810
SUMMARY* IRVING R. TABERSHAW, M.D. Editor Journal of Occupational Medicine Rockville, Maryland
THREE major issues of ethical problems-loyalty, confidentiality, and reporting-were the major subjects, and were set in a base of discussion on the economics and the structure of the corporation itself. In that sense it was well designed. The last two speakers had as much to say as everybody that preceded them, and I am sorry that they did not start the session. Had they started it, I daresay that the discussions would have remained in the spheres that they discussed rather than getting off into many of the areas which represent problems in occupational medicine, but which are not necessarily ethical issues. My basic disappointment was that labor did not participate, and Dr. Wessel's explanation for it may be correct. I have the feeling that labor started this issue of ethics and then walked away. It is like starting a free-for-all fight and then letting everybody fight while the instigator disappears. Labor ought to be in it, but perhaps it should act as an adversary only to keep the fighting going on. Another disappointment was the lack of maintaining a specific view of the real ethical issue, that is, can the occupational physician serve two masters? We all agree that our basic responsibility is to the worker. The assertion was repeatedly made that by doing well for the worker, by being interested in his welfare, we shall do well for the corporation. But the fact remains that the corporation, as Dr. Donald Shriver indicated, may have another ethic, that is, the ethic of the "bottom line," the ethic of creating wealth. And the question arises whether we can serve both masters at once. This issue was addressed, but I do not think it was completely explored. I might comment also that there was not enough soul searching, in my view, as to the role of the occupational physician in specific issues when treating or examining a person for a job. The occupational physician has *Presented at a Conference on Ethical Issues in Occupational Medicine cosponsored by the New York Academy of Medicine and the National Institute for Occupational Safety and Health and held at the Academy June 21 and 22, 1977.
Bull. N.Y. Acad. Med.
SUMMARY -~~U
MA
Y
1
811
always been in a unique position in that he is not only involved in the individual's health, but he may be, and very often is, the key factor which determines whether or not the individual can work. This, then, is the question of the "tradeoff." Which is more important to the man: risk to his health, presuming there is a risk, or his job? Therefore, the occupational physician is perceived-a word I have heard dozens of times in the last couple of days-as a formidable opponent who is looked upon with some degree of dislike and certainly with fear by many workers. Another disappointment I had in the general meeting was the lack of definition of the professional's responsibilities. I think the occupational physicians did discuss our professional responsibilities, but we did not bring out carefully enough the difference, for example, in the lawyer's point of view regarding his client, the corporation. It is legitimate for the lawyer to have this artificial person known as a corporation as his client. When he has to defend that dlient, that is, to support the point of view that the businessman takes, the lawyer is operating within his ethical principles. The physician is in a different position. However, these are generalities, and perhaps it might be well for me to give a very quick review of the details of some of the presentations. The first morning was devoted essentially to the organizational environment. I presume that meant the ethics of business' conduct toward occupational medicine. Our first speaker, Dr. Robert Ackerman, presented a point of view that corporations must adopt and would be considered failures now if they did not respond to changing social conditions such as occupational safety and health. But there are many other social changes, for example, affirmative action, to which the corporation must react. He discussed mostly how to overcome the inertia of the company, how to effect the change. It was a description essentially of how an organization can be made to accept a situation in which the results may not always produce a profit. The mechanisms were discussed, but very little insight into the ethical issues of business, really what is the businessman's ethic, was provided. Our second speaker, or discussant, was much more direct. He discussed the motives of the corporation, and he did bring out that increasing its wealth or profit was its major motive. In introducing social change, he examined the "tradeoffs." This was the word one discussant used and pointed out that it was repugnant for a physician to think in terms of health Vol. 54, No. 8, September, 1978
812 812
I.R. TABERSHAW IR.
