Health Surveillance And Fitness For Work Decision Of Workers Exposed To .

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Health surveillance and fitnessfor work decision of workersexposed to new chemicals(nanoparticles) and new physicalhazards (MSF-MRI) requires anethical analysisG FrancoOccupational Health Unit - School of Medicine University of Modena and Reggio Emilia - Italy

Codes of Ethics

Codes of Ethics Codes document the standardaccording to which the professioncan be held accountable Codes are used as the basis of selfregulation Codes provide a practical guide forsolving dilemmasSoskolne CL. Codes and Guidelines. Encyclopaedia ofOccupational Health and Safety, ILO, Geneva 1998

Weight and Intent of Codes The codes can be enforced throughthe administering of a disciplinaryaction Adoption of “guidelines” or“declaration on ethics” because offewer implication for enforcement The codes do not carry the force oflawSoskolne CL. Codes and Guidelines. Encyclopaedia ofOccupational Health and Safety, ILO, Geneva 1998

The Italian Law

Law and Occupational healthsurveillance in Italy The law dated 1956 (decree 303) The law dated 1994 (decree 626)according the 89/391 EU frameworkdirective The law dated 2008 (decree 81)

Occupational HealthSurveillance the EU Frameworkdirective– To ensure that workersreceive healthsurveillance appropriateto the health and safetyrisks they incur at work,measures shall beintroduced in accordancewith national law and/orpractices the Italian decree– to carry out the medical exams toassess fitness to work,– to set up medical records,– to provide workers and workers’representatives with information toclarify the meaning of medical exams– to provide workers with informationabout the results of the medicalexams– to communicate group results of theexams to workers’ representativesand to elucidate their meaning– to prescribe workers medical examswhen they believe their complaintsare work-related

Functions of the OccupationalPhysician (art. 25/81/2008) Duties of the competent doctor– 1. The competent doctor: a omissis b. carries out the health surveillance withprotocols relevant to the nature of the riskand taking into account the most advancedscientific findings c – n omissis

Evidence based practiceOHS should supply the following key services: Comprehensive services covering medical, psychologicaland social aspects of work,Multidisciplinary services oriented to health riskprevention and health promotion,Quality-oriented services founded on sound evidencebased practiceServices integrated with the core business of thecompany and cooperating with other services of theenterprise,Services based on the principle of participation ofworkers and employers to positively contribute to bothworkers’ fitness and to the overall development of theenterpriseILO Convention n 161, 1985

Assessment of workers’ health 3.8 Medical examinations and test should not becarried out as perfunctory routine. Dueconsideration should be given to their value andrelevance. They should be governed by a set ofprinciples which include:– Selecting appropriate tests which are acceptable toworkers– Discarding tests that cannot meet requirements withrespect to their relevance, specificity and sensitivity– Periodically reviewing health surveillance programs as awhole and modifying them in the light of improvedworking conditionsTechnical and ethical guidelines for workers’ health surveillance. ILO, 1998

Functions of the OccupationalPhysician (art. 39/81/2008) Conditions of execution of activities– The activities of the competent doctor iscarried out according to the principlesof occupational health and of the codeof ethics of the InternationalCommission of Occupational Health

Functions of the OccupationalHealth Physician (art. 58/81/2008) Violations of the article– The violation of the article 25 comma bis punished with the arrest up to 1month or with the fine from 1,000 to4500

http://www.icohweb.org/core docs/code ethics eng.pdf

The ICOH Code The content is structured in 3 parts– Basic principles– Duties and obligations of occupational healthprofessional– Conditions of executions of the functions ofoccupational health professionals It is not easy to be applied in daily practice

Characteristics of the practice Relevance– Nature and degree of risk, biologicalplausibility Accuracy– Reproducibility, sensititvity, specificity Need– Relevance of preventive measures Consequences– Exclusion of workers, social context, privacyCasteleyn L, Van Damme K. Analysis of practices in occupational health. In: Ethical andsocial principles in occupational health practices. Helsinki: Finnish Institute OccupationalHealth, 1998

The Occupational Physician meetsa problem and takes a omeMuir Gray JA, Evidence Based Health Care, 2004

Health surveillance of workersexposed to nanoproductsSchulte PA, Salamanca-Buentello F. Ethical and Scientific Issues ofNanotechnology in the Workplace. Environmental Health Perspectives, 2007

