The International Organization for Standardization (ISO) is a worldwide federation of national standards bodies at present comprising the national standards bodies of 120 countries as of 1996. The object of ISO is to promote the development of standards in the world with a view to facilitating international exchange of goods and services and to developing mutual cooperation in the sphere of intellectual, scientific, technological and economic activity. The results of ISO technical work are published as International Standards.

The scope of ISO is not limited to any particular branch; it covers all standardization fields except standards for electrical and electronic engineering, which are the responsibility of the International Electrotechnical Commission (IEC).

ISO brings together the interests of producers, users (including consumers), governments and the scientific community in the preparation of International Standards.

ISO work is carried out through some 2,800 technical bodies. More than 100,000 experts from all parts of the world are engaged in this work which, to date, has resulted in the publication of over 10,000 International Standards, representing some 188,000 pages of concise reference data in English and French.

Origin and Membership

International standardization started in the electrotechnical field some 90 years ago. While some attempts were made in the 1930s to develop International Standards in other technical fields, it was not until ISO was created that an international organization devoted to standardization as a whole came into existence.

Following a meeting in London in 1946, delegates from 25 countries decided to create a new international organization “whose object shall be to facilitate the international coordination and unification of industrial standards”. The new organization, ISO, began to function officially on 23 February 1947.

A member body of ISO is the national body “most representative of standardization in its country”. It follows that only one such body for each country is accepted for membership in ISO. Member bodies are entitled to participate and exercise full voting rights on any technical committee of ISO, are eligible for membership in the Council and have a seat in the General Assembly. By September 1995 the number of member bodies was 83. More than 70% of ISO member bodies are governmental institutions or organizations incorporated by public law. The remainder have close links with the public administration in their respective countries.

A correspondent member is normally an organization in a developing country which does not yet have its own national standards body. Correspondent members do not take an active part in the technical work, but are kept fully informed of it. Normally, a correspondent member becomes a member body after a few years. Nearly all the present correspondent members are governmental institutions. By September 1995 the number of correspondent members was 24.

A third category, subscriber membership, has been established for countries with smaller-scale economies. These subscriber members pay reduced membership fees that nevertheless allow them to maintain contact with international standardization. By September 1995, the number of subscriber members was eight.

Basic data on each ISO member body are given in the publication ISO Membership.

Technical Work

The technical work of ISO is carried out through technical committees (TC). The decision to set up a technical committee is taken by the Technical Management Board, which also approves the scope of the committee. Within this scope, the committee determines its own programme of work.

The technical committees may, in turn, create subcommittees (SC) and working groups (WG) to cover different aspects of the work. Each technical committee or subcommittee has a secretariat assigned to an ISO member body. At the end of 1995 there were in existence 185 technical committees, 611 subcommittees and 2,022 working groups.

A proposal to introduce a new field of technical activity into the ISO working programme normally comes from a member body, but it may also originate from some other international organization. Since resources are limited, priorities must be established. Therefore, all new proposals are submitted for consideration by the ISO member bodies. If accepted, either the new work will be referred to the appropriate existing technical committee or a new committee will be created.

Each member body interested in a subject for which a technical committee has been authorized has the right to be represented on that committee. Detailed rules of procedure are given in the ISO/IEC Directives.

International Standards

An International Standard is the result of an agreement between the member bodies of ISO. It may be used as such or implemented through incorporation into national standards of different countries.

An important first step towards an International Standard takes the form of a committee draft (CD), a document circulated for study within the technical committee. This document must pass through a number of stages before it can be accepted as an International Standard. This procedure is designed to ensure that the final result is acceptable to as many countries as possible. When agreement is finally reached within the technical committee, the draft proposal is sent to the central secretariat for registration as a draft International Standard (DIS); the DIS is then circulated to all member bodies for voting. In many countries, the DIS is made available for public enquiry, thereby ensuring the widest possible consultations. If 75% of the votes cast are in favour of the DIS, it is accepted for further processing as a Final Draft International Standard (FDIS) which is circulated to all member bodies for formal adoption by ISO. Again, 75% of the votes cast must be in favour of the FDIS in order for the International Standard to be published. Normally the fundamental technical issues are resolved at the technical committee level. However, the member body voting procedure provides assurance that no important objections have been overlooked.

