While occupational health services are becoming more prevalent throughout the world, resources to develop and sustain these activities often do not keep pace with growing demands. Meanwhile, the boundaries of private and work life have been shifting, raising the issue of what can be, or should be, legitimately encompassed by occupational health. Workplace programmes that screen for drugs or HIV seropositivity, or provide counselling for personal problems, are obvious manifestations of the blurring of the boundary between private and work life.
From a public health viewpoint there are good arguments as to why health behaviours should not be compartmentalized into lifestyle factors, workplace factors and broader environmental factors. While the goals of eliminating drug abuse and other deleterious activities are laudable, there are ethical dangers in how these issues are addressed at the workplace. It will also be necessary to ensure that measures against such activities do not displace other health protection measures. The purpose of this article is specifically to examine the ethical issues in health protection and health promotion in the workplace.
Individual and collective protection of workers
While ethical behaviour is essential to all aspects of health care, the definition and promotion of ethical behaviour is often more complex in occupational health settings. The primary care clinician must prioritize the needs of the individual patient, and the community health professional must prioritize the health needs of the collective. The occupational health professional, on the other hand, has a duty to both the individual patient and the collective—the worker, the workforce and the public at large. Sometimes this multiple obligation presents conflicting responsibilities.
In most countries workers have an undeniable legal right to be protected from workplace hazards, and the focus of occupational health programmes should be precisely to address this right. Ethical issues associated with the protection of workers from unsafe conditions are generally those related to the fact that often the employer’s financial interests, or at least perceived financial interests, militate against undertaking the activities needed to protect workers’ health. The ethical stance that the occupational health professional must adopt, however, is clear-cut. As noted in the International Code of Ethics for Occupational Health Professionals (reprinted in this chapter): “Occupational health professionals must always act, as a matter of priority, in the interests of the health and safety of the workers.”
The occupational health professional, whether an employee or a consultant, often experiences pressures to compromise on ethical practice in worker health protection. The professional may even be asked by an employee to serve as an advocate against the organization when legal issues arise or when the employee, or the professional him- or herself, feels that health protection measures are not being provided.
To minimize such real-life conflicts it is necessary to establish societal expectations, market incentives and infrastructural mechanisms to counteract the employer’s real or perceived financial disadvantages in providing worker health protection measures. These may consist of clear regulations that require safe practices, with steep fines for violation of these standards; this, in turn, requires adequate compliance and enforcement infrastructure. It may also comprise a system of workers’ compensation premiums designed to promote prevention practices. Only when societal factors, norms, expectations and legislation reflect the importance of workplace health protection will ethical practice be truly allowed to flourish.
The right to be protected from unsafe conditions and acts of others
Occasionally, another ethical issue arises with respect to health protection: that is the situation in which an individual worker may him- or herself pose a workplace hazard. In keeping with the multiple responsibilities of the occupational health professional, the right of members of the collective (the workforce and the public) to be protected from the acts of others must always be considered. In many jurisdictions “fitness to work” is defined not only in terms of the worker’s ability to do the job, but also to do the job without posing an undue risk to co-workers or the public. It is unethical to deny someone a job (i.e., declare the worker unfit to work) on the basis of a health condition when no scientific evidence exists to substantiate the claim that this condition impairs the worker’s ability to work safely. However, sometimes clinical judgement suggests that a worker may pose a hazard to others, even when the scientific documentation to support a declaration of unfit is weak or even completely lacking. The repercussions, for example, of allowing a worker with undiagnosed dizzy spells to drive a crane, can be extremely serious. Indeed it may be unethical to allow an individual to assume special responsibilities in these cases.