TABERSHAW
as a negotiable item, but that there were tradeoffs. A good deal of the discussion centered around that point-whether, in fact, health is a negotiable item. In the marketplace tradeoffs certainly exist, and therefore the question arises, what role does the doctor play in terms of the evaluation of a worker, whether or not the health tradeoff is worth it to the company or the worker, and whether he should be involved in an advocacy position regarding such tradeoffs. It became evident that the doctor cannot avoid being in that position, much as he dislikes it. Alfred Neal raised a rather interesting issue. He examined the point that if corporations are interested in profits, one great area that is now consuming profits and creating difficulties is the cost of health care, which is being underwritten by corporations, either directly or through taxation. He raised the issue of what role the occupational physician should play in this particularly sensitive area of increasing impact on profits. There was a general feeling-at least I gathered that sentiment from the physicians' responses-that the cost of health care to corporations was not a legitimate concern of theirs, at least not at this time. My own attitude toward this role of the physician as the advisor to management and perhaps as the supervisor of the quality and cost of medical care paid for by the corporation, is that it is a legitimate function and I daresay it is the next step in the enlarged social practice of the occupational physician. We are now concerned mostly with health and safety, but one can foresee that health-care costs to industry may be the next major area of concern. It raises some ethical issues as to whether the corporation should have the right, simply because it pays for medical care, to control its costs and perhaps with it the quality of care and its delivery system. As occupational physicians, we have assiduously avoided that problem. Mr. Neal, in raising this issue, also challenged us to look at ourselves as to how innovative we are in anticipating social change. Out of the discussion of that morning it was obvious that we were not really understanding-at least in my view-that the corporation, the single most dynamic force in our capitalist-industrial society, was geared to efficiency, and that the doctor's role in this institution was a true gauge of what will happen to our economics, to our society, to our future. I was happy to hear Dr. Milton Wessel point out that we are in a period of change in which we are defining a new kind of society. We have been at it for some time, finding a new society, because the Bull. N.Y. Acad. Med.
SUMMARY
SUMMARY
813
813
industrial revolution changed the method of earning, changed the relations of the family to the work situation, etc. We are finally coming to an understanding of and a code of ethics-a code of behavior if you wish-as to how we can further develop the corporation, bearing in mind that previously a corporation which created wealth meant better health through a better standard of living. But we are now facing the problem that the technology that is amassed by this corporation may be detrimental to the health of the worker, to the user of the product, and to the community, and how do we, as physicians, fit into this particular institution-the corporation-which is so embedded in the matrix of the entire society. It was assumed by Dr. Robert Ackerman and Dr. Donald Martin that the modern corporation would accept this social change, but medicine is the most difficult technology or discipline to integrate into the structure of the corporation. I think that the discussion for the last two days demonstrated that, and just our being there raises issues of confidentiality, issues of reporting, and issues of loyalty. And so our presence makes it more difficult for the corporation to change its organizational structure, its administration, and, perhaps, its value system. The goal is no longer just profit, and yet profit must be made in order to assure the existence and continuation of the corporation. In the afternoon the subject was the loyalty of the occupational physician. But loyalty to whom? The dilemma I raised a little earlier was also discussed, that is, whether you can have the worker as your patient, with your entire devotion to his welfare, and at the same time have the corporation, that is, the enterprise, as your patient as well. Dr. Bertram Dinman faced the issue and stated that he feels both are his patients, and he finds no conflict, or if there is conflict, it can be resolved. He indicated that there may be some battles, but he made it plain that if you lose the first one, do not run away. You should stay and fight. Otherwise, if you lose the first skirmish and run, you lose the battle. It is obvious that the physician does have a problem having the enterprise, that is, the corporation as a patient, and at the same time being totally directed toward the welfare of the worker. I think, as a basic ethical premise, the statement that what is good for the worker is good for the corporation, is true. Dr. Dinman also pointed out that this is not necessarily the view of the corporation executive, who is not responsible for long-term planning, but who is responsible only for the next quarter's profit-and-loss statement. In examining the role of top management, the point has been made that Vol. 54, No. 8, September, 1978
814
81
TABERSHAW I.R. TAESA
IR
in the structure of the successful corporation, for the most part, there is a division of responsibility. In the so-called-profit center, while top management or the chief executive officer may very well understand the social implications, the profit-center manager, nevertheless, is judged and is awarded only on the end point, namely, the profit or loss in that quarter. I know this is one of the major stumbling blocks in introducing into industry a social conscience and facing the consequences of preventive medicine. What I have found is that our society is no longer blaming the division or the local plant if something goes wrong. Rather, it blames the chief executive officer. I find this the most effective ploy to make clear to a top executive that he cannot avoid responsibility for what happens. For instance, in the case of the Kepone problem, Allied, and not the Life Sciences Company, was held responsible. Dr. Donald Whorton presented a point of view which essentially is not different from that of Dr. Dinman. He expanded a bit on labor's view of the doctor's role in society and the occupational physician's role in industry, and pointed out that he is perceived as not necessarily being on the worker's side. I myself have reacted to that kind of perception. I personally do not feel guilty in that sense because I recognize that the worker also has his own motivations in wishing to see the doctor in that light. It is true that the physician in occupational medicine does hold that position and therefore there is a need to change the image. A good deal of discussion was then centered around the code of ethics developed by the American Occupational Medical Association to help guide the physician in industry to overcome this perceived image by the worker. This discussion on the code of ethics was somewhat tangential to our real focus, although it represented an important development. It demonstrates that the occupational physician is aware of the situation and is moving toward better understanding of his role and overcoming this presumed dichotomous position. I believe it is, in a sense, dichotomous, but not in terms of the ethics and conscience of the occupational physician. If the physician has the ethical point of view that he is obligated to the worker and that is his basic responsibility, then the problem becomes solvable. The affirmation that the basic effort that what is good for the worker will benefit the corporation was repeated several times. The role of advocacy was brought up over and over again, and it appeared that whether or not the occupational physician was unhappy about the situation, he was forced into the position of advocacy. Bull. N.Y. Acad. Med.
