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Section on Ethics, Work,and Health
ETHICAL PROBLEMS IN THE RELATIONSHIP
BETWEEN HEALTH AND WORK
Giovanni Berlinguer, Gabriella Falzi,
and Irene Fig;-Talamanca
Throughout history, the relationship between employers and workers has
been subject to the equilibrium of power, to legislative norms, to ethical
considerations, and more recently to scientific knowledge. The authors
examine the ethical conflicts that arise from the application of scientific
knowledge to preventive health policies in the workplace. In particular, they
discuss the ethical conflicts in the application of screening practices. in the
setting of “allowable limits’’ of harmful work exposures, and in the right of
workers to be informed about work hazards. Ethical problems are also created
by conflicting interests in the protection of the environment, the health of the
general public, and the health of the working population, and by conflicting
interests among workers, and even within the individual worker, as in the case
of “fetal protection” policies. The authors emphasize the positive use of scientific information and respect for human dignity in resolving these conflicts.
The relationship between work and health is situated at the interface between
human biology and economics, two fields with a growing interest in ethics. In the
field of biology this interest has generated the new area of bioethics. This trend
was predictable given the extraordinary, but also problematic, progress of the
biomedical sciences. It was more difficult to predict, however, that Mr. John Shad,
president of the Securities and Exchange Commission, the control organ of the
U.S.financial markets, would donate $30 million to the Harvard Business School
for instituting a chair in Business Ethics. G. Rossi, the Italian counterpart of
Mr. Shad, wrote in Corriere della Sera, the Fiat-owned newspaper (1):
The problem of the relationship between ethics and economics has always
been at the centre of the most anguished meditations of ancient and modern
thought. This becomes central in moments of crisis or transition. . . . Appealing to ethics is a sign that codes of ethics are lacking in Western economics,
International Journal of Health Services, Volume 26, Number 1, Pages 147-171, 1996
Q 1996, Baywood Publishing Co., Inc.
147
doi: 10.2190/46NE-8RUX-EGYJ-68X2
http://baywood.com
148 / Berlinguer, Falzi, and FigB-Talamanca
and this occurs when the law of the State is in crisis; thus the time is now ripe
for radical reforms of the whole system.
If this is true for the economy of the West, it is even more so for the rest of the
world, heavily influenced by the western economies.
In the last few decades, the moral principles governing the relationship between
human work, economics, and health have been clearly and authoritatively defined.
We will mention a few typical examples only, from three different sources.
One text is the Encyclical Pacern in terris, issued 30 years ago (April 11, 1965)
by Pope John XXIII. The chapter on “Rights Pertaining to the Economic World”
begins with the following two points:
17. Human beings inherently have the right of free initiative in the
economic field and the right to work.
18. Indissolubly bound to the foregoing is the right to working conditions
which are not damaging to physical health and morals, and do not interfere
with the integral growth of human beings in the course of their development.
As far as women are concerned, the right to work must be reconciled with
their needs and duties as wives and mothers.
The second text is the Declaration on Workers’Health, issued in Washington,
D.C., on February 6, 1992, by authoritative representatives from the economic,
political, and scientific worlds, meeting under the auspices of the Pan-American
Health Organization in the year dedicated by PAHO to safety and health at the
worksite. After stressing “the high cost of disabilities and lost lives resulting from
work-related pathologies, unhealthy working conditions and serious occupational
risk factors which could be eliminated and controlled,” the declaration underlines
two ethical aspects of the relationship between work and health, namely:
The aims of economic progress are only justified to the extent that concern
is focussed on human beings and their social wellbeing, and that in order to
ensure viable and sustained development it is essential that workers enjoy
good levels of health.
Knowledge is available about the strategies and techniques for reducing,
eliminating and controlling occupational risk factors; the application of this
knowledge is not only beneficial for workers, but also leads to the attainment
of a more equitable, stable and productive society.
The last document directly concerns those dealing with the problem as professionals. In 1992, following extensive consultations, the International Commission
on Occupational Health (ICOH) published an International Code of Ethics
for Occupational Health Professionals, consisting of 26 paragraphs. The ICOH
summarized the sense of these in three points:
Relationship Between Health and Work / 149
1. Occupational health practice must be performed according to the highest
professional standards and ethical principles. Occupational health professionals must serve the health and social wellbeing of the workers, individually
and collectively. They also contribute to environmental and community
health.
2. The obligations of occupational health professionals include protecting
the life and health of the workers, respecting human dignity and promoting
the highest ethical principles in occupational health policies and programmes.
Integrity in professional conduct, impartiality and the protection of the confidentiality of health data and of the privacy of the workers are part of these
obligations.
3. Occupational health professionals are experts who must enjoy full
professional independence in the execution of their functions. They must
acquire and maintain the competence necessary for their duties, and require
conditions which allow them to carry out their tasks according to good
practice and professional ethics.
The orientations emerging from these three sources appear clear and linear.
However, between appearance and actual fact we encounter two main difficulties.
W e will briefly summarize these two difficulties, although in this article we will
only develop the first of them.
The first difficulty derives from the fact that the development of science, the
rules of the market, civil and criminal laws, and deontological norms of the health
professions do not always provide updated answers to the ethical problems arising
in modem work. Let us consider the conflicts between different values and
interests, none of which can cancel out the others since each of them may claim,
to some degree, its own ethical justification. We are referring in particular to the
following points, each of which comprises a section of this article: (a) the conflict
between the right of workers to life, health, and safety and the right of businesses
to maximize production; (6) conflicts regarding information: the right of workers
to be informed of risks, the right of businesses to industrial and trade secrecy, and
the rights and duties of occupational health professionals; (c) conflict between
production and the external environment and between workers and the population;
(4 internal conflicts among workers; and (e) conflicts between work, reproductive health, and reproduction of life.
The other difficulty is that, while we attempt to develop bioethical themes
relevant to the present day and the future technological-scientific situation, we
still see in many countries not only the continuing existence but the growth of the
oldest and most inhuman type of exploitation. W e are referring to slavery and
servitude, practices morally condemned in past centuries and declared illegal by
the Slavery Convention of 1926, promoted by the League of Nations. The World
Labour Report published by the International Labour Office (ILO) in 1993 (2)
150 / Berlinguer, Falzi, and FigB-Talamanca
devotes its first chapter to an alarming description of the various forms of forced
labor still existing today: the traditional forms of slavery (Mauritania and Sudan);
bonded labor, whereby workers are bound to a business for the rest of their
lives as a result of unredeemable debts (Pakistan, India, and Peru); modem forced
labor of persons who are “uprooted, transferred and obliged to work under armed
threat” (Brazil and the Dominican Republic); and hard labor of the community
type, the lending out of prisoners as manpower for private concerns, and
the forced labor of children. The ILO Report does not deal with other forms
of coercion, such as that experienced by immigrant workers in developed
countries (including Italy). In any case, the picture is an impressive one, justifying the initial statement of the ILO Report that “At the end of the twentieth
century many people assume that slavery has been eradicated. Unfortunately this
is not so” (2).
