Part 1, Chapter 1, Clinical Supervision and Professional Development of the Substance Abuse Counselor: Information You Need to Know
Clinical supervision is emerging as the crucible in which counselors acquire knowledge and skills for the substance abuse treatment profession, providing a bridge between the classroom and the clinic. Supervision is necessary in the substance abuse treatment field to improve client care, develop the professionalism of clinical personnel, and impart and maintain ethical standards in the field. In recent years, especially in the substance abuse field, clinical supervision has become the cornerstone of quality improvement and assurance.
Your role and skill set as a clinical supervisor are distinct from those of counselor and administrator. Quality clinical supervision is founded on a positive supervisor–supervisee relationship that promotes client welfare and the professional development of the supervisee. You are a teacher, coach, consultant, mentor, evaluator, and administrator; you provide support, encouragement, and education to staff while addressing an array of psychological, interpersonal, physical, and spiritual issues of clients. Ultimately, effective clinical supervision ensures that clients are competently served. Supervision ensures that counselors continue to increase their skills, which in turn increases treatment effectiveness, client retention, and staff satisfaction. The clinical supervisor also serves as liaison between administrative and clinical staff.
This TIP focuses primarily on the teaching, coaching, consulting, and mentoring functions of clinical supervisors. Supervision, like substance abuse counseling, is a profession in its own right, with its own theories, practices, and standards. The profession requires knowledgeable, competent, and skillful individuals who are appropriately credentialed both as counselors and supervisors.
This document builds on and makes frequent reference to CSAT’s Technical Assistance Publication (TAP), Competencies for Substance Abuse Treatment Clinical Supervisors (TAP 21-A; CSAT, 2007). The clinical supervision competencies identify those responsibilities and activities that define the work of the clinical supervisor. This TIP provides guidelines and tools for the effective delivery of clinical supervision in substance abuse treatment settings. TAP 21-A is a companion volume to TAP 21, Addiction Counseling Competencies (CSAT, 2006), which is another useful tool in supervision.
The perspective of this TIP is informed by the following definitions of supervision:
“Supervision is a disciplined, tutorial process wherein principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive” (Powell & Brodsky, 2004, p. 11). “Supervision is an intervention provided by a senior member of a profession to a more junior member or members. . . . This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s); monitoring the quality of professional services offered to the clients that she, he, or they see; and serving as a gatekeeper of those who are to enter the particular profession” (Bernard & Goodyear, 2004, p. 8).
Supervision is “a social influence process that occurs over time, in which the supervisor participates with supervisees to ensure quality of clinical care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development. They build teams, create cohesion, resolve conflict, and shape agency culture, while attending to ethical and diversity issues in all aspects of the process. Such supervision is key to both quality improvement and the successful implementation of consensus- and evidence-based practices” (CSAT, 2007, p. 3).
For hundreds of years, many professions have relied on more senior colleagues to guide less experienced professionals in their crafts. This is a new development in the substance abuse field, as clinical supervision was only recently acknowledged as a discrete process with its own concepts and approaches.
As a supervisor to the client, counselor, and organization, the significance of your position is apparent in the following statements:
Organizations have an obligation to ensure quality care and quality improvement of all personnel. The first aim of clinical supervision is to ensure quality services and to protect the welfare of clients.
Supervision is the right of all employees and has a direct impact on workforce development and staff and client retention.
You oversee the clinical functions of staff and have a legal and ethical responsibility to ensure quality care to clients, the professional development of counselors, and maintenance of program policies and procedures.
Clinical supervision is how counselors in the field learn. In concert with classroom education, clinical skills are acquired through practice, observation, feedback, and implementation of the recommendations derived from clinical supervision.
Functions of a Clinical Supervisor
You, the clinical supervisor, wear several important “hats.” You facilitate the integration of counselor self-awareness, theoretical grounding, and development of clinical knowledge and skills; and you improve functional skills and professional practices. These roles often overlap and are fluid within the context of the supervisory relationship. Hence, the supervisor is in a unique position as an advocate for the agency, the counselor, and the client. You are the primary link between administration and front line staff, interpreting and monitoring compliance with agency goals, policies, and procedures and communicating staff and client needs to administrators. Central to the supervisor’s function is the alliance between the supervisor and supervisee (Rigazio-DiGilio, 1997).
As shown in Figure 1, your roles as a clinical supervisor in the context of the supervisory relationship include:
Roles of the Clinical Supervisor
Teacher: Assist in the development of counseling knowledge and skills by identifying learning needs, determining counselor strengths, promoting self-awareness, and transmitting knowledge for practical use and professional growth. Supervisors are teachers, trainers, and professional role models.
Consultant:Bernard and Goodyear (2004) incorporate the supervisory consulting role of case consultation and review, monitoring performance, counseling the counselor regarding job performance, and assessing counselors. In this role, supervisors also provide alternative case conceptualizations, oversight of counselor work to achieve mutually agreed upon goals, and professional gatekeeping for the organization and discipline (e.g., recognizing and addressing counselor impairment).
Coach: In this supportive role, supervisors provide morale building, assess strengths and needs, suggest varying clinical approaches, model, cheerlead, and prevent burnout. For entry-level counselors, the supportive function is critical.
Mentor/Role Model: The experienced supervisor mentors and teaches the supervisee through role modeling, facilitates the counselor’s overall professional development and sense of professional identity, and trains the next generation of supervisors.
Central Principles of Clinical Supervision
The Consensus Panel for this TIP has identified central principles of clinical supervision. Although the Panel recognizes that clinical supervision can initially be a costly undertaking for many financially strapped programs, the Panel believes that ultimately clinical supervision is a cost-saving process. Clinical supervision enhances the quality of client care; improves efficiency of counselors in direct and indirect services; increases workforce satisfaction, professionalization, and retention (see vignette 8 in chapter 2); and ensures that services provided to the public uphold legal mandates and ethical standards of the profession.
The central principles identified by the Consensus Panel are:
Clinical supervision is an essential part of all clinical programs. Clinical supervision is a central organizing activity that integrates the program mission, goals, and treatment philosophy with clinical theory and evidence-based practices (EBPs). The primary reasons for clinical supervision are to ensure (1) quality client care, and (2) clinical staff continue professional development in a systematic and planned manner. In substance abuse treatment, clinical supervision is the primary means of determining the quality of care provided.
Clinical supervision enhances staff retention and morale. Staff turnover and workforce development are major concerns in the substance abuse treatment field. Clinical supervision is a primary means of improving workforce retention and job satisfaction (see, for example, Roche, Todd, & O’Connor, 2007).
Every clinician, regardless of level of skill and experience, needs and has a right to clinical supervision. In addition, supervisors need and have a right to supervision of their supervision. Supervision needs to be tailored to the knowledge base, skills, experience, and assignment of each counselor. All staff need supervision, but the frequency and intensity of the oversight and training will depend on the role, skill level, and competence of the individual. The benefits that come with years of experience are enhanced by quality clinical supervision.
Clinical supervision needs the full support of agency administrators. Just as treatment programs want clients to be in an atmosphere of growth and openness to new ideas, counselors should be in an environment where learning and professional development and opportunities are valued and provided for all staff.
The supervisory relationship is the crucible in which ethical practice is developed and reinforced. The supervisor needs to model sound ethical and legal practice in the supervisory relationship. This is where issues of ethical practice arise and can be addressed. This is where ethical practice is translated from a concept to a set of behaviors. Through supervision, clinicians can develop a process of ethical decisionmaking and use this process as they encounter new situations.
Clinical supervision is a skill in and of itself that has to be developed. Good counselors tend to be promoted into supervisory positions with the assumption that they have the requisite skills to provide professional clinical supervision. However, clinical supervisors need a different role orientation toward both program and client goals and a knowledge base to complement a new set of skills. Programs need to increase their capacity to develop good supervisors.
Clinical supervision in substance abuse treatment most often requires balancing administrative and clinical supervision tasks. Sometimes these roles are complementary and sometimes they conflict. Often the supervisor feels caught between the two roles. Administrators need to support the integration and differentiation of the roles to promote the efficacy of the clinical supervisor. (See Part 2.)
Culture and other contextual variables influence the supervision process; supervisors need to continually strive for cultural competence. Supervisors require cultural competence at several levels. Cultural competence involves the counselor’s response to clients, the supervisor’s response to counselors, and the program’s response to the cultural needs of the diverse community it serves. Since supervisors are in a position to serve as catalysts for change, they need to develop proficiency in addressing the needs of diverse clients and personnel.
Successful implementation of EBPs requires ongoing supervision. Supervisors have a role in determining which specific EBPs are relevant for an organization’s clients (Lindbloom, Ten Eyck, & Gallon, 2005). Supervisors ensure that EBPs are successfully integrated into ongoing programmatic activities by training, encouraging, and monitoring counselors. Excellence in clinical supervision should provide greater adherence to the EBP model. Because State funding agencies now often require substance abuse treatment organizations to provide EBPs, supervision becomes even more important.
Supervisors have the responsibility to be gatekeepers for the profession. Supervisors are responsible for maintaining professional standards, recognizing and addressing impairment, and safeguarding the welfare of clients. More than anyone else in an agency, supervisors can observe counselor behavior and respond promptly to potential problems, including counseling some individuals out of the field because they are ill-suited to the profession. This “gatekeeping” function is especially important for supervisors who act as field evaluators for practicum students prior to their entering the profession. Finally, supervisors also fulfill a gatekeeper role in performance evaluation and in providing formal recommendations to training institutions and credentialing bodies.
Clinical supervision should involve direct observation methods. Direct observation should be the standard in the field because it is one of the most effective ways of building skills, monitoring counselor performance, and ensuring quality care. Supervisors require training in methods of direct observation, and administrators need to provide resources for implementing direct observation. Although small substance abuse agencies might not have the resources for one-way mirrors or videotaping equipment, other direct observation methods can be employed (see the section on methods of observation, pp. 20–24).
Guidelines for New Supervisors
Congratulations on your appointment as a supervisor! By now you might be asking yourself a few questions: What have I done? Was this a good career decision? There are many changes ahead. If you have been promoted from within, you’ll encounter even more hurdles and issues. First, it is important to face that your life has changed. You might experience the loss of friendship of peers. You might feel that you knew what to do as a counselor, but feel totally lost with your new responsibilities (see vignette 6 in chapter 2). You might feel less effective in your new role. Supervision can be an emotionally draining experience, as you now have to work with more staff-related interpersonal and human resources issues.
Before your promotion to clinical supervisor, you might have felt confidence in your clinical skills. Now you might feel unprepared and wonder if you need a training course for your new role. If you feel this way, you’re right. Although you are a good counselor, you do not necessarily possess all the skills needed to be a good supervisor. Your new role requires a new body of knowledge and different skills, along with the ability to use your clinical skills in a different way. Be confident that you will acquire these skills over time (see the Resources section, p. 34) and that you made the right decision to accept your new position.
Suggestions for new supervisors:
Quickly learn the organization’s policies and procedures and human resources procedures (e.g., hiring and firing, affirmative action requirements, format for conducting meetings, giving feedback, and making evaluations). Seek out this information as soon as possible through the human resources department or other resources within the organization.
Ask for a period of 3 months to allow you to learn about your new role. During this period, do not make any changes in policies and procedures but use this time to find your managerial voice and decisionmaking style.
Take time to learn about your supervisees, their career goals, interests, developmental objectives, and perceived strengths.
Work to establish a contractual relationship with supervisees, with clear goals and methods of supervision.
Learn methods to help staff reduce stress, address competing priorities, resolve staff conflict, and other interpersonal issues in the workplace.
Obtain training in supervisory procedures and methods.
Find a mentor, either internal or external to the organization.
Shadow a supervisor you respect who can help you learn the ropes of your new job.
Ask often and as many people as possible, “How am I doing?” and “How can I improve my performance as a clinical supervisor?”
Ask for regular, weekly meetings with your administrator for training and instruction.
Seek supervision of your supervision.
Problems and Resources
As a supervisor, you may encounter a broad array of issues and concerns, ranging from working within a system that does not fully support clinical supervision to working with resistant staff. A comment often heard in supervision training sessions is “My boss should be here to learn what is expected in supervision,” or “This will never work in my agency’s bureaucracy. They only support billable activities.” The work setting is where you apply the principles and practices of supervision and where organizations are driven by demands, such as financial solvency, profit, census, accreditation, and concerns over litigation. Therefore, you will need to be practical when beginning your new role as a supervisor: determine how you can make this work within your unique work environment.
Working With Staff Who Are Resistant to Supervision
Some of your supervisees may have been in the field longer than you have and see no need for supervision. Other counselors, having completed their graduate training, do not believe they need further supervision, especially not from a supervisor who might have less formal academic education than they have. Other resistance might come from ageism, sexism, racism, or classism. Particular to the field of substance abuse treatment may be the tension between those who believe that recovery from substance abuse is necessary for this counseling work and those who do not believe this to be true.
In addressing resistance, you must be clear regarding what your supervision program entails and must consistently communicate your goals and expectations to staff. To resolve defensiveness and engage your supervisees, you must also honor the resistance and acknowledge their concerns. Abandon trying to push the supervisee too far, too fast. Resistance is an expression of ambivalence about change and not a personality defect of the counselor. Instead of arguing with or exhorting staff, sympathize with their concerns, saying, “I understand this is difficult. How are we going to resolve these issues?”
