ethical dilemmas and professional roles in occupational medicine

8
Pergamon Sot.Sci.Med. Vol. 38, No. 10, 1367-1374, 1994 pp. Copyright 0 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/94 $6.00 + 0.00 ETHICAL DILEMMAS AND PROFESSIONAL ROLES IN OCCUPATIONAL MEDICINE* SUE GENA LURIE Department of Medical Humanities, University of North Texas Health Science Center, Fort Worth, TX 76107, U.S.A. Ahairact-Occupational medicine presents ethical dilemmas between worker health and corporate goals, for both physicians and managers. Physicians in occupational practice recognize conflict between ‘moralist’ and ‘utilitarian’ ethical positions. This paper analyzes the relation of professional roles to ethical interpretations by occupational physicians, based on their own and medical ethic&s’ formulations of dilemmas. Physicians’ conflicting responsibilities to workers as patients and to corporate practices and policy are reviewed in the context of occupational risk and the critical anthropology of health. Key words-occupational medicine, bioethics, critical anthropology of health INTRODUCTION Occupational medicine presents ethical dilemmas be- tween workers’ health and corporate goals, for both medical practitioners and industrial managers. Although prevention and treatment of work-related health problems has been critically viewed by anthro- pologists [l], sociologists [2], and workers’ advocates as a means of implementing corporate policies, occu- pational physicians have recognized the conflict be- tween ‘moralist’ and ‘utilitarian’ ethics as inherent in their work [3,4]. This confict is interpreted as a professional hazard, regardless of the direction its resolution may take in physicians’ practice with workers as patients, or in interactions with employ- ers, insurance companies, and regulatory agencies. In the United States, occupational health and related medical practice are influenced by political and economic trends, corporate strategies to promote industrial productivity, and workers’ priorities. Occu- pational physicians attempt to improve workers’ health and mediate conditions of medical practice through application of their professional service roles and related ethical positions. This paper analyzes physicians’ statements about ethical issues in occupational medicine, and compares their formulations of ethical dilemmas with those suggested by medical ethicists. Physicians’ percep- tions of their roles in occupational health are reflected in their normative statements on responsibility for workers as patients, and descriptions of constraints placed on practice by management priorities and workplace environments. These perceptions also influence application of professional ethical codes and their revision in the interactive practice process. *Paper presented to American Anthropological Association Annual Meeting, Chicago, 1991. In this paper, illustrative cases from occupational medical literature are used to address ethical issues and research on physicians’ contemporary attitudes. This literature, however, is limited in contrast with social-historical and epidemiological studies of occu- pational risk and specific health problems [5]. Direct assessment of occupational physicians’ ethical de- ci$qns in particular cases would require further re- search; using a processual approach [6] to relate decision-making to practice settings and occupational environments. The paper explores ethical dilemmas in occu- pational medicine as a significant area often excluded from contemporary theoretical debate in American bioethics. This interdisciplinary field has been histori- cally defined by philosophers’ and physicians’ con- cerns with care decisions for life-threatening illness, and effects of treatments developed through ad- vanced medical technology [7,8]. To place occu- pational physicians’ roles in relevant social context, they are also related to current macro-level trends in occupational risk. This area of health and social policy requires analysis in the critical anthropology of health [9, lo]. BIOETHICAL POSITIONS IN CONFLICT Bioethics has emerged through the convergence of expanded medical technology and life-preserving techniques, clinical research on human subjects, and development of informed consent criteria. Because of the physician-patient relationship in critical illness and legal implications for physician responsibility, physicians have dominant roles in defining ethical issues in biomedicine [7, pp. 201-202, 8, pp. 50-51, 111. Physician responsibilities in primary health care, less severe chronic illness and disability are more 1367

Upload: sue-gena-lurie

Post on 30-Aug-2016

212 views

Category:

Documents


0 download

TRANSCRIPT

Pergamon Sot. Sci. Med. Vol. 38, No. 10, 1367-1374, 1994 pp.

Copyright 0 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved

0277-9536/94 $6.00 + 0.00

ETHICAL DILEMMAS AND PROFESSIONAL ROLES IN OCCUPATIONAL MEDICINE*

SUE GENA LURIE

Department of Medical Humanities, University of North Texas Health Science Center, Fort Worth, TX 76107, U.S.A.

Ahairact-Occupational medicine presents ethical dilemmas between worker health and corporate goals, for both physicians and managers. Physicians in occupational practice recognize conflict between ‘moralist’ and ‘utilitarian’ ethical positions. This paper analyzes the relation of professional roles to ethical interpretations by occupational physicians, based on their own and medical ethic&s’ formulations of dilemmas. Physicians’ conflicting responsibilities to workers as patients and to corporate practices and policy are reviewed in the context of occupational risk and the critical anthropology of health.

