Health sciences librarians' awareness and assessment of the Medical Library Association Code of Ethics for Health Sciences Librarianship: the results of a membership survey.

OBJECTIVE
The Medical Library Association (MLA) Board of Directors and president charged an Ethical Awareness Task Force and recommended a survey to determine MLA members' awareness of and opinions about the current Code of Ethics for Health Sciences Librarianship.


METHODS
THE TASK FORCE AND MLA STAFF CRAFTED A SURVEY TO DETERMINE: (1) awareness of the MLA code and its provisions, (2) use of the MLA code to resolve professional ethical issues, (3) consultation of other ethical codes or guides, (4) views regarding the relative importance of the eleven MLA code statements, (5) challenges experienced in following any MLA code provisions, and (6) ethical problems not clearly addressed by the code.


RESULTS
Over 500 members responded (similar to previous MLA surveys), and while most were aware of the code, over 30% could not remember when they had last read or thought about it, and nearly half had also referred to other codes or guidelines. The large majority thought that: (1) all code statements were equally important, (2) none were particularly difficult or challenging to follow, and (3) the code covered every ethical challenge encountered in their professional work.


IMPLICATIONS
Comments provided by respondents who disagreed with the majority views suggest that the MLA code could usefully include a supplementary guide with practical advice on how to reason through a number of ethically challenging situations that are typically encountered by health sciences librarians.


INTRODUCTION Background and purpose
While considering the priorities for her 2013/14 year as Medical Library Association (MLA) president, Dixie A. Jones, AHIP, noted that it had been nearly five years since a task force had reviewed the MLA Code of Ethics for Health Sciences Librarianship (2010) [1]. Feeling that the association needs to periodically review the code and call attention to its existence as a guide to ethical behavior, especially for newer members who might not realize that MLA has a code of ethics, in spring 2013, she asked the MLA Board of Directors to charge an MLA Ethical Awareness Task Force and recommended that, in addition to other objectives centered around creating general ethical awareness and generating discussion of ethical issues, the nine-member task force should conduct a survey to determine MLA members' awareness of and opinions about the MLA code.
Members of the task force-working in consultation with President Jones, MLA Executive Director Carla J. Funk, CAE, and MLA Membership, Research, and Information Systems Director Kate E. Corcorancrafted a survey instrument with the goal of determining: (1) members' awareness of the existence of and the provisions in the code, (2) members' recent reading or use of the code to resolve professional ethical issues, (3) members' use of ethics codes from other library associations or other related professions, (4) members' views regarding the relative importance or centrality of the eleven statements in the MLA code, (5) members' views regarding the difficulty or challenges that they had experienced in following any of the eleven statements of the MLA code, and (6) members' encounters with any professional situations that were not clearly addressed by the MLA code. The survey also included questions at the end to categorize the responses by the respondents' primary work setting, age group, years of professional experience, and gender.

Literature review
To provide a historical and comparative professional context for this survey study, the authors reviewed the library and information sciences literature for the past approximately 25 years, looking for other studies that have surveyed library professionals regarding their perceptions or uses of codes of ethics. In summer 2014, we searched both the Library Literature and Information Sciences and Library, Information Sciences &Technology Abstracts databases, combining variations of the keywords ''ethics'' with variations of the term ''surveys.'' These searches retrieved a combined total of about 200 different potentially relevant publications. A review of the titles and abstracts, and full text when needed, narrowed the results to just 12 relevant survey studies published between 1987 and 2012.
The articles' survey populations included American Library Association (ALA) members, Special Libraries Association members, leaders of library associations, US academic and health sciences librarians, state associations, and librarians from Norway, Russia, and the United Kingdom. Although the level of familiarity with codes of ethics varied from survey to survey, the primary ethical principles remained the same in most instances: patron privacy, equality of access, intellectual freedom and censorship, preservation of the intellectual record, copyright, and control of the Internet.
In an ALA survey about patron privacy, 76% of respondents agreed that libraries were doing all they can to prevent unauthorized access to personal information [2]. Academic librarians in one study identified service to clientele, intellectual freedom, and information literacy as the top ethical values [3]. Health sciences librarians in one state rated confidentiality and privacy, access to information, professional competence and integrity, and censorship as the most critical issues [4].
Among those who were asked about the impact of a code of ethics on their daily work, only 13% of academic librarians in one study completely agreed that the ALA Code of Ethics (COE) was a useful tool, although those who were more familiar with the ALA COE were more likely to have taken action in response to observing a code violation [5]. In a study of library managers, 21% were unfamiliar with the ALA COE, and 83% thought it was not appropriate to post the code for patrons to read [6]. Two additional articles reported a higher awareness and use of the ALA COE [7,8].
Preservation of the intellectual record was an important principle for the non-US librarians, and they shared the US librarians' opinions that the patrons' interests were a top value [9][10][11]. Librarians in the United Kingdom were more aware of their association's codes of ethics than their US counterparts [12]. One study combined leaders from US and UK organizations, finding that all had similar ethical concerns [13].

