For a profession which is deeply depoliticised, and yet committed to health, conflicts arise over the political dimension of health. This is a fundamental conflict, and, indeed, it is the language of left/right debate in medical politics. If this conflict is severe in relation to NHS cuts, it is even more acute when a health dimension enters into conflicts which are seen as predominantly political, and which are remote from the doctor/patient relationship. It is one thing (frightening, but justifiable) to confront the machinery of the state to assert the demand for resources for patient care. It is quite another to advance the proposition that capitalism is bad for your health.
The ‘politics or health’ conflict arises in this most acute form in the relation of medicine to industry and to the public-health movement. These will be discussed in the next two chapters.
Industrial Doctors — Friend or Foe?
There is a deep-rooted feeling in the labour movement that doctors working in industry are inclined to support management rather than the workforce in any conflict. This view is supported by a number of horror stories that have appeared in print in various sources.
- In 1981 ASTMS published a report of death from coronary heart disease at a North Wales chemical plant. (Association of Scientific Technical and Managerial Staffs, Health and Safety Office, Carbon Bisulphide – an Investigation into Heart Disease at Courtauld’s, Bishop’s Stortford, 1981.) The report alleged that, although a study commissioned by the firm, and carried out for them by respected academics, had found an excess of deaths over that to be expected, and this study had been published, the company had continued to exceed safe levels of the chemical carbon disulphide, and had reassured the workforce instead of telling them about the hazard.
- In 1980 ASTMS published a report alleging that a company doctor at a medium-sized chemical plant had distorted a report given to trade unions about tests carried out on workers handling a suspect chemical. (Association of Scientific Technical and Managerial Staffs, Health and Safety Office, Report on Coalite Chemicals, Bishop’s Stortford, 1980.) It was alleged that the doctor had selected only those test results which were normal and suppressed others which were not. The matter came to light by the actions of the pathologist who carried out the test, who complains of subsequent harassment and damaged career prospects.
- In 1979 a report was made to the ASTMS Health and Safety Committee of a company doctor in a chemical factory who claimed that twelve cases of dermatitis out of 50 workers was perfectly normal and a pure chance phenomenon. ( Watkins Tnd J. Leeson, Fraternal Assistance to the T&GWU – Industrial Dermatitis in a Chemical Factory, Report to the ASTMS Health and Safety Committee. Unpublished, found in internal working papers of ASTMS.) He also denied union claims that a particular machine was spraying out alkali, basing his conclusion on tests carried out at the wrong end of the machine at the time it was being allowed to slow down prior to switching off. The company refused to allow trade union medical advisers onto the site to talk to the safety representatives until the TGWU said that if the union doctors were not allowed in, all the members would come out to meet them on the car park.
- Kinnersley quotes the case of Dr James Allardice, a senior medical officer with Ford, who, in May 1973, was due to present a paper at a conference on industrial stress but was told not to by his firm’s public relations department. (P. Kinnersley, The Hazards of Work and How to Fight Them, London, 1973.)
These stories conflict with the overt expressed ideology of occupational health as existing to improve the health of the workforce, with the doctor as an impartial adviser in conflicts between the worker (or workforce) and the employer.
Ford’s behaviour towards Dr Allardice would certainly be regarded as improper by the medical profession and Dr Allardice could have expected BMA support had he chosen to defy his employers.
There is also no doubt that the doctors in the companies which suppressed information on health hazards would be regarded by most doctors, and probably by the General Medical Council, as having acted unethically.
BMA resolutions over the years on the subject of occupational health have been quite unequivocal about the duty of the doctor being primarily to the health of the workforce, and have condemned improper pressure by employers.
The Roots of Industrial Medicine
The first involvement of doctors in industry in Britain arose out of nineteenth century legislation by which doctors were required to certify the age of children working in factories. It is from that root that the present Employment Medical Advisory Service (EMAS) of the Medical Division of the Health and Safety Executive (HSE) can be traced. The present functions of EMAS include medical advice to the HSE, industrial advice to doctors in the NHS and the operation of the Employment Rehabilitation Centres.
EMAS is not, however, the dominant force in British industrial medicine. The majority of doctors working in industry are employed by companies.
The employment of doctors as medical advisers to companies also has its roots in social-reform legislation, but in a rather different way from that of EMAS. After the 1902 Workmen’s Compensation Act a number of companies began to employ doctors to protect themselves against compensation claims.