Key words-occupational medicine, bioethics, critical anthropology of health

INTRODUCTION

Occupational medicine presents ethical dilemmas be- tween workers’ health and corporate goals, for both medical practitioners and industrial managers. Although prevention and treatment of work-related health problems has been critically viewed by anthro- pologists [l], sociologists [2], and workers’ advocates as a means of implementing corporate policies, occu- pational physicians have recognized the conflict be- tween ‘moralist’ and ‘utilitarian’ ethics as inherent in their work [3,4]. This confict is interpreted as a professional hazard, regardless of the direction its resolution may take in physicians’ practice with workers as patients, or in interactions with employ- ers, insurance companies, and regulatory agencies.

In the United States, occupational health and related medical practice are influenced by political and economic trends, corporate strategies to promote industrial productivity, and workers’ priorities. Occu- pational physicians attempt to improve workers’ health and mediate conditions of medical practice through application of their professional service roles and related ethical positions.

This paper analyzes physicians’ statements about ethical issues in occupational medicine, and compares their formulations of ethical dilemmas with those suggested by medical ethicists. Physicians’ percep- tions of their roles in occupational health are reflected in their normative statements on responsibility for workers as patients, and descriptions of constraints placed on practice by management priorities and workplace environments. These perceptions also influence application of professional ethical codes and their revision in the interactive practice process.

*Paper presented to American Anthropological Association Annual Meeting, Chicago, 1991.

In this paper, illustrative cases from occupational medical literature are used to address ethical issues and research on physicians’ contemporary attitudes. This literature, however, is limited in contrast with social-historical and epidemiological studies of occu- pational risk and specific health problems [5]. Direct assessment of occupational physicians’ ethical de- ci$qns in particular cases would require further re- search; using a processual approach [6] to relate decision-making to practice settings and occupational environments.

The paper explores ethical dilemmas in occu- pational medicine as a significant area often excluded from contemporary theoretical debate in American bioethics. This interdisciplinary field has been histori- cally defined by philosophers’ and physicians’ con- cerns with care decisions for life-threatening illness, and effects of treatments developed through ad- vanced medical technology [7,8]. To place occu- pational physicians’ roles in relevant social context, they are also related to current macro-level trends in occupational risk. This area of health and social policy requires analysis in the critical anthropology of health [9, lo].

BIOETHICAL POSITIONS IN CONFLICT

Bioethics has emerged through the convergence of expanded medical technology and life-preserving techniques, clinical research on human subjects, and development of informed consent criteria. Because of the physician-patient relationship in critical illness and legal implications for physician responsibility, physicians have dominant roles in defining ethical issues in biomedicine [7, pp. 201-202, 8, pp. 50-51, 111. Physician responsibilities in primary health care, less severe chronic illness and disability are more

1367

1368 SUE GENA LURIE

central in occupational medicine [23, pp. 82-841, but relevant ethical issues are regarded as less crucial in bioethics.

Moral responsibilities of physicians as defined in bioethics are a special extension of their professional roles. Physicians, like all professional practitioners, have an obligation and authority to provide com- petent specialized services and protection to their clients, and to adhere to ethical standards of peer associations [12] in exercising individual judgment. Specialized knowledge, autonomy in decision-mak- ing, and commitment to ethical service goals ideally distinguish professional from non-professional workers [13]. In contrast with this model, however, recent sociological and historical literature on the professions has emphasized their self-interested be- havior and efforts to obtain power and dominance [14-171.

Current interpretations of the relation between bioethical dilemmas and physicians as professionals reflect similar perspectives. In “The New Medicine and the Old Ethics” [18], “myth” and history are presented as significant influences on medical ethics. Jonsen [18] identifies a tension in the history of medicine between altruism or social responsibility and self-interest, attributed to similar tension in Judaeo-Christian religious ethics. This paradox is evident in occupational medicine. However, Jonsen considers this less significant than precipitation of the current ‘moral crisis in medicine’ by new “limits to be imposed on competence” [18, p. 221. Societal reaction against heroic, high-technology treatments for critical illness has led to new legislation mandating patients’ rights of self-determination. Physicians may then interpret this as a challenge to their professional competence, opposing their own autonomy to that of the patient.

Medical ethical dilemmas caused by conflicting moral duties of the physician [19] are primarily encountered in the application of ideal principles of patient treatment: beneficence, non-maleficence, autonomy, and justice [20]. The individual phys- ician’s own moral judgment as exercised in applying these principles, with support from ethics committees or consultants in inpatient settings, is often con- sidered superior to reliance on autonomous pro- fessional codes such as those of the American Occupational Medicine Association [21]. Ethicists tend to view professional codes based on collective rules of procedures and common-sense moral atti- tudes as ambiguous or even counter to current moral viewpoints [19, p. 291.

A simple comparison of philosophical principles reveals conflicting positions. The moralist or deonto- logical position adheres to absolute standards of right and wrong, “independent of the good result” [22, p. 3531. In contrast, the utilitarian position values potential consequences for “creating the greatest happiness” [22, p. 3551. In utilitarianism, good and right are identified with happiness, although many

actions result in both happiness and unhappiness. “Act-utilitarianism” is applied in specific cases, and “rule-utilitarianism” is used to guide classes or types of actions [19, p. 81. Utilitarian ethical practice is consonant with pragmatic philosophy and the popu- lar concept of situational ethics, but decision-making in clinical settings is subject to failure if the prac- titioner inaccurately predicts consequences, or if he/she cannot assign relative happiness values to results [22, p. 3551.

