Emphasis on ethical awareness: why ethics? why now?

Ethical issues are important in the profession of health sciences librarianship, as in other professions. Indeed, one of the hallmarks of a profession is having its own code of ethics. Many of us are faced with ethical situations in our daily work. For example, there was a discussion on the MEDLIB-L email discussion list, where a librarian posted that her supervisor was asking for names of people for each requested literature search [1]. The poster expressed the opinion that to provide the names would violate the statement regarding confidentiality for clients in the Code of Ethics for Health Sciences Librarianship [2]. She wondered if she should refuse to turn over confidential information and if other librarians were being requested to turn over such information and were doing so [1]. The consensus was to protect the client’s privacy regardless of the supervisor’s reasons for requesting that information. The code’s statement about confidentiality addresses the broad principle of autonomy, which respects a person’s right to make his or her own choices, including whether or not his or her transactions remain private. Most codes center around general ethical principles, such as beneficence (doing what is in the best interests of the person), justice (being fair), non-maleficence (doing no harm), veracity (being honest), and the aforementioned autonomy. The American Library Association has had a code of ethics since 1939 [3], but the Medical Library Association (MLA) code is relatively young, having first been adopted in 1994 and revised in 2010 [2]. As 2014 is the twentieth anniversary of MLA’s Code of Ethics for Health Sciences Librarianship, it seems an appropriate time to bring it to the attention of new members. The anniversary is also a fitting occasion to remind longstanding members that we have a code to guide our behavior in ethical situations. As MLA Past President Mary L. Ryan, AHIP, FMLA, stated a few years ago, ‘‘a continuing public dialogue will help us to be more aware of ethical issues and different perspectives on them, the awareness of which will help us in making our individual decisions’’ [4]. It has been five years since Ryan appointed the Ethics Task Force to review MLA’s code. It is time again to instill awareness of the code and have some dialogue among health sciences librarians about ethical issues. For that reason, one of my presidential priorities for association year 2014 was ethical awareness and, toward that end, I appointed the Ethical Awareness Task Force. The task force was charged with conducting a survey of the MLA membership to gauge awareness and use of the code, followed by analyzing and disseminating the results. Additionally, the task force was charged with coordinating a few articles on ethics for the Journal of the Medical Library Association (JMLA) and creating ethical scenarios to stimulate thoughtful discussion at an open forum at the 2014 annual meeting.

Ethical issues are important in the profession of health sciences librarianship, as in other professions. Indeed, one of the hallmarks of a profession is having its own code of ethics. Many of us are faced with ethical situations in our daily work. For example, there was a discussion on the MEDLIB-L email discussion list, where a librarian posted that her supervisor was asking for names of people for each requested literature search [1]. The poster expressed the opinion that to provide the names would violate the statement regarding confidentiality for clients in the Code of Ethics for Health Sciences Librarianship [2]. She wondered if she should refuse to turn over confidential information and if other librarians were being requested to turn over such information and were doing so [1]. The consensus was to protect the client's privacy regardless of the supervisor's reasons for requesting that information. The code's statement about confidentiality addresses the broad principle of autonomy, which respects a person's right to make his or her own choices, including whether or not his or her transactions remain private. Most codes center around general ethical principles, such as beneficence (doing what is in the best interests of the person), justice (being fair), non-maleficence (doing no harm), veracity (being honest), and the aforementioned autonomy.
The American Library Association has had a code of ethics since 1939 [3], but the Medical Library Association (MLA) code is relatively young, having first been adopted in 1994 and revised in 2010 [2]. As 2014 is the twentieth anniversary of MLA's Code of Ethics for Health Sciences Librarianship, it seems an appropriate time to bring it to the attention of new members. The anniversary is also a fitting occasion to remind long-standing members that we have a code to guide our behavior in ethical situations. As MLA Past President Mary L. Ryan, AHIP, FMLA, stated a few years ago, ''a continuing public dialogue will help us to be more aware of ethical issues and different perspectives on them, the awareness of which will help us in making our individual decisions'' [4]. It has been five years since Ryan appointed the Ethics Task Force to review MLA's code. It is time again to instill awareness of the code and have some dialogue among health sciences librarians about ethical issues. For that reason, one of my presidential priorities for association year 2014 was ethical awareness and, toward that end, I appointed the Ethical Awareness Task Force. The task force was charged with conducting a survey of the MLA membership to gauge awareness and use of the code, followed by analyzing and disseminating the results. Additionally, the task force was charged with coordinating a few articles on ethics for the Journal of the Medical Library Association (JMLA) and creating ethical scenarios to stimulate thoughtful discussion at an open forum at the 2014 annual meeting.

