Most meatpacking workers are Black, Latinx, and immigrant workers earning low wages and at high risk for occupational injury. Most meat and poultry plants have on-site workplace clinics (OWCs) where workers are required to obtain care for work-related injuries or illnesses before seeking outside clinical assessment or intervention. Although OWCs can help plant managers identify and mitigate hazards, government and other investigations reveal that OWCs in meatpacking plants not only fail to advocate for safer work conditions, but also nurture conditions that exacerbate injury and illness. This article explores ethical challenges for health care professionals in OWCs, including companies' pressure to keep so-called “recordable” injuries low. This article also suggests changes to support OWCs' roles in safety and injury prevention.
There is no limit to the stories about workers injured in meat and poultry plants.1- 3 One of those stories is that of V.L. Griffin Jr who, while working in the blast freezer tunnel at a chicken processing plant, complained of pain and numbness in his right little finger to the plant's on-site workplace clinic (OWC).4 His symptoms were dismissed by the plant's OWC staff, and he returned to work. Mr Griffin later visited an emergency department on his own accord and was diagnosed with frostbite. The doctor placed him on restrictions of no cold work, no use of his right hand, and sent instructions for the plant to refer him to a specialist. The company did take him out of the blast tunnel but moved him to the “live hang” area, one of the hardest jobs in the plant. While this job normally requires the use of both hands, Mr Griffin tried to work with just his left hand. He repeatedly reported the pain to the OWC staff but was told that he had to wait for management approval before he could see a specialist. When the pain became unbearable, Mr Griffin again, on his own accord, visited the emergency department, where he was diagnosed with gangrene and his finger was amputated. The company did not cover the costs of the treatment since he had not received prior approval. The Occupational Safety and Health Administration (OSHA) subsequently conducted an inspection and cited the company for failing to provide him with properly insulated gloves. Mr Griffin had to file suit in order to seek compensation for his medical expenses and pain and suffering. In the 49 states in which employers are required to carry workers' compensation insurance,5 workers give up their right to sue their employer for their injuries in almost all cases, even in cases of negligence, and in exchange the employer is supposed to assume responsibility for providing insurance that covers medical treatment, rehabilitation, and reimbursement for some portion of lost wages. Mr Griffin worked in Texas, the only state that does not require most employers to carry workers' compensation,6,7 and thus was not covered by workers' compensation.
This story is reflective of what government investigations have consistently found in meat and poultry plants: OWCs endanger injured workers by delaying medical treatment and perpetuate unsafe conditions in the plant rather than mitigate hazards and prevent injuries and illnesses.2,8- 12
Almost 500 000 workers nationwide are employed in the US meat and poultry processing industry. The plants are largely located in rural areas and employ between several hundred and several thousand workers, the overwhelming majority of whom are immigrants, Black, and Latinx.13 Many are refugees, and dozens of languages are spoken in most plants.14 Occupational segregation ensures that people of color are disproportionately represented in the most dangerous jobs, such as the meatpacking industry.15,16 Nearly half of meatpacking workers live in families with low incomes, and about 1 in 8 have incomes below the poverty line. Only 15.5% have health insurance.17
The industry ranks among the harshest working environments in US manufacturing.18- 22 In plants across the country, workers stand close together, side by side, in cold, damp, dangerously loud conditions wielding knives and scissors. A typical poultry worker handles dozens of birds per minute.3,23,24 They make the same forceful cuts or movements thousands of times a day. Annual turnover in these plants averages between 60% and 150%.25
Quiz Ref IDAccording to the US Bureau of Labor Statistics' 2020 data based on the industry's own self-reported statistics, meat and poultry workers sustain serious injuries and illnesses that result in lost time or restricted duty at rates more than triple the average for all private industry.15 Furthermore, the government has found that these statistics are undercounted.2 Amputations in poultry workers (which include medical amputations for work-related injuries) were almost 5 times the average for all industries, while meatpacking workers suffered a whopping 14 times as many.26 Among the tens of thousands of companies that reported severe injuries, such as amputations, to OSHA, several major meat and poultry companies ranked among the highest reporters: Tyson Foods, Pilgrim's Pride, Cargill, and JBS are 5th, 13th, 16th, and 17th, respectively.1