The number of doctors employed in industry in the UK has increased considerably since then as the following figures show: (M. Phillips, Government Policy and the Development of Occupational Health Services Since 1939, MMSc Thesis, University of Nottingham, 1976.)
| Full Time | Part time | |
|---|---|---|
| 1921 | 20 | |
| 1939 | 50 | 250 |
| 1945 | 143 | 903 |
| 1951 | 230 | |
| 1960 | 500 | 3000 |
| 1971 | 600 | 2000 |
| 1975 | 700 |
It can be seen that the largest increase in the employment of doctors in industry came in the post-war period, the halcyon days of Butskellism when class conflict seemed less acute and social welfare the accepted goal of all. In such a climate it would be wrong to assume that the motives which led to the employment of doctors by companies in 1902 were the same motives that led to their employment in 1962, still less that those motives would be internalised by the doctors concerned as part of their remit. The overt ideology of occupational health is now one of improving the health of the workforce.
It would undoubtedly be claimed by occupational physicians that the horror stories listed at the opening of this chapter represent isolated instances of abuse. It is, however, understandable that trade union suspicion is present when abuses of this kind continue to be documented, and can be considered against the background of the inauspicious roots of occupational medicine in compensation prevention.
Conflicts of interest between the doctors’ responsibility to the workforce or to the individual worker (the patient) and their responsibility to the company that employs them commonly arise in the following situations: compensation; fitness to work; control of sickness absence; control of information; conflict between the cost of measures to protect health and the profits of the company.
Compensation
Despite the compensation-oriented roots of the occupational medicine specialty, it is unlikely that resisting compensation claims is a major part of the work of any occupational health doctor today. Nye Bevan, when representing miners in South Wales, pioneered the practice of obtaining outside consultants’ opinions to challenge the views of the company doctor in claims for compensation. It would be normal today for company and union to seek the views of consultants in a medico-legal battle. Medicine is strictly neutral in such battles – like the legal profession it provides each side with an advocate for a fee. Or, at any rate, neither side usually has any difficulty in finding somebody to honestly disagree with the honest professional opinion of the other side’s medical adviser. More problematic is the maintenance of health data whose main purpose will be to provide the basis for resistance to compensation claims. For example, workers in noisy industries may have their hearing documented before starting work and if it found that there is hearing loss they may be questioned about the cause (‘Do you attend noisy discos?’). The context of the discussion is a caring, diagnostic professional interview. The sting in the tail is that any subsequent deterioration in hearing may be blamed on the continuation of this process of disco-damage rather than on the job.
This problem is made worse by the existence of professional assumptions, embodied in the mode of thought and hence practice of occupational medicine, which have the effect of limiting the circumstances in which occupational disease is diagnosed, and hence in which compensation may be claimable.
Fox and Adelstein have shown that about 30 per cent of social class variation in disease is occupational in origin. (J. Fox and A. Adelstein, ‘Occupational Mortality: Work or Way of Life’,Journal of Epidemiology and Community Health; 1978, Vol. 32, p. 73.) This implied that about 20,000 deaths a year will occur in Britain from occupational disease. However only a fraction of those cases will be diagnosed as occupational in origin.
There are three main reasons for this:
- Doctors have a low index of suspicion for occupational diseases.
- Where two or more causes interact the non-occupational cause will be considered to be more significant. The worker whose hearing has been damaged by the combination of noisy work and noisy discos will be told that deafness is due to the disco. The worker whose lung cancer has been caused by the combination of asbestos and smoking will be told that cancer is due to smoking. It may be true that these individuals would have remained healthy if they had not smoked or attended noisy discos. But it may be equally true that they would not have become ill if they had not worked in an unhealthy To select one cause as more important than the other is to assume that industry has the right to damage people, and that they have a duty to mitigate the damage, and only deserve compensation if they attempt to mitigate it and fail.
- Because occupational disease can only be diagnosed if the specific case can be confidently attributed to occupation, the occupational components of common diseases are not accounted for.
These criticisms cannot be laid exclusively at the door of occupational medicine, but rather at the door of the profession as a whole, and of the legal system within which compensation claims are considered. But when medicine happily operates within a conceptual framework which has the effect of minimising compensation claims, the labour movement is entitled to point out that this framework shares with occupational medicine its roots in compensation prevention.
It is well known in mining communities that most people who die of pneumoconiosis are certified as dying of something else.
Nancy Tait of the Society for Prevention of Asbestosis and Industrial Disease has pointed out how deaths from asbestosis are frequently diagnosed as some other condition.