The greater part of the work is done by correspondence, and meetings are convened only when thoroughly justified. Each year some 10,000 working documents are circulated. Most standards require periodic revision. Several factors combine to render a standard out of date: technological evolution, new methods and materials, and new quality and safety requirements. To take account of these factors, ISO has established the general rule that all ISO standards should be reviewed every five years. On occasion it is necessary to revise a standard earlier.

A full list of all published ISO standards is given in the ISO Catalogue.

ISO Work in the Field of Occupational Safety

Every ISO International Standard is prepared with concern for safety; the safety factor is an integral part of the work of ISO.

The more than 10,000 International Standards already published by ISO cover a wide spectrum, from aerospace, aircraft and agriculture to building, fire tests, containers, medical equipment, mining equipment, computer languages, the environment, personal safety, ergonomics, pesticides, nuclear energy and so on.

Many International Standards are easily recognized as important in preventing occupational risks: examples are the basic symbol for signifying ionizing radiation or radioactive materials (ISO 361), safety colours and signs (ISO 3864) and the industrial safety helmet (ISO 3873) specified for medium protection in mining, quarrying, shipbuilding, structural engineering and forestry, and so on. Other International Standards are not so easily identified as being directly relevant, but have an equal impact on the prevention of occupational accidents and diseases; one example is ISO 2631, Evaluation of human exposure to whole body vibration, published in three parts, which grades the “reduced comfort boundary”, the “fatigue-decreased proficiency boundary” and the “exposure limit” according to varying levels of vibration frequency, acceleration magnitude and exposure time, and according to the direction of vibration relative to recognized axes of the human body. This Standard, like all others, is continuously updated in the light of research and experience, and relates to such forms of transport as dumpers, tractors, excavators and many other vehicles and worksites.

The ISO technical committees listed in table 1 are among the most prominent in the work for safety and accidents and disease prevention.

Table 1. ISO technical committees most concerned with prevention of occupational accidents and diseases

These technical committees and others have prepared or are preparing International Standards concerned with occupational risks in such areas as building construction sites, factories, docks, agriculture and forestry, nuclear installations, handling of materials and personal protective clothing and equipment.

The field of building provides a very clear example of the intensive concern for accident and disease prevention in the work of ISO. Of the more than 50 ISO technical committees dealing with some aspect of building or building materials, ten deal with the problems of the working environment. The physical factors in the building field cover aspects such as personal safety, vibration and shock, noise, plant and equipment, earth-moving machinery, cranes and lifting devices, and ergonomics. The chemical factors cover air quality, paints and varnishes, protection of welding workers, and protective clothing and equipment.

ISO TC 127 (Earth-moving machinery) has set up a subcommittee to deal specifically with safety requirements and human factors in respect of all the current basic types of earth-moving machinery such as tractors, loaders, dumpers, tractor scrapers, excavators and graders. Standards are already in existence for safe access to driving cabs via steps, ladders, walkways and platforms, and the dimensions of cabs have been established for both large and small operators, sitting or standing and in arctic clothing or not, as appropriate.

Sitting positions and the sizes and shapes of seats for different operators are also the subject of International Standards. Sitting positions are now being related to areas of comfort and to reach for both hand and foot controls, and Standards have been prepared to determine the field of view available to operators of earth-moving machines, based upon determination of the shape, size and position of areas of invisibility caused by obstructing parts of the machines.

To prevent machines from crushing their operators in the event of accidental overturning, roll-over protective structures (ROPS) have been developed and standardized. Falling rocks, trees and parts of buildings in the process of demolition can prove hazardous, so falling-object protective structures (FOPS) have been standardized so as to minimize the possibility of injury to the operator.

ISO 7000, Graphical symbols for use on equipment—Index and synopsis, provides a synopsis of several hundred internationally agreed graphic symbols to be placed on equipment or parts of equipment of any kind in order to instruct the persons handling the equipment as to its use and operation.

ISO work in the building field is both intensive and extensive, just as it is in other fields covered by ISO. (The scope of ISO includes most industrial, agricultural and maritime activities except the electrotechnical field, which is handled by the International Electrotechnical Commission, and pharmaceutical products, handled by the World Health Organization.)

On the factory floor, International Standards take on a special meaning as persons seeking work migrate from one country to another and often to jobs where they cannot speak or read the local language. Easily recognized graphic symbols for controls on machinery that conform to International Standards are vital here as in the building industry; so are standardized locations for foot and hand controls and International Standards for guards to moving parts.