In preparing this article, we consulted the vast bioethical literature on the
question of “human work” without finding a single article that referred to the
problem of forced labor, the continued existence of which has been known for
some time and has now been documented in the ILO Report. This confirms the
existence in the bioethical discussion of a profound cultural deformation:’ attention is concentrated on the themes concerning the most advanced frontiers of
science in the developed countries, while neglecting the moral implications (for
every citizen of the world) of daily living in those areas and among those classes
of people who are undoubtedly afflicted by the greatest sufferings. We realize that
what we say here will to some extent reflect the same distortion.
CONFLICTS IN THE RELATIONSHIPBETWEEN
WORKERS AND MANAGEMENT
A conflict has always existed between the need to ensure workers’ health and
safety and business’s drive to achieve maximum production at minimum costs.
This conflict has changed shape in various epochs and societies, and it proved
illusory to hope that by replacing private ownership with public ownership of
business, it would disappear. The relationship between these values and interests,
at times coinciding but more often conflicting, has usually been regulated on the
basis of three factors: ( a ) what has been brutally (but often realistically) defined as
a “relationship of power” between the social parties; (6)the laws of the State; and
(c) ethical principles. These principles may at times even be antithetical, as is
shown by two typical formulations. One is reflected in the very title of a famous
article by M. Friedman: “The Social Responsibility of Business Is to Increase Its
Profits” (4; cited in 5). The other is the PAHO-WHO declaration quoted earlier:
’
Such deformation. or ai least unilaterality. has already been reported and commented on, with
other examples (3).
Relationship Between Health and Work / 15 1
“The aims of economic progress are only justified to the extent that concern is
focused on human beings.”
But today, in addition to these three factors (relationships of power, laws, and
ethics), a fourth factor is becoming increasingly important in regulating the
relationship between workers and business: scientific knowledge, its impact on
technology and on the attitudes of occupational health professionals. Many
decisions previously taken on the basis of empirical considerations can now be
based on scientific knowledge.
A typical example is the selection of workers when they are first hired, and later
in the periodic check-ups. In the past, hiring took place ad nuturn, with a sign of
the finger; the boss responsible for the selection of workers judged at a glance and
chose those considered most suitable for the job to be done. The medical examination was introduced later, and thereafter aptitudinal tests, and finally more complex screening tests involving genetics, the identification of subjects hypersensitive to certain exposures, predictive medicine, biological monitoring of workers,
and assessment of conditions and behaviors outside the workplace liable to cause
greater susceptibility to illness and more absences from work (obesity, smoking,
insufficient physical activity).
On the ethical plane two problems emerge: the safeguarding of workers’
privacy and the relationship between a person and his or her environment in the
prevention of work-related risks. Infringement of “genetic privacy” may become
very dangerous. Rodota wrote in this connection (6):
We are living in times when, at every moment, the mechanisms of accepting anyone who appears to be different seem to break down. However, the
old forms of discrimination and stigmatisation, which made people inveigh
against drug addicts, homosexuals or communists, are becoming trivial compared to the emphasis placed on genetic diversity. Those against whom such
hateful accusations were directed, however, had a possibility of redeeming
themselves: by disintoxication, sexual abstinence or by abjuring their ideology. Whereas this possibility does not exist in the case of genetic diversity,
which cannot be corrected by individual determination,constituting as it does
the innermost core of the person, marked by a destiny, not a choice. So that
condemnation in such cases risks being final.
One might add, quoting a remark by Harris, that in subjective terms, too, it is
probable “that workers identified as being ‘at risk‘ feel worried about their
condition and the consequences this may have, and that such a situation of anxiety
may continue for the rest of their lives, even though this may be a long and healthy
one” (7).
A government investigation in the United States showed that various businesses
(about 5 percent of the total) have already set up, and others (about 15 percent) are
planning to introduce, programs of genetic screening of workers (8). At times this
152 / Berlinguer, Falzi, and Fig&-Talamanca
policy is instigated by insurance companies that require, in the terms negotiated
with the firms in question, staff preselection. This tendency will probably spread
to other countries. The moral justification is that this is in the interests of those
seeking a job. Once employed, they would run greater risks if they had to work
with chemicals to which they might prove hypersensitive. This may be true and at
times necessary. But various objections may be made. First, in actual fact cases of
genetic hypersensitivityare extremely rare. Second, those who are excluded from
work as a result of such screening tests run the risk of remaining unemployed, and
therefore falling sick as a result of that condition. Third, if this system should
become generalized, only super-resistant individuals would be hired for worknot even Superman. because (if we are not mistaken) he was genetically vulnerable to kryptonite. Finally, preemployment screening tests, based not on the
legitimate criterion of suitability for a specific job but on resistance to a harmful
environment, often take the place of primary preventive measures. Thus they may
constitute an obstacle to the introduction of such measures: in practice, “the
possibility of excluding workers ‘at risk’ may have the effect of lessening the
obligation to make the workplace or the physical environment safe and healthy,
and thus have the effect of making the world in general a more dangerous and
unpleasant place” (7).
Let us turn our attention to a further three conflicts arising in this field, namely,
monetarization of risk versus changes in production, promotion of health versus
control of behaviors, and risks versus benefits.
Monetarization of Risk versus Changes in Production
There is vast experience in this area in Italy because for a long time, until the
mid-l960s, firms offered (and trade unions pressed for) wage increases as a
monetary compensation for harmful work exposures. One of the consequences of
this was that, since there was no stimulus for prevention, the number of accidents
at work rose from an average of 171 cases per 1000 workers per year in 19511955 to a peak of 231 per 1000 in 1963; a similar upward trend was noted in the
case of work-related illnesses. Only then did the trade union organizations initiate
a movement with the ethical-political aim of negotiating on and modifying working environments and organizing to make them more healthy and safe. The motto
here was “health is not for sale” (9; see also 10, 11). In concrete terms, the
movement-which developed vigorously for the next 15 years or so-achieved
three results: accidents at work and work-related illnesses declined by one-third,
and deaths from such causes by one-half; the law recognized workers’ right to be
notified of and to check up on their work environment; and technological innovation was stimulated, so that industrial activities also benefited from all of this.
