Occupational Health Ethics: From Theory to Practice

© Springer Nature Switzerland AG 2020

J. TaminOccupational Health Ethicshttps://doi.org/10.1007/978-3-030-47283-2_1

1. Introduction

Jacques Tamin¹  

(1)

Centre for Occupational and Environmental Health, University of Manchester, Manchester, UK

Jacques Tamin

Email: [email protected]

This book is intended to be a practical ethics guide for practicing occupational health (OH) professionals. It is therefore primarily aimed at all those who practice OH in some way, whether as their main function, such as occupational physicians and occupational health nurses, or part-time, such as primary care physicians. OH is usually provided by a multi-disciplinary team nowadays, so I include other occupational health professionals (OHPs) such as physiotherapists, occupational therapists, occupational psychologists and technicians working in OH, in my target audience. It may also be of interest and relevance to others closely affiliated to OH services (and sometimes working within OH teams) such as occupational hygienists, occupational toxicologists and health and safety (H&S) professionals. I will use many examples from OH practice to discuss and reflect on the ethical issues, rather than use a didactic approach.

Although this book is not specifically aimed at employers, human resource (HR) professionals, trade union representatives, or employment lawyers, it may interest them to understand the ethical issues that their OH colleagues often grapple with, and the ways in which these challenges can be addressed and hopefully resolved.

Integrity

Before we look at ethical principles and theories to guide us through the OH moral maze, I would first like to mention the importance that I attach to personal and professional integrity. I have had the privilege of knowing and working with some OH professionals of the highest integrity. They would stand up for their beliefs and values in the most difficult and challenging of circumstances. I am in awe of them. I would like to believe that I also have acted and would always act with such integrity. At least, that is my hope. But I am not sure that I have always got it right. For those of you who also experience or have experienced such self-doubt, this book may be of special interest to you. It aims to help you reflect on the difficulties you face, and provide some guidance at what might be the best moral approach to that problem. However, it seems pointless to me to seek the most morally correct solution unless we are prepared to act on it. Therein lies the crucial importance of moral courage and integrity.

The International Commission on Occupational Health (ICOH) also highlights the importance of integrity. It lists it as one of the three basic principles in its Code of Ethics. Of course, we are not alone in OH in needing to act with professional integrity. Health professionals in other disciplines can also be subjected to pressures, directly or indirectly, to act in ways which could be against a patient’s best interest.

However, OH does have its special ethical challenges. The reasons for this will be explored in the next section.

Why OH Ethics?

In the preface to a previous edition of the UK Faculty of Occupational Medicine (FOM) guidance on ethics, Dr. David Snashall, then President of the FOM, stated:

Practising occupational physicians probably think about ethics every day. At least they think about the subject more often than most doctors…

Why should practising occupational physicians think about ethics every day, or at least more often than most doctors? After all, they are not usually involved in life or death decisions, or complex moral issues around the beginning and end of life. Furthermore, the experience of thinking about ethics is not confined to the UK. For example, a study of OH physicians and nurses in Finland showed that 97% of them had experienced ethical issues in their OH practice. Nor does this concern only OH physicians and nurses: other members of a multidisciplinary OH team can be similarly affected.

So, what is it about OH that makes it so ethically problematic? Ethical difficulties that arise from OH practice may partly be explained by the intrinsic nature of the discipline of OH itself. The very fact that it places dual obligations (which will be explained in Chap. 2) on OH professionals produces a tension between their obligations to the two (or more) parties, especially when these obligations and/or the parties are in conflict. For example, a worker may believe himself to be too ill to work, whereas the employer does not believe this to be the case. Conversely, another worker may want to continue to work when his employer does not believe it to be safe for him to do so. Therefore, one can understand that on a day-to-day basis, OH professionals might give advice that one or other party might not like. Does this necessarily cause ethical problems? To understand where the ethical problems arise, it would be helpful to understand the basis of what might make one course of action morally preferable to another in our OH practice. We can gain such insights from our own personal moral values (within the context of our cultural and societal values); our professional training and development; an understanding of moral theories and approaches; and specific ethical codes or guidance written for OH professionals. The first section of this book deals with the theoretical underpinning of OH ethics by examining and applying moral theories and approaches in an OH context. But first, let us look at the role ethical codes play in guiding our practice.

Codes of Ethics

Although my aim is to generally keep references separate to the main text (mentioning them in the Notes section to each chapter instead), I believe that one cannot really discuss the topic of Codes of OH ethics without mentioning the seminal work of Peter Westerholm in this area. Most commentators who mention ethics codes in the OH context quote his work on this topic and I will do the same.

