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The Precautionary Principle for Shift-Work Research and Decision-Making

The Precautionary Principle for Shift-Work Research and Decision-Making Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PUBLIC HEALTH ETHICS VOLUME 12 NUMBER 1 2019 44–53 44 The Precautionary Principle for Shift-Work Research and Decision-Making Charleen D. Adams , MRC Integrative Epidemiology Unit (IEU) & School of Social and Community Medicine, University of Bristol Erika Blacksher, Department of Bioethics and Humanities, University of Washington Wylie Burke, Department of Bioethics and Humanities, University of Washington Corresponding author: Charleen D. Adams, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Clifton, Bristol BS8 2BN, UK. Tel.: +44 (0)7771 452912. Email: charleen.adams@bristol.ac.uk Shift work (working outside of 6:00 AM to 6:00 PM) is a fixture of our 24-hour economy, with approximately 18 per cent of workers in the USA engaging in shift work, many overnight. Since shift work has been linked to an increased risk for an array of serious maladies, including cardiometabolic disorders and cancer, and is done disproportionately by the poor and by minorities, shift work is a highly prevalent economic and occupational health disparity. Here we draw primarily on the state of science around shift work and breast cancer to argue that shift work represents a public health threat serious enough to warrant a precautionary stance. We use the precautionary principle to advance our case and view it as a moral compass for shift work research, empowering public health to cast shift work within the domain of health disparities deserving action despite scientific uncertainty. With the precautionary principle, we call for a deliberative decision-making process and formation of a broad shift work research collaboration to protect the health of many millions who work at night. disruption—the failure to coordinate biological Introduction rhythms with the daily light–dark cycle—as a probable Shift work (working outside of 6:00 AM to 6:00 PM) is a (2A) carcinogen (International Agency for Research on fixture of our 24-hr economy. Government statistics in- Cancer, 2007). Although scientific uncertainties remain, dicate that approximately 18 per cent of workers in studies were carried out in the decade since IARC’s the USA engage in shift work, many overnight review further strengthen the evidence that shift work (McMenamin, 2007). However, this estimate is unlikely is carcinogenic. Together with the increased risks for to capture shift work occurring as part of unreported cardiometabolic diseases and mortality observed employment, which is done disproportionately by among shift workers (Pan et al., 2011; Gu et al., 2015; the poor, many of whom are minorities (Saenz, 2008) Lin et al., 2015), this evidence makes shift work a press- and by the sometimes otherwise disadvantaged ing public-health concern. (e.g., middle-aged workers having only a high school Because breast cancer is the most studied example of education, for whom the mortality rate has been the complex health effects of shift work, we draw on the increasing in the USA (Sasson, 2016; Case and Deaton, state of science around this issue to argue that shift work 2017)). Shift work, in this way, represents a highly represents a public-health threat serious enough to war- prevalent economic and occupational disparity. rant a precautionary stance. We use the precautionary Evidence is accruing that shift work is associated with principle to advance our case and interpret its require- a broad array of adverse health effects, including ment for ‘shifting the burden of proof to the proponents cardiovascular disease, obesity, metabolic syndrome, of an activity’ (Kriebel and Tickner, 2001: 1351), one of type 2 diabetes and cancer (Pan et al., 2011; Gu et al., its more controversial elements, as a requirement to 2015; Lin et al., 2015; Bass and Lazar, 2016). In 2007, an share responsibility for shift work research, decision- expert panel at the International Agency for Research on making and policy making through a broad coalition Cancer (IARC) classified shift work involving circadian of diverse parties with a stake in shift work. We do doi:10.1093/phe/phy005 Advance Access publication on 12 March 2018 ! The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 45 not argue that shift work should be avoided until proven private profit over public health and social goods safe by shift work’s proponents. We acknowledge that (Mayer et al., 2002). An oft-cited definition comes from the 1998 such a requirement is infeasible and contrary to the Wingspread conference, which states that when activ- strong societal value placed on the availability of a ities raise the potential for serious harm to human range of services that require shift work. Rather, we health, precautionary measures should be taken even argue that the principle justifies—and in fact re- in the absence of complete scientific knowledge of quires—research directed at finding out how we can cause and effect (Science and Environmental Health reduce harms and an advisory process to inform Network, 1998). Over the years, the principle has been policy making as evidence emerges, with both activities variously defined and applied (Jordan and O’Riordan, taking into consideration the values of the various indi- 2004). Four common elements of the principle are: viduals and groups with stakes in having shift work as a (i) taking preventive action in the face of uncertainty; service and occupational option. On our construal, the (ii) shifting the burden of proof to the proponents of an principle is respectful and protective of the interests of activity; (iii) exploring a wide range of alternatives to shift work’s proponents. possibly harmful actions; and (iv) increasing public par- We sketch in a preliminary way what this shared re- ticipation in decision-making (Kriebel et al., 2005). sponsibility might entail and the obstacles it is likely to Our recommendation for a broad-based consortium face in the US context, and we note how this example that undertakes responsibility for research, deliberative might be applicable to other jurisdictions, especially public engagement and making policy proposals draws other countries with a similar prevalence of shift work. especially on two tenets (ii and iv) of the principle. We begin with a brief overview of the precautionary The requirement to shift the burden of proof to propon- principle and discussion of its utility as an ethical prin- ents of the activity in question (ii) is perhaps the most ciple in guiding public-health research and action, contentious aspect of the precautionary principle building on prior work that has elaborated on the prin- (Pearce, 2004). Some commentators have interpreted ciple in this context (Kriebel and Tickner, 2001; Jordan it to mean that an activity’s proponents must establish and O’Riordan, 2004; Pearce, 2004). We focus on the that an activity is safe, leading to criticisms that it would principle’s particular utility as a moral compass for stifle innovation and waste resources (Pearce, 2004; population health science as an interdisciplinary field Kriebel et al., 2005). Others, however, suggest that a of research that draws on many disciplines to investigate shift in burden of proof does not mean that the activity the disproportionate burden of illness and disease in must cease until proven safe, but rather that proponents minority and low socioeconomic status (SES) groups. of the activity commit to a range of responsibilities, such On our interpretation, the precautionary principle em- as thoroughly studying and monitoring potential powers public health to act from a stance of social just- harms; publicly disclosing information about potential ice, casting shift work within the domain of health harms; and making restorations for damage done disparities that demand social responsibility and collect- (Schettler and Raffensperger, 2004). The call to study ive action in the face of scientific uncertainty. potential harms has been further elaborated as a call for a particular approach to research, one that poses ‘broader hypotheses’, expands ‘characterization of uncertainties’ and studies ‘cumulative and interactive The Precautionary Principle and effects as well as risks to vulnerable sub-populations, and preventive interventions’ (Tickner et al., 2003). Population Health Science These elaborations on the type of research that should The precautionary principle calls for proactive measures be done in the name of precaution make it a particularly to avoid serious harms to human health and ecosystems apt guide for population health studies, including the under conditions of