Meat and poultry workers were deemed essential workers and continued working throughout the COVID-19 pandemic; counties with slaughtering plants suffered disproportionately high rates of COVID-19 illness and death during the first 6 months of the pandemic.27- 29 More workers have died from COVID-19 in the meat and poultry industry than from all work-related causes in the industry in the past 15 years.28 Congressional hearings in October 2021 and May 2022 exposed how the country's largest meat companies actively endangered workers during the pandemic, lobbying to the highest levels of government to force workers to remain on the job despite dangerous conditions, and conducted a coordinated campaign that fought against any requirement to implement common-sense mitigation measures.30,31
Quiz Ref IDDespite the occupational risks to which they are exposed, meat and poultry workers lack adequate health and safety protections.3,12 OSHA, the agency that enforces these rights, has been underfunded since it was created in 1971. In 2019, it would have taken OSHA 162 years to inspect every workplace under its jurisdiction just once.32 In contrast to other workers' rights, workers' compensation bars workers from most private rights of action, such as suing their employers for injuries or treatment.7,33 Most meatpacking companies provide no paid or unpaid sick leave to workers. Furthermore, many companies have punitive leave systems that assign “points” to workers who are injured or ill and must miss work, even for a work-related injury. Workers who accumulate too many points are fired.34,35
Quiz Ref IDOWCs are health units installed in workplaces by employers to provide health care services to employees. In poultry and meatpacking plants, OWCs are usually staffed by licensed practical nurses (LPNs) or emergency medical technicians (EMTs). The employer dictates what health care services are provided and when an employee can be referred off-site to a doctor or emergency room for further medical evaluation and treatment. The LPNs and EMTs follow medical protocols, usually approved by a doctor, but the doctor does not oversee them or evaluate the care provided in the OWCs.36 All states require that LPNs and EMTs be directly supervised. EMTs must be supervised by a physician and LPNs must be supervised by a physician, a registered nurse, or an advanced practice nurse. Direct supervision means that the clinical supervisor is either on-site or readily available for consultation, reviews all patient encounters, and co-signs all medical records.37,38 OSHA investigations of meat and poultry plants have found that most OWC staff are not clinically supervised at all.2,8- 12
Additionally, government investigations have raised concerns about unsupervised OWC staff working outside their scope of practice. Staff frequently gave workers nonsteroidal anti-inflammatory medicines, such as ibuprofen, in quantities that increase the risk of stomach ulcers, kidney injuries, and heart disease. Workers who repeatedly sought help at their OWCs for hand pain, finger pain, and shoulder pain were sent back to the work that caused their symptoms rather than to a doctor. The delay in definitive diagnosis and treatment ultimately resulted in avoidable surgeries for carpal tunnel syndrome, trigger finger, and rotator cuff tendinitis. And workers who suffered medical emergencies, such as head injuries and chemical eye splashes, should have been immediately sent off-site for treatment but were not.2,8- 12
Workers in the meat and poultry industry are “captive patients” in these clinics and often risk disciplinary action and termination if they seek outside medical care. Companies make it clear that workers must seek care from the OWC for a work-related condition in order for insurance to cover it.11 Moreover, by not referring workers off-site, companies can keep their recordable injury rates low. OSHA requires companies to maintain a log of serious work-related injuries and illnesses that require more than first aid or that result in lost time or light duty. If a worker is never sent to an off-site doctor and only receives first aid treatment in the OWC, their injury or illness will not be recorded in the log. If a worker goes to their own doctor without company approval, the company claims the injury or illness is not work related, will not record it, and will not cover related expenses. Workers themselves may be intimidated into not reporting work-related injuries and illnesses for fear of losing their jobs.2,8- 12 With misleadingly low recordable injury rates, the company can claim it is much safer than it truly is.
The ethical issues that guide health care in the United States (respect for autonomy, beneficence, nonmaleficence, and justice)39 are ignored by the meat and poultry industry, leading to direct negative effects on workers' health and safety. Many meatpacking workers are immigrant workers, and language barriers exist to their accessing care. OWCs rarely have translation services and sometimes rely on coworkers to interpret, although they often lack the appropriate skills to do so.34,36 Because of inadequate supervision of OWC staff members, along with employers pressuring them to keep recordable injury rates low, lost employee time at a minimum, and health care costs down, workers are not provided appropriate care and treatment, are not appropriately referred, and suffer worse health outcomes than workers in other private industries. All of these actions lead to a failure to provide safer working conditions, and all violate the ethical duties of health care practitioners (HCPs).
