A) Maritime Health and Maritime Medicine

A.6 Competencies of Professional Staff

Details

Published: 09 January 2022

Introduction

DESPENA ANDRIOTI BYGVRAA

A wide range of professional staff have parts to play in protecting the health of crewmembers and passengers on board vessels. This ranges from those that treat illness and injury when necessary to those that ensure, in many ways, that ill health and disability do not adversely affect maritime safety.  For some groups, such as those who design ships, the whole of their professional training, qualifications and experience is within the maritime sector. Others, for example, clinical staff, develop the competencies needed by the maritime sector only after gaining their qualifications, practical training and experience as part of an onshore profession.

No single group of professionals has the full range of in depth competence to handle all aspects of maritime health. Each needs to be fully competent within their own field and have insight into their own limitations, as well as a good awareness of the skills of other groups and when to utilise them.  In most of their dealings with the maritime sector, maritime health professionals act as advisers to those with management or administrative responsibilities. Hence they also need the ability to advise effectively and fairly, coupled with a clear understanding of the industry and their ethical duties to both individuals at risk and to those who they are advising.

While most professionals work within the framework of competence set by their professional body, the additional competencies needed to advise on maritime health are rarely included in such frameworks. These differ for each of the professions that contribute to maritime health but they can all be considered in terms of the high level purposes that each seeks to achieve, the specific tasks that they perform to meet these aims and the skills needed to do such tasks.  The sections that follow look at the goals, tasks and skills of each of the main professional groups, with the aim of presenting an overview of the professional competencies required to secure maritime health.

Medical professionals and maritime health competence

DESPENA ANDRIOTI BYGVRAA

Undergraduate and specialist training requirements that aim to produce competent medical practitioners are specified in national law and practice and are relatively consistent internationally. However the competency requirements for medical work in maritime health do not form part of any specialist training. They are diverse and may require skills from primary care, emergency medicine, occupational medicine, travel and infectious disease medicine and many others.

There are a few training courses, for instance at the University of Cadiz in Spain and the University of Brest in France, that provide comprehensive training in the subject. Some flag state administrations provide courses for the doctors they approve to perform statutory seafarer medical examinations. Otherwise most training is informal and depends on the individual or their employer to ensure that competence is founded on a secure base of knowledge and experience. Where there are medical re-accreditation requirements the dialogue between the person being accredited and their assessor also provides an opportunity to review professional development needs that relate to the person’s actual job requirements.

There has been little investigation into the training needs and competencies of doctors working in maritime health. One recent study from Denmark, with a representative sample of maritime doctors providing statutory medical examinations for seafarers, showed that length of experience and the number of seafarer contacts are important predictors of valid decision-taking^{[1] [2]}. Most participants were keen to have regular training opportunities.

In other maritime health settings, such as work in a Tele Medical Advisory Service, emergency medicine skills will predominate but an understanding of the maritime sector is vital. The medical aspects of working and living conditions on board, by contrast, fall within the defined competencies of occupational physicians, and they are also likely to have to gain specific knowledge of the maritime environment and the constraints it places on risk management.

^[1] Andrioti D, Faurby M, Videbæk Le J, Jensen OC. Do Danish Maritime Doctors Value Continuous Education Initiatives? Health Econ Outcome Res Open Access. 2017;3(3). 137. https://doi.org/10.4172/2471-268X/1000137

On board healthcare professionals

LUISA CANALS

Introduction

Medical practitioners work on ships including:

• Cruise or passengers ships¹
• Civil, naval or humanitarian hospital ships
• Larger naval ships and those on specific missions like disaster relief, and suppression of piracy
• Support ships accompanying fishing fleets, offshore races etc.

Other health care staff, usually those with nursing qualifications may also work on board vessels with large numbers of passengers and crew. Health care professionals, often nurses or paramedics may also be employed on some longer ferry crossings.

Purpose and tasks

• To provide effective medical care in the event of injuries or illness
• To reduce the risks of harm to health by ensuring appropriate preventive measures, including participation in the Vessel Sanitation Programme²
• To manage the on board medical facilities, medicines and medical equipment and record keeping
• To communicate on health issues with patients, ship’s officers, onshore medical and port health services

Skills and competency

Medical staff

• General medical training, with professional registration in a jurisdiction accepted by the flag state of the vessel.
• Postgraduate training in a relevant medical specialty is desirable. These may vary depending on the role to be performed. Skills in Public and Occupation Health are needed, as is an understanding of the maritime environment and its regulatory, managerial and ethical aspects. A postgraduate training in maritime health such as a Master, University Specialist, Expert Diploma, Continuing Education or a Nationally recognized accredited Speciality in 3 years, can be one way to acquire essential skills. Courses are also available to prepare doctors for work in the cruise industry, offshore oil and gas industry, conducting pre employment medical examinations, occupational risk prevention, ships inspections, research and many more.
• Resuscitation skills in resuscitation and the management of serious illness and injury. Qualification in Advanced Life Support (ALS) is essential and other resuscitation courses should be considered, for example, Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support (APLS) or their equivalents in different countries. Given the need to often assess an illness or injury and offer immediate treatment outside of the ship’s medical centre, courses focusing on pre hospital care may also be relevant.
• Communication skills. These include competence in the working language of the vessel and normally also in English as this is the common language for most maritime international conversations. It is also the language used by the telemedical advisory services that may need to be contacted for additional medical advice or to arrange evacuation and onshore treatment of casualties. Crew and passengers may come from diverse backgrounds and it is important to understand the diversity of health beliefs. Good communication with other officers on board is also essential.
• Management skills to manage other onboard healthcare staff and medical facilities. Medical staff may have line management responsibilities of other staff and have the responsibility for ordering of stock, managing rotas and hours worked and maintenance of equipment. Such skills are also important to aid understanding of the status and priorities of senior officers and ship managers when recommending the evacuation of casualties who need urgent shore based care and implementing health care policies such as public health measures.

Other healthcare staff

These may include staff with nursing or paramedic qualifications. Where there is a ship’s doctor, other staff will usually be working under their management but they may be independent practioners. They require the competencies to carry out their duties and these are likely to be obtained through a mix of general training ashore, relevant shore side experience, formal training courses e.g. ALS and by in service experience. Other healthcare staff may well have responsibility for specific tasks on behalf of the doctor, for example, ordering of medicines, rotas etc.

Where there is no ship’s doctor, other healthcare staff will be required to have demonstrable relevant competencies as required for that particular setting. In addition to relevant training and qualifications ashore such staff have often gained appropriate experience while working in related sectors such as offshore energy or the military.

References

1. The American College of Emergency Physicians. Cruise Ship Medicine section (in ACEPT available from   https://www.acep.org/how-we-serve/sections/cruise-ship-medicine/cruise-ship-medicine-section---cruise-line-directory/#sm.000rhhrst1e2pdu1qyu1fvhw2whhy  (Cited January 2019).

2. Centers for Disease Control and Prevention (CDC) The Vessel Sanitation Program (VSP) https://www.cdc.gov/nceh/vsp/pub/pub.htm (Cited Jan. 7, 2019).

^[2] Shah B, Andrioti D, Jensen OC. Training needs among maritime professionals: a cross sectional study. Int Marit Health. 2018;69(2):129–36.  

Pre Employment Medical Examination (PEME) staff

ILLONA DENISENKO

Introduction

• Pre employment medical examinations of seafarers are usually performed in clinics ashore, either in the seafarer’s home country or in the port in which they are embarking.
• The Maritime Labour Convention 2006 (MLC) and STCW Convention, 1978, as amended include an international requirement that seafarers have a medical certificate of fitness and instructions as how the medical examinations are conducted. These conventions are the basis for national regulations enacted by maritime states.
• Some employers or insurers (P&I Clubs) require a more detailed examination of their seafarers and additional laboratory and radiological investigations.
• Doctors and/or clinics are approved by national authorities or by employers/insurers to perform PEMEs.
• Further, detailed information on the PEME is available in Ch 4.8

Purpose and tasks

• The aim of the PEME is to ensure that seafarers are medically fit to perform their routine and emergency duties at sea and are not suffering from any medical condition likely to be aggravated by service at sea, to render him or her unfit for service or to endanger the health of other persons on board^[1]. Employers and insurers may also expect the examination to reduce operational costs or to help the seafarer live a healthy life.
• The tasks involved include:
  • checking the identity of the seafarer
  • biometric measurements: height, weight, vision, hearing etc.
  • clinical history taking
  • physical examination
  • additional tests: biochemistry, imaging etc.
  • assessment of fitness to work at sea and of any health related limitations. This may require judgements about the probability and severity of future illness, impairment or any increased risk of a health–related safety-critical incident.
  • issue of a medical certificate of fitness, stating fitness using classifications approved by the relevant authorities
  • maintaining records of examination and ensuring that they are confidential.