Physicians’ ethics as traditionally practiced have been described as a special type of utilitarian ethics, based on loyalty to individual patients and determi- nation of what action will benefit the most people [23]. More recent perspectives support development of and adherence to ethical theory based on constant moral principles, with individual morality, moral duty, and respect for self-determination derived from Kantian philosophy [19, p. 181. Physicians have also advocated application of this individualistic ethical framework to occupational practice [4, p. 391.

Ethics of occupational medicine tend to be debated within that practice field rather than within bioethics, which continues to be primarily concerned with dilemmas of preservation and termination of life [8, p. 501. The reasons for this must be sought in the evolution of bioethics as an interdisciplinary specialty in the United States [7, p. 2011, and in the consign- ment of legal cases of occupational illness and injury to the civil judicial system of workers’ compensation [24]. Both bioethics and legal responsibility are so- cially and culturally constructed, and legal issues and decisions have significant policy consequences for occupational risk.

From the moralist ethical perspective, utilitarian social relativism is negatively interpreted as implying that “all moral reflection and deliberation are . . . quite irrelevant”, since in dilemmas of termination of life of a dying patient, ethical relativism “would have us consult a sociologist” to assess public opinion [19, p. 61. This reflects Kant’s dictum that a “pure moral philosophy” should avoid that which is “only empirical and thus anthropology” (Kant 1959 [1785]:5, cited in [8, p. 541).

The case for an anti-relativistic perspective in biomedical ethics runs counter to increasing recog- nition of the significance of sociocultural values for patients and families by primary and critical care physicians, nurses, and medical ethicists [25]. Re- cently, medical anthropologists have also argued that cultural norms and beliefs are instrumental in shap- ing our understanding of bioethics [8,25-271.

Research on ethical decision-making and reflexive interpretation should include the process of selection of cases requiring ethical decisions, directed by the authority and responsibility of physicians and hospi- tal administrators. Treatment decisions involving questions of timing and modification of standard procedures for individual patients are made by phys- icians, within administrative parameters. However,

Ethical dilemmas and professional roles in occupational medicine 1369

nurses, allied health staff, social workers, and chap- lains also interpret care decisions for themselves, patients, and family members as they perform their clinical roles and participate in ethics consultations.

Issues of treatment of patients as individuals or as representing particular groups arise both in critical patient care, and in primary occupational medical practice. Technological advances in areas such as cardiac surgery and kidney transplantation have been applied to various extents in specific populations [28]. Socioeconomic, ethnic, and regional variations in epidemiology of illness and potential responses to treatment also influence primary care, with impli- cations for individual and social justice. Occupational treatment decisions, case reporting to regulatory agencies, and implementation of policy standards for specific groups of workers have collective ethical implications.

In occupational medicine, the moralist and utilitar- ian perspectives have also been posed as antithetical. The utilitarian practitioner is considered particularly vulnerable to corporate pressures toward unethical decisions [4, p. 391. Yet application of either ap- proach occurs in the context of perceived unpre- dictability of medical outcomes for both individuals and groups:

It is dangerous to base moral thought on uncertain out- comes. Yet in occupational health this is often a necessity given the state of the art in predicting risk and future health outcomes and the current lack of scientific knowledge about safe thresholds and effects of long-term, low-level exposures. (Rest and Patterson, 1986, cited in [4, p. 391)

In this environment of uncertainty, reliance on absol- ute moral principles may be advocated as ideal since it avoids the necessity of accurate predictions of risk.

For the physician in occupational practice, guide- lines for an ethical stance may be more ambiguous than in classic dilemmas such as the right to die, since decisions in individual cases have immediate collec- tive implications. Such consequences are inescapable, due to interrelationship with corporate and union policies, legal rules and actions, workers’ compen- sation, and potential effects on the labor force and the public [6, pp. 471.

PROFFSSIONAL ROLES IN OCCUPATIONAL MEDICINE

Professional roles include determination of practice standards, and recruitment and socialization of new practitioners through training, as part of the continuing process of professionalization. Prac- tice qualifications are maintained through self-regu- lation and compliance with state licensing requirements. Approximately half of all American medical schools offer formal training in occupational medicine [29]. In an osteopathic medical school, occupational medicine is taught to all students in a public health and preventive medicine curriculum series. Course goals center on the primary care phys- ician’s role in occupational medicine, developing

skills and knowledge to identify work-related risk and illnesses, and learning effects of laws, standards, and regulatory agencies on occupational medical practice. Specific objectives include learning types of occu- pational, clinical, ancillary, and preventive services, causes and treatment of major occupational diseases and injuries, and legal and ethical issues in practice [29, pp. l-21.