Some of the experiences of this movement (which in the 1980spractically came
to a halt, with a return to the “monetarization of risk” accompanied by a new
increase in the number of accidents and illnesses) had repercussions in other
Relationship Between Health and Work / 153
countries. The Brazilian trade union movement, for example, advanced similar
claims, which were accepted to some extent and embodied in the norms of the
State. These included provision number 5 of the Departamento Nacional de
Seguranca e Saude do Trabalhador, dated August 17, 1992, which specifies the
obligations of firms to draw up “risk maps” and to see that they are made known
to all workers.
Having very briefly described the practical effects of this movement, we can
now summarize its ethical implications as:
1. Primary attention to be paid to the value of life and health, rather than
monetary compensation for their loss.
2. Application, at workers’ initiative, of the moral principle, dealt with, for
example, in Article 41 of the Italian Constitution according to which an economic
activity “cannot be carried out in contrast to social usefulness or in such a way as
to cause detriment to the safety, freedom and dignity of human beings.”
3. A change in the self-perception of workers from “the realization of being
exploited“ or being “a vendor of manpower,” to “an awareness of being a
producer,” that is, of contributing to innovative technological progress.
4. The construction of a model for controlling environmental conditions “from
the bottom up,” that is, based on working experience and knowledge of environmental conditions. This model has as its aim health and life, and as its method
an exchange between the cognitive universe of workers and the specialized
knowledge of professional experts (production technicians, physicians, chemists,
psychologists, etc.).
Promotion of Health versus Control of Behaviors
The conflict between promotion of health and control of lifestyles has been
analyzed primarily in the United States. This is born of the very concept of health
promotion, which consists of combining individual commitment with collective
action, and health education with prevention. On this basis many U.S.firms offer
monetary incentives to workers who adopt more salubrious lifestyles. These
include, for example, a premium for anyone who gives up smoking (to be returned
in the event of relapse); or a compensation for each pound of weight lost by
overweight workers (this too to be made reversible); or even an incentive for
anyone participating in physical and sports activities, spelled out in cents or
dollars according to the number of miles covered or the means of locomotion
adopted: bicycling, walking, running, swimming, etc. Such lifestyles may in fact
enhance health and consequently would be of advantage to both workers and
firms: workers would improve in health, while firms would lose less through work
absences due to illness and would spend less on health insurance.
At times these practices are not only suggested but imposed through monetary
incentives or more or less openly coercive methods. But their usefulness, in any
case, is still under discussion, especially in practical terms. For example, it is
154 / Berlinguer, Falzi, and Figh-Talamanca
almost certain that giving up smoking benefits almost everyone, but it is not
equally clear that weight loss or physical sports activity are beneficial in every
case. Such choices of lifestyles should be made carefully and with an individual
perspective and adopted on the basis of reliable criteria, otherwise there is a risk
that in an attempt to correct one imbalance, another physical or psychological
imbalance may be created in its place.
But the main objections are of an ethical nature, and in turn have implications
for health. One has been clearly described by Allegrante and Sloan in an editorial
in Preventive Medicine (12). According to these authors we often tend “to perceive the world as a just place in which people get what they deserve and deserve
what they get.” The result may be that:
If people become ill, we tend to attribute the cause of their illness to them and
to their behaviour. In this way, at least psychologically, we are protected
against the possibility that we will suffer from the same illness. Following this
logic, it becomes convenient to target health promotion at individuals rather
than organisations, since individuals are seen to be the cause of their illness.
This tendency implies two consequences. One is hefined as “blaming the
victim”: concentrating attention (and condemnation) on the victim instead of on
the circumstancesand the problem. Even if certain illnesses-for example, cardiovascular diseases-are undoubtedly influenced by personal behaviors, it is equally
certain that they are often conditioned by social status and level of education. A
typical example is smoking, which now tends to be more widespread among
the poorer classes. As Minkler (13) stressed long ago, historically there is no
doubt that the predominant blame for illnesses and accidents was ascribed to the
employee rather than the employer, more powerful and immutable, and that a
misunderstood health promotion may accentuate this tendency. The other consequence is this: “Workers exposed to carcinogens in the workplace ‘must’ be
taught not to smoke so as to reduce their risk; hypertensives who work under
perpetually stressful conditions ‘must’ be taught to relax.” In other words, the
imposition of personal behaviors considered conducive to health is preferred as a
less costly and binding solution than the adoption of preventive measures of a
technical, organizational, and environmental nature.
The conclusion reached by,Allegrante and Sloan is the following (12):
We do not mean to suggest that individuals have no responsibility whatsoever in the disease causation; such an assertion would be false and irresponsible. However, blame for lung cancer, for example, cannot be assigned
exclusively to an individual who [is] bombarded with persuasive messages
from advertisers or who works with known carcinogens on a daily basis. . . .
The use of behaviour-change strategies must be balanced with enlightened
practices designed to address organisational-level factors contributing to
health risk.
Relationship Between Health and Work / 155
To these considerations we could add others having ethical implications, such
as: Who decides on these strategies, and for whom? Who informs and who is
informed? On the basis of what certainties are the guidelines assumed? This last
question gives rise to further complex and contradictory problems, which we will
merely mention: the relationship between notions and prejudices in scientific
knowledge; the faculty of physicians (and in particular of epidemiologists) to
decide on the behavior of healthy subjects; the right of everyone to choose
their own lifestyle.
These questions pose ethical problems to those professionally involved in
health education and health promotion. Even though the health professional’s
intent is to help the more disadvantaged to “improve their lot,” she or he may end
up laying the burden of responsibility on them, leaving the causes of their condition unaltered; the emphasis placed on behavioral change may become an alibi for
avoiding social changes. Moreover, while declaring that lifestyles must be chosen
voluntarily, one may still act in a more or less coercive way and tend toward
objectives that do not correspond to the desires and fundamental aspirations of the
subjects one is trying to “educate.” And. lastly, the changes themselves may at
times have undesirable effects on individuals and communities: for example, they
may introduce elements of discord, of division and imbalance among individuals
and social groups.
Risks versus Benefits
This area involves not only work but also, in general, the relationship between
humans and the environment, dealing with the problem of risks and benefits. This
conflict corresponds to an objective dilemma, but may also be seen as a typical
formulation of utilitarian ethics. According to this, every human action must be
judged on the basis of its consequences, not on the basis of absolute value criteria:
actions should aim, above all, to attain the maximum benefits for the largest
number of persons.
An application of this principle to human work is the practice of establishing the
MAC (or maximum allowable concentration) and the TLV (or threshold limit
value). These values, in theory, establish what concentrations of harmful substances are innocuous to health. But in practice, the very fact that over time these
values have been progressively lowered, following more detailed research on the
harmful effects of what had been regarded as low concentrations, means that these
merely serve to determine what risk is acceptable for a group of workers without
compromising the continuity of production-which is considered an advantage
for a larger number of persons. Many scientific and legal controversies have arisen
on this subject. For example, the whole question has been considered on several
occasions by the U.S. Supreme Court. In the case of benzene, the Court did not
accept the TLV of 1 ppm (part per million) that had been established by the
Occupational Safety and Health Administration (OSHA), stating that such a
156 / Berlinguer, Falzi, and Fig&-Talamanca
drastic reduction of the limit was not justified by the documentation presented.