She points out that although a respectable scientific analysis has suggested that 50,000 people will die of asbestos related diseases during the next thirty years, the insurance industry envisages paying compensation to only a fraction of them.
She quotes case histories of people who have been misdiagnosed. For example she mentions a worker in a dusty asbestos cement factory who developed ‘chronic bronchitis’ after thirteen years in the factory. His doctor told him that the bronchitis might be asbestosis but that this would only be confirmed at post mortem. She points out how workers who smoke and develop lung cancer are usually told the cancer is due to smoking, and only in non-smokers is the asbestos exposure taken seriously as the cause.
She also criticises the diagnostic criteria used by official panels. She points out that these panels will only diagnose asbestosis if asbestos bodies are found in the protective coating. These bodies are only formed from asbestos fibres of over twelve microns, but shorter fibres may also cause asbestosis. Usually workers have inhaled a mixture of fibres of different lengths, including the longer fibres, so asbestos bodies will be found. But they could inhale shorter fibres only, especially if they were working at some distance from the source, or wearing masks that kept out the long fibres but not the short ones. White asbestos is particularly prone to produce the shorter fibres and since 1984 only white asbestos has been used.
She also points out how pleural thickening caused by asbestos is usually described as harmless, even though it can cause symptoms, and how symptoms are often attributed to some other cause because of a refusal to accept that pleural thickening can be the cause of them. She attacks refusal of the UK to accept the international opinion that gastrointestinal cancer can be caused by asbestos.
She points out that epidemiological evidence suggests some 3,000 lung cancer deaths each year to be asbestos related, whilst only 70 are recognised as such.
The reluctance of the medical profession to certify death as due to an industrial disease may derive partly from an instinctive loyalty to the system, and partly from a desire for a quiet life and a reluctance to get drawn into justifying a politically contentious diagnosis. Insofar as these factors operate, they represent the ultimate success of the depoliticised ideology in subverting the very integrity it is meant to protect and taking the very political stand it is meant to eschew.
But it would be wrong to indict the medical profession on the charge of well-meaning malevolence without considering that it might plead the defence of ignorance. Medical education does nothing to equip the doctor for an awareness of occupation as a major cause of illness.
An editorial in the Journal of the Society of Occupational Medicine in 1975 pointed out that in a survey of 25 British medical schools, only fifteen gave any training in occupational medicine, and, of those fifteen, most included only a few lectures in their medical course. (Editorial in Vol. 28 of the Journal of the Society of Occupational Medicine, p. 113.)
Of the four most popular textbooks of medicine (Price, Davidson, Cecil-Loeb and Harrison) only Price has a section on occupational medicine. Cecil-Loeb has 66 pages on environmental factors in disease, but in that entire section the only references to occupation are one paragraph in a section on chemical contamination of air and water and six pages on heavy-metal poisoning. Harrison also has a section on environmental hazard^ which deals with tobacco smoking, radiation injury, electrical injury and drowning. There is a separate section on heavy-metal poisoning. Davidson (probably the most popular student textbook) has no section on occupational disease, nor even on environmental hazards which apparently do not have the same significance to medicine as genetic factors (24 pages), immunological factors (28 pages), infection (47 pages) or nutrition (53 pages).
Only Price and Harrison mention occupational asthma in their accounts of asthma. Only Harrison mentions that there are a number of occupations in which occupational asthma can occur, and even then makes no attempt to list them. The reference to occupational asthma in Price is limited to inhalation of redwood cedar dust.
None of the four textbooks mentions any occupational causes of ischaemic heart disease. Price, Cecil-Loeb and Davidson do not mention type A behaviour, a well established risk factor for heart disease consisting of working under pressure to deadlines. Harrison mentions it only in passing and regards it as a personality type rather than as a feature of the work pattern.
All four textbooks mention vibration whitefinger, (a disease of the circulation in the fingers, caused by work with vibrating tools) although Cecil-Loeb hides it in the middle of a long list of rare causes of Raynaud’s phenomenon (white finger) in the following words ‘… after trauma (pneumatic hammer disease, injuries to pianists, typists etc) …’ None of the four mentions industrial dermatitis. None of them lists occupations in which asbestos may be encountered.
Against this background it seems unlikely that doctors are adequately trained to identify causes of occupational disease. But even if all cases of identifiable occupational disease were to be correctly diagnosed the toll of occupational disease would still be considerably understated.
