Question

Choose and research a current ethics issue that is being debated in the field of taxation. Then, write a short paper that provides a brief overview of the issue, explains and supports your position on the ethics of the practice, and provides a solution to the ethical issue consistent with your viewpoint.

If you take the position that a practice is ethical, detail how you would go about addressing and responding to concerns of those opposed to the practice. If you believe a practice is unethical, present an approach that would reduce or eliminate the practice.

Answer 1

ETHICAL ISSUES: INFORMATION AND CONFIDENTIALITY

This article deals with the ethical issues that arise in the practice of occupational health activities, including occupational health research, with respect to the handling of information on individual employees, not in terms of practicality or efficiency but by referring to what may be regarded as right or wrong. It does not provide a universal formula for decisions on whether or not practices in handling information or in dealing with issues of confidentiality are ethically justified or defensible. It describes the cornerstone ethical principles of autonomy, beneficence, non-maleficence and equity and their implications for these human rights issues.

The basic principles used in ethical analyses can be used in examining the ethical implications in the generation, communication and utilization of other types of information as well as, for example, the conduct of occupational health research. Since this article is an overview, specific applications will not be discussed in great detail.

Scenario

On the labor market, in an enterprise, or at a workplace, health issues involve, first and foremost, free-living and economically active people. They may be healthy or experience health disturbances which are, in their causation, manifestation and consequences, more or less related to work and workplace conditions. Furthermore, a broad range of professionals and persons with various roles and responsibilities may become involved in the health issues concerning individuals or groups at the workplace, such as:

1. Employers and their representatives
2. Trade unions and their representatives
3. Health professionals
4. Social security and insurance administrators
5. Researchers
6. Media representatives.

Information arising in the practice or science of occupational health and the issues of need-to-know involve all these groups and their interaction. This means that the question of openness or confidentiality of information with regard to human rights, individual workers’ rights and the needs of employers or the needs of society at large is of broad scope. It may also be of high complexity. It is, in reality, an area of core importance in occupational health ethics.

Basic Considerations

The underlying assumption of this article is that people have a need and also a right to privacy. This means a need, and a right, to conceal and to reveal, to know as well as to be left in ignorance on various aspects of life in society and one’s own relations with the outer world. Likewise a collective, or a society, needs to know some things about individual citizens. With regard to other things there may be no such need. At the workplace or on the enterprise level, the issues of productivity and health involve the employer and those employed, both as a collective and as individuals. There are also situations where public interests are involved, represented by government agencies or other institutions claiming a legitimate need to know.

The question which immediately arises is how these needs are to be reconciled and what conditions should be satisfied before the needs to know of the enterprise or society can legitimately override the individual’s right to privacy. There are ethical conflicts needing to be resolved in this reconciliation process. If the needs to know of the enterprise or employer are not compatible with the needs to protect the privacy of the employees, a decision has to be made as to which need, or right to information, is paramount. The ethical conflict arises from the fact that the employer is usually responsible for taking preventive action against occupational health hazards. To exercise this responsibility the employer needs information on both working conditions and the health of the employees. The employees may wish some types of information about themselves to be kept confidential or secret, even while accepting the need for preventive measures.

Moral Perspectives

The ethical issues and conflicts in the occupational health sphere may be approached using the two classical ethical paradigms—consequentialist ethics or deontological ethics. Consequentialist ethics focuses on what is good or bad, harmful or useful in its consequences. As an example, the social ambition expressed as the principle of maximizing benefits for the greatest number in a community is a reflection of consequentialist ethics. The distinctive feature of deontological ethics is to regard certain actions or human behaviour as obligatory, such as for example the principle of always telling the truth—the principle of veracity—regardless of its consequences. The deontologist holds moral principles to be absolute, and that they impose an absolute duty on us to obey them. Both these paradigms of basic moral philosophy, separately or in combination, may be used in ethical assessments of activities or behaviours of humans.

Human Rights

When discussing ethics in occupational health, the impact of ethical principles on human relationships and the questions of needs to know at the workplace, it is necessary to clarify the main underlying principles. These can be found in international human rights documents and in recommendations and guidelines stemming from decisions adopted by international organizations. They are also reflected in professional codes of ethics and conduct.

Both individual and social human rights play a role in health care. The right to life, the right to physical integrity, and the right to privacy are of particular relevance. These rights are included in:

1. The 1948 Universal Declaration of Human Rights adopted by the United Nations
2. The European Convention for the Protection of Human Rights and Fundamental Freedoms (Council of Europe 1950)
3. The 1966 United Nations International Covenant on Civil and Political Rights

Of particular relevance for occupational health service personnel are the codes of conduct formulated and adopted by the World Medical Association. These are:

1. International Code of Medical Ethics (1949–1968) and Declaration of Geneva (1948–1968)
2. Declaration of Helsinki: Recommendation Guiding Medical Doctors in Biomedical Research Involving Human Subjects (1964–1975–1983)

Individual human rights are in principle unrelated to economic conditions. Their foundation lies in the right of self determination, which involves human autonomy as well as human liberty.