SUMMARY
SUMMARY
815
Other items were discussed but not thoroughly explained. For example, the use of workers for human experimentation. Dr. Collings made a remark which to me was very trenchant-that perhaps the situation would change if the worker could choose the occupational physician. However, the comment was not discussed in any depth. The question of confidentiality moved along a little better. Dr. Alan McLean made a very concise and clearcut presentation on what is involved in confidentiality, and it was obvious that not only occupational physicians but all physicians face this issue. The format or access or control or ownership of data and the use of it are questions that affect every practicing physician, no matter where he is and what kind of practice he has. These questions are of particular interest to the occupational physician, who must be identified and who is operating in a large matrix in which others have some input to whatever is developed about the individual worker. It is not just a personal relation between the patient and the doctor. Therefore, access to the record and how it is recorded and what is recorded are extremely vital to the interpretation, as well as to the fact of how one practices. Those of you who came in recently heard Dr. Shriver's review of Dr. Hilker's doctrinal statement, which I think represents all our views, and which we fully support. He made the point generally that we are living in a complex society, and that there is a real need to produce information. Yet one cannot avoid being pushed into a position of advocacy. The industrial physician, if he is armed with his conscience and his doctrinal ethics, stands for the better health of the worker. He then can practice effectively, and in that way change, to some degree, the attitudes and the so-called rewards in the business system. Miss Muriel Pappert then reviewed the basic principles of the nurse's responsibility and described how the nurse is the recorder, the interpreter, and the communicator of the information to the worker, and at the same time the key to maintaining the privacy of the records. In my view, Dr. Robert Scala and Dr. Bruce Karrh presented concise views of the conscientious men who understand the importance of the information. Recognizing that they are living in a practical and realistic world, they went through the logistics of how and when to report. I do not think there was any question that the health professional has a responsibility and a duty to report health hazards and that the physician within and outside of the framework of industry always bears this responsibility. Dr. David Wegman, an educator looking at the responsibility to report, Vol. 54, No. 8, September, 1978
81681
I.R. IR TABERSHAW TAESA
raised another point. Of course, he agreed with the basic responsibility of the physician. I was struck with Dr. Wegman's comment regarding the order in which people are informed if a hazard is suspected. If I heard him correctly, he said that management would be informed first, then the worker, and then the newspapers. The management should be first because they have to do something about the hazard. Next is the worker, who should know because he has the most at stake. The third surprised me a bit: the public. Therefore, the newspaper was informed next-I would have thought the newspaper would be the last to be notified. When should the government be told and when should the professional groups be told? I mention that not to take issue with Dr. Wegman as to the order of notification, but simply to point out how difficult it is to know whom to tell when. Then Dr. Dinman raised the point: "When do you know there is a hazard?" I think this is the key question. What information do you have? When do you decide that you know enough to say something to somebody? And what are the consequences of not speaking? And when do you stop looking for more information? These go back to ethical considerations, and I do not know that there is any answer to this. It's a matter of conscience, a matter of judgment, a matter of experience. My own problem with this is that I am not sure when I am certain. Let us put it this way-I do know when I know, but there is a large time span when I do not know that the information is adequate enough to make a reasonable judgment. I am talking about being certain, about finding the "smoking pistol." Then the question of whom to tell follows this pattern. You tell management, you tell the worker, and you tell the profession. I believe this agrees with Dr. Scala's approach. When do you know? I can think of many situations I am involved in right now in which I do know, but there are other situations where I do not feel I know enough. I was disturbed, as I think everybody was, with Dr. Wessel's comment that just having had a discussion on a subject with industry means that it should be reported to the government. It occurred to me that the toxicologist has a relatively easy time because he is developing information on animals that may or may not be applicable to man. He can afford to wait for more information in good conscience. As Dr. Wegman brought out very succinctly, when you are dealing with human beings, if you suspect that a disease may be related to workers or if you find some abnormal condition in a group of people, on either a Bull. N.Y. Acad. Med.
