict.
A critical assumption at the very base of this framework of moral judgement is the belief that there is only one real world and that the generic rights apply to everyone in that world, not as ideals that need not be achieved, but as generic conditions of actual existence. If they cannot be applied, it is because we haven’t learned to cope with the fact that knowledge of that world and of the most rational way of conducting ourselves in it is never complete. What we should learn is how to use postulates or axioms not only in ethics, but to describe the world and to guide conduct in the absence of perfect knowledge.
The nature of moral axioms is illuminated by Bertrand Russell’s observation that “all rational conduct of life is based upon the method of the frivolous historical game in which we discuss what the world would be like if Cleopatra’s nose had been half an inch longer” (Russell 1903).
The game of “as if” allows us to act in the face of ever-present moral and scientific uncertainty. But axioms must not be confused with ultimate “truth” (Woodger 1937). They are kept and used if fruitful in the application of basic ethical principles. When they are found to be no longer useful, they can be discarded and replaced with another set of conventions.
Moral axioms bring the framework of judgement to the level of practice, to the “shop floor”. An example is the common practice of developing professional codes of ethics for corporate physicians and other professionals. They are drafted to protect generic rights and their specifications by bridging gaps in knowledge, to organize experience and to permit us to act in advance of morally or scientifically certain knowledge.
These sets of axioms, like all systems of axioms, are neither right nor wrong, true nor false. We act as if they are right or true (in fact they may be) and retain them only as long as they continue to be fruitful in permitting us to act rationally. The test of fruitfulness will yield different results in different cultures at different points in time because, unlike generic ethical principles, cultural norms reflect relative values.
In cultures of the East, powerful social and legal sanctions enforced professional behaviours consistent with the Buddhist belief in the eightfold path to righteous living, the fifth fold of which was righteous livelihood, or with Confucian traditions of professional responsibility. In such settings, professional codes of ethics can be powerful tools in the protection of the patient or research subject, as well as the physician or scientist.
In cultures of the West, at least at this time despite the strong Hippocratic tradition in medicine, the codes are less effective, albeit retaining a limited value. This is not only because the social and legal sanctions are less powerful, but also because of some assumptions that simply do not fit the realities of current western cultures.
It is clear, for example, that the incorporation in codes of ethics of the widespread doctrine, an axiom, requiring “voluntary”, “informed” consent prior to privacy-invasive procedures (such as genetic testing) is irrational. The consent is seldom really voluntary or informed. The information conveyed is seldom certain or complete (even in the mind of the scientist or physician). Consent is usually obtained under socially (or economically) coercive conditions. The promises of the researcher to protect privacy and confidentiality cannot always be kept. The professional may be socially and legally protected by codes that incorporate this doctrine, but the worker easily becomes the victim of a cruel hoax resulting in social stigma and economic duress due to job and insurance discrimination.
Thus, continued use of the consent doctrine in codes of professional behaviour, as in protecting the worker from the dangers of genetic testing, is unethical because a facade is created that doesn’t fit the modern context of a culture westernized and made global by international data banks served by linked telephones and computers. The practice should be discarded and replaced with codes made effective by assumptions that fit the real world coupled with socially and legally enforceable protections.
It is irrational (and therefore immoral) to distribute or allocate the burden of risk by caste, that is, to assign different levels of risk for different sets of humans, as marked by genome, age, socioeconomic status, geographic location within the global community, ethnicity or occupation. Risk allocation by caste assumes that there are humans whose generic rights are different from others. Basic human needs are the same. Therefore, basic human rights are the same.
The concept of “acceptable risk”, widely if not universally used in the setting of standards, is a form of risk allocation by caste. It depends upon the assignment of a risk differential based on calculating the risks of past work practice or prevalent exposure to a toxic substance or hazard in the workplace. This common practice accepts and promotes unnecessary risks by arbitrarily assigning, for example, an “acceptable” risk ratio of one death per thousand in setting a permissible exposure level for workers, compared to one death per million for other members of the same community.
Other examples of irrational (immoral) risk allocation are the acceptance of risk differentials within a caste, as between adults and more vulnerable children (setting one standard for both when stronger protection is needed for children), between the work and community environments, between “guest” (or other less empowered) and indigenous workers, and risks (greater than we have set for ourselves) imposed upon the less protected workers in underdeveloped countries by market demands for their products in more developed countries.
Unnecessary risks are never morally acceptable. A risk is ethically “acceptable” only if it is necessary to protect life (or well-being) and freedom or (1) is culturally impacted and very difficult to eliminate or control in a short time and (2) has a lower priority for control within a rational abatement scheme than another biologically adverse hazard.
The generic rights to life and freedom necessitate empowering workers to rationally make and act upon choices made in pursuit of these rights. Empowerment occurs through access to information, educational opportunities to understand (and not simply react to information), and unfettered or uncoerced ability to act on this understanding in avoiding or taking risks.
Education that yields understanding may not happen in a typical safety training session, since training is meant to induce a conditioned response to a set of foreseeable signals or events, and not to provide in-depth understanding. Yet not all the causal factors, including events under the control of workers or management, that result in so-called accidents can be foreseen.
True accidents themselves are defined as “occurrences by chance” (Webster’s Third International Dictionary 1986). Thus they do not exist in nature. Every event has a cause (Planck 1933; Einstein 1949). The concept of chance is an axiom fruitfully used when a cause is not known or understood. It should not be confused with invariable reality. Even when injury or disease is clearly associated with work, all the causal factors of the events—in or out of the workplace—resulting in harm are never known or understood when they occur (Susser 1973). Thus, even if time, financing and training resources were infinitely available, it is impossible to condition a worker to every possible set of signals for every possible event.
To effectively reduce the risk of “accidents”, understanding a chemical process or a materials handling practice enables the worker to deal with unforeseen events. Education of the worker and his natural set, such as the family and peer group to which the worker belongs, enhances both understanding and the ability to act in preventing or reducing risk. Therefore, it is a specification of generic rights.