An ISO safety code for compressors covers a wide range of safety and environmental factors, such as the prevention of oil inhalation and the control of toxic oil inhibitors, the prevention of oil coke ignition and of crankcase explosion, and the use of relief and safety valves.

The safety of continuous mechanical handling equipment is the subject of nearly 40 International Standards. They cover such aspects as safety and safety codes for the different kinds of equipment, such as belt conveyors, vibrating feeders, overhead chain conveyors, hydraulic conveyors, pneumatic handling equipment, and roller and screw conveyors.

In the field of agriculture and forestry, ISO has developed important International Standards that protect the worker. Anchorages for seat belts for farm tractors are the subject of a well known standard that is making the import-export trade easier for manufacturers as it is implemented, replacing a plethora of national standards and regulations on the subject. ISO standards even provide rules for presenting operators’ manuals and technical publications for agricultural tractors and machines, making them easy to read and understand.

On the docks the worker is protected by International Standards that determine the stability of cranes and mobile cranes in action and determine the effect of wind loads on crane structures. Other Standards cover indicators and safety devices that will operate in the event of an operator’s misjudgement. Still others cover indicators such as wind gauges, overvoltage annunciators and mass, slope and slew indicators and “automatic cut-off”, such as derricking limiters, load-lifting capacity limiters and slack rope stops. The Standards produced and in preparation should not only assist operators in their work, but enhance the working environment by inspiring confidence in all works personnel moving under and around cranage. A related International Standard provides discard criteria in relation to wear, corrosion, deformation and wire strand breaks, and is intended to guide competent persons involved in the maintenance and examination of cranes and lifting appliances. New Standards under development include out-of-service anchoring devices, maintenance, condition monitoring, safe use and safety signs.

Safety for the worker and others at or near nuclear installations is covered by a number of International Standards, and the work continues in this area. Subjects covered are methods for testing exposure meters and dosimeters, a test for contents leakage and radiation leakage, and the general principles for sampling airborne radioactive materials.

International Standards for protective clothing and equipment are the responsibility of ISO TC 94. In addition to the Standard for industrial safety helmets, it has developed a standardized vocabulary for personal eye-protectors, established utilization and transmittance requirements for infrared filters for eye protectors, and general recommendations for users and those in charge of users of clothing for protection against heat and fire.

The production and use of ISO International Standards such as these, produced through worldwide cooperation, have unquestionably improved the quality of the workplace.

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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.

Scenario

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:

• employers and their representatives

• trade unions and their representatives

• health professionals

• social security and insurance administrators

• researchers

• media representatives.

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.

Basic Considerations

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.

Moral Perspectives

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.

Human Rights

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:

• the 1948 Universal Declaration of Human Rights adopted by the United Nations

• the European Convention for the Protection of Human Rights and Fundamental Freedoms (Council of Europe 1950)

• the 1966 United Nations International Covenant on Civil and Political Rights

Of particular relevance for occupational health service personnel are the codes of conduct formulated and adopted by the World Medical Association. These are:

• International Code of Medical Ethics (1949–1968) and Declaration of Geneva (1948–1968)

• Declaration of Helsinki: Recommendation Guiding Medical Doctors in Biomedical Research Involving Human Subjects (1964–1975–1983)

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.

Ethical Principles

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.

Ethical Analysis

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.

Safeguards

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:

• International Code of Ethics for Occupational Health Professionals, adopted by the International Commission on Occupational Health in 1992

• Ethical Guidelines, adopted by the International Epidemiological Association

• International Guidelines for Ethical Review of Epidemiological Studies, adopted by the Council for International Organizations of Medical Sciences (CIOMS)

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.

Conclusion

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.

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Raison d’être and Historical Perspective

The aim of the ISSA is to cooperate, at the international level, in the defence, promotion and development of social security throughout the world, basically through its technical and administrative improvement. The prevention of social risks is today considered to form an integral part of social security.

