Ethical thinking in occupational and environmental medicine: Commentaries from the Selikoff Fund for Occupational and Environmental Cancer Research

Abstract A tribute to Dr. Irving J. Selikoff MD, the founder of this journal, is indeed welcome now more than two decades after his passing. He was known during his lifetime as the US Father of Environmental Medicine which at the time encompassed occupational medicine and much more as industry also polluted the general environment. The 1970s were a busy time as OSHA and the EPA were newly formed and high exposures to workers were no exception. Dr. Selikoff was a brave pioneer examining workers throughout the country and Canada, publicizing their exposures, and writing and presenting the scientific results. Industry was not always receptive and controlled an astounding amount of narrative, with the creation of the American Journal of Industrial Medicine filling a void of scientific need. We four authors write about the ethics of occupational health, the plight of nuclear energy workers, the climate crisis and opportunity for unions to engage workers, and the global march toward educating medical students on workers' health and safety. All four of us interacted with Dr. Selikoff during his tenure at Mount Sinai, and over the years joined each other in promoting his legacy. Toward that end we have written articles honoring his memory.

"Why that history?" I asked.
"It's short," he said, "and I'm looking for some philosophic tradition that will help us!" A "tradition that will help us!" The words of the son of a Talmudic scholar.
"That tradition," I said, "is not in the history books. It exists, but is not taught. It would have to be reinstated." And I described what I thought it was: Darwin's observations and beliefs interpreted, tempered, and expanded through the reconstructed minds of two predecessors, Baruch de Spinoza and Johann Wolfgang Goethe. Mephistopheles rescues Faust from fruitless study and brings him to a practiced life. 12 In our real life, like Faust, we make pacts with the devil. "A solemn obligation," not of a myth in another "world beyond," is needed to counter the real devil serving us on earth as in Faust. For "unlimited pleasures" in a life in which-like Faustwe allow ourselves to be "cast in chains and perish in Hell." 13 One of Selikoff's favorite expressions in elaborating his belief in a moral instinct was: "It all began with Darwin!" Perusal of Darwin's work makes his point about an inherited alternative to the chains of Faust: a moral instinct, of "gestures which are innate or common to all individuals of the same species, … it is extremely doubtful, whether any of them were at first deliberately invented and consciously performed." They were natural gestures." 13 What we witness is the ontogenetic and phylogenetic, clearly epigenetic reappearance of "primitive instincts" among lower species during human evolution, moral instincts.
There was never any doubt in Selikoff's mind about the underlying cause of ethical confrontation. "Man," Augustine observed, "can more easily count than be wise." 14  what ought to be found to be wise for us as a community eludes us. Selikoff would agree with Augustine that "there is wisdom: but whether there is one wisdom common to all or whether each wise man has his own as he has his own soul or mind, that we do not yet know." 14 For Selikoff, this quandary of humankind is left not by wandering among the unknowable, but by engaging in another universe of discourse, the discourse of science. We engage with this universe of "as if," by selecting a vision of the greatest good and the clearest truth framed by that which is most successful in preserving life, or as Augustine stated it, "the means by which every living thing flees death." In his Philosophie des Als Ob (Philosophy of As-If), Vaihinger argued that human beings can never really know the underlying reality of the world, and that as a result we construct systems of thought and then assume that these match reality. 15 We behave "as if" the world matches our models. In particular, he used examples from the physical sciences, such as protons, electrons, and electromagnetic waves. None of these phenomena have been observed directly. Science posits that they exist, and uses observations made on these assumptions to create new and better constructs, i.e. they are heuristic [fruitful].
In Vaihinger, "the whole world of ideas is an instrument to enable us to orientate ourselves in the real world, but is a copy of that world … [they are] relatively objective ideational constructs [not] subjective or fictional …." 15 The difference between fiction and hypothesis is critical. For example when the Darwinian hypothesis is verified the fiction disappears, resulting in real explanation. Similarly, Goethe's schematic animal archetype (which I outline here) is a fiction justified as an expedient, according to Vaihinger, albeit Goethe himself saw it differently: dual possibilities within both the universes of "as if" and "as is". "I soon felt the necessity of establishing a type," the poet-scientist wrote. From the perspective of "as is," he described his search for real primordial starting points, "against which one might gauge all mammals for conformity and deviation; and just as I had once sought out the archetypal plant, I now sought to find the archetypal animal." 16 But in his search, he understood that if his findings were to be systematized and explained, not just an empirical, but a conceptual dimension is necessary.
Thus, Goethe claimed, "in an attempt to study the laws whereby life is given to organic nature … quite justifiably, a force was ascribed to this life for purposes of discourse; and this force could be, indeed had to be, assumed …. We [are] obliged to assume a double point of view, considering ourselves as an entity sometimes perceivable by the senses, and at other times recognizable only with the inner sense or noticed only by an effect." 16 Causation as a law of nature is just such an eternal idea. Variations bridge the worlds of "as if" and "as is." Between these worlds is an abyss-never-filled, nor yet a void, which has expanded with the expansion of technology over the long eons of human evolution with mounting catastrophic strife in the struggle for life and freedom.
Clearly illustrated in the history of controlling atomic technologies, now centuries long, our failures multiply at an ever-quickening pace from the difficulties of controlling our hands and their extensions-simple tools and complex technologies-with mind and reason. The living human being is not a preformed machine built, boxed and controlled by an isolated will for use at a random or selfselected time. Each and together we are organic hierarchies of formative processes. Denoted from ancient times as "epigenesis," each stage of these vital processes has come to be through prior causes.
We become the set of prior causes of the next stage of organization. 17 Formation is not explained by function, which explains usefulness. Use is not its cause or a mechanism, but a description of survival value for the individual and the population bearing the useful trait. Such is the case of our inherited moral instincts.