The link between Evidence andEthics “In the absence of scientific clarity aboutthe potential health effects of occupationalexposure to nanoparticles, a need existsfor guidance in decision making abouthazards, risks, and controls”. “An identification of the ethical issuesinvolved may be useful to decisionmakers, particularly employers, workers,investors, and health authorities”Schulte PA, Salamanca-Buentello F. Ethical and Scientific Issues of Nanotechnology inthe Workplace. Environmental Health Perspectives, 2007

Health Surveillance of Workersexposed to Nanoproducts Target organs– Respiratory tract– Deep lung– Dermal penetration– Gastrointestinal absorption– Eye– Cardiovascular systemSchulte PA et al. Options for occupational health surveillance of workers potentially exposed toengineered nanoparticles: State of the science. JOEM;2008;50:517-526

Health Surveillance of Workersexposed to MagnetostaticFieldsWorld health organization. Environmental Health Criteria. Static fields. Geneva: WHO, 2006

World health organization. Environmental Health Criteria. Static fields. Geneva: WHO, 2006Franco G et al, Med Lav 2008

Health Surveillance of well-knownand uncertain risks Well-known Risks– Epidemiologicalaspects– Target– Biologicalmonitoring– Health examination– Other measures Uncertain Risks*– Few/anedocticalreports on humantoxicity– Pathophysiologicalaspects underexperimental study– Exposure andeffect indicators– Health examination*Schulte PA et al. Options for occupational health surveillance of workers potentially exposed to engineerednanoparticles: State of the science. JOEM;2008;50:517-526*World health organization. Environmental Health Criteria. Static fields. Geneva: WHO, 2006

To deal with the legal obligation to undertakean action and with the uncertainties related tonanoparticles and MSF No relevant, scientifically sound and knowledgebased practice is available for recommendingmedical screening of the exposure The validity of non-specific medical examinationmay be questioned– the health end point to be measured are not known– non specific health examination may identify effectunrelated to the exposure The problem of false positives The availability of baseline data of workers’ groupfor time series comparison

The Ethical Analysis of Dilemmas The approach proposed by Westerholm,Nilstun and Ovretveit, 2004– The stakeholders Employer, Management, OHS, Workers’representative, Union, Insurance company,Inspection agency, Community– The ethical principles The ethical benefits and the ethical costs

Ethical principles Beneficence and non-maleficence–– meaning that actions are taken in order to maximize benefitsto individuals and society. It is the principle of doing goodactions should not harm others. It is derived from theHippocratic "first, do no harm."Autonomy (respect for)–– This is the principle of allowing people to make decisionsabout themselves for themselves.It is related to respecting human dignity, believing in aperson's ability to make good decisions and is the oppositeof paternalism.Justice––This refers to distributive justice and is the principlerequiring that benefits and harms should be equallydistributed among people.It is related ideas are fairness, equity and impartiality.Westerholm P et al, 2004

Westerholm P. Professional ethics in occupational health. Industrial health, 2007

Is it possible to grade cost andbenefits? A practical exercise

A tentative to grading cost and benefitby the ethical nEthical benefit212112Ethical cost6121BeneficienceAutonomy1Ethical benefitEthical cost21112111JusticeEthical benefitEthical cost21211The document is published at http://docs.google.com/Doc?id d5272nd 0d49p48hk&hl it

According to the principles ofbeneficience/not maleficience Ethical costs– no specific tests exist– difficulties of interpreting the results of genericsurveillance– lack of criteria for fitness for work– worker’s perception of false sense of safety– psychological stress after false positive results Ethical benefits– knowledge of the health condition, which makes itpossible to suspect adverse effects

According to the principle ofautonomy Ethical costs– obligation for the worker to beexamined

According to the principle ofjustice– Ethical costs a violation of the privacy exists when theworker is judged unfit for work and thisinformation is made available to theemployer.

How should the OP face theDilemma? To take an action?Which action?To do nothing?To inform about the uncertainties?Who should be informed?To adopt a precautionary approach?

Conclusion No definitive answer forappropriately comply with the newItalian law The method for analyzing ethicalaspects may be adopted as a tool forundertaking ethically-based actionsby the OP

Health surveillance and fitness forwork decision of workers exposedto new chemicals (nanoparticles)and new physical hazards (MSFMRI) requires an ethical analysis

ethical analysis G Franco Occupational Health Unit - School of Medicine - . principles which include: . A tentative to grading cost and benefit by the ethical analysys Ethical cost 2 1 2 1 1 Ethical benefit 1 1 1 Justice Ethical cost 2 1 1 1 2 Ethical benefit 1 Autonomy

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