NITO Norwegian Institute of Biomedical Science

“Never forget that each day

offers you an opportunity -

the opportunity to create lifelong

memories in a fellow human being.

You are possessed of a power,

which means that anyone

accepting your services is in your hands

and subject to your whims, your mood,

your commitment, whether

you are having a good day or not.

In the middle of a hopeless situation

you can choose whether you will be

a good or a bad memory

that the patient will never forget.”

Ingegerd Seljeskog

Ethical reflections for the committed BLS

Ethics for Biomedical Laboratory Scientists

IntroductionContents

Guidelines for the professionalethics of Biomedical LaboratoryScientists were adopted in 1996.They are intended to be a resourcefor the profession and a support tothe individual in challengingsituations. At the same time theyare society’s guarantee that theBiomedical Laboratory Scientist(BLS) practises his profession in anethically sound manner. This ethicsbooklet has been prepared by theEthics Committee (YER) in orderto focus on ethical reflection in thepractice of the BLS profession.Ethical reflection contributes toprofessional awareness andstrengthens our professionalidentity. The booklet builds onprevious work by the NorwegianInstitute of Biomedical Science(BFI) and its predecessororganisation.

The ethics booklet can be used asan aid to focus on ethics and ethicaldilemmas that the BLS meets in hisdaily work situation. This can bedone in various ways: we can, forexample, establish study ordiscussion groups with a mandateto spotlight the ethical dilemmas inthe day-to-day work of a BLS; thebooklet may also be used in thetraining of BLS students. Theexamples can be drawn either fromthe topics described in the ethicsbooklet or from the BLS’experience in his own work.Biomedical Laboratory Scientistsand BLS students who participatein fora in which professional ethicsare discussed will rapidly discoverthat they are better-prepared toencounter ethical issues in theirday-to-day work.

The booklet goes through the BLSprofessional ethical guidelinespoint by point, and for each of thesepoints presents an ethical dilemmafor discussion. These dilemmas aretaken from the professional group’srelationships with the patient, to thediscipline, to the workplace and tosociety. The biomedical scientist is

challenged to discuss thesedilemmas on the basis ofprofessional expertise, experience,values, professional ethicalguidelines, and national legislationand regulations. In many casesthere is no “absolute answer” to thequestions raised in the ethicsbooklet.

The Ethics Committee is anindependent consultative bodywithin the BFI, with a mandate toconsider violations of the BLSprofessional ethical guidelines andif appropriate propose sanctions toBFI’s Board. Other missions of theEthics Committee are to advise andguide the organisation and itsindividual members in questions ofprofessional ethics, to monitorsocial trends that can create ethicaldilemmas for the BLS, and to assistthe BFI Board in its work ofconsciousness-raising as regardsethical reflection. The EthicsCommittee consists of a chairman,two permanent members and adeputy, elected for three years at atime from among the BFI membersby postal ballot. The BFI Boardalso appoints one of its ownmembers to the Ethics Committeeas an observer.

The BFI hopes that the booklet willbe extensively used, and wouldremind the readership that itsjournal Bioingeniøren is a forumfor exchange of experiences andopinions about ethics forbiomedical laboratory scientists.

Supplementary information onethics, contributors, bibliographyand more cases for discussion canbe found on NITO’s website,www.nito.no/bfi, click on ‘yrkesetikk’.

Introduction 3

Professional Ethical Guidelines for Biomedical Laboratory Scientists 4

Theory 6

Preface 6

Important terms and concepts 8

Ethical theories 9

Summary 12

Extracts from the legislation on confidentiality 13

Reflections on the professional ethical guidelines 14

1 The BLS must demonstrate respect for life and for the inherent dignity of human beings 14

2 The BLS must show respect for the patient’s right to informed consent,

autonomy and integrity 14

3 The BLS must perform his work in a professionally sound manner, taking

responsibility for his own actions 15

4 The BLS must treat all biological material with respect 16

5 The BLS should help to promote life sciences 17

6 The BLS must be loyal to workplace agreements and instructions, as long as these do

not conflict with our professional ethical guidelines 17

7 The BLS must demonstrate respect and solicitude for his colleagues 18

8 The BLS must respect other professional groups’ disciplines and areas of responsibility 18

9 The BLS must make his professional expertise available also in crises 18

10 The BLS should be active in the debate about the environment 19

11 The BLS should contribute to highlighting ethical aspects in debates about

health and social issues 19

2 3

1. The BLS must demonstrate respect for life and for the inherent dignity of human beings

1.1 Every human being contains within himself an inherent dignity and an equal right to respect regardless of race, sex, age, culture, religion, political opinion, medical condition and life situation

