Sot. Sci. .Ued. Vol. 23. No. 8, pp. W-796, 1986 0277.9j36,96 53.00 + 0.

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Printed in Great Britain. All rights reserved Copyright E 1986 Pergamon Journals Ltd

DIVIDED LOYALTIES IN MEDICINE: THE

AMBIVALENCE OF OCCUPATIONAL MEDICAL PRACTICE
DIANA CHAPMANWALSH
Boston University Health Policy Institute, 53 Bay State Road, Boston, MA 02215, U.S.A.

Abstract-This paper develops two divergent views of occupational medicine. The first holds that the field
has a major contribution to make in the prevention of disease and the stabilization of health care costs.
The second sees in it all the worst characteristics of contemporary medical practice. Consideration of the
special difficulties of occupational physicians raises fundamental questions about the divided loyalties and
moral conflicts that will increasingly beset the general practice of medicine as bureaucratic forms and
controls continue to proliferate.

Key words-corporate occupational medicine, company doctors

Occupational medicine invites ambivalence. From
one perspective it is a medical discipline whose time
has finally arrived, the ideal platform from which to
launch the “second public health revolution” [ 11,and
to inject needed order and discipline into the nation’s
fragmented and expensive health care system. From
another perspective, industrial physicians stand hope-
lessly mired in grievous moral conflict, responsible
but powerless, divested of the essential symbols of a
physician’s social status, and emblematic of the dete-
riorating future for medicine-the last of the indepen-
dent professions-as it succumbs to the bureaucratic
imperative [2]. This paper juxtaposes those two
starkly divergent perspectives on the discipline of
occupational medicine, in order to bring into focus a
tension between what is and what might be. It argues
that basic conflicts are structured into the corporate
physician’s role and that the special case of
occupational practice raises fundamental questions
about the more generic issue of divided loyalties in
medicine.
THE CASE FOR OCCUPATIONALMEDICINE
The affirmative case for occupational medicine
rests on five major propositions. First, the discipline’s
avowed function of conserving health is winning
acceptance in academic medicine and health policy. A
growing body of scholarly research and govern-
mental directive has hammered home the message
that broad patterns of morbidity and mortality will
not yield in the future to medical care per se, but need
instead to be addressed through efforts aimed at
behavioral modification and environmental en-
gineering [3]. Over 100 million Americans (nearly
60% of the total adult non-institutionalized popu-
lation, male and female) spend over one-quarter of
their lives in civilian workplaces outside the home [4].
The work experience, both physical and psycho-
logical, is known to affect their health in complex
ways, while the workplace, as an elaborate socio-
technical system, offers powerful mechanisms for
789
public health interventions, directed at individuals or
the environment.
A new public health revolution?
Individuals are a target because of the role per-
sonal behavior plays in premature mortality and
chronic disability. The fact in modern industrial
societies that alcohol, cigarettes, diet, accidents, and
stress contribute to or actually cause the great pre-
ponderance of deaths and disabling injuries or dis-
eases striking the young and middle aged [3. j] creates
an unusual opportunity in occupational medicine for
conserving health among the age groups and social
classes represented by wage earners, if they can be
persuaded to modify harmful habits. The fact that
employers have at their disposal the whole range of
change strategies, from education and peer pressure
to incentives and outright coercion [6], makes the
worksite an intuitively appealing location for at-
tempting the persuasive task.
The environment is the preferred target for main-
stream public health because environmental protec-
tion can be carried out without the individual’s
cooperation. Winning active participation in lifestyle-
oriented health promotion programs can be a chal-
lenge and, if incentives are used, may tend to blame
the victim [7]. The working environment lends itself
to social (or ‘passive’) interventions which require
little or no individual initiative. Most workers are
exposed to some kind of occupational health hazard:
biological, physical or chemical agents (including
carcinogens), ergonomic or psychosocial factors,
such as “job-related pressures of noise, crowding,
stress, or boredom, which can have adverse psycho-
logical effects” [3]. Amid considerable debate over the
dimensions of the occupational health problem (and
especially the cancer problem) the annual toll from
occupational illness is ‘probably much greater’ than
the 100,000 deaths and 400,000 new cases reported by
the National Institute of Occupational Safety and
Health [4]. Workplace exposures may account for
some 5% of all cancer deaths (20,000 per year), a
figure which, even though reduced from earher esti-
790 DIASACHAPMAS
mates, still signals a major public health issue [8].
