Choosing A Professional Code For Ethical Conduct In Occupational And Environmental Medicine

On May 1, 1996, the membership of the Association of Occupational and Environmental Clinics overwhelmingly adopted the International Commission on Occupational Health's International Code of Ethics.1 In adopting the International Code, the organization was seeking a document that addressed seven essential principles that should guide ethical practice in Occupational and Environmental Medicine; namely, an obligation to a safe and healthy workplace and environment, an obligation to professional competence, an obligation to advise and report, avoidance of conflict of interest, avoidance of discrimination, an obligation to maintain ethical standards, and an obligation to maintain patient confidentiality.2 The Journal's recent publication of Mark Rothstein's proposed revision of the ACOEM Code for Ethical Conduct, with Dr Teichman's accompanying editorial, represents vital ongoing discussion and debate on the important issue of an effective professional code of ethics for Occupational and Environmental Medicine.3,4 While Dr Teichman notes that, in revising the 1976 AOMA Code, ACOEM's Committee on Ethical Practice in Occupational Medicine intended to provide members with "a standard set of basic principles that could guide their daily professional activities,"4 Mr Rothstein proposes a revised ACOEM Code that would, in its essential features, reintroduce elements of the 1976 AOMA Code that were omitted in the revised 1993 ACOEM document. The elements eliminated from the 1976 AOMA Code represent, in our view, essential principles of Occupational Medicine; namely, avoidance of conflict of interest, and actively maintaining ethical standards, including opposing unethical conduct. Further, the 1993 ACOEM revision substantially weakens the obligation for professional competence, not addressing the need for familiarity with workplace hazards, and the obligation to advise and report, failing to include the scientific community or governmental agencies as specific groups to be contacted when the health of workers is threatened. While we agree that returning to the 1976 AOMA Code would represent a substantial improvement, reestablishment of a prior status quo, would-as Thoreau and Rothstein caution us-be to aim low. The 1976 AOMA Code has several notable deficiencies.2 First, it does not adequately address the public health orientation of Occupational and Environmental Medicine, such as the need for primary prevention, medical surveillance, and worker training. Second, the 1976 AOMA Code does not address protection from discrimination against workers, which has become requisite in addressing challenges to the Americans with Disabilities Act and the increasing disparity between working conditions across national boundaries. Third, the 1976 AOMA Code fails to identify the Occupational Health provider's role in addressing threats to health resulting from non-work-related environmental exposures. While we concur with Dr Teichman's view that an effective Code of Ethics in Occupational and Environmental Medicine should state principles succinctly, we would emphasize that such a code must also address all principles comprehensively, with sufficient detail and rigor to serve as a guide to ethical practice. By completely deleting or substantially weakening the vital principles discussed above, the 1993 ACOEM Code fails to provide such an essential framework, falling short not only of the biblical model of the Ten Commandments but, unfortunately, the 1976 AOMA Code as well. The real-life consequences of these omissions are most evident when challenges to ethical practice occur. A cogent example of such a challenge to the obligation to report is demonstrated by the disturbing situation that recently occurred at Brown University, in which David Kern observed and reported an unusually high incidence of interstitial lung disease in a local nylon flocking plant.5,6 Dr Kern actively undertook to fulfill his obligation to report, informing the company and the National Institute for Occupational Safety and Health of his findings and preparing an abstract for presentation at an upcoming scientific meeting. While the company insisted that the abstract be withdrawn, Dr Kern diligently continued to communicate with management, labor, and the scientific community. The University and its affiliate, however, urged that Dr Kern comply with the company's demands. Dr Kern's ethical obligation to advise and report is no longer stated rigorously in the 1993 ACOEM Code, which only vaguely indicates that he should "communicate to individuals and/or groups any significant observation and recommendations concerning their health or safety (Article 7)," but offers no identification of the entities to which it is referring. In the specific action of reporting to governmental agencies and the scientific community, it provides no support of Dr Kern's important ethical stand, taken at significant professional risk. In contrast, Dr Kern's obligation is well defined in the International Commission on Occupational Health (ICOH) Code (Article 15), which states that "occupational health professionals must report objectively to the scientific community on new or suspected occupational hazards and relevant preventive methods." While the Brown administration has argued that a confidentiality agreement, pertaining only to disclosure of commercial trade secrets in the context of a plant visit, precluded Dr Kern's right to report, the ICOH Code (Article 7) clearly defines the appropriateness of Dr Kern's actions: "Occupational health professionals must not reveal industrial or commercial secrets of which they may become aware in the exercise of their activities. However, they cannot conceal information which is necessary to protect the safety and health of workers or the community. When necessary, the occupational health professionals must consult the competent authority in charge of supervising the implementation of the relevant legislation." Dr Rothstein correctly points out that while the ICOH Code is "an extremely detailed explication of the professional obligation of occupational health professions," it is not without its limitations. In the United States, where medical care is generally administered outside industrial and corporate settings, physicians may not have the authority to ensure implementation of recommendations based on ethical principles. We would argue, however, that these are limitations in implementation and not in the principles of ethical practice themselves. For instance, under ICOH Article 9 (Obligation to Advise and Report), we would note that it continues to be a physician's ethical obligation to advise a worker that a process of appeal exists, should an administrative decision based on that physician's medical evaluation adversely effect the worker's employability. Though the physician may not be involved in establishing or administering an appeals procedure, he or she should determine, and be in a position to advise patients, whether an internal grievance process exists or whether a legal resource is required. Similarly, though few would disagree with the premise of ICOH Article 18 (Avoidance of Discrimination), that "occupational health professionals must build a relationship of trust, confidence and equity with the people to whom they provide occupational health services," not all physicians will be able to establish or maintain channels of communication with senior management of corporations. Nonetheless, all physicians should establish appropriate lines of communication with the supervisors responsible for the work practices or conditions that could adversely effect their patients' health. Analogously, while ICOH Article 23 states an important ethical obligation to maintain patient confidentiality, in practice it may be difficult to exclude non-job-related medical information from work-related health assessments. The ICOH Code thus appropriately states the need to obtain a worker's consent when such records are required "for the purpose of protecting the health of this worker." ICOH Article 23 raised an additional concern from several AOEC members. The limitation to "not seek personal information which is not relevant to the worker's health in relation to work" potentially limits the occupational health professional from providing a comprehensive health examination. Several AOEC member clinics provide additional medical screening for conditions such as diabetes mellitus and hypercholesterolemia. While not directly work-related, these tests can contribute substantially to maintaining the overall health of a workforce and provide an important public health service for working populations with inadequate access to health care. Provided that employers and employees are aware of-and understand the reasons for-such screening and results are kept confidential, we determined that such screening should represent acceptable occupational health practice. While the International Code may present challenges to practical implementation and could benefit from modifications-particularly those emphasizing environmental health-it addresses each of the essential ethical obligations that occupational health professionals must follow in the care of their patients. These obligations are stated succinctly, yet in sufficient detail to guide decision-making. As an effective guide to ethical practice it aims high and, in Thoreau's metaphor, hits close to the mark.