There is another ethical role for a worker’s natural set. Choosing an appropriate location where the worker decides or consents to a risk is a critical factor in assuring an ethical outcome. Many decisions (such as the acceptance of hazard pay) should be made, if they are to even approach being truly voluntary, only in a milieu other than a synthetic setting such as the place of work or a union hall. Family, peer group and other natural sets may provide less coercive alternatives.
Providing an economic incentive to accept an unnecessary risk known to a worker, employer or government—even as the result of a fairly negotiated contract—is always immoral. It is just compensation, if adequate, to a worker’s family when the risk can be justified and when a worker has equal alternative employment available without stigma. Making this choice ethically requires the most neutral or non-coercive setting possible.
If these settings are not available, the decision should be made in the most relatively neutral place associated with the most relatively neutral synthetic set or agency that can protect the empowerment of the worker and his or her natural set. The importance to the well-being of a worker of cultural and ethical values found in his or her family, peer group and community underline the importance of protecting their involvement and understanding as ethically based elements in the empowerment process.
Confusing Axioms and Reality in Communication
Most of us, even physicians, scientists and engineers, have been educated in primary school to understand axiomatic methods. It is not otherwise possible to understand arithmetic and geometry. Yet many consciously confuse assumptions and facts (which can be, but are not always, the same) in an effort to impose personal social values on a specific course of action or inaction. This is most obvious in how information is presented, selected, organized and interpreted.
Use of words like accidents and safe are good examples. We have discussed accidents as events that do not occur in nature. Safe is a similar concept. Most people believe that this word means “free from harm, injury or risk” (Webster’s Third International Dictionary 1986). A riskless void cannot be found, but it is standard practice for “experts” to use this word in describing a condition or chemical, leaving the impression that there is an absence of risk, while assuming or having in mind another meaning—such as their belief that the risk is relatively low or “acceptable”—without informing the audience. If this is done unknowingly, it is a simple mistake called a semi-logical fallacy. If it is done consciously, as is too often the case, it is a simple lie.
The confusion with invariable reality of sets of axioms, models of scientific explanation or assessments of data, seems to be concentrated in the setting of standards. Axiomatic concepts and methods in regulation, the validity of which are assumed and commonly confused with incontrovertible truth, include:
These axioms usually are discussed as if they are the truth. They are no more than discardable assumptions about individuals, risks and their control, based (at best) on limited information.
Social and economic values implicit in the selection and use of these axioms guide the policy judgements of those who govern, manage and control. These values, not scientific data alone, determine environmental and biological norms and standards in the community and workplace. Thus, these values, judgements based on them, and the axioms selected also must be judged by their reasonableness, i.e., their success in avoiding the risk of pain, death and disability.
Law and Contracts: Systems of Moral Axioms
Even the most encompassing system of moral axioms should be understood as an experiment in applying moral principles in the work environment, especially the systems of laws and contracts that govern the workplace.
The laws of the state, the rules of its ministerial bodies and even informally adopted procedures (such as models of risk assessment) can be treated—and changed—just like any system of axioms. Consistent with our framework of moral principles, treated as moral axioms, occupational safety and health laws and rules can be fully integrated with other axiomatic systems that meet other community health needs. They can be a differentiated (but not degraded) part of the total community system.
Health care, education, wage replacement and rehabilitation, social security, protection of the disabled, and other public health and environmental protection programmes are often coordinated by legislatures with occupational safety and health programmes. In doing this, care must be taken not to impose or inadvertently create or perpetuate a caste system.
How is this care to be taken? Participation by workers and representatives from their freely organized unions in contracted workplace and governmental bodies is a safeguard that should be part of the experiment. Participation is another specification of human rights. Tested barriers to caste systems in the workplace include workers’ councils (guaranteed in the constitutions of some countries), labour-management committees, ministerial committees on policies and practices, those dealing with standard-setting and enforcement, and education (both professional and rank-and-file) and other participative structures.
The exercise of participatory “rights” by workers in the determination of their own risks is an ethically mandated means of defence against the rise of castes of humans designated by the colour of their collars. It is the first step to the ethical allocation of responsibility and the distribution of the burden of risk in the workplace. The exercise of these rights, however, may conflict with the rights of management and of society as a whole.
Resolution of the conflict is found in understanding that these rights are specifications of generic rights, the imperative of which is absolute and which must ultimately prevail through recognition of the participatory rights of workers, management and the public at large in decisions that affect life and freedom in the community they each share.
In the last several decades, considerable effort has been devoted to defining and addressing the ethical issues that arise in the context of biomedical experimentation. Central ethical concerns that have been identified in such research include the relationship of risks to benefits and the ability of research subjects to give informed and voluntary prior consent. Assurance of adequate attention to these issues has normally been achieved by review of research protocols by an independent body, such as an Institutional Review Board (IRB). For example, in the United States, institutions engaging in biomedical research and receiving Public Health Service research funds are subject to strict federal governmental guidelines for such research, including review of protocols by an IRB, which considers the risks and benefits involved and the obtaining of informed consent of research subjects. To a large degree, this is a model which has come to be applied to scientific research on human subjects in democratic societies around the world (Brieger et al. 1978).
Although the shortcomings of such an approach have been debated—for example, in a recent Human Research Report, Maloney (1994) says some institutional review boards are not doing well on informed consent—it has many supporters when it is applied to formal research protocols involving human subjects. The deficiencies of the approach appear, however, in situations where formal protocols are lacking or where studies bear a superficial resemblance to human experimentation but do not clearly fall within the confines of academic research at all. The workplace provides one clear example of such a situation. Certainly, there have been formal research protocols involving workers that satisfy the requirements of risk-benefit review and informed consent. However, where the boundaries of formal research blur into less formal observances concerning workers’ health and into the day-to-day conduct of business, ethical concerns over risk-benefit analysis and the assurance of informed consent may be easily put aside.
