Ethical concerns in occupational screening programs

Preventive and anticipatory programs for identifying workers at higher-than-normal risk for occupational injury and/or disease can now draw on an expanding net of sophisticated diagnostic tests. New genetic screening tests may use reagents developed through recombinant DNA technologies, including cDNA probes for genetic variants such as HLA B27 associated with late-appearing disability. Assessments of the readiness of these technologies to be incorporated into standard occupational policy turn on their predictive value, applications, and the locus of control of the data which they generate. The question of responsibility for health protection and obligations accruing to those who uncover genetically fixed risk status has major ethical implications. Issues of potential stigmatization, discrimination, and protection of equal employment opportunity must be resolved before these tests are put into practice. The possible use of genetic testing to assure minimal risk and its equitable distribution among workers is highlighted as a possible benefit of this new applied technology.

Medical surveillance of employees under the Occupational Safety and Health Administration

This paper will consider medical surveillance in the context of the Occupational Safety and Health Act of 1970. The Occupational Safety and Health Administration (OSHA) has issued (after rule making) health standards covering approximately 24 toxic substances, and all these standards have included medical surveillance programs. OSHA is not only empowered but compelled by law to require medical surveillance programs for exposed employees. At the same time, a number of major legal/policy issues relating to medical surveillance have been raised at the standards rule-making stage and litigated in court. Among the more significant of these are access to medical records, selection of physician, and medical removals. Many of these issues were involved in OSHA's Lead Standard, issued in 1978 and affirmed in relevant part by the Court of Appeals for the District of Columbia in 1980, and in the "medical access" rule, issued in 1980 and upheld by the Court of Appeals for the Fifth Circuit. These two proceedings will be used as a focus for the discussions of medical surveillance programs under the OSHA act.

Discriminatory aspects of medical screening

Presently, there are few legal restrictions on the use of medical screening of workers. The Occupational Safety and Health Act (OSH Act) requires that certain medical tests be performed when workers will be exposed to specific toxic substances. The OSH Act does not, however, prohibit the use of any medical screening measure nor does it indicate what actions an employer may or may not take as a result of such information. (A notable exception is the medical removal provision of the Lead Standard). This paper discusses that protection afforded under Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, and the Rehabilitation Act of 1973. This paper will demonstrate that the law has, in general, failed to take into account the discriminatory aspects of medical screening.

Biological monitoring in the workplace: ethical issues

This paper addresses the following questions concerning medical surveillance and the worker's relationship to management: Do workers have a moral obligation to participate in workplace screening and monitoring when undertaken to enhance the interests of occupational health? What conditions would be necessary to establish the existence of such a moral obligation? If such an obligation were to be established, ought it be satisfied solely on the basis of voluntary collaboration? Is compulsory participation in monitoring and screening ever morally justified? Should the principle of informed voluntary consent that obtains in medical research apply to workplace investigations that involve potentially invasive procedures and risks to privacy?

[The Health and Medical Services Law for the elderly and early cancer detection]

Anti-cancer measures in Japan were started in the 1950s, and programs for the early detection of stomach and cervical cancer supported by the National Government were begun in 1966 and 1967, respectively. In 1983 the Health and Medical Services Law for the Elderly was enacted, and under this law nationwide early detection programs for stomach and cervical cancer have been under taken and the number of people screened has been steadily increasing. Accuracy control programs for these cancer detection systems are now being established by prefectural governments. The examination of programs for the early detection of lung cancer and breast cancer will be necessary when suitable methods have been established.

Education, consent, and counseling in sickle cell screening programs: report of a survey

In 1980, we surveyed screening facilities to determine the extent of sickle cell screening and to assess compliance with Maryland regulations. Approximately 52,000 persons were screened per year in Maryland by local health departments, hospitals, primary care centers, correctional facilities, and units dedicated entirely to screening. Thirteen thousand persons were screened without informed consent. Many facilities were deficient in providing education and counseling as well as in obtaining informed consent. Units dedicated entirely to screening were most compliant with the state regulations.

