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Medicine, Health Care and Philosophy

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01.08.2013 | Scientific Contribution

Models of occupational medicine practice: an approach to understanding moral conflict in “dual obligation” doctors

verfasst von: Jacques Tamin

Erschienen in: Medicine, Health Care and Philosophy | Ausgabe 3/2013

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Abstract

In the United Kingdom (UK), ethical guidance for doctors assumes a therapeutic setting and a normal doctor–patient relationship. However, doctors with dual obligations may not always operate on the basis of these assumptions in all aspects of their role. In this paper, the situation of UK occupational physicians is described, and a set of models to characterise their different practices is proposed. The interaction between doctor and worker in each of these models is compared with the normal doctor–patient relationship, focusing on the different levels of trust required, the possible power imbalance and the fiduciary obligations that apply. This approach highlights discrepancies between what the UK General Medical Council guidance requires and what is required of a doctor in certain roles or functions. It is suggested that using this modelling approach could also help in clarifying the sources of moral conflict for other doctors with “dual obligations” in their various roles.

GMC (2009a).

GMC (2009b).

p 22–26.

The GMC (2009b) p 24 state that “dual obligations arise when a doctor works for or is contracted (such as) by a patient’s employer, an insurance company, an agency assessing a claimant’s entitlement to benefits, the armed forces”. The British Medical Association (BMA) (British Medical Association 2012) p 649 describes these as “situations where doctors have clear obligations to a third party that can be in tension to the obligation to the patient”.

p 23.

For example, an applicant who had been found not to meet the medical criteria for an early pension release due to ill-health, could simply refuse consent for this report to be released, and seek a more favourable opinion at a later date from a different physician.

FOM, SOM (2010).

For example, most consent forms for disclosure of a report now offer the opportunity for the worker to read it 2 to 5 days prior to sending to the employer.

It is also part of the wider discipline of OH, which also includes nurses and physiotherapists, as well as ergonomists and occupational hygienists.

An OP is a registered medical practitioner who has undertaken specialist training and qualifications in OM.

For example, in Centre for Workforce Intelligence (2011): “Industry has changed from a manufacturing to a service majority over the last 20 years and this trend may continue. The main hazards have changed from dust, heat, noise and vibration to workplace pressure”.

For example a survey reported in Ballard (2011) found that 17 % of OPs list “dealing with IHRs” amongst their top three priorities (p 22).

FOM (2010a) p 7.

However, there is a statutory requirement for health surveillance of workers working with certain chemicals, or exposed to certain physical or biological hazards, for example, The Control of Substances Hazardous to Health Regulations 2002 SI 2002/267, and The Control of Vibration at Work Regulations 2005 SI 2005/1093.

See for example: WHO Regional Office for Europe (2002) at p 3.

See for example in: FOM (2010a) p 3 para 4.

For example, De Zulueta (2007) p 14.

However, many authors point out that there is not a “single” DPR, and have proposed various models to describe the different types of DPR. See for example Szasz and Hollender (1956) and Emanuel and Emanuel (1992).

p 17.

p 187.

Also known as Family Medicine (FM), but “General Practice” is more commonly used in the UK. A definition of GP/FM by WONCA (2011), the World Organisation of Family Medicine, describes GPs as “personal doctors” (at p 8). In the UK, the GP is usually the first point of medical contact for most patients, other than for accidents and some emergencies, refers to specialist or other health services where appropriate, and maintains a long term relationship with his patients.

p 2.

p 31.

p 9.

p 10. A recent poll commissioned by the BMA, Munn (2011), also confirms that the public trusts doctors far more than politicians.

GMC (2006).

See for example: Dyer and Bloch (1987) p 15; and Brazier and Lobjoit (1999) p 187.

p 111.

p 62.

para 2.4.9.

p 198.

v 131–132.

As in “seeming to be something but not really so”, Oxford Essential English Dictionary, Oxford University Press, 2011.

For example, the term “independent” is used in the title “Independent Registered Medical Practitioner” (IRMP) in the Local Government Pension Scheme (Benefits, Membership and Contributions) Regulations 2007. The IRMP signs the certificate including the following statement: “I have not previously advised, or given an opinion on, or otherwise been involved in this case, nor am I acting or have ever acted as the representative of the member, the scheme employer or any other party in relation to it”. Similar terminology is used in some other public sector pension schemes, such as “IQMP” (Independent Qualified Medical Practitioner) for the Firefighters’ Pension Scheme Order 1992.

Other work that would fall in this category includes OPs sitting on Medical Appeal Boards for these pension schemes.

For the NHS Pension Scheme, which is the largest in the UK, virtually all are done remotely.

