Occupational Health Research Paper

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Abstract

Occupational health and safety aims to protect and promote the health and well-being of all at work. Work affects health and health affects work. Workers, employers, and regulators are important stakeholders. Different occupational health professionals contribute to the management and control of the risks and hazards arising from work. The ethical values behind this commitment and relationship among the different parties are marked by considerations of autonomy, communitarianism, duty, and the public interest.

Introduction

Health and safety at work is an end in itself. They are also the starting points without which other important or worthy personal goals associated with work, such as recognition, income, social inclusion, and community contribution, might be difficult to achieve. Work affects health and health affects work. This understanding is central to the human significance of occupational health for individuals and societies and its import for bioethical analysis.

This entry investigates occupational health with respect to the values and ethical principles behind a commitment to health and safety at the workplace, taking into account the effects of evolving technology and globalization on work arrangements and relationships.

History

Diseases and injuries caused by work have resulted in much harm and suffering. A classic example is the carcinogenic effects of asbestos exposure. With a sordid tale of systematic suppression of information on the risks of unprotected exposure by corporations, insurers, and occupational health practitioners, asbestosis and asbestos-related cancers have resulted in hundreds of thousands of deaths (Koenig and Rustad 2004). Cases which involved the progeny of workers exposed through the contaminated clothing of their parents from work make for grim reading. The story of asbestosis and asbestos-related cancers is a long and protracted saga, spanning from the 1960s and not foreseeably expected to end till the 2030s. This is due to the long latency of the diseases, not atypical for some occupational diseases.

Another example is Minamata disease, which is characterized by profound neurological symptoms and disabilities, caused by mercury poisoning. First observed in the mid-1950s in the small industrial town of Minamata in Japan, the illness resulted from the consumption of fish and shellfish contaminated by mercury. Industrial waste containing mercury was regularly released into Minamata bay by Chisso Corporation, a chemical plant. Symptoms of the disease include delirium, disturbance in speech, involuntary movements, and impaired vision. In severe cases, residents became paralyzed, insane, or comatose, dying shortly following the onset of symptoms (Ministry of Environment, Japan, 2013). The physician and head of the Chisso Corporation Hospital conducted animal experiments which suggested a link between the contaminated fish-based diet and the disease. When the doctor informed Chisso executives of his finding, they told him not to perform further experiments and not to disclose what he found to the public. In his recollection of this incident years later, the doctor recognized that “My appointed lot as a medical expert transcends my loyalty to the employing company” (Shigeto 2012). Unfortunately, he deferred to the wishes of his company superiors at that point in time. Communication of his finding to the public would likely have helped with earlier official identification of the etiology of Minamata disease (Shigeto 2012).

Unprotected risks to unsafe, dangerous, and hazardous working conditions continue to maim and kill in many parts of the world. Workplaces claim more than 2.3 million deaths per year. Of these, 350,000 are fatal accidents and close to 2 million are work-related or occupational diseases. In addition, 313 million accidents occur on the job annually, many of these resulting in extended absences from work (International Labour Organisation [ILO] n.d.). One of the deadliest work accidents is the collapse of the Rana Plaza factory in Bangladesh in 2013 which had a death toll of more than 1,000 workers and an injury list of more than 2,000.

The garment workers in Rana Plaza were reported to be locked in the poorly ventilated factories to work on a 19 h shift. After one such shift, a worker reportedly said, “My feelings are bad and my health is too. In the last 2 weeks, approximately, it has been like this for eight nights.” (Bilton 2013). Fatigue and stress from overwork, which may lead to death, are recognized as workplace hazards and have an invidious history that dates back to Victorian England in 1863, when the death of Mary Anne Walker, among many others, from “simple overwork” was documented in Capital, A Critique of Political Economy (Marx 1867).

In Japan, death and suicide resulting from the stress of overwork affecting all workers are so well recognized that the terms – “karoshi,” the overwork-induced collapse of biorhythms, leading to a state engendered by the fatal failure of a person’s life support functions, and also “karojisatsu,” suicide from overwork – have entered into the occupational health lexicon (Hosokawa et al. 1982).