[Mass screening program for cancer]

Since Japan, a national cancer control program has been initiated in 1957. The fundamental principles were set up in 1965. Under these principles, the Ministry of Health and Welfare granted financial support for stomach and uterine cancer mass screening programs, which were conducted by the local governments. At that time, the number of examinees was limited; 990,000 persons for stomach cancer screening program and 127,000 persons for uterine cancer screening program in 1966. However, it increased rapidly year after year and reached to 4,350,000 examinees for the stomach cancer and 2,656,000 examinees for the uterine cancer In 1983, the Health Promotion Act for the Aged was enacted. The Act prescribes the local municipalities to conduct stomach and uterine cancer mass screening programs for their inhabitants. This report describes a historical review of the development of the mass screening programs, especially on the objection objection against the programs in 1967-69 and in 1978-79, and on the reaction to those objection. The definition of mass screening programs and the future of mass screening are discussed.

Newborn sickle cell screening. Benefits and burdens realized

Seventeen newborns identified by state-mandated screening as having sickle cell disease or homozygous hemoglobin C disease were followed up through interviews of their physicians and their parents to assess benefits and burdens received by the families. Many parents had provided proper care for their children (12/17) and pneumococcal prophylaxis had been given (6/14). However, some parents did not understand the recurrence risk (3/11) and for others genetic counseling may have threatened the parental relationship by focusing attention on the identity of the father (3/11). Deriving the maximum benefit from newborn sickle cell screening will require a better understanding on the part of physicians of the differential diagnosis, treatment, and inheritance of sickle cell disease and guidance regarding comprehensive counseling of families. In the meantime, states mandating such screening need to provide individual case follow-up.

Effectiveness of federally required medical laboratory screening in the detection of chemical liver injury

The increasing concern of industrialized societies over the potential health hazard of synthetic chemicals in the occupational environment has led to government requirements for medical laboratory screening of workers. The specific tests for such screening programs are most often selected on the basis of medical experience which utilized them in symptomatic or hospitalized populations. Required screening tests for hepatic injury including cancer in vinyl chloride workers has been systematically and prospectively studied in an industrial population working with synthetic rubber and plastics. Approximately 1300 employees were studied over a five-year period. A cohort of 969 male employees, for the purposes of analysis, were divided into a "standard" and "nonstandard" population based upon the absence or presence of significant medical disease (including liver disease). A subcohort of 120 individuals was further identified based on availabiliity of liver biopsy. Evaluation of federally required studies included alkaline phosphatase (AP), gamma-glutamyl transpeptidase (GGTP), alanine aminotranserase (ALT, SGPT), aspartic aminotransferase (AST, SGOT) and bilirubin (BR). Also studied were indocyanine green clearance (ICG) and radioisotopic liver spleen scans (L-S scans). The GGTP provided the highest positive predicted value as a screening test for identifying "nonstandard" individuals (individuals with all types of medical disease) followed by ICG, AST, ALT, L-S scan, AP, and BR. In the identification of asymptomatic liver disease the GGTP had the least specificity due to a high false positive rate, while the AP provided the highest specificity. The ICG clearance however, provided the best combination of positive predictive value and sum of specificity and sensitivity. The AP provided additional increase in specificity as a follow-up study. There was no evidence that any of the other federally required tests added any additional benefit and did add significant increase in the false positive rate. These studies support the need for evaluating screening tests as to their sensitivity, specificity and positive predictive value, in asymptomatic individuals, before they are made established requirements.

Early and Periodic Screening, Diagnosis, and Treatment Program

Preventive health care for children can have a significant impact on detecting and treating potential health problems. The Early and periodic screening, diagnosis, and Treatment Program (EPSDT) is a preventive health program under Medicaid designed to improve the health of indigent children. Since this program is the only federal Medicaid program which requires vision screening and treatment services, the opportunity exists for enormous benefits for detecting and treating an indigent child's vision problems, as well as general health problems. Even though the program has been slow in evolving, it is taking an expanding role in all phases of indigent child health care, including vision care.

Legal and social issues in medical genetics

This paper was written for the purpose of providing the physician with a perspective of the conflicting scientific, individual, and societal interests which have been evoked by increasing medical and scientific innovation in the area of human genetic disease. In it the following subjects are considered: (1) obtaining genetic information by amniocentesis, by genetic counseling, and by screening; (2) disclosure of genetic data to the patient; (3) inclusion of genetic data on the medical record; (4) courses of action available to the individual after disclosure of genetic information, i.e., abortion, sterilization, etc.; (5) the state and involuntary sterilization; and (6) prohibitions on marriage.