But subsequently, when the Reagan administrationcalled for the abrogation of the
norms (especially the TLVs for a large number of environmental toxins) for the
safeguarding of workers, maintaining that these had been issued “without sufficient consideration to the economic costs and the possible damage to industry,”
the Supreme Court refused the request, affirming that the primary consideration in
establishing TLVs must be workers’ health (see, e.g., 14).
The difficulties may be dramatic for workers, when their power is slight, when
the State is inert, or when business acts without rules guaranteeing respect for
human life. When, on the other hand, such conditions change, working risks are
usually attenuated; in certain cases they may even become lower than the risks
outside the working environment. In the vast majority of cases, however, difficult
ethical problems arise.
One of these is the problem of asymmetry: most often the risks fall on certain
subjects while the benefits go to others. Even if “the others” are more numerous,
it is difficult to justify, for example, the fact that miners are obliged to work in
particularly unhealthy conditions because the minerals are of use to everyone.
It is also difficult to establish quantitative criteria for an “acceptable risk,” even if
this has been attempted: for example, a British Royal Commission defined as
“acceptable”a risk affecting less than one per million of those exposed. For values
of over one per thousand a “warning” should be given, and if this threshold is
exceeded the risk should be considered unacceptable (15). Another problem lies in
the difficulty of singling out the terms of comparison for values that are far from
homogeneous. An attempt has been made to use money as the yardstick to
estimate human lives at risk or lost, but this appears very questionable in principle
and difficult to apply in practice, given the difficulty of calculating, on the one
hand the advantages that might ensue to the majority, and on the other the value
of every life at risk or lost (16). It is clear that this value, which is absolute for
the affected individual, varies considerably for other people according to the
economic and cultural conditions of the individual society. We do not feel that
utilitarian ethics has the capacity to solve these problems.
CONFLICTS BETWEEN SECRECY
AND INFORMATION
Understanding the relation between oneself and one’s work activity may be
considered an intrinsic component of human nature, formed through biological
evolution and through experience. Both the complexity of modem work and the
distinction between work and ownership of the means of production may make
such an understanding less immediate today. In a sense this constitutes an expropriation of a faculty innate to man and woman, especially when a lack of understanding of one’s work implies a hazard to one’s physical or psychological
well-being.
Relationship Between Health and Work / 157
This tendency has been partly counteracted by recent laws affirming the right
of workers to be acquainted with every aspect of their work. In the area of health,
this right encompasses the collection of data relative to the health and environmental consequences of working activities, both for the individual and the group,
and the availability of and access to data for all those who may have a legitimate
interest to them.
A note by Navarro (17) lists some of the main difficulties arising in the
application of this right. One is that workers should themselves promote the
request for information, and that when there is an imbalance of power, many
brutal or subtle forms exist to prevent this. Another is that workers often do not
perceive an immediate reason for requiring such information, since many occupational diseases either show up only after years of exposure (e.g., neoplastic
diseases), or are not specific (e.g., chronic bronchitis and emphysema), or may be
subclinical and insidious for years (e.g., the neurobehavioral effects of lead). The
right to ascertain the causes may conflict with the right to maintain industrial
secrecy, recognized by the law in all competitive economies. Navarro notes that in
the United States, the Supreme Court has further protected this secrecy by specifying that inspections cannot take place without prior notification of the firm. This
obviously makes it possible for the firm to correct or conceal any unhealthy or
dangerous conditions prior to inspection itself.
In many developed countries, however, workers have succeeded in imposing
laws that sanction their right to be informed. But even in these cases, the duty
of the employer to provide not only formal information (i.e., labels, lists of
substances used, environmental and medical data) but also information of immediate use for the purposes of prevention is hardly ever enforced. In some countries,
such as Italy, workers have the right to refer to experts of their own choice,
avoiding the sole use of specialists that are accountable only to management,
whose immediate interests may not coincide or may indeed conflict with those of
workers. Italian Act No. 300 of 1970, known as the Workers’ Statute, in Article 9
states that “Workers, through their representatives, have the right to control the
enforcement of norms for the prevention of accidents and occupational diseases
and to promote the evaluation, planning and implementation of all suitable
measures to safeguard their health and their physical integrity.”
The difficulties in the application of these norms often arise from the ability of
powerful interests to hide the facts or to give elusive interpretations to data, thus
avoiding having to pay damages to workers or introduce changes in production
procedures. This can occur even when the empirical knowledge of the workers
themselves or the scientific research carried out by the specialists has revealed the
harmful effects of certain substances or work procedures. Many such examples
have been described in the scientific literature.
The cases of exposure to radon in uranium mines and the possible carcinogenic
effects of chlorophenoxyacetic herbicides have been described by Axelson (18).
In the former case, the suspicion of a carcinogenic risk to miners had been voiced
158 / Berlinguer, Falzi, and Figh-Talamanca
as early as 1879. However, the data from various studies were ignored for almost
a century, being considered “inadequate” or “controversial,” even though the
scientific controversy concerned only the dose and not the risk itself. Meanwhile,
miners were the victims of veritable epidemics of lung cancer. The case of
herbicide exposure was similar. Added to the interest of the business establishment in discrediting the scientific research that had documented the
causal nexus between cancer and exposure to these herbicides were military
interests. This was not only a question of image. Huge sums of money
were at stake if damages were to be claimed not only by civilians but by veterans
of the war in Vietnam, where chlorophenoxyacetic herbicides were used as
defoliants.
The case of asbestos has been carefully studied, on the basis of reliable documents, by Lilienfeld and Engin (19). A reconstruction of the story shows that the
industry knew that pneumoconiosis and tumors were caused by asbestos but did
not communicate this information to the persons concerned. The medical consultants to the asbestos industry played down the data on the respiratory pathology, and even committed the capital sin-unpardonable in a researcher-f
“touching up” the results. The two company physicians who identified these
diseases, Lanza and Gardner, for a long time had no opportunity of making known
the results of their research work. Research on the possible carcinogenic effects of
asbestos had started in 1936 with an agreement between the producing firms and
Saranac Laboratory, in which we find the following clause: “The results obtained
will be considered the property of those who are providing the research funds and
who will determine whether, to what extent and in what manner they shall be
made public.”
This secrecy clause had nothing whatsoever to do with the notion of the
so-called industrial secret, which can only be invoked to prevent illicit competition. In this field, two ethical and legal problems are posed. One concerns the
fundamental ethical principle of science, which is that of freedom: freedom of
research but also, and inherent in this, freedom of communication of knowledge.