In a small clinic all of these tasks may be performed by the medical examiner, but in a large one they are likely to be undertaken by a range of health professionals or other staff.

Skills and competency

There are international recommendations on the criteria for medical competence to perform PEMEs^[2]. These include a general medical qualification and training in or experience of maritime issues and knowledge of the duties and ethical position of the examiner under national law.

A few countries provide specific training for their approved doctors, for example Norway, UK, Germany and the Netherlands. Others have a cadre of employed doctors who work using common approaches, for example France and Spain. Employers and insurers do not provide training but will usually employ doctors who have approval from one or more flag states.

Fitness criteria that are specified in detail using clinical terms may require little specific training for their effective application. Where complex risk-assessments are needed then consistent application will only occur if medical examiners have structured and supervised experience in their use.

There are no criteria specific to PEMEs for other health professionals who assist. Assessment of the competence and training of such staff is normally confirmed by the approved doctor and staff will be working under direction from them.

Quality assurance measures based on the audit of doctors and clinics have been adopted by some maritime administrations. Employers and insurers may also conduct audits. However there was resistance to the introduction of a professionally based quality improvement system when this was proposed a few years ago. This was in part because of costs and in part because of resistance from employers and insurers who wished to be autonomous when deciding on which clinics to use^[3]. 

^[1] https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm

^[2] https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm

^[3] Carter T, Bell S, Horneland AM, Idnani S. Standards for quality assurance of pre-employment medical examinations of seafarers: the IMHA Quality experience. International Maritime Health 2017;68(2):99-101

Telemedical Assistance Service doctors

KIMMO HERTTUA

Introduction               

• Telemedical Maritime Assistance Services (TMAS) operate as radio medical advice centres for ships worldwide.
• TMAS need to be available at any hour of the day or night, free of charge, with an optimum use of facilities available.
• All ships shall carry a complete and up-to-date list of radio stations and coast earth stations through which medical advice can be obtained.
• In case of a disease or injury on board, the Master or a delegate is advised to contact
• Different countries have solved their TMAS obligations in various ways. Some have specific centres with dedicated personnel whereas others have their service connected to a hospital department.
• Commercial telemedical providers may be responsible for providing more extensive services to passenger ships, research ships and those working in very remote locations. These often include real time monitoring or imaging support

The International Maritime Organization (IMO) states that the TMAS provision guarantees competence and quality of service¹

Further information on TMAS can be found in Ch 5.7

Purpose and tasks

TMAS medical staff give advice to assist seafarers in managing medical incidents so that morbidity and mortality is minimized. To do so they need to obtain and analyse:

• Information on the incident, the condition of the patient(s), the skills and facilities/medications available on board.
• Location of the vessel and its passage plan
• Availability of air and sea rescue services and their ability to access the vessel
• Appropriate and accessible requisite healthcare facilities and how they can be accessed.

They then need to decide on:

• Initial recommendations for management of the patient(s)
• The need for medical evacuation or ship diversion
• Requirements for longer term care and monitoring if the patient is to remain on board

These tasks often need to be done in co-operation with national or international rescue and coastguard services, while ensuring that medical care is not compromised by the disclosure of medically confidential information or by the economics of ship operations.

The doctor-patient contact is complex. TMAS does not usually have access to the medical history of the patient, except what they can glean from the seafarer themselves. They need to make decisions without medical investigations or laboratory results. They may be communicating with seafarers with limited skills in English or other languages familiar to the advisers and who may well be extremely anxious if the patient’s life is endangered. Further information on the ethics in maritime health is available in Ch 2.9.

Skills and competency

TMAS doctors need to be competent clinicians who have additional knowledge of:

• the training, qualifications and experience of the person delivering medical care on board
• ship board conditions and the limitations these create.
• ship types
• risks from dangerous cargoes,
• medical facilities along the shipping lanes of the world,
• the variations in the content of medicine chests, ship hospitals, joint rescue centres and Search and Rescue (SAR) services.
• communication skills in relevant languages and the ability to tease out key clinical features where there are limited language capabilities on board or anxiety and agitation because of a major incident.
• knowledge of maritime IT capabilities and skills in optimizing their use.
• clinical skills that meet the needs of the service being provided.

It is often stated that emergency doctors are best suited for the advisory and leadership role, as they have the expertise to assess medical problems rapidly. Furthermore, they are familiar with management from a distance, which is similar to the on-line and off-line medical control in an emergency medical services system². However, if the service is also providing primary care support, in addition to advising on major emergencies then skills in this area are essential.

Most TMAS work with teams of doctors, and in service training and advice on complex cases is the main way in which competencies in all but the basic clinical skills are developed.

References:

1. International Maritime Organization (IMO). Medical Assistance at Sea. Circular MSC/Circ.960. IMO, London, 2000.
2. Mahdi SS, Amenta F. Eighty years of CIRM. A journey of commitment and dedication in providing maritime medical assistance. Int Marit Health 2016; 67: 187-195.
3. International Labour Organization. Maritime Labour Convention, 2006.

First aiders and officers responsible for medical care on board

HARIS APOSTOLATOS, & VIVIAN ANDRIA

Introduction

Medical emergencies on board may be challenging situations for maritime personnel. Seafarers must be able to deal with potentially life-threatening conditions despite their lack of medical experience. Equally, seafarers may present to the officer responsible for medical care with less acute and severe illness or injury. These too have to be assessed, treated and reviewed to ensure that the seafarer remains healthy and able to fulfill his routine and emergency duties. Further information on the management of cases on board can be found in Chapters 5.

Purpose and tasks

To ensure that morbidity and mortality from injury and illness on board is minimized by providing:

• appropriate assessment and management of minor illness and injuries
• assessment and immediate first aid to injured seafarers and for medical emergencies
• appropriate short-term care and treatment, taking account of any specific risks present and the facilities available on board
• communication of all valid information on the incident, the present condition of the casualty and their vital signs to a TMAS centre.
• ongoing care as instructed by the TMAS doctor and recommended in the ship medical guide until the casualty has recovered or can be transferred to onshore medical facilities
• safe management of the medical evacuation of a casualty
• adequate record keeping about casualties and their care and treatment in line with the requirements of medical confidentiality
• ongoing and secure maintenance of the medications and medical equipment on board.

Skills and competency

STCW 1995 as amended, requires that seafarers must be provided with basic safety training, elementary first aid, personal safety, and survival techniques to ensure that they can respond appropriately in emergency situations.

Similar regulations have been established through other Conventions such as the Maritime Labour Convention 2006 (MLC) regulating medical care on board and ashore, safety rules and the responsibility of countries and ship owners.

The specification of the contents of statutory training courses in these conventions is in need of updating and there are major international variations in the quality of training provided.

These requirements define the competencies required but the most important element remains the training, experience and decisiveness of the officer responsible for medical care on board. This individual is the eyes and hands of the TMAS provider and is responsible for providing the objective information the provider requires to assess the situation and respond adequately, whether to a minor injury or a life-threatening condition. The officer must be able to cooperate with the remote TMAS, keep calm and be willing to make decisions and assume actions and strategies to manage a challenging situation¹. Further information on the training of seafarers in medical care is available in Ch 5.3.

References

1. Westlund K, Attvall S, Nilsson R, Jensen OC. Telemedical Maritime Assistance Service (TMAS) to Swedish merchant and passenger ships 1997-2012. Int Marit Health 2016; 67: 24-30. 

Maritime Occupational Health (OH) practitioners

OLAF JENSEN

Introduction

• Seafarers often operate under stressful working conditions, long-work hours, lack of good sleep, healthy diet and physical exercises, that contribute to fatigue, impaired well-being, mental ill-health, stress and chronic diseases ^1,2.
• There are known health risks associated with various aspects of ship operations, dangerous cargoes and port visits.
• Practioners include physicians, occupational hygienists and toxicologists.
• Some roles on board are ‘safety critical’. Incapacity or erratic performance can put other seafarers or the ship in danger.

Purpose and tasks

• Perform employment medical examinations for the seafarers’. Further information on PEME medical examiners can be found in Chapter 4.8.
• Advise individuals, ship operators, maritime trade unions, authorities and charities on how to reduce occupational health risks related to the working conditions.
• Advise ship operators and regulatory authorities on how to assess and control the risks associated with ship operations and dangerous cargoes.
• Undertake health surveillance for early diagnosis of mental ill-health, stress, diabetes 2 (by using Hb1Ac) and other chronic diseases.
• Report new cases of occupational diseases to the regulatory authorities
• Advise on how to minimize risks particularly in safety critical roles, often by modifications to fitness criteria or by changes to work practices.

Skills and competency

The competencies for performing seafarer medicals are specified in the Guidelines on the medical examinations of seafarers and fishermen.^3,5

Competency for many of the tasks form part of the training of specialists in occupational medicine.  Other disciplines relevant to occupational health will have more in depth competencies in particular aspects of risk management. An essential additional component is knowledge of the living and working conditions on board ships, job demands and the hazardous conditions and exposures that are related to health.

