Textbook of Maritime Medicine

8.1 Ethical aspects

Brice Loddé

The ethical aspects of maritime medicine must be considered in light of the specificities of a medical practice which can be done on board a ship or on shore.

As he is caring for seafarers’ health, promoting health, preventing diseases, and improving seafarers and passengers’ health status, the maritime physician may face especially hard choices and may have difficult decisions to make.  He must always act respectfully of the maritime community regulations and the colleagues with whom he works.  The maritime physician must have clear and loyal ethics in conducting his missions.  He must use all means available to him to address the specifics 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 as the overall principles governing moral issues in the field of maritime medicine, emphasizing the need to respect human being (1).  It is primarily concerned with three types of activities:

-          Health care and medical assistance to seafarers and passengers

-          Medical fitness to board

-          Medical research

8.1.1   Ethical aspects of health care and maritime 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 (2).

In the last decades, the patient-physician relationship has seen major changes.   Acting according to his conscience and in the best interest of the patient, seafarer or passenger, the maritime physician must ensure autonomy and justice to him.  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 will 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 (3)

Sailors may 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 (4).

During teletransmission of medical data, the maritime physician must be very vigilant about confidentiality.  His conversation with the patient or other crew members are often listened to by external individuals and may even be recorded by emergency personnel or ship authority.  The physician’s primary duty is to take charge of the seafarer or passenger’s health problem.  He 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.

All identifiable information about health, disease occurrence, diagnosis, prognostic, and treatment, as well as any other (private) information concerning the sick or wounded patient must be kept confidential, including after his death. (5).

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 his explicit consent.

All identifiable data regarding the wounded or sick patient at sea must be protected.  Appropriate means of data management or storage must be taken to ensure confidentiality.  Human samples collected (body parts or fluids) must also be managed in order to ensure confidentiality (6).

During their periodic medical examinations to assess health status and fitness at sea, seafarers should benefit from health education.  This will allow them to take informed decisions about their own health and to be aware about 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 individuals bear a responsibility in maintaining their own health.  The maritime physician must take an active part in these health education activities.

Dignity and the right to privacy must be ensured to seafarers and passengers during health care or health education.  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 (7).

8.1.2   Ethical aspects of medical fitness to boarding

Maritime medical practice can have major socio-professional consequences for seafarers since to be able to board, the maritime physician must establish that a seafarer does not have a disease or pre-condition that puts him, other crew members or the ship, at risk. 

Many diseases or pre-conditions prohibit seafarers from going at sea.  To work on board a ship requires the integrity of many physiological functions.  Health conditions determining seafarer’s ability to board are sometimes listed in national maritime regulations.  Without any doubt, certain health conditions do limit seafarer’s ability to board, for others it is less obvious.  In the latter case, prior to deciding about sailor’s fitness to board, the maritime physician may seek expert advice and consider seafarer’s professional experience as well as seafarer’s perception and management of the disease. 

In accordance with the medical code of ethics, the maritime physician must not apply selection criteria for individuals but assess their fitness to work on board.  Thus, he may not discriminate when determining fitness to board and ensure that his decision is impartial and moral (8, 9).

There are several aspects to seafarers’ work environment: occupational, social, or “societal”.  The maritime physician plays a role as preventer in this environment.  The object to determining seafarer’s fitness at sea is to reduce occupational and environmental risks of occurrence of an aggravation of a health problem at sea.  Individual selections or arbitrary limitations of professional activities must be excluded from maritime physician practice.

8.1.3    Ethical practice of 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 care (attention) than patients in a regular therapeutic situation. 

The patient at sea has the right to refuse participating in a research project or medical training.  If the patient at sea is unconscious or cannot express himself, his legal representative must, when he can do it and if it is lawful, give his informed consent. (10).

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 (11, 12).

Finally, maritime medical ethics are based on the same moral principles than medical ethics in general practice.  It has little specificity when compared with other medical practices.  However, the maritime physician must be very vigilant with using telemedicine which increasingly replaces having a physician on-board.  Ensuring seafarers and passengers’ access to high quality health care remains a basic ethical challenge for maritime medicine in the future.