The violation of this principle humiliates and annihilates the “scientific community” and puts an end to the progress of science. Examples include the case of
Galileo, accused not so much of having observed the motions of the celestial
bodies as of having publicly communicated the results of his discoveries; the
case of scientists in the Soviet Union who were hindered in their research and
prevented from participating in meetings with other scientists outside the
U.S.S.R.; and the cases of the researchers in many countries who are constrained
by military secrecy (classified science).
The other problem may be expressed in the form of a question: Is it fair that
information that could save people from illness and death should be withheld as
the private property of those who may have an interest in avoiding prevention or
having to pay insurance premiums or damages? Referring to researchers, the
question might be reformulated as follows: Is it fair not only to hide the truth but
Relationship Between Health and Work I 159
also not to investigate it when there are well-founded suspicions that a product or
a work process may be harmful to workers’ health?
We would do well to bear in mind that, even without signing particular agreements (such as the one on asbestos, a similar form of which is still used in
contracts between industries and universities), this type of wirhholding of viral
information is not infrequent. In the explosion of a chemical reactor at the
ICMESA plant in Seveso in Northern Italy, which contaminated a large area with
a cloud of dioxin, the parliamentary inquiry following the accident ascertained
that the level of information on the problem, for the persons concerned, was
inversely proportional to the risk. The managers of the multinational company
Hoffman-La Roche, to which ICMESA belonged and which was based in
Switzerland, were fully aware of the dangers, so much so that the factory had been
set up south of the Alps, in Italy. The workers and the citizens of the area, on the
other hand, were not even aware of the existence of a highly toxic substance called
dioxin. On a much larger scale, similar or even more serious imbalances exist in
the distribution of risk awareness between the North and the South of our planet.
For example, asbestos continues to be extracted, produced, and used in many
Latin American and Asian countries, without the workers or the populations
concerned being aware of its harmful nature.
In ascertaining and transmitting information, the role of the occupational health
physician may become particularly conflictual. Even the normal doctor-patient
relationship may be affected by interference from management. What information
concerning the workers may the physician pass on to the company, and what
information concerning the company should he or she transmit to the workers?
The ethical dilemmas and professional conflicts for this peculiar professional
medical figure-the occupational health physician-are a much discussed subject
in the bioethical and legal medical literature. A study carried out among members
of the American Occupational Medical Association, for example, showed that
these physicians face ethical problems leading to conflicts of conscience,
on account of their dual responsibilities: to workers and to management. The
main way of solving these conflicts seems to be by referring to traditional medical
deontology, which affirms the priority of the interests of the patient as an
individual (20).
Less discussed, but ever more pressing, are the ethical conflicts of researchers,
both those who cany out biological studies on toxicity and those who study
epidemiology in the field. Having ascertained the harmfulness of a certain substance or procedure, to whom and how should they notify the results? At times
they keep quiet for the sake of convenience; at other times, in the uncertainty
characterizing biological and especially epidemiological research, the temptation
to “protect” workers from anxieties about risks that are not yet completely proven
prevails. To what extent is this an alibi, dictated by lack of confidence in workers’
capacity to understand and appraise the scientific data? An investigation among
workers of both sexes who had been exposed to beta-naphthylamine showed that
160 / Berlinguer, Falzi, and Figh-Talamanca
the news of having a relatively high probability of contracting bladder cancer had
not caused them any “psychological damage”; on the contrary, they received the
information in a rational manner, expressing appreciation to the researchers who
had provided it (2 1).
To conclude this point, we may say that the concept of “professional secrecy” is
valid when the disclosure of information about a worker might harm her or him;
but that when harm may derive from not disclosing information on hazardous
work conditions, the concept of an “entitled disclosure” should be considered
a deontological norm of equal validity to secrecy, both for doctors and for
researchers. A bridge between these two duties is exemplified in the very precise
formulation of Article 105 of the Brazilian Code of Medical Ethics, which forbids
doctors “to reveal confidential information obtained during medical examination
of workers, even when requested to do so by managers of enterprises or institutions, unless keeping silent jeopardises the health of the employees or the
community” (22). In Scandinavia, too, the occupational physician may notify a
work risk not only to the individual worker but to any other workers exposed to
the same hazard (23).
Basically, the main question to be answered is the following: To whom does the
information on the health of an individual or a group belong? The most logical and
correct answer would unquestionably seem to be, to those most directly concerned
insofar as they are living beings, rather than workers or producers. And from this
first answer we can derive all the others, which-we must admit-are not always
quite so simple.
CONFLICTS BETWEEN PRODUCTION REQUIREMENTS
AND THE ENVIRONMENT AND BETWEEN
WORKERS AND THE POPULATION
From the time of the Industrial Revolution until a few decades ago, only a few
intellectuals and politicians, isolated and ignored, had warned about the dangers of
environmental contamination and, more generally, about the potential dangers to
the biosphere. When such phenomena were observed, the prevalent opinion was
that this was the inevitable price to be paid for progress. For a long time the most
serious illnesses were those of microbial origin; the transmission of these diseases,
either by direct contagion or by arthropods, food, air, or water, was first
hypothesized and later demonstrated. Yet people failed to perceive the existence
of another type of “contagion,” consisting of first, the diffusion of pathogenic
factors from the factory to the outside environment, from work to consumptionthrough products (e.g., asbestos) and by the emission of contaminants into the air,
water, and soil (and from there to food, as in the case of pesticides)-and second,
models of organization of life, such as energy consumption and patterns of
work and rest, all of which produce effects on the balance of both the natural
environment and human health.
Relationship Between Health and Work / 161
From the historical point of view, it would be interesting to analyze the reasons
why perception of this type of “contagion” occurred so late compared with
microbial contagion, despite the fact that the latter is due to living organisms that
for a long time remained invisible, whereas the former was, in many cases, evident
by direct perception using one or more of the five human senses. One reason may
be that the immediate advantages deriving from industrial progress were so great
that people overlooked the present damage and, above all, the harm that would
build up in the future. In this too (once more involving the relationship between
risks and benefits), human judgment was probably influenced by asymmetries of
culture and power: those enjoying the advantages had a bigger say than those
suffering the harm, or destined to suffer it in the future.
Coming back to the present, it would be interesting to analyze the reasons
why the two most important environmentalist movements in the last few
decades-the movement for workers’ health and the movement for the protection
of nature-have been so far aparl and on occasion even in conflict. This has
been especially evident in Italy, where both movements have been vast and
influential.