scientific uncertainty. The principle shift work studies we describe. Population health sci- represents a fundamental shift in policy making from a ence, sometimes referred to as social epidemiology or stance of reaction to proven hazards to anticipatory eco-epidemiology, develops frameworks with the theor- action to prevent potentially serious harms (Martuzzi etical and methodological power to contextualize biol- and Tickner, 2004). This approach challenges basic ogy and behavior within broader social systems to tenets of the prevailing paradigm of risk assessment, explain the disproportionate incidence of injury, illness including the assumption that products and activities and disease, such as are seen among minority and low are safe until proven dangerous and the privileging of SES groups (Susser and Susser, 1996). This explanatory Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 46 ADAMS ET AL. enterprise often relies on a notion of social causation in First, we prescribe broad-based research that is ongoing which disease outcomes involve complex interactions and directed at mitigating harmful effects on vulnerable and accumulations of exposures to repetitive and mun- subpopulations. Second, we call for the inclusive delib- dane, yet chronically stressful, circumstances, such as erative engagement of stakeholders, especially vulner- shift work, that produce a general susceptibility to a able subgroups who bear the burden of potential multiplicity of diseases (Hertzman and Boyce, 2010). harms, to ensure their values and needs have the oppor- Thus, population health science findings may entail a tunity to be voiced and included in development of level of complexity and uncertainty that invite scrutiny policy recommendations. not leveled at biomedical research in which singular causes are more directly associated with disease outcomes. Shift Work and Scientific That scrutiny is likely to play out in the public square. Uncertainty Unlike biomedical science, in which findings are typic- ally translated into health knowledge or health-care What we know about shift work is that millions of interventions that rely on individual initiative or re- people engage in it, that it is associated observationally sources, population health findings often have implica- with a modest risk for cancer in multiple cancer sites, as tions for community or societal-level policies and well as other health risks, and that the risk of cancer practices (e.g., clean air regulations or urban planning). increases with years of shift work. Additionally, those As such they are subject to public debate, both about the most likely to do shift work are from minority and low credibility of supporting evidence and priorities for SES groups (Saenz, 2008), which are, in general, exposed public resources and collective action. Such debates to more health risks and experience a greater burden of are ethical and political in nature, involving a plurality injury, illness and disease (Braveman et al., 2010). of values related to determinations about what consti- Because much of the extant research into shift work’s tutes ‘sound science’ and what aspects of human life negative health effects has been concentrated on breast most warrant protection and promotion at public cost cancer, we utilize breast cancer as the example to illus- (Stirling and Gee, 2002; Schettler and Raffensperger, trate current knowledge and remaining uncertainties 2004). about the health effects of shift work. Given the likelihood of conflict among such values and need to make normative trade-offs, we interpret the precautionary principle’s call for increasing public Molecular Mechanisms participation in decision-making (Tenet iv) in terms of Shift work is presumed to have deleterious effects on the public deliberation specifically. Public deliberation is an body’s circadian rhythms. The circadian molecular approach to stakeholder engagement that convenes clock is a transcriptional–translational feedback loop people from diverse backgrounds for in-depth discus- within each nucleus-containing cell in the body, consist- sion of topics of public concern to provide policy ing of a set core of transcription factors whose inter- makers with input about what actions ought to be car- actions produce a near 24-hr (endogenous) rhythm. ried out. Deliberative public engagement that meaning- The clock self-regulates its own daily rhythm as well as fully involves diverse stakeholders, including shift the daily rhythms of the genes it controls, leading to workers and members of the general public, could bene- daily outputs in metabolism, hormone production, fit decision-making in at least two ways. Individuals with varied perspectives and values are likely to see energy balance and cellular homeostasis—our circadian rhythms. The external light/dark signal permits the problems and potential solutions overlooked by experts ‘siloed’ within their fields (Kriebel and Tickner, 2001). clocks in the brain to coordinate their timing with that of the outside world and to use their coordinated Shift workers in particular may have insights regarding potential harms and how they might be mitigated, as we timing as a signal for the rest of the body. Thus, a dis- turbance in the timing of light (such as by light-at-night describe in more detail below. In addition, empiric stu- dies show that public deliberation can yield discussions or traveling across time zones) can interfere with the timing of the clocks in peripheral tissues. This is largely that are well informed and well considered, and recom- mend solutions that are civic-minded and egalitarian what is meant by the term chronodisruption or circa- dian disruption. We experience this as jet lag and mal- (Abelson et al., 2003; Gastil et al., 2010). We believe our interpretation of the precautionary aise, but at the molecular level, the clocks in various principle supports social justice action in two ways. tissues and the genes controlled by the clocks are no Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 47 Table 1. Shift work and breast cancer studies examined by IARC in 2007 Study Type Risk estimate 95 per cent Shift work (extreme group CI definition vs. referent) Schernhammer Prospective cohort 1.36 1.04–1.78 Rotating (3 nights/month + et al. (2001) days) Schernhammer Prospective cohort 1.79 1.06–3.01 Rotating (3 nights/month + et al. (2006) days) Tynes et al. (1996) Nested case-control 1.5 1.1–2.0 Work at night with exposure to artificial light O’Leary et al. (2006) Case-control 1.04 0.79–1.38 Any evening or overnight work Davis et al. (2001) Case-control 2.3 1.0–5.3 ‘Graveyard’ (either permanent or rotating) Hansen (2001) Nested case-control 1.5 1.3–1.7 Night work assigned for trades for which >60 per cent of women estimated to work at night Lie et al. (2006) Case-control 2.21 1.10–4.45 Years of night work imputed based on nursing jobs outside of hospitals Schwartzbaum Retrospective cohort 0.94 (SIR ) 0.74–1.18 Night work assigned for job titles et al. (2007) for which >40 per cent of staff worked at night Adapted from International Agency for Research on Cancer (2007). a b Odds ratios and relative risks. SIR = standardized incidence ratio. longer synchronized. Some clock-controlled genes are Research on Cancer, 2007). However, the specific as- involved in the cell cycle and the DNA damage response pects of shift work that contributed to cancer could (Sancar et al., 2010). The DNA damage response helps not be determined, in part due to variable definitions maintain cellular and genetic stability and is an import- of shift work. ant protection against carcinogenesis (Negrini et al., Since 2007, there have been six meta-analyses of shift 2010). Thus, changing the timing of light impacts work and breast cancer (Ijaz et al., 2013; Jia et al., 2013; circadian genetics throughout the body, potentially Kamdar et al., 2013; Wang et al., 2013; Lin et al., 2015; impacting pathways related to cancer. Eighty per cent Travis et al., 2016). Although one meta-analysis (Travis of the circadian-disrupting animal studies IARC et al., 2016) saw no evidence for an association between reviewed demonstrated enhanced carcinogenesis—con- breast cancer and shift work, the results have been ques- tributing to IARC’s interpretation that shift work is tioned because of a focus on older women (many years probably carcinogenic (International Agency for distant from their shift work exposure), the relatively Research on Cancer, 2007). But the exact underlying small number of breast cancer cases included and the mechanism, though implicating DNA damage, has yet variable amount of shift work exposure among study to be elucidated. participants (Anon, 2016). With the exception of this article, the overall picture is similar to the