There is an unfulfilled need to train all doctors who are in contact with seafarers on how to raise awareness of and support seafarers in the identification and prevention of risks from hazardous working and living conditions and to notify occupational diseases. A recent study has identified that such doctors recognize the benefits from such training and are keen to participate.⁴  

 References

1. Oldenburg M, Baur X, Schlaich C. Occupational risks and challenges of seafaring. J Occup Health. 2010;52(5):249–56. 
2. Jensen OC, Sørensen JFL, Canals ML, Hu YP, Nikolic N, Bloor M. Subjective assessments of safety, exposure to chemicals and use of personal protection equipment in seafaring. Occup Med Oxf Engl. 2005 Sep;55(6):454–8. 
3. Guidelines on the medical examinations of seafarers [Internet]. [cited 2018 Nov 24]. Available from: https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm
4. Shah B, Andrioti D, Jensen OC. Training needs among maritime professionals: a cross sectional study. Int Marit Health. 2018;69(2):129–36. 
5. https://www.etf-europe.org/wp-content/uploads/2021/05/210230_ETF_Fisheries-medical-guidelines-ok.pdf

Competences related to ship design

GEORGE PANAGAKOS

Introduction

The safety of people and cargo onboard is a key functionality of a commercial ship.

The health and well-being of seafarers and passengers is protected through an extensive set of technical specifications, standards and norms that govern the design and commissioning of all vessels.

They differ by ship type and size, while the specific services to be provided and the specific geographic regions to be served also play an important role in this respect.

The requirements are of national and international character and vary also with the classification society that will commission the ship. Thus in a broader sense, all competences related to ship design are related one way or another to maritime health.

Much of the design of ships is overseen by a naval architect or marine engineer. It is rare to have the involvement of a medical professional except in the cruise industry.

Purpose and tasks

To ensure that the design of a ship includes the requirements to protect the health and well being of seafarers. More specifically, to identify areas of intervention that go beyond the usual engineering curricula where, nonetheless, the safety dimension is embedded through international standardization.

Skills and competency

National competency frameworks, for example Akademiet for de Tekniske Videnskaber – ATV (2011) in Denmark, look into the necessary competences and provide a set of guidelines on training in the field of maritime engineering. In addition to the usual skills in mathematics, physics, chemistry and statistics, a naval architect and marine engineer should be competent in:

• hydrostatics and seakeeping,
• ship strength and construction,
• hydrodynamics,
• energy technology,
• machinery,
• internal combustion engines,
• material technology (composites, light metal etc.),
• electrical control systems and automation,
• alternative fuels,
• dynamic analysis and
• acoustics, among others.

However, public health concepts and occupational health issues related to ship design including crew welfare are missing, while the topics of noise and vibration should be given more attention.1

The same 2011 document proposes the so-called T-shaped competence profile for all those involved in ship design. In this profile, the vertical bar of the T represents the depth of related skills in maritime engineering. The horizontal bar, however, is the ability to collaborate across disciplines with experts in other fields and to apply knowledge in areas of expertise other than one's own. 2

The recent widespread digitalization along with rapid developments in automation, robotics and artificial intelligence are already transforming the digital ship of today into the intelligent ship of tomorrow. The future need to collaborate not only with other experts but also with machines places more emphasis on the horizontal part of the profile, calling for communication, collaboration, entrepreneurial and certainly digital skills.
References

1. ATV (2011). Future education in maritime engineering (in Danish). Akademiet for de Tekniske Videnskaber. (http://www.dendanskemaritimefond.dk/wp-content/uploads/2016/02/F%C3%A6rdig-til-tryk-FMI.pdf)
2. Lutzhoft M et al. The Psychology of Ship Architecture and Design. Maclachlan E. (editor). Maritime Psychology. Switzerland, Springer. 2017. 69-98.

Public health inspectors

DESPENA ANDRIOTI BYGVRAA & BARBARA MOUCHTOURI

Introduction

The World Health Organization (WHO) International Health Regulations 2005 (IHR), points out that State parties should have in place systems and services to ensure that vessels calling in their ports are free from infection or contamination [1].

A contagious free ship does not pose any threat related to infectious diseases to the land-based population.

The master of the vessel has to inform the competent authority at the next port of call on the sanitary situation onboard, by completing the Maritime Declaration of Health or by other means.  

Port state authorities are responsible for inspection of the ship at authorised ports and issuance of Ship Sanitation Certificates. This is usually done by trained personnel known as port health inspectors. IHR (2005) Annex 1 B lists trained inspectors as a core capacity at designated points of entry[1]. The IHR (2005) Annex 3 identifies areas, systems and services to be inspected on a conveyance.

Further information on Port Health and Infectious Diseases is available in Ch 5.10 and Ch 8.

Purpose and tasks

• To inspect the ship for compliance with the sanitation principles in line with international and national standards [2-4]
• Issue a Ship Sanitation Certificate (SSC) with a six months validity and/or other inspection reports and check compliancewith the relevant regulations [4]
• Record relevant information on inspections in a database, if applicable at a national or at an international level (e.g. EU SHIPSAN ACT Information System (EUSIS), US CDC Vessel Sanitation Program [5, 6]
• Perfom risk assessment in response to public health events on ships or at ports and implemenent or supervise implementation of control measures [7]

Skills and competency

There are frameworks for skills and competencies for public health inspectors of ships worlwide. The following paragraphs provide an overview of the WHO and European competency frameworks and training programmes.

The World Health Organization provides an eLearning course aiming at introducing the key competencies, with a focus on knowledge and skills, required by inspectors to perform Ship Sanitation Inspections. It is a 10 to 20 hour long self-paced course and a prerequisite to participate in the F2F component (duration of the course may vary according to educational backgrounds and previous experiences of learners): https://extranet.who.int/hslp/training/pluginfile.php/3019/course/section/277/SSC-learning-program.pdf.

The EU-SHIPSAN ACT Joint Action  has developed a competency framework for port health officers conducting inspections against the standards of the European Manual for Hygiene Standards and Communicable Disease Surveillance on passengers ships sailing in European ports. In addition a framework for training was developed including training materials, a pool of trainers based on competency criteria and training courses for port health officers and seafarers including cruise line officers. SHIPSAN European Scientific Association for Health and Hygiene in Maritime Transport (https://shipsanassociation.shipsan.eu/)  continues the activities of the EU-SHIPSAN Joint Action by organising and providing relevant training to public health inspectors and supporting competent authorities in EUMS in the development of an annual inspection plan at EU level and in the conduct of inspections: https://www.healthygateways.eu/European-Inspection-Program-for-ships.  In order to perform these duties, inspecting officers should demonstrate competency in the following areas:

• Assessment of public health risks;
• Communication with authorities, crew and travelers;
• Knowledge of the disease status
• Application of personal protective techniques and related equipment.
• An understanding of the ways in which public health risks from microbiological, chemical and radiological agents affect human health and can be transmitted to individuals via humans, food, air, water, waste, and environmental vectors
• Application of operational procedures for notification, assessment and response,
• Knowledge of environmental requirements relating to the size and type of conveyance
• Knowledge of relevant guidelines issued by the international bodies including WHO, International Labour Organization [ILO], and International Maritime Organization [IMO]).

The US CDC Vessel Sanitation program offers training of cruise ship supervisory employees. This includes a 2.5-day training course to teach cruise ship supervisors the public health practices specified in the current VSP Operations Manual: https://www.cdc.gov/nceh/vsp/training/training.htm.

References

1.         World Health Organization. International Health Regulations (2005). Third ed. Geneva, 2016.

2.         Centers for Disease Control and Prevention. "Vessel Sanitation Program 2018 Operations Manual." U.S. Department of Health and Human Services. U.S. Public Health Service. Centers for Disease Control and Prevention/National Center for Environmental Health, 2018.

3.         EU SHIPSAN ACT JOINT ACTION (20122103) - European Commission Directorate General for Health and Food Safety. European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships. Second ed: EU SHIPSAN ACT JOINT ACTION (20122103), 2016.

4.         World Health Organizartion. Handbook Inspection of Ships and Issuance of Ship Sanitation Certificates Geneva, 2011.

5.         EU SHIPSAN ACT joint action. "Eu Shipsan Act Information System (Sis)." 2019.

6.         Centers for Disease Control and Prevention. "Vessel Sanitation Program Periodic Operational Sanitation Inspections."  https://www.cdc.gov/nceh/vsp/desc/about_inspections.htm (accessed 2 August).

7.         World Health Organization. "Handbook for Management of Public Health Events on Board Ships."  (2016).

Maritime Pharmacists

ILLONA DENISENKO & NICKOLAOS IOANNIDES

Introduction

Maritime pharmacies are the source of the medications and much of the medical equipment and supplies that ships are required to carry. This includes many medicines that would be prescription only on shore and some, such as morphine, that are subject to detailed controls of supply and use. They also accept and safely dispose of unused but expired medications when ships are in port.

