Scope
This Code of Ethics applies to health professionals who are engaged in the practice of occupational or environmental medicine and addresses distinctive ethical issues that are characteristic and recurring in the practice of occupational and environmental medicine.
ACOEM recognizes that many practitioners covered by this Code also engage in other types of work not described as either clinical or public health practice. These include work in the research, teaching, medical/legal, administrative, managerial, regulatory, and insurance realms. ACOEM believes that the fundamental values that underlie its Code are likely to apply to health professionals practicing in all of these areas. The Code applies equally to professionals who are employees of the entities for which they provide occupational and environmental medical services as to those not so employed.
Fundamental Beliefs and Values
Three fundamental values are widely recognized in the health care professions and serve here as the basis of the ACOEM Code of Ethics. These three values are the primary values of the field of bioethics,1 and are also the three fundamental principles articulated in the influential 2002 Charter on Medical Professionalism.2 The principles that overlay the practitioner-patient relationship apply equally to situations where the relationship is between the occupational/environmental health practitioner and a population.
The first value or belief is that the health professional’s role is primarily to do good for the patient. This is referred to as the “principle of beneficence” in the language of bioethics. In the Charter on Medical Professionalism, this idea is discussed as the “primacy of patient welfare.” The Charter describes this principle as dedication to serving the interest of the patient, with the understanding that altruism contributes to the trust that is central to the physician-patient relationship. Serving the patient’s best interest overrules personal considerations such as business needs, societal expectations, and organizational pressures. This belief dates to ancient codes of medical behavior. This principle (and its obverse, “do no harm”) is also directly applicable to public health practice, as when the “patient” is not an individual, but is a defined population such as a community or a workforce.
Another fundamental bioethical value is that of autonomy. Only in the latter part of the 20th century did people begin to view the physician as an advisor, often one of many, to an autonomous patient. According to this belief, the center of patient care is not in the physician’s office or in the hospital; it is where people live their lives – in the home and in the workplace. It is in the home and the workplace that patients make the daily choices that determine their health. And, this value respects the idea that the individual best understands his or her own best interests.
The third important bioethical value underlying the ACOEM Code is justice. In the language of the Charter on Medical Professionalism it is named “social justice,” and calls upon the medical profession to promote a fair distribution of health resources and to work actively to eliminate discrimination. In the public health arena, this value promotes policies that aspire to protect or improve the health of communities while reducing inequities.
Balancing Bioethical Values
In the world of bioethics, none of the values is viewed as inherently morally preeminent. But, in the practice of clinical medicine, as in the protection of human subjects of research, the value of autonomy has been highly weighted. In recent years, these same ethical values above have been used to develop ethical codes for the practice of public health. In this realm, the wishes and claims of the autonomous individual are often weighted less than beneficence and social justice.3
This Code aspires to give occupational and environmental health professionals crisp guidance on many of its innate ethical challenges, while recognizing that many difficult decisions regarding right and wrong behavior where ethical values may conflict are highly case specific.
Ethical Principle I: An Obligation to Enhance a Safe and Healthy Workplace Environment
Occupational and environmental health professionals engaged in clinical practice have a primary responsibility to the health and safety of the individual in the workplace and the environment. Occupational and environmental health professionals should take affirmative measures to ensure that proper attention is given to the health and safety of the individual.
Occupational and environmental health professionals, as public health professionals, have a fundamental responsibility to the health of worker populations and to public safety. Occupational and environmental health professionals should take affirmative measures for the prevention and amelioration of risks in the workplace and environment that can reasonably be expected to cause disease.
Ethical Principle II: An Obligation to Maintain Ethical Standards
Occupational and environmental health professionals should behave honestly and ethically in all professional relationships.
Occupational and environmental health professionals should actively oppose and strive to correct unethical conduct encountered in professional relationships.
Occupational and environmental health professionals should recognize and acknowledge impairments, including substance-related and mental disorders, in themselves and other occupational health professionals that interfere with the ability to follow this Code and take appropriate measures to ameliorate them. If such problems are not remedied and continue to interfere with the practitioner’s ability to practice ethically, that practitioner must refrain from practice until remediation is accomplished.
Ethical Principle III: An Obligation to Avoid Discrimination
Occupational and environmental health professionals should build a relationship of trust and confidence with the people for whom they provide services. All people with whom occupational health professionals come in contact should be treated in an equitable manner, without any form of discrimination with regard to age, sex, social status, ethnic background, political or religious opinions, the nature of the condition, or the reasons that they need medical interaction. Occupational and environmental health professionals should strive to identify and overcome bias or stereotypes which may affect medical care and decision making both in individual patients and in the populations served.
Ethical Principle IV: An Obligation to Maintain Professional Competence
Occupational and environmental health professionals should maintain individual competence and expertise based on current scientific evidence and technical knowledge. They should remain knowledgeable and engage in life-long learning regarding work, work-related hazards, and the environments of those whom they serve, applying appropriate methods to eliminate or minimize risks and recognizing when to call upon specialized expert advice.
Ethical Principle V: An Obligation to Maintain Patient Confidentiality
Occupational and environmental health professionals should keep confidential all individual medical, health promotion, and health screening information, only releasing such information with proper authorization when required by law, for overriding public health considerations, to other health care professionals according to accepted medical practice, to others at the request of the individual, or when there is reasonable concern about potential endangerment of third parties. Highly sensitive information deserves special protection by the health professional.4
Occupational and environmental health professionals should recognize that employers may be entitled to counsel about an individual’s medical work fitness.
Ethical Principle VI: An Obligation to Advise and Report
Occupational and environmental health professionals should communicate effectively and in a timely manner to an individual all significant observations about the health and health risk of that person and provide advice about interventions available to restore, sustain, and improve health or prevent illness.
Occupational and environmental health professionals, while respecting confidentiality, should report findings and observations of health effects in individuals and populations to those in a position to respond to these observations, including employers, employee representatives, scientific community, and relevant government agencies.
Ethical Principle VII: An Obligation to Address Conflict of Interest
When competing interests interfere with clinical or scientific judgments, patients and public health may be harmed as a result. In order to prevent harm, occupational health practitioners have a duty to ensure ethical conduct regarding conflicts of interest by recognizing, acknowledging, and appropriately addressing any secondary interests that might in reality distort the integrity of judgments or be perceived to do so. As such, a conflict of interest is a prevalent condition, not a behavior – being determined by circumstances, not necessarily actions or outcomes. Conflicts of interest are common. A conflict exists not only when judgment has been clearly influenced, but it also exists when judgment might be influenced or might be perceived to be influenced. That is, a conflict exists before any actual breach of trust, and irrespective of whether a breach of trust actually occurs.
Ethical practice must ensure that harm does not accrue as a result of such conflicts. Conflicts of interest may be addressed in multiple, case-specific manners, including, but not limited to, disclosure, informed waiver, or disengagement from potentially conflicted interaction.
1Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press; 1994.
2The Charter on Medical Professionalism, developed by the Medical Professionalism Project, was published in the Annals of Internal Medicine in 2002 (ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-6.). The full text is available on line at www.annals.org/cgi/content/full/136/3/243. (The charter is the product of several years of work by leaders in the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine.)
3Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11)1776-82.
4Additional guidance can be found in the ACOEM position paper, Confidentiality of Medical Information in the Workplace, available on line at www.acoem.org/guidelines.aspx?id=3538.