As one example, consider the Dan River Company “study” of cotton dust exposure to its workers at its Danville, Virginia, plant. When the US Occupational Safety and Health Administration’s (OSHA) cotton dust standard went into effect following US Supreme Court review in 1981, the Dan River Company sought a variance from compliance with the standard from the state of Virginia so that it could conduct a study. The purpose of the study was to address the hypothesis that byssinosis is caused by micro-organisms contaminating the cotton rather than by the cotton dust itself. Thus, 200 workers at the Danville plant were to be exposed to varying levels of the micro-organism while being exposed to cotton dust at levels above the standard. The Dan River Company applied to OSHA for funding for the project (technically considered a variance from the standard, and not human research), but the project was never formally reviewed for ethical concerns because OSHA does not have an IRB. Technical review by an OSHA toxicologist cast serious doubt on the scientific merit of the project, which in and of itself should raise ethical questions, since incurring any risk in a flawed study might be unacceptable. However, even if the study had been technically sound, it is unlikely to have been approved by any IRB since it “violated all the major criteria for protection of subject welfare” (Levine 1984). Plainly, there were risks to the worker-subjects without any benefits for them individually; major financial benefits would have gone to the company, while benefits to society in general seemed vague and doubtful. Thus, the concept of balancing risks and benefits was violated. The workers’ local union was informed of the intended study and did not protest, which could be construed to represent tacit consent. However, even if there was consent, it might not have been entirely voluntary because of the unequal and essentially coercive relationship between the employer and the employees. Since Dan River Company was one of the most important employers in the area, the union’s representative admitted that the lack of protest was motivated by fear of a plant closing and job losses. Thus, the concept of voluntary informed consent was also violated.
Fortunately, in the Dan River case, the proposed study was dropped. However, the questions it raises remain and extend far beyond the bounds of formal research. How can we balance benefits and risks as we learn more about threats to workers’ health? How can we guarantee informed and voluntary consent in this context? To the extent that the ordinary workplace may represent an informal, uncontrolled human experiment, how do these ethical concerns apply? It has been suggested repeatedly that workers may be the “miner’s canary” for the rest of society. On an ordinary day in certain workplaces, they may be exposed to potentially toxic substances. Only when adverse reactions are noted does society initiate a formal investigation of the substance’s toxicity. In this way, workers serve as “experimental subjects” testing chemicals previously untried on humans.
Some commentators have suggested that the economic structure of employment already addresses risk/benefit and consent considerations. As to the balancing of risks and benefits, one could argue that society compensates hazardous work with “hazard pay”—directly increasing the benefits to those who assume the risk. Furthermore, to the extent that the risks are known, right-to-know mechanisms provide the worker with the information necessary for an informed consent. Finally, armed with the knowledge of the benefits to be expected and the risks assumed, the worker may “volunteer” to take the risk or not. However, “volunteer-ness” requires more than information and an ability to articulate the word no. It also requires freedom from coercion or undue influence. Indeed, an IRB would view a study in which the subjects received significant financial compensation—“hazard pay”, as it were—with a sceptical eye. The concern would be that powerful incentives minimize the possibility for truly free consent. As in the Dan River case, and as noted by the US Office of Technology Assessment,
(t)his may be especially problematic in an occupational setting where workers may perceive their job security or potential for promotion to be affected by their willingness to participate in research (Office of Technology Assessment 1983).
If so, cannot the worker simply choose a less hazardous occupation? Indeed, it has been suggested that the hallmark of a democratic society is the right of the individual to choose his or her work. As others have pointed out, however, such free choice may be a convenient fiction since all societies, democratic or otherwise,
have mechanisms of social engineering that accomplish the task of finding workers to take available jobs. Totalitarian societies accomplish this through force; democratic societies through a hegemonic process called freedom of choice (Graebner 1984).
Thus, it seems doubtful that many workplace situations would satisfy the close scrutiny required of an IRB. Since our society has apparently decided that those fostering our biomedical progress as human research subjects deserve a high level of ethical scrutiny and protection, serious consideration should be given before denying this level of protection to those who foster our economic progress: the workers.
It has also been argued that, given the status of the workplace as a potentially uncontrolled human experiment, all involved parties, and workers in particular, should be committed to the systematic study of the problems in the interest of amelioration. Is there a duty to produce new information concerning occupational hazards through formal and informal research? Certainly, without such research, the workers’ right to be informed is hollow. The assertion that workers have an active duty to allow themselves to be exposed is more problematic because of its apparent violation of the ethical tenet that people should not be used as a means in the pursuit of benefits to others. For example, except in very low risk cases, an IRB may not consider benefits to others when it evaluates risk to subjects. However, a moral obligation for workers’ participation in research has been derived from the demands of reciprocity, i.e., the benefits that may accrue to all affected workers. Thus, it has been suggested that “it will be necessary to create a research environment within which workers—out of a sense of the reciprocal obligations they have—will voluntarily act upon the moral obligation to collaborate in work, the goal of which is to reduce the toll of morbidity and mortality” (Murray and Bayer 1984).
Whether or not one accepts the notion that workers should want to participate, the creation of such an appropriate research environment in the occupational health setting requires careful attention to the other possible concerns of the worker-subjects. One major concern has been the potential misuse of data to the detriment of the workers individually, perhaps through discrimination in employability or insurability. Thus, due respect for the autonomy, equity and privacy considerations of worker-subjects mandates the utmost concern for the confidentiality of research data. A second concern involves the extent to which the worker-subjects are informed of research results. Under normal experimental situations, results would be available routinely to subjects. However, many occupational studies are epidemiological, e.g., retrospective cohort studies, which traditionally have required no informed consent or notification of results. Yet, if the potential for effective interventions exists, the notification of workers at high risk of disease from past occupational exposures could be important for prevention. If no such potential exists, should workers still be notified of findings? Should they be notified if there are no known clinical implications? The necessity for and logistics of notification and follow-up remain important, unresolved questions in occupational health research (Fayerweather, Higginson and Beauchamp 1991).