When counselors respond defensively or reject directions from you, try to understand the origins of their defensiveness and to address their resistance. Self-disclosure by the supervisor about experiences as a supervisee, when appropriately used, may be helpful in dealing with defensive, anxious, fearful, or resistant staff. Work to establish a healthy, positive supervisory alliance with staff. Because many substance abuse counselors have not been exposed to clinical supervision, you may need to train and orient the staff to the concept and why it is important for your agency.
Things a New Supervisor Should Know
Eight truths a beginning supervisor should commit to memory are listed below:
The reason for supervision is to ensure quality client care. As stated throughout this TIP, the primary goal of clinical supervision is to protect the welfare of the client and ensure the integrity of clinical services.
Supervision is all about the relationship. As in counseling, developing the alliance between the counselor and the supervisor is the key to good supervision.
Culture and ethics influence all supervisory interactions. Contextual factors, culture, race, and ethnicity all affect the nature of the supervisory relationship. Some models of supervision (e.g., Holloway, 1995) have been built primarily around the role of context and culture in shaping supervision.
Be human and have a sense of humor. As role models, you need to show that everyone makes mistakes and can admit to and learn from these mistakes.
Rely first on direct observation of your counselors and give specific feedback. The best way to determine a counselor’s skills is to observe him or her and to receive input from the clients about their perceptions of the counseling relationship.
Have and practice a model of counseling and of supervision; have a sense of purpose. Before you can teach a supervisee knowledge and skills, you must first know the philosophical and theoretical foundations on which you, as a supervisor, stand. Counselors need to know what they are going to learn from you, based on your model of counseling and supervision.
Make time to take care of yourself spiritually, emotionally, mentally, and physically. Again, as role models, counselors are watching your behavior. Do you “walk the talk” of self-care?
You have a unique position as an advocate for the agency, the counselor, and the client. As a supervisor, you have a wonderful opportunity to assist in the skill and professional development of your staff, advocating for the best interests of the supervisee, the client, and your organization.
Models of Clinical Supervision
You may never have thought about your model of supervision. However, it is a fundamental premise of this TIP that you need to work from a defined model of supervision and have a sense of purpose in your oversight role. Four supervisory orientations seem particularly relevant. They include:
Competency-based models (e.g., microtraining, the Discrimination Model [Bernard & Goodyear, 2004], and the Task-Oriented Model [Mead, 1990], focus primarily on the skills and learning needs of the supervisee and on setting goals that are specific, measurable, attainable, realistic, and timely (SMART). They construct and implement strategies to accomplish these goals. The key strategies of competency-based models include applying social learning principles (e.g., modeling role reversal, role playing, and practice), using demonstrations, and using various supervisory functions (teaching, consulting, and counseling).
Treatment-based supervision models train to a particular theoretical approach to counseling, incorporating EBPs into supervision and seeking fidelity and adaptation to the theoretical model. Motivational interviewing, cognitive–behavioral therapy, and psychodynamic psychotherapy are three examples. These models emphasize the counselor’s strengths, seek the supervisee’s understanding of the theory and model taught, and incorporate the approaches and techniques of the model. The majority of these models begin with articulating their treatment approach and describing their supervision model, based upon that approach.
Developmental models, such as Stoltenberg and Delworth (1987), understand that each counselor goes through different stages of development and recognize that movement through these stages is not always linear and can be affected by changes in assignment, setting, and population served. (The developmental stages of counselors and supervisors are described in detail below).
Integrated models, including the Blended Model, begin with the style of leadership and articulate a model of treatment, incorporate descriptive dimensions of supervision (see below), and address contextual and developmental dimensions into supervision. They address both skill and competency development and affective issues, based on the unique needs of the supervisee and supervisor. Finally, integrated models seek to incorporate EBPs into counseling and supervision.
In all models of supervision, it is helpful to identify culturally or contextually centered models or approaches and find ways of tailoring the models to specific cultural and diversity factors. Issues to consider are:
Explicitly addressing diversity of supervisees (e.g., race, ethnicity, gender, age, sexual orientation) and the specific factors associated with these types of diversity;
Explicitly involving supervisees’ concerns related to particular client diversity (e.g., those whose culture, gender, sexual orientation, and other attributes differ from those of the supervisee) and addressing specific factors associated with these types of diversity; and
Explicitly addressing supervisees’ issues related to effectively navigating services in intercultural communities and effectively networking with agencies and institutions.
It is important to identify your model of counseling and your beliefs about change, and to articulate a workable approach to supervision that fits the model of counseling you use. Theories are conceptual frameworks that enable you to make sense of and organize your counseling and supervision and to focus on the most salient aspects of a counselor’s practice. You may find some of the questions below to be relevant to both supervision and counseling. The answers to these questions influence both how you supervise and how the counselors you supervise work:
What are your beliefs about how people change in both treatment and clinical supervision?
What factors are important in treatment and clinical supervision?
What universal principles apply in supervision and counseling and which are unique to clinical supervision?
What conceptual frameworks of counseling do you use (for instance, cognitive–behavioral therapy, 12-Step facilitation, psychodynamic, behavioral)?
What are the key variables that affect outcomes? (Campbell, 2000)
According to Bernard and Goodyear (2004) and Powell and Brodsky (2004), the qualities of a good model of clinical supervision are:
Rooted in the individual, beginning with the supervisor’s self, style, and approach to leadership.
Precise, clear, and consistent.
Comprehensive, using current scientific and evidence-based practices.
Operational and practical, providing specific concepts and practices in clear, useful, and measurable terms.
Outcome-oriented to improve counselor competence; make work manageable; create a sense of mastery and growth for the counselor; and address the needs of the organization, the supervisor, the supervisee, and the client.
Finally, it is imperative to recognize that, whatever model you adopt, it needs to be rooted in the learning and developmental needs of the supervisee, the specific needs of the clients they serve, the goals of the agency in which you work, and in the ethical and legal boundaries of practice. These four variables define the context in which effective supervision can take place.
Developmental Stages of Counselors
Counselors are at different stages of professional development. Thus, regardless of the model of supervision you choose, you must take into account the supervisee’s level of training, experience, and proficiency. Different supervisory approaches are appropriate for counselors at different stages of development. An understanding of the supervisee’s (and supervisor’s) developmental needs is an essential ingredient for any model of supervision.
Various paradigms or classifications of developmental stages of clinicians have been developed (Ivey, 1997; Rigazio-DiGilio, 1997; Skolvolt & Ronnestrand, 1992; Todd and Storn, 1997). This TIP has adopted the Integrated Developmental Model (IDM) of Stoltenberg, McNeill, and Delworth (1998) (see figure 2, p. 10). This schema uses a three-stage approach. The three stages of development have different characteristics and appropriate supervisory methods. Further application of the IDM to the substance abuse field is needed. (For additional information, see Anderson, 2001.)
It is important to keep in mind several general cautions and principles about counselor development, including:
There is a beginning but not an end point for learning clinical skills; be careful of counselors who think they “know it all.”
Take into account the individual learning styles and personalities of your supervisees and fit the supervisory approach to the developmental stage of each counselor.
There is a logical sequence to development, although it is not always predictable or rigid; some counselors may have been in the field for years but remain at an early stage of professional development, whereas others may progress quickly through the stages.
Counselors at an advanced developmental level have different learning needs and require different supervisory approaches from those at Level 1; and
The developmental level can be applied for different aspects of a counselor’s overall competence (e.g., Level 2 mastery for individual counseling and Level 1 for couples counseling).
Developmental Stages of Supervisors
Just as counselors go through stages of development, so do supervisors. The developmental model presented in figure 3 provides a framework to explain why supervisors act as they do, depending on their developmental stage. It would be expected that someone new to supervision would be at a Level 1 as a supervisor. However, supervisors should be at least at the second or third stage of counselor development. If a newly appointed supervisor is still at Level 1 as a counselor, he or she will have little to offer to more seasoned supervisees.
Cultural and Contextual Factors
Culture is one of the major contextual factors that influence supervisory interactions. Other contextual variables include race, ethnicity, age, gender, discipline, academic background, religious and spiritual practices, sexual orientation, disability, and recovery versus non-recovery status. The relevant variables in the supervisory relationship occur in the context of the supervisor, supervisee, client, and the setting in which supervision occurs. More care should be taken to:
Identify the competencies necessary for substance abuse counselors to work with diverse individuals and navigate intercultural communities.
Identify methods for supervisors to assist counselors in developing these competencies.
Provide evaluation criteria for supervisors to determine whether their supervisees have met minimal competency standards for effective and relevant practice.
Models of supervision have been strongly influenced by contextual variables and their influence on the supervisory relationship and process, such as Holloway’s Systems Model (1995) and Constantine’s Multicultural Model (2003).
The competencies listed in TAP 21-A reflect the importance of culture in supervision (CSAT, 2007). The Counselor Development domain encourages self-examination of attitudes toward culture and other contextual variables. The Supervisory Alliance domain promotes attention to these variables in the supervisory relationship. (See also the planned TIP, Improving Cultural Competence in Substance Abuse Counseling [CSAT, in development b].)
Cultural competence “refers to the ability to honor and respect the beliefs, language, interpersonal styles, and behaviors of individuals and families receiving services, as well as staff who are providing such services. Cultural competence is a dynamic, ongoing, developmental process that requires a commitment and is achieved over time” (U.S. Department of Health and Human Services, 2003, p. 12). Culture shapes belief systems, particularly concerning issues related to mental health and substance abuse, as well as the manifestation of symptoms, relational styles, and coping patterns.
There are three levels of cultural consideration for the supervisory process: the issue of the culture of the client being served and the culture of the counselor in supervision. Holloway (1995) emphasizes the cultural issues of the agency, the geographic environment of the organization, and many other contextual factors. Specifically, there are three important areas in which cultural and contextual factors play a key role in supervision: in building the supervisory relationship or working alliance, in addressing the specific needs of the client, and in building supervisee competence and ability. It is your responsibility to address your supervisees’ beliefs, attitudes, and biases about cultural and contextual variables to advance their professional development and promote quality client care.
Becoming culturally competent and able to integrate other contextual variables into supervision is a complex, long-term process. Cross (1989) has identified several stages on a continuum of becoming culturally competent (see figure 4).
Continuum of Cultural Competence
Although you may never have had specialized training in multicultural counseling, some of your supervisees may have (see Constantine, 2003). Regardless, it is your responsibility to help supervisees build on the cultural competence skills they possess as well as to focus on their cultural competence deficits. It is important to initiate discussion of issues of culture, race, gender, sexual orientation, and the like in supervision to model the kinds of discussion you would like counselors to have with their clients. If these issues are not addressed in supervision, counselors may come to believe that it is inappropriate to discuss them with clients and have no idea how such dialog might proceed. These discussions prevent misunderstandings with supervisees based on cultural or other factors. Another benefit from these discussions is that counselors will eventually achieve some level of comfort in talking about culture, race, ethnicity, and diversity issues.
If you haven’t done it as a counselor, early in your tenure as a supervisor you will want to examine your culturally influenced values, attitudes, experiences, and practices and to consider what effects they have on your dealings with supervisees and clients. Counselors should undergo a similar review as preparation for when they have clients of a culture different from their own. Some questions to keep in mind are:
What did you think when you saw the supervisee’s last name?
What did you think when the supervisee said his or her culture is X, when yours is Y?
How did you feel about this difference?
What did you do in response to this difference?
Constantine (2003) suggests that supervisors can use the following questions with supervisees:
What demographic variables do you use to identify yourself?
What worldviews (e.g., values, assumptions, and biases) do you bring to supervision based on your cultural identities?
What struggles and challenges have you faced working with clients who were from different cultures than your own?
Beyond self-examination, supervisors will want continuing education classes, workshops, and conferences that address cultural competence and other contextual factors. Community resources, such as community leaders, elders, and healers can contribute to your understanding of the culture your organization serves. Finally, supervisors (and counselors) should participate in multicultural activities, such as community events, discussion groups, religious festivals, and other ceremonies.
The supervisory relationship includes an inherent power differential, and it is important to pay attention to this disparity, particularly when the supervisee and the supervisor are from different cultural groups. A potential for the misuse of that power exists at all times but especially when working with supervisees and clients within multicultural contexts. When the supervisee is from a minority population and the supervisor is from a majority population, the differential can be exaggerated. You will want to prevent institutional discrimination from affecting the quality of supervision. The same is true when the supervisee is gay and the supervisor is heterosexual, or the counselor is non-degreed and the supervisor has an advanced degree, or a female supervisee with a male supervisor, and so on. In the reverse situations, where the supervisor is from the minority group and the supervisee from the majority group, the difference should be discussed as well.
Ethical and Legal Issues
You are the organization’s gatekeeper for ethical and legal issues. First, you are responsible for upholding the highest standards of ethical, legal, and moral practices and for serving as a model of practice to staff. Further, you should be aware of and respond to ethical concerns. Part of your job is to help integrate solutions to everyday legal and ethical issues into clinical practice.
