II. OCCUPATIONAL HEALTHCARE PROVIDERS

Occupational-health services—the focus of professional personnel, their healthcare and equipment, the programs offered for the prevention of disease and promotion of wellness—have become an increasingly important field in preventive medicine and public health during the twentieth century. The goal of these services is to develop and implement interventions that improve the health and safety of the workplace. They have advanced not only as a result of general developments in preventive medicine and public health but also because of increasing emphasis on the rights of employees and their overall welfare.

The occupational-health profession faces challenges represented by global economic competition, changes in labor force demographics, expanding markets, and new and different occupational and nonoccupational hazards to which workers are exposed. Occupational epidemiology is flourishing, and detailed studies of groups at risk are demonstrating previously unrecognized associations between work exposure and certain adverse health effects. Striking advances in molecular biology are bringing new tools and new insights into cellular aberrations induced by occupational exposure to physical and chemical agents, potentially offering the possibility of very early detection of occupational disease or risk, including risks to the fetuses or offspring of workers. New rules and regulations are helping workers gain information on the toxicity of materials with which they are working and the precautions that must be taken to prevent excess exposure. Good translations of the technical literature into appropriate language ensure that previously guarded information becomes available to work groups. At the same time, the consumer movement has demanded and spread available data, and the Freedom of Information Act has brought disclosures of data not previously available. All these developments have significant ethical implications for the practice of occupational health, and therefore for those who engage in that practice: occupational-health professionals in occupational-health surveillance, specifically, screening programs. The ultimate goal of these services is to develop and implement interventions that improve some aspect or modify determinants of the health and well-being of people who work. Before embarking on an overview of these ethical issues, it is well to consider the relationships of occupational-health professionals to industrial management, relationships that may have ethical implications. Occupational health services may be provided through: (1) a complete in-plant health program with a full-time physician; (2) a partial in-plant health program with a physician in attendance for a portion of the day; (3) an out-of-plant medical program executed almost exclusively in the offices of private physicians; or (4) contract health programs.

In the complete in-plant health program, organizational placement of occupational-health professionals in the managerial structure may suggest to employees that the surveillance activities operate exclusively to protect the company. And although this situation has markedly improved, too often in the past many occupational-health professionals took the position that the company was always right. Such professionals ignored their responsibility to advise management on all matters pertaining to the health of employees, including deficiencies that required resolution or correction. The economic interest of the company may prompt management to pressure occupational-health professionals into a position of unilateral loyalty. This may lead to the expectation by managers that because the occupational-health physician is "one of them," some or all risk-assessment data, including information regarding chemical or other hazardous exposures for certain employees, will be shared irrespective of its confidential content. Unquestionably, the goal of a healthy company and the goal of healthy workers can collide, and when they do come into conflict, occupational-health personnel must be aware of their ethical responsibility to the health of the workers and to the principles of occupational medicine.

As industries seek to reduce the cost of health services, and as the social and scientific context of the workplace changes, less than full-time on-site occupational-health services may become more common. These arrangements can raise ethical issues of another kind, including questions about active advertising or direct solicitation of contracts for such services and about "self-referral"—the physician's referral of patients to an outside facility in which he or she has a financial interest. Growing evidence suggests that more and more physicians own healthcare facilities to which they refer patients for services but at which they do not practice. The danger in occupational medicine is that part-time physicians may be strongly tempted to see their work as a golden opportunity to generate patients for off-site, private treatment facilities in which they own an interest, including services covered by workmen's compensation (Swedlow et al.).

The principle that guides these relationships of service is that physicians and other occupational-health personnel cannot use their relationship with industry as a means to build their private practice. The American Medical Association's Council on Ethical and Judicial Affairs affirmed:

However others may see the professional, the physicians are not simply business people with high standards. Physicians are engaged in the special calling of healing, and in that calling they are fiduciaries of their patients. They have different and higher duties than even the most ethical business purpose. There are some activities involving their patients that physicians should avoid whether or not there is evidence of abuse. (Council on Ethical and Judicial Affairs)

The Code of Ethical Conduct for Physicians Providing Occupational Medical Service emphasizes this principle in the following way: "Physicians should … avoid allowing their medical judgement to be influenced by any conflict of interest." Addressing the same issue, the Guide to Developing Small Plan Occupational Health Programs states:

The plant physician should never use his industrial affiliation improperly as a means of gaining or enlarging his private practice. If he observes these ethical relationships, the plant physician should experience no difficulty in establishing cordial relationships with other physicians in the community and gaining mutual cooperation on the problem. (1983, p. 13)

Surveillance Screening

Issues of privacy, confidentiality, and informed consent pervade almost every program activity for the assessment, preservation, restoration, and improvement of the health of workers at the place of employment. In screening programs especially, these issues are brought into bold relief. They may relate to the screening program itself or to the use of the results, which are designed to determine if the worker's health remains compatible with the job assignment and to detect any evidence of impaired health that may be attributed to employment.