Physicians with board-certification in occupational and environmental medicine in the United States tend to have training and experience in clinical medicine, physiology, pathology, toxicology, epidemiology, and industrial hygiene, and are routinely involved in assessment and management of occupational risk [30]. A recent survey of board-certified physicians and residency graduates in the field [3 l] finds generational practice trends: among the estimated 650 occu- pational medicine specialists, older physicians tend to practice in particular industrial settings, and younger ones in clinics serving a variety of employees. Cur- rently, only 40% of worksites have occupational safety or health consultants [32].

Decline in occupational medicine as a specialty is predicted, since the majority of recent residency graduates are not pursuing board certification in this field. However, in the United States, as in Britain and Canada [33], primary care physicians such as family and internal medicine practitioners, some with ad- ditional training in public health, complement spe- cialty practice in occupational and industrial medicine [34]. Most physicians treat some occu- pational health problems, and thus participate in related ethical decision-making [35]. Ethical decision- making in occupational cases by non-specialists is a relatively unexplored research area.

Occupational physicians may incur professional role strain in resolving issues of loyalty to corporate employers versus their own professional peers, or conflicts between different groups of clients, such as company managers and workers [12,pp. 321-3271. Role strains in occupational medical practice contrib- ute to situations involving ethical dilemmas. For example, if a patient is examined or treated by a physician employed by a corporation or insurance company, the company may be identified as the client. Conflicting interests of patients and company clients may also create conflicts in moral duties of occupational physicians.

Research analyzing physicians’ attitudes in re- sponse to such dilemmas has been quite limited. In an American Occupational Medical Association survey, about half of the approximately 80 sample respon- dents perceived ethical conflicts as occurring oc- casionally, one-third as rare, and less than one-fifth as frequent. In cases of occupational disease or injury, these physicians had divided ethical loyalty: half considered the patient’s welfare as paramount, and half emphasized their responsibility to the com- pany and the public [3, p. 651. Conflicts over issues of confidentiality, cost, and predictability of risk were

1370 SUE GENA LURIE

resolved by use of personal judgement as well as professional ethical codes.

In this study, occupational physicians’ responses to hypothetical cases indicated that although they tend to rely on traditional models in resolving ethical dilemmas, decisions are made under tension between ‘deontological’, or physician-patient, and ‘utilitar- ian’, or public-health, approaches [3, p. 661. This lends support to analyses of public statements by occupational health professionals which indicate ten- sion over divergent interests of workers and employ- ers [36].

The occupational physician is caught in conflicting sets of expectations from workers, business organiz- ations and economic interests, health and labor re- lations agencies, medical professional associations, lawyers, and the public. As a consequence, evaluation of occupational health surveillance by regulatory agencies has shown most state programs are “not effective due to strong disincentives for physicians . . . to report occupational diseases” [37, p. 91. Organiz- ational-professional role conflicts are comparable to those constraining medical practice in Health Main- tenance Organizations (HMOs), where bureaucratic guidelines structure physician-patient relationships. As salaried professionals, HMO physicians are sub- ject to tensions between organizational loyalty requir- ing adherence to bureaucratic procedures, and their own perceptions of and commitment to service. So- ciological interpretation has extended effects of this tension to practice skills: a “professional’s organiz- ational loyalty (and subservience) is likely to be inversely proportional to his competence” [ 12, p. 3251. Similarly, research on bureaucratic domi- nance over physicians’ practice roles in the British National Health Service has described their resulting decline in autonomy as “deprofessionalization” [38].

The extent to which the occupational physician can perform his or her function of protecting workers’ health may thus depend on the specific base of support and type of professional practice: within a company, or in an independent clinical setting. To assess the determinants of role conflict experienced in particular practice settings, it is necessary to compare the effects of significant contextual variables, includ- ing management’s economic goals and priorities, workplace health and safety practices, and the power of workers’ organizations in assertion of collective interests.

ETHICAL DILEMMAS AND PROFESSIONAL CODES

Occupational physicians addressing ethical prob- lems in practice emphasize adherence to guidelines in the American Occupational Medicine Association’s “Code of Ethical Conduct for Physicians Providing Occupational Medical Service”: primary commit- ment to the health of the worker, professional in- tegrity and competence, avoidance of conflict of interest, observance of ethical behavior, and confi-

dentiality (21, cover). Effectiveness of these guidelines is based both on the adequate qualifications of phys- icians and on their own efforts toward ongoing education of company management concerning phys- icians’ roles [39].

A major historical study by medical ethicists on professional responsibility during the twentieth cen- tury by American occupational physicians, scientists, government technicians, and bureaucrats depicts physicians in the coal mining, lead, and asbestos industries as controlled by corporate managers and politicians [40]. As evidence of this, physicians and scientists avoided blaming the asbestos industry for workers’ illnesses. They set acceptable levels of ex- posure to lead so as to define this as an engineering rather than a medical problem, and attributed black lung disease of miners to silica rather than coal particles. In the coal industry, the decision to become a company doctor is described as the key moral choice, determining both professional commitment and ethical decisions [41]. Critical assessments of physicians’ roles in the asbestos controversy, such as that by Brodeur in 1973, contributed to a crisis of confidence in occupational medicine [42].