SUMMARY
817 SUMMARY
817~~~~~~~~~~~~
cross-sectional or an epidemiologic study, you are in a much more agonizing position to make a decision as to when and whom you should inform. Again, I know no answer to that except to comment that it depends on your judgment, your experience, your own sense of what is the correct thing do so. I consider the last two speakers the highlight of the conference. They took care of most of the things that were bothering me and covered the real issue of our ethical consideration. I would have liked more from the theologian, from the economist, and the lawyer. They did not really describe their own orientation to the ethics of business. I would have liked a discussion from them on the ethics of business, but I was satisfied that they appreciate that there is an ethical problem, at least for physicians. I believe that all of us agree with the basic principle that the occupational physician can practice consistently with his professional obligation to the health of the worker and yet not be destructive of the capitalist industrial society in which he lives, and that the corporation as an effective agent in our democracy can be supported. We are coming to grips with the problem. I begin to see some of the problems being satisfactorily resolved. Once we publish the code we shall be revaluating it and revamping it. It is evident that physicians in industry are willing to examine ethical problems. They are willing to look at them. They speak now of the enterprise as a client. Finally, there will be a publication as a result of this conference. These proceedings, I am sure, will be a standard reference or at least a starting point for continuing discussion.
Vol. 54, No. 8, September, 1978
SUMMARY* IRVING R. TABERSHAW, M.D. Editor Journal of Occupational Medicine Rockville, Maryland
THREE major issues of ethical problems-loyalty, confidentiality, and reporting-were the major subjects, and were set in a base of discussion on the economics and the structure of the corporation itself. In that sense it was well designed. The last two speakers had as much to say as everybody that preceded them, and I am sorry that they did not start the session. Had they started it, I daresay that the discussions would have remained in the spheres that they discussed rather than getting off into many of the areas which represent problems in occupational medicine, but which are not necessarily ethical issues. My basic disappointment was that labor did not participate, and Dr. Wessel's explanation for it may be correct. I have the feeling that labor started this issue of ethics and then walked away. It is like starting a free-for-all fight and then letting everybody fight while the instigator disappears. Labor ought to be in it, but perhaps it should act as an adversary only to keep the fighting going on. Another disappointment was the lack of maintaining a specific view of the real ethical issue, that is, can the occupational physician serve two masters? We all agree that our basic responsibility is to the worker. The assertion was repeatedly made that by doing well for the worker, by being interested in his welfare, we shall do well for the corporation. But the fact remains that the corporation, as Dr. Donald Shriver indicated, may have another ethic, that is, the ethic of the "bottom line," the ethic of creating wealth. And the question arises whether we can serve both masters at once. This issue was addressed, but I do not think it was completely explored. I might comment also that there was not enough soul searching, in my view, as to the role of the occupational physician in specific issues when treating or examining a person for a job. The occupational physician has *Presented at a Conference on Ethical Issues in Occupational Medicine cosponsored by the New York Academy of Medicine and the National Institute for Occupational Safety and Health and held at the Academy June 21 and 22, 1977.
Bull. N.Y. Acad. Med.
