The ethical aspects of maritime medicine need to be considered in light of the specific requirements of medical practice on board ship and on shore.
As the maritime physician is caring for seafarers’ health, promoting health, preventing diseases, and improving seafarers’ and passengers’ health status, they may face especially hard choices and may have difficult decisions to make. The physician always needs to respect the maritime community’s customs and regulations and the colleagues with whom they work. The maritime physician must have clear and loyal ethics in conducting his duties. It is important to use all means available to address the specific demands of the maritime community with honesty, brotherhood, and respect to individuals with whom he will be in contact.
Maritime medicine ethics can be defined in terms of the overall principles governing moral issues in the field of maritime medicine, emphasizing the need to respect human beings (1). It is primarily concerned with three types of activities:
- Health care and medical assistance to seafarers and passengers
- Medical fitness to work on board
- Medical research
Ethical aspects of maritime health care and medical assistance
When providing health care or medical assistance to seafarers and passengers, the maritime physician listens to the individual he consults. He may also give medical advice from a distance, through telemedicine, when it is the only communication means with patients at sea. In both cases, he must provide the most appropriate treatment and medical assistance without imposing his own opinions (whether moral, philosophical or political), and without discriminating on the basis of age, race, nationality, or the social condition of the seafarer or passenger.
In recent decades, there have been major changes to the patient-physician relationship. The maritime physician must ensure that by acting according to his conscience and in the best interest of the patient, seafarer or passenger, their autonomy is safeguarded and justice is done. Patients at sea have the right to receive appropriate medical care. They should be confident that they will be treated by a physician whose clinical and ethical judgment is independent from any external pressure.
The wounded or sick patient at sea should always be provided with the best treatment possible in accordance with globally approved medical principles. Quality of care is an essential part of health care and maritime physicians are major actors in ensuring quality of care.
Sailors should be informed about their own health status or provided with their health data. Confidential information about a patient may not be given to another person without the patient’s consent.
In very rare occasions, a patient (seafarer or passenger), will not be informed about a medical condition if it is believed that this information would constitute a health hazard or be life threatening to him.
During teletransmission of medical data, the maritime physician must be very vigilant about confidentiality. Transmissions of conversations with the patient or other crewmembers are often listened to by others and may even be recorded by emergency personnel or maritime authorities. The physician’s primary duty is to ensure that the seafarer or passenger’s health problem is correctly managed. To do this the physician must talk to the patient in order to determine the best treatment and follow up care needed. Ideally, the diagnosis should only be discussed with individuals involved in treating the patient but, in reality, it is often difficult to ensure full confidentiality. The physician should ensure that all those who could have access to confidential data are aware of their responsibility to safeguard it.
All identifiable information about health, disease occurrence, diagnosis, prognosis, and treatment, as well as any other (private) information concerning the sick or wounded patient must be kept confidential, including after death.
In rare circumstances, family members may have access to the patient’s medical data if this information is relevant to their own health.
Confidential information may not be provided to other individuals without seafarer or passenger’s consent, unless authorized by law. Furthermore, medical data can only be shared with other health care providers if absolutely necessary for treatment purposes or if the patient gives their explicit consent.
All identifiable data regarding an injured or sick patient at sea must be protected. Appropriate means of data management or storage must be adopted to ensure confidentiality. Human samples collected (body parts or fluids) must also be managed in ways that ensure confidentiality (2).
Rarely, the maritime physician will face a situation where a passenger or a seafarer is dying. In these circumstances, the dying patient has the right to receive all appropriate care to reduce his suffering in accordance with current medical knowledge. A passenger who wishes to participate in a last journey at sea while being at a terminal phase of a disease has the right to be treated with humanity and to receive all available assistance to render his death as dignified and painless as possible (3).
Ethical aspects of medical fitness to work at sea
Maritime medical practice can have major socio-professional consequences for seafarers since to be able to embark, the maritime physician must establish that a seafarer does not have a disease or pre-disease condition that puts him, other crew members or the ship, at risk.
Many diseases or pre-disease conditions prohibit seafarers from going at sea (see chapter 7). To work on board a ship requires integrity of many physiological functions. The physician may need to follow requirements for fitness certification as listed in national maritime regulations. Certain health conditions undoubtedly limit a seafarer’s ability to be onboard, for others it is less obvious. In the latter case, prior to deciding about sailor’s fitness to embark, the maritime physician may seek expert advice and consider seafarer’s professional experience as well as seafarer’s perception about and management of the disease.
In accordance with the medical codes of ethics, the maritime physician must not apply selection criteria for individuals except to assess their fitness to work on board. Thus, the physician may not discriminate when determining fitness to embark and ensure that the decision on fitness is impartial and moral (4, 5).
There are several aspects to seafarers’ work environment: occupational, social, or “societal”. The maritime physician plays a preventative role in this environment. The object of determining a seafarer’s fitness at sea is to reduce occupational and environmental risks of occurrence or aggravation of a health problem at sea. Discriminatory individual selection or arbitrary limitation of duties at sea must be excluded from maritime physician practice.
During their periodic medical examinations to assess health status and fitness at sea, seafarers can benefit from health education and it is the maritime physician’s duty to provide it. Such education will allow seafarers to take informed decisions about their own health and to be aware of available health care services. Health education provided during these visits should promote a healthy lifestyle to prevent diseases or detect them early. It should be emphasized that each individual bears a responsibility to maintain their own health.
Ethical practice in maritime medical research
In biomedical research on human beings, including non-therapeutic biomedical research, seafarers and passengers included in a study, a survey or a treatment trial, have the same rights and the same requirements to have care provided as patients in a regular therapeutic situation.