This abstract idea becomes a concrete dynamic that is more than a molecular biological dynamic. It is of course one form of a broader process recognized not only in biology, but in the social sciences as well since Aristotle, as a way of understanding a social analog. The genius of the oft-quoted "experts" neglects an alternative to the Faustian Bargain: a moral sense! It has been long understood that human [and other than human] populations are never permanently without structure. Aristotle, writing centuries ago saw the village as one structure with inherited impulses among its inhabitants.
Aristotle's Politics sets the moral tone: "But when several families are united, and the association aims at something more than the supply of daily needs, the first society to be formed is the village." 18 Within the village, "There are three things which make men good and virtuous; these are nature, habit, rational principle. In the first place, everyone must be born a man and not some other animal; so, too, he must have a certain character, both of body and soul." 18 An example of the moral sense in operation may be found in the modern history of nuclear technology and its community of scientists. Enrico Fermi worked toward bringing Heisenberg, Germany's leading atomic scientist, to America, "to prevent [Heisenberg] from working for Hitler," [but Heisenberg feared that his emigration to the U.S.] "would bring something equally painful: pressure to work on a bomb intended for use against his homeland," thus favoring one side of a two-sided Faustian Bargain. 19 "Explaining the "failure" of the German Bomb program by the "simple incompetence" or "lack of patriotism" of Heisenberg and other Germans "is not looking very hard." Another mechanism was at work.
As horrendous as such issues may seem in an abstract sense, the plague of human ignorance on the virulence of the Faustian bargain coats depth and scope through millenia of human history and our future. In an abyss of ignorance, Faustian man alters the Face of the Earth, becoming a slave of his own creation in the struggle to maintain liberty in an environment dominated by money: cost-benefit analyses in which the sacrificial acceptance of death is seen.
"The last conflict is at hand," Spengler warned, in which civilization is in its conclusive form: the conflict between money and blood. 20 The private powers want free paths for their acquisition of greater resources. They want to make laws that use blood in the struggle for life itself, and with it the freedom to make the Devil's bargain, as seen in cost-benefit analyses, a process of changes in acceptable values in which, as Spengler notes, life seeks itself. 20 To do "population thinking," as Selikoff proposed, he understood that we must first consider the nature of living populations. They don't exist in a vacuum. They exist in an ecumene drawn and tied by communal mechanisms that facilitate organic actions-including changes in the ecumene and its members, such as modes of communication-enabling the life of the member and perpetuation of the member's species, such as modes of communication. The ecumenic environment as well as t-he group environed is subject to cumulative change. Ecumenes can be insular, sheltered from external circumstances. In an ecumenic environment, "the system is the selecting agent." 20 Organization as an adaptive mechanism, Paul Weiss noted, in which "[t]he primacy of the organized state of a living system thus becomes axiomatic, and there is nothing in our practical experience in cellular and developmental biology that would justify the illusion that freely operating genes can be the "source" of organization of the developing system in the sense of imposing order de novo on an extra-genetic matrix not already in possession of an organization of its own." 21 What does that mean?
In the last line of Albert Einstein's last published paper, a discussion of problems of incorporating causal theories of electromagnetic and gravitational fields in a unified system in physics-the theory of general relativity-he wrote that seeking a description of that reality is an attempt to find a purely algebraic theory. 22 "But," he wrote, "nobody knows how to obtain the basis for such a theory." The attempt to develop a general cosmology has a parallel in biological science: integrating theories of phylogeny or ontogeny reduced to physiological chemistry and molecular biology into holistic or organic models of living structures, both at the level of the nano and of the bifurcated mind and body, as done by the construction of epigenetic ecology, developing hierarchies or the suppositions of biological memory.
Some of the issues are intractable, such as found in the study of difficulties in applying population data to the causation of disease: the determination of cause of the same disease for a member of the population. Populations as subjects of study are difficult. The greatest mind of modern times clearly noted that reason is limited, not only his, but everybody's. Thus, Einstein answering fundamental questions of the creative human will said of some: I do not know the answers, nor can anyone else know.
Limits to reason alone as a path for answering our questions of what is good or true-even in the select dialectics of select gatherings of select scientists-is only one reality of the human will. Another is the failure to acknowledge the role of convention to accommodate the limitation of causal explanation, that is, the practical impossibility of tracing every causal pathway-leaving validation as the assumption of what is practically fruitful in answering questions of the meaning of observed fact, or useful contradictory explanations dependent on the heuristic acceptance of a convention.
Still another reality is willful distortion of methods or conclusions of investigation to fit individual or group needs or objectives, which themselves may be neither immoral nor false. The collective result is the plague of ignorance, endemic in human history, reflected in the inventive language of chance-"accidents"-used to explain what we observe as untraceably caused at any one time. "God doesn't play dice!," says Einstein. 22 Conventions can be used provided they are understood as conventions useful until such time as tracking problems are resolved. Bernard Gert ventures that: "Rational persons want to avoid death, pain, disability, loss of freedom and loss of pleasure," but will recognize differences among themselves on how to achieve these ends. 23 Selikoff the scientist would negotiate these differences in the moral instinct at work by following the same kind of rules scientists follow as scientists: rules that are axioms, not given certainties, kept or dismissed by their fruitfulness or success in the work of preserving life.
The human condition is like a heaving Arctic ice pack. Constant friction between the floes and massive bergs close and open leads to sets of axioms from which we must choose in the pursuit of moral judgment. One channel with universal fruitfulness can be found by charting the preservation of human life measured not only by biological persistence of the species, but by the well-being of the SAMUELS ET AL. | 291 individual and the community, facets of life inseparable and no less valuable than the physiologic organism itself. Indeed, biologic persistence and the well-being of the individual and of the community are not even knowable apart from each other. The flight from death is a flight from the death of all three of these.