studies before 2007, with the additional strength that some revealed a Epidemiologic Studies dose effect: the risk of cancer increases with years of shift working. The epidemiologic evidence in humans for the carcino- genicity of shift work is suggestive but inconclusive. Six However, the current data are insufficient to assess whether the effect of shift work on cancer varies by fac- of the eight shift work and breast cancer studies IARC examined in 2007 demonstrated a modest increase in tors that could steer prevention guidelines, a gap in the the risk for breast cancer (see Table 1), mostly among science that constrains experts from suggesting policies long-term shift workers (International Agency for to mitigate harms: namely, by individual characteristics, Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 48 ADAMS ET AL. such as chronotype (preference for engaging in activity preventable morbidity and premature death. These earlier or later in the day) and sleep quality; by shift groups may be exposed to health risks associated with, system (rotating or permanent), years on a particular for example, resource-poor neighborhoods that have non-day shift schedule, and shift intensity (frequency of high levels of pollution and toxins and of violence and shift working; days off between shifts); or by social crime, institutional and interpersonal discrimination conditions that allow for undisrupted sleep when not and inadequate health care, all of which put them working or access to various services, such as gyms at heightened risks of poor health (Waitzman and and childcare, factors that could affect shift worker’s Smith, 1998; Marmot, 2005; Braveman et al., 2010). abilities to cope with the demands of working at night. Additionally, these groups may have few employment In addition, most studies have been performed in options beyond shift work due to low educational at- European populations, limiting generalizability. tainment, language barriers and discriminatory employ- ment practices. These groups may thus be particularly vulnerable to the effects of shift work, raising concerns about social justice. Although public health and precau- Justification of a tionary decision-making are often guided by utilitarian Precautionary Stance aims to maximize the good of the population at large, concerns about a fair distribution of burdens and bene- We think the evidence justifies a precautionary stance fits are also important in precautionary analyses and in toward shift work on three grounds. First, as already public-health ethics (Comba et al., 2004). Taken to- described, about 21 million people (18 per cent) gether, these considerations—the broad impact of po- engage in shift work (McMenamin, 2007) in the USA tentially serious health harms, the inability to eliminate alone, and the body of data on shift work’s effects points shift work and the disproportionate impact on socially to serious and sometimes irreversible harms to health. disadvantaged groups—support a fundamental shift in We focus on cancer in this article, but as noted above, how to think about responsibility for shift work research shift workers are also at an increased risk for common and decision-making. chronic morbidity, such as cardiovascular events (Vyas et al., 2012) and type 2 diabetes (Pan et al., 2011). Moreover, the acute risks of sleep deprivation put those who work the night shift at an increased risk for Shared Responsibility for Research accidents: 32–36 per cent of shift workers fall asleep on and Decision-Making through the job at least once a week; the risk of occupational accidents is 60 per cent higher for shift workers Collaboration and Deliberation compared to those who work during the day As described earlier, the precautionary principle’s core (Rajaratnam et al., 2013). Together, these shift work- tenets include, as two of four key elements, shifting the related health risks constitute a serious set of maladies burden of proof to the proponents of an activity to which a large fraction of the work force is exposed. and increasing public participation in decision- Second, the impact of shift work is broad in potential making. In the context of the uncertainties and potential burdens and benefits, affecting many types of services trade-offs posed by shift work, we interpret these elem- and segments of society. Some forms of shift work, rep- ents to call for a set of shared responsibilities for ongoing resenting essential public safety functions in law en- research and a process of deliberative public engagement forcement, health care and certain public utilities (e.g., that informs decision-making and recommends poli- air traffic control), cannot be eliminated. Other less es- sential forms of shift work (such as 24-hr food stores) cies, including assurances for those harmed by shift work. We envision a model of shared responsibility may be considered so integral to social goals that they for shift work that entails the following phases: conven- might be difficult to eliminate. They might make major contributions to the economy or modern conveniences ing a research consortium, evaluating current evidence to define critical knowledge gaps, gathering evidence to and thus be highly valued by some segments of the public at large and by some segments of shift workers. address those gaps, convening stakeholders for deliber- Third, the health risks of shift work fall dispropor- ation and using the evidence and deliberative output to tionately on members of minority and low SES groups, inform decision-making about shift work policy and who are exposed to an array of additional health risks practice (Figure 1). We describe and illustrate each and who experience a disproportionate incidence of element. Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 49 Figure 1. The proposed shift work research consortium and public deliberation. transportation agencies; other potential private partners Research Consortium include industries with a stake in shift work, such as the We propose the formation of a broad-based consortium health-care and transportation industries. The know- and identify key components for a US context—though ledge gained from this process could be used, for in- the model we propose could be adopted by other coun- stance, in the USA, to inform an Occupational Safety tries, especially those with a prevalence of shift work and Health Administration (OSHA) standard for shift similar to that of the USA, and ideally the findings work, which currently does not exist. from each country shared in a wider, international set- Our conception of those with a stake in shift work is broad. It includes people who represent public and com- ting. But to start, we envision a consortium comprised of diverse US stakeholders to take up a long-term re- mercial sectors that employ shift workers, unions, re- search and action agenda to increase the safety of shift searchers who study the health effects of shift work, work. This effort would include defining and then in- governmental agencies that set safety standards for oc- vesting in research that contributes to knowledge about cupations and public health and shift workers them- selves. Given that some forms of shift work represent potential harms and how they might be mitigated, har- monizing definitions of shift work so that data are com- essential public-health safety functions (e.g., law en- parable across settings, publicly disclosing research forcement and air traffic control), are highly valued by results and convening various publics to weigh the evi- the public (e.g., 24-hr access to retail, services and tech- dence and deliberate alternatives and options to reduce nology), and that its costs may be borne in some ways by harms. An ideal public–private convener would be, for the public (e.g., in lost productivity and health-care example, a partnership between the National Institute costs), members of public also have a stake in shift work. Shift workers should have a special role in the con- for Occupational Safety and Health (NIOSH), the gov- ernmental agency whose mission is to develop new sortium, acting as experts in their own right. There knowledge in the field of occupational health and should be ample and regular opportunities for workers safety and to translate this knowledge for public benefit, to share their insights into the real-world conditions of and the American Medical Association (AMA), whose shift work and to discuss their observations about its effects. Shift workers may be the first to recognize its members could offer medical expertise sometimes over- looked in population-based approaches to health. harmful effects and may have suggestions for mitigating NIOSH could then oversee the research process and harms that are missed