While Codes of ethics are generally useful and have an important role in guiding OH professionals on ethical issues, Westerholm nonetheless identifies three problem areas: the interpretation problem, the multiplicity problem and the legislation problem. The difficulties in translating rules or guidance into real life situations, as well as contradictory advice within the codes, contribute to difficulties in interpretation of the codes. The number of different guidance and codes produced, some of which can be contradictory between each other, causes the multiplicity problem. The legislation problem arises when the question what is the morally right thing to do? is replaced by the narrower what is legally permissible?. If codes are interpreted in this narrower way, then OH professionals might not develop through their reflective practice (which is a key professional behavior), instead they might blindly follow rules in an unthinking and minimalistic way.

At their best, they can be like a lighthouse (analogy by Westerholm 2009) shining light and guiding OH professionals through ethical uncertainties. In this regard, the example par excellence is the ICOH Code of Ethics. It defines and clarifies our moral priorities as OH professionals, and in so doing provides a bearing for our moral compass. Its importance is also highlighted by the fact that it is internationally recognized as being authoritative. However, it does not provide much detail (which is not necessarily a weakness), or much moral theory (which is not its intention in any case). On the other hand, it does articulate the value set of OH professionals (Westerholm 2009), and in so doing, acts as a lighthouse to guide us to practice OH ethically.

Scope of This Book

This book is written primarily for OH practitioners. I will mainly focus on the ethical issues that arise out of their OH practice. To that effect, I will choose the moral theories and approaches that I believe will best help us to discuss and reflect on these ethical concerns. However, as OH professionals we are also uniquely placed at the work-health interface. I believe that each of us has a chance to influence others (such as employers and rule-makers) to make the workplace a fairer, less discriminatory place, especially towards those who are more vulnerable. This then calls for an approach to arguing about social justice and fairness, so I will also consider the theoretical underpinning of such arguments (in Chap. 5).

But there are many areas that I will not consider in any great detail in this book. For example, I will briefly mention (in Chap. 9) what future OH may look like (and the corresponding ethical challenges they might bring), which include the impacts of globalization, demographic changes and newer technologies, but will not analyze the implications in depth. I think that these subjects could form the basis of a whole book by themselves! The other large topic I have not included in this book is the ethics of OH research (though I have mentioned a reference in the Notes section). I do consider research in OH to be something we should promote and foster. Indeed, evidence-based practice needs good research to have been conducted. The importance of evidence-based practice is highlighted at various points in this book. However, most OH professionals do not routinely carry out research, so this topic might have been of a more passing interest to them compared with the ethical difficulties they face in their everyday practice.

Moral Theories and Approaches

In this section, I will review the moral theories and approaches that will be used in the rest of book. Although the emphasis in this book is on practical OH ethics, we need to have sufficient understanding of moral theories which might underpin our ethical deliberations when confronted with these issues in the course of our practice. I will also briefly mention some of the theories or approaches that I will not be using.

The Four Principles

The four principles approach (often known as principlism), originally articulated by Beauchamp and Childress in 1979 is the cornerstone of biomedical and healthcare ethics. It was used for example in the Appleton consensus in 1989, when ethicists and physicians agreed on the ethical issues arising from patients deciding to forego medical treatment. Forty years on, the Beauchamp and Childress textbook of biomedical ethics has undergone many revisions and remains a classic. There are few students in the healthcare and associated professions, I would suggest, who would not be able to list the four principles, namely respect for autonomy, nonmaleficence, beneficence and justice. Let us now look at each of these in turn, in the context of the principles approach (as per Beauchamp and Childress).

Autonomy is defined as self-rule or self-governance, and at an individual level, this means one that is free from controlling interference by others and one has sufficient understanding to make a meaningful choice. Respecting a patient’s autonomy, which is relevant to the healthcare and OH contexts, means that we acknowledge their right to hold views, to make choices, and to take actions based on their values and beliefs. We will see later (in Chap. 3) how autonomy underpins the concept of informed consent, with which we are familiar in both healthcare and OH practice. Indeed, autonomy is a key ethical principle, and in cases of ethical conflict, this often needs to be balanced against other competing ethical principles or values, to reach our best or preferred moral choice in that situation.

The principle of nonmaleficence is also one that resonates well with our values as healthcare professionals. We are used to the notion that first we must do no harm. However, this is one of the principles that can come into conflict with that of autonomy. If respecting the autonomy of one individual/patient/worker could lead to the harm of another or a group, which principle ought we give preference to? There are no easy answers to this. In the examples we will consider later (in Chaps. 6, 7 and 8), we will see that when we are balancing the autonomy of an individual against the possible harm to others, we need to evaluate the likelihood and the severity of that harm. That is, of course, a risk assessment process, which we will be very familiar with, as OH professionals.