The limited statistics point to a problem, but as
well to an opportunity, relatively rare in medicine, to
intervene early enough among a sizeable population
to actually prevent the onset of a significant burden
of disease. Job-related diseases develop in man-
created environments; they are preventable. Work-
places provide relatively manageable settings for pub-
lic health intervention to break the chain of causality.
The populations exposed are (or could be) quite
precisely defined, the exposures are (or could be)
closely monitored and measured, the results of those
exposures are (or could be) relatively easily tracked,
compared to other more diffuse environmental health
hazards. When the workplace is viewed as an ‘early
warning system,’ where workers are exposed in-
tensively to substances destined for wider use, then
protecting workers is the first step towards protecting
the wider public.
While public health specialists in government and
academia define the workplace as an enticing target
of opportunity, they do so from the outside looking
in. Yet real progress in occupational health will often
require costly changes in the design of work. Full-
time corporate physicians, with good access to senior
managers, should in theory be better situated than
outsiders to influence corporate decisions. Within the
firm, physicians should, again in theory, be the health
professionals with the greatest leverage [9]. Physicians
in general have higher social standing than other
health professionals such as industrial hygienists, or
nurses; some are able to draw on this external social
status to augment their formal authority in the
organizational hierarchy [lo].
The first proposition in the case for corporate
occupational medicine, then, is that the health needs
of the general population are being redefined so as to
establish the basic rationale for revitalizing or expan-
ding the medical presence within the corporation.
This rationale rests principally on disciplines kindred
to medicine-epidemiology, public health, and
health policy. But if the scenario is to be plausible and
not merely desirable, economics and management
policy must also lend their support.
Legal incentices for corporate investments in health?
Thus, the second proposition in the case for oc-
cupational medicine holds that economic incentives
to invest in the profession’s ‘product’ are being
bolstered by external pressures on the business firm.
Trends in regulation, litigation, and third-party
financing of health services are seen as incentives for
corporations to invest in programs to conserve their
employees’ health.
Among the many federal regulatory programs en-
acted in the 1970s the Occupational Safety and
Health Act was the watershed for occupational
health personnel. some of whom jokingly suggested
that OSHA’s acronym actually meant “Our Savior
Has Arrived.” Despite a highly politicized, difficult
first decade, followed by a retrenchment from regu-
lation during the Reagan administration, the 1970
OSHA statute has symbolized and supported a cli-
mate of opinion favorable to worker health protec-
tion. While federal enthusiasm for ‘command and
control regulations’ [I I] waxed and (now) wanes,
W.ALSH
state legislatures, the public, organized labor. and the
mass media are expected in this case for occupational
medicine to continue their insistence on corporate
accountability for protecting emplovees’ health and
for generating and disseminating -information on
exposures to risks
Legal pressures are felt not only through formal
statutory obligations, but also through the state-run
workers’ compensation systems. as well as through
protracted grievance proceedings and litigation in the
courts. The ideal public policy for occupational
health would require employers to pay fully for the
consequences of inadequate protection. so that they
would feel a direct incentive to prevent the onset of
disease. But the longer latent periods and ambiguous
etiology of much occupational illness frustrates the
straightforward policy goal of internalizing the costs.
Deliberately, or even at times unknowingly, employ-
ers can and do shift these costs on to the government,
other employers, third-party payers, or the employee
when he or she leaves that employer. is fired, laid-off
or retired before evidence has developed of an oc-
cupational exposure’s effect. For this and other rea-
sons, workers’ compensation has been an un-
satisfactory policy tool, especially in dealing with
illnesses with long latency periods 1121.Nevertheless,
a few firms and some entire industries-asbestos is
the prime example-are now widely-known to have
suffered serious financial setbacks because of failure
in the past to protect the health of workers involved
with their products. Years will be spent in the courts
disentangling the asbestos tragedy. But an obvious
interim lesson is to anticipate and avoid a recurrence
in the future. It would be naive to think that Amer-
ican industry will-unanimously and unilaterally-
heed that lesson, but it would be equally facile and
probably wrong to assume the reverse. Asbestos will
likely have an impact, whether direct or indirect, as
did ‘phossey jaw,’ ‘radium jaw,’ the Gauley Bridge
disaster, kepone and vinyl chloride. All of those
episodes served to arouse public opinion; all
influenced national policies that eventuated in more
rigorous protection.