by policy makers and scientists function as a hub for public deliberation. Other poten- (Stirling and Gee, 2002). In addition, the consortium tial public partners include the National Institutes should foster dialogue among employers and others of Health and state and federal public safety and with the power to effect changes to shift worker Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 50 ADAMS ET AL. schedules, as well as for brainstorming realistic avenues of action that we would expect to be explored if findings for risk assessment on the job in different types of oc- showed enough harm, and the information and political cupational settings. will gained from public deliberation are likely to in- Pairing the voices of shift workers and employers with crease the probability of regulation passing and to those of scientists, policy makers and others will enable shape the decisions about which types of regulation the consortium to develop a research agenda that iden- and which types of less formal policy measures would tifies the types of research projects that are needed to be suitable in different shift work settings. As such, uncover potential alternatives, policies and best prac- public deliberation involves representatives from the tices for shift work. For instance, chronotype is a very groups who have the power to change the culture factor that may impact how workers cope with circadian of shift working and gives them a stake in working with disruption, and it has been hypothesized that people the outcomes of the research. Public deliberation should who work a schedule out-of-synch with their chrono- take place at key moments in research, when evidence type (for example: people with an evening chronotype seems to warrant action. who do day shift work and people with a morning Continuing with the example of chronotype, if an chronotype who do night shift work) may be less able increased risk for cancer is verified for night shift work- to tolerate shift work than those who work in alignment ers who have a morning chronotype, the finding would with their chronotype (Erren, 2013). As such, the con- raise difficult questions about what policy or practice to sortium could make chronotype research an agenda recommend. Approximately 25 per cent of the popula- item, though other factors that affect worker’s abilities tion is thought to be morning-type, 25 per cent evening- to adapt to the demands of the night shift or to get type and the remainder of the population intermediate quality sleep on days off would likely surface once the chronotype (Paine et al., 2006). A recommendation, for members of the consortium start talking to each other. example, that morning-types avoid the night shift or In addition, the consortium might prioritize evaluation that employers avoid hiring morning-types for night of interactions between shift work and other health- shift work may result in a reduced risk of cancer (and related exposures experienced by shift workers. other chronic diseases) among these workers, but it would also place all the risk on evening- and intermedi- ate-type shift workers. It might also eliminate or greatly Gather Evidence reduce employment options for populations that have During this phase, the consortium would plan how do few employment options and who might value the work the research identified as central to resolving knowledge despite its health risks. Reducing shift work generally gaps needed to inform policy. Broadly, we envision the may also harm the economy at large, by reducing effi- consortium identifying funding sources (e.g., National ciencies or the size of the economy. The implications of Institutes of Health, Centers for Disease Control and such a recommendation pose ethical political questions. Prevention, private foundations); coordinating funding The effectiveness of any interventions would depend on and activities among various research organizations; the nature of the shift work setting, given the complex harmonizing definitions of shift work; setting standards interactions between shift work and local economies for data acquisition and data sharing; and assuring im- and, more generally, the different values held by mem- plementation of the research. As research progresses, it bers in different shift work settings. For instance, should will inevitably produce findings with policy, social and low-risk populations bear the entire burden of shift ethical implications that can benefit from a broader de- work? Should high-risk populations be banned or liberative public discussion. strongly discouraged from working nightshifts? Should testing for chronotype be offered and, if so, should it be voluntary or mandatory? More broadly, what obliga- Convene Stakeholders for tions does an employer have to shift workers to monitor Democratic Deliberation health status or to provide health-care insurance, should Public deliberation provides the proponents of shift they develop cancer or other maladies? The answers to work a voice in the research process and doing so an- these questions may vary in different shift work settings, ticipates action on findings, given that shift workers and as alternatives to shift work, services available to shift society would need to be willing to modify their behav- workers and costs to employers may vary. By drawing on ior should the research point to serious harms and par- the values and insights of diverse segments of the public, ticular mitigating approaches. To this end, though it is including those who engage in shift work and those who not the only one, formal regulation would be one form employ shift workers, shared social values can be Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 51 identified to inform best shift work practices, and values through collaborative cross-sectoral models that draw held more or less strongly in different settings could be on the expertise, perspectives and commitments of identified and harnessed to craft more setting- or many social sectors and the public at large. One such region-specific considerations, where appropriate. success story involves bringing together unlikely stake- holders—the National Rifle Association, the Second Amendment Foundation and activists interested in Inform Policy and Practice gun suicide, injury prevention and mental health. Their dialogue led to new law in Washington state to After the findings from research on shift work have been develop suicide prevention messaging and training for publicly deliberated, we envision the consortium for- gun businesses and pharmacies (Stuber, 2016). We be- mulating and publishing a set of guidelines and recom- lieve that protecting public health demands building mendations informed by the public values identified in broad-based coalitions such as this—inclusive of stake- the deliberations. The private–public partnership would holders with diverse interests and values and represent- disseminate the findings and guidelines broadly ing public and private sectors—that are committed to throughout the public and private sectors, working clo- finding common ground. If the current US political sely with state, province and county-level public-health situation has taught us anything, it is perhaps that work- agencies and key figures in the shift work industry (e.g., ing and talking within silos lead to polarization that, heads of hospitals and managers) to deliver the message among other harms, poses serious threats to the public’s to shift workers and stakeholders within industry. health. Conclusion Funding We argue that evidence of health harms associated with shift work justifies a precautionary stance. The harms This work was supported by the Fred Hutchinson associated with shift work are serious, sometimes irre- Cancer Research Center’s National Cancer Institute- versible, affect millions of people and fall disproportion- funded ‘Cancer Epidemiology and Biostatistics ately on minorities and the poor, who are exposed to an Training Grant’ [grant number 5T32CA009168]; array of health risks that include but are not limited to Cancer Research UK (CRUK) [grant number C18281/ shift work. At the same time, shift work enables essential A19169]; the Medical Research Council Integrative health and public safety functions and offers services of Epidemiology Unit at the University of Bristol; and the high value to the public. These considerations support a University of Bristol [grant number MC_UU_12013/2]. precautionary stance focused on generation of evidence and policies to mitigate harms and identify alternatives. 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Annals of and the Future of Our Children. Copenhagen: World Oncology, 24, 2724–2732. Health Organization, pp. 63–84. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