The ISSA had an early forerunner, the Permanent International Committee on Social Insurance (CPIAS), which at first was concerned with the risk of accidents and in 1891 extended its scope to social insurance in general. In 1927, the Tenth Session of the International Labour Conference adopted Convention No. 24, known as the Sickness Insurance (Industry) Convention, and Convention No. 25, known as the Sickness Insurance (Agriculture) Convention. The ISSA was founded at this time, upon the initiative of the International Labour Office, with the aim of gaining support from experts in a number of European countries for the ratification of these instruments. Until 1947 the organization was known as the International Conference of Sickness Insurance Funds and Mutual Benefit Societies (CIMAS).

The concept of prevention already existed in the minds of the CIMAS pioneers when they included this notion in the fundamental policy principles adopted by their Constituent Assembly. It was not until 1954, however, that the Association became actively involved in occupational safety and health activities, through the establishment of its Permanent Committee on Prevention of Occupational Risks. It should be noted that, in this respect, the role of the ISSA is complementary to that of the ILO. The ISSA’s experts may not only be instrumental in bringing about ILO Conventions and Recommendations, but are also called upon to implement them.

Although prevention programmes are obviously most prevalent in the field of occupational safety and health, over the last two decades prevention has gained increasing importance in other branches of social security as well, particularly as regards sickness insurance and, more recently, unemployment insurance, as may be seen from the activities of ISSA Permanent Committees. Over the last decade, activities aimed at preventing employment accidents and occupational diseases have undergone considerable changes in modern industrialized societies, as elaborated below concerning the “Prevention Concept” of the Association.

Structure and Membership

The ISSA is an international organization of services, institutions or bodies administering one or more branches of social security or mutual benefit societies. It has its offices at the headquarters of the ILO in Geneva.

The Association has two categories of membership—affiliate membership, for government departments, central institutions and national federations of institutions administering social security or one of its branches at the national level, and associate membership, open to national non-profit institutions, such as research and safety and health institutions, the aims of which are compatible with those of the Association, but which are not qualified to become affiliate members.

In 1995 the ISSA had over 240 affiliate member organizations in 117 countries, and 95 associate member institutions in 35 countries, for a total membership of some 338 organizations in 127 countries around the world. More than 200 member institutions are directly involved in insurance against employment accidents and occupational diseases and/or in the prevention of accidents and the promotion of safety and health.

Figure 1. Structure of the International Social Security Association (ISSA)

As can be seen from the organigramme (figure 1), all ISSA activities are directed by the General Assembly, which is comprised of delegates appointed by member institutions and is sometimes described as the world parliament of social security. The Council, which consists of one delegate from each country having affiliate member institutions, meets regularly on the occasion of the Association’s triennial General Assemblies. The Bureau, which together with the Council gives effect to the decisions taken by the General Assembly, meets twice a year and is composed of 30 elected members and the Chairpersons of the Permanent Committees.

Activities

The Association has three main programmes:

1. Regional activities. These are aimed at serving the special needs of member institutions in the various parts of the world. For this purpose the ISSA has regional offices for Africa, the Americas, Asia and the Pacific and Europe situated in Abidjan, Buenos Aires, Manila and Paris respectively.
2. Research and documentation. Worldwide developments and trends in social security are monitored and analysed from the perspective of national and cross-national research through a network of correspondents. The Association maintains the largest social security library in the world and collaborates with the ILO’s Social Security Department in providing timely social security information.
3. Technical activities. Ten Permanent Committees and a Study Group each deal with a specific branch or aspect of social security. They investigate sector-specific problems such as those relating to health insurance, pension insurance, unemployment insurance, family protection, rehabilitation, organization and methods, actuarial and statistical issues.

The Permanent Committee on Insurance against Employment Accidents and Occupational Diseases and the Permanent Committee on Prevention of Occupational Risks with its 11 International Sections on Accident Prevention are of particular importance in fostering safety and health.

The Permanent Committee on Prevention of Occupational Risks

Two different and complementary aspects (i.e., promotional activities related to prevention, and technical activities) fall within the scope of competence of this Committee, which together with its Advisory Council monitors worldwide developments and undertakes surveys and studies on overall problem areas.

The Committee is charged with undertaking at the international level the following types of activities for the prevention of occupational risks:

• exchange of information and experience
• organization of international meetings and World Congresses
• implementation of surveys and promotion of research in the field of prevention of occupational risks
• coordination of the activities of the ISSA International Sections for the Prevention of Occupational Risks
• cooperation with the ILO and other agencies active in the prevention of occupational risks
• other measures appropriate to the purposes of the Committee.