Economic pressures
Behind the legal and regulatory pressures is the
threat of economic costs. Economics are at the
forefront of the third source of pressure on the health
and safety programs of large corporations. These are
pressures associated with the problem of health insur-
ance costs. Industry’s growing involvement in the
financing of medical care has been both cause and
effect of escalating health care costs. Corporations’
expenditures for employee health benefits have been
increasing by as much as 40% a year, faster than the
cost of labor or other costs of production, so that in
the share it constitutes of total payroll expenses,
health insurance is growing out of proportion to
wages, pensions and other employee benefits.
The increasing expense of providing employees a
virtually blank check with which to purchase medical
care in the community raises questions about the
services industry provides and pays for in-house.
Would it be feasible to elaborate the company’s
in-house services for employees (and perhaps also
dependants) in a manner that would offset some of
 Divided loyalties
the costs they now generate in the outside medical
care system [13, 14]? ‘Non-occupational’ health care
has been the private practitioner’s exclusive domain
and many corporate physicians still carefully insist
that they generate more business for the outside
practitioner than they take away. But industry’s
growing financial participation in the health care of
employees and their dependants may give the spe-
cialty of occupational medicine new license in pri-
mary care. Some companies have expanded their
corporate physicians’ roles, either as clinicians or as
managers overseeing the work of other clinicians,
inside the company and outside [lS].
The corporation’s internal rhetoric
The fourth important proposition underlying the-
optimistic scenario for occupational medicine stresses
changes in the business-society relationship since
about the 1950s that are presumed to have reshaped
the priorities and prevailing values of the modern
corporation. This thesis rests on elaborations of the
notion of ‘post-industrial society’ [16], and a funda-
mental ‘discontinuity’ [ 171with earlier historical peri-
ods in the pace and the ubiquity of change. Ansoff
catalogues the “novel, unexpected. .,. and far-
reaching challenges” to managers: “inflation, grow-
ing governmental constraints, dissatisfaction of
consumers, invasion by foreign competitors, tech-
nological breakthroughs, changing work habits” [ 181.
The social legitimacy of post-industrial business
has come under attack [19] and public disaffection
has gradually penetrated the attitudes of at least some
modem business managers, who have come to accept
much broader obligations not only to curtail activ-
ities involving social costs but also to initiate new
activities to produce social benefits [18]. Irving Sha-
piro, former chairman of DuPont, places employee
health at the top of the list of a corporation’s social
obligations:
“It may sound like a homily, but corporate responsibility
does begin at home.. perhaps there is no better method of
evaluating a company’s sense of responsibility than to look
at its programs in occupational health and safety. . . . Few
subjects affect people’s lives more directly or arouse greater
interest” (201.
Another important contention of the ‘post-
industrial’ thesis is that technology becomes more
intellectual than mechanical, requiring more special-
ists or ‘knowledge workers’ to tend the engines of
production [21]. A more specialized worker is more
expensive to replace, which should strengthen the
incentives for management to conserve this human
capital. Meanwhile, more highly educated workers
demand individual rights within the corporation and
investments in their own ‘human capital,’ represented
by both education and health services [22]. Evidence
of these trends can be found in the proliferation of
‘employee assistance programs,’ originally designed
to coax problem-drinking employees into treatment,
now commonly offering help with the whole spectrum
of coping problems-parenting, marital relations,
finances, and so on [23]. There are important counter-
arguments to the proposition that corporations are or
will be increasingly solicitous of the needs of their
in medicine 791
employees [ 11. 211, but the case for occupational
medicine needs it to be true.
The ferment in medicine
The fifth and final proposition supporting the case
for an expansion of occupational medicine presumes
that basic changes now taking place in the medical
profession will favor the corporate practitioner. Gone
is the self-sufficient solo practitioner against whose
idealized image the company doctor stood in stark,
invidious contrast. Rare is the practicing physician
who can claim to have pure relations with his pa-
tients, uncomplicated by third-party intrusions and
other conflicts of interest [2, 251. Beyond the outside
influences of insurance carriers and the government,
and the bureaucratic demands of hospitals and other
institutional care settings, are the basic contradictions
within medicine itself, where half-way technologies
[26] in an era of chronic degenerative disease have
written for medicine a crowded agenda of painful
choices concerning when and how to begin and end
life, regulate behavior, and ration scarce resources.