The Precautionary Principle for Shift-Work Research and Decision-Making

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Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PUBLIC HEALTH ETHICS VOLUME 12 NUMBER 1 2019 44–53 44 The Precautionary Principle for Shift-Work Research and Decision-Making Charleen D. Adams , MRC Integrative Epidemiology Unit (IEU) & School of Social and Community Medicine, University of Bristol Erika Blacksher, Department of Bioethics and Humanities, University of Washington Wylie Burke, Department of Bioethics and Humanities, University of Washington Corresponding author: Charleen D. Adams, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Clifton, Bristol BS8 2BN, UK. Tel.: +44 (0)7771 452912. Email: charleen.adams@bristol.ac.uk Shift work (working outside of 6:00 AM to 6:00 PM) is a fixture of our 24-hour economy, with approximately 18 per cent of workers in the USA engaging in shift work, many overnight. Since shift work has been linked to an increased risk for an array of serious maladies, including cardiometabolic disorders and cancer, and is done disproportionately by the poor and by minorities, shift work is a highly prevalent economic and occupational health disparity. Here we draw primarily on the state of science around shift work and breast cancer to argue that shift work represents a public health threat serious enough to warrant a precautionary stance. We use the precautionary principle to advance our case and view it as a moral compass for shift work research, empowering public health to cast shift work within the domain of health disparities deserving action despite scientific uncertainty. With the precautionary principle, we call for a deliberative decision-making process and formation of a broad shift work research collaboration to protect the health of many millions who work at night. disruption—the failure to coordinate biological Introduction rhythms with the daily light–dark cycle—as a probable Shift work (working outside of 6:00 AM to 6:00 PM) is a (2A) carcinogen (International Agency for Research on fixture of our 24-hr economy. Government statistics in- Cancer, 2007). Although scientific uncertainties remain, dicate that approximately 18 per cent of workers in studies were carried out in the decade since IARC’s the USA engage in shift work, many overnight review further strengthen the evidence that shift work (McMenamin, 2007). However, this estimate is unlikely is carcinogenic. Together with the increased risks for to capture shift work occurring as part of unreported cardiometabolic diseases and mortality observed employment, which is done disproportionately by among shift workers (Pan et al., 2011; Gu et al., 2015; the poor, many of whom are minorities (Saenz, 2008) Lin et al., 2015), this evidence makes shift work a press- and by the sometimes otherwise disadvantaged ing public-health concern. (e.g., middle-aged workers having only a high school Because breast cancer is the most studied example of education, for whom the mortality rate has been the complex health effects of shift work, we draw on the increasing in the USA (Sasson, 2016; Case and Deaton, state of science around this issue to argue that shift work 2017)). Shift work, in this way, represents a highly represents a public-health threat serious enough to war- prevalent economic and occupational disparity. rant a precautionary stance. We use the precautionary Evidence is accruing that shift work is associated with principle to advance our case and interpret its require- a broad array of adverse health effects, including ment for ‘shifting the burden of proof to the proponents cardiovascular disease, obesity, metabolic syndrome, of an activity’ (Kriebel and Tickner, 2001: 1351), one of type 2 diabetes and cancer (Pan et al., 2011; Gu et al., its more controversial elements, as a requirement to 2015; Lin et al., 2015; Bass and Lazar, 2016). In 2007, an share responsibility for shift work research, decision- expert panel at the International Agency for Research on making and policy making through a broad coalition Cancer (IARC) classified shift work involving circadian of diverse parties with a stake in shift work. We do doi:10.1093/phe/phy005 Advance Access publication on 12 March 2018 ! The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 45 not argue that shift work should be avoided until proven private profit over public health and social goods safe by shift work’s proponents. We acknowledge that (Mayer et al., 2002). An oft-cited definition comes from the 1998 such a requirement is infeasible and contrary to the Wingspread conference, which states that when activ- strong societal value placed on the availability of a ities raise the potential for serious harm to human range of services that require shift work. Rather, we health, precautionary measures should be taken even argue that the principle justifies—and in fact re- in the absence of complete scientific knowledge of quires—research directed at finding out how we can cause and effect (Science and Environmental Health reduce harms and an advisory process to inform Network, 1998). Over the years, the principle has been policy making as evidence emerges, with both activities variously defined and applied (Jordan and O’Riordan, taking into consideration the values of the various indi- 2004). Four common elements of the principle are: viduals and groups with stakes in having shift work as a (i) taking preventive action in the face of uncertainty; service and occupational option. On our construal, the (ii) shifting the burden of proof to the proponents of an principle is respectful and protective of the interests of activity; (iii) exploring a wide range of alternatives to shift work’s proponents. possibly harmful actions; and (iv) increasing public par- We sketch in a preliminary way what this shared re- ticipation in decision-making (Kriebel et al., 2005). sponsibility might entail and the obstacles it is likely to Our recommendation for a broad-based consortium face in the US context, and we note how this example that undertakes responsibility for research, deliberative might be applicable to other jurisdictions, especially public engagement and making policy proposals draws other countries with a similar prevalence of shift work. especially on two tenets (ii and iv) of the principle. We begin with a brief overview of the precautionary The requirement to shift the burden of proof to propon- principle and discussion of its utility as an ethical prin- ents of the activity in question (ii) is perhaps the most ciple in guiding public-health research and action, contentious aspect of the precautionary principle building on prior work that has elaborated on the prin- (Pearce, 2004). Some commentators have interpreted ciple in this context (Kriebel and Tickner, 2001; Jordan it to mean that an activity’s proponents must establish and O’Riordan, 2004; Pearce, 2004). We focus on the that an activity is safe, leading to criticisms that it would principle’s particular utility as a moral compass for stifle innovation and waste resources (Pearce, 2004; population health science as an interdisciplinary field Kriebel et al., 2005). Others, however, suggest that a of research that draws on many disciplines to investigate shift in burden of proof does not mean that the activity the disproportionate burden of illness and disease in must cease until proven safe, but rather that proponents minority and low socioeconomic status (SES) groups. of the activity commit to a range of responsibilities, such On our interpretation, the precautionary principle em- as thoroughly studying and monitoring potential powers public health to act from a stance of social just- harms; publicly disclosing information about potential ice, casting shift work within the domain of health harms; and making restorations for damage done disparities that demand social responsibility and collect- (Schettler and Raffensperger, 2004). The call to study ive action in the face of scientific uncertainty. potential harms has been further elaborated as a call for a particular approach to research, one that poses ‘broader hypotheses’, expands ‘characterization of uncertainties’ and studies ‘cumulative and interactive The Precautionary Principle and effects as well as risks to vulnerable sub-populations, and preventive interventions’ (Tickner et al., 2003). Population Health Science These elaborations on the type of research that should The precautionary principle calls for proactive measures be done in the name of precaution make it a particularly to avoid serious harms to human health and ecosystems apt guide for population health studies, including the under conditions of scientific uncertainty. The principle shift work studies