In recent years, occupational physicians have be- come increasingly concerned about ethical problems in industrial practice. At an interdisciplinary confer- ence on legal and ethical dilemmas in occupational health in the 198Os, a physician described the ethics of environmental health as involving choices compli- cated by conflict between economics and the power of group interests, as opposed to adherence to constant Kantian moral principles of right and wrong.

In the illustrative case of a Michigan environmen- tal contamination disaster, flame retardant poly- brominated biphenyls (PBBs) were inadvertantly mixed with feed for dairy cows, contaminating feed of other animals, with deleterious consequences for the public. Major health effects were ignored because both the responsible industry and state public health department were unwilling to risk economic losses by acknowledging the diagnosis by a dairy farmer/ chemical engineer and halting sale of sick animals, until public outrage led to litigation [43]. Difficulty in applying absolute moral standards in such cases is attributed to conflicting ethical positions and econ- omic interests of the groups involved.

Such incidents lend credence to the tendency of researchers in occupational medicine to suspect medi- cal practitioners of unethical behavior, although it has also been observed that workers may be suspi- cious of researchers’ motives [44]. Practitioners and researchers are linked by the need to determine long-term health consequences of occupational ex- posures that are not yet known. They must also deal with common problems in adhering to professional codes of ethical conduct. Since researchers in occu- pational medicine must exercise professional compe- tence and accuracy in examining the relationship of workers’ symptoms to environmental exposures,

Ethical dilemmas and professional roles in occupational medicine 1371

evaluation of scientific merit and effects of their research by professional peers and institutional re- view has been proposed.

The process of ethical decision-making for preven- tion and care, including setting exposure standards and safety measures for workers and treatment of disease and injury, involves the individual physician’s judgment and application of principles in specific cases. Although reliance on absolute principles as a means of strengthening professional ethical codes is increasingly advocated by American physicians and ethicists [45, 19, pp. 18-211, a Canadian physician in academic occupational health has supported current codes of ethical practices in the field based on consen- sus among practitioners [34, pp. 2273-22751. This may signify effects of variations in physicians’ roles and professional relationships in the Canadian and United States health care systems.

Positive principles supporting the goal of workers’ health have been proposed: freedom of human action and requisite well-being, including the right to a safe and healthful working environment [46]. Adoption of these ideals incurs the consequence that in conflicts with management’s rights over property or profit, workers’ health and safety have greater priority. This is compatible with principles of informed consent and rights to appropriate treatments and procedures, generally applied in a physician’s clinical practice.

OCCUPATIONAL RISK AND CRITICAL ANTHROPOLOGY OF HEALTH

As the basis of occupational medical practice, occupational risk is a major macroscopic factor and significant social policy issue for the critical anthro- pology of health.

Premature mortality, diseases, injuries, and other unhealth- ful conditions resulting from occupational exposures prom- ise to continue as important national health problems for the next decade. Although the number of fatal occupational injuries has declined in recent years, work-related illnesses and nonfatal injuries appear to be increasing [32, p. 9.11.

Of greater concern than documented illnesses are the unknown number that are unrecognized or unre- ported. This may result from long latency periods prior to appearance of symptoms in workers, or from lack of reporting by companies due to production priorities. The general trend of increased prevalence of work disability, at a time when mortality rates have declined, has been explained in both structural economic and behavioral terms. Demographics and self-reporting patterns have been applied to deter- mine reasons for lower health status of the working- age population [47].

Policy development and implementation require comprehensive analysis of occupational health pro- grams and medical practice, in political-economic and historical context. Worker protection and pre- vention of illness and injury are needed for changing employment conditions, including the shift toward

service industries, and new industrial and non-indus- trial technology and production processes. Debates over cost-effectiveness of employee safety and health protection programs are direct reflections of ethical dilemmas of workers’ rights as contrasted with those of business and industry, and the public.

An anthropological perspective is well-suited to policy-relevant research, integrating agendae of labor, management, practitioners, and planners. The critical anthropology of health applies analytic per- spectives from critical medical anthropology [48,49] and the political economy of health [50, 10, p. 131,511. In the political economy of health per- spective, economic forces are postulated as determi- nants of both social forces and health systems, with the capitalist state striving to maintain health of the workforce at a level necessary for production.

The critical anthropology of health provides a cogent framework for analyzing policy problems and the context of dilemmas confronting both the indus- trial manager and occupational medical practitioner on a routine basis. It focuses attention on major “upstream political and economic forces” (McKin- lay, cited in [52, p. 2371) creating social conditions. For example, analysis of the combined power of the Kerr-McGee corporation in Oklahoma and the fed- eral Nuclear Regulatory Commission over workers and the public in the Karen Silkwood case reveals the role of regulatory processes in defusing public oppo- sition to industrial and environmental hazards [52, pp. 237-2481.