Many such programs are ill-conceived from both a scientific and an ethical point of view. Problems of test validity and predictive values may weaken any appeal of beneficence. For example, some employers may insist on genetic testing even though the science of identifying genetic factors that may contribute to the occurrence of job-related illness is still in its infancy. The correlation of a genetic risk presumed to pose dangers (i.e., chromosomal damage) for the later occurrence of disease may not mean that all or most with the risk factor will become ill. Also, other genetic factors or environmental factors (such as smoking) may be necessary for the development of the disease. Thus, the use of genetic screening to identify and protect workers who might be at increased risk of disease in a workplace cannot be justified by the ethical principle of beneficence where there are low correlations between risk factors like genetic markers and disease. Just as there is uncertainty about who, or how many, could be harmed, so there is uncertainty about how industry should respond. There would be some physical risks associated with medical testing procedures.

Second, there would be risks to the worker from use of the screening information. These include the loss of a job or reassignment to a lower-paying or less desirable job, loss of self-esteem, and, possibly, stigmatization as "genetically inferior." Such a label conceivably could result in the person's exclusion from certain jobs in an entire industry. Historically disadvantaged groups—women and/or ethnic or racial minority workers—would be further disadvantaged. The use of such tests, in short, may provide no real benefit to the company and may cause harm to the worker.

The rapid growth of new molecular and biochemical tools in occupational medicine has resulted in the development of biological indexes or markers for predicting occupational diseases. Scientists hope that these biological indexes or markers will stand as early warnings of the occurrence of occupational risk and disease. Occupational medicine may use biological markers to enhance early detection and treatment of disease; occupational epidemiology may use them as indicators of internal exposure at the workplace or of potential health risks and the need for workplace monitoring. The use of these tools in workplace screening touches on areas of basic concern to most people: opportunity for employment, job security, health, self-esteem, and privacy. In the case of a biological marker known to reflect susceptibility, for example, should a worker who tests positive or has a higher measurement be removed from the workplace? If so, should the occupational-health professional recommend that the worker be offered an equivalent job in the same industry? Or should the occupational-health professional recommend that management clean up the workplace to protect the most sensitive worker? To complicate matters, most biological markers of occupational disease are presumed to predict group risks (increased rates of disease among workers), and these levels of risk are still sufficiently low as to not be reliable guides to which individuals are threatened. Therefore, it is important that workers be informed in advance that the results are interpretable only on the group level. Test results given to workers should be presented and discussed on the basis and in the context of the information that is available on the variability within groups of workers and between individuals (National Research Council).

Of equal importance is the treatment of the data generated by biological-marker testing. One concern of employees who have been screened would be to prevent the spread of embarrassing, damaging, or false information about themselves, particularly to potential employers. The Code of Ethical Conduct for Physicians Providing Occupational Medical Service provides that employers are entitled to receive counsel about the medical fitness of an individual in relation to work but are not entitled to diagnoses or specific details. No one in healthcare challenges the fact that the medical record is a confidential document. But many managers believe they should have access to it when there is interest in an individual employee. However, diagnostic information is not needed for placement of an employee or for changes in his or her workstation because of change in health status. The occupational-health physician can state that an individual is physically or emotionally capable for all work or that an employee should not work in areas where there are high concentrations of certain organic vapors. This information meets the needs of management and does not change the privilege of the medical information under the control of the occupational-health physician. The Code of Ethical Conduct of the American Occupational Medicine Association is clear on this issue:

Treat as confidential whatever is learned about individuals served, releasing information only when required by law or by overriding public health considerations or to other physicians at the request of the individual according to traditional medical ethical practice and recognize that employers are entitled to counsel about the medical fitness of an individual in relation to work but are not entitled to diagnoses or details of a specific nature.

Medical records usually need to be kept for a long time because of linkages between occupational exposure and disease or dysfunction with long latency periods. These are usually the kinds of disease (cancer, for example) that are most sensitive in terms of workers' feelings about privacy. Records become part of large data systems to which government regulatory agencies, courts, and law enforcement officials may have relatively easy access. Workers are concerned that leakage of sensitive information will affect their mobility and employability.

Confidentiality is seldom an absolute value. Information about patients may be revealed under certain circumstances, including those in which workers themselves give consent to provide it to insurance companies or other physicians. Because they are concerned about possible misuse of information from screening programs, or because they wish to know of risks to their health, employees may want access to their medical records. The ethical principle of autonomy implies a duty to provide employees with information about their health, even when it is not clear what the information means. The duty would be even stronger when the information is highly predictive of a risk of disease.

Autonomy would also appear to require that the workers be fully informed of the nature of any screening procedure to which they will be subjected. While the concept of informed consent would be most crucial in occupational-health research, it is also applicable to medical screening. In the latter case, even though the procedures are clearly beneficial, their application to work without informed consent is a paternalistic action.