METHODOLOGY
The survey for this study was conducted using MLA's licensed instance of the web-based SurveyMonkey software [14]. MLA staff coded the questions, using draft versions provided by the task force, and then provided access to the draft survey for all members of the task force to review and edit. The final survey included 8 questions focused on the MLA Code of Ethics for Health Sciences Librarianship. The survey instrument also included a copy of the full text of the code's 11 principles for direct reference in answering questions 2 through 6. As noted previously, the survey concluded with 4 questions asking respondents to indicate their primary work settings, age groups, number of years (in 5 to 10 year ranges) of professional experience, and genders. A copy of the full text of the survey, including the eleven principle statements in the MLA code, is provided in the online only appendix.
Since this survey was restricted to active MLA members, with the goal of better understanding and improving members' ability to make effective use of this association resource, we did not seek formal approval from an institutional review board (IRB) for the study methods. The task force chair did consult informally with the chair of the State University of New York at Buffalo Social Sciences IRB, who advised that the survey would have almost certainly qualified for exemption if it had been submitted for review. Rather than deliberately selecting a sample of MLA members to survey, the task force decided to invite almost all MLA members to participate. An invitation appeared in MLA-FOCUS, an email newsletter, that, in September 2013, was distributed bimonthly to those 2,922 MLA members who had not opted out of email communications from the association. No personal information was collected from survey participants. Internet protocol (IP) addresses were collected automatically from participants, but these were used by the MLA headquarters survey manager solely to remove duplicate responses. IP information was not provided to the Ethical Awareness Task Force members or to the survey analysts.
Our analysis of the survey response data included both simple frequency counts and percentage tabulations of the responses to each survey question. It is important to note that the initial survey response tabulations were revised based on a more careful analysis of the responses to the demographic question regarding ''primary work setting'' (Q9). This analysis showed that 42 of the Q9 responses needed to be changed to another category, based on the respondents' answers to the open-ended text description of ''other library type,'' which these respondents included as part of their responses. In these 42 cases, respondents' descriptions did not match the response categories that they had checked on the survey in Q9. We changed these responses to the category indicated by the text that they entered. The final tabulations and cross-tabulations reported in the ''Results'' include these changes. These Q9 changes resulted in a modest broadening of the ''Special library in a for-profit business setting'' response category. Since a few respondents indicated in their text responses for ''other library type'' that they worked in a nonprofit association or other business-like setting, we also changed these to be part of this ''business setting'' category. Additionally, these changes helped to make a more consistent distinction in the responses between the first 2 response categories for Q9. ''Academic health sciences library serving a school of medicine'' was changed to include all responses for respondents working in libraries that serve a medical school, as well as those that also serve other schools in addition to medicine. And, finally, ''Academic library serving health professions programs'' was broadened to include respondents who worked in any other academic library setting that did not serve a school of medicine. Byrd et al. Finally, in addition to the open ended, ''other'' component of the primary work setting demographic question (Q9), we also tabulated and categorized the open-ended text responses for 5 of the survey questions: Q2, descriptions of other codes of ethics or guidelines that some respondents said they used in addition to the MLA code to guide their professional activities; Q4, why some respondents thought some MLA code principles were more important than others; Q5, why some respondents thought some MLA code principles were less important than others; Q7, some respondents' descriptions of the difficulties or challenges that they had faced with some MLA code principles; and Q8, some respondents' descriptions of ethical challenges, dilemmas, or concerns they felt were not clearly addressed by the MLA code.