In analysis of national occupational health and safety programs, comparison of economic and politi- cal priorities for prevention and treatment of work- related diseases and disabilities over time shows technological and policy trends. This is exemplified by current priority for expansion of ergonomics for musculoskeletal problems and noise-induced hearing disabilities in the public and private sectors in the United States [53]. Development and application of ergonomic preventive techniques and medical treat- ment for problems such as repetitive strain and back injuries are responses to workplace technology and tasks. However, other areas of risk reduction, such as enforcement of safety standards in hazardous work and prevention of exposure to toxic substances, may be more difficult or costly to implement. A critical perspective is valuable in contextualizing reasons for corporate support of health promotion and employee assistance programs for behavioral change, as con- trasted with occupational safety and work-related illness prevention programs [54].

The relation of prevention and treatment to workers’ risks and illnesses varies with workplace, product, workers’ actions, and social policies. Well- known examples include asbestosis and nuclear-in- dustry contamination, both of which also constitute environmental hazards with serious public risk. In other instances, production and service processes posing worker risks may result in products evaluated

1372 Sm GENA Lusts

as generally beneficial to consumers, with ambiguous ethical and policy implications for workers. Risks to certain occupational workers such as miners or farm laborers may be viewed as posing a limited environ- mental threat to the public, and thus depend largely on workers’ political actions for amelioration.

Physicians treating work-related illnesses and in- juries practice in a milieu of negotiation among divergent interpretations of risk and interest groups espousing particular policies. Interpretations of risk, company practice and proposal of interventions for workers’ health are related to professional roles of managers and occupational health planners. Risk can be defined primarily as a technical matter of measure- ment and etiology, as in ergonomics; as a bureau- cratic controversy over regulatory mechanisms and jurisdiction; or as an economic problem of costs and benefits in workers’ compensation for injuries and litigation over diseases. Risk is also a political issue of consumer control, and a moral issue of the right to health and value of human life [36, p. 181.

Diversity of definitions of occupational risk may create conflict over evaluation methods, significance of causal evidence, conclusions on severity of health effects, advocacy of regulatory standards, and com- munication of risk to workers and the public [36, p. 191. From the perspective of the critical an- thropology of health, such conflicts are based in divergent power positions and economic interests of managers and regulatory agencies as opposed to workers and the public. Occupational physicians are caught in between these groups. This is illustrated by negotiations over workers’ compensation in the United States, a system developed and operating in the medical-legal arena to deal with consequences of the “moral organization of production” through “transformation of suffering into money” [24, p. 2251. The occupational physician can assume a leadership role in communication of risk both to workers and various professionals involved in risk assessment [35, p. 141.

Using the critical perspective, anthropologists have contributed significant theoretical analyses and em- pirical research to the interdisciplinary study of occu- pational illness and injury, including historical analyses of social and political responses to industrial hazards, reviewed previously [6, pp. 4-l 11. While knowledge about occupational diseases and trauma has been common among both manufacturers and physicians since the early industrial revolution in the United States, this has had minimal effect on “the political economy of industrial production” [ 1, p. 3461. Although the relative proportion of Amer- ican workers dying from industrial diseases such as asbestosis is far below that from leading causes of death+ardiac disease, lung cancer, and chronic respiratory diseases-governmental and industrial policies and strategies that perpetuate occupational risks are in opposition to the public interest.

Interdisciplinary case studies on health and safety

of American workers have broadened the critical approach, and demonstrated the primacy of contem- porary social, political, and economic issues in occu- pational injury and disease. Hazards to coal miners, workers in lead and radium industries, railroad workers’ accidents, and beryllium disease from man- ufacture of fluorescent lights have been analyzed historically and sociologically in terms of the alterna- tive approaches taken to worker protection and compensation [55]. Study of occupational safety and health in the Progressive Era, New Deal research and advocacy, and industry’s tendency to manipulate applications of research on occupational and en- vironmental effects of toxic substances have provided insight into the political-economic context of policy and practice.

Although the right to a safe workplace is con- sidered ideal by both workers and physicians in occupational medicine, the issue of who should bear the cost of workers’ health and safety is debated in business and government. National and local politi- cal debate has intensified over responsibility for health and medical care, both for workers and those outside the labor force. Recent efforts of insurance companies and employers to reduce amounts of health coverage, or even to blacklist entire occu- pations because of relative rates of hazardous work or exposure to disease [56] have underscored the urgent need for critical evaluation of occupational health protection and care.

FUTURE RESEARCH ON OCCUPATIONAL MEDICINE

Further interdisciplinary research on contempo- rary occupational medical practice in the United States is needed to clarify the context of ethical decision-making. Anthropological research in this area should be expanded and integrated with analyses of worker health, labor relations, and regulatory policy [57]. Comparison of ethical decision-making by practitioners in clinical settings with that of com- pany physicians would be valuable if related to economic and policy contexts. The relationship be- tween ethical principles and practice should also be explored in qualitative research on actual processes by which occupational physicians arrive at decisions and learn from ethical dilemmas [58]. Changes in types of ethical concerns should be compared with trends in the field of bioethics, and related to social and legal influences on bioethical issues.