2. The BLS must show respect for the patient’s right to informed consent, autonomy and integrity

2.1 The BLS must practice his profession in such a way that the patient feels secure

2.2 The BLS must be considerate of the patient and his family

2.3 The BLS must focus his attention on the patient

2.4 The BLS must inform the patient about the bioanalytical aspects of the treatment

2.5 The BLS must protect private and medical information from unauthorised access

3. The BLS must perform his work in a professionally sound manner and take responsibility for his own actions

3.1 The BLS must acknowledge his professional responsibility

3.2 The BLS ought to reflect over the ethical conse-quences of the work he does

3.3 The BLS must maintain his skills and make sure that he renews them

4. The BLS must treat all biological materialwithrespect

5. The BLS should help to promote life sciences

5.1 The BLS must make sure that the research work in which heis participating is approved

5.2 The BLS should turn down research work that conflicts with his own convictions

5.3 The BLS must treat animals with consideration and respect

Professional Ethical Guidelines forBiomedical Laboratory Scientists

6. The BLS must be loyal to workplace agreements and instructions, as long as these do not conflict with our professional ethical guidelines

6.1 The BLS must react if the main objectives conflict with our professional ethical guidelines

7. The BLS must demonstrate respect and solicitude for his colleagues

7.1 The BLS must display tolerance for the work, methods and life-situations of others

8. The BLS must respect other professional groups’ disciplines and areas of responsibility

8.1 The BLS must contribute towards good cooperation with other professional groups. In the event of conflicts of interest, the patient’s life and health shall come first

9. The BLS must make his professional expertise available also in crises

10.The BLS should be active in the debate about the environment

11. The BLS should contribute to highlighting ethical aspects in debates about health and social issues

11.1 The BLS should work for an allocation and use of resources that ensures ethically sound operations in the laboratories and in the rest of the health service

4 5

What is right and what is wrong,what is good and what is evil? Howcan we really encounter one anotherand what happens in these meetings- in communication between humanbeings?

Our actions and attitudes reflect andexpress our values. Values saysomething fundamental about whatis right or wrong, good or evil, trueor untrue, just or unjust. Thesevalues depend on our beliefs, ourconvictions and on the culture andthe age we live in. It is our valuesthat guide us and give us the driveand motivation for our actions andattitudes, and there is much scopefor difference here. We may not beaware of what is valuable for eachone of us until we find ourselvesfacing a difficult encounter, asituation that we haven’t metbefore, a conflict or a life-crisis. Tolook on the bright side, such an

experience gives us the opportunityto get to grips with what actuallycontrols us, the fundamental valuesin our life. Knowing somethingabout this may give us security,solid ground on which to stand andmeet new challenges. Another wordfor this is identity; the core ofidentity is an experience of securityand trust.

Ethics and morality are aboutvalues, about what is fundamentallyimportant in culture, in society andfor the individual. Morality, wemight say, is about what we knowto be right and wrong, what isgenerally known and accepted andwhat governs a society’s legalsystem, the rules of the road for thatparticular society. Ethics, on theother hand, are a matter ofreflecting about what is right orwrong, good or evil, when we areuncertain what is right or wrong, or

when we are facing something newand unknown - a unique situationwith unique individuals. An ethicaldilemma will often be experiencedas a choice between two options,both of which may be right orproper. Such dilemmas are a bigchallenge to our capacity for ethicalreflection. Ethics generally containan element of humility - whatwould be right to do in preciselythis unique situation between theseunique individuals? It is in thiscontext that Ole Danbolt Mjøs’aphorism “ethics iscommunication” becomes relevant.Another expression ofcommunication is dialogue:listening to one another, trying to understand one another, getting toknow one another, and respectingone another’s position and takingresponsibility. For this we need thesecurity and trust to know and feelwhat is important for you and for

Preface

me. Identity and dialogue -dialogueis not possible without identity.

Our view of humanity, how we seeand understand ourselves and oneanother, is an important part of anyencounter. This outlook isfundamental to ethics. Our era isoften dominated by “perfection”;we make heavy demands onourselves and one another - theperfect body, the perfect career, theperfect happiness ...What does sucha view of humanity mean forethics? Where do we find room forthe weak, the vulnerable, theimperfect, for compassion and care,for humanity, for the “terrifiedchild” inside all of us?

We are living in an age with greatchallenges in the form of increasedcommunication, of encountersbetween people from differentcultures and religions, of conflicts,

and of meetings with new ethicalproblems caused by technologicaldevelopments in genetics andbiotechnology. Biomedicallaboratory scientists are caught inthe crossfire every day. Our societyand the age we live in has becomeso much more complex in relationto what came before; this affectssocial ethics and morality, whichare obliged to deal with new andexciting challenges. And thisconfronts biomedical laboratoryscientists with important challengesto the practice of the profession.

The preface was written by EvaBohlin, who has held a numberof offices of trust in theNorwegian Institute ofBiomedical Science and itspredecessor organisations,most recently as a member ofthe Ethics Committee between1999 and 2001 and as itschairperson between 2002 and2004.