Ethical Principles

The principle of autonomy focuses on the individual’s right to self-determination. According to this principle all human beings have a moral obligation to respect the human right to self- determination so long as it does not infringe on the rights of others to determine their own actions on matters concerning themselves. One important consequence of this principle for the practice of occupational health is the moral duty to regard some types of information on individuals as confidential.

The second principle, the principle of care, is a combination of two ethical principles—the non-maleficence principle and the beneficence principle. The first prescribes a moral obligation for all humans not to cause human suffering. The beneficence principle is the duty to do good. It dictates that all humans are under a moral obligation to prevent and to eliminate suffering or harm and also to some extent to promote well-being. One practical consequence of this in the practice of occupational health is the obligation to seek in a systematic way to identify health risks at the workplace, or instances where health or life quality are disturbed as a result of workplace conditions, and to take preventive or remedial action wherever such risks or risk factors are found. The beneficence principle may also be evoked as a basis for occupational health research.

The principle of equity implies the moral obligation of all human beings to respect each other’s rights in an impartial way and to contribute to a distribution of burdens and benefits in such a way that the least privileged members of the community or the collective are given particular attention. The important practical consequences of this principle lie in the obligation to respect the right to self-determination of everyone concerned, with the implication that priority should be given to groups or individuals at the workplace or in the labour market who are most vulnerable or most exposed to health risks at the workplace.

In considering these three principles it is proper to re-emphasize that in the health services the autonomy principle has in the course of time largely superseded beneficence as the first principle of medical ethics. This in fact constitutes one of the most radical re-orientations in the long history of the Hippocratic tradition. The emergence of autonomy as a sociopolitical, legal and moral concept has profoundly influenced medical ethics. It has shifted the center of decision-making from the physician to the patient and thereby re-oriented the whole physician-patient relationship in a revolutionary way. This trend has obvious implications for the whole field of occupational health. Within the health services and biomedical research it is related to a range of factors which have an impact on the labour market and industrial relations. Among these should be mentioned the attention given to participatory approaches involving workers in decision processes in many countries, the expansion and advance of public education, the emergence of civil rights movements of many types and the rapidly accelerating technological changes in production techniques and work organization.

These trends have supported the emergence of the concept of integrity as an important value, intimately related to autonomy. Integrity in its ethical meaning signifies the moral value of wholeness, constituting all human beings as persons and ends in themselves, independent in all functions and demanding respect for their dignity and moral value.

The concepts of autonomy and integrity are related in the sense that the integrity is expressing a fundamental value equivalent to the dignity of the human person. The concept of autonomy rather expresses the principle of freedom of action directed towards safeguarding and promoting this integrity. There is an important difference between these concepts in that the value of integrity admits no degrees. It may be either intact or violated or even lost. Autonomy has degrees and is variable. In that sense autonomy can be more or less restricted, or, conversely, expanded.

Privacy and Confidentiality

Respect for the privacy and confidentiality of persons follows from the principle of autonomy. Privacy may be invaded and confidentiality violated by revealing or releasing information that can be used to identify or expose a person to unwanted or even hostile reactions or responses from others. This means that there is a need to protect such information from being disseminated. On the other hand, in the event the information is essential to discover or prevent health risks at the workplace, there is a need to protect the health of individual employees and indeed sometimes the health of a larger collective of employees who are exposed to the same workplace risks.

It is important to examine whether the need to protect information on individuals and the need to protect the health of the employee collective and to improve working conditions are compatible. It is a question of weighing the needs of the individual versus the benefits of the collective. Conflicts may therefore arise between the principles of autonomy and beneficence, respectively. In such situations it is necessary to examine the questions of who should be authorized to know what and for what purposes.

It is important to explore both these aspects. If information derived from the individual employees could be used to improve working conditions for the benefit of the whole collective, there are good ethical reasons to examine the case in depth.

Procedures have to be found to deny unauthorized access to information and to use of the information for purposes other than those stated and agreed on in advance.

Ethical Analysis

In an ethical analysis it is essential to proceed step by step in identifying, clarifying and solving ethical conflicts. As has been mentioned earlier, vested interests of various kinds, and of various actors at the workplace or in the labour market, can present themselves as ethical interests or stakeholders. The first elementary step is therefore to identify the main parties involved and to describe their rational interests and to locate potential and manifest conflicts of interests. It is an essential prerequisite that such conflicts of interests between the different stakeholders are made visible and are explained instead of being denied. It is also important to accept that such conflicts are quite common. In every ethical conflict there are one or several agents and one or several subjects concerned by the action undertaken by the agent or agents.

The second step is to identify the relevant ethical principles of autonomy, beneficence, non-maleficence and equity. The third step consists in identifying ethical advantages or benefits and costs or disadvantages for those persons or bodies who are involved in or affected by the problem or the occupational health issue. The expressions ethical gains or ethical costs are here given a rather broad meaning. Anything which may reasonably be judged to be beneficial or to have a positive impact from an ethical point of view is a gain. Anything which may affect the group in a negative way is in an analogous way an ethical cost.