The need to balance individual rights with collective rights is not unique to occupational health. In most jurisdictions it is legally required that a health practitioner report to the public health authorities conditions such as sexually transmitted diseases, tuberculosis or child abuse, even if this requires the breaching of confidentiality of the individuals involved. While there are often no concrete guidelines to assist the occupational health practitioner when formulating such opinions, ethical principles require that the practitioner utilize the scientific literature as thoroughly as possible in combination with his or her best professional judgement. Thus public health and safety considerations must be combined with concerns for the individual worker when performing medical and other exams for jobs with special responsibilities. Indeed screening for drugs and alcohol, if it is to be justified at all as a legitimate occupational health activity, could be justified only on this basis. The International Code of Ethics for Occupational Health Professionals states:
Where the health condition of the worker and the nature of the tasks performed are such as to be likely to endanger the safety of others, the worker must be clearly informed of the situation. In the case of a particularly hazardous situation, the management and, if so required by national regulations, the competent authority, must also be informed of the measures necessary to safeguard other persons.
The emphasis on the individual tends to overlook and indeed ignore the professional’s obligations to the overall good of society or even specific collective groups. For example, when the behaviour of the individual becomes a danger either to self or others, at what point should the professional act on behalf of the collective and override individual rights? Such decisions can have important ramifications for providers of employee assistance programmes (EAPs) who work with impaired workers. The duty to warn co-workers or clients who may use the impaired person’s services, as opposed to the obligation to protect the confidentiality of the person, has to be clearly understood. The professional cannot hide behind confidentiality or the protection of individual rights, as was discussed above.
Health Promotion Programmes
The assumptions and the debate
The assumptions generally underlying lifestyle change promotion activities in the workplace are that:
(l) employees’ daily lifestyle decisions regarding exercise, eating, smoking and stress management have a direct impact on their present and future health, the quality of their lives, and their job performance and (2) a company-sponsored positive lifestyle change programme, administered by full-time personnel but voluntary and open to all employees, will motivate employees to make positive lifestyle changes sufficient to affect both health and quality of life (Nathan 1985).
How far can the employer go in attempting to modify a behaviour such as off-hours drug use, or a condition such as overweight, which does not directly affect others or employee job performance. In health promotion activities, enterprises commit themselves to a role of reformer of those aspects of employees’ lifestyles that are, or are perceived to be, harmful to their health. In other words, the employer may wish to become an agent of social change. The employer may even strive to become the health inspector with regard to those conditions which are deemed to be favourable or unfavourable to health, and implement disciplinary action to keep employees in good health. Some have specific restrictions which prohibit employees from exceeding set body weights. Incentive measures are in place which reduce insurance or other benefits to employees who care for their bodies, especially through exercise. Policies may be used to encourage certain sub-groups, i.e., smokers, to give up practices that are harmful to their health.
Many organizations contend that they do not intend to direct the personal lives of employees, but rather are seeking to influence the workers to act sensibly. However, some question whether employers should intervene in an area that is recognized as private behaviour. Opponents argue that such activities are an abuse of employers’ power. What is rejected is less the legitimacy of the health proposals than the motivation behind them, which appears to be paternalistic and elitist. The health promotion programme may also be perceived to be hypocritical where the employer does not make changes to organizational factors that contribute to ill health, and where the principal motive appears to be cost containment.
Cost containment as the primary motivator
A central feature of the context of worksite-based health services is that the “main” business of the organization is not to provide health care, though services to employees may be seen as an important contribution to the achievement of the organization’s goals, such as efficient operation and cost containment. In most cases, health promotion EAPs and rehabilitation services are provided by employers seeking to meet organizational goals—i.e., a more productive work force, or the reduction of costs of insurance and workers’ compensation. While corporate rhetoric has emphasized the humanitarian motives underlying EAPs, the major rationale and impetus usually involves the organization’s concerns about the costs, absenteeism and loss of productivity associated with mental health problems and abuse of alcohol and drugs. These goals are substantially different from the traditional goals of health practitioners, since they take into consideration the goals of the organization as well as the needs of the patient.
When employers pay directly for the services, and services are provided at the worksite, professionals delivering services must, by necessity, take into account the organizational goals of the employer and the specific culture of the workplace involved. Programmes may be framed in terms of “bottom line impact”; and compromises on goals for health services may need to be made in the face of cost containment realities. The choice of action recommended by the professional may be influenced by these considerations, sometimes presenting an ethical dilemma as to how to balance what would be best for the individual worker with what would be most cost-effective for the organization. Where the professional’s primary responsibility is managed care with a stated goal of cost containment, conflicts may be exacerbated. Considerable caution must therefore be exercised in managed care approaches to ensure that health care objectives are not compromised by efforts to limit or reduce costs.