Seen in this light, the ethical conflicts that have
plagued occupational medicine lose some of their
glare. The prospect of an overabundance of physi-
cians in the years just ahead makes it all the more
plausible that physicians in training may look more
favorably than they have in the past on one of the few
specialties believed genuinely in need of new recruits
v71.
The optimistic case for occupational medicine
builds on the implicit assumption that major trans-
formations favorable to the profession are taking
place in the two major sectors it spans. Both include
shifts from an individual to a collectivity orientation:
the corporation’s shift from an ‘economizing’ to a
‘sociologizing’ mode, in Bell’s lexicon, and medicine’s
shift from a personal, curative mission to a “recog-
nition that improvement in health is likely to come in
future, as in the past, from modification of the
conditions which lead to disease, rather than from
intervention in the mechanisms of disease after it has
occurred” [28]. The validity and permanence of these
tendencies can be debated. and certainly they are
more prominent in some industries and firms than in
others. But their importance for the future of cor-
porate occupational medicine seem incontrovertible.
The best-case scenario amounts to a blueprint for
what might be.
ASOTHER SCENARIO: THE WORST CASE
The pessimistic scenario begins with the reality that
less than 1% of all United States physicians are
employed full time in occupational medicine. a pro-
portion which seems to have declined slightly over the
past two decades, although valid statistics are elusive.
Since the availability of statistics on a phenomenon
is one measure of its perceived importance, the dearth
of data on occupational health manpower can be
read as evidence of the specialty’s orphan status. An
imperceptible number of the roughly 10,000 physi-
cians who graduate each year from medical school go
directly into occupational practice, and the few avail-
able residency training opportunities often go
unfilled. Some 4000 practicing physicians define their
791 Dr~sa CHAPMA?; WALSH

primary specialty as occupational medicine. Dis- control over the formulation of policies, the design of
cussing this manpower deficit, one radical critique of programs and the allocation of resources.
occupational medicine some years ago telegraphed its
findings in the sardonic subtitle, “Suppose They Gave The dilemma of ‘dirty work’
a Profession and Nobody Came” [29]. The third and most serious issue for occupational
medicine revolves around the problem of ‘dirty
work.’ Hughes [36] observed that every occupation
Problems of prestige and challenge has certain dirty work that must be done and that
The critics find no surprise in the shortage of those who do it are isolated from the occupational
physicians willing to embark on careers in a low- mainstream, so as to exonerate the ‘good people’
prestige specialty, neglected in medial school curric- from responsibility for the dirty work carried out in
ula and postgraduate training programs, isolated in their midst. This may provide a clue to the historical
an out-of-the-way niche of medicine, concerned with isolation of industrial physicians.
environmental hazards and routine treatment of job- One kind of dirty work from which the profession
related illnesses and disability, or ‘finger-wrapping.’ of medicine needs to distance itself, in order to
Testimony to the tedium was provided by Ernest protect the patient-oriented value system it projects
Hemingway’s son, an industrial physician in New to win public trust, is ‘social control’ work. Parsons
York City, who said in a 1976 New York Times article [37] recognized that social control is an integral
that he left the field because “the work was necessary function of medicine, especially where more direct
but dull” [30]. “Lack of intellectual challenge” was political and legal sanctions cannot be invoked. Med-
one factor cited in a survey of medical students to icine has “an officially-approved monopoly on the
discount public health or preventive medicine as right to define illness” [33], and illness, once legiti-
attractive career options. Other considerations in- mized, confers on the sick person privileges and
clude an “uncongenial subject matter,” ‘*little per- exemption from normal social responsibilities. “The
sonal contact with patients,” and “slow or uncertain physician often serves as a court of appeal, as well as
benefits to patients” [31]. a direct legitimizing agent” [37], hence the problem of
Another related problem is that full-time prac- social control. to which the institution of medicine
titioners of corporate occupational medicine are ‘job- responds with the ideological position that the indi-
holders,’ a term Halberstam attributes to H. L. vidual patient’s welfare always come first in the
Mencken, together with the observation that “the ethical clinician’s mind.