Conceptual Clarifications/Definitions

Occupational Health

The joint response of the International Labour Office (ILO) and World Health Organization (WHO) beginning in 1950 has resulted in various initiatives that emphasize not just an approach to work safety protection but latterly also of support for health promotion activities at the workplace. These include the Global Plan of Action on Workers Health (WHO 2007) and the Stresa Declaration on Workers Health (WHO 2006). The joint definition by ILO/WHO Committee on Occupational Health in 1950 and revised in 1995 states that “Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risk resulting from factors adverse to health; the placing and maintenance of workers in an environment adapted to their physiological and psychological capabilities; and, to summarize, the adaptation of work to workers and of each worker to his or her job.” There is thus a positive duty to help workers to maintain and promote their fitness for work and to ensure that working conditions, culture, and social climate facilitate this. Under this broad definition, occupational health would therefore encompass the following.

Occupational Injuries And Diseases

Occupational diseases and injuries are caused entirely or mainly by work – a direct or clear connection with some harmful aspect(s) of work can be demonstrated. But for the exposure, the disease and injury would not have resulted. Examples of occupational diseases include asbestosis, silicosis, and noise-induced hearing loss. Occupational injuries include those caused by falls from heights and other accidents.

Work-Related Diseases

Work-related diseases are disorders and illnesses that have multiple causes, where factors in the work environment may or may not have played a role, together with other risk factors. Ischemic heart disease, work-related musculoskeletal disorders, and psychosomatic disturbances, such as stress and depression, are examples. Individual resilience, genetic predisposition, and physiological variations play a role in determining susceptibility and therefore causation as well.

Nonwork-Related Diseases

Nonwork-related diseases and health issues include those where current knowledge does not suggest a causative or contributing link with work. They could be borne from lifestyle choices such as smoking. Genetic diseases or diseases such as type 1 diabetes mellitus are other examples. Since occupational health is mainly accepted as a preventive activity consisting of measures to control workplace hazards and measures to ensure a healthy work environment and healthy workers, addressing nonwork-related diseases and enhancing work ability should be regarded as part of occupational health.

The following sections will consider the ethical dimensions – justifications and challenges – of these three components of occupational health. Cases will be used to frame the discussion.

Protecting Health: Preventing Occupational Diseases And Injuries

“Labor Is Not A Commodity”

The above slogan, adopted by the ILO in its Philadelphia Declaration of 1944, encapsulates in many ways the apprehensions and anxieties of the relationship between the employee and the employer. At the outset, this is seen as an unequal relationship. We also see this inequality cascaded down in the form of a hierarchy across the spectrum of the employed; the term “pecking order” therefore is not a misnomer. This would appear to fit neatly into the production unit of business operations, which churn out services and goods for consumption, with the ultimate aim of turning a profit from raw materials, machinery, capital expenditure, and other appurtenances necessary for doing so.

The libertarian view would posit that people in employment contract should be free to exercise their autonomy in choosing which industry and which employer they want to work for. Libertarians accept that employers have the duty to inform workers of existing work hazards during the contracting process so that they can make informed choices as to whether or not to accept the work and its existing risks. Nevertheless, market forces should find its own level to attract workers, and the ethical duty to protect workers should be minimal or nonexistent so as to enable free contract.

In his/her bargaining for employment, however, it does not stand to reason for a worker to bargain away his/her health and life. The voluntary assumption of unacceptable risks from harm or actual harm (e.g., breathing in toxic vapors, effects of which may not be immediate) is not tenable, neither ethically nor legally. Workers are distinct from the goods and services that are produced out of their exertions. They are human beings. The ethical duty in health and safety can be grounded on the Kantian principle of respect for persons. It could also be said that at least for occupational diseases and injuries where the risks are created entirely by work conditions, the duty of risk prevention and reduction falls largely on those with authority, knowledge, and resources. The complementary view is that workers have rights to be safe from these risks. Granted, the worker in expecting this right also has the reciprocal duty to cooperate, acquire the necessary skills, and conform to precautions essential for the safe performance of the job.