The Maritime Labour Convention, 2006, (MLC) includes a requirement for ships to carry a medicine chest. Section 4.1 states that ‘all ships shall carry a medicine chest, medical equipment and a medical guide, the specifics of which shall be prescribed and subject to regular inspection by the competent authority; the national requirements shall take into account the type of ship, the number of persons on board and the nature, destination and duration of voyages and relevant national and international recommended medical standards;’

A maritime pharmacist is a registered pharmacist, usually the owner or an employee in a pharmacy that specializes in the procurement of medicines, medical supplies and equipment to ships. The main difference from a ‘normal’ pharmacist is that he/she does not dispense medicines to sick patients but to potential ones.

In some countries, pharmacists also have a statutory responsibility for the inspection of the ship’s medicine chest to confirm that it is adequately stocked against flag state requirements and to ensure that medical equipment is in good order and no expired products at the time of inspection.

Purpose and tasks

• To advise the ship’s managing company about their fleet’s medicine chest requirements and compile a regulation compliant medicine chest inventory list or software to be used across the fleet for the management of the medicine chest on board each vessel.
• To arrange the inspection of medicine chests at regular intervals, either by physically visiting the ships or by the deployment of tele-pharmacy inspections.
• To issue an annual Medicine Chest Certificate following a satisfactory inspection of the vessel’s medicine chest
• To liaise with port state control authorities if a ship is found to be non-compliant with her medicine chest requirements and helping to resolve cases of regulation misinterpretation.
• In the case of an emergency, to advise TeleMedical Assistance Service (TMAS) or the shipping company on what items are available and where they are located on board
• To advise on the use and supply of medicines, equipment and supplies when new public health threats emerge, for example the COVID-19 pandemic.
• To train the crew in the
  • Safe dispensing of medicines and use of the medical supplies and equipment available on board.
  • Proper storage of medicines, especially those requiring special storage conditions, for exampleg. items requiring refrigeration, or are considered controlled substances, for example morphine, and require special documentation.
  • Disposal of expired items in a way compliant with regulations, especially in the case of controlled medicines that require special handling.
  • Optimal location mapping of medicines, medical supplies and equipment in designated areas to facilitate prompt item retrieval in case of an emergency.

Skills and Competency

Pharmacists working in maritime pharmacies need to have the appropriate national qualifications to obtain and dispense medications. These will vary between countries. In addition, they need to be familiar with each flag state’s list of required medical stores.

When supplying medications, pharmacists need to check the credentials of the person requisitioning for medications and to meet the accountability requirements for the supply of controlled substances. They should be able to advise on the acceptability of entering ports with controlled substances on board, as some substances are prohibited in certain countries. This also means that some medication may not be available in some countries. One of their more challenging tasks is to decide when alternative medications to those requested by the ships master, but not available locally, can be safely supplied.

There has been a recent growth in pharmacies providing on line services to the maritime industry, although the training and knowledge of their staff, the services they provide and the quality of those services is variable.

References

Nittari G, Peretti A, Sibilio F, Ioannidis N, Amenta F. Development of software for handling ship’s pharmacy. Int Marit Health 2016; 67, 2: 72–78

Schlaich C, Ionnidis N, Carter T, Denisenko I et al. Guidance to the International Medical Guide for Ships 3rd edition: Interim advice regarding the best use of the medical chest for ocean-going merchant vessels without a doctor onboard Joint Statement of WHO Collaborating Centres for the Health of Seafarers and the International

Maritime Health Association — 2009 Version. Int Marit Health 2009; 60, 1–2: 51–66

The Republic of the Marshall Islands. Medical Care Aboard Ship and Ashore. https://www.register-iri.com/wp-content/uploads/MN-7-042-1.pdf 

Port Practitioners

DESPENA ANDRIOTI BYGVRAA

Introduction

Physicians in ports come from a range of specialties including general practice, anesthesiology, internal medicine and emergency care. They offer medical advice, health protection and promotion services including dental care, travel medicine and infectious diseases information. They may also offer pre employment medical examinations for seafarers.

Relatively few ports have dedicated medical or dental practices that specialize in the care of seafarers. In many cases, the port shipping agent has to source medical advice and options for medical care. This may sometimes lead to referrals based on the personal contacts of the agent rather than the use of the most competent available services.

Research shows that trauma and occupational injuries are the most common reason for seeking advice in port, followed by urology, upper gastrointestinal, minor surgery, oncology and cardiology incidents (3).

Purpose and tasks

The range of services may include, but is not limited to:

• outpatient treatment for sickness and injury; vaccination and immunization.
• Diagnostic tests including laboratory and radiology
• Referral to hospital for specialist assessment or admission for treatment
• Dental care and emergency dental care
• Health counseling
• Rehabilitation services
• Pre employment medical examinations

Skills and competency

Medical practioners working within a port health clinic must have appropriate qualifications and training as outlined by national authorities. Postgraduate specialist training should cover those tasks outlined above and the majority have experience in primary care and/or occupational health.

Port practitioners should have excellent assessment competencies, knowledge of different treatment protocols, knowledge in public health and cross-cultural understanding, especially as they operate with rather limited clinical diagnostic support and need to be able to give rapid advice, during the time when a ship is in port.

It is difficult to provide integrated care for seafarers. The port physician has to be able to provide suitable care in the absence of the seafarer’s full medical history and has to adapt to the problems of being able to communicate any treatments given to doctors in the seafarer’s home country.

Port practioners should also have a clear understanding of working and living conditions on board. In particular, they should be aware of the limited medical care available at sea and the impact of having a sick or injured seafarer on board. Port practioners also need to have knowledge of how best to ensure that medical information remains confidential, while at the same time giving the ship’s master advice on any continuing treatment needs, danger signs of recurrence of the condition and recommendations on fitness for duties at sea.

References

1. ILO/IMO Guidelines on the medical examinations of seafarers. Geneva: ILO, 2013
2. Baur X, Oldenburg M, Husing UP The Hamburg Port Health Center: history, organisation, activities. Int Marit Health 2005;56(1-4):154-65.
3. MacCalman L, Shafrir A, Cowie H, Crawford J, Ritchie P Seafarers’ Health Care. Health care needs and access to health care among merchant seafarers and fishermen of working age based in the UK. IOM 2011

Port Clinic Medical Assistant

Introduction

Medical assistants may assists a port physician with operational and medical tasks as appropriate.

Purpose and tasks

Tasks may include:

• Administration:
  • patient reception
  • reports,
  • certificates,
  • transport,
  • invoicing,
  • accounting,
  • follow up.
• Reception:
  • Reception of incoming information:
    • Telephone,
    • smart phone, social media
    • internet,
    • regular mail,
    • incoming medical results.
  • Communication
  • Languages
  • Interpreter
• Medical assistance:
  • Stock:
    • Medical materials
    • Vaccinations
  • Instruments:
    • Hygiene,
    • Sterilisation
  • Preliminary examination:
    • Biometry,
    • hearing,
    • vision,
    • ECG,
    • spirometry,
    • x-ray,
    • blood tests,
    • drug and alcohol tests,
    • urine test.

• Nursing:
  • Injections,
  • wound treatment,
  • bandages,
  • instrumentation

Skills and competency

The port clinic medical assistant must be trained according to national standards and requirements to perform the tasks required. In addition they must be good at communication, ideally in English as well as their native language, and be well organised in order to ensure a quality and efficient service.

Policy advisors to the industry

ILLONA DENISENKO

Introduction

Policies on maritime health may be developed at international, regional, national or corporate levels. Some will have legal status, others may be governmental recommendations or they may be mandatory or voluntary policies agreed by sectors of the industry or by seafarer organisations.

Purpose and tasks

Those with competencies in maritime health usually act as expert advisers to others who determine policies within the relevant forum. Their contribution will be based on knowledge about the nature and scale of health risks, the effectiveness of interventions to reduce risks and an understanding of the natural history of illness.

Individuals may be asked to advise, or alternatively professional associations or institutes may be asked to give their collective advice, often based on the report of a working group.

Advice may be given orally in the course of a meeting of a policy making forum, for instance in the International Labour Organisation (ILO) or International Maritime Organisation (IMO). It may also be given as a written report or as a draft policy document for modification and endorsement at the forum.

Skills and competency

A wide range of competencies, usually defined by the professional training and experience of the adviser may be called on, for example:

• clinical, when advising on disease risks and the effectiveness of treatments
• ergonomic, when setting criteria for health and performance related aspects of ship design
• psychological, to help determine optimum working and living conditions
• toxicological and occupational hygiene, when considering the safe handling of chemical cargoes and agents used on board
• T. when optimizing telemedical advisory service provision
• training, for the design of model training courses for ship crew on health matters.

