Written by Nelson S. Haas, M.D.
Introduction - Knowing the workers’ compensation system will prepare physicians for caring for patients who claim workplace injury or illness. This third in a series of articles about the workers’ compensation system covers the medical ethics associated with the workers’ compensation system. Previous articles described the history of, and statutes and rules governing Vermont’s workers’ compensation system. Forthcoming articles will describe an evidence-based approach to determining causation and suggestions for improvements in the system.
Vermont’s workers’ compensation law specifies that the workers’ compensation system provides a remedy to workers that is “expeditious and independent of proof of fault” 1; and includes coverage for medical care, lost time, and other expenses related to traumatic injuries in the course of work, and illnesses that occur due to conditions unique to a work environment or occupation. “No fault” handling of occupational injuries and illness does not mean that designation of an injury or illness as caused by work is a matter of discretion for the claimant/employee, defendant/employer, workers’ compensation insurance carrier, or physician. Rather, there are ethical and technical standards that guide the determination of fault. This article covers the ethical standards.
General ethics that govern the doctor-patient relationship are presented below with consideration of their application to workers’ compensation. Determination of causation, appropriate treatment, disability, and impairment in a workers’ compensation claim often requires the opinion of physician-experts, ethical components of which will be covered in this article. Additionally, the issue of medical privacy in workers’ compensation will be considered.
General Medical Ethics - Medical ethics contain four general principles that orient physician to patient:2
- Autonomy, or respect for the independence of the patient, which entails an obligation for the physician to provide adequate information to the patient to allow informed choices;
- Nonmaleficence, or the physician’s avoidance of harming the patient;
- Benevolence, or the doctor’s provision of a benefit to the patient through prevention or treatment; and
- Justice, or the physician working toward a society where medical resources are distributed fairly and to ensure that those who are injured or ill can be restored to optimal health.
Autonomy - In addition to discussion of risks and benefits of treatment, including no treatment, a complete approach to autonomy in workplace health should include physician-patient conversations about the benefits and risks of work, and of the patient’s personal habits and characteristics. Physicians should be knowledgeable about, inform their patients of patient specific health issues For example, many musculoskeletal disorders (carpal tunnel syndrome, shoulder impingement syndrome, and knee meniscal tears) have as risk factors personal characteristics (elevated body mass index, age, heredity, and comorbidity such as diabetes) that are stronger than occupation and work conditions.3, 4 If a patient misplaces blame for their health problems with their workplace and remains ignorant of their own role in and control over development of disease, they are denied an opportunity to understand and take control of their own health.
Nonmaleficence and Benevolence - With nonmaleficence and benevolence, it is the obligation of the physician to undertake treatment only when likely benefit outweighs likely harm. When advising any patient about prognosis, advice specific to a sub-population to which the patient belongs is most-pertinent. When advising a workers’ compensation claimant-patient about outcomes, the physician should recognize that outcomes are usually significantly worse in workers’ compensation claimants,5-24 which may entail advising for and offering conservative over aggressive treatment.
Justice - Misplaced blame is unjust25-29 and may create fearfulness of work and an adversarial employer-employer relationship. Justice in workers’ compensation is restorative and neither distributive nor punitive. Workers’ compensation benefits are meant only for those whose injuries and illnesses were more likely than not to have been caused by work. Justice in workers’ compensation is restorative, meant to effect recovery or compensate for failure to recover. Justice under the workers’ compensation system is neither distributive nor punitive, although having to pay for negative health effects of employment may induce employers to maintain safe workplaces. Workers’ compensation benefits are meant only for those whose injuries and illnesses were more likely than not to have been caused by work.
Medical Expertise and Testimony - The Eighth Commandment of the Bible admonishes against bearing false witness.”25, 26 The traditional Hippocratic Oath obligates the physician to avoid “any voluntary act of impropriety or corruption,”27 with a modern version of the Oath28 directing the physician to “respect scientific gains,” “not be ashamed to say ‘I know not,’” and “remember that [the physician is] a member of society, with special obligations to all… fellow human beings.” The American Medical Association Code of Medical Ethics (AMA Code) states of medical testimony:29 (§9.07)
- “Medical experts should have recent and substantive experience in the area in which they testify and should limit testimony to their sphere of medical expertise.
- “Medical witnesses should be adequately prepared and should testify honestly and truthfully to the best of their medical knowledge.
- “The medical witness must not become an advocate or a partisan in the legal proceedings.”
The AMACode categorizes misrepresentation of facts to obtain unwarranted insurance payment as health care fraud and abuse and admonishes against it: “[p]hysicians should make no intentional misrepresentations to increase the level of payment they receive or to secure non-covered health benefits for their patients”; and states that “[p]atients should not initiate or participate in fraudulent health care.”