The prevention of and protection against occupational diseases and injuries by providing a safe workplace where risks are controlled share the two important features of a public good. An example would be pollution control. It has a benefit available to all workers as well as the community as a whole (non-rivalrous) and from which no one can opt to be excluded (non-excludable). Viewed this way, even the control of exposure to hazardous substances which involve mainly the workers in the immediate work environment should qualify as a public good if we are to consider the impact from an occupational disease or injury which would affect families, coworkers, and the whole community. Obviously, the resources required for the attainment of public goods are beyond the individual. Therefore, employers and the state should play the dominant role.

Legislation

The state sets the minimum standards for workplace safety through legislation. They specify rights, duties, responsibilities, competencies, and sanctions when these duties are breached. When caught in breach of duties, sanctions, usually of a monetary nature, may be viewed as a cost of doing business. While laws are helpful, they may not be able to meet every contingency of an ethical nature arising in the management of health and safety at the workplace.

Codes Of Ethics

Professional ethical codes express the ethical values, conduct, and rules that bind members belonging to the same profession and form the basis of self-regulation. These codes document the standards to which the profession is held accountable. Code of ethics for occupational health professionals is especially critical and complex because the professionals involved may be specialists from different fields, e.g., occupational physicians and nurses, toxicologists, hygienists, ergonomists, human factors specialists, psychologists, and the parties whose interests are affected include not just the workers, but also the employers, union representatives, regulators, and the community. Important features in the International Code of Ethics for Occupational Health Professionals (2012) include the duty to maintain professional independence, handling of sensitive information and personal data, communication of risks and its management, as well as the wider role of the professionals in the community and environmental protection. The codes to which the individual occupational health practitioner subscribes to because of his/her specialist affiliation, e.g., the American Board of Industrial Hygiene Code of Ethics, the Ethics Guidance for Occupational Health Practice, and the Faculty of Occupational Medicine, UK, would also specify the ethical obligations in greater detail unique to the expertise of the specialty.

Case Study 1

Harms from Fumes

The safety supervisor of a food processing plant recently heard from colleagues that two workers resigned within the past 6 months because of respiratory problems. However, the two workers did not state that as the reason. One more worker is also intending to resign and has said that the job is also causing her breathing problems which she thinks is due to exposure to fumes in the work process.

The safety officer expressed his concerns to the manager more than once. The manager felt that workers should be free to exercise their autonomy in deciding whether to work or not. As far as he can see, none of the others has complained. Even if there is a problem, which he also doubts because respiratory symptoms are so commonplace anyway, it has solved itself now, and he sees no reason to panic the rest of the staff.

Commentary

The causal link between exposure and the respiratory problem is not established, but there are reasons for concern. The safety supervisor has an ethical duty to respond to these concerns, investigate, and manage appropriately with risk reduction measures and follow-up with monitoring, if necessary with the assistance of other experts. According to the guidance of the International Commission on Occupational Health, if there is no help from the manager, the issue should be escalated to the top management in writing. In many countries, there are laws to protect whistleblowers making disclosures in good faith, which are in the public interest to the regulatory bodies, against reprisals by employers. Such reprisals may range from detrimental treatment at work to outright dismissal. Threats to health and safety are matters of public interest.

We learn about the toxic effects when workers suffer or die from the exposures. This sacrifice by the first to be exposed and to have experienced adverse effects is a “first-generation” effect.

Many chemicals in the workplace are not tested for toxicity or at least not tested as thoroughly for safety as would have been the ideal. Sometimes, an inference of safety is made because of analogy to other compounds proven safe. Such inferences are never foolproof. Animal studies have their own ethical issues, and its generalizability to humans is also open to debate, as would be other in vitro testing for carcinogenicity and other harmful effects. Thousands of chemicals have been found so useful or even necessary to modern life that we are willing to run the risk, because it is not reasonable and practical to insist on all tests, even if scientifically possible and valid, before its use. Society in sanctioning this is simply adopting a utilitarian stance, in a rather crude way, since the risks may be largely uncertain or the work is assumed to be safe. However, the utilitarian argument cannot be ethically used once the risk of harm is suspected and remains unmanaged.