Solution

These basic principles of ethics (autonomy, beneficence and equity) and associated steps of analysis apply both for handling of information in the day-to-day practice of professional occupational health work and for handling and communication of scientific information. Seen in this perspective, the confidentiality of medical records or results of occupational health research projects may be analysed on the principal grounds outlined above.

Such information may for instance concern suspected or potential health hazards at work, and it may be of varying quality and practical value. Obviously the use of such information involves ethical issues.

It is to be emphasized that this model for ethical analyses is intended primarily for structuring of a complex pattern of relationships involving the individual employee, the employees at the enterprise as a collective and vested interests at the workplace and in the community at large. Basically, in the present context, it is a pedagogic exercise. It is fundamentally based on the assumption, from some quarters regarded as controversial in moral philosophy, that the objective and correct solution in an ethical conflict simply does not exist.

(We) are ourselves the ultimate and irrefutable arbiters of values and in the world of value nature is only a part. Thus, in this world we are greater than Nature. In the world of values, nature itself is neutral, neither good nor bad, deser- ving neither admiration nor censure. It is we who create values and our desires which confer value. In this realm we are kings, and we debase kingship if we bow down to Na- ture. It is for us to determine the good life, not for Nature—not even nature personified as God (Russell 1979).

This is another way of saying that the authority of ethical principles, as referred to earlier in this text, is determined by the individual person or group of persons, who may or may not agree as to what is intellectually or emotionally acceptable.

This means that insolving ethical conflicts and problems the dialogue between the different interests involved assumes significant importance. It is essential to create a possibility for everyone concerned to exchange views with the others involved in mutual respect. If it is accepted as a fact of life that there are no objectively correct solutions for ethical conflicts, it does not follow that the definition of ethical positioning is entirely based on subjective and unprincipled thinking. It is important to keep in mind that issues related to confidentiality and integrity may be approached by various groups or individuals with points of departure based on widely differing norms and values. One of the important steps in an ethical analysis is therefore to design the procedure for contacts with and between the persons and collective interests concerned, and the steps to be taken to initiate the process ending in agreement or disagreement with respect to the handling or transfer of sensitive information.

Lastly, it is emphasized that ethical analysis is a tool for examination of practices and optional strategies of action. It does not provide blueprint answers to what is right or wrong, or to what is thought to be acceptable or not acceptable from an ethical point of view. It provides a framework for decisions in situations involving the basic ethical principles of autonomy, beneficence, maleficence and equity.

Second Part of the Question

Addressing and responding to concerns of those opposed to the practice

Get the Facts

• What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision?
• What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?
• What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

Evaluate Alternative Actions

• Evaluate the options by asking the following questions:
• Which option will produce the most good and do the least harm? (The Utilitarian Approach)
• Which option best respects the rights of all who have a stake? (The Rights Approach)
• Which option treats people equally or proportionately? (The Justice Approach)
• Which option best serves the community as a whole, not just some members? (The Common Good Approach)
• Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

• Considering all these approaches, which option best addresses the situation?
• If I told someone I respect -- or told a television audience -- which option I have chosen, what would they say?

Act and Reflect on the Outcome

• How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?
• How did my decision turn out and what have I learned from this specific situation.

Dealing with Unethical practice

Here are seven practices to help prevent unethical actions in any organization:

• Create Policies and Practices: Organizations must research, develop, and document policies and processes around defining, identifying, and reporting ethics violations.

• Hire Right: Selecting quality people from day one can make a huge difference in the ethics of your organization. Some organizations scour background checks, purchase screening tools, or use behavior-based interview questions, which may ask candidates to describe a situation when they acted ethically even when it was against social or cultural norms.
• Develop People's Understanding: Most HR professionals will tell you that training people to act "ethically" will not have much of an impact, but developing a process for reporting ethics violations and building staff understanding about ethics expectations is important.
• Incent the Right Thing: Some in the education community are asking, "Do states and school districts incent people to cheat or act unethically by giving more weight to certain measures over others?" Before introducing a new measure in schools--or any other industry--leaders must consider if it encourages the type of actions that are valued by the organization. If there is a risk of impropriety, it is important to have a conversation around what checks and balances will be put in place to make sure unwanted behaviors are handled appropriately.

• Put Controls in Place: Risk management professionals will tell you that even with all the proper policies and processes in place and a staff that understands them, it is also wise to perform regular audits to help reduce opportunities to act unethically, incent individuals who may act unethically to reconsider, help catch issues that have occurred by accident, and mitigate risk all around.
• Build a Culture of Transparency, Openness, and Communication: Cultural management work is difficult. To ensure true success when it comes to organization ethics, people must see and hear what is going on as well as feel comfortable to stand up and speak out if they see something occur that is not right.
• Leadership Must Walk the Talk: Leaders can talk about the importance of policies and processes, incentives, communication, and openness all day, but if they turn around and act unethically, it can be like throwing a large stone into the pond of ethics tranquility. The same goes for promoting staff who have behaved unethically. It doesn't take long for staff at all levels of an organization to recognize a leader who talks the talk, but doesn't walk the walk when it comes to ethics. This can breed suspicion and destroy trust.