History of the Medical Library Association Code of Ethics for Health Sciences Librarianship
According to the ''Proceedings of the Ninety-Fourth Annual Meeting,'' the MLA Board of Directors voted to appoint an ad hoc committee for the purpose of writing a code in 1984. The resulting draft code was presented in 1987. The draft was published in the MLA News, feedback was solicited, and the document was revised but not approved. An open forum was then held at the 1992 annual meeting that resulted in going back to the drawing board to make further changes. An Ethics Task Force was appointed in 1992, and its draft code was presented at an open forum at the 1993 annual meeting. Further discussion ensued on MEDLIB-L and at fall chapter meetings. The task force, chaired by Richard A. Lyders, AHIP, FMLA, used input from these discussions to revise the proposed code, which was approved by the Board of Directors in February 1994 and by the membership in May 1994 [5]. To help with interpretation, Lyders provided a list of definitions to explain certain words and phrases found in the new code in the April 1994 MLA News [6].
There has been one revision since MLA adopted its first code of ethics. In 2008, President Ryan appointed a task force to review the code. The task force sponsored an open forum at the 2009 annual meeting, and additional input was obtained through the MLA Connections blog. Two additions were proposed: The first addition was a statement in the code's preamble noting that the code is intentionally broad and that it cannot ''dictate conduct to cover particular situations'' [2]. The other addition was placed in the area of responsibility to one's self, proposing that ''The health sciences librarian shall be alert to and adhere to his or her institution's code of ethics and its conflict of interest, disclosure, and gift policies'' [2]. Indeed, many of us now have institutional requirements regarding conflict of interest, disclosures, gifts, and human subject research. The revised version was approved by the Board of Directors at its November 2009 meeting [7]. Subsequently, it was approved by the membership at the 2010 annual meeting.