Guidelines from medical organizations for medical experts and testimony advise the expert to use appropriate evidence and unbiased objectivity, and to avoid advocacy.30-40 Generally the medical expert is directed to:
- Be qualified as an expert in the area of testimony;
- Demonstrate scholarly activity in this area at least by virtue of continuing medical education in the area of testimony;
- Be thoroughly familiar with the case in question;
- Be aware of the standards of medical practice related to the case and locale;
- Receive compensation that is appropriate and proportionate to expertise, qualifications, and customary fees;
- Not receive compensation contingent upon outcome of litigation;
- Have compensation for expert testimony as a minimal part of total income;
- Have opinions that do not exclude any relevant information in order to favor one of the adversaries;
- Have consistency opinions;
- Make records from previous expert witness testimony available to the attorneys and other expert witnesses; and
- Be willing to submit transcripts of prior depositions and courtroom testimony for peer review.
Advocacy and Fraud - Physicians may feel that disagreeing with a patient’s assertion of the work-relatedness of an injury or illness is inconsistent with their commitment to patient advocacy. Physician commitment to patient advocacy is reflected in the ethics statement of the Council of Medical Specialty Societies (CMSS), which directs physicians to“resolve conflicts of interest in a fashion that gives primacy to the patient’s interests” and to “advocate for individual patients when organizational, situational or financial circumstances lead unjustly to the withholding or withdrawing of beneficial health care.”41 Physicians may justify falsification of claims and other deceptive actions by claiming responsibility to their patient rather than to society at large.42, 43 However, patient advocacy is balanced by other ethical concerns, including maintaining the integrity of professional judgment. CMSS balances their charge to physicians to advocate for patients with charges that physicians act with honesty and moral integrity, be “stewards of medical knowledge,” “preserve and protect the trust bestowed on them by society,” be aware of the limitations of their expertise, and avoid making decisions that give primacy to their financial benefit.41
Physicians should advocate for and protect their patients when they have adequate information to justify their advocacy. Unfortunately, in workers’ compensation and other situations where patients may benefit from blaming others for misfortunes of health and the presence of disability, there is strong evidence of fraud. Patient behavior consistent with malingering or provision of misinformation is common in the workers’ compensation, disability, and pain settings.44-59 There is much evidence that physician decisions are often not based solely on the best interests of their patients, but on their professional or financial interests. For example, studies have found that compared to control physicians, physicians at physician-owned facilities have been more likely to refer well-insured patients to their own facilities and route less-lucrative Medicaid patients to other places.60
Care at physician-owned facilities appears to have comparatively adverse effects on patients’ access to care, and increase the use of services and costs substantially with no improvement or a decline in quality of care61. Mitchell and Scott62 cite a “general consensus of the empirical evidence… [that] reveals that the financial incentives inherent in [physician self-referral] are associated with increased utilization of services and higher costs to patients.” There is also ample evidence that medical professionals are willing to subvert medical and surgical research for their own financial benefit and the financial benefit of the industries that support them.63-67 Despite the evidence of corruption, many physicians may ignore68 or deny69 the influence that financial gain and industry influence exerts on them.
Privacy - Confidentiality of personal health information relevant to workers’ compensation claims is limited. Part of the rationality for limited protection is the right of the accused employer/defendant to confront their accuser – the employee/claimant – according to the United States70 and Vermont constitutions.71 The confidentiality of individual health records under the Health Information Privacy and Portability Act 1996 of has been circumscribed with respect to employment records, including workers’ compensation claims, and in the case of public health issues.72 (§164.512(b)(v)(A)) The Vermont Statues covering workers’ compensation allow for provision to employers of person health records relevant to workers’ compensation claims.73 (§640 and 655)
Physicians should provide written notice to their patients that protected health information connected to workers’ compensation claims may be disclosed to their employer’s workers’ compensation insurance carrier and the employer.73 (§164.512(b)(v)(D); Â§655a)
Summary - Ethical handling of workers’ compensation patients is the same ethical handling of non-workers’ compensation patients; and additionally involves being aware of and admitting to the patient the limits of knowledge about the role of workplace factors in the development of disease, candid discussion of non-workplace risk factors that are as or more-prominent than workplace risk factors, and honest disclosure in the medical records. With sound evidence of a patient’s workers’ compensation claim being valid, the physician should support the patient. In the absence of supportive evidence of a patient’s health issue being caused by the workplace, designating patients’ problems as caused by the workplace is unethical. In the next article, determination of causation will be presented.
Acknowledgements - I would like to thank John Bielecki, M.D. and Ronald Blum, M.D., Board of Directors, New England College of Occupational and Environmental Medicine (NECOEM); Kurt Hegmann, M.D., American College of Occupational and Environmental Medicine, editor, Occupational Medicine Practice Guidelines, 3rd edition; Phillip Lerner, M.D., President, NECOEM; J. Stephen Monahan, Director, Workers’ Compensation and Safety Division, Vermont Department of Labor; William Nelson, Ph.D, Director, Dartmouth Medical School Rural Ethics Initiative; and John Valente, attorney, Ryan Smith and Carbine for reviewing my manuscript and their invaluable feedback.
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