Given the complexity of all of these ethical considerations, the role of the occupational health professional in workplace research assumes great importance. The occupational physician enters the workplace with all of the obligations of any health care professional, as state by the International Commission on Occupational Health and reprinted in this chapter:
Occupational health professionals must serve the health and social well-being of the workers, individually and collectively. The obligations of occupational health professionals include protecting the life and the health of workers, respecting human dignity and promoting the highest ethical principles in occupational health policies and programmes.
In addition, the participation of the occupational physician in research has been viewed as a moral obligation. For example, the American College of Occupational and Environmental Medicine’s Code of Ethical Conduct specifically states that “(p)hysicians should participate in ethical research efforts as appropriate” (1994). However, as with other health professionals, the workplace physician functions as a “double agent”, with the potentially conflicting responsibilities that stem from caring for the workers while being employed by the corporation. This type of “double agent” problem is not unfamiliar to the occupational health professional, whose practice often involves divided loyalties, duties and responsibilities to workers, employers and other parties. However, the occupational health professional must be particularly sensitive to these potential conflicts because, as discussed above, there is no formal independent review mechanism or IRB to protect the subjects of workplace exposures. Thus, in large part it will fall to the occupational health professional to ensure that the ethical concerns of risk-benefit balancing and voluntary informed consent, among others, are given appropriate attention.
From the onset, we wish to make it clear that we are not experts in ethics, nor do we represent ourselves as experts. Just like the rest of you, we are scientists, doing scientific things, searching for truth. In that arena, we are faced with the same issues as you—the difference between right and wrong, good and bad, and objectivity and subjectivity. As researchers, we grapple with difficult questions concerning methods and outcome. And those of us who become administrators agonize over the same questions, especially in regard to policy decisions in developing adequate occupational standards to protect workers.
In preparing this paper, we reviewed a number of books and documents in search of simple answers to complex problems. We looked not only at papers written by occupational safety and health professionals, but also reviewed some of the classic textbooks on ethics.
On the professional side, we read a number of articles and codes of ethics from various research groups. They all have components relevant to occupational health research. Yet the focus of each is quite different, reflecting the kind of research done by each author. Some include numerous pages of what to do and what not to do. Others are more general in content.
On the textbook side, ethical theories abound, from before Socrates up until today. There is no shortage of articles about ethics, codes of conduct, and written discussions of ethical standards. In the United States at least, most of the medical colleges have medical ethicists on staff, and almost every university with a sizeable department of philosophy has an ethicist on the faculty. It is a discipline to which people devote their lifetimes, which confirms the complexity of the issue.
Before we begin this discussion, it is important that we attempt to make it clear what we are talking about. What is meant by the term ethics? In the English language, the terms ethics and morals are used interchangeably. Since we are preparing this paper for a diverse group, we did what we think to be an interesting poll of some Centers for Disease Control and Prevention (CDC) professionals for whom English is their second language. A woman whose first languages are Slavic, German and Russian replied that there are similar words in all of her first languages. She said that in the Slavic language, neither ethics nor morals stands alone as they do in English. For example, she said that you wouldn’t say that someone is without morals, you would say that they exhibit behaviour that is not moral. She said that in the Slavic language you wouldn’t say that someone is without ethics, you would say instead that the person is without ethical principles. A Chinese national said that there are separate Chinese words for both morals and ethics, but they are used interchangeably. Spanish-, French- and German-speaking people said there are words for both in their respective languages and that the words are used interchangeably.
In the textbooks on ethical theory that we reviewed, however, the ethicists made a distinction between ethics and morals which we choose to accept for the sake of clarity. Melden (1955) and Mothershead (1955) both suggest that the word ethics is used when referring to a set of principles or standards for conduct, and that the word morals is used when referring to the conduct of a person or group, i.e., their behaviour. This usage is consistent with the replies of the CDC professionals.
Professor Melden says in his book, “We are all familiar with such rules of conduct. Each society, religion, professional group, or distinguishable community has its principles, its standards of conduct. As persons who are concerned with being responsible in our conduct, we rely ordinarily upon a body of principles for guidance in conduct.” Examples of these principles are all around us. In the Judeo-Christian community, there are at minimum the Ten Commandments. In every society, we have laws at the local, national and international levels which describe and dictate both unacceptable and acceptable behaviour. There are also the scientific method, the International Code of Ethics for Occupational Health Professionals and Guidance on Ethics for Occupational Physicians, to name a few examples. The list could go on and on. The point here is that we are exposed to a number of standards of conduct, or ethics, as we use the term. It is quite fitting that we begin the work of setting some standards for ourselves.
Why do health professionals need standards for our work? As Professor Melden states, we are persons who are concerned with being responsible. To make good science demands the highest responsibility on our part, which leads to the promotion of safety and health. On the other hand, no matter how good the intentions of the researcher may be, compromised science can lead to death, disease, disability and dismemberment, rather than the protection of workers. The bottom line is that workers suffer when science is compromised.
Why does compromised science happen? From our perspective, there are a number of reasons.
Sometimes science is compromised because we don’t know any better. Take for example three workplace tragedies: asbestos, benzene and silica. In the early days, the dangers of these substances were unknown. As technology improved, as the science of epidemiology developed and as medicine became more sophisticated, the obvious became evident. In each of these histories, the problems existed, but scientists did not possess or in some cases apply the tools available to uncover them.
Sometimes science is compromised because it is bad science. We are certain that all of you have seen bad science or have read about it in scientific journals. It is bad because it isn’t science at all. It is opinion expressed in such a way that it appears scientific and therefore factual. This situation is one that can easily be addressed through a rigorous peer review process.
Sometimes science is compromised because the researcher is rushed, due to unrealistic time constraints, lack of funds or influences other than purely scientific analysis. An obvious example of this is a toxicological cancer study in which the test animals’ lives were terminated after less than a third of their normal life span, thus eliminating a sufficient latency period for them to develop cancer as a result of their exposures. Thoroughness was compromised and conclusions reached with only part of the picture considered.