Promoting Health: Work-Related Diseases, Nonwork-Related Diseases, And Conditions

Health Promotion

Creating conditions so that workers can be enabled to make healthy choices is good. Most people spend a considerable time of their lives at work. There are advantages to health promotion activities being carried out at work. Peers and colleagues attend and interact as a group, and since such activities usually occur during company time at employers’ expense, there is thus a captive audience effect. On their own, such activities may not attract participation especially if workers have to participate on their own time. The ripple effect to the rest of the community such as families and friends is another advantage. This influence on immediate family members, extended by virtue of the economically productive also being family breadwinners, cannot be underestimated.

While health promotion activities are good in themselves with honorable intent, the needs and the wishes of the workers should be ideally sought and taken into account. Health promotion, usually aimed at people to adopt health-enhancing lifestyles, is mostly seen as a state responsibility in public health, acting in concert with the individual. Much of this is spearheaded by lawmakers and national health agencies. Employers may want to complement this very important role. Such initiatives are to be encouraged. Perhaps most pertinently, the question for employers and employees to ask is “how should the business be doing this?” in an atmosphere of good faith and sincerity.

While some activities are clearly nonintrusive, such as the provision of healthy food options in the staff canteen which poses less ethical challenges, others are not. Even a proposed health talk on obesity or cigarette smoking presumably targeting the obese and the smokers is not without its problems of potential stigmatization if not properly thought out.

Interfering with the autonomy of people in making their own choices in their private lives needs strong justification (Nuffield Council on Bioethics Report 2007). Doing unwanted good for the good of the adult person with adequate mental capacity is considered unethical because of a failure to respect the autonomy of the person. About the main reason to persist in doing so justifiably is when doing so prevents harms to others (Mill 1859). The duties of employers to provide and the rights of workers to receive the benefits of health promotion have to be tempered. Virtue ethics dictating the impulse to correct the foolish behavior of an intemperate or profligate lifestyle will have to defer to respect for persons and their interest in the agency.

The ethics of workplace involvement in work-related diseases and other health-promoting activities would be different from the ethics of prevention and risk reduction in occupational diseases and injuries. The determinants of health outcomes in work-related diseases and other nonworkrelated health conditions will depend on the individual himself/herself to a varying extent.

Case Study 2

Work-Related Stress

The manager of a company has noted an excessive sickness absence possibly contributed by mental stress. On the advice of an occupational health professional, the company initiated a stress management program. Components of the program include tips on relaxation, time management, and referrals to an onsite psychologist.

Commentary

A stress management program aimed at relieving mental stress and enhancing coping strategies will have to identify the employees who are affected unless precautions are taken. The identification of people who are so affected can potentially lead to stigmatization and vulnerability. Furthermore, programs to help employees in work-related diseases may be seen as self-serving for the employers. If despite all the employer assistance, the problems still persist, then the blame could fall on the employee himself/herself. Another challenge is for the employer to design programs so that preventive efforts toward the work-related components of the job causative of the problems are not detracted, much as curative efforts are important and necessary. The stress management program, with techniques for coping skills, is a case in point. There is little value in enhancing coping skills when the employer expects its employees to work excessively at the expense of work-life balance.

Case Study 3

Well-Woman Screening And Health Promotion

The manager of a company has a workforce of 95 % female, mostly in their fifties and above. Recently, two employees have been diagnosed with breast cancer. It is extremely unlikely to be causally related to work, based on the existing knowledge. After discussions with the worker representatives and the company nurse, the employer decided to sponsor a yearly well-woman screening, including screening for breast cancer, to be outsourced to an external service provider. A program for assistance for follow-up care was planned. Psychological services were also thought to be a useful need, and this was also outsourced to an external provider. Participation was encouraged, but entirely voluntary. Co-consultation with the company nurse was optional, and all medical information will be treated as confidential and private. The company management will not access the information unless consent by the worker has been specifically granted.