“Ethics is communication!”

With these words Ole Danbolt Mjøs,

Professor of Medicine at the University of

Tromsø and chairman of the Norwegian

Nobel Committee, opened his address to

the 2003 Nordic BLS Conference in

Tromsø.

The recurrent theme of Mjøs’ address

was reflections on the nexus of ethics,

human beings and communication: how

we encounter one another is a matter of

ethics.

6 7

There are several ways to classifyethics and ethical theories. Oneapproach is to divide ethics intothree main categories:metaethics, descriptive ethicsand normative ethics.

Metaethics means the moreabstract and theoretical approach toethics, it is a “theory abouttheories” and involves discussingthe actual cognitive frameworksbehind the specific ethicalreflection.

Descriptive ethics does not take aposition on what is right or wrong,it looks at what is and not whatought to be.

Normative ethics sets up normsfor and evaluations of the rightthing to do in various situations.Normative ethics is further dividedinto ethical theory and appliedethics. Ethical theory deals withdifferent ethical models for rightaction, for example deontologicaland consequentialist ethics, virtueethics, closeness ethics anddiscourse ethics. Ethical theoryforms the basis for applied ethicssuch as for example medical ethics,research ethics and environmentalethics. Professional ethics such asthe code for Biomedical LaboratoryScientists, also comes underapplied ethics. Normative ethics deals with whatought to be, what is right or wrong.Normative ethics may form aspringboard for reflection anddiscussion of ethical dilemmas inone’s day to day work.

We shall now describe five ethicalschools. It is important to

understand that these differenttheories about right action are onlytheoretical models, but they canstill form the basis for right action.It will often be the case that one isnot certain of one’s choice, and thenmore than one theory or model canbe used. Deploying the ethicaltheories together in this way mayhelp to structure our reflection.They can be used to analyse thesituation and the conflict betweencontradictory values so as to find agood solution. This is an excitingchallenge, where the aim must befor all involved parties to accept thechoice of solution and to grow intrust and security. Dialogue andidentity are fundamental values inthis connection.

Deontological ethicsThis term comes from the Greekword for ‘duty’, and this ethicalschool focuses on the act itself,paying much less attention to itsconsequences. A duty is imposed onus by ourselves or by others; it is anabsolute requirement to which wemust simply conform. Duties cangenerally be expressed as rules andnorms, such as for example the TenCommandments’ “Thou shalt notkill” or “Thou shalt not bear falsewitness”. The most famousdeontologist is the Germanphilosopher Immanuel Kant, wholived in the 18th century and set outto base ethics on ‘pure reason’. ForKant, an act was only moral if itwas committed out of a sense ofduty, for objective reasonsindependent of personal likes anddislikes. His Categorical Imperativewas, “Act as if the maxim of youraction were to become, by yourwill, a universal law”. That is, an

act is moral only if everyone can doit in the same situation, there is tobe no special pleading along thelines of “But that doesn’t apply tome!” Of equal importance was theprinciple that a human being mustnever be used as a means to an end,but must always be treated as anend in himself.

An example of an ethical dilemmais the use of fertilised human eggsfor the production of stem cells foruse in research and treatment ofillness. If we regard this from aKantian perspective, and if we alsoregard a fertilised egg as anindependent individual, then itcannot be used as a means forproduction of stem cells, despite thefact that the purpose is a good one.

Professional ethical guidelines havetraditionally been regarded asdeontological rules. In recent yearsthis has been called into question.On the one hand there is a danger inonly relating to the duty, the rule,because the ethical dilemmas are socomplex. On the other side, theduty can be a strength and asupport; we must all deal withdifferent sets of regulations if oursociety and workplace is tofunction.

Consequential ethicsConsequential ethics - also calledteleological ethics (from the Greekfor end) or utilitarianism (from theLatin for benefit) - treats the act assubordinate to the goal of the act,its consequences. The goal of theact is to achieve a good; the actitself is merely a means ofpromoting the general happinessand welfare, the “greatest happiness

Value, value system“Value” means everything offundamental importance for humanbeings. Examples of ethical andmoral values are love, respect,justice, freedom, happiness, hope,security, honesty and compassion.

Norm A “norm” is a rule of action, a valuethat manifests itself in attitudes andis expressed in concrete action. Anexample of the norm is the GoldenRule: “Do unto others what youwould have them do unto you”.Other norms include theprofessional ethical guidelines ofthe health professions; and the TenCommandments.

Morality and ethics“Morality” comes from the Latinmos, plural mores, meaningcustom. “Ethics” comes from the Greekethike, and carries the samemeaning, namely custom.There are, however, importantdifferences between morality andethics.

