Document DvdzV4N6E1xR6pQzj0vRxw5G5

Public Responsibility in AsbestosAssociated Diseases* Prepared by Hans Wellt, Chairman, Margaret R. Becklakt, and Roger Mitchell This position paper was adopretf by fhe ATS Board ot Directors, March 1982. Diagnosis and evaluation of Impair ment In asbestos-related eases ara '"cussed In this paper. For more irformation on evaluation refer to the 1963 ATS Statement "Evaluation of ' Impairment/DtsaWllty Secondary to Respiratory Disease' (Am Rev Respir Ois 1962; 126:945-961). I The American Thoracic Sociaty and Ameri can Lung Association ara plaasad to have this or-ortunity to provide input in the de liberations of this Committee concerning one of the major occupational health is sues feced by our society. We represent a professional society composed of cheat physicians and biomedical scientists, who investigate the causes of and work toward the prevention of lung diseases, ss wall as public volunfssrs committed to reducing the burden of lung disease in communities around the country. At the outset, we would like to emphasize our conviction that, as with many othsr oc cupationally induced disorders, tha asbes tos-associated diseases are beat dealt with by prevention through control of exposures to airborne concentrations of asbestos dust Monetary awards can nevar compen sate individuals for loss of health, or their relatives for loss of life, nor can any com. pensation scheme provide the adequate disincentive for Industry which would lead to the prevention of these conditions; this is due in large pan to the long latency period between relevant exposure and clinical manitaitations of these diseases. Recog nizing, however, that past exposures have produced these conditions, we are coni n' ted to the provision of just resolution of claims by injurtd worktrs. We have testified previously that It is our bellaf that dleeasespeciflc approaches to federal compensa tion legislation ara not optimal In reaching the objective of equitable ar.d timely awards for all workers who develop dis eases as e consequence of their employ ment. The Inadequacies of the black lung legislation have received considerable at tention and have beer the subject of period ic controversy, often focusing on questions of cost sffeetlveness and equity. Thus we regret the extension of a fragmentary ap ISwtimeny o* the American Thoracic Society end the American L-r; Association suomltted tr the Senate SuOcommlltee on Laeor proach to the over-all burden of occupationally-induced lung disease implicit in the passage of further legislation dealing with ths conditions causad by exposure to one specific material. Nevertheless, we recog nize that there may wall be overwtitiming public and economic pressure making It nscsssary to consider seriously legislation dealing specifically with the asbestos-asso ciated diseases. Therefore, in spite of our reservations, we are anxious to provide our views on how this problem might be approached. Much has been written and said recently concerning the inadequacy of the present system in meeting the needs of individuals who have developed asbestos-associated diseases. Ws art in full agrstmtnt with this assessment. In this context, tort litigation has been shown to be inequitable, costly, and markedly unjust in the distribution of resources, a high proportion of awards going to individuals In whom evidance of disease cannot be demonstrated. Indeed one of the main deficiencies in this ap proach is that It distorts medical evidance, calling, for Inatanca, for "proof" whan In fac\ medical diagnosis Is more often hy pothesis, ia., the best available explanation given the facts about a case. Other deficien cies are the failure to rety on objective medi cs! evidence in individual cases, as in mass settlements, and the feet that in the assess ment of Individual cases medical experts may be chosen not for their expertise and objectivity but because their testimony will support one side or the other. Given the na ture of medical diagnosis, the facts about a case are frequently open to more than one interpretation. We ara mindful also of the projections of the future burden ot such liti gation effecting all segments of our socie ty. Similarly, we feel that tha state compen sation systems have often dealt poorly with asbestos end other workplace-associated diseases, and we have testified previously in regard to our view that a uniform federal system of occupational lung disease com pensation should be developed. We have reviewed, with disappointment and consideuble reservation, the draft bills that have been proposed, since it is our opinion that they have not dealt adequately with medical erttaria for the conditions to be compensated. Our testimony on an approach to fhe compensation ot asbestos-associated diseases is predicated on the belief that public policy in this araa should be based on scientific information. The known asbestos-essociated diseases all have been shown to be dose-related, and wa ara perauaded by tha evidance that there are differences in bio logic activity of asbestos related to fiber type and process. While this is not the ap propriate torum for a comprehensive dis cussion of these or other related scientific issues, ft seems raasonab't, however, to suggest that the scientific data base can and should be used in the decision-making process as tha means of assessing the like lihood that the disease is due to exposure, particularly for conditions which also occur in tha general population in the absence of asbestos exposure. While we readily recog nize, however, that many of the decisions made in the clinical tatting concerning indi vidual cases lack precision, informed medi cal opinions most often lead to reasonable conclusion*. So It is with many clinical decisions. The following. In our view, are the necessary elements of a more equitable end workable system of compensating tha injured worker who has been exposed to asbestos. In the individual cate, the major n<edieal issues to be decided are diagnosis, causation, and impairment. The process of reaching a diag nosis depends upon sound medical prac tice irrespective of the underlying cause ot disease. Determining the most likely cause will usually depend on assessing the levels ot exposure to known causative agents; this will be based on epidemiologic studies of oecupationally exposed populations. The assessment of impairment will depend pri- FALL 1963 ATS Nawt ; 5 008274 Asbestos-Associated Diseases minty on evaluation of disturbance (n lung function Ultimately guidelines must be established to facilitate this decision making process- and these must be the sub ject of continuing review m light of emerg ing scientific evidence We strongly sug gest mat these guidelines not be written into