Some of the underlying assumptions of incorporating ethical issues into clinical supervision include:
Ethical decisionmaking is a continuous, active process.
Ethical standards are not a cookbook. They tell you what to do, not always how.
Each situation is unique. Therefore, it is imperative that all personnel learn how to “think ethically” and how to make sound legal and ethical decisions.
The most complex ethical issues arise in the context of two ethical behaviors that conflict; for instance, when a counselor wants to respect the privacy and confidentiality of a client, but it is in the client’s best interest for the counselor to contact someone else about his or her care.
Therapy is conducted by fallible beings; people make mistakes—hopefully, minor ones.
Sometimes the answers to ethical and legal questions are elusive. Ask a dozen people, and you’ll likely get twelve different points of view.
Helpful resources on legal and ethical issues for supervisors include Beauchamp and Childress (2001); Falvey (2002b); Gutheil and Brodsky (2008); Pope, Sonne, and Greene (2006); and Reamer (2006).
Legal and ethical issues that are critical to clinical supervisors include (1) vicarious liability (or respondeat superior), (2) dual relationships and boundary concerns, (4) informed consent, (5) confidentiality, and (6) supervisor ethics.
Direct Versus Vicarious Liability
An important distinction needs to be made between direct and vicarious liability. Direct liability of the supervisor might include dereliction of supervisory responsibility, such as “not making a reasonable effort to supervise” (defined below). In vicarious liability, a supervisor can be held liable for damages incurred as a result of negligence in the supervision process. Examples of negligence include providing inappropriate advice to a counselor about a client (for instance, discouraging a counselor from conducting a suicide screen on a depressed client), failure to listen carefully to a supervisee’s comments about a client, and the assignment of clinical tasks to inadequately trained counselors. The key legal question is: “Did the supervisor conduct him- or herself in a way that would be reasonable for someone in his position?” or “Did the supervisor make a reasonable effort to supervise?” A generally accepted time standard for a “reasonable effort to supervise” in the behavioral health field is 1 hour of supervision for every 20–40 hours of clinical services. Of course, other variables (such as the quality and content of clinical supervision sessions) also play a role in a reasonable effort to supervise.
Supervisory vulnerability increases when the counselor has been assigned too many clients, when there is no direct observation of a counselor’s clinical work, when staff are inexperienced or poorly trained for assigned tasks, and when a supervisor is not involved or not available to aid the clinical staff. In legal texts, vicarious liability is referred to as “respondeat superior.”
Dual Relationships and Boundary Issues
Dual relationships can occur at two levels: between supervisors and supervisees and between counselors and clients. You have a mandate to help your supervisees recognize and manage boundary issues. A dual relationship occurs in supervision when a supervisor has a primary professional role with a supervisee and, at an earlier time, simultaneously or later, engages in another relationship with the supervisee that transcends the professional relationship. Examples of dual relationships in supervision include providing therapy for a current or former supervisee, developing an emotional relationship with a supervisee or former supervisee, and becoming an Alcoholics Anonymous sponsor for a former supervisee. Obviously, there are varying degrees of harm or potential harm that might occur as a result of dual relationships, and some negative effects of dual relationships might not be apparent until later.
Therefore, firm, always-or-never rules aren’t applicable. You have the responsibility of weighing with the counselor the anticipated and unanticipated effects of dual relationships, helping the supervisee’s self-reflective awareness when boundaries become blurred, when he or she is getting close to a dual relationship, or when he or she is crossing the line in the clinical relationship.
Exploring dual relationship issues with counselors in clinical supervision can raise its own professional dilemmas. For instance, clinical supervision involves unequal status, power, and expertise between a supervisor and supervisee. Being the evaluator of a counselor’s performance and gatekeeper for training programs or credentialing bodies also might involve a dual relationship. Further, supervision can have therapy-like qualities as you explore countertransferential issues with supervisees, and there is an expectation of professional growth and self-exploration. What makes a dual relationship unethical in supervision is the abusive use of power by either party, the likelihood that the relationship will impair or injure the supervisor’s or supervisee’s judgment, and the risk of exploitation (see vignette 3 in chapter 2).
The most common basis for legal action against counselors (20 percent of claims) and the most frequently heard complaint by certification boards against counselors (35 percent) is some form of boundary violation or sexual impropriety (Falvey, 2002b). (See the discussion of transference and countertransference on pp. 25–26.)
Codes of ethics for most professions clearly advise that dual relationships between counselors and clients should be avoided. Dual relationships between counselors and supervisors are also a concern and are addressed in the substance abuse counselor codes and those of other professions as well. Problematic dual relationships between supervisees and supervisors might include intimate relationships (sexual and non-sexual) and therapeutic relationships, wherein the supervisor becomes the counselor’s therapist. Sexual involvement between the supervisor and supervisee can include sexual attraction, harassment, consensual (but hidden) sexual relationships, or intimate romantic relationships. Other common boundary issues include asking the supervisee to do favors, providing preferential treatment, socializing outside the work setting, and using emotional abuse to enforce power. It is imperative that all parties understand what constitutes a dual relationship between supervisor and supervisee and avoid these dual relationships. Sexual relationships between supervisors and supervisees and counselors and clients occur far more frequently than one might realize (Falvey, 2002b). In many States, they constitute a legal transgression as well as an ethical violation.
The decision tree presented in figure 5 (p. 16) indicates how a supervisor might manage a situation where he or she is concerned about a possible ethical or legal violation by a counselor.
Deciding How to To Address Potential Legal or Ethical Violations
Informed consent is key to protecting the counselor and/or supervisor from legal concerns, requiring the recipient of any service or intervention to be sufficiently aware of what is to happen, and of the potential risks and alternative approaches, so that the person can make an informed and intelligent decision about participating in that service. The supervisor must inform the supervisee about the process of supervision, the feedback and evaluation criteria, and other expectations of supervision. The supervision contract should clearly spell out these issues. Supervisors must ensure that the supervisee has informed the client about the parameters of counseling and supervision (such as the use of live observation, video- or audiotaping). A sample template for informed consent is provided in Part 2, chapter 2 (p. 106).
In supervision, regardless of whether there is a written or verbal contract between the supervisor and supervisee, there is an implied contract and duty of care because of the supervisor’s vicarious liability. Informed consent and concerns for confidentiality should occur at three levels: client consent to treatment, client consent to supervision of the case, and supervisee consent to supervision (Bernard & Goodyear, 2004). In addition, there is an implied consent and commitment to confidentiality by supervisors to assume their supervisory responsibilities and institutional consent to comply with legal and ethical parameters of supervision. (See also the Code of Ethics of the Association for Counselor Education and Supervision [ACES], available online at http://www.acesonline.net/ethical_guidelines.asp).
With informed consent and confidentiality comes a duty not to disclose certain relational communication. Limits of confidentiality of supervision session content should be stated in all organizational contracts with training institutions and credentialing bodies. Criteria for waiving client and supervisee privilege should be stated in institutional policies and discipline-specific codes of ethics and clarified by advice of legal counsel and the courts. Because standards of confidentiality are determined by State legal and legislative systems, it is prudent for supervisors to consult with an attorney to determine the State codes of confidentiality and clinical privileging.
In the substance abuse treatment field, confidentiality for clients is clearly defined by Federal law: 42 CFR, Part 2 and the Health Insurance Portability and Accountability Act (HIPAA). Key information is available at http://www.hipaa.samhsa.gov. Supervisors need to train counselors in confidentiality regulations and to adequately document their supervision, including discussions and directives, especially relating to duty-to-warn situations. Supervisors need to ensure that counselors provide clients with appropriate duty-to-warn information early in the counseling process and inform clients of the limits of confidentiality as part of the agency’s informed consent procedures.
Under duty-to-warn requirements (e.g., child abuse, suicidal or homicidal ideation), supervisors need to be aware of and take action as soon as possible in situations in which confidentiality may need to be waived. Organizations should have a policy stating how clinical crises will be handled (Falvey, 2002b). What mechanisms are in place for responding to crises? In what timeframe will a supervisor be notified of a crisis situation? Supervisors must document all discussions with counselors concerning duty-to-warn and crises. At the onset of supervision, supervisors should ask counselors if there are any duty-to-warn issues of which the supervisor should be informed.
New technology brings new confidentiality concerns. Websites now dispense information about substance abuse treatment and provide counseling services. With the growth in online counseling and supervision, the following concerns emerge: (a) how to maintain confidentiality of information, (b) how to ensure the competence and qualifications of counselors providing online services, and (c) how to establish reporting requirements and duty to warn when services are conducted across State and international boundaries. New standards will need to be written to address these issues. (The National Board for Certified Counselors has guidelines for counseling by Internet at http://www.nbcc.org/AssetManagerFiles/ethics/internetcounseling.pdf.)
In general, supervisors adhere to the same standards and ethics as substance abuse counselors with regard to dual relationship and other boundary violations. Supervisors will:
Uphold the highest professional standards of the field.
Seek professional help (outside the work setting) when personal issues interfere with their clinical and/or supervisory functioning.
Conduct themselves in a manner that models and sets an example for agency mission, vision, philosophy, wellness, recovery, and consumer satisfaction.
Reinforce zero tolerance for interactions that are not professional, courteous, and compassionate.
Treat supervisees, colleagues, peers, and clients with dignity, respect, and honesty.
Adhere to the standards and regulations of confidentiality as dictated by the field. This applies to the supervisory as well as the counseling relationship.
The goal of supervision is to ensure quality care for the client, which entails monitoring the clinical performance of staff. Your first step is to educate supervisees in what to expect from clinical supervision. Once the functions of supervision are clear, you should regularly evaluate the counselor’s progress in meeting organizational and clinical goals as set forth in an Individual Development Plan (IDP) (see the section on IDPs below). As clients have an individual treatment plan, counselors also need a plan to promote skill development.
Behavioral Contracting in Supervision
Among the first tasks in supervision is to establish a contract for supervision that outlines realistic accountability for both yourself and your supervisee. The contract should be in writing and should include the purpose, goals, and objectives of supervision; the context in which supervision is provided; ethical and institutional policies that guide supervision and clinical practices; the criteria and methods of evaluation and outcome measures; the duties and responsibilities of the supervisor and supervisee; procedural considerations (including the format for taping and opportunities for live observation); and the supervisee’s scope of practice and competence. The contract for supervision should state the rewards for fulfillment of the contract (such as clinical privileges or increased compensation), the length of supervision sessions, and sanctions for noncompliance by either the supervisee or supervisor. The agreement should be compatible with the developmental needs of the supervisee and address the obstacles to progress (lack of time, performance anxiety, resource limitations). Once a behavioral contract has been established, the next step is to develop an IDP.
Individual Development Plan
The IDP is a detailed plan for supervision that includes the goals that you and the counselor wish to address over a certain time period (perhaps 3 months). Each of you should sign and keep a copy of the IDP for your records. The goals are normally stated in terms of skills the counselor wishes to build or professional resources the counselor wishes to develop. These skills and resources are generally oriented to the counselor’s job in the program or activities that would help the counselor develop professionally. The IDP should specify the timelines for change, the observation methods that will be employed, expectations for the supervisee and the supervisor, the evaluation procedures that will be employed, and the activities that will be expected to improve knowledge and skills. An example of an IDP is provided in Part 2, chapter 2 (p. 122).
As a supervisor, you should have your own IDP, based on the supervisory competencies listed in TAP 21-A (CSAT, 2007), that addresses your training goals. This IDP can be developed in cooperation with your supervisor, or in external supervision, peer input, academic advisement, or mentorship.
Evaluation of Counselors
Supervision inherently involves evaluation, building on a collaborative relationship between you and the counselor. Evaluation may not be easy for some supervisors. Although everyone wants to know how they are doing, counselors are not always comfortable asking for feedback. And, as most supervisors prefer to be liked, you may have difficulty giving clear, concise, and accurate evaluations to staff.
The two types of evaluation are formative and summative. A formative evaluation is an ongoing status report of the counselor’s skill development, exploring the questions “Are we addressing the skills or competencies you want to focus on?” and “How do we assess your current knowledge and skills and areas for growth and development?”
Summative evaluation is a more formal rating of the counselor’s overall job performance, fitness for the job, and job rating. It answers the question, “How does the counselor measure up?” Typically, summative evaluations are done annually and focus on the counselor’s overall strengths, limitations, and areas for future improvement.
It should be acknowledged that supervision is inherently an unequal relationship. In most cases, the supervisor has positional power over the counselor. Therefore, it is important to establish clarity of purpose and a positive context for evaluation. Procedures should be spelled out in advance, and the evaluation process should be mutual, flexible, and continuous. The evaluation process inevitably brings up supervisee anxiety and defensiveness that need to be addressed openly. It is also important to note that each individual counselor will react differently to feedback; some will be more open to the process than others.
There has been considerable research on supervisory evaluation, with these findings:
The supervisee’s confidence and efficacy are correlated with the quality and quantity of feedback the supervisor gives to the supervisee (Bernard & Goodyear, 2004).
Ratings of skills are highly variable between supervisors, and often the supervisor’s and supervisee’s ratings differ or conflict (Eby, 2007).