Quiz Ref IDIn this adverse work environment, HCPs in OWCs must routinely navigate significant conflicts captured by the concept of dual loyalty, defined as “clinical role conflict between professional duties to a patient and obligations, express or implied, to the interests of a third party such as an employer, an insurer, or the state.”40 Balancing the ethical challenges of multiple loyalties (viz, to the patient-worker, to the client-employer, and to the safety and health of the workforce as a whole) is a daily practice in occupational medicine.41 A Government Accountability Office (GAO) 2009 study of OSHA's recordkeeping standard found that over one-third of occupational health professionals interviewed reported pressure from employers to keep worker injuries off the OSHA logs by not providing appropriate medical treatment.42,43 The GAO report also found that “44 percent of health practitioners stated that this pressure had at least a minor impact on whether injuries and illnesses were accurately recorded, and 15 percent reported it had a major impact.”43 The American College of Occupational and Environmental Medicine Code of Ethics states: “Occupational and environmental health professionals have an obligation to ensure ethical conduct regarding conflicts of interest by recognizing, acknowledging, and appropriately addressing any secondary interests that might in reality distort the integrity of judgments or be perceived to do so.”44 Conflicts of interest may be especially difficult to navigate if the HCP is an LPN or EMT, who may have little ability or backing to prioritize patient care over the demands and expectations of the company. Even physicians and advanced practice clinicians, who have greater power and influence, find dual loyalty conflicts challenging.41,45
This work environment can also generate moral distress for HCPs, especially when HCPs know the right thing to do “but institutional constraints make it nearly impossible to pursue the right course of action.”46 Power imbalances, limited resources, and unjust institutional practices are all examples of external constraints that HCPs in OWCs confront on a daily basis. Often, HCPs are unable to treat workers, who are their patients, in accordance with the best practices established in their profession, given the conflicts discussed above.
Ramos et al found that Nebraskan meatpacking workers “believed that there was little they could do to prevent and treat health problems” and urged health care workers in meatpacking plants to “foster trust by providing culturally, linguistically, and literacy appropriate services,” along with reducing barriers to care.34Quiz Ref IDHCPs in OWCs have an ethical responsibility to work within their scope of practice. Meat and poultry companies that operate OWCs must ensure that OWCs have appropriate staffing, clinical supervision, continuous quality improvement, confidentiality provisions, and all the policies that are required for good health care. Medical consultants to employers have the ethical responsibility to be certain that OWCs are structured and managed to minimize dual loyalty conflicts, provide good care to workers, and improve workplace health and safety.10,11,36 HCPs should receive workplace safety training, visit the plant floor to observe jobs for which workers report injuries and illnesses, and identify hazardous jobs that must be made safer. OWCs should use the information they have obtained from treating worker injuries to flag dangerous jobs that need safety interventions to mitigate risks. HCPs in OWCs can and should play a significant role in injury prevention.
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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more
AMA Journal of Ethics
AMA J Ethics. 2023;25(4):E278-286.
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Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Debbie Berkowitz, is a practitioner fellow at Georgetown University's Kalmanovitz Initiative for Labor and the Working Poor in Washington, DC. She formerly served as chief of staff and senior policy advisor at the Occupational Safety and Health Administration, safety and health director at the United Food and Commercial Workers Union, and worker safety and health program director at the National Employment Law Project; Anna D. Goff, MA, HEC-C, is a PhD candidate in the Department of Bioethics at Case Western Reserve University School of Medicine and a clinical ethicist intern in the Center for Biomedical Ethics at MetroHealth System in Cleveland, Ohio. Her interests include clinical ethics, ethics in burn care, ethics of addiction, and ethical issues at the end of life; Kathleen Marie Fagan, MD, MPH, is an adjunct assistant professor in the Department of Bioethics at Case Western Reserve University School of Medicine in Cleveland, Ohio, and a board-certified occupational medicine physician and an occupational medicine consultant. She formerly served as a medical officer at the Occupational Safety and Health Administration and has 25 years' experience as a staff physician, medical director, and clinic director of occupational and environmental clinics; Monica L. Gerrek, PhD, is an assistant professor in the Department of Bioethics at Case Western Reserve University School of Medicine in Cleveland. She is also co-director of the Center for Biomedical Ethics and chair of the Ethics Committee at MetroHealth System and serves as chair of the American Burn Association's Ethical Issues Committee. Her interests include ethics in burn care and correctional health care, animal ethics and food ethics, and the ethics of addiction.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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