SUMMARY -~~U
MA
Y
1
811
always been in a unique position in that he is not only involved in the individual's health, but he may be, and very often is, the key factor which determines whether or not the individual can work. This, then, is the question of the "tradeoff." Which is more important to the man: risk to his health, presuming there is a risk, or his job? Therefore, the occupational physician is perceived-a word I have heard dozens of times in the last couple of days-as a formidable opponent who is looked upon with some degree of dislike and certainly with fear by many workers. Another disappointment I had in the general meeting was the lack of definition of the professional's responsibilities. I think the occupational physicians did discuss our professional responsibilities, but we did not bring out carefully enough the difference, for example, in the lawyer's point of view regarding his client, the corporation. It is legitimate for the lawyer to have this artificial person known as a corporation as his client. When he has to defend that dlient, that is, to support the point of view that the businessman takes, the lawyer is operating within his ethical principles. The physician is in a different position. However, these are generalities, and perhaps it might be well for me to give a very quick review of the details of some of the presentations. The first morning was devoted essentially to the organizational environment. I presume that meant the ethics of business' conduct toward occupational medicine. Our first speaker, Dr. Robert Ackerman, presented a point of view that corporations must adopt and would be considered failures now if they did not respond to changing social conditions such as occupational safety and health. But there are many other social changes, for example, affirmative action, to which the corporation must react. He discussed mostly how to overcome the inertia of the company, how to effect the change. It was a description essentially of how an organization can be made to accept a situation in which the results may not always produce a profit. The mechanisms were discussed, but very little insight into the ethical issues of business, really what is the businessman's ethic, was provided. Our second speaker, or discussant, was much more direct. He discussed the motives of the corporation, and he did bring out that increasing its wealth or profit was its major motive. In introducing social change, he examined the "tradeoffs." This was the word one discussant used and pointed out that it was repugnant for a physician to think in terms of health Vol. 54, No. 8, September, 1978
812 812
I.R. TABERSHAW IR.
TABERSHAW
as a negotiable item, but that there were tradeoffs. A good deal of the discussion centered around that point-whether, in fact, health is a negotiable item. In the marketplace tradeoffs certainly exist, and therefore the question arises, what role does the doctor play in terms of the evaluation of a worker, whether or not the health tradeoff is worth it to the company or the worker, and whether he should be involved in an advocacy position regarding such tradeoffs. It became evident that the doctor cannot avoid being in that position, much as he dislikes it. Alfred Neal raised a rather interesting issue. He examined the point that if corporations are interested in profits, one great area that is now consuming profits and creating difficulties is the cost of health care, which is being underwritten by corporations, either directly or through taxation. He raised the issue of what role the occupational physician should play in this particularly sensitive area of increasing impact on profits. There was a general feeling-at least I gathered that sentiment from the physicians' responses-that the cost of health care to corporations was not a legitimate concern of theirs, at least not at this time. My own attitude toward this role of the physician as the advisor to management and perhaps as the supervisor of the quality and cost of medical care paid for by the corporation, is that it is a legitimate function and I daresay it is the next step in the enlarged social practice of the occupational physician. We are now concerned mostly with health and safety, but one can foresee that health-care costs to industry may be the next major area of concern. It raises some ethical issues as to whether the corporation should have the right, simply because it pays for medical care, to control its costs and perhaps with it the quality of care and its delivery system. As occupational physicians, we have assiduously avoided that problem. Mr. Neal, in raising this issue, also challenged us to look at ourselves as to how innovative we are in anticipating social change. Out of the discussion of that morning it was obvious that we were not really understanding-at least in my view-that the corporation, the single most dynamic force in our capitalist-industrial society, was geared to efficiency, and that the doctor's role in this institution was a true gauge of what will happen to our economics, to our society, to our future. I was happy to hear Dr. Milton Wessel point out that we are in a period of change in which we are defining a new kind of society. We have been at it for some time, finding a new society, because the Bull. N.Y. Acad. Med.
