[Occupational physician's decisions on the basis of legislation, ethics and scientific evidence]

BACKGROUND

In the dynamic context of occupational medicine an increasing number of occupational health problems requires a high-quality standard practice supported by decisions consistent both with ethics and legislation.

OBJECTIVES

This paper examines the relationship between legal requirements, ethical values and scientific evidence issues in occupational health practice.

RESULTS

i) Legal requirements. Italian law states that practice must be evidence-based and comply with the code of ethics for occupational health professionals of the ICOH. ii) Ethical values. The code itself emphasizes that practice should be relevant, knowledge-based, sound and appropriate to occupational risks. Furthermore, the objectives and methods of health surveillance and biological monitoring must be clearly defined and indicator must be chosen according to their relevance and predictive value. Any dilemma arising from the practice should be dealt with according to the ethical principles of health benefit, independence and justice. iii) Scientific evidence. Both the law and the code of ethics require that practice be based on available evidence.

CONCLUSIONS

Decisions made on the basis of a comprehensive process founded on scientific evidence should result in effective and high-quality outcomes that respect both the law and the rights of individuals and society.

[Occupational medicine: practice and ethical requirements of the new law on health and safety in the workplace (legislative decree 81/2008)]

Decisions in occupational health may involve ethical conflicts arising from conflicts between stakeholders' interests. Codes of ethics can provide a practical guide to solve dilemmas. The new law on health and safety in the workplace in Italy (decree 81/2008) states that occupational health practice must comply with the code of ethics of the International Commission on Occupational Health. The universally acknowledged ethical principles of beneficience/nonmaleficience, autonomy and justice, which are the basis of the Charter of fundamental rights of the European Union, inspired this code. Although the code is not a systematic textbook of occupational health ethics and does not cover all possible aspects arising from the practice, making decisions based on it will assure their effectiveness and compliance with ethical principles, besides the formal respect of the law.

[Comparative analysis of occupational health physician's duties based upon legislative decree 81/2008 art. 25 and upon the Ethics Code of the International Commission on Occupational Health]

INTRODUCTION

Ethical behaviour consists ofindividual choices inspired by knowledge and professional experience derived from the universally acknowledged ethical principles of beneficience/nonmaleficience, autonomy and justice. However, in spite of the unanimous consent on their universal importance, such principles do not usually have the strength of a law.

AIM

The recently introduced Italian law on the protection of workers' health represents a novelty because it gives the Ethics Code of the International Commission on Occupational Health legal strength. This paper aims at examining article 25 of legislative decree 81/2008 by comparing the points of the Ethics Code and the Deontology Code of the Italian medical profession.

RESULTS

The relationships between the 12 points of paragraph 1 of article 25, the 26 points ofthe Code ofEthics and the 75 articles of the Deontology Code are described with regard to the occupational health physician's duties (i) of collaboration with other occupational health professionals, (ii) of organization and execution of health surveillance, (iii) of recording, securing, transmitting of medical files on workers' health and (iv) of employee and employer information on the importance and meaning of health surveillance.

[Physicians' duty to inform about the presence of health contraindications to driving motor vehicles]

BACKGROUND

The issue concerning the duty of physicians to inform about health problems, which could be a contraindication to driving a motor vehicle, give in practice rise to many questions. Existing regulations do not apply to this issue directly, and the available literature lacks a definite stand on this matter. Information collected by the competent authorities about health problems, which may be a contraindication to driving a motor vehicle could contribute enormously to reducing or eliminating health risks among drivers and other potential road users.

MATERIAL AND METHODS

Current legislation that could in any way refer to the discussed problem were subjected to a thorough analysis and interpretation. with reference to the existing case law.

RESULTS

Despite the lack of clear regulations, physicians are obliged to provide the authorized agencies with the information about health problems, which could be a contraindication to driving a motor vehicle. The transfer of this kind of information is a legitimate exemption from doctor-patient confidentiality, therefore, physicians who transfer it do not expose themselves to bearing the responsibility. In the absence of clear standards governing the scope of information that physicians should make available for relevant authorities, the information does not need, but may include a specific medical diagnosis.

CONCLUSIONS

This article presents first comprehensive approach to the exchange of information between physicians and the body entitled to obtain information on medical unfit to drive motor vehicle, which is a helpful guide in daily practice.