Good feedback is provided frequently, clearly, and consistently and is SMART (specific, measurable, attainable, realistic, and timely) (Powell & Brodsky, 2004).
Direct observation of the counselor’s work is the desired form of input for the supervisor. Although direct observation has historically been the exception in substance abuse counseling, ethical and legal considerations and evidence support that direct observation as preferable. The least desirable feedback is unannounced observation by supervisors followed by vague, perfunctory, indirect, or hurtful delivery (Powell & Brodsky, 2004).
Clients are often the best assessors of the skills of the counselor. Supervisors should routinely seek input from the clients as to the outcome of treatment. The method of seeking input should be discussed in the initial supervisory sessions and be part of the supervision contract. In a residential substance abuse treatment program, you might regularly meet with clients after sessions to discuss how they are doing, how effective the counseling is, and the quality of the therapeutic alliance with the counselor. (For examples of client satisfaction or input forms, search for Client-Directed Outcome-Informed Treatment and Training Materials at http://www.talkingcure.com.)
Before formative evaluations begin, methods of evaluating performance should be discussed, clarified in the initial sessions, and included in the initial contract so that there will be no surprises. Formative evaluations should focus on changeable behavior and, whenever possible, be separate from the overall annual performance appraisal process. To determine the counselor’s skill development, you should use written competency tools, direct observation, counselor self-assessments, client evaluations, work samples (files and charts), and peer assessments. Examples of work samples and peer assessments can be found in Bernard and Goodyear (2004)
CODES AND GUIDELINES
Range of Purposes Behind Codes
Codes of ethics in the professions serve numerous purposes. At the level of the profession itself, codes document the standards according to which the profession can be held accountable for the conduct of its members. Further, because society relegates control for many of the professions to the professional organizations themselves, the professions have developed codes to provide the basis of self-regulation (Soskolne 1989). At the level of the individual professional, codes can provide a practical guide to members of the profession who might be experiencing a moral or ethical dilemma concerning their professional conduct in a particular circumstance. Where a professional finds himself or herself in a state of moral or ethical tension, it is self-evident that codes can be helpful in providing counsel.
The existence of a code provides the basis of a profession�s ethics programme of activity designed to instil ethical standards among its membership (Gellermann, Frankel and Ladenson 1990; Hall 1993). Revisions to the code can be considered through grass-roots individual membership input at organizational meetings, workshops and conferences. This ongoing discussion of issues and concerns constitutes a review process ensuring that any code remains sensitive to changing social values. Professions depending for their sustenance on public support thereby improve their likelihood of remaining publicly accountable and relevant (Glick and Shamoo 1993).
Codes could assist professionals being charged with malpractice and perhaps even in litigation. Demonstrated adherence to one�s professional code would likely be deemed indicative of adherence to standards of practice consistent with professional norms. If such practice were to have resulted in harm, the code-abiding individual professional would be less likely to be found guilty of having committed a wrong. However, based on the principle of trust (Pellegrino, Veatch and Langan 1991), the public has the expectation that the best possible professional judgement will be exercised in the public interest. Where the physician-patient relationship is concerned, the patient has the right under the principle of trust to expect that his or her interests will be best served. However, an ethical tension arises when the public good is potentially harmed in circumstances where the individual patient�s best interests are being served. In such circumstances, it is the public good that will usually need to take precedence over that of the individual. Regardless, codes provide no substitute for legal liability dimensions of conduct for which government has enacted laws to protect the public interest (Cohen 1982).
Weight and Intent of Codes
Codes do have associated with them the notion of statutory force, implying the ability for their enforcement through the administering of some type of disciplinary action. Indeed, the notions of accountability and self-regulation referred to above have associated with them some sense of control (minimally, peer pressure; maximally, the removal of licence to practice) that can be exercised over the members of the profession by the professional organization itself. Because of this, some professional organizations have preferred to avoid these connotations associated with codes and opt rather for �guidelines�. The latter emphasize guidance with fewer implications for enforcement associated with them. Other groups have preferred to avoid all connotations associated with codes or guidelines; instead, they have preferred to develop �declarations on ethics� for their specific organizations (Jowell 1986). Throughout this chapter the term code will imply �guidelines�.
It should be apparent that codes (and also guidelines) do not carry the force of law. In essence, codes and guidelines are intended to provide guidance for professionals, collectively and individually, in their relationships with their clients (including patients and research subjects), with their colleagues and co-workers (including their students), and with the public (including stakeholder groups). In addition, codes require that the quality of professional work and hence the stature of the profession itself is advanced. In general, codes associated with the physician-patient relationship will require that the patient�s interests take precedence over any other interests; the physician is placed firmly in the position of �patient advocate�. One exception to this would arise in the context of infectious diseases, where the patient�s rights may have to be considered second to the public welfare. In contrast, however, it can generally be stated that codes associated with scientific research will require that the public interest take precedence over any individual or other interests. One exception would be where a researcher discovers child abuse in a research subject; here the researcher would have the obligation to report this to the child welfare authorities.
Code Development, Review and Revision
The process by which codes are developed has consequences for their application. By including members of the profession and students of the profession in code development, as well as in code review and revision, ownership of the resultant document by a greater number of individuals is believed more likely. With broad-based ownership, increased compliance by a greater number is believed more assured.
Content and Structure of Codes
The content of a code should be user friendly to maximize its utility. Codes can be of varying length. Some are brief, while some are substantial. The more substantial that a code is, the more specific it is possible for it to be. Codes can be made to be user friendly by virtue of their structure and content. For example, a summary set of the principles upon which the code is based could be presented first, followed by expanded aspirational or prescriptive statements, which constitute the code itself. These can be followed by a commentary that explicates each statement in turn, perhaps noting special circumstances in the form of case studies that might serve as useful examples. The principles and their interpretation(s), however, are highly dependent on the values recognized as inherent to the pursuits of a profession. While these values may be universal, interpretations as well as practices at the local and regional levels may differ. Thus, while a statement of the profession�s core values can provide an anchor for its statements on ethics and should appear as a preface to the guidelines (Gellermann, Frankel and Ladenson 1990), sensitivity to regional differences can be demonstrated through the more detailed commentary and case study materials.
The commentary should incorporate, or could be followed by or complemented with, case study materials that derive from real-life instances of ethical dilemmas or tensions. The case study materials could be ethically analysed in either sanitized (i.e., anonymous) form, or can be made to reflect the parties involved (of course, only with the approval of the parties for their names to be included) (for example, Soskolne 1991). The objective behind case studies is not to seek retribution, but rather to provide examples for teaching purposes. Learning is enhanced by real-life situations.
It is from an understanding of the code that it becomes possible for a profession to develop more detailed standards of practice. These address more specific areas of activity associated with professional conduct, including a broad range of activity from interpersonal behaviours to both how research is conducted and how the results of that research are communicated. Standards of practice for the profession could be included in an ethics package; they reflect on each profession�s skill set and therefore add particular considerations that go beyond the statement of its ethics principles.
Scope of Codes
The development of a code by any profession has almost invariably tended to be driven by issues having a direct bearing on that profession. Consequently, codes tend to have a focus narrowly defined by each profession�s own concerns. However, codes also need to take broader social issues into account (Fawcett 1993). In fact, in a recent analysis of several codes, Summers et al. (1995) found that guidelines on specific social issues, such as environmental effects or conflict resolution, are scarcely mentioned at all in existing codes. Because the professions manifest substantial influence, if their codes indeed were to take broader social issues into account, then a great confluence and concurrence of effort would be brought to bear on those areas of human endeavour that currently fall between the cracks in promoting the common social good. Such pressure could help reduce dangers to human welfare, such as militarism and ecological destruction.
It should be recognized that there exist two schools of thought for ethics training: one is based in a principle-driven approach while the other is case based, also known as casuistry. It is this author�s view, which remains to be tested, that a balance between the two is essential for successful applied ethics training in the professions (Soskolne 1991/92). However, it is well known that ethically analyzed case study material has an invaluable role to play in the education process. Cases provide a context for applying principles.
Because graduate ethics training in the professions is becoming more recognized as an essential place for students to gain awareness of the values, ethical principles and standards of practice of the profession, a model curriculum might ideally be included as part of a code; this will facilitate the training of students intent on entering the profession. The need for this is demonstrated through a recent survey that identified inconsistencies and shortcomings regarding the ethics components in graduate training programmes across the United States (Swazey, Anderson and Seashore 1993).
Recent History of Codes in Selected Professions
In western cultures, the medical profession has had the advantage of discussions about ethics since the time of Socrates (470�399 B.C.), Plato (427�347 B.C.) and Aristotle (384�322 B.C.) (Johnson 1965). Since then, codes have been developed and periodically revised in response to newly recognized issues arising, for example, from human value shifts and, more recently, from technological advances (Declaration of Helsinki 1975; Ad hoc Committee on Medical Ethics 1984; Russel and Westrin 1992). Since the 1960s, other professions have become involved in code development for their own professional organizations. The area of professional codes in fact has become a cottage industry since the 1980s. The American Association for the Advancement of Science (AAAS) has been instrumental in this movement. Under the auspices of its Committee on Scientific Freedom and Responsibility, AAAS initiated a seminal professional ethics project designed to examine the features of and activities associated with codes in the science and engineering professions. The report arising from this effort subsequently generated renewed interest in discussing both code development and revision with many of the professions (Chalk, Frankel and Chafer 1980).
The health/caring professions have long been engaged in discussions of ethical tensions arising from the nature of their professional pursuits. The codes that have evolved have tended, however, to focus on the physician-patient relationship, with concerns about confidentiality being pre-eminent. More recently, perhaps motivated by the growth of applied health research, codes have expanded their attention to include issues pertaining to researcher-patient relationships. Because of population-based research, codes now are addressing concerns for researcher-population relationships. The latter has been aided by the experience of other professions such as sociology, anthropology and statistics.
Many of the caring professions related to the practice of occupational health have been engaged in the discussion of professional ethics. These include: industrial hygiene (Yoder 1982; LaDou 1986); epidemiology (Beauchamp et al. 1991; IEA Workshop on Ethics, Health Policy and Epidemiology 1990; Chemical Manufacturers Association�s Epidemiology Task Group 1991; Council for International Organizations of Medical Sciences 1991, 1993); medicine and numerous of its subspeciality areas, including occupational medicine (Coye 1982; American Occupational Medical Association 1986; International Commission on Occupational Health 1992; Standing Committee of Doctors of the EEC 1980); nursing; toxicology; statistics (International Statistical Institute 1986); psychology; engineering and risk analysis.
In the occupationally specific areas of health services (Guidotti et al. 1989), medicine (Samuels 1992) and health and safety (LaDou 1986), as well as in occupational and environmental health (Rest 1995), relevant portions of professional codes have been abstracted. These presentations serve well the need for furthering discussion in these areas with a view to revising extant codes.
The importance of integrating ethics into the day-to-day activities of professionals is exemplified by these recent texts, which contain appropriately detailed sections on ethics. The professional thereby is reminded that in all aspects of professional practice, all decisions and recommendations have consequences with associated ethical underpinnings.
More recent work on the subject of misconduct in science requires integration into newer texts (Dale 1993; Grandjean and Andersen 1993; Office of the Assistant Secretary for Health 1992; Price 1993; Reed 1989; Sharphorn 1993; Soskolne 1993a; Soskolne 1993b; Soskolne and Macfarlane, 1995; Teich and Frankel 1992). Because one of the fundamental goals of science is the pursuit of truth through objectivity, plagiarism and the fabrication or the falsification of data are counter to the scientific ethic. As the scientific enterprise expands to include more and more scientists, misconduct in science is coming to the attention of the public more frequently. However, it is believed that even in the face of increasing competition and the potential for conflicting interests, the vast majority of those engaged in science do adhere to the principles of truth and objectivity. The frequency of misconduct does, however, remain difficult to assess (Goldberg and Greenberg 1993; Greenberg and Martell 1992; Frankel 1992).
The potential harm to particular scientific efforts as a result of misconduct is one concern. Another concern is the loss of faith by the public in scientists, with consequent reductions in support for the scientific enterprise. The latter has such potentially dire consequences for both science and society that all scientists, and especially students of science, need to be trained in the scientific ethic and reminded of these principles from time to time.
Several case studies serve to demonstrate misconduct (Broad and Wade 1982; Office of Research Integrity 1993; Price 1993; Needleman, Geiger and Frank 1985; Soskolne and Macfarlane, 1995; Swazey, Anderson and Seashore 1993; Soskolne 1991). The determinants of ethical dilemmas are numerous, but one survey among risk analysts in New Jersey (Goldberg and Greenberg 1993) suggests that the two most important causes are �on the job pressure� and �pressure caused by economic implications of result�. The authors of this study noted that possible causes of misconduct include �conflicts of interest, competition with unregulated and unscrupulous competitors, and general lack of individual or societal ethics�. While some codes do address the need for honesty and objectivity in science, the seriousness of current pressures to perform in the presence of apparently declining awareness of societal ethics would dictate that training at all levels include the subject of ethics, values and philosophy. Indeed, the United States Public Health Service requires that universities seeking to obtain research grant support have procedures in place for dealing with and reporting misconduct in science (Reed 1989). Furthermore, university training programmes in public health disciplines must include ethics teaching to qualify for federal funding (Office of the Assistant Secretary for Health 1992).