The separation of biologic persistence, well-being and community destroys the pathway between the three. The human is not a grain of sand, but by choice and by necessity a complex organism in an ecumene, a structured and directed environment that can be examined by unfettering the moral sense.
There is no ecumene in which the unity of the human multitude is not threatened by the conscious perpetuation of the ancient caste of workers and those who are associated with them: a form of aggression that imposes pestilence, deprivation, and the eugenic threat.
Sociopaths embed the governing of the ecumene with economic sophistries. Cannibalism is justified in cost-benefit analyses used to compromise environmental justice, and shorten millions of lives. We have endured a century of workers compensation systems that unfairly transfer the burden of unnecessary uses of toxic agents and thus unnecessary sickness and death to the families of the afflicted, buried under distorted science and corrupted practices in medicine.
Castes, however, are not signified only by the color of one's collar: blue or white. Location, history, and economic or political status are other factors. Thus, we do not find it strange that "due to over four decades of uranium mining that supplied the US government and industry for nuclear weapons and energy, radiation illnesses characterize everyday Din'e (Navaho) life." 24 And this all takes place in full view for all who care to see, with not even a veil of shame. Franz Kafka, who earned his living in Prague in a workers' compensation bureau, understood what has been happening.
"…Nobody can remain content with the mere knowledge of good and evil in itself, but must endeavor as well to act in accordance with it." In this attempt, Kafka concludes, "[M]an is filled with fear; he prefers to annul his knowledge … yet the accomplished cannot be annulled, but only confused. It was for this purpose that our rationalizations were created. The whole world is full of them; indeed, the whole visible world is perhaps nothing more than the rationalizations of a man who wants to find peace of a moment." 25 Yet when it is evil that is being rationalized at the cost of life, we cannot accept even the peace of a moment: every living thing flees death first by demanding that the rationalization of the evil is known and understood, not only by the victim but throughout the ecumene.
Selikoff the optimist disliked my frequent use of the term "cannibalism" to describe the rationalization of evil in the work environment; he believed that it imprints too many negative images, slowing the process of positive dialogue (although he never argued that cannibalism was not alive and well in our space and time). Instead, he sought another framework of explanation that could lead to a fruitful substitute in achieving the primary human objective: the preservation of life.
Irving J. Selikoff, MD was a very private person. He did not want the usual biography focused on his personal life. He was far from shy and he sought recognition, but he had priorities. Conspicuous immortality was not his highest objective. He knew that the charisma of a leader is an important vector in the achievement of any agenda; there is no technician's black box for guiding human progress. It is appropriate to uncover a sense of the man or woman, but the critical idea that becomes an ideal towards which society must move is more important.
Soon after he retired in 1985, Selikoff began examining the moral content of the developing systems of beliefs and practices he and other physicians and scientists employ in discovering and managing the risks of workers to environmental disease. He was convinced that these beliefs and practices should be judged by their fruitfulness in the preservation of life, including the traditions that shape them, and that we ought to illuminate the forces of selection in their evolution.
His message was aimed at his colleagues in medicine and science, but he wanted to reach his followers in government, the labor movement, and even some in industry as well.
He began to link ideas and their origin with people and events in his professional life that cast light on the agenda to which he was dedicated, indeed, with which he was preoccupied to his last hours. 26 The project was not an exercise of warm memories or interesting speculation. The foremost challenge of occupational and environmental health then and now has been in the design of studies in the laboratory and in the clinic, even routine medical surveillance, and in the critical interpretation of the resulting information. The significant dialogue on design and interpretation is not taking place in the seminar or the academic conference, or even published in most of our learned journals. It has been taking place in the courtroom, the legislative hearing, and behind closed doors in the regulatory agencies.
The resulting dialectic, not understood by the public nor fully appreciated by the "experts," is a competition of systems of beliefs and practices each of which select different paths in the fate and wellbeing of hundreds of millions of humans now and in the future.
At the very least, Selikoff not only wanted to understand his own system, but he also wanted to examine the beliefs and practices of those whom he both supported and contested on issues of science or public policy. Most importantly, he wanted to promote a broader understanding among them of the choices implicit in their systems and, if they prevail, before the people. He wanted to drain a swamp of mistakes.
Selikoff wanted to understand how key scientific concepts, including their moral history, are linked collectively to events in our lifetimes and in the lives of those before us that seem to persist and repeat, sometimes on the same and sometimes on different strands of time and space. This was to be an examination of tradition in its fullest dimensions-the logic and politics of its community at the base of discovery, and how it was all held together by the core intuition of the intuitive scientist: unification of what we know in the singular goal of the simplest, successful explanation. The moral nature of traditions of discovery and explanation found in the clinic and laboratory, he appreciated, may be discovered in the arts and literature of the past and present. He had in mind the creations of those who, like Goethe, are both scientists and poets or philosophers. Indeed, in that first discussion, he spoke of the virtue of Goethe's Faust seeking, but failing to attempt without corruption, to "perceive the inmost force that bonds the very universe." 11 Goethe depicts surrendering to the devil reminiscent of both the ethical life seen in Jefferson's belief in a moral instinct in the same era, and of Selikoff's abhorrence of the Faustian Bargain as seen in the governance of professional life in the United States and the western community, a condition encountered in implementation of the work health laws.
Perceptions that persist or are repeated, whether of scientists or common men, are at the base of such traditions. Perceptions are also judgments. What we see is often what we want to end, often the tails of problems we have not solved, obstacles we have not overcome, and tragedies we ought not tolerate.
Selikoff was in many ways a Jeffersonian who would more often than not assign collective responsibility for the moral mistakes we make, and not ascribe personal blame to the individual. He saw great difficulty in judging the extent to which an individual is fully a moral agent in the usually partially-understood circumstances of most cases. This is an important nuance in understanding his optimistic behavior toward those on the other side of the struggles in which he was engaged.
