PRINCIPLES OF TOXICOLOGY

Academic practices welcome complicated referral cases that pose medical or medicolegal diagnostic
challenges and require much time to evaluate and treat; such cases are often used in training physicians
and/or nurses who hope to specialize in occupational health. Most academic units have active programs
of research and service and blend clinical care with study, collaboration with local employers, unions,
and government agencies, and similar activities.
Other occupational medicine providers work in the insurance industry, in consulting firms, and in
government agencies. All of these settings provide opportunities for treating and diagnosing patients
with work-related ailments, and perhaps more importantly, for recognizing, assessing, and controlling
workplace hazards.
20.6 ETHICAL CONSIDERATIONS
20.6 ETHICAL CONSIDERATIONS 507
Occupational medicine sits astride several kinds of competing interests, most notably labor-management
disputes. Sometimes practitioners find themselves caught “between medicine and management.”
The ethical issues that arise are interesting and challenging.
Confidentiality is one issue. An accepted principle of medical ethics is that medical information
about a patient is private and should be released only with the patient’s consent. However, employers
sometimes have access to medical information about their employees obtained through occupational
medical evaluations. In some situations, this information is not protected; it is accessible to personnel
managers, supervisors, and others. Clinicians who collect the information may feel that they owe it to
the employer, since the employer paid for the examination and is in some sense the “customer.”
Occupational health professionals must strive to maintain medical information confidential. A standard
approach is to maintain medical information in locked files, accessible only to medical personnel and
to provide employers only with statements of fitness to work and necessary accommodations.
A second issue has to do with notification of hazards. Physicians and other health care workers are
usually considered to have some ethical responsibility to public health. This implies an obligation to
inform health authorities, and people at risk, of a hazard that is uncovered. However, history records
an unfortunate number of instances in which occupational health professionals were prevented from
disclosing hazards, usually by companies that would be financially threatened by such disclosure. For
example, suppose that a physician contracts with a paint manufacturer to conduct medical examinations
of the workers. The physician finds an elevated prevalence of asthma and dermatitis and localizes these
problems to one area of the plant where chemical exposure levels are high and then reports this finding
to management and plans to notify the workers of their diagnoses. However, management is concerned
that this might trigger workers’ compensation claims and informs the physician that her contract will
be terminated if she informs the patients of their findings.
A related dilemma arises when disclosure would violate the confidentiality of an individual. For
example, suppose that a worker is diagnosed with severe occupational asthma, and the physician
determines that the cause is excessive exposure to epoxy resins. Other workers are potentially exposed
and are at risk of developing asthma. The physician plans to notify the employer, to recommend hazard
abatement, and to inform OSHA of the problem. The patient pleads with the physician not to do so,
claiming that he or she would be identified as the complainant and be fired. In these cases, the
physician’s duty to inform is challenged by competing considerations. A standard approach is to define,
in advance, the occupational health professional’s ethical obligations, including the duty to inform and
to build this into any contract.
A third ethical issue involved employment discrimination. A famous case arose in the 1980s when
a manufacturing facility that used lead prohibited women from working in certain jobs (incidentally,
those with the best pay) unless they had been sterilized. The employer reasoned that if women became
pregnant, their fetuses would be especially susceptible to the toxic effects of lead and that a ban would
prevent this undesirable outcome. However, employees argued that the ban amounted to blatant gender
discrimination and took their claim all the way to the U.S. Supreme Court case, where they prevailed.