Half of those with certified asbestosis will get lung cancer, but lung cancer in an asbestos worker without accompanying evidence of asbestosis is not a recognised industrial disease, and none of this cancer will be attributed to work or attract compensation. Only the rarer cancer, pleural mesothelioma (a cancer of the lining of the chest) will be identified as occupational.
The reason for this is that occupational diseases are only recognised where the individual case of the disease can be confidently attributed to occupation. It is not enough to say that out of 80 cases of an illness amongst a group of workers only 40 would have occurred naturally and therefore each of the cases is partly due to occupation and each sufferer should receive 50 per cent compensation. Only if it were possible to identify the 40 cases could compensation be paid. Otherwise each complainant would be told that it could not be confidently said that his or her illness was occupational, since it may have occurred naturally.
The result of this approach is that diseases which are common in the general population can never be recognised as occupational or attract compensation, however well it may be established epidemiologically that the risk is increased in a particular job. The only diseases that can be recognised as occupational are those which are rare in the general population and become common in a specific occupation.
Thus pleural mesothelioma, which is very rare in the general population but common in asbestos workers, can be recognised as occupational. Lung cancer cannot, even though asbestos kills more people by lung cancer than by mesothelioma.
Doctors operate within this way of thinking without any significant protest, without even acknowledging the shortcomings of it. They teach it to new generations of students and hence incorporate it into their practice. Thereby they acquire a responsibility, collectively as a profession and a set of institutions, for a mode of thought which is ideologically motivated to the minimisation of the perception of occupational disease.
By conniving at that mode of thought the profession consigns occupation to the footnotes of medical textbooks. If the occupational component of common diseases is neglected, all that remains are the occupational diseases is are rare. As rarities doctors can consign them to the backs of their minds.
This removal from consciousness is not valid. Medical diagnosis is a process of analysis of conditional probabilities. Each fact that is learned about a patient’s illness makes some diagnoses more likely, others less likely, others it excludes totally. The patient complains of dimming of vision. Diabetic retinopathy barely figures in the differential diagnosis. The patient admits to being diabetic, and suddenly diabetic retinopathy leaps into prominence as one of the likely causes of dimming of vision, to be actively considered.
So it should be with occupational disease. The patient complains of breathlessness. Byssinosis is a rare possibility at the very back of the doctor’s mind. The patient is a textile worker. With that item of information byssinosis should enter the ring. But it doesn’t. Not even in textile towns. By neglecting the occupational component of common disease, medical education has peripheralised the whole idea of occupation as a cause of ill health, and excluded it from the diagnostic process.
Fitness to Work
Britain has an extremely sophisticated system of ensuring that disabled people obtain their full share of employment. The law requires all employers to employ 3 per cent of their workforce from registered disabled people, and a network of Disablement Resettlement Officers (DROs) exists to persuade employers to employ more disabled people and to assist them in doing so, by helping them solve the problems involved. The DROs have various grants at their disposal, including grants for fares to work and for adaptations to machinery. Employment Rehabilitation Centres exist to develop new work skills in disabled people, and these centres are acknowledged to attain high professional standards.
The major defect in the system is the fact that it doesn’t work.
The quota system has fallen into disuse, so much so that few disabled people now bother to register since the stigma of doing so will outweigh the benefits that the law would give them. This is turn leads to demands that the law be abandoned since ‘there aren’t enough registered disabled people for every employer to employ the quota’. However the collapse of the system is not due to the operation of the policy by enlightened employers, resulting in the withering away of the law. Unemployment rates amongst disabled people can be seen to be extremely high. The law has therefore collapsed without its objective being attained in any other way.
A study carried out in South Manchester of difficulties at work experienced by patients in outpatients departments revealed that sick workers are usually ‘carried’ by their colleagues for a while and then sacked. (S J. Watkins, ‘The Effectiveness of Employment Rehabilitation in NHS Patients in South Manchester’ in Six Aspects of the Relationship Between Economic Activity and Health, MFCM Thesis, Faculty of Community Medicine, London, 1984.) Hardly ever is professional advice sought from the employment rehabilitation services, or a serious search for alternative work made by the employer, or any special arrangements made to accommodate the sick worker. Against this background the undoubted excellence of the Employment Rehabilitation Centres is like beautiful icing on a mouldy cake.
