To serve two masters? A moral analysis of an apparent conflict of interest in the profession of occupational physicians

Grobler, Gerhardus M. (2019-12)

Thesis (PhD)--Stellenbosch University, 2019.

Thesis

ENGLISH ABSTRACT: Occupational medicine is the branch of the medical profession concerned with the health and safety of people at work. A nation’s labour force is a valuable asset and justifies legislation to preserve its productivity and well-being. Along with safety specialists, occupational hygienists, nursing professionals and human resources managers, physicians with specialised expertise in the field endeavour to keep workers safe and safeguard the public against accidents that might result from impaired workers performing safety-sensitive work. While these occupational physicians have a duty towards workers who become their de facto patients, the ultimate social good of occupational medicine and the discipline’s mission is occupational health and safety. An employer is legally responsible for the occupational safety and health of its workforce and has to carry all reasonable expenses. The occupational physician is thus employed by or contracted to the employer and remunerated to deliver an occupational medical service to the workforce. The question then arises whether the appointed physicians should primarily serve the interests of their patient, like doctors have been urged to do since time immemorial, or should serve the masters who pay their fee. Dual loyalty, or at least the suspicion that loyalty to either party would colour the occupational physician’s judgement, has vexed the discipline in recent times and creates ethical ambiguity. Consequently, codes of ethical conduct for occupational medicine have been developed. Occupational health and safety has many stakeholders and participants, rendering it an inclusive discipline. Allowing loyalty to influence decisions is incompatible with professionalism. Part of the answer lies in the unique context of the doctor–patient relationship in occupational medicine. When healthcare is practised in the labour milieu – with its hierarchical structures, employment contracts, disciplinary procedures and legislation – ethical controversy can be expected. This dissertation entails a description of the ethical field of occupational medicine in South Africa as experienced in a career of forty years and analyses various problematic aspects of the discipline. It is not possible to avoid all ethical qualms and suspicion in this discipline of medicine. However, there is some opportunity to raise the discipline’s ethical reputation with stakeholders. This includes acceptance that occupational medicine is not primarily patient centred, raising awareness of ethical codes, and exemplary professionalism of its practitioners. The prominent role of virtue ethics in the equation, emerges. Ethical practice in the field of occupational medicine calls for impartiality, veracity, tact when interacting with stakeholders and trustworthiness in clinical relationships.

AFRIKAANSE OPSOMMING: Bedryfsgeneeskunde (of beroepsgeneeskunde) is die vertakking van die mediese beroep wat by die bedryfsgesondheid en -veiligheid van werkers betrokke is. ʼn Land se werksmag is ʼn waardevolle bate en regverdig wette en stelsels om werkers se produktiwiteit en welsyn te bevorder. In samewerking met veiligheidspesialiste, beroepshigiëniste, professionele verpleegkundiges en personeelbestuurders sien bedryfsgeneeskundiges nie net na die gesondheid van werknemers om nie, maar verseker hulle dat die publiek nie aan risiko’s blootgestel word omdat werkers nie hul werk veilig kan doen nie. Alhoewel bedryfsgeneeshere ʼn plig het teenoor werkers wat ook in effek hul pasiënte is, is beroepsgesondheid en -veiligheid die uiteindelike doel van bedryfsgeneeskunde. Werkgewers is wetlik verplig en aanspreeklik om na die beroepsveiligheid en -gesondheid van hul werknemers om te sien en al die redelike kostes daarvan te dra. Die bedryfsgeneesheer word dus deur die werkgewer aangestel en vergoed om die diens aan die werksmag te lewer. Die vraag is dan of sodanig aangestelde dokters steeds in die eerste plek die belange van hul pasiënte op die hart moet dra, soos dokters nog altyd veronderstel is om te doen, of eerder die belange van die maatskappy wat hulle vergoeding betaal? Dit lei tot gedeelde lojaliteit – of ten minste agterdog dat die bedryfsgeneesheer meer lojaal sal wees aan óf sy werkgewer óf sy pasiënte en dat dit dan sy oordeel sal beïnvloed. Sulke vermoedens voed die etiese twyfel en morele onsekerheid waaraan bedrysgeneeshere nog altyd onderworpe is. As gevolg daarvan is verskeie etiese riglyne vir bedryfsgesondheid ontwikkel. In die veld van bedrysfgesondheid en -veiligheid is daar heelwat deelnemers en belangegroepe, wat dit ʼn inklusiewe dissipline maak. Om toe te laat dat lojaliteit besluite beïnvloed sou onprofessioneel wees. Die oplossing vir die etiese problematiek in die veld van bedryfgesondheid lê deels in die uniekheid van die dokter-pasiënt-verhoudings in die dissipline. Wanneer gesondheidsorg in die arbeidsomgewing plaasvind – ʼn omgewing wat deur hiërargiese strukture, arbeidskontrakte, dissiplinêre prosedures en arbeidswetgewing oorheers word – kan verskillende etiese opvattings verwag word. Hierdie proefskrif behels ʼn bespreking van die etiese problematiek in die bedryfsgeneeskunde in Suid-Afrika soos ervaar in ʼn loopbaan van veertig jaar en probeer die oorsprong en konteks daarvan navors. Dit is ʼn gebied van geneeskunde waar bedenklike etiek, twyfel en agterdog nooit heeltemal uitgeskakel kan word nie. Nogtans is daar geleentheid om dit aan bande te lê en om die professie in ʼn beter lig te stel. Daar moet aanvaar word dat die individuele pasiënt nie die middelpunt van bedryfgeneeskunde is nie, etiese kodes moet beter bekendgestel word en die dissipline se praktisyns moet onberispelike professionaliteit aan die dag lê. Deugsaamheid het ook ‘n belangrike rol in etiese optrede. Bedryfsgeneeshere moet onpartydig, geloofwaardig en eervol wees en takt aan die dag lê in onderhandeling met regmatige rolspelers in bedryfgesondheid.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/107007
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