Which employees are entitled to EAP services, which types of problem should be considered and should the programme be extended to family members or retirees? It would appear that many decisions are based not on the stated intent of improved health but rather the limit of benefit coverage. Part-time staff who have no benefit coverage tend not to have access to EAP services so that the organization does not have to pay additional costs. However, part-time staff may also have problems which affect performance and productivity.
In the trade-off between quality care and lowered costs, who should decide how much quality is required and at what price—the patient, who uses the services but is not accountable for the payment or price, or the EAP gatekeeper, who does not pay the bill but whose job may depend upon the success of the treatment? Should the provider or the insurer, the ultimate payer, take the decision?
Similarly, who should decide when an employee is expendable? And, if insurance and treatment costs dictate such a decision, when is it more cost-efficient to fire an employee—for example, because of mental illness—and then recruit and train a new employee? More discussion of the role of occupational health professionals in addressing such decisions is certainly warranted.
Voluntarism or coercion?
The ethical problems created by unclear client allegiance are immediately evident in EAPs. Most EAP professionals would argue from their clinical training that their legitimate focus is the individual for whom they are the advocates. This concept depends on the notion of voluntarism. That is, the client seeks out assistance voluntarily and consents to the relationship, which is maintained only with his or her active participation. Even where the referral is made by a supervisor or management, the argument is made that participation is still fundamentally voluntary. Similar arguments are made for health promotion activities.
This contention of EAP practitioners that clients are operating on their own free will often falls apart in practice. The notion that participation is entirely voluntary is largely an illusion. Client perceptions of choice are sometimes much less than proclaimed, and supervisory referrals can well be based on confrontation and coercion. So are the majority of so-called self-referrals, which occur after a strong suggestion has been given by a powerful other. While the language is one of choice, it is clear that choices are indeed limited and there is only one right way to proceed.
When health care costs are paid by the employer or through the employer’s insurance, the boundaries between public and private life become less distinct, further increasing the potential for coercion. The current ideology of programmes is one of voluntarism; but can any activity be completely voluntary in the work setting?
Bureaucracies are not democracies and any so-called voluntary behaviour in organizational setting is likely to be open to challenge. Unlike the community setting, the employer has a fairly long term contractual relationship with most employees, which in many cases is dynamic with the possibility of raises, promotions, as well as overt and covert demotions. This may result in deliberate or inadvertent impressions that participation in a particular active preventive programme is normative and expected (Roman 1981).
Health education too must be cautious about claims of voluntarism as this fails to recognize the subtle forces which have great potency in the workplace on shaping behaviour. The fact that health promotion activities receive considerable positive publicity and are also provided free of cost, can lead to the perception that participation is not only supported but highly desired by management. There may be expectations of rewards for participation beyond those related to health. Participation may be seen as necessary to advancement or at least to maintaining one’s profile in the organization.
There may also be a subtle deception on the part of management, which promotes health activities as part of its sincere interest in the well-being of staff, while burying its real concerns related to cost containment expectations. Overt incentives such as higher insurance premiums for smokers or overweight employees may increase participation but at the same time be coercive.
Individual and collective risk factors
The overwhelming focus of work-based health promotion on individual lifestyle as the unit of intervention distorts the complexities underlying social behaviours. Social factors, such as racism, sexism and class bias, are generally overlooked by programmes which focus solely on changing personal habits. This approach takes behaviour out of context and assumes “that personal habits are discrete and independently modifiable, and that individuals can voluntarily choose to alter such behaviour” (Coriel, Levin and Jaco 1986).
Given the influence of social factors, what is the true extent to which people have control over modifying health risks? Certainly behavioural risk factors do exist, but the effects of social structure, the environment, heredity or simple chance must also be taken into account. The individual is not solely responsible for the development of disease, yet this is precisely what many work-site health promotion efforts assume.