Bioethical committees and data protection issues in Poland

In Poland there are only Regional Bioethical Committees. Unlike most EU countries Poland has no coordinating centre on bioethics for human research. However, the Ministry of Health and Welfare has established a Bioethics Appeals Committee.The functioning of the Bioethical Committees in Poland is regulated in detail by the Regulation of the Ministry of Health and Welfare of 1999. All regulations comply with important guidelines such as: the Helsinki Declaration, The Rules of Good Clinical Practice, EU Directives and legal regulations binding in Poland, mainly the Act of the Medical Doctor Profession and the Dentist Profession, as well as the Act of Pharmaceutical Law.In the framework of the Human Biomonitoring Programme, the application for bioethical evaluation will be submitted to the Bioethical Committee at the Nofer Institute of Occupational Medicine in Lodz.The data protection legislation in Poland according to the Act of the Protection of Personal Data of 29th of August 1997 with latest amendments fulfils EU regulations. The Act also contains detailed provisions regarding the duties of the Inspector General for Data Protection. The paper presents data on the activities of the Bureau of the Inspector General for Personal Data Protection in 2005, 2006 and 2007.

[Efficiency of the patient's signature in examinations performed by the occupational medicine doctor]

BACKGROUND

A special relationship occurring between the doctor and the patient, besides many stipulations of the ethical nature, is controlled by numerous legal regulations. In the Polish legislative system, there are no clear and unequivocal regulations that would precisely define the diagnostic-therapeutic process. Communication, namely the exchange of information between the doctor and the patient plays a particular role in this process in which the doctor bears much greater responsibility than the patient, and thus is obliged to provide the patient with the comprehensible information presented in such a way that he or she would be able to interpret it properly.

MATERIAL AND METHODS

The analysis comprised the binding legislation concerning prophylactic examination as well as drivers examination. The problem was discussed taking into account the current court judgments.

RESULTS

The doctor should pay particular attention to adjusting the quality, quantity and way of conveying the information to the patient's ability to acquire and interpret it properly. This ability is associated with the patient's personal traits. There are no algorithms for the doctor-patient communication. The occupational medicine doctors are in a better situation as legislative regulations pertaining to specificity of their health services may indicate proper communication between the doctor and the patient.

CONCLUSIONS

The importance of this communication has been notified in the legislative doctrine, where the idea of informative mistake has been formed. Such a mistake may have significant consequences especially for the occupational medicine doctors due to the specificity of performed functions. The article discusses legislative aspects concerning the exchange of information at the doctor-patient level, and presents some examples of judgments of Polish courts as well as numerous indications useful in everyday practice.

Difficult reputations and the social reality of occupational medicine

This response to Tee Guidotti's (2008) critique of Elaine Draper's 'The Company Doctor: Risk, Responsibility, and Corporate Professionalism' (2003) argues that a forthright examination of the conflicts of those working in the field of occupational medicine is essential to maintaining the health of the profession and to promoting constructive policies. Research for 'The Company Doctor' reveals how doctors walk a tightrope of professional demands on them. The author describes how corporate employment affects medicine and science and how professionals working in corporations are subject to the decisions of company managers and to economic and legal imperatives stemming from their status as corporate employees. Analyzing company doctors' role in confronting toxics and responding to liability fears in corporations, the author argues that problems of lost credibility, stigmatization, and tarnished reputation that company doctors describe largely stem from the organizational constraints, economic interests, and other aspects of the social context of their work. These social forces exert powerful pressure on the ethical framework and daily work lives of these professionals as well as on the reputation of their field. The author discusses ways in which the conflicting demands from being both a corporate employee and a physician are a social and structural problem beyond individual ethics.

Occupational medicine and the construction of "difficult reputations"

The creation of "difficult reputations" is a collective act of disparagement often undertaken to diminish the influence of the target individual or group for political reasons. This process can be observed in efforts to discredit the field of occupational medicine and the American College of Occupational and Environmental Medicine (ACOEM) by revising its history. Examples are given from Draper's 'The Company Doctor: Risk, Responsibility, and Corporate Professionalism' and LaDou, in which new sources of historical information do not support the allegations or impressions conveyed. This tendency is inimical to progress in occupational health in general and may be highly destructive to the field if not recognized and discouraged.