It can be said this way, that moralityis based on tradition and exerts anauthoritarian social pressure on theindividual, whereas ethics aremeant to guide us also in abnormaland unforeseen situations. Wemight also say that ethics meansreflecting over what is right or goodto do in a given situation and ischaracterised by humility andopenness vis-à-vis the ethicaldilemma. One example of such adilemma is free abortion. Herethere are two parties: the foetus thatthe woman is carrying, and thewoman herself. The correctdecision means balancingcontradictory values, the foetus’right to life and the woman’s rightto control her own life. In addition,the father of the child may beentitled to participate in the choiceof solution. There are no simpleanswers, because there arecontradictory ethical principlesinvolved. That is what makes it anethical dilemma.

Important terms and concepts

Ethical theories

8 9

of the greatest number” cannot besolved mathematically, since wecan choose to make everyone alittle happy or some people veryhappy - or even purchase thehappiness of the many with themisery of the few.

If we discuss the use of fertilisedhuman eggs for production of stemcells, the outcome of the discussionwill be different to what we foundusing deontological ethics. Stemcells can be used in research andtreatment of diseases, benefitingmany people. In consequentialethics, a fertilised egg may be ameans to achieving moreknowledge of disease and to curingit. What from a deontological pointof view is unacceptable, therefore,consequential ethics may regard asright and good.

Another relevant dilemma may behow priorities are set in theNorwegian health sector. Thechallenge is to get as much benefitout of the resources available. Insuch a situation, many of the plansdrawn up will be governed byeconomics. The individual mayexperience that his value as ahuman being receives less emphasisin consequential ethics than wouldbe the case in deontological ethics.On the other hand, consequentialethics are essential to the allocationof social goods.

Virtue ethics, associated withAristotle, take a third approach:neither rules nor consequences, butwhat kind of person I wish tobecome, and what kind of personthe act would make me. This schoolis less relevant to the health sector,

and so will not be discussed further.

Discourse ethicsDiscourse ethics is about thecommunicative fellowship as anethical foundation, about discourseand dialogue - the rationalconversation. An ethical dilemmausually arises in a meeting, in aconflict situation, and involvesseveral participants. Each of thesehas a right to be respected. The goalof the conversation should be toarrive at a consensus solution. Ourage, characterised as it is byincreasing complexity, willnaturally enough put the meeting,the dialogue, in the centre, anddiscourse ethics is about preciselythis. A big challenge here is to showrespect for the opinions of thevarious actors who are involved insolving an ethical dilemma.

Traditional ethics focuses on theindividual: “How can I be sure thatI am acting rightly?” For ImmanuelKant it was self-evident that anaction arose from the individual’sreason and objectivity, making itright, good and universal, andconsequently a solution for severalparties in an ethical dilemma.

Discourse ethics is an excitingexample of how ethics and moralityare affected by changes and newknowledge. Behind the words“ethics are communication”(1) liesnew knowledge in psychology andeducational science, and ethics arebeing incorporated intopsychodynamic thinking aboutattitudes and actions. Discourseethics agrees that ethical dilemmasare to be resolved on the basis ofhuman reason, but here the

emphasis is on interaction, thedynamic between several involvedparties and the demand that itshould be possible to reach aconsensus. A fundamental principleof discourse ethics is that all peopleare equal. This means that everyonehas a right to participate indiscussions of matters concernthem, and to be heard (2). Onceagain, it is all about thefundamental values of dialogue andidentity.

Closeness ethics and medicalethicsCloseness ethics, a fifth type ofethical theory developed largely inDenmark and Norway, focuses onthe encounter with the Other, ourfellow-creature. According tocloseness ethics, being in asituation with another human beingis the same as being in a moralsituation (3). Closeness ethicsappeals to values such as duty andresponsibility, respect and care, onthe basis of these values arisingfrom a common human experienceand a common human practice.

The Danish philosopher SørenKierkegaard wrote that “Therelationship between the helper andthe person to be helped must be asfollows - when in truth onesucceeds in leading a person to aparticular place, one must first andforemost make sure to find himthere where he is, and start there” (4).In our ordinary work as biomedicallaboratory scientists, we meet ourfellow-creatures every day. Manyof them are in an exposed lifesituation, struck down by illness,perhaps threatened by the loss ofhealth or life itself. They can be

vulnerable and they appeal to ourcaring instincts, our respect and oursense of responsibility. This meansthat we must endeavour tounderstand and empatheticallyshare in their life situation, and atthe same time maintain a distanceand respect their dignity.