Whatever the professional discipline, the policy adviser needs to understand the policy making process and any potential sensitivities of the interest groups involved.
As most policy outcomes are written, the adviser needs to be fluent in the working language of the forum and to have the skills needed to both draft and scrutinize official documents in order to contribute effectively.
Because of the power of interest groups advisers need to have a clear understanding of their ethical position on matters such as any compromises reached between the costs and quality of intervention, on the requirement to maintain confidentiality of personal information and, above all, on the need to adopt best current practice to secure health.

A.8 Ethics and Confidentiality

Details

Published: 09 January 2022

BRICE LODDÉ

Introduction

Maritime health ethics can be defined as the overall principles governing moral issues in the field of maritime health, emphasizing the need to respect human beings (1, 2).

Ethical issues can arise from many situations in the maritime social environment and involve seafarers, ship owners, occupational health professionals, health care workers and the shipping industries (3).

Maritime health ethics are based on the same moral principles as health ethics in the general population ashore. However, there are some specific features that are not found in other settings. The general principles underlying medical ethics and patient confidentiality, as they relate to seafaring, will be summarized and three areas where there are ethical challenges specific to the maritime sector will then be considered:

• The role of the maritime health practitioner
• Health care at sea
• Pre employment medical selection

Confidentiality

Most countries now have a regulation on the safeguards needed for personal data, for instance the General Data Protection Regulations in EU countries. Data on the health status of human beings raises many ethical issues within the maritime environment. As e-medicine and telemedicine become increasingly common, the handling of such data becomes even more sensitive, as it frequently has to pass through various connections. During this process it may be accessed by individuals who are not health professionals and who may not understand the ethics of only using such data for the benefit of the individual, or the need to maintain confidentiality (3).

Codes of medical ethics have been in existence since the time of Hippocrates. The International Commission on Occupational Health (ICOH)^[1]promotes an international code of ethics and this can be considered as the world standard in ethics for occupational health. It applies to stakeholders in enterprises in private and public sectors as well as within the maritime sector. It also applies to many professional groups with tasks and responsibilities concerning safety, hygiene, health and the environment, in relation to work. The code aims to provide all professionals with guidelines for occupational health practice and to identify a reference level for evaluating performance (3).

Personal health data is owned by the seafarers, be they crew or passengers. It cannot be shared without prior consent of the concerned parties. Such data should neither be misused or exploited, and only be used to promote health, prevent accidents and illnesses at sea, and for treatment on board.

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 (1, 2). Confidential information may not be provided to other individuals without the seafarer or passenger’s consent, unless authorized by law. If the patient at sea is unconscious or cannot express himself, whenever possible their legal representative must give informed consent in their behalf, if appropriate and lawful. (5). Furthermore, medical data can only be shared with other health care providers if necessary for treatment purposes or if the patient gives his explicit consent. Appropriate means of data management or storage must be in place to ensure confidentiality. Human samples collected (body parts or fluids) and clinical test results must also be managed appropriately in order to ensure confidentiality (6).

Ideally, the diagnosis should only be discussed with individuals involved in treating the seafarer or the passenger but, in reality, it is often difficult to ensure full confidentiality.

It can be difficult for non-medical personnel to determine what is, or is not, relevant to the current situation and hence a large amount of information may be shared.

Medical research ethics

In biomedical research on human beings, including non-therapeutic biomedical research, seafarers and passengers included in a study, a survey or a treatment trial, must have the same rights and the same care (attention) as patients in a regular therapeutic situation (4). The patient at sea has the right to refuse to participate in a research project.

According to medical ethics, the maritime physician may not implement research activities with health risks for seafarers or passengers especially when the expected benefits of the research are not known (6). It is normal practice for any research proposals to be scrutinized by a committee for medical ethics, normally based at the investigator’s hospital or university, before it is started.

When maritime health investigations are undertaken the important ethical considerations are:

• Is there informed consent from participants? Have the methods been explained and the ways in which the findings will be used described?
• Will the study design enable valid results to be produced?
• Has the study plan been scrutinised and approved by an independent group of experts – often termed an ethical committee?
• If there is any intervention, to take samples, give treatments or alter living or working environments, could this have any negative effects on the participants?
• Will the study be halted if any adverse effects are found or if any intervention shows such large benefits that it needs to be adopted immediately?
• Has open publication of the findings been agreed, with advance communication of the findings to the participants?
• Is the funding for the study guaranteed so that it can be completed even if one of the parties involved finds the results inconvenient?

The role of the maritime health practitioner

Maritime health expertise, as applied to prevention, treatment and selection for work, can have consequences for many different individuals and organisations. The seafarer themself is central, but employers, trade unions, flag states, insurers and many others all have interests in the advice given and actions taken.  It is the maritime health practitioner, usually a doctor, but sometimes a nurse, psychologist or other clinical professional, who has subject codified ethical duties designed to protect the patients they examine and treat and to protect the health of employees about whom they are asked to advise.

As the interests of patients/employees may at times seem to conflict with those of other interested parties, practitioners need to ensure that their advice and actions safeguard the best interests of patients/employees and are never compromised by any conflicts of interest.  Many such conflicts are similar to those that arise in onshore occupational medical and public health practice, but some are specific to the maritime setting. These include:

1. Onshore medical diagnosis and treatment are provided by recognized health professionals, however, there are special dispensations that enable less highly trained ships’ officers to take provisional decisions on diagnosis and also give them access to prescription medications. During their training by health professionals, officers responsible for medical care need to learn about the requirements for ethical conduct and for maintaining the confidentiality of medical information, even when their fellow officers may be curious or feel they should have such information for operational reasons.
2. On large passenger vessels and on a few specialist ships health professionals will be on board. While they will know about ethical conduct, they can find that the shipping company or their lawyers seek to compromise their position in an effort to avoid liability. Further information on cruise ship medicine is available in Ch xxx.
3. For most ships medical support for illness and injury is provided by TMAS centres. Doctors in these centres rely on information provided from responsible officers on the ship to assess the nature and severity of risk as well as to provide any treatment they advise, prior to recovery, evacuation or arrival in a port where medical care is available. The advice they give can save lives but can also put a ship operator to considerable cost for delay or diversion as well as potentially putting others at risk if emergency evacuation is required. Confidentiality can be hard to maintain when information is shared between ship and TMAS. Ship operators may be reluctant to follow advice because of its operational consequences. TMAS staff need to ensure that their advice supports optimum treatment and enhances the likelihood of a safe and speedy recovery. Additional information on TMAS can be found in Ch xxx.
4. Shipmasters may resist referring a seafarer for medical or dental care when in port because of the risk that treatment will delay departure or that a decision to repatriate a seafarer will cause crewing problems and costs for the company and its insurers. This is both unethical and against the requirements of the ILO Maritime Labour Convention.
5. Maritime health practitioners may identify risks to the health and safety of seafarers or may be asked by others to investigate situations that could pose a risk. Finding a problem and, in particular one that is costly or disruptive to solve, may not always be welcomed by ship operators. Practitioners have an ethical duty to give advice on the actions required based on all available evidence and best current practice, without this being compromised by economic or operational considerations. They may need to recommend that further studies are done or monitoring of risk and active surveillance to look for harm are undertaken.

The sections that follow set out in more detail how ethical conflicts can arise in two settings for maritime health interventions. 

Health care at sea

The seafarer's perspective

Medical care at sea is a major concern for seafarers, just as for passengers. Seafarers’ health, including promoting health and preventing diseases and accidents, as well as passengers’ health, are subjects that need to be part of onboard management responsibilities. The management of medical care on board is often done in conjunction with shore-based Tele Medical Assistance Services (TMAS).

Patients at sea have the right to receive appropriate medical care and they should be confident that they will be treated by a physician whose clinical and ethical judgment is independent from any external pressure. Acting according to his conscience and in the best interest of the patient, seafarer or passenger, the Telemedical physician must ensure autonomy and justice to the seafarer (9).

Quality of care is an essential part of health care and maritime physicians are major actors in ensuring quality of care (10) at sea. Seafarers should be informed about their own health status or provided with their health data. In rare circumstances, family members may have access to the patient’s medical data if this information is relevant to their own health. Dignity and the right to privacy must be ensured for seafarers and passengers during health care or health education (18).

To preserve life at sea and to prevent accidents on board, seafarers must also adopt certain behaviours and encourage others to do the same. Prevention of accidents or illness where possible is better for everybody on board than treatment of the consequences of failures in prevention. (11, 12). Dangerous behaviours and drug consumption (including alcohol) are not appropriate for a safe and healthy environment on board a ship at sea and every seafarer must be aware of this. In addition, seafarers should, with advice and support, follow a healthy lifestyle to prevent diseases or manage the disease progression. It should be emphasized that individuals bear a responsibility in maintaining their own health. 