Commentary

The company management has identified the needs through consultations and has responded appropriately. From the view of ethics, the privacy rights of the workers with respect to their medical information have been assured. Authorized recipients of such information, such as the company nurse, should also be bound by a duty of confidentiality, ensuring that information shall not be disclosed to others. It can be seen that attempts to ensure anonymity and privacy, such as having off-site centers for care, have been made.

Ethics And The Corporate Interest

There are many arguments attempting to either directly or indirectly justify the role for health promoting behavior and health-protecting behavior at the workplace. A commonplace argument especially when health and safety is mentioned as an ethical imperative is one based on economic interests. A healthy workforce humming along without sickness and injuries must be good for business. There are productivity gains; business becomes more successful, and this in turn benefits all stakeholders, including employees. Society as a whole gains from increased wealth. And yet such a utilitarian justification seems to render false the assertion of labor being not a commodity. When the fruits of labor are perceived to be distributed inequitably, the utilitarian imperative also becomes even more suspect of being reducible to promoting the self-interests of particular groups, e.g., senior management, rather than for the greater good. Another troublesome corollary from this line of thought would be that an unhealthy person, for whatever reason, would be a business liability with devalued workplace participation.

Far better for it be judged that a reputation for caring and treating workers fairly, humanely, and with care and concern is a good in itself, its own competitive benefits notwithstanding.

Special Issues

The Aged And People With Chronic Diseases

The impact of health on work takes on a special meaning in the employment context. More people in the world today suffer from chronic diseases than ever before. Life expectancy has also increased in many parts of the world. Work undertaken by people with chronic illnesses, such as diabetes, hypertension, and ischemic heart disease among many others, may not necessarily cause any increased risk to their health compared to not working. Most people would be fit to undertake employment or do so with some restrictions and modifications to job scope. Few jobs are very specialized and/or governed by statutory regulations demanding high levels of physical fitness, e.g., firefighters or the imposition of an age limit.

The employment of such individuals who have a business cost cannot be refuted. Healthcare costs are incurred indirectly when such individuals take time off for hospital visits and sick leave or when on sick days when performance may be suboptimal.

Direct healthcare costs to employers vary. This may range from minimal amounts such as when the state provides for most of the care through the public purse to sizeable amounts in the case of direct full payment by employers. In between are various benefit designs involving co-payment, insurance, and full self-payment.

Seeking to minimize costs is a legitimate business objective. This puts it at tension with providing employment for people with chronic disease. The problem could be particularly acute for small and medium-sized enterprises with limited resources.

Work can be a socially desirable goal with benefits to health and well-being, not only for those who are fit and healthy but also for those who suffer from chronic diseases. Laws prohibiting disability discrimination may offer limited help for the person affected with chronic disease, but not affected by disability within its legally prescribed meaning.

The state can and should promote a business ethos of providing gainful employment for as many of its citizens as possible. Capital can be indifferent, but given enough incentives can, together with the state, help create a moral and ethical community, where people are allowed to find dignity through work when willing and able.

Migrant Workers

Globalization has led to a dramatic increase in migrant workers. Poverty, debt, and lack of economic opportunities prompt hundreds of millions of people in developing countries to flock to developed countries in search of work, which rely on migrant workers to make up for the labor shortfall. They work in sectors that the locals shun, such as commercial sex, domestic work, and hazardous occupations such as construction. More than 900 construction migrant workers from Nepal, India, and Bangladesh had reportedly died while working in Qatar in 2012 and 2013, many of whom were working on the country’s infrastructure to host the 2022 World Cup (Gibson 2014).

Migrant workers face a unique set of occupational health challenges. Vulnerability to workplace hazards is increased by their semi literacy or illiteracy, language barriers and cultural differences, unawareness of local laws, and isolation from family and support networks. Migrant workers may also be reluctant to ask for improvement from their employers or to inform relevant authorities to avoid job loss and subsequent repatriation. Most migrant workers lack access to effective health care. They are either medically uninsured or inadequately insured by their employers; if insured, they seldom know the extent of their coverage.