In closeness ethics the termsautonomy, integrity and informedvoluntary consent are relevant andmeaningful. These are terms thatbelong to medical ethics. It is aquestion of dignity, the preservationand maintenance of human beings’self-respect and quality of life. Autonomy means self-determination, the right to decideone’s own life and destiny. Integrityis about establishing a frameworkfor one’s own identity, preservingself-esteem, authority and respect.Informed voluntary consent meansa right to good and clearinformation on measures andtreatment for the person concerned;it also involves the right to say noand refuse treatment. Knut ErikTranøy puts it like this: “The threeconcepts autonomy, integrity andinformed voluntary consent are partof one and the same package ofmedical ethics. If we accept theone, we accept all of them; and wecannot say no to one of themwithout denying the two others too.Even so we can probably say that itis integrity, the demand for respectfor human dignity, that isfundamental.” (5)

Closeness ethics and medical ethicspoint up an ethical dilemma: not toviolate or abuse the power that aBLS has by virtue of hisprofessional expertise. The patient

may have little knowledge about hisdisease or condition, whichpresents a clear risk of the abuse ofpower. This risk is clear enough tothe patient, who easily feelspowerless. Paternalism in thiscontext means that we as healthpersonnel interpret the patient’sneeds, that we know best. This mayhave the consequence that thepatient’s will and desires areoverridden, that the patient’s voiceis not heard. Paternalism is a threatto integrity and autonomy.

The duty of confidentialityThe duty of confidentiality iscentral to medical ethics. It goesback as far as the Hippocratic Oath,c. 420 BC. Hippocrates wrote that:“Whatever, in connection with myprofessional practice, or not inconnection with it, I see or hear, inthe life of men, which ought not tobe spoken of abroad, I will notdivulge, as reckoning that all suchshould be kept secret.” (6)

The duty of confidentiality isfundamental to a relationship oftrust between the patient and thetherapist, and health personnel’sduty of confidentiality is governedby several laws. It is both necessaryand useful to know what thelegislation says about the duty ofconfidentiality.

Under the Patients’ Rights Act,health personnel have no duty ofconfidentiality vis-à-vis the patient;on the contrary, we have a duty ofinformation. In principle the patientis the owner of all informationabout himself, and as biomedicallaboratory scientists we areresponsible for providinginformation on the bioanalyticalcomponent of his treatment.

Ethical theories

10 11

In order to make the connection between value, norm and view ofhumanity in ethics clearer, we may use the structure of a house asmetaphor.The foundations are the value system and the view of humanity. These willvary between religion, beliefs, society and culture. On the ground floor we find norms and values translated into rules ofaction, ethics, theories and models in moral philosophy, such asdeontological ethics and consequential ethics. These represent differentattempts to answer the question of how to act well. On the upper floor we find the challenge to solve the ethical dilemma,which can be characterised as a conflict between different, perhapscontradictory, values and interests, and involving unique individuals in aunique situation. Here we are challenged to reflect over what would beright and true. A solution of the ethical dilemma or conflict situation willprobably be based on an interaction between different theories andmodels, and on one’s own knowledge, experience and security, outlookand view of humanity. It may be necessary to reconsider one’s valuesystem for attitudes and actions, to try another approach to the dilemma.The links between the various floors in the house must be living and openfor the best solution to be achieved; a solution that gives both security andtrust in which the parties involved can rest; a solution based on dialogueand identity.

Section 13 of the PublicAdministration Act,which governs all public employees,says:“It is the duty of any personrendering services to, orworking for, an administrativeagency, to prevent others fromgaining access to, or obtainingknowledge of, any matterdisclosed to him in the courseof his duties concerning ...”

The main rule onconfidentiality in theHealth Personnel Act isto be found in Section 21: “Health personnel shall preventothers from gaining access toor knowledge of informationrelating to people’s health ormedical condition or otherpersonal information that theyget to know in their capacity ashealth personnel.”

Section 23 restricts the duty ofconfidentiality as follows: “Theduty of confidentiality pursuantto Section 21 is not to prevent:1. information from being madeknown to a person who alreadyhave previous knowledge of theinformation, 2. information from beingprovided when there are novalid interests to indicatesecrecy, 3. information from beingpassed on if the need forprotection must be regarded asbeing adhered to if identifying

characteristics have beenomitted, 4. information from beingpassed on if exceptionalprivate or public grounds makeit legitimate to pass on theinformation, or 5. information from beingpassed on in accordance withrules laid down in or pursuantto law when it has beenexpressly stated or clearlypresumed that the duty ofconfidentiality shall not apply.”

Section 121 of theGeneral Civil Penal Codesays:“Any person who wilfully orthrough gross negligenceviolates a duty of secrecywhich in accordance with anystatutory provision or validdirective is a consequence ofhis service or work for anystate or municipal body shall beliable to fines or imprisonmentfor a term not exceeding sixmonths. If he commits suchbreach of duty for the purposeof acquiring for himself oranother person an unlawfulgain or if for such a purpose hein any other way usesinformation that is subject to aduty of secrecy, imprisonmentfor a term not exceeding threeyears may be imposed. Thisprovision also applies to anybreach of the duty of secrecycommitted after the personconcerned has concluded hisservice or work.”