we describe. Population health sci- represents a fundamental shift in policy making from a ence, sometimes referred to as social epidemiology or stance of reaction to proven hazards to anticipatory eco-epidemiology, develops frameworks with the theor- action to prevent potentially serious harms (Martuzzi etical and methodological power to contextualize biol- and Tickner, 2004). This approach challenges basic ogy and behavior within broader social systems to tenets of the prevailing paradigm of risk assessment, explain the disproportionate incidence of injury, illness including the assumption that products and activities and disease, such as are seen among minority and low are safe until proven dangerous and the privileging of SES groups (Susser and Susser, 1996). This explanatory Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 46 ADAMS ET AL. enterprise often relies on a notion of social causation in First, we prescribe broad-based research that is ongoing which disease outcomes involve complex interactions and directed at mitigating harmful effects on vulnerable and accumulations of exposures to repetitive and mun- subpopulations. Second, we call for the inclusive delib- dane, yet chronically stressful, circumstances, such as erative engagement of stakeholders, especially vulner- shift work, that produce a general susceptibility to a able subgroups who bear the burden of potential multiplicity of diseases (Hertzman and Boyce, 2010). harms, to ensure their values and needs have the oppor- Thus, population health science findings may entail a tunity to be voiced and included in development of level of complexity and uncertainty that invite scrutiny policy recommendations. not leveled at biomedical research in which singular causes are more directly associated with disease outcomes. Shift Work and Scientific That scrutiny is likely to play out in the public square. Uncertainty Unlike biomedical science, in which findings are typic- ally translated into health knowledge or health-care What we know about shift work is that millions of interventions that rely on individual initiative or re- people engage in it, that it is associated observationally sources, population health findings often have implica- with a modest risk for cancer in multiple cancer sites, as tions for community or societal-level policies and well as other health risks, and that the risk of cancer practices (e.g., clean air regulations or urban planning). increases with years of shift work. Additionally, those As such they are subject to public debate, both about the most likely to do shift work are from minority and low credibility of supporting evidence and priorities for SES groups (Saenz, 2008), which are, in general, exposed public resources and collective action. Such debates to more health risks and experience a greater burden of are ethical and political in nature, involving a plurality injury, illness and disease (Braveman et al., 2010). of values related to determinations about what consti- Because much of the extant research into shift work’s tutes ‘sound science’ and what aspects of human life negative health effects has been concentrated on breast most warrant protection and promotion at public cost cancer, we utilize breast cancer as the example to illus- (Stirling and Gee, 2002; Schettler and Raffensperger, trate current knowledge and remaining uncertainties 2004). about the health effects of shift work. Given the likelihood of conflict among such values and need to make normative trade-offs, we interpret the precautionary principle’s call for increasing public Molecular Mechanisms participation in decision-making (Tenet iv) in terms of Shift work is presumed to have deleterious effects on the public deliberation specifically. Public deliberation is an body’s circadian rhythms. The circadian molecular approach to stakeholder engagement that convenes clock is a transcriptional–translational feedback loop people from diverse backgrounds for in-depth discus- within each nucleus-containing cell in the body, consist- sion of topics of public concern to provide policy ing of a set core of transcription factors whose inter- makers with input about what actions ought to be car- actions produce a near 24-hr (endogenous) rhythm. ried out. Deliberative public engagement that meaning- The clock self-regulates its own daily rhythm as well as fully involves diverse stakeholders, including shift the daily rhythms of the genes it controls, leading to workers and members of the general public, could bene- daily outputs in metabolism, hormone production, fit decision-making in at least two ways. Individuals with varied perspectives and values are likely to see energy balance and cellular homeostasis—our circadian rhythms. The external light/dark signal permits the problems and potential solutions overlooked by experts ‘siloed’ within their fields (Kriebel and Tickner, 2001). clocks in the brain to coordinate their timing with that of the outside world and to use their coordinated Shift workers in particular may have insights regarding potential harms and how they might be mitigated, as we timing as a signal for the rest of the body. Thus, a dis- turbance in the timing of light (such as by light-at-night describe in more detail below. In addition, empiric stu- dies show that public deliberation can yield discussions or traveling across time zones) can interfere with the timing of the clocks in peripheral tissues. This is largely that are well informed and well considered, and recom- mend solutions that are civic-minded and egalitarian what is meant by the term chronodisruption or circa- dian disruption. We experience this as jet lag and mal- (Abelson et al., 2003; Gastil et al., 2010). We believe our interpretation of the precautionary aise, but at the molecular level, the clocks in various principle supports social justice action in two ways. tissues and the genes controlled by the clocks are no Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 47 Table 1. Shift work and breast cancer studies examined by IARC in 2007 Study Type Risk estimate 95 per cent Shift work (extreme group CI definition vs. referent) Schernhammer Prospective cohort 1.36 1.04–1.78 Rotating (3 nights/month + et al. (2001) days) Schernhammer Prospective cohort 1.79 1.06–3.01 Rotating (3 nights/month + et al. (2006) days) Tynes et al. (1996) Nested case-control 1.5 1.1–2.0 Work at night with exposure to artificial light O’Leary et al. (2006) Case-control 1.04 0.79–1.38 Any evening or overnight work Davis et al. (2001) Case-control 2.3 1.0–5.3 ‘Graveyard’ (either permanent or rotating) Hansen (2001) Nested case-control 1.5 1.3–1.7 Night work assigned for trades for which >60 per cent of women estimated to work at night Lie et al. (2006) Case-control 2.21 1.10–4.45 Years of night work imputed based on nursing jobs outside of hospitals Schwartzbaum Retrospective cohort 0.94 (SIR ) 0.74–1.18 Night work assigned for job titles et al. (2007) for which >40 per cent of staff worked at night Adapted from International Agency for Research on Cancer (2007). a b Odds ratios and relative risks. SIR = standardized incidence ratio. longer synchronized. Some clock-controlled genes are Research on Cancer, 2007). However, the specific as- involved in the cell cycle and the DNA damage response pects of shift work that contributed to cancer could (Sancar et al., 2010). The DNA damage response helps not be determined, in part due to variable definitions maintain cellular and genetic stability and is an import- of shift work. ant protection against carcinogenesis (Negrini et al., Since 2007, there have been six meta-analyses of shift 2010). Thus, changing the timing of light impacts work and breast cancer (Ijaz et al., 2013; Jia et al., 2013; circadian genetics throughout the body, potentially Kamdar et al., 2013; Wang et al., 2013; Lin et al., 2015; impacting pathways related to cancer. Eighty per cent Travis et al., 2016). Although one meta-analysis (Travis of the circadian-disrupting animal studies IARC et al., 2016) saw no evidence for an association between reviewed demonstrated enhanced carcinogenesis—con- breast cancer and shift work, the results have been ques- tributing to IARC’s interpretation that shift work is tioned because of a focus on older women (many years probably carcinogenic (International Agency for distant from their shift work exposure), the relatively Research on Cancer, 2007). But the exact underlying small number of breast cancer cases included and the mechanism, though implicating DNA damage, has yet variable amount of shift work exposure among study to be elucidated. participants (Anon, 2016). With the exception of this article, the overall picture is similar to the studies before 2007, with the additional strength that