BRICE LODDÉ

A.6.1 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

A.6.2 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.

A.6.3 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?

A.6.4 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. 

A.6.5 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.

A.6.6 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).

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