Conflicts of Interest in the Practice of Occupational Medicine
A conference on medical ethics was held on June 9, 2007 in Bled, Slovenia under the auspices of the Slovenian Medical Chamber and attended by occupational physicians, members of the Slovenian Medical Society and politicians. This event, the first of its kind to take place, was moderated by Dr. Metoda Dodic-Fikfak, Director of the Institute of Occupational Health (Ljubljana), someone who knows only too well the consequences of practising occupational medicine in her country. In 2005, Dr. Dodic-Fikfak was sued by a factory owner for providing her opinion to a colleague concerned about the medical condition of a factory worker. As one of Slovenia's foremost occupational physicians, one would have thought Dr. Dodic-Fikfak's involvement was both acceptable and desirable; the factory owner disagreed, however, and instigated a civil action against her. After intense pressure, serious threats, huge legal bills and more than a year of court appearances, the case was lost. Emerging victorious but battered by her encounter with the legal process, Dr. Dodic-Fikfak was determined that the wider issues exposed by this episode were thoroughly explored by the medical profession. Dr. Dodic-Fikfak told the conference delegates in Bled:
Cases of duel loyalty often arise in the practice of occupational medicine in Slovenia. An inherent conflict pervades the work of company doctors authorized to determine whether a worker is able to work or is suffering from an occupational disease. A decision taken by the doctor which validates a worker's claim can have serious repercussions for the medical practitioner including the termination of his/her employment by an employer which does not take kindly to such costly pronouncements.
Individual doctors tasked with this work are vulnerable to victimization and intimidation; their isolation increases their susceptibility to pressure from bodies, companies and forces which have nothing to do with the ethical practice of medicine and everything to do with the corporate balance sheet. In such situations, it is of great importance that the physician receives the full support and protection of the organization or body he/she belongs to.
Dr. Dodic-Fikfak urged that a new body be established to further discussions on these issues and to advise and support individual doctors caught up in the ethical and moral dilemma of doing what is best for the patient and, at the same time, maintaining his/her employment status with the employer.
The first panel of the day consisted of international speakers who set the discussion in context by exploring relevant situations from their countries or fields of work. In his presentation Doing the Right Thing: Occupational Medicine in the Market Economy, Professor Charles Levenstein from the University of Massachusetts, drew on his extensive experience of emerging economies in Eastern Europe. Discussing his research in Hungary, Professor Levenstein reported that the switch from the command/control economy under socialism to the new free market model in Hungary had lead to a deterioration of health and safety. The position, responsibilities and areas of conflict experienced by medical professionals in a country where social, political and economic systems are rapidly changing is complex:
you have obligations to workers on the one hand and they have little power because of economic circumstances, memories of previous 'worker states', the decline of the trade unions, and the power of state and private investors.
And on the other hand you have all the pressure of obligations to employers and to the state now comes the ethical problem you have no powerful political base, but you have principles.
The Rise and Fall of the Swedish Model for Independent Occupational Health Services was the title of the presentation by Professor Dr. Christer Hogstedt of the Swedish National Institute of Public Health in Stockholm. Drawing on his work in Sweden, Central America and Africa, Professor Dr. Hogstedt analyzed key areas of the occupational physician's job which had the potential for causing friction including:
health surveillance of the workforce
medical interventions in the workplace
measures to prevent occupational health hazards
assessment of working capability of employees
pre-employment health checks
rehabilitation of workers.
Years of fruitful negotiation in Sweden between trade unions and corporations which were encouraged by an independent Swedish occupational health service had created a situation of few conflicts and great improvements to working conditions and occupational health (OH). Unfortunately, since the early 1990s, state subsidies for national OH services have dwindled and the market driven nature of the current situation is already having a negative impact.
A historical analysis of How Asbestos Profits Affected Medical Practices and Judgment on three continents was the subject of the presentation by Laurie Kazan-Allen, Coordinator of the International Ban Asbestos Secretariat who said:
There were multiple warnings which, if heeded, could have prevented the global asbestos epidemic. Alas, there is no foreseeable end to the asbestos catastrophe... Even now, doctors in asbestos-producing countries deny the hazardous nature of chrysotile asbestos in order to preserve the income stream generated by the exploitation of this valuable natural resource...
The part played by individual doctors and researchers in the asbestos story in the U.S., the UK and Australia does not, on the whole, reflect well on their professions There were company doctors who believed that changes could be made; they soon learned, to their cost, that they could not compete with the entrenched greed of powerful corporations.
Calling for mechanisms to ensure that medical professionals charged with protecting occupational and public health in Slovenia are allowed to exercise their duties solely according to their consciences and free from political and commercial interference, Ms. Kazan-Allen concluded:
The right to live and work in a healthy environment is a fundamental human right which will only be achieved with the full support of government, industry, trade unions and civil society. As the 'natural advocates of the poor,' and with a remit which includes 'social problems' doctors have an important part to play.
During the next session, Slovenian physicians presented case studies involving a glass cutter, car mechanic, cook, cleaner and driver all of which generated discussion and debate about viable options. The international experts contributed to the session, making comments as to relevant practices in their countries.
In addition to the information presented and discussions which took place during the one-day conference, a decision was taken by the delegates to commence discussions on the establishment of a Society dedicated to resolving the ethical dilemmas faced by occupational physicians in Slovenia and supporting colleagues falsely accused by vested commercial interests.
June 18, 2007