Irving Selikoff's philosophy of optimism, his "opaque glass half full," is a "perspective" (to use one of his favorite words) of the system of natural science and moral belief of a giant he idolized: Darwin.
Both dissented from the establishment scientists of their day.
Darwin, in addition, was seen as a heretic by the leaders of his community because of views that questioned articles of faith and thus, for some, of morality, views in a tradition of dissent at least as ancient in the British Isles as that of the 5th century Celtic monk Pelagius. Like Darwin, he was educated in theology, but was never ordained. They both believed, as did Selikoff and those in his tradition, in the ability of humankind through science to alter the environment to which we as organisms adapt. To quote John Dewey, we need "to expand and enrich experience" for "self-creation and self-regulation," limited morally and intellectually only by the "defects in our good will and knowledge." 27 If we look for uniformity in this moral perspective among those who also held to the biology of Darwin, we will be disappointed. Without question, events occur in our lives that shake the optimism even of a Darwin, Dewey or Selikoff. The opaque glass often appears to be half empty. Moral sense does not always penetrate the human surface. What Selikoff would call a moral mistake is frequently repeated, repetition that appears to be the constant reality, so that some may conclude that they are not moral mistakes. They are biologically-evolved inherent evil. Arthur Koestler, a leading pessimist of Selikoff's generation, posed "the possibility that Homo sapiens is a victim of one of evolution's countless mistakes," of faulty brain design. 29 Our species, he emphasized, "is virtually unique in the animal kingdom in (our) lack of instinctive safeguards against the killing of … members of (our) own and 300 miles upwind from the city of Amarillo, Texas. The first bomb cost two billion 1945 dollars. 30 The shock waves have not abated.
What originated as a game in the scientists' world of "as if" has become a challenge to human existence.
The first warnings were found in diseases of nuclear workers, the sorrows of their families and social sickness in their communities, as witnessed by Laura Fermi in Chicago, in 1957. There she wrote Atoms in the Family and Atoms for the World. 31,32 The last was her account of the first Geneva conference on the peaceful uses of nuclear energy.
We learn that early in the history of the nuclear industry, in 1940, her husband Enrico Fermi's research assistant became fatally ill of beryllium disease from exposure to fumes in an unvented laboratory at Columbia University. 31 Despite this case and European reports, the Public Health Service had in 1943 declared beryllium dust to be nontoxic. 33  Early studies of these workers focused attention on cancer risks of miners exposed to high levels of radiation and other carcinogens. America. This pattern of excess death has marked social sickness associated with uranium mining since its beginnings in the Erzgebirge of Central Europe centuries ago.

Moral History
Human ecological factors-the caste (a human group within a population perceived to be better or worse than others) and the ecumene (the region where members of castes live) are often inadequately considered in programs of disease prevention, intervention, and therapy, in which health beliefs and behaviors, and, ultimately, health status are shaped. Caste-bifurcated communications networks influence health-promoting actions, affecting the perceived need for services and the individual or group decision to seek medical assistance. Our attention is diverted by economic encounters between the physician and patient. Polarized by communication through the bifurcated social networks of the community, especially family and peer groups, the milieu in which we try to promote screening, monitoring, and early detection of disease is skewed. Yet, we often act as if the caste structure and its meaning for A critical ecological dynamic begins with changes in employer-employee relations. During such times the need for unifying symbols in society and the need to recognize collective moral principles are critical. The workers' sense of social unity is diminished when they are disabled or sick and unable to participate in normal work and community activities. Facilitating mechanisms-such as support groups-for handling these realities of the workplace are the responsibility of those able to respond to these needs. Acting on that responsibility is more likely to occur among those who share a community with the afflicted.
Solidarity alone is insufficient. Trusted information must be brought to the group. But looking outside the group for sources, the worker often sees a barren landscape. It is not unusual to find the absence of independent sources of trusted medical counsel among a community's medical providers. This factor points to the importance of structuring interventions to reinforce access to independent medical judgment that could help interpret information on occupational disease, psychosocial stress, and genetic or other tests. The worker or the worker's family typically manage this cascade of issues without assistance, making determinations with little guidance, on problems that defy expert judgment, in the separation of occupational and nonoccupational causes of disease, modes of treatment, and options for economic relief within the systems of insurance and healthcare. They typically lack effective networks and support structures, without which workers' ability to perform critical social and economic roles may be reduced to the point of nonexistence.

The Legacy of the Erzgebirge
Predating the American uranium experience, in the Erzgebirge Environmental factors in occupational suicide, while long noted and diverse, are not usually identified or accepted. Yet an early study by Mancuso and Locke found an excess of suicide in viscose rayon workers in which exposure to carbon disulfide was the suspected cause. 45 A later review of the literature by Boxer, Burnett, and Swanson disputed this and similar findings, concluding that "any causal relationship between suicide and job-related factors" was not proven. 46 The authors attributed the deaths to personal factors, such as alcoholism. However, Kposowa studied suicides among workers in construction and manufacturing, and identified associations with neurotoxic substances, as well as other stressors, including threats to job security, malpractice lawsuits, and various forms of harassment. 47 Their work is strengthened by workers' experience in vinyl chloride manufacture. On the day the new OSHA standard for this material went into effect, a tire worker in Western Maryland "flunked" the bilirubin test required by the standard and shot himself. At a vinyl chloride plant in Louisville, Kentucky, "failed" workers were put to work in a pallet plant, which they quickly named the "leper colony." NIOSH was excluded from the DOE system except for the ur- increased insurance premiums and payroll taxes that finance social security disability and medical retirement benefits. 48 The immense size of the problem, and the inability of our compensation systems to deal equitably with the issues, was made startlingly clear in the coal miners' struggle to achieve passage of the Black Lung Benefits Reform Act of 1977.