Occupational-health doctors have an important role to play in employment rehabilitation. New staff should be medically assessed to ensure that they are not inappropriately placed in jobs for which they are medically unsuited, whilst the health of existing employees should be monitored, and their sicknesses followed up, so that employment rehabilitation can be commenced early in any illness likely to affect work, and so that searches for alternative work can be made as soon as it becomes obvious that a person is no longer fit for their present job.
It is in that language that occupational physicians discuss their involvement in assessing fitness to work.
The problem is that the language and reality do not correspond.
The pre-employment medical examination is not a way of avoiding inappropriate placements – it is a way of excluding unfit people from employment. Fitness-to-work assessments are not carried out so that alternative work can be found -they are carried out so that unfit people can, after due heart searching, agonising and discussion of the best interests of the employee, be sacked.
I seriously doubt whether it is ethical for doctors to use their skills in the operation of a sophisticated system of oppressing the disabled. Yet that is exactly what happens.
Serious questions of medical confidentiality also arise in this situation which have never been satisfactorily resolved. Is a patient’s consent to the release of information free and untrammelled when it is a condition of employment? If it is not free and untrammelled can the doctor ever ethically give the company information which will harm the interests of the worker? And if doctors can never give harmful information neither can they ethically certify fitness to work, since if they do it implies that withholding of such a certificate implies unfitness.
This conflict over confidentiality could be avoided if the doctor who certified fitness to work was a doctor who never had a doctor/patient relationship with the individual whom he or she was examining. Such a doctor would be in the position of an ‘examining doctor’ and the concept of confidentiality would not apply. But in fact occupational health physicians do have a doctor/patient relationship with the workers and can hardly separate what they know in that relationship from what they discover at a particular examination.
Confidentiality exists to protect the free access of the patient to the doctor. No rational worker would tell an occupational physician about illnessess which are likely to affect fitness to work, if that doctor may use that information as the basis of an adverse opinion to the employer. Therefore, it must follow that the practice of giving such opinions is a breach of the obligation from which the principle of confidentiality arises.
The argument I have just outlined is not accepted by occupational physicians, who regularly practise what I have here categorised, on two distinct and separate grounds, as unethical. (A discussion of this matter can be found in the correspondence columns of the British Medical Journal in the second quarter of 1985 under the title ‘Doctors’ Dilemmas’.)
Policing Sickness Absence
Company managements often believe that doctors are too ready to issue sick notes to their patients and that as a result there is too much loss of production from sickness absence. There is frequently a neat reversal of this position: companies are anxious to prevent their workers returning to work before they are fully fit in order not to interfere with productivity drives, or in order to continue receiving sick pay reimbursement from the state whilst the company is overstaffed.
In either of these situations the company may ask its own doctors to give a second opinion about whether somebody is genuinely sick, or conversely about whether they are genuinely fit for work.
Since the purpose of such a request is to obtain medical support for the company questioning the decision of the worker’s own doctor in order to prevent the worker from following that advice, the request always casts strain on the role of the doctor as the impartial medical adviser to workers and management alike.
Ethical problems can also arise if the doctor conceals the examining doctor relationship and pretends that the examination is for the worker’s own good, or if information given in a doctor-patient relationship is used. Serious practical problems can arise if the company doctor disagrees with the worker’s own doctor, since the worker is then put in the difficult position of deciding whose advice to follow, perhaps incurring disciplinary consequences by following the advice of the independent doctor.
The standard British textbook of occupational medicine dismisses this role in a single paragraph, saying that few occupational physicians would see this as part of their role, and the rest of the chapter on sickness absence is confined to its epidemiology. (R. Schilling, Occupational Health Practice, London, 1973.) However this view is not borne out on the ground, since many trades unions have encountered problems with occupational physicians who don’t seem to have read and appreciated this particular part of Professor Schilling’s expert advice.
In the American literature the situation is more explicit and many references can be found to the role of the company doctor in control of sickness absence. Strasser, for example, writes:
The occupational physician should be encouraged to take an active part in reviewing accident and sickness insurance claims and intervene when there is a dubious claim. Clauses in union contracts that prevent the occupational physician from functioning effectively as the ‘captain of the claims control team’ should be resisted … Controlling medical absenteeism is a challenge that requires all the combined skills of management, labour, government and the private and occupational medicine sectors of the medical community. This team effort most succeed if American industry is to become competitive again in the world markets. (P. Strasser, ‘Controlling Unwarranted Medical Absenteeism’, Occupational Health & Safety, July 1981, p. 13.)