[Alcohol and work: ethical-deontological and medico-legal remark upon the recent set of rules]

BACKGROUND AND OBJECTIVES

The Disposition of the Permanent Conference for the relation among the State, the Regions and the Autonomous Provinces of Trento and Bolzano, published in Gazzetta Ufficiale n. 75 on the 30th March 2006 the list of high-risk occupations under the influence of alcohol, activating de facto a previous law (Legge n. 125, 3017 march 2001, "Legge quadro in materia di alcol e di problemi alcolcorrelati"). We here present some ethical-deontological and medical-juridical profiles on the contents of this law and some consideration about its application.

RESULTS AND CONCLUSIONS

Particular attention is dedicated to deontological aspects about industrial safety rules and to medico-legal aspects about occupation under the influence of alcohol, with references to complex relations among worker's discretion right, employer's right to the protection of his own interests and qualified doctor's (or someone to him comparable) right to the respect for the deontological code, with regard to benefit recipient information before the medical treatment. Authors'purpose is to evidence critical points and interpretative ambiguities of a regulation lacking in its practical applications, to provide further proposals of consideration, available to revalue a thematic rich in questions and with a significant social impact.

Ethics in sports medicine

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts between health and sport. However, modern sports medicine has emerged with the goal of improving performance and preventing injury, and the concept of the "team physician" has become an integral part of athletic culture. With this distinction come unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technology. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues.

The acceptability of waiting times for elective general surgery and the appropriateness of prioritising patients

Background

Problematic waiting lists in public health care threaten the equity and timeliness of care provision in several countries. This study assesses different stakeholders' views on the acceptability of waiting lists in health care, their preferences for priority care of patients, and their judgements on acceptable waiting times for surgical patients.

Methods

A questionnaire survey was conducted among 257 former patients (82 with varicose veins, 86 with inguinal hernia, and 89 with gallstones), 101 surgeons, 95 occupational physicians, and 65 GPs. Judgements on acceptable waiting times were assessed using vignettes of patients with varicose veins, inguinal hernia, and gallstones.

Results

Participants endorsed the prioritisation of patients based on clinical need, but not on ability to benefit. The groups had significantly different opinions (p < 0.05) on the use of non-clinical priority criteria and on the need for uniformity in the prioritisation process.

Acceptable waiting times ranged between 2 and 25 weeks depending on the type of disorder (p < 0.001) and the severity of physical and psychosocial problems of patients (p < 0.001). Judgements were similar between the survey groups (p = 0.3) but responses varied considerably within each group depending on the individual's attitude towards waiting lists in health care (p < 0.001).

Conclusion

The explicit prioritisation of patients seems an accepted means for reducing the overall burden from waiting lists. The disagreement about appropriate prioritisation criteria and the need for uniformity, however, raises concern about equity when implementing prioritisation in daily practice.

Single factor waiting time thresholds seem insufficient for securing timely care provision in the presence of long waiting lists as they do not account for the different consequences of waiting between patients.

Ethical considerations in testing workers for the -Glu69 marker of genetic susceptibility to chronic beryllium disease

OBJECTIVE

The most compelling real-world example of genetic testing for susceptibility to a workplace exposure involves those industries that process or fabricate beryllium. We examined ethical issues associated with testing for susceptibility to chronic beryllium disease.

METHODS

Using ethical and clinical criteria, we examined voluntary employer-sponsored testing programs in which individual results are reported directly to workers in a confidential manner.

RESULTS

Under reasonable assumptions, the longitudinal positive predictive value of the HLA-DPB1-Glu69 marker of susceptibility to beryllium disease is 12%. Interpretive challenges further limit the utility of the test and may inadvertently suggest a false sense of safety among workers. Concerns about confidential participation and pressures to be tested also must be addressed.

CONCLUSIONS

Difficulties surrounding the interpretation of the HLA-DPB1-Glu69 marker, lack of assurance regarding the protection of worker confidentiality, and the potential lowering of social barriers to the implementation of mandatory worker screening combine to make testing beryllium workers inappropriate at this time.