And perhaps worst of all, sometimes science is compromised in pursuit of profit or academic advancement. Likewise, we have all seen evidence of this in the newspapers and professional journals. In some of these instances, the gain to the researcher was academic standing and not financial at all. In others, financial gain, either immediate or future, influenced the outcome. In the first case referred to above, researchers with financial interests in asbestos did not report their own positive findings until many years later, when many thousands of workers had already suffered and died of diseases associated with uncontrolled asbestos exposure (Lemen and Bingham 1994). In some instances, we have seen that those who pay for the research may ultimately influence the outcome.
These are but a few of the cases where a code of ethics could come into play, although any code, no matter how wonderful, will not stop the unscrupulous.
Occupational health is a complex and difficult discipline in which to prevent unethical conduct. Even when we discover methods for prevention of occupational diseases and injuries, the solution to the problem is often viewed as cutting into profits, or the problem is hidden to avoid the expense of the remedy. The profit motive and the complexity of the issues we address can lead to both abuse and shortcuts in the system. What are some of the major difficulties?
Often, occupationally caused maladies have incredibly long incubation periods, giving rise to confounding variables. By comparison, in many infectious diseases results seem quick and simple. An example is a well-managed vaccine campaign for measles in an outbreak situation. In this case, there is a short incubation period, an almost 100% infection rate of those susceptible, a vaccine that is 95 to 98% effective and a total eradication of an epidemic, all accomplished in a few days. That situation is quite different from asbestosis or carpal tunnel syndrome, where some people are affected, but others are not, and most often months or years elapse before disability occurs.
Occupational health concerns are multidisciplinary. When a chemist works with other chemists, they all speak the same language, each has but one interest and the work can be shared. Occupational health, on the other hand, is multidisciplinary, often involving chemists, physicists, industrial hygienists, epidemiologists, engineers, microbiologists, physicians, behaviourists, statisticians and others. In the epidemiological-triad (host, agent, environment), the host is unpredictable, the agents are numerous and the environment is complex. The cooperation of several disciplines is mandatory. A variety of professionals, with totally different backgrounds and skills, is brought together to address a problem. The only commonality between them is the protection of the worker. This aspect makes peer review even more difficult because each speciality brings its own nomenclature, equipment and methods to apply to the problem.
Because of long incubation periods in many occupational diseases and conditions, coupled with the mobility of the workforce, occupational health professionals are often forced to fill in some blanks since many of those workers exposed or at risk cannot be located. This condition leads to a reliance on modelling, statistical calculations, and sometimes compromise in the conclusions. The opportunity for error is great, because we are not able to fill in all of the cells.
Sometimes it is difficult to relate a malady to the work environment or, even worse, to identify the cause. In infectious diseases, the epidemiological triad is often less complex. In the 1990s, CDC staff investigated an outbreak of illness on a cruise ship. The host was well defined and easily located, the agent was easily identified, the mode of transmission was obvious, and the remedial action was evident. In occupationally related disease and injury, the host is defined, but often difficult to find. There are a number of agents in the work environment, often causing synergism, plus other workplace factors which are not directly involved in the health problem but which play an important role in the solution. These other workplace factors include such things as the interests and concerns of the labour force, the management and involved government agencies.
So now to the business at hand—coming up with a code of ethics, a set of principles or standards of conduct, used to guide our conduct, our behaviour, in this complex environment.
As Professor Melden (1955) so clearly writes, “Further, we cannot depend wholly upon such principles for guidance, simply because it is impossible to lay down a set of rules complete enough to anticipate all possible occasions for moral decision.” He goes on to say that “A set of moral principles covering all possible moral eventualities is just as impossible as a set of laws so complete that no further legislation is necessary”. Similarly, Kenneth W. Goodman (1994b), states that “While it is important to realize that science and ethics are closely, even inextricably, linked, there is no reason to suppose that a formal code of ethics will provide closure for all or most disagreements about the nature of data, selection of data, data management, and so forth.” To quote Professor Melden once again, “To be useful, moral principles must be general; but being general, their utility is inescapably limited”.
With the above caveats in mind, we propose to you that the following statements be part of a code of ethics for occupational health.
We have attempted to discuss a complex and sensitive issue. There are no easy solutions. What we are attempting is right and just, however, because its goal, to protect the worker in the workplace, is right and just. We cannot do this alone, we cannot do it in a vacuum, because the problems we address are not in a vacuum. We need each other, and others, to ferret out our natural instincts for personal gain and glory and to uncover our built-in biases. Such an effort will enable us to contribute to the knowledge and enhance the well-being of humanity.
Range of Purposes Behind Codes
Codes of ethics in the professions serve numerous purposes. At the level of the profession itself, codes document the standards according to which the profession can be held accountable for the conduct of its members. Further, because society relegates control for many of the professions to the professional organizations themselves, the professions have developed codes to provide the basis of self-regulation (Soskolne 1989). At the level of the individual professional, codes can provide a practical guide to members of the profession who might be experiencing a moral or ethical dilemma concerning their professional conduct in a particular circumstance. Where a professional finds himself or herself in a state of moral or ethical tension, it is self-evident that codes can be helpful in providing counsel.
The existence of a code provides the basis of a profession’s ethics programme of activity designed to instil ethical standards among its membership (Gellermann, Frankel and Ladenson 1990; Hall 1993). Revisions to the code can be considered through grass-roots individual membership input at organizational meetings, workshops and conferences. This ongoing discussion of issues and concerns constitutes a review process ensuring that any code remains sensitive to changing social values. Professions depending for their sustenance on public support thereby improve their likelihood of remaining publicly accountable and relevant (Glick and Shamoo 1993).