some revealed a Epidemiologic Studies dose effect: the risk of cancer increases with years of shift working. The epidemiologic evidence in humans for the carcino- genicity of shift work is suggestive but inconclusive. Six However, the current data are insufficient to assess whether the effect of shift work on cancer varies by fac- of the eight shift work and breast cancer studies IARC examined in 2007 demonstrated a modest increase in tors that could steer prevention guidelines, a gap in the the risk for breast cancer (see Table 1), mostly among science that constrains experts from suggesting policies long-term shift workers (International Agency for to mitigate harms: namely, by individual characteristics, Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 48 ADAMS ET AL. such as chronotype (preference for engaging in activity preventable morbidity and premature death. These earlier or later in the day) and sleep quality; by shift groups may be exposed to health risks associated with, system (rotating or permanent), years on a particular for example, resource-poor neighborhoods that have non-day shift schedule, and shift intensity (frequency of high levels of pollution and toxins and of violence and shift working; days off between shifts); or by social crime, institutional and interpersonal discrimination conditions that allow for undisrupted sleep when not and inadequate health care, all of which put them working or access to various services, such as gyms at heightened risks of poor health (Waitzman and and childcare, factors that could affect shift worker’s Smith, 1998; Marmot, 2005; Braveman et al., 2010). abilities to cope with the demands of working at night. Additionally, these groups may have few employment In addition, most studies have been performed in options beyond shift work due to low educational at- European populations, limiting generalizability. tainment, language barriers and discriminatory employ- ment practices. These groups may thus be particularly vulnerable to the effects of shift work, raising concerns about social justice. Although public health and precau- Justification of a tionary decision-making are often guided by utilitarian Precautionary Stance aims to maximize the good of the population at large, concerns about a fair distribution of burdens and bene- We think the evidence justifies a precautionary stance fits are also important in precautionary analyses and in toward shift work on three grounds. First, as already public-health ethics (Comba et al., 2004). Taken to- described, about 21 million people (18 per cent) gether, these considerations—the broad impact of po- engage in shift work (McMenamin, 2007) in the USA tentially serious health harms, the inability to eliminate alone, and the body of data on shift work’s effects points shift work and the disproportionate impact on socially to serious and sometimes irreversible harms to health. disadvantaged groups—support a fundamental shift in We focus on cancer in this article, but as noted above, how to think about responsibility for shift work research shift workers are also at an increased risk for common and decision-making. chronic morbidity, such as cardiovascular events (Vyas et al., 2012) and type 2 diabetes (Pan et al., 2011). Moreover, the acute risks of sleep deprivation put those who work the night shift at an increased risk for Shared Responsibility for Research accidents: 32–36 per cent of shift workers fall asleep on and Decision-Making through the job at least once a week; the risk of occupational accidents is 60 per cent higher for shift workers Collaboration and Deliberation compared to those who work during the day As described earlier, the precautionary principle’s core (Rajaratnam et al., 2013). Together, these shift work- tenets include, as two of four key elements, shifting the related health risks constitute a serious set of maladies burden of proof to the proponents of an activity to which a large fraction of the work force is exposed. and increasing public participation in decision- Second, the impact of shift work is broad in potential making. In the context of the uncertainties and potential burdens and benefits, affecting many types of services trade-offs posed by shift work, we interpret these elem- and segments of society. Some forms of shift work, rep- ents to call for a set of shared responsibilities for ongoing resenting essential public safety functions in law en- research and a process of deliberative public engagement forcement, health care and certain public utilities (e.g., that informs decision-making and recommends poli- air traffic control), cannot be eliminated. Other less es- sential forms of shift work (such as 24-hr food stores) cies, including assurances for those harmed by shift work. We envision a model of shared responsibility may be considered so integral to social goals that they for shift work that entails the following phases: conven- might be difficult to eliminate. They might make major contributions to the economy or modern conveniences ing a research consortium, evaluating current evidence to define critical knowledge gaps, gathering evidence to and thus be highly valued by some segments of the public at large and by some segments of shift workers. address those gaps, convening stakeholders for deliber- Third, the health risks of shift work fall dispropor- ation and using the evidence and deliberative output to tionately on members of minority and low SES groups, inform decision-making about shift work policy and who are exposed to an array of additional health risks practice (Figure 1). We describe and illustrate each and who experience a disproportionate incidence of element. Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 49 Figure 1. The proposed shift work research consortium and public deliberation. transportation agencies; other potential private partners Research Consortium include industries with a stake in shift work, such as the We propose the formation of a broad-based consortium health-care and transportation industries. The know- and identify key components for a US context—though ledge gained from this process could be used, for in- the model we propose could be adopted by other coun- stance, in the USA, to inform an Occupational Safety tries, especially those with a prevalence of shift work and Health Administration (OSHA) standard for shift similar to that of the USA, and ideally the findings work, which currently does not exist. from each country shared in a wider, international set- Our conception of those with a stake in shift work is broad. It includes people who represent public and com- ting. But to start, we envision a consortium comprised of diverse US stakeholders to take up a long-term re- mercial sectors that employ shift workers, unions, re- search and action agenda to increase the safety of shift searchers who study the health effects of shift work, work. This effort would include defining and then in- governmental agencies that set safety standards for oc- vesting in research that contributes to knowledge about cupations and public health and shift workers them- selves. Given that some forms of shift work represent potential harms and how they might be mitigated, har- monizing definitions of shift work so that data are com- essential public-health safety functions (e.g., law en- parable across settings, publicly disclosing research forcement and air traffic control), are highly valued by results and convening various publics to weigh the evi- the public (e.g., 24-hr access to retail, services and tech- dence and deliberate alternatives and options to reduce nology), and that its costs may be borne in some ways by harms. An ideal public–private convener would be, for the public (e.g., in lost productivity and health-care example, a partnership between the National Institute costs), members of public also have a stake in shift work. Shift workers should have a special role in the con- for Occupational Safety and Health (NIOSH), the gov- ernmental agency whose mission is to develop new sortium, acting as experts in their own right. There knowledge in the field of occupational health and should be ample and regular opportunities for workers safety and to translate this knowledge for public benefit, to share their insights into the real-world conditions of and the American Medical Association (AMA), whose shift work and to discuss their observations about its effects. Shift workers may be the first to recognize its members could offer medical expertise sometimes over- looked in population-based approaches to health. harmful effects and may have suggestions for mitigating NIOSH could then oversee the research process and harms that are missed by policy makers and scientists function as a hub for