World Congresses

Since 1955 the ILO and the ISSA have organized triennial World Congresses on Occupational Safety and Health in cooperation with the ISSA member institutions and ILO constituents concerned in the host country. It is not easy to quantify the extent to which the World Congresses have kept pace with the different stages of development in the prevention of occupational risks coinciding with the social, economic and industrial progress of the past 25 years, or the extent to which they have given a lead to or encouraged this development. There is no doubt however that the resultant exchange of ideas and information relating to recent research and to its practical application in different countries, both at the national level and within industry, has enabled a large number of participants in these Congresses to be cognizant of the many changes being introduced. This, in turn, has enabled them to make a greater contribution to their particular field of activity.

The last four World Congresses took place in Ottawa-Hull (1983), Stockholm (1987), Hamburg (1990), New Delhi (1993) and Madrid (1996). In 1999, the site is Brazil.

ISSA International Sections for Prevention

Since the end of the 1960s, on the advice of the Permanent Committee on Prevention of Occupational Risks and its Advisory Council, the Bureau of the ISSA has set up 11 International Sections for the Prevention of Occupational Risks. Eight of them deal with accident prevention in various sectors of industry and agriculture and three deal respectively with information techniques, research in the area of occupational safety and health, and education and training for prevention of accidents.

Each ISSA International Section is represented by its Chairman and Secretary General on the Advisory Council of the Permanent Committee, which advises the Bureau of the Committee on fundamental questions relating to the activities of the Committee and its International Sections. A concrete example is the prevention concept (discussed separately below).

The International Sections are financially autonomous, having a decentralized structure and their own membership consisting of full members, associate members and corresponding members. Full membership is open to ISSA member institutions and other non-profit organizations; profit-making entities with activities compatible with the area of competence of a Section may be admitted as associate members, and individual experts may apply for corresponding membership. The Secretariats of the Sections are provided in various countries by member institutions of the ISSA specialized in the respective fields.

Each Section is a clearing house for information in its own area of competence. All Sections organize international symposia, round tables and expert meetings, the proceedings and reports of which are published in the ISSA Prevention Series 1000. The Sections currently have some 45 internationally composed working groups working on specific topical subjects, which range, for example, from safety advice for migrant workers in the construction industry or a checklist for the classification of machines on the basis of ergonomic principles, to safe working with biological agents. The findings of these working groups are published as technical brochures in the ISSA Prevention Series 2000. Most titles exist in English, French and German, some also in Spanish and other languages. Such publications may be ordered directly from the Secretariat of the Section concerned.

Of special interest are the International Film and Video Festivals, which are held during World Congresses and for which a Working Group of the Electricity Section forms a clearing house. All productions submitted to these festivals are listed in a catalogue in four languages which is available free from this Section.

A brief description of each of the ISSA International Sections follows.

ISSA International Section for Research.

The Section offers the latest information on both current and planned research projects worldwide. Two data banks allow quick and efficient access to this information. The Working Group “Research Concepts” promotes the necessary theoretical bases to effectively ensure that more than in the past research further serves both the field and the more practical implementation of research results.

ISSA International Section on Information.

The Information Section provides information on efficient information techniques. The Working Group “Safety and Health Periodicals” informs safety experts on the most effective way to reach their audience. The Section offers expert advice on “advertising for safety”.

ISSA International Section for the Mining Industry.

The Section deals with the classical risks of underground work in coal mines (darkness, dust, heat, gases, explosions, cave-ins) and concerns itself with the training of mine rescue teams.

ISSA International Section for the Chemical Industry.

Although new substances result in new risks, the chemical industry has developed high safety standards that have proven to be exemplary. The Chemical Section strives to ensure that these safety standards transcend borders just as much as—if not even more than—risks do.

ISSA International Section for the Iron and Metal Industry.

The high accident rate in this important branch of activity must be reduced. Safety strategies are developed against the most frequent hazards and causes of accident. The Section’s Working Groups are primarily concerned with new technologies and substitutes for dangerous working substances.

ISSA International Section for Electricity.

“Invisible” energy generates many invisible risks. The Section evolves recommendations for practical accident prevention, principles for a regulatory control of electrical appliances and systems, backed up by effective first aid measures in the event of electrical accidents. The Section maintains a clearinghouse for films and videos in the field of safety, health and the environment.

ISSA International Section for the Construction Industry.