Characteristics of survey responses and respondents
When the survey closed on October 1, 2013, 552 MLA members had opened and completed at least 1 of the questions. To ensure that the data analysis would be uniform and complete, we eliminated 37 survey responses that were duplicates or were significantly incomplete. Thus, the data included in this analysis are based on 515 MLA member responses, for a response rate of about 17.6%. The last 4 survey questions (Q9-Q12) provide an overview of the general characteristics of the MLA members who responded to this survey.
The largest single group of respondents, by a narrow margin, worked in hospital settings (34%), followed closely by those in academic medical centers with a school of medicine (33%) and in other academic settings (21%). Those working in government agencies, for-profit or nonprofit businesses, or a range of other settings together made up less than 12% of the respondents. As noted previously in the ''Methods'' section, 42 of the 67 descriptions of ''other library type'' were used to revise the counts in this question's response categories. Other settings mentioned were university faculty (4), retired (3), independent consultant (2), consumer health (2), student or new graduate (2), and unemployed (2). A large majority (60%) of these MLA members were older than 50 years, 23% were between 36 and 50 years old, and less than 17% were 35 years old or younger. Respondents, collectively, had a great deal of professional experience. Over 31% had more than 25 years of professional health sciences work experience, and another 30% had been working for at least 10 years. Less than 20% were relatively new to health sciences librarianship. Finally, the responses to Q12, ''What is your gender?'', clearly reflected the overall gender makeup of this profession, with men making up only a little over 12% of the respondents.
The demographics of this self-selected sample of MLA members, with a few minor exceptions, matched well with two other recent MLA member surveys: the 2012 MLA member salary survey and the early 2007 MLA member survey [15,16]. The age group distribution of responses for all three surveys was almost identical, as was the gender distribution for this survey and the 2012 salary survey, as well as the distribution of years of professional experience for this survey and the 2007 member survey. However, the distribution of responses from members in various work settings in the three surveys suggested that hospital librarians might be somewhat underrepresented in this survey and that academic librarians might be somewhat overrepresented (Table 1, online only).
Finally, although this survey did not include a question about the country where the member worked (MLA does have many members in Canada and other countries), it is likely that a few responses were submitted by Canadian members and other international members, because the responses to Q2 Interestingly, and perhaps not surprisingly, over 30% of the responses to Q1, which asked, ''when was the last time you read or thought about the MLA Code of Ethics?'', were from members who could not remember the last time they had looked at the code, and another 20% either did not even know that MLA has a code of ethics (13.5%) or had never looked at or thought about the code (7%) (Figure 1). The vast majority of those who responded that they had looked at the code (233 of 252, 93%) did so fairly recently, that is, within the last 5 years or less.
The next question (Q2) asked whether the member respondents had referred to codes of ethics from other professional library associations or from other professions to guide their professional activities, and the question provided a text box to list any other codes consulted. Less than half of the respondents (47.9%) responded that ''yes'' they had referred to other codes. However, as with the question reporting the respondents' primary work settings (Q9 described above), a number of the respondents (8) who indicated they did not refer to any other codes, nevertheless, did list 1 or more others in the text box. Those 8 respondents are included among the 245 who responded that, ''Yes,'' they did consult other codes. These other ''codes of ethics,'' described by 230 respondents, included a rather large number of different library association and other professional codes as well as other published guidelines, legal codes, and even religious texts. The single most frequently cited other code, by a wide margin, was the ALA COE. Most respondents cited only a single other code or guideline, but a few cited many others (in one case, 11 others), with an average of 1.30 other Results of an MLA membership ethics survey codes cited per respondent (the other cited codes and frequencies appear in Table 2, online only).