Rushmore and Youngblood question the very validity of the concept of sickness absence. (C.M. Rushmore and S.A. Youngblood, ‘Medically Related Absenteeism – Random or Motivated behaviour?’, Journal of Occupational Medicine, 1979, Vol. 21, p. 245.) They point out that voluntary and illness-related absenteeism seem to share similar characteristics, in that both types of temporary withdrawal are heavily ‘skewed to the right’ (sic) and a large proportion of lost time can be attributed to a small number of employees. It doesn’t seem to have occurred to them that the small number of employees who are responsible for the large proportion of sickness absence might be those who are sick. They note that ‘a conditional probability analysis of voluntary and illness related absence suggested some degree of interperiod stability of absence proneness’. Again it doesn’t seem to have occurred to them that people in poor health this year may well be in poor health next year.
There are correlations of sickness absence with job satisfaction and personality characteristics. There are clearly marginal situations when sickness absence would be justified but some people may decide to struggle through. Whether that should be encouraged in a moot point. It is also possible that jobs which are more satisfying are more healthy.
Bond, Buckwater and Perkin list ‘assistance in absence control’ as one of the functions of a workplace medical service and include this amongst the benefits of their cost/benefit study. (M.B. Bond, J.E. Buckwalter and D.K. Perkin, ‘An Occupational Health Program – Costs vs Benefits’, Archives of Environmental Health, 1968, Vol. 17,) Whiting presents the process of pressing workers back to the job (where they belong) as a rehabilitation exercise. The ‘psycho-neurotic’ who is ‘beginning to decompensate’ will often find a physician who will ‘allow him to dictate his work excuse’. But company doctors have a duty to rehabilitate. They must be kind and firm. Only in this way is it possible to make ‘progress against the abuse of disability pay’.
There are obvious conflicts between this kind of ideology and the role of the company doctor in employment rehabilitation. It would also be unsurprising if such doctors found that the workforce regarded them with less than unlimited trust.
There are clearly a number of different views about the role of company doctors in policing sickness absence, and it is certain that in many companies doctors will take on this role to a greater or lesser extent. But how can such a role be consistent with the existence of a doctor-patient relationship, with its requirements of confidentiality and complete trust between doctor and patient? How can it be consistent with a prime responsibility to the health of the workforce, when it places the doctor on the wrong side of the capital-labour divide? How can it be consistent with employment rehabilitation for the doctor’& prime role in considering the interaction between health and work to be the maintenance of production and labour discipline and the control of malingering? In short, is the practice of occupational medicine internally consistent?
In collective bargaining information is power, and the occupational-health service is in possession of information which is potentially important for health and safety negotiations.
If the occupational-health physician is an independent medical adviser to management and workforce alike, this information should be available to both sides equally. In fact trade unions suspect that this is not the case.
Medical confidentiality is often raised as an argument against the release of information to unions. However medical confidentiality relates only to information about individuals and not to data about groups. It does not restrict the release of information, even about individuals, when the individual has freely consented to its release. It would not prevent information being made available, under seal of medical confidentiality, to a union-nominated doctor (or other bonafide medical researcher) for the purpose of carrying out an independent analysis. Since medical confidentiality applies equally to unions and management, it can never be unethical to make available to unions information which has been made available to management ethically.
In fact occupational-health physicians are often much more restrictive than medical confidentiality would require them to be. The Faculty of Occupational Medicine advises members not to release data to unions, but to give an interpretation and explanation instead. Unions and individual workers are rarely allowed access to the files of individuals even when the individual consents. The BMA Occupational Health Committee reacted very angrily to a statement circulated by the MPU drawing unions’ attention to the idea of designating a doctor to carry out independent analysis of records. However the precautions taken to keep records out of the hands of management seem to be very limited – in many companies medical records are kept in unlocked cabinets in an occupational-health department to which management has the key.
There is no doubt that occupational physicians go far beyond the demands of medical confidentiality in withholding information from unions, and often justify their action by reference to medical confidentiality, expecting the union representatives to be uninformed about the limitations of this ethical constraint and to accept ‘medical confidentiality’ as a mythical incantation.
The issue of control of information finds its most acute expression when an occupational-health doctor becomes aware that the employer is using a chemical that is hazardous to the health of the workforce.
