Why ethics is important for Occupational health professionals ? The - - PDF document

Ethical Concepts and Challenges in Occupational Health

Sergio Iavicoli, MD, PhD

Italian Workers’ Compensation Authority (INAIL), Research Director International Commission on Occupational Health (ICOH), Secretary General

FACULTY DI SCLOSURE I have nothing to disclose

Why ethics is important for Occupational health professionals ?

The origins of ethics in occupational medicine Bernardino Ramazzini

Compassion: “For we must admit that the workers in certain arts and crafts sometimes derive from them grave injuries, so that where they hoped for a subsistence that would prolong their lives and feed their families, they are too often repaid with the most dangerous diseases and finally, uttering curses on the profession to which they had devoted themselves, they desert their post among the living”. Gratitude: “So, I freely confess that what I now publish is but an imperfect Performance, or rather an Incitement to

• thers to lend their helping hands, till an intire and

compleat Treatise is obtain’d, that may deserve a place in the Commonwealth of Physick. Questionless, we owe this piece of Service to the miserable Conditions of Trademen, whose Handy-Works, even those of the meanest and most sordid Production, are so advantageous and necessary to Mankind”.

Source: De Morbis Artificium Diatriba, 1700

The dilemma of ethical choice

Source: Westerholm, 2009

Laws and regulations Sets of value and culturally conditioned practices in communities /societies Professional norms, codes of ethics, silent knowledge etc Personal set of values

Management of professional dilemmas

Ethics Morals Bioethics Deontology Code of Ethics

Some definitions

The historical roots of ethics and

• ccupational health

Ethics and health in the classical world Plato (427-347 B.C.)

“The slave doctor never talk to their patients individually, or let them talk about their

• wn

individual complaints; rather, he prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, […] but the other doctor, who is a freeman, attends and practices upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him”.

Source: (Laws, IV.10.720)

The origins of ethics in occupational medicine Bernardino Ramazzini

Source: De Morbis Artificium Diatriba, 1700

Portrait of Bernardino Ramazzini, Bianchini Ciarlini Luigi (1758/1830) Civic Museum "Giulio Ferrari, Carpi (MO)

I mpact of the philosophic, economic and social thought on the relationship between work and health

“Almost every class of artificers is subject to some peculiar infirmity, … if masters would always listen to the dictates of reason and humanity, they have frequently

• ccasion

rather to moderate, than to animate the application of many of their workmen”

Adam Smith The Wealth of Nations, 1776

“The division of labour in Manufacture affects the life of individuals at its roots and provides material and impulse for industrial pathology”

Karl Marx Das Kapital, 1867

Finally, work which is quite suitable for a strong man cannot rightly be required from a woman or a child. […] Women, again, are not suited for certain occupations; a woman is by nature fitted for home-work, and it is that which is best adapted at once to preserve her modesty and to promote the good bringing up of children and the well-being of the family

Pope Leo XI I I Rerum Novarum, 1891 Principles of Bioethics

Autonomy

Refers to the right of self- determination, or that people have the right to choose for themselves what is best for them

Beneficence (primum non nocere)

First do not harm

No maleficence

Promoting what is good through minimisation of risks and maximization of benefit

Justice It implies the fair distribution of benefits and requires that we look at the role of entitlement

Source: T. Beauchamp e J. Childress: Principles of biomedical ethics, 1979

Ethical and health issues related to occupational medicine

HEALTH “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946) DECENT WORK “It involves opportunities for work that is productive and delivers a fair income, security in the workplace, social protection and social integration” (ILO,1999)

Health and work Occupational physician

Multiplicity of stakeholders Role in the risk management and protection of workers Multidisciplinarity Complexity and changes in the world of work Social issues Regulatory framework

Society Workers’ families I nsurance, prevention and social system Working environment and impact on human settlement Other OSH professionals