Codes could assist professionals being charged with malpractice and perhaps even in litigation. Demonstrated adherence to one’s professional code would likely be deemed indicative of adherence to standards of practice consistent with professional norms. If such practice were to have resulted in harm, the code-abiding individual professional would be less likely to be found guilty of having committed a wrong. However, based on the principle of trust (Pellegrino, Veatch and Langan 1991), the public has the expectation that the best possible professional judgement will be exercised in the public interest. Where the physician-patient relationship is concerned, the patient has the right under the principle of trust to expect that his or her interests will be best served. However, an ethical tension arises when the public good is potentially harmed in circumstances where the individual patient’s best interests are being served. In such circumstances, it is the public good that will usually need to take precedence over that of the individual. Regardless, codes provide no substitute for legal liability dimensions of conduct for which government has enacted laws to protect the public interest (Cohen 1982).
Weight and Intent of Codes
Codes do have associated with them the notion of statutory force, implying the ability for their enforcement through the administering of some type of disciplinary action. Indeed, the notions of accountability and self-regulation referred to above have associated with them some sense of control (minimally, peer pressure; maximally, the removal of licence to practice) that can be exercised over the members of the profession by the professional organization itself. Because of this, some professional organizations have preferred to avoid these connotations associated with codes and opt rather for “guidelines”. The latter emphasize guidance with fewer implications for enforcement associated with them. Other groups have preferred to avoid all connotations associated with codes or guidelines; instead, they have preferred to develop “declarations on ethics” for their specific organizations (Jowell 1986). Throughout this chapter the term code will imply “guidelines”.
It should be apparent that codes (and also guidelines) do not carry the force of law. In essence, codes and guidelines are intended to provide guidance for professionals, collectively and individually, in their relationships with their clients (including patients and research subjects), with their colleagues and co-workers (including their students), and with the public (including stakeholder groups). In addition, codes require that the quality of professional work and hence the stature of the profession itself is advanced. In general, codes associated with the physician-patient relationship will require that the patient’s interests take precedence over any other interests; the physician is placed firmly in the position of “patient advocate”. One exception to this would arise in the context of infectious diseases, where the patient’s rights may have to be considered second to the public welfare. In contrast, however, it can generally be stated that codes associated with scientific research will require that the public interest take precedence over any individual or other interests. One exception would be where a researcher discovers child abuse in a research subject; here the researcher would have the obligation to report this to the child welfare authorities.
Code Development, Review and Revision
The process by which codes are developed has consequences for their application. By including members of the profession and students of the profession in code development, as well as in code review and revision, ownership of the resultant document by a greater number of individuals is believed more likely. With broad-based ownership, increased compliance by a greater number is believed more assured.
Content and Structure of Codes
The content of a code should be user friendly to maximize its utility. Codes can be of varying length. Some are brief, while some are substantial. The more substantial that a code is, the more specific it is possible for it to be. Codes can be made to be user friendly by virtue of their structure and content. For example, a summary set of the principles upon which the code is based could be presented first, followed by expanded aspirational or prescriptive statements, which constitute the code itself. These can be followed by a commentary that explicates each statement in turn, perhaps noting special circumstances in the form of case studies that might serve as useful examples. The principles and their interpretation(s), however, are highly dependent on the values recognized as inherent to the pursuits of a profession. While these values may be universal, interpretations as well as practices at the local and regional levels may differ. Thus, while a statement of the profession’s core values can provide an anchor for its statements on ethics and should appear as a preface to the guidelines (Gellermann, Frankel and Ladenson 1990), sensitivity to regional differences can be demonstrated through the more detailed commentary and case study materials.
The commentary should incorporate, or could be followed by or complemented with, case study materials that derive from real-life instances of ethical dilemmas or tensions. The case study materials could be ethically analysed in either sanitized (i.e., anonymous) form, or can be made to reflect the parties involved (of course, only with the approval of the parties for their names to be included) (for example, Soskolne 1991). The objective behind case studies is not to seek retribution, but rather to provide examples for teaching purposes. Learning is enhanced by real-life situations.
It is from an understanding of the code that it becomes possible for a profession to develop more detailed standards of practice. These address more specific areas of activity associated with professional conduct, including a broad range of activity from interpersonal behaviours to both how research is conducted and how the results of that research are communicated. Standards of practice for the profession could be included in an ethics package; they reflect on each profession’s skill set and therefore add particular considerations that go beyond the statement of its ethics principles.
Scope of Codes
The development of a code by any profession has almost invariably tended to be driven by issues having a direct bearing on that profession. Consequently, codes tend to have a focus narrowly defined by each profession’s own concerns. However, codes also need to take broader social issues into account (Fawcett 1993). In fact, in a recent analysis of several codes, Summers et al. (1995) found that guidelines on specific social issues, such as environmental effects or conflict resolution, are scarcely mentioned at all in existing codes. Because the professions manifest substantial influence, if their codes indeed were to take broader social issues into account, then a great confluence and concurrence of effort would be brought to bear on those areas of human endeavour that currently fall between the cracks in promoting the common social good. Such pressure could help reduce dangers to human welfare, such as militarism and ecological destruction.
It should be recognized that there exist two schools of thought for ethics training: one is based in a principle-driven approach while the other is case based, also known as casuistry. It is this author’s view, which remains to be tested, that a balance between the two is essential for successful applied ethics training in the professions (Soskolne 1991/92). However, it is well known that ethically analyzed case study material has an invaluable role to play in the education process. Cases provide a context for applying principles.
Because graduate ethics training in the professions is becoming more recognized as an essential place for students to gain awareness of the values, ethical principles and standards of practice of the profession, a model curriculum might ideally be included as part of a code; this will facilitate the training of students intent on entering the profession. The need for this is demonstrated through a recent survey that identified inconsistencies and shortcomings regarding the ethics components in graduate training programmes across the United States (Swazey, Anderson and Seashore 1993).