In the past, the Amarillo metropolitan area, home to the Pantex nuclear weapons assembly plant, was historically afflicted with significant point sources of particulates and sulfur oxides. The particulates of concern were asbestos and metals, especially beryllium. The agent of greatest concern, however, was ionizing radiation. High levels of anxiety were generated by a lack of environmental (area and personal) and medical monitoring and the absence of personal ex- Subcontractor, temporary, probationary, and short-term employees who when exposed to known high levels of radiation were, in the words of one participant, "flushed." They are not fully represented in the records or in any study of this and sister populations. In any one cell of high exposure, there typically might have been only one permanent employee.
It is important to keep in mind that in the early days of nuclear weapons production, fabrication at Pantex was conducted under wartime conditions that have been moderated, but not eliminated, over time. To some extent, this explains cavalier work procedures, personnel policies insensitive to levels or duration of exposure, and unacceptable materials handling.
In meetings convened by the Metal Trades Department of the AFL-CIO in Amarillo of councils of nuclear workers from throughout the DOE system, perceptions of the workers focused on cases of disease reasonably attributable to the work environment. High levels of anxiety and anger had overcome the natural reticence of the patriot-worker to complain. Peer pressures had changed, and the stoic hesitancy to express personal pain endemically characteristic of their culture was pierced. Information on conditions and standard practices of the past and present became more specific and expressed more strongly. The high concern over the absence of adequate personal medical and exposure records was a major factor in the call for energy workers' compensation legislation.
The follow-up mechanism was the MTD-IUD Workplace Health  When first conceived more than a century ago, only one-time, short-term incidents for a relatively small number of victims with a limited spectrum of exposure and acute disease attributable to a specific place, practice, or agent were covered.
A fruitful substitute is the discoverable added burden of risk for populations, not fictional probabilities of causation in individual cases.
This approach requires more comprehensive industry-wide studies. SAMUELS ET AL. | 297 "Data, data, and more data," Irving Selikoff repeatedly insisted, would be needed for multi-factor systems of compensation.
A century of effort by leading elements of the labor movement to achieve occupational disease compensation reform has led to recognition of the need for new structures of trusted institutions. The moral questions arising from the increased use of genetic markers in medical surveillance and, inevitably, in compensation, highlights the absence of trusted structures for detecting and controlling persisting disease in the nuclear industry. The most common process for the discovery of occupational disease is begun by the victims' families.
NIOSH reports provide a partial history of why the Pantex records of occupational exposures are of limited value. The report on Occupational Internal Dose notes "no routine bioassay program before 1972," 49 "little or no tritium bioassay monitoring" in the years 1972 through 1976 or in the year 1984, "only 3% of the files had uranium bioassay results," "no plutonium or thorium bioassay results were found," 49 and "no guarantee that everyone exposed to tritium was monitored." 49 The NIOSH report, however, fails to note the post-1989 watershed effects, illustrated in Table 1.
Data reanalyzed from the report on Occupational External Dose 49 (Table 2) The use of lead aprons were "not included in procedures until the mid-1980s." 49 NIOSH staff note that the process of dose reconstruction is "imperfect," but believe that it is "reasonable," even in the face of past defective practices: "in the case of internally deposited radio-nuclides, the regulatory guidelines before the late 1980s did not require that detailed organ doses be calculated [if the quantities deposited were less than recommended maximums]" 50    The NAS/NRC committee objected to NIOSH's use of the term "probability of causation" because that concept "applied to populations and not individuals and could not be interpreted as the probability that a given cancer was caused by a given radiation exposure." They recommended using the term, "assigned share" because the computed quantities "are not probabilities in the usual sense and are truly properties of the group to which a person belongs, but in practice are assigned to the person for purposes of compensation." [Emphasis added.] The NIH and NCI-CDC working groups were both "sympathetic" to the NAS/NRC views.
The NCI-CDC group, with some justification, rationalized the "assigned share" concept as if it were an actuarial concept and the tables as if they were actuarial tables used by insurance companies. 52 In using actuarial tables, an insurance company applies individual case data gathered by the company's agents and physicians, and does not issue a policy without that data. The problem in using the NIH reconstructions is that the individual case data often does not exist, may never have existed, and often was poorly gathered. Law provides for the establishment of a "Special Exposure Cohort" for these cases.
The Beryllium is ubiquitous in fossil fuel. As a consequence its gas aerosols may accumulate where the fuel is burned. One in- Since then, the number of industrial and remediation workers exposed to beryllium dust has increased with its growing applications, while the total number of industrial workers has decreased. 55 Possibly 800,000 workers in the United States in 1975 were then or previously exposed to beryllium dust, not counting "downstream" users in jewelry and sporting goods. 56 Government priority focused on the primary beryllium industry and Department of Energy weapons facilities, for whom the prevention of disease, the protection of life itself, is a secondary consideration.
Beryllium's toxic effects have been a concern in Europe since the 1930s. 57 Delayed effects were encountered in the 1940s by Harriet Hardy at Los Alamos National Laboratory. 53  About 31% of those found with beryllium sensitivity may progress to chronic beryllium disease after about 4 years. 59 There is no recommended treatment for sensitivity. The treatment for chronic disease-using corticosteroids-has well-known adverse side-effects.   Based on the nuclear industry's safety performance and capacity to produce electricity, it should be considered an essential component of the national clean energy strategy. However, three vexing questions need to be resolved before nuclear power is embraced more heavily: • How are the civilian uses of nuclear power kept separate from weapons uses?
• How do we manage the waste?
• How do we prevent complacency, negligence, or fraud in the operation of nuclear plants, given the very significant consequences of nuclear disasters?