The shipping company's perspective

When a shipping company is employing seafarers, ethical health issues can and do emerge. These issues are mainly related to work conditions and living on board (19).

Shipping companies have a social responsibility as they employ seafarers. Contracts of employment between employers and seafarers give social protection for those who are working on board. For shipping companies, fair terms of employment that ensure equity and respect and protect against any health or gender discrimination may prevent later social and ethical problems.

By contracting with seafarers, shipping companies become the guarantors of security and safety at work. They commit to providing good working and living conditions on board (20, 21). They also respect regulations about time to rest for seafarers. They specify appropriate accommodation and recreational facilities, as well as food and catering that preserve the welfare of those on board.

Moreover, the shipping companies cover all costs of work-related accidents, occupational diseases, repatriations, and any treatment of health problems occurring at sea for any employed seafarer (7).

In return seafarers agree to their duties on board and perform the work as prescribed. They owe a duty of fidelity and loyalty toward their shipping company during their employment at sea. If they are declared fit for work at sea, the Master of the ship can count on them to perform their duties to the best of their ability and to act appropriately (22).

The insurer's perspective

For the insurer’s point of view, three components of activities at sea can be insured in addition to the ship itself (hull and machinery) and the cargo:

• The ship as the workplace and the recreational space for those facing a harsh environment: the sea
• The work on board, the transport of goods and passengers
• Crew and passengers who may suffer from health problems during the trip (23).

Further information is available in Chapter xxx.

In the third case and only for crew, an insurance company will reimburse all the costs of the health problems occurring on board, usually after an agreed amount or deductible has been paid by the ship owner. Nevertheless, in some cases this is the source of disagreement and litigation. This can occur if health problems

• were hidden by individuals before embarkation
• are due to irresponsible behaviours of individuals
• or are linked to a reprehensive act of a third person

In these cases, the insurance company will try to establish if any person is liable for the event and its consequences and attempt to transfer the cost to these liable people.

With regards to fitness for work at sea, the insurance company will try to avoid costs of repatriation or medical care at sea for a seafarer who can be proved to be unfit for work at sea because he suffered from a disease at risk of acute incidents or relapse whilst at sea and so should he have been declared unfit. The liability of the crewmember for non-disclosure and of the maritime physician who declared him fit will be investigated (10-17). Further information on liability is available in Ch xxx.

Practical considerations

Occupational health professionals must always act respectfully of the maritime community regulations and the colleagues with whom they work. They must have clear and loyal ethics in conducting their missions. They must use all means available to them to address the specifics demands of the maritime community with honesty, brotherhood, and respect to individuals with whom they will be in contact.

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 (24).

Actually, 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 (11-18, 20).

Bibliography

1) Beauchamp TL, Childress JF. Les principes de l’éthique biomédicale (traduit de l’américain). Ed Les Belles Lettres Paris 2008 ISBN: 978-2-251-43015-7.

2) Hoerni B. Ethique et déontologie médicale. Ed Masson Paris 1996 ISBN: 2-225-85288-X.

3) Iavicoli S, Valenti A, Gagliardi D, Rantanen J. Ethics and Occupational Health in the Contemporary World of Work. Int J Environ Res Public Health 2018 Aug 10;15(8). pii: E1713. doi: 10.3390/ijerph15081713.

4) Rose SL, Pietri CE. Workers as research subjects: a vulnerable population. Journal of Occupational and Environmental Medicine 44 2002; 9: 801-5.

5) Saarni SI, Halila R, Palmu P, Vänskä J. Ethically problematic treatment decisions in different medical specialties. J Med Ethics. 2008 Apr;34 (4): 262-7.

6) Glickman SW, McHutchison JG, Peterson ED, Cairns CB, Harrington RA, Califf RM, Schulman KA. Ethical and scientific implications of the globalization of clinical research. N Engl J Med 2009; 360 (8): 816-23.

7) Maritime Labour Convention, Manilla, 2006.

8) Stanberry B. The legal and ethical aspects of telemedicine. 2: Data protection, security and European law. J Telemed Telecare, 1998; 4(1): 18-24.

9) Stanberry B. Legal and ethical aspects of telemedicine. J Telemed Telecare, 2006; 12 (4): 166-72.

10) Rosenstock L, Hagopian A. Ethical dilemmas in providing health care to workers. Annals of Internal Medicine 1987; 107: 575-80.

11) Lurie SG. Ethical dilemmas and professional roles in occupational medicine. Social Science and Medicine 1994; 38 (10): 1367-74.

12) Martin J. Ethics in biomedicine: where are we heading? Sante Publique. 2008 Sep-Oct; 20 (5): 501-3.

13) Lewis KS, Kleper AL. Legal issues confronting the occupational physician. Occup Med. 2002 Oct-Dec; 17 (4): 625-35.

14) Soleo L, Romano C, Apostoli P. Fitness for work: the SIMLII Health Surveillance Guidelines. Med Lav 2006; 97 (3): 491-500.

15) Rosenstock L, Hagopian A. Ethical dilemmas in providing health care to workers. Annals of Internal Medicine 1987; 107: 575-80.

16) Lurie SG. Ethical dilemmas and professional roles in occupational medicine. Social Science and Medicine 1994; 38 (10): 1367-74.

17) Higgins, P. et Orris P. Providing employer-arranged occupational medical care: conflicting interests. Occupational Medicine 2002; 17 (4): 601-6.

18) Allegrante JP, Sloan RP. Ethical dilemmas in workplace health promotion. Preventive Medicine 1986; 15: 313-20.

19) Roman PM. Ethics in worksite health programming: who is served? Health Education Quarterly 14 1987; 9: 57-70.

20) Mahmud N, Schonstein E, Schaafsma F, Lehtola MM, Fassier JB, Reneman MF, Verbeek JH. Pre-employment examinations for preventing occupational injury and disease in workers. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD008881.

21) Davezies P. Aptitude, inaptitude, reclassement, entre droit du travail et déontologie médicale. Médecine et Travail, 2000; 183, 38-41.

22) Miller FH. Reviews in medical ethics. J Law Med Ethics. 2008 Winter; 36 (4): 851-5.

23) Pougnet R, Pougnet L, Lucas D, Canals L, Dewitte JD, Loddé B. When do the economic aspect and ecology policies defend health of mariners? Int Marit Health 2017 ;68(3):176-7.

24) Moutel G, Hervé C. The risks of unrestricted application of the principle of precaution in medicine. The need to keep in mind the findings of medical ethics in the development of health care rights. Presse Med. 2001; 30 (3) :125-8.

^[1] http://www.icohweb.org/site/homepage.asp (Accessed August 2019)

A.7 Medical Record Keeping

Details

Published: 09 January 2022

EILIF DAHL; STEVE WILLIAMS

Current practice and limitations

According to the Maritime Labour Convention 2006 (MLC2006) [1], the ship´s Master must, on behalf of the flag state, ensure that seafarers are given health protection and medical care as comparable as possible to that which is generally available to workers ashore. On ships carrying more than 99 persons and ordinarily engaged on international voyages of more than 3 days duration, there will be a qualified physician. However, on most ships, the person responsible for medical care will be the Master or a seafarer designated to provide first aid and medical care on board. 

In case of significant injury or illness, notes are made in the Master´s Bridge Log, and the officer responsible for medical care must enter an individual patient record on standardized forms. This ensures that all of the important medical details are recorded and can later be provided to medical care providers, whether on board or ashore, or to officials,   such as port health authorities, coroners and the police if appropriate and with the seafarer’s consent. [1, 2] Based on information from the patient records and from safety investigations, the Master must provide reports on injuries and occupational illness to flag state authorities and health reports on potentially contagious illnesses and suspicious deaths to local port state authorities.

Individual patient information may also be of interest to others, including insurers, legal representatives, and ship owners. However, the Master and the officer responsible for medical care are, like medical staff everywhere, bound to observe medical confidentiality [2]. Chapter 2.9, 2.4.4 and 4.8.3 gives further information about ethics and confidentiality, but note that patient information can only be revealed to others after obtaining the patient´s informed consent or when the Master considers that the safety of the ship, others on board or the patient is at stake.

The Master is also responsible for the presence on board and the validity of other medical records for every seafarer. Examples include the pre employment medical certificates and mandatory vaccination certificates. In addition, he is responsible for ensuring that there is an accurate and up to date record of the contents of the ship´s medical chest and of all the medical lifeboat kits.

Best practice

General

The patient record must contain all relevant information about

• the current illnesses or injury,
• relevant past medical history, including allergies
• examination findings,
• any treatment provided, and
• requested follow-up on board and ashore.

To ensure that it contains all necessary data, the record should be based on standardized forms [1]. Forms for case reporting, referral, and evacuation can be found in the International Medical Guide for Ships, 3^rd edition, Annex A [2].