The Faculty of Occupational Medicine, in its 1980 handbook on ethics, gave the following advice:
Employers and manufacturers are required to disclose information they may have concerning a process or product which may be a risk to health at the place of work under Section 2 (2) (c) and Section 6 of the Health and Safety at Work etc Act 1974 and the Safety Representatives Regulations. Normally the employer will disclose this information and should such confidential information concerning the injurious nature of a new process or product come into the possession of the occupational physician he should remind the employer of his responsibilities.
Only if the management of the organisation refuse permission for such specific disclosure will the occupational physician have to consider his responsibility of informing other doctors who may need to know of the harmful effects. His responsibility for workers exposed to hazards should take precedence over the management’s refusal to disclose. However, he would be wise to seek the views of other senior occupational physicians before taking further action. He should always keep management informed of the steps he proposes to take.
Although this advice states that the prime responsibility of the doctor is to the health of the workforce, it is hedged with qualifications. It is notable that it refers only to informing other doctors, rather than the workforce, although this omission has been remedied in later editions as a result of the criticism the 1980 edition aroused.
Certainly the Faculty has never come close to repeating the blunt statement of the 1979 MPU manifesto for the General Medical Council elections: ‘The prime responsibility of the occupational physician and the community physician is to the health of the community they serve not to the agency that employs them.’ Nor indeed has it even reiterated BMA policy on the duties of occupational physicians, which is also quite progressive and suspicious of improper employer pressure.
But even suppose that the ethical situation were seen as self-evident and the duty of the doctor as being clear and unambiguous. Consider the circumstances in which doctors might be expected to blow the whistle on an unsafe process. The doctors will be treated by the company as part of management. They will eat in the management dining room and talk to other managers as colleagues. They will feel a loyalty to the company. In fighting for change within the company, if indeed they see that as their role, they will have to forego some immediate objectives in order to achieve others. At the moment that they are called upon to blow the whistle they may be engaged in discussions for new equipment for the medical department, for a sheltered workshop to be established for chronically sick workers, or for the introduction of healthier diets in the works canteen. They will have to compromise and defer in order to achieve some change. In doing this they will be alone and unsupported.
It requires no great stretch of empathy to understand how human beings will react in that situation. They will rationalise the situation, persuade themselves that more research is needed, ‘compromise’ by persuading the company to fund the research, grasp at straws by demonstrating great credulity towards poor-quality negative research-findings published in dubious journals by unknown researchers.
The threat to the integrity of occupational medicine does not lie in doctors who are guilty of blatant cover-ups, who prostitute their medical degrees in the interests of capital. Such doctors can be dealt with, although it is interesting that no doctor has yet been struck off the register for the false certification implicit in telling workers that a process is safe when knowing that it isn’t. (ASTMS has announced its intention of bringing such a case to the attention of the GMC when a suitably clear situation arises.)
The danger lies in the conflict of interest inherent in the role of occupational physicians employed by the companies it is their job to police. In such a situation corruption is not necessary, merely the combination of the human desire for a quiet life with the human capacity for self-deceit.
Health vs Profit
The health and safety movement, comprising of trade union safety reps and sympathetic scientists, has an approach to health and safety at work which recognises conflicts of interest between management and workforce between the requirements of safe, healthy working conditions and the needs of profit. It recognises science as dealing in uncertainties and that the scientific scepticism which is central to scientific method is not the safe side when human lives are at stake. It recognises that management will resist health controls until a high level of scientific certainty is attained in relation to their necessity, whilst unions will often wish to act on lesser degrees of suspicion. It sees collective bargaining as the way to resolve those conflicts. This ideology has its roots in the radical science movement, in trade unionism, and in ideas about distrust of experts.
Management, enforcement agencies and occupational-health professionals have a different ideology. They see health and safety as a technical issue with technically correct solutions to problems. The role of collective bargaining is therefore limited. The professional’s writ runs.
For doctors the radical ideology is very threatening. As impartial technical advisers to a negotiating process which will make decisions based on value conflict and negotiation as much as technical factors, they lose the very basis of their medical identity – the right to decide what is good for people and to prescribe.
Let us consider a hypothetical, but typical, conflict.
The workforce has been told by scientists in a Hazards Group that a particular chemical is unsafe. What is meant by this is that the chemical has not been proven to be unsafe, but that, in the opinion of the scientists concerned (who are zealous to protect the workforce), sufficient suspicion exists to justify a ban, as a precautionary measure.
The company doctor advises the company that the chemical is safe. What that means is that the evidence for its harmfulness is inconclusive and is not such as to warrant the cost of redesigning the production process.
