It's a difficult ethical question for the individual doctor who is likely to be the recipient of strong commercial pressures.  What were the points raised by Stokes vs GKN?

Kate


>>> <[log in to unmask]> 18/06/01 17:56:00 >>>
 
One of the responses to the query on the provision of care for overseas 
travellers which was raised by Kate Venables came from Medical Services 
Overseas Ltd.  This in fact dealt with two issues, that of employees 
travelling from the UK and resident expatriates, as well as with primary, 
secondary and occupational health care of indigenous employees.  I would 
like, if you will, to initiate a discussion about the latter as a completely 
separate issue, and to ask for your opinions, experience and solutions 
concerning what is likely to be a growing and important problem.
 
Many of us who work or have worked for large companies, or who give them an 
OH consultancy service, have had to provide OH and environmental advice for 
overseas subsidiaries.  I assume that this responsibility, both for the 
company and its advisers, extends to the increasing number of factories in 
developing countries to which manufacturing has been outsourced, many of 
which simply do not have the level of resource which is available in Europe 
or the USA. The problem, therefore, is to match the resource to the need, and 
to clarify the position of UK health professionals.  My generation was only 
too well aware of the classic case of Stokes v. GKN, in which Dr Stokes was 
held liable for allegedly failing to provide his employer with adequate 
advice concerning a risk of testicular cancer.
 
It may help to clarify the issue if I were to personalise the problem by 
describing one particular situation.  I was the CMO of a company which, inter 
alia, included secondary lead smelters and lead-acid battery factories 
located around the world, including most African and many Asian countries.  
Most of these had simply transcribed the UK Control of Lead at Work 
Regulations into their own legislation.  For some, such as South Africa and 
Singapore, this worked well enough and the Regs were implemented and 
enforced.  Many, however, just did not have the resources or even the will to 
implement or enforce them.  Local management would point out that if they 
were forced to do so of their own accord, when the competition down the road 
did not, the cost would put them out of business.  I had reluctantly to admit 
that they had a point, as did Head Office management. So we reached the Great 
British Compromise.  Gross breaches, such as smoking and eating at the 
workbench or putting the effluent straight into the water supply were 
stopped, and we produced our own Code of Practice, which was approved by the 
main board and which simplified and, to be frank, watered down the CLW Regs 
and UK environmental legislation of that time, but which was agreed to be 
operable and enforceable by all.  The result was a  decrease in lead in air 
and blood lead levels from the horrendous to the reasonable, (or where 
venepuncture was not practiced, urinary ZPP's),but still not to a level 
required in Europe or the USA. 
 
Thequestions which I would ask are:
 
Where local resources are not available, either through lack of logistics, 
money or will, should UK companies or their medical, nursing and 
environmental advisers, with their knowledge of the risks, be prepared to 
compromise as described above and recommend or provide a lower order of care 
than they would in the UK, whether the risk is associated with lead, 
textiles, or from any other source? 

If they do so, do OH practitioners put themselves at risk, particularly in 
the light of the current level of litigation? 

In the end, when outsourcing to a developing country is proposed, should we 
simply refuse to compromise or to be part of what could be seen as an 
inadequate service, or should we do what we can in an imperfect world? 

Enough for now, the issue of primary and secondary care can wait for another 
day.      
 
Regards to all
 
 Desmond Fanning