Summary Extracts from the legislation on confidentiality

Section 3-2 of thePatients’ Rights Actsays the following on thepatient’s right to information: “The patient shall have theinformation that is necessaryto obtain an insight into his orher health condition and thecontent of the health care. Thepatient shall also be informedof possible risks and sideeffects.”

(Source: www.lovdata.no )

12 13

aware of one’s own attitudes iscrucial to being able to handle analmost unlimited access toinformation in a proper manner(7,8,9).

Many biomedical laboratoryscientists work in close contact withthe patient. This contact is oftenquite short, and it might feel as ifthat the brief moment together witha patient cannot have muchsignificance for the patient. InIngegerd Seljeskog’s words aboutthe encounter with the patient, weare given food for thought in ourdaily meeting with the patient: “Never forget that each day offersyou an opportunity - theopportunity to create lifelongmemories in a fellow human being.You are possessed of a power,which means that anyone acceptingyour services is in your hands andsubject to your whims, your mood,your commitment, whether you arehaving a good day or not. In themiddle of a hopeless situation youcan choose whether you will be agood or a bad memory that thepatient will never forget. The painis forgotten when the crisis is over,but the interpersonal experiencesare something that the patient willremember: I met a person who * cared about me* found me a good position so that I

could rest * wiped my brow* touched me with sensitive hands* gave me time* remembered my questions* when he was in the room, even

for just a few minutes, was really present with me

* who listened and saw that I was down, or saw that I was in pain without my having to say

The patient will remember the bad things also:* you touched me roughly, and

turned me over with sudden movements

* you ignored my pain and despair * you forgot my questions * you were in the room, but you

didn’t see me - your mind was elsewhere

* your words wounded, confused and sowed anxiety in me” (10)

What are your thoughtsabout this situation inrelation to Point 2 of the professional ethicalguidelines?

The BLS is on a phlebotomyround and meets the followingsituation: an elderly woman isin a private room. She isseriously ill. In the room withher are her two daughters, whohave been there all night. Therelatives ask how necessarythe tests are, and they think weare needlessly tormenting her.

Point 3 of theprofessional ethicalguidelines:

The BLS must perform hiswork in a professionallysound manner, takingresponsibility for his ownactions

3.1 The BLS must acknowledge his professional responsibility

3.2 The BLS ought to reflect over the ethical consequences of the work he does

3.3 The BLS must maintain his skills and make surethat he renews them

Under the Health Personnel Act,health personnel shall perform theirwork in accordance with therequirements of professionalismand caring help that can beexpected on the basis of the healthpersonnel’s qualifications, thenature of the work and the situationotherwise. (7)

The statutory professionalresponsibility also involves a dutyof disclosure to partners such asother health professions and theauthorities. We also have theresponsibility for informing thepatient about the bioanalytical partof the treatment.

Our professional responsibilityinvolves a duty to maintain andupdate our expertise. Competencydevelopment is a responsibilityshared by the individual employeeand the employer. An importantpart of the competency

Point 1 of theprofessional ethicalguidelines:

The BLS must demonstraterespect for life and for theinherent dignity of humanbeings

1.1 Every human being contains within himself aninherent dignity and an equal right to respect regardless of race, sex, age, culture, religion, political opinions, medicalcondition and life situation

Respect for life and health isfundamental to the practice of ourprofession. All human beings havean inherent dignity, an innate valueindependent of the factorsmentioned above. The BLS mustrelate to different kinds of peopleamong colleagues, patients andnext of kin. All of us carry with usour own values and norms, whichin turn affect our reflections andactions.

These lines may remind us that it isby no means obvious that we canunderstand what other people arethinking and feeling: I can see that you are laughing, butI cannot see whether you are happy.I can see that you are smiling, but Icannot see whether you like me.I can hear you speaking softly withanother person, but I do not knowwhat about.I can see and hear that you arecrying, but I cannot see whetheryou are afraid, sad or in despair.

What are your thoughtson this situation inrelation to Point 1 of the professional ethicalguidelines?

Imagine a situation in whichyour attitudes are challenged inrelation to the patient. How doyour attitudes affect yourbehaviour? Are there situationsin which your uncertaintymakes it difficult to treatpatients with respect?

Point 2 of theprofessional ethicalguidelines:

The BLS must show respectfor the patient’s right toinformed consent, autonomyand integrity

2.1 The BLS must practice his profession in such a way that the patient feels secure

2.2 The BLS must be considerate of the patient and his family

2.3 The BLS must focus his attention on the patient

2.4 The BLS must inform the patient about the bioanalytical aspects ofthe treatment

2.5 The BLS must protect private and medical information from unauthorised access

All the subordinate points clarifywhat is important in regard to thepatient’s right to informed consent,autonomy and integrity. The BLSmust ensure that the patientunderstands what is to happen, andthat both the patient and his familyfeel secure.