Relative ''importance'' of the MLA code principles
After reviewing all 11 MLA code principles included in the survey, a substantial majority of the respon-dents (393, 76.3%) said in Q3 that all of the code principles are ''equally important or central for the ethical practice of health sciences librarianship.'' The other 122 respondents (23.7%) who said they thought they thought that ''one or more of the principles were more (or less) important or central'' were then asked (in Q4) to select up to 3 of these MLA code principles     Results of an MLA membership ethics survey that they considered either to be ''more important'' than the others and then (in Q5) up to 3 others that they considered to be ''less important.'' The first 4 principles in the MLA code were selected much more frequently (each by around 50% of the 116 Q4 respondents) as being ''more important'' (Figure 2). The next 3 principles (provides leadership and expertise for the institution, advances and upholds professional philosophy and ideals, and advocates and advances knowledge and standards) were selected more frequently (each by about one-third of the 106 Q5 respondents) as being ''less important.'' Smaller majorities of the 122 respondents, who said they thought 1 or more of the MLA code principles was more or less important than the others, also provided brief explanations or comments about their choices. Of the 116 who selected 1, 2, or 3 principles as more important, 70 (60.3%) added an explanation or comment; and of the 106 who selected some principles as less important, 80 (75.5%) added an explanation or comment (Table 3).
''Difficulties or challenges'' with the MLA code principles In addition to what their perceptions of the importance of the MLA code principles were, we also asked in Q6 whether the respondents thought any of the principles were particularly difficult or challenging to follow in their professional activities. As with importance, a substantial majority (397, 77.1%) said they did not find any of the code's principles to be difficult or challenging to follow. For those respondents who in Q6 said they thought 1 or more of the principles were difficult to challenging (118 respondents, 22.9%), Q7 asked them to select up to 3 principles that they considered to be a particular challenge. Almost all of these (117), plus 2 others (who had responded that they did not find any of the principles difficult or challenging!), selected 1 or more principles as particularly challenging, for a total of 119 responses to this question ( Figure 3).
Two of the principles stand out in this analysis as being of particular concern to a large plurality of these respondents: ''provides leadership and expertise in the design…[and so on, of] information systems that meet the information needs and obligations of the institution'' (selected by nearly 43% of these respondents) and ''ensures that the best available information is provided to the client'' (selected by more than 35%). Again, almost all of these respondents (105 of 119), plus 3 others who did not make any selection (108 in all), added a prose description or comment about the challenges they had encountered with 1 or more of the principles (Table 4).
Issues not addressed by the MLA code principles Q8, the last of the survey questions focused on members' assessments of the MLA code of ethics, asked if the member had encountered any professional ethical challenges, dilemmas, or concerns that were not clearly addressed by the principles in the  Results of an MLA membership ethics survey MLA code. A very large majority of the respondents (84.5%) said that they had not encountered situations of this kind. Those who responded that, ''yes,'' they had encountered professional ethical challenges not addressed by the MLA code were asked at the end of Q8 to briefly describe some examples of those challenges. All but 1 of the 79 ''yes'' respondents provided a comment or description of these challenges, plus an additional 5 who had responded ''no'' and 2 others who had skipped the first part of Q8, for a total of 85 comments (Table 5).

DISCUSSION
This survey, created by the MLA Ethical Awareness Task Force, measured MLA members' familiarity with and use of the MLA code of ethics, asking when they last viewed the code and whether they also consulted other codes of ethics or ethical guidelines. Over 30.0% of the respondents did not know when they had last viewed the code, with an additional 13.5% being unaware that MLA had a code of ethics. Nevertheless, most of the majority who were aware of the MLA code (233 of 252, or nearly half of all respondents) had referred to the code within the last 5 years. Just under half of the respondents noted they had referred to other codes, most often the ALA COE, although the codes of other organizations, legal guidelines, and religious texts were also mentioned by some. The majority of survey respondents were aware that the MLA code of ethics existed (although it appears that most did not refer to it on a regular basis), which was a higher percentage of awareness than for the librarians surveyed in the other published studies we reviewed. However, MLA members agreed with those other survey respondents about the most important ethical principles and values for librarians. The review of the literature undertaken in preparation for this study showed that the majority of US librarians agreed that people should be able to control who sees their personal information, that codes of ethics have an important role in professionalism, and that service to patrons, equity of access, and intellectual freedom are the most important core ethical principles. This survey confirmed that MLA members shared these same core ethical values, because while most respondents thought all of the values were equally important, those respondents who ranked the code principles most often chose the first three under clients and society as more important (''works without prejudice to meet the client's information needs,'' ''promotes access to health information for all,'' and ''maintains conditions of freedom of inquiry, thought, and expression''). In more than one of the other studies that we reviewed, relatively large numbers of participants were unfamiliar with the ALA COE (21% were unfamiliar in 1 case, 32% unfamiliar in another). Similarly, a rather large percentage of the MLA member respondents (over 41%) had never read or thought about the MLA code, could not remember when they had, or did not know that MLA had a code of ethics.
Finally, just over 77% of respondents did not find any of the principles of the code to be challenging to follow. Those who thought some of the code principles were more challenging to follow selected ''provides leadership and expertise in the design…of information systems that meet the information needs and obligations of the institution'' and ''ensures that the best available information is provided to the client'' as the most challenging.