Introduction
Samuels (elsewhere in this issue) has described how Dr. Selikoff was fond of referring to the "Faustian bargain" we make when we chose between economic interests and safety/health interests. In my discussions with Samuels over the years, we frequently referred to it as the utilitarian's (meaning me) dilemma. Perhaps nothing describes this bargain (or dilemma) better than our mixed feelings about the use of nuclear fuel as a source of energy.
Since World War II, the exploitation of energy for peaceful purposes from the mining, refining, and processing of uranium ore has been debated heavily. This debate has been unusually bifurcated (much like most issues in this political cycle, but much more so than for most other issues historically). You take your side, either for or against; there has been little room for ambiguity or for straddlers.
It is hard to separate out the peaceful uses of uranium from the military uses, and it is also hard to separate out peaceful uses with The US is ambiguous about nuclear energy. At its peak, the US operated 104 nuclear power reactors. This number has declined to 95, but because of greater efficiency, output per plant has continued to increase and supply roughly 20% of total energy production. 67 In 2017 when the last new nuclear reactor to become operational was inaugurated, and it was the relic of a project started in 1973, before The other, in Waynesborough, GA, will be completed in 2021/22, having taken twice as long to construct as initially projected and costing more than twice as much. 71 It ended up bankrupting Westinghouse, and almost brought down Toshiba, which had bought Westinghouse. 72 Long before these plants were completed, the prospect of them making economic sense in the short term had vanished. The nuclear renaissance petered out, not because of safety concerns, but because of a glut of natural gas resulting from fracking.

The Faustian Bargain
The Benefits These days a "typical" nuclear power plant produces about 1-1. There is one main reason why nuclear power is still an attractive energy source: its capacity factor. Compared to other sources of energy, nuclear fuel wins in the capacity factor race by a long shot. A typical nuclear power plant operates at a capacity factor of about 95%. This means that over its lifetime a nuclear plant will only stop generating energy about 5% of the time. Just as significantly, the lifetime of these plants is proving to be much longer than originally anticipated. While they were originally licensed to operate for 40 years, it now looks like they can easily last twice that long, and many licenses have been extended for an additional 20 years or more. All the while these plants chug along 95% of the time. Compare that to other sources of energy, with much shorter life expectancies and much lower capacity factors: natural gas, 57%; coal, 48%; hydro, 39%; wind, 35%; solar, 25% (see Figure 1). 79 Because of the longevity and capacity factor of nuclear power plants, it is likely that they are more economical than the other currently known sources of energy. But, reaping that benefit can only be achieved over a very long time, making the high initial investment much more uncertain. Few energy players in the United States seem willing to take that risk.
These days natural gas is a favored alternative because of its low cost and the fact that a gas-fired power plant is easier to construct than a nuclear plant, both in terms of capital investment and time. It is also a mixed blessing. Electricity generated with natural gas produces about half the particle pollution (about 1 pound of CO 2 per kilowatt hour) compared to coal (about 2 pounds) or petroleum (1.5-2 pounds). 73 Even so, gas-fired plants produce about 50 times as much air pollution as a nuclear plant per unit of electricity generated. 74 The Risks There are plenty of reasons why nuclear energy should be viewed with caution. First, it is less green than it may seem. The nuclear fuel cycle, from mining to disposing of spent fuel, is filled with energy consumption and creates considerable hazardous waste. To build a nuclear power plant generates huge amounts of CO 2 , and the operation of nuclear power plants also consumes energy. The Fukushima criticality did not result from a reactor failure: it resulted from a power failure. The offshore earthquake first took out the electrical supply that came from the electrical grid to the power plant.
Then, the following tsunami swamped the plant's diesel-powered back-up generators. 75 The electricity supplied to a nuclear power plant is essential to operate the gigantic pumps that drive cooling water to the reactor to keep it from overheating, and for delivering water to the reactor for creating steam to drive the turbines, and finally for pulling the steam from the turbines into condensation facilities that convert the steam back into cold water. In other words, while a nuclear power plant produces massive amounts of energy, it also consumes a fair amount of energy. So, it is quite valid to question how green this energy really is.
Unlike other forms of "green" energy, nuclear-powered plants produce a lot of waste that is highly radioactive. A typical plant needs to be refueled every 18-24 months. This means that existing fuel rods need to be removed from the reactors and replaced with new F I G U R E 1 Capacity factor by type of electricity generation, USA, 2019 ones. This "spent fuel" is still highly reactive. And compared to fossilfueled power plants, which also produce a lot of waste, the nuclear waste has a long toxic half-life. And, when things go wrong in a nuclear plant, it takes forever to remedy the disaster. Fukushima is still highly radioactive, a decade after the disaster there. It has huge ponds filled with radioactive waste that somehow will need to be emptied.
The disposal of nuclear waste has vexed many countries, but especially the US, which has not come up with a permanent solution yet. 76 Much of this waste can be recycled (more commonly known as Until the Fukushima disaster, it had been easy to explain past disasters such as Three Mile Island (it operated on a fossil fuel management model) or Chernobyl (lack of preparedness and accountability). 113 Fukushima resulted not from a lack of being current.
It had adopted a vast array of new safeguards developed since 1980.
There had in fact been the equivalent of a revolution in the way that the nuclear power industry approached safety. 81 Still, there were remnants of the arrogance of nuclear engineering even within the Fukushima operation. The International Energy Administration's review of this disaster found that "A major factor that contributed to the accident was the widespread assumption in Japan that its nuclear power plants were so safe that an accident of this magnitude was simply unthinkable. This assumption was accepted by nuclear power plant operators and was not challenged by regulators or by the Government. As a result, Japan was not sufficiently prepared for a severe nuclear accident in March 2011." 75 Occupational Risks: Comparing Nuclear Energy to Other

Sectors
In our 2011 assessment of energy production risks, we con- On the whole, nuclear power generation plants report rates of occupational illnesses and injuries that are favorable compared to all other industries (Table 3) and other sources of electricity generation (Table 4). 114  And, if we look in more detail at the most hazardous work within electricity generation, which is outage maintenance work, the nuclear sector has outperformed other energy sectors with injury and illnesses rates that are 80% or more lower than in fossil fuel, hydro, or renewable sources. 76 The Core of Nuclear Safety: Zero Tolerance Following Three Mile Island, the US nuclear energy industry concluded it needed to take a zero-tolerance approach to risk. This F I G U R E 2 Average annual radiation dose per worker with measured dose sets it apart from all other industries, where cost-benefit decisions are much more prevalent, and also part of the regulatory landscape.