S U B J E C T S I N V O L V E

D

Subjects involved in the decision-making process of

• ccupational

physician

Legislative framework

OSH Service Providers

Occupational health professionals

Employer WORKER

Health professionals Patient

Doctor-patient relationship

Health Surveillance Contribution to risk management and assessment Who is examined Individuals Groups What is examined Health condition Harmfulness of working environment Examination methods Clinic methodology Epidemiological methodology Objectives Professional suitability Risk assessment Conclusions of the process Diagnosis Assessment of state of health Test characteristics Specificity Sensitivity Benchmarking Reference values Control groups Variables Dichotomy (yes/no),

• rdinals

Continuous (scales or intervals)

Role of Occupational Physician

Privacy and confidentiality Micro and family run enterprises Shared decision making Allocation

• f scarse

resources Innovative technologies Fragmentation Vulnerable workers (e.g.youth,gender, migrant) Overlapping roles

Ethical challenges

Source: Handbook for Rural Health Care Ethics: A Practical Guide for Professionals, William A Nelson (Eds), 2009

Why a Code of Ethics?

PROS

I t results from a shared process of a professional and scientific community I t provides a guide in the professional choices I t gives reference indications on professional conduct

CONS

Single case interpretation Multiplicity of indication on ethic codes I nterface with current legislation framework and evolving knowledge of the world of work

Pros and Cons of codes of ethics

“The occupational health physician is required to act according to the principles of Occupational medicine and Code of Ethics of the International Commission

• n Occupational Health (ICOH)”

I COH Code of Ethics

1906 Milan 1972 Buenos Aires 1975 Brighton 1963 Madrid 2003 Iguassu Falls 1928 Budapest 1931 Geneva 1987 Sydney 1984 Dublin 1960 New York 1954 Naples 1948 London 1938 Frankfurt 1935 Brussels 1978 Dubrovnik 1910 Brussels 1925 Amsterdam 1969 Tokyo 1966 Vienna 1957 Helsinki 1951 Lisbon 1981 Cairo 1996 Stockholm 1990 Montreal 1993 Nice 2000 Singapore 2009 Cape Town 2006 Milan 2012 Cancun 2015 Seoul 2018 Dublin 2021 Melbourne 2021 Melbourne

The I nternational Commission on Occupational Health (I COH) is an international non-governmental professional society whose aims are to foster the scientific progress, knowledge and development of occupational health and safety in all its aspects.

About I COH

1984 1991 1998 2005 2012 2020

1987 Its preparation discussed by the ICOH Board

The impact of I COH code

The ICOH Code of Ethics was approved by the Board 1992 First edition of the ICOH Code of Ethics (translated into English and French) 1994 e 1996 Translations of the ICOH Code of Ethics in another six different languages 2002 Second edition of the ICOH Code of Ethics 2014 Third edition of the ICOH Code of Ethics 2004 The ICOH Code of Ethics was adopted in the Argentinean legislation as term of reference (Resolution 693/2004) translated in Italian

INTERNATIONAL ORGANIZATIONS

Other Code of Ethics from Universities

Post Graduate Programs and Publications

2008 The ICOH Code of Ethics was also adopted in the Italian legislation (art. 39 Legislative Decree n. 81/2008)

I COH Code of Ethics

The Code of Ethics represents an attempt to translate in terms of professional conduct the values and ethical principles in

• ccupational health.

Objective Target

The Code applies to occupational health professionals and

• ccupational health services regardless of whether they operate

in a free market context subject to competition or within the framework of public sector health services.

Basic Principles:

 Occupational health practice must be performed according to the highest professional standards and ethical principles.  The duties of occupational health professionals include protecting the life and the health of the worker, respecting human dignity and promoting the highest ethical principles in occupational health plicies and programmes.  Integrity in professional conduct, impartiality and the protection of the confidentiality of health data and of the privacy of workers are part of these duties.