Similarly, the principle of beneficence is one that we readily subscribe to as healthcare and OH professionals. Beauchamp and Childress make the point that contributing to others’ (that is, patients’) welfare is implicit in the healthcare context. I will later describe how our primary purpose, as OH professionals, is to protect the health of the worker (in Chap. 2), and so, our concern for the welfare of workers is a moral imperative for us. I see this as a positive, one of the lighthouses to illuminate our moral decision-making in OH. However, the principle of beneficence can also come into conflict with that of respect for autonomy, when a worker would rather choose a course that could put his life and health at risk. Ought we override this choice? If we do, we could be accused of acting paternalistically, which is generally not considered acceptable. I will illustrate the possible tension that can arise between the principles of beneficence and respect for autonomy in an OH context later in Chap. 7 (Health surveillance).

The last of the four principles is justice (meaning fairness). In the healthcare context it is often used to mean distributive justice, that is, a fair and equitable sharing of resources that would help improve health and provide healthcare. In our OH context, we are mindful that there should not be unfair discrimination, for example, and justice can provide a conceptual underpinning for arguments in this area of ethics. As you will later see, I echo a plea made by others (in ICOH reports referred to in Chap. 5) that OH professionals should be active in helping the more vulnerable workers and individuals in our society. For that reason, I will cover some theories and concepts of justice (especially the capability approach) that I think are particularly relevant to OH, in Chap. 5.

In addition to the four principles, Beauchamp and Childress also specify four rules, namely veracity, privacy, confidentiality and fidelity. These are relevant in our OH context, but I will not expand on the rules here. Instead, I will discuss fidelity in the context of our professional-worker relationship (Chap. 2), privacy and confidentiality in Chap. 4, and mention veracity in an ethical dilemma described in a case vignette (the case of Ernie) in Chap. 6.

Deontology

The best known of the moral theories that are based on duty, or deontology, is that of Kant. Those who criticize his approach point out, for example, its excessive formalism. However, some philosophers who favor this conceptual approach have shown how it can be applied to contemporary ethical debates. In any case, as healthcare and OH professionals, we are very comfortable with the idea that we have specific professional duties to patients, workers and others. These are usually specified by our regulators and in codes of ethics (see above), but I would suggest that through our education and training, many of these professional duties and attitudes become interwoven into the very fabric of who we are (in our professional roles). This approach gives us much guidance in what the morally right and professionally correct course of action should be. However, when different duties or obligations come into conflict, we still need to have a way of resolving such conflicts. For example, in OH practice, our main aim is to protect the health of workers. That is our primary duty. But what if this conflicts with our duty of confidentiality or our respect for a worker’s autonomy? This could arise, for example, in health surveillance situations where a worker ought to be removed from exposure to a harmful agent to protect his health, but he disagrees with the OH professional and wishes to take the risk to his health. Such scenarios will be discussed in Chap. 7 (Health surveillance).

Rights

We are probably all familiar with the notion of human rights and might think that the discourses from that perspective are a relatively recent phenomenon. However, philosophers from the seventeenth century have argued from a notion of entitlement to certain rights. This approach lost favor, when other schools of thought, such as utilitarianism, became prominent. There has been a resurgence of interest in human rights as a basis for political and moral debate globally, and this has been reflected in the UN’s Universal Declaration of Human Rights in 1948. Further international endorsements have since given this declaration even greater currency. It has been the basis for the development of national and regional human rights legislation. Of particular interest to us in the world of work is Article 23, which not only iterates a right to work for everyone (think of the disabled, for instance), but also that this should be in favorable conditions of work (We will later see, in Chap. 5, that vulnerable workers are especially at risk of being in unfavorable working conditions). Another Article of special interest to us is Article 12, which specifies a right to privacy. I will be referring to a right to privacy in the context of informational privacy, in relation to confidentiality and disclosed information, in Chaps. 4 (Confidentiality) and 6 (Report writing).