SUMMARY
SUMMARY
813
813
industrial revolution changed the method of earning, changed the relations of the family to the work situation, etc. We are finally coming to an understanding of and a code of ethics-a code of behavior if you wish-as to how we can further develop the corporation, bearing in mind that previously a corporation which created wealth meant better health through a better standard of living. But we are now facing the problem that the technology that is amassed by this corporation may be detrimental to the health of the worker, to the user of the product, and to the community, and how do we, as physicians, fit into this particular institution-the corporation-which is so embedded in the matrix of the entire society. It was assumed by Dr. Robert Ackerman and Dr. Donald Martin that the modern corporation would accept this social change, but medicine is the most difficult technology or discipline to integrate into the structure of the corporation. I think that the discussion for the last two days demonstrated that, and just our being there raises issues of confidentiality, issues of reporting, and issues of loyalty. And so our presence makes it more difficult for the corporation to change its organizational structure, its administration, and, perhaps, its value system. The goal is no longer just profit, and yet profit must be made in order to assure the existence and continuation of the corporation. In the afternoon the subject was the loyalty of the occupational physician. But loyalty to whom? The dilemma I raised a little earlier was also discussed, that is, whether you can have the worker as your patient, with your entire devotion to his welfare, and at the same time have the corporation, that is, the enterprise, as your patient as well. Dr. Bertram Dinman faced the issue and stated that he feels both are his patients, and he finds no conflict, or if there is conflict, it can be resolved. He indicated that there may be some battles, but he made it plain that if you lose the first one, do not run away. You should stay and fight. Otherwise, if you lose the first skirmish and run, you lose the battle. It is obvious that the physician does have a problem having the enterprise, that is, the corporation as a patient, and at the same time being totally directed toward the welfare of the worker. I think, as a basic ethical premise, the statement that what is good for the worker is good for the corporation, is true. Dr. Dinman also pointed out that this is not necessarily the view of the corporation executive, who is not responsible for long-term planning, but who is responsible only for the next quarter's profit-and-loss statement. In examining the role of top management, the point has been made that Vol. 54, No. 8, September, 1978
814
81
TABERSHAW I.R. TAESA
IR
in the structure of the successful corporation, for the most part, there is a division of responsibility. In the so-called-profit center, while top management or the chief executive officer may very well understand the social implications, the profit-center manager, nevertheless, is judged and is awarded only on the end point, namely, the profit or loss in that quarter. I know this is one of the major stumbling blocks in introducing into industry a social conscience and facing the consequences of preventive medicine. What I have found is that our society is no longer blaming the division or the local plant if something goes wrong. Rather, it blames the chief executive officer. I find this the most effective ploy to make clear to a top executive that he cannot avoid responsibility for what happens. For instance, in the case of the Kepone problem, Allied, and not the Life Sciences Company, was held responsible. Dr. Donald Whorton presented a point of view which essentially is not different from that of Dr. Dinman. He expanded a bit on labor's view of the doctor's role in society and the occupational physician's role in industry, and pointed out that he is perceived as not necessarily being on the worker's side. I myself have reacted to that kind of perception. I personally do not feel guilty in that sense because I recognize that the worker also has his own motivations in wishing to see the doctor in that light. It is true that the physician in occupational medicine does hold that position and therefore there is a need to change the image. A good deal of discussion was then centered around the code of ethics developed by the American Occupational Medical Association to help guide the physician in industry to overcome this perceived image by the worker. This discussion on the code of ethics was somewhat tangential to our real focus, although it represented an important development. It demonstrates that the occupational physician is aware of the situation and is moving toward better understanding of his role and overcoming this presumed dichotomous position. I believe it is, in a sense, dichotomous, but not in terms of the ethics and conscience of the occupational physician. If the physician has the ethical point of view that he is obligated to the worker and that is his basic responsibility, then the problem becomes solvable. The affirmation that the basic effort that what is good for the worker will benefit the corporation was repeated several times. The role of advocacy was brought up over and over again, and it appeared that whether or not the occupational physician was unhappy about the situation, he was forced into the position of advocacy. Bull. N.Y. Acad. Med.