Research is also needed to place contemporary case studies of occupational risk and illness in the context of political and economic influences on production and regulation in industrial, white-collar, and service settings. This should be complemented by workplace organizational research, and study of relevant occu- pational medical practice. Research on professional roles of occupational physicians in various types of organizations is a relatively unexplored area in both medical anthropology and the anthropology of work,

Ethical dilemmas and professional roles in occupational medicine 1373

organizations, and professions. Physicians’ role per- ceptions and ethical statements should be compared with their participation in work-related illness diag- nosis, treatment, prevention, and policy-making. Role performance of occupational physicians should also be compared with those of less-autonomous ‘semi-professionals’ [59] in occupational health: nurses and physicians’ assistants.

From both the perspectives of the critical anthro- pology of health and the emerging medical anthro- pology focus in bioethics on patients’ sociocultural interpretations of treatment decisions, research should also be expanded on workers’ health percep- tions and priorities, as these influence and are affected by employment and workplace options. Cross-na- tional research on cultural dynamics of workers’ social and political actions [60] and efforts by groups of workers to render work processes and environ- ments benign and protect their rights [61] should be complemented by research on contemporary Ameri- can workers’ actions related to occupational risk. Such research should be oriented toward application in the development and implementation of policies to enhance safety of workplace environments and im- prove the quality of workers’ lives, with potential consequences for reducing ethical dilemmas in the practice of occupational medicine.

REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Kaprow M. Manufacturing danger: fear and pollution in industrial societv. Am. Anrhroool. 87, 342-356. 1985. Navarro V. The labor process and health: a historical materialist interpretation. Crisis, Health, and Medicine: A Social Critique (Edited by Navarro V.), pp. 103-140. Tavistock, New York, 1986. Brandt-Rauf P. W. Ethical conflict in the practice of occupational medicine. Br. J. Indust. Med. 46, 63-66, 1989. Polakoff P. Moralist, utilitarian ethics clash in practice of occupational medicine. Occup. Hlrh Safety 39, 56, 1990. Lurie S. G. Occupational illness and injury in the United States: issues for research, policy and practice. Paper presented to American Anthropological Associ- ation Annual Meeting, New Orleans, 1990. Gordon A. Influences on biomedicine in rural Domini- can Republic: an analysis of process. Med. Anrhropol. 13, 315-336, 1992. Fox R. Evolution of American bioethics. Social Science Perspectives on Medical Erhics (Edited by Weisz G.), pp. 201-215. Kluwer, The Netherlands, 1990. Marshall P. Anthropology and bioethics. Med. Anrhro- pal. Q. 6, 49-73, 1992. -- Singer. M. The coming of age of critical medical anthropology. Sot. Sci. Med. 2& 1193-1203, 1989. Morgan L. Dependency theory in the political economy of health: an anthropological critique. Med. Anrhropol. Q. 1, 131-154, 1989. Zussman R. Inrensive Cure: Medical Erhics and the Medical Profession. University of Chicago Press, Chicago, 1992. Moore W. Economic and professional institutions. Sociology: An Inrroducrion (Edited by Smelser N.), pp. 273-328. Wiley, New York, 1967.

13. Parsons T. Professions. Inr. encycl. Sot. Sci. 12, 536-546, 1968.

14. Freidson E. Professional Dominance. Atherton Press, New York, 1970.

15. Johnson T. Professions and Power. MacMillan,

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

London, 1972. Larson M. The Rise of Professionalism: A Sociological Analysis. University of California Press, Los Angeles, 1979. Starr P. The Social Trunsformarion of American Medi- cine. Basic Books, New York, 1982. Jonson A. The New Medicine and the Old Erhics. Harvard University Press, 1990. Arras J. and Rhbden N. Erhical Issues in Modern Medicine. 3rd edn. Mavfield. Mountain View. CA. 1989. Engelhardt T. The Fbundc&ions of Bioethics. Oxford University Press, New York, 1986. American Occupational Medical Association. Code of Ethical Conduct for Physicians Providing Occupational Medical Services. J. Occup. Med. 18, cover, 1976. Brody H. Erhicul Decisions in Medicine, 2nd edn. Little, Brown and Company, Boston, 1981. Veatch R. Case Srudies in Medical Erhics. Harvard University Press, Cambridge, 1977. Bale A. The American compensation phenomenon. Inr. J. Hlrh Services 20, 253-275, 1990. Kunstader P. Medical ethics in cross-cultural and multi- cultural perspective. Sot. Sci. Med. 14B, 289-296, 1980. Fabrega H. An ethnomedical view of medical ethics. J. Med. Philos. 15, 593-625, 1990. Lieban R. Medical anthropology and the comparative study of medical ethics. Social Science Perspectives on Medical Ethics (Edited by Weisz G.), pp. 221-239. Kluwer Academic, Netherlands, 1990. Goldberg K. et al. Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients. J. Am. Med. Assoc. 267, 1473-1477, 1992. Taylor S. Occupational Medicine. Lecture outline (un- published), Texas College of Osteopathic Medicine, Forth Worth, Texas, 1990. Sparks P. and Cooper M. Risk characterization, risk communication, and risk management: the role of the occupational and environmental medicine physician. J. Occup. Med. 25, 13-19, 1993. Pransky G. Occupational medicine specialists in the United states: a survey. J. Occup. Med. 32, 985-988, 1990. Public Health Service. Promoting Health/Preventing Disease: Year 2000 Objectives for the Nation. U.S. Department of Health and Human Services, Washing- ton, DC, 1989. Markham J. Occupational medicine: new interface for family medicine? can. Fam. Phys. 35,2279-2282, 1989. Guidotti T. Occunational medicine: opportunities for family physicians. Can. Fum. Phys. 35, i2i5-2269, 1989. Haines T. Ethics in occupational health. Can. Fum. Phys. 35, 2273-2275, 1989. Nelkin D. Ethical conflicts in occupational medicine. The Language of Risk: Conflicting Perspectives on Occu- pational Health. Sage, Beverly Hills, CA, 1985.