essence of a professional man is that he is answerable But the structure of corporate medicine removes
for his professional conduct only to his professional this ideological veil, The industrial physician’s clear
peers. A physician cannot be fired by anyone, save accountability not only to an individual patient, but
when he has voluntarily converted himself into a also to a corporate employer, brings this social
jobholder” [32]. Seven out of eight of the respondents control role into full view [38]. He may be called
in the survey of medical students’ career aspirations upon, for example, to make a medical determination
reported a preference for fee-for-service or unsalaried on which will hinge the decision whether or not an
practice. Reasons most frequently given for the employee will receive some kind of ‘secondary gain’
rejection of salaried status were fear of restrictions [37] (such as early retirement with disability pay-
and limitations on practice, unsatisfactory ments) or suffer some kind of penalty (such as
physician-patient relationships, little variety in reassignment to a less desirable job, or outright
cases, and “chances for advancement determined by termination). Allegations have been made that em-
others” [31]. ployers have on occasion altered a worker’s job status
Close behind the terms and actual content of work, on fictional medical grounds [39]. Even without this
the second item in the case against occupational clear breach of the profession’s ethical code, cor-
medicine is its deviation from the ideal of an auton- porate physicians’ necessary involvement in the appli-
omous, self-employed, free profession. In extended cation of a medical yardstick to decisions in the
analyses of the profession of medicine, Friedson employment context places them in a situation, un-
[33-351 emphasizes the dominant position physicians like that of orthodox private practitioners, where
have had in the division of labor (they “give orders they have “coercive sanctions at [their] command”
to all and take orders from none”), and the control [37]. These are the situations which typically give rise
they have had in determining the substance of their to the complaints on the part of union spokesmen or
work. Corporate physicians’ inability to exercise representatives of advocacy groups that corporate
either dominance or control to the degree that outside physicians are :‘indentured” [40] that they “fail to
physicians do may in part account for the absence in make common cause with the worker,” and are
the corporate culture of the high social status that “tools of the boss” [41], and that the “ghettoized
most community physicians automatically enjoy. company doctor system” [42] ought to be entirely
Another factor accounting for lack of prestige may replaced with one in which the physician serves at the
be termed the specialty’s strategic burden. This is the behest of the employee, not the employer [43,44].
obverse of the strategic market advantage-standing
between the buyers and sellers of health care-to Cooling out or helping to cope?
which Starr traces the extraordinary “social privilege, In these situations, the conflict sits close to the
economic power and political influence ” enjoyed by surface. A deeper problem in the case against oc-
modem American medicine [35]. Corporations stand cupational medical practice-still related to social
between occupational physicians and their potential control and role conflict-arises from the possibility
markets; companies are in a position to exert decisive that the only moral justification for anything less
 Divided loyalties in medicine
than full protection of an individual employee’s
health is the utilitarian calculus. foreign to the clinical
ideal. of a greater good for a greater number: the
unemployment or the loss of a socially-useful product
that could result from closing a high-risk industrial
operation. A poignant articulation of this perspective
was offered by a victim of angiosarcoma, a rare liver
disease associated with occupational exposure to
vinyl chloride. Approaching death, Pete Gettlefinger
interpreted his own fate in a utilitarian framework:
“I think about this a lot-it’s helped me a whole lot-the
fact that we got 6500 guys in the United States makin’ a
livin’ workin’ with polyvinyl chloride in the form I was usin’
it in. And I’ll bet you we’ve got a million that are makin’
a livin’ in plastics. And I feel that our industry must
survive. It has economically given millions of people
things that they couldn’t have. If it wasn’t for plastics, now,
the price of wood would be so expensive that the average
man couldn’t afford to have a rockin’ chair like this one.
And, yet. that’s killin’ people. It may kill me. Look how
much safer it’s made an automobile or at the safety features
in the home. So far now they only got twenty-eight dead. .
It’s so important for the industry to survive-for
employees that work with it. You’ve got to look at every-
one’s viewpoint. 1 can’t say that I’m one of the lucky guys,
but I must say that as long as we have put products on the
market that has helped the average person economically-
that must be weighed against all that’s bad too” [45].
Even if the good should outweight the bad in this
balancing of incommensurables, the risk falls inequi-
tably on a subset of all those who may enjoy the
benefit. In this context, occupational medical pro-
grams can be conceived, cynically perhaps but not
unreasonably, as serving the function of “cooling out
the mark”? in Goffman’s [46] brilliant metaphor.