All medical information about each patient should be gathered in one file, preferably on a secure computer. The record should contain the completed standard forms and all other available relevant information, for example, conversations or emails with tele-medical assistance services, referrals to shore-side practitioners and their feedback, as well as documentation regarding sick-leave, details of any evacuation and a copy of the patient´s pre-employment medical certificate etc. [2].

Cruise ships

Most vessels with ship´s doctors, such as cruise ships, carry more passengers than crew. On such ships, a regular medical record must be kept for each passenger and crew patient, and all the ship-related information mentioned above must be included. For legal reasons, the medical records must be made, and subsequently stored, according to the rules and regulations of the flag State, and of the country in which the doctor holds a medical license. This is particularly important if the doctor is an independent contractor and not an employee of the shipping company [3].

US-managed cruise ships

For doctors and nurses working on board ships owned and managed by US-based cruise lines there are additional medical documentation requirements under the current legal framework within the US. Since 2014 doctors are no longer considered independent contractors but agents of the cruise line irrespective of their employment status. This change in their legal status occurred because of the case of Franza vs Royal Caribbean Cruise Lines .  that overturned the previous legal precedent set in 1988 by Barbetta vs S/S Bermuda Star [3,4].  It effectively means that cruise lines are held liable for the medical malpractice of their doctors and nurses. More information on liability is available in Ch 2.10.

In any medical encounter, the doctor must consider that in any subsequent litigation his documentation will be carefully scrutinized down to the very detail of every aspect of the medical encounter.  As well as documenting actual clinical findings and the patient examination, it is necessary to document any ‘pertinent negatives’.   In litigation it is often the clear documentation of the absence of physical findings or symptoms at the time of the examination that can be as important as documenting actual findings. 

On most larger cruise ships the medical records are now fully computerized and may be coordinated fleet-wide through the company´s medical headquarters ashore. Confidentiality is a challenge; the computer systems must be secured to allow access only for relevant medical professionals.  

Establishment of a database (SW)  

The cruise medical sector has always been well suited for electronic medical record systems. The need to compile comprehensive crew and guest medical records across fleets of ships sailing internationally is a prime example of how technology can support improvements in clinical care. Essential criteria for such a system include:

• All entries should be dated and electronically signed. For legal reasons it must not be possible to change signed documents.
• Medical programs must ensure data security, confidentiality and privacy, and providers must guarantee 24/7 global support for all services. More information on ethics and confidentiality is available in Ch 2.9.
• The system must be easy to learn and utilise as handover time is often limited with many things to cover.

Tritan Software, which by 2020 supported approximately 95% of existing cruise lines, claims to fulfil those quality criteria [5].

References

1. International Labour Organisation. Maritime Labour Convention 2006 //www.ilo.org/wcmsp5/groups/public/@ed_norm/@normes/documents/normativeinstrument/wcms_090250.pdf"
https://www.ilo.org/wcmsp5/groups/public/@ed_norm/@normes/documents/normativeinstrument/wcms_090250.pdf (accessed 19 October 2018 19 June 2021)

2. World Health Organization. International Medical Guide for Ships, 3^rd edition. WHO Press, Geneva 2007

3. Dahl E. Cruise ship´s doctors – company employees or independent contractors? Int Marit Health 2016; 67, 3: 153-158

4. “Patricia Franza vs RCCL”. The United States Court of Appeals, Eleventh Circuit.  Case No. 13-13067, filed 11/10/2014. http://media.ca11.uscourts.gov/opinions/pub/files/201313067.pdf5.

5. Tritan Software. SeaCare. https://www.tritansoft.com /cruise-lines/#cl-health-medical-operations (accessed  October 2018 19 June 2021)

A.9 Shipowner liability for illness and injury

Details

Published: 09 January 2022

KIM JEFFRIES

Shipowner liability for illness and injury and P&I Insurance

Introduction

Shipping is global and liability for illness, injury and death is formed from a complex web of international convention, contractual agreements and local and statutory law, which may sometimes conflict. This chapter provides a broad overview of the principle sources of shipowner liability and the insurance cover provided by Protection and Indemnity (P&I) Clubs that responds to that liability. Liability insurance for about 90% of the world’s commercial tonnage is provided by P&I Clubs (Source igpandi.org) - mutual insurance association that pool risks. Further information about P&I clubs is available in Ch 3.8.4.

Liability for illness and injury can arise in relation to the following different categories of people, who have different roles to play in relation to the ship:

• Seafarers
• Passengers
• Persons other than crew or passengers that are carried on board such as pilots, repair gangs, stowaways and persons rescued at sea
• Persons that do not travel with the ship but work on it in port can also be injured or made ill by ship operations, for example, stevedores, surveyors, and port officials.
  
  

Liability to Seafarers

Introduction

The Maritime Labour Convention 2006^[1] (MLC) came into force on August 20, 2013.  This international convention includes provisions that govern liability for the illness of, injury to, or the death of seafarers. The MLC consolidates and updates more than 68 international labour standards related to the maritime sector and aims to be globally applicable, easily understandable, and uniformly enforced. Title 4 of the convention imposes minimum standards for ship owner liability, or employer liability if employed by a crewing contractor, in respect of the financial consequences of illness and injury.

The minimum standards imposed by the convention must be met in seafarer’s contracts of employment, seafarer’s articles or collective bargaining agreements (CBAs). MLC minimum standards cannot be lowered. If they are not met, such contracts etc. cannot be recognised in countries that have ratified the convention and incorporated it into domestic law. However, if the relevant articles or CBAs do satisfy the minimum standards imposed by the convention, they will continue to govern the liability of the employer. Many employment contracts exceed the minimums required. 

Liability under the seafarer’s contracts

Shipowners will normally agree legally binding contracts with seafarers and/or the labour organisations that represent them in the form of individual contracts of employment, seafarer’s articles of agreement or collective bargaining agreements (CBAs). Such contracts normally include not only the terms of the employment but also provisions establishing a right of assistance and financial compensation in the event of illness, injury or death.

The most common form of contract is based on Collective Bargaining Agreements (CBAs). Collective Bargaining Agreements are normally negotiated between a shipowner or a shipowners’ association and the corresponding national seafarers’ unions, many of which are affiliated with the International Transport Workers’ Federation (ITF).An important example is that which regulates the employment of Filipino seafarers. The Philippines supplies the largest number of seafarers to oceangoing vessels and the employment of such seafarers is subject to the minimum standards set out in the Standard Employment Contract of the Philippine Overseas Employment Administration (POEA). Employers are not permitted to reduce these statutory benefits including the amount of compensation that is payable in the event of death or personal injury and the dispute resolution forums for seafarer claims in the Philippines (Labor Arbiter, National Labor Relations Commission and the Filipino Courts) are normally very vigilant in seeking to protect the rights of Filipino seafarers.

Statutory Obligations

The local legislation of the flag State will often protect certain fundamental labour rights including the duty of employers to provide a safe working environment, to restrict working hours and to ensure that compensation is available in cases of illness, injury or death. Local social security schemes may also oblige employers to take out compulsory insurance, frequently from a P&I club, to cover such obligations.

However, the matter can be more complicated in the event of a maritime casualty, since the shipowner may also incur liability under the statutory law of the following countries:

• The country where the seafarer is a citizen and/or is resident
• The country where the employer, shipowner, manager, or operator of the ship is domiciled or has their principal place of business
• The country where the incident, or the act which caused such incident, occurred
• The country where the crew member entered into the relevant employment contract
• The country designated to have jurisdiction in the contract of employment

In the final analysis, the law which will be applied, and the weight that is to be given to each source of law in any particular dispute, will depend upon the law of the country where the court or arbitration panel determining the claim is situated. Therefore, claims arising because of the illness of, injury to, or the death of seafarers may be subject to complex issues of international private law and result in much forum-shopping.

Liability to seafarers in the United States

The United States is not a signatory to the Maritime Labour Convention and under US law an injured or ill seafarer may be entitled to claim damages in tort or under statute in addition to his contractual remedies. The Jones Act, 1920 entitles a seaman, or his next of kin, to claim certain damages from his employer if the latter is guilty of negligence resulting in injury to, or death of, the seaman during the course of his employment. For the purpose of the Act a ‘seaman’ is any person who is employed on board the ship, which includes, in the case of cruise ships, hotel and catering staff.

US general maritime law also provides seafarers a right to ‘maintenance and cure’ meaning that in the event of illness or disability, the seaman is entitled to maintenance, a daily subsistence allowance, primarily for food and lodging, and cure, the right to receive whatever medical and other treatment that may be necessary. This is applicable until the crew member reaches the so-called stage of ‘maximum medical cure’, which is the point at which further treatment is deemed not to have further curative effect. Failure to pay maintenance and cure may expose the employer to punitive damages.     