The extremely high accident risks in the construction industry call for a safety strategy that can deal with the continuous changes of the working environment on construction sites. The Section’s aim is not only to solve individual problems, but to increase safety and accident prevention in construction industry operations overall, especially by intensified cooperation between the various trades working on the same site.

ISSA International Section for Agriculture.

The mechanization of agriculture and the use of chemical substances in agriculture are worldwide problems. The Section advocates a rapid socio-technical evolution in the light of the technical revolution, while endeavouring to ensure that the production of food does not put life at risk.

ISSA International Section for Machine Safety.

The Section deals with system safety and accident prevention relating to machines, appliances, apparatus and systems. Standardization of safety appliances, ergonomic questions, noise reduction, safety switches and the prevention of dust explosions are focal points of the Section’s Working Groups.

ISSA International Section for Education and Training.

Technical progress is expanding in all areas of life; but at the same time it brings along new risks. The major factor in accidents is the lack of education and training in the field of safety. Safety must be an integrated part of human behaviour in all areas of life. The Section deals with pedagogical aspects of education and training for prevention and aims at a global approach of prevention, making use of the experiences gained in prevention at the workplace for safety in all areas of life.

ISSA International Section for Health Services.

The Section endeavours through international cooperation to overcome the safety deficits in the health sector. The health sector has typical professional risks which in part differ greatly from those in other fields of activity—for instance, direct exposure to diseases, risks from medications, particularly gas anaesthetics, disinfectants and infectious waste.

The ISSA Prevention Concept “Safety Worldwide”

The ISSA Bureau adopted this concept in October 1994 under the title “ISSA Prevention Concept ‘Safety Worldwide’—The Golden Path to Social Policy”.

Because only seven out of every 100 fatal accidents are work accidents, with all others occurring in traffic, in the home, during sports or at school, the concept seeks to make meaningful use, in other areas, of the experience gained in prevention in the world of work.

Starting from the viewpoint that the preservation of health is a fundamental mission of humanity and thus a central aim of social security, the concept calls for the interlinking of prevention, rehabilitation and compensation and for the preservation of an intact environment. Emphasis will be laid on the human factor at the planning, organization and implementation stages and the need to begin education in prevention during early childhood. Efforts will be made to address all those who, through their own activities, can provide better protection against hazards for individuals. These include legislators and standard-setters, social partners, persons responsible for developing, planning, designing and manufacturing products and services, and school curriculum planners and teachers, as well as information specialists in public information work, occupational health physicians, supervisory and consultative bodies, responsible officials in social and private insurance, decision-makers and programme managers in international organizations, professional and other organizations and so on—and, last but not least, parents and children.

The thorough promotion of safety and health at work and elsewhere requires measures of three types—technical measures, behavioural change measures and organizational measures. To this end, the ISSA’s prevention concept defines three levels of intervention:

1. informing the general public and developing awareness relating to safety and health matters through the mass media, newspapers, brochures, posters and so on
2. achieving both broad and in-depth impact by seeking to change attitudes and behaviour through agents with a multiplier effect and using target-group-specific media and techniques such as educational films and other educational materials
3. aiming at an in-depth impact on groups directly at risk through specific measures such as counselling or subject-specific brochures.

The first step in the implementation of the concept will be a stock-taking of prevention activities to determine regional needs and deficiencies. An inventory of existing support facilities and materials will also be drawn up. In addition, the ISSA will step up its information and research activities and its programme of meetings, strengthen cooperation with international organizations active in the prevention field, and take their projects into account in its own activities.

In summary, the only sure way to success lies in cooperation between prevention, rehabilitation and compensation services; the positive experiences of prevention within enterprises must be carried over into non-occupational fields; and greater account must be taken of the human factor.

Publications

The ISSA issues a whole range of periodical and non-periodical publications, studies, surveys, newsletters and bulletins; further information concerning them is contained in the ISSA Catalogue of Publications, which may be ordered free of charge at the following address: ISSA, Case postale 1, CH-1211 Geneva 22, Switzerland.

In addition to the proceedings of World Congresses on Occupational Safety and Health, which are published by the National Organizing Committee of the host country, the publications issued by the International Sections are listed in the ISSA Prevention Series 1000 and 2000, and are also available at the above address.

Back

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.

Health Protection

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.

Confidentiality

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.

Conclusion

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.

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