Consequences

Another approach to moral theories is to see what the consequences would result from acting or not acting in a certain way, which action or inaction leads to the morally preferable or desired outcome. The best known of the consequentialist theories is the utilitarian approach. The latter approach is underpinned by the view that the morally correct approach is that which would maximize utility (such as happiness) for the greatest number. I will later touch on utilitarianism again in the context of theories of justice (in Chap. 5) but will not generally be using utilitarian arguments in our OH context. However, I will apply consequence-based arguments in some of the analyses of OH ethical problems. I think that looking at consequences may be fairly intuitive to those of us who face these problems at a practical level, rather than a purely theoretical one. For example, it may be reasonable to make a case that one should act in a certain way in a certain situation, based on our duties, but if the practical consequence of doing so results in bad outcomes (broadly conceived), then we may reject the duty-based argument. I am not suggesting that consequentialist arguments are always preferable, merely that we need to take account of several types of theories (and sometimes they may be in conflict) when we are faced with a practical ethical problem.

Summary

To summarize this section on the approach to moral theories that this book will take, I would say that it is a pluralistic approach that will be used. I will often use arguments derived from principlism in our OH situations, as much of OH is similar to healthcare, where the four principles are extensively used, so the approach works equally well in many OH situations. However, I will also use deontology-based, rights-based and consequentialist-based arguments where these approaches might help us understand an ethical issue better. To illustrate this, if we look at how we justify keeping worker information confidential, we can use duty-based (our fiduciary duty of confidentiality), rights-based (the worker’s right to privacy) and consequence-based (worker trust in OH) as reasons why we should respect the confidentiality of that information (see Chap. 4). Throughout the book, I will make constant reference to our dual obligations, which other healthcare professionals may not need to grapple with as much as we do, as OH practitioners. Furthermore, I will take our primary duty to protect the health of workers as a guide for our moral compass, to be the lighthouse in situations of ethical uncertainty (to paraphrase Westerholm).

Lastly, the above list is not intended to be a comprehensive summary of moral theories, it merely draws attention to those ethical theories and approaches I will mainly use in this book. There are many other moral theories that could be of interest to us, such as virtue theories and care theories, but I have not currently found an application for these in our OH context. I say currently, because moral theories continue to evolve, as does OH practice (as I will mention in Chap. 9). Indeed, I envisage that in future, more ethical theories will have direct appeal to OH ethical theory and practice. This is but the beginning.

A Guide for the Reader

This is an overview of how this book is structured.

The remaining chapters of this book are divided into two main parts. Part 1 (Chaps. 2–5) deals with the theoretical basis of OH ethics. In Part 2, I review some of the main OH practical activities through the lens of OH ethics (Chaps. 6–8), with Chap. 9 as the concluding chapter. Finally, the notes to each chapter, which include references and commentaries to provide supporting arguments and evidence for the contents of Parts 1 and 2, will be at the end of the book.

The following is a brief synopsis of each of the remaining chapters:

Chapter 2: The doctor-patient relationship and dual obligations in Occupational Health.

In this chapter, the similarities and differences between the OH professional-worker relationship and the traditional doctor-patient relationship are explored, particularly the role that trust plays in these relationships. The OH professional’s duties to the worker and the employer (the dual obligations) are reviewed and the ethical tensions that can arise from owing obligations to these parties are described. I suggest that an approach to reducing potential ethical conflicts would be to clarify our different OH roles in terms of the trust, power imbalance and fiduciary obligations that each role would entail. This would make it easier to explain to all parties which obligations take priority in different situations, and this transparency may help to improve trust in OH professionals.

Chapter 3: Consent.

This chapter on consent gives us an opportunity to consider one of the most important principles in healthcare ethics, namely autonomy. This is because our requirement to obtain patient or worker consent before we carry out any intervention is understood to reflect our respect for their autonomy. However, the wishes of an individual must sometimes be balanced against what is best for the community, so we will look at this in the OH context. In addition, there is a small but significant difference in the type of consent given to perform an intervention and that given for the release of personal information. I argue in this chapter that this means there are effectively two types of consenting processes at play in many of our OH activities, and discuss the relevance making this distinction more explicit in OH practice.

Chapter 4: Confidentiality.

In this chapter, I examine why confidentiality is so crucial in healthcare and OH practice. One of the reasons for its importance is that patients and workers entrust us with private and sensitive information. We should act in ways to merit that trust. Another reason is that workers have a right to have their privacy respected. However, there are instances when the duty of confidentiality can (or even should) be breached, for example, if others might be harmed by non-disclosure. This confidentiality paradigm, with its allowed breaches, is arguably confusing for practitioners and patients/workers, and could reduce worker trust in OH. Nonetheless, this is the paradigm we usually work within, and I argue that if we are to be trusted by workers, then we must be open and transparent about the circumstances where confidentiality might be breached.

Chapter 5: Sickness absence

Although sickness absence is a very practical topic in OH, I have included this chapter in the theory section of this book. This is because I deal with the wider issues that can lead to sickness absence. For example, disadvantaged