
The latest edition of ethics guidance from the UK Faculty of Occupational Medicine 1 (FOM) was published in December 2012. It is now entitled 'Ethics guidance for occupational health practice' as opposed to 'Ethics guidance for occupational physicians' which was the title of previous editions. This is partly because in the UK occupational health is largely delivered by a multi-disciplinary team rather than a physician on his or her own, and it is expected that non-medical members of this team will be bound by the same ethical constraints. However, this commentary is written not for those occupational health professionals (OHPs), but primarily for those clinicians such as general practitioners (GPs) or hospital specialists who occasionally interact with OHPs about their patients. In the UK, GPs will be the ones who in practice communicate the most with OHPs, so I will concentrate on interactions between GPs and OHPs.
The main interest that GPs are likely to have in OH ethics is around the communication of information about their patients. Indeed, issues about confidentiality and consent form the basis of most of the ethical problems in OH. The information exchange can be considered in two directions: first, information from the GP to the OHP, and second, information from the OHP to the GP. In terms of the first type of informational flow, GPs will not infrequently receive requests for reports or other clinical information about their patients. This may be in order to provide the OHP with more information in their evaluation of the patient's fitness to work. In other cases, it could be to see whether the patient meets the medical criteria of a particular pension fund for ill-health retirement. In England and Wales, all such situations where a GP discloses such information are covered by the Access to Medical Reports Act (AMRA). 2 This process will already be familiar to GPs. Patient consent is required for this disclosure, and the patient has up to 21 days to read the report if he so chooses. What may be less familiar to GPs is that OHPs then need further patient (or worker) consent to disclose any information 3 to the commissioning party, such as managers or pension fund trustees. AMRA does not apply in the latter situation as the OHP is not the 'medical practitioner who is or has been responsible for the clinical care of the individual'. 4 The main difference is that the 21-day delay does not apply, and although it is not specified how long the patient has to read the report beforehand, most OH services allow between two and five days. In the UK, OHPs have very different roles and functions, sometimes in a 'quasi-therapeutic' relationship, and at other times in a very arm's length one, especially when advising whether a particular pension fund's medical criteria for ill-health retirement have been satisfied. 5 I have previously argued that the ethical guidance in those different roles should be different, but the current edition of the FOM guidance does not address this. For example, when the OHP is required to be completely independent when advising pension funds, this requirement for the worker to see the OHP report first (and consent to its release) is 'akin to a judge offering a defendant first sight of his judgment, and requiring the defendant's consent before delivering it'. 6 However, this is a matter that affects OHPs rather than GPs, so I will not discuss this further here. What matters to the GP though is to realise the extent to which his patient's clinical information continues to be kept confidential after he has shared it with an OHP, as it is not divulged to managers without the patient's consent. 7 In terms of the extent of information disclosure, the guidance warns that this should be 'suitable and relevant and not excessive. Blanket requests for a complete set of records can rarely be justified in occupational health practice'. 8 A clinical summary including functional capabilities and prognosis is usually helpful, but an opinion from the GP on the possible effect on employment or ill-health retirement is discouraged, not least because the GP is unlikely to be fully conversant with pension scheme rules, and would be straying outside his area of competence.
What about information exchange in the opposite direction, that is, from OHP to GP? Although the guidance recognises that sharing such information with the GP is likely to be beneficial, it advises that 'it should not be assumed that the worker would wish information to be shared in this way and consent should be sought on each occasion unless there are exceptional reasons for making a disclosure without it'. 9 At first sight, this may appear uncontroversial, as we generally expect any information exchange to be done with the worker's/patient's permission. However, in the UK, GPs have a long-term relationship with their patients and retain clinical responsibility for their care. So it would be unusual for other clinical information, say from secondary care or from an accident and emergency department, not to be shared with a patient's GP. Why would information held by an OHP be any different? Workers/patients may have their own reasons for not wanting their GP to know a particular piece of their medical history, whether it be their alcohol or illicit drug use, their raised blood pressure or their emotional symptoms. It is likely that the OHP will try to explain the benefits of their GP knowing such information. However, unless the OHP deemed that there were 'exceptional reasons', this information would be withheld from the GP. Although any piece of clinical information in itself may be unexceptional, a GP will hold a set of records which is usually the most comprehensive on that patient, and the additional information could be important at some point. If at a later stage, the lack of this particular information contributed to the patient suffering an adverse health outcome, could or should the OHP be held responsible? Does the OHP's wish to respect the worker's autonomy (if this is the justification in requiring consent) outweigh the possibility of harm in this way? This commentary aims to point this out as an issue worthy of further thought and debate, rather than to provide a definitive analysis of this question.
If I were to be critical of this guidance, then this criticism would be exemplified by the above. By taking a dogmatic approach on the issue of consent, it fails to consider the possible consequences against which this advice ought to be balanced, and this moral deliberation might at least have led to a more qualified statement about the need for consent before sharing a patient's information with his GP. Although the guidance aimed not to be a 'rule book', it is difficult to see how it would not be one if it fails to justify or explain the moral basis for the majority of its advice. However, this is not a problem that is confined to this guidance, but one that it shares with other codes of ethics. 10 On the other hand, to its credit, this edition includes vignettes which can form the basis of further reflection and moral deliberation. Future editions could build on this, with more ethically complex cases, and with more in depth analyses of the ethical conflicts that can arise. If in future phrases such as 'the ethical position is clearly. . .' could be avoided, without giving explanations and justifications for such statements, this would be a further area of improvement. If ethical guidance is indeed to guide, then it would be helpful if readers could gain insight in such reasoning, as well as the uncertainties and conflicts that arise in reaching that position. I would expect this would be helpful in their deliberations when faced with their own ethical problems.
In summary, for non-OH clinicians, this recent guidance can help in reassuring them that information disclosed to OHPs does not simply go directly to the employer. Their patient does have a further choice in how much of that information is disclosed by the OHP to the employer. On the other hand, some GPs may be surprised that OHPs are advised to withhold information from them if their patient does not consent to this being disclosed to their GP. I would suggest that this is an area that merits further discussion between GPs and OHPs.

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