A health promotion programme in which individual responsibility can be overstated, leads to moralizing.
Although personal responsibility is undeniably a factor in smoking for example, social influences such as class, stress, education and advertising are also involved. Deeming that only individual factors are causally responsible facilitates blaming the victim. Employees who smoke, are overweight, have high blood pressure, and so on, are blamed, albeit sometimes implicitly, for their condition. This absolves the organization and society from any responsibility for the problem. Employees may be blamed both for the condition and for not doing something about it.
The tendency to assign responsibility solely to the individual ignores a large body of scientific data. Evidence suggests that the physiological sequelae of work may have an impact on health which continues after the workday is done. It has been widely demonstrated that linkages between organizational factors (such as participation in decision making, social interaction and support, pace of work, work overload, etc.), and health outcomes, particularly cardiovascular disease, exist. Implications for organizational interventions, rather than or in addition to individual behaviour change, are quite clear. Nonetheless, most health promotion programmes aim to change individual behaviour but rarely consider such organizational factors.
The focus on individuals is less surprising when it is recognized that most professionals in health promotion, wellness and EAP programmes are clinicians who do not have a background in occupational health. Even when clinicians do identify workplace factors of concern, they are seldom equipped to recommend or carry out organizationally oriented interventions.
Diverting attention from health protection
Rarely have wellness programmes proposed interventions in the corporate culture or included alterations in work organization such as stressful management styles, the content of boring work or noise levels. By ignoring the contribution of the work environment to the health outcomes, popular programmes such as stress management may have a negative impact on health. For example, by focusing on individual stress reduction rather than altering stressful working conditions, workplace health promotion may be helping workers to adapt to unhealthy environments and in the long term increasing disease. Moreover, the research conducted has not provided much support for the clinical approaches. For example, in one study, individual stress management programmes had smaller effects on catecholamine production than did the manipulation of pay systems (Ganster et al. 1982).
In addition, Pearlin and Schooler (1978) found that while various problem-solving, coping responses were effective in one’s personal and family life, this type of coping is not effective in dealing with work-related stressors. Other studies further suggested that some personal coping behaviours actually increase distress if applied in the workplace (Parasuramen and Cleek 1984).
The advocates of wellness programmes are generally uninterested in the traditional concerns of occupational health and, consciously or otherwise, turn attention away from workplace hazards. As wellness programmes generally ignore the risk of occupational disease or hazardous working conditions, health protection advocates fear that individualizing the problem of employee health is an expedient way for some companies to deflect attention from costly but risk-reducing changes in the structure and content of workplace or jobs.
Employers sometimes feel they have the right to have access to clinical information about workers who receive services from the professional. Yet the professional is bound by the ethics of the profession and by the practical need to maintain the trust of the worker. This problem becomes particularly troublesome if legal proceedings are at issue or if the problem at hand is surrounded by emotionally charged issues, such as disability from AIDS.
Professionals may also become involved in confidential issues related to the employer’s business practices and operations. If the industry in question is highly competitive, the employer may wish to keep secret such information as organizational plans, reorganizations and downsizing. Where business practices may have an impact on the health of employees, how does the professional prevent the occurrence of such adverse effects without jeopardizing the proprietary or competitive secrets of the organization?
Roman and Blum (1987) argue that confidentiality serves to protect the practitioner from extensive scrutiny. Citing client confidentiality, many oppose quality review or peer case review, which might reveal that the practitioner has exceeded the bounds of professional training or expertise. This is an important ethical consideration given the power of the counsellor to influence the health and well-being of clients. The issue is the need to clearly identify for the client the nature of the intervention in terms of what it can or cannot do.
The confidentiality of information collected by programmes which focus on individuals rather than systems of work may be prejudicial to the worker’s job security. Health promotion information can be misused to influence the employee’s status with health insurance or personnel issues. When aggregate data are available, it may be difficult to ensure that such data will not be used to identify individual employees, especially in small work groups.