Normative Nature of Codes
Codes of professional conduct tend to be a narrative description of an assemblage of normative practices. These practices pertain to the moral and ethical standards of a group, be it a professional organization, association or society, having a common skill set in the service of people.
The basis of respective codes has been the so-called Golden Rule, which prescribes that one should do to others what one would have others do to oneself, do one�s level best, and call to the attention of others any act of misconduct.
Approaches to Developing Codes
Most professional organizations have produced codes through the top-down approach, where the elected officials of the profession have undertaken the task. However, as noted earlier (see �Code development, review and revision�), the bottom-up approach is more likely to result in compliance with codes, because grass-roots participation in the process results in a feeling of ownership of the outcome and hence a greater likelihood of compliance. The view that the power brokers of the profession have major influence over the specification of what constitutes appropriate professional conduct could detract from the credibility associated with any resultant code. The more that the �final� code is reflective of community norms, the greater the likelihood that it will be adhered to.
Codes developed by international organizations do have the power of influencing regional groups of people to consider the concerns and statements included in international codes. In this way, regions that have not given attention to the development of codes might be stimulated to do so. Presumably, provided the intent of international codes is limited to a function of providing stimulus, ongoing interaction could serve to iteratively modify and update international codes so that ultimately the international code could well reflect transnational concerns. Care must be exercised to respect regional cultural norms that are not in conflict with, for example, accepted declarations on human rights. Hence, code makers should be sensitive to cultural differences, and not allow their work to homogenize human behaviour; cultural diversity must rather be encouraged.
Mechanisms for Enforcement
Noted earlier was the fact that codes do imply some degree of self-regulation if the expectation of accountability is to have meaning. This would suggest the existence of procedures for investigating allegations of misconduct (or malpractice) of any type, and for correcting conduct deemed professionally inappropriate (Price 1993; Dale 1993; Grandjean and Andersen 1993). In addition, some remedy might be provided for any harms that might have derived from professional misconduct.
The procedures to be invoked in investigations of allegations of misconduct or malpractice must be pre-specified. The maxim of �innocent until proven guilty� should be evident and be seen to be applied. However, because public confidence rests on professional self-regulation, investigations should be dealt with as efficiently as possible with respect for due process at all times (Sharphorn 1993; Soskolne 1993a, b).
The threat of revoking professional licence to practice is one way that the profession has leverage to maximize among its members adherence to any codes. Many professions have no such leverage; their membership is made up of dues-paying individuals with a wide range of qualifications for which regional legislatures have not required licensure as a requirement of membership in the profession. The loss of the right to practice one�s profession therefore is not applicable in many professions as a penalty for misconduct. The only recourse in such instances is that of peer pressure.
Current Issues of Concern to Occupational Health Professionals
It is not within the scope of this article to develop a comprehensive code, but rather to present the process by which codes are developed. It is the intent in so doing to provide motivation for the ongoing discussion of codes (as a component of a broader-based professional ethics programme) and to alert the reader to current issues about which further discussion is needed for the possible inclusion of such resolved matters into revised codes.
As noted by Guidotti et al. (1989), certain issues had been overlooked in codes that existed at that time. These included the virtue of full access to accurate information, and that the burden of risk should not be taken by the worker in the presence of unproved but sound evidence. The question of accurate information and implied truth has associated with it issues of scientific integrity (as referred to in North America) or of scientific dishonesty (as referred to in Denmark) (Andersen et al. 1992; Grandjean and Andersen 1993). Clearly, the pursuit of truth as the main target of scientific endeavour must be reinforced at every opportunity, including its full integration into codes, case study materials and ethics programmes generally (Hall 1993).
With technological advances, the ability grows to more precisely measure biological parameters. For example, biomarkers is one area that opens up a Pandora�s box of ethical issues and resulting tensions that have yet to be addressed in codes. Several such issues have been identified by Ashford (1986) and by Grandjean (1991). Since existing codes were developed prior to the availability on a commercial scale of this technology, codes would serve the occupational health community better if they were updated to provide some guidance on related concerns. To achieve this, explication of such thorny questions as the workers� right to work in the face of high-risk susceptibility identified through biomarker assays, requires extensive discussion in workshops and conferences specially convened for the purpose. Case study materials would assist in this effort. So profound are the ramifications of biomarker studies that their implications, as well as those related to other potential high technology breakthroughs, could be best addressed through the profession�s continual review of the code.
Because issues such as biomarkers can be difficult to resolve, it may be appropriate for like professions dealing with similar issues to consolidate their efforts and establish mechanisms for exchanging information to assist in the resolution of difficult and challenging related ethical issues. In particular, the need to address the timing for introducing high technology procedures for which ethical considerations have not yet been established also needs to be recognized and addressed by standing committees on ethics for the respective occupational safety and health professions. Other stakeholder groups probably should be included in such deliberations, including the community representatives themselves on whom such studies would be conducted.
In a researcher�s enthusiasm to implement new technological measures into studies for which the ramifications are not fully understood (in the belief that benefit would result), it should be recognized that greater harm than benefit to the subjects of these studies could, in fact, arise (e.g., job loss today is potentially more harmful than the possibility of premature death at some future date). Hence, great caution must be exercised in advance of the implementation of such technologies. Only after due discussion has been exercised by the professional groups having an interest in the use of such technologies, together with a broad range of stakeholder interest groups, should their implementation be considered.
Another current issue involves the notion of data privacy, which is one that returns to the public arena periodically. In the age of computers, the potential exists for linking records created for one purpose with records created for another purpose. Advocates of data privacy have been concerned that records so created could be potentially damaging to individuals. While individual rights to privacy must take precedence over the research needs of the community, the fact that population-based research is uninterested in the data at the individual level must be brought to the attention of the data privacy advocates. In so doing, it should be easy to demonstrate that the public good is better served by allowing appropriately qualified researchers, trained in data processing and confidentiality, access to individual data for population-based research purposes.
Concern about the extension of principlism applied in the physician-patient setting to that of the community-research situation has been noted above (see �Recent history of codes in selected professions�). Vineis and Soskolne (1993) have found that the established principles of autonomy, beneficence, non-maleficence and distributive justice are not easily applicable at the societal level. For example, available information about the safety of exposures often is too scanty to allow decisional autonomy; beneficence is considered from the societal viewpoint rather than from that of the individual; and equity is frequently violated. Ethics require careful consideration when defining what is acceptable to society; the simple mathematical formulations used for risk-benefit evaluations cannot be applied directly to individuals. Further development and integration of these ideas are necessary.
In conclusion, codes have a fundamental role to play in the professions. They also could play an important role in safeguarding the common good if they took broader social issues into account. They need to be developed with grass-roots and stakeholder input as part of a broad-based programme of ethics supported by each profession. Codesincluding the profession�s core values, the commentary associated with a code and case study materialsmust be subjected to a process of periodic review and revision. Now, more than ever, codes are needed not only for professional accountability and self-regulation purposes, but also to help practitioners with the moral and ethical challenges faced by constantly advancing technologies that have implications, amongst others, for the rights and duties of all affected individuals and interest groups. A substantial and challenging task lies ahead.
RESPONSIBLE SCIENCE: ETHICAL STANDARDS AND MORAL BEHAVIOUR IN OCCUPATIONAL HEALTH
From the onset, we wish to make it clear that we are not experts in ethics, nor do we represent ourselves as experts. Just like the rest of you, we are scientists, doing scientific things, searching for truth. In that arena, we are faced with the same issues as youthe difference between right and wrong, good and bad, and objectivity and subjectivity. As researchers, we grapple with difficult questions concerning methods and outcome. And those of us who become administrators agonize over the same questions, especially in regard to policy decisions in developing adequate occupational standards to protect workers.
In preparing this paper, we reviewed a number of books and documents in search of simple answers to complex problems. We looked not only at papers written by occupational safety and health professionals, but also reviewed some of the classic textbooks on ethics.
On the professional side, we read a number of articles and codes of ethics from various research groups. They all have components relevant to occupational health research. Yet the focus of each is quite different, reflecting the kind of research done by each author. Some include numerous pages of what to do and what not to do. Others are more general in content.
On the textbook side, ethical theories abound, from before Socrates up until today. There is no shortage of articles about ethics, codes of conduct, and written discussions of ethical standards. In the United States at least, most of the medical colleges have medical ethicists on staff, and almost every university with a sizeable department of philosophy has an ethicist on the faculty. It is a discipline to which people devote their lifetimes, which confirms the complexity of the issue.
Before we begin this discussion, it is important that we attempt to make it clear what we are talking about. What is meant by the term ethics? In the English language, the terms ethics and morals are used interchangeably. Since we are preparing this paper for a diverse group, we did what we think to be an interesting poll of some Centers for Disease Control and Prevention (CDC) professionals for whom English is their second language. A woman whose first languages are Slavic, German and Russian replied that there are similar words in all of her first languages. She said that in the Slavic language, neither ethics nor morals stands alone as they do in English. For example, she said that you wouldn�t say that someone is without morals, you would say that they exhibit behaviour that is not moral. She said that in the Slavic language you wouldn�t say that someone is without ethics, you would say instead that the person is without ethical principles. A Chinese national said that there are separate Chinese words for both morals and ethics, but they are used interchangeably. Spanish-, French- and German-speaking people said there are words for both in their respective languages and that the words are used interchangeably.
In the textbooks on ethical theory that we reviewed, however, the ethicists made a distinction between ethics and morals which we choose to accept for the sake of clarity. Melden (1955) and Mothershead (1955) both suggest that the word ethics is used when referring to a set of principles or standards for conduct, and that the word morals is used when referring to the conduct of a person or group, i.e., their behaviour. This usage is consistent with the replies of the CDC professionals.
Professor Melden says in his book, �We are all familiar with such rules of conduct. Each society, religion, professional group, or distinguishable community has its principles, its standards of conduct. As persons who are concerned with being responsible in our conduct, we rely ordinarily upon a body of principles for guidance in conduct.� Examples of these principles are all around us. In the Judeo-Christian community, there are at minimum the Ten Commandments. In every society, we have laws at the local, national and international levels which describe and dictate both unacceptable and acceptable behaviour. There are also the scientific method, the International Code of Ethics for Occupational Health Professionals and Guidance on Ethics for Occupational Physicians, to name a few examples. The list could go on and on. The point here is that we are exposed to a number of standards of conduct, or ethics, as we use the term. It is quite fitting that we begin the work of setting some standards for ourselves.
Why do health professionals need standards for our work? As Professor Melden states, we are persons who are concerned with being responsible. To make good science demands the highest responsibility on our part, which leads to the promotion of safety and health. On the other hand, no matter how good the intentions of the researcher may be, compromised science can lead to death, disease, disability and dismemberment, rather than the protection of workers. The bottom line is that workers suffer when science is compromised.
Why does compromised science happen? From our perspective, there are a number of reasons.
Sometimes science is compromised because we don�t know any better. Take for example three workplace tragedies: asbestos, benzene and silica. In the early days, the dangers of these substances were unknown. As technology improved, as the science of epidemiology developed and as medicine became more sophisticated, the obvious became evident. In each of these histories, the problems existed, but scientists did not possess or in some cases apply the tools available to uncover them.
Sometimes science is compromised because it is bad science. We are certain that all of you have seen bad science or have read about it in scientific journals. It is bad because it isn�t science at all. It is opinion expressed in such a way that it appears scientific and therefore factual. This situation is one that can easily be addressed through a rigorous peer review process.
Sometimes science is compromised because the researcher is rushed, due to unrealistic time constraints, lack of funds or influences other than purely scientific analysis. An obvious example of this is a toxicological cancer study in which the test animals� lives were terminated after less than a third of their normal life span, thus eliminating a sufficient latency period for them to develop cancer as a result of their exposures. Thoroughness was compromised and conclusions reached with only part of the picture considered.
And perhaps worst of all, sometimes science is compromised in pursuit of profit or academic advancement. Likewise, we have all seen evidence of this in the newspapers and professional journals. In some of these instances, the gain to the researcher was academic standing and not financial at all. In others, financial gain, either immediate or future, influenced the outcome. In the first case referred to above, researchers with financial interests in asbestos did not report their own positive findings until many years later, when many thousands of workers had already suffered and died of diseases associated with uncontrolled asbestos exposure (Lemen and Bingham 1994). In some instances, we have seen that those who pay for the research may ultimately influence the outcome.
These are but a few of the cases where a code of ethics could come into play, although any code, no matter how wonderful, will not stop the unscrupulous.
Occupational health is a complex and difficult discipline in which to prevent unethical conduct. Even when we discover methods for prevention of occupational diseases and injuries, the solution to the problem is often viewed as cutting into profits, or the problem is hidden to avoid the expense of the remedy. The profit motive and the complexity of the issues we address can lead to both abuse and shortcuts in the system. What are some of the major difficulties?