While in the 1960s and 1970s the rise of the problem of the work environment unified trade union, scientific, and professional forces and created a
common moral sense in the country, in the 1980s different situations emerged. In
some industries, especially those dealing with chemicals, such as ACNA in
Cengio, FARMOPLANT in Massa, ENICHEM in Manfredonia, and SOLVAY in
Rosignano, the workers’ demand to keep up production came into conflict with
the right of the surrounding communities to live in an uncontaminated environment. The clash was fierce, and in certain cases there were even two contemporaneous demonstrations in front of the National Parliament: one by citizens
calling for the closing of the factory and the other by workers urging that measures
be taken to reopen the plant and resume production. The solutions adopted
(FARMOPLANT was closed; SOLVAY gave up the development of its plant as
planned; ENICHEM and ACNA continue their production, after controlling pollution to some extent) were undoubtedly far from satisfactory. This was due to the
lack of scientific background, to the inertia and hesitations of the public institutions concerned, to the lack of adequate laws, and to the sectarianism of the
movements (both trade union and environmentalist), which had not understood
one another’s reasoning. But above all this clash occurred because such conflicts
can only be prevented in the planning phase of production activities by foreseeing
their impact. If this is not done, the costs thereafter become prohibitive: costs in
terms of health, the environment, and the economy, but also of social cohesion and
personal well-being. In many of the examples given above, conflicts of interests
arose between workers and their families.
The ethical problem, that of the conflict between the workers’ legitimate interests and the population’s legitimate interests, can rarely be solved a posteriori,
because this would mean sacrificing the one for the other. As mentioned above,
162 / Berlinguer, Falzi, and Figh-Talamanca
the solution requires the incorporation of a system of human and natural values
already in the planning stage. In comparing the advantages to be achieved by
production and consumption, it is important to bear in mind that when there is no
production, lack of work and poverty may also lead to illness and deterioration of
the environment.
Planning production sites with respect for the environment could help the two
movements close the distance that so far has divided them and even seen them in
direct confrontation. In Epelman’s (24) opinion, mutual prejudices have to be
overcome: “On the one side the workers very often take the view that the environmentalist movement, with its action against pollution, is threatening their sources
of work. Whereas on the other, the environmentalists think that the trade union
movement is only interested in fighting for its economic advantages.” We do not
think these are mere prejudices: in many cases they are after-judgments deriving
from real experiences. However, it is only right to stress the requirement for a
unitarian concept and orientation. This may be based on a substantial coincidence
of interests, that is, on objective roots, which continue to be obscured by the
contradictions created by the type of development that predominates today.
So far we have discussed ethical conflicts and problems arising within
countries. Along with these, three more complex themes also emerge, which we
will briefly summarize.
Global Space
In the face of legal codes tending to regulate the environmental and health
impacts of industrial activities in the developed countries, there is a growing
tendency of the multinational companies, and even of smaller firms, to move
into the poorer countries (25). Forbidden toxic substances such as asbestos,
dyes, and other carcinogens are also exported, along with their toxic industrial
waste. This has created two regulatory systems, corresponding to two different
estimates of the value of human work, life, and the environment: one for the rich
and one for the poor countries (26). For some time now the World Health
Organization and the International Agency for Research on Cancer (IARC) have
drawn attention to this question, without any significant reversal of the present
trend (e.g., 27,28).
Generational Time
By “generational time” we mean the influence of our actions on future human
generations and on the global balance of the biosphere. The difficulty of comparing this with the existence of other rights has been pointed out by Jonas (29). He
observed that, according to the traditional pattern, “once certain rights of other
people have been established, it also follows that I have the duty of respecting
Relationship Between Health and Work / 163
them and if possible fostering them.” Such a pattern does not work in this case. In
fact “what does not exist cannot offer grounds for any claims, nor can it suffer any
infringement of its rights” (20, p. 49). However, Jonas suggests that the problem
should still be dealt with from the ethical point of view, since “a metaphysical
responsibility in and for itself has stepped in, once Man has become a danger not
only for himself, but for the whole biosphere”; consequently, “Man’s interest
coincides in the most sublime sense with the rest of life insofar as it constitutes his
cosmic abode.” Accordingly, reference should be made “to the guiding concept of
duty towards Man, without thereby falling into an anthropocentric reductive
vision” (29, p. 176).
It is easy to see how far from these ideas are the method and substance of
politics, in its daily practice. Democracy itself, inasmuch as it represents the
power of the existing and voting citizens, if it is to be in a position to interpret
these responsibilities should speak out for those without a voice: those as yet
unborn, who constitute a numerical majority, almost infinitely greater than the
number of living human beings, and the other animal species that have evolved in
parallel and live side by side with our own species.
The Duty to Act in the Face of Scientific Uncertainty
The health and environmental consequences of work activities are not always
scientifically clear. In certain cases, although the certainty of harm has yet to be
established, another certainty may exist: if steps are not promptly taken, it may be
too late and the damage may have become irreversible.
The best known example is the problem of global climatic change, presumably
caused by carbon dioxide emissions and by the thinning of the “ozone layer”; but
there are also substances suspected of being carcinogenic by the IARC. The list of
these substances is as long as that of the “proven?’ carcinogens, but as testing
continues substances pass from the former to the latter category. In epidemiology
the phrase “data awaiting confirmation” or “data not sufficiently valid“ is very
frequent. One does not need to have absolute certainty or to understand the
mechanisms of action before applying preventive measures. When, in the middle
of the 19th century, John Snow discovered that the cholera epidemic then raging
was propagated by the water of a certain pump, he did not hesitate to suggest that
it should be closed, even though the cholera vibrio was not even suspected as yet.
Resistance to action in the face of unconsolidated data is not always due to
scientific doubt; rather, it may be due to powerful interests. This was the case for
asbestos, for pesticides, for ethylene oxide, and for tobacco smoking. It follows
that the medical principle in dubiurn abstirte, aimed at avoiding, in case of doubt,
any action potentially harmful to the patient, should also apply as an ethical
principle for governments in all of their actions-including omissions-that could
cause collective harm.
164 / Berlinguer, Falzi, and Figh-Talamanca
CONFLICTS AMONG WORKERS
Conflicts among workers may arise when one or more are affected by a contagious or mental disease or a psychosensorial handicap, or display behaviors (as
in certain cases of drug addiction) liable to harm their fellow workers. This may
occur in different ways: by the direct transmission of infections, by the propagation of unhealthy habits to other workers, or by increasing the probabilities of
accidents. These questions are not new; however, in recent times controversies
have become more common as a result of the emergence of two new causes of
conflict: the existence of HIV-positive workers and recognition of the pathogenic
effects of “passive smoking.”
