This thesis seeks to examine the ethical basis for occupational medicine, as it is practised in the United Kingdom (UK). There is empirical evidence of occupational physicians being confused with regard to confidentiality and consent, and variations in their practice. It is argued that the ethical guidance from the General Medical Council and the Faculty of Occupational Medicine on these matters, contributes significantly to such confusion. The doctor-patient relationship, consent for disclosure of a medical report, and medical confidentiality, all in the context of occupational medicine practice, are explored. These issues are addressed in the core part of this thesis in the form of the three published papers. In the first paper, the doctor-patient relationship in occupational medical practice is reviewed, and it becomes apparent that in the UK, the occupational physician carries out different roles and functions, ranging from duties that mirror those of a therapeutic encounter, to those that require the occupational physician to be completely independent for the purposes of a particular type of assessment (for ill-health retirement). The former is compatible with the assumption of a fiduciary relationship between doctor and patient, whereas in the latter situation, it would be incongruous to expect the doctor to be independent and owe the patient a “duty of undivided loyalty” simultaneously. In the second paper, consent for disclosure of information, in particular a medical report, is distinguished from the “informed consent” for treatment or interventional research, and the phrase “permission to disclose” is proposed for the disclosure situations. Although this distinction may not have much significance in therapeutic practice, the output of virtually all occupational physician activities results in the writing of a report, so this difference between the two “consents” has greater relevance. The third paper reviews the ethical, and in particular, legal basis for medical confidentiality with reference to an independently commissioned report. In such a situation, UK courts have been consistent in stating that disclosure of such a report to the commissioning party does not breach confidentiality, and no further consent for such disclosure is required. This conflicts with ethical guidance to occupational physicians on this matter. Such conflict between the law and ethical guidance are a further, and important, source of ethical confusion for occupational physicians. Indeed, a common theme through the three papers is that ethical guidance to occupational physicians is in parts either incongruent, incoherent, or conceptually flawed. This may not be surprising, as current ethical guidance is predicated on a doctor-patient relationship that exists in the usual setting for most doctor-patient encounters, that is, the therapeutic setting. It seems unreasonable to expect that simply transposing such an ethical paradigm into a different setting, with dissimilar roles and obligations, could work in a seamless manner. The occupational physicians’ ethical confusion thus reflects the confusion in their ethical guidance.

AIMS Managed care is a market model of health care distribution, aspects of which are being incorporated into the Australian health care environment. Justifications for adopting managed care lie in purported claims to higher levels of efficiency and greater ‘consumer’ choice. The purpose of this research, then, is to determine the ethical implications of adapting this particular administrative model to Australia’s health care system. In general, it is intended to provide ethical guidance for health care administrators and policy-makers, health care practitioners, patients and the wider community. SCOPE Managed care emerges as a product of the contemporary, neo-liberal market with which it is inextricably linked. In order to understand the nature of this concept, then, this research necessarily includes a limited account of the nature of the market in which managed care is situated and disseminated. While a more detailed examination of the neo-liberal market is worthy of a thesis in itself, this project attends, less ambitiously, to two general concerns. Firstly, against a background of various histories of health care distribution, it assesses the market’s propensity for upholding the moral requirements of health care distributive decision-making. This aspect of the analysis is informed by a framework for health care morality the construction of which accompanies an inquiry into the moral nature of health care, including a deliberation about rights-claims to health care and the proper means of its distribution. Secondly, by way of offering a precautionary tale, it examines the organisational structures and regulations by which its expansionary ambitions are promoted and realised. CONCLUSIONS As a market solution to the problem of administering health care resources, the pursuit of cost-control, if not actual profit, becomes the primary objective of health care activity under managed care. Hence, the moral purposes of health care provision, as pursued within the therapeutic relationship and expressed through the social provision of health care, are displaced by the economic purposes of the ‘free’ market. Accordingly, the integrity of both health care practitioners and communities is corrupted. At the same time, it is demonstrated that the claims of managed care proponents to higher levels of efficiency are largely unfounded; indeed, under managed care, health care costs have continued to rise. At the same time, levels of access to health care have deteriorated. These adverse outcomes of managed care are borne, most particularly, by poorer members of communities. Further, contrary to the claims of its proponents, choice as to the availability and kinds of health care services is diminished. Moreover, the competitive market in which managed care is situated has given rise to a plethora of bankruptcies, mergers and alliances in the United States where the market is now characterised by oligopoly and monopoly providers. In this way, a viable market in health care is largely disproved. Nonetheless, when protected within a non-market context and subject to the requirements of justice, a limited number of managed care techniques can assist Australia’s efforts to conserve the resources of health care. However, any more robust adoption of this concept would be ethically indefensible.

No description available.