We health workers are bound toconfidentiality by law, and havesigned a non-disclosure agreement.Confidentiality is a fundamentalprinciple in the health services, andit is vital for each individual healthworker deliberately to keep in mindwhat information is necessary andwhat is a breach of this non-disclosure promise. Becoming

Reflections on the professionalethical guidelines

14 15

Point 5 of theprofessional ethicalguidelines:

The BLS should help topromote life sciences

5.1 The BLS must make sure that the research work in which he is participating is approved

5.2 The BLS should turn down research work that conflicts with his own convictions

5.3 The BLS must treat animals with consideration and respect

The BLS discipline is undergoingrapid development. It is importantthat we are aware of thedevelopments so that we cananticipate any ethical problemswhen new technology or analysesare developed or come into use.

Practice in Norway is that allmedical and health-related researchprojects must be approved byregional research committees. Inaddition, the national committee formedical and health-related researchethics is mandated to work to makeresearch regulations better-knownamong scientists and the generalpublic. This committee is to be thecoordinating body for the regionalcommittees for medical and health-related research ethics, andconsiders appeals against decisionsmade by those regional committees.The BLS has no statutory right torefuse work that conflicts with hisown conviction. It is therefore up tothe individual to speak out and takethe consequences of such a refusal. Many research projects includeanimal experiments. It is thereforeimportant to treat these animalswith consideration and dignity, be

aware that they feel pain and not tosubject them to needless suffering(13).

What are your thoughtsabout this situation inrelation to Point 5 of the professional ethicalguidelines?

The laboratory has been askedto participate in the collectionof sample material for a newresearch project. What shouldthe laboratory demand in theway of information anddocumentation beforeparticipating in the collection of the sample material?

Point 6 of theprofessional ethicalguidelines:

The BLS must be loyal toworkplace agreements andinstructions, as long asthese do not conflict with our professional ethicalguidelines

6.1 The BLS must react if the main objectives conflict with our professional ethical guidelines

The health sector is in constantchange; there are constant newdemands for prioritisations andchoices. Medical progress leads tomore treatments and examinationsbeing offered. The resourcessociety spends on the health servicecannot cover everything, and it isnecessary to set priorities.

The demand for profitability andrationalisation leads to constantreorganisation of the medicallaboratories. It is important to speakout if we think that this ishappening at the expense of thework we are doing. A qualitysystem with non-conformanceprocedure is a useful tool foruncovering system faults and poorroutines.

What are your thoughtsabout this situation inrelation to Point 6 of the professional ethicalguidelines?

They want to save money in thelaboratories: the departmentalmanagement asks you to cutback on the number of qualitycontrols. Biomedical laboratoryscientists discuss whether thisis professionally acceptable.

development is ethical reflectionover the work that each one of us isdoing as health workers. Ethicalreflection enhances professionalsecurity and is important ballast tokeep us on an even keel whiledoing that work.

What are your thoughtsabout this situation inrelation to Point 3 of the professional ethicalguidelines?

New analytical instrumentshave been purchased, theemployees have undergonetraining and are now to use themachine. You think you needeven more time to become fullytrained, but feel inadequatecompared to your colleagues.You know that you yourself areresponsible for asking for morefollow-up, but you are assignedto running the machineunassisted - tomorrow.

Point 4 of theprofessional ethicalguidelines:

The BLS must treat allbiological material withrespect

The Biobanks Act defines humanbiological material as “organs, partsof organs, cells and tissue and partsof such material obtained fromhuman beings, alive or deceased.”(11)

Blood samples, tissue samples andother human biological materialthat comes to the laboratories areused to diagnose, prevent and treatdisease. The handling and analysis of thesample material can be crucial forpeople in many situations; it canprovide knowledge that makes thedifference between life and death.The BLS has a responsibility tomake sure that the sample materialis handled correctly and asintended.

The Danish theologian andphilosopher Knud E. Løgstrupreminds us that we as human beingsare tied to one another’s fates. Wecan transfer this significance to howimportant the results from ourlaboratory analyses can be for aperson: “The individual never dealswith another human being withoutholding something of his life in hishand. It may be a small part, apassing mood, but it can also be afrighteningly big part, so that it isup to the individual whether theother person’s life is a success ornot.” (12)

What are your thoughtsabout this situation inrelation to Point 4 of theprofessional ethicalguidelines?

The laboratory receives anunlabelled sample from abiopsy. The patient has beenunder anaesthetic to have thesample taken, and theintervention is now over. Is itproper, considering the patient,not to analyse this sample inthe laboratory?