Cooling out the mark involves an effort “to keep the
anger of the mark” (the victim of a confidence game)
‘.within manageable and sensible proportions.” This
is accomplished by guiding him to a definition of the
situation that “makes it easy for him to accept the
inevitable and quietly go home. The mark is given
instruction in the philosophy of taking a loss” [46].
Gettlefinger spoke like a mark who had been cooled
out. and the account of his final months makes clear
that his equanimity came in large part from his
conviction that “I’ve got the best [doctors] doin’ their
best. What else could they do?” [45].
Other than by Marxists, the employment re-
lationship tends not to be conceived as a confidence
game, but Goffman’s very point is that the cooling
out process occurs in a wide variety of ordinary
interactions. “Persons who participate in what is
recognized as a confidence game are found in only a
few social settings, but persons who have to be cooled
out are found in many. Cooling the mark out is one
theme in a very basic social story” [46]. Goffman’s
genotype is the situation where the mark’s self-
conception or expectations can no longer be sus-
tained: in courtship or ‘de-courting,’ the process by
which “one person in a marriage maneuvers the other
into accepting a divorce without fuss or undue
rancor;” in work situations, where “the process of
personnel selection requires that many trainees be
called but few be chosen;” in restaurants and de-
partment stores, whose hostesses, floorwalkers, and
complaint departments pacify deprived customers.
793
Most difficult of all because it strikes a ‘vital spot,’ is
the ultimate cooling out, “when a person must be
dissuaded from life itself’ [46].
To the extent that the cooline out task does fall to
the corporate physician, even-if only indirectly or
symbolically, it both violates basic notions about
medicine’s curative role (its manifest function) and
vulgarizes one of its most powerful latent functions,
countering what Powles calls “the existential threat
that disease poses to the individual” [47]. “Through
explanation, ritual, and symbols-those doctor-
patient interactions which do not alter the course of
events but which both parties nevertheless feel to be
worthwhile-the patient’s situation is defined, ambi-
guity is reduced and reassurance-as doctors call
it-results” [47]. A fine line separates Powles’s
“helping-to-cope” side of medicine, oriented toward
mitigating the patient’s worry and suffering, from
Goffman’s “cooling-out” side, oriented instead to-
wards deflecting the mark’s justified sense of outrage
to minimize his disruptiveness. Helping to cope serves
the patient; cooling out the operation (or the or-
the
ganization). But it is the need to draw this line, on a
case-by-case basis that creates many of the conflicts
in the corporate physician’s role.
In the pessimistic view of the role, cooling out is
and has long been its central task. The case against
occupational medicine rests, finally, on the past.
Nearly all critics of the profession invoke a history of
less than full or timely disclosure by employers of
known risks to which their workers were being
subjected, censorship by management of scientific
information that might have prevented deaths or
serious illnesses, and complicity by company doctors
in their employers’ abuses of power [39,48-501.
Seeking a reconciliation: the 1976 ethical code
The leadership in occupational medicine has been
mindful of the negative case. The discipline’s profes-
sional journals are full of essays examining the ‘com-
petence’ and ‘credibility’ [5 1, 521, ‘responsibilities’
[53,54], ‘ethical issues’ [55, 561, ‘duties’ (571, ‘di-
lemmas’ [58] and other such challenges [59] facing
their profession-issues like ‘whose agent’ the oc-
cupational physician is [60] and how to “assure that
the worker’s health is the occupational physician’s
primary concern” [61]. An undercurrent for nearly as
long as physicians have practiced in American indus-
try, this preoccupation reached an apotheosis in the
mid- 1970s as the sting of OSHA was beginning to be
felt.
The result was a code of ethics unusual in the
medical profession, whose specialty and sub-specialty
groups normally consider the American Medical
Association’s ethical codes adequate to their needs.
The American Occupational Medical Association’s
(AOMA’s) ethical committee, chaired by Norbert
Roberts, M.D., then corporate medical director of
Exxon Corporation, drafted a “Code of Ethical
Conduct for Physicians Providing Occupational
Medical Services” [62], adopted by the AOMA Board
in July 1976 and subsequently by the Board of the
American Academy of Occupational Medicine. The
code was promulgated because of the ambivalence of
occupational medicine: “to deal specifically with the
accusations of ethical misconduct leveled from time
794 DIANA CHAPMAN WALSH
to time against those who provide occupational
health services” [S].