I COH Code of Ethics

 Proactive role of occupational physicians for the improvements in the safety and health of workers

What is new in this edition:

 Promotion and protection of workers’ health and well-being  Interdisciplinary approach to occupational medicine (psychology, ergonomics, environmental protection) and to continuous learning  Focus on the need to make occupational medicine services globally accessible  Removal of language and cultural barriers and overcome of cultural differences  Health surveillance based on scientific evidence and good practices  Extended scope of application of the code of ethics to organisations and not only to OSH professionals  Contribution to scientific knowledge and research

Ethical dilemmas management 3 cases

Pier Luigi Viola (1917-1985)

• Prof. Viola supervised the Occupational

Medicine service

THE VI NYL CHLORI DE CASE

anni ’60 ‐’70 60s-70s

Plastic becam e used in Fashion, Design and Art

Solvay Company, Rosignano (Livorno), Italy)

XVI I nternational Congress on Occupational Health

Tokyo, 1969 VIOLA P.

XVI International congress on

• ccupational health, 1969

International Cancer Congress, 1970 Cancer Research, 1971 Medicina del Lavoro, 1974 Environmental Health Perspective, 1981

Cesare Maltoni

Annals of the New York Academy of Sciences, 1988

Pier Luigi Viola IARC,1974 IARC,1979 IARC,1987 IARC,2008

Directive 78/ 610/ CEE “To you who have responsibility for the health of many thousands of workers, I hope you continue to exercise your art with vocation, perseverance and competence even if this may cause suffering…the anguish of the researcher for whom the results of the scientific investigation create ethical problems in respect of human health and for which he has to make decisions alone, based essentially on one’s

• wn conscience”

First page of handwritten notes

THE GERMANWI NGS CASE

History of flight

Take off from Barcelona Take off from Barcelona Lubitz locked the captain out of the cockpit, changes the autopilot to accelerate the descent speed Lubitz locked the captain out of the cockpit, changes the autopilot to accelerate the descent speed Air traffic control contacted Lubitz and continued to do so

• ver the coming

minutes - but received no answer Air traffic control contacted Lubitz and continued to do so

• ver the coming

minutes - but received no answer Noises similar to a person knocking on the cockpit door were recorded Noises similar to a person knocking on the cockpit door were recorded Collission with the terrain Collission with the terrain

Andreas Lubitz

Co-pilot Aged 27 German nationality Flying career:  1 September 2008: started his training at the Lufthansa flight training pilot school  5 November 2008: suspended his training for medical reasons  26 August 2009: restarted his training  June 2011-December 2013: flight attendant for Lufthansa  December 2013: joined Germanwings  919 flying hours

Civil Aviation Safety I nvestigation Authority (BEA) Accident Investigation Report

Started to suffer from a severe depressive episode treated with anti-depressive medication, psychoterapy According to the psychiatrist working for Lufthansa aero- medical center, Lubitz had fully recovered. He was readmitted after passing company medical and psychological tests. Lubitz visited a series of doctors, some

• f whom

pronounced him unfit for work (possible psychosis)

Key Moments in Lubitz’s Mental Health History

Started to exhibit symptoms possibly associated to a psychotic depressive episode (e.g. vision problems and sleep disorders)

Lufthansa aero-medical center stated that the class 1 medical certificate would become invalid if there were a relapse into depression

Sick leave certificates (for a total of 30 days) were not forwarded to Germanwings Lubitz was found fit to fly at each class 1 revalidation or renewal examination visits

Mental health in Commericial Airline Pilots

Prevalence of depressive disorders in aviation pilots vs depression in general population Date

19 December 1997 Summary Suicide by pilot Site Musi River (Sumatra) Flight of origin Jakarta Destination Singapore Passengers 97 Crew 7 Fatalities Survivors 104 I ncident Aircraft

Silkair Flight 185

Date 31 October 1999 Summary Suicide by pilot Site Atlantic Ocean Flight of origin Los Angeles Destination Cairo Passengers 203 Crew 14 Fatalities Survivors 217 I ncident Aircraft

EgyptAir Flight 990

Date 29 November 2013 Summary Suicide by pilot Site Bwabwata National Park (Namibia) Flight of origin Maputo (Mozambique) Destination Luanda (Angola) Passengers 27 Crew 6 Fatalities Survivors 33 LAM Mozambique Airlines Flight 470 I ncident Aircraft Date 8 March 2014 Summary Suicide by pilot Site Southern Indian Ocean (presumed) Flight of origin Kuala Lumpur Destination Beijing Passengers 227 Crew 12 Fatalities Survivors 239 (prsumed) 0 (presumed) I ncident Aircraft Malaysia Airlines 370