Recent History of Codes in Selected Professions
In western cultures, the medical profession has had the advantage of discussions about ethics since the time of Socrates (470–399 B.C.), Plato (427–347 B.C.) and Aristotle (384–322 B.C.) (Johnson 1965). Since then, codes have been developed and periodically revised in response to newly recognized issues arising, for example, from human value shifts and, more recently, from technological advances (Declaration of Helsinki 1975; Ad hoc Committee on Medical Ethics 1984; Russel and Westrin 1992). Since the 1960s, other professions have become involved in code development for their own professional organizations. The area of professional codes in fact has become a cottage industry since the 1980s. The American Association for the Advancement of Science (AAAS) has been instrumental in this movement. Under the auspices of its Committee on Scientific Freedom and Responsibility, AAAS initiated a seminal professional ethics project designed to examine the features of and activities associated with codes in the science and engineering professions. The report arising from this effort subsequently generated renewed interest in discussing both code development and revision with many of the professions (Chalk, Frankel and Chafer 1980).
The health/caring professions have long been engaged in discussions of ethical tensions arising from the nature of their professional pursuits. The codes that have evolved have tended, however, to focus on the physician-patient relationship, with concerns about confidentiality being pre-eminent. More recently, perhaps motivated by the growth of applied health research, codes have expanded their attention to include issues pertaining to researcher-patient relationships. Because of population-based research, codes now are addressing concerns for researcher-population relationships. The latter has been aided by the experience of other professions such as sociology, anthropology and statistics.
Many of the caring professions related to the practice of occupational health have been engaged in the discussion of professional ethics. These include: industrial hygiene (Yoder 1982; LaDou 1986); epidemiology (Beauchamp et al. 1991; IEA Workshop on Ethics, Health Policy and Epidemiology 1990; Chemical Manufacturers Association’s Epidemiology Task Group 1991; Council for International Organizations of Medical Sciences 1991, 1993); medicine and numerous of its subspeciality areas, including occupational medicine (Coye 1982; American Occupational Medical Association 1986; International Commission on Occupational Health 1992; Standing Committee of Doctors of the EEC 1980); nursing; toxicology; statistics (International Statistical Institute 1986); psychology; engineering and risk analysis.
In the occupationally specific areas of health services (Guidotti et al. 1989), medicine (Samuels 1992) and health and safety (LaDou 1986), as well as in occupational and environmental health (Rest 1995), relevant portions of professional codes have been abstracted. These presentations serve well the need for furthering discussion in these areas with a view to revising extant codes.
The importance of integrating ethics into the day-to-day activities of professionals is exemplified by these recent texts, which contain appropriately detailed sections on ethics. The professional thereby is reminded that in all aspects of professional practice, all decisions and recommendations have consequences with associated ethical underpinnings.
More recent work on the subject of misconduct in science requires integration into newer texts (Dale 1993; Grandjean and Andersen 1993; Office of the Assistant Secretary for Health 1992; Price 1993; Reed 1989; Sharphorn 1993; Soskolne 1993a; Soskolne 1993b; Soskolne and Macfarlane, 1995; Teich and Frankel 1992). Because one of the fundamental goals of science is the pursuit of truth through objectivity, plagiarism and the fabrication or the falsification of data are counter to the scientific ethic. As the scientific enterprise expands to include more and more scientists, misconduct in science is coming to the attention of the public more frequently. However, it is believed that even in the face of increasing competition and the potential for conflicting interests, the vast majority of those engaged in science do adhere to the principles of truth and objectivity. The frequency of misconduct does, however, remain difficult to assess (Goldberg and Greenberg 1993; Greenberg and Martell 1992; Frankel 1992).
The potential harm to particular scientific efforts as a result of misconduct is one concern. Another concern is the loss of faith by the public in scientists, with consequent reductions in support for the scientific enterprise. The latter has such potentially dire consequences for both science and society that all scientists, and especially students of science, need to be trained in the scientific ethic and reminded of these principles from time to time.
Several case studies serve to demonstrate misconduct (Broad and Wade 1982; Office of Research Integrity 1993; Price 1993; Needleman, Geiger and Frank 1985; Soskolne and Macfarlane, 1995; Swazey, Anderson and Seashore 1993; Soskolne 1991). The determinants of ethical dilemmas are numerous, but one survey among risk analysts in New Jersey (Goldberg and Greenberg 1993) suggests that the two most important causes are “on the job pressure” and “pressure caused by economic implications of result”. The authors of this study noted that possible causes of misconduct include “conflicts of interest, competition with unregulated and unscrupulous competitors, and general lack of individual or societal ethics”. While some codes do address the need for honesty and objectivity in science, the seriousness of current pressures to perform in the presence of apparently declining awareness of societal ethics would dictate that training at all levels include the subject of ethics, values and philosophy. Indeed, the United States Public Health Service requires that universities seeking to obtain research grant support have procedures in place for dealing with and reporting misconduct in science (Reed 1989). Furthermore, university training programmes in public health disciplines must include ethics teaching to qualify for federal funding (Office of the Assistant Secretary for Health 1992).
Normative Nature of Codes
Codes of professional conduct tend to be a narrative description of an assemblage of normative practices. These practices pertain to the moral and ethical standards of a group, be it a professional organization, association or society, having a common skill set in the service of people.
The basis of respective codes has been the so-called Golden Rule, which prescribes that one should do to others what one would have others do to oneself, do one’s level best, and call to the attention of others any act of misconduct.
Approaches to Developing Codes
Most professional organizations have produced codes through the top-down approach, where the elected officials of the profession have undertaken the task. However, as noted earlier (see “Code development, review and revision”), the bottom-up approach is more likely to result in compliance with codes, because grass-roots participation in the process results in a feeling of ownership of the outcome and hence a greater likelihood of compliance. The view that the power brokers of the profession have major influence over the specification of what constitutes appropriate professional conduct could detract from the credibility associated with any resultant code. The more that the “final” code is reflective of community norms, the greater the likelihood that it will be adhered to.