In defining the problem thus, AOMA’s ethical
committee took on characteristics Wilensky [63] dis-
covered among occupational groups that are aspiring
to professional status. One view of AOMA’s ethical
code, then, is that it may reveal occupational
medicine-a subspecialty of the quintessential
profession-itself to be somehow less than fully
professionalized. Like other occupations striving for
professional status (librarianship, pharmacy, city
planning, hospital administration, advertising, fu-
neral direction) occupational medicine adopted an
ethical code without first passing through the series
of antecedent stages Wilensky identified as marking
the evolution of truly ‘established’ professions.
Wilensky’s seven stages are: (1) full-time practice of
the occupation; followed by (2) the establishment of
a training school and then; (3) a university curricu-
lum; (4) a local; and then (5) a national professional
association; (6) the passage of a state licensing law;
and finally (7) a formal code of ethics. When aspiring
occupations promulgate codes of ethics before ac-
complishing the six earlier tasks, as occupational
medicine has apparently done, the ethical codes func-
tion chiefly as a bid for respectability.
Without the structural underpinnings, these free
standing ethical codes put the onus on the individual
practitioner to follow a set of rules. Writings on
professional ethics in occupational medicine have
tended to emphasize personal qualities of the partic-
ular practitioner: his or her character, credibility,
competence, training, neutrality, allegiance, loyalty,
reputation, managerial skills, medical skills, com-
munication skills, his or her humanity. All of these
words and concepts echo in the literature on prob-
lems in occupational medicine. But seldom is the
connection made between these performance issues
(or rules) and questions of structure (or roles).
Some ethicists argue that when moral problems
seem irresolvable and debate becomes shrill, it is time
to abandon the quest for acceptable outcomes or
rules and to search instead for acceptable decision-
making processes or roles. The effect is to redefine the
issue as a structural one and to look for structural
solutions. This suggests another way to look at
AOMA’s ethical code (other than as a public re-
lations gesture). It can be seen as an effort on the part
of the specialty’s leaders to construct some structural
protections around a role that has been fluid and
ambiguous. The need for structural protections be-
comes clear when occupational medicine is placed in
the broader context of medicine more generally.
In this broader context, medical practice settings
can be arrayed along a simple hypothetical con-
tinuum,with organizational norms dominant at one
pole and professional norms at the other. On such a
continuum, the full-time practice of occupational
medicine falls near the organizational pole. For solo
or small group practice, even for highly bureaucratic
tertiary care institutions, the basic mission is patient
care, more or less attenuated by the survival demands
of the organization and its personnel. For the cor-
poration. by contrast, the basic mission is profit and
an ancillary medical mission has to be sold in man-
agement terms. In this simple conception, the profes-
sional pursues health and service, the corporation
profit, and the challenge for those seekine to protect
the patient’s interests is to structure the iituation so
that the professional’s norms will serve as a kind of
countervailing force within the organization. But that
conception may be tee simple in its idealization of the
professional norms of medicine.
A more complicated way to think about divided
loyalties in medicine is to ask not SO much whether
physicians in non-medical organizations do or do not
have enough influence or autonomy-whether their
norms are allowed to prevail-but rather whether the
structure of their situation reveals in ways normally
hidden from view the social or moral uses to which
the profession’s technical ‘medical’ judgments are
often put. That as a guiding question leads to a series
of derivative questions about how alternative uses of
‘medical’ judgments may relate to different concep-
tions of the social order in the workplace, different
notions of justice-of who should bear risks and reap
benefits-and different meaning systems through
which physicians in non-medical organizations inter-
pret their existence and combat their doubts. Do
physicians in various practice settings differ in their
definitions of illness and their interpretations of
scientific evidence? Within diverse medical practice
settings, what important differences can be discerned
in the manifest and latent goals of the organization
as it supports and/or undermines the health of indi-
vidual members and what effects do these differences
have on the physician’s scientific and moral world
view? What are the sources of income and incentives
for physicians in various practice settings? How direct
(or dilute) is their accountability, both legal and
moral, for the patient’s welfare? What circumstances
bring patients and physicians together and, when
strictly therapeutic goals are confounded by other
factors, how explicitly is this specified for patient and
physician to acknowledge to themselves and one
another and what formal protections are structured
into the encounter? Failure to deal adequately with
these kinds of issues lies at the heart of the enduring
ambivalence of occupational medicine. But they are
issues of equal weight for medicine more generally in
complex modern societies.
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