GMC (2008).

para 14.

Devaney (2012).

However, he must not knowingly mislead the Court (Bar Council 2012, paragraph 302).

It is beyond the scope of this paper to offer a solution to this situation, except to note this intrinsic tension in the therapeutic role. It is the aim of this paper however to show that the differences between a treating doctor and an OP are such that in some aspects of the OP role (as expert, or model 2), this ethical conflict should not exist.

“Impartial” being defined as “not favouring one person or side more than another”, Oxford Essential English Dictionary, Oxford University Press, 2011.

75 % of their workload, as previously mentioned, from the survey reported in: Suff (2007).

“Occupational physicians also need to build good relationships with managers. Integrity, respect, good communication, and a focus on impartial (emphasis added) evidence-based medical advice are important elements in building a relationship of trust in which patients’ health problems and health and safety issues can be discussed constructively”, FOM (2010b) p 12.

FOM (2006) p 4.

This is not intended to be a criticism of the GP, as the latter is clearly expected to put his patient first, and in addition he would have only one side of the story.

See for example http://www.hse.gov.uk/stress/standards/downloads.htm.

One of the consequences would be that less OH would then be available to UK workers, arguably to their detriment, as they would have even less access to expert advice and diagnosis for work-related conditions.

As described by Bartlett (1997).

For example Gillon (1985), p 158: “despite this acceptance (of obligations to society) doctors often talk and think as if they believe that they invariably give absolute moral priority to their patients over the moral demands of society”. The GMC appear to reinforce this message: “you must make the care of your patient your first concern” (GMC 2006).

In their role, one would find this partiality towards their patient acceptable, similar to Holm’s (2011) arguments in support of such partiality in the context of public health care systems.

This is the case for the largest fund, the NHS Pension Scheme. The other schemes may involve either a similar paper review, or a face-to-face assessment of the applicant.

For example, if the property is to be let.

On the other hand, the power imbalance can be reversed, for example when the applicant or his union representative threatens the OP with referral to the GMC and the courts if early ill-health retirement is not recommended.

Although these examples serve to illustrate the different levels of obligations in model 3, the main aim of this paper is to demonstrate that at the extremes (i.e. models 1 and 2), the underpinning ethical reasons for doctors’ obligations are different, so that the anomalies and conflicts arising in the ethical guidance are due to its being based on wrong assumptions. .

That is, monitoring workers’ health from workplace exposures to chemical, physical or biological agents, under legislation such as mentioned at ref (14).

However, this is also to a lesser extent for the benefit of employers, for example, in discharging their duties under health and safety legislation.

But as seen from the examples, the middle ground is not a fixed point on the Fig. 1 “model2/treating doctor axis”, but will vary according to the type of activity, and maybe the context.

O’Neill (2002), where at p 9 she gives the following examples: “I might trust a schoolteacher to teach my child arithmetic but not citizenship … I might trust my bank with my current account, but not my life savings.”.

GMC (2006).

It is accepted that even in the DPR, a GP may occasionally feel threatened by his patient, and prescribe some medication or write a certificate, against his better judgment.

These models are intended to be a description of current UK OM practice, rather than what it ought to be. It is accepted, for example, that if OH provision became state rather than employer funded, this would change the pressures arising from the employer-OP relationship. Alternatively, OPs could adopt a definite servant-master approach with employers, which arguably would make it clearer for all parties to understand the OP role(s). However, whether one of these, or other approaches were to be pursued, it would still take some time to come into effect. In the meantime, it is hoped that a clearer understanding of the different tensions, and why they arise, will help OPs in their practice, and regulators producing ethical guidance.

For example, passengers and other members of the public, when a train driver suffers from epilepsy and does not want this to be disclosed by the OP.

For example, Grubb (1994) p 334, opines that the insurance medical context would not give rise to a fiduciary relationship: “One of the most important conditions for the (fiduciary) duty to arise is absent: an entrusting of power by the beneficiary which is to be exercised only for his benefit.” This condition is also absent in OM models 2 and 3, and presumably in some sports medicine and military medicine situations.

It is envisaged that the equivalent of models 1 and 2 could be reasonably clearly established for other dual obligation disciplines, though they would be different to the OM models. For example, in sports medicine, model 1 would actually be therapeutic, and the arm’s length model 2 arises for example during a pre-transfer medical assessment of a prospective team player. The middle ground, model 3, could arise for example when the team coach wanted a player recovering from injury to play possibly too early in an important match, and the club doctor had to advise.

Ballard, J. 2011. OH professional practice, Part 1: Jobs, priorities, concerns, threats and opportunities. Occupational Health [at Work] 8(1): 21–27.