public deliberation. Other poten- (Stirling and Gee, 2002). In addition, the consortium tial public partners include the National Institutes should foster dialogue among employers and others of Health and state and federal public safety and with the power to effect changes to shift worker Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 50 ADAMS ET AL. schedules, as well as for brainstorming realistic avenues of action that we would expect to be explored if findings for risk assessment on the job in different types of oc- showed enough harm, and the information and political cupational settings. will gained from public deliberation are likely to in- Pairing the voices of shift workers and employers with crease the probability of regulation passing and to those of scientists, policy makers and others will enable shape the decisions about which types of regulation the consortium to develop a research agenda that iden- and which types of less formal policy measures would tifies the types of research projects that are needed to be suitable in different shift work settings. As such, uncover potential alternatives, policies and best prac- public deliberation involves representatives from the tices for shift work. For instance, chronotype is a very groups who have the power to change the culture factor that may impact how workers cope with circadian of shift working and gives them a stake in working with disruption, and it has been hypothesized that people the outcomes of the research. Public deliberation should who work a schedule out-of-synch with their chrono- take place at key moments in research, when evidence type (for example: people with an evening chronotype seems to warrant action. who do day shift work and people with a morning Continuing with the example of chronotype, if an chronotype who do night shift work) may be less able increased risk for cancer is verified for night shift work- to tolerate shift work than those who work in alignment ers who have a morning chronotype, the finding would with their chronotype (Erren, 2013). As such, the con- raise difficult questions about what policy or practice to sortium could make chronotype research an agenda recommend. Approximately 25 per cent of the popula- item, though other factors that affect worker’s abilities tion is thought to be morning-type, 25 per cent evening- to adapt to the demands of the night shift or to get type and the remainder of the population intermediate quality sleep on days off would likely surface once the chronotype (Paine et al., 2006). A recommendation, for members of the consortium start talking to each other. example, that morning-types avoid the night shift or In addition, the consortium might prioritize evaluation that employers avoid hiring morning-types for night of interactions between shift work and other health- shift work may result in a reduced risk of cancer (and related exposures experienced by shift workers. other chronic diseases) among these workers, but it would also place all the risk on evening- and intermedi- ate-type shift workers. It might also eliminate or greatly Gather Evidence reduce employment options for populations that have During this phase, the consortium would plan how do few employment options and who might value the work the research identified as central to resolving knowledge despite its health risks. Reducing shift work generally gaps needed to inform policy. Broadly, we envision the may also harm the economy at large, by reducing effi- consortium identifying funding sources (e.g., National ciencies or the size of the economy. The implications of Institutes of Health, Centers for Disease Control and such a recommendation pose ethical political questions. Prevention, private foundations); coordinating funding The effectiveness of any interventions would depend on and activities among various research organizations; the nature of the shift work setting, given the complex harmonizing definitions of shift work; setting standards interactions between shift work and local economies for data acquisition and data sharing; and assuring im- and, more generally, the different values held by mem- plementation of the research. As research progresses, it bers in different shift work settings. For instance, should will inevitably produce findings with policy, social and low-risk populations bear the entire burden of shift ethical implications that can benefit from a broader de- work? Should high-risk populations be banned or liberative public discussion. strongly discouraged from working nightshifts? Should testing for chronotype be offered and, if so, should it be voluntary or mandatory? More broadly, what obliga- Convene Stakeholders for tions does an employer have to shift workers to monitor Democratic Deliberation health status or to provide health-care insurance, should Public deliberation provides the proponents of shift they develop cancer or other maladies? The answers to work a voice in the research process and doing so an- these questions may vary in different shift work settings, ticipates action on findings, given that shift workers and as alternatives to shift work, services available to shift society would need to be willing to modify their behav- workers and costs to employers may vary. By drawing on ior should the research point to serious harms and par- the values and insights of diverse segments of the public, ticular mitigating approaches. To this end, though it is including those who engage in shift work and those who not the only one, formal regulation would be one form employ shift workers, shared social values can be Downloaded from https://academic.oup.com/phe/article/12/1/44/4930654 by DeepDyve user on 19 July 2022 PRECAUTIONARY PRINCIPLE FOR SHIFT WORK 51 identified to inform best shift work practices, and values through collaborative cross-sectoral models that draw held more or less strongly in different settings could be on the expertise, perspectives and commitments of identified and harnessed to craft more setting- or many social sectors and the public at large. One such region-specific considerations, where appropriate. success story involves bringing together unlikely stake- holders—the National Rifle Association, the Second Amendment Foundation and activists interested in Inform Policy and Practice gun suicide, injury prevention and mental health. Their dialogue led to new law in Washington state to After the findings from research on shift work have been develop suicide prevention messaging and training for publicly deliberated, we envision the consortium for- gun businesses and pharmacies (Stuber, 2016). We be- mulating and publishing a set of guidelines and recom- lieve that protecting public health demands building mendations informed by the public values identified in broad-based coalitions such as this—inclusive of stake- the deliberations. The private–public partnership would holders with diverse interests and values and represent- disseminate the findings and guidelines broadly ing public and private sectors—that are committed to throughout the public and private sectors, working clo- finding common ground. If the current US political sely with state, province and county-level public-health situation has taught us anything, it is perhaps that work- agencies and key figures in the shift work industry (e.g., ing and talking within silos lead to polarization that, heads of hospitals and managers) to deliver the message among other harms, poses serious threats to the public’s to shift workers and stakeholders within industry. health. Conclusion Funding We argue that evidence of health harms associated with shift work justifies a precautionary stance. The harms This work was supported by the Fred Hutchinson associated with shift work are serious, sometimes irre- Cancer Research Center’s National Cancer Institute- versible, affect millions of people and fall disproportion- funded ‘Cancer Epidemiology and Biostatistics ately on minorities and the poor, who are exposed to an Training Grant’ [grant number 5T32CA009168]; array of health risks that include but are not limited to Cancer Research UK (CRUK) [grant number C18281/ shift work. At the same time, shift work enables essential A19169]; the Medical Research Council Integrative health and public safety functions and offers services of Epidemiology Unit at the University of Bristol; and the high value to the public. These considerations support a University of Bristol [grant number MC_UU_12013/2]. precautionary stance focused on generation of evidence and policies to mitigate harms and identify alternatives. 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Public Health EthicsOxford University Press

Published: Apr 1, 2019

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