Neither the workforce nor the company understands the advice they have been given. They believe they have been given scientific facts, rather than value-laden interpretations of conflicting evidence.
The company concludes that the Hazards Group is composed of left-wing agitators. The workforce conclude that the company doctor is in league with the company to suppress the facts.
What is essentially a value conflict, resolvable by negotiation between workers and management, has been turned into a scientific disagreement, a conflict about personal integrity, and a power battle. In this form it will be almost impossible to resolve without bitterness and struggle. Interventions by the Health and Safety Executive will not assist since they will adhere to the same ideology of technical disagreement instead of identifying the value conflict. It may be that the HSE requires a conciliation section, perhaps established in conjunction with ACAS.
The Labour Movement and the Case for a State Occupational Health Service
A powerful case can be made out for transferring responsibility for occupational health to a state-run service, probably part of the National Health Service.
There would be three main arguments for this. One would be the need to protect occupational health staff from conflict of interest. A second would be that occupational health services most need to be improved in small workplaces where private provision is least likely to be effective. The third argument would be the need to unite the occupational- and environmental-health services and inject into the occupational health field some of the traditions which community medicine and environmental health derive from their roots in nineteenth-century social reform.
If, as matters are currently arranged, a lorry carrying dangerous chemicals crashes at a factory gate and the wind is blowing into the factory, that is a problem for occupational-health services, but if it is blowing into the street it is a problem for environmental-health services. Occupational-environmental health and general-environmental health are not really different disciplines, merely the same discipline practised in different settings. The same is true of industrial epidemiology and general epidemiology.
It has been the policy of both the Labour Party and the TUC for some time to carry through this reform. However the TUC has now virtually abandoned any campaign in favour of its own policy of a comprehensive NHS-run occupational-health service to such an extent that all its recent statements on the subject, including its booklet Workplace Health and Safety Services, assume the continuation of the present structure of employer provided services, with perhaps some legislative controls and some trade union involvement in the running of the services. The TUG representative on the Royal Commission on the National Health Service actually wrote a document, appended to the Report, which argued against absorbing occupational health into the NHS. (This appendix, written by P. Jacques, appears to have been written to justify the Royal Commission’s decision to regard occupational health as beyond its remit.)
In this respect history seems to be repeating itself, for in the 1945 Labour government Ernest Bevin successfully argued against the incorporation of occupational health into the new NHS. (Phillips, op. cit.)
There is no opposition in the labour movement to the policy of creating a state-run occupational-health service, but there is considerable inarticulate resistance (a major source of inertia) to actually implementing it, which may well derive from the traditional division between the ‘hard’ and ‘soft’ political issues.
The ‘hard’ issues are the questions of economic and industrial policy which relate to ‘wealth creation’ in its conventional sense. The ‘soft’ issues are the questions of health, social services, social policy and civil liberties, which relate to the well being of the citizen.
Capitalism subordinates soft issues to hard issues. The labour movement does not subordinate either group of issues to the other, but it does see them as separate.
The widespread assumption is that successful policies in the hard areas create wealth which can then be distributed by an effective policy in the soft areas. But this paradigm has serious limits. It may be that certain mechanisms of achieving economic success damage soft policy areas to a greater extent than the resulting wealth could repair. This is the message of ecology and of some aspects of public health. It may be that the mechanism for achieving hard area success can itself influence soft policies. This is the message of those who call for health considerations in food or transport policy. It may be that the soft policy areas can be the engine of growth for the hard areas. This is the message of the Lucas Aerospace Shop Stewards’ Plan which would revive the engineering industry, jewel in the crown of hard policies, by setting it to work achieving soft policy goals, such as providing aids for the disabled. It may be that resources devoted to hard policy success could have been more effectively used in soft areas. This is the message of analyses which show that more jobs are created by spending directly on health and personal social services than by defence spending or industrial job creation.
Such analyses which cross the boundary of hard and soft politics strike deep into the psyche, not to say the machismo, of the labour movement. They force the rethinking of a major paradigm. They are for acclamation not implementation.
In the same way the idea of an NHS-run occupational-health service crosses the same boundary-. It suggests that the NHS, jewel in the crown of soft policies, has a role in industry, centrepiece of hard policies. It is like suggesting that women should fly aeroplanes.
It is ironical to recall that in 1945 it was the British Medical Association which campaigned for the incorporation of industrial health into the NHS, and a Labour government which rejected that campaign.