The concept of minimal risk has been an essential element of nuclear safety since health physicists established there is no safe level of human exposure to radionuclides. This led them to adopt the ALARA ("As Low as Reasonably Achievable") Standard for radiation exposures.
Nuclear generating plants in the United States are regulated by the Nuclear Regulatory Commission, which has vastly more power and resources than any other safety regulatory agencies in the United States. Unlike in general industry, where a workplace may be inspected once in every 30 years or so, each nuclear power plant has at least two resident NRC inspectors that perform daily walk-throughs of the plants. 80 And the NRC has a power which no other agency has: it issues, and can revoke, the operating licenses granted to nuclear facility operators.
Moreover, around 1980 the nuclear power operators established a self-regulatory system, The Institute of Nuclear Power Operators (INPO), which may well have more influence over how nuclear plants are operated than even the NRC. 81 Conclusion Work in nuclear energy facilities is much safer than work in general industry, or in other sources of energy production, including the renewable energy sources. Nuclear facilities cannot afford even minor mishaps. The owners of these facilities have adopted a system of self-regulation that is unprecedented, and they abide by a regulatory system that is much stricter than in any other industry.
The Three Mile Island disaster was a watershed that led to the recognition that a general industry approach to safety was not nearly sufficient for nuclear work. This led to the establishment of INPO. In 2011, when the NRC adopted a nuclear safety culture framework, 82 the transformation of the industry from high risk to exemplary safety was complete.
As a result of these actions, safety indicators for nuclear power plants have declined on average by over 90% since Three Mile Island.
Meanwhile, the capacity of nuclear power plants has increased by more than 60%. That is a remarkable transformation.
Does that mean that the industry is out of the woods? Not at all.
There remain three great challenges that both nuclear proponents and policy-makers would like to see disappear by themselves: How do we keep civilian uses of nuclear power separate from weapons uses? Many countries have so-called "dual use" reactors that can generate electricity but also produce high grade nuclear materials such as plutonium. The US has one, at Watts Bar, TN, which has been used to produce tritium. 83  including to an extent in the Fukushima melt-down, and the response to that disaster. 75 We need energy, and now more than ever we need clean energy.   Paleo-ecologists going back in the fossil record millions of years have found periods of 2°C warming due to increased CO 2 which correlated with more than 10 m of sea level rise above current levels.

Health Consequences from Global Warming
There are consequences from global warming that we can observe in the present, and with the knowledge that worse is yet to come. [86][87][88]  These storms cause a huge loss of life during and after the event, and cost hundreds of billions of dollars in damages causing many insurers to take pause in insuring coastal housing.
Burning fossil fuels cause tremendous air pollution, with emission of fine particulate matter, nitrogen oxides, and ozone formation. York City also has many large apartments that burn heating oil, while most of the recently constructed apartments, businesses, academic institutions, and hospitals burn natural gas. Cooking stoves are heavily committed to natural gas, illustrating the opportunities to convert to electric or induction stoves and clean electricity fronted by off-shore wind, for example. Changing to LED lighting in thousands of apartments would increase energy efficiency.

States, Unions, and Renewable Energy
The Apollo Alliance two decades ago brought together unions,   formally trained in occupational medicine, and I also found no such faculty member at one of the private medical colleges.

Conclusions: A Sad State
While it is obvious that there is now considerable worldwide concern about environmental issues such as climate change, and even some growing concern about injuries and illnesses at work-  Darwin, Selikoff noted, found "truth" in the universal struggle for life. The positive checks-war, famine, endemics-raise the mortality rate. Moral restraints, he believed, reduce the rate. He would give the struggle to control asbestos as an example but noted that success in that struggle too often leans on "professionals" in a "think tank" claque who make moral mistakes. Thus, the necessity to challenge myths of professional objectivity, informed by insights such as those of Ludwik Fleck. 109 " The "accumulated experience-not only of an individual but of a well-trained collective," Fleck wrote, is one in which the members "teach others to see" 'facts'. 109  If herd immunity declines, disease and death increase, raising moral issues on supposed rights of free unimpeded speech or expression. More, self-contagion of the spewing agent increases disease and death among the sub-population of spewers of untruths.
The likelihood of herd immunity is increased by their suicides.
The increase in such social suicide, reflecting social chaos he labeled "anomie," was described by Durkheim in a series of publications initiated in 1893. 38 Its long conceptual life has not reduced its importance in understanding this dynamic of human communities. pers. 111 Cost/benefit analysis assumes that all the variables with which it deals are or can be made commensurable with one another so that there is a common denominator into which the costs and benefits can be translated: a person's preferences in the allocation of resources, for example, in allocation of money. He found five difficulties with this position: • Distributive justice.
• No market price.
• Those who set a price on human life are not those being valued.
• Permits polluters to pay to prolong the risk.
Social suicide through desecration of reason embodied in cost-benefit analysis prevails not only in United States regulatory policy but also in setting priorities in the nation's budget. This is done by accepting a skewed meaning of "growth," whether in sociological, biological, or economic dialogue.