Bar Council 2012. Code of conduct accessed at http://www.barstandardsboard.org.uk/media/1408606/code_of_conduct_-web_version_13_june_2012.pdf.

Bartlett, P. 1997. Doctors as fiduciaries: Equitable regulation of the doctor–patient relationship. Medical Law Review 5: 193–224.PubMedCrossRef

British Medical Association 2012. Medical ethics today: The BMA’s handbook of ethics and law. 3rd edition. London: Wiley.

Brazier, M., and M. Lobjoit. 1999. Fiduciary relationship: An ethical approach and a legal concept? In HIV and AIDS testing: Screening and confidentiality, ed. R. Bennett, and C.A. Erin, 179–199. Oxford: Oxford University Press.

Brody, H. 1992. The healer’s power. New Haven: Yale University Press.

Centre for Workforce Intelligence. 2011. Medical specialty workforce factsheet: Occupational medicine. http://www.cfwi.org.uk/intelligence/cfwi-medical-factsheets/recommendation-for-occupational-medicine-training-2011.

Devaney, S. 2012. Balancing duties to the court and client: The removal of immunity from suit of expert witnesses. Medical Law Review (forthcoming).

De Zulueta, P. 2007. Truth, trust and the doctor–patient relationship, 1–24. Radcliffe-Oxford: Primary Care Ethics.

Dyer, A.R., and S. Bloch. 1987. Informed consent and the psychiatric patient. Journal of Medical Ethics 13: 12–16.PubMedCrossRef

Emanuel, E.J., and L.L. Emanuel. 1992. Four models of the physician-patient relationship. JAMA 267: 2221–2226.PubMedCrossRef

FOM. 2006. Guidance on ethics for occupational physicians, 6th ed. London: Royal College of Physicians.

FOM. 2010a. Future directions for the occupational health care in the UK, A strategic overview. http://www.facoccmed.ac.uk/library/docs/pp_natstrat.pdf.

FOM. 2010b. Good occupational medical practice. London: Royal College of Physicians. http://www.facoccmed.ac.uk/library/docs/p_gomp2010.pdf.

FOM, SOM. 2010. Joint statement to FOM & SOM Members, New GMC Guidance on Confidentiality 2009. http://www.som.org.uk.

Gillon, R. 1985. Philosophical medical ethics. Chichester: Wiley.

GMC. 2006. Good medical practice. London.

GMC. 2008. Acting as an expert witness: Supplementary guidance. London.

GMC. 2009a. Confidentiality. London.

GMC. 2009b. Confidentiality: Supplementary guidance. London.

Grubb, A. 1994. The doctor as fiduciary. In Current legal problems, vol. 47 b, ed. M.D.A. Freeman, 311–313. London: University College London.

Holm, S. 2011. Can “giving preference to my patients” be explained as a role related duty in public health care systems? Health Care Analysis 19: 89–97.PubMedCrossRef

Kennedy, I. 1996. The fiduciary relationship and its application to doctors and patients. In Wrongs and remedies in the twenty-first century, ed. P. Birks, 111–140. Oxford: Oxford University Press.

Law Commission. 1992. Fiduciary Duties and Regulatory Rules, Consultation Document 124, HMSO.

Munn, F. 2011. Public declares doctors the most trusted professionals. BMA News Review: 2.

O’Neill, O. 2002. A question of trust, the BBC Reith Lectures 2002. Cambridge: Cambridge University Press.

Rogers, W.A., and A.J. Braunack-Mayer. 2009. Practical ethics for general practice, 2nd ed. Oxford: Oxford University Press.

Suff, P. 2007. Welcome to the working week (OH work survey). Occupational Health [at Work] 4(3): 22–28.

Szasz, T.S., and M.H. Hollender. 1956. The basic models of the doctor–patient relationship. AMA Archives of Internal Medicine 97: 585–592.PubMedCrossRef

WHO Regional Office for Europe. 2002. Good practice in occupational health services: A contribution to workplace health. http://www.euro.who.int/__data/assets/pdf_file/0007/115486/E77650.pdf.

WONCA EUROPE. (2011). The European definition of general practice/family medicine. Accessed at http://www.woncaeurope.org/.

Titel: Models of occupational medicine practice: an approach to understanding moral conflict in “dual obligation” doctors
verfasst von: Jacques Tamin
Publikationsdatum: 01.08.2013
Verlag: Springer Netherlands
Erschienen in: Medicine, Health Care and Philosophy / Ausgabe 3/2013
Print ISSN: 1386-7423
Elektronische ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-012-9426-4

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Models of occupational medicine practice: an approach to understanding moral conflict in “dual obligation” doctors

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