THE QATAR CASE

2010 2011 2012 2013 2014 2015 Qatar won its bid to host the 2022 World Cup First spotlight shone

• n the Migrant

Workers issue Public attention rises Tight scrutiny from International Community

ICOH State me nt on Qatar 2022 Wor ld Cup and migr ant wor ke r s

5 June 2015

Compla int file d a g a inst Qa ta r

1.200

deaths since 2010

4.000

deaths estimated before the World Cup 2022

THE DARK SIDE OF WORLD FIFA CUP 2022

Source: ITUC. The case against Qatar, 2014 Source: Ministry of Development Planning and Statistics. Labor Force Sample Survey, 2016, 2017, 2018 Source: UN International migrant stock estimation: The 2017 revision Source: Gulf Research Center. Demography, Migration, and the Labour Market in Qatar.

• N. 3/2017

452.000 India 339.000 Nepal 83% males 40% 25-34 years 99% of the total workforce in Construction 165.000 Philippines

Migrant workers by country of origin

130.000 Bangladesh

QATAR WORKFORCE PROFILE

Total: 2.079.000 Non Qatari: 1.974.000 95% of total workforce

I COH Statem ent

• n Qatar 2 0 2 2

W orld Cup and Migrant W orkers

There are nearly 2 million Nepali migrant workers in the Gulf and Malaysia, and another 2 million seasonal migrants in India. Between July 2014–July 2015, 1002 of them died – most of them in

• Malaysia. More than half the deaths are due to what is called sudden unexpected death syndrome

(SUDS). The workers go to sleep and never wake up. Health experts say the cause is overwork, stress, dehydration and poor diet. On average, 1,500 Nepali workers fly out to the Gulf and Malaysia every day from Kathmandu Airport. And every day three bodies of dead migrant workers are air freighted back to Nepal.

The Nepali perspective

Source: Nepalitimes (https://nepalitimes.atavist.com/nepalis‐killed‐in‐the‐line‐of‐duty)

WHERE I S THE PROBLEM? The Nepali perspective Malaysia

Deaths 425 (2014 ‐2015) 307 (2013‐2014) Nepalese migrants 242,328

Saudi Arabia

Deaths 273 (2014 ‐2015) 220 (2013‐2014) Nepalese migrants 165,321

Qatar

Deaths 178 (2014 ‐2015) 203 (2013‐2014) Nepalese migrants 625,356

Kuwait

Deaths 33 (2014‐2015) 36 (2013‐2014) Nepalese migrants 21,210

Baharain

Deaths 12 (2014‐2015) na (2013‐2014) Nepalese migrants 12,681

United arabs Emirate

Deaths 57 (201‐2015) 69 (2013‐2014) Nepalese migrants 170,434

South Korea

Deaths 12 (2014‐2015) 15 (2013‐2014) Nepalese migrants 55,000

Malaysia 0,18% Qatar 0,03% Saudi Arabia 0,17% United arabs Emirate 0,03% Kuwait 0,16% July 2014–July 2015 Annual percentage of deaths out of total Nepalese workforce present at the time in the country South Korea 0,02% Baharain 0,09% TCP between Qatar and the ILO 2018–20 is aimed to the annulment of the sponsorship system, the improvement of labour inspection and occupational safety and health systems, and giving a voice to workers.

2015 2016 2017 2018 Tight scrutiny from International Community Acknoweledgement of Qatar commitment in addressing the issue

High- le ve l IL O tripartite de le gation visit to Qatar to asse ss all the me asure s take n to addre ss all issue s raise d in the c omplaint file d at the 103rd Se ssion of IL

• C. 1–5 March 2016
• de c ide s to c lose the c ompla int

proc e dure unde rartic le 26 IL O Dir e c tor

• Ge ne r

al Guy Ryde r signe d a par tne r ship agr e e me nt with HE Ministe r

• f Administr

ative De ve lopme nt, L abor and Soc ial Affair s of Qatar , Dr . Issa bin Saad Al Jafali Al Nuaimi for a thr e e -ye ar te c hnic al c oope r ation pr

• je c t.