Where the clinical utilization patterns of the EAP draw attention to a particular work unit or site, practitioners have been loath to bring this to management’s attention. Sometimes the citation of confidentiality issues in reality masks an inability to make reasonable recommendations for intervention due to fears that management will not be receptive to negative feedback about their behaviour or organizational practices. Unfortunately, clinicians sometimes lack the research and epidemiological skills which allow them to present solid data in support of their observations.
Other concerns relate to the misuse of information by a variety of different interest groups. Insurance companies, employers, trade unions, client groups and health professionals may misuse both collective and individual information gathered in the course of a health promotion activity.
Some may use data to deny services or coverage to employees or their survivors in legal or administrative proceedings dealing with compensation or insurance claims. Participants in programmes may believe that the “guarantee of confidentiality” provided by such programmes is inviolate. Programmes need to clearly advise employees that under certain circumstances (i.e., legal or administrative inquiries) personal information gathered by the programme may be made available to other parties.
Aggregate data may be misused so as to shift the burden from one party to another. Access to such information may not be equitable, in that collective information may be available only to organizational representatives and not those individuals seeking benefits. While releasing data on workers focusing on the individual lifestyle contributions to a condition, organizations may be able to restrict information about corporate practices which also created the problem.
Epidemiological data about patterns of conditions or work-related factors should not be gathered in such a manner as to facilitate exploitation by the employer, the insurer, the compensation system or by the clients.
Conflict with other professional or service standards
Professional standards and values may be in conflict with practices already in place in a given organization. Confrontational methods used by occupational alcoholism programmes may be unproductive or in conflict with professional values when dealing with other disorders or disabilities, yet the professional working in this context may be pressured to participate in the use of such methods.
Ethical relationships with outside providers must also be considered. While EAPs have clearly articulated the need for practitioners to avoid referrals to treatment services with which they are closely affiliated, health promotion providers have not been as resolute in defining their relationships with external providers of services that may be attractive to employees for personal lifestyle counselling. Arrangements between EAPs and particular providers which lead to referrals to treatment based on economic advantages to the providers rather than clinical needs of clients present an obvious conflict of interest.
There is also the temptation to engage unqualified individuals in health promotion. EAP practitioners do not normally have the training in health education techniques, physiology or fitness instruction to qualify them to provide such activities. When programmes are provided and administered by management and cost is of primary concern, there is less motivation to scrutinize skills and expertise and to invest in the best qualified professionals, as this will change the cost-benefit outcomes.
The use of peers to provide services raises other concerns. It has been shown that social support from one’s co-workers could buffer the health effects of certain job stressors. Many programmes have capitalized on the positive influence of social support by the use of peer counsellors or self-help support groups. However, while peers can be used as a supplement to some extent, they do not eliminate the need for qualified health professionals. Peers need to have a strong orientation programme, which includes content on ethical practices and not exceeding one’s personal limits or qualifications whether overtly or through misrepresentation.
Drug screening and testing
Drug testing has become a quagmire of regulations and legal interpretation and has not proven to be an effective avenue to either treatment or prevention. The recent report from the National Research Institute (O’Brien 1993) has concluded that drug testing is not a strong deterrent to alcohol and drug abuse. Further evidence suggests that it does not have a significant impact on work performance.
A positive drug test may reveal much about an employee’s lifestyle but nothing about his or her level of impairment or ability to perform work.
Drug testing has been seen as the thin edge of the wedge with which employers drive out all but the most invulnerable employee—the super-resilient person. The trouble is how far does the organization go? Can one test for compulsive behaviours such as gambling or for mental disorders, such as depression?
There is also a concern that organizations may use screening to identify undesirable traits (e.g., predisposition to heart disease or back injury) and to make personnel decisions based on this information. At present this practice appears to be limited to health insurance coverage, but how long can it be resisted by management attempting to reduce cost?
The government-stimulated practice of screening for drugs, and the future possibility of screening for defective genes and excluding whole classes of high-cost employees from health insurance coverage, advances the old presumption that characteristics of workers, not work, explain disabilities and dysfunctions; and this becomes a justification for making workers bear the social and economic costs. This leads again to a perspective in which factors based on the individual, not work, become the focus of health promotion activities.