Codes developed by international organizations do have the power of influencing regional groups of people to consider the concerns and statements included in international codes. In this way, regions that have not given attention to the development of codes might be stimulated to do so. Presumably, provided the intent of international codes is limited to a function of providing stimulus, ongoing interaction could serve to iteratively modify and update international codes so that ultimately the international code could well reflect transnational concerns. Care must be exercised to respect regional cultural norms that are not in conflict with, for example, accepted declarations on human rights. Hence, code makers should be sensitive to cultural differences, and not allow their work to homogenize human behaviour; cultural diversity must rather be encouraged.
Mechanisms for Enforcement
Noted earlier was the fact that codes do imply some degree of self-regulation if the expectation of accountability is to have meaning. This would suggest the existence of procedures for investigating allegations of misconduct (or malpractice) of any type, and for correcting conduct deemed professionally inappropriate (Price 1993; Dale 1993; Grandjean and Andersen 1993). In addition, some remedy might be provided for any harms that might have derived from professional misconduct.
The procedures to be invoked in investigations of allegations of misconduct or malpractice must be pre-specified. The maxim of “innocent until proven guilty” should be evident and be seen to be applied. However, because public confidence rests on professional self-regulation, investigations should be dealt with as efficiently as possible with respect for due process at all times (Sharphorn 1993; Soskolne 1993a, b).
The threat of revoking professional licence to practice is one way that the profession has leverage to maximize among its members adherence to any codes. Many professions have no such leverage; their membership is made up of dues-paying individuals with a wide range of qualifications for which regional legislatures have not required licensure as a requirement of membership in the profession. The loss of the right to practice one’s profession therefore is not applicable in many professions as a penalty for misconduct. The only recourse in such instances is that of peer pressure.
Current Issues of Concern to Occupational Health Professionals
It is not within the scope of this article to develop a comprehensive code, but rather to present the process by which codes are developed. It is the intent in so doing to provide motivation for the ongoing discussion of codes (as a component of a broader-based professional ethics programme) and to alert the reader to current issues about which further discussion is needed for the possible inclusion of such resolved matters into revised codes.
As noted by Guidotti et al. (1989), certain issues had been overlooked in codes that existed at that time. These included the virtue of full access to accurate information, and that the burden of risk should not be taken by the worker in the presence of unproved but sound evidence. The question of accurate information and implied truth has associated with it issues of scientific integrity (as referred to in North America) or of scientific dishonesty (as referred to in Denmark) (Andersen et al. 1992; Grandjean and Andersen 1993). Clearly, the pursuit of truth as the main target of scientific endeavour must be reinforced at every opportunity, including its full integration into codes, case study materials and ethics programmes generally (Hall 1993).
With technological advances, the ability grows to more precisely measure biological parameters. For example, biomarkers is one area that opens up a Pandora’s box of ethical issues and resulting tensions that have yet to be addressed in codes. Several such issues have been identified by Ashford (1986) and by Grandjean (1991). Since existing codes were developed prior to the availability on a commercial scale of this technology, codes would serve the occupational health community better if they were updated to provide some guidance on related concerns. To achieve this, explication of such thorny questions as the workers’ right to work in the face of high-risk susceptibility identified through biomarker assays, requires extensive discussion in workshops and conferences specially convened for the purpose. Case study materials would assist in this effort. So profound are the ramifications of biomarker studies that their implications, as well as those related to other potential high technology breakthroughs, could be best addressed through the profession’s continual review of the code.
Because issues such as biomarkers can be difficult to resolve, it may be appropriate for like professions dealing with similar issues to consolidate their efforts and establish mechanisms for exchanging information to assist in the resolution of difficult and challenging related ethical issues. In particular, the need to address the timing for introducing high technology procedures for which ethical considerations have not yet been established also needs to be recognized and addressed by standing committees on ethics for the respective occupational safety and health professions. Other stakeholder groups probably should be included in such deliberations, including the community representatives themselves on whom such studies would be conducted.
In a researcher’s enthusiasm to implement new technological measures into studies for which the ramifications are not fully understood (in the belief that benefit would result), it should be recognized that greater harm than benefit to the subjects of these studies could, in fact, arise (e.g., job loss today is potentially more harmful than the possibility of premature death at some future date). Hence, great caution must be exercised in advance of the implementation of such technologies. Only after due discussion has been exercised by the professional groups having an interest in the use of such technologies, together with a broad range of stakeholder interest groups, should their implementation be considered.
Another current issue involves the notion of data privacy, which is one that returns to the public arena periodically. In the age of computers, the potential exists for linking records created for one purpose with records created for another purpose. Advocates of data privacy have been concerned that records so created could be potentially damaging to individuals. While individual rights to privacy must take precedence over the research needs of the community, the fact that population-based research is uninterested in the data at the individual level must be brought to the attention of the data privacy advocates. In so doing, it should be easy to demonstrate that the public good is better served by allowing appropriately qualified researchers, trained in data processing and confidentiality, access to individual data for population-based research purposes.
Concern about the extension of principlism applied in the physician-patient setting to that of the community-research situation has been noted above (see “Recent history of codes in selected professions”). Vineis and Soskolne (1993) have found that the established principles of autonomy, beneficence, non-maleficence and distributive justice are not easily applicable at the societal level. For example, available information about the safety of exposures often is too scanty to allow decisional autonomy; beneficence is considered from the societal viewpoint rather than from that of the individual; and equity is frequently violated. Ethics require careful consideration when defining what is acceptable to society; the simple mathematical formulations used for risk-benefit evaluations cannot be applied directly to individuals. Further development and integration of these ideas are necessary.
In conclusion, codes have a fundamental role to play in the professions. They also could play an important role in safeguarding the common good if they took broader social issues into account. They need to be developed with grass-roots and stakeholder input as part of a broad-based programme of ethics supported by each profession. Codes—including the profession’s core values, the commentary associated with a code and case study materials—must be subjected to a process of periodic review and revision. Now, more than ever, codes are needed not only for professional accountability and self-regulation purposes, but also to help practitioners with the moral and ethical challenges faced by constantly advancing technologies that have implications, amongst others, for the rights and duties of all affected individuals and interest groups. A substantial and challenging task lies ahead.