Often, occupationally caused maladies have incredibly long incubation periods, giving rise to confounding variables. By comparison, in many infectious diseases results seem quick and simple. An example is a well-managed vaccine campaign for measles in an outbreak situation. In this case, there is a short incubation period, an almost 100% infection rate of those susceptible, a vaccine that is 95 to 98% effective and a total eradication of an epidemic, all accomplished in a few days. That situation is quite different from asbestosis or carpal tunnel syndrome, where some people are affected, but others are not, and most often months or years elapse before disability occurs.
Occupational health concerns are multidisciplinary. When a chemist works with other chemists, they all speak the same language, each has but one interest and the work can be shared. Occupational health, on the other hand, is multidisciplinary, often involving chemists, physicists, industrial hygienists, epidemiologists, engineers, microbiologists, physicians, behaviourists, statisticians and others. In the epidemiological-triad (host, agent, environment), the host is unpredictable, the agents are numerous and the environment is complex. The cooperation of several disciplines is mandatory. A variety of professionals, with totally different backgrounds and skills, is brought together to address a problem. The only commonality between them is the protection of the worker. This aspect makes peer review even more difficult because each speciality brings its own nomenclature, equipment and methods to apply to the problem.
Because of long incubation periods in many occupational diseases and conditions, coupled with the mobility of the workforce, occupational health professionals are often forced to fill in some blanks since many of those workers exposed or at risk cannot be located. This condition leads to a reliance on modelling, statistical calculations, and sometimes compromise in the conclusions. The opportunity for error is great, because we are not able to fill in all of the cells.
Sometimes it is difficult to relate a malady to the work environment or, even worse, to identify the cause. In infectious diseases, the epidemiological triad is often less complex. In the 1990s, CDC staff investigated an outbreak of illness on a cruise ship. The host was well defined and easily located, the agent was easily identified, the mode of transmission was obvious, and the remedial action was evident. In occupationally related disease and injury, the host is defined, but often difficult to find. There are a number of agents in the work environment, often causing synergism, plus other workplace factors which are not directly involved in the health problem but which play an important role in the solution. These other workplace factors include such things as the interests and concerns of the labour force, the management and involved government agencies.
So now to the business at handcoming up with a code of ethics, a set of principles or standards of conduct, used to guide our conduct, our behaviour, in this complex environment.
As Professor Melden (1955) so clearly writes, �Further, we cannot depend wholly upon such principles for guidance, simply because it is impossible to lay down a set of rules complete enough to anticipate all possible occasions for moral decision.� He goes on to say that �A set of moral principles covering all possible moral eventualities is just as impossible as a set of laws so complete that no further legislation is necessary�. Similarly, Kenneth W. Goodman (1994b), states that �While it is important to realize that science and ethics are closely, even inextricably, linked, there is no reason to suppose that a formal code of ethics will provide closure for all or most disagreements about the nature of data, selection of data, data management, and so forth.� To quote Professor Melden once again, �To be useful, moral principles must be general; but being general, their utility is inescapably limited�.
With the above caveats in mind, we propose to you that the following statements be part of a code of ethics for occupational health.
· That, at a minimum, peer review be required and include tripartite review with worker, industry and government representation, as well as review by academia. This process is difficult because it takes timetime to identify learned reviewers from all three areas, time to bring them together for discussion, and often considerable time to address each of their concerns. For the US National Institute for Occupational Safety and Health, at least, this process is required for all publications. We do not pretend to have all the answers, nor do we alone have all the facts. Much can be learned from labour and industry about workplace situations and problem resolution. Tripartite review is the only way we know of to minimize the effects of special interest groups.
· That even perceived compromises are avoided. Sometimes good science has no credibility because of perceived compromise. Examples of compromises include the funding source for the study, the interest groups selected to review the study, and known bias of reviewers. There are judgement calls on the part of the researcher, and even though the judgement and subsequent decision may be sound, there can be a perceived compromise in the study.
· That study protocols receive review by peers before the study is undertaken. The best-intentioned researcher can build a bias into a protocol. This will become obvious only upon careful protocol review.
· That the scientific method is followed from the start: (a) form a hypothesis, (b) do a literature search, (c) collect data, (d) collate data, (e) test the hypothesis and (f) disseminate results.
· That when using science to develop an occupational health or safety standard, all parties involved in the decision declare their affiliations, their financial interests, their potential conflicts with the industry or substance being regulated, and that all of these facts are clearly delineated in the final documentation of the standard. For any standard or recommended standard, perception is of utmost importance. If it is viewed that the standard was based on a biased interpretation, then the standard will lack credibility. Standards based solely on the interpretation of the science by individuals associated with the industry under consideration would suffer from such an interpretation or, worse yet, could fall short of adequately protecting the workers at risk. Building in check factors such as those described above during the development of the new standard will assure that this will not occur.
We have attempted to discuss a complex and sensitive issue. There are no easy solutions. What we are attempting is right and just, however, because its goal, to protect the worker in the workplace, is right and just. We cannot do this alone, we cannot do it in a vacuum, because the problems we address are not in a vacuum. We need each other, and others, to ferret out our natural instincts for personal gain and glory and to uncover our built-in biases. Such an effort will enable us to contribute to the knowledge and enhance the well-being of humanity.
ETHICAL ISSUES IN OCCUPATIONAL HEALTH AND SAFETY RESEARCH
In the last several decades, considerable effort has been devoted to defining and addressing the ethical issues that arise in the context of biomedical experimentation. Central ethical concerns that have been identified in such research include the relationship of risks to benefits and the ability of research subjects to give informed and voluntary prior consent. Assurance of adequate attention to these issues has normally been achieved by review of research protocols by an independent body, such as an Institutional Review Board (IRB). For example, in the United States, institutions engaging in biomedical research and receiving Public Health Service research funds are subject to strict federal governmental guidelines for such research, including review of protocols by an IRB, which considers the risks and benefits involved and the obtaining of informed consent of research subjects. To a large degree, this is a model which has come to be applied to scientific research on human subjects in democratic societies around the world (Brieger et al. 1978).
Although the shortcomings of such an approach have been debatedfor example, in a recent Human Research Report, Maloney (1994) says some institutional review boards are not doing well on informed consentit has many supporters when it is applied to formal research protocols involving human subjects. The deficiencies of the approach appear, however, in situations where formal protocols are lacking or where studies bear a superficial resemblance to human experimentation but do not clearly fall within the confines of academic research at all. The workplace provides one clear example of such a situation. Certainly, there have been formal research protocols involving workers that satisfy the requirements of risk-benefit review and informed consent. However, where the boundaries of formal research blur into less formal observances concerning workers� health and into the day-to-day conduct of business, ethical concerns over risk-benefit analysis and the assurance of informed consent may be easily put aside.
As one example, consider the Dan River Company �study� of cotton dust exposure to its workers at its Danville, Virginia, plant. When the US Occupational Safety and Health Administration�s (OSHA) cotton dust standard went into effect following US Supreme Court review in 1981, the Dan River Company sought a variance from compliance with the standard from the state of Virginia so that it could conduct a study. The purpose of the study was to address the hypothesis that byssinosis is caused by micro-organisms contaminating the cotton rather than by the cotton dust itself. Thus, 200 workers at the Danville plant were to be exposed to varying levels of the micro-organism while being exposed to cotton dust at levels above the standard. The Dan River Company applied to OSHA for funding for the project (technically considered a variance from the standard, and not human research), but the project was never formally reviewed for ethical concerns because OSHA does not have an IRB. Technical review by an OSHA toxicologist cast serious doubt on the scientific merit of the project, which in and of itself should raise ethical questions, since incurring any risk in a flawed study might be unacceptable. However, even if the study had been technically sound, it is unlikely to have been approved by any IRB since it �violated all the major criteria for protection of subject welfare� (Levine 1984). Plainly, there were risks to the worker-subjects without any benefits for them individually; major financial benefits would have gone to the company, while benefits to society in general seemed vague and doubtful. Thus, the concept of balancing risks and benefits was violated. The workers� local union was informed of the intended study and did not protest, which could be construed to represent tacit consent. However, even if there was consent, it might not have been entirely voluntary because of the unequal and essentially coercive relationship between the employer and the employees. Since Dan River Company was one of the most important employers in the area, the union�s representative admitted that the lack of protest was motivated by fear of a plant closing and job losses. Thus, the concept of voluntary informed consent was also violated.
Fortunately, in the Dan River case, the proposed study was dropped. However, the questions it raises remain and extend far beyond the bounds of formal research. How can we balance benefits and risks as we learn more about threats to workers� health? How can we guarantee informed and voluntary consent in this context? To the extent that the ordinary workplace may represent an informal, uncontrolled human experiment, how do these ethical concerns apply? It has been suggested repeatedly that workers may be the �miner�s canary� for the rest of society. On an ordinary day in certain workplaces, they may be exposed to potentially toxic substances. Only when adverse reactions are noted does society initiate a formal investigation of the substance�s toxicity. In this way, workers serve as �experimental subjects� testing chemicals previously untried on humans.
Some commentators have suggested that the economic structure of employment already addresses risk/benefit and consent considerations. As to the balancing of risks and benefits, one could argue that society compensates hazardous work with �hazard pay�directly increasing the benefits to those who assume the risk. Furthermore, to the extent that the risks are known, right-to-know mechanisms provide the worker with the information necessary for an informed consent. Finally, armed with the knowledge of the benefits to be expected and the risks assumed, the worker may �volunteer� to take the risk or not. However, �volunteer-ness� requires more than information and an ability to articulate the word no. It also requires freedom from coercion or undue influence. Indeed, an IRB would view a study in which the subjects received significant financial compensation�hazard pay�, as it werewith a sceptical eye. The concern would be that powerful incentives minimize the possibility for truly free consent. As in the Dan River case, and as noted by the US Office of Technology Assessment,
(t)his may be especially problematic in an occupational setting where workers may perceive their job security or potential for promotion to be affected by their willingness to participate in research (Office of Technology Assessment 1983).
If so, cannot the worker simply choose a less hazardous occupation? Indeed, it has been suggested that the hallmark of a democratic society is the right of the individual to choose his or her work. As others have pointed out, however, such free choice may be a convenient fiction since all societies, democratic or otherwise,
have mechanisms of social engineering that accomplish the task of finding workers to take available jobs. Totalitarian societies accomplish this through force; democratic societies through a hegemonic process called freedom of choice (Graebner 1984).
Thus, it seems doubtful that many workplace situations would satisfy the close scrutiny required of an IRB. Since our society has apparently decided that those fostering our biomedical progress as human research subjects deserve a high level of ethical scrutiny and protection, serious consideration should be given before denying this level of protection to those who foster our economic progress: the workers.
It has also been argued that, given the status of the workplace as a potentially uncontrolled human experiment, all involved parties, and workers in particular, should be committed to the systematic study of the problems in the interest of amelioration. Is there a duty to produce new information concerning occupational hazards through formal and informal research? Certainly, without such research, the workers� right to be informed is hollow. The assertion that workers have an active duty to allow themselves to be exposed is more problematic because of its apparent violation of the ethical tenet that people should not be used as a means in the pursuit of benefits to others. For example, except in very low risk cases, an IRB may not consider benefits to others when it evaluates risk to subjects. However, a moral obligation for workers� participation in research has been derived from the demands of reciprocity, i.e., the benefits that may accrue to all affected workers. Thus, it has been suggested that �it will be necessary to create a research environment within which workersout of a sense of the reciprocal obligations they havewill voluntarily act upon the moral obligation to collaborate in work, the goal of which is to reduce the toll of morbidity and mortality� (Murray and Bayer 1984).
Whether or not one accepts the notion that workers should want to participate, the creation of such an appropriate research environment in the occupational health setting requires careful attention to the other possible concerns of the worker-subjects. One major concern has been the potential misuse of data to the detriment of the workers individually, perhaps through discrimination in employability or insurability. Thus, due respect for the autonomy, equity and privacy considerations of worker-subjects mandates the utmost concern for the confidentiality of research data. A second concern involves the extent to which the worker-subjects are informed of research results. Under normal experimental situations, results would be available routinely to subjects. However, many occupational studies are epidemiological, e.g., retrospective cohort studies, which traditionally have required no informed consent or notification of results. Yet, if the potential for effective interventions exists, the notification of workers at high risk of disease from past occupational exposures could be important for prevention. If no such potential exists, should workers still be notified of findings? Should they be notified if there are no known clinical implications? The necessity for and logistics of notification and follow-up remain important, unresolved questions in occupational health research (Fayerweather, Higginson and Beauchamp 1991).
Given the complexity of all of these ethical considerations, the role of the occupational health professional in workplace research assumes great importance. The occupational physician enters the workplace with all of the obligations of any health care professional, as state by the International Commission on Occupational Health and reprinted in this chapter:
Occupational health professionals must serve the health and social well-being of the workers, individually and collectively. The obligations of occupational health professionals include protecting the life and the health of workers, respecting human dignity and promoting the highest ethical principles in occupational health policies and programmes.