The patient at sea has the right to refuse to participate in a research project. If the patient at sea is unconscious or cannot express himself, his legal representative must, when he can do so and if it is lawful, give informed consent for any participation in research (6). According to medical ethics, the maritime physician may not implement research activities with major health risks for seafarers or passengers especially when the expected benefits of the research are not known (7, 8).
Finally, maritime medical ethics are based on the same moral principles as medical ethics in general practice. A few aspects, as noted above, differentiate maritime medical ethics from those in other areas of medical practice. However, the maritime physician must be very vigilant when using telemedicine. Ensuring seafarers and passengers have access to high quality health care remains a basic ethical challenge for maritime medicine in the future.
The 2011 ILO /IMO Guidelines on Seafarer Medical Examinations establish an indicative list of disabilities and pathological conditions that can lead to fitness restrictions with respect to periods of time, duties, geographic area of work, the type of ship or the medical assistance available (9). Some of the conditions can result in the seafarer being made temporarily or permanently unfit. They may form the basis for lists in national regulations. These lists should be used as a guide, but cannot replace a sensible medical judgement. The maritime medicine physician in charge of the assessment of the fitness of seafarers enjoys some liberty to make a decision. This liberty is mainly used for the active seafarer who will adhere closely to the relevant treatment for their condition. A decision of unfitness nearly always indicates the end of a maritime career, and may represent a source of conflict.
The Convention on Standards of Training, Certification and Watchkeeping, as amended (IMO STCW-Manila 2010), and the 2006 Maritime Labour Convention (ILO) underline that any seafarer who has been denied a fitness certificate, or granted a certificate with limitation in terms of time, field of work, or trading area shall have the opportunity of a further medical examination by another practitioner, or by a medical referee who is fully independent of ship owners and trade organizations.
The contesting a decision of unfitness is the most common conflicting situation in which the maritime physician can be involved. Normally, the possibility of a second medical opinion by a specialist, or a presentation of the case to an expert panel, will solve the problem. The procedures for obtaining a second opinion may differ from one country to another, but will remain within the framework of the ILO Maritime Labour Convention 2006. Most countries with an Anglo-Saxon cultural background rely on a second medical expert's advice and then turn to a medical commission in case of a persistent disagreement, whereas other countries present the case directly to a medical panel. The qualified physician who issues a certificate of unfitness, or one with limitations, must inform the applicant, explain the reasons for the decision and give information on appeal procedures. The applicant must confirm that he has received and understood the information by signing the document.
It is most important that the medical form from the initial application is fully completed and that it includes all the relevant medical evidence necessary to make a sound decision. Exchange of information among practitioners would improve the process. A national register with records from all examinations and accessible for all physicians would be even better, provided the obligation of confidentiality is guaranteed. A system of this kind would secure homogeneity in the evaluation process and possibly prevent different physicians making conflicting decisions.
In France the medical commission deciding in cases of conflict is composed of some maritime physicians and one counselling practitioner from the social security establishment for seafarers (ENIM). These commission members have good knowledge of the maritime industry, but are completely independent of ship owners’ organizations and seafarer unions. However, to find medical experts who are totally independent to any organization belonging to the maritime industry is difficult because matters concerning aptitude for service at sea, and decisions on medical conditions that are not compatible with work at sea, require good knowledge of working conditions and thus a fair acquaintance of the maritime industry. However, it is imperative that the situation of any seafarer, when appealing against a decision that went against him, is treated with objectivity and that his rights are protected.
The maritime medicine physician on board or at shore is committed to the ethics of medical practice: serve the individual with total respect of confidentiality and respect their freedom of action, including the freedom to choose their own practitioner. The latter may be difficult when we consider the situation on board a ship and when seeking medical advice from a telemedical service. This situation must be acknowledged and accepted by the physicians and by the seafarer in order to prevent the potential conflicts.
Maritime physicians also act as occupational physicians in the maritime industry and hence become advisers to the ship owners. They must follow the law and the flag state regulations in medical matters, and may also take action in matters of safety, particularly in questions regarding the role of the human element. The abuse of alcohol, narcotics and medicines plays an important part in this setting.
There are different approaches to the question of drug and alcohol abuse: In the USA systematic testing and control systems were introduced in the eighties, prescribed by law. Personnel, who often do not have medical competence or training, perform tests and take decision based on the results. In Europe there is no specific legislation to govern the question of drug and alcohol abuse. Hence, the question of individual liberty will sometimes come into conflict with the concern for collective safety. Here, physicians may have to involve themselves in drug testing and consequently find themselves trapped between obligations for confidentiality and obligations to report events that are potentially threatening to safety. Because the obligation for confidentiality is absolute and their loyalty is divided, this situation can in some instances only be solved by declaring the seafarer unfit without releasing any medical information.
A situation of this kind will not occur under the American system since their drug testing is made routinely upon recruitment, after every injury, accident or disease, and even randomly. Physicians are not involved in these testing processes, which increasingly rely on breath analysers and saliva tests. The testing is carried out by dedicated employees, or by personnel outside of the company. The biological material is analysed in certified laboratories, if necessary. The employer is informed directly of the results and will take the appropriate measures. It has to be noticed that lately the general attitude has changed from a systematic repressive and disciplinary one to an orientation towards medical care for the employees who test positive.
The lack of a clear and uniform regulation at a European level may place the maritime physicians in an ambiguous position between medical ethics not founded on legislation on one side, and a situation with voluntary drug and alcohol testing and the responsibility for collective and individual safety on the other. The ethical position here is similar to that of an occupational physician.
European countries lag 10 to 15 years behind the USA in this matter. Only generally accepted legislation making drug and alcohol testing mandatory would relieve the maritime physicians from this potentially conflicting situation. As seen in the USA it can also lead to other problems of confidentiality, ethics and discrimination.