me law because of the dynamic nature of scientific knowledge The legal system must accept the uncertainties of diagnosis, wnicn invariably depends upon assessment of medical probabilities The structu e of a workable system should first include a national panel of experts ic develop and periodically modify, guidelines and criteria tor the adjudication of claims for asbestos-associated diseases Second ly. there should be regional panels that would, of course include health profession als knowledgeable in occupational lung dis eases and that would be responsible for the case-bv-case determinations. Finally, a mechansm must be developed to make possible an appeal of me medical deci sion . rendered by the regional panel. While the selection of boih the national and regional panels, and the development of an appeals system should be dealt with in the legislation, me details ot these aspects are beyond the scope of our testimony, al though a few brief comments seem appro priate The naimnai panel ot experts should cor highly experienced and respected members of the biomedical community They should be selected from outside the government, ar be maximally immune to short-term political influences Similar con siderations should determine the selection of the regional compensation panels. Recognizing the importance of the guide lines. which are the responsibility of the national expen panel we have appended to this statement an outline of what we con sider to be a reasonable set of guidelines concerning the asbestos-associated dis eases based or present knowledge An of tn# diseases which have resulted from asbestos exposure m the workplace have serious conseouences to hea'*h ind may impan function and reduce longevity with their implicit personal tragedy For the indi viduals at risk because of past exposure to asoestos dust, public responsibility is to in sure that those who are injured receive the necessary support and assistance This has not always been the case The bieme for this must be shared by elements of the legai and medical system, as well as seg menfs o< manage-ism and labor The system Oufnned in this testimony attempts to maxi mize rationality and equity We have every expectation that the Congress will respond appropriately to this difficult challenge Proposed Guidelines for Case Evaluation Based on Assessment of Evidence Available March 1983 The case evaluation process involves estab lishing the presence of disease (diagnosis), its cause, and the extent ot its functional effect on the individual (impairment). (. Diagnosis and Qatarmlnation of Cause A. Asbastosis Asbestosis is a pneumoconiosis defined as diffuse fibrosis of the lungs caused by asbestos exposure, its features include rales (crackles), breathlessness, finger club bing. lung function abnormalities (usually reduced volumes and impaired gas ex change). radiographic changes (irregular and linear opacities), and histopathologic demonstration of fibrosis with tissue fiber identification. The first four of these are non-specific; changes on the X-ray and pathologic tissue examination have in creasing. but by no means absolute, specifi city. individually, these are not sufficient to make a diagnosis, in combination, the diag nosis depends upon weighing probabilities and assessing the evidence m toto. an im portant component of which is estimation of past exposure, tn practice, the diagnosis is usually established on radiographic and exposure evidence. An expert committee of the College ot American Pathologists and the National Institute for Occupational Safety and Health has recently developed guidelines for the pathologic diagnosis of asbestos-associated disease. When lung tissue is available for histopathologic examination, a diagnosis of asbestosis de pends minimally upon the demonstration of discrete foci ot fibrosis in the walls of respi ratory bronchioles associated with accumu lations of asbestos bodies (light micro scopy) Additional findings are diffuse inter stitial pneumonia and fibrosis. Neither fibrosis nor asbf tos bodies alone is suffi cient for the histopathologic diagnosis of asbestosis B Nonmahgnant Plaural Etfacts These include pleural effusions, focal hyaline thickening (plagues) and diffuse pleural fibrosis Plaques indicate exposure, not disease, because they do not cause symptoms or functional impairment Attributabiiity >s assessed on the basis ot an exposure history and the absence of other causal factors C Lung Cance' The diagnosis of lung cancer in asbestosexposed individuals is no different than in other clinical settings. In population studies of various occupational groups, evi dence of asbestosis has been found when excess tung.cancer risk is demonstrated for comparable levels of exposure. In the mpi vidual case of lung cancer, the cause can not be determined precisely For this reason, the judgment must take into ac count length, intensity and character of ex posure. evidence of' other asbestos-asso oated diseases, and smoking history D, Malignant Mesothelioma The primary issue is valid diagnosis This diagnosis generally cannot be established clinically, radiographically, with pleural fluid examination, or with limited biopsy tissue. Since the potential tor misdiagnosis is considerable, adequate tissue specimens shcuid be examined by pathologists expenenced and expert in the diagnosis of this tumor (c.g.. mesothelioma panels). When the diagnosis has been estab'ished. a his tory of exposure, even if short, is sufficient for a judgment of causation II. Assessment of Impairment This follows the establishment of an asbes tos-associated disease. In cases of exten sive asbestosis or extensive pleural fibro sis. reference should be made to criteria for impairment in restrictive disorders outlined in the ATS Statement on Evaluation ot lmpairment/Disabiiity Secondary to Respira tory Disease (t). Use will be made ot puimonary function tasts and exercise perfor mance testing when necessary Regional panels will be responsible for periodic up dating of impairment level. t ATS Statement on Evaluation of Impairment Disability Secondary to Respiratory Disease Am Rev Respir Dis 1982, 126 915-951 Chapter News MTS Makes Heme Care Outcome Manual Available Outcome criteria for home health care agencies on the subjects of obstructive lung disease, restrictive lung disease, infan tile apnea, pediatric and adult asthma, and lung cancer are now available from me Massachusetts Thoracic Society Home Haalth Care Outcome Criteria Volumes i and II define appropriate home health care procedures and includes third party payer documentatic.. instructions Fo' more information contact Colleen McComas. Massachusetts Thoracic Society. 263 Summer Street. Boston. Massachusetts 02210, (617)426-8330 6 ' ATS News FALL 1983 00S275