Exploitation by the client
On occasion it may be clear to the professional that workers are attempting to take improper advantage of the system of services provided by an employer or by its insurance carrier or by workers’ compensation. Problems may include clearly unrealistic rehabilitation demands or outright malingering for financial gain. Appropriate methods of confronting such behaviour, and for taking action as needed, have to be balanced against other clinical realities, such as psychological reactions to disability.
Promotion of activities with questionable effectiveness
Despite the broad claims for worksite health promotion, the scientific data available to evaluate them are limited. The profession as a whole has not addressed the ethical issues of promoting activities which do not have a strong scientific support, or of choosing to engage in services which produce more revenue rather than focusing on ones which have a demonstrated impact.
Ironically, what is being sold is based upon little conclusive evidence of cost reduction, decreased absenteeism, reduced health care expenditures, reductions in employee turnover or increased productivity. Studies are poorly designed, seldom having comparison groups or long-term follow-up. The few that meet the standards of scientific rigour have provided little evidence of a positive return on investment.
There is also some evidence that the participants in worksite health promotion activities tend to be relatively healthy individuals:
Overall it appears participants are likely to be nonsmokers, more concerned with health matters, perceive themselves in better health, and be more interested in physical activities, especially aerobic exercise, than nonparticipants. There is also some evidence that participants may use less health services and be somewhat younger than nonparticipants (Conrad 1987).
Individuals at risk may not be using the health services.
Even where there is evidence to support particular activities and all of the professionals agree on the necessity for such services as follow-up, in practice services are not always provided. Generally EAPs concentrate on finding new cases while devoting little time to workplace prevention. Follow-up services are either non-existent or limited to one or two visits after return to work. With the chronic relapse potential of alcohol and drug cases, it would appear that EAPs are not devoting energies to continuing care, which is very costly to provide, but rather emphasize activities which generate new revenues.
Health examinations for insurance purposes and determination of benefits
Just as the boundary between private life and work factors affecting health has become increasingly blurred, so too has the distinction between fit and unfit or healthy and sick. Thus instead of examinations for insurance or benefits focusing on whether or not a worker is ill or disabled, and therefore “deserving” of benefits, there is an increasing realization that with workplace changes and health promotion activities, the worker, even with his or her illness or disability, can be accommodated. Indeed “adaptation of work to the capabilities of workers in the light of their state of physical and mental health” has been enshrined in the ILO Occupational Health Services Convention, 1985 (No. 161).
The linking of health protection measures and health promotion activities is nowhere as important as it is in addressing workers with special health needs. Just as an indexed patient may reflect pathology in a group, a worker with special health needs may reflect needs in the workforce as a whole. Alteration of the workplace to accommodate such workers very often results in improvements in the workplace that benefit all workers. Providing treatment and health promotion to workers with special health needs may decrease costs to the organization, by containing insurance or workers’ compensation benefits; more importantly, it is the ethical way to proceed.
In recognition that prompt rehabilitation and accommodation of injured workers is “good business,” many employers have introduced early intervention, rehabilitation and return to modified work programmes. Sometimes these programmes are offered through workers’ compensation boards, which have come to realize that both the employer and the individual worker suffer if the benefit system provides an incentive to maintain “the sick role,” rather than an incentive towards physical, mental and vocational rehabilitation.
The International Code of Ethics for Occupational Health Professionals (reprinted in this chapter) provides guidelines to ensure that health promotion activities do not divert attention from health protection measures, and to promote ethical practice in such activities. The Code states:
Occupational health professionals may contribute to public health in different ways, in particular by their activities in health education, health promotion and health screening. When engaging in these programmes, occupational health professionals must seek the participation ... of both employers and workers in their design and in their implementation. They must also protect the confidentiality of personal health data of the workers.
Finally, it is necessary to reiterate that the ethical practice of occupational health could best be promoted by addressing the workplace and societal infrastructure that must be designed to promote the interests of both the individual and the collective. Thus stress management, health promotion and EAPs, which until now have focused almost exclusively on individuals, must address institutional factors in the workplace. It will also be necessary to ensure that such activities do not displace health protection measures.