These conflicts concern values and interests, each of which has its own moral
dignity. On the one hand, there is the right of everyone to work. Work in this case
may be even more important for subjects needing special support and therapy,
such as the mentally sick, the handicapped, and drug addicts. If such individuals
are excluded or segregated, their discomfort and risks may increase. On the other
hand, there is the right of “normal” or “healthy” workers not to be harmed and
not to be exposed to additional risk due to the condition or behavior of other
“abnormal” or “sick” workers. Added to this is the fact that, albeit rare, such
conditions or behaviors may constitute a danger for other persons, for example,
passengers in trains or airplanes. In ethical terms there is a confrontation between,
on the one hand, solidarity with those who are suffering and tolerance and
acceptance of “deviants,” and on the other, the question of collective safety.
The objective nature of this type of conflict cannot be denied. In certain cases it
may become necessary .to apply measures of restriction and even exclusion of
subjects who, even though not at fault, are in fact dangerous. Much more often,
however, the situation is rendered more acute by the prevalence of prejudices that
tend to exaggerate the risk, and even to invent it where it does not exist. This often
happens with the handicapped, persons suffering from mental disorders, and
HIV-positive individuals. The stigmatization of certain illnesses and behaviors
that tend to be accepted as “normal” (one example is the violence against and
sexual harassment of female workers by male workers and company executives)
often alters the objective situation. However, a synthesis is almost always possible, which consists of a compromise respecting both the value of solidarity and
the value of safety.
It is only right to point out, to the credit of Italy, that these areas of conflict
among workers have so far been fairly circumscribed. Indeed, there are many
exemplary experiences of the integration in the workplace of the physically and
psychosensorially handicapped, of the mentally sick, and of drug addicts. Among
other things, the Italian legislation obliges companies to employ on their staff a
minimum of 2 percent of handicapped persons, and there are many positive
examples of this sort (30). The factors that have had a positive influence are,
primarily, the feelings of generosity and solidarity that, when suitably encouraged
Relationship Between Health and Work / 165
and accompanied by appropriate information, have always been expressed by
workers; the favorable attitude of many entrepreneurs; and the bills approved
by Parliament. Among the latter, the act on AIDS is especially interesting. It
precludes HIV testing by the employer and forbids considering seropositivity as a
ground for exclusion from work, except for the rare circumstances where it would
in fact constitute a risk for fellow workers or for the citizens at large. In Italy and
in many other countries there has always been strong opposition to attempts to
introduce obligatory drug-testing of workers. Another issue, which has led to
serious controversies in the United States and elsewhere and which is destined
to cause further discussion, is the risks and the nuisance caused by “passive
smoking.” In principle this problem is easier to solve; however, a whole series of
other conflictual situations have arisen around this issue.
One unsolved problem for which few improvements are expected is the
relationship of the community to immigrant workers. Even though on occasion the
trade unions have protected them, the fact remains that these workers invariably
carry out the heaviest and most harmful jobs, earn lower wages, receive insufficient health and pension benefits, live in unhealthy and precarious housing, and
run the risk of being dismissed or expelled from the country. These problems exist
not only in Italy but elsewhere in Western Europe and in the United States.
However, Italy is the only one of these countries to have gone through the opposite
experience of mass emigration, between the 19th and 20th centuries (in fact, in
one century 25 million citizens left Italy!). Now that Italy has become a country to
which other populations emigrate, it ought to show greater sensitivity to this
problem than do other nations. The ethical dilemmas arising around this problem
are similar to those surrounding the export of harmful industrial processes and
toxic and harmful waste: we are faced with two different evaluations of the value
of work and life in this case, on ethnic or geographical grounds.
CONFLICTS BETWEEN WORK, REPRODUCTIVE HEALTH,
AND REPRODUCTION OF HUMAN LIFE
In introducing this subject we can repeat the statement from Pacerii iii terris,
which envisages a peculiar condition for women: “the right to working conditions
which reconcile work with their responsibilities and duties as wives and mothers.”
The underlying intent of this statement is clear and praiseworthy; however, its
formulation (in contrast to others contained in the same encyclical, which are
forward-looking) is outdated. For example, it only mentions responsibilities and
duties “as wives and mothers,” omitting any mention of the existence of similar
responsibilities and duties for men ‘‘as husbands and fathers.”
We do not intend to discuss here the function traditionally assigned by the
Catholic Church to women. However, it should be mentioned that while in the past
research emphasized the negative consequences of heavy or harmful work by the
mother on the unborn child, epidemiological and toxicological research has now
166 / Berlinguer, Falzi, and FigA-Talamanca
shown that damage to the reproductive function, to fertility, and to the genetic
material may be equally important for the male sex. This theme has been particularly developed by Figh-Talamanca (3 1,32), whose research and conclusions
we will now summarize.
Various pathological signs affecting reproductive health arise from exposures to
working conditions that do not normally damage other organs and functions. For
example, in the period prior to conception, ionizing radiations, heavy metals, and
certain pesticides such as dichlorobromopropane (DBCP) are a known cause of
damage to spermatogenesis and of male sterility. During gestation, prenatal death
and abortion may be caused by anesthetic gases, ionizing radiations, and other
physical and chemical agents in the working environment. Furthermore, such
factors increase the risk of premature births and, in certain cases, of congenital
defects.
From the ethical point of view, until now attention has been paid exclusively to
the conflict between the right of the woman to work and the rights of the unborn
child. Since the fetus is more susceptible to many environmental toxins, the
solution proposed by industry has often been to remove the pregnant woman, or
even the “potentiallypregnant” woman, from such dangers rather than to make the
environment safer (e.g., 33). In the years 1970-1980 several chemical industries
in the United States adopted policies of “safeguarding motherhood,” which
obliged women of reproductive age to be transferred to “safe tasks”; if this proved
impossible, many of them were dismissed. The argument that by doing so, every
attempt is being made “to secure the protection of the future generations,”
although attractive, fails to stand up to scientific analysis, for three reasons.
First, research shows that both sexes are vulnerable to reproductive toxins. For
example, exposure to lead is equally dangerous to young males and females (34).
In fact, exposure of male workers to lead not only damages the male reproductive
apparatus, causing impotence, sperrnatogeneticanomalies, and even sterility, but
may also harm the fetus. It increases the rate of “spontaneous” abortions and of
stillbirths among the wives of the men thus exposed. In addition, there is good
scientific evidence that exposure of the father to radiation may be the cause of
childhood leukemia; however, no one has yet proposed excluding males from jobs
carrying such risks in order to safeguard their future offspring.
Second, almost always, the woman is not given a choice between one job and
another but between work and unemployment, which carries an even greater risk
for the unborn child. In Italy, for example, in the period of economic growth
following the Second World War, the improvement of maternal and child health
indicators was most evident among women working in industry and on the land,
and least among housewives. Recent research finds unemployed women to be in
lowest place with regard to indicators of reproductive health and perinatal and
infant mortality (35,36).