In addition, the participation of the occupational physician in research has been viewed as a moral obligation. For example, the American College of Occupational and Environmental Medicine�s Code of Ethical Conduct specifically states that �(p)hysicians should participate in ethical research efforts as appropriate� (1994). However, as with other health professionals, the workplace physician functions as a �double agent�, with the potentially conflicting responsibilities that stem from caring for the workers while being employed by the corporation. This type of �double agent� problem is not unfamiliar to the occupational health professional, whose practice often involves divided loyalties, duties and responsibilities to workers, employers and other parties. However, the occupational health professional must be particularly sensitive to these potential conflicts because, as discussed above, there is no formal independent review mechanism or IRB to protect the subjects of workplace exposures. Thus, in large part it will fall to the occupational health professional to ensure that the ethical concerns of risk-benefit balancing and voluntary informed consent, among others, are given appropriate attention.
ETHICS IN THE WORKPLACE: A FRAMEWORK FOR MORAL JUDGEMENT
There is no ethical possibility of serious dialogue on moral issues without disclosing the framework of critical decision-making toolsthe assumptionsof the participants. Different tools result in different decisions.
The most important critical assumptions made in labour-management relations are those which become the basis of assigning obligations or duties in the face of multiple and often conflicting paths to the protection of �rights� of workers and their employers.
How do we decide to meet different and often conflicting needs found both in natural sets of humans (such as individual, family, peer group, community) and in synthetic sets of humans (such as political party, union, corporation, nation) which may include many diverse natural sets?
How do we decide who is responsible to provide family health care and �safe� tools to design a work station? How do we choose a level of risk in setting a permissible exposure limit?
How do we allocate moral responsibility and distribute the burden of risk?
The �Ladder of Social Justice�
To allocate responsibility, we can posit a �ladder of social justice�. On this ladder, those most able to act are rationally obligated to rise to the highest rung of responsibility so that they may act first in pursuit of a moral objective. They are obligated to act before others, because they are best or uniquely able to do so. This does not mean that only they should act. When those with special obligations fail to act, or need assistance, the obligation falls on the shoulders of those on the next rung.
By rational we mean not only an action that logically follows another. We also mean actions taken to avoid pain, disability, death and loss of pleasure (Gert 1993).
An application of the ladder is found in the US Occupational Safety and Health Act of 1970. The Act provides that �employers and employees have separate but dependent responsibilities and rights with respect to achieving safe and healthful working conditions�.
An employee has a duty to comply with rules uniquely �applicable to his own actions and conduct�. The employer has duties based on a unique ability to ensure compliance with rules applicable to an entire workplace. Government has a separate duty based on its unique abilities, for example, to mandate rules if persuasion fails.
There are other assumptions in the framework common to any system of ethical values in any culture. Here, we need to highlight those having to do with the nature of our community, the meaning of �rights�, the method of moral axioms, truth or the good, risk allocation, ideals and reality, and the ethical need for worker participation.
We exist, ecologically, as a global community. In our niche, natural sets of humans (such as families or peer groups) are more meaningful than synthetic sets (such as a corporation or politically defined entity). In this community, we share necessary obligations to protect and to help everyone to act rationally in accordance with their rights, just as we should protect our own rights, regardless of differences in mores and cultural values. These obligations, when they result in actions that protect workers across an international border, are not the imposition of the synthetic values of one nation upon another synthetic set of people. They are acts of reverent recognition of natural, timeless, universal moral values.
Basic human rights, the generic rights to freedom and life (or well being) derive from needs which, if met, enable us to be human (Gewirth 1986). They are not given us by any government or enterprise. We always have had them, logically and phylogenetically. Laws governing the work environment, and rules consistent with rights they implement, are not gifts of charity or benevolence. They are expressions of morality.
The specifications of basic rights, such as personal privacy and the �rights� to know and act in the avoidance of the risks of work, while expressed differently in different cultures, fundamentally are the same among all people in every nation.
Acting on the specifications of our rights may result in conflicts between those rights which protect the individual, such as protecting the privacy of personal medical records, and those concerned with the duties of the employer, such as deriving information from medical records to protect other lives through the avoidance of health hazards thus made known.
These conflicts may be resolved, not by depending upon the ability of a lone physician or even a professional society to withstand court or company challenges, but by choosing axioms of moral behaviour that are rational for everyone collectively in the workplace. Thus, taking encompassing action through stewardship of personal medical records by agencies such as a government-supervised labour-management �neutral� entity (like Germany�s Berufgenossenschaften) may resolve this conflict.
A critical assumption at the very base of this framework of moral judgement is the belief that there is only one real world and that the generic rights apply to everyone in that world, not as ideals that need not be achieved, but as generic conditions of actual existence. If they cannot be applied, it is because we haven�t learned to cope with the fact that knowledge of that world and of the most rational way of conducting ourselves in it is never complete. What we should learn is how to use postulates or axioms not only in ethics, but to describe the world and to guide conduct in the absence of perfect knowledge.
The nature of moral axioms is illuminated by Bertrand Russell�s observation that �all rational conduct of life is based upon the method of the frivolous historical game in which we discuss what the world would be like if Cleopatra�s nose had been half an inch longer� (Russell 1903).
The game of �as if� allows us to act in the face of ever-present moral and scientific uncertainty. But axioms must not be confused with ultimate �truth� (Woodger 1937). They are kept and used if fruitful in the application of basic ethical principles. When they are found to be no longer useful, they can be discarded and replaced with another set of conventions.
Moral axioms bring the framework of judgement to the level of practice, to the �shop floor�. An example is the common practice of developing professional codes of ethics for corporate physicians and other professionals. They are drafted to protect generic rights and their specifications by bridging gaps in knowledge, to organize experience and to permit us to act in advance of morally or scientifically certain knowledge.
These sets of axioms, like all systems of axioms, are neither right nor wrong, true nor false. We act as if they are right or true (in fact they may be) and retain them only as long as they continue to be fruitful in permitting us to act rationally. The test of fruitfulness will yield different results in different cultures at different points in time because, unlike generic ethical principles, cultural norms reflect relative values.
In cultures of the East, powerful social and legal sanctions enforced professional behaviours consistent with the Buddhist belief in the eightfold path to righteous living, the fifth fold of which was righteous livelihood, or with Confucian traditions of professional responsibility. In such settings, professional codes of ethics can be powerful tools in the protection of the patient or research subject, as well as the physician or scientist.
In cultures of the West, at least at this time despite the strong Hippocratic tradition in medicine, the codes are less effective, albeit retaining a limited value. This is not only because the social and legal sanctions are less powerful, but also because of some assumptions that simply do not fit the realities of current western cultures.
It is clear, for example, that the incorporation in codes of ethics of the widespread doctrine, an axiom, requiring �voluntary�, �informed� consent prior to privacy-invasive procedures (such as genetic testing) is irrational. The consent is seldom really voluntary or informed. The information conveyed is seldom certain or complete (even in the mind of the scientist or physician). Consent is usually obtained under socially (or economically) coercive conditions. The promises of the researcher to protect privacy and confidentiality cannot always be kept. The professional may be socially and legally protected by codes that incorporate this doctrine, but the worker easily becomes the victim of a cruel hoax resulting in social stigma and economic duress due to job and insurance discrimination.
Thus, continued use of the consent doctrine in codes of professional behaviour, as in protecting the worker from the dangers of genetic testing, is unethical because a facade is created that doesn�t fit the modern context of a culture westernized and made global by international data banks served by linked telephones and computers. The practice should be discarded and replaced with codes made effective by assumptions that fit the real world coupled with socially and legally enforceable protections.
It is irrational (and therefore immoral) to distribute or allocate the burden of risk by caste, that is, to assign different levels of risk for different sets of humans, as marked by genome, age, socioeconomic status, geographic location within the global community, ethnicity or occupation. Risk allocation by caste assumes that there are humans whose generic rights are different from others. Basic human needs are the same. Therefore, basic human rights are the same.
The concept of �acceptable risk�, widely if not universally used in the setting of standards, is a form of risk allocation by caste. It depends upon the assignment of a risk differential based on calculating the risks of past work practice or prevalent exposure to a toxic substance or hazard in the workplace. This common practice accepts and promotes unnecessary risks by arbitrarily assigning, for example, an �acceptable� risk ratio of one death per thousand in setting a permissible exposure level for workers, compared to one death per million for other members of the same community.
Other examples of irrational (immoral) risk allocation are the acceptance of risk differentials within a caste, as between adults and more vulnerable children (setting one standard for both when stronger protection is needed for children), between the work and community environments, between �guest� (or other less empowered) and indigenous workers, and risks (greater than we have set for ourselves) imposed upon the less protected workers in underdeveloped countries by market demands for their products in more developed countries.
Unnecessary risks are never morally acceptable. A risk is ethically �acceptable� only if it is necessary to protect life (or well-being) and freedom or (1) is culturally impacted and very difficult to eliminate or control in a short time and (2) has a lower priority for control within a rational abatement scheme than another biologically adverse hazard.
The generic rights to life and freedom necessitate empowering workers to rationally make and act upon choices made in pursuit of these rights. Empowerment occurs through access to information, educational opportunities to understand (and not simply react to information), and unfettered or uncoerced ability to act on this understanding in avoiding or taking risks.
Education that yields understanding may not happen in a typical safety training session, since training is meant to induce a conditioned response to a set of foreseeable signals or events, and not to provide in-depth understanding. Yet not all the causal factors, including events under the control of workers or management, that result in so-called accidents can be foreseen.
True accidents themselves are defined as �occurrences by chance� (Webster�s Third International Dictionary 1986). Thus they do not exist in nature. Every event has a cause (Planck 1933; Einstein 1949). The concept of chance is an axiom fruitfully used when a cause is not known or understood. It should not be confused with invariable reality. Even when injury or disease is clearly associated with work, all the causal factors of the eventsin or out of the workplaceresulting in harm are never known or understood when they occur (Susser 1973). Thus, even if time, financing and training resources were infinitely available, it is impossible to condition a worker to every possible set of signals for every possible event.
To effectively reduce the risk of �accidents�, understanding a chemical process or a materials handling practice enables the worker to deal with unforeseen events. Education of the worker and his natural set, such as the family and peer group to which the worker belongs, enhances both understanding and the ability to act in preventing or reducing risk. Therefore, it is a specification of generic rights.
There is another ethical role for a worker�s natural set. Choosing an appropriate location where the worker decides or consents to a risk is a critical factor in assuring an ethical outcome. Many decisions (such as the acceptance of hazard pay) should be made, if they are to even approach being truly voluntary, only in a milieu other than a synthetic setting such as the place of work or a union hall. Family, peer group and other natural sets may provide less coercive alternatives.
Providing an economic incentive to accept an unnecessary risk known to a worker, employer or governmenteven as the result of a fairly negotiated contractis always immoral. It is just compensation, if adequate, to a worker�s family when the risk can be justified and when a worker has equal alternative employment available without stigma. Making this choice ethically requires the most neutral or non-coercive setting possible.
If these settings are not available, the decision should be made in the most relatively neutral place associated with the most relatively neutral synthetic set or agency that can protect the empowerment of the worker and his or her natural set. The importance to the well-being of a worker of cultural and ethical values found in his or her family, peer group and community underline the importance of protecting their involvement and understanding as ethically based elements in the empowerment process.
Confusing Axioms and Reality in Communication
Most of us, even physicians, scientists and engineers, have been educated in primary school to understand axiomatic methods. It is not otherwise possible to understand arithmetic and geometry. Yet many consciously confuse assumptions and facts (which can be, but are not always, the same) in an effort to impose personal social values on a specific course of action or inaction. This is most obvious in how information is presented, selected, organized and interpreted.
Use of words like accidents and safe are good examples. We have discussed accidents as events that do not occur in nature. Safe is a similar concept. Most people believe that this word means �free from harm, injury or risk� (Webster�s Third International Dictionary 1986). A riskless void cannot be found, but it is standard practice for �experts� to use this word in describing a condition or chemical, leaving the impression that there is an absence of risk, while assuming or having in mind another meaningsuch as their belief that the risk is relatively low or �acceptable�without informing the audience. If this is done unknowingly, it is a simple mistake called a semi-logical fallacy. If it is done consciously, as is too often the case, it is a simple lie.
The confusion with invariable reality of sets of axioms, models of scientific explanation or assessments of data, seems to be concentrated in the setting of standards. Axiomatic concepts and methods in regulation, the validity of which are assumed and commonly confused with incontrovertible truth, include:
· thresholds of toxic effects in populations (never found)
· levels of observed effects (depend on methods)
· statistical confidence factors (arbitrary by definition)
· exact risk extrapolations (seldom fit data)
· zero risk tolerances (exist only with zero exposure)
· margins of �safety� (always speculative)
· control feasibility (depends on values)
· measurement methods (choice of instruments)
· physiological norms (abstractions from averages)
· biological end-points (valuing an effect)
· lifestyle and genetic homogeneity (never found).
These axioms usually are discussed as if they are the truth. They are no more than discardable assumptions about individuals, risks and their control, based (at best) on limited information.
Social and economic values implicit in the selection and use of these axioms guide the policy judgements of those who govern, manage and control. These values, not scientific data alone, determine environmental and biological norms and standards in the community and workplace. Thus, these values, judgements based on them, and the axioms selected also must be judged by their reasonableness, i.e., their success in avoiding the risk of pain, death and disability.
Law and Contracts: Systems of Moral Axioms
Even the most encompassing system of moral axioms should be understood as an experiment in applying moral principles in the work environment, especially the systems of laws and contracts that govern the workplace.