Protection of third parties in current legislation and preventive practice

The problem of safety and the management of risks to third parties, which may be caused by a change in the mental or physical health of an employee, is one which affects a number of different areas (infectious diseases, psychiatric illnesses, conditions of drug and alcohol abuse, etc.). Italian legislation deals with the issue of fitness for work through a variety of laws, decrees and regulations which, because many of them were issued in different historical circumstances, are not always mutually harmonized. The growing complexity of the workplace makes the role of the Occupational Physician more complex, and to this person the law assigns the exclusive task of monitoring the health of employees in the cases covered by the current regulations. In our opinion, the Occupational Physician, to the best of his knowledge and conscience, having taken into consideration all the aforementioned factors, must take each case on its merits, in the most responsible manner possible, weighing up the complexity and delicacy of the aspects discussed earlier, and decide to deliver a verdict of fitness and/or to break or not to break the obligation of confidentiality, tending, in our view, to favour the need to safeguard collective health, or that of third parties, should there be a conflict of interest.

Is globalisation outpacing ethics and social responsibility in occupational health?

INTRODUCTION

The definition of globalisation is varied. However, one certainty is that in a globalised world the borders are porous in many aspects; people movement, goods exchange, knowledge sharing and redistribution of labour. The concept of globalisation, its impact on society, and its direction leads to a two-sided argument. Could this be the effect of globalisation on ethics and social responsibility, as it is perceived? This paper endeavours to further our understanding of the dynamic relationship of globalisation, ethics and social responsibility in occupational health.

METHOD

The multidisciplinary activity approach to occupational health was used. The globalisation, ethical and social responsibility relationship of the activities in occupational health was analysed using a schematic map of the direct and indirect influences.

RESULTS

The analysis revealed areas that can be clustered to address the interaction between driving forces in occupational health ethics and social responsibility for a healthy workforce.

DISCUSSION

Each cluster is discussed highlighting areas of concern. In the discussion proposals are made on how we can modify the way we think in order to avoid repeating mistakes. Suggestion is made of using an innovative method borrowed from other disciplines and adopted for use in occupational health. A partnership approach is proposed and explored on how it will be applied in situations of unequal balance of power.

Framework for considering genetics in the workplace

There has been aproliferation of genetic information in the last 25 years resulting in a spectrum of existing and potential uses in the workplace. These uses of have different issues and implications which may be more clearly considered in a framework that identifies three distinct uses (research, practice, and regulation/litigation) for inherited genetic factors and acquired genetic effects. Inherited genetic factors pertain to the characteristics of the genes, and acquired genetic effects to the impact on genes and chromosomes of environmental and constitutional factors. Critical in assessing the issues involving genetics in the workplace is attention on the rights of workers, validity and clinical utility of genetic information, cost pressures on employers, and societal implications. Genetic information may provide mechanistic and diagnostic insight into occupational diseases and allow for targeting high-risk groups, improving risk assessments, and providing early indicators of risk. However, these benefits are more likely to be realized and problems avoided when the different uses are considered in a framework that distinguishes them by type and content. The application of such a framework makes it easier to assess whether there is a sufficient evidence base and worker safeguards in place for any particular use of genetic information.

The threat to scientific integrity in environmental and occupational medicine

Over the last century, environmental and occupational medicine has played a significant role in the protection and improvement of public health. However, scientific integrity in this field has been increasingly threatened by pressure from some industries and governments. For example, it has been reported that the tobacco industry manipulated eminent scientists to legitimise their industrial positions, irresponsibly distorted risk and deliberately subverted scientific processes, and influenced many organisations in receipt of tobacco funding. Many environmental whistleblowers were sued and encountered numerous personal attacks. In some countries, scientific findings have been suppressed and distorted, and scientific advisory committees manipulated for political purposes by government agencies. How to respond to these threats is an important challenge for environmental and occupational medicine professionals and their societies. The authors recommend that professional organisations adopt a code of ethics that requires openness from public health professionals; that they not undertake research or use data where they do not have freedom to publish their results if these data have public health implications; that they disclose all possible conflicts; that the veracity of their research results should not be compromised; and that their research independence be protected through professional and legal support. The authors furthermore recommend that research funding for public health not be directly from the industry to the researcher. An independent, intermediate funding scheme should be established to ensure that there is no pressure to analyse data and publish results in bad faith. Such a funding system should also provide equal competition for funds and selection of the best proposals according to standard scientific criteria.

[Occupational selection in industrial medicine]

The article deals with contemporary state of occupational selection (educational, social and psychologic, medical) in Russia, its importance in industrial medicine and connection with ethic problems. The author defined topical directions in research of occupational selection and occupational fitness examination.