Third, the solution of moving away from exposure the subjects considered “more susceptible”-whether male or female, young or old, or otherwise
Relationship Between Health and Work / 167
vulnerable in some way-is not only a form of discrimination but an obstacle to
prevention, for the susceptible subjects themselves and for everyone else. In fact,
these same hazards may also affect workers considered “normal”-perhaps less
frequently and less severely, but in absolute numbers the harm may still be
considerable. In figurative terms, the more susceptible individuals are like the
sentinels of a fortress: if they are dismissed, the attack becomes easier and the
lives of the whole garrison are endangered.
The choice of removing women from work based on policies of “fetal protection,” however, continues to be applied, on occasion through the use of barbarous
methods. The American Cyanamid Company, a colossus of the U.S. chemical
industry, for example, decreed the exclusion from the departments with lead
exposure of all women who were not sterilized or willing to undergo sterilization,
offering the operation free of charge and proposing, in case of refusal, to transfer
the woman to some otherjob (37,38). Only seven of the 30 women who had to be
removed from their previous jobs found alternative work in the plant; many were
dismissed, and five opted for “voluntary” sterilization in order to keep their jobs.
The painful choice between two conflicting values, work and motherhood, in this
case was apparently solved by the decision of the women themselves; but in fact
it was made by the company, by its refusal to modify the hazardous conditions of
the production cycle. Other even more ethically dubious methods have been
reported in developing countries. In some cases female workers of reproductive
age were required to undergo an obligatory pregnancy test; those found to be
pregnant were offered the choice, but in actual fact were obliged, to terminate
their pregnancies.
However, between more or less coercive sterilization and loss of job there are
intermediate alternatives. The principal one is prevention, which is valid for
everyone. All other solutions carry both advantages and disadvantages. In Italy
and in other developed countries the law requires removal from work (accompanied by prohibition of dismissal) of women in the last two months of pregnancy
and the three months post partum. It has been shown, however, that the most
vulnerable period for the fetus is not the last months but rather the early stages of
gestation, even before the pregnancy has been ascertained. Legislation may therefore need to be updated. If we also take into account the fact that damage to the
unborn child may derive from the exposures of both the mother and the father, it
would appear difficult to solve the problem by means of legislative measures and
controls on an individual basis. Surveillance would have to be conducted of both
the conjugal and extramarital sexual activity of both male and female workers
undergoing exposure at work.
In any case, anyone required to decide on a conflict of such a difficult nature,
whether technical expert, legislator, trade unionist, or individual male or female
worker, must have access to objective scientific information so as to arrive at a
judgment based on facts and not prejudices, and to be able to work out freely his
or her own ideas.
168 / Berlinguer, Falzi, and Figh-Talamanca
CONCLUSIONS
Our choice to deal with this topic and attempt to explain its ethical conflicts and
dilemmas may raise some objections, since all the problems discussed have more
than one possible solution. For example, one could adopt a historical approach in
dealing with technological development and ethical orientations. Ethical values
have in fact changed considerably since the times of slavery and especially after
the Industrial Revolution, when the working class emerged, affirming its rights.
One could also adopt an approach based on the typical concepts of the relationship
between health and work, such as the risk approach or cost-benefit analysis. Or
one could examine the ways in which the various bioethical schools have dealt
with this topic. We hope that others will choose to follow these alternative ways
of thinking. We have chosen to base our analysis on the conflicts, because they
exist and because it would be wrong to conceal them. Although these conflicts
may at times be interpreted as the result of divergent ideologies, they do not cease
to concern interests and persons that represent legitimate albeit divergent values.
Finally, starting with an analysis of the conflicts may be the only way of overcoming them, after identifying their causes and suggesting valid ethical-practical
solutions.
Conflicts are caused by gaps in knowledge and by the imbalance of power, the
type of power that in this case determines the physical dimension and dignity of
humans by conditioning them or placing them at risk, and sometimes undermining
their health and reducing the duration and quality of life itself. The only correct
moral yardstick may in fact be the human physical dimension and the dignity of
individuals. Without this, even professionals respectful of deontology may end up
protecting powerful interests, which may not always coincide with the good of
the community.
Interesting in this respect is the study carried out in the United States on the
ethical orientations of occupational physicians (20). The answers to the questionnaires revealed a conflict between the role of the occupational physician as a
doctor to the individual patient versus his or her duties as a public health official
and as a company employee. According to Sgreccia (39), the essential element
emerging from this study was the conflict between two schools of thought:
(a) maintenance of one’s own deontological identity, which, while bearing in
mind all interests and values, keeps the focus on the individual worker; and
(b)accepting teleological utilitarianism as the guiding principle. From the point of
view of work, however, utilitarianism, especially in its more recent versions, fails
to consider minority groups exposed to particular risks. In fact, it is guided by
what may be the true or the presumed interest of the majority. It may also attempt
to appraise the future environmental balance and the good of the “generational”
majority, constituted by the generations to come, who will be (in the absence of
disasters) far more numerous than those now living.
Relationship Between Health and Work / 169
Taking as one’s reference the human physical dimension and the dignity of
the individual workers, one can stimulate changes in production processes,
in work organization, in materials used, and so forth, which may prove more
suitable to men and women and more respectful of nature. We are not suggesting
that this course will eliminate all the conflicts we have mentioned; however, in
many cases they may be avoided, and in others their dimensions and seriousness
may be reduced.
This has already happened in the many different circumstances where positive
solutions have been found for the relationship between health and work. The
conflict between employees and employers has already become less dramatic
since the two parties have reached a more even balance of power. And many
conflicts on questions of information have also been solved, once workers were
guaranteed access to useful preventive information and the confidentiality of
personal data on individual workers was maintained. The conflict between
workers and the population, between industry and the environment, has not even
arisen in settings where the health and environmental impact of a new plant was
evaluated in advance. The conflicts between “dangerous” and “normal” workers
have been reduced to a few cases only, once the real risk was examined rationally
and objectively and not on the basis of prejudice. The potential conflict was
replaced by an ethical and effective mutual growth every time the spirit of
integration got the better of victimization and segregation. Conflicts between
work and reproduction have been greatly reduced once the rules of environmental
prevention took the place of dismissal of women of reproductive age.
Undoubtedly these positive experiences in themselves are not enough to settle
conflicts between values and interests that cannot always be reconciled; nor do
they provide guidance on the theoretical level for choices that are almost always
contradictory and difficult. But the more bioethical deliberation converges with
the historic evolution of our daily lives, the more it finds in human individuals, in
this case the male or female worker, its central point of reference.
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Direct reprint requests to:
Dr. Giovanni Berlinguer
via di San Giacomo 4
00187 Rome
Italy
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