Limitations
As with all survey research, this study had some limitations, including the method that we used to recruit respondents, which was not a scientifically random or demographically stratified sample. Instead, the MLA-FOCUS email newsletter invitations to participate were sent to almost all MLA members; thus, there were likely significant differences between those members who were likely to open those issues of MLA-FOCUS and decide to open this survey, and those who were more likely to not open those issues or to decide they did not want to participate, even with the incentive offered. Nevertheless, a large number of members did respond, and both the numbers and distribution of responses across work locations, age groups, levels of experience, and gender were all fairly comparable to the responses to previous MLA membership surveys. It should also be noted that the questions in this survey might have confused some respondents since we did not pretest

Implications
Member comments on the survey about some code principles that they found to be unimportant (Q3) or particularly difficult or challenging to follow (Q7) and any encounters they had had with ethical challenges not addressed by the MLA code (Q8) together suggest that these members find the code to be irrelevant to their daily practice (for example, one respondent working in a smaller library thought the location of a checked-out item in this setting sometimes can be revealed), that influencing society about the value of health information is beyond the reach of the librarians, or that licensing restrictions (including lack of funding) limit the ability to provide acceptable levels of access to information for all. Other commenters thought the MLA code principles were not unique to the profession, that their institutions' ethical guidelines adequately covered their situations, or that individual code principles were too vague. Some thought that stronger advocacy for the value of our profession should be included in the code. On the other hand, a number of the respondents commented that the code does a good job of upholding our values as a profession and reminds us of important ideals and our fundamental relationship with our clients. For those who found the principles outlined in the code to be too generic, perhaps another type of ethical guidance document, in addition to the code, would be helpful. As the preface to the MLA Code of Ethics makes clear, its principles ''are expressed in broad statements to guide ethical decision making. These statements provide a framework; they cannot and do not dictate conduct to cover particular situations'' [1]. A manual of ethical advice for everyday situations in the health science library setting might be a way to offer more guidance. That type of practical instruction could also be useful in helping overcome the challenges that some respondents reported with some code principles; for example, the frustration a number of commenters expressed about not being able to provide their users with the most current and up-todate information due to budget constraints or insufficient staff. Others noted a lack of understanding by their institutions' leaders about copyright policy, licensing restrictions, vendor gifts, or financial conflicts of interest. These and other areas where some survey participants would like guidance could be addressed outside the code in an accompanying resource. For example, a short manual of practical advice could include other frequently mentioned dilemmas like dealing ethically with electronic licensing negotiations and restrictions and explaining these to others, and how to ethically and effectively advocate for the value of our profession.
In a world of changing and conflicting values, and increasing concern for the privacy of personal information, including health information, librarians are key torch bearers for the ethical principles and standards needed to ensure that our professional services and information resources will lead to wellinformed decisions. The MLA Code of Ethics for Health Sciences Librarianship is a valuable tool to help with our profession's ethical challenges and can be used to help guide decision making, policy development, and services, but it remains an underutilized resource. Perhaps by adding a supplementary resource to the code, with suggestions on how to deal with some of the more ethically challenging situations reported by this survey's respondents, MLA members will want to turn to the code not only to reconfirm our ethical principles and values, but also, perhaps more frequently, as a resource for practical professional ethical advice. Nothing I encounter would be addressed by the Code of Ethics, as the code is an overly general set of principles that doesn't appear to have any meaning other than a ''feel good'' philosophy. Results of an MLA membership ethics survey