SUMMARY
SUMMARY
815
Other items were discussed but not thoroughly explained. For example, the use of workers for human experimentation. Dr. Collings made a remark which to me was very trenchant-that perhaps the situation would change if the worker could choose the occupational physician. However, the comment was not discussed in any depth. The question of confidentiality moved along a little better. Dr. Alan McLean made a very concise and clearcut presentation on what is involved in confidentiality, and it was obvious that not only occupational physicians but all physicians face this issue. The format or access or control or ownership of data and the use of it are questions that affect every practicing physician, no matter where he is and what kind of practice he has. These questions are of particular interest to the occupational physician, who must be identified and who is operating in a large matrix in which others have some input to whatever is developed about the individual worker. It is not just a personal relation between the patient and the doctor. Therefore, access to the record and how it is recorded and what is recorded are extremely vital to the interpretation, as well as to the fact of how one practices. Those of you who came in recently heard Dr. Shriver's review of Dr. Hilker's doctrinal statement, which I think represents all our views, and which we fully support. He made the point generally that we are living in a complex society, and that there is a real need to produce information. Yet one cannot avoid being pushed into a position of advocacy. The industrial physician, if he is armed with his conscience and his doctrinal ethics, stands for the better health of the worker. He then can practice effectively, and in that way change, to some degree, the attitudes and the so-called rewards in the business system. Miss Muriel Pappert then reviewed the basic principles of the nurse's responsibility and described how the nurse is the recorder, the interpreter, and the communicator of the information to the worker, and at the same time the key to maintaining the privacy of the records. In my view, Dr. Robert Scala and Dr. Bruce Karrh presented concise views of the conscientious men who understand the importance of the information. Recognizing that they are living in a practical and realistic world, they went through the logistics of how and when to report. I do not think there was any question that the health professional has a responsibility and a duty to report health hazards and that the physician within and outside of the framework of industry always bears this responsibility. Dr. David Wegman, an educator looking at the responsibility to report, Vol. 54, No. 8, September, 1978
81681
I.R. IR TABERSHAW TAESA
raised another point. Of course, he agreed with the basic responsibility of the physician. I was struck with Dr. Wegman's comment regarding the order in which people are informed if a hazard is suspected. If I heard him correctly, he said that management would be informed first, then the worker, and then the newspapers. The management should be first because they have to do something about the hazard. Next is the worker, who should know because he has the most at stake. The third surprised me a bit: the public. Therefore, the newspaper was informed next-I would have thought the newspaper would be the last to be notified. When should the government be told and when should the professional groups be told? I mention that not to take issue with Dr. Wegman as to the order of notification, but simply to point out how difficult it is to know whom to tell when. Then Dr. Dinman raised the point: "When do you know there is a hazard?" I think this is the key question. What information do you have? When do you decide that you know enough to say something to somebody? And what are the consequences of not speaking? And when do you stop looking for more information? These go back to ethical considerations, and I do not know that there is any answer to this. It's a matter of conscience, a matter of judgment, a matter of experience. My own problem with this is that I am not sure when I am certain. Let us put it this way-I do know when I know, but there is a large time span when I do not know that the information is adequate enough to make a reasonable judgment. I am talking about being certain, about finding the "smoking pistol." Then the question of whom to tell follows this pattern. You tell management, you tell the worker, and you tell the profession. I believe this agrees with Dr. Scala's approach. When do you know? I can think of many situations I am involved in right now in which I do know, but there are other situations where I do not feel I know enough. I was disturbed, as I think everybody was, with Dr. Wessel's comment that just having had a discussion on a subject with industry means that it should be reported to the government. It occurred to me that the toxicologist has a relatively easy time because he is developing information on animals that may or may not be applicable to man. He can afford to wait for more information in good conscience. As Dr. Wegman brought out very succinctly, when you are dealing with human beings, if you suspect that a disease may be related to workers or if you find some abnormal condition in a group of people, on either a Bull. N.Y. Acad. Med.
SUMMARY
817 SUMMARY
817~~~~~~~~~~~~
cross-sectional or an epidemiologic study, you are in a much more agonizing position to make a decision as to when and whom you should inform. Again, I know no answer to that except to comment that it depends on your judgment, your experience, your own sense of what is the correct thing do so. I consider the last two speakers the highlight of the conference. They took care of most of the things that were bothering me and covered the real issue of our ethical consideration. I would have liked more from the theologian, from the economist, and the lawyer. They did not really describe their own orientation to the ethics of business. I would have liked a discussion from them on the ethics of business, but I was satisfied that they appreciate that there is an ethical problem, at least for physicians. I believe that all of us agree with the basic principle that the occupational physician can practice consistently with his professional obligation to the health of the worker and yet not be destructive of the capitalist industrial society in which he lives, and that the corporation as an effective agent in our democracy can be supported. We are coming to grips with the problem. I begin to see some of the problems being satisfactorily resolved. Once we publish the code we shall be revaluating it and revamping it. It is evident that physicians in industry are willing to examine ethical problems. They are willing to look at them. They speak now of the enterprise as a client. Finally, there will be a publication as a result of this conference. These proceedings, I am sure, will be a standard reference or at least a starting point for continuing discussion.
Vol. 54, No. 8, September, 1978