The laws of the state, the rules of its ministerial bodies and even informally adopted procedures (such as models of risk assessment) can be treatedand changedjust like any system of axioms. Consistent with our framework of moral principles, treated as moral axioms, occupational safety and health laws and rules can be fully integrated with other axiomatic systems that meet other community health needs. They can be a differentiated (but not degraded) part of the total community system.
Health care, education, wage replacement and rehabilitation, social security, protection of the disabled, and other public health and environmental protection programmes are often coordinated by legislatures with occupational safety and health programmes. In doing this, care must be taken not to impose or inadvertently create or perpetuate a caste system.
How is this care to be taken? Participation by workers and representatives from their freely organized unions in contracted workplace and governmental bodies is a safeguard that should be part of the experiment. Participation is another specification of human rights. Tested barriers to caste systems in the workplace include workers� councils (guaranteed in the constitutions of some countries), labour-management committees, ministerial committees on policies and practices, those dealing with standard-setting and enforcement, and education (both professional and rank-and-file) and other participative structures.
The exercise of participatory �rights� by workers in the determination of their own risks is an ethically mandated means of defence against the rise of castes of humans designated by the colour of their collars. It is the first step to the ethical allocation of responsibility and the distribution of the burden of risk in the workplace. The exercise of these rights, however, may conflict with the rights of management and of society as a whole.
Resolution of the conflict is found in understanding that these rights are specifications of generic rights, the imperative of which is absolute and which must ultimately prevail through recognition of the participatory rights of workers, management and the public at large in decisions that affect life and freedom in the community they each share.
SURVEILLANCE OF THE WORKING ENVIRONMENT
Since Ramazzini published the seminal text on occupational medicine (Ramazzini 1713), we have come to realize that working at certain jobs can cause specific illnesses. At first, only observational tools were available to survey the work environment. As technology developed, we began to be able to measure the environments in which workers plied their trades. Measuring the workers� environment has helped identify the sources of workplace stresses. However, this improved knowledge brought with it a need to set exposure limits to protect workers� health. Indeed, we have found ways to detect the presence of toxic substances at low levels, before they can create health problems. Now we often can predict the results of exposures without waiting for the effects to appear, and thus prevent disease and permanent injury. Good health in the workplace is no accident; it requires surveillance of workers and their environments.
Workplace Exposure Limits
Early workplace exposure limits were set to prevent acute illness and death. Today, with much better information, we try to meet much lower limits in order to prevent chronic illness and subclinical health effects. The most successful systematic attempt to develop occupational exposure limits was the effort of the Committee on Threshold Limits established by the American Conference of Governmental Industrial Hygienists (ACGIH) in 1943. (The ACGIH is a US organization with no formal ties to any government regulatory agency.) The success of this effort is shown by the fact that many countries around the world have adopted the threshold limit values (TLVs) published by ACGIH, which now number more than 600, as workplace exposure standards. Their wide use as enforceable standards has invited critical examination of TLVs and the process by which they were set. Despite their usefulness, TLVs have been criticized from three sectors of the decision-making process: scientific, political and ethical. A brief review of several criticisms follows:
Scientists criticized the fact that the TLVs set on the basis of substantial data are not distinguished from those based on considerably less data.
TLVs were never intended to be �safe� exposure levels for all workers. The TLV Committee recognized that the biological variations among workers, and other factors that could not be calculated, made it impossible to set limits that would guarantee safety for all workers in all environments. Adopting TLVs as enforceable standards creates a political problem, because part of the worker population is not protected. Only zero exposure can provide this guarantee, but zero exposure and zero risk are not practical alternatives.
The data that the TLV Committee worked with were often produced and paid for by industry, and were unavailable to the public. Those protected by this limit-setting process argue that they should have access to the data upon which the limits are based. Industry�s attempts to restrict access to their data, no matter what the reason, are seen by many as unethical and self-serving.
TLVs are still widely respected as guidelines for workers� exposures to environmental stresses, to be used by professionals who can interpret them properly.
Community Exposure Standards
There is a link between occupational and community exposures. Any adverse health effects seen in workers are a result of their total exposure to environmental contaminants. Total dose is important in selecting appropriate exposure limits. This need is already recognized for poisons that accumulate in the body, such as lead and radioactive substances.
Present exposure limits differ for workers and for the community, in part, because workers� exposures are intermittent, not continuous. TLVs were set for a five-day work week of eight-hour days, the norm in the United States. TLVs reflect the action of human repair mechanisms. However, many argue that community and occupational exposure limits should not be different.
Without specific information about synergistic or antagonistic effects, exposure limits for both workers and the public reflect only additive interactions between multiple environmental contaminants. When setting limits for a single substance, the complexities of the environments in which we live and work make it impossible to evaluate all potential interactions among environmental contaminants. Instead, we make the following simplifying assumptions: (1) the basic mix of chemicals in our environment has not changed materially; and (2) the epidemiological information and the environmental criteria used to set standards reflect our exposure to this mix of chemicals. By making these assumptions when setting community exposure limits for individual substances, interactions can be ignored. Although it would be useful to apply the same reasoning to setting workplace exposure limits, the logic is questionable because the mix of substances in the various work environments is not uniform when compared with that in our communities.
A part of the political debate is whether to adopt enforceable international exposure standards. Should an individual country set its own priorities, as reflected in its exposure limits, or should international standards be adopted, based on the best data available? Many governments of developing countries take the position that the developed countries should have stricter community exposure standards, because the latter�s industrial and agricultural pollution has created a less healthy environment.
Health Criteria Based on the Type of Risk
Currently, we rely heavily on toxicity testing of animals to set human exposure limits. Today�s sophisticated technology makes it possible to determine both the degree and kind of toxicity that a body will suffer after exposure to a substance. We measure a substance�s ability to cause cancer, to damage a foetus, to cause even benign tumours. We also measure the degree to which that substance can affect somatic systems. Many scientists assume that there is a safe level of exposure, and this has been validated by observations of mankind�s early diseases. However, such an assumption may not be justified today, especially for cancer. Experts still argue both for the existence and absence of a no-effect or �safe� level of exposure.
We co-exist with natural carcinogens in our environment. To deal with them, we must calculate the risk associated with exposure to these substances, and then use the best available technology to reduce that risk to an acceptable level. To think we can achieve zero risk is a misleading idea, and possibly the wrong path to take. Because of the cost and complexity of animal testing, we use mathematical models to predict the risks of exposures to substances at low doses. The best we can do is compute statistically reliable predictions of what are likely to be safe levels of exposure to environmental stresses, assuming a level of risk that the community accepts.
Monitoring the Working Environment
Monitoring of the working environment is the speciality of occupational hygienists. (In North America, they are called industrial hygienists.) These professionals practice the art and science of identification, evaluation and control of occupational stresses. They are schooled in the techniques of measuring the environment in which people work. Because of their obligation to protect the health and well-being of employees and the community, occupational hygienists have a deep concern for ethical issues. As a result, the principal industrial hygiene societies in the United States recently completed a revision to their Code of Ethics, which was originally drafted in 1978 (see box �Canons of Ethical Conduct and Interpretive Guidelines�).
Canons of Ethical Conduct and Interpretive Guidelines
These canons provide standards of ethical conduct for industrial hygienists as they practice their profession and exercise their primary mission, to protect the health and well-being of working people and the public from chemical, microbiological and physical health hazards present at, or emanating from, the workplace.
CANONS OF ETHICAL CONDUCT
Industrial Hygienists shall:
· Practice their profession following recognized scientific principles with the realization that the lives, health and well-being of people may depend upon their professional judgment and that they are obligated to protect the health and well-being of people.
· Counsel affected parties factually regarding potential health risks and precautions necessary to avoid adverse health effects.
· Keep confidential personal and business information obtained during the exercise of industrial hygiene activities, except when required by law or overriding health and safety considerations.
· Avoid circumstances where a compromise of professional judgment or conflict of interest may arise.
· Perform services only in the areas of their competence.
· Act responsibly to uphold the integrity of the profession.
Practice their profession following recognized scientific principles with the realization that the lives, health and well-being of people may depend upon their professional judgement and that they are obligated to protect the health and well-being of people.
· Industrial Hygienists should base their professional opinions, judgments, interpretations of findings and recommendations upon recognized scientific principles and practices which preserve and protect the health and well-being of people.
· Industrial Hygienists shall not distort, alter or hide facts in rendering professional opinions or recommendations.
· Industrial Hygienists shall not knowingly make statements that misrepresent or omit facts.
Counsel affected parties factually regarding potential health risks and precautions necessary to avoid adverse health effects.
· Industrial Hygienists should obtain information regarding potential health risks from reliable sources.
· Industrial Hygienists should review the pertinent, readily available information to factually inform the affected parties.
· Industrial Hygienists should initiate appropriate measures to see that the health risks are effectively communicated to the affected parties.
· Parties may include management, clients, employees, contractor employees, or others dependent on circumstances at the time.
Keep confidential personal and business information obtained during the exercise of industrial hygiene activities, except when required by law or overriding health and safety considerations.
· Industrial Hygienists should report and communicate information which is necessary to protect the health and safety of workers and the community.
· If their professional judgment is overruled under circumstances where the health and lives of people are endangered, industrial hygienists shall notify their employer or client or other such authority, as may be appropriate.
· Industrial Hygienists should release confidential personal or business information only with the information owner�s express authorization except when there is a duty to disclose information as required by law or regulation.
Avoid circumstance where a compromise of professional judgment or conflict of interest may arise.
· Industrial Hygienists should promptly disclose known or potential conflicts of interest to parties that may be affected.
· Industrial Hygienists shall not solicit or accept financial or other valuable consideration from any party, directly or indirectly, which is intended to influence professional judgment.
· Industrial Hygienists shall not offer any substantial gift, or other valuable consideration, in order to secure work.
· Industrial Hygienists should advise their clients or employer when they initially believe a project to improve industrial hygiene conditions will not be successful.
· Industrial Hygienists should not accept work that negatively impacts the ability to fulfill existing commitments.
· In the event that this Code of Ethics appears to conflict with another professional code to which industrial hygienists are bound, they will resolve the conflict in the manner that protects the health of affected parties.
Perform services only in the areas of their competence.
· Industrial Hygienists should undertake to perform services only when qualified by education, training or experience in the specific technical fields involved, unless sufficient assistance is provided by qualified associates, consultants or employees.
· Industrial Hygienists shall obtain appropriate certifications, registrations and/or licenses as required by federal, state and/or local regulatory agencies prior to providing industrial hygiene services, where such credentials are required.
· Industrial Hygienists shall affix or authorize the use of their seal, stamp or signature only when the document is prepared by the Industrial Hygienist or someone under their direction and control.
Act responsibly to uphold the integrity of the profession.
· Industrial Hygienists shall avoid conduct or practice which is likely to discredit the profession or deceive the public.
· Industrial Hygienists shall not permit the use of their name or firm name by any person or firm which they have reason to believe is engaging in fraudulent or dishonest industrial hygiene practices.
· Industrial Hygienists shall not use statements in advertising their expertise or services containing a material misrepresentation of fact or omitting a material fact necessary to keep statements from being misleading.
· Industrial Hygienists shall not knowingly permit their employees, their employers or others to misrepresent the individuals� professional background, expertise or services which are misrepresentations of fact.
· Industrial Hygienists shall not misrepresent their professional education, experience or credentials.
Provided by the American Board of Industrial Hygiene (1995).
Problems of Secrecy
Data developed from monitoring the work environment are critical to improving exposure limits both for workers and for the community. In order to come up with the best limits, which balance risk, cost and technical feasibility, all data from industry, labour and government must be available to those who set the limits. This consensus approach seems to be growing in popularity in a number of countries, and may become the procedure of choice for setting international standards.
Regarding trade secrets and other proprietary information, the new Code of Ethics provides guidelines for industrial hygienists. As professionals, they are obliged to make sure that all parties who need to know information regarding health risks and exposures are given that information. However, hygienists must keep key business information confidential, except when overriding health and safety considerations require them to reveal it.
ETHICAL ISSUES: INFORMATION AND CONFIDENTIALITY
This article deals with the ethical issues that arise in the practice of occupational health activities, including occupational health research, with respect to the handling of information on individual employees, not in terms of practicality or efficiency but by referring to what may be regarded as right or wrong. It does not provide a universal formula for decisions on whether or not practices in handling information or in dealing with issues of confidentiality are ethically justified or defensible. It describes the cornerstone ethical principles of autonomy, beneficence, non-maleficence and equity and their implications for these human rights issues.
The basic principles used in ethical analyses can be used in examining the ethical implications in the generation, communication and utilization of other types of information as well as, for example, the conduct of occupational health research. Since this article is an overview, specific applications will not be discussed in great detail.
On the labour market, in an enterprise, or at a workplace, health issues involve, first and foremost, free-living and economically active people. They may be healthy or experience health disturbances which are, in their causation, manifestation and consequences, more or less related to work and workplace conditions. Furthermore, a broad range of professionals and persons with various roles and responsibilities may become involved in the health issues concerning individuals or groups at the workplace, such as:
· employers and their representatives
· trade unions and their representatives
· health professionals
· social security and insurance administrators
· 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.