Migrant workers may also come from countries with communicable diseases endemic in their own countries, e.g., tuberculosis. Tuberculosis may be latent without symptoms. If, however, their latent tuberculosis develops into an active form, contributed by stress and overcrowded housing, employers may cancel their work permit with immediate effect and send them back to their own country as soon as possible. Some countries also have restrictive rules on employment of workers found to be positive for human immunodeficiency screening, requiring them to be repatriated.

The Office of the United Nations High Commissioner for Human Rights (2013) highlights the lamentable fact that many migrant workers, of sound physical and mental health before leaving their countries, often end up in a debilitated state because of their host country’s failure to provide primary and ongoing care. States may recognize the human right to health care and yet may not regard the health care of migrant workers as an entitlement, at least to the extent their citizens enjoy.

Genetic Susceptibility To Workplace Hazards

 Genetic testing in the workplace poses ethical challenges. Advances in genome sequencing will increasingly identify genetic susceptibility to occupational diseases, which is in the interest of all to prevent.

However, the application of genetic testing raises many challenges in ethics. The benefits and harms must be evaluated. The value society places on justice must also be considered. Is it fair to restrict employment based on traits that are inborn? Furthermore, tests which turn out to be diagnostically positive and yet with no available cure in sight may be distressing and have further impact on insurance eligibility and other future employment. Consent and the implications of the results also have to be discussed with the worker.

Some genetic tests have reasonably high predictive value for susceptibility to occupational diseases that are fatal or extremely harmful. Mandating such tests as a condition for employment may appear beneficial. Employers can use this information and find alternative work arrangements for the affected employee.

However, employers may attempt to use genetic tests to dispute liability for occupational diseases that have ensued, claiming that it is the workers’ own susceptibility rather than negligent exposures that were causative. A case in point would be the genetic testing program for susceptibility to carpal tunnel syndrome conducted by Burlington Northern Railway Company (United States District Court 2001).

Each genetic test proposed to be done in the context of occupational health has to be considered on its own individual merits. The accuracy of its prediction on likelihood of disease occurring because of occupational exposure, the gravity of the disease in question, and the extent to which environmental measures can be put in place to ensure a safe workplace for everyone, rather than to rely on exclusion, are factors to be considered.

Research Participation

International guidelines, such as the Declaration of Helsinki, establish the ethical norms in biomedical research. The ethical principles, which are also relevant to occupational health research, include the need for independent review of the research proposal, sound objectives, voluntary participation, assessment of risks, harms and benefits, respect for data privacy and integrity of participants, and sharing of research findings. In the context of occupational health, particular care must be taken to ensure workers do not feel coerced or pressurized to consent or decline participation by parties with potential vested interests, such as management or unions. Research objectives should advance the safety and health interests of workers and not be misappropriated for partisan agenda. Any potential dual interest that might give rise to conflict, such as research sponsorship, should be made known, and workers should be free to make decisions about participation without undue influence or threats of repercussions. Confidentiality of trade and commercial secrets should be respected; however, the safety and health of workers and/or the community should take precedence.

Conclusion

Occupational health, the objective of which is to protect and promote the health of workers, is an undertaking involving many different professional disciplines and stakeholders. The ethical issues are therefore complex. Codes of ethics and the law can set standards and provide guidance.

The scope of occupational health includes occupational diseases, work-related diseases, and non work related diseases and conditions.

Workplace factors as causative and contributory progressively fall across this spectrum. Poorly controlled workplace health and safety risk cannot be said to be voluntarily assumed and are different from other personal risk factors, like lifestyle choices. Correspondingly, the employers’ duty to protect and promote health, and the workers’ duty to cooperate, ethically, transforms from one that is obligatory to one that is of encouragement and support.

Health affecting work also has ethical challenges. The state together with employers should seek to provide an inclusive working environment, helping all who are able and willing to gain employment. Attention should be paid to vulnerable populations less able to assert their rights.

Work environments and workers vary throughout the world. The nature of work takes on myriad and diverse forms. The key ethical challenges center on the core of treating all workers with respect and dignity and the corresponding reciprocal duty of workers to cooperate and for all to maintain an atmosphere of mutual trust and confidence.

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