Issues of science and ethics that beset society have at their core ideas central to the dialectic. Combining natural and moral philosophy in research and teachings on the progressive character of the descent of man yields the idea that man is naturally supplied with a special moral sense, a Darwinian factor in the evolution of the civilized human, demonstrating that moral phenomena are no less real than their physical expression. Our chronic failure to prevent disease associated with the sea of toxic agents in the community and work environments in great measure can be attributed to our failure to link natural with moral phenomena which in a critical sense are no less 'natural'. The priest said: "Well, you know that he was buried amid much controversy." "But, I countered, "that was more than a century ago." The answer: "He remains buried amid much controversy." I said no more but thought that we must mourn more than the dead. We must mourn the living absurdities of our species, absurdities that take life itself, the preservation of which ought to be our civilization's highest value, as taught by all the great leaders of western religion. Correcting mistakes that plague application of Darwin's moral and scientific thinking in the reduction of environmental risk had long been a concern but became a preoccupation in Selikoff's final months of life. As a physician, his days had been spent meeting the needs of his patients, who more often than not were also his research subjects.
As a scientist, he had struggled to promote acceptance of multifactordeterministic causation. As a human, he sought exorcism of a deathperpetuating ghost in the thought collectives of our professions seen on the moral surface of human consciousness.
"Is the result of our work in environmental health," asked Selikoff, "to end as mere entries of economic price balanced in the ledgers of industry and government?" Selikoff's answer was optimistic.
We The moral instinct is drawn from the aggregation called "society," the structure analyzed by Aristotle (born 384 BC), in which the basic unit is the family.
"The family is the association established by nature for the supply of men's every day wants. … But when several families are united, and the association aims at more than the supply of daily needs, the first society to be formed is the village. And the most natural form of the village appears to be that of a colony from the family … When several villages are united in a single complete community … the state comes into existence … continuing in existence for the sake of a good life.
… And it is a characteristic of man that he alone has any sense of good and evil, of just and unjust … and the association of living beings who have this sense makes a family and a state." 18 Anomie.
Despite broadening recognition of Darwin's personal and family history of human rights advocacy, mistakes about his work continue to draw blood. The wide-spread use of the term "Social Darwinism" is common, a symptom of the anomie identified by Durkheim. 38 Normally the division of labor, he noted, produces social solidarity.
Sometimes it presents pathological forms that negate solidarity, such as disunity in the ideas and methods of science. Unity is an indispensable condition of happiness built on spontaneous consensus. "But it appears certain that happiness is something besides a sum of pleasure. … All pleasure is a sort of crisis … Life, on the contrary, is continuous. What happiness expresses is … the health of physical and moral life in its entirety." "… [W]hat ever may be part of hope in the genesis of the instinct of conservation," he wrote, "is a piercing witness of the relative bounty of life. [Yet when] evil increases or the causes of suffering increase, or the relative force of individuals is reduced, then as this sentiment passes in societies … with one stroke we shall be able] to measure those of the average unhappiness in these same environments. This fact is the number of suicides." … "But suicide scarcely appears except with civilization." … "It is not an act of despair but of abnegation. … In all these circumstances, man kills himself, not because he judges life is bad, but because the ideal … The Genesis of Hope In Philosophie des Als Ob, Vaihinger argued that human beings can never really know the underlying reality of the world, and that as a result we construct systems of thought and then assume that these match reality. We behave "as if" the world matches our models. 15 In "the whole world of ideas is an instrument to enable us to orientate ourselves in the real world, but is a copy of that world … [they are] relatively objective ideational constructs [not] subjective or fictional …." 15 The difference between poetic fiction and a scientist's hypothesis is critical, for example, when Darwinian hypothesis is verified fiction disappears, resulting in real explanation. Poetry is eternal.
Goethe's schematic animal archetype is a fiction justified as an expedient, according to Vaihinger, albeit Goethe himself saw it differently: dual possibilities within both the universes of "as if" and "as is." "In doing this, I soon felt the necessity of establishing a type," the poet-scientist wrote from the perspective of "as is," in describing his search for real primordial starting points, "against which one might gauge all mammals for conformity and deviation; and just as I had once sought out the archetypal plant, I now sought to find the archetypal animal." But in his search he understood that if his findings were to be systematized and explained, not just an empirical, but a conceptual dimension is necessary.
Thus, Goethe claimed, "in an attempt to study the laws whereby life is given to organic nature … quite justifiably, a force was ascribed to this life for purposes of discourse; and this force could be, indeed had to be, assumed. We being is not a preformed machine built, boxed, and controlled by an isolated will for use at random or self-selected time. Each and together we are organic hierarchies of formative processes. Formation is not explained by function, which explains usefulness. Use is not its cause or a mechanism, but a description of survival value for the individual and the population bearing the useful trait.

ACKNOWLEDGMENTS
This study arose from an assignment Knut Ringen received from the Blue Ribbon Commission on America's Nuclear Future (BRC) in 2010.
The BRC had been established by President Obama to investigate the pros and cons of continued reliance on nuclear fuel as a source of energy. Knut Ringen made the assessment of occupational risks from working in the nuclear energy sector compared to fossil (coal, petroleum, and natural gas) and renewable (e.g., hydro, solar, wind, tidal and current) sources of energy. The White Paper that resulted from this assessment 76 is the source of any statement in this paper unless there is a reference to another source. This report also contains acknowledgement of the scores of industry and academic experts who helped him understand the vast costs and benefits associated with energy production regardless of source.

DISCLOSURE BY AJIM EDITOR OF RECORD
John Meyer declares that he has no conflict of interest in the review and publication decision regarding this article.

AUTHOR CONTRIBUTIONS
All four authors reviewed and approved the final manuscript.
All four authors contributed to the Introduction. Sheldon Samuels wrote the following: Conversations with Irving's Ghost: The

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are openly available in public data at https://www.apple.com/.