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Point 10 of theprofessional ethicalguidelines:

The BLS should be active inthe debate about theenvironment

Laboratory work involvesdischarge of substances that may beenvironmentally hazardous. Wastedisposal is regulated by theNorwegian Pollution ControlAuthority (SFT) in the form ofrules and legislation. Both internaland external control bodies arelinked to such issues. We cannotuse that as justification for leaningback with our feet on the table; wemust continue to ask criticalquestions about the way waste isdisposed of at every singleworkplace.

What are your thoughtsabout this situation inrelation to Point 10 ofthe professional ethicalguidelines?

You work in a department thatuses a lot of solvents. Usualpractice is to pour all solutionsdown the plughole.

Point 11 of theprofessional ethicalguidelines:

The BLS should contribute tohighlighting ethical aspectsin debates about health andsocial issues

11.1 The BLS should work foran allocation of resources and good useof resources that ensures ethically sound operations in the laboratories and in the rest of the health service

Biomedical laboratory scientists arethe biggest professional groupworking in medical laboratories. Itis important that we endeavour toinfluence our employers andauthorities in the direction of aresource allocation that enables usto operate the medical laboratoriesin an ethically sound manner. Byvirtue of our professional expertise,we are also obliged to illuminatethe ethical aspects of medical andtechnological developments.

What are your thoughtsabout this situation inrelation to Point 11 ofthe professional ethicalguidelines?

When new analyses come ontothe market, we are often askedby the requisitioners to makeuse of the new methods. Whatfactors should the laboratorytake into account when newanalyses are being introduced?

Point 7 of theprofessional ethicalguidelines:

The BLS must demonstraterespect and solicitude for hiscolleagues

7.1 The BLS must display tolerance for the work, methods and life-situations of others

We spend a lot of time togetherwith our colleagues; we are part ofone another’s daily lives, for betteror worse. This means that we havean important responsibility for oneanother’s well-being, security andjob satisfaction.

What are your thoughtsabout this situation inrelation to Point 7 of the professional ethicalguidelines?

One of your colleagues haspersonal problems that areadversely affecting patients,colleagues and the quality ofhis work.

Point 8 of theprofessional ethicalguidelines:

The BLS must respect otherprofessional groups’disciplines and areas ofresponsibility

8.1 The BLS must contribute towards good cooperation with other professional groups. In the event of conflicts of interest, thepatient’s life and healthshall come first

Most biomedical laboratoryscientists work in a milieu in whichcollaboration with otherprofessional groups is necessary.Inter-disciplinary cooperationmakes for enhanced understandingand respect for others’ disciplinesand areas of responsibility.

What are your thoughtsabout this situation inrelation to Point 8 of theprofessional ethicalguidelines?

In what situations can a BLSfind himself coming into conflictwith other professional groups?How do we resolve suchconflicts?

Point 9 of theprofessional ethicalguidelines:

The BLS must make hisprofessional expertiseavailable also in crises

As health personnel, we are obligedto make our professional expertiseavailable (7). Acute crisis situationsin and outside the workplace mayarise, for example people sufferaccidents or fall sick. In some casesthere may also be a need for BLScompetencies and we are thenobliged to make our professionalexpertise available.

What are your thoughtsabout this situation inrelation to Point 9 of the professional ethicalguidelines?

Can you as a BLS take short-cuts in relation to applicableprocedure when gettinganswers is extremely urgent?

1 Mjøs OD. Lecture at the Tromsø Nordic BLS conference in June 2003

2 Henriksen JO, Vetlesen AJ. Nærhet og distanse. Oslo: Gyldendal akademisk, 2000

3 Vetlesen AJ, kapittelforfatter. I Henriksen JO, Vetlesen AJ. Nærhet og distanse. Oslo: Gyldendal akademisk, 2000:202

4 Kierkegaard S. Bruddstykke af en likefrem Meddelelse. København: 1859

5 Tranøy KE. Medisinsk etikk i vår tid.Bergen: Sigma forlag, 1999: 33

6 Translated by Francis Adams:http://classics.mit.edu/Hippocrates/hippooath.html

7 Lov om helsepersonell mv(Helsepersonelloven) - the Health Personnel Act

8 Lov om spesialisthelsetjenesten med mer (Spesialisthelsetjenesteloven) - the Specialist Health Services Act

9 Lov om behandlingsmåten iforvaltningssaker (Forvaltningsloven) - the Public Administration Act

10 Seljeskog I. Livskvalitet - den største utfordringen mot år 2000. Kommuneforlaget, 1989

11 Lov om biobanker (Biobankloven) - The Biobanks Act

12 K. E. Løgstrup. Den etiske fordring. Copenhagen: Nordisk forlag, 1991. (ISBN 87-01-66050-0)

13 Lov om dyrevern - the Animal Protection Act

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NITONorwegian Institute of Biomedical ScienceLakkegata 3Box 9100 Grønland0133 OsloNorwayTelephone +47 22 05 35 00Telefax +47 22 17 24 80epost@nito.nowww.nito.no

1. editionEnglish version2006

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