Epidemiologic Investigations

The results of screening programs may suggest the need for epidemiologic studies to provide additional information on adverse health effects from occupational exposure. These studies may be conducted by occupational epidemiologists. Even prior to the U.S. Occupational Safety and Health Act of 1970, companies involved in formulating and synthesizing chemicals had hired epidemiologists to conduct in-house studies. Such research is an important aspect of an employer's obligation to employees, consumers, and the public in general.

In conducting epidemiologic studies, occupational-health professionals have obligations to workers who are the study subjects as well as to the company's management, who ordered the study and will pay for it. Sometimes these obligations conflict, and the occupational-health professional must sort out ethical as well as scientific priorities. Depending on where the request for the study originates, for example, there may be conflict even in the initial decision as to whether the study should be undertaken. The analysis and interpretation of the data the study generates may be affected by its expected implications. Economic implications may be intertwined with political ones. Epidemiologic studies of workers who are occupationally exposed to neurotoxins or reproductive toxins, for example, may lead to political conflict between labor and management, with government as a possible third party. The dispute is essentially about the occupational environment rather than economic issues with political factors as a secondary concern. Here the company's epidemiologist may be under pressure to respond more fully to his or her responsibilities to the employer than to any professional obligation to the workers (Gordis).

As the research project proceeds, the subjects should be kept informed of its progress, subjects' privacy should be respected, and confidentiality of data should be maintained. This is an important task because the concept of research can be disquieting to workers and to management as well. When, in the course of the study, management and other investigators who are not part of the study ask that investigators share data on an individual basis, investigators face conflict between professional obligations and legal ones. Under the provisions of the Toxic Substances Control Act, for example, epidemiologists are required to communicate substantial risk to the U.S. Environmental Protection Agency within fifteen days after learning of such risk. This information is then made available to the public. Here the professional obligation is to make the best interpretation of the facts, perhaps even to the extent of realizing that the best interpretation cannot be made without additional facts. When there is no time for the investigator to gather additional data, he or she has an obligation to make the best interpretation of the data that is available (Bond, 1991).

Ethical guides for communicating potential health risk have not been defined. In this context, occupational-health personnel are often called on to distinguish between the significant and the trivial. The problem does not lie where real risk can be identified and effective action by the company can result in real benefit to the worker. The technical and ethical conflicts arise when the occupational-health specialist must decide whether a given risk is acceptable, or whether it must be disclosed when not enough is known to be able to measure the presumed risk, and when there are acceptable alternatives. In such cases the occupational-health investigator must act judiciously, in the best interest of the health and well-being of the workers. Withholding pertinent information or providing unqualified, incomplete, or uncertain data may be detrimental to the worker and/or the company.

Conclusion

Economic performance is not the only responsibility of industry any more than educational performance is the only responsibility of a college or university. Unless economic performance is balanced with broader responsibilities for the health and safety of workers, industry will ultimately fail. The public's interest in health and safety, and its broader interest in the rights of workers, including the right to know of risks they face, seem a permanent feature of modern American capitalism. The demand for socially responsible industries and for workers' health and safety will not go away. These responsibilities involve concern about all factors that influence the health of employees, including assuring the availability of health services that are preventive and constructive. These services are not the work of any one group but depend on the cooperative activities of medicine, chemistry, toxicology, engineering, and many others. In this setting industry must recognize and respect the unique position of occupational-health-service providers and assist them in providing impartial, professional counsel to both management and employees. The occupational-health-service providers must be honest, consistent, courageous, and defenders of confidentiality.

Albert Jonsen states the case well:

In a general way, the environment of modern industry comes about through investments from employer and employee alike, each making certain sorts of contributions. In our modern concept of relationship of those diverse contributions, we attribute right of ownership to employers and a variety of rights regarding wages and working conditions to employees. It is now common to consider that among these employees' rights is the right to know about hazards of the work environment.

They also have the right to know about interrelated elements of occupational safety and health. Ensuring those rights involves a great diversity and complexity of ethical responsibilities—interlocked with privacy, confidentiality, and professional and legal obligations—of the occupational-health-service provider.

Anticipating these complex ethical issues and developing sound approaches for resolving them are significant challenges to those healthcare professionals who have the responsibility to promote the health and well-being of people who work. Specifically, however, their responsibility is played out in the context of the workplace where many other healthcare professionals have the responsibility to promote workers' health.

bailus walker, jr. (1995)

bibliography revised

SEE ALSO: Conflict of Interest; Corporate Compliance; Divided Loyalties in Mental Healthcare; Environmental Health; Hazardous Wastes and Toxic Substances; Harm; Public Health Law;Injury and Injury Control; and other Occupational Safety and Health subentries

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