37. Baker E. et al. Surveillance in Occupational Illness and Injury: Concepts and Content. Am. J. publ. Hlrh 79, 9-l 1, 1989.

38. Fielding A. and Portwood D. Professions and the Stat-towards a typology of bureaucratic professions. Sot. Rev. 28, 23-53.

39. Prior R. Responsibilities of the company physician. Legal and Ethical Dilemmas in Occupational Health (Edited by Lee J. S. and Rom W. N.). Ann Arbor, Michigan, 1982.

40. Bayer R. The Health and Sufery of Workers: Case Srudies in the Politics of Professional Responsibility

1374 SUE GENA LURIE

41.

42.

43.

44.

45.

46.

47.

48.

49.

(Edited by Bayer R.). Oxford University Press, New York, 1988. Seltzer C. Moral dimensions of occupational health: the case of the 1969 coal mine health and safety act. The Health and Safety of Workers: Case Studies in the Politics of Pro&ion& Responsibility (Edited by Bayer R.). Oxford Universitv Press. New York. 1988. Murray T. RegulatingVasbestos: ethics, politics, and the values of science. The Health and Safety of Workers: Case Studies in the Politics of Professional Responsibility (Edited by Bayer R.). Oxford University Press, New York, 1988. Corbett T. Ethics and Environmental Health. &al and Ethical Dilemmas in Occupational Health (Editedby Lee J. and Rom W.). Ann Arbor, Michiaan. 1982. Coye M. Ethical issues of o&upati&al medicine re- search. Legal and Ethical Dilemmas in Occupational Health (Edited by Lee J. and Rom W.). Ann Arbor, Michigan, 1982. Samuels, S. Ethics and ethical codes in occupational medicine. Environmental and Occupational Medicine (Edited by Rom W.). Little-Brown, Boston, 1983. Gewirth A. Human rights and the workplace. Am. I. Indust. Med. 9, 31-40, 1986. Wolfe B. and Haveman R. Trends in the prevalence of work disability from 1962 to 1984, and their correlates. Miibank Q. 68, 53-80, 1990. Baer H., Singer M. and Johnsen J. Introduction: toward a critical medical anthropology. Sot. Sci. Med. 23, 95-98, 1986. Singer M. Developing a critical perspective in medical

anthropology. Med. Anthropol. Q. 17, 128-129, 1986. 50. Doyal L. The Political Economy of Health. South End

Press, Boston, MA, 1981. 51. Morsy S. Political economy in medical anthropology.

Medical Anthropology: Contemporary Theory and Method (Edited by Johnson T. and Sargent C.), pp. 26-46. Praeger, New York, 1990.

52. Baer H. Kerr-McGee and the NRC: From Indian Country to Silkwood to Gore. Sot. Sci. Med. 30, 237-248, 1990.

53. Wegman D. and Fine L. Occupational health in the 1990’s. A. Rev. publ. Hlth 11, 89-103, 1990.

54. Conrad, P. Worksite health promotion: the social con- text. Sot. Sci. Med. 26, 4851489, 1990.

55. Rosner D. and Markowitz G. Dying for Work: Workers’ Safety and Health in 20th Century America. Indiana University Press, Bloomington, Indiana, 1987.

56. Freudenheim M. Health Insurers, to reduce losses, blacklist dozens of occupations. N. Y. Times, 5 Febru- ary, p. C5, 1990.

57. Susser I. Directions in research on health and industry. Med. Anthropol. Q. 2, 195-198, 1988.

58. Bosk C. Forgive and Remember. Universitv of Chicago Press, Chicago, IL, 1979.

59. Etzioni A. The Semi-Professions and Their Organiz- ation. Free Press, New York, 1969.

60. Sabel C. Work and Politics: the Division of Labor in Industrv. Cambridge Universitv Press. New York, 1982.

61. Elling k. The Struggle for Woikers’ Health: A Study of Six Industrialized Countries. Baywood, Farmingdale, NY, 1966.