26 October–9 November 2017 331st Session of IL O Governing Body:

• approve s a n a gre e d T

e c hnic a l Coope ration Programme (T CP) and its imple me ntation modalitie s

ILO inaugurates its first project office in Qatar April 2018

“Qatar has set a new standard for the Gulf States, and this must be followed by Saudi Arabia and the United Arab Emirates (UAE) where millions of migrant workers are trapped in modern slavery”

Sharan Burrow, General Secretary, International Trade Union Confederation (ITUC) 08-11-2017

Laws and regulations Sets of value and culturally conditioned practices in communities /societies Professional norms, codes of ethics, silent knowledge etc Personal set of values

Management of professional dilemmas

Source: Westerholm, 2009

An integrated approach to ethics in occupational health

Person/ body involved Individual Expert Institution, company, etc Arena of operation Home, private life, community life Workplace, association Community, public environment Philosofical cultural basis Religious ethics, ethnicity Deontology Deontology Field of application Family, school, workplace School, workplace, professional Institution, workplace, global association, community economy, community Value content Honesty, integraty, respect, Autonomy, beneficence, justice Trasparency, fair business, fairness, compassion, caring non-maleficence, skill, fairness worker’s right, accountability competence enviromental responsibility Learning arena Family, school, association, Training institutions, University, University, business school, religious context school, professional stages continuing education Guidance Guidance in general Professional codes of conduct, Corporate Social Responsibility upbringing and school or good practice, guidelines, etc (CSR) religious education

Laws and regulations Sets of value and culturally conditioned practices in communities /societies Professional norms, codes of ethics, silent knowledge etc Personal set of values

Management of professional dilemmas

Source: Westerholm, 2009

Conflicts of interest Role ambiguity Discrimination Defensive approach Lack of training and updating Monodisciplinarity Isolation COMPETENCE LEGISLATION ETHIC INSTRUMENTS PARTICIPATION EXPERTISE PROFESSIONAL NETWORK

The ethical choice Next steps useful to resolve ethical challenges

The development

• f a corpus of

ethical principles that adequately consider the changing world of work The introduction in the curricula of both medical undergraduates and postgraduates of ethical courses A closer collaboration between OHPs and other key professionals Develop scenarios that highlights ethical dilemmas

DRI VERS OF THE CHANGI NG W ORLD OF W ORK RADI CAL CHANGES I N OCCUPATI ONAL HEALTH

ETHI CAL CONCERNS I N A CHANGI NG W ORLD OF W ORK Accessibility to personal data and sensitive information ICT development connectivity and working anywhere, everytime Automation, robotics and AI impact on work Impact

• f

innovative technologies in

• ccupational

healthcare practice You cannot fell two trees in exactly the same way, nor dig two ditches exactly alike. Then, too, a man could set his own pace, speed up for a bit, then slow down. Now a great deal of works requires no skill, and the machine sets the pace and makes the man feel he is its slave, not its master. He loses pride in his work and he loses his sense of individual importance

(Alice Hamilton, Exploring the dangerous trades, 1943)

CME Question and answer

• 1. Which are the basic principles of bioethics?
• A. Autonomy, Beneficence
• B. Maleficence, Justice
• C. Autonomy, Beneficence, Non-maleficence
• D. Autonomy, Beneficence, Justice, Non-maleficence
• 2. Who provided one of the first ethical considerations on the doctor-

patient relationship?

• A. Bernardino Ramazzini
• B. Karl Marx
• C. Adam Smith
• D. Plato

• 3. The name and work of Pier Luigi Viola are unequivocally connected

with the history of the discovery of the toxic effects of vinyl chloride. What was his professional activity?

• A. IARC Researcher
• B. Labour inspector
• C. Occupational physician in the chemical industry
• D. Professor of occupational medicine at University of Milan