Furthermore, the seafarer may be entitled to claim damages if he is able to prove that the illness or injury was caused by the unseaworthiness of the ship or by the negligence of a third party, for example, the owners of another ship with which the carrying ship has collided. While some seafarer employment contracts attempt to limit the amount of compensation that is payable in the event of injury or death, such provisions may not protect the employer when liability is incurred under statute or the general maritime law.

Claims may be brought in US courts by seafarers or their next of kin who are not US citizens and not serving on US flagged ships if the incident which caused the injury or death occurred in US waters. The US courts are not automatically required to accept the case where there is a more appropriate forum for the claim. Jurisdiction may be challenged on the basis of forum non conveniens which requires the court to weigh certain factors to determine whether to maintain jurisdiction and allow the case to proceed.  Traditionally, US courts look to the following eight factors:

• Place of the wrongful act
• Law of the flag
• Allegiance or residence of the injured seafarer
• Allegiance of the defendant shipowner
• Place where the contract of employment was made
• Inaccessibility of the foreign forum
• Law of the forum
• Shipowner’s ‘base of operations’

More recently, US courts also look carefully at the foreign seafarer’s employment contract and any choice of law/forum clause it may contain. In particular, if the employment contract includes an arbitration clause, a US court is likely to dismiss or postpone any action in the US pending the outcome of the foreign arbitration. For example, the POEA contract for Filipino Seafarers contains such a provision which means a US court is likely to require the seafarer to comply with his or her contractual remedies and arbitrate the claim in the Philippines according to the contract. 

Liability to Passengers

Contractual Liability

The primary source of the legal relationship between a passenger and the carrier is the contract of carriage that in most cases is the Passenger Ticket Contract.  However, contractual provisions may be superseded by international conventions, national statutes or the common law depending on the laws that are applied in any given forum. The terms and conditions that are included in the passenger ticket normally impose liability on the carrier for the death, injury or illness of passengers caused by the fault or neglect of the carrier, its employees or agents acting within the scope of their employment. These may be ’marine-type’ incidents such as collision, stranding, explosion or fire, or ‘hotel-type’ incidents related to guest cabins, catering, leisure services or entertainment.  For marine-type incidents, fault is generally presumed.

Although the carrier is responsible for negligent acts of its employees, in the course of their employment that result in the injury to or illness of passengers, the passenger ticket may seek to exonerate the carrier from liability for services or activities not provided on board, for example, shore excursions.

International Conventions

The Athens Convention on the Carriage of Passengers and their Luggage by Sea, The Athens Convention^[2], binds only those countries that have adopted it and applies to international carriage where:

• The ship is flying the flag of, or is registered in, a Convention State or
• The contract of carriage was made in a Convention State or
• The carriage commences or terminates in a Convention State

Countries in the European Union are subject to the Athens Convention.  The United States is not a signatory but US courts have been prepared to enforce the provisions of the Athens Convention when the convention is incorporated into the passenger ticket contract by agreement.

The 2002 Protocol to the Athens Convention 1974 provides that the carrier is strictly liable in the event of the death of, or personal injury to, a passenger resulting from a ‘shipping incident’. These are defined as the ‘shipwreck, capsizing, collision or stranding of the ship, explosion or fire in the ship, or defect in the ship’. The carrier is liable unless they prove that the incident resulted from ‘an act of war, hostilities, civil war, insurrection or a natural phenomenon of an exceptional, inevitable and irresistible character’ or ‘was wholly caused by an act or omission done with the intent to cause the incident by a third party.’ Where death or personal injury is caused by a non-shipping incident, the carrier is liable only if the claimant is able to prove that the death or personal injury has been caused by the fault or neglect of the carrier.  Examples of common non-shipping related injuries would be slips and falls and illness caused by lack of proper hygiene in food preparation or swimming pools. In such cases, the burden of proof of negligence is on the passenger.  

In any event, irrespective of the cause, the passenger has the obligation to prove the extent of the loss or damage, Liability of the carrier can be reduced, in whole or in part, if the carrier can prove contributory fault on the part of the passenger.

Carriers are required to maintain insurance or other financial security, such as the guarantee of a bank or similar financial institution that is sufficient to underwrite the minimum limit of 250,000 per passenger and to provide documentary evidence in the form of a certificate attesting that insurance or other financial security is in force. Thus, for cruise ships carrying 5,000 passengers, the required certification of insurance would by 5,000 X SDR 250,000 (Special Drawing Rights). Such certificates will be provided by the International Group of P&I Clubs except for war and terrorism risks.

Liability for passenger injury, illness and death in the United States

Under the general maritime law of the United States a carrier owes a duty of reasonable care to passengers, but in many cases, there is a legal presumption that the carrier has been negligent, thereby requiring the carrier to disprove negligence in order to escape liability. Where the activity is uniquely maritime in nature, for example, when using tenders or gangways or engaging in safety drills, the carrier is subject to a more stringent duty of care on the basis that passengers require greater protection when engaged in activities that they would not normally encounter ashore. Nevertheless, passengers are required to exercise reasonable care for their own safety.

The United States is not a signatory to the Athens Convention. However, the Athens convention will apply to a claim by an American passenger, for example where a cruise begins or ends in a port within a signatory country.  To cater for the different application of law, the major international cruise line ticket contracts include provisions stating which law will apply depending upon where the voyage embarks or disembarks. Under US law, terms included in the passenger ticket that limit the rights of passengers to bring claims cannot be enforced unless they have been brought to the passenger’s attention in a very clear and timely manner. For example, a clause in the ticket that requires the passenger to provide notice of a claim within a certain period and that require the passenger to make the claim in a particular jurisdiction will be prominent in passenger ticket terms. If a passenger has died on the high seas as a result of the negligence or other wrongdoing of the carrier, liability is governed exclusively by the provisions of the US federal statute, Death on the High Seas Act (DOHSA). 

US law prohibits a carrier from contractually limiting its liability to passengers for injury or death due to negligence^[3]. Under the law of the United States the owner or charterer of a passenger ship that either is, or may become, engaged in voyages to or from US ports is required to provide a guarantee from an authorised insurer, surety company or other provider, for legal liabilities that he may incur for the death of, or for injury to, passengers or other persons who are carried on board during such voyages. The guarantee is to be provided to the US Federal Maritime Commission (FMC) and is normally supplied by the ship’s P&I club.

Vicarious corporate liability for shipboard medical malpractice in the United States

Companies act through their agents and employees and can be sued based on the negligent act of an employee or agent committed within the scope of the employment or agency. The corporation is not vicariously liable, however, for negligent acts of independent contractors. Doctors and other medical staff were considered independent contractors by the Fifth Circuit Court of Appeal in Barbetta v. S/S Bermuda Star, 848 F.2d 1364 (5^th Cir. 1988)^[4].  In 2014, the 11^th Circuit Court of Appeal in a similar case found that the medical staff were agents and not independent contractors and thus the cruise line could be vicariously liable for their negligence. Franza v. Royal Caribbean Cruises, Ltd. 772 F.3d 1225 (11^th Cir. 2014)^[5].  The 11^th Circuit includes Florida where many of the cruise companies are located and subject to suit and at least in that jurisdiction, the cruise line will be subject to suit based on vicarious liability.

Liability to Persons other than seafarers and passengers for injury or illness

People other than crew or passengers are often on board operating ships. Some persons are carried on board the ship during the whole or part of the voyage in order to provide services or are otherwise on board with the consent of the master, for example pilots, supercargoes, riding repair crew. Other persons may be on board despite the fact that this was not planned or that the Master did not originally consent to their presence on board, for example stowaways, migrants and refugees rescued at sea. Furthermore, some persons may be on board whilst the ship is in port because they have some function to perform for example stevedores, port agents, government and local officials, ship suppliers or even if they have no function to perform but are merely visiting the ship or seafarers on board. In general terms the shipowner has a duty of care to all of these categories of persons and, since there are no relevant international conventions, the duty may arise either solely or collectively under a contract for services, statute or common law.  

The duty of care is not normally absolute since persons that are on board also have a duty to take reasonable precautions for their own safety and to comply with any safety instructions that may be made by the ship’s crew. The standard of care that is expected of them will often differ depending on the knowledge and experience that such persons are expected to have. For example, a technical person who has experience in ship operations is normally expected to exercise a greater degree of caution for his own safety than a family member who is visiting one of the seafarers.

^[3] Ref. 46 U.S.C. Section 30509

^[4] https://casetext.com/case/barbetta-v-ss-bermuda-star

^[5] https://casetext.com/case/franza-v-royal-caribbean-cruises

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In common law countries, (essentially the UK and former English colonies including the USA) a tort is an act or omission that causes harm to another and amounts to a civil wrong for which the courts impose liability.  The tort of negligence requires the claimant to prove that the defendant owed him or her a duty of care, that the defendant breached that duty and, as a consequence, the claimant suffered an injury.  Injuries are compensated through monetary damages.  https://www.law.cornell.edu/wex/tort