Ethical decision making
When there is not a law, policy, or regulation addressing a particular situation, the code can offer guidance for ethical decision making. As the code states, however, advice for particular situations cannot be offered. Nor can the code provide guidance for ethical dilemmas that involve conflict between principles in the code. Sometimes people think there is an ethical dilemma when they are faced with a situation that makes them uncomfortable. However, discomfort does not constitute a true ethical dilemma. Dilemmas occur when two ethical principles conflict, such as veracity and beneficence. For those kinds of situations, individuals have to make personal decisions about which principle takes precedence over another. For example, the MLA code states, ''The health sciences librarian ensures that the best available information is provided to the client,'' encompassing the principle of beneficence. It also has a statement regarding the principle of respect: ''The health sciences librarian conducts all professional relationships with courtesy and respect'' [2]. If you hear a colleague provide misinformation to a client just as that client is heading toward the exit, do you stop the client to provide the correct information (beneficence) thereby embarrassing the colleague, or do you let the client go to save face for your colleague (respect) thereby not giving accurate information to the client? What are the alternatives? Stimulating discussion by providing scenarios helps people think about what they would do. Exercising ''ethical muscles'' through such discussion can help people prepare for uncomfortable situations and dilemmas.
There is some controversy about whether or not decision-making models should be applied to ethical dilemmas. There are potential situations in which someone has to act quickly and does not have time to apply a complex, multistep model. Models can work well when there is some time to think-such as in many personnel, collection development, or technology decisions. Models do not work as well in situations where immediate decisions are required, as they often are in public service situations. In a recent article in The Reference Librarian, Lane Wilkinson expressed a similar idea, stating that codes are ''generally silent when it comes to moral decision making at the point of service'' [8]. He believes that principlism, which is dominant in medical ethics, can be applied to librarianship. This approach bases the decision for action on whatever action is ''most consistent with the plurality of general moral principles rather than falling into the traditional normative trap of identifying the one and only 'right' obligation to follow'' [8]. He espouses six principles for librarianship: I highly recommend reading Wilkinson's paper, which provides background on the philosophy of ethics as well as three case examples, including a medical case [8].
Some people find that establishing a hierarchy of values is helpful in ethical decision making. Do you rank confidentiality for an individual above the good of society? The Potter Box, developed by Ralph B. Potter in 1965, is a decision-making model described in Martha Montague Smith's ''Infoethics for Leaders'' [9]. Like other models, two people can apply this model to an ethical dilemma and come to different decisions. Remember that the nature of true ethical dilemmas is that there are no absolutely right or wrong solutions. They force people to choose between two good principles. The value of using a model is not that it leads to the one, true answer, but that it provides an organized way of analyzing a situation in order to make a decision according to ethical principles. Basically, the Potter Box involves four factors: the situation or definition of the problem, the values involved, the relevant principles, and loyalties (their prioritization) [9].
Frank J. Sileo and Mary Kopala find that ethical dilemmas in counseling are like those in librarianship or any other profession in that resolving them requires consider-ation of competing alternatives. They believe that ethical codes may be used as guidelines for behavior but realize that codes can be ambiguous or contradictory and, therefore, do not provide answers to dilemmas. Their proposal for handling dilemmas is encompassed in their ''A-B-C-D-E Worksheet,'' which serves as a reminder of the key elements involved in ethical decision making: assessment, benefit, consequences and consultation, duty, and education [10]. This model helps organize an attack to analyze an ethical dilemma and assists in ultimate resolution.
Other models exist. I encourage you to explore the literature and find the one that works best for you or use creative thinking rather than analytic thinking to solve a dilemma. Carolyn Whitbeck believes that rather than reducing a dilemma to a choice between limited alternatives, we should use creativity and wisdom to devise a course of action that is better than any of the obvious choices [11], in other words, think outside of the box. Try different methods of decision making with case studies so that you are better prepared to handle the real thing when it comes along. Having given some thought to ethical values will better prepare you to make quick decisions when necessary.

The future
While 2014 is a year of introspection as we think about the MLA code and how to handle ''What would you do'' types of situations, the current emphasis on ethics can serve as the basis for future action. Task force survey results reported in this issue of the JMLA indicate that some respondents would like to see examples of how the code can be applied to specific situations [12]. Certainly, a sampling of such illustrations can be forthcoming, possibly through the use of a mix of hypothetical and real-life case scenarios submitted by the membership. Examples of situations for each statement in the Comment and opinion code can be placed on MLANET or published in the MLA News to assist members with interpreting the code. Another potential activity is replicating the 2013 survey to determine if focused efforts in the 2013/14 association year have had any effect on the percentage of members who are aware of and/or use the MLA code. On a broader scale, there is the prospect of developing a unified code of ethics for health professionals. An opinion piece published in JAMA in early 2014 proposed such a code [13]. While some ethical issues are unique to particular professions, there are a number of common ethical principles that are supported by multiple health sciences professions. Time will tell as to whether a single, transdisciplinary code of ethics is adopted and shared among health professions and whether health sciences librarianship is one of the participants. While I support the idea of a code composed of principles common to all health sciences professions, I believe that MLA will need to maintain its own code as well, in the event that a unified code is adopted by multiple professions.

Conclusion
Periodically emphasizing MLA's code is warranted, as the survey results mentioned above indicated that 13.5% of the respondents did not know the code even exists [12]. Health sciences librarians continue to be confronted with the same kinds of ethical situations that we have always faced, in addition to some new ones related to technology and research. Toni Carbo has stated that ''Understanding what it means to be an ethical person is a huge challenge. Translating the results of our reflection into action each day is an even greater one. It is only by doing this that we will continue to earn and keep the trust given to us'' [14]. As the profession adapts to the changing health care and information technology environments, it must maintain its foundation of ethical principles, and health sciences librarians must strive through ethical behavior to maintain the trust of our constituents.