Ella A. Kordysh , MD, Ph.D, and John R. Goldsmith MD, MPH
Department of Epidemiology and Health Services Evaluation
Faculty of Health Sciences, Ben-Gurion University,
Beer-Sheva, 84120, Israel
* A paper from the Second Bioethics Roundtable on Israel in Asian Bioethics held at BGU in August, 1998, in cooperation with the Eubios Ethics Institute.
Eubios Journal of Asian and International Bioethics 9 (1999), 6-7.

The literature elucidates ethical problems related to the conduct of epidemiological studies or linked to societal issues in practice of environmental epidemiology (1-5). Our objective is to show the possible role of environmental and occupational epidemiology as discipline which is able to reconstruct the destroyed elements of bioethics in medical care. Modern diagnostic equipment and therapeutic means can lead to depersonalization of medicine, to its dehumanization.. Some doctors tend to regard the prevention of disease as being outside their sphere of responsibility. To the extent this occurs medical ethics risks the loss of one of its most important functions, which was following the Ancient credo of medicine "To treat patient, not disease". We can ask why?

A way to turn to each patient

We propose that inclusion of environmental epidemiology in physician training may be considered as a way of minimizing the problem. Accumulated knowledge concerning associations of health status (diseases, symptoms, biochemical changes, molecular and genetic disorders) with environment ( including occupation and psychological factors), habits, behavior and genetic specificity will require the physician to turn to each patient, to look and see their 'small world" (microcosm) in order to search for reasons for symptoms, impairments or disease in each individual.

The same applies to family units.

Advantages of the approach

Based on data on environmental exposures, physician can often assure : 1) patient's recovery without any treatment, due to identification and removing the causal factor; 2) cure after therapy (symptomatic or specific one , directed to neutralization of xenobiotic) and removing causal factor; 3) determination of the first chain in the pathogenesis of illness (for example, diagnosis was nephritis and data on work conditions help suspect chronic strepp tonsillitis as a trigger) ; 4) precise diagnosis (for instance, well known manganese related Parkinsonism or mercury linked Minamata disease); 5) purposeful treatment, for example, male infertility due to oligospermia, which may coexist with varicocele, as well as with exposure to lead ;elimination of the lead exposure could be tried along with consideration of corrective surgery.

This approach also creates the opportunity to prevent diseases, a goal permitting the realization of one of the most ethical components of medical care.

The role of knowledge on genetic susceptibility and gene-environment interaction in diseases

prevention is difficult to overestimate. The characterization of a genetic polymorphism of a commonly occurring gene (we can expect that in the not far-distant future these tests will be routine analyses like a biochemical indicators, without any psychological impact on patient due to knowledge of genetic risk).

Decision making on professional fitness of the employee - Possible Situations

1. Exposure is accepted as an occupational risk factor.

The answer needed may be easily established, with maintenance of principle of worker health protection. Examples: Person with coronary heart disease cannot be employee at rayon manufactures with exposure to carbon disulfide, alike as men with neuropathology cannot receive physician's agreement on fitness for work with exposure to lead.

2. Uncertainty regarding risk factors

A. An underestimation, under these condition due to lack of scientific evidence, is fraught with the hazard of increased exposure of workers to risk. Recognition of such problems must be the most critical step toward optimal procedures for dealing with them. Example: A woman works at the factory on production of agricultural chemicals, for which there has not been shown a strong association with unfavorable reproductive outcomes. A few cases , for example this year, were reported . .Evaluation of these cases on the basis of the number of women at risk suggests an excess. Physician has to propose for patient try to change place of work.

B. Overestimation of occupational risk can provide an unfavorable constraint on the interest of patient as a person and sometimes , by excluding a person from a well paid job profession, can impair the quality of life. Example: Young bright physics experienced Hodgkin disease., successfully treated. He cannot imagine his life out off work with ionizing radiation. There is no convincing evidence on association of this disease with radiation, but physician has doubts. Ionizing radiation is not indifferent exposure, especially for person with immune disorders (moreover after chemotherapy). So, physicians has to discover for men all aspects of the situation, and if his patient insists, the decision probably should be to permit to work under condition of medical monitoring .

3. Individual identified as being at genetic risk for definite chemicals

Example: Persons with the ALAD-2 ( delta-aminolevulinate dehydratase) genotype can be more susceptible to lead exposure (6).

Decision making are comparable with situation 2 or (in the future) with situation 1.

Dealing with public response to reported risk factors

Growing number of reported risk factors , including genetic risk, can cause

Three types of public response: 1. Skepticism and unwillingness to take responsibility for own health; 2. Anxiety, panic, " epideiogenic" health disorders; 3. Preference to address " hot" issues with weak evidence while ignoring well established risk factors; smoking, alcohol consumption, sun exposure.

Physicians with a background in environmental epidemiology should be able - to provide balance in such situations by:

1. Interpretation of epidemiology study data for public (public is increasingly prepared to this communication because of enhanced education and increased awareness of scientific issues) on the basis of (a) consistency, (b) strength of association, (c) biological plausibility;

2. Escaping frightening situations;

3. Advising for reasonable protective measures and common sense in perception of epidemiological investigation results;

4. Minimizing of psychological problems related to spreading among population finding on genetic risk.

Conclusions

It may be argued that we merely affirm that good clinical practice requires use of insights available from environmental epidemiology and such practice is inherently more ethical than it would be in the absence of such insights. Thus, epidemiology can cause not only the "birth" of ethical problems, but also help physician practice in a more ethical manner with major emphasis on prevention. These topics should be an important components of physician and medical students training.

References
1. Goldsmith JR. Ethical issues and motivation in environmental epidemiology. In: Environmental Epidemiology: Epidemiological Investigation of Community Environmental Health Problems, Ed. by JR. Goldsmith, 1986; CRC Press Boca Raton, Florida; pp. 26-29.
2. Gordis L. Epidemiology , W.B. Saunders Company, A Division of Harcoutt Brace & Company ,1996.
3. Ethical and Philosophical Issues in Environmental Epidemiology. Special issue. The Science of the Total Environment 1996, 184 (1,2).
4. Beauchamp TL. Ethical theory and epidemiolody. J Clin Epidemiol 1991; 44 (Suppl):5S-8S.
5. Weed DL, McKeown RE. Epidemiology and virtue ethics. Int J of Epidemiology 1998:; 27: 343-9.
6. Smith CM, Wang X, Hu H, Kelsey KT. A polymorphism in delta-aminolevulinate acid dehydratase gene may modify the pharmacokinetics and toxicity of lead. Environ Health Perspect 1995, 103: 248-253.